Another Q&A episode!

In this episode, we cover:

1:45 What you need to know before deciding to consume raw milk
14:40  What to do – and not do – if you have iron overload
18:32  The best science to study before naturopathic school (and why Chris started this blog)
30:15  Does consuming fat in the morning get in the way of intermittent fasting?
35:22  What to do if your fasting blood sugar is high, even when you stop intermittent fasting
41:56  Specific strategies to find calm during stressful situations
51:17  Does hypothyroidism cause dry eyes?

Links We Discuss:

• How to measure your post-meal blood sugar

Full Text Transcript:

Steve Wright:  Hey everyone, and welcome to another episode of the Revolution Health Radio Show.  I’m Steve Wright from SCDLifestyle.com and with me is Chris Kresser, health detective and creator of ChrisKresser.com.  How are you doing, Chris?

Chris Kresser:  I’m pretty good, Steve.  How are you?

Steve Wright:  I’m doing well, I’m doing well.  You’ve been off for a little while, and we’re back on the show, so how have you been?

Chris Kresser:  I’ve been well.  It was nice to have some time off, you know, just to rest and be out in the sun for a little while, we had some really nice weather here, and catch up on a few projects I’ve been wanting to work on but haven’t had the chance to, and spend lots and lots of time with my family, so it was a great break.

Steve Wright:  Awesome.  Well, before we get started, I want to let you know that this radio show is brought to you by ChrisKresser.com and if you’re new to the paleo diet or you’re just interested in optimizing your health, check out Beyond Paleo.  It’s a free 13-part email series on burning fat, boosting energy, and preventing and reversing disease without drugs.  To sign up, just go over to ChrisKresser.com and look for the big red box.

All right, Chris, well, today we’re gonna do a mixed bag of things, so you want to kick it off?

What you need to know before deciding to consume raw milk

Chris Kresser:  Sure.  Yeah, we’re gonna answer some questions again today, but I wanted to begin by talking a little bit about the article on raw milk safety that I wrote earlier this week and just some of the discussion that’s happened around it, because I think it’s an interesting topic both specifically in terms of raw milk safety itself and also generally in terms of risk/benefit analysis for any health-related activity or choice that we might make, and just how we go about making those choices, because I get a lot questions through my blog and from my patients and just in general about, you know, do you recommend raw milk?  Or do you recommend eating eat seafood and raw oysters?  Or do you recommend vaccination?  Or do you recommend home birth versus hospital birth?  And these are all questions that are on a lot of people’s minds, and they’re important questions, and I think it’s helpful to talk a little bit about how to answer those questions, because I never will respond just by saying:  Yes, I recommend this, or yes, I recommend that, because it’s not that simple.  There are a lot of factors that go into a decision like that, and some of them are data-driven.  You know, we can look at the scientific literature, and we can determine from that what the relative risks and benefits are for a particular choice.  And then some of them are values-driven, and in all of the cases that I mentioned, they’re both.  You know, so values might include our particular worldview, what’s important to us, other non-measurable factors like, for example, in the case of home birth, there are a number of considerations like skin-to-skin contact with the baby after the baby is born, the type of environment a woman might want to give birth in, like in her home, in a place that she feels comfortable versus in a hospital, the type of people that she might like to have around her during the birth.  These are things that won’t be covered in scientific studies, and yet they’re very important factors that go into how that decision is made.

So, I wrote an article this week, as I’m sure many of you are aware by now, about raw milk safety, and my purpose in writing that article wasn’t to make a “recommendation” for whether someone should drink raw milk or not, because I think that’s a choice that everybody needs to make on their own, based on their evaluation of the data, the risk, the possible benefits, and their own value system.  But my purpose in writing that article, though, was to clarify what the data actually says about the risk of drinking raw milk, because that is fairly objective.  There are data available, and we can interpret those data, and then we can decide what to do about that data.  In other words, we can make a choice weighing the potential benefits versus the potential risks.  Now that’s something that I don’t think we can argue about.  If somebody evaluates the data and then determines that they don’t want to drink raw milk even if the risk is relatively low, then I’m not gonna argue with that.  You know, that’s someone’s personal choice, but what I do take issue with is the distortion of the data or exaggeration of the risk of drinking raw milk, which is what I see all the time in the mainstream media.  And it’s unfortunate that this issue has become so highly politicized, and it’s really become a lightning-rod or hot-button issue, and when that happens, the victims are people like you and me who just want to know what the facts are so that we can make our own informed decision, but those facts are being obscured by a tremendous amount of hype and propaganda, and in an issue like this, it tends to happen on both sides.  So you get really entrenched viewpoints, and then it just, in my experience on issues like this, it just becomes kind of an “I’m right, you’re wrong” type of argument, and it’s not very productive, and the facts and the data are what get obscured, and it becomes more of just a battle of will or belief system.

So, the CDC and the FDA — I’m not going to go into all of the details because those are available in this article, and there’s a lot of data there for people who want that, but the summary is that the CDC and the FDA have been making a lot of noise about dangerous raw milk is, and it’s true that there is a risk with raw milk, and it’s true that there’s about a nine times greater risk of becoming ill from drinking raw milk than pasteurized milk, but what’s also true is that the absolute risk of becoming ill from either raw or pasteurized milk is incredibly low.  In the case of raw milk, it’s about 1 in 94,000, and in the case of pasteurized milk, it’s about 1 in 880,000.  So, this is a good time to talk about the difference between relative and absolute risk, which is really important to understand.  We’ve talked about this before in the context of evaluating other scientific studies.  If you talk about a nine times greater risk of something, it sounds really significant and scary, and that’s true if you’re talking about the risk going from 5% to 45%.  That’s a gigantic leap, and it would have huge implications in terms of safety, but if you’re talking about the risk going from, you know, one ten-thousandth of a percent to one one-thousandth of a percent, then that’s a much less significant jump, and the absolute risk, even though it’s nine times greater in that example, is still very minute.  So, this is an important thing to understand in this whole decision on raw milk, and you see these headlines, you know, “Raw Milk Much More Dangerous Than Pasteurized Milk,” and for someone who doesn’t look any deeper, that might be enough to turn them off to it, but it’s really important to understand that the absolute risk of getting sick from drinking raw milk is really low, and the absolute risk of getting sick to the point where you would need hospitalization is even lower.  In the period that I looked at from 2000 to 2007, the absolute risk was about 1 in 6 million, and I used some comparisons in the article to just give people a kind of rough idea of how that risk compares to other risks that people take on a regular basis, and it’s not an exact comparison, of course, because they’re just generalizations.  They don’t take into account the frequency with which people engage in these activities, but according to the US Department of Transportation, the risk of dying on a plane crash is about 1 in 2 million, you know, for the person who flies an average amount.  So, the risk of dying in a plane crash is greater than the risk of becoming hospitalized from drinking raw milk during the period of 2000 to 2007.

So, really it’s a small risk, but it really boils down to risk tolerance.  So if somebody reads the article that I wrote and they understand what the facts actually say, and they still decide after reading that:  Hey, you know what?  I understand that the risk is small, and I just don’t want to take that risk.  I don’t want to take it myself or I don’t want to take it for my children.  That’s fine.  I completely respect that.  But it’s just important to me that the facts are clear, and that was my purpose in writing that article.  And, in fact, that’s my purpose when I wrote about home birth.  I wanted to set the record straight on what the relative risks were for home birth versus hospital birth, because that’s something that there’s also a lot of hysteria and misinformation around that issue.  And when we talked about vaccinations, my point was not that there’s no risk in not vaccinating.  I think that’s untrue, there is a risk, but there’s also a risk in vaccinating.  So these are all decisions that really can’t be made just based on the data alone, and you have to consider your values and your priorities and your world view and what you’re comfortable with, and that’s why I think that the “debate” will never end with these types of issues, because a lot of the factors are subjective.  And as long as we’re thinking and unique individual human beings, there are going to be these differences.

Steve Wright:  Well, I appreciate you writing that article because I, for one, was getting mixed up between the two sides of propaganda.  There are just so many YouTube videos one side and so many articles on the other that it’s very helpful to see that in this light, so I appreciate it.

Chris Kresser:  Yeah, sure.  And there are a couple more articles coming in the series.  The next one we’re gonna talk about what the potential advantages of unpasteurized milk are versus pasteurized milk, and again, there are some things that are more clear than others there.  There’s some epidemiological research that suggests that raw milk might help prevent allergic diseases and asthma and other immune-mediated conditions, but as we know, epidemiological data don’t prove causation, so we can’t know for certain that raw milk is the deciding factor in those studies.  And then there are other claims that are made about the nutritional differences, some of which are more easily substantiated than others, but the truth is there’s just not a lot of high quality research on the differences between raw and pasteurized milk.  So, for the people who say that hasn’t been proven, yes, that’s true, but lack of proof is not proof against.  And for a lot of people, just experientially or the experiential difference, you know, they drink pasteurized milk, they notice how they feel, and then they drink unpasteurized milk, and they notice the difference in how they feel, frankly that’s gonna be enough for a lot of people.  And for most people who are drinking raw milk now, that is enough because the average person doesn’t dig into the scientific literature and read every study there is on the differences, and they don’t wait for scientists to do that kind of research before making up their mind.  Again, there are a lot of things to consider, but I think the main point I want to get across here is that a lot of the decisions that we make about health and wellness are not just driven by data alone.  They’re driven by our value system and our priorities and our world view, and that’s perfectly valid, and they’re important criteria in the decisions that we make.

Steve Wright:  Well, I’m looking forward to the rest of the series, and I hope that you also do a piece on homogenization because I’m interested in that.

Chris Kresser:  Yeah, we’ll talk a little bit about that, I think.  It’s hard to keep these articles short enough so that people will actually read them!  The first article was almost 3000 words, and I felt like it could have been a lot longer than that.  So, we’ll be as thorough as we can without being overwhelming.

Steve Wright:  OK.

Chris Kresser:  So, we can move on to the questions now.  That’s all I have to say about that.

What to do – and not do – if you have iron overload

Steve Wright:  OK, great.  Let’s roll onto the first question.  This one’s from Robbie, and he asks:  “I’ve been cooking with a cast iron skillet for about eight months now.  Is iron overload from this utensil a concern, especially when making sure that I eat liver once or twice a week?”

Chris Kresser:  Not for the average person.  So, we have mechanisms where the cells in the stomach can sense how much iron we have in our body stores, and when the body stores are low those cells will absorb more iron from our gut, and when our body stores are sufficient they won’t absorb as much iron.  They won’t absorb any iron, and we’ll just excrete it.  That’s the way normal iron metabolism works.  But some people have mutations in the genes that code for some of these proteins, and then that whole system gets messed up.  For example, in hereditary hemochromatosis, which is one of the most common genetic mutations in people of European descent, which causes pretty aggressive iron overload, that regulatory mechanism is broken, so the body can’t communicate how much iron that it actually has, and so the cells in the gut just keep absorbing more and more iron inappropriately, and more iron gets stored up in the body.  So, for someone with a genetic mechanism like that, like a genetic mutation like that, it’s possible that cast iron might have an effect, especially if the pan is old and hasn’t been well seasoned over time to protect it.  Eating liver regularly definitely would be a risk factor for people who have an iron storage mutation like that.  It’s not for people who don’t, because as I said, in normal physiology you just excrete any additional iron that you take in, but as I said, it’s one of the most common mutations in people of European descent.  In fact, about 1 in 200 to 1 in 300 people in the US have hemochromatosis, so it’s actually not that rare, and that’s one of the reasons that I always run iron panels on my patients, particularly men, because it’s a pretty common thing, and it’s often not diagnosed.  Almost every patient that I’ve diagnosed with iron overload, it was the first news they had ever heard of it.  It’s something that just seems to fall through the cracks a lot.  So in summary, if you don’t have one of these mutations, you don’t generally have to worry about how much iron you’re eating in food or cooking in cast iron, but if you do have one of these mutations or you’ve tested high in iron previously, than it’s something you probably should pay attention to.

Steve Wright:  Great.  So do you use cast iron, or do you recommend it?

Chris Kresser:  Yeah, I use cast iron, but we mostly use ceramic cookware, like the Le Creuset.  We use some stainless steel for applications when we just want to heat something up quickly, you know, boil some water or whatever, and then we have one cast iron skillet that we use.  So it’s kind of a combination of things.

The best science to study before naturopathic school (and why Chris started this blog)

Steve Wright:  Gotcha.  OK.  Great, well, let’s roll on to the next question.  This one’s from Josh, and he’s wondering what you thought the best science to major in before he goes to naturopathic school would be.

Chris Kresser:  Yeah, that’s a good question.  I get that one a lot.  I think it really depends on your interests.  There are a number of potentially good choices.  Like, biochemistry would be one.  Physiology would be another one.  And I don’t think it matters all that much.  What I do think matters is that you’re interested in the subject matter and you’re engaged in it, and that’s probably the most important factor of all, because as you progress through your medical education, whatever route that you choose to do, if it’s naturopathy or medical school or something else, you’re gonna be exposed to all of the other disciplines and everything from anatomy to physiology to pharmacology to biochemistry.  You’re gonna cover it all, so I think early on it’s just important to do something that interests you and that you can get excited about and you feel engaged by.  I don’t think it matters too much within those basic sciences what you do. 

Steve Wright:  Is there anything that you should be doing on the side while you’re going to school, because I know school can be demanding, but a lot of times there’s some free time?

Chris Kresser:  Yeah.  Well, when I was in graduate school, I did a lot on the side.  I did a lot of continuing education programs.  I did some mentorships with other practitioners and teachers, and I did have some spare time, and I was at a point in my life because I went back to school fairly late in my life, I was very focused on my career and getting the ball rolling, so I actually started my blog, which was formerly The Healthy Skeptic, while I was still in school, and that was primarily a way for me to just keep track of my own research.  I don’t know if I’ve told this story before, but when I started my blog, I had absolutely no idea that anybody else would ever read it.  It was just that that format seemed to be the easiest way for me to kind of keep a record of what I was interested in and the kind of research that I was doing, and I’m the sort of person that learns well by doing.  You know, I’m a kinesthetic learner, so if I read something and then I take notes on it and then I write something about it, then it’s imprinted in my brain in a way that it never gets imprinted if I just listen or read.  So, I started The Healthy Skeptic, and then I was surprised to find out that people were actually reading it and leaving comments, and one thing led to another.  So, that can be really useful.  If you’re in grad school or even as an undergrad, just start writing because it’s a really good way to test your knowledge of the material.  When you read something and then you write, you’re taking it through your own filters, and if you’re able to write about it in your own language, you’re gonna be much more likely to retain that information and be able to talk about it with other people.  So, I think that’s something you can get started with right away, and then looking around and seeing what’s available in terms of…I think this person is interested in functional medicine even though he is going to study naturopathy, so you can look around for some functional medicine courses that might be available.  Usually they have student rates.  I mean, I really took advantage of that when I was a student.  Many of the companies that teach these seminars, and some of them are nutritional supplement companies or some of them are lab testing companies, like Metametrix does some seminars.  Almost all of the lab testing companies have seminars where they talk about their lab tests but also just functional medicine topics in general, and some of them have just amazing student discounts.  One company, Apex Energetics, I did some seminars with Datis Kharrazian and some other people.  You know, their normal weekend seminar rate was something like $450 or $500.  I could be misquoting that, but something like that, and for students it was $50.  So, I mean, I just took every single course that they offered while I was a student so I could take advantage of that discount.  Those are all good options, and then of course, make sure you save some time and have fun and manage your stress because graduate school and even undergrad when you’re doing pre-med type of stuff can be, like you said, Steve, really stressful, and I see a lot of people graduate from school being totally burnt out and wrecked, so it’s a good idea to protect your health and make sure to take care of yourself while you’re doing all of this stuff. 

Steve Wright:  Yeah, that’s all good.  I’m glad you shared that story, and I think there have been a lot of masters that have said you don’t necessarily truly learn something until you teach someone else.

Chris Kresser:  That’s right.  There’s an old Daoist saying:  True knowledge is action.

Steve Wright:  Yeah, and that’s a great point.  You know, I hate to hear about people who have the best of intentions when they go into undergrad for pre-med and then end up burning out before they ever finish, so have a lot of fun, people!

Chris Kresser:  Yeah, and you know, along those lines, I know I already said this, but you have to find a way to make it interesting for yourself, and that’s the biggest piece of advice that I have to anyone who is pursuing that kind of path.  I got really interested in cholesterol and heart disease and that whole myth and debunking that, and that’s how I started writing my blog, and I just kind of went from one topic to the next like that while I was in school, and that kind of became primary while I was in school.  Like, the research I was doing outside of school and the writing for my blog was my main fascination, and then school was a way of sort of fueling that and helping to learn about research methodology and some of the other things.  Like, when I was in school, a lot of the people that I was studying with, like in my research methodology class, just hated it.  They were bored out of their minds, and I think part of it’s because a lot of people who go to study acupuncture they don’t really care about that.  They’re more interested in Chinese medicine, not Western medicine, but for me that was such an amazing resource.  The guy who taught it was a researcher at Stanford at the Cancer Center at Stanford, a really knowledgeable guy, and it was just so cool to be able to learn about that, learn how to evaluate studies, and I had a context, you know, a reason to learn it because I was reading all of these studies and it was on a topic that I was passionate about.  So, yeah, finding a way to make it really interesting is important.  I think that’s what makes a difference between people who burn out and either don’t make it through or just are miserable the whole time and people that end up really enjoying it and getting a lot out of it.

Steve Wright:  Do you have anything to say to the people out there who are in any of these disciplines and they think along the paleo, evolutionary health perspective, but they’re stuck with professors in classes that are of the previous paradigm?

Chris Kresser:  Yeah, I guess that’s a similar evaluation that we were talking about before.  I mean, it’s a question of how you want to spend your energy.  I mean, in some cases I think making a lot of noise about it is equivalent to beating your head up against a brick wall.  You know, you just kinda have to look at the situation and evaluate how much energy you want to spend trying to change other people’s minds in that situation, how likely you think it is that that will even happen, you know, how open are they to hearing the information that you have to share.  So for me, it varied from situation to situation.  Like, I was already doing presentations and talks when I was a student in graduate school at the school, so when I was working on my heart disease and cholesterol research, I started giving presentations, and that was a good way for me to kinda get this information out there without spending all of my time being that guy in class who was always, like, contradicting everything that the professor says.  And a lot of times it was hard because I’d have to sit there and listen to stuff that I knew was not true and not accurate, but in the end, in some cases I would raise my hand and say:  Well, what about this?  Or have you heard about that?  But in a lot of cases during that time I would just be sitting there thinking about my other research or taking notes on something else, so I think that’s kind of a personal decision and it depends a lot on someone’s personality and how much energy they have for that kind of stuff and choosing your battles.  Like, I choose to spend the vast majority of my energy helping people that really want my help.  That’s just me.  There are some people whose vision is to get out there and change everybody and change everybody’s mind, and I think that’s great, and ultimately, of course, I’d like everybody to know the facts about all of these things that we talk about and to follow a lifestyle and a diet that makes them healthy and feel good, but I’m not generally the kind of person that will…I choose my battles.  Let’s put it that way, and you know, there’s a limited amount of time in the day.  There’s a limited number of days in the week.  You know, I don’t have unlimited energy, so I choose to spend that writing my blog and doing this radio show and making this information available to people who want to come find it.  I’m not the guy who will go to a vegan blog and leave a bunch of comments that are trying to convince them that eating a paleo diet is the best choice.  That just doesn’t make any sense to me.  To me, that’s a complete waste of energy and time.  But to each his own. 

Steve Wright:  Yeah, I think that’s really wise, and I’m glad you covered it, and I think the sum there is if you’re really angry and you pick and choose your battles, write your words on a blog somewhere, and we’ll probably all be reading it someday.

Chris Kresser:  Yeah.

Does consuming fat in the morning get in the way of intermittent fasting?

Steve Wright:  All right.  Well, let’s move on to the next question.  This one comes from Yoshi, and it’s about Dave Asprey and his blog, The Bulletproof Executive, and his question is:  Dave recommends bulletproof coffee in the morning with your first meal.  And he wants to know if you’re having fat in your coffee, which bulletproof coffee is grass-fed butter, MCT oil, and coffee, I believe.  So, if you’re doing that in the morning, are you actually intermittent fasting?

Chris Kresser:  Yes.  I mean, probably opinions will differ on this, but the idea behind intermittent fasting or one of the main things is to promote autophagy, which is the cellular garbage recycling process basically, and fat will not get in the way of that.  Eating protein or carbohydrates will.  So, if you are intermittent fasting and you have some coconut oil or, in this case, coffee, which has no carbohydrate or protein, and you add some fat to it, that doesn’t technically, in my opinion, get in the way of the potential benefits of intermittent fasting.  If you’re doing intermittent fasting for weight loss, depending on what your beliefs are about weight loss, that may or may not interfere.  If you’re just doing a very low carb, intermittent fasting type of approach, then eating fat wouldn’t interfere.  If you’re doing a caloric-restricted kind of program, then adding a whole bunch of fat to your coffee, you’d have to obviously consider that in your overall calorie intake.  But if it’s more of a question of health and autophagy, then it’s not gonna interfere.

Steve Wright:  OK.  Well, that’s good to know because I know some of the more popular intermittent fasting routines such as Martin Berkhan’s at Leangains.com and Brad Pilon’s Eat Stop Eat, those are more around losing weight, not necessarily lifelong health.

Chris Kresser:  Right.

Steve Wright:  And I have been trying the Bulletproof Exec coffee, and it’s very delicious.

Chris Kresser:  Yeah?  You like the MCT oil in it?

Steve Wright:  I do!  The only thing that I don’t like about it is it’s almost like a latte, and I like my coffee black.

Chris Kresser:  Do you?

Steve Wright:  So, you actually throw the MCT oil in there and some grass-fed butter and you spin it up in a blender like he recommends, it really turns all frothy.

Chris Kresser:  Yeah, I tried that, and I mean, nutritionally I think it’s great, but coffee and cream, to me, is the best combination ever.  Especially raw cream that I get from our local farmer here.  It’s like heavenly. 

Steve Wright:  Do you blend it?

Chris Kresser:  I don’t blend it.  No.

Steve Wright:  Interesting.

Chris Kresser:  Just adding cream.  And the ratio for me is like one-third cream, two-thirds coffee, so it’s very, very creamy. 

Steve Wright:  Do you do a couple cups of that?

Chris Kresser:  No, and I don’t do it every day, because I don’t do that well with a lot of caffeine.  I’m one of those really caffeine-sensitive people. 

Steve Wright:  Gotcha.

Chris Kresser:  Just maybe three to four mornings a week, and even then, it’s probably weaker than some coffee aficionados would like.

Steve Wright:  Yeah, the one thing I did notice just switching to Dave’s brand, believe it or not, I’ve been trying a lot of different organic brands, and the phlegm that I was getting some mornings from various coffees, I kinda actually ended up tracking it down to the coffee.  You know, I’m not sure how much science there is to the mycotoxins and what he does over there, but I’ll tell you, when I switched to that coffee, the problems that I was having with your high-end, big-box coffee store stopped.

Chris Kresser:  Right.  Yeah, I think when it’s roasted is really important, and there aren’t that many places that you can buy coffee that are really, really fresh roasted.

Steve Wright:  Great.  Well, I’m gonna have to get my hands on some raw cream because I don’t have any sources for that over here.

Chris Kresser:  Well, I mean, even pasteurized cream can be pretty good, but the raw cream here that we can get is even thicker than the cream that you can typically buy in stores.  It’s la crème de la crème.  Yeah, very, very good. 

Steve Wright:  All right, well, we’re all coming over to your house for coffee next week. 

Chris Kresser:  Yeah.  It’s actually making me want some coffee right now.  Hang on a sec.

Steve Wright:  Pause for the cause!

Chris Kresser:  I’m just kidding.

Steve Wright:  And we’re back!

Chris Kresser:  Now I’m bouncing off the walls.  Let’s go!  Let’s go!

What to do if your fasting blood sugar is high, even when you stop intermittent fasting

Steve Wright:  Ha, ha.  OK, well, the next question, after our coffee break here, is from Ryan.  And this one’s a bit of a long one, but we’ll get it all in because it’s important.  So, Ryan says:  “First, I just want to say thanks for all the great information you provide.  I really appreciate it, and I know a lot of others listeners do too.  I have been attempting to lower my fasting blood glucose for the past year or so.  It had been steadily rising over the past year and a half, so it was routinely now around 110 when I was first waking up.  My total cholesterol has been rising at the same time to where at last check it was around 300 (HDL was 80, and triglycerides were 80).  So, first I tried supplementing with magnesium citrate and had no effect.  I just recently heard on your podcast about glycinate and malate forms, which are better,” or he heard that they were better.  “Next I tried increasing my overall carbohydrate intake, which hasn’t helped.  Then I came across a post on your site from 2010 describing the negative effect that intermittent fasting can have in certain cases.  I had been doing intermittent fasting daily 16 to 20 hours” total, I’m guessing there, “along with heavy weight training in the fasted state four times a week for about a year, so your post hit home with me.  For the past week and a half, I’ve been eating throughout the day, but so far my morning glucose is still around 110.  I have not been eating breakfast right after waking and usually two to three hours later,” so it sounds like he’s eating breakfast two to three hours after he wakes up, and then after that he tries to eat a meal every three hours or so.  It’s been two weeks now on this new eating schedule, and he was hoping to see some improvement, but nothing’s happened.  He wants to know how long patients who switch from intermittent fasting to regular meals have taken to see improvement.

Chris Kresser:  It can take a couple of weeks usually, but there may be something else going on here.  One thing to consider is latent adult autoimmune diabetes.  Most people probably know there are two main types of diabetes.  There’s type 1 diabetes, which is usually an early onset during childhood, autoimmune diabetes, and then there’s type 2 diabetes, which usually comes on later in life and has certainly a genetic predisposition but is also triggered by a lot of environmental factors.  Recent research suggests that the lines between those two might not be as clear as we previously thought and that there’s another type of diabetes.  Sometimes it’s called type 1.5, or sometimes it’s called LADA, latent adult autoimmune diabetes, and it’s kind of a combination.  It has an autoimmune component, but it manifests more like type 2 diabetes than it does like type 1.  And I’ve forgotten the exact numbers, but I think one estimate that I saw suggested that as many as 15% of people who are incorrectly diagnosed with type 2 diabetes actually have type 1.5.  So, it’s possible something like that might be happening, and in that case, diet would certainly be important, but you’d also have to take steps to address the immune dysregulation to make some progress with it.  Another thing to consider is iron overload, which we were just talking about earlier in the show.  Iron overload can damage the beta cells of the pancreas and cause insulin deficiency and insulin resistance, and there’s a type of hemochromatosis that is earlier onset called juvenile hemochromatosis.  It’s fairly rare.  I wouldn’t guess that’s what’s happening, but the main form of hemochromatosis can start to come on in the late 20s and early 30s.  That’s a possibility.  You know, I originally was thinking that a very low carb diet can cause this dawn effect where you can have high fasting blood sugar and then your blood sugar will come down to normal levels after you eat a meal. 

I think that the next step here would be, if you haven’t already done this, to measure your post-meal blood sugars.  So you get a glucometer, and I have some posts on my blog that describe how to do this.  We can put it in the show notes.  And you measure your blood sugar in the morning.  I assume he already has one if he’s taking his blood sugar all the time, but you measure just before lunch, then you eat lunch, and then you measure at one hour, two hours, and three hours after.  The targets that you want to be under are 140 at one hour and 120 at two hours, and if you’re under those targets and well under those targets but your fasting blood sugar is still high in the morning, that indicates a few different possibilities.  Number one, fasting blood sugar is more of an indicator of liver insulin sensitivity, and post-meal blood sugars are more of an indicator of muscle and fat cell insulin sensitivity.  So, it’s possible in that situation that there’s a liver insulin resistance issue, and again, that could be mediated by iron, that could be an autoimmune mechanism, or possibly a genetic mechanism because there’s a really strong family history there that he mentioned.  If the post-meal blood sugars are elevated, you know, above 140 at one hour or above 120 at two hours, and the fasting blood sugar is elevated, then I would pretty strongly suspect some kind of autoimmune mechanism at that point in light of how much exercising and, you know, it sounds like the diet is pretty clean, so in that circumstance I think getting some help from someone who can help figure it out would be a good idea.

Specific strategies to find calm during stressful situations

Steve Wright:  OK, well, hopefully that helps him out.  OK, the next question is from Anonymous or we lost his name, so sorry.  “Chris, could you address strategies for controlling sympathetic nervous response when facing a pressure-filled situation like an interview, presentation, or audition?  My wife is an actress and is looking for ways to go into auditions more relaxed.  At times, her sympathetic nervous system gets going too fast, and she shakes and gets dry throat.  On the other hand, the times when she feels at ease and relaxes, she knocks auditions out of the park.  She would like to be able to control her nerves consistently.”  And he wants to mention one strategy that has seemed to help is taking magnesium glycinate and calcium AEP before the audition.  Also simply doing more auditions helps.  What else could it be?

Chris Kresser:  Yeah, so there are a number of ways to approach this, of course.  One is nutritionally, which he discussed.  The way that I would tend to think about this, though, is more from a behavioral perspective, and there are a number of things that can be done to help manage stress and dampen the sympathetic nervous system response before an audition or a speech, public talk, anything like that.  One of those is mindfulness practice, and we’ve talked a lot about this on the show and on the blog.  Just bringing your awareness into the present moment can be really, really helpful in reducing that stress response, and that can be done in a variety of ways.  The simplest way of doing it is just bringing your attention to your breath, and importantly because I think a lot of people when they talk about this, they talk about doing deep breathing.  That can be helpful, for sure, but I’m not a big fan of that technique because that involves manipulating your breath, and for some people, trying to control their breathing, which is really one of the most natural processes there is, can actually add stress and can be stressful in its own right.  So, when I say bring your attention to your breathing, what I mean is just that.  Just be aware of how your breathing is without trying to intervene and control it or make it deeper or shallower or anything else, just bringing your attention to your breath, watching what it’s doing kind of just like you’d watch clouds moving through the sky.  That’s one way.  Another way is what’s called a body scan or a progressive relaxation exercise or a body sweep, and this where, for example, if you’re sitting in a chair outside the audition room waiting or in your car when you’re waiting, you just sweep your attention through your body.  You start maybe with the toes on your left foot, and you gradually sweep your attention from the toes of your left foot into the ball of your foot and the top of your left foot, then to your heel, and you just move through the body that way, all the while just letting your breathing be easy, and any time your mind wanders, which it almost certainly will, just bring your attention right back to where it was before.  There’s no need to start over.  There’s no need to beat yourself up for your mind wandering.  Just bring your attention right back to where it is, and just doing that, getting all the way through the body, by the end of that, I can almost guarantee you you’ll be significantly more relaxed.  There are some MP3s that are available for free online that guide you through these body scans and similar techniques, and we’ll put a link in the show notes.  So, doing that can be really helpful, and I really recommend that because it’s something that you can teach yourself to do, and it’s something that will always be available to you.  It doesn’t involve taking any supplements or making any changes as far as that goes.  And there’s nothing wrong with taking supplements, but I always believe that less is more, so if you can accomplish something without adding something new just by working with your own awareness, then that’s probably a better choice. 

Another thing along those same lines that can be really effective in reducing stress and optimizing performance is visualization.  There is a lot of research behind the positive effects of visualization on all kinds of performance-based activity from athletics to public speaking.  I’m not sure if there are any studies on acting specifically, but I’m sure that whatever the studies are for public speaking would apply there.  So, getting a good book on visualization or some tapes on visualization techniques would be another good choice.  And something that I used to use before a big exam like the state board examinations or a final exam or something like that is tai chi and qigong, which is something that I learned years and years ago in college and then have studied pretty consistently on and off for about 20 years with various teachers.  You could think of them both as moving meditations, and qigong, in particular, focuses on the breath and various breathing techniques coordinated with movement, and tai chi also does, although to a lesser degree.  But for some people who have trouble just doing seated meditation techniques or visualization or mindfulness because their mind is so busy or if they’re so triggered, like they’re really nervous about an audition, doing some kind of moving meditation like tai chi or qigong might be even more beneficial because when you’re waiting for an audition, some of that nervousness is probably…it’s just energy.  I mean, we can label it as fear or nervousness, but it’s energy, and a lot of the best performers find a way to channel that energy into the performance.  The idea isn’t to get rid of that energy because that’s what’s gonna fuel the performance.  The idea is to learn to work with it and channel it in positive ways.  So, I think doing a moving type of meditation might be even more helpful in that regard, and just recognizing that some amount of nervousness is probably a sign that you’re in the right place.  You know, it’s still an activity that’s really alive for you.  There’s a quote from Sammy Davis, Jr., that I’ve always really liked, where he said:  The day I stop getting nervous before I perform will be the day that I stop performing.  And I think that just kinda gets at the juice there was for him in performing.  So, all of those are good options, and I think they can probably be helpful.

Steve Wright:  Yeah, I guarantee that it can be, and speaking from someone who is more of the…I get real amped up, a couple things that I’ve done in the past was actually, like, if you get really worked up and you’re not about to do a physical performance-based thing is just to drop down and just do push-ups until you’re exhausted.  That’s one to way to get out of your head and kinda get into your body.

Chris Kresser:  That’s right, that’s right.  Get a heavy bag!

Steve Wright:  Yeah!  Basically just figure out a way to dissipate some of the energy so you can calm things down a little bit.

Chris Kresser:  Yeah.  Another thing, and this is maybe not so much for an audition, although I think it would apply there too, but for tests it’s a really bad idea to be studying right before a test.  From a neurological standpoint and how memory works, the best way to do it is to get all the studying done the day before, and on the day of the test to wake up, do some exercise, do some mindfulness practice or meditation, something relaxing, you know, something to actually take your mind off of the test, and just make sure you’re really prepared the day before.  And I’ve seen some interesting research that people who do that tend to be perform a lot better than people who are, like, standing outside, reading all their notes just before they go in the test or, in this case, studying the lines.

Steve Wright:  Yeah, and I’m sure sleep has a big to-do there as well.

Chris Kresser:  Yeah, absolutely.  OK, so I think we have time for one more short one.  How about the dry eyes question?

Does hypothyroidism cause dry eyes?

Steve Wright:  OK.  All right, here we go.  This comes from Grace, and she says:  “Hi, Chris.  Recently I went to a new optometrist, and on my new patient forms I indicated that I had hypothyroidism.  I was diagnosed with hypothyroidism about five years ago, and I’ve been on various medications since.  During my appointment, the optometrist explained that the reason I have dry eyes is due to my hypothyroidism.  I had never heard of this before.  Could you explain the mechanisms of how this works?  Are there any foods or supplements you would recommend to reduce the dryness in my eyes?”  And she notes that she recently started the 30-Day Paleo Challenge, and she is hoping to see some change in her symptoms.  Thanks.

Chris Kresser:  Yeah, well, there’s a condition called thyroid eye disease, and that is potentially what we’re talking about here, and the majority of thyroid eye disease cases are associated with hyperthyroidism more than hypothyroidism, but about 10% are associated with either euthyroid, which is normal thyroid, numbers or hypothyroidism.  And in most cases, whether it is hyperthyroidism or euthyroid or hypothyroidism, it’s caused by autoimmune thyroid disease, which involves specifically a cross-reactivity against shared antigens in the thyroid and eye tissue.  So, the immune system is attacking antigens in the thyroid tissue that are similar to antigens in the orbital tissue, so you get a cross-reactivity there.  So, the first thing that I would do if I were her would be to get thyroid antibodies tested, thyroid peroxidase (TPO) and thyroglobulin (Tg) antibodies, to see if you have Hashimoto’s, which since you mentioned hypothyroidism, that’s much more likely than Graves’, which causes hyperthyroidism.  And if you have autoimmune thyroid disease, then the key, as I have said before, is going to be addressing the immune dysregulation, so taking steps to balance and regulate the immune system.  That involves optimizing vitamin D levels, optimizing glutathione status, removing food toxins from the diet, which it sounds like you’re already doing with the Paleo Challenge.  Low-dose naltrexone can be really effective in stimulating T regulatory cell function.  So, that would be addressing the root of the problem if it is autoimmune in origin.  Fermented cod liver oil.  I’ve seen some benefits and success with fermented cod liver oil / butter oil blend from Green Pasture with dry eyes and dry skin, for that matter, dry scalp.  Vitamin A is really important for the eyes, and vitamin A is in the fermented cod liver oil, preformed vitamin A.  And then the EPA and DHA, the omega-3 fats, can be helpful as well.  So, first step, see if it’s autoimmune in origin, and if it is, address that.  And in the meantime, if you’re not already doing it, try the fermented cod liver oil / butter oil blend.

Steve Wright:  Is it bad in the meantime to be using any of those eye drops that remove the red and kinda lubricate things?

Chris Kresser:  I don’t actually know a lot about those eye drops.  It’s just not something that I’ve come across very frequently in my practice, and I don’t really know, to be honest, what the downside of those drops might be, if any.

Steve Wright:  Gotcha.

Chris Kresser:  And I don’t have any eye problems myself, so I’ve never had any reason to look into it, so I’ll have to put that on my list of topics to learn about.

Steve Wright:  Yeah, I’ve had them in the past, not so much lately, but I know back pre-SCD, pre-paleo, I did have a lot of eye problems. 

Chris Kresser:  OK, well, that’s gonna do it for today.  We’re never able to get through quite as many questions as I think we’ll be able to, but we’ve got some great questions on deck that we’ll get to soon, and keep sending us your questions.  We’re gonna get to them eventually. 

Steve Wright:  Yep, we keep them on the list, and maybe next time if we don’t take such a long coffee break we’ll get through more questions.

Chris Kresser:  If I’m not so long winded, you mean!

Steve Wright:  No, that’s not what I said!  All right, well, thanks everyone for listening today.  Please keep sending your questions at Chriskresser.com using the podcast submission link.  And if you enjoyed listening to today’s show, please head over to iTunes and leave us a review.

A new addition to the Meal Plan Generator, our next recipe in the safe starch series is one that hails from Latin America – plantain fritters. Known as “mofongo” in Puerto Rico, “bolon de verde” in Ecuador, and “tacachos con cecina” in the Peruvian Amazon, these fritters are a delicious addition to your palate. I was especially taken with the Peruvian use of crunchy bacon and rich lard to bring the fritter together, which is then served with a huge hunk of ham and topped with a piece of chorizo for a filling meal. I’ve taken some inspiration from the savory use of pork to include lard and bacon in the fritter, but if you’d prefer to go without pork for this recipe, skip the bacon, use coconut oil instead of lard and just add a little extra salt.

Ingredients:

• 1 green plantain
• 2 strips bacon (omit if you prefer without pork)
• 1 heaping tsp lard (or substitute coconut oil)
• pinch salt

Directions:

1. In a skillet, cook the bacon. When the bacon is done, remove from the pan to a paper towel-lined plate or rack. Don’t clean the pan: save the pan and bacon fat in it for the final step of the recipe.
2. Peel the plantain and cut into four pieces: cut once across and once lengthwise. Cook the plantain pieces. I like to bring a pot of water to a low boil, add the plantains, and simmer the pieces for 5 minutes. Then, check for doneness as you would for a potato, by inserting a knife to see if it will go through easily. If they aren’t done, they may need another 5 minutes or so.
3. The plantains could also be grilled, sautéed, or any other method, as long as they are cooked. Drain plantains and place in a bowl. Mash with a potato masher or place them in a mortar and pestle to do the job.
4. Chop the bacon into small pieces and mix into your mashed plantain.
5. Mix in a heaping teaspoon of lard, and stir to create a batter. If you find the batter to be dry or crumbly, add more lard bit by bit until it becomes moist enough to shape into fritters.
6. Add and mix in pinch of salt to taste, keeping in mind that the bacon adds some salt already.
7. Shape the batter into fritters, in round shapes or patties. I like to make 3-inch round patties of 1 inch height. One plantain should make 3 fritters, using about 6-8 TB of batter for each fritter. Since all elements are already cooked, the fritters can be the size or shape you prefer.
8. To add a nice browning to fritter before serving, heat the skillet in which bacon was cooked over low heat. Gently place the fritters in the skillet and allow to cook for 3-5 minutes per side.

Enjoy!

If you missed out on the inaugural PaleoFX event this year, here’s your chance to pick up a DVD set including all of the fantastic talks and panel discussions.

The PaleoFX Ancestral Momentum – Theory to Practice Symposium took place this year from March 14-17 at the University of Texas – Austin campus in the Stark Center for Physical Culture and Sports. The event consisted of talks and mastermind panels from Robb Wolf, Mark Sisson, Paul Jaminet, Keith Norris and many other paleo/primal lifestyle practitioners. My talk at the event was “What to do – or not do – about high cholesterol”.  This is the most current and concise summary of the relationship between cholesterol and heart disease that I’ve ever offered.  I also participated in a few mastermind panels including “Bloodwork, Body Composition, and Hormones”.

If you weren’t able to make it out to Austin this year, I encourage you to take a look at these videos as they contain a wealth of useful information from the many practitioners in attendance. The talks are great for everyone – whether you are a practitioner yourself, or just someone who wants to learn more about the paleo/primal lifestyle.

Keith and Michelle Norris worked their butts off organizing this conference. I was amazed at how smoothly it ran, especially considering it was the first one. Unfortunately, they’re still in the red – but they hope to at least break even from the DVD sales.  They hired an A-list production team and the quality is fantastic (check out the trailer below). If you’d like to purchase a set of the DVDs, please click here.

Note: I earn a small commission if you use the links in this article to purchase the PaleoFX DVD.  Your purchase helps support this site and my ongoing research.

Back in February, the Center for Disease Control (CDC) published a study targeting raw milk as dangerous and unsafe for human consumption. The media jumped on it in typical fashion. You may have seen headlines like this:

“Raw Milk Causes Most Illnesses From Dairy, Study Finds.”
- USA Today

“CDC: Raw Milk Much More Likely to Cause Illness.”
- Food Safety News

“Raw Milk is a Raw Deal, CDC Says.”
- LiveScience

While two of these headlines are technically accurate – raw milk is responsible for more illnesses than pasteurized milk when the number of people who consume each is taken into account – the concern they convey about the risk of drinking unpasteurized milk is dramatically overstated.

I’m going to break this series into three parts. In this first article, we’re going to examine what the research really says about raw milk safety, and compare the risks associated with drinking unpasteurized milk with other foods and activities. In the second article, we’ll explore the benefits of drinking raw milk from several different perspectives: nutritional, health-related, social, environmental and ethical. Finally, in the third article I’ll make recommendations and provide guidance on finding a safe and responsible raw dairy producer in your area.

This series is called “Raw Milk Reality” because, as is the case with other hot button issues like vaccination and homebirth, propaganda and hype have overshadowed facts and common sense.  If you only saw the headlines from the CDC and FDA reports, you’d be left with the impression that raw milk is a dangerous food and anyone that consumes it or gives it to their children is reckless and irresponsible.  The purpose of this series is to present the other side of the argument, and give you the bare facts without bias or hyperbole so you can make an informed decision about whether unpasteurized milk is a good choice for you and your family.

I’m not here to convince anyone that they should drink raw milk.  That’s a decision each individual has to make on their own by weighing the potential risks against the potential benefits.  But to do that, you need an accurate understanding of the risks (which we’ll cover in this article) and the benefits (which we’ll cover in the next.)

Just how “dangerous” is raw milk? A little perspective…

Before we do that, however, let’s put the current discussion of unpasteurized milk safety into a wider context. Foodborne illness is a concern for many types of food. According to the most recent review of foodborne disease outbreaks in the U.S. in 2008 by the Center for Science in the Public Interest (CSPI), seafood, produce and poultry were associated with the most outbreaks. Produce is responsible for the greatest number of illnesses each year (2,062), with nearly twice as many illnesses as poultry (1,112). Dairy products are at the bottom of the list. They cause the fewest outbreaks and illnesses of all the major food categories – beef, eggs, poultry, produce and seafood.

According to the CDC, during the period from 1990 − 2006, there were 24,000 foodborne illnesses reported each year on average. Of those, 315 per year are from dairy products. This means dairy products account for about 1.3% of foodborne illnesses each year. That’s not exactly an alarming number, considering that more than 75% of the population consumes dairy products regularly.

It’s also important to note that the outbreaks and illnesses associated with dairy products are generally mild compared to other foods. According to the CSPI report above, approximately 5,000 people are killed every year by foodborne illness. From 2009 − 2011, three high profile outbreaks involving peanuts, eggs and cantaloupe alone accounted for 2,729 illnesses and 39 deaths. (1) Yet there have only been a handful of deaths from pasteurized dairy products in the last decade, and there hasn’t been a single death attributed to raw fluid milk since the mid-1980s, in spite of the fact that almost 10 million people are now consuming it regularly.

The takeaway is that thousands of people are killed each year by foodborne illness, but they’re dying from eating fruits, nuts, eggs, meat, poultry, fish and shellfish – not from drinking unpasteurized milk.

Why the CDC report can’t be taken at face value

The CDC report claimed that unpasteurized milk is 150 times more likely to cause foodborne illness than pasteurized milk, and such outbreaks had a hospitalization rate 13 times higher than those involving pasteurized dairy products.

According to senior author of the CDC study, Barbara Mahon:

When you consider that no more than 1% of the milk consumed in the United States is raw, it’s pretty startling to see that more of the outbreaks were caused by raw milk than pasteurized.

But can these claims be taken at face value? No.

There are several problems with the CDC report:

• First and foremost, the CDC doesn’t include the dataset they used, so we can’t analyze how they reached their conclusions. Fortunately, the CDC data for foodborne illness, as well as data from other institutions and peer-reviewed studies, are readily available online.
• There are about 24,000 foodborne illnesses reported each year. Yet by the CDC’s own admission, this represents only a tiny fraction of the true number of foodborne illnesses that occur. In 1999, CDC scientists used an estimate of the overall prevalence of diarrhea and vomiting to calculate the “true” incidence of foodborne illness as 76 million cases per year! Put another way, 99.97% of foodborne illnesses go unreported.
• A food vehicle was identified in only 43% of the reported outbreaks and only half of these were linked to a single food ingredient. What this means is that the true prevalence of foodborne illness that can be attributed to a particular food is much higher than what is reported. It also means that the data linking specific outbreaks with specific foods is such a tiny sample of the total that even small errors or biases in the reporting of outbreaks would seriously skew the results.
• To calculate the number of people that drink unpasteurized milk, the CDC used an older, lower estimate (1%) of the number of people that drink raw milk. This is curious because a FoodNet survey done by the CDC itself in 2007 found that 3% of the U.S. population – about 9.4 million people  - regularly consumes raw milk. That number is likely even higher today with the growing popularity of raw milk. (In 2010 alone, raw milk sales increased by 25% in California.) Why did they do this? If you’re a cynic, you might conclude that they used the lower estimate to exaggerate the risk of drinking raw milk.
• They combined data from outbreaks and illnesses associated with “bathtub cheese” (i.e. Mexican-style Queso Fresco made illegally at home) made from raw milk, and raw fluid milk. Queso Fresco is inherently more dangerous than raw milk, and is associated with more serious outbreaks and illnesses. Again, this distorts the data and makes raw milk seem more dangerous than it really is. (Note: commercial, properly aged raw milk cheese has never been implicated in a disease outbreak.)

In light of these weaknesses, I decided to conduct my own analysis using a more comprehensive data set including the CDC foodborne disease outbreak surveillance tables, an online outbreak database published by the Center for Science in the Public Interest (CSPI), public health reports such as the Morbidity and Mortality Weekly (MMWR), a CDC line list produced in response to a Freedom of Information Act (FOIA) request to CDC by the Farm to Consumer Legal Defense Fund (FTCLDF), and peer-reviewed studies in the scientific literature (2,3,4).

I purposely excluded outbreaks associated with Queso Fresco cheeses, because we are concerned here with the safety of raw milk and not raw cheese made in a bathtub, which I would never eat and would never advise anyone else to eat. I chose to focus on the most recent data available, from 2000 – 2007, since unpasteurized milk consumption increased significantly over the last decade.

I also included two notable outbreaks in California that were missing from both the CDC and CSPI databases: a large outbreak of campylobacteriosis in 2006, involving over 1,644 illnesses among prison inmates that was linked to pasteurized milk produced by an on-site prison dairy and another campylobacteriosis outbreak in 2007, that caused 8 illnesses following consumption of commercial raw milk and/or raw colostrum. (5,6)

What does this more reliable, peer-reviewed dataset tell us about the safety of raw milk?

The chart below lists all outbreaks and illnesses associated with unpasteurized milk from 2000 − 2007. Click the link to display the chart.

Raw milk data

There were 37 outbreaks and 800 illnesses from unpasteurized milk during from 2000 − 2007, with an average of 100 illnesses per year. The estimated U.S. population as of today is approximately 313,500,000. Using the CDC’s own 2007 FoodNet Survey data indicating that 3% of the population consumes raw milk, we can estimate that approximately 9.4 million people drink unpasteurized milk (as I said above, the number is likely higher because of the explosive growth in the popularity of raw milk over the past 5 years, but 2007 is the latest reliable estimate we have).

This means you had a roughly 1 in 94,000 chance of becoming ill from drinking unpasteurized milk during that period.

Now let’s compare this to pasteurized milk, as the CDC did in their study. The chart below lists all outbreaks and illnesses associated with pasteurized milk from 2000 − 2007. Click the link to display the chart.

Pasteurized milk data

There were 8 outbreaks with 2,214 illnesses, with an average of 277 illnesses per year. According to the CDC FoodNet survey, 78.5% (246,097,500) of the U.S. population consumes pasteurized milk.

This means you had a roughly 1 in 888,000 chance of becoming ill from drinking pasteurized milk.

According to these data, it’s true that you have a higher chance of getting sick from drinking raw milk than pasteurized milk. But the risk is 9.4 times higher, not 150 times higher as the CDC claimed.

Perhaps this is a good time to review the difference between absolute and relative risk. When you hear that you have a roughly 9 times greater (relative) risk of getting sick from drinking raw milk than pasteurized milk, that might sound scary. And indeed it would be, if we were talking about the absolute risk moving from 5% to 45%.

But when the absolute risk is extremely small, as it is here, a relative 9-fold increase is rather insignificant. If you have a 0.00011 percent chance of getting sick from drinking pasteurized milk, and a 9.4 times greater risk of getting sick from drinking unpasteurized milk, we’re still talking about a miniscule risk of 0.00106% (one one-thousandth of a percent) .

And to truly gauge the risk, we should ask how serious these illnesses are. An “illness” in these data can mean everything from an upset stomach to bloody diarrhea to hospitalization for serious disease. During the 2000 − 2007 period, there were 12 hospitalizations for illnesses associated with raw fluid milk. That’s an average of 1.5 per year. With approximately 9.4 million people drinking raw milk, that means you have about a 1 in 6 million chance of being hospitalized from drinking raw milk.

As I said earlier in the article, there has not been a single death attributed to drinking unpasteurized milk since the mid-1980s. There were 5 stillbirths attributed to an outbreak linked to bathtub-style Queso Fresco in 2000 in North Carolina. These were the only deaths during the 2000 − 2007 period I analyzed.

Therefore, your risk of dying from drinking raw milk was 0%.

How does the risk of drinking raw milk compare to other foods?

Now let’s put some of these abstract numbers into perspective.

According to the CDC Morbidity and Mortality Weekly (MMWR), from 2006 − 2008 there were an average of 13 outbreaks and 291 illnesses per year associated with shellfish and mollusks. According to the CDC FoodNet Survey, about 5.7% of the population (17,869,500) consumes shellfish. This means you had a roughly 1 in 61,000 chance of becoming ill from eating shellfish. That’s about 1.5 times the risk of becoming ill from drinking raw milk (1 in 94,000).

The risk is even greater – and more serious – if you eat raw oysters. 7.4% of people who eat oysters consume them raw (1,322,343). There are 15 deaths a year on average attributed to raw oyster consumption. This means you have about a 1 in 88,000 chance of dying from raw oysters. In other words, you have a greater chance of dying from eating raw oysters than you do of getting sick from drinking unpasteurized milk.

What about other more commonly eaten foods?  Check out the chart below, from the 2008 CSPI report. It shows the relative incidence of foodborne illness from 1999 – 2006, adjusted for consumption.

As you can see:

• Seafood caused 29 times more illnesses than dairy
• Poultry caused 15 times more illnesses than dairy
• Eggs caused 13 times more illnesses than dairy
• Beef caused 11 times more illnesses than dairy
• Pork caused 8 times more illnesses than dairy
• Produce caused 4 times more more illnesses than dairy

But how do these risks compare to other activities that most American engage in?

According to the U.S. Department of Transportation, you have a roughly 1 in 8,000 chance of dying in a motor vehicle accident if you live in the U.S.. This means you are about 12 times more likely to die in a car crash on your way to pick up your milk than you are to get sick from drinking it.

Don’t drive? You still have a greater chance of being killed while crossing the street (1 in 65,000) than you do of getting sick drinking unpasteurized milk.

What about flying? Although some people are afraid of flying, the risk of dying in a plane crash (1 in 2,000,000) is orders of magnitude lower than dying in a car accident (1 in 8,000) – and most people who are afraid of flying don’t hesitate to get in their car. Yet as unlikely as dying in a plane crash is, it’s about 3 times more likely than you becoming hospitalized (not dying) from drinking unpasteurized milk.

What about something as seemingly benign – and even necessary – as visiting the doctor or going to the hospital?  According to a landmark study published in the Journal of the American Medical Association, you have about a 1 in 1,300 chance of dying from an iatrogenic cause (unnecessary surgery, medication errors, adverse effects of medications, hospital mistakes and infections). This means you have about a 72 times greater chance of being killed by a medical error in a doctor’s office or hospital than you do getting sick from drinking raw milk, and a 4,600 times greater chance of being killed by such an error than getting hospitalized from drinking unpasteurized milk.

I hope this helps you understand the true risk of drinking unpasteurized milk within the context of other risks most of us take on a daily basis without a second thought.  Of course, the next question that naturally arises is why someone might be willing to take any additional risk with raw milk - however minuscule it is on an absolute basis – when pasteurized milk is readily available.

In Part 2 of the Raw Milk Reality series, we’ll address that question by exploring the benefits of raw milk from a variety of perspectives.

As you may realize by now, salt has had a very colorful history, both in the development of human civilization as well as public health politics in the past century. While salt was originally prized by many cultures for thousands of years, in the past century it has been demonized; some have gone as far as calling it the single most harmful substance in the food supply. Yet as we know, sodium plays a crucial role in optimal health, and too little salt intake can be dangerous in the long run.

In Shaking up the Salt Myth: The History of Salt, I described the history of salt production and use, and its place in the Paleolithic and Neolithic diets. In The Human Need for Salt, I explained the physiological roles of salt in the human body and the basic dietary requirements for salt. In The Dangers of Salt Restriction, I examined potential negative health consequences of restricting salt unnecessarily. In When Salt Reduction May Be Warranted, I described conditions in which salt restriction may be necessary, and other minerals that are essential in determining blood pressure.

In this final article, I will describe the types of salt I recommend, and how much salt is ideal for most people.

How much, and what kind of salt to include in the diet

According to research, there exists a range of sodium intake that likely confers the best health outcomes for most people. As I explained in part 3, findings from a 2011 study demonstrate the lowest risk of death for sodium excretion between 4000 and 5990 milligrams per day. (1) Sodium excretion greater than 7000 milligrams or less than 3000 milligrams per day was associated with a higher risk of stroke, heart attack and death. This lowest risk range equates to approximately two to three teaspoons of salt per day.

Figure 1: Mean sodium intake among the participants of the Japanese National Nutrition Survey: 1973–2000

The average American consumes about 3700 milligrams of sodium a day. This value has remained constant for the last fifty years, despite the rise in rates of high blood pressure and heart disease. (2) As a comparison, the Japanese, with one of the highest life expectancies in the world, consume an average of 4650 milligrams of sodium per day, and have a lower risk of cardiovascular disease than most other developed countries. (3, 4) Their average sodium intake has consistently hovered in the low risk range over the past 30 years, despite attempts by public health organizations to reduce Japanese salt consumption. (5) A caveat is that the Japanese also have a high risk of stroke, so their extremely high salt intake is not necessarily recommended as a model for our own intake. (6)

While salt recommendations vary between individuals based on age, gender, physical activity, and health conditions, I feel that the data supports an intake between 3000 and 7000 milligrams of sodium, or 1.5 to 3.5 teaspoons of salt, per day. People who are quite active or sweat a lot should consume salt on the higher end, and those who are less active may want to consume on the lower end. Of course, there may be some conditions where moderate salt restriction is warranted, but for the majority of healthy individuals, salting to taste will provide an appropriate level of sodium in the diet.  Natural sources of sodium include sea vegetables, fish, shellfish, and meat, plus certain plants such as beets, carrots, celery, spinach, and turnips.

What type of salt should you buy?

One question frequently brought up in the Paleo community is what type of salt is best. This is a difficult question to answer. There are a wide variety of salts available on the market, all claiming health benefits over the others. While the answer to this is unclear, there is some research demonstrating a difference in mineral content and flavor intensity of certain salts that would be better options than common table salt.

A fascinating 1980 study examined the different indigenous, pre-industrial methods of salt production, and their respective mineral contents. (7) Some salt production methods included drying marine algae or fish eggs, fermenting marine fish blood and entrails, and even using sea water soaked in peat that was dried and burned to create salty ash. This study compared the mineral contents of these traditional salts with industrial table salt, as well as a variety of sea salts and other “health salts” on the market. The indigenous salts were found to be higher in combined essential and nonessential trace elements than both the table and sea salts.

Most of us do not have access to these traditionally prepared salts. Fortunately, sea salt and other commercially available natural salts have been shown to contain a higher trace mineral content than refined table salt. (8) In this study, the mineral content of sea salts differed depending on the harvesting location, but all salts tested contained various amounts of trace minerals (with the exception of table salt), and had small amounts of calcium, potassium, magnesium, sulfur, zinc, and iron. The various natural salts also had different time intensity profiles, due to the variety of minerals, so less of the salt is necessary to achieve the same level of flavor intensity compared to table salt.

Types of salt that are not recommended

One sea salt that is not recommended for dietary consumption is Dead Sea salt, due to its high bromide content. (9) The Dead Sea has the highest bromide concentration of any large body of water in the world, and bromide toxicity can occur after consumption. Some argue that sea salt is no longer healthy due to the level of pollution in our oceans today, though evidence for this is scant. (10) If this is a concern, there are salts produced from ancient geological oceans, like Real Salt from Utah beds or Himalayan pink salt, which would not have the same level of pollution as salt from much of the world’s oceans.

Regular table salt, conversely, is heavily processed, generally devoid of trace minerals, and commonly contains undesirable additives such as anti-caking agents like sodium silicoaluminate or sodium ferrocyanide. Therefore, generally avoiding table salt is a good idea, though care must be taken to ensure adequate iodine intake from other sources once iodized table salt has been removed from the diet.

Don’t stress the salt!

The amount of conflicting research that exists on salt is astounding. Hundreds of studies have been conducted on salt intake, and a consistent pattern has never been established for sodium’s role in a variety of negative health outcomes. At a minimum, it seems absurd that so much time, energy, and money is spent on trying to reduce the amount of salt that Americans eat, considering how weak the evidence is on this issue.

Ultimately, my perspective is that adding unrefined salt to a whole foods Paleo diet is perfectly healthy. By limiting grains and processed foods, the amount of sodium in your diet will already be drastically reduced as compared to the standard American diet. A bit of salt can make certain healthy foods, particularly bitter vegetables, far more palatable. Considering the evidence I’ve presented in this series, I believe that salt restriction for the general population is not only unnecessary, but potentially dangerous.

Now, I’d like to hear from you. Have I changed your perspective on salt? Do you disagree with my analysis of the data? Tell me your thoughts!

Now that Best Your Stress month has concluded, I’d love to hear from you. Were you able to stick with your commitment? If so, what differences did regular stress management make in your health and your life overall?

If you weren’t able to stick with it, what got in the way? What did you do instead of stress management? It’s crucial not to beat yourself up about this. What’s most important is to be aware of how you get derailed and what stops you from reaching your goals. Then be compassionate with yourself and use this new awareness to improve your success the next time around.

Now that you’ve tasted the benefits of stress management, what commitment will you make to yourself on an ongoing basis? Let us know in the comments section.

I’m happy to say we finally managed to do a Q&A episode!  In this episode we cover how to know when it’s time to ditch GAPS or very low carb (VLC) diets, what causes night-time leg cramps and what to do about them, how to treat migraines naturally, vaccinations, red meat/protein and kidney disease and CoQ10.  Enjoy!

In this episode, we cover:

2:41 What to do – and not do – if you get worse on Paleo, GAPS, or other Low-carb diets
13:41  Simple supplements for night-time leg cramps, even if Natural Calm isn’t working
21:31  Remove these 3 foods to naturally treat chronic migraines
32:36  What is your opinion on vaccinations for early infants?
45:18  The myth that you should avoid red meat if you have kidney disease
50:04  Is it necessary to supplement with CoQ10, even on a Paleo Diet?

Links We Discuss:

• Vaccine Epidemic: How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children
• Vaccinations: A Thoughtful Parent’s Guide: How to Make Safe, Sensible Decisions about the Risks, Benefits, and Alternatives
• Jarrow Formulas Q-Absorb Co-Q10, 100mg, 120 Softgels
• Doctor’s Best High Absorption Chelated Magnesium (200 Mg Elemental), 240-Count
• Proferrin ES Iron Supplement – 90 tablets

Full Text Transcript:

Steve Wright:  Hey everyone, and welcome to the Revolution Health Radio Show.  I’m Steve Wright from SCDlifestyle.com, and with me is Chris Kresser, health detective and creator of ChrisKresser.com.  How are you doing today, Chris?

Chris Kresser:  I’m pretty good, Steve.  Just getting ready to start a little bit of time off, which I’m looking forward to.

Steve Wright:  How long are you gonna be off?

Chris Kresser:  Close to two weeks total from seeing patients.  It’s been a while since I’ve taken that much time, and I’m looking forward to getting a chance to spend even more time with Sylvie and Elanne and just having some time to rest.

Steve Wright:  Well, good for you, man.  It’s well deserved and well earned, I’m sure.

Chris Kresser:  How are you doing?

Steve Wright:  Doing well, doing well.  We got some new, exciting developments over at SCD Lifestyle.  We just came out with a new stress product, and we’re working hard on some other new products, so it’s a busy time of the year for us.

Chris Kresser:  Cool.  So you’re gonna teach people how to get stressed out?

Steve Wright:  We’re gonna try to remove the stress from stress management programs, because I have a stack of them that I’ve fallen off the wagon with, and it just seems like every program that we’ve bought, Jordan and I, we never stick with it, and so we wanted to try to strip them down and recombine them into a new product that sorta removes that, and we’re looking for people to commit 2 minutes a day, just 2 minutes, and if you can do that, we can guarantee that we’ll lower your overall stress.

Chris Kresser:  Sounds like a good plan. 

Steve Wright:  Yeah, we hope so.  OK, well, before we get started, I want to let you know that this radio show is brought to you by Beyond Paleo, and if you’re new to the paleo diet or you’re just interested in optimizing your health, then you’re gonna want to check it out.  It’s a free 13-part email series on burning fat, boosting energy, and preventing and reversing disease without drugs.  To sign up, go over to ChrisKresser.com and look for the big red box.

OK, Chris, so we’re finally gonna get around to the Q&A today, right?

Chris Kresser:  We’re gonna do it!  I’m excited.

What to do – and not do – if you get worse on Paleo, GAPS, or other Low-carb diets

Steve Wright:  All right, well, let’s dive right in so we can get as many in as possible.  The first one — and I apologize ahead of time, but I’m gonna do my best with this name — is from Aglaée, and she asks:  “For someone with SIBO, which is small intestinal bacterial overgrowth, who is following a GAPS/Paleo/low-carb, grain-free, sugar-free, and dairy-free, and nightshade-free, and fruit-free, and nut-free” –

Chris Kresser:  Holy moly.  What are they eating?

Steve Wright:  She says she’s eating bone broth, some probiotics, and some cod liver oil, but she’s not eating a lot of things, a lot of things that you’ve said in the past could make a gut hurt.  She wants to know how long it’s gonna take to heal on something like this because she feels that her tolerances have worsened on this plan as of seven months ago.  She used to be able to tolerate butter and can’t anymore and has to resort to ghee now. 

Chris Kresser:  Yeah.  This is an interesting question from a lot of different perspectives.  Well, let’s see.  Let’s break it down into a few parts.  So, the first question:  How long does it take to heal a gut?  Unfortunately, there’s no way I can answer that generally.  Some people tend to respond very quickly to gut-healing protocols.  I’ve had patients who have gone from pretty intractable gut symptoms to almost no gut symptoms at all within the space of a one-month dietary regimen similar to what she has described here, and then I have other patients for whom it takes years for their gut to fully recover.  And the difference, I think, depends on what the initial cause of the gut problem is, whether it’s just dietary, you know, diet related or whether it’s related to a gut-brain axis issue or a pathogen or dysbiosis and SIBO or an autoimmune inflammatory condition like Crohn’s disease or ulcerative colitis or some combination of all of the above.  It also seems to have something to do with how long somebody has had a gut issue.  With nervous systems problems in the gut obviously being part of that, when we get into a certain groove or a pattern, the longer that pattern has become entrenched, the longer it can take to set a new pattern.  So, it’s a really broad range, and it just varies from person to person. 

However, there’s another part of this question that’s interesting and that tends to come up a lot, which is what happens when you go on a restrictive diet and foods that you weren’t previously sensitive to you are now more sensitive to?  The example that she used was that she used to be able to tolerate butter, but she can’t anymore, and now she can only tolerate ghee, which has really no detectable casein or lactose in it.  And I’ve heard variations of this question, like they remove gluten from their diet and whereas they didn’t really notice a strong reaction to gluten, after they’ve eliminated it for 30 to 90 days and they add it back in, all of a sudden they feel horribly ill when they eat it or any number of other foods that people can be sensitive to.  So, to be honest, I’m not entirely sure what’s happening here, and I’m not sure it’s the same thing in every case because I have witnessed this in my patient population, and I’ve heard from enough people out in the blogosphere to know it’s real.  My first thought and my first response to it is that sometimes when you’re having a number of reactions simultaneously, it’s difficult to know what you’re reacting to with any clarity.  And then when you do one of these elimination diets and then add something back in and you have a very clear, strong reaction, it’s just more obvious than it was when you were in kind of a permanent state of reaction.  That may be the case with some people, but I don’t think it accounts for all of the phenomena that we’re talking about.  It’s also true that the body is pretty adaptable, and it’s probably the case that if you eat something that you react to, you can build up a little bit of a tolerance to it.  That doesn’t mean it’s optimal food for you or that it’s a good idea to go on doing it, but it may have some kind of hormetic effect or the body may have some mechanism for protecting itself against the damage that that does, and so the reaction isn’t quite as severe.  This isn’t really the case with allergies, like a true food allergy.  That rarely happens, but maybe with an intolerance it’s possible.

The other thing is that with an extremely low-carb diet like the GAPS diet, it really starves the gut flora, and that’s a good thing when you’re trying to deal with SIBO, but over a longer period of time, I think it can also starve some of the good gut flora, and I have seen people worsen over the long term with the GAPS or SCD type of approach that’s very low-carb, and I think in certain cases that may be what’s happening, is the good gut flora is getting starved and their digestion actually worsens over time rather than improves.  The truth is I don’t think we fully understand the whys and the hows to the extent that we’d like to with all of this stuff, and that’s why I do pay a lot of attention to people’s symptoms and I try not to be too dogmatic about any one particular approach.  I know if you go on the GAPS forum and you say you’ve been on the diet for nine months and you’re getting worse, the responses that you’ll get are usually you’re not doing it right or you need to do it more, better, harder, faster, you know, whatever…longer!  Because understandably a lot of the people on that forum have had their lives transformed by the diet, they really believe in it, and they kind of assume that it should work that way for everybody else, but the truth is it doesn’t always, and that’s why I sometimes will recommend when someone’s been on a really restrictive approach like this for a long time and they feel like they’re getting worse, Occam’s razor would suggest that the simplest explanation might be that that’s not the right program for you and that you might consider adding some foods back in that you had eliminated, particularly starch, and see what happens.

As a matter of fact, I just got an email yesterday from one of my patients who had a very similar story to the questioner here, and she had been on a GAPS diet for a longer period of time, probably 18 months, and just felt like she was spinning her wheels and getting worse, and her energy was extremely low, her digestion was really bad.  She was gassy and bloated and constipated and was just having tons of trouble, and so I suggested that she not consider herself on the GAPS diet anymore, that she add some starch back in, and that she actually pretty dramatically reduce her intake of insoluble fiber and plant foods, because when you have a really inflamed gut, a lot of insoluble fiber-containing vegetables and fruits like winter greens and broccoli and cauliflower and things like that she was eating a lot of and that most people eat a lot of when they’re on a low-carb, GAPS type of diet can be really irritating to the gut.  So, I talked to her, I don’t know, maybe two weeks ago or something, and I got this email from her yesterday that said that she was just doing so much better, that her energy levels had improved dramatically, that her digestion had improved dramatically.  She had liberated herself from the idea that she had to eats tons of vegetables every day.  I suggested that that wasn’t necessary because of the nutrient density of all of the other foods she’s eating, like bone broth and meat and liver and things like that.  You don’t really need to rely on getting all of your micronutrients from plant food.  So, now her meals were much more simple.  They were just consisting of a portion of protein, a portion of starch, and maybe one vegetable that’s cooked well and that’s not particularly high in insoluble fiber, like carrots or squash.  Or if she was going to eat winter greens, she would remove the stems and cook them very well, and that has really made a huge difference for her.  So, it’s just one example, but I’m kind of a fan of people not beating their head up against the wall for too long.  If they’re trying an approach and it’s not working, it might be worth trying something different.  Now, having said that, of course, that’s not to say that someone should do something for a week and then skip to the next thing.  I see that a lot, too, and that’s not an effective way of approaching things.  But if you’ve given it a fair trial, and in my mind, you know, six to nine months is a pretty fair trial on something like the GAPS diet, and if you’re just worsening that entire time and not really experiencing much improvement, then I think it’s probably not a bad idea to try something different.

Steve Wright:  Yeah, I think it’s important to definitely look to change especially if you’ve been on something for, like you said, six months.  At SCD Lifestyle, this is kind of a plan that we basically try to start everybody on, something this small, and so we do get some of these emails every week, and so I’d like to share just kind of a tip that I’ve found to be in common for a lot of these people, and it’s usually, like you said, it could definitely be that this is just not the way for them to heal, and a lot of other times it’s that there’s an underlying problem.  And you’ve talked about this many times, like there could be a parasite problem that they really need more testing.  And a lot of other times it’s actually a defective digestive problem, like stomach acid, they might have a problem there, and so it doesn’t matter how stripped-down you strip your diet.  If you’re not producing the right amount of stomach acid, you’re really not gonna digest anything very well.  And so that might be something for her to look into.

Chris Kresser:  Definitely.

Simple supplements for night-time leg cramps, even if Natural Calm isn’t working

Steve Wright:  OK, let’s move on to the next question, Chris.  This one comes from Cecilia, and she would like to know what to do about nighttime leg cramps.  “Ever since going paleo, I get cramps at night similar to the ones I would get when pregnant in my third trimester.  I’ve been supplementing with magnesium (Natural Calm at night) and this hasn’t made a difference.  Any suggestions?”

Chris Kresser:  Yeah.  Leg cramps are tricky because they’re kind of a nonspecific symptom, which means they can be caused by a number of different problems, and they don’t point to any one particular problem without doing more investigation.  But in my clinical experience, I can say that the most common perpetrators are either iron deficiency or excess iron, magnesium deficiency, potassium deficiency or imbalance, sometimes B12 deficiency, and then sodium imbalance or dehydration.  Low blood sugar, hypoglycemia, or elevated blood sugar can also cause leg cramps.  So, those are kinda the basic things to think about.  Potassium, in particular, it’s one of the minerals that regulates muscle contraction, so potassium imbalance can definitely trigger leg cramps.  It would be unusual for someone to experience that after going on a paleo diet.  Usually people’s potassium levels increase when they go on a paleo diet because a lot of the most potassium-rich foods are fruits and vegetables that people tend to eat more of when they go on a paleo diet, especially like sweet potatoes and yams, pumpkin, spinach, avocados, bananas, oranges.  Some of the melons are pretty potassium-rich, as are mushrooms.  But it’s a pretty same thing to do to try and increase your intake of those potassium-rich foods and also supplement.  You can consider supplementing with 100 mg of potassium a day. 

In terms of magnesium, Natural Calm, I’m not a big fan of that product.  A lot of my patients come to me, people when I first start working with them, they’re taking it, and I test their magnesium, red blood cell magnesium levels, and they’re low.  They still have a lot of signs and symptoms of magnesium deficiency, and they’ve been taking Natural Calm.  So, it does seem to help with sleep for some people and with constipation for some people, but I don’t know that it’s particularly well absorbed, and I usually recommend a chelated form of magnesium, like magnesium glycinate or magnesium maleate, and those especially at slightly higher doses, like 400 mg to 600 mg, even up to 800 mg a day, tend to be really effective for leg cramps if they’re caused by magnesium deficiency.  You can also take epsom salt baths.  That’s another thing that might help, like especially before bed if it’s happening at night during sleep.  So, just soak in some epsom salts and given that a shot.

Check your iron levels using an iron panel and ferritin, so that would be serum iron, total iron binding capacity, unsaturated iron binding capacity, and iron saturation or transferrin saturation plus ferritin.  And if all of those suggest that you’re iron deficient, then you’d want to eat more iron-rich foods.  Organ meats like liver, and shellfish like oysters and mussels, and lamb are the highest dietary sources of iron.  And you could also consider supplementing with iron.  I prefer using the heme form of iron as a supplement, which is the form that you find in animal products.  It’s much more readily absorbed than the plant or ferrous forms of iron.  Unfortunately, there aren’t a lot of choices for heme iron supplements, but the one that I know of that’s most accessible is called Proferrin ES.  Unfortunately, it’s got some somewhat unsavory ingredients in the capsule, but I think for short-term use, probably the benefit is gonna outweigh any harm that some of the additives that they put in the capsule might do.  There are also iron chelates, like iron bisglycinate, that you could try.  And that has been shown to be better absorbed than some of the more typical forms of iron that you find in supplements.  Iron is tricky to supplement with because a lot of the plant-based forms of iron that are used cause pretty intense GI symptoms.  Like, constipation is one of the classic symptoms or just gut pain or gas or bloating.  So, Ferrochel is a popular brand of iron bisglycinate.  You could try that.  And acupuncture actually can be quite helpful for this kind of thing, for musculoskeletal stuff.  It’s one of the things that I refer people to acupuncture for.  So, if you have access to a good acupuncture clinic, you might give that a shot as well.

Steve Wright:  You’re doing a big series right now on salt.  Is salt sometimes a problem with leg cramps for paleo people?

Chris Kresser:  Right.  Yeah, I did mention that before with sodium imbalance and dehydration, so thanks for reminding me.  I think it is an issue.  I’m not sure that it’s a big problem, but certainly if someone is switched to a paleo diet and they’re only using sea salt or they’re not using sea salt, I mean, a lot of people switch to a paleo diet and they don’t salt their food at all, so getting one to two teaspoons, even up to three teaspoons of sea salt a day might be something to try as well.

Steve Wright:  OK, so start with some potassium-rich foods and probably some sea salt and then get the rest of that tested.  Does that sound like a plan?

Chris Kresser:  Yeah.  I will say that magnesium is really hard to test for.  Serum magnesium is not an accurate marker.  Red blood cell magnesium is a little bit more accurate.  It measures the amount of intracellular magnesium in the red blood cell.  But frankly the best way to determine if you have a magnesium imbalance is to take a high quality chelated form of magnesium like maleate or glycinate and see how you respond.

Steve Wright:  With those chelated forms, I’ve heard a lot of people with the Natural Calm will be in, like, the 800 mg, 1200 mg a day.  Do you suggest a lower amount and then sort of building up? 

Chris Kresser:  Yeah, I think a starting dose if you’re experiencing constipation or cramps or something like this would be two 100 mg capsules twice a day, so in the morning and with dinner, and that usually does the trick for most people.  I think it’s safe to go up to 800 mg or even 1000 mg for short-term purposes, but yes, they usually will need less because it’s better absorbed than citrate or oxide or some of the other forms that are typically used.

Remove these 3 foods to naturally treat chronic migraines

Steve Wright:  Awesome.  Thanks, that’s great knowledge.  OK, great.  Let’s move on to the next question from Ellyn.  She asks:  “Any thoughts on naturals treatments for chronic migraine in a teenage girl?  It’s been suggested that a ketogenic diet (a la the Perfect Health Diet) could be helpful along with magnesium supplements.  Any thoughts?”

Chris Kresser:  Yeah, that certainly could be helpful, and I have used that in my practice.  But actually there’s something that I try first before I do that, and I think that a paleo/primal/Perfect Health type of diet is a great starting place.  So, if you’re not already doing that, I would recommend doing that.  Sometimes that’s all people need, but a lot of people often need more than that.  So, what I do is a low tyramine, histamine, arginine diet, and I’ll go into a little more detail about why and where you find those in food in a second here, but as a general rule, total elimination of all of these foods is rarely necessary, and restricting or limiting them is usually all that you need to do, but I do recommend eliminating them to the extent that’s possible for 30 to 60 days just to see if this is gonna work for you, and then you can try gradually adding them back in in small amounts, class by class, to see which one has had the greatest impact, because some people, for example, tend to be particularly sensitive to tyramines but not as much to histamines or maybe the other way around or they don’t have any issue at all with arginine.  So, just like any other elimination protocol, you really have to experiment and find what works for you. 

So, tyramines are derivatives of the amino acid tyrosine, and they are present in some foods and some medications.  Normally they’re inactivated by an enzyme called monoamine oxidase, or MAO, in the liver and the intestines, and it’s possible, some research suggests that MAO function might be compromised in migraine sufferers, which then leads to excess levels of tyramines in the blood, and excess tyramine in the blood can cause a temporary rise in blood pressure, sweating, nausea, migraine headaches, and a lot of the symptoms that are associated with migraines.  So, tyramines are found primarily in fermented foods like smelly and strong cheeses, like blue cheese, for example; high-yeast alcohol like beer and wine containing sulfates; broad beans; brewer’s yeast; fermented foods, so like all the dairy ferments and sauerkraut and kimchi; sulfur-dried fruits; grapes; preserved meats and fish; and then in some OTC cough and cold medications.  Some of these foods, of course, aren’t really typically considered to be on a paleo diet, but a lot of them are, and some of them are even very beneficial at least for people who don’t have this issue, like fermented foods, so it’s not necessarily something that would be done over the long term, and you can meet your need for probiotic organisms by taking a commercial, like an encapsulated probiotic while you’re doing this diet, but for anyone who has experienced migraines and the suffering that that can cause, it’s definitely worth giving this a shot for a period of time.

So, histamines, they occur in food as a result of microbial enzymes converting the amino acid histidine, which is found in all proteins, into histamine.  And pretty much all foods that are subject to that kind of microbial fermentation as they’re made contain histamine, so this would include all cheeses, fermented soy products and all other fermented foods, like kimchi and sauerkraut, as well as alcoholic beverages and vinegars.  There’s some overlap, as you probably noticed, between histamine and tyramine foods, so in addition to the list of tyramines that I just mentioned, you’d also want to restrict or eliminate for a period of time things like cinnamon, cloves, cocoa, certain vegetables like tomatoes, spinach, eggplant, and avocado, fruits like strawberries, banana, papaya, some tropical fruits like pineapple and mango, and then tangerines and grapefruit.  And you can find lists of all of these foods online, by the way, if you just Google high-tyramine foods or high-histamine foods.  We’re also talking about balsamic vinegar, peanuts and cashews and walnuts, and mustard and ketchup.  So, what’s happening here with histamines is that people with histamine intolerance — and a lot of migraine sufferers seem to have that — have low levels of either or both of two enzymes:  diamine oxidase, DAO, and histamine N-methyltransferase, and that’s sometimes abbreviated HNMT.  These enzymes bind to and metabolize histamine, so if you have inadequate levels of these enzymes, you’re gonna have excess levels of histamine in your body.  So, in addition to lowering your intake of histamines in the diet, another thing that you can do is take an enzyme, take DAO, diamine oxidase, which is one of the enzymes I just mentioned that metabolizes histamine.  You can actually take it as a supplement, and that can improve histamine tolerance and reduce your symptoms.  It doesn’t mean you should eat a whole bunch of histamine foods and just gobble a lot of DAO capsules, because that’s not gonna work very well, but those capsules in conjunction with a lower-histamine diet can make it more effective, and for some people, they can slightly increase histamine tolerance so that you can eat some of the foods that tend to have higher histamine levels in them without suffering.  So, there’s one product called DAOSin.  I think Swanson has one.  It’s one of those things like Metafolin.  It’s kind of a patented product that a number of different manufacturers use.  It’s diamine oxidase from pork kidneys, porcine kidney, and that can help in conjunction with everything we’re talking about here.

And then lastly, arginine increases the amount of nitric oxide in the blood, which acts as a vasodilator.  And migraine pain is thought to be caused by vasodilation in the cranial blood vessels, which is an expansion of the blood vessels, while headache pain, in contrast, is thought to be caused by vasoconstriction or a narrowing of the blood vessels, and this isn’t still very well understood, but this is one theory of how it works.  So, avoiding foods that are rich in arginine can help prevent that vasodilation that’s thought to lead to migraine headache pain.  And the paleo diet excludes most of the foods that are highest in arginine, but there are two foods that are permitted on a paleo diet that do contain high amounts of arginine, and those are nuts and chocolate, unfortunately!  Those are usually the hardest ones to give up for people that are doing this antimigraine diet.  So, that’s where I would start for migraines, and it’s a pretty successful approach.  I would say probably 70% to 85% of my patients with migraines experience significant relief.  I have some patients who have had intractable migraines for 20-plus years who have been on all of the medications and, you know, are just at their wits’ end, and they’ve tried this dietary approach in conjunction with an herbal formula that I make for them that has some foods that help prevent the histamine response and that are anti-inflammatory and have beneficial effects on the vascular system.  So, the diet alone or the diet in combination with the herbal formula and the DAOSin, the DAO enzyme product, in some cases has completely stopped migraines after 20-plus years of just really debilitating episodes.  So, it’s very effective.  I think it’s absolutely worth a try, especially when you consider the alternatives.  You know, some of the drugs that are used for migraines are not very effective and have a lot of side effects, so I think it’s worth a shot, for sure.

Steve Wright:  Yeah, that sounds like a great natural, alternative way to see if you can get some help without referring to some drugs.  Now, you mentioned that some people can kind of, like, eliminate them for some time and then slowly add these foods back in.  Is that just because the body needs a little bit of time to clear out these byproducts?

Chris Kresser:  I think that’s part of what it is.  It’s like if you think of it like a cup and you pour water into a cup, and if the level of water is all the way right at the top, then any amount of new water you add to it will make it overflow.  But if the water level drops in the cup, then you can add some more in without it overflowing.  It’s kind of a rough analogy with what might be happening in this situation.  But I think the other thing that happens with the elimination diet is when people eliminate all of these foods because they don’t really know which ones are the most problematic, and then they start adding things back in and trying them class by class, like histamine, tyramine, arginine, but then also even within a class, like within the histamine class, maybe the cinnamon and cloves and spices like that aren’t really a problem for them, but certain nuts and vinegar are really problematic.  So, there’s a range of tolerance even within a particular category, and that’s the sort of thing that people can figure out through experimentation, which means that ultimately the diet isn’t as restrictive, you know, over time as it was for that first 30 or 60-day period.

What is your opinion on vaccinations for early infants?

Steve Wright:  OK, awesome.  Let’s move on to the next question from Judah.  “What is your opinion on vaccinations and early infants?”

Chris Kresser:  I’m just chuckling a little because it’s a little bit like walking into a room and saying:  What’s your opinion on abortion?  You know, and then just closing the door and seeing all hell break loose.

Steve Wright:  Putting the ball on the tee, man!

Chris Kresser:  Yeah, talk about a hot button issue in the world of health and medicine!  I mean, I can’t really think of a more contentious topic, and unfortunately there’s a lot of hype and propaganda on both sides, and the people that end up suffering are people like this who just generally want to know what the science says about it so they make the most informed decision as parents.  So, I do intend to cover this in more detail at some point, but I’ve frankly delayed doing it, partly because of how contentious it is and it’s a monumental undertaking.  I mean, you can spend a whole lifetime researching this stuff and still not really feel like you’re completely on top of it, and it’s just something I haven’t really had the time to put together in a series yet.  I hope to do it at some point but haven’t been able to.  Of course, it is something I’ve researched extensively and thought a lot about, especially as a new parent, and as Elanne was pregnant with Sylvie, I did a lot more research on it, and we came to a decision that we felt comfortable with, but I think the way I’m gonna answer this question for now is by sharing a little bit about our process in deciding and then just kind of a general recommendation that I have for people in terms of making this decision. 

So, the first thing I’ll say in that regard is that I don’t think this is a decision that can be made based on the data alone.  The data are conflicting.  There’s a lot that we don’t fully understand about how vaccination affects the body.  There’s a lot that we probably will never fully understand or that it will be difficult to fully understand, and this is similar to what we talked about in either the last episode or the episode before that about the difficulty doing randomized clinical trials with certain kinds of conditions because with vaccination, for example, it’s very difficult to say, let’s say if you vaccinate a group of children and you want to find out if vaccinations contribute to immune dysregulation and autoimmunity and, you know, allergies and asthma and things like that.  So, let’s say you take a group of children and one group of children is not vaccinated and another group of children is vaccinated, and you follow them 15 years later and the group of children that’s vaccinated has higher incidence of autoimmune disease.  Well, that doesn’t prove anything.  You can’t say for sure, as we talked about in the red meat study, that it was the vaccinations that caused that higher incidence of autoimmune disease, because there could be a lot of potential confounding factors.  Maybe parents who are more likely to vaccinate are more likely to follow mainstream dietary advice, for example, and parents who are less likely to vaccinate are more “health conscious” and they’re considering, you know, maybe they have their kids on healthier diets, and there are any number of other intervening factors.  So, to really find out whether vaccinations contribute, you’d have to do very long randomized, controlled trials that would be extremely expensive, and it’s unlikely that the pharmaceutical company’s gonna pay for that trial, right?  Because they’re the ones manufacturing the vaccines, and they’re not really interested in proving that vaccines cause immune dysregulation.

So, I think that the most important sort of meta-comment I can make here is that, yes, we can look at the data here and then we can also look at known and understood physiological mechanisms, ways by which vaccines could potentially cause immune dysregulation, and that’s part of the Hill criteria that I alluded to in designing better epidemiological research, is when you have an epidemiological connection or a correlation between two things, if there is also a mechanism, a plausible mechanism that can explain that correlation, it strengthens the correlation.  It makes it more obvious, which is why the red meat and cancer connection isn’t as strong because nobody’s ever explained what the plausible mechanism is there.  So, when people ask me this, in the most basic sense I tell them you can’t make a decision on whether to vaccinate your children only based on the data, because the data are insufficient to lead to a really conclusive recommendation.  So that’s number one.  Number two is that I emphasize to people that there is a risk in vaccinating, and there is a risk in not vaccinating.  And anyone who tells you differently is not acquainted with the research literature, and that’s why I said there’s a lot of hype and propaganda on both sides, because you have some anti-vaccine proponents saying that’s completely safe not to vaccinate.  And then you have pro-vaccine people saying it’s completely safe to vaccinate, and of course, we can easily find examples that disprove both of those statements.  There is a risk when you don’t vaccinate.  There’s a risk of your child contracting an acute illness that could even potentially be fatal, and anyone who chooses not to vaccinate has to understand that, because it’s a real risk.  Now, how big of a risk that is, that’s, of course, a whole other question, and it’s something that I’ll be talking about in detail when I finally get around to discussing vaccines.  And on the other hand, there’s clearly a risk with vaccination, and there are studies that have shown vaccine injuries and particularly vaccines that contain mercury in them, and then there’s a lot of, like I said, correlations and plausible mechanisms and other data that point to the distinct possibility that vaccines cause immune dysregulation and can increase the risk of autoimmunity as kids get older.

So, I will tell you what Elanne and I have decided to do.  I actually hesitate to do it because my concern is that somebody will just follow what we did because that’s what I said that I do, because sometimes people are busy and it’s natural to find someone that you trust and just follow their recommendation, but I actually strongly urge you not to do that in this case.  It’s something that you really, really need to investigate.  And I’ll recommend a couple of books that we can put in the show notes that you can read, but I just really stress that this is a personal decision.  It’s something that has to fit with your philosophy and worldview with your risk tolerance.  Like, for example, do you consider the, I think, very, very small chance of your child contracting a serious and potentially fatal acute illness to be the greater risk?  Or do you consider the much larger chance, in my opinion, my interpretation of the data, of your child experiencing chronic immune dysregulation as a result of being vaccinated a bigger risk?  And that’s not a rhetorical question.  You know, some people, I’m sure, who are listening to this might think:  Well, you know what?  I could not deal with the possibility of my child getting really sick or dying from an illness that they could have been vaccinated against.  Now, having said that, keep in mind that a lot of children die from those illnesses who are vaccinated against those illnesses, so getting vaccinated is not a guarantee by any stretch of the imagination.  It’s not 100% protection against serious illness or death, and in a lot of cases, the kids who are getting sick and dying are vaccinated.  But you have to ask yourself what are you most comfortable with, and that decision is gonna be really different based on someone’s worldview and philosophy and approach to health and wellness.  And I don’t have any judgement about that.  You know, I have my own opinions and ideas, and I know where I stand on that spectrum, but we all have to kind of meet this wherever we are and where we’re coming from.  So, at the moment, and Elanne and I continue to talk about it, so it’s something that could change, but at the moment, we’ve decided we haven’t given Sylvie any vaccinations at all.  She’s 9 months old now, which is amazing.  It goes so fast!  But she’s 9 months old, she hasn’t been vaccinated, and the only vaccination that we’re considering at this point is tetanus, partly because it’s one of the vaccines that seems to have the fewest adverse effects, and tetanus is a very, very serious illness.  So, that’s our current thinking on it.  Again, who knows?  We may change our mind, but that’s where we’re at right now.

So to summarize, I think, number one, the decision can’t be made on the data alone.  You really have to consider your own philosophy and worldview and risk tolerance.  And number two, please don’t make this decision based on what I do or somebody else that you know does.  Do your own research, and speak to people that you know and you trust, and really give it the thought that it deserves.

Steve Wright:  Well, I want to thank you as a listener of the show for sharing that, because I know it puts you out on a ledge to stand there and tell us about your personal life and the decision that you’re currently making with your little daughter, so I want to thank you, Chris, and I just want to add on to the doing the research that, you know, Chris is going to raise and feed and all of the reasons why a drug trial cannot really prove vaccinations one way or the other way is another reason why it’s really important to do your own research and come to your own conclusion because all the different factors that happen throughout life as you raise your child will be different. 

Chris Kresser:  Absolutely.  Yeah, and I hope this was helpful.  I imagine some people might be frustrated and wished that I have gone further into the data, and I understand that, and like I said, I’ll do my best to get to it at some point, but it’s a really big, big topic, as I’m sure most of you know.  And I’ll give you a couple of book recommendations, like I said, that can get you started.

• Vaccine Epidemic: How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children
• Vaccinations: A Thoughtful Parent’s Guide: How to Make Safe, Sensible Decisions about the Risks, Benefits, and Alternatives

The myth that you should avoid red meat if you have kidney disease

Steve Wright:  OK, great.  Well, let’s move on to a simpler question from Rachel.  First, she loves the podcasts.  Thank you, Rachel.  And second, of the info that you gave people who may need to minimize their red meat intake on one of our past shows, we mentioned hemochromatosis and not individuals with kidney disease.  Do you not feel that limiting protein is necessary among this population?

Chris Kresser:  Well, actually, thanks for pointing that out, Rachel.  I do think that in some cases that might be necessary, and there are probably other populations that I didn’t mention there as well.  I was just, I think, trying to hit the major ones.  In the scientific literature, we could say that a high-protein diet is often defined as a daily consumption of more than 0.7 grams per pound per day or 1.5 grams per kilogram per day.  So, when we say a high-protein diet, just so everyone understands, that’s what we’re referring to.  So, it’s not red meat, per se, that’s problematic for people with kidney issues if you’re eating a moderate amount of protein.  I mean, that’s a pretty high protein intake of 0.7 grams per pound per day.  So, you could eat red meat in a moderate amount, even with kidney disease, and as long as you’re not exceeding that amount, then you’re not really eating a high-protein diet and you wouldn’t be at any additional risk for kidney problems, so I think that’s the first thing that I would say.  The second thing I would say is that there is some evidence that suggests that people with kidney disease should not eat a high-protein diet.  There’s a big, big trial called the Modification of Diet in Renal Disease Study, MDRD.  It’s the largest randomized multicenter controlled trial that’s been done to evaluate how dietary protein restriction affects the progression of renal disease.  And they found that patients with kidney disease that were following a low-protein diet had slightly lower, not hugely, but slightly lower decline in glomerular filtration rate, which is a measure of kidney function, compared with patients that were eating the higher-protein diet.  And then they did some further data analysis that showed that patients with lower total protein intake would have a longer time to reaching late-stage kidney disease or renal failure and suggested that a lower protein intake would postpone the progression into those later stages of kidney disease, because chronic kidney disease is classified in five stages, stage one being the mildest and stage five being the most serious with kidney failure.  And then there have been meta-analyses of studies on protein restriction in diabetics and nondiabetics with kidney disease that found that the progression of renal disease in both of those populations could be effectively delayed with restriction of dietary protein. 

But the important thing to take away from this, as we talked about with the red meat study, is you can’t extrapolate findings from one population to another population, so just because high-protein diets might be harmful in people with kidney disease, that doesn’t mean they are for healthy people.  I know I’ve probably used this example before, but if someone who has had their gallbladder removed doesn’t tolerate fat and doesn’t digest it very well, it doesn’t mean that healthy people with an intact gallbladder will have the same experience.  And indeed, a lot of different studies have shown that high-protein diets don’t reduce kidney function in healthy people, and they don’t even reduce kidney function in populations that are generally at risk for kidney disease, like people with dyslipidemia or obesity or hypertension.  So, yes, if you have chronic kidney disease, particularly later-stage chronic kidney disease, you don’t want to eat a high-protein diet, but that doesn’t mean you need to avoid red meat.  It just means you need to avoid eating red meat and other protein in excess of 0.7 grams per pound per day or 1.5 grams per kilogram per day.  I think that’s it for this question.

Steve Wright:  OK.  Well, I think you covered it pretty in depth there.  So, do we have time for one more question?

Chris Kresser:  Let’s do the CoQ10 question.

Is it necessary to supplement with CoQ10, even on a Paleo Diet?

Steve Wright:  OK, so Carrie asks:  “If you haven’t already, would you speak about CoQ10 levels with paleo nutrition and your opinion of supplementing with it?  I.e. do CoQ10 levels decrease with age the same as the general population?  Thanks!”

Chris Kresser:  Yeah.  It’s a great question.  It’s one that I get fairly regularly, actually.  CoQ10, it’s found in most cells, primarily in the mitochondria, and it’s a component of the electron transport chain, and it participates in aerobic cellular respiration, which is generating energy in the form of ATP, so I don’t know if you all remember back to your high school biology class and the Krebs cycle, citric acid cycle, and ATP production, ATP being the fundamental energy unit of the cell.  This is what we’re talking about here.  And 95% of the human body’s energy is actually generated this way, so it’s a very important process.  You can think of CoQ10 kinda like the spark plug in a car, and without that initial spark that CoQ10 supplies, the body can’t function properly.  CoQ10 deficiency can produce not only subjective signs of low energy and fatigue but all kinds of different — You know, the range of symptoms that it can produce is vast because ATP fuels cellular energy production, and cellular energy production is what makes the body function properly.  So, if you’re CoQ10 deficient, a lot can go wrong.  Now, CoQ10 can exist in three redox states and be fully oxidized as ubiquinone, it can be semiquinone as ubisemiquinone, and then fully reduced in the ubiquinol form.  And this enables it to perform functions both of energy production in the electron transport chain that I mentioned, and also it can function as an antioxidant.  And when it does that, CoQ10 inhibits lipid peroxidation, so the oxidation of fats by preventing the production of lipid peroxyl radicals.  So, that’s a lot of scientific mumbo jumbo, but basically the thing that most people need to understand about CoQ10 is that it plays a crucial role in energy production, and it plays a crucial role in preventing oxidative damage.  So, lately in my patient population, I’ve been doing some urine organic acids testing, and one of the things that shows up on that test is several different markers for CoQ10 deficiency, and I would say probably 80% to 85% of people that I test with the organic acids test are CoQ10 deficient.

Steve Wright:  Wow.

Chris Kresser:  Yeah, really high.  And I think that probably can be explained by the level of oxidative stress that most of us are living with in modern lifestyle.  There’s a lot of oxidative stress that we’re subject to, and CoQ10 would be depleted in those conditions. 

Steve Wright:  Are there any patterns that you see?  Is it gender or age?

Chris Kresser:  Well, CoQ10 production tends to decline with age, so I’ve seen some statistics that suggest that by the time we’re 50 we have half the amount of CoQ10 that we had than we were 20 years old.  So, simply aging can decrease CoQ10 levels, but we experience oxidative stress as we age, so that’s not an underlying mechanism, but it’s just something to be aware of.  And then there are genetic factors that can also lead to CoQ10 deficiency, because the biosynthesis of CoQ10 requires at least 12 different genes, and mutations in many of them can cause CoQ10 deficiency.  I don’t do a lot of that kind of genetic testing, but I have some colleagues that have done that, and apparently those mutations in those genes are not uncommon.  CoQ10, as many people know, shares a biosynthetic pathway with cholesterol, so the synthesis of mevalonate, which is an intermediary precursor of CoQ10 is inhibited by some drugs, like beta-blockers, in particular, and blood-pressure-lowering drugs and, of course, statins.  Statins inhibit the production of cholesterol and CoQ10, and that’s why statins have been shown to reduce serum levels of CoQ10 by up to 40%.  So, anybody who’s taking a statin should absolutely be taking CoQ10.  That’s just a no-brainer.  And fortunately, I think the awareness for this is increasing in the general medical community, and I think a lot of doctors even recommend it now, but if anyone knows someone who’s taking a statin or you’re taking one yourself, that’s definitely something you should speak to them about or you should be doing.  And if you have CoQ10 deficiency, whether you’re on a statin or not, supplementing is really good idea. 

There are a couple of things I want to point out regarding CoQ10 supplementation.  Number one, despite a lot of claims by supplement manufacturers, there’s no solid evidence that ubiquinol is a superior form to supplement with than ubiquinone, which is the cheaper form that’s been used for decades in the research.  And I’ve never seen any study that has convinced me that ubiquinol is better to use, so just stick with the ubiquinone.  The main factors that determine CoQ10 absorption are, number one, whether you eat it with fat, because CoQ10 is fat-soluble, so whenever you take a CoQ10 supplement, you should always take it with a meal that includes some fat or just a snack that has some fat.  And then there are certain forms of CoQ10, certain delivery mechanisms, I guess you could say, that have been shown to be better absorbed than others.  There’s one called the Kaneka Q-absorb process that’s a proliposome lipid-soluble delivery system, and that makes sense because CoQ10 is fat-soluble, right?  So, that’s been shown in one study to increase CoQ10 levels up to 400% from baseline.  The one product that I will often recommend is Jarrow Q-Sorb.  That uses this Kaneka Q-absorb delivery mechanism, and it’s pretty affordable.  I don’t see any need to buy anything fancier than that.  And the dosage can vary a lot, but generally with a mild to moderate deficiency, 60 mg to 120 mg a day is a good starting place.

Steve Wright:  This is interesting because I’ve looked into this before.  Once you start supplementing with this, do you build the levels back up in the body, or is this something that if you’re under oxidative stress and you’re on a paleo diet that you’re gonna be taking this supplement part of your daily regimen for a while?

Chris Kresser:  I think you kind of answered the question to some extent in asking it.  It depends on how you’re able to alter the things that led to the CoQ10 deficiency in the first place, right?  If you have a genetic mutation, there’s not too much that you’re gonna be able to do about that probably, so some people may need to take CoQ10 indefinitely.  They just might feel better on it, more energy, their body might function better.  People who are dealing with significant levels of oxidative stress, of course, the recommendation there would be to take steps to reduce oxidative stress, and then if that’s possible, it’s possible in that case to get off the CoQ10.  Some people, I think, going back to the analogy we used before with histamine, I think taking CoQ10 for a therapeutic period of time and repleting CoQ10 levels is enough to get things functioning properly again, and then you can discontinue maybe after three to six months or something like that, and that doesn’t rule out the possibility that you might need to start taking it again at some point, but generally I consider three to six months to be kind of a therapeutic window for repleting levels of CoQ10 or any nutrient that’s been depleted.  And then, of course, if somebody’s on a statin, for as long as they’re taking a statin or any other drug that’s known to inhibit CoQ10, then they’ll have to continue taking the CoQ10.  So, it really depends on the circumstances. 

Steve Wright:  OK.  Thanks for clearing that up.  Last question about this:  If, say, you don’t have access to some organic acid testing, you’re not taking a statin, you’re just doing paleo and trying to live a healthy life, are any sort of symptoms that might indicate that I’m likely to be CoQ10 deficient?

Chris Kresser:  It’s pretty hard to make that determination just with symptoms because a lot of the symptoms are so nonspecific.  I would say fatigue is probably one of the biggest ones, particularly, I mean, fatigue on exertion, like getting tired more quickly than you think you should.  Muscle fatigue could be another one because CoQ10 is involved in energy production in the muscles, so if your muscles are getting really fatigued even after short periods of activity, that’s another one.  And cardiovascular issues because the tissues that have the highest energy needs are the ones that have the highest levels of CoQ10, like the heart.  The organic acids test, though, is pretty accessible.  It’s not too expensive.  It’s like $180 for the basic version.  Genova Labs does one.  Metametrix does one, which is the one that I use.  And I think even now, someone told me the other day that there are some websites now that you can order the test through without having a clinician.  I’m not sure what they are.  Maybe I should mention which one, but maybe I can find that out for the future.  I do, however, recommend working with a clinician, particularly with that test.  It’s pretty complicated to interpret, and oftentimes patients are pretty overwhelmed when they see the results, and it takes quite a bit of interpretation and explaining, because even when you see that something is deficient or in excess on that test, it doesn’t tell you why, and that’s where you need some deeper understanding of the mechanisms involved and the connections to be able to figure out why those things are deficient so that you don’t end up just taking a million different pills because the test says you should.

Steve Wright:  That is the key:  working with somebody who’s seen the patterns. 

Chris Kresser:  Yeah, I mean, the example, something that tends to come up a lot on that organic acids test is a marker for biotin deficiency, and what is usually the case in that situation is that someone has gut dysbiosis.  Why?  Because biotin is produced by the intestinal bacteria.  And so, if you don’t have enough of the type of intestinal bacteria that produces biotin or you have an imbalance, a gut dysbiosis, that’s probably, in part, what’s contributing to the biotin deficiency rather than a decrease in not eating enough biotin in the diet, although that’s possible, too.  So, in that situation, you’d want to address the gut dysbiosis primarily and then secondarily probably supplement with biotin for a particular period, but you really need to get to the underlying cause.

Steve Wright:  Wow.  You are just a resource of information.  That’s awesome.

Chris Kresser:  I’m a geek, as you know, Steve.  That’s what I spend my time doing.

Steve Wright:  But so much more.  We don’t even know it.  You might have, like, a Batman call, like a light or something out there in California.  I’m gonna look more into this.  I might travel out there and do some research.

Chris Kresser:  Yeah, come on out and say hi.  All right, we did it!  We did a Q&A episode!

Steve Wright:  Yeah!  We got all the way through it.

Chris Kresser:  Yeah.  We’ve got lots of great questions lined up.  There were some other ones that we hoped to get to today, but we have them on the list, and we’ll continue to get to them in the future episodes, so thanks for your patience. 

Steve Wright:  Yeah, thanks everyone for listening.  We’re gonna send Chris on his vacation, and I’m hopefully gonna send you over to ChrisKresser.com to use the podcast submission link and send us more questions.  And also, if you’ve enjoyed the show today, please head over to iTunes and leave us a review.

Full disclosure: I make a small commission if you use the links in this article to purchase the supplements, books or other products I’ve mentioned.

I have a new feature to share: recipes! Every other week I’ll be releasing a new, exclusive recipe that will also be available in the Meal Plan Generator.

This week, I’ve got a delicious recipe for those of you that are starting to get sick of your go-to safe starch – sweet potatoes. If you’re looking to try some different starches, give these yuca fries a shot! Pair them with a nice burger or steak and you’ve got a quick and easy meal ready to go. We’ll be exploring other safe starches in the coming weeks, so stay tuned.

YUCA FRIES
*Serves 4

Ingredients:

• 2 medium yuca roots (about 6-8 inches long each)
• Duck fat, lard or tallow (if you don’t have these, you can use olive oil – but they won’t be as good!)
• Sea salt & pepper

Directions:

1. Bring about 3 quarts of water to a boil.
2. Peel yuca using sharp knife.
3. Cut into the shape of fries, about 2.5 – 3 inches long and 1/2″ thick.  (Don’t cut them thinner than this, or they’ll get too tough/crispy when you roast them.)
4. Boil the fries for 12 minutes. You want them to be soft, but not falling apart.  Meanwhile, pre-heat the oven to 400 F.
5. Put 3-4 TBS of duck fat (or whatever fat you’re using) into a small saucepan and heat until liquid.
6. Drain fries and put them in a mixing bowl.  Pour fat over fries and mix around to distribute evenly.
7. Spread fries on a baking sheet, and season generously with sea salt and pepper.  Paprika or chili powder are a nice touch here as well.
8. Roast for about 15 minutes.
9. Remove from oven and flip the fries.
10. Roast for another 10-15 minutes, or until golden brown.

Note: each yuca root has a tough, stringy bit in the center of the root.  This will turn up in some of the fries – so watch out for it.  I used to boil the yuca in halves and remove this stringy part before cutting into fry shapes, but found that it was easier to do it this way and just avoid it while eating the fries.

Enjoy!

As we have discussed in the last three articles in my series on salt, the evidence for universal salt reduction is weak and often conflicted. Across different cultures, dietary salt intake is at best weakly correlated with blood pressure or cardiovascular risks, and associated with poorer health outcomes at either extreme of salt intake, both low and high. As a general recommendation, it seems that salt restriction for most people may be both unnecessary and possibly harmful in the long run.

While most people have no reason to restrict salt to the levels recommended by various health organizations, there are a few health conditions in which lower salt consumption may be necessary, based on clinical and population data. Generally, these are people with serious health problems, particularly suboptimal kidney function, and the data supporting salt restriction in these individuals is somewhat controversial.

Salt intake with impaired renal function

For those who have high blood pressure, there is evidence that some hypertensive individuals have inherited salt sensitivity, thought to be caused primarily by impaired sodium transport in the kidney. (1) Our understanding of the salt-sensitivity mechanisms is still underdeveloped, but we do know that certain individuals are far more sensitive to fluctuations in dietary salt. Those individuals with this trait will have a significant blood pressure response to a high salt intake, and would likely benefit from reducing their intake of salt. However, it is thought that potassium intake can greatly impact these effects, and may even eliminate salt sensitivity symptoms. (2, 3) In fact, salt sensitivity is dose-dependently suppressed when dietary potassium is increased within its normal range, so these individuals may benefit more from including ample potassium rather than limiting sodium.

Though the evidence is mixed, patients with chronic renal disease may have better outcomes consuming a lower amount of salt. (4, 5) Those with impaired kidney function typically have reduced glomerular filtration rates and may have more difficulty excreting high levels of sodium. It’s possible that increased dietary salt exposure is toxic to the kidneys when sodium filtration is impaired, and may lead to unsafe levels of proteinuria. These patients need to be cautious about the amount of salt in their diet, though this is a highly individual situation, and largely depends on the type and severity of kidney disease.

High sodium intake may cause excess calcium excretion

Additionally, those who are prone to kidney stones may need to reduce their salt intake, as high sodium excretion also leads to a higher level of calcium excretion in the urine. (6) Again, evidence on this topic is mixed, but it has been demonstrated that excess sodium intake is associated with increased urinary excretion of sodium and calcium, and subjects who consumed the highest levels of sodium tended to have the greatest urinary calcium excretion. Higher calcium excretion may lead to kidney stone formation, particularly if fluid intake is inadequate.

Because of this increased calcium excretion with higher sodium intake, those with osteoporosis may benefit from a lower salt intake as well. (7) Increased losses of calcium in the urine, particularly in the context of low dietary calcium, could be problematic for those at risk for low bone density. However, a high salt intake is not believed to cause osteoporosis, and the potential osteoporotic effects of a high salt intake can be offset by an adequate intake of calcium and potassium.

Of course, it’s important to remember that the majority of these studies have been conducted on subjects consuming the standard American diet of sodium-laden processed food with a heavy emphasis on grains and a deficit of many important vitamins and minerals that we know play significant roles in hypertension, cardiovascular disease, and kidney health. If these sodium studies were conducted in a population consuming a nutrient dense Paleo-type diet, it’s possible the negative effects associated with a high sodium intake would be negligible. As we’ve seen, many of the cultures eating the highest levels of salt have less incidence of cardiovascular disease, kidney disease, and osteoporosis than Americans do. There is evidence that adequate consumption of other minerals may be far more important in blood pressure regulation and other related health outcomes.

Other minerals important for controlling blood pressure

There has been much research into the other dietary minerals that may play a role in blood pressure. The evidence has been mixed on whether certain minerals, particularly supplemental minerals, reduce blood pressure or risk for cardiovascular disease. However, epidemiological and anthropological data suggest that a diet high in certain minerals, such as potassium, magnesium, and calcium, may be beneficial in reducing high blood pressure.

Potassium is likely far more important than sodium intake in the control of blood pressure, as well as reducing the risk of hypertension, kidney stones and osteoporosis. (8) It is believed that human biological machinery evolved to process dietary potassium in amounts many times those of sodium, as Paleolithic man consumed an estimated 10500 mg of potassium each day, compared to a current US intake of 2500 mg. (9) Therefore, the sodium-potassium ratio of the modern diet is hugely mismatched to our genetically determined renal processing machinery. Additionally, the cardioprotective effects of a relatively high potassium intake have been hypothesized as a basis for low CVD rates in populations consuming primitive diets, where hypertension has been shown to affect only 1% of the population. (10)

Research suggests that increased intake of potassium, found in fruits and vegetables, may be more effective than, and possibly synergistic with, moderately restricting dietary NaCl in reducing not only the renal excretion of calcium, but also the level of blood pressure, the expression of hypertension, and the development of osteoporosis and kidney stones. (11) Therefore, a diet high in potassium-rich plant foods is crucial to preventing the negative outcomes typically associated with a high salt intake.

Magnesium has also been studied for its potential effects on blood pressure, which are poorly understood. Epidemiological studies have typically shown an inverse relationship between dietary magnesium intake and blood pressure, however data from clinical studies have been less convincing of magnesium’s role in treating hypertension. (12) Despite this conflicting evidence, some studies have shown that intracellular magnesium deficiency affects insulin resistance, alters vascular tone leading to hypertension, and induces pro-inflammatory changes and endothelial dysfunction, ultimately increasing the risk for CVD. (13) Therefore, a diet high in magnesium is likely beneficial for anyone at risk for hypertension or heart disease.

Calcium is another major mineral thought to play a role in blood pressure management. A high dietary intake of calcium, but not calcium supplementation, has been associated with both a decrease in blood pressure and the risk of developing hypertension. (14) In fact, calcium supplementation has been associated with a 30% increased risk of heart attack, and is potentially dangerous for those at risk for heart disease. (15) For those looking to protect themselves against hypertension and subsequent cardiovascular disease, a calcium-rich diet should suffice, with no supplementation required or recommended. (And of course, remember to keep vitamin K2 intake adequate as well!)

Take home message? Use your own judgment!

Ultimately, the amount of salt required for good health is based on individual needs, health status, and genetic predisposition to salt sensitivity. The evidence for salt restriction, even for those with cardiovascular or renal disease, is mixed and often times inconclusive. It’s important to remember that the data regarding sodium intake has been from populations typically eating a standard American diet, and it’s unknown whether salt intake would demonstrate any detrimental effects in a population eating a potassium, magnesium, and calcium rich whole foods Paleo diet. These are important points to consider when deciding how much salt to include in your own diet.

For my final article on salt, I will discuss the types of salt I recommend, and how much salt is ideal for most people.

“In an era when dietary advice is dispensed freely by virtually everyone from public health officials to personal trainers, well-meaning relatives, and strangers on check-out lines, one recommendation has rung through three decades with the indisputable force of gospel: Eat less salt and you will lower your blood pressure and live a longer, healthier life.” Gary Taubes, 1998

In my last two articles, I discussed the history of salt in the human diet and the physiological need for salt. Many proponents of the Paleo diet suggest limiting salt based on evidence of low salt intake during the Paleolithic era. This limitation meshes with recommendations made by various health organizations, such as the USDA and the American Heart Association, who suggest limiting sodium to at least 2,300 mg per day and even as little as 1,500 mg per day. (1, 2) And if our Paleolithic ancestors ate a low salt diet, then it certainly must be healthy, right?

Not necessarily. Recently, evidence has been mounting against universal salt restriction guidelines. A low-salt diet may cause serious health consequences and higher overall mortality, especially in the presence of certain chronic health conditions and lifestyle factors. In this article, I will discuss scientific evidence that contradicts salt restriction recommendations, as well as potential health risks of consuming a diet too low in salt.

Serious health consequences of long-term salt restriction

While salt-induced hypertension is typically blamed as a cause of heart disease, a low salt intake is associated with higher mortality from cardiovascular events. A 2011 study in the Journal of the American Medical Association demonstrates a low-salt zone where stroke, heart attack and death are more likely. (3) Compared with moderate sodium excretion, there was an association between low sodium excretion and cardiovascular (CVD) death and hospitalization for coronary heart failure. These findings demonstrate the lowest risk of death for sodium excretion between 4 and 5.99 grams per day. (Figure 1.)

Figure 1. Estimated 24-Hour Urinary Excretion of Sodium and Composite of Cardiovascular Death, Stroke, Myocardial Infarction, and Hospitalization for Congestive Heart Failure

Another 2011 study confirmed this observation; not only was lower sodium excretion associated with higher CVD mortality, but baseline sodium excretion did not predict the incidence of hypertension, and any associations between systolic pressure and sodium excretion did not translate into less morbidity or improved survival. (4)

Low salt diets contribute to an increase in hormones and lipids in the blood. A 2012 study in the American Journal of Hypertension found that people on low-salt diets developed higher plasma levels of renin, cholesterol, and triglycerides. (5) The authors concluded that the slight reduction in blood pressure was overshadowed by these antagonistic effects, and that sodium restriction may have net negative effects at a population level.

In addition, low sodium intake is associated with poor outcomes in Type 2 diabetes. A 2011 study study showed people with Type 2 diabetes are more likely to die prematurely on a low-salt diet, due to higher all-cause and cardiovascular mortality. (6) Additionally, a 2010 Harvard study linked low-salt diets to an immediate onset of insulin resistance, a precursor to Type 2 Diabetes. (7) These studies call into question the appropriateness of guidelines advocating salt restriction for patients with Type 2 diabetes.

Restricting salt is also problematic for athletes, particularly those participating in endurance sports. (8) Recent studies have shown that endurance athletes commonly develop low blood sodium, or hyponatremia, even in the absence of cognitive symptoms. In the 2002 Boston Marathon, it was found that 13% of 488 runners studied had hyponatremia, and studies of other endurance events have reported the incidence of hyponatremia to be up to 29%. (9, 10, 11, 12)  While the majority of these sodium deficient athletes are asymptomatic or mildly symptomatic with nausea and lethargy, severe manifestations such as cerebral edema, noncardiogenic pulmonary edema, and death can occur. (13) It is extremely important that athletes engaging in high intensity or long duration exercise be sure they adequately replace the salt lost through sweat.

Salt restriction may be especially dangerous for the elderly. Elderly people with hyponatremia have more falls and broken hips and a decrease in cognitive abilities. (14, 15) Hyponatremia is a common finding in the elderly, with an especially high prevalence in those with acute illness. (16) This is another population at risk for serious health consequences due to universal sodium restriction.

 Why is the government still recommending salt restriction?

Conventional healthcare experts have been recommending salt restriction ever since the 1970s, when Lewis Dahl established “proof” that salt causes hypertension. (17)  In his research, he induced high blood pressure in rats by feeding them the human equivalent of over 500 grams of sodium a day; 50 times more than the average intake in the western world. (18, 19, 20) Dahl also invoked evidence that cultures consuming higher levels of salt tend to have higher blood pressure than those who consume less salt. (21)

Figure 2. Correlation of average daily salt (NaCl) intakes with prevalence of hypertension in different geographic areas and among different races, from Dahl, 2005

However, when Intersalt researchers investigated this possible association, while controlling for confounding factors, the correlation between blood pressure and salt intake almost disappeared. (22, 23) For some reason, this contradictory evidence is still being used today to justify restricting salt intake.

In 1998, Gary Taubes wrote an article for Science magazine highlighting the clash of public policy with controversial scientific evidence for salt reduction. (24) He described how most of scientific discord over salt reduction has been overshadowed by the public attention given to the benefits of avoiding salt.

As Taubes explained over a decade ago, “the data supporting universal salt reduction have never been compelling, nor has it ever been demonstrated that such a program would not have unforeseen negative side effects.” The 1988 Intersalt Study, designed to resolve contradictions in ecological and epidemiological studies, failed to demonstrate any linear relationship between salt intake and blood pressure. Now, in 2012, we have data that suggests long-term salt restriction may pose serious risks for much of the population. Yet major health organization guidelines still recommend the restriction of salt for all Americans, regardless of blood pressure status.

In short, there is a healthy range of salt consumption for most people. When eating a whole foods diet, most people tend to consume an appropriate amount of salt simply due to an innate preference for saltiness. In fact, the consumption of salt around the world for over two centuries has remained in the range of 1.5 to three teaspoons per day, which appears to hold the lowest risk for disease. (25)

Our bodies may have a natural sodium appetite through which our ideal salt intake is regulated. By following a whole foods, Paleo diet, and eliminating processed foods, excess sodium in your diet will be drastically reduced. Thus, you can be confident in following your own natural taste for salt when adding it to your food during preparation. In other words, there are few reasons to deprive yourself of salt!

In my next article, I will discuss the conditions in which salt reduction may be warranted, and nutrients that may be more important than sodium in controlling blood pressure and promoting overall health.

I’m adding a new feature to the website today – testimonials. I love the ancestral health community because it is such a supportive and encouraging group of people. I’d like my website to be a place where those who have found success with this approach to health and wellness can share that success with others. After all, this is a movement – we want to help as many people as possible get on the road to health.

In the top right hand corner of the webpage, you should now see a link that reads: Share Your Story. You can click it to send in your success story. I’d love to hear how the information I provide on this website, on my radio show and in programs like Beyond Paleo, Personal Paleo Code and Healthy Baby Code have made a difference in your life.

I plan to release these stories on a bi-weekly basis so others can learn what the information on this site can do for them. I can’t wait to hear about your success and I hope you will generously share your story with this community.

Just a quick note to check in and see how you’ve all done with the first two weeks of the Best Your Stress challenge. Have you been able to stick with the commitments you’ve made? What have you noticed so far?

Most people have more trouble sticking with stress management programs than they do making dietary changes or following a supplement regime.  Adopting a new diet or taking some pills does involve changes in behavior, but it doesn’t challenge our concept of who we are in the world in the same way that committing to a stress management program can.

For example, if you have a belief that your self-worth is directly tied to the amount you get accomplished during a day, you will probably find it very difficult to set time aside for rest and relaxation.  Starting a Paleo diet and taking some supplements won’t interfere with this belief – but making time to meditate (which is essentially doing “nothing”) or lie down and do a deep relaxation technique certainly could.

If you’re having trouble sticking with your commitment for the month (or even getting started), here are 3 tips that can help:

• Something is better than nothing. For example, if your goal is to meditate for 30 minutes every morning but you overslept and don’t have time to do the full session, even 5 minutes is better than not doing it at all.
• Don’t beat yourself up. I’m sure you can appreciate the irony of getting really stressed out about stress reduction. It’s counterproductive.
• Begin again. If you didn’t get off to a great start, don’t worry. Just begin again. We have the opportunity to start fresh in each moment.

I’d love to hear more about your experiences so far.  What successes have you had? What challenges or obstacles are you facing? And how are you working with them?

Please let us know in the comments section below.

In the first part of my series on salt, I discussed the historical significance of salt and its role in the evolution of humanity. Salt has been a highly prized substance for thousands of years across all cultures and continents. Yet over the past few decades, excess salt and sodium intake has been blamed for a variety of serious health conditions plaguing our country, such as heart disease, hypertension, and stroke.

Much debate has centered around determining the level of dietary salt required to maintain optimal health, but over the years the suggested upper limit has continued to shrink. According to the CDC, the average intake of sodium for American adults is about 3,300 mg of sodium a day, which is well above the standard recommendations. (1) The USDA urges Americans to consume less than 2,300 mg of sodium per day, and the American Heart Association (AHA) has an even more strict guideline of consuming less than 1,500 mg a day for general health and disease prevention. (2, 3)

It has been theorized that dietary salt consumption was extremely low in the Paleolithic diet – approximately 768 mg of sodium daily – and that inland hunter-gatherers added little or no salt to their food on a regular basis. (4) We know these hunter-gatherer diets did not lead to the chronic, Western diseases we see today. The question is, does low salt intake by our distant ancestors mean that adding salt to our food is necessarily harmful? Should we adhere to the AHA sodium guidelines of 1,500 mg or less per day? Or is there a healthy range of salt consumption that can not only support but optimize our health?

Physiological roles of salt in the human body

Despite its recent bad press, there is no doubt that an adequate intake of salt in the human diet is required to maintain good health. The Institute of Medicine recommends that healthy adults consume 1500 mg of sodium, or 3.8 grams of salt, to replace the amount lost daily on average through sweat and urination. (5) (Ironically, this recommendation is almost double the amount theoretically consumed by Paleolithic man.) The minimum physiological requirement of sodium simply to sustain life has been estimated to be 500 mg of sodium per day. (6)

Sodium is a vital nutrient. It’s a major component of extracellular fluid, and is essential for maintaining the volume of the plasma to allow adequate tissue perfusion and normal cellular metabolism. (7) Because sodium is used as an extracellular cation, it is typically found in the blood and lymph fluid. The maintenance of extracellular fluid volume is an important physiologic function of the sodium in the body, particularly in regards to cardiovascular health.

Besides helping to maintain fluid balance and cardiovascular function, sodium and chloride ions also play an important role in the nervous system. Changes in the concentrations of these ions allow neurons to send signals to other neurons and cells, allowing for nerve transmission as well as mechanical movement. Chloride ions provided by salt are secreted in the gastric juice as hydrochloric acid (HCL).  And HCL is vital to the digestion of food and the destruction of food-borne pathogens in the stomach. (8)

If a true sodium deficiency occurs, mammals experience symptoms of hyponatremia such as brain swelling, coma, congestive heart failure, cardiovascular collapse following acute blood loss, and impaired sympathetic cardiovascular adjustments to stress. (9) Animals in a truly sodium-deficient state will seek out salty food and often consume far more sodium than needed to restore homeostasis. (10) These behavioral changes in response to inadequate salt intake further demonstrate the biological importance of dietary salt.

Regulation of plasma sodium levels by the kidney

The kidney, when healthy, regulates sodium and water excretion using hemodynamic, neural, and hormonal inputs.  This allows it to respond appropriately to a wide range of dietary sodium intake. Aldosterone, a steroid hormone secreted by the adrenal glands, helps regulate the balance of water and electrolytes in the body.

An abrupt increase in dietary salt can cause a redistribution of fluid from the intra- to the extracellular space.  But after a few days, the kidney is able to compensate with extra sodium excretion to match the dietary intake. Therefore, healthy people are generally able to adapt to a wide range of salt intakes without a significant change in blood pressure. (11)

If sodium intake drops too low, our metabolism shifts into a sodium-sparing mode.  This stimulates the renin-angiotensin-aldosterone hormonal system, which in turn maintains osmotic balance and adequate blood pressure. (12) A significant increase in renin and aldosterone is a symptom of sodium insufficiency, and has been shown to occur as salt intake drops below 1.5 teaspoons per day. (13) Interestingly enough, the recommendation for 2,300 mg of sodium equates to approximately one teaspoon of salt. An intake this low is associated with an even more rapid rise in renin.

Another important dietary determinant of this renin-angiotensin-aldosterone hormonal system is potassium intake. Our biological machinery (which developed in the Paleolithic era) evolved in conjunction with a diet not only very low in sodium, but also very high in potassium-rich plant foods. (14) Unlike our Paleolithic ancestors, Americans are consuming very low amounts of potassium: approximately 3,200 mg per day in men and 2,400 mg per day in women. (15) The adequate intake as defined by the IOM is 4,700 mg per day, and preagricultural humans are estimated to have consumed fully 10,500 mg of potassium each day.(16)

This modern reversal of electrolyte consumption is another important consideration in determining the population-wide increase in rates of hypertension. Dietary potassium has been demonstrated to dose-dependently counter the pathophysiological effects associated with modern dietary excess of salt, including salt-sensitivity, a likely precursor of hypertension. Therefore, dietary potassium intake, in addition to the sodium to potassium ratio, may play a crucial role in the development of those diseases typically associated with a simple excess of sodium in the modern diet.

Evidence about human salt consumption

The human body has adapted complex physiological mechanisms in order to prevent blood pressure fluctuations in response to these variations in sodium intake. Not surprisingly, epidemiological data has revealed an average sodium intake range of 2400 mg to 5175 mg of sodium per day in developed cultures. (17) Certain isolated groups in areas such as Brazil, Papua New Guinea, and rural African communities have been found to live on sodium intakes of as little as 1150 mg per day. However, despite finding generally low blood pressure in these remote communities, the little evidence that exists on these low salt societies suggests shorter life expectancy and higher mortality rates.

An example from the Intersalt Study, which examined the impact of population-wide salt consumption on blood pressure, is the Yanomami Indians of the Brazillian rainforest, who are known for having far lower average blood pressure than that of Western populations. (18, 19) Their lifelong low blood pressure has been attributed to their extremely low consumption of salt, and this has been used as evidence to further support the effort to restrict salt from the American diet.

A major problem that arises from using the Yanomami as an example of the salt-hypertension hypothesis is the wide variety of confounding variables that may also affect their blood pressure. The Intersalt Study researchers admit that:

“In addition to low Na+ intake and high K+ intake, other factors that may contribute to the absence of hypertension and lack of blood pressure increase with age among the Yanomami Indians are as follows: their low body mass index and the almost nonexistence of obesity, no alcohol ingestion, low ingestion of saturated fat, high ingestion of fibers, relatively high physical activity, and the several cultural consequences of living in an isolated community without the psychosocial stress of civilization and without a monetary system or dependence on a job.” (20)

This data suggest there are many reasons the Yanomami have such low blood pressure.  These include high potassium intake, high physical activity, low stress levels, and complete lack of alcohol consumption. Furthermore, although the Yanomami have low blood pressure and nearly nonexistent rates of cardiovascular disease, their overall health outcomes are less than stellar. (21) They are described in ethnographic literature as having small stature, high mortality and a low life expectancy ranging between 29 and 46 years. (22) Despite these high mortality rates and confounding lifestyle factors, the Yanomami people are still used as a prime example in support of the salt-hypertension hypothesis.

The results of the Intersalt Study did not indicate any clear pattern between the level of salt intake and blood pressure in those countries studied. (23) And when average life expectancy is plotted against the countries’ average salt intake, the trend shows that higher salt consumption is actually correlated with longer life expectancy. While this correlation does not imply causation, it is interesting to note the compatibility of a high salt diet with a long life expectancy.

As we can see, there is an enormous range in the daily dietary sodium intake of various cultures around the world, ranging from quite low (1150 mg) to fairly high (5175 mg). Additionally, we know that the healthy kidney is capable of adjusting to fluctuating levels of sodium in the diet in order to maintain fluid homeostasis. Finally, we know that hunter-gatherer and Paleolithic diets were very low in sodium, and that salt was rarely, if ever, added to food. Therefore, it would seem that limiting salt in the diet to those levels recommended by the AHA and USDA would not have any significant consequences, and would be an ideal dietary choice when mimicking the diet of our ancestors. However, evidence is mounting to the contrary: a low-salt diet may actually lead to serious health consequences and higher overall mortality, particularly in conditions like heart disease and diabetes.

In my next article in this series, I will discuss the contradictory evidence regarding the dietary guidelines for salt reduction, as well as the potential risks of consuming a diet too low in salt.

You’ve heard of insulin resistance, leptin resistance, and possibly even thyroid resistance.  But have you heard of “cortisol resistance”?  Recent research suggests that resistance of cells and tissues to the actions of cortisol – rather than high cortisol levels in the blood – may be the primary factor in the stress-disease connection.

In this episode, we cover:

1:43  Concrete evidence linking chronic stress to inflammation and modern disease
17:21  The new-found health benefits of probiotics
25:02  What really causes irritable bowel syndrome?
31:56  A non-toxic treatment protocol put 4 cancer patients into remission
53:42  Could low cholesterol be associated with a higher risk of cancer and death?

Links We Discuss:

• Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk
• Gut microbiota is not modified by Randomized, Double-blind, Placebo-controlled Trial of VSL#3
• ALA/N Protocol for People With Metastatic and Nonmetastatic Pancreatic Cancer

Full Text Transcript:

Steve Wright:  Hi everyone, and welcome to the Revolution Health Radio Show.  I’m Steve Wright from SCDlifestyle.com, and with me is Chris Kresser, health detective and creator of ChrisKresser.com.  How are you doing, man?

Chris Kresser:  Oh, I’m pretty good.  How are you, Steve?

Steve Wright:  I’m good.  I’ve got my green tea next to me, and I’m ready to rock and roll.

Chris Kresser:  Nice.  All right, let’s do it.  I’m always reading studies.  People send them to me.  I find them myself.  I’m, as many of you know, kind of a research dork, so I found some interesting ones this week, and they’re on some themes that I’ve been writing about and talking about the show previously and just thinking about a lot myself, so I want to talk a little bit about some of these studies, and then we should have some time to jump into some questions.  Sound good?

Steve Wright:  Yeah, it sounds like a good plan.  And I was just gonna let everybody know that if they’re new to the Paleo diet or if they’re just interested in optimizing their health, they should check out Beyond Paleo.  It’s a free 13-part email series on burning fat, boosting energy, and preventing and reversing disease without drugs.  To sign up, just go to ChrisKresser.com and look for the giant red box.

Concrete evidence linking chronic stress to inflammation and modern disease

Chris Kresser:  All right, so the first study is right in line with the April Best Your Stress Challenge, and if you haven’t heard of this, go check out my blog, ChrisKresser.com.  You now, there are a lot of 30-day diet challenges.  There’s the Whole30, and there’s the Personal Paleo Code, my program where we ask people to give the Paleo diet a try for 30 days and give it that chance to change their lives and make a big difference in their health.  But I’ve talked a lot about the importance of stress management and improving stress tolerance and mitigating the impacts of the stress that we can’t get rid of on our life, so I thought it would be a good idea to spend April doing a 30-day Best Your Stress Challenge.  So, the idea is to apply that same concept of a 30-day diet challenge to stress management, and I wrote a post about this a little while back, I think, on March 30 and offered some ideas for what people can do to manage their stress throughout the month of April and just to make a commitment and preferably a small, fairly manageable one because oftentimes we have a tendency to commit to more than we can do and then we don’t follow through, so just setting a small goal, like meditating for 10 minutes in the morning or doing a deep relaxation exercise every afternoon or taking a walk in the woods or on the beach — whatever it is that helps you manage your stress — and doing that throughout the whole month of April and seeing how that improves your health overall.

So, the other day, I saw a new study with the title Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk, and since I’ve been thinking a lot about stress and the effects of stress on disease, I thought it would be a good idea to talk a little bit about this study because it’s really interesting, and it takes our traditional concept of how stress contributes to disease and kinda turns it on its head.  It’s some relatively new information.  I’ve seen a few other studies with a similar theme, and if anything, it just reinforces what we’ve been talking about in terms of the connection between stress and disease and the importance of managing stress and either reducing the symptoms of a disease that we already have or helping to cure it entirely or preventing the risk of acquiring a new disease.  So, stress is associated with just about every modern disease that you can name, from depression to cardiovascular disease to type 2 diabetes to autoimmune conditions like rheumatoid arthritis and Crohn’s disease and multiple sclerosis to upper respiratory infections and even the common cold.  And up until pretty recently and still now, I think, most people think that stress causes disease by dysregulating the hypothalamic-pituitary-adrenal axis, but this notion that stress acts simply by elevating cortisol levels is becoming less and less likely, at least in the current scientific literature.  So, what this new paper and other recent papers suggest is that it’s actually the sensitivity of cells or the target tissue to cortisol, not absolute levels of cortisol that’s most important.  So, glucocorticoid resistance, which is a decrease in sensitivity of immune cells to glucocorticoid hormones like cortisol, makes it more difficult to shut off the inflammatory response.  So, let me break that down.  When you’re insulin resistant, you’re producing enough insulin, but your cells are resistant to the effects of insulin, so it’s like insulin’s knocking on the door, but nobody’s inside or whoever’s inside isn’t listening, so the door doesn’t get open, and insulin can’t perform its function.  The same is true with leptin resistance, and there’s even thyroid hormone resistance where thyroid hormone can’t activate the cellular receptors for thyroid hormone, so even though there’s plenty of thyroid hormone circulating around, you experience all the signs and symptoms of hypothyroidism because thyroid hormone isn’t affecting the receptor.

So, this study and others like it suggest that there’s a similar phenomenon with cortisol resistance.  So, it’s not high levels of cortisol, per se, that are contributing to an increased susceptibility of disease, but it’s instead the insensitivity of cellular receptors to cortisol that’s the problem, because one of cortisol’s jobs is to turn off the inflammatory response once it gets started.  So, let’s say you catch a cold or you get a cut or you have some kind of injury or illness, and inflammation is the natural response to that.  Inflammation is not all bad.  In an acute setting, inflammation is what helps us to heal.  The problem happens when inflammation doesn’t get turned off appropriately, and then it just kinda runs wild and you get chronic inflammation, and it’s that chronic inflammation that is a risk factor for disease, not the acute inflammation that helps us to heal.  So, in a normal functioning person, what would happen is that you’d get a cold or you’d get some kind of injury or acute condition that causes inflammation, and then the glucocorticoids, like cortisol, are produced and they turn off the inflammatory response by activating the glucocorticoid receptors.  So, what these researchers have found is that people who are under chronic stress, that doesn’t work right.  The cortisol gets secreted, but it doesn’t activate the receptors, and then you get a runaway inflammatory response.  And this has been shown in other studies.  They’ve found that cortisol resistance is present in spouses of brain cancer patients, in parents of children with cancer, and in people that are very lonely, and all of those populations are known to be experiencing significant stress.

So, in this study, the researchers used, I think, a pretty ingenious model to demonstrate this effect.  I mean, it’s well established that chronic stress increases the susceptibility to the common cold and upper respiratory infections, as I mentioned earlier.  So, the researchers actually did two studies in one.  The first one was meant to determine whether stress causes cortisol resistance and whether people with cortisol resistance are more likely to develop a common cold in the first place.  And then the second one was meant to determine whether cortisol resistance could predict the amount of local inflammation in the nose, for example, in response to a viral infection.  So what they did is they actually purposely infected people with a virus, a rhinovirus that causes the common cold and respiratory infection, and as expected in the first study, the results did show that exposure to stress increased cortisol resistance, and in the control group they found that exposure to an acute stressor was associated with white blood cell count, but in the group that was under chronic stress there was no association.  So, in other words, what should happen is that when you’re exposed to a stressor, as I mentioned, cortisol should turn off the inflammatory response and reduce the white blood cell count, but that didn’t happen in people that were under chronic stress and had cortisol resistance.

In the second study, they found a correlation between cortisol resistance and the levels of various proinflammatory cytokines locally, like interleukin-6 and TNF-alpha.  And then they also saw a decreased sensitivity of white blood cells to the inhibitory effects of cortisol, like we’ve been talking about.  So, in other words, when you’re stressed out, the immune system cannot turn off the inflammatory response like it’s supposed to, and then you’re more likely not only to get sick in the first place, but you’re more likely to stay sick for longer because that inflammatory process doesn’t get inhibited.  So, the interesting thing also about this study is that there was no correlation between actual cortisol levels, like circulating cortisol levels, and disease risk or inflammation.  So, it seems like it’s the cellular receptivity to cortisol, the sensitivity of the receptors to the actions of cortisol, that’s the most important, rather than the circulating levels of cortisol themselves.  So, I thought that was pretty interesting, and it may not change things from from an end-user perspective too much because the idea is still that you want to take steps to manage your stress, but for me, every study I see like this is just another affirmation of the importance of stress management, and I see it in my work with my patients, I see it in my own life and my own experience, and people might be getting tired of hearing me talk about it, but I’m gonna keep talking about it because I thinks it’s kinda the elephant in the room in a lot of cases.  In my patient population, I think I can pretty safely say that people who are taking active steps to manage their stress have significantly better clinical outcomes than people who don’t, and I just think it’s a much bigger contributor to the whole disease process than most of us really realize.

Steve Wright:  That’s pretty insightful, man.  And I thinks it’s awesome that we’re getting more data on what the problem is because you do hear a lot about, well, you’re not totally stressed out or you can go do another CrossFit workout as long as your cortisol isn’t over 20 or something like that.

Chris Kresser:  Yeah.

Steve Wright:  So, this is cool to have a new model.  Now, do you know if, for instance, because we’re a little bit better at measuring insulin resistance and leptin resistance, are the three correlated?  So, if I’m insulin resistant, I’m likely leptin resistant or I am leptin resistant.  Am I also cortisol resistant then?

Chris Kresser:  I don’t know what the exact relationship between all of those would be, but I certainly think that HPA axis dysregulation can contribute in some way to leptin and insulin resistance and probably vice versa.  I wish there was a way of testing for cortisol resistance in the commercial setting.  I don’t think there is.  I think it’s only available in research settings.  But what’s interesting about this study is that I think, like you said, the idea that we can just run an adrenal stress index or any kind of hormone profile where we measure cortisol, and if the person has normal cortisol we say:  OK, you’re clear to do, you know, five CrossFit workouts a week.  We can’t really make that assumption because that test is not gonna show cortisol resistance in the white blood cells.  I think ultimately just paying attention to symptoms is a pretty good guide because if you have this cortisol resistance pattern, you’re gonna have more difficulty recovering from workouts because that inflammatory response won’t get turned off.  I mean, working out, especially lifting weights, but doing any kind of intense workout is basically like a controlled stimulation of inflammation.  You’re breaking down tissue when you lift weights.  You’re breaking down your muscle tissue, and the idea is that when it builds back, it builds back bigger and more able to deal with the next stressor, in that case, lifting weights.  So, that works well if you give the body long enough to recover, if you give the body long enough to turn off that inflammation and then to start the anabolic process rather than the catabolic process of building the tissue back up.  And if you’re a healthy person with no significant stress levels and you’re not dealing with any chronic inflammatory condition, that should happen fairly quickly and commensurately with the amount of exercise that you did.  But if you’re dealing with chronic stress and you have cortisol resistance, here’s what’s gonna happen:  You’ll do the intense workout, you break your tissue down, which is what happens and is the whole point, but the recovery process will be very, very slow, and the inflammation will persist.  So, instead of taking one day or maybe two days to get back to baseline and then start building new tissue, stronger tissue, you’ll take several days to get back to baseline, or maybe you really never fully do get back to baseline.  And then you do another intense workout, so then you break down more tissue and cause more inflammation, and then it’s a downhill slide from there.  And I see this a lot in the CrossFit community, people who come to me who have been doing CrossFit.  And this is not all people who do CrossFit.  I’m talking about people who are under significant stress and who may be dealing with a chronic health challenge.  But the fact is most of us in this modern world are under stress, and some of us are better at managing it than others, and some of us pay more attention to that than others, but I think this is a very real phenomenon and it’s not just affecting people who have kids with cancer or spouses with cancer or people who are socially isolated.  It’s affecting all of us to some degree or another.

Steve Wright:  Way to wrap that up.  I think it’s important to keep learning about it.

The newfound health benefits of probiotics

Chris Kresser:  So, here’s another study that I think you’ll be interested in, Steve and Jordan.  It’s about probiotics.  The common assumption is that probiotics work by restoring normal gut flora, and this is partly because several studies have shown that the gut microbiota in people with gut diseases is different than the gut microbiota in people that are healthy, and I’ve talked about this a lot, and I’ve written about it a lot, and there’s certainly a lot of evidence to support that, but over the last maybe, I don’t know, probably just two or three years, there have been some really interesting studies that have come out suggesting another possibility for how probiotics work, and the idea in these studies or what these studies suggest is that probiotics don’t work by altering the gut flora, per se, but through a whole bunch of other immunomodulatory, anti-inflammatory effects.  So, these could include antibacterial and antiviral properties, an increase in mucus production in the intestinal epithelium, reducing the migration of neutrophils, white blood cells, into the intestinal epithelium, and all of these properties can basically reduce the neurochemical and impaired motor function found in conditions like irritable bowel syndrome.

So, this study that I saw was on VSL3, which is a probiotic formulation that’s very potent, and it has several different strains of probiotics at a very high concentration, and it’s one of the most studied probiotics in the medical literature, and it’s been shown to improve inflammatory bowel disease and IBS and some other gut conditions.  So, what was unique about this study, really interesting, is that previous studies have looked at this question of if you take probiotics, does it really change your gut flora?  Does it create a permanent change in your gut flora?  And a couple earlier studies used stool microscopy to answer that question, stool culture, and I think we’ve talked about that on a previous show.  That’s basically where they take stool and they put it under a microscope or they culture it and they look for organisms, whether beneficial organisms or pathological organisms, in the stool.  And it’s not very accurate for a number of reasons, but one reason is the culture can’t identify certain strains of bacteria very well.  So, this study, instead of using a stool culture, they used DNA PCR analysis, which is a much more accurate way of characterizing the commensal gut flora, and so they administered VSL3 at a pretty high dose.  I think that people were taking about 600 to 900 billion CFU a day, which is a very high dose, and they did that for a period of time.  They looked at their gut flora before they started taking the VSL3, and then they looked at the gut flora at the end of the study after they had taken it.  And they found in the study that, sure enough, the people who took the probiotics experienced significant improvements in a number of different ways, but they also found that the gut microbiota in those people was essentially unchanged from the beginning to the end of the study, which is really interesting, right?  It sorta goes against our idea of what probiotics are doing.

So, these researchers hypothesized that the probiotics, like VSL3 or other probiotics, work by some of the mechanisms that I just described, antibacterial, antiviral, increasing mucus production.  They can alter stool and gas formation, which in turn can reduce constipation and diarrhea.  They have anti-inflammatory effects.  For example, people with IBS, it’s now known that they have an abnormal ratio of inflammatory cytokines, like interleukin-12 and interleukin-10, and that taking probiotics like VSL3 can normalize that ratio.  Certain probiotics like E. coli Nissle have been shown to affect intestinal motility.  They have strong immunomodulatory properties.  They can prevent the invasion of pathogens into the mucosa.  They can induce the synthesis of antimicrobial peptides, so not only do they have antimicrobial effects themselves, but they can increase the synthesis of antimicrobial peptides.  And then they also promote the synthesis of tight junction proteins in the gut epithelium, and as we’ve discussed on previous shows, leaky gut or intestinal permeability involves a dysfunction of the tight junctions in the gut, so essentially this suggests that probiotics, one way that they might work is by tightening up those tight junctions and making the gut less permeable.

And there are other possibilities too, like the probiotics, when you introduce a large amount of bacteria and yeast into the gut, that stimulates an immune response, possibly in a similar way that helminth therapy or other pathogens have kind of a tuning effect on the immune system.  I wrote an article recently about the “hygiene hypothesis,” also referred to as the “old friends hypothesis,” where we coevolved with a number of organisms like helminths and other organisms that we might have been exposed to in the soil, and those organisms have a balancing and modulating effect on the immune system, and it’s possible that probiotics are working in a similar way.  So, again from an end-user perspective, this might not change things very much because the studies are still suggesting that probiotics have beneficial effects for people with these kinds of gut conditions and other conditions, but the mechanism by which that effect is happening may be different than we assumed originally.

Steve Wright:  Yeah, it seems like more of a better justification because it’s easy to come across a lot of opinions on the Internet who say:  Well, there’s no need to take probiotics because they’re only transient, and there’s no reason to eat fermented yogurt or kefir because it’s only transient, the bacteria are.  But I’ve read some of the same research you have, and it’s really cool to see this stream continue to get wider, and it’s gonna be really cool in the future when we can start pinpointing certain strains that might come down the line, and if you have a motility problem you’ll take this strain, and if you have an immune modulation problem you’ll take this strain, and I think that’s gonna be a future that we’ll see pretty soon.

What really causes irritable bowel syndrome?

Chris Kresser:  Yeah, that’s right, and what’s gonna be part of that is breaking down the various diseases into more distinct categories.  Like, I think it’s pretty clear at this point that IBS, or irritable bowel syndrome, is not a single disease, that it’s really probably a number of different conditions with different etiologies, different causes.  You know, postinfectious IBS, for example, might be a distinct entity, where the initial problem was an infection of some sort, and that dysregulated the gut flora and caused a number of other issues because of that, and then there may be another form of IBS that is more mediated by the gut-brain axis.  There may be another form of IBS that is more related to small bowel bacterial overgrowth.  So, we’re learning a lot more.  This thing that we call IBS, it’s not really a clinical entity in itself.  It’s a diagnosis of exclusion, which means that if you go in to the doctor and you say:  Oh, I have gas and bloating and abdominal pain.  And they say:  OK, well, let’s do a colonoscopy and an endoscopy.  And they do that, and they don’t find any ulcer.  They don’t find any inflammatory bowel disease, ulcerative colitis, or Crohn’s.  They don’t find diverticulosis or diverticulitis.  They don’t find anything structurally wrong with your gut, and then they ask you a few questions about your symptoms.  You’re gonna walk out of there with the diagnosis of irritable bowel syndrome, which is kind of maybe a letdown because you go in there and you say:  Hey, doctor, my bowel is irritable.  You go through all of these tests, and then they tell you:  Guess what?  You have irritable bowel syndrome!  And you’re like:  Thanks a lot.  Thanks for the diagnosis.  But when you look at the current scientific literature around IBS, we find that actually there’s quite a lot going on there.  It just isn’t stuff that can be found with a colonoscopy and an endoscopy.  We have a lot of evidence for fructose intolerance, strong correlation for fructose intolerance and irritable bowel syndrome, and that’s probably mediated by small bowel bacterial overgrowth, and so something like 40-plus percent of people with IBS have been shown to have small bowel bacterial overgrowth.  We have disruptions in the gut-brain axis that have been very well demonstrated now.  The inflammation in the brain, chronic stress response that can cause decreased output into the vagus nerve, which innervates the whole digestive tract, and then that causes “IBS.”

Then we have dysbiosis, which we’ve been talking about now, changes in the gut microbiota because of an infection that’s either still present — I think a lot of people who are diagnosed with IBS actually have a gut infection.  I see that in my practice a lot.  You know, they come to me and they say:  I have IBS.  And do a Metametrix stool test and find out that they have H. pylori or they have some other kind of opportunistic or pathogenic bacteria, or they have a fungal infection, which is actually less common.  I see a lot more bacterial infections than fungal infections, and that’s one of the reasons I think candida is really overdiagnosed.

So, my point is there are a lot of different diseases that are right now characterized as irritable bowel syndrome, and getting more specific about what the causes are in each case is the very first step in successfully treating it, because the drugs for IBS are a joke.  They’re drugs that increase motility or decrease motility or just kind of they’re pain-relieving drugs, but they don’t do anything to address those underlying causes, whatever they may be.  So, I think a combination of getting a lot more specific about what’s actually going on, which is happening at least in the scientific literature, and then, like you said, Steve, getting more specific about particular strains of bacteria or emerging treatments like fecal microbiota transplants or even helminth therapy is kinda the wave of the future here.  It’s like in the 20th century it was all about antibiotics and things that would just indiscriminately kill bacteria, and now it seems like the 21st century is much more about immunomodulation with probiotic organisms or any kind of organisms that can modulate the immune system.

Steve Wright:  Yeah, I think you hit the nail on the head there that IBS is a joke.  I was told it by several doctors, and like you said, the standard treatment is fiber or a couple drugs that don’t help at all, but I think with all of the digestive conditions, because it seems that if you have diverticulitis or Crohn’s or ulcerative colitis, normally you have all of the IBS symptoms as well, and so I really feel bad for those folks who talk to a conventional gastroenterologist who doesn’t really help them address their IBS symptoms on top of their ulcerations lower in the intestinal tract, because they’re really getting the brunt end of the stick there.

Chris Kresser:  Yeah, definitely.  One of these days when I can carve out the time, I really want to write a series on a kind of 21st century view of IBS.  Like, we know so much more about it than the conventional understanding of it.  It’s such a hot topic in the research literature, and we’re really coming to the point where we have the tools diagnostically to identify underlying causes and address them, and like you said, it’s really a shame that that’s not happening more, and I’m itching to write that series, but I just haven’t been able to find the time for it yet, but soon enough.

Steve Wright:  We’re gonna need to clone you.  Is that OK?

A non-toxic treatment protocol put 4 cancer patients into remission

Chris Kresser:  I don’t know.  I’ll have to think about that!  So, let’s move on.  I could say a lot more about that, but I’ll save some of it for the series.  The next study I want to talk about, really interesting.  I’ve talked about low-dose naltrexone before, and that’s partly what this study is about.  It’s about a natural treatment for cancer that is being used at the Integrative Medical Center of New Mexico.  So, the study basically reports four cases of people with aggressive forms of pancreatic cancer, and most of you probably know that pancreatic cancer is very serious.  The prognosis is not good.  The usual length of survival is something like three to six months, and patients with advanced disease rarely live more than a few weeks.  I’m sure most people who are listening to this are aware that Steve Jobs died of pancreatic cancer.  So, anything that can potentially successfully treat pancreatic cancer is pretty exciting because it’s one of the most aggressive forms of cancer and one of the worst prognoses that you can have.

So, these folks at this Integrative Medical Center in New Mexico have been using a protocol that involves a few different components.  The main two components are intravenous administration of alpha lipoic acid at 300 mg to 600 mg two days a week and 4.5 mg of low-dose naltrexone, which is the standard low dose of naltrexone.  They also were giving 600 mg per day, which is a pretty high dose, of oral alpha lipoic acid; 400 mcg per day of selenium — I wish they would’ve said which form they’re using.  I imagine they’re using the methylselenocysteine form, which is the one that’s been shown to have more anticancer effects than other forms, and then they’re using 1200 mg per day of milk thistle extract, which is another potent antioxidant.  So, I’m sure they’ve done this with more than four patients, but they reported on four patients in particular with pancreatic cancer.  The first patient, J.A., had pancreatic cancer with metastases to the liver, so this isn’t just pancreatic cancer; it’s metastatic pancreatic cancer.  The doctor basically told J.A.:  Get your life in order.  There’s nothing we can do.  You probably have a few weeks to live.  And he went to the center in New Mexico, and he did the protocol.  Seventy-eight months later, he is in complete remission with no signs of cancer at all and feels like a totally normal person.

Steve Wright:  Did you say seven or eight?

Chris Kresser:  Seventy-eight!

Steve Wright:  Woo!

Chris Kresser:  Seventy-eight months later.  So I mean, considering that the usual length of survival for pancreatic cancer is three to six months and the usual length of survival for metastatic advanced pancreatic cancer is a few weeks, seventy-eight months is pretty impressive.

Steve Wright:  Yeah.

Chris Kresser:  The next patient, G.B., was diagnosed with pancreatic cancer and refused chemo because of religious reasons, and she did the protocol and is now alive and symptom-free 39 months after diagnosis at the time the paper was published.  So, another really impressive result.  J.K. was diagnosed with pancreatic carcinoma with metastasis to the liver, and she was jaundiced, exhausted, in constant abdominal pain and nausea when she first came to the center.  And after a few weeks of the protocol she improved significantly, and after six months her PET scan showed absolutely no sign of cancer, and she felt normal, without any pain or nausea.  And unfortunately — and this is very sad — she returned to her home state because she had traveled to New Mexico specifically for this treatment.  So, she goes back home, and her doctors refused to continue the protocol even though she had basically no signs of cancer, and then she died within a couple of months after going home.

Steve Wright: That’s sad.

Chris Kresser:  Yeah.  I’m gonna have to resist going off on a tangent here about –

Steve Wright:  You didn’t say.  So, once they started that treatment, the intravenous drip as well as the supplements, they were on that for life basically then?

Chris Kresser:  Yeah, it seems to be that this is not curative.  It doesn’t look like you do this for a period of time and then you stop and you’re fine.  I think you have to continue with the protocol, but when you compare this to, like, chemotherapy, you’re doing a supplement regime plus low-dose naltrexone, which is an extremely well-tolerated, very low dose of a medication that has no documented complications or risks, and then an IV of alpha lipoic acid a couple times a week.  I think that’s a pretty small price to pay to survive pancreatic cancer.

Steve Wright:  Totally.

Chris Kresser:  But the sad thing is that this poor woman goes home and even though she has proof that she’s free of cancer and feeling great, the doctors wouldn’t do it.  It just blows my mind, and nothing makes me more upset than that.  It’s just crazy.  Anyhow, the next patient, R.C., had three malignancies.  Three.  Prostate adenocarcinoma, non-Hodgkin’s lymphoma, and pancreatic adenocarcinoma.  You know, two of those, in particular, are very lethal.  So, he improved significantly on the protocol, and he felt so much better that he decided to have surgery to internalize his percutaneous biliary drain, which is something that people use when they have serious gallbladder issues, and unfortunately he died from complications of the surgery.  So, the protocol worked in his case, but he got septicemia from the surgery and he passed away.

So, in all of these cases, the protocol worked extremely well.  In two cases, the people are still alive with no signs of cancer and are continuing the protocol.  In another case, the protocol worked well, but she wasn’t able to continue it and she passed away.  And then in the fourth case, the protocol worked very well, but the person died of unrelated surgical complications.  So, pretty impressive.  This is certainly something, like, if myself or a family member or a friend or anybody I knew was diagnosed with not only pancreatic cancer, but just about any cancer, because there’s nothing in these results that suggest that they’re unique to pancreatic cancer, I would definitely consider this protocol, either going to New Mexico or trying to convince your doctor to do it, because it’s not that exotic.  I mean, the supplements are readily available.  You could order them from just about any online source.  And then the IV alpha lipoic acid, you’d just have to find someone who’s willing to do a drip.  Alpha lipoic acid is cheap and readily available, and low-dose naltrexone is off patent, very affordable, and fairly easy to obtain if you find a doctor who’s familiar with the oncology literature.

Steve Wright:  Chris, so the milk thistle, the alpha lipoic acid, the selenium — those all make sense to me.  So, what role do you think LDN is playing here?

Chris Kresser:  Yeah, well, let me tell you a little bit more about alpha lipoic acid, because some people might not be familiar with it, and I think it’s really interesting in the context of cancer.  Alpha lipoic acid is a cofactor that’s active in a number of different enzyme complexes that control metabolism, including the conversion of pyruvate to energy in the mitochondria.  So, it helps us to transform the food that we eat into usable energy.  But it’s also really effective as a free radical scavenger, which means it reduces oxidative stress.  That’s very important in any inflammatory disease, and it’s definitely important in cancer.  Alpha lipoic acid also induces hyperacetylation of histones, and histones are proteins that are active in the proliferation of a lot of different cancer cell types, and anything that inhibits histones will drive the cancer cells to apoptosis, which is cell death, programmed cell death.  And indeed, human cancer lines have been shown to become apoptotic after exposure to alpha lipoic acid, so alpha lipoic acid helps kill cancer cells.  Another mechanism that it might work by is that ALA, which is the shortened name of alpha lipoic acid, stabilizes nuclear factor kappa beta or NF-KB, for short.  And when NF-KB is activated, it launches the induction of more than 200 genes that suppress apoptosis, and that will, in turn, increase cellular proliferation, invasion, metastasis, chemo resistance, and inflammation, which are all characteristics of cancer.  And so, studies have shown that high doses of ALA have been shown to inhibit the activation of nuclear factor kappa beta.  Another mechanism is that ALA selectively stimulates apoptosis in cancer cells.  So, in other words, it promotes the death of cancer cells without harming normal cells, and that’s, I mean, that’s amazing.  That’s kind of the holy grail in cancer treatment, right?  The ability to shut down cancer cells without harming the normal cells, because that means the side effects of the treatment are not gonna be extremely harmful, as is the case with chemotherapy.

Steve Wright:  Quick follow-up question here on ALA:  So, just for everyone listening, there’s no known upper limit for ALA?  No side effects?

Chris Kresser:  Actually, that’s a good question.  I wouldn’t recommend that anybody do this without supervision.  And I hope that goes without saying when we’re talking about cancer.  I don’t prescribe more than 200 mg or 300 mg a day of alpha lipoic acid unless the circumstances are pretty extreme.  And that’s one of the things.  When you’re dealing with terminal cancer, you’re a little bit less concerned about any potential short-term side effects from a treatment like this because, you know, what’s the alternative?  For example, selenium has been shown to be potentially toxic at doses of 400 mcg a day, but in this case, the antioxidant benefit of selenium over this period of time and because there’s so much oxidative damage, those effects are less likely to be a concern.  So, yeah, thanks for pointing that out.

Steve Wright:  Well, yeah, because I’m sure I’m not the only listener of this podcast who has read The 4-Hour Body by Tim Ferriss, and in that, actually his weight loss, his non-stimulant weight loss stack that he recommends includes about 300 mg of alpha lipoic acid per meal, so I think that’s somewhere between 900 mg to 1200 mg a day.  So, I was just curious if there was, because being familiar with that knowledge and hearing the study, milligram doses, I was like:  Wow, it’s not quite as high as what I would’ve thought it would’ve been.

Chris Kresser:  No, because it doesn’t really need to be much higher.

Steve Wright:  OK.

Chris Kresser:  I think a lot of times supplements, there’s a kind of more-is-better mentality, you know, with supplements, and that’s definitely not always true, because as in the case of selenium, like I was just saying, there’s a sweet spot where too little is not good and too much is not good because selenium in excess can be toxic.  So, I don’t know what the toxic dose of ALA would be, but I would be hesitant to recommend that somebody take almost 2 grams a day of it for any significant length of time.

Steve Wright:  OK.

Chris Kresser:  I’ll have to look into that more, and we can talk about it on another episode.

Steve Wright:  Yeah, well, I think you pointed out the most important thing, which is most supplements operate on a U-curve, which means that there’s a sweet spot in the middle and if you’re underdosing you’re not really gonna get the effect, and if you’re overdosing you’re probably gonna cause something else to happen that you don’t want to.

Chris Kresser:  Right.  And as is the case as we’ll see with low-dose naltrexone, in some cases if you increase the dose, it doesn’t work the way that you want it to.  So, low-dose naltrexone is, as the name implies, a low dose of a drug called naltrexone.  And the full dose of naltrexone at 50 mg used to be used a while back, I think, in the ‘70s and ‘80s for opiate withdrawal, like with people who were addicted to heroin and also, I think, in some cases with alcoholics, because what it does at the full dose is it completely blocks the opiate receptors in the brain, and the opiate receptors are what mediate our experience of pleasure, so if you block those receptors, somebody like a heroin addict who took 50 mg of naltrexone could shoot up and feel pretty much nothing.  Unfortunately, they felt pretty much nothing at all from anything else in their life, so naltrexone turned out to have severe depression, suicidal ideation, things like that as a side effect because people who took it, sure, they didn’t get the stimulation from heroin and it was effective in that sense, but they didn’t experience much of any pleasure in their life at all.

But this pretty brilliant doctor named Dr. Bihari back in the ‘80s and ‘90s, he was treating HIV and AIDS when hardly anybody else was, and he was also starting to treat cancer, and he discovered that if you used a low dose of naltrexone, 4.5 mg, what it does is it blocks the opiate receptors in the brain just like the full dose does, but only for a short time.  So, for example, the typical way of taking LDN is to take it at about 9 o’clock at night and then that creates a 2-to-3-hour blockade of the opiate receptors from, like, 3 to 5 in the morning.  And that has the effect of tricking the body into producing large amounts of opiates in response to the blockade.  So, the blockade happens, the body senses that opiate receptors aren’t being activated, it thinks that that must mean there are not enough opiates in the body, so then it produces a whole bunch.  The reason this is significant is that we now know that white blood cells have receptors for endorphins and opiates, which suggests they play an immunoregulatory role.  Specifically, they balance and regulate the various sides of the immune system.  They stimulate T regulatory cells, the Th3 cells, which turn off the inflammatory response, or they have an overall regulatory effect on the immune system.  So, in the ‘90s, Dr. Bihari gave LDN to about 450 patients with cancer, and these are folks who had failed the standard treatments.  You know, they tried all the other, the chemo and the standard stuff, and they ended up with him.  And of 354 patients that he followed up regularly, 86% showed at least a three-quarters reduction, 75% reduction, in tumor bulk, and 125 of the patients, which is I guess about 33%, were reported to have achieved remission or close to remission.

Steve Wright:  Wow.

Chris Kresser:  So, that’s pretty impressive.  There’s other research that has shown that LDN has slowed the growth of neuroblastoma cells in culture, so that’s just an in vitro study, but promising.  And then another study showed that LDN plus radiotherapy was more effective than radiotherapy alone for malignant astrocytomas, and malignant astrocytomas are thought to be incurable, also a pretty nasty form of cancer.  And in this study, the survival rates at one year were higher for people who did the LDN plus radiotherapy than people who just did the radiotherapy alone.  So, I think it’s a really promising area of research.  Like I said, if I had a friend or a relative or a patient that was diagnosed with a cancer like this, it’s definitely something that I would advise them to look into.

Steve Wright:  One last question on this, because this treatment is so heavy on the antioxidant side:  There are a lot of papers coming out lately that are saying — I mean, I think they’re mostly epidemiological, but they’re saying that supplementing with antioxidants could actually be a bad thing.  And obviously we talking about very specific compounds in this study versus what you could classify as antioxidant is, I don’t know, thousands of different things, and I was just curious if you had any thoughts on that.

Chris Kresser:  It’s another good question, and I’m glad you brought it up because it allows me to remind everybody again that there is no one-size-fits-all approach, and something that works for people who are sick may actually cause harm in people who are well.  That’s fairly easy to forget, but it should also be fairly obvious.  Chemotherapy can help people to survive cancer, but you would never give chemotherapy to somebody who doesn’t have cancer, right?  And I think that’s a more extreme example than this, but if someone’s just under extreme amounts of oxidative stress, as you find with cancer, something like high doses of all of these antioxidants might be beneficial, but in someone who’s otherwise healthy, it may have undesirable effects.  In the same way, you know, we get questions about diet.  If somebody has no gallbladder and a lot of difficulty digesting fat, they may have trouble with a really high-fat diet, but that doesn’t mean someone who has an intact gallbladder and good digestion is gonna have trouble with a high-fat diet.  So, we always have to consider who we’re talking about, what the goal is, and even what the length of time is that we’re talking about, you know, short-term versus long-term supplementation, or supplementation for therapeutic uses versus supplementation for longer-term, just kind of indiscriminate, indefinite use.  I use supplements a lot in my practice, but I tend to use them more for a specific goal for a specific period of time than I do just, you know, hey, take this forever.  I mean, there are certain exceptions like vitamin D and magnesium, which I’ve talked about on my blog, I think that are good, just smart to take indefinitely because they’re hard to get from the diet, but otherwise it’s always tailored for who the person is, what condition they’re dealing with, and what length of time we need to use them to achieve the effect that we want to achieve.

Steve Wright:  OK.

Chris Kresser:  Here again, I’ve just talked the whole entire episode, and we don’t have any time for questions!  But we’ll do a Q&A episode soon here.

Steve Wright:  I won’t let him talk about any studies next time!  I’m sorry guys.  It’s my fault.

Could low cholesterol be associated with a higher risk of cancer and death?

Chris Kresser:  We’ve got a lot of good questions.  So, this last one is quick, and it’s a follow-up on cholesterol, one of our favorite topics.  I just saw a post by Dr. Briffa, who was reporting on a meeting that happened at the American College of Cardiology.  And they got together specifically, I guess, to discuss the results of a study that was recently published that looked at cholesterol levels 19 years prior to people receiving a diagnosis of cancer, and what they found is that there was a significant association between low cholesterol and cancer.  In other words, people who had low cholesterol were much more likely 19 years later, or at some period of time later, to develop cancer.  Now, as we have discussed with the red meat study, we have to remember that this kind of prospective study does not prove causality.  It’s just an association.  It doesn’t prove that the low cholesterol was the cause of developing cancer, and in fact, some scientists have argued that causality is the other way around in this situation, that those patients had cancer and that’s what caused the low cholesterol, but there are a few things that argue against that:  Number one, the length of the study and the fact that low cholesterol appeared many years before cancer did suggests that reverse causality is not what’s happening, that low cholesterol actually preceded the cancer.  And then there’s another study that found that individuals with a low serum cholesterol maintained over a 20-year period had the worst outlook in terms of overall mortality risk.  The authors of that study actually wrote an editorial, where in their conclusion they said:  “Our present analysis suggests that this [reverse causality] hypothesis is implausible and is unlikely to account for the adverse effects of low cholesterol levels over 20 years.”  So, in other words, according to them, it’s more likely that low cholesterol causes chronic disease than the other way around.

I just want to emphasize again that this study doesn’t prove that.  That’s the opinion of the authors, and we can’t know that just from this data, but as I said with the red meat study, one of the ways that you can use this kind of prospective data and epidemiological data is to generate hypotheses and then try to test them.  Now, that’s a little bit difficult in the world of cancer research, and I got an email from a graduate student in epidemiology after we talked about the red meat study, and she brought up some good points that I didn’t mention when we talked about the red meat study, but it is possible to use epidemiological research or to design it in such a way where you can draw conclusions about causality that are a lot more likely to be true.  She pointed out even randomized clinical trials don’t necessarily prove anything, and there’s a Greek researcher, Ioannidis — I’m probably butchering his name.  I really love his work, but he’s written some very interesting editorials.  Like, I think the name of one of them was something to the effect of “All published research is false,” and he’s talking about how bias and all kinds of other methodological problems make it very difficult to rely on even the results of randomized clinical trials.  There are ways of designing epidemiological studies that are more likely to yield conclusions that we can rely on, and in fact, there’s a set of criteria, the Hill criteria, Bradford-Hill criteria, which outline a number of factors that can make the conclusions from epidemiological research more sound.  One of them is whether there’s a plausible mechanism to explain the finding, and that was one of my criticisms of the red meat study, that there was no real plausible mechanism for how red meat was increasing mortality risk, nor was there a plausible mechanism for how red meat was increasing cancer, which has been claimed many times.  In the case of low cholesterol and cancer, of course, then we might ask what is a potential mechanism that can be contributing here?  The truth is I don’t know, but there are a few ideas that come to mind:  One is that cholesterol is the building block of vitamin D.  You can’t produce adequate levels of vitamin D without adequate levels of cholesterol.  When you’re exposed to sunlight, you convert cholesterol into vitamin D, and vitamin D has chemoprotective properties.  Cholesterol is a precursor to all hormone production.  We know that hormones and dysregulation of hormones can be involved in cancer, and cholesterol has antimicrobial and antioxidant properties, and you know, cancer involves oxidative damage, and in some cases infections, viral infections and things like that, can be a trigger for a cancer process.  So, I think there are some plausible mechanisms, and there’s quite a bit of data.

It’s very difficult with cancer to do a randomized clinical trial because cancer takes so long to develop, and the other problem with randomized clinical trials as a means of proving causality is that in certain cases, you’ll never, ever see a randomized clinical trial because ethically it’s not possible.  So, for example, if you want to study whether an herb or a medication causes birth defects, the only way you can really do that is epidemiological data, like, look at a population of people who were taking that substance and see what happens to them in retrospect or prospectively.  It’s not ethical, for obvious reasons, to take two groups of pregnant women and give one of them a drug or an herb and the other one not and see what happens.  That’s obviously never gonna happen.  I think I was perhaps overly dismissive of epidemiological research when we talked about the red meat study and didn’t convey that there are ways of using epidemiological research, designing it better so that we can rely more on the outcomes.  And the kind of classic example of that is that for many years there was never any proof that smoking was causally linked to lung cancer, and that was the defense that the cigarette companies used is, you know, there’s no proof; there’s just this association that people who smoke more are more likely to get lung cancer.  But if you apply the Hill criteria to those studies and you demonstrate that there is a plausible mechanism and you go down the list, you can see that actually we can be pretty certain that that data is reliable and that is points to a causal link.

Steve Wright:  Yeah, I think that it’s really important for — I’m glad you explained it to me again and everybody that’s listening because research of all types is sort of on a sliding scale on how much you should value it, and the unfortunate thing is you can’t label a randomized control trial versus epidemiological because you have to apply that scale individually for every situation.

Chris Kresser:  That’s right.

Steve Wright:  And that’s the problem.  And that’s where it gets really confusing for doctors and just people like me who go to PubMed.  I think one of the best pieces of advice that I heard — and you can go ahead and destroy it if it’s not very good advice — is if you’re gonna dissect a study and really take the results of that study to be concrete in your life, you better make sure that the people in that study, that everything that they’re doing is exactly who you are.  So, for instance, if they studied a bunch of young, college-age women who were taking a supplement and it did some really great stuff, that would not be something that I would take because I’m not a young, college-age woman.  And for instance, if they did this study on ALA and cancer, again, it’s not something that I should be doing because it wasn’t done exactly on my type of who I am and where I am.

Chris Kresser:  Yeah.  That’s one of many variables we need to use when we evaluate a study, and of course, we’ve talked about that a few times in this episode, but another classic example is statin drugs.  They have never been shown to reduce total mortality in women and in certain populations of men, particularly men over the age of 65.  So, the mistake that a lot of primary care doctors and just the general public make is assuming that because statins have been shown to reduce very slightly the risk of total mortality in men with preexisting heart disease and reduce the risk of cardiovascular mortality in other populations, that we just assume that we can extend those results to women and to men and women who are over 65, which we can’t because that’s never been shown.  So, it is a good point, and it’s true.  It makes it really difficult for the average lay person to kind of piece through all of this stuff, but I don’t think that the appropriate response is what I have seen with some people in the blogosphere of just going to the other extreme and saying:  Oh, well, published research is just unreliable then.  We might as well not even pay any attention to studies.  I mean, there are some kind of prominent bloggers out there who that’s their kind of shtick is that studies are worthless.  That’s an oversimplification in the other direction.  Just because a lay person is not qualified to evaluate the quality of a study, that doesn’t mean there aren’t people that are.  I mean, there are a lot of people who work in research settings and even people outside of research settings who are perfectly qualified to evaluate the validity of a study.  So, we just need to apply those standards and be judicious about the conclusions that we draw from studies based on the quality of the study.  We don’t need to get rid of all research or throw out all research results.  We just need to be better and more conscious of what conclusions we draw and more conscious of what studies we’re drawing conclusions from.

Steve Wright:  Yeah, I agree.  There’s no reason to just rule out something just because you can’t make sense of it.

Chris Kresser:  Yeah.  So, OK, we’re a little over an hour here, and we’ll get to your questions.  We will.

Steve Wright:  We swear!  Well, hopefully you listen you next time, because we will do some questions next time.  And we want to thank you for listening this time.  And please keep sending us your questions, they will get to the show, and you can do that at ChrisKresser.com using the podcast submission link.  If you’ve enjoyed listening to the show today, please head over to iTunes and leave us a review.  Thanks.

Chris Kresser:  Bye everybody.