This week I update you on what’s happening in my private practice and my plans for the next couple of years. I also answer some questions about adrenal fatigue, glutathione and rheumatoid arthritis.
In this episode, we cover:
5:30 Important private practice updates and future plans (HINT: new book coming)
17:00 Chris opens up about his experience with adrenal fatigue
33:13 Does Acetyl-glutathione really improve glutathione status?
44:53 Specific steps to reverse rheumatoid arthritis
Links We Discuss:
Full Text Transcript:
Steve Wright: Hi, and welcome back to another episode of the Revolution Health Radio Show brought to you by ChrisKresser.com. I’m your host, Steve Wright from SCDLifestyle.com, and with me is integrative medical practitioner, licensed acupuncturist, and healthy skeptic, Chris Kresser. How are you doing, dude?
Chris Kresser: I’m pretty good. I just had an awesome breakfast.
Steve Wright: Did you? What did it comprise of?
Chris Kresser: I had a duck crepinette, which is this little patty of duck meat wrapped in… I guess it’s like back fat from pig. There’s a guy who sells a lot of meats and prepared meats, sausages, things like that, charcuterie. He sells it at the farmer’s market, and they’re so good. So I had one of those, and then I had some plantains fried in a ghee/coconut oil combo. I get that from Green Pasture, so they blend ghee and coconut oil together, and I buy a huge gallon-size of it!
Steve Wright: You drink it with a straw!
Chris Kresser: And then I had some sauerkraut that’s made with cabbage and beets and carrots, so it’s this beautiful red-orange color. That was it.
Steve Wright: Sounds delish, man, and very high-end. I like it.
Chris Kresser: Yeah, it was good. How are you, Steve?
Steve Wright: I’m doing pretty well. I’m a little tired, but I’m also just excited because my boys, the Detroit Tigers, they’re headed to the World Series again, so by the time the listeners hear this, hopefully we’ll be playing a few games, and hoping to bring the World Series back to Detroit.
Chris Kresser: I get all my sports news from you, Steve.
Steve Wright: Can’t talk about food the whole time, Chris.
Chris Kresser: I used to be a big Lakers fan because I grew up in LA, and I followed basketball all the way up until my early 20s, but since then I don’t even have a clue at all, I confess. I went to the first baseball game I’ve been to in probably 20 years, though. I went to a Giants game about three months ago. It was pretty fun.
Steve Wright: Well, it just so happens that the Tigers could be playing the Giants in the World Series, so if you have some free time in the next few weeks, you might head over there.
Chris Kresser: My main exposure to the Giants games is being irritated by how much traffic there is on the bridge whenever there’s a Giants game, so that’s probably what’s gonna happen!
Steve Wright: OK, well, hey, tell us about the High Cholesterol Action Plan. It’s been a few weeks since you let that out to everyone. What was the reception, and what have you heard about it?
Chris Kresser: Oh, I’ve had some great feedback about it. It’s been doing pretty well. A lot of interest, a lot of people have signed up. I’ve received a number of emails and Facebook messages from people who are appreciating it and learning a lot, and yeah, I think it’s something that was probably, the timing was right, a lot of people have been educated a lot over the past few years about this stuff, but there’s still, of course, a lot to learn. And in some cases, more information has just made people more confused, and I think there’s still quite a lot of misconception out there. So it’s been good, and I think the people who joined right when it started are now in the sixth week of nine weeks, so nobody’s gone all the way through it yet, so the people who just began when it started are about halfway through. So it’s been great. It was a lot of fun to put it together, and I’m also glad it’s behind me because it was a lot of work!
Steve Wright: I understand that, I understand that. Well, I haven’t started going through it yet. I plan to as well. I’ve been a little bit busy with some other stuff, but it’s on my list. So today we’re talking. We’re gonna have a great Q&A episode, and we’re gonna talk a little bit more about what you have going on at ChrisKresser.com. So you should probably do some calisthenics, get a drink of water, because you’re gonna be doing a lot of talking, and in the meantime, I’m gonna tell everyone about Beyond Paleo. Beyond Paleo is a free 13-part email series that Chris has put together, and I believe over 20,000 people have already downloaded it. And what it is is it’s an email drip, and you’re gonna get an email probably about once a week, whenever Chris feels like it, and it’s gonna be on topics like burning fat, boosting energy, and preventing and reversing disease without drugs. So if you’re new to the paleo diet, you’re just interested in optimizing your health, or interested in learning more about what Chris thinks when it comes to these topics, head over to ChrisKresser.com, look for the big red box, and go ahead and enter your name and email into that box, and he’ll send that over your way.
OK, Chris, it looks like I need a drink of water, so why don’t you take over for a little while
Important private practice updates
Chris Kresser: Haha, OK. So I just wanted to give everyone a little bit of an update on what’s happening in my private practice and what my plans are for the next couple of years. I wrote a blog post about this, but I realize that not everyone who listens to the radio show reads the blog, and vice versa, so I figure it’s probably a good idea to do it in both places. One of the main pieces of news I wanted to share is that I’m scaling back on my private practice to about two days a week. And many of you know that my private practice has been closed to new patients for the past several months, and that’s because the waiting list had just gotten too long, and it was taking several weeks for existing patients to schedule follow-up appointments, which was not OK, and the wait list for new patients had gone out to four or five months, which just seemed to be kind of ridiculous, so I closed the practice to new patients mainly to make it easier for existing patients to get appointments, which has happened now. Most of my existing patients can get an appointment sometimes the same week and certainly almost never have to wait more than past the next week to get an appointment, which has been really good.
And the reason I haven’t reopened my practice yet was because at the same time that I was making those changes, I also reduced my clinical hours down to a couple days a week, and that’s because — There are a few reasons behind that, actually. One is that there are a lot of ways that I can help people, and one thing that I realized after doing this for a few years is that the number of people that I can help on a one-on-one basis, there’s a hard limit to that. You know, there are only so many hours in the day and days in the week, and with all of my other commitments, I’m never gonna be the kind of practitioner that can see patients 40 hours a week. And the way that I work with people is so in depth that I could never do that anyway. It would just be completely exhausting. So of course, I have the blog and the radio show, and those are fairly time consuming. Then I have the educational programs that I develop, like the Healthy Baby Code and the Personal Paleo Code and the High Cholesterol Action Plan, and I have plans for others in the future on different health issues, and those can reach a lot of people. Then I have talks, conferences that I speak at. And then I’m also planning to write a book next year, which I mentioned on the blog, and the topic of that book is gonna be the real causes and solutions of gut problems. So I’m really excited about that, and in order to do that, I needed to free up some extra time in my schedule because as I’m sure most of you know, especially those of you who have written a book, it’s a mammoth undertaking, and to try to do that — Oh,there’s Sylvie!
Steve Wright: Haha.
Chris Kresser: Banging on my home office door. To try to do that without creating some additional space in my schedule would have just been a really bad idea in short.
So the third thing that I want to do, and this probably won’t happen until 2014 and won’t launch until 2015, but one of the ways that I think I can help the greatest number of people is by developing a clinician training program where I train others to work in a similar way that I do. It’s been a real thorn in my side that I don’t have that many practitioners that I feel like I can refer patients to when they ask me for referrals, which of course, a lot of people are because I haven’t been seeing any new patients for the past several months. And it’s not to say that there aren’t a lot of great practitioners out there. I’m sure there are. I just think there’s not really a network for them. Robb’s doing the Paleo Physicians Network, which is great, but even then, it’s hard to know what kind of training people on that network have had. I have pretty high standards for myself, and of course, if I’m gonna make a referral, I want to be very confident in who I’m referring to and that they follow a similar approach that I do, and so it dawned on me that the only way that I’m really gonna ensure that that’s possible is to develop my own clinical training program and start putting people through it. And you know, if I can train a couple hundred people a year and then they go on to see 10, 15, 20 thousand patients in their entire lifetime as a practitioner, then the number of people that I can help directly and indirectly that way is exponentially greater than the number of people I could help in my private practice, even if I was seeing patients 40 hours a week, which I can’t do.
So that’s gonna take time, and I want to free up some time for that, so the next few years, that’s kinda what it looks like is I’ll continue to see patients a couple days a week, I’m gonna be writing a book next year, and I’m gonna be developing a clinician training program after that, and that will cover all of the kind of lab testing that I do for my patients, how to diagnose people, how to treat them using botanicals and supplements and other natural remedies. We’ll talk about functional interpretation of blood work. We’ll talk about saliva testing, stool testing, the urine tests that can be useful, everything from adrenal issues to gut problems to thyroid to female hormone imbalances. It’s gonna be pretty comprehensive, and we’ll do case studies and didactic learning, and we may even have some in-person stuff. So I haven’t gone into a lot of detail on developing the training yet because it’s still a couple years off, but I’m pretty excited about it, and I think it will be a great opportunity for people once it’s ready.
Steve Wright: Yeah, I think you have put a lot of thought into it already. That’s what’s coming through to me, and I know there are a lot of people. We get a lot of emails from listeners who are headed into the health field or are currently in the health field looking to gain more skills and more ways to work with patients, so I think it’s gonna be very well received. And as long as we keep the radio show going, hopefully we’ll all allow you a few extra minutes every day to work on that.
Chris Kresser: Yeah, and that’s the other thing. The blog is gonna continue, and the radio show is gonna continue for sure. Those are just kind of non-negotiable. They’re free, they’re accessible to everyone. That’s really important to me to have. And that’s another reason that I’m doing what I’m doing. There are only a certain number of people that can afford to see me in my private practice, and that’s unfortunate. It’s something I struggle with, but thus far I haven’t been able to figure out a solution to that. So you know, there’s my private practice, and that’s probably the most expensive way to work with me. And then there are these educational programs, and one of the reasons I created those was to be able to go into more depth on treating particular health issues than I can go into on my blog or the radio show and to make those accessible to a wider number of people than my private practice would be. And then the next level down would be books and ebooks, which I haven’t done yet, and that’s of course this next phase with the book on gut health that I’m really excited about. Yeah, let’s talk about that just for a second.
One of the things that’s always struck me about conventional medicine in general and gut conditions in particular is that so many of the diagnoses are just fancy names for the symptoms that people experience. So you go in to the doctor. You say: Well, you know, I’ve got gas and bloating, and sometimes I have constipation. Sometimes I have diarrhea, and I have this pain right here in my abdomen. What do you think, Doctor? And they go: Well, I think you have what we call irritable bowel syndrome. And it’s like: Wait. I just told you that!
Steve Wright: Haha.
Chris Kresser: It’s like, I came in here to hear that? And then if you have acid reflux into your esophagus, they tell you you’ve got GERD, which is gastroesophageal reflux disease. If you have a pain in your colon and blood in your stool, you have ulcerative colitis, which just means an inflamed colon with ulcers and bleeding. So the diagnoses basically just describe the symptoms, and the treatments mostly just suppress the symptoms. And that’s problematic because if you’re just suppressing symptoms, you’re not really promoting health. You’re just managing disease. And certainly that’s helpful and, you know, if someone’s in a lot of pain and discomfort, reducing those symptoms is beneficial, and I’m not saying that that’s not necessary or helpful. I’m just saying it’s not what we should be shooting for. It’s not where we should stop. If we really want to benefit people, we want to figure out what the underlying cause of these problems is and address it at that level. And so far, I haven’t really seen a book that does that with gut conditions.
There’s so much more that we know now. You know, the last 10 or 20 years has just been phenomenally productive in the research on gut conditions and what causes them. So we have things like SIBO, small intestine bacterial overgrowth. Actually quite a few even very conventional physicians are now aware of the link between SIBO and IBS and other gut conditions. We have the contribution of low stomach acid. We have a greater understanding of how infections like H. pylori and parasites and fungal infections, which used to be considered to be rare or abnormal and now are understood to be a lot more normal, how they contribute to gut issues. We have intestinal permeability, aka leaky gut. So all of these are what are actually causing the diseases like IBS, inflammatory bowel disease, constipation, diarrhea, GERD, etc., and so we should really be exploring these causes on a deeper level and what to do about them and worrying less about the particular label that we give to the symptoms that people experience. So that’s what my book is gonna be about, and I’m really excited about reaching a much wider audience with this information. That’s why I’m gonna do a printed book instead of just a digital program. There probably will be a digital program to go with it, but I really want to get this out to the broadest audience that I possibly can, and I think doing a printed book is the best way to do that.
Steve Wright: Well, you know me. I’m pretty passionate about that subject.
Chris Kresser: Yeah, definitely.
Steve Wright: So I will be waiting with bated breath to read it, but I think I know a lot that might go into it.
Chris Kresser: Yeah, so that’s it for the update. Sorry, for those of you who had already read the blog post and had to listen to that again, but maybe you picked up a few extra things you didn’t know from reading the blog post.
Steve Wright: Turn it off two times now and go back to one time.
Chris opens up about his experience with adrenal fatigue
Chris Kresser: We can use this as another segue, too, because there’s another reason that I decided to cut back to two days a week in my private practice, and that is my own concerns about some health issues that I’ve been having lately. And mostly it was just manifesting as a slight, but noticeable decrease in brain function. And it might not sound like a big deal, but a decrease in brain function to me is kind of an ominous sign, because the brain controls everything. So if the brain is not functioning optimally, then I get worried because the brain-gut connection, which we’ve talked about a lot and we’re gonna be talking about a lot more when I write that book, but of course, there’s a brain-everything connection because no brain = no life.
Steve Wright: Haha, simply put!
Chris Kresser: At the risk of overstating the obvious! So I was having issues, little things, like I had difficulty with word recall, even for certain common words, not frequently, but enough to notice that it was happening. I wasn’t able to write and process information at quite the speed that I’m accustomed to, which is troublesome with all of the things that I have planned for the coming years. And my energy levels were pretty good. This is kind of why it took me a while to hone in on it, because I don’t have typical adrenal — what people call adrenal fatigue symptoms. My energy levels are good. I don’t have an afternoon crash. I wake up with a considerable amount of energy. For me, it was manifesting more as, like I mentioned, like this slight decrease in brain function and some muscle fatigue. Like, I wasn’t recovering from workouts as well as I normally do. I would experience some muscle soreness even that didn’t seem commensurate with the level of activity that I was doing in a day. So being who I am, I decided to go ahead and do some additional testing. Although I ignored my own advice that I often give other healthcare practitioners, which is not to treat yourself. There’s that old saying: The doctor who treats himself has a fool for a patient.
Steve Wright: Ha, nice.
Chris Kresser: But I guess I’m a fool, because I went ahead and I ran an adrenal panel on myself. And I definitely did have some issues going on with my HPA axis. My cortisol, the rhythm was a little bit off, the overall output was a little low, and my DHEA was borderline low. So that was a red flag to me because I have some patients that are in much later stages of adrenal issues, like full-fledged adrenal fatigue, which you know, I really don’t like that term because it’s not specific and it doesn’t capture the fact that adrenal issues are always also brain issues. The hypothalamic-pituitary-adrenal axis, or HPA axis, I just get tired of saying HPA axis dysregulation.
Steve Wright: Let’s just call it HPA inflammation levels or something. We need a better word for that. I agree.
Chris Kresser: Whenever I say adrenal fatigue, I mean HPA axis problem. So anyhow, people who are in very late-stage adrenal fatigue, it can be pretty hard to dig yourself out of that hole, and it requires a lot of commitment and focus and time. And when I saw those results, I know enough to know that I don’t want to go there and I want to intervene as much as I can, as quickly as I can. So that was one reason I stepped back to two days a week. I feel like I needed some more time to rest. The last 18 months have just been crazy. The birth of Sylvie, which she’s the absolute joy of my life, and every moment with her is precious and I love it, but as many new parents out there will certainly understand, it’s a lot of work. It can be challenging at times, and sleep for the last year and a half has certainly been suboptimal. During that time, I also really ramped up the blog, publishing several articles a week, a lot more effort into the radio show. I think I launched four different new programs, the Healthy Baby Code, Personal Paleo Code, Meal Plan Generator, and now the High Cholesterol Action Plan. Of course, ongoing attention to my private practice and speaking at several conferences and preparing talks for that. I mean, it’s just been a crazy, crazy 18 months, and it really took its toll on me, I think. So I’m feeling the need to step back a little bit and do some more self-care and follow my own advice that I’m often giving to patients. Part of the reason I’m speaking about this is because everybody knows that doctors and healthcare practitioners are the absolute worst patients in the world!
Steve Wright: Haha.
Chris Kresser: They’re so busy trying to take care of other people that they often forget to take care of themselves. And I think it’s really important for me to model the kind of things that I talk to my patients about, and I think there was a little period of time there where I was feeling some cognitive dissonance between what I was telling my patients and what I was doing myself. So I’ve recommitted to a lot of the practices that have always been important to me, and I’m doing some mindfulness-based stress reduction on an almost daily basis or this Rest Assured Program, the Mini-Moves that I often prescribe to my patients, and making sure to have some time to just sit out in the sun and rest during the day, and plenty of time to exercise, and more time with my family and with Sylvie. So it’s been good. The last month, month and a half since I’ve made these changes, it definitely feels better.
Steve Wright: Well, I appreciate you sharing that with me and the rest of the listeners, Chris, because we’ve all had the experience, I guess, of even maybe like a personal trainer who’s not as fit as what you’d like to be telling you what to do, and so it speaks well for a leader and for anyone giving anybody else advice when you totally have genuine integrity in why you do and then what you tell other people to do, so I appreciate you sharing that, and it also says that, hey, everyone’s a real person. You know, life changes and you just have to adapt to it, and you know, things are gonna go wrong.
Chris Kresser: Yeah, we all have these struggles. I always say when I write about stress management: Look, I know it’s hard. It’s the hardest thing. It’s by far the hardest thing for me. I think there’s no question it’s the hardest thing for most of my patients. And the more I learn about it, like in doing this research for my presentation at the Wise Traditions, the Weston A. Price Conference in a few weeks, I’m talking about the gut-brain-skin axis, and a lot of the research was centered around the connection between the brain and the gut and the brain and the skin, mostly related to stress, but also anxiety and depression and things like that. But the more I learn about the effects of stress on the body, the more convinced I become that it’s really the crucial piece for many people. And I know I’m always talking about this and harping on it, and that’s mostly because I’ve seen it to be true in my own experience and in my practice with patients and also in the research that I’ve done. So I’ll continue to share updates on what’s going on with my treatment. But I also thought it would be a good time, along those same lines, to kind of give an update on how I’m treating these kinds of issues since I’m thinking a lot about it in my own case and I do it a lot in my practice.
A couple years ago or maybe a year and a half ago, early on in the podcast, I think I mentioned that’s it not my preference to use hormones when treating hormone problems or adrenal issues. And I think my viewpoint on that has evolved and changed a little bit since I first started. Certainly it’s not the place where I begin. With adrenal issues, I’ll almost always start with adrenal adaptogens, botanical adaptogens like ashwagandha and rhodiola, eleutherococcus, which is Siberian ginseng, and some micronutrients that are good for general adrenal support, like pantothenic acid and vitamin C, because that’s kind of the lowest level of intervention and has the least potential for causing any adverse effects. And if you can fix adrenal problems just by doing that, that’s fantastic and that’s preferable, so that’s the good starting place. And people can really just do that stuff on their own. They don’t need a healthcare practitioner, really, to help with that stuff. They just get a good botanical supplement like Adaptocrine or Adrenotone. You know, they get a good B-complex. A lot of these supplements have both the botanicals and the B vitamins and vitamin C in them. So you just get a good formula. I think Robb Wolf likes to recommend the Gaia Herbs product with some botanicals. So there’s a whole bunch of them out there. A lot of them are good, some of them not so good, but you can start on that, and that will deal with a lot of the basic kind of adrenal problems.
But what I’ve learned in working with a lot of people is that that’s often not enough because people are pretty advanced down the track of HPA axis issues, and the adaptogens and the micronutrients help, but they don’t really fully bring those people back, and I know that from doing treatment and then retesting people and seeing that they have improved but not as significantly as we had hoped. So I do now think that in cases where people are in a further stage of adrenal issues, stage 2, stage 3, and even in stage 1 sometimes, depending on where they’re at, that using some sublingual bioidentical hormones like pregnenolone or DHEA for a temporary period of time can be really helpful. And the concern, of course, is that when you use hormones, they’re very powerful. Even minute amounts of hormones can have a profound effect on the body, and the concern when you use hormones is always that they can disrupt the body’s natural feedback and regulatory mechanism. So for example, if you use melatonin every night for a long period of time, then that will decrease your body’s own natural melatonin production and you become dependent on it, and when you stop the melatonin, you’re gonna have a really hard time producing your own and sleeping. But I’ve found that some hormones tend to do that more than others. Melatonin is actually a good example. I still don’t tend to use it very often in my practice because it does tend to cause these feedback problems more so than other hormones like pregnenolone or DHEA, and that might be because pregnenolone and DHEA are precursor hormones. Pregnenolone is a precursor to both DHEA and progesterone, and DHEA is a precursor to testosterone and estrogen, and then progesterone gets converted into cortisol and can be converted into estrogen via androstenedione. So it’s possible that there’s less of a feedback inhibition cycle there because they are the precursor hormones, whereas melatonin, first of all, it’s in a completely different place and it has different physiological effects, but you know, there are several precursors that go into melatonin production, including 5-HTP and serotonin. So I’m not sure exactly what it is, but I have noticed that certain hormones are more likely than others to cause those feedback problems.
So in the case of more advanced problems, I do think it is a good idea to work with an experienced practitioner to get a good test. I’m no longer using Diagnos-Techs testing because I don’t trust it anymore. I’ve seen some really wacky results that didn’t make any sense to me, and after talking with some of my colleagues — I’ve been doing this for a long time — I’ve just decided that I’m not confident in the saliva results from Diagnos-Techs, and I’m using BioHealth Labs now. And matter of fact, one of the things that happened when I was kind of figuring this out is I did a test from Diagnos-Techs on myself and my adrenals and it came back completely normal. And I’ve done those tests before, and I know my body pretty well, and I knew that my adrenals and HPA axis were not functioning normally, so I went ahead and did a BioHealth test right after that, and the results matched pretty much exactly what my symptoms are and what I knew to be true or suspected to be true. And that’s happened a few times with a few different patients. So the first thing is getting a good saliva test for cortisol and DHEA from a reputable lab. And then the second thing is finding someone who knows what to do with those results, and that’s important because the test results will determine the treatment, and the treatment might look quite different, depending on what the rest results are. For example, in some cases, like in the earlier stages of adrenal issues, you’d want to use more DHEA and less pregnenolone because cortisol levels are high. Cortisol is catabolic and DHEA is anabolic, so you want the increased amount of DHEA to balance out the catabolic effects of cortisol. But DHEA can antagonize cortisol, so if you’re in the later stage of adrenal fatigue where cortisol is really low and you take a bunch of DHEA, that could actually make things worse. So if you’re gonna use sublingual hormones like pregnenolone and DHEA, make sure you know what you’re doing or that you’re working with somebody that does. If you’re using therapeutic-strength adaptogens in a liquid extract formula or something, I still recommend that you work with a good herbalist, but if you’re just taking formulas like Adaptocrine or Adrenotone, I think it’s pretty safe to do that on your own.
Steve Wright: Hey, Chris, I’m just trying to save you some emails. I’m not trying to back you into a corner here, but since I’m going through the Kalish Method training right now, is there a way for people who are not seeing you, they’re not part of your practice and they’re not gonna become part of your practice, is there a way for them to ask questions and identify a practitioner who maybe has done some training like the Kalish Method or something else so they can identify someone who has experience with DHEA and pregnenolone?
Chris Kresser: I don’t know, actually. Maybe the Institute of Functional Medicine might have a listing of practitioners, although I don’t think that that guarantees any kind of training. I don’t know what their criteria is for listing someone on that site and what kind of training they’ve had and if they’ve been through that. Maybe the best thing to do would be to contact BioHealth Lab and then see if they have a listing of practitioners that use their lab testing in your area. That’s probably the best way to do it.
Steve Wright: OK, cool. Thanks.
Chris Kresser: Even then, that doesn’t guarantee any particular proficiency, but if someone’s ordering a lot of those panels, chances are they know how to interpret them.
Steve Wright: Very good tips.
Chris Kresser: So I know we’re almost done with the show, haha. We haven’t even gotten to a question yet.
Steve Wright: Haha, are we stringing them along? Do you have anything else you want to talk about? We’ll just make this an update show, or should we ask a question?
Chris Kresser: No, let’s do some questions. I think I’ve blabbed on enough now.
Does Acetyl-glutathione really improve glutathione status?
Steve Wright: Haha. OK, well, let’s ask a few questions here. We want to thank everyone for sending in their questions. We do plan to get to them and get through them. So the first question we’ll start with comes from Ben, and his question is that he’s seen acetyl-glutathione recently being marketed as the first form of glutathione to be well absorbed orally in a form that’s actually bioavailable. He wants to know your thoughts on the overall importance of glutathione, and how would I even know my glutathione status and whether it’s something that’s even advisable to supplement? And I guess that’s assuming that this oral acetyl-glutathione actually works. So do you have any thoughts on that?
Chris Kresser: Yeah. Glutathione is extremely important. It’s the master antioxidant in the body, and a lot of studies show that glutathione depletion is associated with everything from autoimmune disease to cardiovascular disease. I actually talk about that in the High Cholesterol Action Plan a little bit. One of the main functions of glutathione is to promote healthy T regulatory cell function, and the T regulatory cells’ job is to, as the name would suggest, regulate and balance the immune system. So if you don’t have enough T regulatory cells or they’re not functioning properly, then the immune system is gonna go out of whack, and of course, that’s happens in autoimmune disease. And there aren’t too many diseases that don’t have some immunological basis, so glutathione is extremely important. And then we have studies that show that people who have autoimmune disease and cardiovascular disease often have low levels of glutathione.
So we want to do what we can to keep our glutathione levels up, and the best way to do that if you’re not ill and you don’t have glutathione depletion already is just eat a healthy diet. Glutathione precursors are present in a lot of nutrient-dense foods. Particularly, though, raw dairy has a lot of glutathione precursors in it and raw meats. Now I’m not necessarily recommending that people consume raw meat because there are some risks associated with that, but what I’m trying to point out is that pasteurization and cooking of meat and dairy dramatically reduces the glutathione content of those foods. Sulfur-rich vegetables, like onions, those also are good glutathione precursors in the diet. But probably the best glutathione precursor that’s accessible to people is the biologically active whey protein, like non-denatured, grass-fed whey protein made from raw milk. That’s the best way to naturally boost glutathione levels using a kind of a food-based thing. I mean, it’s a supplement, but it’s derived from a food.
As far as S-acetyl-glutathione, I have seen quite a few studies about this lately, and let me just back up a little bit and say what glutathione is and what the problems with supplementing orally are, because otherwise this isn’t gonna make much sense. Glutathione is a tripeptide, so it’s composed of three amino acids that are connected in tandem: glycine, cysteine, and a kind of unusual bond to its acidic group, glutamate. So what happens is, because these are just three amino acids, once glutathione reaches the stomach it’s rapidly degraded and broken down and it’s not absorbed intact as glutathione into the cells. The other problem is that glutathione is not taken up by the cells directly but needs to be broken down into amino acids and then resynthesized to glutathione intracellularly. And that process is often impaired in people who are ill with inflammatory conditions and people that have viral infections. So as we’ve discussed, I think, several times on the show, taking oral glutathione in its reduced form is not a really effective way of raising serum or intracellular glutathione levels. So there’s been this search for a way of supplementing with glutathione. Mostly the way that people do it now is taking glutathione precursors like lipoic acid and N-acetyl Cysteine. I just mentioned whey is probably the best way to do it, whey protein.
But this acetyl-glutathione has come up in the literature a few times over the past several years. It’s an orally stable form of glutathione that’s absorbed intact, and it appears to increase intracellular glutathione levels. The acetyl group in this case is attached to the sulfur atom of cysteine in the glutathione molecule, and placing the acetyl group on the sulfur atom of cysteine protects it from oxidation in the digestive tract, essentially. And then once S-acetyl-glutathione reaches the bloodstream, the acetyl group protects it from breakdown by peptidases. And then some studies have shown that S-acetyl-glutathione crosses the cell membrane more easily than glutathione itself, and once it’s inside the cell, the acetyl group on the S-acetyl-glutathione is removed and the glutathione molecule is free inside the cell, which is exactly where it’s needed.
So that was a lot of technical mumbo-jumbo, but the long and the short of it is that I could cautiously say that based on the studies that I have reviewed, it appears that S-acetyl-glutathione is effective in raising intracellular and serum glutathione levels. But these are small studies. Some of them are animal studies. I think there are about six to seven studies in total that I reviewed. So I’m not certain about it. We definitely need more research in this area before we know, and I haven’t had a chance to use it much in my practice. I still use whey because I think the evidence for whey’s effectiveness in raising glutathione levels is much greater. There’s another reason, too, that I tend to use whey versus acetyl-glutathione, and that’s cost. One bottle of acetyl-glutathione of like 30 or 60 capsules, I can’t remember, is $100 retail. So not cheap if you’re gonna be taking it over the long term.
Steve Wright: No, no. Have you looked into liposomal glutathione?
Chris Kresser: There’s only one study that I could see in the peer-reviewed literature on liposomal glutathione, and it did suggest that it was effective, but that’s one single study, and I sure would like to see a lot more research on that as well.
Steve Wright: Yeah, and it’s pretty expensive to mess around with as well.
Chris Kresser: Yeah. So, you know, I’ve said this before: Lack of proof is not proof against. So it doesn’t mean that S-acetyl-glutathione isn’t effective or that liposomal glutathione isn’t effective, and I’m completely open to continuing to revisit it, and I’ve got an ongoing search for glutathione in the literature, so I’d like to stay on top of it, but for now, I still think that whey protein, provided that you can tolerate it. Some people are obviously allergic. But as long as you can tolerate it, I think that’s the best method.
Steve Wright: That was a great answer. I think there’s one thing that we kinda skipped over. You said it in several ways, but I’d just like to hear you clarify it. Is anyone who is sick, are they gonna be glutathione depleted? Or are there some very common signals that you might want to look into whey protein or any of these precursors?
Chris Kresser: Oh, yeah. Good catch. I do probably think it’s pretty safe to say that if you have autoimmune disease, you’re likely to be glutathione deficient. You know, there are correlations there. And we know that that doesn’t mean that that’s true in every case, that there’s even a causal relationship, but there are a lot of known mechanisms, and I think the overall evidence base is pretty solid on this.
In terms of figuring out if you are glutathione deficient, one test that I like for that is the organic acids panel from Genova or Metametrix, and they’re actually the same thing now. Genova bought Metametrix recently, and so they’re merging. I mean, they’re still kind of separate entities, but I think that’s gonna change over the next few months. Anyhow, they do a urine organic acids panel, and this test, as I said before, measures levels of organic acids in the urine that are byproducts of central energy pathways and microbial metabolism. So there are a lot of cycles in the body, and each step in that cycle requires specific enzymes to complete and go to the next step, and each of those enzymes requires particular nutrients. And so if one of those enzymes isn’t functioning properly, you’ll get a buildup of the metabolite prior to that step on the cycle, and that will spill over into the urine — Well, you know, if it’s in the digestive tract, it will go through the gut barrier in the blood and it’ll be filtered out by the kidneys and end up in the urine. And there are other ways it can end up in the urine, too. And then based on which metabolite is showing up in higher concentrations in the urine, you can trace it backwards and say: OK, so that enzyme in that cycle is not working very well, and what nutrients does that enzyme require? OK, glutathione is something that that enzyme requires. So there are a number of markers on the organic acids panel that when elevated or low can signal a glutathione deficiency, and they can also signal a glutathione demand, meaning the body is under some kind of oxidative stress and glutathione is being required to deal with that. And so in that situation, that person might not be glutathione deficient at that time, but if that oxidative stress or whatever is causing the glutathione demand continues, they will be eventually. So that test is pretty helpful for that, and I do use it pretty regularly in my practice. It’s becoming one of my favorite and most useful tests, and of course, that will be something we’ll cover in that clinician training program.
I think there’s a serum test for glutathione — I mean, I know there is, but I’m not sure how helpful that is because where you really want glutathione is inside of the cell. The intracellular levels are most important. And I’m just not sure how much of a correlation there is between serum and intracellular glutathione and whether the serum level of glutathione is that significant. But I don’t use it in any event, the serum test. I just do the urine test.
Steve Wright: Awesome. Well, I know from my own experience that getting your glutathione levels back up to where they should be makes a big difference in how you feel.
Chris Kresser: Definitely.
Steve Wright: We have time for one more?
Chris Kresser: Yeah.
Specific steps to reverse rheumatoid arthritis
Steve Wright: OK, the next question comes from DJ. He says he loves the podcast, and one of the reasons why he really likes it is because, Chris, you seem very flexible and not completely rigid in your approach to ancestral eating. He wants to know more about your take on rheumatoid arthritis.
Chris Kresser: Yeah, this actually will relate pretty well to what we were just talking about, because rheumatoid arthritis, as I’m sure most of you know, is an autoimmune inflammatory condition. So the body essentially mistakes the joints for foreign invaders and mounts an immune attack on them, and that’s what makes it different from osteoarthritis, which is not autoimmune in origin. So we’ve talked a number of times — I think we maybe even talked about rheumatoid arthritis before, but we’ve certainly talked a lot about autoimmune conditions and how to heal them. And one of the biggest differences between functional and conventional medicines in the approach to treating autoimmune disease is in functional medicine we look at all autoimmune diseases as sharing a common origin, which of course, is immune dysregulation. And certainly there are different things we do in different autoimmune diseases to deal with the different symptoms and manifestations, but at root, we treat them all in the same way.
So the crucial thing here, as I’ve talked about a lot, is healing the gut because as Dr. Fasano discussed when we had him on the show, it may be true that you can’t even have an autoimmune condition unless you have a permeable gut. And autoimmunity can cause gut permeability and be caused by gut permeability. So taking all of the necessary steps to heal the gut — identifying potential pathogens, improving stomach acid, rebalancing the gut flora, removing things that are harmful for the gut from the diet, etc. — that’s like a crucial first step, and I would always begin with that if the person isn’t already doing something like that when they come to see me.
The second thing would be improving glutathione status, which we just talked about. So there are all the natural food-based ways of doing that: whey protein, possibly S-acetyl-glutathione, liposomal glutathione. So another important thing is optimizing vitamin D status. I think most people should be in a range of about 35 to 60. Vitamin D, like most other nutrients, has a sweet spot, a U-shaped curve. Too little is not good, and too much is not good. But in the case of people with autoimmune disease, I do like to see them towards the upper end of that range, usually somewhere between 50 and 60. Vitamin D, like glutathione, promotes healthy T regulatory cell function and has a number of other effects on inflammatory conditions, and a lot of people with inflammatory autoimmune arthritis have vitamin D deficiency.
And then the third thing is low-dose naltrexone, which we’ve talked about a lot as well, and we don’t have time to go into detail again. You can look it up on some past shows, but of these three things, it’s the most potent thing that I know of for improving T regulatory cell function.
A couple other things that would be helpful for rheumatoid arthritis would be long-chain omega-3 fats, EPA and DHA. So you want to make sure you’re eating a pound of fatty fish a week, and then you might consider in this case taking some additional EPA and DHA, either in the form of a high-quality fish oil or probably even better if a fermented cod liver oil/butter oil blend that has EPA and DHA as well as fat-soluble vitamins like A and K2 and E and D, all of which can be beneficial in this kind of situation.
And then finally, there’s a growing body of evidence suggesting that curcumin and particularly certain forms of curcumin, which is found in turmeric in food, can be helpful for inflammatory conditions, including both osteoarthritis and rheumatoid arthritis. But eating turmeric is not a good way of boosting your serum curcuminoid level because the curcuminoids in turmeric are not very well absorbed. And even oral curcumin supplements are often not very well absorbed, and the amount of time they spend in the blood when they are absorbed is pretty short. So there are a couple of newer forms of curcumin. There’s the Meriva form that I think a lot of manufacturers use. Thorne is one of them. And that’s better absorbed than regular curcumin. And then there’s the BCM-95 form, which as far as I can tell from the studies I’ve seen is even better absorbed than the Meriva form. So taking some BCM-95 curcumin might be a good way of dealing with not only the symptoms of inflammation because it has similar kind of anti-inflammatory effects to things like Advil, but also to dealing with the systemic autoimmune dysregulation. Curcumin may have an immunoregulatory effect and do some other things that are more than just managing symptoms; they’re actually addressing the underlying problem.
One thing to be aware of with curcumin is that we don’t have any really long-term studies of the safety profile of curcumin. The longest-term human randomized clinical trial I’ve been able to identify was an eight-month-long trial where people with prediabetes, they split them into two groups, and one group was control and the other group took this BCM-95 form or actually, I think, even a regular form of curcumin. And there was a significant difference in the number of people that went on to develop type 2 diabetes in the control group versus the curcumin group, which had a much lower rate of progression to diabetes. And that lasted for eight months. There were really no adverse effects at all, and there were no issues with safety.
So it’s probably safe to take over the long term, but we don’t really know that for sure. And one reason to think that there’s some cause for concern is that Stephan Guyenet has written about curcumin and other flavonols on his blog extensively. And we originally thought that they had an antioxidant effect, but actually what a lot of research suggests is that the way they work is they’re pro-oxidants and they have more of a hormetic effect, meaning they engage the body’s healthy, natural defense systems because they have a mildly toxic effect. And when you get a small amount of these things in foods like in turmeric spice, for example, or if you’re getting resveratrol in wine, you know, in naturally occurring amounts in foods, that hormetic effect is beneficial, but if you’re taking isolated high doses of things like resveratrol or curcumin, that may not be beneficial over the long term.
It’s tricky, though, because none of this is happening in a vacuum, and there are risks to not treating things like rheumatoid arthritis. It’s a systemic inflammatory disease, and it’s associated with all kinds of other diseases like cardiovascular problems and, I think, diabetes and some other issues. So not treating is dangerous. And then, of course, there are drugs that are used to treat rheumatoid arthritis, like prednisone and steroids and immunosuppressive drugs that have a lot of adverse effects and can cause some really nasty problems over the long term. So for me, if I had rheumatoid arthritis, and I’m evaluating: OK, do I do nothing, you know, in terms of supplementation or medicine? Do I take systemic anti-inflammatory drugs like prednisone? Or do I use an anti-inflammatory paleo type of diet, some bone broth, and some maybe whey protein to boost glutathione, some low-dose naltrexone, and then possibly some curcumin extract? I know what I would choose, but that comes down to the patient and your own risk tolerance and understanding. But for me, I think the least risky choice of those three would be to use curcumin even though we don’t know for sure what the long-term safety profile is.
Steve Wright: Well, I think I would take you recommendation as well, or I would choose the same treatment path because those drugs, those immunosuppressants and the prednisone, the side effects are very awful.
Chris Kresser: They’re nasty. And as anyone who has rheumatoid arthritis knows, not doing anything is not really much of an option either. I mean, it can be a crippling disease where people can’t even get out of bed without help, and it can be really, really debilitating. So sometimes we just have to make the best decision that we can, given the amount of information that we have, and there are no guarantees. I wish it weren’t that way. I wish, as a practitioner, that we had all the information we needed to make these choices, but we don’t always, and we just have to do the best we can.
Steve Wright: Well, Chris, we got through two questions, but we covered them really deeply and very well.
Chris Kresser: Well, hopefully the discussion on adrenal treatment and stuff was helpful for people and a good update, too. And next time, we’ll just dive right into it with the questions.
Steve Wright: Yeah. Oh, I’m sure the adrenal thing was a big update, so we’ll go ahead and give ourselves two and a half questions for this week’s show.
Chris Kresser: Haha, OK. Yeah, I wanted to end by thanking everyone for listening to the show. The other day I got into the website where the podcast is hosted and just happened to notice the statistics. And we’re coming up on a million downloads of the show total since it’s been live, and almost 100,000 downloads a month, which just blew me away. I couldn’t believe it. So I’m just so excited that this stuff is getting out there and that people are listening to this. And we’ll announce it when we hit the one million mark. Maybe we’ll have some kind of party or celebration!
Steve Wright: Virtual party! Yeah! No, but seriously, it’s awesome. Thanks everyone for listening. Obviously if you guys weren’t listening, we wouldn’t be doing this. And you guys make the show, so it’s obviously your questions that make these types of shows that allow us to drill into Chris’ head and get this awesome knowledge out. But if you guys have anyone that you want to hear on the show, if there are any experts that you’d like to have Chris interview — You know, keep sending us your questions, obviously, but if there are any other topics, like big topics that you’d like us to discuss, please send those in, and we’ll do our best to cover them.
Chris Kresser: All right. Well, again, thanks for listening. Thanks for your continued support, and I hope I get to see some of you at the Weston A. Price Conference the second weekend in November.
Steve Wright: Yes. I’ll see you guys there as well, and if you’d like to take action and send us some things, you can do that by going over to ChrisKresser.com. You’re gonna see a little podcast button. It’s a submission link. Click on that, and you can go ahead and send us a message with whatever you’d like us to know. We appreciate all your feedback, and we also appreciate it when you go over to iTunes and you leave us a review. It helps us in our iTunes rankings, and it’s gonna help us get to a million, so we really appreciate any actions you take there. Thanks, and we’ll see you on the next episode.
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