The Dr. Hedberg Show

Histamine is often overlooked as a cause of chronic health problems yet the fix for this issue can be quite straightforward. In this article, I cover the details of histamine and how to follow a low histamine diet. Histamine intolerance (HIT) affects approximately 1% of the population. Approximately 80% of those affected are middle-aged. Histamine intolerance occurs when an individual has more histamine in their system than they can breakdown. Excess systemic concentrations of histamine can result from overproduction, overconsumption, and/or having a reduced ability to clear out histamine from the body. For those with HIT, eating a diet that results in increased histamine can contribute to chronic inflammation due to the ongoing exposure to histamine. This excess histamine often accumulates as a result of decreased diamine oxidase (DAO) activity. The resulting excess histamine contributes to the physical symptoms associated with HIT. Following a low-histamine diet along with supplemental DAO is often recommended to decrease the symptoms associated with HIT. Eating a low-histamine diet involves more than simply eliminating foods that are high in histamine. This article will help to explain the challenges with following a low histamine diet and will highlight the many ways excess histamine can occur in food and in the body. Histamine Synthesis and Degradation Excess histamine concentrations may be exogenously released from food or endogenously produced. Histamine is synthesized by a variety of cells in the body including mast cells, basophils, platelets, histaminergic neurons, and enterochromaffin cells. Endogenous histamine is released in response to a variety of immune and inflammatory related stimuli as well as certain foods, alcohol, or drugs which can activate release. Endogenous histamine supplies are also controlled by genes that code for the enzymes that synthesize and degrade histamine. Genetic polymorphisms in histamine receptors and DAO can decrease the rate of DAO activity, reducing the rate of clearance and increasing systemic histamine concentrations. Exogenous sources of histamine mainly comes from ingested foods. Several factors in food processing and storage can increase the histamine content of certain foods as well. Histamine is normally metabolized by amine oxidases in healthy individuals. These amine oxidases include monoamine oxidase (MAO), DAO, and histamine N-methyltransferase (HNMT), with DAO being the primary enzymes for metabolism of histamine. It is thought that low gastrointestinal levels of DAO contributes to an individual being unable to break down histamine in the intestines, resulting in the increased sensitivity to histamine found in common foods. As excess levels accumulate, intolerance symptoms develop. Symptoms Associated with Histamine Intolerance There is great heterogeneity in the presentation of symptoms in those with HIT, making it difficult to define a clear clinical picture. Histamine intolerance is generally suspected when symptoms appear after the ingestion of histamine containing food. Symptoms may develop immediately or can be delayed as much as three hours following ingestion. Histamine receptors are found ubiquitously throughout the body, making different organ systems susceptible to adverse reactions due to excess histamine concentrations. This results in a wide variety of symptoms that may be exhibited by an individual, contributing to the difficulty in diagnosis. These symptoms include gastrointestinal issues such as abdominal pain, bloating, diarrhea, and constipation. Extraintestinal complaints may affect neurological, respiratory, dermatological, and/or hemodynamic systems. Histamine has vasoactive properties that may result in flushing, headaches, and/or hypertension. Other common symptoms related to HIT include brain fog, fatigue, dizziness, itching, and difficulty swallowing, low blood pressure, nasal congestion, sneezing, and menstrual cramps. Low-Histamine Diet and DAO Supplementation Following a low-histamine diet along with DAO enzyme supplementation is currently the recommended strategy to prevent the symptoms associated with HIT. Sanchez-Perez et al. (2021) reported a >70% efficacy rate among the clinical studies examined in their review of low-histamine diets.  They also found that only 32% of the excluded foods in a low histamine diet contained histamine.  Foods containing other biogenic amines (BAs), like putrescine, were thought to be responsible for the increased symptoms related to HIT. They state that it is possible that certain foods, while containing no or low levels of histamine, may act as histamine liberators resulting in excess accumulation of histamine. There is also great heterogeneity in the foods recommended for a low-histamine diet. Fermented food products and beverages were consistently recognized as a primary food group to be avoided. Decreasing the amount of histamine in the diet has been shown to decrease symptoms related to HIT. Following a low histamine diet can be confusing as there is a lack of consensus as to which foods should be included versus excluded. It can also be difficult for individuals to monitor the intake of histamine from the diet as there are no labeling requirements on foods for histamine. The daily intake of histamine, on average, is 1000mg/kg. Healthy individuals should be able to metabolize this amount without any problems. The recommended range for those undertaking a low-histamine diet is between 5-50 mg/kg.  Some experts suggests that even lower levels are necessary and recommend an intake of foods with histamine levels below 1 mg/kg.2 Supplementation with DAO may also prove beneficial in reducing symptoms. Manzotti et al. (2016) demonstrated that individuals with DAO activity <3U/mL were highly likely to have HIT and those with DAO activity <10 U/mL were likely to be intolerant. Histamine intolerance was not expected in individuals with DAO activity >10U/mL.8 Biogenic Amines and a Low-Histamine Diet Fermented foods (cured cheese, sausages, fish, fermented foods, certain vegetables) and fermented beverages (wine and beer) contain biogenic amines (BAs). These BAs are produced when amino acids undergo decarboxylation by substrate specific decarboxylase enzymes. The BA, histamine, is formed from the amino acid histidine. Other common BAs in foods include tyramine, putrescine, phenylethylamine, spermine, spermidine, cadaverine, and agmatine. High amounts of histamine have been found in semi-cured and grated cheeses—particularly parmesan and bleu cheese, fermented foods such as fish paste and fish sauce, sauerkraut, fermented soy products, and cured sausages. The BA tyramine is found in some aged cheeses and can be related to increased symptoms such as increased blood pressure and migraines in HIT individuals. Other substances and foods may affect histamine levels. Foods high in putrescine (citrus fruits, bananas, and fermented foods—sausages, soy products, and cabbage) may interfere with DAO activity in the intestines. Food sources of putrescine may also enhance the toxic effects of histamine. Foods high in any of these BAs should be avoided on a low-histamine diet as they may affect the metabolism and degradation of histamine. Alcohol and Nutritional Deficiencies May Affect Histamine Levels Alcohol and certain medications may elicit a release of histamine or inhibit MAO and DAO. Consumption of alcohol can also increase the toxic effects of histamine. This results in competitive inhibition as the acetaldehyde produced in the breakdown of alcohol competes with histamine for the enzyme aldehyde dehydrogenase, resulting in increased histamine. It is worth noting that a deficiency in any of the cofactors needed by the enzymes used in the metabolism of histamine may impair its biotransformation and elimination, resulting in increased systemic levels of histamine as well. Therefore, nutrient deficiencies may need to be addressed for those that do not get sufficient relief solely from dietary avoidance of histamine-rich foods. For example, cofactors used by DAO include copper, vitamin C and Vitamin B6. A deficiency in any of these would affect DAO synthesis. Factors Affecting Histamine Levels in Foods—Length of Storage, Temperature, Vacuum Packing, and Additives It is impossible to completely eliminate histamine from the diet. There are many factors that determine the content of BA and histamine including freshness, pH, food source, salt content, content of proteins, processing and storage. There are several factors involved during the manufacturing process that affect the BA concentration in foods. Increased storage times increases the amount of BAs formed by the microorganisms present in food during storage. For those with HIT it is important to choose fresh foods sourced with a minimal amount of contamination prior to and during processing. Choosing foods as fresh as possible helps decrease the histamine content, providing less time for the creation of histamine from the increased bacterial decarboxylase activity seen during storage. Foods with a shorter period of fermentation may also have lower BA levels. Several bacterial groups have been shown to have decarboxylase activity and can thereby increase BAs and histamine specifically. These include yeasts found in cheeses and some bacteria species found in seafood, wine, fermented soy products, and  yogurt. An increase in BAs is also noted as storage temperatures increase. It is therefore a good idea to keep histamine-rich foods chilled during storage. Storing and processing fish at or below temperatures of 39.9 degrees Fahrenheit has been shown to decrease the amount of histamine that is formed.

The National Institutes of Health (NIH) states that five out of every 100 Americans over the age of 12 have hypothyroidism. The prevalence of this disease increases with age.(1) This makes hypothyroidism the most common disease arising from a hormonal insufficiency.(2) Gender is an influencing factor, as women are three to seven times more likely to develop hypothyroidism than men.(1) Known risk factors that increase the likelihood of developing this disease include having a family history of hypothyroidism and pregnancy.(1) Recent research by the British Medical Journal (2021) suggests that taking birth control pills, or oral contraceptives (OCs), may also increase the odds of developing hypothyroidism.(3) Birth Control Pills Statistics Oral contraceptives are a widely used form of birth control by women. Many individuals turn to these medications for reasons other than birth control such as relief from symptoms such as abnormal uterine bleeding, endometriosis, hormonal and menstrual irregularities, etc.(3)Approximately 6 million women in the US, aged 15-49, take oral contraceptives (OCs) each year.(4) The National Survey of Family Growth (2015-2017) reported that OCs are the second most common method of contraception used by women between the ages of 15-49.(4) The use of OCs is higher among younger populations and decreases with age. Approximately 90% of women taking birth control pills are < 40 years old and 54% are under the age of 20.(1)Therefore, an association between the use of OCs and the risk of hypothyroidism could potentially affect a significant number of individuals. These individuals, when presented with other options for contraception and/or better monitoring of thyroid function, may be able to avoid the increased risk of morbidity and mortality associated with hypothyroidism. Birth Control Pills and Risk of Hypothyroidism The British Medical Journey (2021) recently stated that women with a history of taking OCs for more than 10 years have greater odds of developing hypothyroidism (OR, 3.837; 95% CI 1.402-10.500; p=0.0090). Their finding was the result of a retrospective, cross-sectional study derived from information gathered in the National Health and Nutrition Examination Survey (NHANES) 2007-2012. This large epidemiological survey included a total of 30,442 participants. Of this number, 5116 females met the inclusion criteria for participation in the study. These individuals were divided into two groups: those with a history of OC usage (n=3034) and those that had never used OCs (n=2082). Approximately 16% (830) of the combined individuals were identified as hypothyroid. Hypothyroidism was more frequently diagnosed in those with a history of taking OCs (17.7% vs 14.1%). The state of being hypothyroid was defined as either those taking levothyroxine, regardless of thyroid stimulating hormone (TSH) or those with a TSH >5.6 mIU/L.(3) Women should therefore consider the long-term health effects of OCs and the increased odds of developing hypothyroidism associated with their use. This study had several strengths, including the large population surveyed, and the strict criteria used to control for confounders. Limitations were also inherent in this type of study. One of the main limitations is the lack of data to differentiate between the types of OCs used, including their chemical composition. Knowing the types of contraceptives used, i.e.: combined contraceptives containing estrogen and progestin versus progestin only contraceptives, may have provided different outcomes. Other limitations included possible recall bias due to the use of self-reported data from individuals, which can often be incorrect. These factors may have skewed the results obtained. It is also important to recognize a cross-sectional, retrospective analysis can only demonstrate an association between the OCs and hypothyroidism and cannot establish causation.(3) According to the National Institute for Health (NIH), hypothyroidism can be mild and present with few symptoms.(1) Common hypothyroid symptoms include constipation, weight gain, fatigue, lethargy, cold intolerance, change in voice, and dry skin.(1),(2) Other symptoms may include depression, anterior neck pain, dizziness, wheezing, hair loss, difficulty swallowing, restlessness, palpitations, shortness of breath, and mood lability.(5)  The presentation of these symptoms decreases as an individual ages, making symptomatology an unreliable diagnostic tool for individuals over 60.(5) For this population, tiredness and respiratory issues are the prevalent symptoms that may signal the onset of hypothyroidism.(5) The non-specific nature of these symptoms contributes to the difficulty of reaching a definitive diagnosis. Including the prior use of OCs in a patients’ history may help identify those with increased odds of developing this disease.(3) Oral Contraceptives Increase Thyroxine-binding Globulin The estrogenic effect of OCs has been shown to increase various proteins synthesized by the liver involved in processes such as atherosclerosis, hypertension, and thrombosis. These proteins include thyroxine-binding globulin (TBG), sex hormone binding globulin (SHBG), and coagulation factors.(6) Torre et al. (2020) reviewed the effect of OCs on the hepatic production of TBG and the coinciding effect on serum levels of thyroxine (T4) and triiodothyronine (T3). They stated that increased estrogen resulted in decreased TBG renal clearance, which led to an increased amount of TBG available for binding to thyroid hormones. The increased TBG resulted in increased binding of T4 and T3 and therefore an increase in TSH and thyroid hormone synthesis. Thyroid hormone synthesis is controlled by the hypothalamus and the anterior pituitary. The hypothalamus releases thyrotropin-releasing hormone (TRH) which stimulates the anterior pituitary to release thyroid stimulating hormone (TSH). An increase in the concentration of TSH triggers the thyroid into producing the iodine containing hormone thyroxine (T4). This T4 is converted to the biologically active form, triiodothyronine (T3), in peripheral tissues.(6) The majority (99.8%) of circulating T4 and T3 are bound to serum proteins, with 70% binding to the high affinity, low concentration, protein—TBG. The remainder binds to the low affinity proteins—transthyretin (TTR) and albumin.(6) This binding is necessary for their transport in the blood stream as well as the extension of their half-life. These bound T4 and T3 hormones are unavailable to tissues, making them inactive.(7) An increase in the concentration of TBG, as has been noted with the use of OCs, can therefore impact the concentrations of total thyroid hormone available for use by binding up more T4 and T3. The body produces more TSH to try and make more hormone available. As this TSH level continues to rise, hypothyroidism develops. A review conducted by Torre et al. (2020) concluded that an increase in estrogen production in the body, either through OCs or hormone replacement therapy (HRT) was shown to increase TBG and T4.  They stated that the serum concentrations of TBG increased due to an increase in salicylation stimulated by the natural estrogens. They observed a 30-50% increase in TBG concentrations and a 20-35% in T4 concentrations within two weeks of beginning standard dosages of OCs (ethinyl-estradiol—20-35 ug/d; conjugated estrogens—0.625 mg/d). Due to the increased binding of thyroid hormone to the increased TBG present, it was necessary to increase the dosage of Levothyroxine by ~45% to maintain normal TSH concentrations in those being treated for hypothyroidism and in pregnant women.(6) It is important to note that this increase in TBG and T4 was only observed with oral administration of estrogen. Transdermal applications did not alter TBG or T4 levels. Adding progesterone to the OCs did not alter the change in TBG and T4 concentrations observed. Progesterone, when used alone, acted in an opposite fashion, and was shown to decrease TSH levels and increase FT4 levels. Progesterone based OCs, therefore, were found to be a safer choice for those with or at risk of developing hypothyroidism.(6) Oral Contraceptives Increase the Risk Of Venous Thromboembolism Torre et al. (2020) also reported a three to eight times higher risk of venous thromboembolism (VTE) in those that used combined OCs (estrogen and progesterone) compared to those that did not. They noted a positive correlation was found between increased levels of TBG and increased levels of activated protein C resistance (APCR), linking increases in both to an increased risk of venous thromboembolism (VTE). Using combined OCs (estrogen and progesterone) was associated with an even higher risk than estrogen alone. As previously noted with estrogen-based OCs, the transdermal application of estrogen and progesterone was not linked to an increased risk of VTE, making transdermal application a safer choice for those at risk.(6) Subclinical hypothyroid (SCH), defined as normal FT4 and elevated TSH levels, has been associated with an increase in mean platelet volume (MPV) and an increase in pro-thrombotic events. Abnormal lipid profiles and hypertension have also been observed in SCH individuals. The larger platelets present with an increased MPV have increased metabolic activity and an increased potential for thrombotic events. An elevated MPV can therefore be used as a useful predictor of cardiovascular disease (CVD) and VTE. As TSH increases, so does the risk of abnormalities associated with CVD including dyslipidemia, hypertension, and increased markers of inflammation (C-reactive protein).(6) This increased risk of CVD and VTE with hypothyroidism, whether clinical or subclinical, necessitates the monitoring of thyroid status for those on OCs.

In this episode of Functional Medicine Research, I interview Palmer Kippola on how to beat autoimmune disease and her new book "Beat Autoimmune: The 6 Keys to Reverse Your Condition and Reclaim Your Health". We had a great talk walking through her F.I.G.H.T.S. protocol which includes food, infections, gut health, hormones, toxins, and stress. Our focus in this interview was on practical strategies for those with autoimmune disease to implement right away into their lives. Palmer has dealt with autoimmune disease herself, so she offers a unique perspective. Full Transcript on How to Beat Autoimmune Disease with Palmer Kippola Dr. Hedberg: Greetings everyone, and welcome to "Functional Medicine Research." I'm Dr. Hedberg, and I'm looking forward to my conversation today with Palmer Kippola. She's a best-selling author, speaker, and functional medicine certified health coach who specializes in helping people reverse and prevent autoimmune conditions. She developed a framework called F.I.G.H.T.S, which stands for food, infections, gut health, hormone balance, toxins, and stress to help others beat autoimmune conditions based on her two-decade battle to overcome multiple sclerosis. Her book is "Beat Autoimmune: The 6 Keys to Reverse Your Condition and Reclaim Your Health," with a foreword by Mark Hyman. And as she shares the science stories and strategies to help people heal and thrive, today she provides total health transformation programs for people who seek to heal from any autoimmune condition by addressing the root causes head-on with functional lab testing and comprehensive mind-body strategies. She also serves a growing community of people in a guided online membership program called Beat Autoimmune Academy. Palmer, welcome to the show. Palmer: Thank you so much, Dr. Hedberg. It's such a pleasure to be here. Dr. Hedberg: Right. So, as I mentioned in the bio, you dealt with multiple sclerosis. So, I'm sure there's a story there. So, why don't you walk us through your healing journey, what that was like, and that whole process? Palmer: Sure, sure. I do need to take you back in time a little bit because I was diagnosed at 19. Let me tell you the story. I was a happy, healthy, well-adjusted 19-year-old, by all accounts. I was home for summer after my freshman year of college, and I was working as a hostess in a restaurant. And one day I woke up and the soles of my feet were tingling, like that feeling you have when you've slept on a limb too long, when the blood flows back, it gets all tingling. But this particular morning, the blood wasn't flowing back. But I thought it'll just go away, so I went off to work. And the tingling just continued to creep up my legs like a vine. It got to my knees and by that time, I knew something was really wrong. So, I called my parents who called the family doctor who said, "Get her over to the neurologist at UCLA today." And we did. That's where we were that afternoon. And this particular neurologist had me do really simple heel-toe walking across her floor and tapped my reflexes. And after about five or six minutes, pronounced that she was 99% certain that I had MS, multiple sclerosis. And if she was right, there was nothing I could do except take medication. And we were absolutely shocked. Remember, this was in the mid-80s, so there was no guidebook, there was nothing. We had never heard of MS. And we just left that office completely confused, devastated, and with very little hope. But I was sent home and that night, my mom lay in bed with me and she was holding me and I was crying and she was crying and it turned out that all of the parts of my body that had been tingling, which by the time I got to the neurologist's office, it had reached right under my collarbone, so all the way up, full body. And then by the time we got into bed that night, all my body went completely numb from the neck down and I would stay numb for a full six weeks. So, an absolutely terrifying first experience, not having any information, not having any idea how this came on, or what my future was gonna look like. But that summer, the Olympics were on TV and I was really grateful because that's about all I could do is lie on the couch and watch the Olympics. And I do have to say that I'm so grateful that my parents were so supportive and rocks and I had friends that came by and brought gifts, like, you know, 19-year-old friends do, books and watch movies with me. But this one family friend who was into things metaphysical came and asked me a question, which at the time I didn't think was a gift, but it turned out to be the guiding light for the rest of my life because she asked me the question, "Palmer, why do you think you've got the MS?" And I was incensed like, "How dare you? What do you mean why do I think I got this? Are you accusing me of doing something that brought this on?" So, I lay there like a dog with a bone just chewing on that question. And it did come to me in a flash of insight as I lay on the couch. So, I'm 19, I'm on the couch, and I just need to take you a tiny bit farther back in time because I had been adopted at three days old by very loving parents. But my dad had been a fighter pilot and his way was proverbially the right way and so we butted heads quite a bit. He was verbally abusive, very judgmental. And the earliest memory that I had that came to me in that flash of insight lying on the couch was my dad is calling my mom names, she's locked herself in the bedroom, and I can't remember if I'm three or four, but whatever, I'm standing with my little dukes up with words to the effect of you call my mom names and I'll suck lights out. So, I had become this little child warrior. And that had meant that I wasn't sleeping through the night, I developed insomnia because I was always scanning the environment for safety. So, that initial hypothesis of why I got the MS of chronic stress still rings true for me today, even though I know there's much more to the story. So, I'll pause for a moment and see if you have any particular questions at this point. Dr. Hedberg: Right. Well, we often see that strong adverse childhood experiences or some kind of ongoing stress or a stressful event as a major player in the triggering event and that could be a single event or like I said, something ongoing. And we're just so vulnerable as children as our immune systems and central nervous system is developing. And so, I'm sure you see it with the people you work with and we often see something like that that leads up to the development of an autoimmune condition. So, that must have been really scary, especially something like MS because I've seen MS patients in wheelchairs and there's some pretty devastating effects for some individuals who have MS as it progresses. So, did you do anything else other than focusing on nutrition and lifestyle to help you get through that? Palmer: Sure. Well, I can address that. You're absolutely right. I do wanna add that after we left the neurologist's office, the neurologist held my parents back and said to them privately, "You better get ready for her life in a wheelchair because that's where she's heading," which just you know, makes me angry. But that's the best that some have to offer and that certainly at the time, the best that could be done. So, yeah, I did multiple experiments over the years. I was fortunate that the numbness faded enough for me to go back to my sophomore year of school. So, it didn't completely go away for a couple of years, but I was functional. I could walk and I had good cognition. So, off I went back to school and there was a period of denial, which is probably normal. But there was also no internet. I was really left to my own to figure out what to eat, you mentioned nutrition. And the only thing I had was the public library, and the only thing available on MS was the Swank diet, which purported that a low-fat vegetarian diet was the best for MS. So, I gave it a try. And that did not help me. In fact, it made my gut symptoms worse. Now, for my entire life, I had symptoms of constipation. So, I kinda thought that was normal and I always felt a little tummy grumbling after eating, but I also chalked that up to being normal. I didn't think it was a problem. So, it would take more than two decades for me to address what was really going on. And I wanna really be clear to say this is something that now we have the science, we have the stories and the strategies, it doesn't need to take nearly the time that it took me because I was really going on my intuition that if stress was the big problem, I needed to figure out how to reduce the stress. So, that led me to meditation, that led me to yoga, started doing those in the late 80s, early 90s. And I did notice almost immediately that when I was able to bring the stress down, and as my yoga teacher would say let it go with this very long go, I would actually have a diminishment of symptoms. It turned out that I had relapsing-remitting MS. So, that means it comes and goes, it's not necessarily progressively worsening. But it became really clear that the more stress I had in my life, whether that was conflict at home or exams at school, or whatever I perceived as being stressful, you could almost count on it that I would develop more MS symptoms, whether that was numbness and tingling or tightness or this symptom called Lhermitte's syndrome where you bend your head down and get this zapping energy down your back. All of these things got worse with stress and better with relaxation. So, that was a big win, but it wasn't complete. Nutrition, as I said, I wouldn't learn for years what I was doing wrong. And finally in 2010, I decided to pay attention to what was going on with my gut after eating and that is when I went to a functional medicine nutritionist who did some tests and found out that I had non-celiac gluten sensitivity.

Functional medicine practitioners often take a “Foods First” approach, recommending dietary modifications to improve health. However, for those with low stomach acid, diet alone may not be enough to ensure adequate nutrition. Low stomach acid can impair digestive ability, causing nutritional deficiencies even in those individuals consuming an optimal diet. This article will focus on the main digestive chemical associated with the stomach, hydrochloric acid. The causes of low stomach acid and the associated symptoms will be covered. In addition, natural treatment options for low stomach acid, such as betaine HCL and herbal bitters will be discussed. What is Digestion? Digestion is the process of breaking food down into particles small enough so that the nutrients in the food can be absorbed and then transported throughout the body. Digestion begins in the mouth with the mechanical process of chewing along with salivary enzymes that begin the digestive process. This process is continued as the food passes into the stomach, activating the release of hydrochloric acid. The bolus of food then passes to the small intestines where the majority of digestion takes place. The useful nutrients are digested and absorbed and the waste products are sent through the large intestines for evacuation as feces. Why Does the Stomach Contain Hydrochloric Acid? The stomach is a naturally acidic environment, especially following a meal, with a normal pH value of <3. Low stomach acid (hypochlorhydria) is observed with a rise in pH >3 and an absence of stomach acid (achlorhydria) is obtained with a pH > 7.1 This acidity comes from the hydrochloric acid that is secreted by the parietal cells in the lining of the stomach. Healthy stomach acid levels serve as an immune system barrier, providing a first line of defense against unwanted bacterial or microbial invaders that enter the stomach. Hydrochloric acid is also necessary for the digestion of proteins. Proteins are a conglomeration of amino acids folded together into different shapes. Stomach acid serves to denature (unfold) the proteins and expose the bonds that hold the amino acids together. These bonds can then be cleaved by pepsin, which breaks the protein down into smaller, easier to digest, amino acids. The formation of pepsin from pepsinogen is dependent on sufficient stomach acid levels as well. Hydrochloric acid is also responsible for deactivating the enzymes of salivary amylase as it enters the stomach and for stimulating the release of cholecystokinin in the small intestines. Both processes are essential for healthy digestive function. Certain vitamins and minerals depend on hydrochloric acid to liberate them from their carriers, such as vitamin B12 and calcium. Having low stomach acid levels can impair all of these functions. What causes low stomach acid levels? Factors that contribute to low stomach acid include: Chronic stressAgingPoor dietInfectionsMedication use Stress—Stress impairs digestion. Chronic stress may decrease the production of hydrochloric acid in the stomach due to associated nutrient deficiencies.2 Stress also causes the vagus nerve to lose its proper tone. The vagus nerve is a major part of the parasympathetic nervous system, and it is deeply involved in stomach acid production. With chronic stress it loses its ability to fire properly which disrupts normal stomach acid production. Aging—Low levels of stomach acid following a meal are more common with aging. Studies that compared stomach acid levels in young individuals (mean age 25) versus older individuals (mean age 75) found that older individuals experienced low levels of stomach acid following a meal for a greater length of time than their younger counterparts. It took 89 minutes for the elderly participants versus 42 minutes for the younger participants to regain normal stomach acid levels (pH 3.0) following a “standard meal”.1, 3, 4 These studies help support the existence of “functional low stomach acid levels” in the elderly following meals. Poor Diet—Eating a diet comprised of highly refined sugars and carbohydrates, alcohol, and/or smoking may result in nutritional deficiencies of B vitamins or zinc, both necessary for the production of hydrochloric acid in the stomach. Infections—Healthy stomach acidity provides a barrier for the immune system's first line of defense against invading substances. Low stomach acid results in an impaired immune response and an increased susceptibility to viral and/or bacterial infection and to bacterial/microbial overgrowth. Common conditions associated with low stomach acid include Helicobacter pylori, small intestinal bacterial overgrowth (SIBO), and Clostridium difficile.1 Medications—Medications, such as antacids, proton-pump inhibitors (PPIs), and H2-receptor antagonists (H2-RAs), are another widespread cause of low stomach acid. These medications are used to decrease the symptoms of gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). Long-term use of these drugs has been associated with an increased risk of fracture due to nutrient deficiencies connected to low stomach acid. Approximately 25% of Americans may be using some form of acid reducing medication as the prevalence of GERD in North American has been estimated to be between 18.1% to 27.8%.5 Surgery—Gastric bypass surgery can reduce the production of stomach acid. What are the symptoms of low stomach acid? Burping, Bloating and Gas—An adequate level of stomach acid is necessary for the digestion of minerals and proteins into smaller amino acids that can be passed into the small intestines for further digestion and absorption. Low stomach acid can lead to undigested proteins being present in the stomach and being subsequently passed into the small intestines. These undigested particles are too large for absorption and create increased burping, bloating, and gas as they ferment. This increased gastrointestinal inflammation can set the stage for the development of intestinal permeability, commonly referred to as leaky gut. Indigestion/Heartburn—Heartburn may occur when stomach acids leak up into the esophagus, causing burning. This displacement of stomach acid away from the stomach leaves low stomach acid levels in the stomach. If left untreated, this acid reflux can lead to conditions such as asthma and/or esophageal cancer. Undigested food in stool—The undigested food particles may be passed through the digestive tract and expelled in feces. These can often be visible in the stool. Food allergies and/or hypersensitivities—In the presence of intestinal permeability, the large, undigested protein particles can pass through the leaky intestinal membrane barrier. This activates the immune system into action as these large particles are targeted as invaders. The net result is the development of food allergies and/or hypersensitivities. Stomach pain—Inflammation in the lining of the stomach (gastritis) can result in stomach pain. This is often due to a H. Pylori infection. Increased levels of gastrin are produced that destroy parietal and chief cells. This results in a decrease in stomach acid and can result in a loss of intrinsic factor, leading to a B12 anemia. There is an increased risk of gastric cancer if left untreated. Avoidance of Meat—Many individuals will avoid eating meat due to their decreased ability to digest the proteins when stomach acid is low. They find they experience fewer digestive complaints when they do not eat meat. Weak or Brittle Nails, Hair, Bones—The inability to digest proteins and certain minerals and vitamins, such as calcium, magnesium, iron, vitamins B6, B12, and folic acid, can be related to low stomach acid. These nutrients are necessary for the growth of healthy nails, hair, and bones. Common diseases that may develop include anemias, osteoporosis, and osteoarthritis. Neurological issues—The nutritional deficiencies, particularly the B vitamin anemias and magnesium, can contribute to neurological issues such as numbness, tingling, and vision changes. Diarrhea—Low levels of stomach acid increases the risk of gastroenteritis, diarrhea, and Clostridium difficile colitis. Fatigue—Ongoing nutritional deficiencies, infections, and/or diarrhea can contribute to fatigue. Betaine HCL and Herbal Bitters supplementation Guilliams and Drake (2020) reviewed the practice of using Betaine HCL with meals as a treatment option for individuals with low stomach acid. In this review they discussed many of the issues that we have discussed associated with low stomach acid. They also reviewed research that supports methods to increase stomach acid easily. Two of the more practical methods included the use of plant extracts, commonly known as bitters, and the use of betaine HCL to temporarily increase acid levels with meals.1 Bitters promote digestion by stimulating the secretion of stomach acid, digestive enzymes, and bile. Original Bitters is a liquid herbal formula developed by David Winston that can be used for this purpose. It is recommended to take this mixture 10-15 minutes before meals to ensure adequate time for the digestive secretions to develop prior to food entering the system. They do suggest caution in those individuals with gastric ulcers, GERD, or gastritis. The use of bitters is not recommended in those with too much stomach acid. Betaine HCL Betaine HCL can replenish stomach acid levels, increase the body's ability to digest proteins and minerals, and help decrease the symptoms associated with a deficiency. Betaine HCL works by easily donating its H+ ions in an aqueous environment, creating an acidic solution. Because of this, it is important to never chew supplements containing betaine HCL. The acid can easily corrode dental enamel or burn sensitive esophageal tissue. The stomach, with its protective mucus lining,

In this episode of Functional Medicine Research, I interview Sally Norton in a discussion about how oxalates affect your thyroid and your health. We covered what oxalates are and how they can damage the body. We also discussed how oxalates affect gut health, liver health, thyroid health as well as all the symptoms and associated conditions connected to oxalates. If you're really struggling to get well, but your diet appears to be healthy, oxalates may be the missing link. Full Transcript on Oxalates and Thyroid Health Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg, and I'm really looking forward to my conversation today with Sally Norton. Sally is a consultant writer, educator, and speaker with over 30 years in the health promotion and wellness field. Sally specializes in helping people improve their health with an oxalate-avoiding diet. Sally holds a nutrition degree from Cornell University and a Master's of Public Health degree from the University of North Carolina at Chapel Hill. She worked in the field of medical education at UNC Medical Schools Program on Integrative Medicine and as a research grant writer and research administrator at the Virginia Commonwealth University School of Medicine. Despite a healthy lifestyle, she struggled for over 30 years with seemingly unanswerable health challenges, including chronic pain and fatigue. When she finally discovered the cause and turned her health around, she committed to teaching and reaching out to others stuck in similar frustrating situations. Sally, welcome to the show. Sally: Thank you. It's great to be here. Dr. Hedberg: Yeah, I'm looking forward to this and we were kind of discussing this early on. Oxalates is something that I've always kept my eye on for the last 17 years and I was really looking forward to this conversation. So why don't we lay a little bit of bedrock for the listeners? And if you could just talk about what are oxalates, and do we know why plants actually have oxalates? Sally: Yes. Plants are a major producer of oxalate and obviously, it's also ubiquitous in nature itself. Soil is loaded with it. Even apparently sea spray produces some oxalate and polluted air produces oxalates, so, in really heavily polluted cities, the air has got oxalate in it too. So oxalate is this really minuscule molecule that its parent compound is called oxalic acid. And acids ionize and become charged particles because they drop off the acidic protein and so they become these negatively charged ions that attract positively charged things and oxalates can have a one negative or two negative. It is a tiny, tiny little compound. It has four oxygens, which is a heavy load of oxygen on just two little carbon molecules. So it's very oxygen-heavy, which is probably partly why it's such a pro-oxidant molecule, you know. Oxidation is very bad for tissues, membranes, mitochondria, and it is a great mitochondrial poison, membrane destroyer, and troublemaker. And it's not just the oxygen, though. It's much more about this reactivity that the charge creates where it bonds with minerals and becomes salts. And so, salt is a chemical term for things that can dissolve, but when it...because it can have two negative charges, it will also hook up with minerals that won't dissolve well. So calcium, for example, is a two positive charge mineral. With that double-positive and double-negative marriage between the two, you create an insoluble oxalate, which is the backbone of oxalate you see in nature because calcium is everywhere in soils and in nature, and plants are having to manage their calcium. And one of the ways they do that...because too much calcium can be toxic to the plant. So one of the ways they do that is they make oxalic acid. Often they make vitamin C first, very similar compounds, and vitamin C naturally degrades just hanging around into oxalic acid and oxalates. So plants will create vitamin C and they'll create oxalic acid so they can manage their calcium and store it away like a pantry. And in a siege, you need to store that calcium because calcium can be an enzyme co-factor and promote the germination process. So you store it, you deep-six it in these crystals in your seeds, and then when you germinate as a seed, you liberate off the oxalic acid in the calcium and you get your enzymes going. And in the meantime, those lovely crystals of calcium oxalate in the seed coat protects the seed from degeneration and from predators, and from deterioration, so it helps preserve the seed. But the oxalate has many other uses for plants, and plants deliberately construct special shapes of crystals. They lay out this kind of protein matrix and then the crystals nucleate and create these crazy shapes, including a double-pointed toothpick, super fine invisible toothpicks made in bundles of like 200 or more. And the plants literally use them as poison arrows to disturb the mucous membranes of predators and so on and it can kill off caterpillars and bugs and can be damaging to be eating a lot of them in certain foods. Or they haven't actually studied, like, what shape crystals in food plants that much. So we know of a handful. The kiwi is notoriously full of these tooth-picky [inaudible 00:05:05] crystals, for example. So, they use them for self-defense in a direct kind of...I say that plants invented warfare because they have these poisoned arrows and they put on these arrows, proteases and soluble oxalate-related and things that are quite toxic to cells, and if you injure the mucous membrane, then you can enter the intercellular space and potentially enter the circulation and be quite dangerous and hazardous to the victim. But, like, trees will put out hundreds of pounds of oxalate crystals in these cube blocks in their bark, which helps make the bark inedible to the beetles. And so, they figure maybe six or seven uses of oxalate, and in desert plants, plants make oxalate during the nighttime, create the calcium oxalate crystals, and then during the day in the desert, they have to close their breathing holes under the leaves in order to not dry out. But if you can't get CO2 through your breathing holes in your leaves, you can't produce energy as a plant. You need sunlight and you need air. So instead of using CO2 to do photosynthesis in the day, you use calcium oxalate. You break off that... Oxalate becomes a reservoir for carbon because there's so much oxygen, CO2, right? There's so much oxygen in that oxalate so perfect carbon-oxygen sync so you can make energy as a plant in the desert. So, like, there's this really cool stuff. The plants need it for their biology and they're using it against the predators, against them, and so in us, oxalate is quite toxic. In a plant, it's a clever strategy for survival. Dr. Hedberg: Okay. So that was really interesting, and it's interesting that you bring up the structure of the oxalates because I do remember seeing some microscopic pictures of oxalates and I just thought, "Wow, that looks really deadly looking at them." The number of spikes, the size of the spikes, how sharp they look. And, you know, you've mentioned plants defending themselves and we see that not just with oxalates but also, you know, like, things like methylxanthines in coffee beans and cocoa beans are, you know, natural pesticides and a large human usually can detoxify those but sometimes small amounts or moderate amounts can also be damaging. So can you talk a little bit more about what foods contain oxalates and what foods people should look out for? Sally: Yes, yes. So the animal kingdom does not have a lot of oxalates, although there's one rare exception of some giant snail in Asia that is not going to run across your menu anytime soon. It is the plant kingdom. It tends to be the seeds. There are four leafy greens that are particularly problematic and, unfortunately, a lot of people have flattened out the idea about where oxalates are to say all leafy greens are high in oxalate, and that's just not the case. There's spinach, which is the poster child of a high oxalate food. Beet greens and...Swiss chard is basically beet greens without the beet, is even worse than spinach. Swiss chard and beet greens are...Spinach is plenty bad enough, but that's even worse. And then there's sorrel, which is popular in other countries, not so much here unless you're going to upmarket restaurant. So those are leafy greens. Beans as a group are generally quite bad, the white beans, the black beans. The peas are not as bad, like a better choice would be black-eyed peas, green peas, and chickpeas would be much safer to use than black beans, for example. Let's see. And the grains, it's almost all of them because the bran and the germ contains oxalate. So bran, whole wheat, bran-related things can really add up to a lot of oxalate. So the white flour stuff tends to be lower in oxalate but, of course, that's really devoid deficient food, and even that can add up. So even heavy bread users can get into a lot of oxalate, but I think the two most, or I would say the three most common foods that's universally interesting to modern people across the planet include potatoes and sweet potatoes. You know, the French fries, the tater tots, the potato chips, that is loaded because we eat it so much. Peanuts and peanut butter and anything made with peanuts, nuts in general, and then chocolate. So if you love your Reese's Peanut Butter Cups and your super dark chocolate and you like nuts, or if you're on a keto diet, you're probably super overloading your diet with oxalates. Dr. Hedberg: Right. And one of the things that I've found is that the resources outline for oxalate content in foods tends to be highly variable. So on your website, I purchased the oxalate handout. And then if you compare that to, you know, some of the other handouts that are out there from certain universities and other...you know.

In this episode of Functional Medicine Research, I interview Dr. Theodore Belfor in a discussion on cranial facial development and airway resistance. If you have read James Nestor's new book "Breath" then you are aware of Dr. Belfor's work. We talked about the causes of abnormal cranial development and how this causes airway resistance and a number of health problems including sleep apnea, insomnia, IBS, bruxism, and more. Our cranial bones don't form properly when we aren't breastfed and eat a modern diet of processed foods. Dr. Belfor's oral appliances help to correct these abnormal developments to restore proper facial bone structure and improve the airway. Full Transcript with Dr. Theodore Belfor Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg, very, very excited today to have Dr. Theodore Belfor on the podcast. I first heard about Dr. Belfor in James Nestor's new book called "Breath." And we're gonna be talking about all of that today on the show. And Dr. Belfor, he's a graduate of New York University College of Dentistry, and a senior certified instructor for the International Association for orthodontics. In the 1960s, Dr. Belfor was sent to Vietnam to work as the sole brigade dentist for 4000 soldiers of the 196 Light Infantry from the jungles of Vietnam to Park Avenue in Manhattan. Upon his return, he opened his own private dental office in New York City, and has been in private practice for more than 40 years. And Dr. Belfor specializes in the treatment of the cranial facial system, and that's what we're going to be diving into today. So, Dr. Belfor, welcome to the show. Dr. Belfor: Well, thank you for having me. It's my pleasure. Dr. Hedberg: Excellent. So, why don't we start by talking about how this all began, and go back to, you know, what happened that changed the cranial bones, the cranial structure, our skulls, that led to this epidemic of airway issues, breathing issues, and all of the health issues that come with that? Dr. Belfor: Well, how we develop, how we grow and develop is based on how we breathe, how we swallow, and how we chew. So, just looking at how we chew, according to the U.S. Department of Agriculture today, in the U.S., 63% of our diet is processed and refined foods. So, without the proper stimulation to the body, we are not fully expressing our genes, we're not developing to our full potential. Because of that, particularly when our jaws do not grow forward enough, the retrusion of those jaws helps to push the tongue backwards into the airway and down the throat, so now we have compromised sleep and breathing. Dr. Hedberg: So, it's a combination of things. I know Dr. Nestor talks about it in his...or James Nestor talks about in his book, the changes in diet, soft food, not enough hard foods, not breastfeeding. Can you talk a little bit more about these changes in our society and some of these predisposing factors that can cause an abnormal airway? Dr. Belfor: Well, for me, the enlightenment came, when almost 20 years ago, I was treating performing artists who couldn't wear braces and they wanted straighter teeth, and I used an appliance and had a unilateral bite block, which basically, in essence replaces the missing hard food in our diet. And guess what? The actors, performers were coming in, and their makeup artist was telling them that their faces are changing, and the singers were coming in and saying they were reaching higher notes. So, that's what set me on the path. You see, the concept in dentistry is to balance the bite all the time. And it's kind of an anathema to have, when you bite down, to hit on one side. However, if I give you a stick of gum to chew, nobody on the planet is going to chew on both sides at the same time. We chew on one side then we chew on the other. And apparently from the research, many articles that have been written, the latest one in August 2018, the Journal of Orthodontics and Dentofacial Orthopedics the concept, they used a mammal, a pig, and they sent cyclical signaling to just two cranial sutures. And the result was that that changed...it reached all the cranial sutures, it created strain on the sutures, and that's the key word, because we chew on one side, we create strain at the suture level. And the result was a widening and mineralization of the sutures. So, in other words, there's your direct example of how we're chewing works. And, by the way, chewing is basically a communication that the body uses for development. The body works this way. There's only certain things the body understands. So, chewing is really a reciprocal pressure, alternating pressure. And that reciprocal, alternating pressure and strain is what helps to generate the growth. So, our breathing is reciprocal, cyclical, alternating pressure. And from a lot of articles which are written, when we breathe correctly, as we're developing, that air goes into all of the spaces in our skull, and that helps to stimulate the growth. So, the body is responding to alternating pressure. And for swallowing, when we swallow, we create a volume pressure change. So, all of this is how we develop. So, the concept is, let's take an oral appliance and let's duplicate what the body expects. And as a result of that, what we get, literally, is we get expression of genes that have not been expressed before. We get cranial facial growth and development. We get the upper jaw growing bigger. But the key element is the central bone of the skull where the jaw hangs off. That's known as the sphenoid. And what we want is balance in the neurocranium, which is the eight bones, including the sphenoid, which are central to the skull. And I can go on and on about this, but we just had a conversation you and I, what I believe is, when this is an imbalance, your jaw is misaligned, for example, then your head is crooked, your neck, the shoulders, your back, everything is crooked, your body is in stress 24 hours a day. That's high allostatic load, according to the U.S. government. That basically reduces the body's resilience. Reduction in resilience can lead to all kinds of issues and problems. So, I believe by aligning, by developing the cranial suture, by getting a jaw balance, by getting the jaw to grow bigger so you breathe better, for example, all of this is a key, central factor for improving your health. Dr. Hedberg: So, we have a lack of breastfeeding and then we have increased consumption of processed foods that don't put enough strain on the chewing mechanism that would normally create healthy bones in the cranium. It sounds like that's one of the real main issues here and the drivers of this. Dr. Belfor: [inaudible 00:07:26]. Dr. Hedberg: And so, I just think back when I was a kid, I mean, I was raised on breakfast cereal, and the rest of the day didn't really entail much consumption of foods that were difficult to chew. And what we're seeing now...and you have a list of conditions that you like to see and things that you can help. So, can you talk a little bit about some specific conditions that you see a lot of? Dr. Belfor: Well, I start with an evaluation. I do a very, very comprehensive evaluation. What we do is we have the patient...We send them for a cone beam scan, or we take a cone beam scan, it's three-dimensional cranial scan and also a facial photo. Now understand this, even if you look in the mirror, you can tell whether you have a facial asymmetry. So, for example, one eye is lower, or you have a deeper depression on one side between your nose and the corner of your mouth. What's this all about? Well, our midface, our midface, the way it grows, it's two separate bones. It's called one bone, it's called the maxilla, the upper jaw, but that is actually two bones. And it literally grows downward and forward as we grow. Now, if one of those two bones does not grow as downward and forward as much as the other, then that bone is set back, your face ages more rapidly on that side. And by the way, your jaw is up and back on that side, so your jaw is crooked. So, literally, my first evaluation I can help to diagnose a patient's problem by just looking at their face. Then we also are interested in the head posture. Where we look at the cervical spine, the head posture, forward head posture. Let me explain forward head posture. Today, it's a disaster. Everybody's on their computer, their cell phone, their tablet, they have forward head posture. Dentists, for example, they're working all day long in a forward head posture. So, what's the story with the forward head posture? Well, if you have your head forward and then you lift your chin to look around, what happens is literally your...the back to your tongue drops down your airway. So, you have either folks who start out using their computer too much, cell phones, etc., with forward head posture, and they end up with a tongue in the airway, or it is the reverse. That is the folks that don't develop their jaw forward, they have retruded mandible and the tongue is in the airway. And when the tongue is in the airway, since the air has to go through our nose and make a right turn to go down behind our tongue, because our tongue is in the airway, our head must come forward for us to breathe properly. So, in the end, either way, we end up with forward head posture, and the forward head posture makes things worse when the back of the tongue drops down the throat. So, this is part of my diagnosis, first the face, then the posture. Then, we actually look at your development. Now, the whole cranial system, the development of the face, for example, is based on, in our womb, in our womb, when we're growing, the first thing that grows is the brain, the cranium, and the basicranium, the base of the brain that supports the brain. That basicranium, those dimensions are what determine or should determine the dimensions of your face.

In this episode of Functional Medicine Research, I interview Dr. Ron Parks in a discussion about COVID-19 and the mental health crises. Dr. Parks has written a new book "COVID-19 and Mental Health Crises" which we discuss as well as a variety of other topics that can help those afflicted by this pandemic. The mental health aspects of COVID-19 are often overlooked with more of a focus on the physical aspects of the illness, medications, vaccines etc. As usual in the United States, mental health is pushed to the back of the bus with little to no dialogue or support for those who need psychological support. Dr. Parks provides a voice for those in need with his excellent new book. Full Transcript on COVID-19 Mental Health Crises Dr. Hedberg: Well, welcome, everyone, to Functional Medicine Research. I'm Dr. Hedberg. Very excited today to have my good friend and colleague, Dr. Ron Parks, on the show. And we're gonna be talking about his new book. And Dr. Parks is a respected physician, teacher, book author, writer, and mentor, with an integrative and holistic perspective. He especially trained in internal medicine, nutrition, preventive medicine, and board-certified in psychiatry. Currently, Dr. Parks is the medical director and psychiatrist for The Center for Spiritual Emergence and Katharos Sanctuary in Asheville, North Carolina. He has an MD from the University of Maryland and a master's degree in public health and health service research from the University of California at Los Angeles. He has completed specialty training and internal medicine at George Washington University, preventive medicine at UCLA, and psychiatry at the University of Maryland. Dr. Parks is a former assistant professor at the Albany and University of Miami Medical School, chief of internal medicine at the Homestead Air Force Base Hospital in Florida, former director of the Center for Preventive and Nutritional Healthcare in Baltimore, Maryland, and founder of the MacroHealth Medicine, a comprehensive and holistic consultative and treatment service, formerly in Asheville, North Carolina. Dr. Parks, welcome to the show. Dr. Parks: Well, thank you, Nik. Thank you for having me. Dr. Hedberg: Yeah. I'm looking forward to this. So, you've written a new book, it's called "COVID-19 and Mental Health Crises." So, we're gonna dig into that. But before we do that, can you just talk a little bit about how you got into integrative functional medicine and psychiatry? Dr. Parks: Well, that's a good question. Actually, it started when I was very young. I think I write a little bit about this in the book. I came down one summer as a kid with polio. And it was very upsetting, of course. And I compared it to the current COVID crisis. Back then there was no treatment and everybody had been waiting 10 years, 8 to 10 years for a vaccine. But here I was, a young, healthy, athletic kid that suddenly was running high fevers and a stiff neck. So, I ended up in the hospital at a children's ward. And back then the only treatment they had was more of a natural treatment called the Sister Kenny treatment. It was like a heat treatment. They wrap you in warm towels. And so that was my first exposure to, you know, what I would call functional medicine or holistic medicine. Though I had a sweat through it, but luckily, I didn't end up with the paralytic form of it, but sometimes I do think I have some of the long...they're talking about with a new virus, the long hauler syndrome. But with polio, there were some aftermaths there, and I think maybe some of the weakness I had some time in the legs and things like that might be from that. But anyway, that got me started on the path of interest in broader treatment programs. But a lot of it came, though, from my being formally, formally trained in internal medicine, where everything was about labels and diagnosis. And I remember in training, I got yelled at by the pathology teacher because I looked at a slide and I said, "I know what this is. It's such and such." He said, "The secret and the art is you spend time looking at that, you get the full picture, you let it sink into you before you tell me what it is." So, maybe he was seeing, you know, or trying to lead me in the right direction. But after working in more traditional medicine and you've seen my credentials, I mean, I would see some of the most rigorous formal training. I just finally decided to get out of it. And actually, you know what, Nik? This is very, very interesting. I always keep up to date, you know, and I start my morning with doing some review of some current stuff. And I came across an article about burnout syndrome they call with COVID-19, and how that's affected many academics and professional people because it's so changed their lives, that it's caused them to relook at themselves. And this article just snapped something in my head and I realized in writing this book and in telling some personal stories in there, I missed the most important one. And guess what that was. When I was an internist, you know, like that conventional internist-type person, one day I was seeing somebody in my office and suddenly, it was like somebody kicked me in the gut. I never felt anything like that. And it doubled me over the floor. And the patient was, you know, on the table and I said, you know, much of like...I said, "Well, you'll have to excuse me." And I literally crawled out of the room and I called my associate, he used cover for me. And he said, "Oh, that doesn't sound too good, Ron." I said, "Why don't you go home and I'll cover for you?" I said, "Go home. You kidding? I'm going to the emergency room." So, he said, "Okay." So, long story short, it turned out I had pancreatitis. And I thought everybody was thinking it was for alcohol or something, but it was from small gallstones. But I was in crisis, you know, and I had to, you know, go into surgery and everything. And while I was in that stressful crisis situation, my life changed. I did a whole evaluation. And I said, "I don't wanna be a traditional internist anymore. I want to see all the depths and breadth of things." And so from there, I thought the solution, of course, was to go into psychiatry. So, I sorted in the residency with the right intentions and, eventually, I went from there into holistic integrative medicine where I really belonged. But that crisis situation is what changed my life. And in the book, I tried to bring that across, you know, that there's a little bit of a raised stretch and a silver lining and sort of a place where, you know, crisis and tragedy can bring opportunity. I think that comes from oriental medicine. And just to end this little thing, I realize that I missed in the book one of the most important chapters, but don't worry. I'll write that as a new sequel or a blog, I don't know. I forgot that most important experience. But anyway, so that's a little bit how I ended up in holistic integrative medicine. Dr. Hedberg: So, this book, you know, "COVID-19 and Mental Health Crises," we're obviously just over a year now into the pandemic. And obviously, there's gonna be a lot of mental health issues as a result of this. We know that social isolation increases inflammation and can cause mood issues and affects the immune system, all kinds of things. And then you compound that with, you know, losing jobs. And I know that divorce rates are, you know, increasing. And there's all kinds of these stresses going on because of the pandemic. And as usual, mental health is kind of pushed to the back of the bus, so to speak, and not a lot of people are really talking about it. I mean, there's a little bit out there on mental health and COVID-19. But what is this... How would this book, you know, benefit someone who has been really traumatized by this pandemic or has...you know, family members who have been traumatized and people like that? So, who are you looking to target with this book? Dr. Parks: Actually, that's a very good question. And that triggers a whole lot of things in my mind. Let me just take the first thing that came to mind, and that was this is typical of the whole dimension between conventional medicine and holistic integrative medicine because a lot of people now that are having, you know, significant problems, and they're getting deeper into it. And so they will reach out to help. And so where they end up and, you know, mostly what's available is very conventional-oriented thinking and treatments so on. They'll say, "Oh, this is COVID-related. This is related to isolation," as I think you were saying. "This is related to the lack of being able to socialize or to get outside or..." But, again, they're missing the broader perspective. This person or the people who are listening, I mean, they know darn well, there are other issues that need to be looked at. For instance, there could be a marital problem going on. And in the close contains of, you know, an apartment or house, it could bring this to the forefront, it could flare. And that needs addressing. I mean, it's not diminishing the impact of COVID, but they need to address that. There could be other issues. These people could have had prior trauma in their lives or even to the extent to what we call post-traumatic stress disorder. And that needs to be addressed. I mean, because when you have a new trauma, it just plays back on the old one, you know, because most people never really worked out those things. So, they're more susceptible. So, anybody that's going through the COVID experience, it's gonna be a much broader picture. For instance, you know, we're all interested in broader things like nutrition and all that kind of thing. And you were talking about inflammation of the brain. I mean, all these things were at work, but it's not just because of COVID. It's because of all the underlying things that haven't been addressed in the past and they've just gotten compounded. So,

In this episode of Functional Medicine Research, I interview Tom Fabian, PhD in a detailed discussion about the GI-MAP stool test interpretation. We covered virtually every aspect of the GI-MAP stool test including what the test results mean and how to use them in clinical practice. Dr. Fabian has tremendous knowledge of the gut microbiome and the intricacies of the GI-MAP stool test markers. This is a vital interivew to listen to if you're utilizing the GI-MAP stool test in your practice. Full transcript of the GI-MAP Stool Test Interpretation interview with Dr. Tom Fabian: Dr. Hedberg: Well, welcome, everyone to Functional Medicine Research. I'm Dr. Hedberg, and I'm looking forward today to my conversation with Dr. Thomas Fabian. He is a PhD., and he's a clinical laboratory consultant, translational science expert, functional nutrition practitioner, educator, and speaker. He is a former biomedical research scientist and deep expertise in the role of the human microbiome and health, chronic disease and aging. As a leading expert in translational applications of microbiome research and functional medicine and integrative health settings, Tom's primary focus is on providing educational resources and consulting services for practitioners and scientific advisory and consulting services for clinical testing laboratories. Dr. Fabian, welcome to the show. Dr. Fabian: Thanks so much, Nik. It's great to be here today, and I'm looking forward to the conversation. Dr. Hedberg: Excellent. So, we're gonna be talking about the diagnostic solutions, lab, GI-MAP test, and we're gonna cover interpretation, you know, what these markers mean. And so, for all the practitioners listening, they'll have a strong idea of how to approach this test and how to use these things clinically. So, why don't we start with...take it from the top in the pathogen section? And I wanted to ask you specifically about C-diff. There's toxin A and toxin B Clostridium difficile markers on this test. And what is your interpretation of this if it's positive and the patient is symptomatic, and then you treat them, and then they're no longer symptomatic, but the toxin still shows up on the stool test? Can you elaborate a little bit on that type of presentation? Dr. Fabian: Sure. No, I haven't personally seen that particular scenario but, in general, it's important to keep in mind a lot of people can be carriers of C-diff. So, the majority of the time that we see it detected positive, whether it's low levels or high levels, typically, patients don't have the classic symptoms. So, that suggests that they're probably just a carrier. And there's, sort of, kind of, a gray area in between where there still may be some effects of C-diff. Of course, that's one of the purposes of looking at the markers on GI-MAP like calprotectin, zonulin, etc. to see if there seems to be any evidence that may be have an impact, even if there aren't symptoms. So, we're also learning a lot more from research about factors that can control or influence the ability of various pathogens to thrive and also whether or not they can cause infection or if they have their, you know, typical pathogenic effects. So, that's essentially factors that influence virulence. So, one of the first things I want to mention is all the microbial markers on GI-MAP are assessed based on detection of DNA. So, when you're looking at DNA, you're looking at detection of the organisms or the genes but not necessarily whether the genes are being expressed. And that's definitely true for toxins. So, lots of research has been coming out in research years in terms of, again, as I mentioned, things that regulate toxins, and it's very specific. So, pathogens tend to only express those toxins under very specific conditions when conditions are favorable for them. So, for example, if you've detected C-diff and it really syncs up with what's going on with the patient, symptomatically, and you decide to treat, and then on a retest, symptoms are better, but the C-diff is still detected, that's telling you that it's still there. But you may have improved the gut environment to the point where they're not expressing their toxins at that point. So, they may just at that point become carriers. Dr. Hedberg: Yeah, that just makes me think about, you know, some of these patients because we can't or I can't necessarily say that it's the C-diff, you know, that was causing the symptoms because then these other patients, they had other pathogens and dysbiosis and other issues. And so, that could have also been the reason why they were symptomatic. Dr. Fabian: Absolutely. Dr. Hedberg: Yeah. So, that can make it difficult to really get a clear picture of what exactly is causing the symptoms if there's multiple issues there. So, that makes sense. And, you know, for the practitioners listening, so when it says less than DL, that's less than the detectable limit. Correct? Dr. Fabian: Correct. Yeah. Dr. Hedberg: And then, if we see a number there but it's in the black, can we assume that it has been identified, it's just not at a high enough level to be flagged in the red? Dr. Fabian: Correct. Yeah. We do see that pretty frequently. And, of course, through our extensive validation that's required as a CLIA-certified laboratory, those are, you know, definitely true positives. So, it is there when they're present at low levels. And the type of method that we use called quantitative PCR is highly sensitive and also highly accurate in terms of its quantitation. So, you can have a high level of confidence in those numbers when you see them at low levels. But there is a lot of confusion or misunderstanding, I should say, among clinicians about these low levels because that's, essentially, kind of, a new way of looking at pathogens. Because in the past, most of the methodology, whether it's culture or standard PCR, for example, those methods generally have higher cutoff levels, in many cases, due to lower sensitivity. And so, essentially, what you're seeing in those tests is when it's positive, it's at a much higher level. So, clinicians, if they're coming from that sort of background and using those sorts of tests, they assume if it's "positive," then it's likely to be high and produce symptoms. And so, this looking at pathogens at a low level is, kind of, a new scenario. And, of course, it's a gray area. In some cases, it does appear that they still can cause symptoms for some patients. For example, with H. pylori, we do often see that below that cutoff for being considered high. Clinicians have reported anecdotally that, in some cases, it fits with the symptoms. So, they've decided to go ahead and treat, even though it wasn't officially high. And in many cases, they reported that symptoms improved. So, that suggests, at least for some patients, that lower levels may still be relevant for that particular patient. There are other things, though, that you can potentially get insights from just by the presence of pathogens, whether they're high or levels. And, again, this is all coming out from relatively recent research that indicates that the gut environment, as you can imagine but there's really a lot of research now supporting this, that the gut environment influences whether or not pathogens can basically thrive in the GI tract, you know, again, at low or high levels. Just to, kinda, cut to the chase, common ones that have emerged from research that we also see clinically would be low stomach acid. So, for example, it's commonly known that proton pump inhibitor use can lead to an increased risk for various infections, including C-diff. Also, poor digestion, potentially, can contribute, as well. So, there's a lot of growing research around the idea that, particularly for pathogens that are in the colon, that typically thrive in the colon, that they often depend heavily on the presence of amino acids, the availability of amino acids, which in a healthy colon are present at very low levels. And that's due to, when digestion is working as it should, digestion absorption, very little protein gets into the colon. And then the protein that does get in the colon is broken down and then quickly used up by the normal, healthy bacteria to fuel their growth. So, when you have certain types of disruptions like antibiotics, etc., or even a really poor diet that lacks fiber, that potentially can increase the risk for pathogens because it leads to less competition for those amino acids. And then the pathogens can use those amino acids to fuel their growth. C-diff is a classic example. That one, actually, has been shown to thrive on a number of amino acids, in particular an amino acid called proline, which happens to be present, and ironically in high levels, in collagen and, of course, products that have collagen in them. Also, bone broth, for example, collagen supplements. And this is something that we actually do see occasionally clinically, that patients who have relatively high levels of C-diff may or may not be symptomatic. But when I asked a clinician, "Are these patients on any sort of collagen supplement?" oftentimes, the answer is, "Yes." And, again, that really fits with what we know from research. Dr. Hedberg: Yeah, interesting. You brought up some really great points. And, I mean, that's one of the things I like about the GI-MAP. As you said, it allows for a gray area rather than just a binary, you know, positive or negative. And that leaves a lot of interpretation to the clinician, because if all you did was just report the so-called positive and then nothing else, then maybe, you know, they could have say 5, 6, 10 different pathogens but they're all just at a low level. But they're just not technically positive. And so, I like that. And that would allow me to do things like make some indirect interpretations. And you brought up a really great one, which is hypochlorhydria,

In this episode of Functional Medicine Research, I interview Robb Wolf about his new book and documentary Sacred Cow. We had a great conversation dispelling some of the myths about meat and saturated fat as well as climate change, plant-based diets, sustainable agriculture, veganism, cattle and methane, and the ethics of eating animals. This was a well-rounded interview packed with information that should help people make better decisions about what they eat but also become educated about the facts around meat. I highly recommend watching the Sacred Cow documentary and reading the book which goes into tremendous detail on these issues. Full Transcript of Sacred Cow with Robb Wolf Interview Dr. Hedberg: Well, welcome, everyone, to "Functional Medicine Research." I'm Dr. Hedberg. And I'm really looking forward to my conversation today with Robb Wolf. And Robb is a former research biochemist, and he's a two-times "New York Times," "Wall Street Journal" bestselling author of two books, "The Paleo Solution" and "Wired to Eat." And he coauthored a book with Diana Rodgers, which we'll be talking about today, called "The Sacred Cow," and that explains why well raised meat is good for us and good for the planet. Robb has transformed the lives of hundreds of thousands of people around the world via his top ranked iTunes podcast, books and seminars. He's known for his direct approach and ability to distill and synthesize information to make the complicated stuff easier to understand. Robb, welcome to the show. Robb: Doc, a huge honor to be here. Thank you. Dr. Hedberg: Great. Yeah, I had Diana on last year. And we talked a little bit about plant-based diets and meat and things like that. And then since then, we've had the "New Sacred Cow" book that you co-authored, and the documentary, which is excellent. And so, why don't we begin by...I'd really like to focus on helping the listeners understand some of, you know, the misunderstandings and the truths and the myths about eating meat versus plants and things like that. And so why don't we start with a discussion about why meat has become a scapegoat. And I think, and you can expand on this, of course, but I think part of this probably goes to Ancel Keys' work in the 20th century, his promotion of misinformation on saturated fat. Can you take us from that point up to where we are now, and why you think meat has been getting such bad press? Robb: Yeah, you know, it's interesting and worth noting the book covers the health, environmental, and ethical considerations of a meat or animal product-inclusive food system. You know, so the raising and the selling and the slaughter and the whole deal. And all of those points are important, and all of those points have some really interesting, historical antecedents, I guess, kind of describing why in different cultures meat would become vilified to varying degrees. And like, food is an interesting cultural tool for defining self from non-self. Like, if we look within the Abrahamic religions, there are some very specific delineations of what is and is not allowed within, say, Judaism versus Christianity versus Islam. And we see similar things within different Buddhist traditions and whatnot, so I mean it...Or even just within Christianity itself, you have like the Seventh Day Adventists versus, you know, certain rules and followings within Catholicism, you know. And so, it's interesting that food is a powerful tool for defining self from non-self. And not infrequently it is the beginning point of creating out of accepted groups of people. Like, there's some pretty ugly historical examples of where the different food practices of one religion or one type of people start being used as a means of, kind of, ostracizing and, kind of, walling those folks off. But we have these three different pieces that if we're really gonna do diligence on this topic that we have to address. And, you know, the Ancel Keys piece is interesting in that he was a very well-known biochemist, did some early research that suggested that fat intake, in general, and animal fat intake specifically was, kind of, a linear correlation with cardiovascular disease. And he did this around the 1950s and it was called the Seven Countries Study. One of the problems with this was that he omitted, either purposefully or unpurposely, a bunch of other data that didn't really fit this linear demarcation. Like, there were places where folks eat far less fat than, say, in westernized countries and have higher incidences of cardiovascular disease. And there are places that eat far more fat than, say, like Western Europe and the United States that have far less. And so there's really, kind of, a not great overlap there. And it's worth noting that Keys spearheaded some really fascinating research. And one of these research projects is something that we could never ever do today, there's no IRB board that would sign off on this. And it involved a study with thousands of institutionalized mental patients who were fed, kind of, a standard diet and, you know, fairly rich and saturated fat, and then a modified diet that was enriched with, in theory, heart-healthy, polyunsaturated fats from like corn oil and safflower oil and what have you. And what's interesting is, this is as close to like a metabolic ward study as one is ever likely to have, and it had a lot of people in it. So, you know, the power there is fantastic from a statistical standpoint. But what they found in this is that the folks that were eating the polyunsaturated fats, their cholesterol did in fact go down. But that actually correlated with increased rates of morbidity and mortality as it relates to cardiovascular disease, more stroke and heart attack. So it was completely counterintuitive to what, you know, kind of, the standard diet, heart hypothesis would put forward. And it's worth noting that this study was completed, wrapped up, and then never published, and ended up just, kind of, sitting in a basement for the better part of 40 years, until somebody found it. Not that long ago, maybe 2016, 2017, this thing was rediscovered and got a fair amount of airplay. Because it really calls into question all of the Ancel Keys' original, kind of, findings and suggestions. And it certainly flies in the face of what we're generally told to follow from the United States dietary guidelines. So in the book, we kind of detail the work of Ancel Keys, kind of some interesting developments, kind of, socio-politically. Like, Richard Nixon was looking to get reelected and he wasn't doing so well. And he needed a loyal, conservative base that would support him. And farmers were a pretty good option in that regard. And part of his offerings for building loyalty was re-expanding the farm subsidies programs that had been largely wound down after World War Two. And with this, the subsidies program, these farmers were incentivized to just produce. It didn't really matter if we needed more corn or soybeans or wheat or what have you, we were just incentivizing that production. And so for several years, we had these huge gluts of food that we didn't know what to do with it. And then right around this time, a process had been understood to convert corn syrups into high fructose corn syrup, and make it very, very sweet, very palatable. But it was a very expensive process. But it was right around this this early 1970s that an industrial scale, inexpensive process for converting corn into high fructose corn syrup was developed. And this was the beginning of the relationship also between what we would now, I think, call the junk food industry and the governmental food surplus, you know, kind of, scenarios. So we needed to do something with this food. This food needed a long shelf-life and, you know, these food manufacturers were all too happy to employ their food chemists in figuring out how to make this stuff both taste tasty and also kind of like a Twinkie, like have a nearly infinite shelf-life. So, some folks present this as, kind of, like this evil cabal of people, you know, twisting moustaches to enslave the masses. And I don't buy into that stuff at all. But I do think that we are the recipients of a bunch of really dumb luck, that some decisions that were unconnected initially but became connected on the backend ended up leading us to what is our modern, industrial row crop food system, and the dietary guidelines that go along with it that support the perpetuation of basically what that row crop food system stands for. And so, you know, it's been a 60-years-long process with that. And there's back and forth on the topic, you know, one week, high-carb diets are good for you, the next week, low-carb diets are good for you. I think the one commonality within this whole story is that highly processed foods are probably a big problem. And that also depending on the individual, higher or lower-carb diets may be more appropriate given an individual's circumstance. And you know, we are investigating topics like individualized or personalized medicine. Like, they're finding that some people when they undergo chemotherapy, they do far, far better if the chemotherapy is administered in the morning versus the evening, and other people are the exact opposite. And so when we understand things like that, when we understand that, you know, within a population if you give, you know, a thousand people a blood pressure medication, some percentage of those people may see a 10-point reduction, and some people a 20-point reduction, and some people, you see no reduction. We know that with pharmaceuticals, we know that with the dose response to exercise. But we still haven't applied that same latitude to dietary practices, that there may be different ways of eating that suit different people better. And that is a lot of what we attempt to unpack in the book,

In this episode of Functional Medicine Research, I interview Ashok Gupta about his limbic system retraining program. Trauma of any kind can change the brain and nervous system in a way that prevents one from getting well. Many people never get well because they don't address the underlying trauma that has triggered or contributed to their health challenges. If you've tried eating right, exercising, sleeping well, taken the best supplements, and managed your stress, but you still aren't feeling well, your brain and nervous system may be out of balance. The Gupta Program is designed to change the neuroplasticity of your brain and nervous system so you can heal and feel well again. We discuss a new and exciting published paper that validates this method of limbic system retraining. Full Transcript on Limbic System Retraining Interview Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg, and I'm very excited today to talk to Ashok Gupta about limbic system retraining. And Ashok is an internationally renowned speaker, filmmaker, and health practitioner who has dedicated his life to supporting people through chronic illness and achieving their potential. Ashok suffered from myalgic encephalomyelitis or chronic fatigue syndrome about 25 years ago when he was studying at Cambridge University, and through neurological research that he conducted, he managed to get himself 100% better. He then set up a clinic to treat others and then published the well-known recovery program known as "The Gupta Program" in 2007. He's published several medical papers and he's continually researching these conditions. You can find out more information at guptaprogram.com. Ashok, thanks for coming on the program.Ashok: Thank you so much for inviting me. Very excited to be here. Dr. Hedberg: Yeah. So, the limbic system is something that I've been interested in since I started practicing 17 years ago, and you know, I have a variety of recommendations that I give to patients for that. You know, things like meditation, mindfulness training, therapy, or just a number of things, but your particular limbic system-intensive program, I heard about it recently and became very interested in it. And why don't we begin by talking about just the limbic system itself? Can you give people kind of an overview of what the limbic system does and why it's important? Ashok: Yes. So, there are many different ways of describing the limbic system. I think primarily if we start with this idea of it being a defensive system to ensure survival, right? So, most people would associate the limbic system with our emotional responses and medicine often separates the kind of psychology and the emotional responses from defense responses as if they're something different, you know, physiological defense responses versus emotional defense responses. But I see the limbic system as the automatic survival systems that we've inherited over generations of different animals and whatever that actually create responses that ensure survival. And so, a fight or flight response, a fear response, an anger response, a memory of a previous experience, all of these things are designed to ensure survival. So, that is for me the primary motive or motivation of that limbic system. And within that limbic system, there are different structures that play specific roles. And a lot of our research focuses on the amygdala, which are two almond-shaped structures that sit behind our eyes that essentially are taking all the incoming information from the outer world and the inner world, process it according to the previous experiences we've had in life, our memories, and then creates a coordinated response across the brain to ensure survival, yeah? And one way to look at this Dr. Hedberg, which I find fascinating is to ask the biggest question of all, you know, why are we here? And we can answer that question from a philosophical perspective, but from a scientific perspective, we're here because over so many generations over millions of years, this nervous system that we've inherited, this immune system has adapted to the environment to ensure survival, which is ultimately culminated in this nervous system, this brain, and this limbic system that knows how to identify threats and ensure survival so we pass on our genes to the next generation. Dr. Hedberg: Right. And let's talk a little bit about how that gets out of balance. I've done a few podcasts talking to guests about adverse childhood experiences and how to overcome trauma and things like that. So, it just seems like, I mean, pretty much any kind of trauma input into the system, whether you're young or an adult could potentially cause imbalances in the limbic system. So, can you talk about all the potential things that can happen to someone that can cause an imbalance in their limbic system? Ashok: Yes. It's fascinating. And it's great that you're incorporating that as part of your integrative approach because it's so important. The way we look at it is the combination of nurture and nature. So, we know that there can be, and it's a fascinating area, inherited trauma that can actually be passed on through our genes, and then even experiences within the womb can impact on how reactive our amygdalas are, right? So, research has shown that if a mother is having a particularly stressful pregnancy, that can impact on the stress of the child moving forward. The actual experience of childbirth can impact on the limbic system, and then obviously, adverse childhood experiences. So, that might be bullying, abuse, physical or emotional abuse, even sexual abuse, all of these things impact on what we call the factory setting of the amygdala. So, we have the factory setting when we're born and then it keeps adapting and changing according to those adverse childhood experiences. And then even during teenage years, that can be impacted. Then during our adult lives, we have that genetic and nurture inheritance that then impacts on our reactivity to the world around us. And that is why those adverse childhood experiences can impact on our mental, physical, and emotional health. Now, I think it's well-documented that our emotional health can be impacted, but the processes on how our physical health is impacted is what we focus here on in terms of our research. And as I said earlier, if we go back to this idea that our brains don't differentiate between emotional, physical, chemical, or biological threats, the brain simply asks the question, "How do I survive?" So, if we've had adverse childhood experiences, which make our brains more defensive, then when we then are exposed to physical dangers, the brain becomes hyper-reactive and hyper-responsive, which then can lead on to so many different chronic illnesses that we experience, you know, in the surgery. Dr. Hedberg: Right. Right. And one of the things that we'll see, and I'm sure you see as well is the people who they seem to be doing everything right. You know, they're sleeping well, exercise, eating well. They're just doing a lot of the things that one would expect to achieve good health, but they're just still not feeling well. And so, I think this is one of the areas that is just really the sticking point for a lot of people with chronic illness, the limbic system is out of balance and it's just not able to recover. So, what are some of the symptoms or conditions that would make someone think they potentially have an imbalanced limbic system? Ashok: Yes. We collectively call these conditions neuroimmune condition syndromes or NICs. And generally, as you say, someone's resting, they're having a good lifestyle, but still, there seems to be, you know, a low level of functioning or continuing background illness or severe illness. And we believe, yes, it's an imbalance not only in the limbic system, but also, especially in the insular. Now, the insular cortex kind of sits between the kind of limbic system and the cortex. So, it's more a part of the cortex than the limbic system. And the insular is where we also believe a lot of the imbalances lie. So, it's not purely in the limbic system in our research. And if I can just describe to you an overview of the hypothesis and that will help then your listeners to kind of understand how it impacts on chronic illness. So, let's take the example of flu virus or, in fact, even COVID-19, which are obviously in the news right now. If somebody has, let's say a lot of ACEs or a lot of adverse childhood experiences or is going through a lot of stress, we know that stress reduces the effectiveness of the immune system. And then let's say they have the flu virus, the brain is prioritizing survival. So, it thinks, okay, we've got to now overcome this flu virus. This is potentially life-threatening or COVID-19. And the brain and the nervous system and the immune system coordinate to facilitate that, to overcome this virus and rid it from the body. But if there is a compromised immune system, then that whole system takes a lot longer to fight off that virus. And there comes a point at which the brain becomes traumatized. The amygdala, the insular, the anterior cingulate become traumatized in this response, like a physiological traumatic response where the body says, actually, we don't seem to be fully and effectively fighting off this virus. We must now go into an overdrive as it were and keep stimulating the nervous system and the immune system to anything that reminds us of the original sensitizing event. So, the brain keeps overstimulating immune responses and nervous system responses, and it learns that. So, that's a neurological conditioning in the brain. And even once someone recovers from flu or COVID-19, it's left a legacy in the brain. The brain has now learned that anything that reminds it of the original infection indicates danger and potentially death. So, even once the virus is gone,

In this episode of Functional Medicine Research, I interview Dr. Deb Matthew about her new book on male sexual health "Why Can't I Keep Up Anymore?: A Guide to Regaining Energy, Focus, and Peak Physical & Sexual Performance for Men Over 40". We discussed the causes of male sexual dysfunction, lab testing, causes of low testosterone, stress and cortisol levels, sex hormone binding globulin, testosterone replacement methods, how sleep affects hormones and much more. This book isn't just for men. If your male partner is showing signs of low testosterone then this book is a must-read with resources on how to find the right kind of doctor to get well. Male Sexual Performance with Dr. Deb Matthew Interview Transcript Dr. Hedberg: Well, welcome, everyone, to "Functional Medicine Research." I'm Dr. Hedberg, and I'm really excited today to have Dr. Deb Matthew on the show. Dr. Matthew is a medical doctor, and she's also known as the happy hormones doctor. She's a best-selling author, international speaker, educator, wife, and mother of four. And after suffering for years with fatigue and irritability, her quest to resolve her personal health led her to change everything about her practice of medicine. She has been featured on national podcasts, radio, and broadcast shows, including NBC, ABC, CBS, and Fox. Dr. Matthew, welcome to the show. Dr. Matthew: Thank you so much. It's great to be here. Dr. Hedberg: So, we're going to be talking about your new book, "Why Can't I Keep Up Anymore?: A Guide to Regaining Energy, Focus, and Peak Physical & Sexual Performance for Men Over 40," which I read recently. It's an excellent book. Wanted to have you on and talk about something that is...well, I would say most male issues are overlooked, but testosterone is really a big one and so is sexual performance and male hormones. So, why don't we begin by talking about why testosterone is so important for men? Dr. Matthew: Yeah. You know, hormones, in general, play a big role in how we feel on the inside, how we relate to the world around us, how we react to other people. And so, testosterone drives a lot of how men feel and even behavior, and it really plays a role in men feeling like a man. So, it's important for drive and for motivation so that when you wake up in the morning and your boots hit the floor, you're ready to take on the world. And when testosterone levels are not quite right, men just don't quite feel right. And for women, when we go through our hormonal changes, it's pretty obvious. We either get menstrual problems or, you know, we get hot flashes. And so, there's some pretty obvious things that happen at some pretty obvious times in our life in order to notify us that our hormones may be changing. But for men, it's much more subtle. So, it is something that often happens gradually over time. And so, what I hear men say a lot is, you know, "I just don't quite feel like myself anymore. I'm just not quite keeping up the same way that I used to. But you know, maybe it's just my age." I hear that all the time, "It must just be my age. I'm not 18 anymore." And so, you know, maybe it's not fair to compare to an 18-year-old, but if you're 40 or 50, like let's not blame it on age. If you're 95, okay, fine. We'll blame it on your age. But when you're younger, even though things change, they don't have to feel that way. And so, one of the things that could be contributing to not quite feeling like yourself anymore is low testosterone. Dr. Hedberg: One of the things I see in practice is men who, you know, they're diagnosed with low testosterone or they have the symptoms and they see their conventional medical physician and they try a testosterone, but it doesn't work at all. Sometimes they get a little bit worse. Sometimes there's really no change. What do you think the conventional medical approach is missing when something like that happens to a man? Dr. Matthew: Oh, am I ever glad that you asked this question because this is what we deal with all day every day. So, if all we do is replace testosterone with topical gels or whatever it is, some men do feel better, like you said, some don't really feel better because there's a whole lot of factors that affect why the testosterone was low in the first place and how that new testosterone is going to react in your body. So, it's, first of all, important for us to have some basic understanding of why the testosterone was low in the first place. So, again, like if you're 95, we're going to blame it on your age. But we see low testosterone in younger and younger men. We have men in their 20s in the practice that have low testosterone. And so, you know, if a man is in his 40s or in his 50s and testosterone is low, we still want to think about the why behind it. And there's a whole bunch of reasons you know, that I'd be happy to talk about because I think that's important. But there is lab testing that we can do to get a better understanding of the why's behind it. And then what we'd love to be able to do is address some of those factors, because if we can correct the factors causing the testosterone to be low, then there's an opportunity for the testosterone to get better even maybe without the testosterone replacement. So, that's one thing is we want to know the why behind it. And then the next is when we're giving a man testosterone replacement, we need to make sure that it's going to work properly in their body. So, one of the things that I see, not that uncommonly is testosterone naturally, it gets converted into estrogen to some degree in all men and that's normal, but for some men, the problem is that the testosterone gets converted too much into estrogen. And there's a list of reasons why that may be, diabetes, obesity, especially like that belly fat, or inflammation in the body. So, if a man is making testosterone into estrogen at a greater rate than they should, then the testosterone will be low and the estrogen will be higher than it should. So, now, if their doctor measures their testosterone level, finds it low, gives them more testosterone in the form of a gel or shot or whatever, then as the testosterone level goes higher, the estrogen level just goes higher too. And so, the relationship or the ratio between testosterone and estrogen is important because too much estrogen doesn't feel good for a man. So, the testosterone level might look better on their test, but they don't feel better because estrogen is getting in the way. So, that's another reason why they may not feel better even if they're on testosterone and even if their lab value goes up. Another thing that I see that's a problem is that it's actually difficult to get an accurate testosterone blood level for men who are on topical testosterone gel, which is the most common way of giving testosterone. So, it matters how many hours it's been from when you applied the gel to when you get your lab done. So, if you get up in the morning and if a man puts the gel on, say at, you know, 8:00 a.m. and then goes to the lab and gets the lab tests done at 10:00 a.m. their level's expected to be quite a bit higher than if they went on the way home from work at 4:00 p.m. Or if they put the testosterone on their arm and then somebody sticks a needle in their arm right through the spot where they rubbed the gel, then the level could be quite high. So, it makes it difficult to really accurately dose it based on a blood test, and you know, a lot of doctors have recognized it's not quite so perfect and it's not quite so accurate. So, they let men sit with relatively lowish levels of testosterone so that even though they're taking the testosterone, as long as their lab test isn't ridiculously low, they're told that it's fine, even if it's not that great. So, there's a bunch of reasons why just because you've been handed a prescription for testosterone and just because you've been applying it properly that it's not really doing all the things that it's supposed to be doing. Dr. Hedberg: Right. And that's kind of the issue sometimes with conventional medicine is just looking at a single hormone and then taking a single approach when obviously everything is connected. So, one of the other things that I'll see sometimes is I might actually see elevated testosterone. It could be elevated total and elevated free testosterone, but they're not on testosterone and they have all the symptoms of low testosterone. And I might also see the sex hormone binding globulin is actually elevated. Can you talk a little bit about what might be some of the issues with that particular picture? Dr. Matthew: So, sex hormone binding globulin that you mentioned is a protein in the bloodstream that attaches to testosterone and kind of carries it through the bloodstream. So, sometimes I describe it it's like a bus and that loads up all the testosterone molecules onto the bus so that it can't be used, and the only testosterone that your cells can use and feel is the testosterone that's free or you know, the stuff that's walking, no room for it on the bus. So, when men have a high amount of sex hormone binding globulin, a whole fleet of buses, then they can bind up most of the testosterone and there's not much left for their cells to use. So, the vast majority of the testosterone gets loaded up on the buses there's hardly any left for when they're walking. And with age, sometimes SHBG or sex hormone binding globulin levels go high. So, for whatever given amount of testosterone a man has, like the total amount, like you said, it could even be, you know, nice and generous, but if it's all bound, if it's all on the bus, then they can't use it. So, they don't feel better. They have all the symptoms of low testosterone, but they're told that everything is normal, and that can be really frustrating.

In this episode of Functional Medicine Research, I interview my friend and colleague Cass Nelson-Dooley, M.S. in a discussion on how to heal your oral microbiome. Cass recently published the book "Heal Your Oral Microbiome" and we discussed many important topics about this often overlooked health issue. We discussed what conditions may be connected to a dysbiotic oral microbiome, how oral microbiome dysbiosis affects your health, health sweeteners, strategies to heal the oral microbiome, testing, dental products and more. If you're struggling with healing your gut or have a health issue that won't resolve, your oral microbiome may be the missing link. Full Transcript on How to Heal Your Oral Microbiome Dr. Hedberg: Well, welcome, everyone, to "Functional Medicine Research." I'm Dr. Hedberg. And I'm very excited today to have my friend and colleague, Cass Nelson-Dooley, on the show. And Cass studied medicinal plants in the rainforests of Panama in 2003 as a Fulbright Scholar and then launched a career in science and natural medicine. She researched the pharmacology of medicinal plants at the University of Georgia and AptoTec, and then joined the innovators at MetaMetrics clinical laboratory and Genova. She enjoys teaching, presenting, writing, and researching how to address the underlying causes of disease, not just the symptoms. She has over a decade of experience teaching doctors about integrative and functional laboratory results. In 2013, she started Health First Consulting, a medical communications company with a mission to improve human health using the written word. She created innovative videos and patient education handouts to improve practice efficiency and motivate patients. Miss Nelson-Dooley is the author of the book "Heal Your Oral Microbiome," which we'll be focusing on today. And has published case studies, book chapters, journal articles about natural medicine, nutrition, and laboratory testing. Her website is healthfirstconsulting.com. Cass, welcome to the show. Cass: Thank you, Nick. So happy to be here. Dr. Hedberg: Yes. It's been a while. We were just kind of reminiscing about the days at MetaMetrics and I read your new book, "Heal Your Oral Microbiome." So, I was excited to have you on about that because no one's really talking about it. So, why don't we talk about, kind of, the foundation of what we're talking about here, which is periodontal disease? And so can you just talk a little bit about what that is? Cass: Sure. Sure. So, yeah, it's great talking with you after all these years and in the starting out, getting to know you in the functional lab industry. But, yeah. So, this book was a really fun book to write, especially from the jumping-off point of gut health, right, which is kind of a central tenet in functional medicine. And that's some of the testing that we used to talk about years ago. So, so much of what we know about the gut really just perfectly translates to the mouth. And periodontal disease, you know, I kind of like to just simply say that it is a dysbiosis. It's an oral dysbiosis that...and an aberrant or an over-reactive immune response to that dysbiosis. So, one of the fascinating things, when I was writing this book, was realizing that so many of the things that plague our mouths are really just dysbiosis, you know, which we talk about all the time in regards to the gut. So, periodontal disease is an imbalance of oral bacteria that triggers an immune response that attacks and destroys bone and teeth. Cavities are a bacterial dysbiosis in the mouth. Root canal infections are bacterial imbalance in the pulp of the tooth. And then you can get cavities on the root of a tooth, which is, again, dysbiosis. So, it was pretty fun to realize, wow, all of these problems just go back to the oral microbiome and we just need to try to rein in that oral microbiome and make it healthier in order to prevent these diseases. Dr. Hedberg: Yeah. And when you think of the microbiome, most people think of the gut, beginning with the stomach, but there's a microbiome almost everywhere. Like you point out in your book, the sinuses, the mouth, you know, everywhere and... Cass: The skin. Dr. Hedberg: ...the skin. Yeah. So many places. Anywhere there's a cavity. So, it's not just the gut. And, you know, really, people are not talking about the oral microbiome. They'll look at, you know, stool analysis results and just think about the intestine or the stomach, or they talk to the patient, and they're just thinking about their symptoms in relation to the gut. But the oral microbiome, I mean, it has just a significant impact on everything downstream going into the stomach, small intestine, and the colon. So, why do you think this isn't a bigger issue? Why aren't more people talking about it? Cass: Well, I think it's coming. I think we're just at the front edge of it. I mean, the gut has been in the spotlight. The gut microbiome has really gotten a lot of attention over the last decade or two, at least, if not more. So, I really just think it's a matter of time. I mean, this book, "Heal Your Oral Microbiome," is the first one on the topic. So, I mean, people certainly know about the oral microbiome and talk about it. And I would argue that this is what dentists are working with on a daily basis is the oral microbiome. But no one had written a book about it before. And that was kind of neat that the publisher saw that opportunity, you know, that the time was right for this topic. The oral microbiome is second in biodiversity only to the gut. So, I mean, it really is time to talk about it. It's time to talk about the oral microbiome. And I think for anyone who has been interested in functional medicine or practicing functional medicine, it's just kind of a natural next step. It just kind of needs to be folded in, like, instead of thinking of the gut as, you know, the stomach and downward, we need to think of it as starting at the mouth. Dr. Hedberg: Right. Right. Many years ago, I was reading an interview with the gastroenterologist who wrote the book "The Second Brain." I'm blanking on his name now, but they asked him what he thought of the idea of leaky gut and he said leaky gut is garbage. That's just quackery. And now we have, you know, so many published papers on leaky gut. And so it's a real thing now. And you talk about leaky mouth, which I thought, you know, is really interesting. So, can you expand on that? Cass: Sure. And this is something that, you know, I have written about and mentioned and other dentists, I know Dr. Mary Ellen Chalmers had mentioned it, kind of, in passing years ago. This is just, kind of, an idea and I think it's something that various of us have come to on our own because it's just an extension of the leaky gut idea. But the lining of the mouth is very similar to the lining of the gut. And we know that, actually, it's a little bit more porous, a little bit more porous than the gut lining. And we do know that just even in a healthy person when they chew or brush their teeth or get a dental cleaning, of course, anything like that, when they eat a meal, they develop some bacteremia from that, you know, kind of, action, that disruption in the oral microbiome. So, the bacteria from the mouth go through the oral lining and the mucosal lining and get right into the bloodstream, so, even in a healthy person. So, you know, it's like, okay, we've got that barrier there. So, what about someone with gingivitis? What about someone with cavities or a root canal infection that hasn't been addressed or periodontal disease? What happens when they brush their teeth or eat or get a dental cleaning? That's dysbiotic flora going right into their bloodstream. So, I think the concept of a leaky mouth, you know, when there is oral disease, I think this is a really big thing we need to consider. I mean, we know that oral bacteria flood into the bloodstream. We know that we can find oral bacteria in the joints or in the heart or in arteries or, you know, in various distant sites from the mouth. So, I mean, we really want to have a healthy microbiome in the mouth because that barrier is not...even in a healthy person, it's not a watertight barrier. Things pass through it. Dr. Hedberg: And, you know, cavities and gum disease and things like that is basically what you're talking about in the book is dysbiosis in the mouth. So, if someone has one of those or it's happening all the time, why don't we get into what they can do to begin to shift their microbiome in the right direction? Cass: Sure. Dr. Hedberg: What would you say is the biggest way to begin that shift? Cass: Yeah. So, I mean, for me, it's diet every time, you know, kind of we are what we eat, right? And our microbiome is what we eat. And this is, again, such an easy jump to make from integrative and functional medicine because we already know how critical the diet is to the whole body health. So, it's, you know, going into a healthy diet, meaning, you know, no sugar, no refined carbs, no packaged foods like breads and cookies and, you know, pasta and things like that and, really, working toward a whole foods, plant-based diet with plenty of fiber if a person can tolerate that if there isn't a gut dysbiosis they're managing. But, yeah. So, a healthy diet, I think, is one of the best ways to shift the oral microbiome and even things like, you know, in greens, you know, leafy greens and beets. I mean, it's so interesting the foods that our oral microbiome really likes, you know, and thrives off of. So, lots of veggies and fiber. That's really, you know, how the microbiome evolved with us, we would be on that type of a diet. But that's not all. There's a lot of other things to do to improve the oral microbiome. I mean, since writing the book, I'm a big fan of oral probiotics, especially...Hold on one sec. Oh, yeah. Excuse me. Oral probiotics are really great.

In this episode of Functional Medicine Research, I interview dietician Tracey Long in a deep discussion about how to overcome mold and biotoxin illness. Tracey has firsthand experience with mold and biotoxin illness so she brings a unique and valuable perspective to this topic. We discussed Tracey's personal journey with mold and biotoxin illness, how to test your home for mold, lab testing, associated conditions, symptoms, and management strategies to get well. Full transcript on How to Overcome Mold and Biotoxin Illness Dr. Hedberg: Well, welcome, everyone, to "Functional Medicine Research." I'm Dr. Hedberg. Really excited today to have my good friend and colleague, Tracey Long, on the show. Tracey is a registered dietician, with specialty certification training in Integrative and Functional Medical Nutrition Therapy and The Bredesen Protocol to End Alzheimer's. She owns a private practice, Big Picture Health in Hendersonville, North Carolina, where she sees clients via video consultations. She specializes in working with clients with neurodegenerative conditions, biotoxin illnesses, gastrointestinal conditions, and nutrigenomics. She is a published author and teaches health coaches for Chris Kresser's Health Coach Training Program. Tracey's education includes a master of public health, an emphasis on nutrition and exercise physiology from the Colorado School of Public Health, where she studied under Dr. Loren Cordain who many of you may know as the author of "The Paleo Diet." And she's also a registered yoga teacher and certified exercise physiologist. Her personal interest include hiking with her husband and dog, urban farming, teaching yoga, foraging for mushrooms in the mountains of Western North Carolina, growing medicinal herbs and produce, paddleboarding, and visiting her three grown daughters in Colorado. Tracey, welcome to the show.   Tracey: Thank you so much, Nik. I'm so happy to be here with you today. Really appreciate the opportunity. Dr. Hedberg: Yes. Yeah. It's gonna be fun. So why don't we begin by talking about your personal journey with mold? And that's gonna be the topic of today, mold and biotoxin illness. So why don't you share your personal journey? Tracey: You bet I'd love to. And really, my personal journey, Nik, really started with a professional journey in that I became very interested in neurodegenerative conditions and I completed Dr. Bredesen's training, as you mentioned, The Bredesen Protocol to End Alzheimer's. And Dr. Bredesen has sub-categorized underlying causes of Alzheimer's, and one of those underlying causes he refers to as type three Alzheimer's that's really related to toxins. And he's identified three categories of primary toxins. The first one is heavy metals and the second one is biotoxins. And in that category, biotoxins, certainly, mold is included and also tick-borne illnesses. And now even recently we've added COVID-19, especially from the standpoint of, you know, people who have had COVID-19 and they haven't recovered. You know, we're referring to them as long haulers. And I bring that up. I'll tie that all in in just a minute. The third type of toxin Dr. Bredesen addresses are organic compounds. So there are things like herbicides and pesticides, things that we can be highly exposed to in the environment. It was interesting in that journey that I had that training and I started working with clients with all the subtypes of Alzheimer's, little did I know that I would end up having my own personal experience. So I was assisting clients who had been exposed to mold, certainly, and then we ended up moving to North Carolina. It's in the South. It's very moist here, as you know, I know you live here too. So, you know, we've had a year of record rainfall here. So I moved from Colorado, which was very hot and dry to the Southeast, which is living like in the tropics, really. We're living in a rental house. And when we found the house, we were really excited because, for a rental, it looked really great on the surface. We just thought, "Wow. We found such a treasure in this house." And I was able to set up my office in the basement, which happens to have...it's kind of a partial basement, so it's got some really nice natural light and big windows and I thought, "Oh, even for a basement office this is just great." And got set up and started working. And after living in this house for about five months I just gradually started to get sicker and sicker. And it's interesting that even though I was assisting clients who had biotoxin illness, and especially mold illness, certainly some people with tick-borne illness as well, it's almost like I couldn't see it in myself. And that rings true with people with biotoxin illness, the impact that it has on us neurologically can really impair our ability to think and process information. And so I certainly was becoming more cognitively imperative myself. I ended up gaining about 20 pounds almost overnight, which really bothered me as a dietician because I practice what I preach. I eat a whole foods, paleo-based diet and, you know, a big exercise fiend, and I hadn't changed anything. So I'm just like, "Where the heck did this 20 pounds come from?" And then as I continued to get more sick, I suddenly was like not sleeping, like, I mean literally not sleeping. The insomnia was horrible, then exacerbated by hot flashes. And so I just continued down this decline. I had to cut my work back by at least half. I really was becoming dysfunctional. And then this profound fatigue set in where I almost...I would be sitting at my desk working and I would get hit with this fatigue where I almost just had to, like, lie down in the floor. I didn't have enough strength left in me to up the stairs and, you know, lie on the couch or even get in my bed. And I would curl up on the floor in my office and just fall asleep for two hours, you know, and it was really at about that point that I just thought, "My gosh, what is wrong with me?" And so I ran the tests on myself and discovered that I had really high mold levels. And we started... We had our home inspected. Our landlord happened to be very much on board with that and very supportive, and we found some pretty significant high levels of very toxic mold growing in this house kind of underneath the surface. So I ended up leaving the home for about three weeks, my husband, who was not feeling, you know, the drastic health issues. And I would love to talk about that too, Nik, in that you can have people in the same household who, you know, one person can be very sick or a few family members, very sick, and then other people not sick at all. And we have theories around why that's happening. But luckily, my husband maybe was experiencing some hormonal dysregulation and some issues, but I was able to go back to Colorado and stay at a friend's house for three weeks. And our landlord's very fortunate because my husband's very handy and he was able to do a bulk of the remediation to making the house at least safe for me. And I didn't mention too that I'd also kind of spontaneously developed asthma, which I never had in my life. So it was interesting, you know, just getting out of the house and, you know, being in that safer place in Colorado, my asthma just went away immediately and I'd had to go... I went to see a doctor and I was using an inhaler here in North Carolina. And so I instantly started feeling better when I got out of this environment. But I ended up coming back and I was able to help my husband with some of the remediation. It really took us about three months total. And it's been a journey. I mean, this has been really going on about a year and a half. And I would say that I'm about 80% improved, but I still have a little ways to go. So mold really did a number on me. Yeah. That's an overview for you. Dr. Hedberg: The immune system remembers, that's one of the difficult parts about it. And you mentioned testing. So what does that look like for people if they suspect that they have a mold issue? Why don't we start with home testing? Are there regional labs that will do this? Or is there, you know, a standard test people can get? Tracey: You know, that it's a tricky area to work in because it's relatively new. And, you know, I don't mind sharing with you that I've done a deep dive. I love learning. And then when something like this happens, I think, you know, "I wanna advocate for myself and my clients." So I've recently attended three big deal mold conferences. I mean, it was really bringing the best in the world to these conferences and they were presenting on this very issue. And I mean, I do wanna come back to something you said, you know, how does someone, if they suspect they have mold, how do they start testing? And I wanna answer that question, but I would like to circle back around to how does someone know or how would they suspect they might have a mold issue? So I I'd like to come back and speak to that in a minute. Right now, we could really look at this two different ways. You could start by testing your home or if you suspect that you have mold illness, you could test yourself. And our best tests right now are urine mycotoxin tests. So think about it this way. Mold is an organism. I think we're all familiar with it. We can picture mold growing on yogurt or bread, and it's white, or green, or blue, and it's fuzzy. So when mold grows, it needs substrate, like in the case of bread, that works. And then it also needs moisture. So if you have those two things combined, you can grow mold, but mold makes spores. Spores are very tiny and they can float around in the environment. I mean, just walking through a room or having your HVAC system running and circulating air, these spores will filter all throughout, you know, the area and then they can land on surfaces. And if those surfaces have dirt or substrate like wood and then also moisture,

The Paleo Diet is a popular diet that can work well for many chronic diseases, especially autoimmune diseases like Hashimoto’s disease. However, the Paleo Diet can be somewhat restrictive which can result in deficiencies if the dieter doesn’t carefully review their food and micronutrient intake. Iodine is one important micronutrient that may become depleted on a Paleo Diet. The Autoimmune Paleo Diet is an even more restrictive diet so the same deficiency may happen. Let’s review what the research shows about the Paleo Diet and iodine deficiency. A paper published in the European Journal of Clinical Nutrition entitled, “A Paleolithic-type diet results in iodine deficiency: a 2-year randomized trial in postmenopausal obese women” sheds some light on this question. Introduction to this study on the Paleo Diet and iodine deficiency This study was done in Sweden and the authors begin by stating >50% of iodine intake comes from iodized table salt followed by dairy and seafood. The Paleo Diet is void of dairy, grains, legumes, refined sugar, processed oils, and salt thus removing two important sources of iodine. 150 micrograms of iodine per day is recommended by the Nordic Nutrition Recommendations (NNR) but the thyroid can function at 70 micrograms of iodine per day. Urinary iodine concentration (UIC) by spot urine is recommended for determining iodine status. Adequate iodine intake is a UIC of 100-199 ug/l. Mild iodine deficiency is a UIC of 50-99 ug/l. Moderate iodine deficiency is 20-49 ug/l. Severe iodine deficiency is <20 ug/l. However, the authors do state that the best way to measure iodine status is a 24-hour urinary iodine excretion over multiple days. The authors point out that those at greatest risk for iodine deficiency include pregnant or lactating women and vegans. How was this study done on the Paleo Diet and iodine deficiency? This was a randomized controlled trial consisting of one group following the Paleo Diet and the other following an NNR-based diet for two years. Urine and blood samples were collected at baseline, 6-months, and 24-months. Testing included 24-hour urinary iodine concentration and excretion as well as thyroid hormones. 24-hour urine was collected on three separate days. TSH, Free T4, and Free T3 were the thyroid hormones tested. 70 post-menopausal women were included of which 74% were obese and the rest overweight. 49 subjects completed the study of which 22 followed the NNR diet and 27 followed the Paleo Diet. What were the study results? Women following the Paleo Diet totaled a weight loss of 10.7% compared to 7.7% in the NNR group. The Paleo Diet group developed iodine deficiency but the NNR group maintained normal iodine status. TSH, Free T4, and Free T3 levels did not differ between the groups at any time except for Free T3 levels declined after 6 months in the Paleo Diet group. The author’s conclude that pregnant women should avoid the Paleo Diet because iodine deficiency can cause impaired brain development of the fetus. The weakness of this study is the 30% drop out rate but the authors state that they don’t believe this affected the results because those most likely to adhere to the diets remained. Dr. Hedberg’s Comments This study was done well but a larger group would have provided stronger results. 24 months is an adequate time to assess micronutrient deficiencies from dietary interventions. The Paleo Diet group did lose more weight but when you look at the NNR recommendations you’ll see a much higher carbohydrate intake of 60% compared to the Paleo Diet group who only consumed 30% carbohydrates. These women were obese or overweight, so they were insulin resistant which means that they won’t do well on higher carbohydrate intake. The Paleo Diet group also consumed 30% protein compared to just 15% in the NNR group. The decline in Free T3 on the Paleo Diet is due to the lower carbohydrate intake which isn’t necessarily a bad thing as long as each individual doesn’t develop symptoms of hypothyroidism. T3 is going to change based on caloric intake and carbohydrate intake so if you lower either one of those variables you’re T3 levels will decline. TSH and Free T4 levels remained stable indicating the hypothalamus was comfortable with the changes in calories and carbohydrates. How should you get iodine on a Paleo Diet? If you have Hashimoto’s disease, you may have been falsely scared about iodine. You must have some iodine to maintain healthy thyroid function. You just don’t want excessive amounts of iodine. 150 micrograms a day of iodine from food or a multivitamin is fine for most people. I recommend an unrefined Celtic sea salt product from Selina Naturally called Gourmet Seaweed Seasoning which is basically unrefined sea salt with some seaweed added. A ¼ teaspoon contains 375 mcg of iodine so just use a little here and there throughout the week to get enough iodine if you’re following a Paleo Diet or Autoimmune Paleo Diet. Although iodized table salt will prevent iodine deficiency, this is strictly sodium chloride which isn’t real salt which may result in many long-term health consequences. You could also increase your consumption of seaweed products but be careful of where they are sourced because our oceans are becoming more and more polluted. Always remember to work with a healthcare professional if you’re going to follow a specific diet, so he or she can help you identify deficiencies that may arise. I have seen many patients who come in to the practice with multiple micronutrient deficiencies due to restrictive dieting.

“Adrenal Fatigue” is a term used for many years by alternative medicine practitioners but does it exist? This is certainly a term that I have used for some time but not in the way that most practitioners use it. I will use terms at times that are widely searched for on the internet so that I can spread the science behind these terms but it doesn’t necessarily mean that I endorse the term or subscribe to the existence of a condition. There are a few published papers that tackle this very issue that I’ll cover in this article on “adrenal fatigue”. What does the research show about "adrenal fatigue"? The first paper I’d like to mention is entitled, “We are tired of ‘adrenal fatigue’” by Ross et al. The title of this paper quickly gives you the underlying frustration of the authors about this term. This paper is a position statement and not a clinical trial, review, or analysis of any kind. The authors begin by outlining the adrenal fatigue theory and that is doesn’t exist as a defined medical condition. The authors do point out a valid adrenal disorder called adrenal insufficiency which is characterized by insufficient cortisol production after an adrenocorticotropic (ACTH) hormone stimulation test. They also mention Addison’s disease which is true adrenal failure. Interestingly, those who suffer from fatigue actually showed a greater rise in cortisol with an ACTH stimulation test which indicates excessive cortisol production not insufficient cortisol production in those with adrenal insufficiency. And another study actually found no difference in salivary cortisol levels taken throughout the day in two-thirds of healthy subjects compared to those who suffered from fatigue. Dehydroepiandrosterone sulphate (DHEA-S) has also been used as a marker for adrenal fatigue but research has shown this to be unreliable. The most recent systematic review of adrenal fatigue is entitled, “Adrenal fatigue does not exist: a systematic review” by Cadegiani and Kater. The authors searched 3,470 published papers but only 58 of them fulfilled proper criteria for evaluation. Of the 58 studies, only 10 actually used the term “adrenal fatigue” but none of them did any kind of testing to validate this false condition. Some studies tried to use the term “burnout” instead of “adrenal fatigue” but no scientific evidence was presented in these papers. None of the studies in the above review were able to validate any of the functional tests used to assess adrenal hormone production including cortisol and DHEA. Additionally, no valid information was found in these tests to assess HPA axis dysfunction which is one of the hallmarks of “adrenal fatigue”. The authors rightly point out that anytime there is a suspected issue of HPA axis dysfunction, the following must be ruled out as a cause of this dysfunction: 1. Sleep apnea 2. Adrenal insufficiency 3. Mental illness 4. Overwork 5. Night-shift workers 6. Other hormonal imbalances 7. Liver and kidney dysfunction 8. Heart conditions 9. Lung disease 10. Autoimmune disease Some alternative practitioners are not adequately assessing each patient for the above list of potential issues and jumping into treatment of “adrenal fatigue”. The authors conclude that there is no demonstrated evidence that “adrenal fatigue” is a real condition. Their two final statements are: 1. “The results of previous studies were contradictory using all the methods for assessing fatigue and the HPA axis.” 2. “The most appropriate methods to assess the HPA axis were not used to evaluate fatigue.” It is clear from reviewing the above paper that the methodology in all the studies reviewed was very poor and did not provide any valid scientific support of “adrenal fatigue”. What about corticosteroids? Many integrative practitioners are prescribing oral corticosteroids to treat adrenal fatigue which can have many negative consequences. Corticosteroids will immediately improve one’s sense of well-being no matter what condition they have thereby giving the false impression that this treatment was necessary for the patient. Corticosteroids can lead to osteoporosis, glaucoma, myopathy, insomnia, psychiatric disorders, cardiovascular disease, and metabolic disorders. It can be difficult to come off of corticosteroids the longer someone has been taking them which can be a long and arduous process. This overuse of corticosteroids is a major problem in integrative medicine today. Dr. Hedberg’s Comments on "adrenal fatigue" Unfortunately, I see many patients who believe they have “adrenal fatigue” either because another practitioner told them they have it or they read something on the internet that lead them to believe they have it. There is no doubt that HPA axis dysfunction exists but the majority of the time this doesn’t lead to adrenal glands that aren’t producing enough hormones as claimed in "adrenal fatigue". Adrenal insufficiency or Addison’s disease as noted above are two real conditions that lead to very low levels of adrenal hormone production. These require specific testing to diagnose and must be treated through conventional medical therapies. Adrenal hormone testing through combined urine and saliva such as the DUTCH test by Precision Analytical can be useful to determine if the patient has adrenal insufficiency or to investigate further for Addison’s disease. The interpretation of the DUTCH test can also help to determine inflammation and insulin resistance depending on the patterns found on this test. If you do have HPA axis dysfunction then it can be useful to take adrenal adaptogens as outlined in my article on the best adrenal adaptogens. I rarely do testing for adrenal hormones because this is rarely the primary issue with each patient as most of the issues that cause adrenal hormone imbalances are addressed through my treatment plans. These include things like trauma history, gut health, insulin resistance, thyroid health, metabolic acidosis, dietary factors such as protein and carbohydrate ratios, insomnia, too much or too little exercise etc. which can all stress the body and the HPA axis. It is unhealthy to cling to a label of any condition but it is even worse when that condition doesn’t exist. If you have been told you have “adrenal fatigue” or believe that you have it, the best thing you could do for health is to let go of this label and move on to figuring out why you aren’t feeling well. This is why it’s important to work with a functional medicine practitioner who takes a science-based approach to health so you’re not paying for unnecessary tests or supplements. You can now enjoy a new lease on life by letting go of this label and continue to focus on what is really going to help you get well.

In this episode of Functional Medicine Research, I interview naturopathic physician Dr. Ilana Gurevich on overcoming inflammatory bowel disease.  We had a deep discussion about testing and treatment options for inflammatory bowel diseases including Crohn's disease and ulcerative colitis.  We covered diagnostic testing, the pros and cons of stool test markers, probiotics, fiber, digestive enzymes and hydrochloric acid, gut healing nutrients, diets like the Specific Carbohydrate Diet, helminths, and much more.  It was a pleasure to have Dr. Gurevich's expertise on inflammatory bowel disease. Below is a transcript on How to Overcome Inflammatory Bowel Disease with Dr. Ilana Gurevich Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research" I'm Dr. Hedberg, really looking forward to my conversation today with Dr. Ilana Gurevich. She is a naturopathic physician and acupuncturist. She graduated from the National University of Natural Medicine in 2007, with her doctorate in naturopathic medicine, and in 2008, with her masters of Oriental medicine. She is currently co-owner of two large integrated medical clinics, one in Northwest Portland and one in Northeast Portland. She runs a very busy practice specializing in treating inflammatory bowel disease, which we'll be talking about today, as well as IBS, SIBO and other functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for gastrointestinal conditions, including inflammatory bowel disease, SIBO, and IBS. She's one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. Dr. Gurevich also acts as a mentor in the naturopathic community, educating and consulting with physicians about GI disorders. She supervises residents and consults with doctors about their most difficult GI cases. She was nominated as one of Portland's top docs by the Portland Monthly in 2014, 2016 and 2020. So Dr. Gurevich, thanks for coming on the show. Dr. Gurevich: Thank you so much for having me. Dr. Hedberg: Yeah. So this is gonna be really interesting. I've heard you talk before and I wanted to have you on because you're extremely a research-based, you know, scientifically sound. And of course, you have tremendous experience in inflammatory bowel and SIBO and IBS. So why don't we just lay some groundwork? And if you could just talk a little bit about what have you found to be the real causes, the triggers of inflammatory bowel in your patients? Dr. Gurevich: You know, it is such a multifactorial disease. So with inflammatory bowel disease, there are these two peaks of when people generally get diagnosed. The first is, you know, adolescence, right around puberty to like the mid-30s or 40s. And then the second is menopause, andropause in your 60s, 70s, 80s. And those patients tend to get found a lot just on their basic screening colonoscopy. And so, you know, because there are these bi-modal peaks of diagnosis, it really makes me think that one of the issues is hormonal changes that happen. And, you know, we're learning more and more recently about how hormones affect the GI, mainly using the estrobolome as an example, and then how the estrobolome affects how you conjugate or process your hormones. And so there's definitely a hormonal component. Research is also exceptionally clear that diet is a huge component. You know, in parts of the world where they don't really see inflammatory bowel disease like Africa, like Asia, when people from those countries move to a Western civilization, they start getting diagnosed with inflammatory bowel disease equal to people of the West, which means that the way that we're eating is definitively changing our microbiome, which is then causing onset of inflammatory bowel disease. What's interesting is the opposite now is also happening as we introduce the Western diet into more diverse countries that in the past were, you know, utilizing their own natural forms of eating as opposed to processed food. Now, those countries are seeing an upsurge in inflammatory bowel disease. And so the microbiome and us killing the microbiome or shunting it is definitely causing lots of changes that then upregulate the immune response in the intestine that's causing the onset of inflammatory bowel disease. And then there's always the mental, emotional component. You know, the majority of your neuro-transmitters from your GI, from your brain are made in your GI and so the higher stress, the higher depression, the higher changes that happen. Then there's also an upregulation, not so much with diagnosis, but definitely with flares of disease. So I have a fair amount of patients, you know, I've been at this a while, and so patients are with me for a long time and we'll have them super, super well-controlled, and then they'll go through like one of the most stressful events of their lives and then all of a sudden, they'll go into yet another flare. So that's another thing. And then my big thing is I will...it's pretty well-documented that antibiotics and certain antibiotics in particular will cause onset of an inflammatory bowel disease flare. And so antibiotics is the fourth big pillar that I'm always educating patients about. You know, my rule of thumb is you get an antibiotic if you go into the hospital. And if not, we have ways to treat you. And generally, using all of the natural tools that we have, I can get you out of whatever you need the antibiotic for so that you don't need an antibiotic so you won't go into a flare because I have just seen it so many times when they have an abscess or they need dental work or something like that and they end up getting a flare because of the antibiotics. Dr. Hedberg: Yeah. I see that as well, emotional traumas triggering autoimmunity. And you mentioned moving from certain countries into the West. Do you think that, you know, things like intestinal parasites or just hygiene in general has any connection with that? Dr. Gurevich: I really do. And I really, really do, especially because I'm looking at some of the research that we've done, that we've seen recently with helminths there's that one study that was done, I wanna feel like 10 years ago that was done in Argentina. Do you know the study I'm talking about? Dr. Hedberg: I do. Dr. Gurevich: Okay. So he was an MS doctor. And so when their entire economic system collapsed, so did a lot of their sewage system and stuff like that. And people used to come in with helminths that they were finding and all of a sudden, their MS was going into remission. And so, yeah, I definitely, you know, there's this whole theory called this old friend theory, which is we evolved with these parasites, protozoa and worms. And because of that, when our immune system is targeted at those parasites, protozoa and worms, it's not likely to target us. And I also wanna say, I have also seen the opposite be true, which is parasites, protozoa and worms could also be causing dysfunction because they are pathogenic species. And so I've definitely seen both happen. Dr. Hedberg: And have you seen viruses as a player? This is a, you know, one of the real areas that I focus on and I'm interested in things like Epstein-Barr and other viruses like that. Have you seen that as well? Dr. Gurevich: You know, I think just because of how hyper specialized my practice is, I don't focus on it as much. I'm also in a relatively large integrative clinic. So if people are coming in with that chronic-infection-like picture, then generally, I'll refer them over to one of my more infectious-disease-specialized colleagues. And so, you know, I feel like when we're talking about when patients are having both going on, and their GI is, you know, they're not in a flare, I usually take a back seat and let one of my colleagues really manage the infectious disease aspect of it. Dr. Hedberg: Excellent. It sounds like you have a really great team where you work, so... Dr. Gurevich: I'm exceptionally fortunate. Dr. Hedberg: Yeah. So once you've established that someone has inflammatory bowel, let's talk a little bit about lab testing. I know you've done tremendous research on this, and I'm going to assume that you're gonna be doing stool testing on a lot of these patients and some of these markers are somewhat questionable. So why don't we just talk about some of these starting with pancreatic elastase? Have you found that that is a good marker, a good test? Dr. Gurevich: So when you were talking about working up in inflammatory bowel disease patient, you are, you know, where I usually start with is, I usually start with actually not specialty labs, but just the regular standard Quest lab labs. And if it's an ulcerative colitis patient, I'm always, before I start any treatment, I'm always gonna get a baseline. And the baseline for UC that's been most validated is a fecal calprotectin or a stool calprotectin. This is a stool test that I will say, I don't trust specialty labs. I've seen their values go up and down. And I have a theory about it. I don't know if my theory is correct. And so I'll always run a calprotectin through one of the standard labs. It's looking for white blood cells within the intestine. When you have white blood cells in the intestine that means there's an inflammatory response. The number, depending on how high that calprotectin is, that tells us how much of a flare they're in. And it's something like 96% predictive for equal to a colonoscopy. So that's a really good test for the large intestine. It's less so a good test for the small intestine. Efficacy of calprotectin for the small bowel is somewhere between 30% and 90% effective, depending on what study you look at. And so what I've done recently is I've pivoted away from stool testing for small bowel Crohn's patients to a blood test that's put out by Prometheus Labs.

In this episode of Functional Medicine Research, I interview Dr. Liz Lipski in a discussion about how to choose the best therapeutic diet for gut health.  We discussed the low FODMAP diet, comprehensive elimination diet, Simple Carbohydrate Diet (SCD), GAPS diet, Paleo diet, histamine, pancreatic elastase and low HCL levels.  Liz discussed why we would choose each one of these diets for an individual and what each diet entails.  I use all of these diets in my practice so it was nice to have an overview of each diet from one of the top experts in gut health. Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg. And I'm really looking forward to my conversation today with Dr. Liz Lipski. And Dr. Lipski, she's a Professor and the Director of Academic Development for the Nutrition Programs at Maryland University of Integrative Health. She has a PhD in Clinical Nutrition, two board certifications in nutrition, one in functional medicine, and she's a fellow of the American College of Nutrition. She's the author of the fantastic book "Digestive Wellness" which I highly recommend. And she's the founder of the Innovative Healing Academy. She's on faculty for the Institute for Functional Medicine and the Metabolic Medicine Fellowship in Integrative Medicine. She's been a pioneer in the field of functional nutrition for four decades. Liz, welcome to the program. Dr. Lipski: Thanks, Nick. It's so nice to be with you today. Dr. Hedberg: Yeah. This is gonna be a great talk. We're gonna be talking about how to choose the best diet for gut therapy. And why don't we start by just a general question about, you know, what is the best overall diet for GI health? Do we really know, based on the research at this point, what the vast majority of the population should follow? Do we have any insights on that? Dr. Lipski: I do. I think a lot about what's different between people who are healthy and wanna work on tweaking their health or preventive health, and then people who are already in a deep hole where already their health is compromised. And hands down, when we look at research, it looks like a whole foods diet based on a Mediterranean-type diet is the very best diet. When we look at it, cancer rates go down and diabetes rates go down and cardiovascular disease rates go down, but we also have some research on GI. And one of the main issues in the way that we're eating... And I know you see this in your practice, Nick. What we see is, when you ask people, "Well, how do you eat?" And what do they tell us? They say, "I eat pretty well." Right? Don't you hear that all the time? Dr. Hedberg: Yeah. Yeah. Dr. Lipski: And then you look at somebody's food diary and maybe they do, but usually they don't. And so for me, steering somebody at first to a whole foods diet is the most important thing because what we know is that according to a recent study based on kind of looking at every food that has a barcode and it represented, you know, any food company that had more than, you know, a tiny share of the market, they looked and they said 70.9% of the foods that we Americans are eating are ultra-processed. Ultra-processed. And so we now have other studies that say, "Well, if you have more than two servings a day of these ultra-processed foods, we have a 62... For each 10% increase in ultra-processed foods, we increase our risk of cardiovascular disease by 12%, and heart disease by 13%, and strokes by 11%." So, we also have some research on cancers as well. And so, you know, it's not that we can have a treat. It was just my son's birthday and I made a cake and we all had cake. It's not like, you can't have some treats, but at least I made the cake. I knew every ingredient that was in it. And most of us are just eating, the majority of our food is fast, easy, cheap, and filled with all kinds of additives and highly-processed foods. And so the first step is moving towards a whole foods diet and trying to make at least 80% of what you eat every day as real food and cooking. And so that's kind of a long answer to, like, what's the best diet for GI? So, for people who are healthy, you know, tons of vegetables and fruits and legumes and nuts and seeds and whole grains and good-quality proteins. That's really what our diet should look like. And for the most part. But then, when we're sick, we have to do different things. Dr. Hedberg: Right. Right. It's such a confusing topic for the consumer. We're talking about colonizing Mars and we can't even figure out what to eat, you know, on our own planet. But we can wade through some of that, especially when we're talking about specific therapeutic diets. Why don't we jump into this area and go through a few specific therapeutic diets? Why don't we start with the elimination diet? This is a diet that I've used quite a bit over the last 16 years. And so can you tell us, you know, how do you choose the type of patient to use an elimination diet with and what does that diet look like? Dr. Lipski: Okay. When both of us started, this was pretty much our only therapeutic diet. And so, like you said, you have a lot of experience with it, I have a lot of experience with it. And I've said over and over that if you can take somebody who has inflammation, maybe even somebody with autoimmune disease, and put them on a comprehensive elimination diet, within two weeks they often feel at least 50% better. And so I think that this is one of the greatest reducers of inflammation of all time is dietary change because eating is the most inflammatory thing we do, depending on what we're eating and who we are. So, the comprehensive elimination diet, I think about it for somebody who has a lot of pain, somebody who has migraines, somebody who has arthritis, somebody, again, maybe if they have autoimmune disease and they're not ready to kind of turn their lives 100% upside down. And what you can eat on an elimination diet is you can eat poultry, preferably organic. You can eat bison and meats that aren't eaten that often. You can eat fish. You can have fruits and vegetables. You can have non-gluten containing grains like rice and wild rice and buckwheat. You can have seeds like amaranth and quinoa. You can have other seeds like sunflower seeds and pumpkin seeds. And you can use oils like avocado oils and olive oil and walnut oil and sunflower oil. You can use herbs and spices. And that's pretty much what comprises it. One of the things I like about the diet a lot is you can pretty much walk into most restaurants and be able to find something that you can eat. You could have a salad or you can have grilled chicken with some vegetables and baked potato. What's not on this diet is alcohol, sugar, gluten, dairy, eggs, soy. Unless somebody is a vegetarian, I don't include any legumes because legumes, as people know, can cause a lot of gas and bloating if people aren't used to them. But if they're already part of somebody's diet, we can talk about that. One of the big deals that I typically make is if somebody is a big coffee drinker, we negotiate on that. Do you do that too? Dr. Hedberg: I do. Yeah. Because cold turkey on coffee can be very, very hard for some people. Dr. Lipski: Yeah. It's not the most... We know that coffee has, you know, probably a couple of hundred different components to it and some of those are really anti-inflammatory and antioxidant and helpful for us. So, usually, it's not caffeine, is usually not somebody's biggest issue. It's usually, usually, usually in 80% to 90% of cases, it's gluten, dairy or eggs. But I really like to start with a pretty, you know, broad-brush because what I'll ask somebody to do is to do this diet 100% for two weeks and then come back into the office and then we reevaluate where they are. If they have zero benefit, then it's kind of like, "There is zero benefit? Well, maybe we are barking up the wrong tree." Right? But for most people, I've seen people come in who had arthritis, depression or have mental health stuff. This works so amazingly well for depression, anxiety. And I've seen people come in, they're fatigued, they're not sleeping well, they're depressed and anxious and they have pain. And they come in after a couple of weeks and they go, "Oh, my gosh. I feel like a different person." And that's when I say, "Do you think you could do this two more weeks?" Because I'd like to give a longer period of time. We know that the half-life of antibodies is about 21 days. So, if we can have somebody stay on this diet for at least three or four weeks 100% then we can kind of tamp down that antibody response. And then when they actually reintroduce foods, they get often a big kind of kick that says, "Uh-oh, my symptoms are coming back." And how I like to do this, and everybody does it a little bit differently, is I like to have people, for example, if they're gonna add eggs back into their diet, I would like them to have eggs at least a couple of times that first day and a couple of times the next couple of days. And if they have any negative reaction, sometimes people have a negative reaction immediately, then eggs are off their list, and they know that. But if they don't really notice anything, I want them to keep eating eggs for a few days in rather high amount to see what happens. Because often somebody feels fine the first day and it's a second or third day, all of a sudden, their symptoms kick back in. I'm sure you've seen that too. So, that's kind of the comprehensive elimination diet. And it always used to be my first go-to diet. And it's still one of my main first go-tos and I think it's because people can wrap their heads around it pretty easily and because it works remarkably well so often. Dr. Hedberg: And you're doing around three weeks to start or do you do it a little longer, a little bit shorter? Dr. Lipski: Well, I have them do it for two weeks and then come back into the office. And then based on where they are,

We have known since the early 1970s that infections can trigger autoimmune diseases and now we have an interesting hypothesis on the potential triggering of Hashimoto’s disease by COVID-19 infection. A recent case study out of Singapore published in the Singapore Medical Journal entitled, “COVID-19 complicated by Hashimoto’s thyroiditis” presents an individual who developed Hashimoto’s thyroiditis after contracting COVID-19. COVID-19 can cause a hyperinflammatory state in the body which is a potential recipe for developing autoimmune disease. The authors begin by pointing out the most current literature on COVID-19 connections to the autoimmune diseases antiphospholipid syndrome, autoimmune thrombocytopenia, autoimmune hemolytic anemia, and Guillain-Barre syndrome. This patient was a 45-year-old Chinese man who developed a non-productive cough and rhinorrhea for one day after exposure to COVID-19 in his dormitory. On the second day of his symptoms he was diagnosed with confirmed COVID-19 infection. His symptoms went away after 7 days, but he reported new onset of severe generalized fatigue and muscle weakness. Before these symptoms happened, he was in good health, not taking any medications or supplements, working productively, and no history of smoking. He had no family history of autoimmune disease. His physical examination was unremarkable and his thyroid was normal without goitre. However, his TSH level was high at 6.49 and his free T4 was low at 9.19 which is a classic presentation for hypothyroidism. His thyroid peroxidase antibody was extremely high at >2,000 confirming Hashimoto’s disease. His inflammatory markers were normal as well as electrolytes and other metabolic tests. Chest x-ray was completely normal. He was prescribed 25mcg of levothyroxine once a day and five weeks later he reported increased energy, and he had started running again. His TSH was 6.59 and free T4 was 10.91 so those markers did not improve despite the medication and his energy improving. The authors state that the onset of his symptoms from the time he first developed COVID-19 to the time he developed Hashimoto’s disease was similar to the onset of the other 4 autoimmune disease connections noted above in previous studies. The authors conclude that the hyperinflammatory state triggered by COVID-19 also known as a “cytokine storm” can predispose patients to developing autoimmune diseases such as Hashimoto’s thyroiditis. Dr. Hedberg’s Comments Some patients will develop Hashimoto’s disease after getting the flu or other infections such as Epstein-Barr virus, H. pylori, Yersinia enterocolitica, Blastocystis hominis, Parvovirus-B19, Hepatitis C, and Herpes 6 to name some of the most common triggers. Infections can cause abnormal shifts in the immune system thus triggering autoimmunity in predisposed individuals. Normally, it takes three important factors to trigger autoimmune disease: 1. A genetic predisposition. 2. A gut problem such as leaky gut or intestinal dysbiosis. 3. A triggering event such as infection, physical or emotional trauma, giving birth, mold exposure, medications, radiation exposure, excessive iodine exposure, or toxin exposure such as mercury. What is interesting about this case is that he did not have a genetic predispostion at least not that we knew of or was stated in this paper. We also don’t know if he had any gut problems. The cytokine storm caused by COVID-19 can be quite intense compared to other infections so perhaps any predisposing factors were overriden by the storm. This is just speculation on my part but with only a single study subject and not more data about this individual, there isn’t much more to go on other than what we know about how the immune system responds to infections and how autoimmune diseases are triggered. Additional speculation on my part would be that if you have an autoimmune disease like Hashimoto’s disease, contracting COVID-19 could cause a major flare up of your symptoms. This is all the more reason to wear a mask and practice all the recommended guidelines for minimizing exposure to this virus. Remember that if you have one autoimmune disease you have a greater chance of developing a second autoimmune disease. A COVID-19 infection may be a trigger for another autoimmune dsease which would be a tragedy for someone already dealing with one autoimmune disease. We are still learning more and more each day about COVID-19 and based on the research cited in this paper we may be seeing increased rates of autoimmune disease or exacerbation of existing autoimmune disease symptoms due to this pandemic.

It this episode of Functional Medicine Research, I interview Dr. Lucy Mailing in a discussion about the best diet for your gut microbiome.  We had a fascinating discussion focused on all of the different diets out there and how they affect the gut microbiome including the ketogenic diet, plant-based diets, high-fat, low FODMAP, and the autoimmune paleo diet.   We also talked about fiber, protein, hydrogen sulfide, resistant starch, butyrate, gluten, lectins, stool testing, and whether or not you should take probiotics after taking antibiotics.  I think you'll find this conversation quite eye-opening about a number of exciting topics related to the gut micobiome. Below is a transcript on the best diet for your gut micobiome: Dr. Hedberg: Well, welcome, everyone to "Functional Medicine Research". I'm Dr. Hedberg and I'm really looking forward to my conversation today with Dr. Lucy Mailing, PhD. She is a microbiome researcher, educator and passionate scholar of integrative, evidence-based gut health. Lucy received her bachelors in biology from Kalamazoo College and her PhD in nutritional sciences from the University of Illinois where her graduate research focused on the impact of diet and exercise on the gut microbiota. She has authored numerous peer reviewed journal articles, regularly presents at national, international conferences and was named an emerging leader in nutritional sciences by the American Society for Nutrition in 2017. Lucy is the founder and sole author of lucymailing.com, a website dedicated to integrative, evidence-based articles about the gut microbiome, health and nutrition science. Dr. Mailing, welcome to the show. Dr. Mailing: Thanks so much for having me. Dr. Hedberg: Great. So you've done some great writing and research on some topics that a lot of people are interested in. That's why I wanted to have you on. So why don't we begin by really focusing on diet and the gut microbiota and what the research is really showing at this point? So why don't we start with one of the very popular diets out there which is the ketogenic diet and we can kind of lump in just the high-fat diet in general with that. So what can you tell us about high-fat diets, ketogenic diets and how it affects the gut microbiota? Dr. Mailing: Sure, yeah. That's a great place to start. I think one of the key things to keep in mind here is that we're still in the infancy of microbiome research and especially in our understanding of what constitutes a healthy microbiome. And we have certainly done a number of studies looking at how diet can impact the microbiome. A lot of this has been done in animal models where we can essentially really control the diet of the animals and determine what effects that has on their microbiome. So a lot of the studies with the high-fat diet in the literature are kind of misleading because they're labeled as a high-fat diet but they're really more accurately a diet that is very high in refined fats and also high in refined sugar and low in fiber. So we can't really take that and compare it to the equivalent of a very healthy, like a health-conscious ketogenic diet that's got lots of non-starchy vegetables, healthy fats. There's just really not much comparison we can make there. And the other thing is that the gut microbiome has really evolved with us, often in the context of periodic ketosis. So if we think about human evolution, we've been coevolving with our gut microbiome for thousands of generations. And the environment we evolved in required regular adaptation to changing conditions. When there was nutrient scarcity or even just carbohydrate scarcity, our metabolism would shift to reflect what was available in our environment to consume. And so we have that metabolic flexibility in our host genome, right. As humans, we have the ability to metabolize carbs or metabolize fats in periods of carbohydrate scarcity. So the real question is why would our bodies not have this...why would our bodies have this metabolic flexibility to deal with the shifting availability of foods and our gut microbiome not also have that same metabolic flexibility and ability to be healthy even when carbohydrates are scarce? Dr. Hedberg: Interesting. You brought up a really great point about some of these research papers that, you know...the media's guilty of this and different websites and things like that where they'll post a kind of really catchy tagline about this diet does this and this diet does that and it's just focusing on one variable like fat, but they fail to discuss all the other factors in the diet of those individuals. Like you said, what is the quality of the carbohydrates, the fat, the protein, the sugar intake and then everything else in someone's life? You know, how much are they exercising? Do they smoke? Do they drink alcohol? And things like that. Do you see any good science out there where they take those considerations into account? Dr. Mailing: Yeah, definitely. There have been quite a few studies actually now on ketogenic diet and how it impacts the human gut microbiome where they're using a relatively healthy ketogenic diet and generally controlling for all those other variables or at least including them in their analyses. And so for example, in 2014, there was a study by Dr. Peter Turnbaugh's group at UCSF where they essentially put healthy human volunteers on a short-term plant-based diet or an animal-based ketogenic diet. You know, just for five days but they found that there were distinct gut microbial communities that emerged within as little as three days. So there was a distinct shift with the animal-based ketogenic diet. And not necessarily one that was, you know, any more pathogenic. There was some increase in hydrogen sulfide producers, which we can talk about a little more later if you want. So in some cases, there might be certain gut microbial patterns that might be...you know, certain overgrowths that might be exacerbated on a ketogenic diet for the average person going on a ketogenic diet, I don't think we have any real evidence to suggest that that's gonna be bad for the gut microbiome. Dr. Hedberg: Excellent. Yeah, that makes sense just because it was...like you said, we evolved with various types of diets and there were certainly sometimes long periods where very low fiber, not much plant food was available and people were only eating meat. We can see certain populations around the world that eat diets like that. So based on your research and what's showing now, there...correct me if I'm wrong. So there's not much evidence that a ketogenic diet is necessarily bad or pathogenic for someone's gut microbiota other than you mentioned if there's some level of bacterial overgrowth. Is that correct? Dr. Mailing: Yeah, specifically hydrogen sulfide overgrowth because there's certain hydrogen-sulfide-producing organisms like Desulfovibrio and Bilophila wadsworthia being the two most common. Those, if they're overgrown, they tend to really thrive on animal protein and fat and so if you have an overgrowth of those particular bacteria at baseline and then you go on a ketogenic diet, you're probably going to exacerbate those overgrowths just because they thrive on those particular types of foods. Dr. Hedberg: Yeah, that makes sense. So a lot of people...you know, there's talk about diversity and the importance of that but there's also, at least from my research, that's not necessarily all that conclusive either and it seems from my understanding that the real key is reducing inflammation in the gut and if you can reduce inflammation in the gut, then the type of diet isn't going to have much of a negative effect on the microbiome. What can you say about diversity and where we are as how we look at that and is it really important to have a lot of diversity or are we okay...certain individuals for some periods of time eating a diet that is going to decrease diversity of the gut microbiota? Dr. Mailing: Yeah, great question. So diversity is definitely tricky to think about. It's clear that Western populations have significantly reduced diversity compared to much more traditional cultures like the Hadza hunter gatherers, some Nepalese populations that have been studied that are more agrarian. They definitely tend to have higher microbial diversity and that's also associated with a lack of chronic disease. So we think that this loss of diversity in our essentially industrialized microbiota is potentially contributing to our predisposition to chronic disease. Now within a western population we tend to see that higher microbial diversity is more associated with health but that's not always a perfect correlation. I think I've seen a few studies. For example, there was one with individuals with major depressive disorder and they found that those individuals actually had higher diversity than healthy controls but it wasn't necessarily a healthy type of increased diversity. So diversity does tend to correlate with health but it's certainly, you know, not the only thing we should be considering when we're determining, you know, whether we've got a healthy microbiome. And honestly, like I mentioned earlier, we're still really in the early stages of defining a healthy microbiome but I think what you said about inflammation is really key because if we have...you know, there's many unique states of a healthy microbiome. You know, you and I only share about a third of our gut microbiota and the rest is unique to us. But if we're both healthy, we should both have, you know, very low inflammation. And so that seems to be a key that is shared across healthy individuals is lower inflammation and a healthy colonic metabolism that actually promotes a healthy microbiota that's unique to us. Dr. Hedberg: And just wanna ask you about protein because usually the conversations tend to revolve around fat and carbohydrate and fiber intake.

In this episode of Functional Medicine Research, I speak with therapist Martina Barnes about how EMDR can help people overcome trauma.  I have personally used EMDR with great success in overcoming trauma and I routinely refer for EMDR to help patients get well.  One of the most important aspects of practicing functional medicine is understanding how much trauma can be connected to chronic illness.  Many patients won't get well until they address their past and how it is affecting their current health issues.  All the healthy diets, supplements, exercise, sleep, exposure to nature, community etc. won't be enough if there is underlying trauma history wearing you down.   Mental health professionals are severely underutilized yet they should be the first line of therapy for the majority of patients with chronic illness.  Unfortunately, they usually end up being the last.  This interview should help shed some light on the benefits of EMDR and how it can help you heal and get well for lasting health and well-being. Below is a transcript on overcoming trauma with EMDR Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg and really excited today to have Martina Barnes on the show. Martina has a Master's Degree in Counseling Psychology from Western Carolina University and that was completed in the year 2000. So, many, many years of experience and Martina's theoretical underpinnings are informed by attachment theories of human development which determine our interpersonal basis for relationships. And when working with individuals together, we seek to understand the attachment wounds developed in childhood and how your style impacts your relationship with yourself and others. And Martina says you can transform your life by transforming the way your brain and nervous system are wired. She utilizes a range of evidence-based yet cutting-edge holistic modalities such as Trauma Resilience Model, EMDR, which is what we're gonna be talking about today in detail, Internal Family Systems, Neuro-Linguistic Programming, and mindfulness, and Martina has been a speaker and educator at trauma recovery conferences and seminars for victims of murder, suicide, and even sudden death. So, Martina, welcome to the show. Martina: Thanks, Nick, and great to be here. I'm excited to share what I know about EMDR. Dr. Hedberg: Yeah. I'm excited as well. This is something that I've been wanting someone on the show for a long time to talk about EMDR. This is something that I've used myself and recommended to many patients. So, why don't we just talk about some of the basics and why don't you give us an idea of what exactly is EMDR and what does it stand for? Martina: Yeah. Great. So, EMDR stands for Eye Movement Desensitization Reprocessing. And it's a modality that originally only used eye movements to help give the brain bilateral stimulation to help clear trauma. It's gone to incorporate other types of bilateral stimulation. Maybe hand taps or also bilateral auditory tones can be incorporated as well. And it's one of the most powerful trauma recovery modalities that I've ever utilized. It was discovered in 1988. So, it's been around quite a long time. Dr. Hedberg: And who invented EMDR? Martina: Francine Shapiro who was a psychologist invented EMDR quite by accident. She loved to take long walks and when she was walking, she would notice if she was thinking about something that's setting or something disturbing that her eyes would dart back and forth, back and forth, and then they would stop darting, and she would notice that she had cleared that disturbing thought. So, it occurred to her that she might be able to develop some kind of protocol that would involve the eye movements to help clear disturbing thoughts. And she first decided to try this on veterans who had PTSD. Dr. Hedberg: Fascinating. And so, this modality, so, like you said, it's been around for quite a long time and I've had it with two different practitioners. One used the lights and the handheld vibration device. Martina: Yes. Dr. Hedberg: And then the other one just used her hand with her finger moving back and forth. So, can you talk about the different ways to do EMDR? Is there any advantage to one way of doing it over the other? Martina: That's really up for debate. There's been a lot of clinical studies on EMDR and some of the clinical studies have indicated or the meta-analysis of several research studies have indicated that there is a higher benefit to doing the eye movement. However, other studies indicate that that's not necessarily the case, as long as the brain is getting the bilateral stimulation. So, when I began, I would say, probably the first 8 to 10 years, I just use my hand or my fingers and would have the client follow the backend force of my hand with their eyes. And sometimes I would speed up, sometimes I would slow down. Then these machines, like the light bar came into and that could sound like the clinician use with you. There are handheld devices that individuals can use that they will administer, like, a vibration back and forth to the palms of the hands, which again is bilateral stimulation. And then as I mentioned before, sometimes auditory tones are used. And I found in my experience that it's really dependent on the patient because some patients don't tolerate eye movements well without feeling a little bit off-balance or dizzy, sometimes a little nauseous, some tolerate the hand vibrations or the hand taps better. So, some like a combination of the hand taps and the auditory stimulus. So, the most important component seems to be that you are getting the brain bilateral stimulation. So, personally, I have not found any significant difference. The differences are really in the individuals. Dr. Hedberg: Let's talk about trauma because that's what it's mainly used for. Trauma is such a difficult thing to deal with for any type of practitioner. And obviously, there's different types of trauma. Some can be a single event or trauma can be an ongoing, you know, stress to the body. How do you define trauma? How do you look at trauma? And what kind of trauma do you think EMDR is best used for? Martina: Those are all great questions. So, in the trauma recovery field, we often talk about big traumas and small traumas. And right now, as we're recording this, we're in a pandemic. I would say that to most everyone in the world, this is resulting in some type of trauma and defining trauma to be an incident that occurs to the brain that impacts the survival mechanism, the fight-flight mechanism. And it's defined really as having an incident or several incidences or exposure to long-term incidences that are more than the body's system can process. So, I would include in that the body, I would include the nervous system, I would include the brain. So, in my experience, single episode traumas such as having a car accident, going through a really difficult divorce, moving through the after effects of being raped or sexually assaulted or mentally abused, if it's a single event like a car accident, for example, or one rape, or maybe several single incidences, I find that the EMDR is most helpful in clearing those types of trauma. When you get into the trauma that comes out of childhood with repeated exposure to trauma which we call complex trauma, then the EMDR may need to be paired with some other modality such as the Trauma Resiliency Model, which is helping regulate the nervous system, or perhaps internal family systems, which is working with the young parts that are traumatized. We can also use EMDR. However, I find that we need a multipronged approach when there has been long-term exposure. Also keep in mind that if a child is exposed to physical, mental, or emotional abuse, alcoholism as a child or a parent that is mentally ill, then that trauma is occurring while their body's developing, their nervous system is developing, and their brain is develop. So, it's a much more complex situation that we're trying to treat. Does that make sense? Dr. Hedberg: Yeah. It makes perfect sense. So, for example, I'm just thinking through, you know, patients that I've had. So, for example, let's take a woman who was forced to be a ballerina at the age of five, and she had an ongoing critical mother about her body and also, a highly critical, you know, teacher for years. That would be something that, like you said, that would be kind of an ongoing trauma that EMDR might not be the best thing for. Would that be correct? Martina: Yes. That's exactly correct because the neural pathways in the brain have been formed as that individual is developing. So, we can imagine those grooves are quite deep. If you contrast to that, another situation where a person has a single-event trauma, for example, someone came in with a car accident, they have not been in a car accident before, but it was quite traumatizing, they're having PTSD symptoms, they're having flashbacks, they don't feel safe driving anymore, their startle response is quite heightened, then EMDR is such a beautiful and effective choice for that. Also, if a person has done, let's say, one tour adaptive duty as a military person, and there are perhaps a couple of incidences that were quite traumatic, EMDR would be an excellent choice. One of the reasons is because we are not requiring the individual to go through that entire week counting or recalling of that trauma blow by blow. Instead, we work with a template, we work with a protocol, and we're pulling out significant aspects of the trauma to treat. And because the brain has otherwise been healthy, we just need to clear some of the inroads, not vast amounts of the network. Does that make sense? Dr. Hedberg: Yes. Yes. Definitely. Yeah. You know, as someone who is not trained in mental health as a practitioner,