Recently, I interviewed Dr. Brittany Henderson, and we discuss her integrative approach to thyroid care, the differences between thyroid nodules and cysts, diagnostic criteria, toxic nodules, subacute thyroiditis, the role of iodine in thyroid health, conventional treatment options, minimally invasive alternatives like alcohol ablation and radiofrequency ablation, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with Dr. Brittany Henderson, as we are going to talk about thyroid nodules, thyroid cysts. It’s going to be a great conversation. 

Let me dive into Dr. Brittany’s bio here: Dr. Brittany Henderson, M.D. is a dual board-certified physician in both internal medicine and endocrinology. She is a thyroid expert working to bridge the gap between functional and conventional medical approaches to thyroid care. 

It’s a short but sweet bio. Welcome. Thanks for joining us, Dr. Brittany. 

Dr. Brittany Henderson: 

Thank you. I’m excited about the conversation. 

Dr. Eric: 

Let’s get a little bit more into your background. I always appreciate a brief bio compared to spending five minutes on a bio. We were chatting before this, and I know there’s a lot more to your background to what motivated you to become an endocrinologist. You don’t only help people with thyroid nodules and cysts, but you do things that are different compared to a lot of endocrinologists, including overall taking an integrative approach. How did you make that transition, that you would do things differently than most endocrinologists? 

Dr. Brittany: 

I was conventionally trained. I am an MD by training. Did the classic T32 fellowship at a major institution. Did basic science research in thyroid. Ended up joining the faculty. My focus has always been on the thyroid. A lot of that goes back to medical school and residency when I had a lot of good influences as far as endocrinology. I have a chemistry background; I really liked it.

I just listened to my patients. That’s what it boils down to. Thyroid care in the U.S. is not done well. Actually, thyroid care internationally is not done well. By that, people don’t know how to diagnose it well. People don’t know how antibodies affect thyroid symptoms for people. They don’t know how to dose medication correctly. There are millions of people on thyroid medicine; I think it’s one of the most prescribed medications in the U.S. Over 20-25 million prescriptions a month. 

The conventional medicine world, it’s a one size fits all approach. Everybody gets on the same medication, and you’re just supposed to be well. But that isn’t the case in real life. A lot of the recommendations from the American Thyroid Association are very outdated.

I just felt drawn to help people in this field really try to do thyroid care right by looking at a full thyroid panel and dosing things appropriately. In our practice, we also integrate thyroid ultrasound for all of our patients. We really think it’s important, just like a stethoscope for a cardiologist. 

We need to see the thyroid itself, see the how the gland looks, blood flow, whether or not there are cysts or nodules. Those are things that you can’t always detect via physical exam. There are nodules that sit far back, and you can’t feel them. I never want to miss a cancer. I always want to make sure we know exactly what’s going on with the full picture because thyroid care is complicated.

I started listening to my patients. I did a lot of my own research. I started integrating a lot more functional medicine into my practice. Integrating supplements, vitamins, lifestyle measures, gut microbiome work, looking at food intolerances. All of those things are so important. Wellness and decreasing systemic inflammation, which helps the autoimmune process and the nodules, too.

That’s what we do. We try to do thyroid care right. I think there’s only one right way to do it. That’s what we’ve integrated both into our brick-and-mortar practice in Charleston, South Carolina and our online practice. 

Dr. Eric: 

Wonderful. You do ultrasounds on every patient who walks through your door? 

Dr. Brittany: 

Yeah. 

Dr. Eric: 

That’s good. I was diagnosed with Graves’. When I spoke to the endocrinologist, she palpated my thyroid and said she didn’t think there were nodules. She actually didn’t recommend an ultrasound. I asked her for one specifically. “It’s not that I don’t trust your palpation skills, but I’d still feel more comfortable.” I was paying out of pocket, and that might have been part of the reason, too. They are not crazy expensive paying out of pocket for the ultrasound. 

Dr. Brittany: 

It’s so much information. It’s so worth it. If you have somebody who knows how to interpret it correctly.  

Dr. Eric: 

Exactly. I’m with you that it’s probably a good idea to get that thyroid ultrasound. If you have a thyroid problem, it makes sense to look at it. Apparently, there are some doctors, even endocrinologists, who don’t order ultrasounds on all their patients. 

Dr. Brittany: 

In the same vein as the stethoscope used for hearts, people image the heart all the time. They do echos, cardiac caths. Same thing. When you have a thyroid condition, to look at it, structurally, it’s important. 

Dr. Eric: 

I agree. For those who are unfamiliar with thyroid nodules and thyroid cysts and the difference between the two, can you explain what thyroid nodules are and how they differ from thyroid cysts? 

Dr. Brittany: 

I get that question all the time, whether a thyroid nodule is a nodule next to the thyroid or within the thyroid. A thyroid nodule is an accumulation of either fluid, which is what a cyst is, or cells—which is what a nodule is. It’s more of a solid component—within the thyroid gland. 

Within the structure of the thyroid gland, you can get these little bumps. You can sometimes feel them. You can feel them on your own self if you look into the mirror, drink a glass of water, and swallow. When you swallow, the thyroid moves. Sometimes, you can feel it. The thyroid sits right at the base of your neck before your sternum. Not always though. You don’t always feel thyroid nodules.

The reason that people get these is because of gland inflammation typically. The thyroid gland receives blood flow just like every other organ in the body. When there is inflammation within the thyroid itself due to Hashimoto’s, Graves’, trauma to the thyroid, or if the thyroid is not functioning properly, like if someone has iodine or iron deficiency, or lots of chemicals in the environment can increase the risk for these nodules to occur because of inflammation of the gland, the gland doesn’t drain the way it’s supposed to. 

The cells don’t behave the way they’re supposed to because they’re inflamed. Because there  not continuous, normal drainage pathways, you can get an accumulation of fluid within the thyroid itself, which is a cyst, or you can get a proliferation or expansion of thyroid cells, which is a nodule. Those thyroid nodules can have gene mutations, which means the cells start behaving erratically or irregularly. That can lead to thyroid cancers or thyroid precancers. 

Dr. Eric: 

How common are thyroid nodules? I imagine in your patient population, it’s common because a lot of people come to see you specifically for that problem. There are other cases as well. Just in the general population, do you know the percentage? 

Dr. Brittany: 

Yeah, it’s super common. It goes up with age. I always tell people 30% of 30-year-olds, 40% of 40-year-olds, 50% of 50-year-olds, and so on. They have done autopsy studies, where they found up to 80% of people who die, especially in their 80s, have thyroid nodules. They just pass away with them. They never know about them.

The good news is 95-99% of them are benign. They are not cancerous. There are cancerous thyroid nodules, and it is one of the fastest-growing cancers in the world. Women get thyroid nodules much more commonly than men do. When men have thyroid nodules, we take it a lot more seriously because they are more prone to cancer, and more prone to aggressive forms of thyroid cancer. We don’t know why. 

Dr. Eric: 

That’s interesting. I know in general, or at least I’m pretty sure in general, most thyroid cancers- There are four types of thyroid cancers, I believe. Two of them are not aggressive, and most people have the non-aggressive forms. I did not know that men with thyroid cancer, not all the time, but are more prone to having the more aggressive forms. Whether it’s a woman or a man, you have to look at certain characteristics of the nodules.

Let’s talk about that. How do you determine who gets a biopsy and who doesn’t? 

Dr. Brittany: 

If you have a simple thyroid cyst, meaning a fluid accumulation with no solid component, typically, those are benign. Almost always. But they can be really annoying and can cause issues. We can get into that in a little bit. 

When we look by thyroid ultrasound, we use several criteria to figure out who gets a biopsy or which ones we can just follow with serial ultrasound. The first criteria is the American Thyroid Association and the American College of Radiology have determined how big does the nodule have to be before you recommend a biopsy? It’s either one centimeter, usually the lowest size. 

It depends on the echo texture of the nodule, meaning on ultrasound, is the thyroid nodule dark, hypoechoic, or bright, hyperechoic? Or is it mixed solid cystic? It just depends what it looks like by ultrasound. 

We have different criteria for size based on how it looks. How dark is it? How big is it? Does it have suspicious features? Does it have calcium deposits in it? We call those microcalcifications, which is a sign for cancer. Or linear calcifications, ram calcifications. There are different types of calcium deposits.

We also look at blood flow. Follicular nodules or follicular carcinomas, which is one of the more common cancers, can have a lot of blood flow by doppler on ultrasound. That is a more aggressive sign as well. Versus papillary thyroid cancers, which don’t necessarily have blood flow.

We also look at the edges. If a nodule is very round and smooth versus a nodule that is very irregular-looking or growing into muscle or trachea or other things. There are lots of criteria we use. 

Ultrasound is the most sensitive modality to look at this, better than MRI and CT scan, which is why we use it in the practice. It’s so easy and cost-effective. It doesn’t expose anybody to radiation, and it gives us a lot of information. 

Then we recommend biopsy or serial ultrasound to monitor for growth. Even benign nodules can grow with time. 

There is so much that has come out in the last 5-10 years for personalized medicine to figure out risk stratification for patients and how aggressive might a cancer be versus how not aggressive a cancer might be. A lot of that is using genetic testing. There are genetic tests we use when we do a biopsy, which can tell us if the nodule has a gene mutation that is suspicious for cancer or not. 

There are so many decision pathways. Really, it’s come a lot farther than what we used to do, which was just to suggest everybody have it removed. Before you remove a very important endocrine gland, which is really hard sometimes to dose and get right and mimic with our imperfect human medicines, it’s worthwhile to get a second opinion or a third opinion or really figure out if this is the right course of action before making a dramatic decision like surgery. 

Dr. Eric: 

Makes sense. If you do a thyroid ultrasound and detect nodules, you don’t just decide that the person doesn’t need a biopsy. It sounds like you do follow up with another ultrasound in the future. I don’t know if you do that across the board, to make sure the nodules aren’t getting bigger. 

Dr. Brittany: 

We do. Usually, it depends on the size of the nodule and the appearance as to how often we follow that. Primarily, it’s about a year that we look.  

Dr. Eric: 

Okay. Usually, a year. Any indication sometimes for six months? 

Dr. Brittany: 

If it looks hypoechoic, or dark, or it has suspicious features, and it’s smaller than a centimeter, we will recommend a closer follow-up, like the six-month mark. If there is a nodule that is actively growing, and we have a fearful patient who isn’t a fan of needles, which who is? But sometimes, we will do a closer follow-up in 3-6 months to make sure we are on top of it.

If someone does have a thyroid cancer history, we always look by ultrasound every six months for the first two years and then every year after that. 

I we see anything like lymph nodes, which thyroid cancer primarily goes to lymph nodes when it spreads somewhere, then we either recommend biopsy of the lymph nodes or serial ultrasound surveillance every 3-6 months, depending on the aggressiveness of the original tumor. 

Dr. Eric: 

When you do a biopsy, you also do genetic testing as well, just to determine what type of cancer it is? 

Dr. Brittany: 

Yes. There are three ways a nodule can come back after a biopsy. There is benign, which is the most common; cancer, which is the least common; or in the middle, indeterminate. That happens about 10-20% of the time. It just means that the cytologist can’t say 100% there is a benign nodule here because the cells overall look good, but there are some funny features. They’re either bigger than normal or inflamed-looking or have some suspicious features for thyroid cancer. They can’t say either way.

In that situation, we collect a special test, which basically runs all of the known gene mutations for thyroid cancer and gene fusions and other things. Then we can tell somebody, “You had an initially 10-20% chance of cancer. We ran this gene test. It’s telling us that you have a genetic mutation in the tumor that says that you have a 50/50 chance or a 95% chance of cancer.” 

That really helps us to risk stratify people and give them a good idea of whether they should have half the thyroid removed, the full thyroid removed, lymph node dissection, depending on the aggressiveness of the mutation. We run that mutation as well for suspicious for thyroid cancer patients. It does help with understanding how aggressive the tumor might be. 

Dr. Eric: 

If someone comes back with a biopsy, and you conclude it’s benign, you don’t do the genetic testing. Is that correct? 

Dr. Brittany: 

Yes. 

Dr. Eric: 

Just wanted to clarify. What are toxic thyroid nodules? 

Dr. Brittany: 

Toxic thyroid nodules are just nodules that are overactive. It sounds terrible. It actually feels terrible for people because the thyroid is then no longer under the control of the brain and the pituitary system, which is the master gland. That is supposed to be tightly regulating thyroid hormone production. 

Sometimes, if thyroid nodules have been there for a long time, they develop mutations that affect the TSH receptor. Instead of allowing the pituitary gland to signal with a TSH, signal to the thyroid nodule to produce thyroid hormone, the thyroid nodule starts producing thyroid hormone all the time by itself because it hits the on button for the TSH signaling and just always is producing thyroid hormone. 

It doesn’t produce thyroid hormone in a good way. It just basically spits out thyroid hormone randomly whenever it makes some. That can feel like a person is having hyper symptoms, hypo symptoms. They can feel terrible. It doesn’t feel good.

Over time, especially in older patients, people can be at a higher risk for osteoporosis because of the thyroid secreting extra hormone. They can have a higher risk for atrial fibrillation or heart arrythmias because of that. It really contributes to all of the symptoms of thyroid: heart racing, heart jittering, anxiety, insomnia, weight gain, fatigue, brain fog, all of the different hypo and hyper symptoms because of the thyroid nodule behaving irregularly. 

Dr. Eric: 

Whereas just a regular thyroid nodule or cyst are quite common, is it safe to say that toxic nodules are not as common? 

Dr. Brittany: 

I would say that’s probably true. By the way, most toxic nodules are benign. They are not cancerous typically. Some can be, but most of them are not. 

I see those primarily in regions where people grow up with not as much iodine, or they have had long-standing iron deficiency. That is because the nodules typically have been there for a very long time. Those patients who are nutrient deficient many times will have them from childhood or teenage years. They are the ones who typically develop them. 

But of course, there are many factors and variables. We don’t know every single variable that predisposes a person to have a toxic nodule. 

You can by the way have more than one. You can have a toxic multinodular goiter, which are many nodules that are overactive. Typically, these are patients who grew up not eating seafood or seaweed. They grew up in the mountains, where they didn’t have a lot of fresh fish or iodine exposure. Or they have had a lot of heavy periods as women and haven’t eaten a lot of red meat, so they’re iron deficient. Those are the people I see most often. 

Dr. Eric: 

Hot and cold nodules. Do you do the uptake test at your clinic? 

Dr. Brittany: 

Not at the clinic. Usually, a nuclear medicine department at a hospital is who does that. There are some free-standing clinics that do it, but not very many.

A thyroid uptake scan is a scan where the person ingests iodine. It’s not radioactive iodine. It’s just iodine attached to a radiopharmaceutical, so they can actually image the thyroid. 

What it’s doing is concentrating primarily in hot nodules and not in cold nodules. Cold nodules are nodules that do not pick iodine up very well. Those are nodules that don’t make thyroid hormone. 

With a scan, you can actually figure out is a nodule hot on one side of the thyroid and then maybe cold on another side of the thyroid? That can help you understand if a person has hot nodules, do they require treatment on one side of the thyroid gland? Do they need their whole thyroid removed if there are hot nodules all over the place? It can really help you identify where the problem is.

We use thyroid uptake scans all the time, not just for nodules, but for a form of Hashimoto’s called Hashitoxicosis. For Graves’ patients, it is helpful when it’s helpful. Even if it’s normal, sometimes it doesn’t completely rule out a problem. For toxic nodules, it is a helpful test. 

Dr. Eric: 

Good to know. For those with Hashitoxicosis, Graves’, you recommend for that category of patients to get the uptake. 

Dr. Brittany: 

Yes, those are the people it really helps with. Or people who have something called acute or subacute thyroiditis, which is where you get a viral infection like COVID, for example, and your thyroid spits out all its thyroid hormone. You get really hyperthyroid. The uptake scan will look like low uptake on the scan because it’s been completely destroyed by the virus, really by the immune system. We see that occasionally as well. 

Dr. Eric: 

Speaking of subacute thyroiditis, just curious, what is your treatment approach? Usually, they’re transiently hyperthyroid but eventually become hypo. I know some endocrinologists are hesitant to give antithyroid medication because they know eventually the person will become hypo. At the same time, you do want to do things to manage hyperthyroid symptoms. I don’t know if you recommend antithyroid meds or a beta blocker or another approach. 

Dr. Brittany: 

Antithyroid meds in subacute thyroiditis don’t work because they work primarily on stopping the thyroid from making thyroid hormone. You could use PTU because it stops T4 to T3 conversion, but I don’t usually do that.

For someone who has subacute thyroiditis, we just treat symptoms. We put people on beta blockers to treat heart rate issues. We put people on prednisone if there is pain. It’s really waiting it out and letting the disease take its course. Typically, people will become hypothyroid, but many of those people can go back to euthyroidism. They can go back to normal thyroid function. It takes a little bit, 3-6 months. It’s a thing. We see it not very infrequently. 

Dr. Eric: 

You mentioned iodine. Very controversial in the world of thyroid health. You mentioned that it could be a factor when it comes to thyroid nodules and even toxic thyroid nodules. I guess your approach, when it comes to iodine, because there is a lot out there. Some practitioners recommend massive amounts of iodine supplementation. Others recommend the opposite, to restrict iodine supplementation. It depends on the practitioner. It’s not just hyperthyroidism; some suggest that with Hashimoto’s, too. What are your thoughts on iodine and hyperthyroidism, Graves’, Hashimoto’s? 

Dr. Brittany: 

Iodine is one of the micronutrients that follows the Goldilocks rule. It has to not be too much or too little; it has to be just right, and it’s patient-specific.

With thyroid nodules, most of the time, I recommend the recommended daily allowance of iodine. Unless somebody is iodine-deficient, and you can measure that typically in the 24-hour urine iodine. It doesn’t make sense to check serum iodine levels in people because it’s transient. If you eat something that has a big load of iodine, your serum levels will go up acutely. Then the iodine is transferred into cells. Serum level doesn’t mean anything.

A urine level can be helpful. People who are iodine-deficient, people who don’t eat seafood or are vegans or vegetarians, they tend to get thyroid nodules and goiters or enlargement of the thyroid because the thyroid is working overtime to try to make thyroid hormone with only having a little bit of iodine to make it. 

In those situations, we do recommend a little bit higher dose of iodine. By that, I don’t mean 12,500mcg. 300-500mcg short-term, and the recommended daily allowance for adults in the U.S. is 150-250mcg. Higher for breast-feeding or lactating women.

In autoimmune thyroid disease, it depends. We know there is an effect called the Wolff-Chaikoff effect in Hashimoto’s. The thyroid tissue is being attacked by the immune system. Too much iodine in a patient who has Hashimoto’s can stun the thyroid tissue and actually make it not produce any iodine, just stop completely. 

We know that too much iodine can actually worsen some of the Hashimoto’s antibodies, like thyroid globulin antibodies, which can get tagged with iodine and alert the immune system to worsen the autoimmune attack on thyroid.

In those situations, we don’t recommend an excess amount of iodine. I never recommend super low iodine states. I don’t think that really helps to reverse things. A recommended daily allowance, 150mcg, whether it’s through a vitamin or normal exposure is fine. 

There is data as well to show that Graves’ patients, hyperthyroid patients do take iodine. Their glands are overactive, so they take the iodine, and their thyroid glands make tons of thyroid hormone. In order to help get Graves’ into remission, usually we do try to restrict too much iodine. We try to avoid it or reduce it. 

In those situations, a lower iodine diet for a short time might help get into remission. Once remission is achieved, normal iodine intake is probably fine. That’s my approach. 

I think it’s really highly personalized medicine. It depends on the patient’s clinical picture. I don’t have a lot of patients where I use a ton of high doses of iodine to try to help. 

Dr. Eric: 

That makes sense. For thyroid nodules, the same approach. I don’t know if it depends on the situation. As far as there is a chance that in some cases, not all cases, iodine deficiency can be a factor for thyroid nodules. I don’t know if you recommend- You mentioned sometimes urinary iodine testing to see if that might be an underlying factor. If it is, you don’t go to massive amounts of iodine, but maybe have them take a little bit more. 

Dr. Brittany: 

If they’re deficient and have a thyroid goiter or multiple nodules that are not toxic, just normal, it makes sense to go ahead and give them more iodine. Maybe not a crazy amount, but higher than the recommended daily allowance.

Toxic nodules have been shown in the literature that after a high iodine load, they can really start revving up. They use that iodine to make lots of thyroid hormone. That can actually cause “thyroid storm” or excess hyperthyroidism. I have never seen that. 

Usually, a thyroid storm is reserved primarily for Graves’ patients. It is theoretically possible in a big thyroid nodule that is toxic, that it uses iodine load to make a lot of thyroid hormone. I usually don’t recommend high iodine loads for people with toxic nodules. 

Dr. Eric: 

Let’s talk about treatment. As far as conventional treatments, regarding most endocrinologists, most of them don’t need treatment. Most are benign and won’t do anything. if they meet the criteria of certain characteristics that you discussed, typically, it’s partial or not as common to see partial thyroidectomies. A lot of times, with cancer, it’s understandable. Sometimes, I see in cases where someone is benign, but it’s a really large thyroid nodule, they will recommend for the person to get surgery. Is that the conventional approach? Either surgery or no surgery? 

Dr. Brittany: 

I would say that’s true. I would say that most cases, a conventional endocrinologist will recommend total thyroidectomies for most people. Knowledgeable endocrinologists who specialize in the thyroid will make a less aggressive approach to this. They will recommend more of the hemithyroidectomies if it is a benign nodule. If it is a big nodule causing a person to choke or feel like they’re choking, they will recommend just half. If it’s a low-risk thyroid nodule, meaning we did the biopsy and have the genetic test and know that the mutation is typically low risk, we will recommend half of the thyroid. I think that’s the better approach. 

That’s the approach that we take in our practice. We always try to preserve as much thyroid tissue as possible because it’s a big deal to take out the thyroid gland. We used to just say, “Oh, it’s fine. We have Synthroid.” Replacement medicine is not the same as your own endogenous endocrine gland, which controls everything. There are thyroid hormone receptors in every bodily system. Before removing a very important organ, it makes sense to think through that. 

Even in thyroid cancers, for example, in my practice, if it’s intrathyroidal, meaning it’s not growing outside the thyroid, and I don’t see a lot of lymph nodes—I always do the ultrasound before surgery to make sure I know what to tell the surgeon as far as if there are any lymph nodes underneath the thyroid that have cancer or over to the side in the lateral neck, and how to direct them as how to perform the surgery correctly. It’s very important that the surgery be done right the first time.

Even for thyroid cancers that are within the thyroid, they don’t have a lot of lymph nodes present, we sometimes recommend hemithyroidectomy. I don’t always recommend a complete thyroidectomy, even if it’s a higher stage or there are a couple lymph nodes present. I love to be able to preserve thyroid function for patients and minimize the amount of tissue that we’re removing. 

Dr. Eric: 

That’s wonderful. There aren’t a lot of endocrinologists who do that. It’s good to know that if absolutely necessary, you will recommend a complete thyroidectomy. There is a time and place for that. You will do everything you can to try to preserve some of the thyroid tissue and recommend a partial thyroidectomy if you feel that’s warranted. 

I didn’t realize in cancer, too. Probably just because the approach is usually to remove the whole thyroid gland. I don’t hear about endocrinologists who try not to do that, so that’s great that there’s that option. 

I wanted to talk about alcohol ablation. That’s something that most endocrinologists don’t do. That’s something that you offer. Can you discuss what alcohol ablation is, when it’s indicated? 

Dr. Brittany: 

Along the same lines, we like to use minimally invasive approaches to care. We want not to disturb regular normal thyroid tissue. If I see a thyroid that looks beautiful, and it’s working optimally, I don’t want to remove it. 

Even for thyroid cysts. If it’s a simple cyst, meaning it’s just a pocket of fluid, and we see that on ultrasound. That is how we figure out if it’s a cyst. The best way to approach that, the most effective way without disturbing any thyroid tissue or having to go on thyroid medicine lifelong, is a minimally invasive approach called alcohol ablation therapy, or sclerotherapy. 

Not every endocrinologist does this. There are very specialized endocrinologists who know how to do it throughout the U.S. I think they have some at the Mayo Clinic. There are some specialty practices. Very few people are trained on how to do it unfortunately because it’s a very effective treatment option for thyroid cysts. It’s very low risk as far as any complications. 

The way that we do it is we drain the thyroid cyst. If you have a cyst, your endocrinologist can just drain it. They can just take a needle, stick it in the thyroid cyst, and drain the fluid. Many times, in big thyroid cysts especially, which are causing people to feel like they’re choked or you can see it, that cyst fluid just comes back. The reason it comes back is because the cyst probably has been there for a long time and has a thick wall that stops fluid from being allowed to be drained. It just fills back up.

With alcohol ablation or sclerotherapy, we do the same thing. We drain it. But at the same time, we will inject the cyst with pure alcohol, ethanol. One of the side effects is feeling a little bit weird. That doesn’t usually happen. It stays within the cyst wall, so you shouldn’t feel any effect from that. The alcohol kills off the blood supply to the cyst wall, so the wall involutes within itself over time, and the cyst goes away. 

I just had a patient that we did this on a couple months ago. This person came back yesterday to my clinic actually. He had a huge cyst. Trouble swallowing. Had it drained multiple times, and it just kept coming back. 65ccs, which is a big nodule. That is a lot of fluid in somebody’s neck. This is not a big space. We did the alcohol ablation, one round of it. He came back yesterday, and it’s down to less than 2ccs, 96% volume reduction. No symptoms. Doesn’t see it anymore. Completely normal thyroid function. Not having to be on thyroid medicine.

That is a very easy, minimally invasive way to take care of this. Conventional doctors, if it comes back after it’s been drained, will recommend surgery. That is not the right approach to these cysts. This is such a better option for people. 

Dr. Eric: 

Anything you can do to save the thyroid. Sounds like low risk, too. Are there any contraindications? 

Dr. Brittany: 

I always tell people the main complication would be if the alcohol leaks outside the cyst and causes pain at the site or theoretically affects the nerve that goes to the voice, so you get hoarse voice. That would be transient. It would come and go. I have never seen that ever. The cyst fluid stays within the cyst, so the likelihood of it leaking out should not happen. 

Most patients don’t have any pain with it because there is no nerve endings within the thyroid, so it doesn’t hurt. It takes about 15-20 minutes, and you’re off to the races. Really minimal side effects, if any. 

Dr. Eric: 

You’ve been doing this for quite some time, correct? 

Dr. Brittany: 

I have been doing this procedure for almost 10 years with my practice. We do it regularly. We have people who fly internationally to come see us to have it done. It’s hard to find people in your local area who know how to do it or know how to do it well. It’s so easy, and it’s so effective. It should be the standard of care honestly. 

Dr. Eric: 

Is it just for cysts, or can it help with nodules as well? 

Dr. Brittany: 

It’s just for cysts. Sometimes, I have people if they are interested send their images to me, and I can look at them on a secured email, so I can make sure it’s a candidate before they travel. It usually is just reserved for cysts, not solid nodules. 

We do use it for some isolated thyroid cancer lymph nodes. Usually, that is best reserved for older patients who are not surgical candidates. Surgery to remove a cancerous lymph node is probably better. It does work effectively for cancerous lymph nodes as well if someone only has one or two. If they have lots, surgery is better. 

For solid nodules, somebody could consider something called radiofrequency ablation, which is a different minimally invasive option for these solid nodules. Solid nodules can’t be drained. They are full of cells. They are usually more vascular, so they have a lot of blood flow. 

With radiofrequency ablation, the way that works is the needle tip has a positive and negative electrode. The physician will place that needle tip within the solid nodule, and the positive and negative electrode cause heat. They are thermal ablation, pretty much. That heat kills off the blood supply from inside out and causes the nodule to involute and go away. 

It’s more invasive, a little bit, and a bigger, longer procedure than the alcohol ablation. For people who have solid nodules and don’t want surgery or want to preserve thyroid function or have a toxic nodule, which is the overactive nodule, radiofrequency ablation can sometimes be a minimally invasive option to fix that. 

Dr. Eric: 

Okay. Alcohol ablation is for cysts. If you have a solid nodule, then maybe look into radiofrequency ablation, including in some cases, toxic nodules. That’s great. 

Unlike draining a cyst, when you use the alcohol ablation, it’s unlikely to come back? 

Dr. Brittany: 

It’s unlikely to come back although if you start with a cyst that is really big, and by that, I mean over 20ccs. That’s the cutoff in the literature. If it’s over 20ccs, it’s more likely to need a couple courses of alcohol to kill it off. That’s because those bigger cysts have thicker walls. The alcohol doesn’t always get throughout the whole cyst wall, and it can still accumulate. Usually, it will go down after the first treatment. 

With those huge cysts, I can do up to three treatments. By that point, it will usually have shrunk enough that the patient says, “This is great. I don’t have any symptoms anymore. Even if it’s still there a little bit, it’s okay.” We can always do it down the road again. For most nodules, it works the first time. 

Dr. Eric: 

You just gave an example of a patient. I think you said it was 65ccs. It went down to 2ccs. What’s the follow-up procedure? Is it a few weeks later that you reevaluate? 

Dr. Brittany: 

Usually, I give it a good 2-3 months before we reevaluate with the ultrasound. The patient should notice an improvement the minute they leave the door. They should notice that it’s gone, that they’re able to swallow again, that they don’t feel like they’re being choked. That should persistently get better. 

The thyroid cyst over time involutes, so it takes about six months to see the final result. I usually look at that halfway mark. I’m happy when there is at least a 50% volume reduction in the cyst. Usually, we’re getting 80-90% reduction. It’s still going to be there. It will have involuted enough that it’s not going to do anything. Sometimes, it goes away completely. Those are really good results. 

I always tell patients after you’ve had that procedure, when you have had another endocrinologist look at it with an ultrasound, they will say, “Oh my gosh, this looks terrible. You have thyroid cancer.” You just have to know that it looks involuted. It doesn’t look like nothing. Education of outside providers that are not comfortable or familiar with alcohol ablation by the patient even sometimes is helpful to prevent additional workup that is not needed down the road. 

Dr. Eric: 

It’s great to have an alternative. In this situation, if that person went to a conventional endocrinologist with a 65cc cyst, they will probably be told to get a thyroidectomy. Is that correct? 

Dr. Brittany: 

Yeah, most of the people who come to see us have been told to get a total thyroidectomy, or at least a hemithyroidectomy, and they don’t want to lose their thyroid, smartly and after some research, they decide to pursue another opinion. It is usually a great option for people. 

Dr. Eric: 

You covered a lot. Is there anything else that I should have asked you that I didn’t ask you? Anything else you want to share when it comes to nodules or ethanol ablation? 

Dr. Brittany: 

We are happy to look at cysts if patients want me to look at their images. I usually want to look at the images. 

Also, if people want to learn more about thyroid nodules, goiters, iodine deficiency, iron deficiency, or anything thyroid, we just launched a new online patient course. It’s a six-week, learn at your own pace, patient course directed to people. Everything from what is the thyroid? Where is it located? How do you feel with thyroid nodules? How do I know if I’m on the right thyroid medicine? We talk about all of that. We talk about Hashimoto’s, Graves’, antibodies, lifestyle measures, all of it. it’s called Everything Thyroid. If people want more education, they want to be more knowledgeable about their thyroid issues, I think it’s a good starting place as well. 

Dr. Eric: 

You have a brick and mortar in Charleston, SC. That website is CharlestonThyroidCenter.com. 

Dr. Brittany: 

That’s right. 

Dr. Eric: 

A virtual practice, MyThryoidDoctor.com. Yes? 

Dr. Brittany: 

That’s right, yes. The virtual thyroid practice, we see patients in select states all throughout the Southeast. We’re in the Carolinas, Tennessee, Virginia, Florida, Georgia. We are also licensed in Minnesota and Arizona. If patients are located in those states, or their loved ones are, they can see us and get our professional opinion and treatment from us online without having to come in person. 

Dr. Eric: 

Sounds great. Any other places? Instagram, Facebook? I don’t know if you’re on social media. 

Dr. Brittany: 

Our biggest presence is on Instagram. We provide videos all the time about thyroid care, thyroid nodules. We have a whole series on thyroid ultrasound and nodules on our social media. You can follow us, @DrHendersonMD. We’re also on TikTok and Facebook.  

Dr. Eric: 

Thank you so much, Dr. Brittany. This was amazing. You provided some great information when it comes to nodules. I’m glad you’re also trying to help save people’s thyroids through the alcohol ablation. Keep up the good work. I’ll definitely have to have you back on the podcast in the future. 

Dr. Brittany: 

So much fun. Anytime we can spread awareness and knowledge for people and help change the course of their health, I’m all for that. That’s great.  

Dr. Eric: 

I agree. Again, thank you so much. 

Dr. Brittany: 

You’re welcome. Thanks for having me.

 

Recently, I interviewed Dr. Jessica Drummond, and we discuss her journey into women’s health, the complexities of endometriosis, its symptoms, the challenges in diagnosis and treatment, integrative management approaches, the relationship between endometriosis and thyroid health, why it’s crucial to find a skilled surgeon, non-surgical options for managing endometriosis and more.. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am excited to chat with today’s guest, Dr. Jessica Drummond. We are going to talk about endometriosis. It should be a fascinating conversation. Let me dive into Dr. Jessica’s impressive bio here: 

Dr. Jessica Drummond is the founder and CEO of the Integrative Women’s Health Institute. For over two decades, she has worked with women with complex chronic illnesses such as endometriosis, pelvic pain, painful bladder syndrome, and vulvodynia. She has educated practitioners in over 60 countries. She takes the root cause innovative approach to healing in collaboration with her clients and students. Welcome, Dr. Jessica. 

Dr. Jessica Drummond: 

Thank you so much for having me. It’s a pleasure to be here. 

Dr. Eric: 

It’s a pleasure to have you here as well. Looking forward to talking about endometriosis. Before you explain what endometriosis is, for those who are unfamiliar with it, let’s go a little bit deeper into your background. How did you start helping women with endometriosis as well as pelvic pain, painful bladder syndrome, all these complex chronic illnesses? 

Dr. Jessica: 

I became a physical therapist first. I graduated from physical therapy school back in 1999. I thought I would work in orthopedics and sports medicine, which I did. 

Within the first year, I became really interested in women’s health specialty physical therapy, which at the time was a lot of focus on an orthopedic approach to things like athletes in pregnancy. I had one patient who had breast cancer surgery and then had shoulder issues. That evolved. Women’s health and pelvic physical therapists do that kind of work still. But we also did a lot of work around incontinence and pelvic organ prolapse and birth injuries, which are actually surprisingly similar to orthopedic injuries of intense athletics. 

My most challenging patient population were those who had chronic pelvic pain. Back in that time, in the early 2000s, we didn’t have a lot of options for therapies. Many of our clients were either struggling with opioid addiction or had to have nerve stimulators surgically implanted. None of these things worked very well. Our physical therapy tools were also limited. 

At that time, in 2003, my oldest daughter was born. I had what I understand now, being a functional medicine practitioner and clinical nutritionist, it was a reactivation of EBV. I had intense fatigue and what we used to call adrenal burnout. I was wiped out, which was surprising for me because I had been an active, athletic physical therapist. Now, I’m a new mom and trashed. 

I learned the tools of clinical nutrition and functional nutrition. I eventually went back and got a doctorate in functional nutrition. I was board certified in health coaching. I really slowed my practice down to start looking at what could be some of the root causes of these chronic pain conditions. Since they’re also hormonally related, as I was working with women’s health and menstrual health, endometriosis has some of that menstrual, cyclical relationship to the pain. 

If we could, from more of a nutritional, biochemistry standpoint, start to have more tools than just opioids and nerve stimulators and pelvic PT, which in some cases were helpful and some cases were harmful and in some cases were just not enough, that’s where I really began to sub-specialize in more complex chronic pain conditions. 

Dr. Eric: 

Thanks for sharing your background. Let’s dive into endometriosis. For those who are unfamiliar with it, what is it? How common is it? 

Dr. Jessica: 

It’s very common. The underlying cause of endometriosis is a combination of genetic predisposition, so 1/9 female fetuses are born with endometriosis cells pre-birth. We know that there is some genetic predisposition. Then there is usually some kind of immune dysregulating trigger. It’s a chronic inflammatory condition. In some cases, there are autoimmune markers that can be elevated. There are a lot of autoimmune comorbidities. Hashimoto’s, Celiac, things of that nature. 

It’s common in people with uteruses. Roughly 1/9-1/10 of people with uteruses have it. The tissue that is similar to the tissue that lines the uterus, which is called the endometrium, grows outside of the uterus. By definition, this is a disease that is systemic. These lesions are often in the pelvic cavity, so around the ovaries, the fallopian tubes, the bowel, rectum, bladder. These lesions can also grow anywhere else. 

I think of it as a benign cancer. These lesions can grow through the diaphragm, on the lung. They can be a cause of collapsed lung. They can grow in joints. There have been case studies of endometriosis lesions on the knee, inside of the nose. It really can be anywhere. 

The original theory was that there was a retrograde menstruation that pushed cells out of the uterus in the wrong direction during the menstrual cycle. Things would get inflamed from there. We know that’s not true because we know these cells can be there from birth, but they are similar as the lining of the uterus. 

One important thing to note about that is because by definition, these lesions, little growths that are like cancer but not cancerous, they have their own hormone supply. They create their own blood supply. They hijack the immune system to sustain themselves. They are by definition outside of the uterus. Hysterectomy is not a treatment for endometriosis. 

There is a sister condition, if you will, called adenomyosis, which is similar types of lesions on the uterine muscle, so inside the uterus. That could in some cases be treated, and the current standard of care is it could be treated by hysterectomy. Endometriosis is not treated by hysterectomy. 

Dr. Eric: 

From what I understand, based on your explanation, endometriosis itself is not an autoimmune condition, but it’s common for it to be present in other autoimmune conditions. You mentioned Hashimoto’s and Celiac. 

Dr. Jessica: 

We don’t really know for sure whether or not endometriosis is autoimmune. It’s absolutely inflammatory. It does have some features of autoimmune diseases. It’s a combination of a disease state that is autoimmune. In some cases, maybe all cases, chronic inflammatory, and genetic. 

Dr. Eric: 

Okay. Is it something that’s commonly misdiagnosed, where a woman will be having it for many years before someone finally hopefully is able to diagnose it? 

Dr. Jessica: 

Yeah. The standard delay of diagnosis is 12 years. For most women, it presents in prepuberty, around 8-12 years old, as gut issues, digestive issues, bloating, what’s known as endo belly in the endometriosis world but is really SIBO or SIFO, an overgrowth of bad microbes in the small intestine. The menstrual pain can present and be irregular early on. At any time, too. It’s not always cyclical pain. 

Some key red flags are those digestive issues, fatigue, and intense menstrual pain or intense pelvic pain outside of menstruation. Because this disease is systemic, there could also be pain or other symptoms pretty much anywhere in the body. 

Ideally, the time for diagnosis would be roughly middle school, maybe early high school. Unfortunately, it’s a surgical diagnosis at this point. We don’t have any easy blood markers. It doesn’t always show up on imaging. The only way to diagnose it truly is with a skilled orthoscopic surgery, which is another reason why often the complete diagnosis can be delayed. It is even possible to be diagnosed in perimenopause, menopause, or beyond. It gets complicated because each case can present differently. 

Yes, unfortunately, often women are misdiagnosed with things like IBS or SIBO without underlying the endometriosis driver or menstrual pain. They’re often just brushed off and given hormonal birth control to try to quiet the symptoms, but it’s difficult to get good, early diagnosis of endo, even now. 

That number from the start of my career 25 years ago has only declined three years. It used to be 15 years to diagnosis; now it’s 12. 

Dr. Eric: 

It’s still a long time. I didn’t know the relationship between endometriosis and SIBO. If someone gets diagnosed with SIBO and has underlying endometriosis, that person might take rifaximin or herbal antimicrobials, which might temporarily help, but it’s not going to resolve the SIBO unless the endometriosis is resolved, correct? 

Dr. Jessica: 

Yeah. That is really challenging. Like I said, it’s known as endo belly in the endometriosis community because you’re exactly right. The SIBO or SIFO could be treated either from an integrative or a more conventional perspective. 

Imagine if you have little lesions growing on and anywhere around the small or large intestine. You’re going to have motility issues. You’re going to have little pockets where the fungal or bacterial overgrowth can thrive. That can always remain, even if those lesions are surgically removed because sometimes, you then have little areas of adhesions or inflammation. 

Sometimes, a combination of really skillful integrative therapy for SIBO and SIFO, including bowel function and gut microbiome, and skilled excision surgery, which is the robotic surgery that removes those lesions from the root, then you can sometimes eradicate endo belly, but it can be difficult. 

We often have to manage it with things like pelvic or visceral physical therapy, rotational movements, breathwork, things that help with motility, like ginger and artichoke. Then a kind of occasional, maybe quarterly or semi-annually support with those antimicrobial herbs. A lot of times, it won’t stick because there’s that structural change to the gut. 

Dr. Eric: 

Makes sense. There is some train of thought. Maybe that’s not the case currently, but I’ll let you share your thoughts. Endometriosis, being an estrogen dominance condition, problems with estrogen metabolism could be a factor or even the main factor in the development of endometriosis. What are your thoughts on that? 

Dr. Jessica: 

In 2018, we had a great study out of Belgium that showed that endometriosis lesions, about ¼ of them had estrogen upregulation in the receptors. ¼ had progesterone upregulation. ¼ had both. ¼ had neither. The challenge is that multiple kinds of these lesions could be in the same person. 

Yes, some endometriosis lesions are “fed” by estrogen in the same way that you can have an estrogen-provoked breast cancer. Only about ¼ of those. It makes sense as to why some women do well with estrogen suppressive therapies. Anything from GNRH agonists to hormonal birth control to an integrative or functional approach to support reducing estrogen, better metabolizing estrogen. 

But that’s not really the driver of the condition. It’s part of the condition. In some cases, it’s actually progesterone that is the problem. In some cases, both. In some cases, neither. 

I really think of endometriosis as more of a structural immune disorder than hormonal. Depending on the age of the patient, usually if we can optimize the gut microbiome in the immune system, the hormones- We want them to be in balance for the whole system. 

We have started having interesting conversations about endometriosis and perimenopause and menopause. The original thought was absolutely avoid giving these women hormone therapies. But there should be an individualized conversation around using hormone therapies if women have significant menopausal symptoms because they’re not always going to exacerbate the endometriosis. Even if they do, there is a cost benefit analysis of that. As you and I know, we do things like support the liver, support the gut microbiome, support bowel function, support the detox pathways. It’s not necessarily problematic to the endo. 

It’s not 100% of the time that estrogen suppression or even support of estrogen metabolism will help with endometriosis. It’s about 25% of the time. Same thing with adding hormones. Sometimes, that’s appropriate; sometimes, it will really exacerbate the symptoms. 

Unfortunately, there is no quick test for that. If any given person’s lesions have that histology is after taking the lesions out, after surgery and doing histology on them, but by then, it doesn’t matter because the lesions are out. We have to do this from a trial and error perspective. 

Dr. Eric: 

That’s interesting. You said 25% involves progesterone upregulation. In those cases, at least in some of those cases, giving progesterone might actually exacerbate. Like you said, if you’re taking a whole body approach, if someone is only given progesterone, maybe that might be problematic. If you give them progesterone and are doing other things like supporting the liver and the gut microbiome, then maybe not. 

I’m sure you’re familiar with the DUTCH test. A few years ago, with the different metabolites, I recall during one of their lectures, they were saying that endometriosis is commonly characterized by elevated 16 hydroxy metabolites. Based on what you said, maybe in some people, that’s a pattern. If someone has perfectly normal metabolites, or if they have elevated 4 hydroxy, and their 16 hydroxy looks fine, you can’t use that to rule out endometriosis. 

Dr. Jessica: 

Absolutely not. It’s not a diagnostic test. I would say I see both. Sometimes, I see people with perfectly normal estrogen metabolism. I actually would say that I more commonly see 4 hydroxy estrogen because it’s an inflammatory condition. Both of those, elevated 16 or elevated 4 could be problematic.

For me, looking at a DUTCH test in women with endometriosis, the most important and first thing I will look at is the cortisol curve. It’s very difficult to help them heal in an environment of autonomic dysregulation. Optimizing nervous system regulation really helps with everything else. 

We do know that some particularly anti-inflammatory, antioxidant supplements, things like quercetin and resveratrol and curcumin in the right people can be very helpful. In many women with endometriosis, especially those who have significant pain with their condition. Not everyone does. Some people have very silent endometriosis until they struggle with fertility or until they hit perimenopause or menopause. Different things can trigger the disease in different people. 

For me, I think more about the immune system than the hormone system. Thinking about how all of these systems interact, the nervous system, the immune system, digestive function, then the gut microbiome. 

Dr. Eric: 

You said silent endometriosis, so you can’t just go by symptoms. When it comes to symptoms, you mentioned SIBO, like GI symptoms, bloating, gas, pretty common. Pelvic pain. Would you say those are the two most common symptoms, the pelvic pain and GI symptoms? 

Dr. Jessica: 

Yeah. GI symptoms, pelvic pain, menstrual pain. If a period is taking a woman or girl out of work or sports, if you have to be in bed one day a month, that’s a big red flag. If you need pain medication every single month, that’s a big red flag. 

It’s genetic. If a person’s mother struggled with endometriosis or infertility or pelvic pain or menstrual pain, a lot of times, the older generation of women weren’t appropriately diagnosed, especially if they were able to have children. Look for those red flags of women in the family either not being able to have children or having really painful periods. 

That is where it can become a bit of a gaslighting situation. You have a nine-year-old girl who has really painful periods. Every woman in her family is like, “This is just how it is for us. It’s fine. You’ll be fine.” Painful periods. 

Painful sex. Especially pain with deep penetration. It’s common that’s deeper in the cervix and the connection posteriorly by the rectum. That’s a very common place for endometriosis to grow. Painful sex with penetrative sex is a big red flag. 

Also, with the menstrual pain, it’s beyond pain. It can also be diaphoresis, like sweating, dizziness. POTS or any kind of dysautonomia is common with endometriosis. 

There are two sets of what we call terrible triplets, common comorbidities in endometriosis. One set is bladder pain, so endometriosis with painful bladder symptoms. It’s not just pain, it could be urgency, frequency, things like that. It is common for endometriosis to grow on or around the bladder. Then vulvodynia, so pain at the very opening of the vulva. That is one set.

The other set is endometriosis with mast cell activation syndrome (MCAS), so a lot of histamine issues, redness, heat, feeling allergic to everything. Can’t tolerate a lot of foods. Hives is really common. Plus dysautonomia, which might mean you have been dizzy your whole life. You’re a person who can’t skip breakfast, or you’re feeling like you’re about to pass out. Purely diagnosed POTS or another form of dysautonomia. Hypermobility. If you’re double jointed or you went into dance or gymnastics because you’re very flexible, that’s a big red flag for that kind of constellation of presentations. MCAS or histamine issues, dysautonomia, and hypermobility. 

Dr. Eric: 

Sounds like it could be pretty complex, which falls into your bio, dealing with complex conditions. It’s not just endometriosis itself, but MCAS is pretty complex. 

Dr. Jessica: 

Most people with endometriosis have a lot of these things, not just painful periods. 

Dr. Eric: 

It’s not a two- or three-month process as far as getting their health back. Some of these people might take in excess of a year to get their life back? 

Dr. Jessica: 

Yeah, I would say in an ideal situation, we have about three months to get the body strengthened in terms of nervous system regulation, good digestive function, calm some of the inflammation, balance the immune system. 

Then they would have skilled excision surgery, with someone who specializes in endometriosis and is just really skilled at finding those lesions and cutting them out from the root robotically. Then it’s about a six-week to six-month acute recovery from the surgery and about 6-24 months for full recovery back to all activities, no more fatigue, much less pain, fertility more optimized. 

There is a window of opportunity post-op where the immune system is more balanced from an autoimmune standpoint, where fertility improves significantly. There are these windows of opportunity, depending on what the person’s goal is. Are they experiencing pain? Are they experiencing fertility issues? Are they most stressed by their digestive problems? What are their key problem areas? Then we can set up a plan that helps prepare for and recover from surgery.

Now, not everyone has to have surgery or chooses to have surgery. It is an elective surgery. The vast majority of the time, endometriosis is not life-threatening. There are some rare cases where it is, such as when it’s growing on the lung or things like that. The vast majority of the time, it’s not life-threatening, but it is dramatically quality of life-threatening, as you can imagine. 

When possible, at least having an assessment by a skilled endometriosis excision surgeon is a good part of the healing experience. Not everyone has to or chooses to have surgery. It depends on a lot of factors. 

Dr. Eric: 

Okay. Let’s say someone does choose to go through the surgery. You mentioned the first three months, you’re doing things to support the body, the gut microbiome, the autonomic nervous system. Trying to do things to optimize their health. If you do that, and then they get the surgery after that, you’re still doing things to optimize their health. 

I think you said it’s six months post-recovery. Is there still a risk of the lesions coming back? It does depend on the skill of the practitioner, which is why you said you want to make sure they choose someone who knows what they’re doing.  

Dr. Jessica: 

Yeah, it depends a lot on the surgeon. Even the best surgeons will tell you that sometimes, the lesions come back. Either they missed something, or something grew back. It’s hard to say.

I’ll say that surgical techniques have dramatically improved. When I was first doing this back in the early 2000s, it was very common for people to have 16-20 surgeries, almost a surgery every year for their entire child-bearing years. Now, I would say that the majority of people have 1-2 surgeries max in a lifetime. Sometimes, three, depending on the complexity of the recovery or if there were multiple organ systems involved, or if a general surgeon needed to be called in. It’s much more common to only need one good surgery in a lifetime. 

Depending on where a person lives, that can be challenging to access. In the United States, almost all of the surgeries are out of network. There is not good billing support. Because of how complicated these surgeries are, it’s very difficult to get them covered by insurance. In the United States, they can be very expensive. 

Outside of the United States, there can be long delays to accessing them. In Canada or the UK, where there is socialized medicine. There are challenges with surgery no matter which country you’re living in. 

It’s still worth trying to hold out for a skilled surgeon because another non-skilled surgeon can set you up for needing more surgeries. 

Dr. Eric: 

Makes sense. Even if someone has to wait a little longer to see a skilled surgeon, it’s probably better because seeing one that is not as skilled, maybe you’ll get some relief, but there is a greater likelihood that you’ll need multiple surgeries. With a skilled surgeon, still no guarantee that you won’t need another surgery, but less likelihood that you will. Makes sense. 

I know you said a lot of these women have autonomic nervous system dysregulation. MCAS, hypermobility. I assume some don’t have all that going on. It’s still not a simple case of endometriosis. I guess, if they’re not having the autonomic dysregulation and MCAS, is it not as long of a journey in most cases? Is it still something where you can expect a similar process? I guess the process would be similar, but the duration. 

Dr. Jessica: 

Yeah, the recovery would be easier. It’s interesting: I was just talking on my podcast to one of the top endo surgeons. Her episode is coming out in July or August of this year [2024]. We both noticed, since almost everyone has been infected with COVID at this point, almost everyone I’ve talked to, if not everyone, with endometriosis in the last four years post-COVID infection do have all three of those things as well. 

It may be that we are dealing with a new environment now where there is a large pathogen overload. I’m not sure what we’re dealing with now when it comes to endometriosis, but I have very rarely met a simple case in the last few years. 

Now, that also could be because the work that I do is pretty specialized. Same with her. We often see the most complicated of cases. It is hard to say. 

If I was working in a hospital based pelvic rehab practice, there may be occasions where we find a “simpler” case of endometriosis. Let’s say there are very visible lesions. They’re in the common places. A person has a skilled surgeon. They’re eating an anti-inflammatory diet. They’re doing a lot of stress management. They already have a healthy heart rate variability. They exercise. Their cycles become more regulated. Maybe they’re younger, they’re only in their 20s or early 30s. 

Absolutely, we can see a more simple, complete recovery, which could look like six months or so, just with some pelvic floor downregulation. If that person is already doing a lot to take care of their gut microbiome and balance their immune system, and they’re already a meditator or something like that, then yes, there is a wide range of complexity. 

As I said, there are people who do have silent endometriosis who don’t even know they have it until they struggle with fertility. There absolutely could be people with no symptoms of endometriosis who maybe aren’t interested in having children. You can have the genetic predisposition and also not express endometriosis. 

I had a patient in my practice last year who had an identical twin sister who did not have endometriosis. There is certainly a wide range of expression for sure.  

Dr. Eric: 

Similar with autoimmune conditions. You could have identical twins, one who has Hashimoto’s or another autoimmune condition, and the other twin is perfectly fine. Environment does play a big role.

For someone who chooses not to get the surgery, what other options do they usually look into? Could things like visceral manipulation help? It won’t get rid of the lesions completely, but maybe to get some relief. I imagine some people try acupuncture. 

Dr. Jessica: 

There are some nutrients to stabilize the lesions. Quercetin is helpful. Some of the other anti-inflammatories. 

Doing a nutrient program to support gut microbiome and immune health and lower inflammation in combination with pelvic floor physical therapy, which does have really strong evidence to support its effectiveness for quality of life and pain management. Pelvic floor physical therapy, including visceral mobilization, including things like cardiosacral, which is helpful for nervous system regulation, all of that can manage, and in some cases, people don’t need surgery. I have seen that happen in some cases.

In other cases, their symptoms are managed enough that they choose not to have surgery. I had a patient probably eight or nine years ago who was about to have surgery. She decided she wanted to try to get pregnant first, which there is a cost benefit to getting pregnant pre- or post-surgery. She decided she wanted to try to get pregnant. She did get pregnant, and her symptoms were quieted. Sometimes, pregnancy, because of its impact on the immune system, can reduce the symptoms a bit temporarily. 

She was pregnant. She nursed. She had that one child. She chose not to have any more children. She was going to have the surgery after that, but she felt, given everything she had done to get herself healthy, optimize her fertility, optimize her gut health, she did have some symptoms, but they felt manageable enough to her that she chose not to have the surgery. She had the one child that she wanted. Her quality of life was okay. She just continued to really take care of her health, and she was fine without surgery. 

That may change in the future, but at this point, this is what her decision was. It worked well for her. 

Dr. Eric: 

That’s awesome. One of the questions I was going to ask is since most of the listeners have a thyroid or autoimmune thyroid condition, the relationship between endometriosis and thyroid health and thyroid autoimmunity. 

You earlier mentioned Hashimoto’s being more common in those. That’s one potential relationship. Another one I could think about is gut issues are common. Part of that triad of autoimmunity is that increase in intestinal permeability, which SIBO can potentially lead to. That could potentially be a link between autoimmune conditions. I don’t know if you know any other relationships. 

Dr. Jessica: 

I agree with you. Commonly, autoimmune diseases tend to copresent. Endometriosis in many people does have autoimmune factors, things like elevated ANA in some people. Those are the kinds of markers we can measure declining post-surgery. I agree with what you’re saying. Some of these risk factors for both could contribute to people having both at the same time. 

The other thing I would look at is what is their HPA axis? How much neuroinflammation are we dealing with? If they’re under either emotional stress, because it’s very stressful to live in chronic pain. In fact, we’re hosting a viewing of a new movie called Below the Belt, which is about people with endometriosis trying to navigate the healthcare system. You do the same kind of thing. Complex chronic illness, navigating the healthcare system is horrible. That in and of itself is very stressful, which can then impact the thyroid because you have the HPA axis out of whack. 

You have the brain, where the HPT axis originates. Anything that causes neuroinflammation or emotional stress, which is a condition where at any moment, you can be in really intense pain, that is very stressful, especially when you go to the emergency room, and they say you’re fine or a drug seeker or whatever. That can certainly contribute to thyroid issues, just dealing with low grade or high grade chronic stress for 12 years. 

Dr. Eric: 

I see that in a lot of patients with dysregulation of the HPA axis. A good point about the neuroinflammation as well.

You covered a lot of information. Anything that I should have asked you that I didn’t ask you? Do you want to summarize anything before we wrap up? 

Dr. Jessica: 

I would say that if someone is struggling with pelvic pain, even if it’s not cyclical, even if it doesn’t seem to be related to your estrogen, especially if you also have digestive issues, because about 90% of people with endometriosis have some kind of digestive issue ask about it, it’s hard to be diagnosed because it’s such a vague condition and has a surgical diagnosis. Especially if there are any genetic clues, it’s something to start looking at. 

Dr. Eric: 

Wonderful. Dr. Jessica, where can people find out more about you? 

Dr. Jessica: 

Our website is IntegrativeWomensHealthInstitute.com. We also have the Integrative Women’s Health podcast. Our Instagram is @IntegrativeWomensHealth. We share a lot of information about endometriosis, perimenopause, menopause, and other women’s health conditions. You can find more about that there. 

Dr. Eric: 

Thank you so much. I’m sure everyone learned a lot. I definitely learned some new things related to endometriosis. Appreciate everything you shared. 

Dr. Jessica: 

Thanks so much for having me. I appreciate it. 

 

Recently, I interviewed Dr. Bindiya Gandhi, and we discuss leptin’s role in metabolism, what leptin resistance means, factors contributing to leptin resistance, how to test for leptin resistance, the connection between thyroid conditions and leptin resistance, dietary recommendations, the use of supplements, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with Dr. Bindiya Gandhi, as we are going to talk about leptin. You will learn a lot about leptin. Let’s dive into Dr. Bindiya’s impressive bio here: 

Dr. Bindiya Gandhi is a double board-certified integrative and functional medicine doctor who helps thousands transform their overall health. She is the medical director at Atlanta Functional and Integrative Medicine and Revive Atlanta MD, a comprehensive clinic focused on total body healing, including decreasing inflammation, improving hormonal balance, helping women get pregnant, weight loss resistance, chronic stress, gut health, and more.

After dealing with her own medical crisis and eventually improving her overall health to rebalance her hormones and conceive naturally, she has been focused on finding the cause of issues instead of treating the symptoms. She holds a special passion for female hormonal cases. 

Dr. Bindiya has worked with A-listers, including professional singers and athletes, to reclaim their health. Her newest podcast Reset, Renew, Revive has gained tons of traction since its launch in April 2021. Bindiya regularly engages with her community of approximately 65,000 followers via Instagram, where she produces compelling content and educational material to continue to inspire people to live healthier lifestyles. Thank you so much for joining us, Dr. Bindya. 

Dr. Bindiya Gandhi: 

Thank you so much for having me on. I am so excited to talk about leptin. 

Dr. Eric: 

Really excited as well. Before we do that, of course, as is common with many podcasts, I’d like to talk a little bit more about your background. We got a brief history, but what led you to become a leptin specialist and focus on female hormone issues? 

Dr. Bindiya:

I always share this story of my own personal journey. I thought I was the epitome of good health. In residency, I thought I ate well, exercised well, meditating, doing yoga all the time. I thought I was doing everything right. 

It was my own health crisis. At the time, it was a skin rash on my face that really triggered something was going on internally. I had spent time, hours, money at all the dermatologists’ offices and was told that everything was normal. I had biopsies. I was on antifungals, steroids, antivirals, antibiotics. I took everything because I was desperate to get this rash off my face. Nothing worked. 

I kept asking questions and digging deeper. Thinking it could be an autoimmune condition, I asked to get tested. After begging, I was allowed to see an allergist/immunologist who just told me I was a stressed-out resident. That was the turning point. There is something going on with me. You can’t figure it out. I will figure it out on my own. 

Fortunately, I was working with an integrative and functional medicine doctor at the time. Long story short, I learned I had Celiac and a lot of food sensitivities. The minute I cut out gluten, the rash went away and never came back. That was just the beginning of the journey.

Once I realized it, I thought, I’m healthy now! I’m good! That was just the first part of the problem. Of course, I got married. Life was stressful. I was working as a full-time newly minted family medicine doctor at a really busy practice. I was working all hours. At that time, I was doing my integrative medicine fellowship and my Institute for Functional Medicine training. No kids at the time, but I was trying to get pregnant. And it wasn’t easy. I didn’t understand why. 

I knew the data. If you have Celiac and eliminate gluten, you should be able to get pregnant. I was eating clean, or I thought I was. But my hormones were all off. I was maybe too healthy at the time. There is such a thing. It took me a while to play with things and realized exactly what it was that was going on and what I needed to do. Then I got pregnant and now have three kids, so it’s not an issue. Now, I’m trying not to get pregnant… 

As far as leptin goes, because I was at a new practice, not so new anymore. In 2017, I was 7.5-8 months pregnant with my first child. I was seeing a lot of patients. People were coming to me for help getting pregnant. I saw a lot of menopausal women struggling to lose weight. 

Leptin fell in my lap. I was doing research, trying to figure out how I could help these women with all these hormonal imbalances not only get pregnant, but lose weight. I started seeing patterns. That’s when I started diving deep and learning everything I could about leptin, so I could help these women. Here we are today, talking about leptin. 

Dr. Eric: 

Thank you so much for sharing that story. For those who are listening who are unfamiliar with leptin, can you briefly describe what it is? 

Dr. Bindiya: 

It’s such an important hormone. Unfortunately, it’s not talked about. Leptin is a hormone produced by our fat cells that communicates with our brain. It lets us know we are hungry, if we need to eat more or less. It’s also known as our satiety hormone. Leptin is a big buzz right now because everyone is obsessed with GLP-1 medicine. I’m sure we’ll talk about that later. 

Leptin is important because leptin does impact your metabolism. This is why I think we need to learn more about it.Oonce we are able to learn more about it, we’re able to identify how we can help our patients improve their leptin resistance, if that’s what they have. 

Dr. Eric: 

A lot of people are familiar with insulin resistance. There is also leptin resistance. There is some overlap. Essentially, with insulin resistance, you have too much insulin, not getting in the cell. Similar with leptin when you have leptin resistance? 

Dr. Bindiya:

Correct. In a perfect world, we like our leptin levels to be between 7-10. Over time, because of the standard American diet, life, stressors, medication, our environment, so many different things, our microbiome is changing, different sicknesses, ailments, autoimmune conditions, our metabolism changes, and we can become leptin resistant.

I am going to use women moreso than men. I see women who have been on these restrictive diets, like keto or intermittent fasting, etc. It slows down their metabolism. The metabolism has something called a set point. The metabolism likes to be at a certain weight. Because of all of these different things that are happening simultaneously or over time, we tend to notice that our leptin hormone is now slowing down and starts accumulating. It doesn’t want to work as well. 

What does this mean? For a lot of patients who are eating well and exercising but are still having trouble losing weight, they are doing things perfectly. They are following a calorie in, calorie out diet, but it’s not working. They are exercising, at the gym. They are still struggling. They probably have a leptin resistance issue. That’s what this means. 

Dr. Eric: 

What are some of the causes? Is it just diet-related then? Is it stress? 

Dr. Bindiya: 

There’s a lot of different things. There is definitely correlation between insulin resistance and leptin resistance. Other hormones interplay with leptin. Ghrelin, which is the opposite of leptin. Leptin is the satiety hormone. Ghrelin is your hunger hormone. They work synergistically together. If you’re hungry, you’re going to eat. 

What happens with leptin is you are not getting the signaling that you’re full. An hour later, you’re going to want to eat again. Two hours later, I’m hungry. I’m not full. I need to eat more, even though you just ate. The receptors of ghrelin and leptin work together.

The other things that happens with leptin resistance is we tend to see a thyroid issue underlying that could be contributing to it. A lot of inflammation. Maybe there are some infections or other essential pathogens that could be causing changes in your microbiome or gut health. There are a lot of different things happening at the same time that could be contributing to your leptin resistance.

Sometimes, it’s all the things that cause leptin resistance. Sometimes, it’s because of the leptin being off, so other things could be triggered. They work together.

Dr. Eric: 

You mentioned thyroid. Most of the listeners, if not all, are people with thyroid conditions, autoimmune thyroid conditions, like Hashimoto’s and Graves’. If someone has a thyroid imbalance, that could be a factor with leptin resistance. If so, then you would want to address that. 

Dr. Bindiya: 

For sure. Actually, sometimes it’s not the overt what we call hypothyroid condition. Sometimes, it’s a subclinical thyroid condition, which I often see. What happens, I’ll use this example, due to chronic stress, which is probably most of us unfortunately.

By the way, if you’re listening to this and have chronic stress, I want to talk to you. I want to know what you’re doing. I haven’t met anyone who is not dealing with some sort of chronic stress. With chronic stress over time, one thing that happens is it starts slowing down your thyroid hormone. Maybe not your TSH, but it does slow down your T3 and free T3 receptors, which makes it harder to convert T4 to T3. It slowly manifests as slower metabolism, dry skin, constipation, fatigue.

One thing that patients complain about when they go to their GP who just checks their TSH. Their GP says their TSH is fine. Keep going, you have a good life. You and I do more digging and research and realize we need to check more than just TSH. When we look at the whole picture, you can see, “You have a subclinical thyroid issue that we need to treat.” That does impact your metabolism. That does impact not just stress, but chronic T3/free T3 being low really does impact how your leptin is talking to your hormones. 

Dr. Eric: 

You’re right. A lot of people do have that conversion problem of T4 to T3. There is a time and place for taking T3, but you ultimately want to correct that conversion problem. 

You mentioned the gut microbiome. So many people have gut microbiome issues, not just people with thyroid autoimmunity although there are certainly people with Graves’/Hashimoto’s. Most if not all have disrupted gut microbiomes. You said that can also play a role in leptin resistance. 

Dr. Bindiya: 

Again, many of us have had what we call gut dysbiosis. Or an imbalance of bad bacteria. What happens over time is we develop a little bit of inflammation in our lining of our stomach. Foods that we eat are supposed to bounce off of the lining of the stomach, but now they are getting absorbed due to inflammation due to an imbalance of microbiome or an infection or something else.

When this happens, we develop something called food sensitivity. The foods we enjoy eating, like blueberries. Now we are sensitive to it. We are having some bloating, some gas, some malabsorption. Those are one of the big things I tend to see with leptin resistance over time: having a change in gut microbiome. 

If you have taken antibiotics for a sinus infection, it changes your gut microbiome. I hate saying this again, but if you have been under a lot of chronic stress- I just saw a patient prior to coming here who is under a lot of chronic stress. It changes the gut microbiome. Gut microbiome is so important for overall health. 

Specifically for leptin resistance, because that change is really where for example, ghrelin is housed in the stomach. This is your hunger hormone. Leptin is usually housed in your hypothalamus, which is part of your brain. Ghrelin is housed in your stomach. When your microbiome is off, the communication of everything else is going to be off, too. 

Dr. Eric: 

Let’s talk about testing and how people could determine if they have a problem such as leptin resistance. I’m guessing you test leptin. There are other markers, I’m sure; it’s not just leptin. We spoke about thyroid. Maybe you look at some other blood sugar markers like insulin. You don’t have to cover everything you test for, but maybe some of the more important markers that might be related as well. 

Dr. Bindiya: 

If you’re listening to this, “Oh my god, that sounds like me,” the first thing I want you to do is go to my website and take the free quiz, DrBindiya.com/quiz. It’s an 11-question quiz. It asks you a series of questions, like, “Do you have trouble losing weight? Are you doing everything you need to do to lose weight? Do you have high cholesterol? Do you have high blood pressure? Do you have high blood sugar? Do you have a lot of sugar cravings?” These questions will give you a guide if you are leptin-resistant. 

If you take that little quiz and are definitely coming up with leptin resistance, then what I’d like you to do is maybe ask your doctor, I don’t know if your doctor is going to do this. I’ve had patients ask endocrinologists, and even they won’t check this hormone because it’s newer. We’re still learning about it. I do test it on all my patients to see what your metabolism is doing and what is going on there, especially if weight is an issue.

This is not always going to be the case, but in a perfect world, leptin is measured based on your height and weight, or something called your body mass index (BMI). Our BMI is different based on muscle mass and how much fat we have. I’m not usually a big fan of BMIs personally. I like to do body composition in our office, and we get a more personalized approach as to what is going on with your metabolism and composition.

But leptin should be between 7-10. People who have a higher BMI tend to have higher leptin levels. When your leptin levels are higher, it usually indicates that it’s harder to lose weight. Your body is slowed down. Your body is in reserve and wants to hold onto that weight. It wants to protect you. It’s like a protective mechanism.

This happened many years ago when we were hunter-gatherers. What that meant was we weren’t sure when we were going to eat again. Our body would store food for us as a protective mechanism. That is essentially what happens with leptin resistance. It’s storing the food, so you get frustrated. “I’m eating well, and I cut my calories. I’m doing all the things that all the books and experts are telling me to do,” but it’s not working. I will check leptin hormone and get an idea. 

Leptin hormone can rapidly come down with lifestyle changes, with supplements and prescriptions. Every individualized approach is different because we have to look at the whole picture.

In my case, I’m looking at making sure there is no underlying autoimmune conditions leading to inflammation. I’m looking at the thyroid picture, making sure there is no Hashimoto’s or subclinical active thyroid going on. I am looking at toxins to make sure the liver is optimally working like it should. Making sure there is no underlying infections. It is a very comprehensive approach.

Yes, the leptin number itself will give me an indicator of what’s going on.

Dr. Eric: 

Like with insulin resistance, it’s not always easy. It’s just cleaning up your diet and exercising. You certainly want to do that, but many times, there is an underlying inflammatory component. It sounds like it’s similar with leptin resistance. 

Dr. Bindiya: 

I hate saying this. Most of the time, it’s probably something lifestyle-related. It’s probably something that if we just gave it a little TLC, it would improve. For example, stress. We learn how to manage stress a little bit better. Or just focus on getting good quality sleep. If that means going to bed earlier, or maybe that means we are not going to do work an hour before bed. Everybody’s different. 

I promise, I’ve been doing this for many years now. It’s usually something lifestyle that we’re doing or don’t realize we’re doing or things we could improve on that will fix them. We don’t always need a prescription or supplement.

Dr. Eric: 

If I heard you correctly, I think you said optimal levels are 7-10. It also is dependent on your BMI. If you do a leptin test, they will be all these values. If someone has a leptin of 25, but they’re within that BMI that is on the lab, they’re considered to be normal. Their BMI might be higher than it should be. Can you expand on that a little bit, so people don’t get alarmed? Or maybe they should be alarmed if they see a leptin of 15 or 20.

Dr. Bindiya: 

When I first started testing leptin when I first got into this world 10 years ago, I was reliant on the BMI as a tool for leptin. These women are all within normal ranges; their leptin levels are fine. Then I am looking at them, “It looks a little overweight.” 

By the way, I am using the Lab Quick Chart, so I am talking about LabCorps specifically. I am using the LabCorps reference, and I didn’t have that. That’s when I started doing a lot of research on leptin. Something wasn’t adding up. 

According to the labs, which I always mention this because I think it’s really important that we talk about this. When they came up with lab results or averages of lab results, they take healthy individuals and unhealthy individuals and put them in a pot and take the average. I don’t know about you, but I don’t want to be compared to someone who is unhealthy, overweight, older, etc. I want to be compared to the cream of the crop, healthiest people of my age, stature, etc. 

That’s not what’s happening when it comes to LabCorps data. This is why I was doing some more research. It’s BS; it doesn’t make sense. It’s not appropriate. You can’t compare someone who has a BMI of 20 because you could put 10 women who have a BMI of 20, and they’re all physically different. It does not make sense.

That’s when I started doing my own work. The integral range is 7-10. That is more of an accurate range than 20 or 25 or something that may look normal. When you realize that, especially with the work I do, you see the number go down. You see they are able to lose weight on their own by doing the things they should be doing.

Dr. Eric: 

With insulin resistance, what do you use to determine that? Is it hemoglobin A1C? Do you look at fasting insulin as well? 

Dr. Bindiya: 

Lots of different things. Leptin, fasting insulin, hemoglobin A1C, fasting blood glucose. Sometimes, I’ll have people use continuous glucose monitors. Not a big fan. Sometimes, it works, and sometimes, it doesn’t. We can get false readings on those. 

The other one I do is insulin resistant panel score. That is one of the tests we do get. It gives us an idea of if someone is insulin resistant or not. We do use tests like that.

It’s looking at the whole picture. Sometimes, I will look at hemoglobin A1C, and it’s 5.5. But when I do the insulin resistance- It’s the HOMIR score, and it will be like 69. They are definitely insulin resistant because that number should be below 40. There are different markers I look at. I will get a fasting glucose of 83, but their A1C is 5.7. You have to look at the whole picture sometimes.

Dr. Eric: 

Sometimes, I look at hemoglobin A1C, and it might be 5.5-5.6. Within the range. On the higher side. Then sometimes, insulin will be on the higher side. I don’t know what you consider optimal for insulin. 

Dr. Bindiya:

I could talk about this all day, mainly because there is also- I hate this. There is a reference integral. I talk to lab companies about all this. It can technically be .2, up or down, either direction. Sometimes, A1C is 5.5. It could technically be 5.7 or 5.3. Which one is it? It could be really frustrating. 

The way you and I look at ranges is looking at the whole picture and assessing all these other markers as well. If you look at “Oh, this person is insulin resistant,” but if you dig a little deeper, maybe a little underlying smidgeon starting. Let’s nip this in the bud with some lifestyle changes.

Dr. Eric: 

One question I almost forgot to ask you with leptin is if leptin can be too low. Are there concerns there? 

Dr. Bindiya: 

Yes. I’m so glad we’re talking about this. We don’t want leptin to be high, but we don’t want leptin to be too low. If leptin actually falls below 3, it’s slightly problematic, especially in women who notice they are trying to conceive. 

Leptin is also correlated with estrogen. A lot of times, in my post-menopausal females who end up having osteoporosis, sometimes it’s because their leptin levels are too low. There are a lot of different things we tend to see when leptin levels are too low, so I’ll highlight that. When leptin levels are low, it can impact pregnancy, and you are more likely to be osteoporotic. 

Dr. Eric: 

When it comes to addressing leptin resistance, some of it you already spoke about. If someone is chronically stressed, which describes most of us, you want to do things to block out time for stress management, and of course, getting sufficient sleep. When it comes to diet, there is no perfect diet that fits everyone, like intermittent fasting. What is your approach from a dietary perspective? 

Dr. Bindiya: 

Diet is always so confusing. It’s eat this, don’t eat this. If you eat too much of this, it will cause this. It’s all over the place.

I can give you generalized guidelines. What I will highly recommend is to actually eat three times a day. As much as I love intermittent fasting, I think there is a time and place for it. I think it’s great for insulin resistance. It does sometimes improve leptin resistance. 

However, sometimes, extreme intermittent fasting can trigger leptin resistance. The body doesn’t want to starve, and it doesn’t know when you’re going to feed it again, so it will hold onto fat. It will store every time you eat because it’s unsure when you’re going to get fed. Sometimes, it’s a protective measure. Intermittent fasting is plus or minus.

However, one of the things I highly recommend is forcing people, not forcing, but encouraging people to eat. Eating is good. We should eat three meals a day. Physiologically, this is what we should be doing. The meals should be about 4-6 hours apart. We should be eating three meals a day.

And we should make sure that the meal is protein-rich, so eating a lot of protein, 20-30g of protein a meal. After that, you’re probably not really absorbing it. Maybe you are if it’s true animal-based protein. If it’s a lot of processed protein or plant-based protein, some studies show you’re probably not absorbing all the protein. 

20-30g is safe for everybody depending on what’s going on with you. Most people tend to do really well with that. Not only does it balance your blood sugars, by eating three meals a day spread apart, you will also get a good amount of protein in, which is perfect. That is the first thing I will have people do.

I didn’t really say this, but hopefully it means you’re also eliminating all the sugars, processed crap, seed oils, and I don’t even know what exists these days. All the crap. You want to make sure everything you put in your body is organic, clean, non-GMO. 

Dr. Eric: 

With protein, did you say 20-30g per meal? 

Dr. Bindiya: 

Yes, approximately. 

Dr. Eric: 

Yes, 60-90g per day, if you’re recommending 3 meals per day. You would try to avoid snacking because you mentioned 4-6 hours between meals. 

Dr. Bindiya: 

Ideally, no snacking. Everybody is on a different path to their health fitness journey. If you’re someone who is heavily working out, you will probably need to eat snacks and get more calories in. Every single person is different. 

On average, the goal is to have larger meals at breakfast, lunch, and dinner, and let your body rest. Also, that rest is important for your gut health. You’re not stressing your microbiome and your gut but also letting it rest, which is important. 

Dr. Eric: 

You also mentioned something interesting: Fasting potentially can cause insulin resistance. Extreme fasting especially. 

Dr. Bindiya: 

Leptin resistance, not insulin resistance. 

Dr. Eric: 

Oh okay. 

Dr. Bindiya: 

Fasting is excellent for insulin resistance. Extreme fasting can sometimes be the culprit for leptin resistance. I hope I explained that properly. 

Dr. Eric: 

Okay. I misunderstood. I’ll be honest. When you say “extreme,” maybe it helps with insulin resistance, but I don’t know if extreme fasting is good, period. Of course, there is the 16-8 fast. I think for a lot of people, that’s okay. Even that depends on the person. I’ll speak with people who are doing 20-hour fasts every day and only have a four-hour eating window. 

Dr. Bindiya: 

No. I can talk about fasting all day, too. It needs to be done supervised, properly. You can’t fast when you’re stressed. You can’t fast when you’re going through a divorce or whatever is going on in your life. It has to be done very strategically.

The biggest mistake I tend to see in my patients, why I don’t think they do well with intermittent fasting, is they are cutting their calories while intermittent fasting, which causes a slew of other problems.

I love/hate intermittent fasting. I think if you do it right and do it very appropriately, it works really well. If you’re not doing it right at the wrong time- For females, unfortunately, we have a hormone cycle that we should consider for when and when not to fast. Or it could be helpful or problematic. 

Insulin resistance tends to improve. But if you’re doing extreme fasting, like 36 hours or 48 hours, I am not a huge fan of that. Even when I recommend fasting for some patients, I’m also breaking it up. You’re not doing 12-8s every day; maybe it’s a couple of times a week. Maybe it’s 14-10s a couple times a week. It needs to be realistic and make sense. You don’t want to add additional stress. 

Dr. Eric: 

How about supplements? Are there supplements that can help with leptin resistance? GLP1 meds. Peptides.  

Dr. Bindiya: 

I am a huge fan of supplements. I personally take a billion of them myself. I don’t know about you, but I do. I try not to age these days, let’s be honest. 

Supplements really do help. There are a lot of good things. We tend to notice that if your thyroid needs some help, maybe we support your thyroid with a supplement. For example, I know that because if I am checking your iodine, selenium, ferritin, then we supplement you with that. If we need to support your leptin, because we tend to notice your leptin is a little off, there are a couple I like.

One is Akkermansia. I never know if I’m saying it right. It tends to work well. It’s a natural GLP1 agonist. The data is promising on it.

The other one I really like is berberine, which I am sure everyone has heard of. It’s great for blood sugar and insulin resistance, but it can also help with leptin resistance. It can also help with your microbiome.

The problem I will caution is people who are taking it unsupervised on their own, and you take it for an extended period of time. I want you to be aware berberine is an antimicrobial. It can also change for the better in a good way your microbiome, but if you take too much of it, it can cause diarrhea. 

Right now, one of my favorites is Ortho Molecular HiPhenolic. It is a supplement that is targeted toward leptin resistance. It has a green tea extract in it, which works up the metabolism. It is decaffeinated, but it tends to decrease appetite and cause early satiety, like the GLP1 agonist does. A lot of my patients do really well with it.

Sometimes, these supplements help, and sometimes, they don’t. Every person is different. It also depends on how consistently and appropriately they are taking it.

One thing I have probably said multiple times is most of my results are from lifestyle changes versus supplements. I’ll be honest. Of course, GLP1 agonists work amazing. I do prescribe them in our practice, especially when I see patients who have leptin levels over 100 or really high. There is a place for GLP1 medication. They do work fabulously. Sometimes, they have side effects, and sometimes, they don’t. It works really well on that leptin hormone. I see it directly in my lab results. 

Dr. Eric: 

You mentioned Akkermansia. I don’t know if you do a GI Map.  

Dr. Bindiya: 

Yeah. 

Dr. Eric: 

If there are less than detectable limits, that’s when you recommend an Akkermansia supplement. 

Dr. Bindiya: 

Yeah, exactly. I am a big tester. Depending on what their stool test shows, I will treat them accordingly. If I am suspicious of it, then I will. It’s usually based on a stool test. 

Dr. Eric: 

Okay. I have had this conversation about berberine before. I don’t know if you’re familiar with Dr. Jason Hawrelak; I had him on the podcast. We had a conversation about berberine. He is not a big fan of it because of the potential antimicrobial effects. it can help in cases like SIBO. There are also a lot of updated studies, which are really interesting, showing that berberine can benefit the gut microbiome. 

You mentioned you don’t know how it’s going to affect the gut microbiome. If you are experiencing diarrhea, maybe listen to your body, and either don’t take it, or if you are taking a high dose- 

Dr. Bindiya: 

You and I probably know berberine just got a big buzz recently because of the GLP1 medications. You and I have been using it for the last 15 years, right?

I was using berberine before for a lot of my insulin resistant patients. It has similar properties to metformin. Sometimes, it’s so funny because now everyone loves GLP1 medication. Berberine is a natural GLP1. No, it’s more like metformin. I don’t know where you are getting this information from. 

Yes, it does. It does work the same. The concept is the same, including blood sugar improving. Yeah, it’s interesting. I agree, it does help with infections. It does help with SIBO. It does help with yeast overgrowth. Berberine is not necessarily going to hurt anybody. However, long periods and extensive- A year on berberine is not a good idea. Short-term berberine use, you will get some great results probably. It will help you at the right doses. If you are taking it for an extended period of time, not good.

Also, if anyone is listening to this and trying to get pregnant on berberine, you won’t. If you’re breast-feeding, probably not a great option for you. There are certain populations it works really well for. Please talk to your provider. Think twice about starting prescriptions without talking to a doctor. 

Dr. Eric: 

Well said. Anything else I didn’t ask you that I should have asked you or that you want to talk about regarding leptin resistance? 

Dr. Bindiya: 

No. I think it’s a fascinating topic. I’m excited, as new data is going to emerge over the next few years, what we’re going to learn about it and how to optimize our health. I am hoping this is going to empower us to be consistent with some really good lifestyle changes, where we can- I joke, age backwards, but more importantly, biohack your metabolism so it’s working for us. We’re gaining muscle, not fat, as we age. 

Dr. Eric: 

All right. This was a wonderful conversation. Dr. Bindiya, where can people find out more about you? Feel free to mention your quiz again. 

Dr. Bindiya: 

You’re more than welcome to follow me on Instagram, social media, Facebook, @DrBindiyaMD. Everything’s there, Instagram, TikTok, YouTube. I don’t know what else there is these days social-media-wise.

My website is DrBindiyaMD.com. 

Our practice is in Atlanta or Decatur, GA. 

Our quiz, you’re more than welcome to check it out. It’s free. DrBindiyaMD.com/quiz. 

I do have an amazing Metabolism Takeover course. For people who are not able to work with me and want to jumpstart their metabolism, it’s an amazing 28-day course that you can start and finish at your own time. It’s great because it really takes you to all these things I do one-on-one with my patients without doing all the bloodwork. 

I obviously love working with my patients one-on-one. That is the type of doctor I am. However, people who live all over the country and the world, I honor and recognize that. That course jumpstarts your metabolism. We’ve had some amazing results on it. It’s a great way to literally start making the right healthful or lifestyle changes to biohack and get you to where you need to be. 

Dr. Eric: 

Thank you so much. This was an amazing conversation. Really enjoyed chatting with you. I’m sure the listeners learned a lot about leptin. I learned a few good things as well. 

Dr. Bindiya: 

Perfect, thanks so much again for having me on. 

Dr. Eric: 

Thank you. Have a great day! 

Dr. Bindiya: 

You, too. 

Recently, I interviewed Dr. Roy and Debbie Steinbock, who developed the Elemental Diet Success Plan, to discuss how an elemental diet can benefit those with gut issues. In this conversation, Dr. Roy, Debbie, and I discuss how the elemental diet works, the benefits for conditions like SIBO and IBD, their experience with the elemental diet personally and with hundreds of patients, how the diet should be tailored to each patient, who can benefit most from it, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to talk about the Elemental Diet with Debbie and Dr. Roy Steinbock. This is going to be a great conversation. The Elemental Diet, I might have briefly spoken about it with regard to SIBO. It can help with SIBO and other conditions, which they will talk about. Let’s dive into their bios here.

Starting with Dr. Roy Steinbock: He is a board-certified pediatrician with an integrative and patient-centered approach. He believes that investigating the root cause rather than only addressing symptoms is the best root to achieving and maintaining optimal health and wellbeing. 

Dr. Roy combines evidence-based Western medicine with a functional and mindful approach. His areas of expertise include digestive disorders, allergies, eczema, frequent and recurrent illness, anxiety, OCD, ADHD, and other difficult to treat cases. 

Debbie Steinbock is a certified holistic health coach and nutrition counselor with a special interest in digestive disorders and autoimmune disease. Her 20+ years in clinical practice includes working with complex conditions that often involve gastrointestinal disease, thyroid imbalances, food allergies and sensitivities, nervous system dysregulation, and more. 

Debbie brings a uniquely personal perspective to her work with clients that was gained by navigating her own health challenges. Debbie’s deep, personal understanding combined with a passion for and commitment to continuing education and research makes her a compassionate clinician with an insightful perspective.

Dr. Roy and Debbie are the co-creators of the Elemental Diet Success Plan, a step-by-step road map that teaches participants their proven tips and strategies to complete an Elemental Diet with clarity, direction, and confidence. Thank you so much, Dr. Roy and Debbie. 

Dr. Roy Steinbock: 

Thanks for having us.

Debbie Steinbock: 

Thank you. 

Dr. Eric: 

Very excited. Let’s just talk a little bit more about how you started focusing on the Elemental Diet. You do a lot more in your practice. But I don’t know any practitioners that have a program dedicated to the Elemental Diet. What led you to create this? 

Debbie: 

I have been using Elemental Diets in my clinical practice for almost 25 years now. The Elemental Diet gained a lot of popularity back then with inflammatory bowel disease (IBD). I would use it with my clients who had Crohn’s or ulcerative colitis. 

Then it was about in 2013 when I met Allison Siebecker and learned that the Elemental Diet was being used for SIBO. Wait, are we talking about the same Elemental Diet I had been using in my practice before? At that point, we really dove into the research of it for SIBO and also learned about all these different conditions that the Elemental Diet was being used for. We expanded in our combined clinical practices what we had been using it for. That was how it was all born.

Dr. Roy: 

We decided to try the Elemental Diet ourselves.

Debbie: 

Right.

Dr. Roy: 

That was huge. Once we went through it, and we saw how it was on one level quite challenging, but on another level, it was actually quite doable. 

Debbie, being who she is, the magic of her practice, which is paying so much attention to the details, bringing all the tools together to make her clients become very successful. Prior to doing the Elemental Diet Success Plan, Debbie had a 99% success rate with getting people through the Elemental Diet. 

There are always a few people who are maybe overzealous in their desire to do it and decide they can’t do it. Anyone who wants to can really make it through it. We found that first in Debbie’s practice. Then she turned that into our program.

Debbie: 

As Roy said, I had known I wanted to try the Elemental Diet myself. I was using it in more extreme cases, somebody who had Crohn’s, colitis. They are very symptomatic but hadn’t dawned on me to use it for something that wasn’t potentially dangerous or life-threatening. 

When I decided to try it for myself, Roy always says that when I get into something, I can find the bottom of the internet. Every day, I’d be like, “Look what I learned about it for rheumatoid arthritis. Look what I learned about it for this.”

A few days before we were going to get started, Roy turned to me and said, “I think I want to try it with you.” “Oh my god, are you serious?” It just made it that much more fun that we got to experience it together. 

Dr. Roy: 

It was. We’re so different that we had really different experiences doing it. It was a really valuable starting point for our knowledge base as well.

Debbie: 

Yeah. 

Dr. Roy: 

One of the reasons that we were only using it for really extreme cases is the initial formulas that were out, the medical shakes that you could get, oftentimes prescription-only, were absolutely disgusting and not palatable. You had to be really miserable to want to drink that for several weeks. 

Because of the work of Dr. Mark Pimentel and Allison Siebecker, bringing it more to the forefront, companies have started using shakes that- 

Debbie: 

And Jenny Patel Thompson. 

Dr. Roy: 

And Jenny Patel Thompson. Shakes that are actually not disgusting. I don’t know that I would call them delicious. After a few days, you are relatively happy to drink them. You get used to it. It is totally doable now. Before, they really tasted like vomit. 

Dr. Eric: 

For those who are not familiar with the Elemental Diet, can you talk more about what it consists of? What’s in the powders? What are you actually drinking? 

Debbie: 

Elemental shakes are a powdered medical food. The nutrients get combined with water to make a shake. The shakes basically combine all the nutrients that humans require to live off of for an extended period of time. You can go into detail if you want. 

Dr. Roy: 

Typically, for SIBO, people will do it for two or three weeks. For other conditions, for example, Crohn’s or ulcerative colitis, people can do it for much longer periods of time. Sometimes, for six weeks. 

Sometimes, people will even do versions of the Elemental Diet where they are not doing 100% Elemental Diet; they are doing what we call a partial Elemental Diet, where they will drink some of their calories as shakes and eat some of their calories as food. 

There is some really good research, particularly with Crohn’s, even Crohn’s in pediatrics, where they showed significant improvement for people who had difficult to treat, resistant cases doing a partial Elemental Diet for up to 12 months.

Debbie: 

When you break down what’s in the Elemental shake, everything is broken down in its elemental form, so its most simple form. What that looks like is there is no protein in the shakes. Typically, when we say an elemental shake, it’s just freeform amino acids. 

There are some semi-Elemental shakes, and they’re now classified as semi-Elemental. They actually used to be called Elemental. These have short-chain peptides, like dipeptides and tripeptides. Generally, the definition of Elemental means just freeform amino acids.

The carbohydrate form of everything is monosaccharide. Your really simple sugars, which are glucose, fructose, and dextrose. You can also add in glucose polymers, i.e. maltodextrin. Those are the only acceptable carbohydrate sources in Elemental shakes.

Then we have fats. Fats can be any kind of fat. The most common would be MCT oil, flaxseed oil, or fish oil. 

Then they add in nutrients and electrolytes. 

Dr. Roy: 

Vitamins, minerals, electrolytes. It’s basically everything you need to survive for a period of time. It’s not like a health food diet. It’s not a diet I recommend everybody goes on. If you are suffering from inflammatory disorders, digestive disorders, it’s an amazing gut rest and rest from inflammation. It can even turn significant inflammation around. 

Debbie: 

Yeah, we can talk about some of the benefits if you want.  

Dr. Eric: 

Let’s go for it. It gives the body a rest, the digestive system a rest. It helps with inflammation if someone has gut inflammation. 

Let’s talk more about some of the benefits of an Elemental Diet and why people with some of these conditions—SIBO, IBD, even I’ve heard in some of the interviews you’ve had on other podcasts, like some autoimmune conditions. I’m not sure about Hashimoto’s, but I know you mentioned rheumatoid arthritis. I don’t know if you have seen success with thyroid autoimmunity. I’ll let you take over. 

Dr. Roy: 

I will talk about the conditions first and then the mechanisms, why it’s so powerful. The different conditions that have been studied. There are some that haven’t been studied, but we have seen in mini clinical studies, like you mentioned, autoimmune arthritis. There are studies in pediatrics and adults with that being very successful.

For Crohn’s and colitis, it is actually the primary, mainstage, first-line treatment in many countries, like Japan. Some countries in Europe. When someone is diagnosed, they don’t get put on a biologic like they do in the United States. They get put on the Elemental Diet. The remission rates are huge.

Also, things like really difficult to treat cases of eczema, food allergies, other food sensitivities, resistant Celiac, chronic pancreatitis. eosinophilic esophagitis. 

I was digging in to see if there is specific research with thyroid, and there really isn’t. There obviously is a significant tie between hypothyroidism and SIBO because of the issues with peristalsis that can be caused by hypothyroidism. That can lead to SIBO. It’s very common to see that comorbid condition together. It can help with the treatment of that. But we haven’t seen anything specific for treating autoimmune thyroiditis. 

Debbie: 

I have been asked that question a lot. I don’t have to tell you, Eric, how common thyroid disease is. Many of my clients have done Elemental Diets who have thyroid disease. 

What I always tell people is I don’t think that two weeks is going to lower someone’s thyroid autoimmunity. We know that the gut is behind all autoimmunity that’s happening. Anything that’s working to rest, heal, seal the gut is going to help with autoimmunity. Again, these two-week Elemental Diets, which is really what most people are doing, I don’t think is long enough to make an impact on thyroid hormones. But make a dent in it? Yes. 

Dr. Roy: 

I don’t think it would hurt. It’s probably relatively good in general. I think because thyroid, at least in my experience, seems to be more of a smoldering autoimmune condition. It’s crippling in the long run and pervasive in every part of your life. But it doesn’t typically, in my experience, have these huge flares, like a Crohn’s or colitis flare, where you’re really debilitated for a relatively short period of time. Or something like rheumatoid arthritis, where you have these really acute flares. We can have that with thyroid, but it’s less like that. It’s a little harder to see the improvements as well. 

The other thing I have seen with thyroid is as you improve, it also happens slowly. You don’t get this one treatment, and all of a sudden, you feel 100% better from thyroid. It takes your body time. Because of the way thyroid works with energy production and energy usage in the body, it takes a while. I usually tell people that people improve after being on the right dose of thyroid for three months. It’s not right away. People don’t generally feel better right away in my experience. It’s harder to tell if this would help. 

It works in a bunch of different ways. The most obvious, studied way is the stuff that’s being seen with SIBO. That’s because of the elemental components. The fact that everything is absorbed incredibly high up in the digestive tract. Super high up in the small intestine.

Debbie: 

And rapidly.

Dr. Roy: 

You don’t need to digest anything, so things are just absorbed. Therefore, you don’t get any substrate or food for the bacteria. After a period of several days, 4-5 days, the bacteria begin to starve, and that is the benefit. 

We know that overgrowth of bacteria in the small intestine is inflammatory. Even large intestine bacterial overgrowth can be inflammatory. That alone is well studied and well documented. That is a huge part of it.

They have actually shown that even some of the freeform amino acids themselves decrease pro-inflammatory cytokines and increase anti-inflammatory cytokines. Just the amino acids themselves.

In addition, it’s like a fast. You’re not fasting calorie-wise though. You’re basically giving your digestive tract an opportunity to rest. You’re not putting in solid food. You’re not needing to digest. Therefore, you’re decreasing the amount of energy that your body is using toward inflammation and digestion in the gut. That’s really important for healing as well. 

Debbie: 

What you’re speaking to is the hypoallergenic nature of the shake. They’re typically either free of allergens. There are some Elemental shakes that do use some corn or soy products, but they are just broken down. I always equate it to hypoallergenic infant formula, where they are broken down into such tiny, predigested pieces. 

Dr. Roy: 

The large majority of people can tolerate really almost any of the shakes, though because of the nature of the clientele we see and the people who tend to seek Elemental Diets, there are some people who are very sensitive. If they don’t tolerate one, they might try another and be quite successful. We’ve had a few people who don’t tolerate one shake and then tolerate another.

Dr. Eric: 

Have your clients tried any homemade ones? I know Dr. Allison Siebecker has her homemade formula. I’m sure there are other ones out there. Is it typically the ones that are premade that they are taking? 

Debbie: 

It’s a testament to the benefits of Elemental Diet that every year, more and more companies are coming out with Elemental shakes. In this last year, we have two more in our basement for us to invite some friends over and sample with us.

Dr. Roy: 

Believe it or not, we actually do that.

Debbie: 

More and more companies are coming out with these premade formulas. The taste has gotten so much better over time. 

Yes, I have had clients and participants in our program who use Allison Siebecker’s homemade formula. I would say that generally is done for one of two reasons. One is accessibility. They live in a country where Elemental shakes are not as available to them.

Dr. Roy: 

Or only by prescription.

Debbie: 

The second reason is, as Roy spoke to, that person is really sensitive, and they want to control everything that’s going into the shake, ingredient by ingredient, and pick and choose that way. Otherwise, I think she would agree and say this, too: The premade formula, the flavor profile of them, is so much better than the homemade shake.  

Dr. Eric: 

Okay. That’s good to know. Do you use it as a starting point with your SIBO patients? Is it something where you maybe put them on an herbal antimicrobial protocol or Rifaximin, and then if they don’t respond, give the Elemental Diet? Does it depend on the person? Maybe you speak about the Elemental Diet as an option. Depending on how they’re reacting, “I’m not sure if I want that,” let’s start with something else and then see how they respond. 

Debbie: 

Good question. I say it’s really self-selecting. People seek me out to do an Elemental Diet with me. I get a lot of clients who are really interested in Elemental Diets. That may be because they have failed other treatments before. That might be that they do a SIBO test, and their numbers come back so high that when they’re faced with the option, it’s 2-3 weeks of an Elemental Diet or potentially three courses of antibiotics, 12-16 weeks of herbs. Okay, I think I can muster it up to do this for 2-3 weeks.

For us, a lot depends on the person and what the person wants. You don’t want to twist anyone’s arm into doing an Elemental Diet. If it’s something that they’re willing to do, we want to give them the tools to do it appropriately and easily.

Dr. Roy: 

Because we both have personally done them, and we’ve had so much success—Debbie has gotten so many people successfully through the Elemental Diet—we have more testimonials than we could put up of people’s incredible success.

Oftentimes, there is these amazing success side effects. They didn’t do it for the fact that they had back pain and neck and shoulder pain and aches and pains, but they get dramatically better from that even though that’s not why we did it.

Because we sell it very enthusiastically, and we have seen so many people do it successfully, and we guide people through it very successfully, we probably use it a lot more than other people.

In pediatrics, generally, I start with medications. Mostly because of compliance. Sometimes, you have to take multiple medications, depending on if they have hydrogen and methane SIBO or just methane SIBO. The compliance on the herbs can be very challenging. A lot of kids don’t swallow pills, so we have to crush up tablets. I tend to start with that. If we get success- 

It’s also harder to get kids to do this, and to get most of my kids’ parents in my practice to think about an Elemental Diet. We have done it with some teenagers really successfully. And a few younger than teenagers. But much more in adults. 

Dr. Eric: 

Makes sense. 2-3 weeks in the case of SIBO, is that usually enough to eradicate it? I’m sure it depends on the person. If someone follows Elemental Diet for three weeks, let’s say, I don’t know if you do a follow-up breath test or just go by symptoms. If it’s a lot better, but maybe they still are not quite where they need to be. What approach do you take then? Can they go an extra week or two? 

Debbie: 

It depends on the person. We have jokingly said this many times, so you may have heard us say this. There are some people who finish their last shake and say, “I will never touch this again.” There are other people who finish their last shake, and they incorporate shakes ongoing into their healing toolkit.

A client specifically with SIBO, we will do a follow-up breath test. I have been saying for years that I think it’s 80-85% effective for both hydrogen methane and hydrogen sulfide SIBO. The research had only been from 2004 on hydrogen SIBO. I heard Mark Pimentel speak recently. He did a study on methane SIBO and found that same success rate. I have seen that for years.

Generally, we see an improvement even if it’s not 100% eradication. For those people who still have some SIBO, they might choose to go back on the Elemental Diet, or they might choose to follow things up with an herbal protocol or sometimes one course of antibiotics. It’s really individual. 

I say often that what I’m trying to flesh out with my clients is the stress that continuing on the Elemental Diet is causing versus the healing benefits that it’s providing. Any time someone gets into the situation where they are simply white knuckling it and don’t want to do this anymore, I believe that is a stress on their body. Then it’s not really the same healing tool. 

Dr. Roy: 

Some people have the opposite reaction, where they are feeling so good on the Elemental Diet that if you tell them to do another week, they’d do it happily. That’s the minority though. 

Debbie: 

Some people are slow to go back on food because they feel such a relief from symptoms that they’re afraid that food is going to cause their symptoms to come right back.  

Dr. Eric: 

Do you take a similar approach with IBD? Ulcerative colitis, Crohn’s, where you give them the option? Talk to them about the Elemental Diet. I think Dr. Roy, you mentioned in the case of IBD, they could actually be on it longer, maybe 4-6 weeks. 

Dr. Roy: 

People do Elemental Diets for around six weeks, 100% Elemental Diets. Then we use it in our practice a few different ways. That answers your question. If people need to be on it longer, they can be. Even past three weeks. 

Our program for example is self-led, so you can do it by yourself. Doing 2-3 weeks, as long as we have contraindications of when you shouldn’t do it, as long as you fit the model, which is 99% of people, who can do it very safely by themselves at home, that’s fine.

If you are going to go past three weeks, you probably should be under the supervision of at least a very well experienced nutritionist, dietician, medical physician. At that point, you’re also shutting down your digestive functions in your body. You need to know how to turn that back on. After a couple weeks, you do. But even longer for sure. That’s something I would experiment with at home by myself.

But we do use it in other ways in the practice as well. Do you want to talk about the other ways that we do it, like the rests and the resets? 

Debbie: 

With IBD, we have markers that we can be monitoring. We might be monitoring someone’s fecal calprotectin or ESR. You will generally see those coming down. We won’t necessarily keep someone on an Elemental Diet until those have completely normalized. 

In those cases specifically, we will often transition someone onto a half Elemental or partial Elemental diet, which is what we call it because it’s not really half. They might continue to consume shakes for a portion of a day, like breakfast or breakfast and lunch, and then do a well-tolerated whole foods dinner. A lot of people can do that ongoing for an extended period of time. 

Jus as an example, my sister, who has a plethora of different autoimmune conditions, did an Elemental Diet last summer through our program. Still to this day, her afternoon snack is an Elemental shake. She likes it. It gives her that period of bowel rest in the day. There are ways to extend it like that.

As Roy just said, we also teach people about how to use them ongoing, where they might do an Elemental Diet reset. We have some clients where very quickly, they will feel the anti-inflammatory benefits. They might go back to an Elemental Diet after they go on vacation, and they indulge, and things flare back up for them. A short period of bowel rest doing an Elemental Diet can be very helpful for them not to continue a downward spiral but go back on the ups. 

Dr. Eric: 

How about SIFO (small intestinal fungal overgrowth)? We spoke about SIBO. Is the Elemental Diet helpful with that? 

Dr. Roy: 

Nobody knows.

Debbie: 

We don’t know. 

Dr. Roy: 

It hasn’t been studied. In theory, because the carbohydrates are being absorbed so high up, and fungus love carbohydrates, so they can grow things as well. You would think it would have a similar effect.

Early on, there were concerns that you could actually exacerbate fungal overgrowth because the early shakes, and some still do, have really high amounts of carbohydrates and sugar. There were concerns. We have at times put people on either antifungals, pharmaceuticals, or moreso herbal, just to prevent that. 

It doesn’t seem like that’s really the case. We haven’t seen that be an issue, even in groups. Debbie did a group with a larger number of people who treat a lot of SIBO. It doesn’t seem an additional fungal overgrowth, if you didn’t have SIFO to start with, or mild SIFO gets worse. It doesn’t seem like it gets worse. No one has specifically studied that, so we don’t really know.

Debbie: 

There are some practitioners who hypothesize that it also treats SIFO. Like Roy said, we really don’t know.

When we did an Elemental Diet ourselves, this was really when that next generation of shakes were coming in that used the glucose polymers and were lower in carbohydrate content. That was a question that I had for us: Do I put us on a prophylactic antifungal treatment? That was what we were doing previously with these older versions of shakes. 

Generally, if people can tolerate it, we do that because they’re tolerating it. We may be helping treat a comorbid case of SIFO at the same time. 

Dr. Roy: 

Most people do tolerate it. Pharmaceutical antifungals, like nystatin, are not systemically absorbed. They are relatively tolerable for most people. Some people feel great after taking a course of nystatin in general. Same with using more botanicals. We have good tolerance, except with more sensitive cases.

Debbie: 

What we don’t recommend people do is throw in a whole slew of supplements or medications, not that people throw in a slew of medications, but more supplements, while they are on an Elemental Diet. With an Elemental Diet, we are restricting those complex carbohydrates. Even cellulose capsules, things that people with a lot of these conditions often want to take, would not be considered Elemental. We don’t want to put in all this effort to do an Elemental Diet and then be taking handfuls of pills that are counter to an Elemental Diet.

Dr. Roy: 

Also, depending on what pills you’re taking, some of these pills are very difficult to tolerate on an empty stomach.  

Dr. Eric: 

Makes sense. That was one of the questions I was going to ask you. Would you recommend typically not taking any supplements or just minimal supplements? If someone was taking magnesium and Vitamin D for example and a fish oil, would you say just take a break from those while following an Elemental Diet? 

Debbie: 

Generally, yes. The shakes have all that stuff in them. 

There are times where we might add in a select number of supplements, just to address a condition that somebody has more than- They don’t need Vitamin D. That’s in the shake. They don’t need fish oil. There are fatty acids or oils in most of the shakes. Maybe we need to add some magnesium citrate because their bowels got really sluggish and backed up on an Elemental Diet. 

Dr. Roy: 

We don’t prophylactically start with that. We do it on a case-by-case basis. We actually in the course go over how to decide whether you need that or not. Just with a handful of supplements. We keep it really simple.

We have probably said a million times we are Elemental Diet purists. It’s so powerful that you don’t need a whole lot when you’re doing it. Especially if you’re doing it for SIBO, just do the Elemental Diet.  

Dr. Eric: 

How about coffee, tea, herbal tea? 

Debbie: 

Technically. Let me say it this way. I was answering for SIBO. For SIBO, technically, you can do some weak coffee and some weak teas on an Elemental Diet. We do not recommend that both in our program and with our clients. We want this to be bowel rest. To have a bowel rest diet that involves caffeine is generally not the direction that we want to go in.

I have used this example a couple times I have spoken. I had a client that was drinking a pot of coffee a day. She is a nurse and would work the night shift. She would drink coffee to get herself through her night shift. 

When she contacted me to do an Elemental Diet, we really worked to wean her off of caffeine before she started. A few times during her shift, she would have half a cup of coffee while she was on the Elemental Diet. That was such a huge improvement from where she was at. 

She had amazing results from the Elemental Diet. Completely got off her prescription laxatives that she had been on for years. She was having normal bowel movements afterwards.

Dr. Roy: 

And stayed off of caffeine for the most part. 

Debbie: 

If people can get off of caffeinated teas and coffee, that’s best. Herbal teas, you can definitely drink. I’m a little bit more specific about which ones when somebody has SIBO. If they’re doing it for another condition like IBD or rheumatoid arthritis, really any teas are going to be careful. I do think about the roots and carbohydrate content of certain teas, if we’re specifically dealing with SIBO.

Dr. Roy: 

One thing I feel is really special about the program and was in Debbie’s approach prior is there is a whole preparation phase. The program is not buy the shakes, drink it. Anyone can do that. With preparing your body for optimal success, and not just success through eradicating SIBO, but just to have general good foundational health. 

I know in the holistic world, some people are very pro-coffee. There are maybe some benefits to it. I had been a coffee drinker during my residency and many years of college. But I can tell you that removing those things generally makes you feel healthier. It really does for most people. It’s not mandatory to get off caffeine, but we do find that people feel better when they do. 

Dr. Eric: 

Okay. Ideally, avoid coffee, avoid black tea, probably green tea, too, since it has some caffeine, not a lot, but still avoid pretty much anything with caffeine. Herbal tea, it really depends.

Dr. Roy: 

You have to prepare yourself for that. The last thing you want to do is if you are a pot a day a drinker, to stop and just start your Elemental Diet. You will feel terrible.

Debbie: 

You will feel horrible.  

Dr. Eric:

I agree. I can’t say I put a lot of people on the Elemental Diet. But if I am putting someone on an elimination diet, usually I will recommend for them to take a break from coffee and other things with caffeine. If they are drinking 3-4 cups a day, it’s not a bad idea to gradually decrease. I am sure you have come across people who say they can just stop, and they actually do stop, and it seems like they’re okay. More times than not, that’s not the case.

Debbie: 

Totally. There are people who feel the caffeine hit from white tea and can’t drink it because we are so sensitive to caffeine.

Dr. Roy: 

One thing I want to jump back to for a second, I know it’s a little far back in our conversation, but I think it’s important to mention. We mention that Elemental Diets are used for the first line for Crohn’s and colitis. That’s not what our first line is generally. 

If someone comes in who is really inflamed and in bad shape, that might be our first line for them. but generally, we start with more holistic, health-promoting approaches, looking at things like removing coffee from their diet, looking at their diet, a more foundational, functional, holistic, whatever you want to call it approach. 

We have a ton of success with that. It’s still relatively a minority of patients we see who end up on the Elemental Diet. This is more for people who have done the foundational, health promoting, holistic approaches and are still suffering. Or if they come in in really bad shape initially.

Debbie: 

One thing I will add is people who have IBD a lot of the time live with that fear of what if the bad flare-up happens. “I have been pretty okay now, but I have read XYZ, and it can get worse.” 

I always tell people that it makes people feel so good psychologically to know that this tool exists that they can have in their back pocket. A lot of my clients in particular don’t want to go on some of these heavy-hitting drugs. They are maintaining on some of the less heavy-hitting drugs, but they think if things turn for the worse, that’s where they have to go, and they don’t want to go that way. Knowing that the Elemental Diet is an option for them brings a lot of relief for them psychologically.

Dr. Roy: 

Especially because they feel better, but we can also measure markers of inflammation, the calprotectin, the ESR, the CRP. That is really useful. It’s a nice tool to have because it does mirror how they’re feeling most of the time. If their markers are great, then they can decide for themselves whether they want to be on medications or not. If their markers are still not great, we need to look a little deeper. Maybe medications are appropriate at that point. 

Dr. Eric: 

What about side effects? You mentioned constipation potentially. Then the magnesium citrate if someone is experiencing constipation is maybe an option to consider. Anything else people should look for if they are going through your program? Anything common or uncommon but might be concerning? 

Debbie: 

You used a good word. We have two lessons in our course that go through this. There are the psychological challenges that people go through of not having food. Then there are the physical challenges of being on an Elemental Diet. 

We’ll speak to the physical ones because those are the ones most people are curious about. As far as bowel stuff, literally all over the board. Roy and I were opposite ends of the Elemental Diet spectrum. 

Dr. Roy: 

We’re on opposite ends of the physical spectrum. I say this on every podcast. It’s hard to tell because Debbie is sitting on a cushion, but I’m a foot taller than her. 

Debbie: 

Naturally, our bowels go in different directions. On an Elemental Diet, many people go to the extreme of what their bowels generally gravitate toward. Some clients that have slower transit time and motility will end up with constipation. We always point out that an Elemental Diet was used by NASA to send astronauts up into space because it produces little fecal matter. 

Dr. Roy: 

Very low residue; therefore, some people don’t produce a lot of poop. 

Debbie: 

Some people get really low fecal output. It’s not actually constipation. 

Dr. Roy: 

They don’t feel constipated. They don’t get abdominal pain. They feel great. 

Debbie: 

It’s just low fecal output, whereas other people are like a breast-fed baby. Everything comes out and looks like it did in your baby’s breast-fed or bottle-fed diaper. That is also completely normal. 

A lot of what we’re doing is preparing people for what we call par for the course normal. When it happens for them, they don’t freak out about it. 

The things we have people looking out for are changes in their bowels, changes in their energy level, brain function, blood sugar regulation. 

There are oral symptoms that can come with an Elemental Diet that are by nature of not eating and chewing. Things change in your mouth as a result of that. 

People have to think about their relationship with exercise when they’re on an Elemental Diet. That falls into energy and blood sugar sometimes. 

They can get any side effects of die-off, microbial shifts. That’s what we’re going for here. Those bacteria sometimes are not going to go down without a fight. As the lipopolysaccharides get into people’s bloodstreams, they might feel the side effects of die-off, and that can feel like headaches, flu-like, muscle aches, fatigue, brain fog.

The other thing we teach people is we have a detox support guide in our program. How do you do the things? We can’t go to binders. That’s not Elemental. We teach people what are the things you can do on an Elemental Diet that will help you move those toxins through your system? 

Dr. Roy: 

While most people do feel some symptoms typically, they won’t feel all of them. They are probably not going to feel bad the entire time. I felt great on the Elemental Diet. Debbie did not. She didn’t feel bad the entire time. We have not really seen people who feel terrible the entire time.

We’ve had a couple people who psychologically struggled the entire time. It depends on where they are. They are taking it at a time where they need to do it for their health, but they are not prepared for it. They white-knuckle through it. That’s a tiny minority of the people we have guided.

Debbie: 

I’m glad you pointed that out. What we often say is in the beginning, we didn’t know how people would react to this. We can speak now with this confidence of working with hundreds of people one-on-one and hundreds of people through our program. We have not seen those people that just feel absolutely awful the whole time. It really does come in pockets for people. 

Dr. Eric: 

The last thing I wanted to ask you. We spoke about specific conditions, like SIBO and Crohn’s and ulcerative colitis. For someone who has been undiagnosed, maybe they went to a gastroenterologist, and everything looked okay according to the endoscopy and whatever other testing they did. Maybe that same person got a comprehensive stool test, and for the most part, usually we will find some dysbiosis, but nothing screaming out. 

Dr. Roy: 

We call it the garden variety dysbiosis. 

Debbie: 

Yep, that’s our term for it. 

Dr. Eric: 

Overall, the composition of the stool test looks okay. The SIBO breath test comes back negative. We know no test is perfect, but that’s the point. It looks like everything’s okay, and they have done elimination diets and followed all these diets and protocols, yet they are still having gut issues, digestive symptoms. It sounds like there is no harm for a person in this situation to give the Elemental Diet a try for two or three weeks.

Debbie: 

I would agree with that. You said the key words I was thinking. They have tried the other things. They have done a whole foods diet, some sort of elimination diet of allergens. As long as they have done all those things- I used my sister as an example. The only thing she has been diagnosed with is Hashimoto’s, but she has other autoimmune issues.

Dr. Roy: 

Mystery autoimmune thing.

Debbie: 

Nobody has put their fingers on it.

Dr. Roy: 

There is not an exact diagnosis, but it is clearly inflammatory autoimmune.

Debbie: 

Exactly. I am even running a client through right now who is in that same boat. The picture of this person is just screaming inflammation, but there is not really the diagnosis to support it. Oftentimes, an Elemental Diet is incredibly successful for those people. 

Dr. Roy: 

Let’s say it’s an extreme elimination diet because you are literally eliminating all proteins, which tend to be the bigger issue. Fats and carbohydrates can cause problems as well. You can really introduce things very slowly. We don’t recommend people finish an elemental Diet and go- 

Debbie: 

Eat a pizza.

Dr. Roy: 

You have this unique opportunity. If you are feeling great, start introducing things really slowly. See which foods you’re reacting to. It’s a clean plate. 

Dr. Eric: 

Makes sense. This has been great. This is definitely the most in-depth anybody on the podcast has gone into with regards to the Elemental Diet, and will in the future, unless we have you back for an update in the future. Is there anything that I should have asked you that I didn’t ask you? Anything else you wanted to talk about before we wrap up? 

Debbie: 

The only thing that comes to mind for me, and I’m curious what you say, Roy, is we touched upon this a little. We often say that sometimes when people hear about Elemental Diets or hear us speak about them, they get really excited, and they want to try it. 

But what we always tell people is that it is something that you should absolutely plan for. Understand what you’re getting into. Understand the side effects that you might experience. The term we always say is those people who plan are really planning for their success. 

I think the more someone goes into it, educated, thoughtful, understanding what to experience, understanding how to transition off of it, what testing they might want to do before and after, they generally will have better results than the person who at 2am listens to this podcast, feels desperate, orders it, and starts the next day. 

Dr. Roy: 

Which there seems to be a decent number of people who do that.

In addition to what Debbie said, also having the time to order the shakes. Knowing which shake to order. There is a variety, and different ones can be used for different conditions. We go over that in our program. 

The one thing we didn’t talk about that I think would be important, particularly for people who are really suffering with chronic illness, is weight loss. We get a lot of people, particularly with IBD or SIBO for long periods of time, who are really struggling with keeping on weight. They get worried they are going to lose weight when on the Elemental Diet. 

Although you generally lose a little bit of weight, like water or poop weight, because you actually have a decent amount of poop in your body. You are not putting in any solid mass in your body, so you are not going to gain the daily weight. People with significant digestive and absorption issues can gain weight better than they could on regular diets because it’s still highly absorbable. You can build some muscle mass, especially when using semi-Elemental Diets. There are a lot of details. We do cover most of that in our program.

Debbie: 

I spoke on a recent podcast. We had a client that has Crohn’s. She got her period back a few days into the Elemental Diet. She hadn’t had it for years after having four children and because of IBD. While that sucked for her, it was such a great sign that her body was actually getting nutrients that it had not been getting. She was able to get her period again. 

Little bit of a tangent. There are a lot of details to think about as Roy was saying in terms of how people’s bodies are going to respond.  

Dr. Eric: 

All right. This has been amazing. Let’s go ahead and tell people where they can find you. Throughout this presentation, you spoke about the Elemental Diet Success Plan. Is there anything else you want to briefly talk about with that? You also have your five free diet tips. Where can people find out more about you? 

Debbie: 

They can find us at MindfulFamilyMedicine.com. You will learn about both me and Roy there.

Dr. Roy: 

That’s our shared website.

Debbie: 

Under our Programs tab, you’ll find the Elemental Diet Success Plan. 

Dr. Roy: 

And some other programs.

Debbie: 

We have a couple other programs. What I have added in recently after launching the Elemental Diet Success Plan, what we learned is there are some people who, even with all that information, just want that one-on-one support through the Elemental Diet. 

There is a separate program that I call One-on-One Elemental Diet Guidance, which combines the Elemental Diet Success Plan with check-in sessions with me along the way, so they can make sure they have their plan clear before they get started and along the way. I’m available for questions they have as well. 

Dr. Eric: 

Wonderful. Thank you so much, Dr. Roy and Debbie. It was great chatting with you. I’m sure the listeners learned a lot about the Elemental Diet. I learned some things as well. 

Dr. Roy & Debbie: 

Thanks for having us! 

 

Recently, I interviewed Dr. Sarah and we discussed the Nutrivore principles, the concept of nutrient density and why it matters, how the Nutrivore score works, the value of a diverse diet, common misconceptions about certain foods, the roles of macronutrients and micronutrients, balanced eating patterns, sustainable nutrition practices, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am beyond excited to have the following conversation with our repeat guest, Dr. Sarah Ballantyne, as we will be chatting about her new book Nutrivore, which is one of the most comprehensive and well-researched books related to nutrient density. Let me go ahead and dive into Dr. Sarah’s impressive bio. 

Dr. Sarah Ballantyne, Ph. D, is the founder of Nutrivore.com and New York Times best-selling author of Nutrivore: The Radical New Science for Getting the Nutrients You Need from the Food You Eat. She creates educational resources to help people improve their day-to-day diet and lifestyle choices, empowered and informed by the most current, evidence-based scientific research. 

Dr. Sarah began her career as a science communicator and health educator when she launched her original website in 2011. Since then, Dr. Sarah has continued to follow the science, diving deep into immune health, metabolic health, gut microbiome health, nutritional sciences, and the compelling evidence for health at any size while also observing the harm of healthyism, diet culture, dogmatic misinformation, and predatory marketing. 

With Nutrivore, Dr. Sarah has created a positive, inclusive approach to dietary guidance based in science and devoid of dogma, using nutrient density and sufficiency as its basic principles, nourishment, not judgment. Welcome, Dr. Sarah. 

Dr. Sarah Ballantyne: 

Thank you so much for having me back.  

Dr. Eric: 

Very excited to speak with you. We were chatting before about how I listened to the audiobook, which I thought was truly amazing. You did a great job. Really enjoyed listening to it. I will read the print book, too. The audiobook is just a lot easier when making smoothies and doing other things. 

Dr. Sarah: 

Yes. Lovely to make that driving time also productive time, to be able to listen to a book. I do the same. 

Dr. Eric: 

Exactly. Let’s dive into nutrient density. Why is nutrient density so important? If you could also explain the difference between nutrient deficiency and nutrient insufficiency. 

Dr. Sarah: 

The 30,000-foot view answer is our bodies need nutrients. Nutrients are what we’re made of. They are used up in all of the different chemical reactions that keep us alive. We need to be continuously topping up our nutrient stores from the foods we eat. That’s why we eat. It’s not just for energy; it’s for all of these different resources, all of the chemical reactions that make us us. That’s why we need vitamins and minerals and other essential fatty acids, essential amino acids.

We’re at an interesting moment in time where even though most people have enough food, the nutrient density of that food, meaning how much nutrients there are for the amount of energy that food has, for most people, it’s not enough. We’re getting enough energy, most of us, but we’re actually not getting all of those building blocks, all of those chemical resources that our body needs in order to be healthy. 

What happens when we don’t have those nutritional resources is it puts a strain on all of the different systems in our body: the cardiovascular system, the immune system, the neurological system. That strain builds up over time when those parts of our body don’t have the things that they need to function optimally. It’s like driving a car without oil. It’s going to create this wear and tear. Eventually, the engine will seize. That’s what happens to us.

But like a car needs more than oil, it also needs gas, etc. We’re the same. We need those nutritional resources. We need energy. Then we also need sleep and activity and our stress not to be crazy. We also have genetics and epigenetics that are factors. What high quality motor do we start off with? That also interacts with social determinants of health, things that are influencing our health that we have no control over. 

Altogether, that is what leads to the car breaking down. That is what leads to some kind of chronic condition or even increased risk of infection. Nutritional resources play a really important part, even though they’re not the whole picture in terms of what influences our health. 

Most of us are not getting all of the nutrients that our bodies need to be healthy. But it’s not solo that we develop a disease of deficiency. That’s where the difference between deficiency and insufficiency comes in.

We don’t see a lot of scurvy nowadays. We don’t see a lot of Rickett’s or beriberi or pellagra. These are diseases of malnutrition that are caused by incredibly low intake of essential vitamins. If our intake is so low in Vitamin C, we can develop this thing called scurvy, where we have bleeding gums. Maybe if it’s bad enough, our teeth will fall out. There’s a rash. There’s various distinctive symptoms. 

Instead, we are in what’s called the insufficiency range. Our intake of these essential nutrients is high enough to avoid diseases of malnutrition that used to be very common. They are not very common anymore. It’s still falling short of what we need. That is the range called insufficiency. We could also refer to it as a dietary shortfall. We are not quite getting as much as we actually need in order for all of our biological systems to have all of the nutritional resources they need to function well and hopefully reduce our risk of disease instead of increase it.

That weird gray, in-between, where we are not getting enough, but it’s still enough not to have this really obvious disease of malnutrition. What is so insidious about it is we don’t recognize it. There’s very vague symptoms if there are any symptoms at all. It might just be a little bit of fatigue, or maybe you get stressed out more easily, or maybe we have a little brain fog. Maybe there is nothing. Maybe there’s absolutely no obvious symptoms of these nutrient shortfalls. But they’re there. That wear and tear is still happening. That’s still interacting with all of these other risk factors to potentially lead to poor health outcomes.

We don’t recognize it because we don’t feel nutrient insufficiencies. We would feel a nutrient deficiency. We would have a disease of malnutrition. Nutrient insufficiency is weird, like you are not getting enough sleep, but you’re not so sleep-deprived that coffee isn’t enough to get you going in the morning. It’s that same kind of weird in-between, where it’s increasing risk of bad things happening, but it’s not obvious to us walking around in day-to-day life that that is this thing happening in the background that is going to catch up with us eventually.

That’s why nutrient density is so important. We want to be able to get the recommended dietary allowance of all of the essential nutrients. There is a lot of non-essential nutrients that are still really important for reducing our risk of long-term health problems. When we can understand what nutrients do in the body, what foods contain what nutrients, what different types of foods we want to be eating so we are getting the full range of nutrients our body needs, that is my goal with Nutrivore. 

Then, within our other dietary priorities, within our budgets, within the foods we have access to, it’s pretty easy to make some small changes, not to have that thing happening in the background of nutrient insufficiency to be a contributor to long-term health problems. Instead, we can be getting all of the nutrients that we need, improving our long-term health, never having that moment where those nutrient shortfalls catch up with us. 

Dr. Eric: 

Thanks for that explanation. I like the analogy with sleep you made. I was going to ask you about the Nutrivore philosophy, but you answered it with that response. 

Some people might already be familiar with the Nutrivore Score. I want you to talk more about that. I find that fascinating. The goal obviously is not just to focus on the foods highest in Nutrivore, but just like you said, you want to try to get a good variety of foods. Still, it’s nice to see the rankings, see what’s highest. 

For those who are not familiar with the Nutrivore Score, why don’t you talk more about it? 

Dr. Sarah: 

If we think of Nutrivore as the goal of getting all the nutrients our body needs from the foods we eat, that is the overarching principle of Nutrivore. The follow-up question is how do we do that? 

The Nutrivore Score is one tool of many. It is not the only thing we want to look at as you already alluded to. It is quite simply a way of quantifying the nutrient density of foods, which is scientifically defined as nutrients per calorie. You can think about it as the quality of the calorie of food. How many nutrients am I getting for each calorie in this food?

There are limits. It doesn’t tell us what nutrients we are getting. It’s total nutrients per calorie. It doesn’t tell us nutrients per serving. We need extra information on top of the Nutrivore Score to be able to work that out. It’s a great way to identify those foods that are really nutritionally important. Foods that have a ton to offer us per calorie. 

You can divide those foods into two buckets. There are the foods that have a ton to offer us per calorie but also don’t have a lot of calories. Vegetables would fall into that range. Fruit in general would fall into that range. 

Then what are the foods that do have more calories but are still so valuable? Even more nutrients for each calorie. That is where I would put seafood, nuts, and seeds. Foods that are calorically dense, but those calories are so worth it because that food is contributing a lot of nutrition in addition to energy to our overall diet. 

That is what the Nutrivore Score is about. It’s about doing some math and figuring out what foods have the most nutrition to offer us per amount of energy it offers us. That is one tool for achieving that Nutrivore goal among others, like identifying overall eating patterns, identifying foundational foods. There are lots of other ways we can get more sophisticated. 

If we are going to talk about nutrient-dense foods being valuable, we need a way to identify what those are that is objective. Prior to the Nutrivore Score, in our broader wellness community, there have been a lot of us talking about the importance of nutrients and nutrient-dense foods for a long time. The only way we could identify what foods are nutrient-dense is to look at a list of nutrition facts and see, “Yep, that looks good! That looks like a nutrient-dense food.” We didn’t have a way of actually mathematically defining it. 

We have had a lot of foods over the years that have reputations for being nutrient-dense, some of which are. But when you actually crank the numbers, some foods are better than you would have thought based on the gut check of looking at the nutrients per serving. Some foods are not as good as you would have thought. It’s about bringing in a more objective lens to that identification of nutrient-dense foods rather than it just being “This feels like a valuable food.” It’s being more sciencey. 

Dr. Eric: 

Makes sense. I know we both said you don’t want to just focus on the top Nutrivore Score foods. That being said, I’m sure some people want to know what are some of the top Nutrivore Score foods? There might be some surprises that people aren’t expecting. 

Dr. Sarah: 

There is lots of surprises. All of the really top scores are all very low energy density foods. If we are going to define nutrient density as nutrients per calorie, which is not my definition, it’s the scientific community’s definition. Then that means that a food that doesn’t have a lot of calories doesn’t need to have as much nutrition in order to have a really high score. A food that has a lot of calories needs to have a lot more nutrients in order also to have a high score.

This is why I am not going to choose between watercress or liver on my plate, for example. They are not going to give me the same nutrients, and they are not going to contribute the same amount of nutrition to my overall diet. One is a very low energy density food, and one is a very high energy density food.

I like to use the Nutrivore Score practically by identifying simple swaps. What could I have in place of a dinner roll that is going to have more nutrition? A baked potato will double my nutrients per calorie. What could I have in place of a baked potato? A baked sweet potato. It will double my nutrients per calorie again. What could I have in place of the baked sweet potato? Let’s go for butternut squash. That is about 50% more nutrients per calorie. 

Identifying those easy places to swap something out that occupies the same role in the overall meal rather than saying, “I am going to look at these top 10 Nutrivore Score foods and just eat those.” If we did that, we would find ourselves in a position where we are only eating these very low energy density foods, and we wouldn’t be getting that full range of nutrients that we need.

The fun thing about this calculation is I would have never guessed what the most nutrient-dense food is. If you’d asked me, I would have said something like kale or liver. Those are extremely nutrient-dense; they’re very high. But the single most nutrient-dense food is canned clam liquid, which I do not want us to start a trend of drinking canned clam liquid. That is not what this math is designed to do.

But the reason why canned clam liquid is so high is it’s very low energy density. It’s about five calories per cup. That cup of canned clam liquid has 500% of the daily value of Vitamin B12. Plus lots of other vitamins and minerals. It has a ton of nutrition but also not very many calories, which is why it has such a fantastic Nutrivore Score.

Leafy vegetables in general tend to have really high scores. The next highest food is gardencress, which is not very common in North America but is a grocery store vegetable in Europe. It’s very peppery, arugula’s very angry big sister. So peppery. I have grown it myself because as soon as I saw the math, I needed to know what that tasted like.

Watercress is up there. Rainbow chard is up there. Coffee is up there. It has a ton of polyphenols, some B vitamins, and one or two calories per cup. That is another good example of those foods that have really tremendous scores, even though they aren’t contributing a ton of nutrients because typically, we would only have a few calories’ worth. 

Of the foods that are doing both, contributing a ton of nutrients per calorie but also just a ton of calories to our diet, that is where you see foods like organ meat, shellfish, seafood in general, root vegetables, fruit, legumes. Legumes are very nutrient-dense. That is where nuts and seeds fit in. Those are all the foods that offer a lot of nutrients per calorie as well as nutrients per serving. 

Dr. Eric: 

When it comes to the vegetables in the Nutrivore Score, is that based typically on raw vegetables compared to cooked? 

Dr. Sarah: 

You can look up the Nutrivore Scores of close to 8,000 foods on my website, Nutrivore.com/Search. There, I have Nutrivore Scores of every form that I have enough nutrition data to do the calculations. Raw broccoli but also boiled broccoli with salt and boiled broccoli without salt. I can’t remember if broccoli in the microwave. Frozen broccoli. There is a ton of different broccoli forms.

Canned green beans along with frozen green beans with fresh green beans. Canned green beans drained along with canned green beans not drained. You can fall down the rabbit hole of the math and see how the nutrient density differs a little bit with different cooking methods.

Overall, those differences are not meaningful. You are getting roughly the same nutrition having your broccoli raw versus steamed versus roasted versus boiled versus in a stir fry versus blended into your smoothie. However you want to eat it, that is a nutritious vegetable. It has a lot of beneficial things.

When I am comparing foods, for example, there is an appendix in the book that lists the Nutrivore Score of 700 common foods, mostly whole foods. In that case, I just put in the score for the raw, whole version. That gives us a really good benchmark to compare to because cooking can be complex. 

Some foods might be more nutrient-dense cooked one way and less nutrient-dense cooked a different way. It’s partly because we are all in the noise in terms of nutrients per calorie when we are comparing those very small differences. Some nutrients go up a little bit when you cook, and some can be lost. They are more lost if it’s a high water technique. 

It’s all fascinating if you are a data nerd like I am. Not the type of detail that the average person just looking to increase their nutrient intake needs to worry about. It’s much more beneficial at that point to see that broccoli has a Nutrivore Score raw of 2,318. It’s a fantastic food. The cool nutrients that it has that benefit your health are these types of phytonutrients called glucosinolates. That is plenty of information to go, “Broccoli is great,” and eat it however you like from there.

I do have the math on those differences. It’s a little bit of a level of attention to detail that doesn’t have a meaningful impact on diet quality at the end of the day. 

Also, I think it’s where the Nutrivore Score gets into gamification in a way that is not healthy. One of the things that I really struggle with in terms of communication, and I am really trying, is to share this really cool thing that the Nutrivore Score tells us. It’s fascinating. It’s really fun to compare different foods and go, “How cool is it that cantaloupe melon has double the nutrient density as honeydew melon?” That’s interesting. 

How cool is it that strawberries are more nutrient-dense than blueberries? That doesn’t go with what we’ve heard about blueberries being so amazing. Yet strawberries are even more amazing from a nutrient density perspective.

I love sharing those types of fun facts. But I think it’s really important to caution against a really simplistic view of food. Swapping out our old view of calories or carb grams to the Nutrivore Score. That’s not what we want to be doing with that. We don’t want to just choose the highest Nutrivore Score foods. 

It’s really important that we don’t use the Nutrivore Score to try to moralize foods. That’s a real problem in the diet culture and wellness community at large. There are always these lists of good foods and bad foods, yes foods and no foods. 

The biggest thing I’ve learned in building Nutrivore is when you look at the full database, all 8,000 foods, that’s something you can download and peruse if you join my Patreon. It’s a 227-page table. You can scroll through it. You see quickly that all foods lie on a spectrum. There is no line where you can say, “All of the whole foods are above this line, so above this line is good. All the ultra-processed foods are below this line, so we can say below this line is bad.” 

You start to see there are some whole foods with much lower scores, but they are still nutritionally valuable. They still have science showing they are beneficial. There are ultra-processed foods that have higher scores. A lot of breakfast cereals have high scores. Thanks in part to fortification. They are still beating a lot of whole foods in terms of their nutrients per calorie. 

When you start to let that fact sink in, you go, “Oh, there is no line. There is no above this is good and below this is bad.” There is this whole range of gray, where you then start to see the benefit of a varied diet, where we are eating a lot of different foods. You start to see the importance of proportion of food in the whole diet. “Is this food contributing nutrients to my whole diet? Am I eating so much of it that it’s displacing other nutritionally important foods?” We give ourselves permission in that once we have that realization to stop viewing any food as good or bad and start viewing eating patterns as health-promoting or not. 

That is also where the Nutrivore philosophy lies. It’s not in Yay to this food and Nay to that food. I understand where the Nutrivore Score intuitively aligns with moralization of foods. That’s not where we want to go with it. We want to actually use it as a tool to get over moralization of foods. 

There are so many rumors online. Iceberg lettuce is the nutritional equivalent of cardboard, that it’s just crunchy water, that it’s a waste. Why bother eating it? It has more nutrients per calorie than cucumber, celery, or artichoke. It has a lot of valuable nutrition. That’s how I want the Nutrivore Score to be used. Drop our moral judgment of iceberg lettuce as being nutritionally pointless, and view it as a nutritionally valuable food, helping us to get over those moral judgments rather than propelling them. 

Dr. Eric: 

It comes down to variety. I always thought the same thing, too, with iceberg lettuce. I don’t want iceberg lettuce if I have a salad, not knowing it is more nutrient-dense than celery and some other foods. I would never have guessed. 

On a side note, we’ll bring this up again later. You mentioned the Patreon, which I am a member of. Definitely recommend joining Sarah’s Patreon. Great value. 

Macro nutrients. You have a chapter on macronutrients, micronutrients. With macronutrients, you get, just like anything else, different perspectives. Eat a high fat diet. Eat a high protein diet. Low carb diet. Just like with what you spoke about with the Nutrivore score, don’t just focus on high Nutrivore Score foods. Same thing with macronutrients. It’s about balance. 

Dr. Sarah: 

Yes, I agree completely. I think of Nutrivore as a diet philosophy rather than a diet or a diet modifier. It’s a focus on more nutrient-dense foods and getting the full range of nutrients that we need that can be overlaid on top of other dietary priorities. 

If you have other recommendations from your doctor to focus on certain types of foods or to limit other types of foods, you can still apply the Nutrivore philosophy on top of that. If there are certain foods you don’t eat for religious reasons, or you’re allergic, or you just have a diet that you really resonate with, that you really like, that has worked really well for you, you can apply Nutrivore on top of that. You could be a Nutrivore vegetarian. 

Nutrivore is a way of focusing food choices. There is a default state, which is balanced macronutrients. If you have medical reasons for following a low carb diet, or it’s something that’s worked really well, you could be Nutrivore low carb. That is something that could happen.

What would then happen is you would use Nutrivore as a way of identifying those nutrients that are a lot harder for you to get on a low carb diet. There is a list for all of the main, major, popular diets in chapter one of the book, of the nutrients that are hardest to get on those dietary templates. 

On this diet, I am going to struggle to get fiber, if we are talking about low carb because that is one of the hardest ones. What are the foods that I can eat that are going to match my other dietary priorities but help me achieve that Nutrivore goal of all of the nutrients that my body needs? How am I going to get this fiber? Nutrivore can be used to improve the quality of however you eat now, whatever your preferred diet is, or even anti-diet. It’s very aligned with intuitive eating for example.

What is Nutrivore without other dietary priorities? Without other reasons for choosing foods, what I think of as the default mode. What does Nutrivore look like right out of the box? It just opened. What is the shiny new Nutrivore? That is macronutrients. A proportion of the diet that is protein, carbohydrates, and fat, falling within the accepted macronutrient distribution ranges. That is set by the Institute of Medicine. Those are the happy mediums for approaching carbs and fat that studies show reduces risk of long-term health problems the most. 

Also, one of the things that goes into that calculus is the fact that we tend to get certain types of micronutrients packaged with certain types of macronutrients. Carbohydrate-containing foods tend to be plant foods, root vegetables, fruit, and legumes. There are certain vitamins and minerals and fiber types and phytonutrients we are getting from those types of foods. That actually is a thought process that goes into the accepted macronutrient distribution ranges. Those are the ranges that make it easiest to achieve the Nutrivore goal. 

Not low or high of anything is where the starting point is on Nutrivore. Not that we can’t apply Nutrivore to a macronutrient manipulation diet. The default is balance. 

Dr. Eric: 

Makes sense. Micronutrients. The audience consists of those who have a thyroid or autoimmune thyroid condition. Feel free to focus on other minerals as well. Brazil nuts are fascinating to the thyroid community. They love to eat Brazil nuts for selenium. Of course, you not surprisingly spoke about selenium and Brazil nuts. Some also wonder if you can eat too many Brazil nuts. From what you said in the book, if you eat more than 10 every single day, that might be problematic. If you are eating three or four a day on average, probably not a big deal. Or even 10 every now and then usually isn’t an issue, correct? 

Dr. Sarah: 

Correct. If I had to distill the message that I’m trying to give with my book to one sentence, it would be: Why should I care about nutrients? Me the reader, why should I care about nutrients? The entire book is geared at helping you care. 

It’s about understanding the role of nutrients in that big picture, but also making the value of nutrients personal. What I do to achieve that goal is in the second part of the book, the chapters are organized by nutrient type. Macronutrients, vitamins, minerals, and phytonutrients. Each chapter is a series of short stories, where I examine the link between one specific health condition or symptom and one nutrient. To round out that resource, there is a table on the appendices that lists all of the nutrients that have been strongly associated with 120 different health conditions and symptoms. 

If you have thyroid problems, here is why selenium is so amazing. With thyroid, you get a twofer because I also talk about the discovery of iodine in the introduction in the minerals chapter. And how that related to treating goiter, which is fascinating history. Then talk about how selenium is important for thyroid function. 

Brazil nuts is by far the most concentrated source of selenium. After that, seafood is our main source. Brazil nuts are so concentrated. Even though we don’t see selenium toxicity in practice, even in communities that are eating a lot of Brazil nuts, it is, at least on paper, possible. It’s something for us to be aware of. You can overdo any food, but there are certain foods. I highlight them all in a section in the book where I talk about the tolerable upper limit. 

The three foods that really come up again and again, which is really easy to overdo these foods, and it’s really easy to hit a potentially toxic level of a certain nutrient. Brazil nuts potentially have too much selenium. Certain types of seaweed, especially kelp, can be extremely high in iodine, which is relevant to people with thyroid problems. Then liver can be so high in Vitamin A and copper that you can hit hypervitaminosis A, which is Vitamin A toxicity, or copper toxicity. A serving or two per day will get you there. With kelp, even half a serving a day. Some varieties of kelp are extremely high in iodine. With Brazil nuts, about 10 Brazil nuts per day. 

There is not too many cases in the medical literature of nutrient toxicity from foods. Foods seem to have competing nutrients that will compete for absorption, which blocks us from absorbing too much. They tend to have more synergistic amounts of different nutrients in food. We tend not to have to worry about getting too much of any nutrient when we are focusing on getting our nutrients from food. That is usually something you only have to think about in terms of supplements. Except these few foods that really can deliver too much of a good thing.

With Brazil nuts, three or four is well in the range of a good amount of selenium. One is actually more than enough to hit your selenium for the day. 10 is right at that chronic toxicity level for selenium.

Fun fact: One of the symptoms of selenium toxicity is garlic breath without the garlic. If that’s a thing that’s happening, I would talk to your doctor and get tested for selenium levels. 

Dr. Eric: 

You mentioned foods higher in iodine. That is a controversial area in thyroid health also. Kelp is the main type of seaweed. The other ones don’t have nearly as much iodine where it’s a concern for those with Graves’. 

Dr. Sarah: 

Yep. 

Dr. Eric: 

Wonderful. 

Dr. Sarah: 

At one point in the book, I had a graphic representation of the iodine content of different sea vegetables. It got removed for a variety of reasons. In the interest of not having complicated graphics that need a lot of explanation. 

Really the only one there that we need to worry about is kelp. The most common varieties of seaweed, like nori sheets that sushi is made out of, you don’t need to worry about that. You can have a serving or two of that every single day, and you will be just fine.

The thing with all nutrients is we want to stay in that happy medium. We want to be getting enough and not too much. We want to hit the recommended dietary allowance while staying well clear of the tolerable upper limit.

Iodine is fascinating because both too little and too much iodine affects thyroid function, hence all the controversy. 

What is fascinating about iodine is we don’t have a complete data set in terms of how much iodine content there is in different foods. 

Also, the iodine content of food varies geographically. This is why there was a goiter belt prior to iodized table salt in the United States. It’s because there was this region in the upper Midwest where the iodine content of the soil was so low that those crops grown in that soil didn’t have very much iodine. The animals feeding off of those crops, the chickens eating that corn, their eggs didn’t have much iodine. There wasn’t much iodine in the food supply.

Iodine is a weird one because it varies so much, depending on growing conditions in different foods. We don’t have good nutrition data for a lot of different foods in terms of iodine. It’s actually really hard to gauge iodine intake for the average American. Is it in the happy medium range? Is it not enough? Is it way too high? That also helps with the controversy, I think. 

Dr. Eric: 

Yeah, I agree. One of my favorite chapters in the book was the myths. I was going to bring up this myth last, but I am going to bring it up now because it ties into what we were talking about, which is goitrogenic foods. The myth of eating broccoli and inhibiting thyroid hormone production. You mentioned not only that being a myth, but I’m pretty sure you said even if someone is low in iodine, that is usually not a concern. 

Dr. Sarah: 

This was one of the fun things about writing this myth-busting chapter. I initially didn’t intend the myth-busting section of the book to be an entire chapter. Then as I started, I had this list of myths that I knew were things I had bought into in the past, which I knew were really important to include in the book from my own narrative story arc. I also wanted to make sure that I was busting all of the most prevalent myths about foods that are among all different diets right now. 

I talk about why red meat is probably not bad for you, but also busting the myth of plant toxins. Talking to a wide variety of communities in that chapter. 

The reason I realized it had to be a whole chapter is the philosophy is designed to be a landing place on the other side of diet dogma, of misinformation, of all of the things that we learn from different fad diets that are actually wrong, not supported by the scientific literature, and hurting us healthwise.

Nutrivore is as much to me the solution to diet culture in general and how to understand how to eat a higher quality diet without depriving ourselves of our favorite foods, so we are setting ourselves up to eat that higher quality diet sustainably for the rest of our lives. 

It’s as much about understanding food outside of these moral judgments. In order to create that clean slate, to be able to view foods in this new, simpler way, and this new, non-judgmental way, I realized I had to at least briefly, with some citations for the people who want to dig into it in a lot more depth, bust all of the myths that come from not just our corner of the wellness community, but from all corners of the wellness community.

Among those was plant toxins in general and foods like soy and cruciferous vegetables being goitrogenic. What’s fascinating is a lot of those myths come from some time prior to the science that would have supported them ever being performed. They are myths that became common knowledge before there would have actually been the discovery that would have said yes or no to that myth. 

Some of them come from science. They come from early scientific studies that you would interpret one way, and more science comes, so you go, “Actually, now we know better.” Some of those myths actually come from early studies. 

The goitrogenic cruciferous vegetables is one of them. That myth originates from these early studies done in rabbits that were eating a ton of cabbage in an area with iodine-depleted soil and developing goiters. The idea being okay, now we can identify in cabbage, iodized sulfinate interfering with thyroid hormone production. Aha, we have our goitrogens in this cabbage. Therefore, people with hypothyroidism should not eat cabbage.

Then the science started to evolve. Those rabbits also had low iodine, so there is this series of studies done using the isolated compounds where they gave it to animals with iodine deficiency or not. That is where the surprise was, oh, we can’t actually explain why these rabbits had goiters. It must have been more complex than just the cabbage. When we give this to rats, it doesn’t actually cause hypothyroidism with or without iodine. 

Then we have this collection of human clinical trials, where people are given what were thought of as goitrogenic compounds. In a Petri dish, yes. They for sure interfere with thyroid hormone production. In the complex human being, they don’t seem to.

In humans, we have a radish sprout extract or broccoli sprout extract. These supplements were given to humans. We see that it doesn’t impact thyroid hormone function at all. 

We now have this collection of science that refutes these early studies. That’s why reproduction in science and building on our knowledge is so important. We never just want to do one study and go, “Aha, now we know this thing.” Can we reproduce this? Does it work in other animals? Does it work in humans? Does it work in this dose or that dose? Does it work in this context or that context? 

That’s why understanding science as an iterative expansion of human knowledge is really helpful for understanding the evolution of these myths, and then being able to be receptive to where scientific consensus leads once we have a big enough body of scientific literature to support that. Being receptive to that is the answer to this question once we can say for sure that’s the answer.  

Dr. Eric: 

Even before listening to your book, I did some research. Personally, I haven’t seen a problem in most people with cruciferous vegetables. I still encourage people with Hashimoto’s to eat broccoli and other cruciferous vegetables.

I don’t know when I told you this last year when I interviewed you. With hyperthyroidism, in the past, I intentionally had people take larger amounts of cruciferous vegetables to see if it would suppress thyroid function. It didn’t. I actually tried to test the goitrogenic properties, see if it had those goitrogenic properties. I agree with what you said. 

Dr. Sarah: 

It would be lovely in the context of Graves’ to have such a simple solution, wouldn’t it? 

Dr. Eric: 

Exactly.  

Dr. Sarah: 

I actually think it’s sad that it didn’t. It would have been a nice thing just to be able to say, “You have Graves’. Eat all the Brussels sprouts.” That is where the scientific studies are, too. 

Dr. Eric: 

There are other interesting myths, like it’s fine to eat non-organic foods. It sounds like you will choose organic, but it depends on the situation. If the non-organic produce for example looks better than the organic produce, you mention that you will go for the non-organic produce.

I do agree to some extent. I definitely recommend organic. The #1 thing is whole, healthy food. If that’s all they can afford is non-organic produce, they are still eating whole, nutrient-dense foods. To me, that’s still okay. I’ll let you expand on that because it was very interesting. 

Dr. Sarah: 

We have this collection of studies that show that organic foods are healthier than conventional. The couple of meta-analyses that have been done that look at the body of scientific literature as a whole. 

What’s so important about meta-analyses is they do a couple of really important things. They look at everything. What are all the studies that have looked at this question? What do they all say together on average? They pool together all of the data from all of these different studies, so they have a much larger data set. They have much higher statistical power that is really important.

They also include a step where they evaluate the quality of studies. They look for things like: Was this controlled properly? Was this blinded properly? Nutrition studies are tough to do blinded because you know what you’re eating. Did this have an appropriate control? Did the statistical analysis include these types of corrections? They will include stuff like that.

Right now, there is only a few meta-analyses that are actually looking at this question of organic versus conventional. In this particular field right now, there is not really good, really big studies yet, so we definitely need more studies. The ones that have been done don’t control for healthy user bias very well. Healthy user bias is something that we see in epidemiological studies. You have to control for it in your statistical analysis. Even then, sometimes, it’s so impossible to get rid of this residual effect. 

What it refers to is a person who does a lot of things that are good for their health that is associated with this one thing. A great example is the studies are now showing that red meat is probably pretty health-neutral and is a really good source of some important nutrients that a lot of people are short on. That’s where this science comes from.

Red meat has been demonized as a cause of cardiovascular disease for 50-60 years. A long time. Now, somebody who’s health-conscious is putting a lot of effort into their health. Someone who is more likely not to eat a lot of red meat. People who don’t eat much red meat are much more likely to eat a lot of vegetables, to be more active, not to smoke, not to drink. They are also more likely to have social determinants of health working in their favor, so they are more likely to come from middle class, not to be poor, things that are really important for overall health. They are more likely to have quality medical care.

These big studies will try to account for as many of these factors as we can. They will do these complex statistical analyses, where they go, “What is the effect of red meat if we control for BMI and annual income and age and gender and race and ethnicity? Then we will also control for activity, smoking status, etc.” They add all of these things together. Once I have controlled for everything else, is there still an effect?

The problem, when so many different health-promoting behaviors stack, there is a residual. Even if the statistical analysis is saying, I am going to control for all of these different things, there is a leftover. You still see this signal of organic foods are better than conventional. 

One of the things that these studies don’t control for is diet quality. They are just looking at if this person is eating organic or conventional. They are not looking at how much vegetables or seafood or legumes they are eating. That is something we also see. 

Again, it’s healthy user bias at work. Someone who eats more organic food is more likely to have more money and actually more likely to be younger and female. Females have lower risks of a lot of health problems compared to males. They are more likely to be active, not to smoke, not to drink. All of these things stack. 

Where the science is at right now is it’s not clear that organic foods are better. They don’t seem to be worse. It’s really those overall eating patterns that matter. 

For me and my life, I grow a lot of my own vegetables now. I have been growing my own vegetables for about four years. Every year, I add a bed to my vegetable garden. My plan is to keep doing that until it is too big, and I can’t keep up. 

Every year, I add 15 more square feet, which is one more. I will dig it out and make my garden bigger. Every year, a bigger percentage of the vegetables my family and I eat come from my own backyard. 

In my backyard, I grow organically. Part of that comes from the studies on pesticide use show that as an occupational hazard, absolutely. Also, pesticide use in home gardens can be a risk factor for a bunch of health issues. That level of exposure, even if it’s not occupational, can still be a problem. 

In my garden, I just sacrifice a certain percent of my vegetable yield to slugs and aphids. It just is what it is. 

In the grocery store, I would say I buy more often conventional than I buy organic now. I tend to go for organic. Sometimes, organic looks so much better. This week, the organic asparagus was only a dollar more, but it looked just amazingly so much better than the conventional asparagus. That is typically when I will buy organic in the store. 

Also, most of my vegetables are organic because they are coming from my own garden now. 

Dr. Eric: 

Makes sense. For the sake of time, I will refer the listeners to your book for the other myths. Canned foods and BPA and raw versus pasteurized milk. There is plenty of great and interesting information. 

As we wrap things up, if you could just talk about how people could apply the Nutrivore principles. How can people get started? 

Dr. Sarah: 

The easiest first step depends on where you are now. You can get incredibly sophisticated. I have weekly serving targets of 12 different foundational food families if you want to get into the weeds in terms of making sure you’re getting that full breadth of nutrients.

The easiest place to start is just focusing on those overall eating patterns. There are three overall eating patterns that we know from every scientific study ever performed. They support long-term health and reduce just about everything that can go wrong with us health-wise. 

The first is to get ideally at least 80% of our calories from whole and minimally processed foods. That can include canned foods. That can include frozen foods. A lot of those are minimally processed. If it’s just green beans, water, and salt in that can, that is a minimally processed food. 

Actually, nutrient retention is the cool thing of the Nutrivore score. It shows us nutrient retention in canned foods is actually way higher than I would have thought. I would have thought you would lose a lot of nutrients in canning. We don’t; it’s fascinating. That’s eating pattern #1. 

The other 20% can come from anything that we like. Obviously that we are not allergic or intolerant to or we can’t eat for whatever other reason. 20% is really important for the sustainability part of an overall healthier diet. Worth a slight tangent. 

One of the goals of Nutrivore is sustainable nutrition. Higher diet quality that doesn’t leave us feeling deprived, that doesn’t have us doing the diet rollercoaster, the on again/off again, yoyo thing. It has to necessarily then be a diet where we are enjoying the foods we eat. It is not taking too much time or energy or money in order to continue to eat that way. 

In my life, that has also meant being very intentional to incorporate what I refer to as quality-of-life foods. These are treats in my life. It’s dessert. For me, that’s what it is. It’s foods that are really tasty, not objectively nutrient-dense by any stretch, but they’re foods that make sure I am getting enough joy from my diet that all of those other healthy choices are easy to keep going with. 

Under that same umbrella is permission to cook vegetables in ways that you enjoy. One of the most toxic messages from diet culture is this idea that a healthy food doesn’t count if we’re enjoying it. Salad only counts if it’s plain. Vegetables only count if you are gagging them down. 

We can absolutely add salad dressing or other flavorful ingredients to a salad that doesn’t take away from the nutrients in that salad. That salad dressing will actually make some of the fat-soluble nutrients easy to absorb. There are benefits to adding salad dressing. 

All of that is under that first dietary pattern. If that’s the only place you start, that can be fantastic. It can be a big shift for a lot of people to reduce ultra-processed food intake and eat more whole foods. That is why I would recommend and think it’s important to talk about doing that in a way that is intentional, to make sure we are still getting joy from food.

Thes second eating pattern that is really important for overall health is dietary diversity: eating a wide variety of different foods. This is fascinating. I am working on a video to answer a question on social media that is tackling this topic. At the end of the day, I am so tired. I don’t have much energy. It’s really easy to eat the routine thing I always eat. There is actually a lot of benefit to routine as well. 

Finding where we can increase dietary diversity in a way that again makes sure we are keeping it sustainable. It’s not taking too much time or energy or financial resources to do. What are the ways where we can mix it up in a way that still fits with our other constraints, the other things that we need to maintain our time and energy and money for? 

Ideally, maybe it’s something to 30-35 different foods in a week. That sounds like a really big number. Getting a different variety of apple counts. Spices in your food count. Every single way that we can mix it up counts. 

The reason why that is such a great eating pattern is diversity of foods tends to mean diversity of nutrients. It tends to lower the chances that there are shortfalls of any one nutrient if we are eating a wide variety of food.

The third eating pattern that is really important to work on is eating lots of fruits and vegetables. Ideally, the science is mixed on this. I interpret it as five or more servings of vegetables per week. A different scientist might look at it and say three or more is great. I always like to couch that because five servings of vegetables per day can feel extremely intimidating for some people. If three is an easier place for you to start, then three is a great place to start. Someone could also make a strong case for three being a great serving target for vegetables. 

Then two or three servings of fruit is the Goldilocks zone for fruit. That is a long-term eating pattern. 

Those eating patterns, it’s not counting anything. It’s not measuring anything. It’s just getting used to a slightly different meal composition. Maybe a slightly different grocery shopping list. Maybe getting used to cooking at home more often. Those overall eating patterns get us most of the way to Nutrivore. 

Then we can get sophisticated. That gets us most of the way. All of those eating patterns are beneficial above and beyond just also being nutrient dense. 

Dr. Eric: 

All right. Whole foods, variety, and eat your fruits and veggies. This was amazing. Thank you so much for sharing. If you could let people know where to find out more about you. Obviously, your book is Nutrivore. Make sure to share your Patreon. I told you that I am a Super Nerds tier member of that. Right now, I’m telling people where they can find you. I’ll let you take over. 

Dr. Sarah: 

Thank you. My new book is called Nutrivore: The Radical New Science for Getting the Nutrients You Need From the Foods You Eat. It is available wherever books are sold. Any online bookseller. Many local, independent bookstores. It might be at your local library. If it’s not at your local library or local bookstore, you can also put in a request to get it in, whether you want to purchase it or borrow it. 

It’s available in hardcover, digital format like Kindle, or audiobook, which I narrated myself. It’s also accessible in whatever way you like to read books. 

Everything we talked about today is in the book. Plus 100x more. That is the most comprehensive resource I have for Nutrivore. 

I also have a website, Nutrivore.com. That is where the most academic articles live. That is where if you want to know everything that Vitamin C does in the body, you can read about every single thing Vitamin C does. There is over 60 articles on different nutrients on the site right now. 

It’s also where you can learn about every nutrient in different foods. If you want to know everything that is in iceberg lettuce, you can see that. There are lots of other practical strategies and Q&As on the site. 

It’s a really humongous resource. My team and I are adding to it almost every day still. If something that you are looking for is not there, come back and check again later because it almost certainly will be very soon.

My Patreon is a wonderful community of supportive people like you who are really into Nutrivore. 

I also create resources every single month specifically for my Patreon family. I create an e-book every single month. Right now, we are doing the rainbow series. I know what’s coming next, but I’m not quite ready to announce it. I am even more excited about what’s coming next in e-books.

I podcast every single month. We are going to start doing weekly videos, answering questions. 

I also have what’s called a Nutrient Fun Fact sheet. It’s a two-pager of the most important things about a nutrient. There is a different nutrient featured every month. It’s in bullet points, so you don’t have to read detailed articles.

Also, recommended dietary allowance by all of the different age and gender groups. 

Tons of great resources for Patreon. Tiers start as little as $3 a month. It can be a great place to come hang out with other nutrient nerds, all for the price of less than a coffee nowadays. I used to say $3 a month was the price of a coffee, but coffee is more expensive now. It’s 2/3 of a coffee, which helps support me and my team continue to build out the website.  

Dr. Eric: 

Check out her amazing book, her website, and become a Patreon member. She puts together amazing videos. 

Dr. Sarah: 

I didn’t even say social media, did I? 

Dr. Eric: 

YouTube, so much valuable information. 

Dr. Sarah: 

I realize the other place to get more information, I’m @DrSarahBallantyne on YouTube, Facebook, Instagram, Threads, Pinterest, and TikTok. I actually post different content on all of those platforms. Wherever you like to hang out, there’s something there for you. If you hang out multiple places, I have different things for you. There is a lot more bite-sized content in those places. 

Dr. Eric:

Thank you so much, Dr. Sarah. This was a great conversation. Really enjoyed listening to your book. I’ll also read it as well. Thank you so much for your time. This was great. 

Dr. Sarah: 

Thank you.

 

Recently, I interviewed Dr. Meg and we discuss the basics of histamine and its metabolism, symptoms of histamine intolerance, the connection between histamine and thyroid health, the impact of gut health, hormonal balance, and the microbiome on histamine levels, practical tips for managing histamine intolerance, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with Dr. Meg Mill, as we will be talking about histamine and tying it into thyroid health. A lot to talk about when it comes to histamines.

Let me dive into Dr. Meg’s impressive bio here. Then we will start our conversation. Dr. Meg Mill is a Pharm.D. and certified functional medicine practitioner with over two decades of clinical experience. She is also a bestselling author, podcast host, summit host, and sought-after corporate wellness speaker. 

Her virtual functional medicine practice has transformed the lives of hundreds of clients worldwide by connecting the dots between the diverse, unexplained, and often overlooked health struggles such as migraines, gut issues, chronic fatigue, skin reactions, anxiety, or allergies. She uses her EAT Method to uncover and resolve the underlying connections, whether it’s histamine intolerance, hormone imbalances, gut dysfunction, or MCAS (mast cell activation syndrome). Welcome, Dr. Meg. 

Dr. Meg Mill: 

Hi! Thank you so much for having me. 

Dr. Eric: 

It is a pleasure to have this conversation, talking about histamine. So many people have histamine imbalances. Many of these people don’t know they have histamine imbalances. Let’s first dive a little bit more into your background. How did you start helping people with histamine intolerance as well as MCAS? 

Dr. Meg: 

I actually have it myself. I didn’t realize it for so many years. I was the kid who had tons of allergies. I remember my parents actually redid a dresser for my room, had it painted, and I couldn’t keep my clothes in the dresser after it was painted because it would make me so sick. “My clothes make me sick.” My mom was like, “Why? What’s wrong with your clothes?” There are all these clues for people over time.

What I started to find was that histamine issues, MCAS, they are growing more. They are connecting a lot of different symptoms. I am saying I was someone who had allergies. I was highly reactive. Then I started having GI issues, where I couldn’t even eat anything. I was having so much stomach pain. I jumped around from gastroenterologist to gastroenterologist and was told I was fine, that I was the picture of health. Then I got anxiety, which led to insomnia. All of these things that started happening and building on each other seemed to me unrelated, but they all have this common link, which is histamine. 

Sometimes, when you’re looking at it through the histamine lens, you start to connect all of these dots and think, “My anxiety and my allergies and my gut issues, they don’t all seem related.” But when we are looking at it from that point, if we can get the histamine to be lower, to get it under control, a lot of things will clear up.

I was having a lot of my own personal health issues. Then I also was not getting any answers and being told I was fine. Here I am in the health space, and I can’t get answers for myself, which led me to functional medicine.

I actually made a career change. I got certified in functional medicine and opened a functional medicine practice. Now I help people all over the world get to the root of their mystery health conditions. Looking at the connections of all of these different symptoms and how your body builds on the connections. We can just unwind it to get you feeling a lot better. 

Dr. Eric: 

Histamine issues can definitely be complex. It’s safe to say some people watching this are familiar with histamine. There are some people who aren’t familiar with histamine. That is my next question. For those who are asking what histamine is, can you explain what it is? We will go deeper. We are not going to get too much into MCAS. Or we could. It depends on you actually. I want them to know the basics of histamine and histamine metabolism. 

Dr. Meg:

Histamine is the new cortisol. When you think of cortisol, you think of bad. When you think of histamine, you think of bad. But they do have purpose in your body. 

Histamine is what we call a biogenic amine. When your immune system detects an allergen or invader, histamine is released primarily from your mast cells or basophils as part of your immune response. 

In your immune system, we have two different systems. We have your innate immune system and your adaptive immune system. The mast cells are part of this innate immune system, so they are ready to go. They are ready to fight. They are not selective. Let’s get this. 

One of the things they release is histamine in order to do things like increase permeability of the blood vessels, which allow immune cells to reach the area more quickly. Histamine helps with immune defense.

It helps with regulating your gastric acid secretion to break down food and aid in digestion. 

It affects your neurotransmitters. It can affect serotonin, norepinephrine, acetylcholine. It can be involved in your wakefulness, your alertness, your cognitive function, your mood. 

It’s a part of the allergic response. That’s what most of us think of when we think of histamine. It can also cause broncho restriction. It constricts your airways to prevent harmful airborne substances to enter too deep into the lungs. 

And it actually also creates an inflammatory process. It actually creates inflammation. It recruits immune cells to the site of infection or injury through this increased vascular permeability and blood flow to create this inflammatory response.

However, when it’s excessive or not regulated, it can lead to chronic inflammation. That is when we start to get a lot of these symptoms and problems.

Dr. Eric: 

I’m glad you mentioned an excess. Histamine by itself isn’t a bad thing. It’s important. We need histamine, just like inflammation by itself is not bad. It’s when it becomes excessive and chronic. 

Let’s talk about histamine, especially the metabolism. There are different enzymes: diamine oxidase (DAO). I’ll let you take over because you are the histamine expert. 

Dr. Meg:

Let’s use a bucket analogy. Think of your body like a bucket with holes in the bottom of the bucket. You’re filling it up, and it’s draining. You’re filling it up, and it’s draining. We keep doing that. Everything is fine. You feel good. You’re moving through life.

When we start to have these symptoms of histamine intolerance, we start to have one of two or both things happen. We are either pouring too much water into that bucket, and it’s overflowing. Or we plug the holes in the bottom of the bucket. Or both.

When we plug the holes, it fills up too much. When we fill it up too much, we fill it up too much. If we get this overflow, that is when we start to have all of these symptoms.

 We will talk about what plugs the holes. You break down histamine by two different pathways in the body. One is diamine oxidase, which you mentioned. The other one is histamine n-methyl transferase (HNMT). 

The diamine oxidase is the main enzyme responsible for breaking down histamine from foods in our intestinal tract. We will get into some of these histamine-producing foods that are often healthy foods. That can be really confusing sometimes because things you think are eating for certain purposes to help your body can also be high in histamine and create some of these problems. 

We want to look at some of the other reasons that diamine oxidase can become compromised. First of all, people can have genetic variations. I am one of those people. I told you, I had some of these symptoms forever. Generally, they build because even if you have the genetic variations, we’ll get into how gut health can play a huge role. If everything is functioning properly, we can usually overcome some of the genetic variants. You can have genetic predisposition not to process histamine as well.

The main thing we see are imbalances in your microbiome. We need to have certain gut bacteria that can help us break down the histamine. Then we have bacteria that actually inhibits the DAO. We can have histamine-producing bacteria. We can have mast cell-activating bacteria. We can also have things start to happen that compromise this enzyme function. 

Once we have compromised enzyme function, then we can’t break down histamine very well. Everyone pretty much knows about lactose. There are certain people with lactose intolerance. When you have lactose intolerance, you can’t eat dairy because you have problems breaking it down. It’s a very similar enzymatic reaction. 

When we are eating histamine, we need diamine oxidase to break down those foods, so they are not affecting us. We can also see that once we start to get intestinal permeability or leaky gut, we can also get chronic inflammation. This inflammatory response can also downregulate the regulation of diamine oxidase, so the body can shift more toward resources for managing inflammation. Then it can further exacerbate histamine-related issues. We are seeing some of those things happen.

We can also see certain nutrient deficiencies. We know that certain nutrients are required to make diamine oxidase. Things like Vitamin B6, copper, and Vitamin C can also be a problem. I know I keep coming back to the gut, but sometimes, even if we are eating all those nutrients, but we can’t digest or absorb them, we may not really be getting the full effects of those.

We are looking at all of these things together to look at how well are you really breaking down histamine? 

Another one that might be surprising to you is fluctuation in hormones. Estrogen can cause the mast cells to release histamine. Estrogen can also influence diamine oxidase activity. Higher levels of estrogen can lead to a reduced diamine oxidase activity. 

Progesterone actually helps increase diamine oxidase. 

When we start to become estrogen-dominant, having high estrogen to progesterone, we can also see hormones creating an imbalance that can affect it. That can play a role in one pathway.

We have another pathway, which is HNMT. You have probably heard of methylation at this point. Everyone is talking about that now, which is good. We are starting to see that we need methylated B vitamins. We need to be able to methylate in order to break down histamine. 

Histamine is methylated into HNMT. It goes through this methylation process and is excreted in the kidneys.

One thing I just want to clarify is a lot of people are talking about MTHFR. A lot of people are talking about methylated B vitamins, which is great. That is not the only thing that is affected in this pathway. Sometimes, we actually need to look further down the pathway. 

We can also see an MAO variant, monoamine oxidase, affect this pathway. You may need a riboflavin, B1, or B2. You can push some methylated B vitamins. If you feel worse, it might be because you have blocks further down that pathway. That’s something to keep in mind.

We also need certain vitamins and nutrients for that. We mentioned folate, B12, B6. Different nutrient deficiencies can play a role. Sometimes, we see poor liver function affecting the methylation pathway. Some drugs. We want to make sure that we really have those pathways open. 

Dr. Eric: 

I’m glad you shared that. I will summarize. There are two main enzymes that break down histamine. DAO, diamine oxidase, is the main one. HNMT, which is the other enzyme that can help with that. There are different factors that can influence these enzymes. You mentioned the importance of the gut microbiome and of course genetics. When you talk about genetics, it’s not just MTHFR. With HNMT, you mentioned methylation. You mentioned MAO.

One thing related to that is COMT. You also mentioned that COMT is involved in methylation. But you mentioned, and I am going down a rabbit hole here, estrogen can inhibit DAO. The COMT also plays a role in estrogen metabolism as well. If someone has a genetic variation in the COMT enzyme, can that also affect the breakdown of histamine at all?  

Dr. Meg: 

It can. A lot of these pathways we are seeing are interconnected. That is one of the main points of functional medicine, right? When you’re talking about something, you’re looking at this one thing, but I’m always telling people, this relates to that, and this is connected here. They’re all connected to each other in various ways. When we look at this, we are looking at it from a whole person perspective. We are looking at how each one of these pieces, your lifestyle, your genetic factors, all of your levels are playing a role into what’s going on in a unique way for you. A lot of different things can play in when looking at some of these pathways and breaking down.

Dr. Eric: 

What are some of the more common symptoms people will experience when having a histamine intolerance? 

Dr. Meg: 

I think this is a tricky one for people to understand. We think of nasal congestion, sneezing, asthma, difficulty breathing. Then you’re thinking about highly reactive, maybe hives, rashes. Those all can be. But we can also see headaches and migraines. The people I work with with migraines, a high majority of people have histamine intolerance. We see fatigue, heart palpitations, dizziness, anxiety, depression, difficulty concentrating, PMS, irregular periods, flushing, joint pain, insomnia, high or low blood pressure. As you can see, there is a lot of different symptoms. 

A lot of digestive difficulty. There is more and more research with IBS and histamine intolerance and the effect of mast cells. A lot of IBS symptoms are also coming from histamine issues, too, that are playing a part. 

I think that’s one of the messages I’d love to hit home in this episode. Like we’re saying, it’s more than just allergies. When you’re talking about your thyroid, let’s say you could overlap some of these symptoms with thyroid. You can overlap some of these symptoms with a lot of different things. It’s really looking at what lens are you looking at it through? Could histamine be a part of this picture? 

Dr. Eric: 

Speaking of thyroid, would some of the relationships between histamine and thyroid that you’re aware of? 

Dr. Meg: 

Thyroid hormone, particularly T4 and T3, can influence the metabolism of histamine. We do want to make sure that we have proper thyroid function to help maintain balanced histamine levels. They can play a factor in the activity of the diamine oxidase and HNMT. Looking at making sure your thyroid levels are balanced. 

We are talking about histamine intolerance as gut health. When we are looking at Hashimoto’s and thyroid, the leaky gut, gut health is really critical. We want to make sure that we are optimizing our microbiome, that we are looking at what good bacteria we have, what overgrowth we have, and really getting a balanced microbiome in order to optimize this function. 

Also, we are going to talk more about- I can bring this up a little bit here, too. The mast cells. We sometimes can see mast cells present in the thyroid gland. Their activation can affect thyroid function. 

We brought up mast cells. Histamine is released from mast cells. Some people can get what’s called MCAS. When we’re talking about filling the bucket, one of the things that starts to fill that bucket is MCAS. 

When we start to have this, our body starts to go into what we call a cell danger response. We start to feel like our cells are under attack. Once we go into the cell danger response, we start to react to everything. If someone has MCAS, they are more likely to be someone who is reacting to a lot of different foods. Sometimes, we can react to heat, smells, sounds, EMFs. We start to be more hyperreactive. Our mast cells almost are getting angry, and they are firing for no reason.

An example I like to use here is if you’re smelling a rose, and you’re touching a stove at the same time, every time you smell the rose, you touch the stove. This beautiful smell is associated with this pain. Then the person tells you, “Smell the rose, but take your finger off the stove.” You can smell the rose and still feel that pain because your body is still associating that it’s in danger. It’s associating that the smell of that rose is going to cause you pain even though that’s not there anymore. 

That’s what starts to happen in MCAS. Our body is starting to release these mast cells even when it’s not necessary, when we’re not in danger. In that case, we need to look at what is the root cause? What is happening to your body that is causing this excess release of mast cells? 

We sometimes also need to work on nervous system rewiring, working on bringing our body back into that parasympathetic nervous system to feel calm, to feel safe, to be able to do some different exercises to rewire our body and feel safe in where we are. 

Dr. Eric: 

Not everyone who has a histamine intolerance has MCAS, correct? That’s more advanced, you would say? As you explained, if you have an abnormal amount of mast cells, and things go a little bit haywire. 

Dr. Meg: 

Yes, exactly. Not everyone who has histamine intolerance has MCAS. A lot of people that have MCAS will have histamine intolerance because one of the chemicals released from mast cells is histamine. One of the major symptoms of that are histamine issues. 

You can just have simply an inability to break down histamine and maybe are putting too much histamine in your body with the inability to break it down well. All we really need to do is help you break it down, help you rebalance your gut microbiome through the lens of histamine intolerance. Look at some of these specific things and make sure some of these pathways are open. We can create balance very easily. 

Dr. Eric:

Is there a way to differentiate the two? I don’t know if you officially diagnose histamine intolerance by looking at histamine and looking at DAO. I know there are ways to do that, or if it’s more looking at the whole picture and the symptoms. Similar with MCAS. Are there markers that you look at on a blood test or elsewhere? 

Dr. Meg: 

Yes. There are diagnostic criteria for MCAS. You have to do certain testing a few days in a row. There is often urine testing. There are more diagnostic criteria. It’s hard to do. A lot of people aren’t actually always getting the diagnosis. They just can feel the symptoms. 

With histamine intolerance, we can test histamine levels in the blood, so that is a place to start. I personally don’t find that the end-all be-all marker because I see a lot of people with histamine issues who aren’t necessarily showing high blood histamine or DAO levels on a blood test. 

I personally like more of the diagnostic criteria. We do stool tests. We look at the microbiome. We look at some of the different factors to see what the person needs.

I think that’s another frustrating feature of people who have this issue. Sometimes, even the testing isn’t showing up as something that is conclusive. You feel like, “I’m having these symptoms. I don’t feel well.” Everyone is saying, “You’re fine.” It’s not so clear. Listen to your body. If you’re saying, “Okay, I do have some of those symptoms. I do have a cluster of more than one thing. I want to see what’s going on. I do feel like I’m more reactive.” Listen to yourself, and start thinking of this. 

It’s going up and up. We are seeing more and more cases. It’s becoming more mainstream because more people are really experiencing it than ever before. 

Dr. Eric: 

It’s a good point. Even if you are able to diagnose histamine intolerance or MCAS, you still need to address the cause of the problem. You mentioned that you do stool testing. You also mentioned earlier that you do things to balance the parasympathetic nervous system and some rewiring. People still want to have an answer. If they have type 2 diabetes, insulin resistance, it’s nice to see that on a blood test. When it comes to histamine intolerance, they may or may not get the answer. Either way, you want to do things to address the cause. 

You mentioned earlier IBS. I don’t know if this still holds true, but I know at least a few years ago, there is an overlap between SIBO and IBS. Not all cases of SIBO are IBS. Maybe it’s a percentage. I guess there is that overlap with histamine intolerance and SIBO. The question I’m trying to ask is: When you see people with SIBO, a lot of those people then do have histamine intolerance? Or is that something that you see in a lot of SIBO patients? 

Dr. Meg: 

Yes, there is three different ways. Great question. First of all, when you start to have SIBO or IBS, you have a disruption in the mucosal layer of your gastrointestinal system. That is where diamine oxidase is produced. When we start to get this imbalance, we start to potentially have a compromised function of diamine oxidase. That’s one bucket.

We also know there are certain bacteria that are histamine producing. We have things like certain forms of Lactobacillus, Morganella, Pseudomonas, Citrobacter, Klebsiella. We have certain bacteria that can actually be histamine-producing and be behind some of these triggers on their own. 

I am going to tell a side story because I think it’s very interesting. I worked with a man who had Urticaria, itching so bad for 20 years. He had to take hydroxyzine every day, which is a prescription antihistamine. It makes you very drowsy. As soon as it would start to wear off, he would just full body itch. He would have to take another one. He was getting shots. He had been to so many different doctors. 

He had no GI symptoms. I said, “I want to do a stool test.” He said there was nothing wrong with his gut. I said, “Bear with me.” He had really high levels of Morganella. That is a histamine-producing bacteria. We treated the Morganella. Within 3-4 weeks, his itching was gone. 

I think it’s such a profound story. It’s showing that 20 years of this really severe problem that had nothing to do with his gut health in his mind was really a histamine issue from some of these microbes. They are very powerful. We sometimes don’t realize that. I wanted to give you some context around some of the things that can be going on that you’re not even realizing from the microbes.

The third bucket is when we have SIBO, when we have a parasite, when we have H-pylori, when we have some of these invaders, that can be a root cause. “I have to create an immune response. I have to fight this invader all the time.” That’s stimulating your immune system. If you’re sensitive in your immune system, you can be releasing more mast cells to degranulate and create more histamine, more mast cell issues. 

There is three different ways. All of them can be playing into this dynamic. 

Dr. Eric: 

All right. You gave the example of Morganella, but if you have other imbalances, like H-pylori or parasites or candida overgrowth. How about SIFO? 

Dr. Meg: 

Yes. 

Dr. Eric: 

When people are aware they have histamine intolerance, or they suspect it, some people just eliminate foods higher in histamine. That could in some cases make a big difference in the symptoms. It’s not addressing the cause of the problem, but do you still have people do that while they are addressing the cause of the problem, to avoid those foods, to do the low-histamine diet? 

Dr. Meg:

I think it’s a very good tool to use. I love how you said that. I think people can get really caught up in the low histamine diet and the nuances and start to feel like this is how they need to live. I want to stress that’s not the end-all be-all. It’s not just stop eating all histamine foods forever. It can be a really good resource for you to start.

We want to start looking at different kinds of foods. We know there are certain foods that are high in histamine, such as cheeses, fermented foods, cured meats, alcohol. 

We are talking a lot about gut health here. If you are looking at a generalized protocol for gut health, fermented foods and bone broth are generally on those protocols. We know they support the microbes and are good in general, but not for people with histamine intolerance. You just have to be careful that when you’re looking at this, you’re doing it through this lens. That can be very confusing. You might be stimulating some reactivity in yourself. 

We also can see histamine liberating foods, like strawberries, tomatoes. We can have foods that limit diamine oxidase. Tea is a good example of that. Caffeine can block diamine oxidase. 

The other interesting component here is that when it comes to this freshness count, you can actually have issues with histamine from cooked meats. If you’re a meal prepper, you might want to flash freeze. We have a lot of people have issues with leftovers because histamine can grow in cooked meat. Always make sure you are eating more fresh foods than leftovers or canned products. 

Dr. Eric: 

That makes sense. Be careful about some of the foods. Bone broth and fermented foods, you’re right. They’re healthy foods, but if someone has histamine intolerance, it could cause other problems from a symptomatic perspective. Also, you mentioned increased inflammatory pathways as well? 

Dr. Meg: 

Yes. 

Dr. Eric: 

Okay. Supplements. Just like how eliminating foods can help but not fix the cause of the problem, same things with supplements. There are certain ones like quercetin or DAO. What are your thoughts on those? 

Dr. Meg: 

I think they’re great tools. We want to calm down the mast cells. We want to reduce the histamine load. While we’re working on the root cause, I do think finding relief is really important. 

You can get the DAO enzymes. I like some combinations of the quercetin with some other bromaline and nettles. There are different things we can put together that really are effective to bring some of these symptoms down. They can be very helpful for a lot of people. 

Dr. Eric: 

Gut microbiome, stress, adrenals. You mentioned nutrient deficiencies. Having healthy hormones because estrogen dominance can inhibit DAO. You mentioned the thyroid and the importance of having a healthy thyroid. A lot of different factors out there. 

What would be the first steps people should take for someone who is thinking they might have a histamine intolerance? Should it be working with a practitioner like yourself? Are there things they can do on their own to get started? 

Dr. Meg: 

I would say start with the low histamine diet. I have a handout that lays that out nicely. A lot of low histamine diets out there maybe are inaccurate or confusing. I will give that to you as a resource. If anyone wants to go to that, it’s a lot of information on histamine and foods. You can follow that. It’s nice to have a road map in what to do. Start with this low histamine diet.

If you’ve done that and are still having issues, or if you don’t want to stay on this low histamine diet forever, people just do that alone for too long, and they start to react to foods when they start to put them back in. Then work with a practitioner to get to the root and put some of these pieces together. If you do, you can see a dramatic difference in the way you feel. 

Dr. Eric: 

You have a summit coming up. Before you talk about the summit, where can people find out more about you, like your website? Anything else you want to share? 

Dr. Meg: 

My website is MegMill.com. I do free discovery calls. If you want to learn more information, I’d love to get on the phone with you and talk through what you’re going through. You can book that on the website.

I am on Instagram @DrMegMill. I also have a podcast called A Little Bit Healthier, where we talk about all different health topics. I’d love to see you over there. 

I’m really excited about this summit. It’s going to have so much great information. I’ve spent the last eight months working on this. There are over 50 experts in this field. We are going to talk about histamine intolerance, mast cells, and all of the different ways it can affect you. 

It’s a free event, June 18-24. It’s with DrTalks. Go to DrTalks.com. Just sign up, and you can watch about 50 hours of education for free. That’s a great place to start. We will put a lot of these connections together and give you some great tangible tips. 

Dr. Eric: 

That’s going to be awesome. Check that out. Check out her website and podcast. Thank you so much. You shared some great information about histamine intolerance and MCAS. Looking forward to the summit as well. 

Dr. Meg: 

Thank you so much. Thank you for having me.

 

Recently, I interviewed Nagina and we discuss how adding metabolism-boosting foods and spices helped her lose 40 pounds, the importance of incorporating adequate protein and vegetables into the diet, the benefits of spices like cinnamon, turmeric, and cayenne pepper, intermittent fasting, the need for personalized dietary choices, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky:

I am very excited to chat with Nagina Abdullah. We are going to be talking about metabolism and spices. It will be an exciting conversation. Let me go ahead and dive into Nagina’s bio. Then we will get more of a background.

Nagina Abdullah is a weight loss coach for women in midlife and founder of the website MasalaBody.com. She teaches women to boost their metabolism by adding and combining metabolism-boosting foods to reduce body fat and overall weight gain in midlife.

Nagina has a degree in molecular and cell biology from UC Berkeley. She has helped over 1,500 midlife women successfully lose weight and create a lifestyle change. Thank you so much for joining us, Nagina.  

Nagina Abdullah: 

I’m so excited to be here, Dr. Eric. Thank you for having me. 

Dr. Eric: 

It’s great to have this conversation. I think a lot of people will find it to be fascinating, especially when you talk about some of the different spices. I’m really excited about that. Of course, you have a lot of other things to share, too. If you could give more of your background, how did you start helping midlife women to increase their metabolism? 

Nagina: 

Absolutely. This is really a product of a personal transformation, where I had struggled my entire life with getting healthy, being at the weight I wanted to be at, at a healthy weight, having control over my sugar cravings, and actually creating a lifestyle versus going off and on diets, which I did for my entire life. 

I had tried every single diet out there from Weight Watchers to eating less and exercising a lot to Atkins to South Beach. For all of those diets, I would lose some weight, but then I would put it back on pretty quickly after because I would just start doing all those things I had restricted myself from for the weeks it took me to lose my weight.

After I had children, I actually was at my highest weight ever because I had pregnancy weight from two children. I also never had really gotten to a place where I was very satisfied with my overall balance of how I was managing my weight. That is where I reached into my background. I have a degree in molecular and cell biology from UC Berkeley. Let me do my own research instead of reading magazines and website posts. I no longer have the time to go on diets with two children, with a full-time career. I needed to lose the weight, feel good about myself, and be healthy. It was more about having more energy for myself and my children for all the years to come.

I started researching that information. I started finding foods we can add to our diet instead of take away. When you add foods, they boost your metabolism. There are other things you can add like certain spices that actually help you boost your metabolism and make your food taste good. 

I started doing those things. I lost 40 pounds in nine months. This was not easy. Right now, when I’m saying it, I just said it in one moment, but it was a lifetime of transformation that happened in nine months. It was because I learned how to eat differently.

That is when I started coaching women. A lot of people asked me how I did this. How did I look more in shape after children? Everything was working really well. 

Then I hit midlife, and things started changing. I realized there is definitely something different happening. There was more belly fat. More plateaus. No matter how much I exercised or what I ate, it wouldn’t come off. 

That’s where I started looking more at blood sugar management, balancing what you’re eating, and hormones. My weight was able to come down. Increasing muscle mass, too. It’s not even about weight; it’s about changing your body. That’s how I specialized in helping women in midlife. I have helped over 1,500 women lose weight, gain strength, and create a healthy lifestyle, which is the most important of all. 

Dr. Eric: 

I like that you said 40 pounds over nine months because some people might say, “That’s it? It took you nine months to lose 40 pounds?” Some people say 20 pounds in one month. I think what you did is reasonable. You want people to have reasonable expectations, and you want them to do it in a healthy fashion. Not to say some people might lose more weight in that period or a shorter period of time. 

To me, that sounds very realistic. If you said, “I lost 40 pounds in two months,” not to say that can’t happen, you might have clients where that did happen. Again, you’re being up front and not coming up with a crazy number in a short duration. Appreciate your honesty. 

Nagina: 

Absolutely. The thing is, a lot of times, when someone has 40, 50, or more pounds to lose, even 30 pounds, it can seem pretty daunting. Especially when you start doing things, and it feels like the scale is moving so slowly, it feels like it’s a long journey. Setting yourself up for that by doing increments of either two pounds or five pounds is really helpful. I lost the first five pounds. I couldn’t believe it. Then I lost ten pounds. That is where I realized this was a real journey I was on. It felt so easy, so I kept going. Then it just adds up. 10 pounds can turn into 20 pounds, 30 pounds, and more. 

It’s just about getting started, but getting started in the right way, where you can feel like you can keep doing this. Once you get to the weight you want, you don’t want to start reversing all of the things that you had done to get there. You want to enjoy that journey, love what you’re doing, so you can keep it up even when you’re there. 

Dr. Eric: 

One thing you also mentioned is to improve metabolism by adding certain foods, not necessarily removing certain foods. I am guessing if someone is eating a lot of inflammatory foods, you probably would recommend cutting those out. If they are eating a lot of refined foods and sugars, fast food, maybe they could still lose weight, even if they followed your recommendations. From an overall health perspective, would you still recommend for people to eat relatively clean? 

Nagina: 

The way I educate and teach people to make this lifestyle change is by focusing on what you can add. As a result, you don’t have a craving for those processed foods or inflammatory foods. You actually feel the difference in your body. You don’t want to feel like that anymore. 

By adding the metabolism-boosting foods, which we will talk about, the cravings for other things go away. An example of how this works is a lot of the inflammatory foods or unhealthy foods break down to sugars. Lots of carbs break down into sugars. That is the definition of what they are. They are carbs but positioned in a different way. They may not even be sweet.

When you are eating foods that break down to sugar, sugar makes you want to have more sugar. If you’re eating those foods that are not clean, that are breaking down to sugars, even if you’re not eating sweet foods, your body is going to feel overwhelmed in craving more sugary foods. It’s really hard to get off the cycle.

When you start introducing and leading with foods that don’t break down to sugar as quickly or at all, what happens is your body doesn’t want that anymore. Sugar is a drug. You give yourself a little bit, and it wants more of it. When you replace it with other really good foods for your gut, your brain, your metabolism, then it starts to become a very easy cycle, where you don’t even have those sugar cravings anymore. 

Dr. Eric: 

Do you recommend a lower carbohydrate, or a medium carbohydrate? 

Nagina: 

Overall, the most important part of carbs is you are eating the right kinds of carbs, so the sources of carbs should be important. The amount of it is going to vary with where you are in your journey. 

When you are losing weight, you want to have more of these what I call slimming carbs. Slimming carbs are carbs that don’t break down as quickly. Instead, they break down slowly, so they’re not elevating your blood sugar. When your blood sugar is elevated, that is when you’re storing fat. When your blood sugar is going up and down, insulin is being released. It’s taking that excess sugar out of your bloodstream and being stored as fat.

Ideally, you want to keep your blood sugar levels even. You can do that by adding carbs. Just eat slimming carbs. Slimming carbs are things like lentils. Lentils are amazing. They are carbs, but they are full of fiber. They also have some protein. That causes them to break down more slowly, so your blood sugar stays even. You can have carbohydrates in your diet, but you’re not feeling like you want more because you’re not feeling that up and down in energy. It’s also better for our stress levels. 

Lentils, beans, high fiber bread, like Ezekiel bread or even rye bread or sourdough bread are good options. Also, starchy veggies. Things like zucchini, squash, along those lines, sweet potatoes. Finally, what I call slimming grains, which are alternatives to rice. There are things like buckwheat or farro, other things that look and feel like rice, but they are not breaking down quickly. 

When you are in this weight loss mode, you don’t want to lead with carbs. I recommend having carbs to once to twice a day. Have them at lunch and either at dinner or breakfast. Have about a half cup to a cup. Your body is going to break it down slowly because these are slimming carbs. You also won’t be craving more carbs because you will be adding a lot of other foods as well that are anti-inflammatory. 

Dr. Eric: 

Here’s a question. If someone is following a paleo diet, is it okay for them to eat starchy vegetables but not eat some of these other slimming carbs, like Ezekiel bread? I know it’s healthier than other types of bread, but if they are following a paleo diet, they will be avoiding grains and Ezekiel bread. Can they focus on the starchy vegetables and some other foods you will mention? 

Nagina: 

Oh yeah, they can do that. Carbs is something that is like a lever. If you want to have more, you can. You don’t have to have more. A lot of people respond better to less carbs. Some people need more.

In general, you’re not leading with carbs anyway. Carbs are coming from these healthier sources. Yes, you can absolutely get them from vegetables. Over the course of the day, we get a lot of our carbs from vegetables. If you’re eating fruit, they’re going to be in your fruit because they will have more sugar. You will get them in different ways, but if you are wanting to have that extra serving of carbs, those are those alternatives that I talked about in terms of slimming carbs. You can use any source you like. 

Dr. Eric: 

Speaking of fruits, do you recommend minimal fruit or no fruit? 

Nagina: 

Fruit is something you can have, but I recommend low sugar fruit. Then you are not getting that sweetness, that breakdown of sugar. You are not feeling the need for more sugar. 

Fruits like berries, especially strawberries, taste so good. Raspberries, blackberries. Blueberries have more sugar than other berries, but if you do it in a mix, it’s okay. Tangerines are lower sugar. Having an apple or a pear, if it’s small, or having half of it, is really key. 

If you’re having apple or pear, which are higher sugar fruits, combining that with a healthy fat or a protein like peanut butter or nuts, because that slows down your blood sugar absorption, and you are not getting that elevation of blood sugar. Having fruits is good.

I really advocate having veggies with every single meal. With breakfast, have your fruit, but keep it on the low sugar side. Pair it with a protein or fat as part of a healthy breakfast. 

Dr. Eric: 

Sounds good. How about protein? How much protein do you recommend people consuming on a daily basis? 

Nagina: 

Protein is the #1 food to add to boost your metabolism. Protein is going to solve so many problems. Most women are undereating protein. We do need a significant amount of protein. You actually have to try to get that protein. You have to be diligent to have the right servings of protein and to have enough over the course of your day. 

First of all, I’ll talk about how much. But the #1 thing is if you add protein to every meal, and then have one snack that has protein, you are going to feel such a decline in your sugar cravings and your cravings for all the unhealthy foods we were talking about earlier, whether it’s processed foods, packaged foods, sweets, unhealthy, fast-burning carbs. You will no longer have those cravings. 

That may seem unbelievable, but watch. This is the quickest way to switch over having an unhealthy diet to a healthy diet: add protein. Really start by adding it. All the other things are naturally going to fall away. You will not feel like it. 

This is the #1 thing that my clients say has helped them lose their first 15 pounds, is to start adding more protein at breakfast. That is the #1 way. That is an area that so many people skip, especially women for many reasons, maybe because they’re busy, because they feel like if they eat less, they will lose weight, or they are following an intermittent fasting diet. They are not getting protein in the morning, and that adds up over the course of the day. You will likely not have enough protein for your body.

What I recommend is to have .8-1g of protein per body weight. What that means is if you’re somebody who is around 150 pounds, that is having somewhere around 120-150g of protein. You do have to try for that, but once you start doing it, your appetite is going to be reduced all across the day. 

It’s easy to start to get that protein if you start thinking about having 30g of protein at each meal. Having 30g at breakfast, which is something like two eggs and a cup of egg whites. You cook it together and have a side of berries or any of the other fruits we talked about, or have a breakfast salad, which could be arugula with strawberries, or something like that. Having your two eggs with a cup of egg whites gets you to 30g of protein. 

You can also do Greek yogurt, which has 20g of protein. Oikos 20 just came out. 

Or cottage cheese. I love good cottage cheese because they have almost 20g of protein there. You are getting a good boost of it. 

Try to get to 30g by layering on different things. Maybe you have two eggs and Greek yogurt. That can be a really great way. That’s a good start to your day.

Protein is so important. If you focus on anything, adding protein to your breakfast is going to get your metabolism going, and you will see your cravings shift. You won’t have to fight with yourself throughout the day. 

Dr. Eric: 

I agree with making sure to get enough protein. Usually, I recommend at least 75%. 80-100% is what you’re aiming for, so we’re close. If someone is 120 pounds, I would recommend 90-120g of protein. We are pretty close with that. 

Also, I’ll add people could have leftovers for breakfast. If someone is a vegan/vegetarian, maybe a different story. If someone eats meat, and they are having beef or chicken for dinner, they could have leftovers for breakfast to make sure they get enough protein. If they are not eating eggs for whatever reason. 

I know a number of people in the community don’t consume dairy, but I agree dairy could be a good source of protein. Either way. Sufficient protein is definitely important, not only for curbing appetite but also for maintaining healthy muscle mass. 

You mentioned intermittent fasting. I am not against intermittent fasting. One of the concerns is if someone has a very small eating window, they might not be able to get enough protein. Besides the curbing of the appetite, I am concerned about them not maintaining a healthy muscle mass if they only have a four-hour or six-hour eating window.  

Nagina: 

Oh my gosh, absolutely. Let’s touch on protein increasing muscle mass. This is so key. This is why this is more important than ever for women in midlife. In midlife, around age 40 or before, our muscle mass starts rapidly declining. It’s by multiple percentages a year, anywhere from 1-3% a year. 

If you feel like you’re at a place where you’re stuck, and what was working before wasn’t working, a lot of this, there’s a big hormone aspect to it. The other aspect is because your muscle mass is declining, that means your metabolism is declining. Muscle is burning more calories than fat. When your muscle is transitioning to fat, you might be at the same weight, but you’re not able to lose it as much because you don’t have the same metabolism. You can create that by building your muscle back up. 

What is surprising is you can actually rebuild muscle just by taking in protein, not even working out. Of course, working out is great. It’s going to accelerate it. It’s what you will need to add on at some point. I have seen so much research of my clients who are simply adding the amount of protein that we talked about, and their muscle mass is increasing week after week. This is so important to keep your protein intake high.

The other thing is that protein actually digests more slowly than other food. That is part of the reason that you are not feeling as many cravings for sugar if you’re eating protein. You’re feeling more satisfied and full for longer with less calories. That protein is digesting more slowly, so you’re not hungry again. It didn’t go through your system so quickly.

Touching on intermittent fasting. I have to say I would be an advocate only for the right person. That person is a very small percentage of our population. If you are looking to feel more energy and lose weight in a healthy way. This is because I have seen intermittent fasting work well only if you are somebody who is significantly overeating, and you really need to cut your calories over the course of the day. Or you’re binge eating at night, and you need to control that. 

What is happening more often with women in midlife is that women are not eating enough to begin with. That is because of the stories that we have been told for so many years, that you have to eat less to lose weight. We have this running story in our head that we have to eat less. Skipping breakfast is an easy way to do that. 

What is actually happening is you’re staying stuck because you’re not getting nearly the amount of calories that you actually need. Our body needs calories. We have to take care of ourselves with food and eating the right amount. When you eat the right kinds of food, that is going to help you lose weight versus trying to eat less of the calories that you actually need. You’re just going to stay stuck because your metabolism has slowed. You’re not giving your body enough to burn. You’re just giving yourself enough barely to survive. That may be why you’re not feeling that much energy; you’re undereating. 

Dr. Eric: 

I agree. Most people who are struggling with losing weight, it’s not a calorie problem. There are other issues. Many people who are listening to this have Hashimoto’s or hyperthyroidism. Hyperthyroidism could go either way. 

When I dealt with hyperthyroidism, I lost a lot of weight unintentionally, even though some people with hyperthyroidism gain weight. Arguably, that is more the case with Hashimoto’s, having low thyroid hormone. Even in those situations, balancing the thyroid hormone many times won’t cause the person to lose weight. Same thing with caloric restrictions. Same thing with exercising. 

You don’t want to overeat carbs and eat unhealthy foods. You don’t want to be a couch potato. For those who have low thyroid hormone, you want to make sure you have healthy thyroid hormone levels. There are a lot of other factors when it comes to losing weight. With talking about some of the factors, too: not enough protein, making sure you are eating the right foods. You mentioned combining foods.

Spices. I haven’t had anybody talk about spices, at least not in great detail like you have on some other interviews. I don’t know if there are any other foods you want to talk about. If so, feel free to do so. I want you to start talking about spices as well. 

Nagina: 

Yes! Spices are so exciting and fun. If you could imagine losing weight could be fun, it actually can be. When I lost 40 pounds, it was the most exciting moment of my life. I was loving what I was eating, and I was seeing my waist shrink. I was seeing my pants fit me again. I had more energy. I was loving what I was eating every day. It was because of the spices.

Spices come from my background. I am Indian. I grew up in a traditional Indian household where spices were like water to us. We had them with breakfast, lunch, and dinner. 

When I started learning about how to get healthier when I was an adult, nothing that I saw out there had spices. It was all about plain chicken and broccoli with maybe a little bit of something on it. For somebody who loves flavor and food, which is a lot of us, it was impossible for me to eat healthy because I thought healthy equaled boring. I really needed that excitement, flavor, and pleasure in the food I was eating.

When I had gone back and done the research, which preceded my 40-weight loss, one of the other things I had done was made It my own. I started adding spices I knew about from growing up with them. This really accelerated my weight loss journey. I ate more than I was eating growing up. 

My husband, who is not Indian, got healthier with me, and he just really stood by the fact that cayenne pepper helped him lose 20 pounds in the first month. He was sweating. He felt that his weight was coming off whenever he added cayenne pepper.

Spices have a lot of metabolism-boosting effects, and they help your food taste really good. One of the first spices I recommend for people to try is one that we mostly all have in our kitchen cabinet. So are all the ones I mentioned. They are very common. They are not hard to find. They are not exotic. 

This one is to use a spice that is sweet. That is because a lot of times, when you’re on this journey, we have a taste for sweet. Using a sweet spice, which is otherwise known as cinnamon, is a really great way to get started.

One of the ways I first kickstarted my weight loss journey was I added cinnamon to my coffee. It took the place of my sugar or Splenda. I was using an artificial sweetener, which there is a lot of studies and reasons that artificial sweeteners are keeping us addicted to sweet foods. You really want to replace that with something that is natural. 

Having cinnamon in my coffee helped me prevent the need for artificial sweetener. It also helped me no longer need my creamers like a French vanilla creamer. Those things you end up using more than you think, and it’s not that those are causing you to keep your weight on, but it’s causing you to have sugar cravings throughout the day. That’s really adding up over the course of the day. 

Putting some cinnamon in your coffee, you can add some almond milk to it or some milk if you want to have some type of creaminess in there. Milk doesn’t have as much sugar as a creamer does, or you can use an almond milk creamer. That’s a really great start to your day. 

Cinnamon helps you lower your blood sugar. The spikes we were talking about, going up and down, if you add cinnamon, you prevent those spikes from happening. As a result, you store less fat. It starts in your belly; you store less belly fat.

When I started doing this, I was so excited because I realized how good my coffee was. I saw the benefits and effects on my body. I not only was storing less fat in the morning, but it was giving me the sweetness I needed. I wasn’t having sugar cravings either. 

Starting with cinnamon and getting proactive with adding that into your coffee, tea, or on top of your fruit is also going to help you counteract some of those blood sugar spikes. Cinnamon is a top one to get started with. 

You can use any cinnamon. There is a lot of research on which one you can use, which we can talk about. Overall, it doesn’t really matter unless you are using large quantities. Get started with the cinnamon you have. 

A really great spice to add is a spice I call neutral taste. This is turmeric. Turmeric is very popular right now. A lot of people are using it for anti-inflammation, and that’s exactly what it does. It’s anti-inflammatory. You want to combine it with black pepper because that increases the absorption of the compound called curcumin, which is in turmeric, by 2,000% in your body. 

Let me tell you a little bit about turmeric. It is a gorgeous bright yellow color. It actually has hardly any taste. It is very neutral in its taste. You can really add it to so many things. 

A natural blend is to add it to your eggs if you eat those. Add a half teaspoon to your eggs. Turmeric is yellow, so it goes with eggs. It doesn’t really add too much of a different flavor. It has a slightly earthy taste. It’s nowhere near spicy. It’s extremely neutral in its taste. That’s really good.

If you are somebody who has a protein shake, if you go to the gym and work out, adding it to your protein shake, doing a half teaspoon, will help your muscles relax even more because it’s anti-inflammatory. You will feel that relaxation. 

Or making a tea at night with turmeric tea is such an amazing replacement to something like wine if you have a wine habit at night. Have turmeric tea instead. It actually relaxes your entire body because it’s so anti-inflammatory. It’s great if you can make your own. I have a turmeric tea recipe on my website. You can also buy a turmeric teabag from anywhere you can find it. Trader Joe’s has some good ones.

Turmeric is the second one. I will share one more that is a complement to these other two. That is a spicy spice, or the spice that my husband credits for helping him lose 20 pounds in the first month of eating this way. That is cayenne pepper. Cayenne pepper has a compound called capsaicin in it. It’s in most of the spicy spices, things like cayenne pepper, red chili powder, jalapenos, serrano peppers. That is the compound in it.

If you want a milder version to get started with, you can try paprika, which has less capsaicin. It’s a little spicy and a little sweet, so it’s a good way to get your foot in the door. You actually do learn how to eat more spicy foods when you start eating some spicy food. Your tastebuds open up.

What cayenne pepper does is increase calorie burning. It increases your metabolism. You’re burning more calories when you add this on. You can also use it in the form of red chili flakes, which are what we see at pizza places. Those are a little milder as well. It increases calorie burning. It adds flavor. 

A really good way to use cayenne pepper is to add it on any protein you’re having, whether it’s chicken, fish, or on your veggies. Just add a sprinkle on, whatever your preference is. Doing 1/8 of a teaspoon or less is really great because you’re getting some of those benefits and the flavor. 

Starting with cinnamon, a sweet spice, to lower your blood sugar and store less fat. When you use turmeric, you will lower inflammation. When you use cayenne pepper, it’s going to help you increase your metabolism. These are all different elements of losing weight in a healthy way that is sustainable and using natural ingredients to do that. 

Dr. Eric: 

You said half a teaspoon of turmeric. With cayenne pepper, a sprinkle, maybe up to 1/8 of a teaspoon. With cinnamon, is it half a teaspoon of cinnamon, like turmeric? 

Nagina: 

That’s a good question. For cinnamon, you just want to have a sprinkle. That is because cinnamon can actually get spicy if you have too much. If you want to have something to measure it with, 1/8 of a teaspoon is the most you should have. It starts to get spicy after that. I really recommend that you just sprinkle some on and don’t go over what 1/8 of a teaspoon would be because the flavor shifts.

Also, if you’re putting it in your coffee, you don’t even have to mix it in. You can just sprinkle it on top and drink it. It doesn’t always mix in as well. Having a sprinkle of it is great. 

Dr. Eric: 

Okay. Cinnamon, turmeric, cayenne pepper. I heard you on another interview talk about using spices to make your veggies taste better. There are people who just don’t enjoy eating vegetables. I imagine you’re probably not using cinnamon on your vegetables although I could be wrong. What spices do you use on your vegetable to make them taste good? 

Nagina: 

This is so important. Vegetables are one of the secret ways to keep yourself full and give your body the nutrients it needs without adding a lot of extra sugar or extra calories that are above and beyond what your body needs. Because vegetables have so much fiber in them, when you pair them with protein and have 50% of your plate for protein and 40-50% for vegetables, you’re really going to have a lower appetite for other foods. You’re giving your body what it needs. You’re taking care of your body with the right foods.

One of the core terms that I talk about is “tasty veggies.” We all know we are supposed to eat veggies, but the biggest reason many people don’t is because they don’t like the taste of them. Imagine if you were able to get to a place where you’re craving vegetables, where your body is needing vegetables, where if there is a plate of breads and other carbs and protein and veggies, you go for the veggies first. That will happen when you start adding this amount of veggies to your diet.

The way to do it is to have them be tasty. The best way is to add these spices. 

The other way is to roast your vegetables. They are very tasty when you put them in the oven for 15-20 minutes on a sheet pan. Just spray the sheet pan with cooking spray. The sweetness comes out from the veggies. 

Some really good spice blends I recommend are to add either turmeric, because you are getting the anti-inflammatory benefits, with black pepper. You can add cayenne pepper. 

You can also do what I love, which is what I call a belly fat-burning blend. We can talk about the amounts, as it depends on the amount of veggies you have. Cumin, coriander, salt, and pepper. Cumin has been proven to burn belly fat in multiple studies. 

If you are adding cumin to your day, you will burn more belly fat than if you don’t. Of course, you need to eat these foods we are talking about as well. Coriander is debloating, so it reduces water retention. That is really good. Cumin is a smoky flavor. Coriander is a fresh, tangy flavor. They are both neutral in terms of heat. You are really getting a nice compliment when you do cumin, coriander, sea salt, which is a little healthier salt, and black pepper. That is a really great combo. 

You can also add turmeric and cayenne pepper to that if you want some heat. Those are some levers you can pull. Those are some really great ones. 

If you want to have a couple blends that you don’t have to add separate things, I recommend using lemon pepper. It’s lemon as well as pepper. Have that with some salt. It’s really refreshing. Even black pepper actually helps you burn more calories than you would in a 20-minute walk. Having black pepper is really good. 

In addition, another spice blend is called garam masala. It is an Indian blend, but you can find it everywhere. It has a combo of a lot of the spices we talked about. It has some coriander. It may have cumin, depending. It has cinnamon, which actually goes well with it. It has a little bit of cloves. It nicely goes on everything. It’s a go-to spice blend. 

Put your veggies down on aa sheet pan. Spray it with cooking spray. Put a blend of this. You could do about two tablespoons total. If you put ¾-1 teaspoon of each of those spices I told you about, so you get to 1-2 tablespoons. Sprinkle some olive oil on your veggies, add the spices, and mix it with your hands if you want, if you are able to do that. 

Veggies that are really good are things like asparagus, red bell pepper, green bell pepper, broccoli. If you really want to go in a debloating direction, a really good combo is doing asparagus with coriander, salt, and pepper. Asparagus is very debloating in that it reduces water retention. So is coriander. 

If you mix those two things once a day for three days, you’re going to notice your bloating is going down. You will immediately need to go to the bathroom soon after you have that meal even if you didn’t drink anything because it’s pushing water out of your system.

This is real science. It’s chemistry in our bodies. We can use it to get our metabolism high, slim down, make our food taste good. All of those are important. We want our food to taste good in order to make this a sustainable lifestyle. 

Dr. Eric: 

I really enjoyed this spice conversation. I don’t think anybody has focused on some of the different spices. Glad that you touched upon them. 

Like I mentioned, over the years, there have been so many people who don’t want to eat vegetables and asked if they can have a veggie powder. I have to say it’s better than nothing, but it’s not the same as eating vegetables. 

It’s safe to say that many people haven’t tried to get creative with cooking. To be fair, it’s not like I’m an amazing chef who is creative. It doesn’t take a lot of creativity when adding spices. I have learned that. 

I use a number of ones you mentioned. I actually don’t use cayenne pepper; I do use paprika. Maybe I will try to get a little more daring and add cayenne pepper to my food. I do use coriander and oregano and thyme, which you didn’t mention. It can make a big difference to add some of these spices as well as some others. 

Nagina: 

Oregano is such a great flavor booster. It’s so good. It goes well with so many things. Same with thyme. All the spices we’re adding have benefits to them. They’re really good. 

This comes back to my concept of adding more. Instead of taking away, it’s more about adding more protein, more veggies, more spices. Making it taste delicious. Naturally, your body is not going to crave the foods that were keeping you stuck and keeping you feeling low energy. It will naturally start to transition when you’re consistent with this. 

Dr. Eric: 

Anything else that you wanted to discuss? Anything that I should have asked you that I didn’t ask you about boosting metabolism? 

Nagina: 

We talked about so many things, so that’s great. I could maybe touch on a bit more of the food combining, in terms of how to combine foods, just for a moment. 

I mentioned that if you’re going to have a higher sugar fruit, to pair it with peanut butter or nuts or a protein. Keeping that in mind when you are going to have a carb or sugar, definitely don’t have it alone. 

One of the biggest things I see is women will grab a banana and run. What I recommend is to have some with peanut butter. Only have half of the banana. You will be eating more with the peanut butter. You will be slowing your blood sugar spikes, so you won’t store as much fat, and you won’t need as much of that banana as you have something else as well.

The other thing is when you are eating something like pizza or spaghetti, you don’t have to avoid those. What you can do is make sure that you’re having a protein with it. You’re also having greens with it. Have a salad. What that does is lower your blood sugar spikes. Instead of your blood sugar going up and down, it won’t go up as much. It’s not going to need to come down as much, which means you’re not storing as much fat. 

A key way to do this is not to say, “I don’t ever get to have pizza or pasta.” Instead, have your pizza with some protein on it, so if you eat meat, having protein with it, or you can have a protein shake on the side if you don’t eat meat. Or having meatballs or vegan meatballs with your spaghetti. Have a salad first. 

When my family orders pizza, a lot of times, I make sure that I have my salad. I order a salad. I will often get a seafood salad, and then you have protein in the salad. Then I will have one or two pieces of pizza versus if I was only having pizza, I would have had three or four pieces. You really adjust naturally, but you are not getting as much of that spike.

In general, think about always adding on a protein or a healthy fat but then also having some greens if that makes sense for that meal. Then having your carb or sugar. You will see it will make a lot of difference. It’s just about educating yourself and understanding what these foods are and how to eat them together.

Dr. Eric: 

I always love talking about pizza. I will say that many of the people I work with, I tell them to take a break from pizza and pasta while healing. On a wellness basis, I can’t say that I never eat pizza. Usually a cauliflower-crust pizza. I do add protein, too. I just added cheese in the past but realized that’s a good way to add some chicken, for example. That’s something I try to do. You can definitely get some protein when someone is eating pizza.

For those who aren’t eating pizza now, maybe in the future, if/when you reintroduce pizza, try to have some protein as toppings, whether it’s chicken or something else. 

You did cover a lot of information. I really appreciate everything you shared. 

Nagina, can you tell people how they can find out more about you? Also, I know you have an upcoming five-day metabolism boost event. If you could talk about that as well. 

Nagina: 

Absolutely. You can find me at my website, MasalaBody.com. That is where I have lots of blog posts as well as a lot of success stories, if you click on Success Stories, of other women in midlife, women in their 40s-70s who have lost a significant amount of weight. You will hear about how it was so doable and sustainable, and now it’s a lifestyle, not a diet.

I would love to invite you to my upcoming five-day Metabolism Boost, where I will be teaching every day for five days in a live workshop. It’s completely free. I will be teaching how to boost your metabolism. 

The first day is about creating your metabolism boosting morning routine. I will talk about how to get your day started, what to add to your morning, so that you get your metabolism boost going immediately. 

I am also going to be talking about the four-part fat-burning food framework, where I teach you exactly how to pair your foods and the quantities of foods you need for lunch and dinner. 

Then I will be talking about how to get off sugar without feeling tired or restricted and show you how to combine your foods and how to prevent those blood sugar spikes so you can store as little fat as possible and really work on getting leaner and stronger.

I am so excited for the five-day metabolism boost coming up so soon. 

Dr. Eric: 

Thank you so much. This was so great. I really enjoyed this conversation. I found some of the information, especially the spices, valuable. I always enjoy talking about pizza as well. We don’t talk too much about pizza on this podcast, but sometimes we do. Thank you so much, Nagina. Really appreciate you taking the time to talk about boosting metabolism. 

Nagina: 

Thank you! 

Recently, I interviewed Dr. Campbell and we discussed her inspiration for writing The Blood Pressure BluePrint, the connection between blood pressure, oral health, and thyroid function, insights into proper blood pressure measurement, the importance of holistic approaches in healthcare, supplements that can help with managing blood pressure, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

Dr. Campbell is a native Chicagoan and a graduate of the University of Illinois, The Kirksville College of Osteopathic Medicine, and the Medical College of Georgia. Board certified in family medicine for 30 years, she also holds certification from the American Board of Integrative Medicine. 

She is a solo physician especially interested in interdisciplinary collaboration, functional medicine, reversing chronic disease, cardiovascular disease prevention, natural treatments for high blood pressure, and the many oral systemic connections. 

She also enjoys live theater, gardening, healthy cooking, hiking, travel, and playtime with her husband and three adult daughters. 

Thank you so much, Dr. Campbell. Great to have you here. 

Dr. Ellie Campbell: 

Thanks, Dr. Eric. It’s my pleasure to be here today. 

Dr. Eric: 

I just finished reading your book. It’s an amazing wealth of information. There is a lot of topics that you could write books on. Blood pressure is one of those things where a lot of people think it’s basic: high blood pressure or low blood pressure. Obviously, there is a lot more than medications, which we’ll talk about. Really interesting. Some topics I wouldn’t have guessed would have been in the book, like oral health. Very excited to talk to you about this. 

I know I gave a little bit of your background with the bio. If you could dive a little bit deeper. What led you to write the book? 

Dr. Ellie: 

Thanks for the intro. I have bene a family physician for 30 years. One of my greatest joys is taking care of multiple generations in the same family. 

When Cheryl came to see me, she originally wanted to have a baby. She was 42 years old, and she’d had one child but wanted to have another. She was a little bit old to be pursuing this, but she went to fertility doctors. They all told her that her and her husband’s genes were incompatible with each other, and they could never have a baby. She went, “That doesn’t make any sense to me because I have a perfectly healthy kid. We did it once, so we can do it again.” 

To make a long story short, I worked with her using a functional medicine approach to her fertility, and we were able to get her successfully pregnant and have another beautiful baby boy.

At the end of that, she said, “You’re pretty good with hormones. I think my mother could use your help as well.” Now I am taking care of the two boys, the daughter, and now the grandmother. 

The grandmother comes to see me. She has high blood pressure, and we take care of that with medication and therapeutic lifestyle changes. She has high cholesterol, so I have her on medication for that. Now she wants bioidentical hormone replacement therapy, so she can keep up with her much younger boyfriend, go line dancing, drive four wheelers, play with the grandkids, and do all these wonderful things that this spunky grandmother did. I did all of those things. I was managing her standard of care the way everyone in the community does.

One day, Cheryl calls me, devastated. She was crying. She said, “Mother did not show up to work today.” I went to her house, peeked in every door and window, and discovered her crumpled on the floor next to her computer. She’d had a massive stroke, and she was paralyzed on one side. 

I felt devastated. I am the primary care doctor. It was my job to take care of her. Strokes are supposed to be preventable. We knew she had risk factors, but I thought we were managing them. She had an event anyhow. I felt somehow like my system had failed me. 

She joked with me that she was going into rehab, and it was going to take a lot of therapy to help her start dancing again. Dragging one paralyzed leg behind her was really challenging. 

About five days into her hospitalization, she had an unexpected but not that rare complication that happens in about 10-20% of strokes. That weakened blood vessel that had had the stroke burst. Dee had a brain hemorrhage, and she died. 

I felt like I had been punched in the gut. It was my responsibility to take care of this lady, and we failed her. The system failed her. 

I spent the next three years of my career studying everything I could about high blood pressure, high cholesterol, and stoke prevention. I finally feel like I cracked the code on it. Once I did that, I felt compelled to write this book, not only to help myself, but all the other patients I provide care for, and more importantly, to reach a larger audience. 

There are so many DIY things that people can do to get their blood pressure and their cholesterol under control, and reduce their risk for cardiovascular events, which are the #1 killer in our country. 

I was going to write a book. Spoiler alert. The #1 hidden risk factor to the #1 killer in our country and the problem that Dee had that I missed was a dental infection. It was a deep-seated dental abscess. Once I learned that, I wanted to write a book about how oral health can change your entire life. If you take better care of your mouth, you’ll take better care of your brain, your heart, your kidneys, your gut. You can’t have an unhealthy mouth and have a healthy body. 

I wrote this book about oral systemic connections. Nobody wanted it. I pitched it to 82 publishers, and nobody would publish this book. It was really boring. Fast forward. This was right before the pandemic. I Googled what were the health topics that people were really interested in? Blood pressure came up to be the #1 thing that people wanted to know about. The top 10, 10 years in a row. 

I thought that is indirectly connected to my message. I am going to flip it around. I will make it my message and teach people what they really need to know, which is they need to eat clean food, drink clean water, exercise, reduce stress, get good sleep, and have good oral health. If we get that message across, we will save so many lives.

I’m so grateful for you because those same fundamentals correct almost every chronic illness from hyperthyroid to hypothyroid to diabetes to obesity. If we get those fundamentals right, we can reduce the risk of every chronic disease and dramatically reduce our risk of the #1 killer in our country. 

Dr. Eric: 

I agree. Oral health is important. Even though I was surprised that you brought it up, I shouldn’t be because I talk every now and then about the importance of oral health. I interviewed my biological dentist Dr. Eric Kempter on the practice. I agree that having, whether it’s simply gingivitis, inflammation of the gums, but an abscess, an infection, mercury amalgams, there is a lot of issues we could have when it comes to the mouth. Most people think it just stays in the mouth, but it definitely doesn’t. 

Dr. Ellie: 

It definitely doesn’t. We know oxidative stress and inflammation are probably at the root of most chronic illnesses. Oral health is a primary driver of oxidative stress and inflammation. Beyond that, we now know we are supposed to have bacteria in us. We are a microbiome having a human experience. We need to have this microbiome. We use their genes to do all of our metabolic processes. We have to have a healthy microbiome. 

When we get unhealthy, and we have a pathogenic burden, these pathogens do nasty things to us by driving inflammation. There is one in particular I’d like to mention. It has a long name: Porphyromonas gingivalis, PG for short. This particular bacteria lives off of blood. When it gets into your gums as a pathogen, it makes a really bloody gum inflammation. When you floss or brush, you get pink in the sink. PG is often present when you have that gingivitis or periodontal disease. It makes that bloody mess, so it has fuel for its own self to live. 

Now, it’s really tricky. That PG bacteria buries itself inside the red blood cell and becomes a hitchhiker. Wherever in your body red blood cells go, which is everywhere, the PG can hitch a ride and land wherever that blood cell lands. Once it gets there, it secretes a little fatty molecule called phosphorylated dihydroceramide. It’s a wax. It’s a plaque. It makes plaque in your teeth. 

If that blood cell lands in your brain, it can make plaque in your brain. That can lead to dementia and Alzheimer’s. If that PG bacteria lands in your neck artery, it can cause hardening of the arteries, corroded artery atherosclerosis. That leads to increased stroke risk. If that bacteria lands in the coronary arteries and makes phosphorylated dihydroceramide in that space, it makes plaque in your coronaries, increasing risk for heart attack. 

Where did that bacteria come from? Your mouth. I can’t have my patients have a healthy brain or heart if their dentists and hygienists aren’t helping me to make their mouth healthy as well. 

Dr. Eric: 

You of course recommend regular checkups. Do you recommend for someone to see a holistic, biological dentist? Or just as long as they are getting regular checkups. 

Dr. Ellie: 

I think that first of all, a dentist who is not holistic is generally not educated in the fact that the mouth affects the rest of the body. They’re focusing on this part. They don’t really think about all the other connections.

Furthermore, I have blood tests that I do as part of my routine cardiovascular prevention. I didn’t know about this when I was working with Dee way back eight years ago, but I know this now. I do something called the fire panel. It includes markers of oxidative stress and inflammation. 

One of them is called Lp-PLA2, Lipoprotein-associated phospholipase A2. It’s an enzyme. It’s made by white blood cells. When those white blood cells are in plaque in the arteries, and that plaque is inflamed, and those white blood cells are angry, Lp-PLA2 levels go up. 

Turns out Lp-PLA2 is also found in white blood cells in gum tissue. I have a leading indicator in my cardiovascular bloodwork that tells me, “Dentist, I have a patient I need to send to you because I did their heart bloodwork, and they have a clue that they have a dental problem.” If you’re not using a biological or holistic dentist, they may not be educated, and you will take them this bloodwork, and they won’t know what to do with it.

You not only need a holistic dentist, but one who has been educated in what these markers mean, what they need to look for, and most importantly, how to correct the problems once they found them. Because we know that these mouth bacteria that cause this inflammation and lead to the plaque and oxidative stress that lead to increased risk are not easy to get rid of. 

Of course, it requires good home hygiene. You have to be brushing your teeth and flossing and rinsing but not with the wrong mouthwashes because the wrong mouthwashes will decimate the good bacteria, actually raising your blood pressure, so we need to be careful about that. So good home hygiene.

Then a really good dental cleaning, often scaling and planing, deep cleaning. Those unfriendly bacteria are coming back in four hours unless you have done something to taint the terrain. We have to work with our biological dentist to talk about nutrition and pH and saliva flow and oral probiotics that are specifically targeted to help shift the balance of the unfriendly bacteria and chase them away and let the friendly bacteria that are supposed to live in our mouth flourish. That requires a complex, personalized, precision, individual medical dental care team working together. 

Dr. Eric: 

I want to discuss some other factors that can affect blood pressure. Before we do that, can we go over some of the basics, like what is considered to be normal versus optimal? How to measure blood pressure? 

Dr. Ellie: 

That is different. When I was in medical school, we were getting people by 160/100 if they were over 70. You have high blood pressure, it’s normal. Just because it’s common doesn’t mean it’s normal or healthy. It doesn’t mean you won’t have risks associated with that.

We now have determined that a normal blood pressure reading, believe this or not, is 119/79 or lower. That is a normal blood pressure. Even 120-129/80 is considered elevated. 

In the old days, we used to call that pre-hypertension, but they took that diagnosis away. We just call it elevated blood pressure. The new guideline for hypertension, you are officially diagnosed with hypertension at 130/80-139/89. That is stage one hypertension. 

If it’s 140/90 or higher, which was our old definition, that is now considered stage two hypertension, and a much higher health risk for the development of heart attacks, stroke, kidney failure, blindness, erectile dysfunction, and all of the other downstream organ damage that results from the pressure caused on those blood vessels from hypertension. 

Recapping, we want our blood pressure to be less than 120/80. If we are more than 140/90, we probably need to be under the care of a medical provider to get that targeted and under control. Certainly, many things are DIY. There are so many things that people can do to get their blood pressure under control. First, we have to know how to measure it properly. I was doing it wrong for years. 

We now have guidelines that tell us what is proper to measure your blood pressure. The first, most important thing is you’re not supposed to eat, drink, vape, or smoke 30 minutes before you go in to get your blood pressure checked. If you do that, the temperature changes. The physiologic processes of running digestion can alter your blood pressure. We are trying to standardize it, so everyone has the same guidelines, and we are comparing A to B to C to measure blood pressure. First, no eating or drinking.

Next, we have to make sure that the blood pressure cuff is the proper size, and it goes directly on your bare arm. You should not put your blood pressure cuff over clothing, especially not over a sweater. Even a T-shirt can affect your blood pressure five or ten points. A sweater can affect your blood pressure by 30 points and give you a false hypertension reading when all you really have is sweater pressure, and you don’t really have hypertension. 

The next thing, and this is a mistake that we made in my office for decades because I wasn’t smart enough to know better, and the CDC hadn’t published their guidelines until 2019. You have to have an empty bladder when you check your blood pressure. Your bladder has very sensitive pain receptors. When it stretches, it stimulates those receptors, and it can raise your blood pressure. A painfully enlarged bladder can raise your blood pressure for three hours after you check it. 

In my old days, we used to have the patients come into the waiting room, sit down. When they were ready to go back, we’d put them in the exam room, sit them down, take their history, check their blood pressure, and send them to the bathroom to get a urine specimen. 

We don’t do it that way anymore. They come to the waiting room and are escorted to the bathroom first thing, and they empty their bladder before anything else is done because we want them to have an empty bladder. It is a very important part of measuring your blood pressure. Most offices, including myself, don’t do it properly.

The next thing, once we fitted your blood pressure for the proper cuff, we want to make sure that your arm is resting at heart level. You are not holding it up. You are not dangling it down. It is resting on an arm rest at heart level. 

You are not allowed to talk. You are not even allowed to listen intently for five minutes. In our office, we always used to chitchat. How are you? How are the kids? How is the dog? How are things going? Hold on one second. Then we tell them to be quiet, so we can take their blood pressure. That chitchat can raise your blood pressure 10 points. 

Even intently listening to that really interesting conversation that is happening in the medical office next to you can raise your blood pressure five or ten points. No talking, no chitchatting, no active listening while you are trying to get your blood pressure checked.

The next thing is you have to be seated properly with your bottom to the bottom and back to the back and feet on the floor. If you are using your back muscles to hold yourself up, you can raise your blood pressure 15 points. If your feet are dangling, like you are sitting on the edge of an exam table, you can raise your blood pressure 10 points. 

I have a secret. I am vertically impaired. I am only five feet tall. I cannot sit in 90% of chairs with my bottom to the bottom and my back to the back and have my feet touch the floor at the same time. If your patients are vertically impaired like me, and you want to measure an accurate blood pressure, you need to offer them a foot stool to rest their feet, so their feet are not dangling, as dangling feet can raise blood pressure. 

Never check blood pressure on an exam table. If you are a dentist, and you are a wonderful dentist who is checking blood pressure in the dental office, the patient can’t be laying supine in the dentist chair to check their blood pressure. That is also not an appropriate way to do it. 

We did lots of things wrong when I was measuring blood pressure. Now that we have standardized it and follow these guidelines, we get much better, reliable data. We also want our patients to check their blood pressures at home with these guidelines, so they, too, can get proper blood pressure readings. 

Dr. Eric: 

Scary that there might be then some people on medication who are falsely diagnosed with blood pressure if they were doing multiple thing wrong. If they didn’t empty their bladder, if the doctor didn’t have them test with the bare arm. Maybe they were wearing a sweater or a T-shirt. If they weren’t resting for four or five minutes, if they just sat down right away. If they had three or four of these variables, maybe normally they would have had a blood pressure that is below the 120/80, but they read as higher. 

You would assume they wouldn’t give blood pressure medication based on a single reading, but if that is the way they measured every single time the patient came in and didn’t have them do it on their own at home the proper way, some people might be on medication when they don’t need it. 

Dr. Ellie: 

You’re right. We also know that there is a component of white coat hypertension. This is a very real phenomenon. There’s something psychological, emotional that happens to people when they see the white coats or the doctor’s office sign. Their blood pressure will go up much higher than it ever does at home. 

Those people deserve to have home blood pressure readings, just like we would never treat a diabetic based on a single reading of sugar that they get in our office. We should not really be treating hypertensive patients based on single readings we get in our office. 

We need a lot of data. We want home blood pressure data or even a 24-hour ambulatory blood pressure monitor, where they’re wearing a same monitor for 24 hours, and every few minutes, it gives a reading. It’s uncomfortable and hard to sleep with. 

But we can get a pretty decent reading with frequent at-homes. Sometimes, you’re stressed. Sometimes, you’re relaxed. When you’ve slept well. When you’re sleep-deprived. I want to see the whole gamut of readings. 

Just as there are some people who have white coat hypertension, some people have something called masked hypertension. These are people who are really good at getting into their zen before they go to the doctor’s office, and their blood pressure looks perfect. When they get home and have a spat with their spouse or get into traffic, their blood pressure goes crazy high. The only way we would ever know this is if they are getting home data. 

That is a message I want to bring to the audience: For anybody whose readings are not routinely 120/80 or less, they have a home blood pressure monitor and start checking some data at home. Get it at different times. Keep track of it. You don’t have to check every day or every hour, but you have to check some and keep the data going. 

Dr. Eric: 

How accurate are other devices? There are wrist cuffs compared to arm cuffs. 

Dr. Ellie:

So far, we don’t think they’re ready for prime time. They don’t seem to correlate quite as well. I think they’re getting better as our technology gets better. 

At this moment in time, I absolutely do not trust a phone app or a finger app. The wrist, maybe if you are holding it properly at heart level with your arm resting, maybe they are getting closer. I still think the gold standard is an arm cuff. 

Dr. Eric: 

Other causes of blood pressure. One that gets a bad rap and has for a long time is salt. If you could talk about that. 

Dr. Ellie: 

There are some people who are salt-sensitive. This is true. It’s not the majority of hypertensive patients. Furthermore, it’s been my clinical experience, and probably yours as well, that people who are nutrient-deficient, especially magnesium, potassium, manganese, iodine, are much more salt-sensitive. They eat a normal amount of salt, and their blood pressure goes up.

When we replete these micronutrients, they can handle salt, and it’s not such a problem anymore.

 I think every patient who has been newly diagnosed as hypertensive or has long-standing hypertension deserves a trial to see if they are salt-sensitive. Go two weeks with very low salt, less than 2g/2,000mg. That pretty much means you can’t eat anything from a box or a can. You can’t eat anything from a restaurant for two weeks. You are cooking your food at home, and it’s pretty bland, unless you use lots of spices. You can use turmeric and Indian spices and Mexican spices and Asian spices. You just can’t use salt. 

Take your blood pressure for two weeks with low salt. Then go heavy on the salt, and enjoy everything you like. Eat all the crazy salty stuff you want, and see what your blood pressure looks like. 

If you are one of those people who has a 30-point differential between the no salt and high salt diets, you are probably salt-sensitive. Make sure you get yourself on magnesium, potassium, manganese, trace minerals, zinc, and iodine. Make sure all those things are replete first. Then you can tolerate your salt most likely with no problem. 

Most people who are salt-sensitive are using the wrong salt. Just like we never in integrative medicine recommend that people eat foods made with white flour or white sugar, we want unrefined, natural, whole grains and unrefined sweeteners, we don’t want refined salt in a blue can that pours when it rains. That salt is highly refined. Sometimes, they add iodine back into it. Sometimes, they don’t. it’s highly refined. 

Let’s use natural salt, full of minerals. It’s usually pink or gray. It’s Celtic or Mediterranean. Those salts are often much better tolerated than the refined white salt in the blue box. 

Dr. Eric: 

I agree. That’s what I use. I use the more natural salts, either Celtic sea salt or pink Himalayan salt. Glad you mentioned that.

How about thyroid? A lot of the audience is thyroid. Some might think if someone has low thyroid hormone, they will be more likely to have low blood pressure, not high. Maybe vice versa, if they have hyperthyroidism. I can’t say I see that in my practice. There are definitely people with hypothyroidism with high blood pressure, and people with hyperthyroidism with low blood pressure or normal blood pressure. I’m sure you see the same in your practice.

Dr. Ellie: 

I do. I think they overlap a lot. I also think that probably there is more correlation between the underlying root causes. What is an underlying root cause of hypothyroidism? For many people, it’s nutritional or environmental or toxic. If we are living in a toxic soup, then our blood pressure is likely to be high, and we might have hypothyroid or hyperthyroid in that instance. 

We want to work on a lifestyle of detoxification. We want to work on a lifestyle that doesn’t bring toxicants into our body. That means looking at our home environment. What are our cleaning products? What are our personal care products? What are our foods? How are they prepared? When we lower our toxic burden, our blood pressure is easy to control. 

We have heavy metals. In heavy metal toxicity, you will often see thyroid dysfunction. I have seen hyperthyroid and hypothyroid from heavy metal toxicity. We work on chelating those metals one way or another, whether that’s oral, rectal, IV, however we are going to get these heavy metals out of the body. As we do that, the arteries get softer, and blood pressure is easier to control. The same underlying root causes for one condition can drive the other. 

Dr. Eric: 

Any other direct or indirect causes of high blood pressure?  

Dr. Ellie: 

Yeah. We have talked about the mouth. In Dee’s case, what caused her blood pressure to spike and caused her stroke was that she had a dental abscess. She actually had an appointment to have her tooth extracted a week after her stroke that killed her. She never made it. She never lived long enough to have that event. 

I know that if the dentists knew what a medical emergency this was, and how it was driving her oxidative stress, we would have been on either stronger antibiotics or done the procedure sooner. We would have intervened in some way. Neither of us were smart enough at that time in our careers to make that call. 

Now I’m smarter. Now when I see people with dental abscesses, it’s like a 911 dental emergency. We got to get you on anti-inflammatories. You want to take baby aspirin. We have to do things to get you prepared.

Oen of the probably #2 root causes that I have seen since I have been paying attention, and it’s also oral related, is sleep apnea. Many people have undiagnosed sleep apnea. I used to think I could look and tell. That person is morbidly obese. They have a size 17 or 18 neck. This Jabba the Hutt body composition. That person has sleep apnea. Often, they do, but not always. 

Some people who are very slender, very tall, very athletically fit have horrible sleep apnea. One of my patients came to see me after his heart attack. He is a very strong, very fit triathlete. He had undiagnosed sleep apnea. He had undiagnosed familial hyperlipoidemia. He had undiagnosed insulin resistance. We got to all those root causes to try to make sure he never has another event. 

Sleep apnea was a major contributor. His oxygen levels were dropping in the middle of the night down into the 80s. When that happens, one of the things that your body does besides waking you up at night to try to get some deep breaths to pull your oxygen level back up is that’s a physiologic stressor, and it raises your cortisol. 

If you ever do a cortisol test, and you have your morning cortisol nailed to the ceiling with these very high AM cortisols, that is an important clue to me that you’re likely being woken up in the middle of the night by something. That something is commonly undiagnosed sleep apnea. 

Most people with sleep apnea have obstructive sleep apnea. There is an obstruction in your airway. Either your nasal passages are clogged, your oral pharyngeal airway, their adenoids are too big. Their uvula is too large. Their palate is too soft. Their tonsils are too large. Or it could be down farther in the oral pharynx. 

In my case, when I was a teenager, they pulled four teeth out. I had an overbite. They put me in headgear to pull my overbite back and make my teeth straight. That was lovely, except for one problem. By taking four teeth out, they narrowed my airway 15mm. I had no room for my tongue except to stick it in the back of my throat. When I laid down in bed, not only would I snore, but I would choke off my airway. 

I developed sleep apnea as I got older. I developed a horrible snoring habit, which I didn’t know I had, but I found out when I spent the night with my sisters on vacation. When I asked my husband about it, he said, “You’ve been snoring for years.” “Why didn’t you tell me?” “I thought you knew.” 

We need to have a conversation with our partners about this. Let’s find out if each other snores. If you snore, get a sleep test. Not all snorers have sleep apnea. Not all sleep apnea patients snore. If you wake up unrefreshed, you need a sleep test. If you have ADHD, you need a sleep test. If you wet the bed, or your child wets the bed after around age five, you need a sleep test. These are often symptoms of not getting deep, restorative sleep. One of the reasons is sleep apnea. 

Some people have an upper airway condition, and they just need nose surgery, and their sleep apnea is cured. Some people need more than that. Some people do need CPAP. I don’t like to use CPAP as my first treatment of choice. I have about five other things we do before we ever talk about CPAP, except in the most severe cases. 

I would say sleep apnea is a very common and underdiagnosed trigger for hypertension. 

Dr. Eric: 

You said you are not against CPAP, but you try four or five other things prior. If someone has to be on CPAP, do you look at it as temporary, just for a period of a few months? 

Dr. Ellie: 

When CPAP was first invented, it was intended to be a temporary bridge until we fixed their underlying root cause. Sometimes, we put patients on CPAP, and they get deep, restorative sleep and lose 25-30 pounds without trying. For the first time in their life, they are not making high cortisol. They don’t have a steroid burden. They are getting deep sleep. Everything calms down. They are not trying to keep themselves awake all day by eating extra calories or caffeine, driving their metabolic function, insulin resistance, etc. Sometimes, CPAP makes them lose weight, and then their sleep apnea goes away. Sometimes, 6-12 months on CPAP, and they are cured. They don’t need it anymore.

 That doesn’t happen as often as I’d like it to, but it can happen. Often, when I see someone with sleep apnea who needs CPAP, I get them to see an oromyofunctional therapist. OMT is like physical therapy for the lips, jaw, and tongue. Sometimes, we can strengthen the soft palate. We can strengthen the lips and jaw. We can get that jaw pulled slightly forward, just by retraining. Those patients now don’t need CPAP the way that they used to.

In some cases, however, there can be a curative surgical procedure. For somebody like me, who had four teeth pulled, and they changed the shape of my jaw growing up, I was fortunately able to correct this wearing an oral device. It’s called a Vivos device. They put it in the roof of the mouth, and at the bottom of the jaw, there was a little key. I was advancing the key a couple of turns every couple of nights, spreading out my jaw. Painlessly, I might add. 

Both my upper jaw and lower jaw, over two years’ time, I was able to expand my jaw and get back most of the 15mm I had lost when they pulled my teeth out. I had to wear Invisalign to close up the spaces that had been made in my teeth by widening my jaw. Now, I have straighter teeth again and no snoring and no sleep apnea. For me, that was curative. 

If I had more moderate or severe sleep apnea, I might be on a CPAP while simultaneously wearing the oral device. 

The final thing is pretty drastic, but it’s curative in 90% of cases of sleep apnea. It’s paid for by every insurance. Most people don’t know about it. It’s called a maxillary mandibular advancement surgery. It’s a really big deal. They cut your jaw in half on the top. They cut your jaw in half on the bottom. They push everything forward. They do bone grafts and make extra room, so your entire face moves forward. Now your tongue and jaw move forward and get out of your airway. 

Is that my first or second or third choice? Not really. I would rather you had cured permanently your sleep apnea and not required to go to Tahiti with a CPAP suitcase than suffer from any kind of consequences of sleep apnea. If we can permanently cure it, and a surgery is the way to do it, it’s on the consideration table. 

Dr. Eric: 

Many cases, a last resort. But there is a time and place, just like with thyroid surgery. I am not a proponent of- It depends on the situation. 

Dr. Ellie: 

Sometimes, they need it. 

Dr. Eric:

Exactly. 

Dr. Ellie: 

I think a really important point that is often not emphasized is the preventative nature. If we go back 1,000-2,000-10,000 years, we ate really nourishing food. We had to rip the meat off of our bones. We hadn’t invented knives and forks yet. We were using our hands and teeth to eat root tubers and strip the leaves off plants to get to the soft bark and the nutrients underneath. 

That mastication, that chewing, that gnawing caused our cheek and jaw muscles to be really well developed. When we had really broad faces and broad jaws, we did really well from a perspective of not having a small, narrow airway that caused crooked teeth and obstructed airway disease.

Fast forward to today. What do we give our kids to eat? We don’t let them use a breast too often. We have them bottle fed. They don’t develop strong jaw muscles. We give them baby food that has already been pre-chewed. Babies do not develop the jaw muscles and grow their jaws the way that we need to. 

Pediatricians have a responsibility now to talk to our bottle-fed babies about jaw exercises. Giving their kids specific pacifiers, something called a Myo Munchie, for example, that works those jaw muscles. It gets them to use those muscles, so these kids can grow. 

We want to talk about an airway assessment before age five and make sure the kid doesn’t have a tongue tie, a lip tie. If a baby is not a good nurser, it is probably not the mom’s fault. It’s not that she is not good at this. The baby has a physiologic restriction because they were vitamin deficient during the pregnancy, or if they have this tether of tissue that is preventing the baby from getting their tongue in the right position. 

The proper position of the tongue resting is not how it looks in our anatomy books, which is on the floor of our mouth. The proper position of the tongue is resting on the roof of our mouth when we are sitting at rest or sleeping. If a kid or adult can’t get the tongue on the roof of their mouth, they have a problem. That can lead to sleep apnea, which can lead to hypertension. 

If we knew about it before the age of five, they wouldn’t ever need braces. Their jaws would be big. Their airways would be large. They wouldn’t have hypertension. We could prevent a whole litany of health problems in adulthood by addressing it in kids. 

Dr. Eric: 

This should be evaluated by a pediatrician over a dentist, or maybe both? 

Dr. Ellie: 

Ideally, it’s a pediatric dentist and pediatrician working together. Or a family physician and a pediatric dentist working together. Or a general dentist or general family physician who is particularly trained and educated in paying attention to this. 

Dr. Eric: 

How about certain supplements? I am thinking about licorice root. How concerning is that? I know if they have high blood pressure, it’s a concern. Is it a concern if someone has normal blood pressure? 

Dr. Ellie: 

Generally speaking, no. There is a component of glyceridic acid that is in the licorice supplement itself that is the problem. If it’s DGL, which is deglycyrrhizinated licorice, most people can tolerate that with no effect on their blood pressure. Most of the supplement companies make that DGL.

However, we do use licorice a lot. It’s a great sweetener. It’s an adaptogen. There are lots of advantages to licorice. Some people are very sensitive to it. I had one person develop profound edema. Gained 30 pounds of fluid and jacked up their blood pressure by taking licorice when we were treating something else. 

We do have to respect it and be careful and know about it, but it’s reversible if you stop the supplement and pay attention and change to something else. You can get rid of it with no permanent problems by taking a short course of licorice. 

Dr. Eric: 

Most of the focus has been on hypertension. When is it a concern with hypotension, when blood pressure is too low? 

Dr. Ellie: 

It’s a concern when it causes symptoms. Many people run around with blood pressure of 90/40, and there are no symptoms whatsoever. Often, these are petite people, adults who are under five feet tall, under 100 pounds. They have a blood pressure of 90/40, and that is perfectly fine. They are getting perfectly good blood flow to their brain. They don’t have any symptoms if they change positions.

But if they get weak or dizzy when they stand up, that blood pressure is too low for them. It’s likely an indicator of a problem. That problem might be mitochondrial, nutritional, thyroid, adrenal. 

Or we are seeing a lot of vascular damage post-COVID from postural orthostatic tachycardia syndrome, POTS. There is a lot that can be done to help those people. Retraining of their sympathetic/parasympathetic nervous system can be done, but it’s not easy to do. Often, they’re nutritionally not balanced either. Low blood pressure can be a problem when it causes symptoms.

That being said, if you have chronic kidney disease, and we are trying not to get you on dialysis, the lower the blood pressure, the better. It preserves the kidneys for a much longer period of time. As long as you are not having symptoms, and we keep your blood pressure low, that is what our goal is. 

Dr. Eric: 

I tend to be on the lower side. Sometimes, I will be 100/60 for example. I feel fine, so as long as symptom-wise I feel okay, I shouldn’t worry about it. 

Dr. Ellie: 

I wouldn’t worry about it. I would count yourself in the lucky box. 

Dr. Eric: 

Good deal. Let’s talk about some natural options. Of course, it comes down to addressing what you spoke about: oral health issues, thyroid, if someone is using refined salts instead of natural salts. I’ll let you take over. If someone is listening to this, what are some steps they can take to help with their high blood pressure? 

Dr. Ellie: 

In my experience, probably the #1 most common missing nutrietnt in hypertensive patients is magnesium. We have lots of different choices of magnesium out there. There is magnesium oxide, magnesium citrate, chelated magnesiums like magnesium glycinate or magnesium malate or magnesium threonate. 

In general, for the most part, I don’t like to use magnesium oxide. It’s the cheapest one. It’s available at every hospital pharmacy. It’s available at every drugstore. It’s not very well absorbed, and it doesn’t get into the cells the same way that one that is chelated to amino acid does. 

I would switch somebody if they are on magnesium to a magnesium malate or magnesium malate/glycinate combination. That is what I take myself every day. I take three capsules once a day. Every skeletal muscle cell requires calcium to make it contract and magnesium to make it relax. That is including the tiny muscles on the surface of our blood vessels. If they don’t have magnesium to relax, they will be stuck in a constricted state. 

Magnesium is often super helpful as long as it’s inside the cells and not in your bowels and being pooped out, like magnesium citrate tends to do. Magnesium citrate is a wonderful laxative but not really great for your blood pressure. That’s why I like the malate or malate/glycinate combos.

I take three every day. They don’t make me sleepy. Some of my patients find they’re so relaxing that they can’t stay awake if they take them. I take mine in the morning. That’s when I take my magnesium. As long as I take it daily, I poop like a champ and sleep like an angel. Magnesium is my miracle. If I am stuck on a desert island, and I can only bring one supplement, I am bringing magnesium. That’s a simple one.

What if you really do have hypertension, but you don’t want to go to a medical doctor? You are going to be very diligent about checking your blood pressure and keeping your target above 120/80 or maybe 130/80. If you have end organ diseases, if you have heart disease, if you have diabetes, if you have kidney disease, if you’ve had a stroke or a heart attack, you probably should really aim for those lower readings, 120/80. If you have never had a problem, we can be a little softer with you. We can go up to 130/80 and not have to take anything for it. 

What’s one of the best things you can take? One of the biggest bang for your buck supplements is hibiscus. It’s that pink flower that we see here in Georgia growing all over the place in the summertime. If you make a tea and drink hibiscus tea, hot or cold, you can make hot tea or sweet tea out of it. Everyone in Georgia drinks sweet tea in the summer. 

I recommend you sweeten it with xylitol, not sugar. Xylitol is a polyol often made from birch bark. It also happens to be a prebiotic that supports oral health and lowers blood pressure just a little bit. 

Hibiscus tea, three servings a day, can lower your blood pressure 20-25 points. It’s one of the biggest bang for our buck nutritional supplements. I really do like hibiscus.

There are many others. One of the common ones we think about is hawthorn. Both the berries and the root have antihypertensive properties. They also act a little bit like a beta blocker, so they tend to slow down a fast heart rate. If you’re one of those people who tends to run at 90-100 blood pulse rate, as well as high blood pressure, hawthorn berry might be a really good choice for you to help get both things under control.

There are many other supplements we can use. Ginger for example and cardamom. Parsley. These all have antihypertensive therapies. Each one will typically lower your blood pressure. Some are around 2-5 points, except for hibiscus. Hibiscus is the big bang for our buck one, in the 20-point range.

One thing I do want to mention is mouthwash. Traditional mouthwashes like Listerine that make that really napalm clean in your mouth have been shown to raise your blood pressure up to 5-7 points and persist for many hours after you use that mouthwash. Why would that be? How could that possibly affect something? 

In the 1990s, there was a Nobel Prize awarded to three doctors for the discovery of a gaseous signal and molecule called nitric oxide. I like to call this “the miracle mouth molecule” because it has so many downstream effects. 

As they were trying to turn their nitric oxide discoveries into a commercially available pharmaceutical, they were trying to make a blood pressure medicine. One of the things that nitric oxide does is opens and dilates blood vessels, thereby lowering blood pressure, which is a nice thing. They had this supplement, Sildenafil, they were trying to manufacture for blood pressure. It wasn’t working very well. They were getting real disappointed. 

Man after man in this clinical study was coming in, “Guess what happened to me? I haven’t been able to get an erection for years. Since I started taking your blood pressure medicine, I get a good erection in the morning.” They discovered that this medication had nitric oxide benefits mostly in the pelvic floor, much more so than in the peripheral arteries. They turned it into Viagra. It was based on this nitric oxide research. 

We now know that if we do the pathways a little bit differently and not try to trick Mother Nature and use Mother Nature’s nitric oxide instead of the drug company’s artificial one, we can get really big benefits. 

Nitric oxide is made in every cell in your body, but it’s predominantly made by cells in the floor of your sinuses. There is an enzyme that is made in your tongue by friendly mouth bacteria. This nitric oxide synthase is annihilated when you use mouthwash. We want to use only mouthwashes that have been shown not to affect nitric oxide and make sure we’re supplementing with the things that drive nitric oxide pathway. 

That includes nitrite-containing vegetables. Beet root and arugula are two of the biggest, most common ones. Leafy greens in general. 

Supplements. Berkeley Life has one. N1o1 has one. They contain a little bit of B vitamins and some citrulline and beet root extract. They can be used to help our bodies make more nitric oxide. 

As an aside, about 50% of Viagra non-responders, if they pre-treat with a nitric oxide lozenge, like Berkeley Life or N1o1 and then take Viagra, it works. Little tip and tidbit for controlling blood pressure but also increasing nitric oxide is to use these nitric oxide tablets. 

I recently had the blessing and opportunity to go to Peru. I was in Cusco at 12,000 feet, where altitude sickness is a major problem. In part, your oxygen level is lower, and your cells don’t carry oxygen as well. Nitric oxide will improve the oxygen carrying capacity. 

I use those nitric oxide lozenges for myself to prevent my altitude sickness. I don’t have any issues with blood pressure, but I didn’t get altitude sickness when I used my nitric oxide supports. It’s a nice thing to have in your tool chest at home. 

Dr. Eric: 

Interesting. I didn’t know there were nitric oxide lozenges, so that’s pretty interesting. How about CoQ10? What impact can that have on blood pressure? 

Dr. Ellie: 

We know there is an age-related decline in CoQ10 levels. This is one of our body’s natural antioxidants. There are different amounts in different organs in our body. 

Our heart is one of the ones that has the most rapid decline in CoQ10 levels as we age. Utilizing CoQ10 to get those levels up to 20-year-old or 30-year-old levels can really make a difference in the resiliency of our heart and can lower blood pressure as well. You get five or seven points of blood pressure lowering by supplementing with CoQ10. It’s also heart-protective. 

We know the same pathway, the HMG-CoA reductase pathway that turns mevalonic acid into cholesterol, that is the pathway we block with statin drugs. That same pathway makes CoQ10. When we block the production of cholesterol using Lipitor or Crestor, we also block the production of CoQ10. A consequence can be high blood pressure. 

Supplementing with CoQ10 can reduce muscle aches and headaches and fatigue caused by lowering CoQ10 but can also improve blood pressure. CoQ10 is another great supplement to include. 

Dr. Eric: 

You shared a lot of amazing information. Really appreciate it. Before we wrap up, is there anything else that I should have asked you that I didn’t ask you? Any last words that you have? 

Dr. Ellie: 

Where can you get my book? The Blood Pressure Blueprint. It’s on Amazon on e-book and paperback. It will be coming out in 2024 as an audiobook. 

Dr. Eric: 

We were gonna get there, to where people can find out more about you. Definitely check out her book. 

That’s great that it will be on audiobook. I listen to audiobooks. If it was on audiobook, I probably would have read it. As of recording this, there is only the print edition, so I wanted to read it before our interview. Appreciate you sending me a copy. Highly recommend reading it or listening to it later. 

Can you remind people of your website and anywhere else people can find you? 

Dr. Ellie: 

Sure. I see patients in Georgia. I am accepting new patients. I am very proud to report that since I cracked the code on this root cause resolution approach to managing hypertension and cardiovascular risk reduction, we have had zero heart attacks or strokes in any patient for seven years. 

I am taking new patients, even if you have already had a heart attack or stroke and don’t want to have another one. But you have to come to Georgia to see me. I can only see patients face to face the first time; we can do remote visits after that.

CampbellFamilyMedicine.com in suburban Atlanta. That is my practice.

The website for the book is just getting started. There is not a lot of information other than links to all the podcasts I have been on if you think I tell interesting stories or like what I talk about. There are a bunch of podcasts on TheBPBlueprint.com. 

If you want me to come to your event and speak, DrEllieCampbellSpeaker.com is another website where people can find me. 

Dr. Eric: 

Wonderful. Thank you so much, Dr. Ellie. Appreciate you taking the time to talk about blood pressure. I’m sure the listeners learned a lot, and I learned a few things as well. 

Dr. Ellie: 

Thank you for having me. I appreciate it. We all work together. Everybody has their little niche. None of us can do everything. No cardiovascular prevention program is complete without a medical doctor, dentist, and hygienist on the team. We really have to work with interprofessional, interdisciplinary collaboration.

Another point, something I didn’t mention is chiropractic adjustment. I have seen many people normalize their blood pressure once we get their spine and posture in alignment. Don’t forget about that, too. 

Dr. Eric: 

Definitely glad you mentioned that. My background is as a chiropractor. 

I agree. Working as a team and not just relying on a single healthcare practitioner, because no one practitioner has all the answers. You have a lot of knowledge. I do, too. 

Dr. Ellie: 

Then we’re better. 

Dr. Eric: 

Exactly. Thank you again. This really has been a great conversation. 

Dr. Ellie: 

You’re so welcome. 

Recently, I interviewed Dr. Sandi and we discuss the role of health coaches in managing chronic conditions and thyroid health, Dr. Sandi’s career journey and why she founded the Functional Medicine Coaching Academy, the scope of health coaching and how it differs from a medical provider, the importance of individualized treatment protocols, collaboration between health coaches and medical professionals, mind-body medicine techniques, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with today’s guest. We are going to be talking about health coaching as well as mind/body medicine. I am excited to chat with Dr. Sandi Scheinbaum, who trains people to become functional medicine health coaches. It’s going to be a great conversation. Let me finish up her bio that I just started here: 

Dr. Sandi helps practitioners and businesses hire health coaches because she believes that health coaches are key to combating chronic disease and reducing healthcare costs. As founder and CEO of The Functional Medicine Coaching Academy, a collaboration with the Institute for Functional Medicine, Sandi is a leader in the field of health coaching education. Thank you so much for joining us, Dr. Sandi. 

Dr. Sandi Scheinbaum: 

Thank you. It is a pleasure to be here. 

Dr. Eric: 

Let’s dive in with your background. I’ve listened to some of your other podcast episodes. I know you haven’t been doing this your whole career. You have another career in the background. You used to do clinical psychology, I think? 

Dr. Sandi: 

Yes. Where I started is not where I am ending up. I started back in the very early ‘70s in education. I was in special education, and I spent some time training teachers for how they can work with children. We talked about children with special needs at the time, learning disabilities, behavior disorders. 

That led to an interest in stress management. I was doing workshops for parents, teachers, kids. I did relaxation tapes. I taught kids how to get a calm, quiet state. 

As a result, I went back and got my doctorate in clinical psychology. For close to 35 years, I was a psychologist. I was kind of a renegade psychologist. Mind/body medicine did not have a name at that time, but I was teaching people breathing techniques. We didn’t call it “breathwork” back then. 

The approach that I used was integrating all of these ways of thriving: cognitive behavior therapy, which is where you identify thoughts that are irrational and change those; mind/body medicine; relaxation strategies; and working with people with physical conditions, like migraine headaches, for example. 

Then I learned about the Institute for Functional Medicine. I went through their training program. I was in the first class to get certified. I was the only psychologist. Now there might be a few more of us. It was really eye-opening to learn about functional medicine. I was putting those principles together with the principles from positive psychology, mind/body medicine, cognitive therapy, principles that I knew were so effective in working with my clients as a psychologist. 

I was encouraged to start to train people who were health coaches. There were coaches coming to me. They had trained in other programs. They said, “We just don’t feel confident as health coaches.” I had a co-founder, and we approached the Institute for Functional Medicine. They thought it was a great idea. They had wanted to have a school to train health coaches for some time. The right people didn’t come along.

Together with IFM, we built the Functional Medicine Coaching Academy. That’s my mission, my passion today: training as many people as possible of all ages all around the world because we really need health coaches to help people live happier, healthier lives. 

Dr. Eric: 

I agree. Before we get into that, you said you were the first class for the IFM CP. What year was that? 

Dr. Sandi: 

That was back in 2013, a little more than 10 years ago now. 

Dr. Eric: 

We have a few things in common. First of all, many listening to this probably don’t know this, but I actually got my bachelor’s in psychology. Then I switched to chiropractic. Long story, but I went to Queens College in NYC, got my bachelor’s in psychology, then decided to change careers. I also eventually went through the IFM certification. It was three years later, 2016. That was eight years ago now. 

I definitely agree that health coaches play a key role. They help combat chronic diseases, including thyroid conditions, which is what this podcast focuses on, helping people with hyperthyroidism and Hashimoto’s. As you know, I started using health coaches. I didn’t tell you how long, but it’s been about 5-6 years since I started using them. They not only help to fill in the gaps, but they also help to free up more time, which allows me to see more people and help more people with thyroid and autoimmune thyroid conditions.

Let me have you take over. Why is there such a dire need for health coaches? 

Dr. Sandi: 

Today, people are suffering like never before. We are seeing skyrocketing rates of metabolic conditions. It’s been estimated that only 7% of adult Americans are considered metabolically healthy. So many people have chronic conditions. We are talking about type 2 diabetes. We are talking about the rise in neurodegenerative conditions, dementia, Parkinson’s, which is just off the charts, like we have never seen before. 

We are also seeing our children affected. When I was in special education, back in the early ‘70s, it was considered very rare to have a child with autism. In fact, I supervise student teachers, and for an entire county, this was the northern suburbs of Illinois, there was only one class for children with autism, where they would pull them out of the regular classroom. There were so few children. We are talking about the incidence being extremely rare. Now, it’s very common.

We are also looking at skyrocketing rates of anxiety and depression. Unfortunately, there is a huge shortage, particularly mental health professionals. That is where coaches can really step in. They are not psychotherapists; they are not psychologists. They do not diagnose any medical or psychiatric conditions. They don’t do psychotherapy. They help people with emotional wellness, with regulation of their emotions, and be listeners. First and foremost, that’s what health coaches are trained to do. That’s what they are the experts in: listening. 

When you feel heard and understood, and you have that relationship with your coach, that alone can be very healing. You end up leaving that conversation feeling better. When you combine what coaches can do in terms of encouraging you and guiding you for behavioral change and changing habits, like perhaps, you are moving more throughout the day, going out and taking walks, that is a great antidepressant, for example. There are so many reasons that health coaches are needed now.

We also have a doctor shortage. Good luck trying to find a new primary care doctor. My thing is health coaches are the new primary care. Why do I say that? It’s because lifestyle should be first. That is the first line before you consider anything else. What about someone’s day-to-day habits? What kinds of foods are they eating? How are they moving throughout the day? What’s their sleep like? Their stress level? Their relationships? Those are the areas that health coaches can address. 

Dr. Eric: 

Just to confirm, I know you’re not saying that health coaches are going to replace one’s primary care doctor. I agree with you. We want to focus on diet and lifestyle. Typically, when you go to a PCP, many times, they will just give a prescription. There is a time and place for that, but for many people, arguably, everybody needs to eat well. They want to be active. Mind/body medicine, which you’ll talk about, is important. I don’t know of any PCP who will sit down with you and talk about mind/body medicine, let alone eating a healthy diet. There are some functional medicine doctors who practice primary medicine and I’m sure do that. On average, you’re not going to expect that when you go to a PCP. 

Especially if someone is going to have to wait three months, four months, six months, during that time, if you do need to see a medical doctor, go to the ER if it’s an emergency. But if you are waiting to get a physical, why not see a health coach? We will talk about what they can’t do specifically, but as far as listening to you, giving you encouragement, maybe reviewing what you’re doing from a dietary and stress management perspective. Help to hold you accountable. I don’t know if you want to further expand on what they can do, but I definitely want to talk about what differentiates a health coach from a medical doctor or other practitioners. 

Dr. Sandi: 

Absolutely. We refer to this as their scope of practice. At the present time, health coaches do not hold state licenses. They are not licensed medical providers. That’s why they don’t keep medical records. 

They are not the ones who provide a diagnosis. A health coach is not going to diagnose you with hypothyroidism. They are also not going to have a treatment plan for you. They are not going to prescribe medication, or even things like supplements. They do not write out a meal plan. 

There is a but here. Many health coaches do hold those licenses. We actually have medical doctors who train with us. If they have that license, if they are a nurse practitioner or a registered dietician in addition to being a health coach, that would be different. 

Health coaches, unless they hold that license to practice medicine for example, do not order labs. They do not interpret labs. They are the educators. That’s a very important role. Somebody might get a lab result back. Increasingly, we are seeing people going to direct to consumer lab companies. They are getting assessments and results. The health coach doesn’t say, “Based on this, you have a Vitamin D deficiency.” “Looks like you are type 2 diabetic.” They are providing the education about what each test means. “Here’s your hemoglobin A1C. This is what this test measures. What are your thoughts about this?” You might see changes, like it was at 1 a year ago, and now it’s at this point. A health coach asks the right questions. “What are your thoughts about it?” That leads to how can we work together to change some of the behaviors that might be driving these lab results? That’s where the health coaches intervene. 

There are programs that say, and you might see this advertised, “Become a health coach in three months. You can order labs!” That is not true. You can do that, but it is out of your scope of practice. You didn’t go to medical school to learn about the rare medical conditions that you might not be able to pick up.

What we do is look at all of the things that a health coach can do and not get into those territories that are out of their scope. The value is in collaboration, which you referred to earlier. Our health coaches are collaborating with the medical doctors. They might have clients, and they might have a consult with a medical doctor who is the expert in ordering and interpreting those labs for example. 

Dr. Eric: 

That’s exactly how it works in our practice with the health coaches. They don’t actually order labs or give recommendations when it comes to supplements or even diet. Initially, I consult with the coaches when it comes to each of the patients. The patient has a pretty good idea of what diet to follow after that initial consultation with me. The health coach may review the recommendations. Same thing with supplements. The recommendation for supplements comes from me; the lab orders come from me. 

I agree. I know there are coaches out there who are doing those things. You’re saying that they shouldn’t be doing them. If they are just a health coach, and they are working on their own and recommending labs and supplements, that is out of their scope of practice. 

Dr. Sandi: 

Correct. 

Dr. Eric: 

You mentioned asking the right questions, so that’s important. Being a good listener is important. Those are some good, important qualities of a health coach. 

You mentioned also the duration. You gave an example of if someone just went through a three-month coaching program and ordered labs. Forget about the ordering of labs. Let’s talk about the duration. There are different lengths of programs. Three months is on the shorter side. I don’t know if there are any real certifications that offer it that quickly. I’d be a little bit nervous about seeing someone who just went through that, unless if they were trained also by a doctor. Let’s talk about the program from IFM. I think it’s a 12-month program, right? 

Dr. Sandi: 

Yes. Our program is 12 months. The reason is because human lives are at stake here. In order to have the skills, in order to have exposure to all of the nuances that have to do with when you have an encounter with another individual, it takes time to feel confident and also to learn things like motivational interviewing, like appreciative inquiry. 

Let me backtrack. Health coaching came from life coaching. Think of it like a spinoff from life coaching. Where did life coaching come from? That came from psychotherapy. Specifically humanistic psychotherapy, which was very big when I trained in the late ‘70s/early ‘80s. 

It was Carl Rogers, for example, gestalt therapy. This notion of client-centered, where you as the therapist are not in the driver’s seat. You are not telling that person what to do or what’s wrong with them. You are listening. The conversation goes in whatever direction that client wants to go. You have an unconditional positive regard for that individual. 

Where does this become problematic in health coaching, with a health coach who does not have that kind of rigorous training such as what we provide? Maybe they went to a course for three or four months and learned from an expert in many coaching programs that are established there. There is an orientation. Everybody should be paleo or keto or whatever their orientation might be. As a coach, what’s going to happen is you’re going to come out of that program, “I’m a vegan.” “I’m paleo, and everybody should be. That’s the healthiest way to go.” 

Now, you are taking your belief system, whatever that might be, and even on an unconscious level, you are communicating that. This Is what the client should be doing. That’s not unconditional positive regard. That’s not client centered. 

Health coaching, following this humanistic approach from psychotherapy, means that you are sitting with that individual. For that encounter, you are so mindful. That is your whole world. You are asking the right questions, so that client has that aha moment. “Yeah, what I am eating or not eating, maybe that is impacting how I’m feeling in my energy level, so I think I will give this a try.” But they come to that conclusion. It’s not the health coach telling them. 

They can be the educators. They can give their opinion, but only if that client wants it. It’s never forced on them. 

Dr. Eric: 

That makes sense. The timing of this question is good because I just came out with a book called The Hyperthyroid Healing Diet. Despite the name of the book, it’s not just one single diet. There’s three different diets. One of them is similar to an autoimmune protocol. Another one is similar to a standard paleo diet. Let’s say if the health coach is going over these diets, they wouldn’t say, “You have Graves’ or Hashimoto’s. You should follow an autoimmune protocol.” Rather, they should say, “These are the options. Many of our patients may be following autoimmune protocol, but some of them follow these other diets. Ultimately, it’s up to you to make the decision.” Would that be accurate? 

Dr. Sandi: 

Absolutely. It would be, “Here are the diet plans.” You are giving those because they are created by you, Dr. Eric, the expert. Then you encourage the client to be the detective, or possibly to go back and think about in the past: When did you feel best? If you eat these particular foods, what happened in the past? How did you feel the next day? They might have some insights into that. Or they might say, “I never did well, or I could never stick with a food plan that had this food.” “I don’t like the taste of it.” They will arrive at that decision.

Also, more importantly, they are going to arrive at where they want to start. A perfect example is the elimination diet. This was a diet that was developed by the Institute for Functional Medicine, and our coaches are trained in how to guide people through it. You eliminate for 3-4 weeks those foods that are likely to trigger a reaction. It can be challenging because you’re asked to give up coffee and chocolate and so many foods and beverages that you may depend on.

We actually did a randomized control trial with IFM. It was published in the peer review journal Medicine. This was for medical professionals going through IFM’s initial training course. They were asked, it was volunteer, to try the elimination diet. If they were going to be teaching it to be recommending to their patients, it would help to have that personal experience. It was hard for them. “How could I give up my coffee?” 

We paired our graduates for five sessions of coaching. The group that got the coaching, the compliance went up. The waiting room control group that just got the PDF guides to the elimination diet did not do as well in terms of their compliance. It does increase compliance.

With that individual, be in the driver’s seat. What does that mean? They might tell you, “This is when I’m ready to start. I’m not ready to start.” Or, “This is what I can do.” Perhaps, it’s starting very small, and the coach will ask, “How can I help you?” Often, it’s accountability. “We will chat again next week, and I will ask you how that went, giving up your coffee.” Or maybe it was, “I am going to do half decaf.” That was what they could tolerate. 

It’s always listening to the client. Where do they want to start? When do they want to start? What are going to be the potential obstacles? How can I support you? 

Dr. Eric: 

Great points. Everybody is in a different place. Some people might be used to eating fast food every day, and they may not be ready to start a strict elimination diet. People work with me all the time, and they have already done it on their own. They have made a lot of dietary changes. It does depend on the person. Some people may be ready to do it, except for coffee. Or maybe the dark chocolate. Usually, it’s coffee, if anything that they don’t want to give up. It might be, “Let’s compromise. Ultimately, it’s up to you.” 

A health coach can’t say this. I guess I could say, “This is the diet I want you to follow.” Even if I say this, it’s up to the person ultimately. I won’t follow them around their home. Ultimately, it is the person. 

If I say my preference is for someone to follow an autoimmune protocol or a paleo diet, then that is part of the health history, too. Usually, the person will say, “I don’t know if I can give up my coffee.” Then we might have a conversation.

Honestly, them and the health coach, that’s where they get into a deeper conversation with that. That’s usually what I have the health coaches talk about. Sometimes, they will bring it up to me. “Do I have to give up coffee? Do I have to give up gluten?” I will give them my opinion but also say they could talk to the health coach about that.

What you said, I completely agree with. 

Dr. Sandi: 

Nine times out of ten, it’s what you don’t want to give up, what you’re resisting, that is probably doing you in. If they say, “I can’t give up bread,” that’s probably the culprit. Same with coffee. Maybe now with people having Oura rings, they might notice, “Let’s do an experiment.” Could you go a couple days? What would happen to your sleep? Are you getting better sleep? They have that aha moment. “Oh my gosh, I did see that connection. I think I can do this now.” 

Dr. Eric: 

Excellent point. If someone is a little bit hesitant, “I can’t just give up coffee,” and they are drinking two or three cups, or the gluten, then you’re right. At least that is one of the things that they probably need to take a break from or eliminate. That’s an excellent point.

I wanted to talk to you about the different ways that health coaches are used. In my practice, a lot of it is one on one. There are group options, too. What do you see other practitioners do? Even maybe some health coaches who have their own practice. As far as seeing people one on one. How many sessions do they typically see on average? Is there a recommended number of sessions? How does it work for health coaches who help people in a group setting? 

Dr. Sandi: 

Sure. First of all, how they can work is multiple ways. It can be in person. They can come into the office. We even have some coaches who make home visits. They help with pantry makeovers for example or hands-on cooking, if they have that background. 

Most of the time, it is now increasingly remote. Health coaches, because they are not licensed by the state, and they don’t have the regulations as many practitioners do only to work in the state or states where they hold a license to practice, as non-practitioners, they are not bound by that, so they might be in Illinois but seeing someone in California or any part of the world. That allows practitioners who have health coaches to expand their reach because their health coaches can practice out of the state, as their own medical license may have more restrictions. 

They can be one on one. Increasingly, they can see people in groups. I love groups. We teach people how to do group coaching. In group coaching, the community is the healing element, the medicine. We feel like we’re not alone when we’re in a group. When we are with others, “If this person can change, I can, too.” There is that social modeling. The impact of going along because you are in the group with the group norms, so you’re more likely to change. It is a wonderful way of working. 

There are a lot of practices that are insurance-based, and this is something that can be billed through insurance. There are ways the doctor or nurse practitioner can take people out of the group for breakout sessions, where they have that individual time, and they bill for that through the health insurance system. The coach is facilitating the group.

We have found the sweet spot for the number of sessions to be around 5-8 sessions. That’s enough time. Often, there is some check-ins. Again, because it’s client-centered, how do you want to check in? Some people will say text or email or a phone call. It’s highly variable how many sessions. The average tends to be around 5-8. 

That depends on what’s going on. Depending on the chronic condition, etc. Sometimes, people may work on one issue, and when that’s resolved, they want to work on something else. 

Dr. Eric: 

I’m sure you’re familiar with HIPAA and patient privacy. That’s been a concern. I do group coaching calls. The way I do group coaching calls is they don’t interact with each other. I just finished a five-day challenge, which was not for patients, just the general public. Everybody was on Zoom, and we had a Facebook group. Everyone was interacting. They’re not patients of mine. 

When I do a group call with patients, they’re not seeing each other or communicating because I’d have to have their permission to do that. Is it similar with health coaching, where you would have to get everybody who joins permission that it’s going to be in a group setting, and they will be interacting? 

Dr. Sandi: 

Yes. It’s usually best if you are a practitioner and want to run a group. You have that first session with somebody. It’s a private session to explain why coaching in a group is a good choice for them. You go over the rules of engagement. One of the most important rules is you are going to abide by HIPAA. 

I should point out, because health coaches are not what’s called “covered entities,” they don’t hold medical records, so they are not legally bound by HIPAA. But they are ethically, morally bound. Through the National Board for Certification for Health Coaching, NBHWC, if you are a board certified health coach, you abide by the rules of that professional body. That includes abiding by confidentiality. You are not going to disclose anything that is revealed in your health coaching session. That’s a given.

When you have a group, what you would do, if you are leading a group, is go over the rules, just like a classroom. You want to speak in a courteous way. There would be no talking over somebody else. You want to be respectful of others’ opinions. These are the standard classroom rules. 

A big rule is that what is heard in that setting stays in that room. However, because each individual who is in the group, you have no personal control over them. Somebody may go out and post something on social media. That’s very rare because what happens is the group, they become close with one another and honor bound. You would go through those rules every time that you start the group, just to remember that what we share stays in our group room. People do abide by that. 

But it is not legally bound. Somebody who goes out and inadvertently discloses something, they are not legally bound. They are just private individuals; they are not medical practitioners violating HIPAA. 

Dr. Eric: 

Okay. Any other roles that you see health coaches play besides what you mentioned, one on one, either in person or remotely, or working in a group setting? 

Dr. Sandi: 

If you’re a primary care doctor, your health coach might be in the session/visit. They are the ones assuring that people understand what is recommended. They understand the diagnosis. Some practices use health coaches that way. 

Increasingly, we are seeing health coaches being the patient advocate. If you are going through the conventional medical system, you may feel overwhelmed, especially people who are not technically/computer-savvy. They can’t just call up the old-fashioned way. Maybe they had a primary care doctor who they would just pick up the phone, the receptionist answers, you make an appointment. That’s old school. 

Now you call, and it’s this huge medical conglomerate, and you are feeling lost in this system of talking to robots. It’s very stressful. A health coach can help you with that.

If you are a health coach and have your own business, they might help you with referrals to specialists, for example, finding a functional medicine doctor. If you are dissatisfied with the care you’re getting, suppose your medical team is in one of these huge hospital conglomerates. You feel you are given seven minutes, and they’re ignoring what you really wanted to discuss. A health coach can help you find that right practitioner, or they are the ones who are your primary contact. They can help you navigate this increasingly complex medical system, where you just feel like a number.

Dr. Eric: 

A lot of different roles that health coaches can play. I want to talk with you a little bit about mind/body medicine. Before we do that, is there anything else that I should have asked you that I didn’t ask you about health coaching? Anything you have a burning desire to talk about that you didn’t talk about? 

Dr. Sandi: 

Well, I should say that if anybody is listening, and they are thinking, “Gee, I think I would like to be a health coach,” we need so many health coaches because of people getting sicker and sicker. This is a career. If you are a practitioner and learn health coaching skills, it brings meaning and purpose to your life. 

You are personally transformed. We know that. Every session, it is client and coach who are personally transformed. It’s not like you are the teacher if you are the coach, and the client is the learner. You are both the learners. You’re learning that person’s story, and it’s also a personal transformation and a process.

Dr. Eric: 

Toward the end is when I ask how people can find out more about you. I am going to ask you to do it now also. FunctionalMedicineCoaching.org is the website for people who are interested in learning more about becoming a health coach. 

Dr. Sandi: 

Yes. 

Dr. Eric: 

Wonderful. Mind/body medicine. What is your definition? 

Dr. Sandi: 

Well, this was a saying that I started to describe way back in the late ‘70s: What’s real in the mind is real in the body. That is mind/body. You can’t separate. Every thought, every emotion that you have is going to be inflammatory or anti-inflammatory. It goes to the cellular level. 

That was just a wild hypothesis back then. Today, we have the advanced technology to show that that happens. It affects our microbiome. It affects our cellular functioning. 

What you imagine, the power of imagery, the power of what you are experiencing and how you are defining your circumstances, goes so far in terms of your physical wellbeing. It’s remarkable how many ways that you can impact your physical health. 

Dr. Eric: 

A two-part question: What type of mind/body medicine techniques do you recommend? What do you personally incorporate? 

Dr. Sandi: 

It always starts with breathing. We hear a lot about breathwork. Sometimes, some of the strategies out there can actually be detrimental if you perhaps are prone to panic and anxiety. You can induce a panic attack if you are working some of the breathwork where you are hyperventilating. 

The easiest, most effective way is to notice where your breath is coming from. Put your hand on your stomach. Put your hand on your chest. Are you initiating with the diaphragm, where you push your stomach out, the slow belly breathing? James Gordon talks about it, a soft belly breathing. You become aware of where you’re breathing from. 

Then you become aware of how fast you’re breathing. Is it very fast or slow? I have taught this to thousands of patients as a health psychologist. 

Then it’s using imagery. As you feel the breath, what images occur to you? Whatever direction your mind goes, that is what is at the moment. It can also be an image or sensation where you imagine the warmth of that breath. 

Where does that lead? It leads to warmth in your heart. That is actually a heart math technique for better heart rate variability. As you take these slow, deep breaths through your belly, and as you exhale, you imagine they’re warm. That warmth is flowing through your heart. Now you’re sending a warmth through your heart out to all parts of your body.

I personally love a strategy which is again very old. I don’t see it very often, but it is autogenic phrases. This is in a nutshell self-programming. What does that mean? You repeat some things over to yourself, maybe 2-3 times. “My feet feel loose and relaxed. My hips and thighs are feeling loose and relaxed. My breathing is slow and regular. Warmth is flowing down my arms into my hands and fingers.” You keep repeating these. It can be whatever you think about, whatever areas need a bit of extra love. 

I go through this. I might focus on my adrenal glands. I talk to them. Or I am talking to for example my digestive tract. Imagining all of the good bugs in the microbiome and giving them some love. That is the power of imagery. 

Some people use external imagery, like imagining a beach, mountains, whatever appeals to them. This is so personalized. It’s not one size fits all. 

There is progressive muscle relaxation, another very tried and true technique. It was developed in the ‘20s by Edmund Jacobson. You are taking each body part and squeezing and tightening as hard as you can. When you release, you release as much as you tightened. 

I did that for kids. They loved it. They tighten up and squeeze. You’re holding your breath. Then you let go. These are very simple strategies that you can incorporate into your daily routine. 

Dr. Eric: 

I heard you mention heart math. Do you utilize heart math on your own or with clients? 

Dr. Sandi: 

Yes. I used to use it quite a bit. In fact, I trained back in the day when it was first established. You’re impacting heart rate variability, which is movements between each heartbeat. It has been highly correlated with a quieting response. 

Dr. Eric: 

I use the Inner Balance pretty regularly. The emWave for my computer. Not that you need to use both of them. One is sufficient. 

Another two-part question. Do you utilize mind/body medicine every single day? Is it 3-4 days a week? When you do utilize it, how long is an average session? Is it spread out throughout the day, where you do it for five minutes, three times a day? Or a single session of 20-30 minutes, whatever technique you end up using? 

Dr. Sandi: 

I do it the same way I approach exercise, as snacks throughout the day. I might have a longer session as well. I was never one to meditate for 20 minutes a day, just sit there and see what comes. I am very full of zest and hyper, so that never worked. I need something more structured. 

I might do a meditation walk for example. Or I take ballet class. That is a very meditative state as far as practicing relaxation techniques. Perhaps if I am out in the sun and feeling the warmth, that is going to lead to a few moments of going through this. If I am sitting in a sauna, I might go through that round of autogenic phrases. 

Most importantly, it’s throughout the day. If something happened that was potentially stress-producing, like before recording this podcast, I always like to check, “Do I have the call-in?” I checked on my phone, and I didn’t see anything. It could have been that moment of stress, like, “Oh no, what if I don’t have the link, and I’m late to getting on for this interview?” Luckily, I found it on my computer, so it was all good. 

That is where I said to myself, which comes through cognitive behavioral therapy. I consider those relaxation strategies as well, “So what if I don’t have the link? I have Eric’s email. I’ll get it.” Or, “Okay, what if I can’t get ahold of him? What if I’m late? What is the worst thing that can happen then?” 

Often, you take it to the nth degree. Is this worth dying over? At my age, I’m 74. I hear almost every day my contemporaries who have passed away. Really, it’s that perspective that is also very important to practice. “Will this matter in five years, 10 years? Will I remember this?” We tend to upset ourselves and get into that stress response over things that are relatively trivial in the long run. 

I wear a CGM. For me, what causes those blood sugar spikes is not the foods I am eating as much because I eat a really healthy diet, but it is those variations in terms of potential stress that is going on.

Dr. Eric: 

I am glad you said that about spreading it out throughout the day. I think some people get the impression that you have to do it 20 minutes. Just like some people exercise. When I exercise, it is all at once. I try to move throughout the day, but if I am doing weightlifting, it is usually blocking out whatever time, an hour, to do the weight lifting. It’s not spread out throughout the day. Some people think it has to be the same with mind/body medicine, that you have to have larger chunks. 

What I encourage people to do is get into the routine. If you are not doing it, just start with five minutes. Don’t try to do 15-20 minutes at a time. It will be more difficult. I’ll start that routine to begin with, and some people stay there. It’s really about getting started.

I’m glad you didn’t say people should be doing 20-30 minutes a day consecutively. Some people, it’s fine if they do that. If some people are already doing that, there is not one way that everybody should do it. It’s different. 

I’m glad you gave your perspective that someone can do smaller chunks, 5-10 minutes, multiple times per day. That can just be as effective as blocking out 20-30 minutes to incorporate mind/body medicine. 

Dr. Sandi: 

I used to teach people to take 30 seconds, a minute in between emails. You set a timer. Or the times when you most need it, let’s say you’re in an airport and waiting for your luggage to come off the carousel. Instead of checking your phone, do some shoulder rolls and breathe at the same time to let go of tension. It’s often when you most need it that you can just do this quick relaxation response. 

Dr. Eric: 

I agree. Thank you for sharing. Anything else on mind/body medicine before we wrap this up? 

Dr. Sandi: 

It is the most powerful tool. It is really something that you have within you because your mind and body are always interacting, but they may be producing a stress response. They can be turned around to produce a profound healing, relaxation response.  

Dr. Eric: 

I agree. Going back also to what you said about the CGM, you notice more the stressors than the diet because you’re eating a pretty clean diet. But the stress also can affect blood sugar, adrenals. I’m glad you mentioned that. 

This was an amazing conversation on both health coaching as well as mind/body medicine. As far as people finding out about you, I’ll let you take over. Your website or anything else you’d like to drive the listeners to, feel free to share. 

Dr. Sandi: 

FunctionalMedicineCoaching.org is the website. If you’re on Instagram, my personal is @DrSandi. @FunctionalMedCoach is our main Instagram site. Those are the main places that you can reach us. We’re also on Facebook, Functional Medicine Coaching Academy. 

Dr. Eric: 

Thanks again, Dr. Sandi. I really enjoyed this conversation. I learned some things, and I’m sure the listeners did as well. 

Dr. Sandi: 

Thank you so much.

Recently, I interviewed Dr. Jen and we talked about the role of peptides in thyroid health, benefits for autoimmune conditions, the use of specific peptides for managing inflammation and supporting patients with mold exposure and stealth infections, how peptides can be a part of your stress management strategy, the importance of high-quality sourcing for peptides, broader implications for health and longevity, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with Dr. Jen Pfleghaar, as we are going to be talking about peptides. Of course, relating them to thyroid health. Let me go and dive into Dr. Jen’s bio here. 

Dr. Jen Pfleghaar is a double board-certified physician in integrative medicine and emergency medicine. She attended medical school at Lake Erie College of Osteopathic Medicine. She went on to residency at St. Vincent’s Mercy Medical Center for emergency medicine and spent one year flying with Life Flight as a flight physician. Dr. Jen now works at local emergency rooms in a community and office in Perrysburg, Ohio, practicing integrative medicine and medical aesthetics.

She is a graduate from the University of Arizona Andrew Weil Center for Integrative Medicine’s Fellowship program. Dr. Jen loves speaking and lectures to physicians at conferences, including the American Osteopathic Association. She hosts The Integrative Health Podcast with Dr. Jen. 

Her own health history of Hashimoto’s, which is now in remission, sparked her interest in integrative medicine, and she is very passionate about helping patients with chronic disease and teaching them how to let their body heal itself. 

She is a published author of the book Eat, Sleep, Move, Breathe: A Beginner’s Guide to a Healthy Lifestyle. She is a board member for Invisible Disabilities Association. Her hobbies include spending time with her husband and four children, being in nature, weight lifting, wake surfing on the Maumee River, and reading the Bible. Thank you so much, Dr. Jen.  

Dr. Jen Pfleghaar: 

Hi, thank you, Dr. Eric. So nice to be here. 

Dr. Eric: 

Excited about this. You spent one year flying as a flight physician. Is it as exciting as it sounds? 

Dr. Jen: 

Yeah, it was really fun. Whenever I see Life Flight fly over the helicopter, I think back to the days where I put on that jumpsuit. You come out of the helicopter and walk toward danger and help people out. It was a lot of fun. You’re there to fix what they can’t fix and to get people to where they need to be, to trauma centers. We would stop in the middle of the highway. Pretty cool flying with really talented pilots. My life was in their hands. 

Probably wouldn’t do it anymore now that I have a bunch of kids. But it was a really fun time in my career. 

Dr. Eric: 

Definitely sounds like it. We’re going to be chatting about peptides. Before we get started, how did you start learning about peptides? Of course, at the end, we’ll talk about your Peptide Summit, which I recommend for people to attend. How long have you been working with peptides? What led you to start recommending them to your patients? 

Dr. Jen: 

About 2018, I started to look into peptides. What are these? People are using them; they’re working well. Then I got cold feet for about six months because we had heard that the FDA was going to take them away. I don’t want to learn this whole new language. As we dive into the names of these peptides, it’s like a different language, a lot of alphabet soup. I got a little bit of cold feet. 

Then I joined this peptide group on Facebook. One of my colleagues, Dr. Rose, runs it. I decided to dig into peptides and get some education on them and start using them. I want to talk to the compounding pharmacists about them. 

I was just so happy I did. It just levels up some of the struggles patients have getting to that extra 10% of wellness. Or if it’s a really sick patient, and they’re doing all the things they can, sometimes it just moves the needle a little bit for them. It’s been really great to bring it into practice. 

IF you’re listening and look up “peptides,” it’s a gray area right now. The FDA just put 22 more peptides on this class 2 list for pharmacies. Compounding pharmacies aren’t making certain peptides that we were so used to having. Most of these are the injectable forms. We’re in a weird area right now with peptides. 

The good news is we are going to talk about oral peptides that we can take. They are looked at more as nutraceuticals and supplements. Those aren’t going to go away. That’s the good news. 

Dr. Eric: 

That is good news. Unfortunate about some of the injectables. It sounds not all of them. You said 22 specifically, and I know that could change. 

Dr. Jen: 

Yeah. The definition of peptides. What is a peptide? There have been some big names out there that have recently done podcasts and YouTubes on peptides. Let’s go over the definition. 

Peptides are chains of amino acids, usually about 4-50 amino acids. When you get higher than that, then you get proteins. Less than 4 amino acids, technically these are bioregulators. 

With peptides, people are like, “Oh, peptides. They are starting to get this weird, biohacking name.” No. We have peptides in our body naturally. Insulin is a peptide. Oxytocin, which is the love hormone, which breastfeeding women need, that’s a peptide. When we are getting dramatic talking about peptides, no, we make them in our bodies. The peptides we are talking about today, most of them are found naturally in our body also.   

Dr. Eric: 

Let’s dive into some of the benefits of peptides. This audience consists of people with thyroid and autoimmune thyroid conditions. Why would those listening to this be interested in peptides to improve their health? 

Dr. Jen: 

What these peptides do is go into your body—whether you take them intranasally, injection, orally—and they turn on and off genes in the body. It’s not like they’re going in there and disrupting things or forcing different pathways and having side effects. They’re working with your body, turning on and off genes, which is pretty amazing. 

That’s why I love peptides so much. They have pretty good safety profiles. Some of them, you have to be careful with certain things going on. Most of them are very safe. 

If we look at the studies, most studies are animal studies. The reason for that is it’s hard to get clinical trials done. They cost a lot of money. Usually, they are funded by drug companies. 

These peptides are really hard to patent. Some of them are starting to patent, and they’re turning them into actual drugs. One example is Thymosin alpha 1. Thymosin alpha 1 is a thymic peptide. Our thymus sits about here on the chest, and it is an organ that is really good for our immune system. It really is going to modulate immune health and our immune system. This is something that goes away as we age. 

These thymus peptides are really good at modulating our immune system. Thymosin alpha 1 is one of the ones that is amazing for autoimmune diseases. It was also in many studies. You can look them up on PubMed with COVID-19 and Thymosin alpha 1. They were using it a lot in China in the hospitals there. The patients were getting Thymosin alpha 1 injected daily when they tested positive, and they were doing really well. That was a great one when we could still get it in the U.S. to use for autoimmune diseases, like Hashimoto’s, and COVID-19, which was an immune dysregulation, when the cytokine storm would take over, and that’s when people would really get sick. 

About two years ago, the FDA said no more. Compounding pharmacies can’t make this anymore. it was really frustrating for a lot of us that were using it. Our patients were doing really well with autoimmune diseases. It was helping them get better faster, to go into remission faster. Now it’s a biologic pharmaceutical. I think it’s about $20,000 a month or something like that.

Dr. Eric: 

Wow.  

Dr. Jen: 

It’s a little frustrating. That was the first step that happened with the FDA, how they’re classifying some of these peptides. Now though, some creators, Dr. Kent Holtorf is one of them. They took the Thymosin alpha 1 and made thymogen, which is an oral peptide. That is going to have some of that thymus response, too. 

That’s what I’ve been using in my patients with autoimmunity issues going on. When I think it’s the right time to use it, I will give them thymogen, and that will help. It’s not as good as what we used to have, but it’s still helpful. 

When we talk about peptides, we’re just trying to use what we have available right now. The doctors that are out there using peptides, we’re trying to go with the flow, not be discouraged by the ones we can’t use, and just look forward to what we can use and how to work them into our patients’ protocols. Are you using peptides currently in your practice? 

Dr. Eric: 

As of now, no. I’m not using them. This is the first episode where we’re focusing on peptides. I have had some others where they talk about peptides along with other things. This episode is just focusing on it. 

With the previous episodes, they would talk about Thymosin alpha 1 as an option. It’s been a while since I had anybody talk about peptides. I should probably have you or someone else come on once a year because it sounds like it’s evolving. Hopefully, the thymogen will be available for the foreseeable future, but you never know. Or maybe something else will come along that’s better. 

Dr. Jen: 

Exactly. Along with the thymus peptides, there is also Thymosin beta 4. That was injectable. Those were used together. A lot of people use that for cellular repair. A lot of athletes use that. It’s a thymus peptide, so it’s good for autoimmunity.

That one, same thing. Can’t really get it anymore. There is something called TB4-FRAG, so it’s a fragment of that Thymosin beta 4. It’s oral also. That is another one for autoimmunity, which is really helpful to calm everything down. 

There are some oral peptide companies that put those two together, the Thymosin and the TB4-FRAG. Those would be a really good regimen for someone. 

I like to be aggressive with new onset Hashimoto’s, when we have just discovered it, to try to put it in remission really quickly, so maybe they don’t have as much damage to their thyroid gland. Also in those hard chronic cases, where there are all those other layers, like Lyme would be a good one. Those two peptides would help maybe because it’s focusing on that immune system and rebuilding that. That is some of the ways you can just use the oral ones. 

It’s sad we don’t have the injectables, but we’re just moving forward with technology. The oral peptides actually do really well. Not everyone likes to give themselves shots. I find it’s a little easier for patients, even though patients do get pill fatigue, too. 

Dr. Eric: 

With the Thymosin and TB4-FRAG, they can be used for any autoimmune condition? Are there any autoimmune conditions they shouldn’t be used for? 

Dr. Jen: 

You’re not using them long-term. That’s another thing with peptides. You’re going to cycle them. You don’t want to be on the same peptide all the time. You want to work with someone who knows how to cycle them, usually for about three months, see what happens, and then reassess. 

Another favorite peptide that is also a good peptide for thyroid, Hashimoto’s, Graves’, all those autoimmune diseases, Crohn’s- There are a lot of studies with BPC 157 and Crohn’s. BPC 157, body protection compound. It’s actually made in our gastric juices. That’s how it was discovered during those polyp experiments. BPC 157 is very good when you take it orally for healing the gut, healing gastric ulcers, Crohn’s, IBS. Anything with inflammation, BPC 157 is great.

It’s also great for tendon healing and ligaments. That’s the injectable version. Now that we can just take it orally, that’s another one where we don’t have the injection available anymore. They say it still helps with their tendons when they take it orally. 

I found the injection works a little bit better when it’s closer to the site of injury. I had an injury with my left shoulder. I could not do shoulder presses. Now it’s healed, and I used BPC 157 to help heal and repair it, especially as we’re aging.

I’ve also had patients who have had chronic pain in their joints from playing football in high school. We put them on two months of BPC 157 and cycled it. They were able to get out of bed, and they were feeling a lot better. It’s a great peptide. 

Interestingly enough, it is banned by the NFL and all of those professional sports, which is interesting because I don’t know how you would test for it. Maybe there is a drug screen that I don’t know about. 

I’ve spoken with orthopedic doctors that were more conventional. “I don’t know what that is.” Of course you don’t because what’s your goal as a surgeon? It’s to go to surgery, not to avoid surgery. That’s why I think a lot of these, if they were used consistently by all of medicine, it would probably make people really well and would cut back on hospital stays, surgeries, all of that. 

BPC 157 is available to take orally. 500mg, once a day. Great for gut health, like I said. Sometimes, it’s paired with Larazotide, which is another peptide, but it’s also a pharmaceutical. It helps with gut health and repairing the gut lining, those tight junctions, and also modulates zonulin a little bit. I’ve seen them in combination before. 

I’ve had patients who have had chronic diarrhea, Crohn’s, all of these horrible GI things recovering from GI viruses, illnesses, really recover well with the BPC 157. I always keep it with me when I’m traveling because you never know if you are going to get food poisoning or a virus somewhere. That’s a good one to take with you when you’re traveling, too. 

Dr. Eric: 

How about with H-pylori and/or parasites? Can that be beneficial at all? 

Dr. Jen: 

It would help with the inflammation. I don’t think it’s really going to take care of the H-pylori or the parasite. 

Dr. Eric: 

It’s not an antimicrobial. 

Dr. Jen: 

That would be LL-37. That one is injectable. We can’t get it right now. That was a great antimicrobial, anticandidal. That one was injectable. In really hard cases, I would pull it out as a big gun. A few human studies on that one also. 

Back to BPC 157. It’s like a different language. BPC 157, if you write that one down, I feel like it’s talked about a lot. It also could be compounded into eyedrops. You can put it into wound cream. 

I have compounded it for a patient with a really bad scar wound. He was at the misfortune of a couple urgent care visits, where they totally messed him up. We got him on some BPC 157 and GHK-Cu (copper) peptide cream, and it healed beautifully. 

They can make BPC 157 in all these compounds. The eyedrops were really cool. Some studies with corneal healing on that. I’ve had patients with dry eyes. One patient had dry eyes post-chemotherapy, and the BPC 157 was the best thing that had ever worked for him. The downside is the eyedrops are really expensive to get compounded. Those are a little pricey. 

Dr. Eric: 

You said that with the BPC 157, there was another injectable peptide you could take along with it that can help with gut healing. Can you also take the BPC 157 with the TB4-FRAG or Thymosin? Is that something you’d want to cycle, where you’d go back and forth between the two every few months? 

Dr. Jen: 

You can stack them. You’d also want to take a break and cycle. It depends on the patient in front of you. Say someone comes in. I usually start with gut health. I usually look at their GI Effects or stool study or organic acids test, if they have mold or candida. I will tailor it to that. And their symptoms. If they are having a lot of gut inflammatory symptoms, like diarrhea, bloating, pain, we might want to change their diet first. Make sure they’re getting sleep. We might want to add on a peptide. 

I talk to them about it. “Here’s all the things we can do.” First, what can they afford? What are they comfortable doing? 

If there is an H-pylori or parasite or candida or SIBO, we will take care of that first. Then layer in peptides in there, like BPC 157. After we fix their gut, then I usually do the Thymosin and the TB4-FRAG after that. 

Peptides work better when you’re optimized. Say someone is a mess, and they’re not willing to work on anything. If you throw some peptides at them, they might be like, “This isn’t doing anything,” and they spent all this money. I have noticed once you optimize a patient a little bit more, then add on the peptides, it’s like icing on that cake. They work so well. 

These are basic things like nutrition, sleep, and stress. I never want patients to waste money obviously because these kinds of things aren’t covered by insurance, but they work well. Optimizing those things and adding on peptides a little bit later as a therapy is sometimes good. 

Unless they are in a crisis, and you want to throw the kitchen sink at them. Or while you’re waiting for test results, it wouldn’t hurt to put them on BPC 157 to calm things down. 

Another good peptide for inflammation is KPV. This is actually a part of alpha-melanocyte stimulating hormone, α-MSH. This one is great because it’s so good for inflammation. This will be the one that’s paired with BPC 157. It will add another layer of calming inflammation down. 

I love this product for mold patients. Really helpful. They’re often low in α-MSH anyway because of all the narcans. This will be really helpful with them. I’ve had some patients where giving this intranasally, they really liked it that way. They felt it calmed down the inflammation in their head that they felt. You can also take it orally. 

I like to take this every once in a while if I am feeling more inflamed. Sometimes, I take it with PEA just to help with inflammation, too. KPV is a great one. Really like that. 

I’ve had some mold patients who will stay on that for a couple months at a time. Then we will take a little break. Then they might go back on it. I really like that one.

With your autoimmune patients, thyroid, Graves’, of course that will help a lot, too. Usually, these patients are the ones who have underlying mold going on. In your area, where are you at again, Eric? What part of the country? 

Dr. Eric: 

North Carolina. 

Dr. Jen: 

You probably see a decent amount of mold, right? 

Dr. Eric: 

It seems like it’s increasing. I am also more aware of it. I can’t say I test everybody for mold. Maybe five, six, seven years ago, I wasn’t doing urinary mycotoxin testing at all. Now, I’m more aware of the situation and will do that if necessary. Have them test their house for mold. 

Even though I’m in North Carolina, I also work a lot with people from all over the place. I don’t think there’s any place that’s safe from mold. Some places will be more susceptible, but I’m sure people even in places where you wouldn’t suspect mold might have cases of mold. 

Dr. Jen: 

I also feel like building material now is so cheap. It’s just cardboard. It’s all mold food. You have one little leak, one slow drip, and then mold. I am so paranoid about mold because of what I see in my office. 

Last Christmas, we were out of town, and there was a freeze. One of our pipes burst. The water went down to our basement. It had been about 24 hours since it had happened. We looked at the water use charge, and it was tons and tons of gallons. 

I was freaking out to my husband. “It all needs out right now.” Everyone thought I was being a little crazy. “Here, she’s being crazy again.” “No, I’m not.” 

Guess what? There was mold all over the drywall in the basement because it was a bathroom going down to a bathroom. There was already mold formed within 24 hours. We got it out, but it was a reminder with all of these houses that there are floods or hurricanes or standing water. That has to come out. Unless it’s plaster, which is cement basically, it’s going to have mold, and you will get those VOCs and mycotoxins.

What that does is messes with your immune system. It hurts your gut health, makes you more susceptible to different autoimmune diseases. 

I really enjoy talking about mold because I feel like it’s not talked about enough. A lot of people suffer from it. Peptides are really helpful with mold. They are a really good tool in the toolbox if you are working with mold patients or are a mold patient.

Dr. Eric: 

It goes without saying that if you have a mold issue, KPV can help, but you of course have to address the mold problem. You can’t just take the KPV. I guess you can do that, but it’s not going to have optimal benefits unless you get rid of the source of the mold. Assuming you have mycotoxins in your body, do things to detoxify them from your body as well. 

Dr. Jen: 

Absolutely. When you’re just buying time, figuring out if you’re still living in the mold or it was an old exposure, I have a lot of patients with that. They are waiting to get their house inspected or get an ERMI tester, whatever they’re going to do. Or they can’t get out of it for a while. That’s where things that help with inflammation or calm things down are good. Maybe your brain fog will get better. Binders supporting liver health. All those can be helpful. It’s pretty devastating for sure. 

Dr. Eric: 

How about stealth infections, something like Lyme or bartonella. Would the KPV be beneficial?  

Dr. Jen: 

Yeah, I would put that in the mix. These patients are usually really inflamed. You’d use the thymus peptides. You could also add on BPC 157, KVP. Those would be helpful. 

Other ones that are hard to get right now, Semax and Selank will help with brain, like brain fog and ADHD sometimes. Biohacking, people use Semax a lot for neurocognitive health. Those are nasal. Once again, those are harder to find now. We have to be a little patient. Sometimes, those are also used with these patients if they have really bad brain fog. They’re nice to use. 

Dr. Eric: 

Any peptides that can help with stress, adrenals? Obviously, you have to block out time for stress management and improve your stress handling. Any support specifically for adrenals? Anything you would recommend, maybe not directly supporting adrenals? 

Dr. Jen: 

For stress, you can use different peptides. The Semax, Selank. 

It’s not really a peptide, but DHH. It’s from the magnolia bark tree. It’s really good for calming anxiety. It’s almost a Xanax derivative. Similar action. I’ve had patients say that to me. I like DHH-B a lot. 

One that’s really cool that’s an oral peptide is 5 amino 1 mq. Because it’s a mitochondrial peptide, it really helps with energy and mood. I would think that would be a good one. It’s working on all the mitochondria. I would think that would help the adrenals, too. 

I have patients who really love it. I have them stay on it for a few months. Then I suggest to take a break for a month, and they can go back on it. Maybe I’m being a little bit conservative with that. It’s just a mitochondrial peptide, so it’s boosting energy to all of the cells. It’s helping with that cellular energy and the pathway we get our energy. 

That one, you can take up to three times a day. I usually tell patients once or twice. You don’t want to take it too late in the day because it can be more stimulating. It also has a little bit of thermogenesis effects, so weight loss and pilosis. I would say 10% of patients don’t like it or don’t notice it does anything. The rest of my patients really love it.

I’ll use that one when I’m traveling more. If I’m going across time zones, instead of coffee, I’ll use that to support my body. That one is the closest in the peptide world.

For the adrenals, one thing you can do is go on a bioregulator for the adrenals. A bioregulator would be a good choice. Bioregulators, which are those four or less amino acids, they are basically purified amino acids from animals. They’re purified down and put in a capsule. You take the capsule. Same thing as peptides, going in and turning on and turning off genes. 

Bioregulators came from Russia, Dr. Khavinson did most of the studies for that. Started out doing studies on the Russian Navy because they were going away to war and coming back very ill, not looking well. They started using bioregulators on them. Great safety profile. Used more and more for longevity.

I really like using Thyreogen, which is the thyroid bioregulator. I usually do pair that with an adrenal bioregulator. As we know, thyroid and adrenals really play off of each other, so it’s really great for patients, maybe if they are just on the verge. Their thyroid needs more help, a little bit more reserve. 

I also use it for patients that have Graves’ and Hashimoto’s. Bioregulators are not a stimulant; they are not going in there and revving things up. They are going in there and repairing those genes. That is a great one. I love bioregulators. 

The awesome news is toward the end of May/June, we are going to be able to get bioregulators a little bit easier. They have been really hit or miss because of supply chain, because of what’s going on in Russia and Ukraine. It’s really exciting that they are going to be available. It’s been so hit or miss the past year. It’s been a little bit frustrating for me and patients. “I want you on these bioregulators, but we can’t get them right now.” They’re out of stock everywhere. 

For adrenals, I would definitely try the bioregulator. Of course, we want to remember the other tools in our toolbox, like making sure you’re getting good sleep, turning off blue light at night, making sure you’re eating well, balancing the blood sugar. Also, we can’t forget adaptogens. Adaptogens are so great for our adrenal glands. 

Dr. Eric: 

I agree with you there. With bioregulators, they’re also administered orally? 

Dr. Jen: 

Yes. That’s the great thing. They are administered orally. They get absorbed really well. They’re so little, so they just cross right over. Your body doesn’t even have to digest them. I’m a big fan of bioregulators. 

Dr. Eric: 

You might have mentioned this earlier, but I’ll ask anyway. With peptides and bioregulators, if you take injectables, it sounds like you need a prescription. If they’re oral, does that mean you don’t need a prescription? 

Dr. Jen: 

Yes and no. Things are changing. Most peptides, I will do a prescription and get them from a compounding pharmacy. There are oral ones, like the TB4-FRAG and the thymogen that you can get as nutraceuticals, supplements. Some of the companies, you can just buy them. Some, you need to buy through a healthcare provider. 

Similar to supplements, you are going to want to make sure that you are going to high-quality sources. You don’t want to just get them from wherever. Now, with the injectables, what has happened is people can’t get them anymore from the compounding pharmacy, so there is a few other countries, like China or Russia. They are ordering these vials. You don’t know what you’re getting. You want to make sure that your company has a certificate of analysis, that they are testing batches. This is the stuff the compounding pharmacy does to make sure you are getting what you’re really getting.

When we talk about peptides, I guess we should talk about the weight loss peptides, Semaglutide, which is Ozempic; Tirzepetide; Mounjaro; Zepbound, all the different names. Wegovy, another one. Every compounder is making these. 

You want to make sure that you are getting it from a high-quality place. They are testing the batches. You’re injecting this into your body. We don’t want to inject things that shouldn’t be there. Peptides are good things, but you need to make sure you are getting them from quality sources, similar to supplements.

I can dive a little bit into those GLP-1 agonists. You can’t turn on your phone without getting an advertisement for them, right? My friend texted me and said, “Costco is now offering these GLP-1s.” You can do an online visit and pick it up at Costco. What do you think about these? I’m curious what your thoughts are. People are really one way or the other about these, I find. 

Dr. Eric: 

Yeah. First of all, I didn’t know that. I do have a Costco membership but did not know that you could get peptides through them. I guess certain ones, like GLP-1. Probably can’t get BPC 157 through Costco. 

Dr. Jen: 

No, just these. 

Dr. Eric: 

When it comes to weight loss peptides, keep in mind, I’m not recommending them to my patients as of this recording. I guess it sounds too good to be true. You’re the expert, so I imagine, just like you mentioned with the other peptides, it’s not just a matter of taking the peptides and losing weight. You need to eat a healthy diet, manage your stress, get sufficient sleep. If you just take them alone, maybe they do help to some extent. If you combine them with a healthy diet and lifestyle, I imagine they work even better. 

Dr. Jen: 

This is the thing. First, we don’t want to do any harm. I want to cycle peptides still. I don’t want to put the gas on this pathway all the time. There are natural GLP-1 things that we can do. Berberine is a slight GLP-1 agonist. Akkermansia is a slight GLP-1 agonist. It’s a gut bacteria. There are different things that activate this pathway.

It’s an injectable. You are activating that GLP-1 agonist pathway. You will be feeling fuller longer. It slows down gastric emptying. It does have an effect on the brain. We know it affects that brain pathway. It’s going to be helping your body create more insulin. It’s also going to stabilize blood sugar more. It really has a good place. 

I’ve been using GLP-1s before all the celebrities were. I’ve been using them in select patients. What do we do first? We work on the habits we talked about: sleep, nutrition, etc. We fix their gut health. We balance their hormones. We balance their thyroid. Sometimes, I have them wear continuous glucose monitors. We really try to do things before the peptides. 

Sometimes, they are doing all the things, and they just need a little bit of help for a few months. Most of my patients are on the Semaglutide or Tirzepatide just for a few months. 

When you are going on this, I tell them you need to eat enough protein, and you need to be lifting weights. One of the side effects is muscle loss. Once you hit 40, you lose 1-2% of your muscle mass a year. Or you can. So you really have to fight that. It’s harder to gain muscle, too, when you get in your 40s, 50s, 60s, 70s. I really tell them we have to make sure you’re maintaining muscle, eating protein, and staying hydrated.

One thing that can happen is patients will go to a med spa and go on these shots. They’re dosed really high right away, so they’re super nauseous, so they can’t even drink water. They’re throwing up. They go into kidney failure or have kidney damage. We don’t want that.

It’s nice to get it compounded because you can titrate up really slowly as opposed to the dosing that the pharmacy has. 

Right now, the compounding pharmacies are still not able to compound this medication because it’s on back order in so many places. It’s just exploded. I don’t think people just should be on Semaglutide or Tirzepatide 24/7/365 and then not change their actual habits. When they get off of them, they gain the weight back. Their blood pressure goes up. Their cholesterol and triglycerides go up again. 

We know this from the actual studies. There are so many studies that show this again and again. The drug company is saying, “You have to stay on this forever. You have to pay for this forever.” Yes, maybe in a type 2 diabetic that isn’t going to change their lifestyle. But I don’t think that’s good either. I think they should really weave in lifestyle to that. 

A lot of the times, when someone is on a GLP-1 and GLP-1 GYP, which is Tirzepatide, we can put them on something like Tesamorelin, Sermorelin, which is a growth hormone releasing hormone. That could help them with that building. Those are a group of peptides. They are not growth hormone; they are growth hormone releasing hormone. They tell your body to release more growth hormone. As we age, our growth hormone goes down.

One thing with these peptides is you do want to make sure there is no active tumors. You want to check IGF-1 levels and make sure they are not too high. These are great peptides that can really help boost muscle mass. 

I have a patient that was a mold patient and post-vaccine injury. He lost so much muscle mass. He was so weak. After we treated the mold, “How do you feel about going on a growth hormone releasing hormone? Let’s get some of your muscle mass back up.” He was in his 50s. That’s really important to his health to have muscle and for his hormones. He was good with it. He really did well on it. We had him on it for a few months. It really got some of this strength back, got him motivated. He just kept improving from there. 

This is why peptides are so beautiful. We live in such a toxic soup bowl. There are so many things that we have to heal from that no one had to worry about 50 years ago. They pair nicely with integrative, functional treatments, to elevate and get patients better faster. It’s really fun. 

Dr. Eric: 

They do sound amazing. One other question I have for you is do you take any on a wellness basis? If someone is in a relatively good state of health. I think you said you take some peptides earlier, which isn’t a surprise since you’re a peptide expert. 

Dr. Jen: 

It’s really fun to biohack. The growth hormone secreting hormones, I did that for a while. I sleep really well on them. I took a break though. Maybe I’ll start that back up this month. I don’t know. I sleep really well when I’m on them. 

That’s something you cycle five days on, two days off. I usually do Monday-Friday and then take the weekend off. Those are a lot of fun.

One peptide I didn’t talk about yet is GHK-Cu peptide. I mentioned it for a second with wound healing. I have never taken this one injectable; I’ve heard it’s amazing. That is another one that was on that list, so I’ll just talk about the topical, which you can still get compounded and over the counter. 

GHK-Cu is another peptide made in our body. This does decline as we age. I love it for skin. I use it on my skin every day. It helps with fine lines, wrinkles. It really supports that outer skin layer. Your skin is not going to get as dry. 

It helps with redness. While I am working on their gut health, too, because we know rosacea is gut health. I put patients with rosacea on the copper peptide cream, and they have thrown away four prescription bottles from their dermatologist of junk. It’s crap what they give their patients. They use the copper peptides and are like, “Wow, this works better than all of those prescriptions.” “Yeah, isn’t that crazy?” Not really, but… 

Anyway. That one’s great. It helps with crepey skin. Such a fun peptide. Really good with wound healing. 

It was funny. Well, it wasn’t funny, because I got mad at my son. He got sunburned when we were in Mexico for spring break. I had my copper peptide serum for my face, and I was putting it on his sunburn. It actually does help with DNA. DNA damage, UV protection. 

There is a study they did on GHK-Cu. It either upregulates or downregulates more than 50% of up or downregulation of about a third of our genes, 32%. This is a peptide that is going in there and affecting almost a third of our genes. It’s really cool. I really love that one. 

If you dig into the research with GHK-Cu, really cool things they were doing in rat studies with hemorrhagic stroke, like reversing symptoms. Amazing, crazy cool studies. I wish they would keep on studying. We’ll see. 

I don’t know where that peptide is going to end up. I think it could do beautiful things. I don’t know what the FDA wants to do with it. I wish I knew. That’s a great one topically if you’re not using it topically. 

Some people will say, “I have peptides in my skin care.” No, you probably have these weak collagen peptides. This is GHK-Cu. If you go to my website or Instagram, there are a bunch of companies I love for that.

Another peptide, I actually just learned about a few months ago, and I take it every day. It’s a plant derived peptide. There is this company called Nuritas. They use AI technology to find plant peptides. It’s a company in Ireland. Such cool stuff they’re doing. They’re rolling out 1-2 new peptides a year. They do clinical human studies on these peptides. This is so cool. I geek out. I get so excited about it. 

The one is called PeptiStrong. It increases muscle synthesis. It supports MTOR. It also affects myostatin, so you’re not getting that soreness post-workout. I take it in a blend in an oral capsule. You need 2.4g of it orally to stimulate the muscle synthesis. It helps retain muscle basically. 

The studies they did were on patients where they immobilized a knee and did muscle biopsies. The patients taking the PeptiStrong maintained more muscle and muscle mass while they were immobilized than the controls. 

Also, it showed it was helping with osteoporosis and increasing bone density. If my patient’s taking a GLP-1, I’m offering and recommending for them to take this and lift weights and eat protein. 

Also, my post-menopausal women, I want them to take PeptiStrong. 

Talking about cool stuff with this, they’re talking about putting it in soup at nursing homes to help with keeping that muscle. We know muscle is a longevity organ. It helps with insulin sensitivity. You need to be able to lift yourself up off the toilet. It decreases falls. Really cool stuff. I’m really excited about that one. I take it every day. 

BPC 157, like I said, on and off. It’s rare for me to get stomach issues, but when we did go on vacation, I don’t know if I got gluten bombed or something that last day. My stomach was a mess. This is so weird for me. I’m not used to this. I took some peptides. Within 24 hours of some peptides and some supplements, I was fine. 

I like to keep it all handy. What else do I have in my fridge? I’m trying to think. The BPC 157 injectable, I do have that still because I got it before the FDA said no more. I have that for when I have some tweaks and injuries. I was thinking about putting more in my shoulder to get it a little stronger. 

Those are the peptides I take right now. I think it’s fun to try them. I always like to try things before suggesting them to my patients if I can. Some things I don’t need, but there are so many great things out there.

Are there any peptides that you want to try now? 

Dr. Eric: 

Oh yeah. 

Dr. Jen: 

First on your list? 

Dr. Eric: 

You mentioned the PeptiStrong. I have been working out for a long time and lifting weights. I haven’t gone heavy until the last year. I’ve been focusing more on muscle mass. I hired a personal trainer for both myself and my wife. I might want to take PeptiStrong for a few months. You said you take that every day, but is that still something you cycle? 

Dr. Jen: 

This one, I spoke with the creator of it at the Peptide Summit. He said you didn’t have to cycle this one. I probably still would just take a break from it for maybe a week or two depending. The plant-based peptides coming out, it’s pretty cool. It’s really exciting. It’s a nutraceutical; it’s a supplement. We’re good to weave them into our protocols. 

Dr. Eric: 

This is awesome. I learned so much. I’m sure the listeners learned a lot. It has motivated me to try peptides and eventually recommend them, too.

Before we wrap things up, I want to talk to you about your summit. But is there anything else? You shared so much information, but anything else you want to say? 

Dr. Jen: 

With peptides, I would say to make sure you’re working with someone who knows how to use peptides and when to use them. You don’t want to waste your time and money. There is an art to using peptides. That comes with experience of using them on patients. Most of them have a safety profile. There is a lot of oral peptides now, which is also really exciting. 

Dr. Eric: 

Quality- Like you said, with supplements, it’s important. Peptides, just as important. You want to make sure you’re safe, even though that’s another thing we didn’t really talk about, the contraindications. You mentioned earlier that they are relatively safe, correct? 

Dr. Jen: 

Yes. 

Dr. Eric: 

Definitely work with someone like Dr. Jen, who has a good amount of experience with peptides. Definitely more experience than myself. You just blew me away with the knowledge you have.

If you could tell people where they could find out more about you, your website. Tell them about your podcast, and of course, if you could talk a little bit about this upcoming summit. 

Dr. Jen: 

Awesome, thank you. The best social media where I hang out is Instagram. My handle is @IntegrativeDrMom. I have a YouTube that is the same handle. 

My podcast is The Integrative Podcast with Dr. Jen. My website is HealthyByDrJen.com. That is my main one for health coaching. I Have a brick and mortar called PflegMed in northwest Ohio. The website has a lot of blogs. 

May 21 starts the Peptide Summit. This is with DrTalks. If you guys are subscribed to Dr. Eric’s newsletter, he will send out some information. It is free to attend. You will be blown away by the experts there in peptides. It is amazing. You will learn more than you’d want to know about peptides and a lot about longevity and biohacking. It’s such a fun summit. You’re going to learn from the experts. Some of the names we have on there are amazing. I had so much fun at each interview and learned so much. I know if you guys enjoyed this podcast, you’ll really enjoy this summit. 

Dr. Eric: 

I look forward to learning more. I’m going to make sure to register for it and check out the talks. Thank you so much. This was really amazing. I learned a lot, and I’m sure the listeners learned a lot. I appreciate you taking the time to talk about peptides, Dr. Jen. 

Dr. Jen: 

Yes, of course. Thank you so much for having me.