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.

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.

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.

I’m sure by now most of you have heard about the news reports about the Harvard study which claimed that red meat increases your risk of death.  In this show I present 4 reasons why you shouldn’t take these claims seriously.  I also discuss several reasons why eating red meat is beneficial to your health, as well as one little known reason that some people may need to limit red meat consumption (hint: it has nothing to do with saturated fat, cancer or heart disease).

In this episode, we cover:

2:40 Should you worry about the claims against red meat?
7:27 What the research does – and doesn’t tell us about red meat and mortality
38:41 The truth about red meat and colorectol cancer
46:18 Is processed meat bad?
58:08 Why red meat can be good for you
1:02:58 One reason you may need to limit red meat consumption

Links We Discuss:

• Red Meat and Colorectol Cancer Study

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 today, Chris?

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

Steve Wright:  I’m doing well, as well.  I don’t know if I can say that, but I just did.  Yeah, it’s been, like, 85 in Michigan and it’s March, so that’s awesome.

Chris Kresser:  Well, we’ve stolen the rain from you apparently.  It’s actually sunny today, but it’s been raining cats and dogs here for a while.

Steve Wright:  Well, keep it.

Chris Kresser:  So, this is gonna be my first stand-up radio show here.  I got a standing desk, which I’m really excited about, and so we’re gonna record this whole thing with me standing up for the first time ever.

Steve Wright:  Do you normally work standing up for, like, an hour at a time?

Chris Kresser:  Yeah, I do.  I alternate.  I still have a sitting desk and a standing desk, and I alternate between the two.  But at my sitting desk I sit on a ball, you know, one of those yoga balls, and then I have a chair, and I have this little disk that you put on top of the chair that keeps you moving, keeps your muscles engaged so that I’m not sitting there on my butt all day.  So, I’m rarely actually just sitting in my chair.  I have a bunch of different stuff that I do throughout the day.

Well, I spend more time than I want to in front of a computer and on the phone, so I have to do something to keep my body active.

Steve Wright:  OK, well, we’re gonna have to post some links for that, and I’m gonna have to buy some new products so I can be just like you.

Chris Kresser:  Ha-ha, all right.

Steve Wright:  OK, cool, so before we get going here, why don’t you grab a drink of water and do some stretches so you don’t hurt anything.

Chris Kresser:  Ha-ha, OK.

Steve Wright:  And I’m gonna tell the listeners that 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, go to ChrisKresser.com and look for the big red box.

And we’re back, Chris.  Are you doing OK still?

Should you worry about the claims against red meat?

Chris Kresser:  I’m here, and we’ve got a good show today.  We’re gonna just take the red meat study that I’m sure everybody has heard about now that claims that red meat increases your risk of death, and we’re gonna just hopefully destroy it, take it to the curb, beat it down, whatever you want to call it.  You know, it created such a stir in the blogosphere, and I got so many emails and comments on my blog and questions about it, and I know there has already been a lot written about it, some really great analyses by Denise Minger and Anthony Colpo.  Robb Wolf had an article about it.  You know, there has been plenty of stuff written, but I want to kind of pull material from a bunch of different sources and just put it all together in a way that’s hopefully very easy to understand.  And part of the purpose of this is to educate people on how to critique a study like this on their own.  And granted, you know, most people may not ever acquire the skills to do what Denise Minger is doing and some of the other people in the blogosphere and some of the types of critiques that I do, but you can pick up some of the basics pretty easily so that when you see a news report like this you’ll be able to look at it with a discerning eye and not just accept the interpretation of the clueless science reporters and media that just kinda parrot the party line or whatever the researchers claim that their data showed, which as we’re gonna see is often not what their data showed.

Steve Wright:  Before we get started here, you got off on a really graphic start.  Should we put in a “not safe for work” sign, or are we gonna be tame enough to –

Chris Kresser:  Oh, we’re tame.  Yeah.  That’s gonna be the worst of it, ha-ha.

Steve Wright:  All right, well, before we beat all over some scientists and throw all the red meat myths under the bus, how did PaleoFX go?

Chris Kresser:  PaleoFX was a lot of fun.  I didn’t get to go to AHS last year because Sylvie was born.  I mean, so obviously I didn’t regret that, but I didn’t get to meet everybody that I’ve had so much contact with over the last few years via email or through my blog and on the phone, so I was really excited just to meet people and get a chance to hang out with them in person.  Spent quite a bit of time with Robb Wolf and to meet Mark Sisson and Jimmy Moore, and of course, all the other folks that were there.  And I really enjoyed my talk, the chance to get up in front of people and do my thing.  It’s always fun for me.  I didn’t really get a chance to see much of Austin.  I basically would get to the conference at about 8 in the morning, and I was there both nights until about 9:30 or 10 at night, and so the only part of Austin I saw was my hotel and looking out the window of the shuttle from my hotel to the convention center, which was at the football stadium at the University of Texas.  So, there were some great talks.  There were a lot of panels that I participated in and some good time just connecting with people.  I got to meet some of my long-distance patients, some of whom came from as far away as North Dakota, Maine, so yeah, it was a great trip.

Steve Wright:  Awesome, well sounds like from what I read on the Internet, because I wasn’t there, that most everyone had a really good time.

Chris Kresser:  Yeah, the organizers did a great job, especially since it was their first conference.  I mean, it’s hard to even fathom how many details need to be pulled together to pull something like that off, and it went without a hitch, at least from my perspective, and it was really well done.  They had a professional AV crew there the whole time, so I think they’re gonna be putting out a really high quality DVD or a conference package that people will be able to buy if they weren’t able to make it.  Yeah, I think it’s a good start for that event.  I think they’re already planning on doing it next year, and I’ll definitely go back if they invite me.

Steve Wright:  Awesome.  OK, well let’s get back to beating up red meat, or –

Chris Kresser:  Or beating up the people who are beating up red meat.

Steve Wright:  Yeah, that’s what I meant.  So where do we start?

What the research does – and doesn’t tell us about red meat and mortality

Chris Kresser:  Yeah, I mean, there are so many ways we can go with this, and I think I want to focus it in on four basic problems with the study and with epidemiology research.  But first I want to just briefly talk about what the claims were from that study and also from all the media reports that were done afterward.  So, there have been a lot of observational studies in the past that have claimed that red meat increases the risk of cancer, especially colon cancer, but this one went even further.  It claimed that red meat makes you die of everything, so it increases the risk of total mortality, which is death from all causes.  And they followed over 120,000 women from the Nurses’ Health Study and Health Professionals Follow-up Study over 28 and 22 years, respectively, and the data was published by a research group out of Harvard, which for better or worse — I think worse in this case — gives it some kind of instant credibility.  You know, a lot of people when they hear Harvard, they think:  Oh, it must be true.  If it comes out of Harvard, it must be true.  And they found that a single serving of unprocessed red meat is associated with 13% increased risk of death from all causes, while a single serving of processed red meat, like bacon or hot dogs, increased total mortality by 20%.  And then they made the claim, though they didn’t even study this at all, so I have no idea how they can possibly make this claim, that replacing red meat with whole grains, nuts, and chicken would extend your lifespan.  I mean, they didn’t even look at that in their study, so I’m not sure where that came from, but they said it in their report.  And in fact, they suggested that 1 in 10 deaths could have been prevented if people limited their red meat intake to under a half a serving a day.  So, let’s first talk about the problems with this study, and then we’ll look at other studies that I think are better designed that have examined red meat and particularly the relationship between red meat and cancer, and then we’ll look a little bit at the benefits of eating red meat and why you might want to eat red meat in spite of what this study says, and then we’ll talk about if there are any circumstances where someone might want to limit their red meat consumption and what those would be.  So, jump in anytime, Steve, if you have questions so I’m not just sitting here doing a monologue the whole time.

Steve Wright:  Got it.  Yeah, I don’t have anything yet other than I can’t believe they actually stated that 1 in 10 deaths could have been prevented.

Chris Kresser:  Yeah, it’s pure speculation.  OK, so it’s hard to know where to start because there are so many things that are wrong with this study, but for the sake of this show, we’re gonna group it into four categories, and I’ll just briefly mention them now and we’ll talk about them each in a lot more detail.  So, number one, and I think a lot of my listeners already know this by now, but we’re gonna talk about it in case you don’t, observational studies or epidemiological studies can never prove causality, and correlation is not causation.  It’s one of the first things you learn if you study research methodology, and I’m gonna go into a lot more detail about it, but epidemiological studies can only show association.  They can show the presence of two variables occurring together.  So, for example, in this study the claim is that people who ate more red meat tended to have a higher risk of death, but it does not prove that red meat consumption caused those people to die more frequently than people who were not eating red meat.  So, that’s number one.  Number two is that the data collection methods that they used in this study were highly questionable, to say the least.  Number three was that they didn’t adequately control for confounding variables, and this is related to number one, that it’s a problem with all epidemiological research because we don’t live in a vacuum, so if somebody is eating red meat but they’re also smoking more, exercising less, have higher rates of diabetes, higher body mass index, etc., then how do we know that it was the red meat that increased their risk of death versus all of those other factors?  And you know, many of those things that I mentioned are known to affect total mortality.  They’ve been shown to do that in other studies.  So, that’s a major problem with this study and with epidemiological research in general.  Number four, even if all of those weren’t true in number one through three, the data that these researchers presented don’t paint nearly as dire a picture of the increased risk that comes with eating red meat as they would like you to think they do, and we’ll get into that in more detail.

First let’s talk about correlation versus causation or the main problem with epidemiological research.  As I said before, anybody who has taken a research methodology course, even at the undergrad level, this is sort of probably what they teach you on the first day.  And observational studies where they take groups of people and then they observe them over a period of time — in this case it was over 20 years in both groups — they can’t prove causality.  They can only be used to generate hypotheses that should then be studied with a clinical trial, also referred to as an experiment.  We should always look at epidemiological or observational research as the first step, and it can be very useful for that.  It’s a good way of generating ideas that we would then pursue further with clinical trials, but it’s never the last step.  For that, we need to do an experiment, or a randomized clinical trial is kind of the gold standard now, double-blind placebo-controlled if we’re looking at a drug, and these experiments are designed to test the hypotheses that we come up with from epidemiological data.  So, using the red meat study as an example, if observational research suggests that red meat increases the risk of death, to prove that that’s true, you’d have to take two groups, or randomize people into two groups, and then put them on two different diets, one that has a low amount of red meat and one that has a high amount of red meat, but then you’d also have to make sure that everything else they’re doing is identical.  So, you’d have to make sure that they are all nonsmokers, for example, they’re getting an equivalent amount of exercise, that they have equal rates of diabetes and other conditions that are known to contribute to mortality, that they’re eating a roughly equal amount of fresh fruits and vegetables.  You have to make sure that all of those other factors are consistent, which these are known as confounding factors, otherwise we have no way of knowing whether one of those things that changed might be the cause of the change in mortality versus the red meat itself.

So, just to illustrate why observational studies don’t prove anything, we can use some somewhat ridiculous examples.  I posted a graphic on my Facebook page with some of these examples a couple of days after the red meat study was published.  So, one is that from 2005 to 2011 the number of Facebook users climbed from zero to 750 million, and during that same period the yield on a 10-year Greek bond climbed from 3.6% to 16.8%.  So, does this mean that Facebook is driving the Greek debt crisis?  Probably not.  I think that’s pretty clear to most people, right?  We can think back.  Another classic example is when you think back several decades ago when the whole “cholesterol causes heart disease” hypothesis was being formulated, there was a great study out of the UK by Professor John Yudkin, and I think his whole goal was to prove the ridiculousness of using epidemiological data to establish causality.  And he did research to try to determine what the strongest predictors of heart disease were, and he found that television ownership and car ownership were, in fact, much more strongly correlated with heart disease than cholesterol levels.  So, does this mean that owning a TV there’s some toxin in the TV that kind of emits from the screen and zaps your heart and causes you to have heart disease, or that sitting in a car or driving a car around gives you a greater risk of having a heart attack?  No, that’s not what that means.  It means that there is probably some other indirect factor, like people who own TVs perhaps are less likely to exercise, and low levels of physical activity, we know, is a risk factor for heart disease.  So, that’s just another example of how dangerous it is and how silly it can be actually to use that epidemiological data for causality.  Another fun one is in Florida ice cream sales and shark attacks are strongly correlated.  So, you know, if these Harvard researchers got a hold of that data, they might publish a news story that says that shark attacks are more likely when ice cream sales are high or that eating more ice cream might cause you to be more likely to get attacked by a shark.

Steve Wright:  Yeah, I’m not eating ice cream in Florida.  Not at all.

Chris Kresser:  Ha-ha!

Steve Wright:  But, I mean, so with these epidemiological studies, Chris, like you said, they can teach us some things, but is it true that basically what’s happening here is in all of these or most of these epidemiological studies, especially this one, they’re literally, they just have a giant questionnaire, like, lots of questions about all kinds of things, not just diet, and they follow up with these people at random time intervals, and they get all these data points, you know, they said yes or no or 5 or 2, and then they just look at the numbers, you know, they remove everything else and they just look at the numbers, and they’re just hoping to find a couple links.  Is that kinda how this works?

Chris Kresser:  Yeah, basically.  Or they may go into it with a particular idea or agenda or hypothesis, which is probably the case here.  And that’s really dangerous, and that’s an important point to raise.  Another issue with epidemiological data is, like, you think of the China Study, which has been thoroughly debunked by now, and Denise Minger did the best job of that.  If anyone still believes that the China Study shows that red meat causes cancer and is harmful and that saturated fat is bad for you, you definitely have to go over and read her blog post on that.  But T. Colin Campbell who put that together is a vegan and has an agenda, and he set out to prove that.  And when you look at data and you have an agenda, it’s very easy to find connections and correlations where they don’t really exist and to ignore the things that don’t support your idea.  And that’s a big risk that faces any researcher, and it happens in the Paleo/Primal community too, and it’s something I try to constantly be aware of.  I’m human.  I have the tendency just like everybody else.  I think it’s a natural human tendency to want to find things that support our worldview and our way of looking at things, but I do my best to guard against that, and I think it’s really important to be aware of that because it’s one of the real risks of interpreting this kind of data.

I’m gonna talk a little bit more about the data collection methods in a second, but I just wanna make a couple more points about the danger of using epidemiological research to establish causality.  So, a lot of people probably remember the whole hormone replacement or HRT fiasco a while back, and what happened there was that there were about 30 observational studies that suggested that women taking estrogen had a significant decrease in heart disease risk, so almost 50%, like 45% decrease in heart disease risk.  So, there was this mad rush of women then to take estrogen in an attempt to lower their risk of heart disease.  Unfortunately later clinical trials, which of course are what are needed to prove or disprove a hypothesis, found that hormone replacement therapy not only didn’t decrease the risk of heart disease, but it actually increased the risk of heart disease by 30%.  So, these poor women who had listened to the mainstream media reports on these observational studies suggesting that estrogen would decrease their heart disease risk had actually increased it by 30%.  So, this is real.  I mean, it’s not just, like, an academic point we’re making here.  There are real consequences, and I think it’s irresponsible and borderline unethical and almost criminal for a researcher to come out and say that their data proves something when it clearly doesn’t.  There’s really no excuse for that at all, and I don’t understand how a Harvard researcher could say — I mean, this is what Frank Hu, the lead researcher, said:  Our data “provides clear evidence that regular consumption of red meat, especially processed meat, contributes substantially to premature death.”  That’s just false.  There’s no way that statement can be supported, and it might seem like it’s relatively benign, like, if someone doesn’t eat red meat, is that going to kill them?  Well, we don’t know what they might choose to replace red meat with and how that might affect their health down the line, and the HRT thing is a good example of how that can go really wrong.  So, what happened there was that the observational data that suggested that estrogen was protective — And if you look closer at that data, the women who were taking the hormone therapy smoked less and exercised more and had better lifestyle habits than the women that weren’t taking the hormone therapy.  So, those things, as it turned out, were probably what decreased the risk of heart disease, not the estrogen alone, as later clinical trials suggested.  So, this is serious stuff, and it has real impact on people’s health and their lives, so I think it’s really crucial to get the word out.

Chris Kresser:  OK, so let’s now talk about the data collection methods that were used in this study.  But before we get into this, let’s do a little experiment of our own.  So, everyone listening to this, take out a piece of paper.  If you’re driving, you can skip this step; you can just think about it in your mind.  But I want you to write down how many servings of red meat you had last Monday, whenever it is you’re listening to this.

Steve Wright:  Ooo, that’s a good one.

Chris Kresser:  And then write down exactly how much red meat you had.  You know, how many grams of red meat did you have at that serving?  OK, now I want you to do the same thing and tell me how much red meat you had on March 15, 2009.  How many grams did you eat during that day?  And then I want you to tell me how much red meat you had in March of 2008.

Steve Wright:  Um, Chris, I don’t know where I was in 2008.

Chris Kresser:  Ha-ha, so how’s your list looking right now?  Do you feel confident that you can recall how much red meat you ate four years ago and how often you ate it and how many servings and what amount?

Steve Wright:  Yeah, I don’t think so.

Chris Kresser:  Yeah, I don’t think so either.  I don’t think anybody could.  And yet that’s the method that was used in this study.  It’s called a food frequency questionnaire, and they ask you to write down, to estimate your food consumption, but they only were filled out once every four years.

Steve Wright:  Really?

Chris Kresser:  Yeah.  Every four years.

Steve Wright:  And you had to answer questions about the previous four years?

Chris Kresser:  You had to answer questions about the previous four years, how many servings of red meat you had, how much you ate, how many servings of vegetables, fruits, dairy products, and other foods, and you know, most people hardly can remember what they ate yesterday, much less a year ago, much less four years ago.  And what’s more important is that even if people could remember what they ate accurately, that’s not what they report on these food frequency questionnaires.  Instead they report what they should have eaten.  And this isn’t just my opinion.  This has been scientifically documented over and over again.  Researchers have compared the food frequency questionnaires with more accurate diet records where they take food and they meticulously weight it and measure it, and in fact, a validation report like this has been done for both the Health Professionals Follow-up Study and the Nurses’ Health Study, and I’m gonna read you a quote from each of these validation studies.  So, from the Health Professionals Follow-up Study, which is one of the data sets that the researchers reported on, the researchers said:  “Foods underestimated by the food frequency questionnaires compared with the diet records (i.e., the gold standard) included processed meats, eggs, butter, high-fat dairy products, mayonnaise, creamy salad dressing, refined grains, and sweets and desserts, whereas, most of the vegetable and fruit groups, nuts, high-energy and low-energy drinks, and condiments were overestimated by the food frequency questionnaires.”  And then the validation report from the Nurses’ Health Study came to a similar conclusion and said:  The “mean daily amounts of each food calculated by the questionnaire and by the dietary record were also compared; the observed differences suggested that responses to the questionnaire tended to overrepresent socially desirable foods.”  In other words, this is just basic human psychology.  Most people want to look good.  We’re flooded with messages about how fat and red meat are bad and how veggies and whole grains are good, so when people come to fill out these questionnaires, they tend to overreport so-called “good for you” foods and underreport so-called “bad for you” foods.

And if you have any doubt that people misrepresent their food intake on these questionnaires, all you’d have to do is look at the average reported calorie intake for women.  So, in this study, the red meat study, women in the first quintile of red meat intake, meaning the women who ate the lowest amount of red meat, reported that they ate only 1200 calories a day.  So, you know, for most people, that’s a starvation diet.  If they eat 1200 calories a day for 22 years, they would be dead.  You know, they’d waste away to nothing.  Women in the highest quintile of red meat consumption, on the other hand, reported 2000 calories a day, which is much more likely.  So, that’s an 800-calorie gap between those two groups, and that makes it pretty obvious that the difference in their diet wasn’t just about the amount of red meat that they were eating.

Now, there’s been an argument that — You know, some people argue that food frequency questionnaires are accurate because everybody kind of under- or overreports their intake by the same amount, so it all kinda comes out in the wash.  Right?  However, that’s not actually true.  There’s a big difference in the extent to which people under- or overreport their food intake, and some interesting studies out of Australia have shown that the degree to which people distort their food intake depends on their personality characteristics and other factors like gender, age, medical status, body mass index, occupation, how much education they’ve had, and then their use of dietary supplements.  So, one study, for example, found that people who have a diagnosed medical condition like diabetes or coronary heart disease are much more likely to overreport their meat consumption, and this is kind of strange when you think about it at first, but it could have something to do with the fact that people who have lifestyle-related health conditions like diabetes or heart disease are less likely to pay attention to what they eat.  So, if you’re following this, if people with diagnosed medical conditions that increase your risk of death have a tendency to overreport their meat consumption, then that would have profound effects on any associations you might find between meat intake and mortality, right?  So, that’s how they got the data for this study, and I’m personally not at all confident that it’s reliable, and I’m sure most of you after hearing this aren’t either.

Steve Wright:  And if you’re not, keep a food journal for, like, 30 days and then try to recall some of those foods, like, every Monday without looking at it and see how you do.

Chris Kresser:  Ha-ha, yeah, I mean, this is the work I do, right?  I pay a lot of attention to what I eat, compared to most people, I think, and I know a lot about the constituents of food and calories and grams of carbohydrates and fat and serving sizes and all of that, and I would be extremely hard pressed to tell you, you know, how many servings of red meat I had last week or the week before versus a year or two or three years ago.  It’s just — It’s impossible.

Steve Wright:  Yeah, I’m with you.  I pretty much keep a really close eye on what goes into my body, and I don’t know whether I ate red meat last Monday, but I think I did, so I’m not sure.  That was only seven days ago.

Chris Kresser:  Yeah.  So, the next thing we’re gonna talk about, and this is, of course, the problem with all epidemiological data, and it was a problem in this study as well, is that they didn’t adequately control for confounding factors.  And I say “adequately” because they did attempt to control for confounding factors using what’s called a multivariate analysis, but as we’re gonna discuss, that’s very difficult to do with any kind of accuracy.  So, with any observational data, there’s an almost infinite number of variables that could potentially affect the outcome, some of which we understand and some of which we might not understand very well.  So, one example is stress.  There’s an increasing amount of research that connects stress very directly as a causal factor to heart disease, and there’s never any mention of stress in any of these studies.  They don’t even bother trying to control for it because it’s extremely difficult to control for because it’s so intangible.  But there are other factors that are known risk factors for heart disease, like smoking or lack of physical activity or alcohol intake, things like that.  So, the questionnaire in the study asked about red meat consumption, but it doesn’t track other things that could potentially be a risk factor that the researchers maybe don’t think is a risk factor or aren’t weighing as heavily as we might.  For example, the questionnaire didn’t ask about refined grain intake.  It had a question about whole grain intake but not refined grain intake.  So, if somebody is eating a lot of burgers at a fast food restaurant, how do we know that it was the red meat that increased mortality rather than the hamburger bun or the hot dog bun that they ate with the meat or the polyunsaturated fat that it was fried in?  We don’t.

And then it’s also worth pointing out, which the researchers actually did in their study, they didn’t mention this so much in their reports of the study, that people eating the most red meat were also the least physically active, the most likely to smoke, the least likely to take a multivitamin, which is kind of a proxy indicator for how much somebody is thinking about health in our culture.  They had higher body mass index, higher alcohol intake, and a trend towards less healthy non-red meat food choices, so they were probably eating more packaged and processed junk.  Also important to note that they had higher rates of diabetes, which is a disease of poor glycemic control that has really no plausible connection to red meat but does have strong links to excess calorie and refined carbohydrate consumption.  So, again, if this group of people that was eating more red meat also had higher rates of diabetes, we might think they’re eating a lot more refined carbs and a lot more calories in general and that that was increasing their risk of death rather than the red meat itself.  So, as I said, they did try to control for some of these factors with the multivariate analysis, but it’s extremely difficult to objectively and accurately put a value on all of these lifestyle and diet factors that we know contribute to disease, and then there are others like stress that weren’t even a part of the equation.  Running a statistical model after the fact is a really poor substitute for a real clinical trial where participants are randomized into two groups and then given explicit instructions on what to eat and then objective measurements of their food intake and then controlling all of the variables so that there aren’t any confounding factors.  And then, of course, this is not to mention the fact, as we discussed, that people have a tendency to underreport other unhealthy choices they are making and overreport the amount they exercise and perform other activities that they think are healthy.

Steve Wright:  So, we got a plausibly flawed beginning based on just the type of study it was to the conclusion that was drawn, we have an inaccurate way to collect data regardless of what the conclusion would be just in the study design, and we have an inability to accurately discern any correlation because of known problems with what we’re looking at.  What else is wrong with this study?

Chris Kresser:  Well, one little interesting tidbit here in terms of confounding factors that wasn’t reported on, which I’m not surprised by but it’s pretty interesting:  The people who ate the most red meat had the lowest cholesterol, and in fact, the more red meat people ate, the lower their cholesterol was.  It was a linear relationship.  So, the headline of this study could have just as easily been “Eating red meat lowers your cholesterol,” or even better, “Lower cholesterol associated with increased total mortality,” but of course, that wasn’t what they reported, but it does illustrate again the ridiculousness of using this epidemiological data, and it also shows how convenient it is for researchers to ignore parts of their data set that don’t support their agenda or their hypothesis.  The last thing that we’re gonna talk about is the actual data in the study itself and whether the data, when you look at the raw data, is convincing that eating extra red meat is actually correlated even, not causally related but even correlated strongly with an increased risk of death.  And if you look at this more closely, another way to summarize the data would be that 286 people would have to reduce their intake of red meat from two servings a day to about a half serving a day for 22 years to save one life, or that those same 286 people would need to eat about 3.2 million more pieces of meat between them to kill one more person over 22 years.  And that’s assuming, of course, that this data was accurately reported, which it wasn’t, and that it controlled adequately for all of the confounding factors, which it didn’t.  So, when you look at this way, even if all those other things were not true that we’ve already talked about, it doesn’t exactly sound like cause for alarm, does it?

Steve Wright:  No, no, I’m not really concerned anymore.

Chris Kresser:  Ha-ha, I don’t think you ever were, Steve, but –

Steve Wright:  Yeah, you’re right.  I’m eating a steak right now.

The truth about red meat and colorectal cancer

Chris Kresser:  Ha-ha, OK, so let’s talk briefly about other studies that have been done on the association between red meat and health problems like cancer.  That’s the most common thing is you see these correlations between red meat and particularly colorectal cancer, and to the point where a lot of people just take that as a given.  There have been more than 50 epidemiological studies done on that association, and probably, like, in the last 20 years, I think 35 of those were prospective studies.  There’s a really great paper that critically analyzes the claims that are made that show an association between red meat and colorectal cancer, and we’ll put that in the show notes.  But basically these researchers did a meta-analysis of all of these studies, and they found that the associations were very weak in magnitude; the relative risks were below 50%; most of the studies weren’t statistically significant, which means we can’t be sure that the difference isn’t just due to chance; and there was a lack of a clear dose-response trend, so you didn’t see, like, a linear association where the more red meat they ate, the higher their risk of cancer was.  The results also varied by anatomic tumor site, so there’s a stronger association between red meat intake and cancer of the rectum than there is in the proximal colon, and they also varied by gender, so there is no association at all with women and red meat consumption and cancer even though there is a weak association with men.  So, the thing is there’s really no plausible explanation for why red meat would be more likely to cause cancer in the distal colon or the rectum than in the proximal colon, nor is there any plausible explanation for why red meat would cause cancer in men but not in women because we have the same basic physiology.  And it’s worth noting that the studies on women had a much larger sample size, and there was no association at all in those studies.

And then, of course, there are confounding factors to consider.  Red meat has been shown to correlate positively with several known dietary and lifestyle risk factors for cancer.  For example, people who consume more red meat also tend to smoke more, consume more calories, exercise less, and eat less fresh fruit and vegetables, and have a higher body mass index.  And the researchers in this paper, in contrast to the ones who published the red meat study, were well aware of this, and they said:  “Colinearity between red meat intake and other dietary factors (e.g. Western lifestyle, high intake of refined sugars and alcohol, low intake of fruit, vegetables, and fiber) and behavioral factors (e.g. low physical activity, high smoking prevalence, high body mass index) limit the ability to analytically isolate the independent effects of red meat consumption.  Because of these factors, the currently available epidemiological evidence is not sufficient to support an independent positive association between red meat consumption and colorectal cancer.”  In other words, they said very succinctly what we’ve been talking about in this whole show.  There are too many confounding factors to be able to isolate the independent effects of red meat on cancer, and the data of all of those 50 epidemiological and prospective studies that have been done that suggest that there might be an association are not sufficient to prove that.  So, some people have argued that, OK, well maybe fresh red meat, unprocessed red meat is OK, but processed red meat is not.  And I’ve been wanting to talk about this for some time.  I think I did discuss it a while back on another show, but I’d like to cover it briefly again because I think there are a lot of misconceptions out there about processed meat, like bacon.

Steve Wright:  Can we do one thing before we get into that?

Chris Kresser:  Sure.

Steve Wright:  Because I love bacon and I want to talk about bacon.  But, say that I’m six months into the Paleo Diet or I’m just starting today, so I’m not, you know, one of us.  Tell me, Chris, how you in Chris Kresser’s world who wants to prove or disprove this finally forever that red meat causes or doesn’t cause cancer, tell me how you would set up this study, because I would love to hear you articulate how difficult it would be, because I know how I would do it, and it’s actually not possible in this free society that we live in for this to actually work.  So, can you do that real quick?

Chris Kresser:  Yeah, well, you’d take a group of people, you’d randomize them into two groups, and then you would put them in a metabolic ward setting –

Steve Wright:  So jail basically.

Chris Kresser:  Right, basically, like in a hospital.  They can’t leave.  You would give them the same exact diet, meaning they eat the same amount of fresh fruit and vegetables, they eat the same amount of everything except for red meat, and then you’d give one group a low amount of red meat and the other group a high amount of red meat.  Then you make sure they’re all doing the same amount of exercise.  You make sure that they’re equivalent in terms of body mass index, they have equivalent rates of diabetes and other modern lifestyle type of diseases.  If I were doing it, I would want to control for stress in some way if possible.  You make sure that they are not smoking or that they have the same amount of smokers or nonsmokers in each group, and then you would have to follow them for about 25 years, because that’s how long it takes some cancers to develop.  The cost of that study would be astronomical.  There’s absolutely no way that that could happen, and so, yeah, I agree with you that in this world that we live in, that study’s just not going to happen.

Steve Wright:  Yeah, we’re not gonna lock anybody away for 25 years and restrict who visits them and what those visitors have in their pockets and what they eat every day for 25 years.  OK, I just wanted to hear that, because sometimes when you’re not too familiar with studies and how they have to be critically designed to control for things, you might not think about what it would actually take to plausibly prove these links, and that’s what it would take.

Is processed meat bad?

Chris Kresser:  Right, but I just want to say that there are other ways you can build a case that wouldn’t be 100% conclusive but that would be more convincing.  For example, if we discovered a known carcinogen that’s been studied elsewhere that is in red meat and that red meat had a lot of that carcinogen and nothing else that would offset the effect of it, then that might be a more convincing argument, and that’s why I want to talk about the whole processed meat thing because that’s often an argument used against red meat or at least processed red meat.  The idea there is that nitrates and nitrites and nitroso compounds are carcinogenic, as has been seen in some animal studies, but the problem with this is that exposure to these compounds isn’t specific to meat intake, and in fact, exposure to them is a lot higher from other sources.  So, here’s another pop quiz:  Which of these food sources will give you the most ingested nitrites: 467 hot dogs, one serving of arugula, two servings of butter lettuce, four servings of celery or beets, or your own saliva?  What’s the answer, Steve?

Steve Wright:  Oh man, you threw in a couple — I thought you were going to make it easy, like, you know, 401, 400, but I’m gonna go ahead and I’m gonna go with the number one, arugula.

Chris Kresser:  OK.  So, the answer is your saliva.

Steve Wright:  Dang it!

Chris Kresser:  Ha-ha, but you’re close.  Nitrites are produced by your own body in greater amounts than we get from food, in general.

Steve Wright:  Is it the same chemically?

Chris Kresser:  We’ll get into that in a little more detail here.  Salivary nitrites account for 70% to 90% of our total nitrite exposure on a daily basis, but if you consider food alone outside of that, vegetables are actually the primary source of nitrite, and on average, and it varies place to place, but on average we get about 93% of the nitrites we obtain from food from vegetables alone.  And yes, nitrite is nitrite, nitrate is nitrate.  It’s the same chemical formula, the same chemical composition.  So, getting back to the quiz, you were right actually in your guess that a single serving of arugula is the highest dietary source of nitrite.  But two servings of butter lettuce and four servings of celery and beets — they’re all equivalent, and they all have more nitrite than the 467 hot dogs.  And your saliva has more than all of them.  So, the other thing that’s important to understand is that nitrite has beneficial impacts on immune and cardiovascular function.  In fact, it’s been studied recently as a potential treatment for hypertension, heart attacks, sickle cell disease, and some circulatory disorders.  And besides that, there’s very little nitrite in cured meats, as our pop quiz illustrated.  The USDA only allows about 120 parts per million of nitrite in hot dogs and bacon, but during the curing process most of that nitrite forms nitric oxide, which binds to iron and gives hot dogs and bacon that pink color that they have, and the amount of nitrite left after that is only about 10 parts per million.  It’s also really important to understand that neither nitrate, nor nitrite really accumulate in the body in significant amounts.  When we get nitrate from food, it’s converted into nitrite when it contacts the bacteria in our saliva, and then about 25% of the nitrate we eat is converted into salivary nitrite, and 20% is converted into nitrite in the gut.  The rest is excreted in the urine within about 5 hours, and what nitrate is observed has a very short half life.  It disappears from our blood stream in about 1 to 5 minutes.  Some nitrite in the stomach reacts with the gastric contents and forms nitric oxide, which may have some beneficial effect.  That’s been studied a lot lately.  And you kind of alluded to this, Steve, but the so-called natural nitrite or nitrate, or nitrite- and nitrate-free hot dogs and bacon, they use naturals sources of the same chemical, like celery and beet juice and sea salt, but it’s still NO3, which is nitrate.  And as Mat LaLonde is fond of reminding us, when it’s the same chemical structure, it’s the same chemical.  They’re no more free from nitrates and nitrites than the standard hot dogs and bacon.  They have the same chemical.  It’s just a different source.  So, I think the whole nitrite and nitrate things is overblown.  The WHO, World Health Organization committee on food additives says that the safe range is about 0.1 mg/kg/day, and in order to exceed that, you’d have to eat about 2222 hot dogs every day.

Steve Wright:  Whoa!

Chris Kresser:  Good luck with that, ha-ha.  Even the hot dog eating contest winners aren’t coming close to that.

Steve Wright:  No, I think we might be OK in the hot dog realm.  So, the big question is do you eat bacon, then, that has nitrites on the label?

Chris Kresser:  Yeah, I mean, I would.  We get our bacon from a local farmer, and I don’t think they, I mean, they use natural sources for curing, and you can still buy uncured bacon at the store, but if out somewhere, you know, like on a trip, traveling or something, I’ll eat whatever bacon is in front of me.

Steve Wright:  Gotcha.  OK.  Yeah, and I’m glad you brought up the point about natural, basically it’s preservatives, natural preservatives on a label versus a chemical preservative, and that I think actually what most companies are starting to find is that it’s cheaper and more effective to use the natural than the synthetic forms, and I’m starting to see them all over labels now, the celery extract in the various ones, so I think that’s going to be a growing trend that everyone is going to continue to observe for the next 5 to 10 years.

Chris Kresser:  Well, these methods have been used for a long time, right?  I mean, curing of meats goes back a very long time, and so they were using these “natural” sources long before the synthetic ones.  So, another theory of how red meat might be harmful is it’s not the red meat itself but cooking it at high temperatures, and that creates heterocyclic amines or polycyclic aromatic hydrocarbons, which may be carcinogenic, and I’m certainly open to this as a possibility.  There is quite a bit of research that shows that cooking methods do alter the health benefits or effects of food that we eat.  Stephan Guyenet has talked about this a few times, and someday I might write an article about it, and I imagine he might, as well, but the study results for the harmful or mutagenic activity of these compounds in relation to colon cancer have been pretty mixed.  So, it’s difficult to draw any conclusion about cooking red meat at high temperatures and relationship to colon cancer based on the available data.  And then lastly, of course, it’s been suggested that red meat might cause cancer because of its saturated fat content, but there have been good meta-analyses done of the prospective studies in this area that have shown no association at all between saturated fat intake and cancer.  And in fact, a lot of recent evidence suggests that conjugated linoleic acid, which is a natural trans fat that’s found in beef, may have anticarcinogenic properties.  So, if anything, red meat might be protective against cancer.

Steve Wright:  Oh no!  Did you just say trans fat in red meat protects against cancer?

Chris Kresser:  I sure did!

Steve Wright:  Oh man, the FDA’s gonna get us.

Chris Kresser:  That’s crazy, huh?  These studies are pretty interesting, and it’s one of the benefits of particularly pastured animal products.

Steve Wright:  Gotcha.  Can we back up one sec on a cooking topic?  Did you say anything about advanced glycation end points or AGEs and ALEs?  Is that what you were talking about?

Chris Kresser:  Not exactly, but that’s another potential mechanism, and you know, I’m curious about this.  I’m not sure.  I’ve seen some evidence that is pretty convincing, and yet I also think about from an evolutionary perspective the history of how we cooked and consumed meat, you know, directly in a fire for a long period of time before we had slow cookers, and I wonder about that.  But in general, I think there are a few reasons that it’s probably a good idea to eat meat, and food in general, that’s prepared with gentle cooking methods and particularly if you have a gut issue.  I mean, the slow cooked foods or the braised foods, low temperature cooking methods can make these foods, especially when you’re using broth, a lot more assimilable.  So, personally I don’t avoid high temperature meat all the time.  We have a grill.  I sometimes use it.  I don’t really tend to fry things, but I will grill things occasionally.  But I do favor stews or low temperature roasting or slow cooking or braising, things like that, because I just feel like it’s more nourishing, they’re easily to assimilate and digest, and I’m also kind of hedging my bets a little bit until I’m more clear on the effect of cooking temperatures.

Steve Wright:  And the cooking temperature problem — correct me if I’m wrong — is because the protein structures at different temperatures will actually go from, say, a line to a ball and they’ll sort of get all crumpled up and then it becomes actually hard to break them back apart once it’s in the body?

Chris Kresser:  Yeah, I mean, there are a lot of different theories.  That’s one, and then we just talked about these heterocyclic and polycyclic compounds that may be carcinogenic, and AGEs, and there are really quite a few ideas about what could be a problem.  So, as I said, I do favor the lower temperature cooking methods for a number of reasons, but I’m not afraid of having a grilled ribeye steak every now and then.

Steve Wright:  Yeah, it seems like is part of the 0.5% that you need for your health.

Chris Kresser:  Yeah, I mean, some people think it might be more significant than that, but I think that if you’re healthy and taking care of yourself in all of the other ways that we talk about, having a grilled steak once a week is unlikely to have a significant impact.  That’s just my sense at this point.

Steve Wright:  OK.

Why red meat can be good for you

Chris Kresser:  Let’s very briefly, because I know we’re getting close to the end of the hour here, talk about some benefits of red meat, and then I want to end up by talking about who, if anyone, should limit their red meat consumption and why.  So, red meat, I think, is one of the best meats from the perspective of the omega-6 to omega-3 fatty acid ratio, and that’s particularly true of pastured beef because — The main difference actually between pastured and grain-fed beef is not the omega-6 content, it turns out to be about the same in both, but the omega-3 content, which is about three times higher in pastured beef, and of course, it’s the ratio that we’re concerned with between omega-3’s and omega-6’s.  So, pastured beef has three times more omega-3 than corn-fed beef or factory-raised beef, and so it’s gonna have a better ratio.  That, in turn, has a beneficial impact on inflammatory loads, less likely to cause inflammation.  Red meat is a good source of other fats like saturated fat and then the natural trans fat that we just talked about, conjugated linoleic acid, which may be anticarcinogenic.  It’s particularly nutrient dense.  It’s a great source of a lot of vitamins and minerals and actually a very absorbable form of these vitamins and minerals.  So, for example, beef is a great source of heme iron.  Heme iron is much easier to digest and absorb than the ferrous form or plant forms of iron.  For example, when I have patients with iron deficiency, I’ll often recommend if they’re not already eating a lot of red meat, eating red meat or liver and oysters, and that can bring up their iron significantly.  A lot of people who take iron supplements experience gastrointestinal discomfort, constipation, and things like that, and that’s because usually the form of iron in there is the ferrous form and it’s not well absorbed and it can be hard on the gut.  Red meat, of course, is a great source of zinc, as well, and we talked about in a previous show the problems associated with zinc deficiency or excess copper, or elevated copper-to-zinc ratio.  And then red meat is a really highly assimilable source of protein, easy for the body to break down.  It’s a complete protein.  So, there are a lot of reasons to eat red meat, especially pastured red meat.

Steve Wright:  So, if you had to, like, if we wanted to rank meats, when maybe we actually don’t even want to, but if we had to rank meats just based on o6 and the ratio of omega-6 to omega-3, what would be the order of the meats that you would eat?  If you were basing it just on the o6/o3, which is not the only consideration you should give or take.

Chris Kresser:  Yeah, I mean, from the commonly consumed meats?

Steve Wright:  Yeah.

Chris Kresser:  Beef is number one.  Lamb, I think, would be next.

Steve Wright:  What about seafood?

Chris Kresser:  Well, seafood is higher, I mean, like, salmon has significantly more omega-3 and not very much omega-6, so that would be the highest.  Beef would be the number one for the commonly consumed meats, I think lamb would be next, pork would be after that, and then chicken comes up last actually, which most people are surprised by, especially the dark-meat chicken or chicken with skin.  So, that’s kinda the hierarchy.  If you throw game meats in there, wild game meats, it’s different, and I don’t know those off the top of my head, but in general, they tend to be lower in omega-6 especially because they’re not factory farmed, you know, so they’re all kind of pastured for the most part.

Steve Wright:  Right, and then if you wanted to throw one more, like, you wanted to just put eat more red meat on there, I would say that polyunsaturated fats, which we’ve talked about before, oxidize quickly within heat, which is another problem that people talk about when they talk about what temperature are you cooking your meat.  So, therefore, if you have a high load of omega-6 plus omega-3 fat in the type of meat, which is true in poultry versus red meat as much lower, you might consider red meat a better meat at that point too.

Chris Kresser:  Yeah, fried chicken in corn oil, dark-meat chicken with skin on it, is probably not the best choice.

Steve Wright:  No, ha-ha.

Chris Kresser:  Sounds good, though, huh?

Steve Wright:  Yeah?

Chris Kresser:  No, doesn’t sound good.

Steve Wright:  No, not really.  It makes my stomach turn a little.

One reason you may need to limit red meat consumption

Chris Kresser:  Minus the corn oil, ha-ha!  OK, so the last point here, and this really short:  There is one population of people that might want to limit their red meat consumption a little bit, and these are people with iron overload conditions like hereditary hemochromatosis, where they have a genetic predisposition to storing excess iron.  So, I see a lot of these people in my practice, and my talk at the Ancestral Health Symposium this year is gonna be on iron overload and its consequences, so I’m gonna be talking and writing about it more, but there are different ways to manage it.  The main way is phlebotomy or withdrawal of blood.  Once you have an accumulation of iron, there are only two ways to get rid of it, and one is phlebotomy and the other is chelation.  And chelation therapy has a lot of side effects and is pretty risky and is only indicated if somebody is simultaneously anemic and has iron overload, so they can’t withdraw blood because they’re anemic.  But the other thing to do is you have to actually make some dietary and lifestyle modifications to do things to decrease iron absorption and decrease your intake of iron.  So, in that situation, you might want to favor fish and pork and maybe light-meat chicken, eat less red meat, and take cod liver oil instead of eating organ meats because liver is a really high source of iron, oysters are pretty high in iron.  So, those people would do better eating a little bit less red meat, and if they do eat red meat, there are some more advanced stuff they can do to limit the absorption of iron when you eat red meat that I don’t actually want to get into right now.  But it’s a fairly common pattern, but it affects maybe 1 in 200 to 1 in 300 people, I would say.  So, that’s pretty much it.  I couldn’t really think about any other population of people that would have a reason to limit red meat aside from that.

Steve Wright:  Well, that’s good to know because the people I talk with a lot, they have the gastrointestinal issues and they’re already at increased risk for cancer, so I’m glad that we were able to talk about, you know, colorectal cancer and all types of cancers in regard to red meat and the fact that everybody is gonna be just fine.

Chris Kresser:  Everybody is gonna be just fine.  Good words to live by.

Steve Wright:  Yeah.

Chris Kresser:  All right, so thanks, Steve, and we’ll see you all in a couple weeks.

Steve Wright:  OK, sounds good, Chris.  Well, Chris and I would like to thank you for listening today, and please keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show, please head over to iTunes and leave us a review.

The placebo effect defies the mainstream medical understanding of the relationship between mind and body and its role in health and disease.  In this episode we discuss what placebo (and its lesser known twin, nocebo) can teach us about the human capacity for self-healing, and how we can harness that power to optimize our health.

In this episode, we cover:

2:45 The latest study revealing the power of placebo, nocebo, and belief in healing
8:57 Does the placebo effect really show measurable results in humans?
23:25 The little known “nocebo effect” and how it impacts your health
27:47 Harnessing the body’s amazing capacity to self-heal

Links We Discuss:

• JAMA study: Lessons From Recent Research About the Placebo Effect—From Art to Science
• JRSM study: The power of context: reconceptualizing the placebo effect
• SCD Lifestyle article: The power of social interaction on healing

Full Text Transcript:

Steve Wright:  Hi, 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, Chris?

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

Steve Wright:  I’m doing good, as well.  You had a big week, didn’t you?

Chris Kresser:  Yeah, it’s crazy.  We moved.  We moved last Friday.  Still in Berkeley, but we’re up in the Berkeley Hills now, and it’s really nice.  I’m really happy to be here.  I’m looking out right now from my office into the redwood trees and overlooking Wildcat Canyon back in Tilden Park, so it’s really peaceful, quiet; air is cleaner.  It kinda feels almost like living in the country, but we’re only 5 minutes away from all the good stuff.  But I’m surrounded by cardboard boxes, and it’s crazy moving with a 7-month-old baby.  I wouldn’t recommended it, ha-ha!  So I’m pretty beat, but it was a good move, and we’re happy to be here.

Steve Wright:  Awesome, so you’re literally moving up in the world!  I like it.

Chris Kresser:  Ha-ha, I guess you could say that!

Steve Wright:  Yeah, nobody likes moving.  I’ve moved way too much in the last three years, and it’s — Getting out of the boxes, I think, is the worst.

Chris Kresser:  Yeah!

Steve Wright:  They linger.

Chris Kresser:  It’s so much easier packing them than unpacking them for some reason, at least for me, and in our last place because we knew it was temporary, we had some boxes that were still unpacked before we moved again, so I really do not want to do it again any time soon.

Steve Wright:  Is there any research regarding human behavior and unpacking boxes?

Chris Kresser:  Ha-ha, I don’t know.

Steve Wright:  The pain scale?

Chris Kresser:  I think moving has got to be up there — I think it is actually one of the top five stressors.

Steve Wright:  I believe it.

Chris Kresser:  Yeah, so, glad to be done with it.

Steve Wright:  All right, great.  Well, you kinda threw a curveball at me this week, so what did you want to talk about this week?

Chris Kresser:  You know I like doing that, Steve.

Steve Wright:  Yeah, yeah, spring training’s just starting.  I’ve been working on my swing, man.

The latest study revealing the power of placebo, nocebo, and belief in healing

Chris Kresser:  Ha-ha, yeah, so we were gonna do a 100% Q&A episode this time, and I like doing those, but also, as I’m sure a lot of you know, I like sometimes just riffing on a particular topic.  And there’s one topic that really fascinates me, and it has for a long time, even before I went into medicine as a career, and I saw an editorial in the Journal of the American Medical Association on this topic, and it inspired me to want to spend some time talking about it.  So, the topic is placebo, or the placebo effect, nocebo, which some of you might not have heard of, and the power of belief in healing.  And I want to kind of talk about the specifics of placebo and nocebo because I think they’re interesting, but more particularly, I want to talk about them as a way of getting at the role of belief and the mind and our attitude in the healing process, which I think is what’s most important about all of this stuff.  And the more I work with patients and the more I observe myself and my own experience, the more convinced I am of the role of mind in healing, the importance of the mind in healing, and that it’s the thing that most of us tend to neglect.  It’s so much easier to take a new supplement or even to change the diet than it is to make changes in our behavior and our beliefs and our way of interacting with the world and ourselves, our relationship with ourselves and our relationship with others, that I think in a lot of cases that I see in my patient population and even in my own journey with healing and health, it’s something that tends to get left behind or at least diminished, and I think that that can be a problem or it can be something that holds us back from being as healthy as we possibly can.  So, I just want to share this recent study and then some older studies that I reviewed and some other information about it that I think would be interesting.  Then we can talk a little bit more about what the significance of all of this is in terms of healing and health.

So, this article in JAMA was specifically focused on the role of the clinician and the clinical ritual in the healing process, and there was a commentary about it on one of the blogs I follow, Dr. Sharma, and the first line of that commentary was, “Witch doctors were onto something.”  And the idea is that the clinical encounter between the doctor and the patient turns out to have a real, measurable, objective effect on the treatment, and we’ve seen — Neuroimaging studies have been done now in the past decade that have shown activation of neural pathways in the brain involving endorphins and dopamine that are elicited when subjects receive a placebo, and that’s especially true when they think that they’re getting an active ingredient.  And even effective drugs benefit from this effect, so authors of the study describe examples of other studies where the effectiveness of a drug, like for pain or anxiety, is greater when the subject knows they’re getting the drug than if it’s administered to them without their knowledge, so that’s fascinating.  So, like, they’ll give a patient a pain-relieving drug, you know, in an open way, so hand them the drug, they know they’re receiving the drug, they know they’re taking the drug.  But if they give the patient that same drug and they deliver it via a pump that hidden behind a screen so the patient does not know when or if they’re getting the active drug, that same exact dosage of the drug will have much less of an effect.  So, of course, this completely suggests that the context of the healing encounters — so the delivery of the medication, the patient’s association with the medication, everything they’ve read about it or heard about it or seen on TV, and they’re friends have told them about it, or the doctor telling them that it’s gonna be effective when he gives it to them — that those aspects of the clinical encounter are as important and perhaps in some cases more important than the actual ingredients of the drug themselves.  And so, I’m gonna quote from the study.  They said: “Positive beliefs about future outcomes, especially when connected with an intervention recommended by a clinician, may trigger those outcomes.  Moreover, much of medical practice consists of repeated rituals that may create conditioned responses that can be reactivated in the future by placing the patient in a similar environment.  In conscious persons, conditioning overlaps with learning, thus creating positive expectancies.”  So, in other words, just the ritual of going to the doctor and getting a prescription or a diagnosis or the doctor telling you that you’re going to get better can have a real, measurable, biological effect on healing.  And we also know that the healing power of simply providing a positive experience to the patient should never be underestimated.  Quoting again, they say:  “…inviting and listening carefully to the patient’s story of illness experience, or offering a satisfying explanation for the patient’s distress, expressing care and concern, communicating positive expectations for therapeutic benefit, and helping the patient to feel more in control of life in the face of illness.”  All of these things contribute to healing and to a positive clinical encounter.

Does the placebo effect really show measurable results in humans?

Chris Kresser:  So, there are a lot of ideas about what the placebo effect is.  And you know, for a long time it was thought that it was just all in the patient’s mind, so to speak, so there weren’t any objective or measurable effects associated with it.  It was just the patient believing that they were better and that belief was all that there was to it.  And then there have been a bunch of studies that have shown, no, there actually are measurable biochemical effects that can be elicited by taking placebo.  So, it’s kind of mixed and it depends to some extent on what condition is being treated.  For example, there was a recent study on asthma treatment, and they separated the patients into two groups.  One group got an albuterol inhaler, which is, you know, the typical treatment.  And the other got a placebo inhaler, so it was just a fake inhaler with nothing in it.  So, the placebo inhaler had no measurable effects on lung function, but when it came to patient-reported outcomes, it was equally as effective as albuterol in relieving discomfort and self-reported asthma symptoms.  So, in other words, the placebo inhaler was just as effective as the drug version in helping people feel better, which I think is really interesting.

Steve Wright:  That’s really interesting because that’s, I mean, that’s your breathing, right?  So, that would suggest that maybe they feel less stressed once they take the inhaler, because I have asthma, or I have chronic, you know, like, exercise-induced asthma, so I know the feeling, and that’s really interesting.

Chris Kresser:  Yeah, it really makes me think a lot about not only just what’s happening physiologically, because they didn’t see a measurable effect on lung function, but the subjective experience of the lung function was different and it was improved with the placebo.  So, it implies that it’s not just that there is an objective aspect to illness and to health that can be measured, but there is also a subjective aspect to health and illness that really is difficult to measure.  At least we don’t know how to measure it yet.  And that makes me think of — and this might be a little bit of a tangent, but we’ll get back to it — You take, you know, I’ve often talked about the importance of having a purpose and of patience in the healing process, and I think part of what that’s about for me is that if you’re dealing with a chronic illness and all you do is focus on your illness and trying to get well and that consumes you and that constitutes the bulk of your experience on a day-to-day basis, I think that patient is not gonna do as well as someone who is struggling with a chronic illness but is, you know, able to still devote themselves to something that they care about, whether that’s a cause or work that they believe in or, you know, relating to friends or taking care of their family or whatever it is.  And I think that subjective experience of how they live with that illness and how they experience the illness on a day-to-day basis has a really significant effect on, you know, compared to just the objective things that we can measure about the illness itself.

So, getting back to the placebo, there have been some other pretty interesting studies that I just want to go through quickly.  One recent study used placebo to reduce the active dose of steroids needed to successfully treat psoriasis, which is an inflammatory skin condition, by about 50% to 75%.  So, the researchers in this study wanted to determine if a drug’s therapeutic effect could be triggered by the qualities that are associated with that drug, like the shape or the color, smell, packaging, as well as the administration of it by an authority figure in a white lab coat, and this has been known for a while, that these factors do play a role in the placebo effect.  The theory is that these — it’s kind of like a Pavlov response, so the repeated associations of drugs with all of these features of how they’re administered creates a conditioned response, you know, like the ringing of the bell and the salivation, and the therapeutic effects of a drug are caused not by the ingredients of that drug alone, but by the stimuli associated with the rituals of giving the drug.  And so, the researchers looked at about 50 patients with mild to moderate psoriasis, and one group got a full dose of steroid cream with every dose, and the other group got a full dose only 25% to 50% of the time, and then they got a placebo cream, just like a moisturizer, the other 50% to 75% of the time.  And guess what?  Both groups improved by the same amount, and there was no difference in relapse between the two groups.  And the dose that the second group was receiving was theoretically not even enough to be effective.  It was below the active dose of the drug, and they still improved to the same degree as the other group of patients that was receiving the full dose of the drug.

There’s another study where patients who were in a lot of pain after wisdom tooth extraction got just as much relief from a fake application of ultrasound as patients who got the real ultrasound as long as both the patient and the therapist thought that the machine was on.  And it didn’t work the same way if one or the other knew that it was fake.  It’s pretty well known now, as I just mentioned, that the color of pills affects the outcome of a treatment, and that effect is widespread across all different cultures.  For example, in Italy blue placebos make really good sleeping pills for women, but they had the opposite effect on men.  Like, they actually gave men worse insomnia.  And they were really trying to figure out why this would be until somebody pointed out that the Italian soccer team’s color is blue and, you know, Italian men are crazy for soccer, it gets them really excited, so the theory was that the association of Italian men with blue was as a really stimulating color, and that actually affected the outcome or the effect of these placebo treatments.

Steve Wright:  That’s interesting, because I thought of Viagra.

Chris Kresser:  Right.  So that’s the US association, right?  So, it would work differently here.  Yellow pills are known to make the most effective antidepressants.  It’s kind of, you know, giving you a little dose of sunshine.  And red pills are more stimulating.  Green pills, in general, reduce anxiety.  White pills, especially those that are labeled as antacids right on the pill themselves, have a greater effect on ulcers than other colors of pills or pills that aren’t labeled as antacids.  Placebos that are taken four times a day give more relief than those that are taken only twice a day.  So, just the ritual of swallowing a pill has some effect.  Placebos that are stamped with widely recognized trademarks, you know, names that we know of, companies, are more effective than generic placebos.  And pills — speaking of Viagra, Steve — pills with clever names have been shown to increase effectiveness.  Like, Viagra implies both vitality and a Niagara Falls’ worth of sexual performance.  That was certainly intentional when they named it that way.  And interestingly enough, the placebo effect is not limited to pills or medicines.  There’s a Dr. Bruce Moseley, an orthopedic surgeon, I think he’s in Seattle, and he’s performed studies doing placebo surgery, which is also referred to as “sham surgery.”  And he took 180 patients who needed knee surgery, and he put them into three groups.  Two groups received the actual surgery, and I think there was some variation in those two groups; I can’t remember what it was.  And the third group received a sham surgery.  So, what they did is they went through the whole routine, so they opened up the knee, and then they just, like, I think, sprayed it with a little bit of water or they did something that kind of — You know, they went through the ritual that they normally go through, and the patients in the third group who didn’t get the actual knee surgery improved just as much as in the first two groups.

Steve Wright:  Did they know they were part of a study?

Chris Kresser:  Yeah, they did, and this brings up a whole other interesting topic:  the ethical questions about placebo use in clinical practice.  And you know, a lot of doctors actually admit to giving placebo to patients, especially patients that are requesting, you know, drugs that aren’t really indicated in a particular situation, like an antibiotic for a cold or something like that, and there’s been a real debate about whether that’s ethical, you know, to give somebody a placebo when you tell them that you’re giving them a drug.  And I don’t really want to get into that whole discussion now, but there have been a lot of new techniques in the research to deal with that question.  But a lot of these studies, they know there’s a placebo arm, but they don’t know whether they’re receiving the placebo or not, so it’s double blind.

Steve Wright:  I don’t know.  I guess I wouldn’t sign up for a –

Chris Kresser:  A sham surgery!

Steve Wright:  A placebo knee replacement!  I feel like surgery is at another level compared to taking pills.

Chris Kresser:  Yeah, isn’t that interesting, though?  I mean, there is speculation about why, you know, how could that happen, and certainly just cutting the knee would initiate an inflammatory reaction in the body and a self-healing response that could have a significant impact, but you might not expect that impact to be as significant as going in and actually repairing the ligaments in the knee.

Steve Wright:  Yeah.

Chris Kresser:  But I remember reading about that study when it came out, and it was actually — I think there was even, like, a documentary or at least a short news feature about a guy who was in the third group, and he was in a wheelchair before he went into the hospital.  He couldn’t even walk, he was so out of it, and then in the show, you know, they show him after the surgery and he’s out in the backyard playing basketball with his son, and they talked to him about it, and he — You know, some people were actually quite angry, even if they were better, but he had had kind of like a revelation or an epiphany because it totally changed the way he looked at healing and his own body’s capacity to heal itself, and it inspired him to really have a much deeper respect for the body’s capacity for self-healing, and he was ecstatic that he had been through that experience.  But, yeah, people have different responses.

Steve Wright:  That’s really amazing.  So, in any of these studies that you looked at, did they ever measure — like, for instance, in the albuterol one — did they ever measure, like, cytokines or any IL-6 markers to see if placebo versus active treatment actually lowered stress at a physiological level?

Chris Kresser:  Yeah, they do.  Some of the more recent studies do measure those markers, and I mentioned the neuroimaging study that looked at levels of dopamine and endorphins, so those are, you know, real biochemical markers that are changing.  That’s pretty recent, you know, maybe in the last 10 years that that’s been happening.  The older studies didn’t tend to look at those things or report on them.  I don’t know of a study specifically about placebo measuring cytokines and other markers of stress, but certainly one of the main theories about how placebo effect works is that it works by regulating the hypothalamic-pituitary-adrenal axis, mitigating the impacts of stress on the body and, you know, decreasing that stress response.

Steve Wright:  Yeah, because it would make sense, I mean, when you talk about the pattern of if your preconditioning before this has been that you go to an office and talk with a doctor and he gives you a pill and then, you know, it’s happened a few times before that after you take that pill you get good results, that when you do that same pattern again, you’ll expect the same results, which should lower your overall stress around the situation probably.

Chris Kresser:  That’s right, and so it has, like, a cascade of effects, as you’re pointing out.  So, it’s the expectation that you’re gonna get well, which itself seems to help people to get well, and then it’s the conditioned response where you’ve been through this ritual of action several times and it’s had a certain result at the end of all of those actions, and so that’s more likely to happen again, and then there’s just the impact of the reduction of stress that comes from going to the doctor, having a positive interaction, and you know, maybe getting a diagnosis or an explanation for how you feel and some reassurance that it can be dealt with.

The little-known “nocebo effect” and how it impacts your health

Chris Kresser:  Now, of course, there’s another side of this coin, right?  The other side of the coin is the nocebo effect, which is the sort of evil twin of the placebo effect.  Have you ever heard of the nocebo, Steve?

Steve Wright:  No, I have not heard of the nocebo.

Chris Kresser:  Yeah, it’s interesting because it’s not very well known compared to placebo, but it describes the opposite of what we’ve been talking about so far.  So, placebo refers to the benefits produced by a treatment that should have no effect, but the nocebo effect is just the opposite.  And of course, this has been well known outside of the medical community for a very long time.  It’s even in our language, like, if you say the phrase “scared to death” or “worried sick.”  The phenomenon of voodoo death in traditional cultures is pretty well documented.  I mean, we don’t understand how it works, but it’s true that in certain traditional cultures a medicine man or a witch doctor or whatever you want to call it will put a hex on somebody in the tribe or in another tribe, and then that person when they know that the hex has been put on them, they die of fear, essentially.  But in a more modern context, there are still plenty of examples of it.  In the Framingham Heart Study, which I’m sure a lot of people have heard of, the longest running study on heart disease that’s been done so far, women who believed that they were prone to heart disease were nearly four times as likely to die as women with similar risk factors who didn’t hold the same views.  So, just the belief that they were going to get it, you know, they died four times as often as, or died earlier than women who didn’t.  And that’s just an association.  There’s no causality there, of course, but it’s interesting.

Steve Wright:  Yeah, that opens a whole door to should you get your genetics tested or not.

Chris Kresser:  Yeah.  We can talk a little bit about that too.  In studies done of people going into surgery who want to die, like to reconnect with a loved one, so you know, maybe they’ve been married for 50 years and their partner dies and then they’re having a surgery and they really want to die because they’re so sad, close to 100% of those patients will die in surgery.  Men taking a commonly prescribed prostate drug who were informed that it might cause sexual dysfunction were twice as likely to become impotent.  And there are a lot of studies like this, where they’ll take two groups of people, they’ll give them a drug, and in the one group they don’t say anything about it, and in the other group they read them the list of side effects.  And the group that has been informed about the side effects, they’re way more likely to experience all of those side effects.  One of my favorite nocebo studies was a study that happened in Japan, and they took 57 high school boys and tested for their sensitivity to allergens, and they filled out questionnaires about past experiences with plants, including lacquer trees, which cause itchy rashes that are pretty similar to what poison oak or poison ivy do here.  And the boys who reported having severe reactions to this tree were blindfolded, and then the researchers brushed one arm with leaves from a lacquer tree, but they told the boys that they were chestnut tree leaves.  And then they stroked the other arm with chestnut tree leaves, but they said that that foliage actually came from a lacquer tree.  And within minutes, the arm that the boys believed to have been exposed to the lacquer tree began to react even though it was the chestnut tree, and it turned red and they developed a bumpy, itchy rash.  And in most cases, the arm that had contact with the actual lacquer tree did not react.  That’s just amazing to me!

Steve Wright:  Ha-ha, I want the video!

Chris Kresser:  Yeah, it’s almost hard to believe, but all of these studies are reported in peer-reviewed journals and, you know, it’s –

Steve Wright:  I don’t care.  I want the video.

Chris Kresser:  Ha-ha, OK.  It sounds fantastic, but this is the power of belief in healing and disease.

Harnessing the body’s amazing capacity to self-heal

Chris Kresser:  So, what does all of this mean for clinicians and patients?  For patients, I think it means that, like I just said, I would hope it gives us an appreciation of the body’s innate ability to heal itself.  And one paper I like referred to this as the “endogenous health care system,” so it’s our — I mean, it’s pretty miraculous actually.  The more you understand about the body and how it works and how the immune system works, the more miraculous it seems.  Like, every moment as we’re sitting here and breathing and recording this podcast, walking down the street, whatever it is, the body is just constantly healing itself, without our awareness or conscious control at all.  And you know, in our culture and particularly in the last hundred years, there’s been such a huge focus on science and technology in medicine, and I think we’ve forgotten about the amazing capacity of the body to heal itself.  So, that’s something whenever I read about this stuff, the placebo and nocebo, that’s kind of what I come away with, is just a renewed appreciation of that.  But also, though, it means that it’s really important, I think, for patients to believe in what they’re doing.  And as we’ve discussed, just having the expectation that what you’re doing is going to work actually makes it more likely to work.  And you know, some people might be saying:  Well, sure, I get that, but how can I manufacture that?  Like, it’s hard to just pull that out of nowhere, and a lot of these things that we’ve been talking about are deeply conditioned responses that are outside of our conscious control, and it is hard to manufacture, but I think there are some ways that you can avoid interfering with that.  And one of the main ways to interfere with that system of expectation and belief is information overload.  So, these days, you know, any particular perspective that you adopt or embrace, you can get on the Internet and within 5 minutes you can find about 50 other perspectives that conflict with it.  And I see people in my practice and, of course, on my blog who are just paralyzed with, you know, as my dad would say, the paralysis of analysis.  There are just so many completing points of view, so many different perspectives, and they all conflict, and then the person just gets literally paralyzed and can’t move forward and doesn’t know to do.  And so, I think one of the things as a patient if you’re under somebody’s care, one of the best things to do is just to put your faith in whomever you’re working with at least for a period of time, and stick with it, and kind of — I wouldn’t say keep your head down, but you know, like, try to resist the impulse to going on the Internet and poking a bunch of holes in whatever it is that you’re doing because that’s probably not going to benefit you.

Steve Wright:  Yeah, I think you hit on the key right there, which is if you’re working with a doctor or specialist or whoever you’re working with, coach, if you come in with the mindset that everything that they say you want to find out if it’s true, then you’re always gonna be looking to find the opposite.  You’re never gonna look for the info that might back up the person that you’ve entrusted with your health and your money.  So, you want to be very careful of that, because I find a lot of people, get a lot of emails from people who are in that paradigm.

Chris Kresser:  Yeah, it’s a hard road, that one, and I mean, I understand.  I’m very, ha-ha, I’m not the sort of person who just accepts what people tell me, and so I completely relate to that impulse, and I think it’s an important impulse and one that we should — that in certain contexts is really crucial to engage, but I also know that I work with — You know, sometimes I’ll hear from patients, you know, I’ll do an initial consult, and they’ll call me up, and they’ll say:  Yeah, you know, I’m dealing with this, this, and this, and my doctor says this, and I have an holistic MD and he says that, and my chiropractor says that, and you know, and now I’m calling you and I want to start working with you.  And my response is usually:  What is it that’s not working for you?  They’re like:  Oh, well, it’s OK, but I just kind of want to get a different perspective.  And 9 times out of 10, I’ll tell those patients to just go back to what they’re doing with their other practitioner and give it a shot, and really stick with what they’re saying, you know, for a period of time, not forever, and just do it, instead of constantly looking for the next thing because, again, while I understand that, I understand the urgency if you’ve been sick for a long time, it sucks, nobody likes that, they want to start feeling better as soon as possible, but I think this is where patience and a little bit of faith and commitment come into it, because otherwise you end up digging a bunch of shallow wells and you never hit water.

Steve Wright: Yeah, I couldn’t agree more, and if I could take a second to do my own little riff here, because this is a topic that really hits home with me, is that I hear from a lot of people who are still in a lot of pain, and they can hardly get by on a daily basis, and they have several people in their life that they’re taking advice from on their health, and it makes since to me what you’re talking about, Chris, with people who would call you and say:  I have all of these people in my life that are giving me advice, and I’m not getting anywhere.  And I think really what it comes down to is instead of trying to poke holes in the recommendations of the various people in your life that are trying to help you, is that you need to properly evaluate whether those people need to be giving you advice and learn to fire who is not giving you advice that’s working for you after you’ve properly tried what they’ve done.  Don’t pick and choose treatment A from so-and-so, treatment B from so-and-so, and then, you know, number two from other guy that you read about on the Internet.  You know, try a treatment from someone and do it fully like they asked you to do it, but even before you do that, vet who these people are.  You know, if you’re trying to lose weight and you’re taking advice from someone who’s overweight, maybe you want to look somewhere else.  So, that’s something that I get a lot on our blog, and so I just want to throw that out there.

Chris Kresser:  Yeah, exactly.  And you know, I just want to be clear.  This isn’t a criticism, and if it were, I’d be criticizing myself because early on, you know, when I first got sick and I got back from Indonesia, where it all started for me, I was in a real hurry to get well, you know, because understandably I was in a lot of pain and discomfort, and I was young, and I just wanted to get on with my life.  And so, I did that.  I played that game early on, where I was kind of balancing from one practitioner to the next, and if a few weeks went by and I wasn’t better, I’d go on to the next person, or even while I was working with one person, I was already researching for the next person.  And I can say from direct experience that that didn’t turn out very well.  You know, that period of time was really stressful for me and not very effective in terms of my own healing process.  And yet, I look back on it and I think, well, I was just doing what, you know, it was pretty natural for me to do that at that point, and I’m not judging myself and I don’t judge any other people for doing that.  I’m just maybe trying to share a little bit of my experience personally and also working with patients that if possible, you know, like you said, sticking with a particular approach, and not doing the kind of buffet style of treatment, and giving it enough time to work.  I alluded to that before when I said that patience and having a purpose, I think, are two of the most underrated qualities we can have in terms of our journey towards health.  If we just stick with it and give it enough time to work before we do that evaluation, I think that can be really helpful.

Steve Wright:  I just want to jump in real quick and say that I didn’t mean to say the same thing that you said, and I did the exact same thing that you have done as well and jumped through many different doctors and everything, and I’ve been through that spiral as well, so what I’m curious to hear from your perspective is that same person that we both were who, you know, they’re not sure who to listen to or they’re not getting results fast enough for them, what questions should they be asking?  Because I feel like it’s a question problem, that when I was younger I wasn’t asking the right questions from the medical people that I was talking to.

Chris Kresser:  Yeah, that’s a great question.  I think some of it boils down to strategy and approach.  Like, my belief is that it’s always best, if possible, to get to the underlying cause of a problem and address it at that level.  And I want to know, if I’m working with a practitioner myself, I want to know if that’s their approach.  You know, I want to know that the things that they’re doing are geared towards getting to the deepest level possible of what the disharmony is and addressing it at that level instead of just, you know, I have this symptom.  OK, you take that supplement or drug.  I have that symptom.  You take that supplement or drug.  So, asking questions about if you’re given a diagnosis, OK, well, why?  What’s causing that?  Do you have any ideas or thoughts about why that might be happening?  Just being inquisitive and trying to get to the bottom of it.  And if your practitioner gets defensive when you ask those kinds of questions, then that’s probably not the best person to work with.  In general, I think for me, as a practitioner and having been on the other side of it, being able to have kind of a collaborative relationship is really important, and that means feeling free to ask questions like that without fearing the practitioner getting really defensive, you know, or just shutting down.  That’s important.  I think some of the more obvious things like being in alignment with some of the patient’s own beliefs and perspectives.  Like, you know, if you’re someone who really has had a fantastic experience on the Paleo/Primal type of diet and you go to a doctor and he or she suggests you go on a raw food diet, you know, that may not be the best practitioner for you.  I don’t know.  What else comes up for you, since you’ve been through that?

Steve Wright:  I think for me, one of the questions I always want to know is when have they seen this problem before or how many other people like me have they treated.

Chris Kresser:  Um-hum, that’s definitely a good one.

Steve Wright:  I’m always looking to, like you said, ask a deeper question, like, you know, once they give you an answer:  Oh, it’s your tonsils or something.  OK, well, what is it about my tonsils? or something like that.  And then the other thing that I always ask is if they say take, you know:  My advice for you is to take this pill or this supplement, and it’s always:  OK, is there another option, and is there a benefit to the other option?  Because I feel like, for the most part, even if you ask me for advice, I would give you what I believe is the best option, and I might not tell you about some other ideas that could work as well just because I’m vetted in this one idea, and so I think it’s really natural for all humans to give advice that way, so I kind of want to also know from them what else might work for me because it’s still my choice whether I do it or not, so I might want to, you know, look at options A through C and then choose them, because I’ve done that before on medications and chosen B instead of A even though the practitioner wanted to go with A.

Chris Kresser:  Yeah, I mean, that’s all important stuff, and it just, I think, boils down to a gut feeling too is really something that’s guided me.  If you trust your intuition, I mean, if red flags are going up in the initial consult or the conversation or you feel at any time really uncomfortable with the relationship, I think that’s something to pay attention to as well.  So, I want to just briefly mention the other side of it for what all this stuff we’ve been talking about means for clinicians, because I know we have a lot of people who listen to the show who work with patients or clients in some way or another.  And for me as a practitioner, all of this stuff means that the way that I interact with patients, the attention I give them, the way that I listen, and even the rituals that I go through may be just as important as the, you know, nutritional recommendations or supplements and things that we prescribe.  And in fact, there’s a guy named Ted Kaptchuk who was — he started out in Chinese medicine, but now he’s a researcher on placebo at Harvard, which is an interesting career path.  But he’s argued that the placebo response should actually be renamed and it should be called “contextual healing,” and he defines it as that aspect of healing that’s produced, activated, or enhanced by the context of the clinical encounter.  And scientific medicine is mostly focused on how effective a treatment intervention is, but this really obscures the fact that the technological tools of medicine, whether we’re talking about drugs or surgery or something else, are always applied in some context, and that context actually does contribute significantly to a therapeutic benefit.  And that’s always been referred to as, you know, maybe the art of medicine, and I think early generations of doctors were aware of it, the kind of Norman Rockwell painting type of doctor.  You know, he did house calls and really spent a lot of time with patients and was, I think, really much more aware of the art of medicine and, you know, also aware of the science but appreciated both.  And I think that art of medicine has become a lost art in the last few decades, and we’ve focused too much on science and technology.  I mean, and that kind of shows up in the language that we use to talk about placebo and words like inert or inactive or dummy or sham, and that’s partly due to the inconvenience of placebo for drug companies because drug companies have to prove that their drug is more effective than placebo in order for it to be approved, and so placebo is a big thorn in their heel, but I think there’s a great opportunity for celebrating placebo more as a reflection of the body’s ability to self-heal, and instead of trying to get rid of it like the drug companies are busy doing in trials, to use it more as a springboard for studying these self-healing abilities more thoroughly, and that’s what I’m really interested in, and that’s why I wanted to do this show.  So, I know this was kind of maybe out on a limb for some people, and some of you might not share my fascination with this subject, so I’m sorry you had to endure this, but I hope it was useful, and I hope it inspires something for you or triggers some thought process that leads to, you know, more awareness and more health and healing.

Steve Wright:  Yeah, I think it’s gotta be somewhere in everyone’s mind because the shelf space in a bookstore dedicated to these types of books is about the same as almost any other health book, you know, when you split them into the books that are all about believing in healing and those types of spiritual healing stuff.  It’s a huge section, so there’s a lot to this, and I think it’s really, really interesting.

Chris Kresser:  All right, well, let’s stop there.  I think, you know, we’re coming up on an hour, and just going into questions about nuts and phytic acid and stuff doesn’t seem quite right at the moment, ha-ha.

Steve Wright:  Well, I think, did you mention that there are three ways to avoid interfering with your body’s natural ability to heal?

Chris Kresser:  I probably did, but I don’t — I think the main one that I was getting at was just reducing information overload.

Steve Wright:  OK.

Chris Kresser:  Like, you know, and we spent quite a bit of time talking about that, so I don’t think we need to rehash it.  Sticking, making a commitment to whomever you’re working with for enough time, and that’s kind of amorphous.  What is enough time?  I wish I could give you a number, because it really varies depending on how long you’ve been ill and what your condition is, but I’m talking probably more about months than I am about weeks.  So, that could be number two.  I think just doing what we can to maintain that belief in what we’re doing and put our faith in someone or something while we’re doing it and just stick with that for a period of time.

Steve Wright:  Gotcha.  OK.

Chris Kresser:  Anything else?

Steve Wright:  Yeah, the only other point that I think was really important that you hit on was — and the reason why it’s important is because I was this person and I think there are probably a lot of listeners who have been this person in the past — is the person who is completely consumed by their problems, who has, you know, hours of time on their hands, and they go about researching this day in and day out, and they forget a lot of the things that you were talking about, like maybe having hobbies and a purpose and, you know, family and friends that you go see.  We tend to get really consumed in finding the answer and sometimes put off social interaction and stuff, and I’ve seen a lot of studies on social interaction that that can be so beneficial in healing, and I think it comes down to that stress again, so I think that’s definitely one to avoid if you can, even when the pain’s there, to try to go to the family gatherings, try to get out of the house if you can, even though it’s gonna be a little different and you might not be in the best head space to get out there, it’s really important.

Chris Kresser:  Yeah, I agree, and the reason I started laughing there for a little bit was that I sent a bunch of — I wanted to get some papers on — I’ve read some of those studies, Steve, on the benefit of positive social interaction.  I think you guys wrote an article about that a while back that I tweeted out.  And I sent some links to get the full text of some of those papers to Mat LaLonde, and he called me a dirt-worshiping hippie.  Ha-ha!  But it’s true!  That stuff is in the scientific literature, and it’s real, it’s completely documented, and I mean, speaking personally, I think when things really turned around for me was when I — You know, the first couple of years when I was sick, I was that guy too.  I was spending most of my time trying to figure out how to get well, and it was all-consuming, and it was really unhealthy.  And I decided at some point to go back and study medicine so I could help other people who were dealing with similar stuff, and that’s when things really turned a corner for me.  And now especially, like, the more I do this work and the more I tune into this sense of purpose, the better my health is, and of course, the happier too, and it all, it becomes like there’s momentum there, and it just keeps improving and improving.  So, it’s easier said than done.  You know, I know when I was in that place I wanted to have a purpose and I wanted to do all those things and I was finding it difficult, but I think at least aspiring to that and being aware of it can really help.

Steve Wright:  Yeah, I think you’re right.  Awareness is the first step.

Chris Kresser:  OK, everybody, so thanks for listening and sorry we missed a show.  It was because of the move, and we’ll be back on our normal schedule now.

Steve Wright:  Yeah, thanks everyone.  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, go to ChrisKresser.com and look for the big red box.  Chris and I want to thank you for listening today and staying with us through voodoo dolls and all kinds of topics.  You can keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show, head over to iTunes and leave us a review.

Well, folks, I blew it with the audio this time.  My recording settings weren’t set properly, so we had to use the Skype back-up.  Sorry!

Pork has been getting a bad rap in the blogosphere lately.  In this episode we explore whether pork deserves the harsh treatment, or whether it’s merely a victim of misunderstanding.  We also discuss a novel treatment for chronic sinusitis, which by some measurements is the most common chronic disease in the U.S., as well as a few other great questions.  Enjoy!

In this episode, we cover:

4:38  Is pork a “dirty meat” that causes liver disease?
17:20  What do you recommend for chronic sinus infections?
27:58  Does high intra-abdominal pressure always cause GERD?
35:11  Are “properly prepared” grains OK to eat?
45:45  Is postnasal drip a sign of a bigger problem?
47:35  Should pregnant moms supplement with folic acid?

Links We Discuss:

• Ned Kock – Health Correlator Pork and Liver Disease Article
• Chronic Rhinosinusitis (CRS) and Biofilm Studies:

http://www.ncbi.nlm.nih.gov/pubmed/21739098
http://www.ncbi.nlm.nih.gov/pubmed/21814734
http://www.ncbi.nlm.nih.gov/pubmed/22144052
http://www.ncbi.nlm.nih.gov/pubmed/21865700
http://www.ncbi.nlm.nih.gov/pubmed/22088282
http://www.ncbi.nlm.nih.gov/pubmed/22182736
http://www.ncbi.nlm.nih.gov/pubmed/22241786
http://www.ncbi.nlm.nih.gov/pubmed/22287462

• Xlear Nasal Spray
• Histamine and Tyramine Diet Changes – Gut-Skin Axis Episode
• Pure Encapsulations Nutrient 950 Vitamins

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’s it going today, Chris?

Chris Kresser:  It’s going pretty well, Steve.  How are you?

Steve Wright:  I’m doing great, man.  I got my sling off yesterday, so I’m finally back to two arms.

Chris Kresser:  Glad to hear it.  I bet that’s liberating.

Steve Wright:  It is, it is; however, I have a bunch of new pains now, and I’m gonna have to learn how to sleep again.  So.

Chris Kresser:  Right.  Ah, well, it’s all part of the fun, huh?

Steve Wright:  Yeah.  Only like four more months, right?  So.

Chris Kresser:  Ha-ha.  You’ll hardly remember it in a few years.

Steve Wright:  Exactly!

Chris Kresser:  Cool.  So, we have some good questions.  We’re gonna do a 100% Q&A episode today, which is a little unusual, but lots going on for me right now, and didn’t have time to prepare anything for the show, and I actually like doing these Q&A episodes every now and then.  Before we do that, though, I want to tell everyone — I’m sure most of you have already heard of this, but in case you haven’t, I want to tell you about a really cool event that’s coming up starting on February 26 and running through March 4.  It’s put on by my good buddy, Sean Croxton, over at Underground Wellness, and it’s called The Paleo Summit.  So, this is an online conference with tons of great speakers in the Paleo/Primal niche, a lot of familiar names:  Mark Sisson, Jack Kruse, Erwin Le Corre from MovNat, Paul Jaminet, Diane Sanfillipo, myself, Sarah Fragoso, Mat Lalonde, Amy Kubal, Denise Minger.  So, it’s a great group of speakers.  And then even Matt Stone is gonna be there for the anti-Paleo perspective, so Sean is really interested in hearing from a number of different voices.  I think that’s great.  I enjoy that.  And it’s really cool because it’s free.  Free is good.  It’s gonna be accessible to everybody, and all you have to do is go there and register and you get a couple of bonus videos:  an interview with Mark Sisson and Sean and another with Sean interviewing Gary Taubes.  So, definitely check it out.  It kicks off on Sunday, February 26, and go to CKPaleoSummit.com to register.  So that’s CKPaleoSummit.com.  And I hope you enjoy it.  It’s a great opportunity to get exposed to some cool stuff, and unlike the Ancestral Health Symposium and PaleoFX, which are awesome events too that I’m speaking at this year, this one’s totally free, and you can participate from the comfort of your own home.

Steve Wright:  Yeah, I’m pretty jacked about this.  I’m all signed up, and I think it’s gonna be great.  I think the speaker lineup is just amazing.  There are 24 people, right? 

Chris Kresser:  Yeah, 24 people.  I think eight days and three people on each day, and then there’s gonna be full transcripts and PDFs and videos and a whole package.  That part is not free, but if you want to have the whole thing so you can refer back to it afterwards, you’ll be able to do that.  So, it’s a cool format.  I think Sean is doing a great thing, and I’m looking forward to being a part of it.  My talk actually is gonna be — it’s called An Update on Cholesterol, so I take a lot of the information that we discussed in the three-part series with Chris Masterjohn, and I distill it down into a really practical framework of what to do — if anything — if you have high cholesterol, when is it a problem, when is it not a problem, and what do you do about it from a natural perspective.  So, yeah, check it out.  It’s pretty exciting.

Steve Wright:  All right, so should we roll on to the first question?

Chris Kresser:  Yeah, let’s do it.

Is pork a “dirty meat” that causes liver disease?

Steve Wright:  OK, so here’s question number one from Marianne:  “I would love to hear what you think about pork consumption and liver disease, as referenced from an article this week from the Perfect Health Diet website.”

Chris Kresser:  Yeah, this has caused a little bit of a stir.  So, for those of you that didn’t see it, Paul wrote an article quoting a 2009 study by Bridges showing a stronger correlation between liver cirrhosis and pork than liver cirrhosis and alcohol.  And Paul’s argument was, therefore, that eating pork may cause liver cirrhosis.  But, of course, correlation is not causation.  We talk about this a lot.  That’s research 101.  Two things occurring together does not necessarily mean that one thing causes the other.  So, it’s really crucial and important to understand that basic principle.  And Ned Kock, who has a blog called Health Correlator, which is pretty technical — he’s a statistician and sometimes it’s over my head.  I’m not a statistician.  I get basic statistics, but when it gets really advanced, my eyes start to glaze over.  But this article is pretty easy to follow, and you should check it out if you are concerned about pork consumption after reading Paul’s article.  Ned did a more sophisticated multivariate analysis on the same study, and he found that the total effect of alcohol consumption on cirrhosis was actually 94% stronger than the total effect of pork consumption on cirrhosis.  He also pointed out that another factor that’s associated with liver cirrhosis is obesity, so in countries where pork is a staple, you might think it’s reasonable to assume that pork consumption may be correlated with obesity, but people who consume a lot of junk food also consume a lot of saturated fat, and they show up in the disease stats, but this is exactly the kind of confusion that led to the mistaken idea that saturated fat causes heart disease, right?  So, that idea rose out of epidemiological studies that saw:  Oh, these people are eating a lot of saturated fat and they have heart disease.  But what they didn’t control for was the fact that those people were also eating tons of other processed junk food that could very well have been contributing to heart disease, and it had nothing to do with the saturated fat, because later when they looked at studies that isolated those variables and they just compared saturated fat with other types of fat, they found that saturated fat did not increase the risk of heart disease.  So, we don’t want to make that same mistake here with pork and liver cirrhosis, and that’s why we can’t look at epidemiological data like this and draw causal relationships from it.  So, Ned went on to — just for the other side of the coin — to look at evidence that pork might be good for you.  And he took some data from NationMaster.com on pork and alcohol consumption and life expectancy, and it was a much larger list of countries than was used in the Bridges study, so it included Australia, Brazil, Canada, China, Denmark, France, Germany, Hong Kong, Hungary, Japan, Mexico, Poland, Russia, Singapore, Spain, Sweden, the UK, and the US — so a broad representative sample from all different parts of the world.  And in that study, the link between pork consumption and life expectancy is actually positive, with a 0.36 correlation.  So, according to this data set, the more pork is consumed in a country, the longer people live.  And in fact, the data suggested that each additional gram of pork consumed per person per day adds an extra 13 days to their life expectancy.  Now before everyone runs off and goes on a 100% pork diet, you have to realize that this is merely a correlation too, so we can’t draw conclusions about causal relationships from this data either, but we can say that the data don’t prove that pork consumption causes liver cirrhosis unless, perhaps, you become obese from eating it.  Now there was a second part to that question, which was:  What about the idea that pork is a “dirty meat”, which is somewhat prevalent in the mainstream?  Conventionally raised pigs or pigs raised in confinement feeding operations are given a lot of antibiotics because of the conditions of their confinement, and the problem with this is that just like in humans, if you give animals a lot of antibiotics, they’ll develop antibiotic-resistant super strains of bacteria.  So, Canadian researchers have found antibiotic-resistant staph bacteria in conventionally raised pork products, and that could, indeed, be a problem.  Also improperly cooked and prepared pork may harbor parasites that can cause disease in humans, and there are two helminths or worms that we have in common.  Both humans and pigs can be affected by them, and they cause the same diseases in pigs and in us.  One is the nematode Trichinella spiralis, which causes trichinosis.  That’s the disease most people have heard of associated with pork.  And then a tapeworm, Taenia solium.  And both of these diseases were known to ancient cultures, including the Egyptian and Greek cultures, and then later on Jews and Muslims, which is probably why both Judaism and Islam proscribe the eating of pork.  But today, I mean, if you completely cook pork, if you cook it thoroughly, that should effectively kill the parasites if they’re present, and that’s probably why trichinosis has become pretty rare in the US, because cooking pork thoroughly has become a widespread practice.  And traditionally pork was marinated or cured, i.e. bacon, before cooking because the marinating and curing helped kill the pathogens, as well.  So, if you’re concerned about the potential of pathogens in pork, (1) don’t eat conventionally raised pork.  Get grass-fed, pasture-raised pork from a local farmer or a farmers’ market or a store that sells that.  And that will reduce the risk of super strains of antibiotic-resistant staph that you would find in conventionally raised pork.  (2)  You can marinate or cure pork before eating it.  One way to do that without using nitrates or nitrite salts is just to use a little bit of salt and a natural sweetener, like maple sugar, to treat the meat, to marinate it for a period of time, maybe 18 hours, 24 hours, and some spices with flavor, and then just make sure to cook it all the way through, and it shouldn’t be an issue.  So, you know, based on the evidence that I’ve seen, I don’t think that you can make an argument that pork is unhealthy or is associated with disease.  I think you can make an argument that undercooked pork or improperly prepared pork that’s raised in confinement feeding operations can contribute to that, but I think we need to be a little more specific, you know, when we make these kinds of statements. 

Steve Wright:  I’m glad you cleared that up, because I was really sweating about my bacon.

Chris Kresser:  Ha-ha, I know!  A lot of people out there were freaking out.  Don’t mess with their bacon.

Steve Wright:  Do you eat pork on a regular basis at all?

Chris Kresser:  I do eat pork.  I like pork, and we get it from a local farm, and we do marinate it and prepare it that way, and we often, you know, we cook it for — we’ll usually slow cook pork, like, if we get a pork shoulder roast or something like that, and we’ll turn it into carnitas, and we’ll roast it for a long period of time at a low temperature, and that will kill any potential pathogens in there.  I do eat bacon.  I’m not, you know, I don’t eat it every day, but I have it probably two or three times a week.  And I love pork chops, actually.  That’s one of my favorite kinds of meat.  So, I think, like I said, as long as you prepare it well and as long as you cook it thoroughly, it shouldn’t be a problem.  Now the other issue with pork is the omega-6 content, and this has less to do with how the pork is raised, although certainly pork that’s raised in confinement feeding operations is likely to have more omega-6 because of the food that they’re given, but even pasture-raised pork will have more omega-6 than beef or lamb or any other kind of wild game meat, of course.  But it has less omega-6 than chicken, than dark-meat chicken, so I don’t think the omega 6 issue is a reason to completely avoid pork.  I just think it’s probably a reason not to make it your staple meat that you eat every day, twice a day, but I don’t think it’s a reason to avoid it completely.

Steve Wright:  I’m glad you brought that up, because I think most people hold chicken to be like the super-safe meat, but little do they know that it might not be so safe. 

Chris Kresser:  Yeah, I mean, it’s all in moderation.  Like, we have the ability to deal with some amount of omega-6, and eating dark-meat chicken, you know, once or twice a week, I don’t think it’s gonna cause any serious health problems for anybody.  I think that the risk in doing what I do and making people aware of these things is it’s sometimes difficult to convey the — What am I trying to say?  It’s easy, I think, sometimes for it to come across too literally, and I’d like to find a way of communicating it where that’s less likely to happen.  But, you know, if I write an article that says omega-6 is proinflammatory in excess and contributes to various disease states, then sometimes that gets interpreted like I shouldn’t eat any omega-6; you know, like even half of an avocado is gonna make me keel over and die of a heart attack.  And I just don’t think that’s the case.  I don’t see evidence really to support that, and I don’t see it clinically in my practice.  I think it’s wise to reduce our omega-6 consumption significantly, as I’ve pointed out several times, but that doesn’t mean we can’t have dark-meat chicken or avocados or walnuts or things like that occasionally as part of an overall healthy diet.  And so, I think the same is true with pork, provided you follow the guidelines that I just mentioned.

Steve Wright:  Yeah, I’m glad you brought that up.  I didn’t mean to demonize chicken in favor of pork or anything, because I think you’re right.  It’s hard for us as we read what you write and as we all do our own research, we’re always looking for a black-and-white answer.  And I think I’ve learned as you get deeper and deeper, you start to become more appreciative of the body we have and its systems, and you start to realize that everything is kind of on a continuum.

Chris Kresser:  Um-hum.

Steve Wright:  And there’s usually never a supremely right or supremely wrong way to eat some things. 

Chris Kresser:  Um-hum.  Very well said.

Steve Wright:  Or natural foods, that is.

Chris Kresser:  Um-hum.  Yeah, and it depends on a lot of factors too, like how healthy you are now, what your goals are, you know, where you’re coming from, and I think there’s a question later where we’ll get into more detail about this, but it’s just good to point out in the context of the whole pork thing.

What do you recommend for chronic sinus infections?

Steve Wright:  Cool.  Well, let’s roll on for the next question from David.  He asks, “What do you recommend for chronic sinus infections?  This is, according to some reports, the most common chronic disease in the United States.  Research by Mayo Clinic in 1999 found that virtually all (96%) cases of chronic sinusitis are caused not by bacteria but by fungus.  So, what is your approach to this?”

Chris Kresser:  Yeah, this is a big topic, and maybe we’ll do an entire show on it, and we’ll have Kurt Harris come and help us out.  He is somewhat of an expert on this topic, and I’ve consulted him about it a few times.  And, yeah, I’ve read that Mayo Clinic thing, and it turns out to be a little bit of a red herring.  The consensus that I respect on fungus is that except for true fungal rhinosinusitis — which is what the technical term is for chronic sinus infections, chronic rhinosinusitis or CRS — true fungal CRS is easily diagnosable by the presence of eosinophilic mucin, but that’s actually pretty rare, and fungus in the nose is commensal, meaning it’s just part of the body’s natural terrain, and most cases of CRS have nothing to do with fungus being present, and furthermore, there is no good evidence that antifungal agents help in the treatment for fungal rhinosinusitis, which is relatively rare.  So, I don’t actually buy the fungus hypothesis for that reason, and my view on it is that it’s probably more like chronic, recalcitrant, difficult-to-treat sinus infections are more related to biofilm than fungus, and particularly in those who have had surgery and those who have poor immune function.  And there’s a bunch of studies that I’ve looked at connecting CRS to biofilm — and we can put those studies in the show notes for anybody that’s interested — but there are some pretty interesting emerging treatments for chronic sinusitis that relate to this biofilm hypothesis, and one of them is nasal irrigation with Johnson’s baby shampoo solution.

Steve Wright:  What?!

Chris Kresser:  Ha-ha, yeah, no joke.  This is in the scientific literature.  You’ll find studies in PubMed about this.  So, it’s a 1% Johnson’s baby shampoo solution, so you do kind of like a Neti or a nasal irrigation with the 1% baby shampoo.  And in the study, 60% of patients noted a significant improvement in symptoms, you know, reduction of thickened mucus and postnasal drainage.

Steve Wright:  Is this biofilm, is this in the gut or is this in the nose or the cavities?

Chris Kresser:  Biofilm is everywhere.  Biofilm is an extracellular matrix that bacteria reside in, and most pathogens actually we think now.  One really good example of biofilm is plaque, you know, the thin film that covers our teeth.  And this extracellular matrix allows the bacteria to share nutrients and also even DNA, and it protects them from our own innate immune defenses and also from any external antimicrobials that we might take.  So, it’s kind of like a protective community, strength in numbers, and as long as the bacteria are in the biofilm, a lot of the antibacterial agents that we use don’t really work.  So, that explains why some people take antibiotic after antibiotic after antibiotic with sinus infections and they just don’t recover.  So, one therapeutic approach is to disrupt the biofilm, and there are ways to do that topically, and there are ways to do that systemically.  So topically, one way is this Johnson’s baby shampoo irrigation, and the way it works is that Johnson’s baby shampoo has chemical surfactants in there, and you can think of them as like a therapeutic detergent to break up and assist in the eradication of biofilms, and that’s been known for a while.  That’s been used in the orthopedic literature, this use of chemical surfactants to break up biofilm.  But in chronic sinusitis, it probably has two benefits:  One is as a mucoactive agent, and mucoactive agents work either to increase the ability to expectorate sputum or to decrease mucus hypersecretion.  Or, number two, it has potential bactericidal activity; in other words, antibiotic activity.  So, that’s one.  Another solution that’s maybe a little bit more accessible to people and a little bit easier to get your head around are xylitol nasal drops.  Now xylitol is a sugar alcohol, but it has activity against biofilm, and this is one of the reasons why xylitol chewing gum has become popular amongst dentists.  As I just mentioned, plaque is a biofilm, so if you chew xylitol gum, that can actually help break up plaque.  So, these xylitol nasal drops, or there’s actually a nasal spray that’s called — I’m not sure how to pronounce it.  It’s a very bad name.  Anyways, Xlear nasal spray.  And I’ve read a couple studies that use a similar solution and some accounts from doctors who are working with this stuff, and the consensus seems to be that it needs to be used pretty frequently, like up to three to four times a day, for it to work.  But unlike steroid sprays, which are often used in nasal sprays, xylitol doesn’t dry out the nasal passages, and it doesn’t inhibit the immune defense of the body.  Instead, it acts more as a lubricant, which makes it easier for natural mucus secretions to occur that kind of eliminate the pathogens.  I mean, the way it should work is that the mucus forms, and then you blow your nose and it carries the pathogens out of the nasal passage, and xylitol helps that to happen by lubricating them and acting as a surfactant that allows the nasal passages to clear.  So, another potential avenue, although I haven’t seen any research on this, is using a systemic biofilm disruptor, which would be something like InterFase Plus, and that’s a product that has EDTA and some enzymes that chelate — Well, EDTA chelates some of the minerals that are needed to produce biofilm, that biofilm formation depends on.  And then there are some systemic enzymes that have been shown to break up biofilm.  So, that needs to be taken on an empty stomach, because if you take it with food, the enzymes in there will help digest the food, which is nice but it’s not really, you know, what you’re taking it for.  So, InterFase Plus needs to be taken on an empty stomach a couple hours after a meal or a half hour before a meal.  And, like I said, I haven’t seen any studies on systemic biofilm agents like this in chronic rhinosinusitis, but I do use InterFase for other kinds of infections, and I’ve found it to be extremely effective in most cases.  In fact, it seems to cause more of a Herxheimer or die-off reaction in treating infections than a lot of the botanical antimicrobials, which is indicative that it’s working. 

Steve Wright:  Interesting.  So, let’s back up to the very beginning of the question just to clarify this for everyone.  Chronic rhinosinusitis, you said, was kind of rare, so what’s –

Chris Kresser:  No, chronic rhinosinusitis is actually pretty common.  It might be one of the most common diseases there is, but the fungal chronic rhinosinusitis or fungal RS, as it is called, which is caused by a fungus, that’s rare. 

Steve Wright:  OK.

Chris Kresser:  And that is easily diagnosed by looking for eosinophilic mucin, and there’s been an idea that — I don’t know if it started with that Mayo Clinic article, but it’s been bounced around a lot in the blogosphere that all sinus infections are fungal in origin, and what I’m saying is I don’t think the evidence really supports that.

Steve Wright:  All right, I gotcha.

Chris Kresser:  Yeah, it’s more about biofilm than it is about fungus.

Steve Wright:  OK.  That makes much more sense now.

Chris Kresser:  Yeah, so I mean, of course, all of the other things apply, like all of the other things that you would do to regulate your immune system and not eating food toxins and making sure you have the micronutrients that support immunity, like vitamin C and iodine and selenium and, you know, exercise, all the basics apply here.  But I am assuming a lot of people are already doing that who are listening to this show, and they’re already eating a Paleo/Primal type of diet, and if they’re still having sinusitis, then you might want to investigate this biofilm angle.  I think the easiest way to do that is the Xlear — or however you say that — nasal spray and then possibly a systemic biofilm agent like InterFase Plus.

Steve Wright:  OK, and don’t forget to check your vitamin D if this is a problem for you, as well. 

Chris Kresser:  Absolutely.

Does high intra-abdominal pressure always cause GERD?

Steve Wright:  All right.  So, let’s move on to the next one.  This comes from Brendan:  “I’ve got one regarding your position on GERD.  In my medical nutrition therapy class at school my professor taught us that increased pressure from the other side of the lower esophageal sphincter actually helps to keep the sphincter closed and that a lack of pressure allows it to relax and allows the reflux to occur.  This seems to conflict with your idea that bacterial overgrowth leads to increased intra-abdominal pressure and causes reflux.  I tend to trust your information more, but I wanted to get your opinion on this.”

Chris Kresser:  A real tongue-twister, huh?

Steve Wright:  Man!  Got me all messed up.

Chris Kresser:  Ha-ha.  So, I think the first thing I want to say is I don’t believe that all GERD is caused by one thing.  GERD is a pretty vast landscape of varying conditions, and a lot of what is referred to as GERD, gastroesophageal reflux disease, is actually NERD, which is non-erosive reflux disease.  There are lots of different presentations, lots of ways that it shows up and manifests, and I don’t think they’re all caused by the same thing.  In fact, some people do produce excess stomach acid, and that is the cause of their problem.  That’s a minority.  According to the scientific literature, it’s a small number of people, but it doesn’t mean that, you know, the fact that I wrote that series suggesting that GERD is caused by low stomach acid primarily and bacterial overgrowth doesn’t mean that that’s true in 100% of cases.  So, just wanted to clarify that.  The main pathology involved in GERD or NERD is transient lower esophageal sphincter relaxations or TLESRs, as they are referred to in the literature.  And so, just a little anatomy/physiology here:  The esophagus is separated from the stomach by the lower esophageal sphincter, and that sphincter should most of the time be closed, and it opens, of course, when we eat and when we burp and things like that.  One of things, I mean, the main thing that happens with GERD or NERD is that you get these transient relaxations of that sphincter at inappropriate times, so the sphincter will open or relax when it should be closed, and then you get a reflux of acid or bile into the esophagus, and that causes the symptoms associated with reflux.  So, studies have shown that gastric distension increases the number of TLESRs, the number of these transient relaxation events.  And, of course, gas can increase gastric distension and thus can increase the number of transient relaxations and reflux.  So, I think you can make an argument — I understand where the question is coming from, and it’s true that pressure could, in theory, keep the sphincter closed, but it turns out that, according to the studies, that this gas and gastric distension actually increases the number of relaxations that happen.  And if you do a search on PubMed for gastric distension and TLESRs, you’ll see the study come up, and you can take it in and show it to your professor.  Also, I think it’s important to look at actual clinical results.  I’ve talked about this three-legged framework I use for determining whether something is valid or for testing a hypothesis.  And one of those legs is modern scientific research; that’s important.  Another leg is traditional wisdom, evolutionary medicine, which is also important.  You know, does it check out according to what we know about ancestral health?  And then the third leg, which I think is also very important, is clinical experience.  And, so, for something to really check out for me, it has to pass all three of those tests.  And if you look at the comments on some of those GERD articles, particularly the three steps to curing GERD article, you’ll see literally hundreds of people that have tried this protocol and that were suffering tremendously and had been on PPIs in some cases for as much as 20 years or acid-suppressing drugs for 20 years and were able, using this protocol, which is geared, you know, towards reducing the bacterial overgrowth in the small intestine and improving, increasing stomach acid production via HCl, have been able to stop for the first time in their lives their acid-suppressing drugs and have been able to eat food without reflux for the first time in their lives.  So, I think that’s highly significant and shouldn’t be ignored as part of this whole picture of figuring out reflux and GERD.  I will say that there are some people that that protocol doesn’t work for, and they very well may be the people that do produce excess stomach acid for other reasons, and in those cases something like melatonin and methylation precursors, serotonin precursors might be a better option because melatonin has been shown to regulate the contractility of the lower esophageal sphincter, and that’s probably why it works in a couple studies as well as PPIs, a combination of melatonin and serotonergic nutrients like 5-HTP and methyl donors like B6 and B12 and folate.  So, I think that’s it.  That’s how I’m tying together the gastric distension and gas and the transient lower esophageal relaxations.

Steve Wright:  You know, the one thing I’ve never really understood, Chris, is with the lower esophageal sphincter, is that like a flap, like a trapdoor flap, or is it more like an opening and closing of, like, a hole?  How does it actually work?

Chris Kresser:  It’s more like a flap, I think.

Steve Wright:  OK.

Chris Kresser:  I’m not totally sure, actually.  It would be interesting to see a picture.

Steve Wright:  Yeah, I’ve never seen one, and I was just curious because with some of these, you know, low pressure / high pressure kind of is determinant upon how it actually mechanically works.

Chris Kresser:  Yeah, I’m pretty sure it’s a flap.

Are “properly prepared” grains OK to eat?

Steve Wright:  Interesting.  OK.  Let’s more on to the next one.  This comes from Monica, and she would like to know your thoughts regarding several real food bloggers who are recently posting about wheat, grains, and even gluten and the fact that they are not inherently bad and if properly prepared after having undergone a gut-healing protocol, can be consumed without ill effects.

Chris Kresser:  I bet she’s talking about Matt Stone.

Steve Wright:  Yeah, I’ve seen some from, I think, Cheeseslave, as well.

Chris Kresser:  Yeah.  Just getting a little sip of water here.  Let’s get back to what you and I were talking about at the end of the first question on pork.  Health is a continuum, so if you have on the one hand death, which is the end of health, and on the other hand you have perfect health, then there’s a huge, huge spectrum of what you can experience in between those two extremes.  And I just assume that most people who are listening to the show and who are reading my website are interested in optimizing their health, and so that’s the audience that I’m speaking to.  I’m also, because I’m a health care practitioner, I’m speaking in particular to an audience that’s dealing with chronic health issues and disease, so you know, above and beyond just people who want to optimize their health, I’m really more focused on people who have health problems, and I’m trying to help them recover.  So, a lot of what I speak and write about is geared towards that audience, and that’s important to understand because that audience is more likely to experience difficulties with foods that may not be problematic for people that are otherwise healthy, and I think grains and wheat and even gluten fall into this category, where — Well, let’s break them down separately.  So, gluten, I think, is an inflammatory protein on its own, and so I don’t actually recommend that even healthy people eat it for that reason, but does that mean if someone who is very healthy, has a really healthy gut and no real health issues to speak of is gonna keel over and die if they eat a piece of bread a few times a week?  I don’t think so.  Probably not.  And, you know, we can handle some amount of inflammation.  We can handle some amount of toxicity, of toxins.  You know, there’s a concept called hormesis where a small amount of toxin actually sensitizes our immune system and our ability to cope with larger amounts of toxins.  So, I think that you really have to consider who is asking the question, where are they coming from, again, what are their goals, are they trying to optimize their health to the greatest possible degree and feel as good as they possibly can?  Most people in that situation do better without wheat and gluten, in my experience.  That doesn’t mean there aren’t people that are exceptions.  It doesn’t mean that you can’t eat some wheat and gluten if you’re healthy and still feel fine.  But if you’re interested in absolutely optimizing your health, I think you’re better off without it.  Now, with grains — and there is a distinction here between grains that are not properly prepared and grains that are properly prepared.  Grains that are not properly prepared have a number of food toxins in them that are part of the plant’s natural defense system, and of course, people who are following a Paleo and Primal type of diet are well aware of all of this.  But again, you know, for someone who is basically healthy, some small amount of grain may not be that big of a deal.  And even for people who are not that healthy, if you properly prepare the grains and break them down, break down the phytic acid, break down some of the food toxins by soaking or fermenting or sprouting, then grains may not present any problem at all, even for someone who is not at the top of their health.  But I’ll say in my experience as a clinician that most people who are sick or who are dealing with gut issues or immune dysregulation or any number of other conditions generally feel better without grains, as a general rule.  But these are all general guidelines, and they’re all subject to all of the variables that I’ve mentioned.  You know, what’s the current health status, what’s the constitutional health, what are the goals?  So, I think that’s why I get a little bit irritated about all of the debating because it’s kind of nonsensical unless you know what the context is. 

Steve Wright:  That makes sense, and I think you brought up something really important there, which is the toxic load.  You know, if you’re pretty healthy and you recovered your health, if you keep the toxic load pretty low and you eat a non-prepared grain every once in a while, it’s likely that you probably wouldn’t see a problem because your body is designed to handle that load.

Chris Kresser:  That’s right.  Exactly.  And then let’s take it a step further:  I’ve said this in the Beyond Paleo, previously the 9 Steps series, but there’s more to health than food.  You know, there is!  There’s a lot more to health than food.  There’s movement and exercise.  There’s sleep.  There’s stress management.  There’s cultivating pleasure.  There’s having a purpose and feeling like your life is meaningful and you’re serving others or some higher purpose that goes above and beyond just, you know, getting what you want.  I think that’s actually a really crucial element that contributes to health.  There’s relationships, how you relate to your partner, your kids, your colleagues at work.  There’s connection with nature, and you know, this whole earthing movement that’s kind of taken on steam lately in the Paleosphere; there’s concern with that.  So, there are so many things that contribute to whether we feel healthy on a daily basis and whether we prevent disease or recover from disease, and food is a huge part of that equation, of course.  I think it’s pretty clear that I believe that from what I write.  But it’s not the only variable, and when obsession with food happens at the expense of all of those other things that contribute to health, then actually even eating really healthy food can become problematic.  I think we talked about this on a previous episode, my beer and pizza story. 

Steve Wright:  Yeah, I’m not sure I remember that, but sounds like a fun diet, maybe?  I don’t know.  Ha-ha!

Chris Kresser:  Ha-ha!  OK, I’ll tell it again.  It’s not my beer and pizza story, but I’ll tell it briefly again for people who are new to the show.  So, I was in San Diego way back when I was in school, and I was interning with a holistic doctor, and he specialized in, you know, treating people who were dealing with chronic mysterious kind of diseases.  And we had a young guy, I think he was like in his early 20s, and he came to us and he was really emaciated, really sick, and just couldn’t eat anything.  And, so, the doctor further restricted his diet, and I mean, he got down to the point where he was eating like boneless, skinless chicken breasts, broccoli, and quinoa, I think were the only three foods he was eating.  And each time he came back to the office, he was just literally wasting away in front of our eyes.  He looked like death.  You know, he looked so sick.  And he was this young guy, you know, like totally in the prime of his life.  So, he disappeared, stopped coming.  We didn’t see him for, like, six to seven months, and then he came back to the office and he was literally — We didn’t even recognize him.  He looked like a different person.  He had gained like 40 pounds, no dark circles under his eyes, really good complexion, you know, looking extremely healthy.  And the doctor and I were both like, “Whoa!  What happened here?  What was it?  Was it diet?”  And he’s like, “Yeah, it was diet.”  And we said, “Well, what was it?  The anti-candida diet or the macrobiotic diet?  Which one was it?”  And he said, “It was the beer and pizza diet!”  Ha-ha, and we were like, “What?”  And he said, “Yeah.  I just got to the point where I thought if I’m gonna die,” which he though he might, “I’m gonna just forget about all these dietary restrictions and have some fun before I check out.”  And so, he decided that at three days a week he would go out with his friends and have beer and pizza and the rest of the time he would eat whatever he wanted.  And after, you know, several months of doing that, he was completely transformed and completely well.  And, you know, there are a lot of caveats to the story, but in his case, I think, a lot of what was happening was social isolation and he had broken up with his girlfriend because she just, you know, couldn’t handle being with him, and there was a lot going on behind the scenes there, and I’m not suggesting that it’s as simple as just, you know, having fun and eating whatever you want.  That’s ridiculous.  It doesn’t work that way for everybody.  But I am suggesting that that’s how powerful the mind and the heart can be in the healing process and that sometimes eating the wrong food with the right attitude is a better choice than eating the right food with the wrong attitude. 

Steve Wright:  Hmm.  Good advice.  OK, well I know we don’t have that much more time here, so let’s ask at least one more question.

Chris Kresser:  All right.

Is postnasal drip a sign of a bigger problem?

Steve Wright:  This one comes from Warren, and he’s wondering — and it kind of might relate to a previous question — he’s wondering about postnasal drip.  Is it a sign of a larger problem, and could it be helped by just eliminating dairy?

Chris Kresser:  Uh, yes, it is a sign of a larger problem.  That’s not a normal physiological process.  And eliminating dairy is certainly a good step.  I think if you’re not already eliminating wheat and grains, that’s important too.  Wheat tends to have a really strong connection with sinus problems, in my experience.  And, so, a Paleo type of diet as a starting place, maybe a 30-day challenge where you eliminate dairy and — I don’t really know necessarily that an autoimmune version is necessary, but if you wanted to be really thorough, you could do that and eliminate eggs and nightshades and all dairy for 30 days and then start adding those things back in sequentially.  And if you’re still having the postnasal drip at that point, it’s possible that there’s a histamine issue there.  You could try a low histamine and tyramine diet, which we’ve talked about before on the show when we talked about skin problems, the gut-skin issues.  And then if you’re still, after that, having issues, it’s probably time to seek out some help and see what’s happening with the immune system.

Steve Wright:  So, if you’re already on a Paleo diet and you don’t think you have a histamine problem, it’s indicative of an immune system dysregulation?

Chris Kresser:  Yeah, immune dysregulation, some inflammation there in the sinuses.  Yeah, definitely.

Steve Wright:  OK.

Chris Kresser:  We can do one more.  I see that the next one is pretty short, too.

Should pregnant moms supplement with folic acid?

Steve Wright:  All right.  This one comes from Sally, and she would like some advice on the whole folic acid issue.  Is there any prenatal vitamin you do recommend?  And if so, which?

Chris Kresser:  Yeah, so, folic acid is a synthetic form of the active methyltetrahydrofolate, or there are different versions of active folates other than that.  But folic acid — the important thing to realize is it’s a synthetic chemical that’s not found in nature in the body, and it has to be converted via several steps into the active forms of folates, which are what the body needs and can utilize.  So, the problem is that most multivitamins, including prenatal vitamins, use folic acid, and what happens in a lot of people is that that conversion is poor from folic acid to active folates, and you get a buildup of unmetabolized folic acid.  And unmetabolized folic acid has been linked with cancer and other health problems, and this can happen at doses as low as 400 mcg a day.  It certainly is more likely to happen at higher doses of 800 mcg per day, which is often what’s in pregnancy multis.  So, you want to make sure if you’re taking supplemental folate that it’s an active form of folate.  So, sometimes it’s abbreviated as L-5-MTHF, which is 5-methyltetrahydrofolate.  There’s a brand name called Metafolin.  It is used in Thorne products and Pure Encapsulations and some other products.  You just want to make sure on the bottle that it says “folates” on there and not “folic acid.”  But in terms of a prenatal that I do recommend, there aren’t that many because most multivitamins, in my opinion, have too much of the wrong thing and not enough of the right thing.  But the one I would recommend is Nutrient 950 with Vitamin K, and that’s by Pure Encapsulations, and you can find it online.  It’s more expensive than other choices, but it’s definitely worth it.  There’s not much that’s more important than nourishing your body with the right nutrients if you’re trying to conceive.  That said, I think prenatals are not strictly necessary if you’re getting all of the nutrients that you need from food.  Additional folate is one of the few things that I think is crucial even if you’re eating a Primal/Paleo type of diet because it’s so important for the development of the fetus and the prevention of neural tube defects that I think it just makes sense to take some extra folate during prenatal period and during pregnancy. 

Steve Wright:  And you couldn’t really get that from food or you’d have to eat too much greens or anything probably?

Chris Kresser:  Yeah, I mean, you can get some folate from foods, but folate is highest in chicken liver, lentils, and leafy greens.  You’d have to eat a lot of, you know, like, six to eight cups of dark leafy greens a day to get the recommended folate amount.  You’d only have to eat 3 ounces or so of chicken liver, but I don’t know that many people that are eating 3 ounces of chicken liver.  And then grains and legumes are other sources of folate, and those are not happening on the Paleo and Primal type of diet, so I think supplemental folate is a good idea.

Steve Wright:  OK, awesome.  Good to know.  I think that will help a lot of people.

Chris Kresser:  Yeah, and if, you know, folks need more guidance on this specifically, you can check out The Healthy Baby Code, HealthyBabyCode.com.  That’s my whole program with a lot of detailed information about fertility and pregnancy nutrition. 

Steve Wright:  If someone is thinking about getting pregnant, how soon should they begin supplementing?  Is it a couple months or a year?

Chris Kresser:  Well, yeah, probably.  I mean, honestly, in some ways the sooner the better.  I mean, to an extent.  There’s no need to start 10 years in advance, but if you started a year in advance, you would just improve your chances of conceiving easily probably.  And, you know, there’s no reason not to do that maybe other than expense because folate at the kind of dose I’m recommending is well tolerated and is not gonna cause any problems.  So, you know, six months to a year before, I think, starting the special fertility stuff is a good idea. 

Steve Wright:  You definitely want to pick up The Healthy Baby Code so you get all the info about what you should be doing. 

Chris Kresser:  All right.  I think that’s it.

Steve Wright:  Yeah, I think that’s what we got for questions this time.

Chris Kresser:  Let’s call it a wrap.

Steve Wright:  All right.  It’s been a good show.  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, go to ChrisKresser.com and look for the big red box.  Chris and I want to thank you for listening today, and please keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show today, 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.

In this episode we conclude the excellent 3-part series on cholesterol and heart disease with Chris Masterjohn.  It’s been a pleasure to have Chris with us throughout the series, as he’s the most knowledgeable person I know about these topics.  We’ll certainly have him back in the future!

In case you missed them, here are links to Part 1 and Part 2.

In this episode, we cover:

2:30 The role of cholesterol in heart disease
11:26 What to do – or not do – about high cholesterol
24:11 The thyroid-LDL connection and why iodine matters
29:36 Are goitrogenic foods inhibiting your thyroid function and raising your cholesterol?
46:01 The telltale sign you need more carbs

Links We Discuss:

• Chris Masterjohn Blog - The Daily Lipid
• Thyroid Toxins Special Report
• Chris Masterjohn article: Bearers of the Cross:  Crucifers in Context
• Super Selenium Complex from Life Extension
• Nutrition and Physical Degeneration, By Weston A. Price

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 today is Chris Kresser, health detective and creator of ChrisKresser.com.  How’s it going, Chris?

Chris Kresser:  It’s going pretty well, Steve.  How are you?

Steve Wright:  I’m doing good.  The shoulder is healing up, and I’m pretty excited for our special guest today.

Chris Kresser:  Yeah, me too.  We’ve got Chris Masterjohn back for Part 3 of the Cholesterol Series.  Really excited to wrap this up.  It’s been a really popular series so far.  We’ve gotten a lot of great feedback.  People are learning a lot.  I’m learning a lot.  It’s always a pleasure to have Chris on the show.  So, for those of you who don’t know Chris, it’s time for you to crawl out from under that rock you’ve been hiding under!  He’s one of my favorite bloggers in the Paleo/Primal food sphere, and he is just super knowledgeable about all this stuff.  He is pursuing — well, actually I’ll let him introduce himself.  He knows more about what he’s doing right now, but he is pursuing a PhD, and I think those of you who know his work know how much he has to bring to this discussion.  So, we’re happy to have you back, Chris.  Why don’t you just give a really quick intro for people who don’t already know you, and then we’ll dive in. 

Chris Masterjohn:  Sure!  Thank you so much for having me back, Chris.  My website is Cholesterol-and-Health.com.  I have a blog there, The Daily Lipid.  Right now, I’m just wrapping up my PhD.  I’m almost done.

Chris Kresser:  Woo-hoo!

Chris Masterjohn:  I am getting my PhD in nutritional sciences, and that is studying how diet and nutrition works on a physiological and biochemical level, and I’m currently writing a dissertation on how oxidative stress regulates the production of methylglyoxal and its detoxification, which is a key player in advanced glycation endproducts, which are believed to play a role in diabetes and cardiovascular disease. 

Chris Kresser:  That’s some light reading for the weekend, maybe.

Chris Masterjohn:  Ha-ha, yeah.

Steve Wright:  Yeah, that’s a mouthful! 

Chris Kresser:  Cool.  So, we’ve already done Part 1 and Part 2 of this show, and now we’ve got transcripts and you can go back and listen to the original episode.  Chris, why don’t we do just, like, a really super-quick recap of what we talked about in the first couple parts, and then we’ll dive into this last part so we have plenty of time to cover that material?

The role cholesterol plays in heart disease

Chris Masterjohn:  Absolutely.  So, in Part 1 we just outlined my basic ideas about the role of the degeneration of lipids in heart disease, and we talked about the two camps:  the cholesterol warriors who are making a war on cholesterol because they see cholesterol as the enemy and, you know, the aggressor in heart disease, and the cholesterol skeptics who basically say, well, blood lipids don’t really have any role in heart disease.  And the basic conclusion of Part 1 is that blood lipids do play a role in heart disease, but it’s not that their high concentration is infiltrating the vessel wall; it’s that their degeneration is posing a danger to the blood vessels, and the immune system comes and mops them up to create the atherosclerotic plaque.  And that is a positive adaptation to this process of degeneration, but it poses a risk in the long term because that plaque can ultimately break down and cause a heart attack.  So, from Part 1, what we concluded was that we don’t want to modify the concentration of lipids in the blood so much as prevent their degeneration.

Chris Kresser:  Right, so let me just jump in and summarize there.  So, the original theory, the infiltrative theory, is sort of like arteries are like pipes and cholesterol is like gunk, and the pipes get clogged up with cholesterol, and then you have a heart attack.  Right?  That’s kind of how it was broken down in the mainstream.  But, what you’re saying is that what really happens is that the cholesterol — or more accurately, the lipoproteins that are carrying cholesterol and other fats — get damaged by oxidation, and then the immune system’s response to that oxidative process is what causes the buildup of plaque and then ultimately the rupture of plaque and heart attack.  Is that accurate?

Chris Masterjohn:  Yeah, absolutely.  So, what we’re trying to do is protect the vulnerable lipids and get them to go where they need to be.  And what we want to do is we want to metabolize the lipids and fat-soluble nutrients and everything that’s in our bloodstream and use them properly.  So, for example, cholesterol we want to turn into bile acids for our digestion, sex hormones for our fertility and virility, and we don’t want them left in the blood to be damaged and contribute to atherosclerosis. 

Chris Kresser:  OK, cool.  So, then Part 2 we talked a lot more about testing normal variation of cholesterol markers, particle size, etc.  So, take us through that.

Chris Masterjohn:  Sure.  So, we have to keep in mind that since we’re focused on the degeneration of lipids and protecting those lipids in the blood, when we look at concentrations of lipids, we’re not trying to look at necessarily a cause-and-effect scenario.  So, if we’re concerned when total cholesterol goes really high, it’s not because that is causing heart disease, but we’re using this as a metabolic clue.  So, in the initial parts of Part 2, what we did was looked at some of the traditional cholesterol levels in populations that have not been through industrial modernization, that have been studied and have been shown to be free of heart disease, to try to see what normal lipid metabolism is like.  And we looked at two groups in particular:  the Masai and the Kitavans, who have been well studied and shown to be free of heart disease; and we used them to define basically the lower and upper limits of blood cholesterol.  And what we see is the Masai have pretty low cholesterol levels, but the Kitavans, who are eating a diet based on fish, coconut, starches, and so on, the men tend to have cholesterol levels around 180, the women tend to have cholesterol levels around 200 to 210, and these tend to increase with age.  So, in their 40s and 50s, the women might have cholesterol around 250.  In general, the LDL/HDL ratios are between 2 and 4 in these tropical populations.  And there are some other populations that have not been studied quite as well but also seem to be free of heart disease, like Tokelau, where the consumption of coconut is much higher, and their cholesterol levels in the case of the men increase from about 180 to 220 with age and in the women tend to increase from about 200 to 245 with age.  So, around 250 total cholesterol is where we might set the upper limit of what seems to be normal, according to these traditional populations eating traditional diets that are free of heart disease.  That doesn’t mean that a cholesterol level of 251 is gonna kill you.  It just means that that might be the point where we might start looking at some other signs and symptoms to see if there is a problem, not necessarily assuming that there is one.  And then we went through how do I know when my cholesterol is really increased, because there is a lot of variation that we can normally expect.  And we said that if we’re just looking at two measurements — say, we changed our diet, we measured cholesterol once before and once after the diet — if we hadn’t measured our cholesterol very often to get a sense of our own variation, then we should be careful not to assume that it has increased unless we have an increase of at least 35 mg/dL for total cholesterol, about 10 mg/dL increase or decrease for HDL, 30 mg/dL for LDL, and about 40 mg/dL for triglycerides.  So, we should be concerned when we see these large increases and they go outside the range of what is considered to be traditional.  And the total/HDL cholesterol ratio seems to provide the most information, and particle size and other of these emerging tests probably need to wait on the bench until we can standardize them better and be able to utilize them to provide clearer information than what we have now.

Chris Kresser:  Right.  Not ready for prime time.  There is one interesting test.  Maybe in Part 4, eventually when we have that, we’ll talk about it.  It’s an oxidized LDL test, which has only been available in the research settings, but there’s a lab in New York that is starting to offer this, and I’ve been corresponding with them.  They’re not quite there yet, but hopefully in the near future that will be available.  Again, it’s not totally clear how useful that would be yet.  I mean, what’s your impression of that from your reading of the literature, Chris, the oxidized LDL marker?

Chris Masterjohn:  Well, I think the way that you just summarized it is probably pretty good.  It’s not clear how useful it is yet.  I do think that it’s probably going to offer some advantages, but there is always gonna be some lack of clarity in interpreting it, because when LDL oxidizes in the blood, it’s cleared very quickly from the bloodstream.  So, you have to remember that if you’re looking at oxidized LDL, you’re taking a snapshot of what is in the plasma at an instant, and I think we need to study it more to see how reliably it gauges the actual process of oxidation.  We want to try to infer the processes that are going on and not just look at the snapshot as if things are static. 

Chris Kresser:  Um-hum.  OK, so we’ll come back to that maybe when we have some more info on it, but let’s now talk about the meat of Part 3 here, which is the question that’s on a lot of people’s minds, and actually in my practice I still get quite a few of these questions, even people who have read all of your work, Chris, and my work and, you know, they’ve been exposed to these ideas for a long time, but when their cholesterol is somewhere around 250, there are still many, many years of conditioning around the idea that high cholesterol is gonna cause heart disease, and so understandably people, when their cholesterol starts to creep up a little bit like that, their question is — So, you know, they’ve changed to a Paleo Diet or a Weston A. Price / Primal type of diet, and they get their cholesterol checked, and their total cholesterol or LDL cholesterol are out of range, you know, out of the lab range and maybe up towards that 240 or 250 mark that you just mentioned.  So, what could be going on here in these cases?  This is what we’re gonna talk about today, and what kind of steps can people take to investigate a little further to determine whether that slightly elevated total cholesterol and LDL cholesterol is a problem or whether it’s just part of a natural physiological process.

What to do – and not do – about high cholesterol

Chris Masterjohn:  Absolutely.  So, the first thing that we need to understand is that there are good reasons and bad reasons for increases in cholesterol in the blood.  So, one of the reasons that cholesterol can increase is if we’re clearing lipids from the liver.  Let’s say, for example, that a person has nonalcoholic fatty liver disease and they start resolving it.  Well, one of the key problems with fatty liver disease is that the lipids get stuck in the liver and they’re not being released into the bloodstream, so once you start clearing that, part of what may happen is you may get an increase in triglycerides, and you may get an increase in cholesterol in the blood.  And that is a good thing because nonalcoholic fatty liver disease is not only very dangerous for the liver, but it’s actually a much stronger predictor of cardiovascular disease risk.  And this is a currently emerging field, but there is one study that was done in Japanese people, and they just looked at a number of a Japanese population that was apparently healthy, and they looked to see if they had fatty liver or not, and then they followed them over a number of years.  And they found that fatty liver disease increased the risk of cardiovascular disease by over fivefold; whereas, LDL cholesterol predicted it somewhat, but the study wasn’t even statistically powerful enough to make that connection to LDL cholesterol statistically significant.  And then when they incorporated LDL cholesterol and metabolic syndrome in a statistical analysis, they found that LDL cholesterol and metabolic syndrome, neither of those were even significant, and nonalcoholic fatty liver disease raised the risk of cardiovascular disease by about threefold or fourfold for men and about fourteenfold for women.  So, if we’re clearing lipids from the liver, then this is a good thing.

Chris Kresser:  Yeah, that’s a pretty phenomenal statistic there, especially in light of some of the estimates that I’ve seen that up to one in three Americans have nonalcoholic fatty liver disease, which would really go a ways to explaining the cardiovascular disease epidemic.

Chris Masterjohn:  Absolutely.

Chris Kresser:  So, you’ve written about this, Chris, what you were just talking about in terms of switching to a Primal/Paleo type of diet and the lipids going up because the fatty liver is sort of unpacking itself.  And you’ve written about this extensively that choline is one of the nutrients that makes that possible, so can you say a little bit more about that?

Chris Masterjohn:  Sure.  So, the best sources of choline are liver and egg yolks.  There are also a number of other nutrients such as folate, for example, that reduces the need for choline.  So, it you’re increasing your intake of liver, egg yolks, and leafy green vegetables — you know, a general increase in nutrient density in your diet — it’s very likely that if you do have fatty liver you are going to contribute to its resolution, because choline is the key nutrient that is needed to package the fats in the liver and export them into the bloodstream so they can be metabolized by other tissues.  Now, like you said, one in three Americans might have fatty liver, and the best way to diagnose fatty liver, to get certainty, the least invasive way is with an ultrasound.  It can also be diagnosable with MRI or biopsy.

Chris Kresser:  One of the names for that is FibroSURE.

Chris Masterjohn:  For the test?

Chris Kresser:  Yeah.  Just to let people know, if they want to ask for that test.  I mean, in my experience, a lot of doctors won’t order it, but if you want to ask for it, that’s what it’s called.

Chris Masterjohn:  Right.

Steve Wright:  Are there any blood markers that would, you know, predate that, because you can’t just walk into your doctor’s office and just say, “Hey, can you ultrasound?”

Chris Kresser:  You might see a mild elevation in aminotransferases, so like AST and ALT.  They’re sometimes called liver enzymes.  And ALT is fairly specific to the liver, but AST can reflect tissue breakdown in other organs.

Chris Masterjohn:  Yeah, but none of the aminotransferases are very specific to fatty liver, so the best predictor of fatty liver is obesity and insulin resistance.  So, among obese Americans, over three-quarters have fatty liver. 

Chris Kresser:  Wow.

Chris Masterjohn:  So, if you are correcting obesity and insulin resistance and you don’t want to have a biopsy or your doctor won’t order an ultrasound, I think you can assume that resolution of fatty liver is a very likely candidate reason for why blood lipids may increase, but they should normalize over time. 

Chris Kresser:  Yeah, let’s say someone is obese and they go on a low-carb diet and they start eating liver and a lot of coconut oil and, you know, egg yolks and a lot of the foods that are choline-rich and folate-rich, and they experience this change in lipids, do we know from the literature how long we could expect that to take? 

Chris Masterjohn:  No, I haven’t seen anything good on it, so I think what we need to do is track people’s experiences and start to get some anecdotal evidence on this, and hopefully we’ll see, you know, some guidelines coming out in the scientific literature.  But I think if we monitor these things and share some experiences, that might give us some clues sooner. 

Steve Wright:  Is it a big deal with the egg yolks to cook them or eat them raw?

Chris Masterjohn:  I don’t think so.  When I eat egg yolks, I usually eat them raw, but I don’t think that that’s going to make a big difference in resolving fatty liver disease.  I think providing the choline is the main factor.

Chris Kresser:  OK.

Chris Masterjohn:  So, clearing lipids from the liver is good.  You can have a decreased clearing of lipids into atherosclerotic plaques, and that’s also going to be good.  You can have increased weight loss.  And weight loss, if you’re clearing lipids from adipose stores, that could elevate your blood lipids, and this could be good or it could have negative effects in some cases.  You know, if you have an overweight person, they are a lot more likely to have fatty liver, they are a lot more likely to have insulin resistance, but probably the person who’s probably in the worst-case scenario is the overweight person who is trying to lose weight by restricting calories and is in a sort of chronic starvation mode, where instead of getting a good diet that’s lowering their set-point, they’re always operating underneath their set-point, and that can contribute to a lot of stress and release of free fatty acids and things that can have negative effects on thyroid hormone.  But I think if you follow a weight loss strategy that is not leaving you hungry and stressed, I think you can expect a moderate elevation of lipids in some scenarios.  And we talked about this in the second episode, so we shouldn’t go into too much detail; but in my opinion, if someone is losing weight and they’re losing it at a healthy pace in a sustainable way and they see fluctuations in their blood lipids, in my personal opinion, they should wait until their weight has been stable for three to six months before trying to interpret it.  In other words, if blood lipids go up while you’re losing weight, concentrate on losing the weight and normalizing your metabolism.  Then once your weight has been stable, start looking at blood lipids and so on. 

Chris Kresser:  Yeah, and maybe get a few readings once your weight is stable, given the normal variation that they’ve talked about in the previous show.

Chris Masterjohn:  Exactly.  So, you always want to get two or three readings to look at that variation.  And, you know, while you bring that up, that’s a source of error.  I have also seen cases where people go on a diet that seems to be helping, and they say:  Why have my blood lipids increased?  And it was a simple error like they were fasting one time and they weren’t fasting the other time.

Chris Kresser:  Right.  Great point.

Chris Masterjohn:  So, obviously if it’s due to error, then we can’t say this is good or bad.  We need to say, “Correct the error and repeat it once you have the conditions kept the same.”  But there are bad cases of increased lipids, and the bad cases are where we are decreasing the clearance of lipids from the blood.  And I think that there are basically three reasons that this is likely to happen when someone is switching to a more ancestral diet, which seems to be what most people in this circle are concerned about.  Why would these blood lipids increase when we are eating a more Paleo Diet or a more Weston Price type approach, a more ancestral diet?  And there are some bad things that can happen, and I think that we should discuss those a little bit.  One is that you can have decreased thyroid activity either due to extreme and chronic carbohydrate restriction.  The other is that you may have an iodine deficiency if you have increased some of your intake of plant goitrogens and haven’t included enough iodine-rich foods, especially seafoods, in your diet.  And I think the other case is in certain cases someone might have familial hypercholesterolemia, and when they switch their diet to a diet that contains more cholesterol and more saturated fat and less polyunsaturated fat, there are reasons why that would increase blood cholesterol that might not be harmful in someone who doesn’t have familial hypercholesterolemia but might actually be harmful in some cases for someone who does have familial hypercholesterolemia. 

Chris Kresser:  So, just to save us all the breath, because we I think we might talk about this a little bit more, let’s call familial hypercholesterolemia FH.  It’s a codeword.  I’ve been stumbling over that in previous episodes, so FH from here on out.  So, Chris, let’s talk a little bit — I see this actually quite a bit in my practice with iodine and thyroid and activation of the LDL receptors, so let’s talk a little bit more about that.

The Thyroid-LDL connection and why iodine matters

Chris Masterjohn:  Sure.  OK, so thyroid hormone is the central governor of the LDL receptor, and the LDL receptor is, in turn, the central governor of clearance of LDL cholesterol from the blood.  And basically thyroid is a messenger who is communicating that we are in a state of abundance, we have all of the food and nutrients that we need, and it is time to utilize those nutrients for the purposes of reproduction, high physical performance, and other things of that nature.  And cholesterol is the precursor to a lot of these key hormones, like the sex steroids, for example, and the bile acids that improve digestion.  So, thyroid hormone basically communicates to our cells that all of these nutrients that we need are available, so our cells respond by taking in LDL cholesterol from the blood and making lots of good things out of it, like testosterone, for example.  Now, one of the key things that can happen when people start increasing their intake of fruits and vegetables and decreasing their intake of grains, which is a common dietary shift in the Paleo community, for example, is that you can increase your intake of plant goitrogens.  Goitrogens are named because they have the ability to cause goiter, which is a problem that occurs as a response to insufficient thyroid hormone, and basically these plant chemicals have the ability to decrease the production or activation of thyroid hormone.  Now, in most of the cases, I don’t want to suggest that eating these plants is a bad thing.  In most of the cases, all you need to do to compensate is increase your intake of iodine.  But in certain cases, if someone is not eating iodized salt, for example, and they’re living in an area where the iodine quality of the soil is poor, and they’re not eating seafood, which is the most reliable source of iodine, they may not be getting the iodine that they need to deal with that level of plant chemicals in the diet.  So, it’s not that the plants are intrinsically bad.  It’s just that we need to achieve that dietary balance.  So, the number of plant chemicals in the plant kingdom that inhibit thyroid function, at least in a sort of test tube assay, is almost innumerable.  I mean, there are thousands of plant chemicals.  Basically all of the polyphenolics — the flavonoids, for example — they basically all inhibit the enzymes of thyroid hormone.  But a lot of these plant chemicals don’t really make it into the system because we detoxify them properly, and sometimes they also even have beneficial effects.  So, what we need to do is look at some of the areas where there is really convincing research done either in humans or in laboratory animals showing that certain foods, in the absence of adequate iodine, can contribute to decreased thyroid function.

Chris Kresser:  So, I want to jump in here too and just mention that for most people who come to me with thyroid issues, I do a 24-hour urine iodine test, and I would say probably 80% of the people that I test are iodine deficient or have excess bromide levels, which can cause some of the symptoms of iodine deficiency.  So, it’s a pretty common problem, and I think that’s partly because a lot of people aren’t eating much seafood these days maybe because of concerns for mercury or just they don’t like it or it’s not available to them in an easy way.  And then a switch from iodized salt to natural salt, which has less iodine; that’s pretty common when people are switching to a Paleo or Primal type of diet.  So, I don’t think this is a rare problem.  I think this is actually something that is fairly common, at least in my patient population.

Steve Wright:  When you say “in seafood,” is it everything — shrimp, fish, seaweed — or is it specific to certain types?

Chris Masterjohn:  Well, I think seaweed is the most abundant source, but all seafood generally has some iodine in it.  The problem with land food isn’t that it doesn’t have iodine.  It’s just that it’s so unreliable.  You can have, you know, a potato grown in one part of the country and in another part of the country, and their iodine content might vary a hundredfold, but the ocean is rich in iodine, so seafood, in general, tends to be a more reliable source of iodine, but seaweed, of course, is the most abundant.

Chris Kresser:  Right.  And then, Chris, the other thing I wanted to talk to you about is you’ve written pretty extensively about goitrogens and a great article — I know you had a special report that I read, but also, I think, some articles on your blog about how different methods of preparation can alter the goitrogenic effect of food.  So, without going into too much detail about that, can you just give us a little summary?

Are goitrogenic foods inhibiting your thyroid function?

Chris Masterjohn:  Yeah, absolutely.  So, I went into the most detail, like you said, on my Thyroid Toxins Special Report available on my website, and I think the other article you were thinking of was one that I wrote for Wise Traditions called Bearers of the Cross:  Crucifers in Context.

Chris Kresser:  Yeah.

Chris Masterjohn:  OK, so there are a few different classes of goitrogenic foods, and the way preparation affects them is different depending on the class.  The most common that people on an ancestral diet are probably going to be eating is crucifers.  So, crucifers, for example, include broccoli, brussels sprouts, cauliflower, cabbage, collard greens, kale, kohlrabi, mustard, rutabaga, turnip, bok choy, arugula, horseradish, wasabi, watercress, maca, and even canola oil is a crucifer.

Chris Kresser:  Oh, wow.  I didn’t know that. 

Chris Masterjohn:  It’s a close relative of the turnip.

Chris Kresser:  I didn’t know maca was either.

Chris Masterjohn:  Yeah.

Chris Kresser:  That’s interesting.  Yeah.  OK. 

Chris Masterjohn:  So, crucifers have natural pesticides called glucosinolates, and these can be metabolized when we chew the crucifer or when we chop them up and so on.  So, whether we’re eating them raw or cooked, we’re gonna get some of these goitrogens.  And basically what happens is there’s an enzyme that frees a chemical called isothiocyanate, and then in our bodies we metabolize this to thiocyanate, and thiocyanate decreases the uptake of iodine into the thyroid gland because it basically competes with it.  So, if you have a high ratio of isothiocyanate to iodine, then isothiocyanate actually gets into the thyroid gland.  It also gets into breast milk, and it crosses the placenta in place of iodine.  And then once it’s in the thyroid gland, it will compete for the utilization of the enzyme that makes thyroid hormone.

Chris Kresser:  Right.

Chris Masterjohn:  Now, thiocyanate, you can completely protect against it simply by getting enough iodine in your diet.  Now, a lot of people think that cooking or fermenting cruciferous vegetables is going to get rid of the goitrogens, but that is not true.  Fermenting actually activates them.  It actually does the conversion to the thiocyanate right in the jar of sauerkraut.  So, if you’re eating sauerkraut and kimchi, you are not getting rid of the goitrogens.  That doesn’t mean the foods are bad, but it means that you need more iodine when you’re eating those foods.  If you steam the vegetables, it decreases the goitrogen yield about 30%, but it leaves about 70% of them there.  Not only that, but when you steam the vegetables, the rate of liberation of the true goitrogens in the intestines varies fourfold between different people depending on their intestinal flora, so steaming is not a reliable way of getting rid of them.  If you boil them for a half an hour and you keep the water, for example, in a soup, then that gets rid of 65% of the goitrogens, so about two-thirds.  And if you get rid of the water, then that gets rid of about 90%, so if you boil them and then you pour the water out.  Now, I don’t think that you need to go through all this extensive boiling.  I think you just need to increase your iodine.  But you have to realize if you have marginal iodine status and then all of a sudden you start eating sauerkraut and kimchi at every meal and then steaming broccoli for dinner, then that may push you over the edge into a frank iodine deficiency if you were on the border.

Chris Kresser:  So, Chris, what’s the dose of iodine that’s required to prevent, you know, a moderate intake of goitrogenic foods like we’re talking about now in the context of a Paleo or Primal type of diet from inhibiting thyroid function?

Chris Masterjohn:  Unfortunately, that has not been well characterized, but I think if we’re looking at the RDA, we’re looking at about — I think the RDA is still 150 mcg, and there are people out there who are using 50 mg, so I suspect that if you were taking 1 mg, for example, then that should be well more than sufficient to take care of the goitrogens themselves.  But again, like you said, with environmental bromine exposure and so many other things, it’s possible that people may need more than that.  But I think if we’re just talking about goitrogens, then that should be enough.

Chris Kresser:  A minimum, yeah, a minimal dose.  OK.

Chris Masterjohn:  So some of the other foods are — another common food is cassava, which also goes by tapioca, manioc, yuca; flax; lima beans; and the fruits of all of the Rosaceae family, which includes cherries, almonds, plums, peaches, apricots, pears, raspberries, strawberries — these all contain cyanogenic glycosides, and sweet potatoes also contain a pretty small amount.  Now, most of these foods come in different levels of bitterness, and in the more bitter varieties, that’s where you get more of the cyanogenic glycosides, and in the less bitter and more sweet varieties it’s less common.  But these are also a source of thiocyanate because they actually release cyanide, and we detoxify the cyanide to thiocyanate, and it has all of the same effects as crucifers.  And the most reliable way to detoxify these is to crush the foods and leach them in running water for a few days.

Chris Kresser:  Ha-ha!

Steve Wright:  Oh, yeah.

Chris Masterjohn:  But, seriously, this becomes a key issue when you are consuming massive amounts of these.  There are some people, for example, you know, certain populations where they rely on cassava for the main starch.

Chris Kresser:  Sure.

Chris Masterjohn:  And they actually deliberately breed the bitter varieties because it protects against insects, and they are very vulnerable to goiter unless they process these so extensively.

Chris Kresser:  Right.

Chris Masterjohn:  So, again, I don’t think that these are going to be a major problem unless you’re adding it on top of the crucifers and on top of the low iodine intake.  And the two others are soy and millet.  I don’t think that people who are, you know, eating the Weston Price or Paleo ways are really going overboard with soy, but there is a myth out there that fermentation decreases the goitrogens, and it doesn’t.  It does the opposite; it increases their bioavailability.  So, if you add some fermented soy on top of everything else with low iodine, that can be a problem.  And probably the most goitrogenic food in the world is millet, and this could be a problem if people are getting rid of gluten and they start eating a lot of gluten-free bread that’s made from millet, for example.  And millet basically inhibits every step of thyroid metabolism, and high iodine intakes cannot overcome the effect of millet.  But again, if it’s a minor component of the diet, it’s probably not a problem, but when you’re compounding it with all of these other foods and a low iodine intake, that’s when it can really be an issue.  So, I think the solution to all of this is to eat these foods in moderation.  Don’t go crazy with them.  You know, don’t get the Vitamix out and load it with as many cruciferous vegetables as you can and drink cruciferous vegetable juice all day long.  There are people who do that and suffer the consequences.  You know, eat these foods in moderation, and make sure that you compensate for their inclusion in the diet with eating more seafood, perhaps some occasional seaweed, and if you need it — you know, you get the iodine test that you do, for example — if you need more iodine, supplement to bring that level up to where it needs to be. 

Steve Wright:  Hey, Chris or Master J, if I can, because I want to keep you guys straight.

Chris Kresser:  Ha-ha!

Chris Masterjohn:  Yeah, that’s how I roll.

Steve Wright:  OK, that’s what I thought.  So, you just touched on it, and I’m glad you brought it up, and that’s the shakes or the juicing because there are a lot of us — and I don’t do it, because I hate cleaning my blender — but a lot of people like to make a shake in the morning, and you’ll see a lot of bloggers telling you to make a green smoothie.  Is even doing, like, a cup a day or something in my smoothie, over time is this gonna be a problem? 

Chris Masterjohn:  I don’t think it’s going to be a problem as long as you have adequate iodine in your diet.  I mean, a cup of cruciferous vegetables is not a lot.  In all honesty, I sometimes, you know, I’ll eat a whole plateful of kale or something like that, so I don’t think it makes any difference if you just throw it in the juicer.  But what I mean is if people are juicing so that they can consume exorbitant quantities of these vegetables compared to what they would be able to eat if they were eating them whole, that’s where you get the problem. 

Chris Kresser:  And, Chris, you don’t have any thyroid problem that you know of, so maybe someone that does might not necessarily want to eat a plateful of cruciferous vegetables.

Chris Masterjohn:  Absolutely.  This is the key issue:  It’s an individual thing.  Like I said, steaming, the goitrogen yield varies, you know, fourfold between different people, and different people have different iodine status.  So, I am not saying these foods are bad.  I’m saying that if you have symptoms of hypothyroidism when you made a dietary shift towards including more of these foods, then you might suspect those foods and their balance with iodine to be a culprit.

Chris Kresser:  Um-hum.  Your mileage may vary.

Chris Masterjohn:  Right.

Chris Kresser:  So, I want to throw in a couple things here just from my clinical practice.  One is that I’ve found that for people with elevated LDL and some symptoms of hypothyroidism, even if they’re euthyroid — like, their T4 and T3 are normal and their TSH is fairly normal — that using slightly higher of a dose than we talked about, like 1 mg, more in the range of maybe 2.5 to 6 mg and sometimes even up to 12.5 mg of iodine can have a pretty dramatic effect on total cholesterol and LDL cholesterol, and I’ve been keeping some data, you know, just anecdotally for my practice.  Eventually maybe I’ll have enough to do something interesting with, but I have seen that work.  One word of caution, though, is that it’s really important that if you do start iodine supplementation that you start at a low dose and you build up slowly over time.  And the reason for that is that if you go too quickly, if you just start taking 6.5 mg, for example, or 12 mg, in my experience, that can provoke or exacerbate an autoimmune thyroid response, particularly if you don’t have enough selenium in your diet.  And I’ve seen that happen, and I’ve seen people kind of start experiencing hyperthyroid symptoms or symptoms of immune dysregulation or immune attack against the thyroid.  So, if you do start to take iodine, I’d recommend starting at a lower dose, like maybe 250 mcg, sticking on that for seven to ten days, maybe doubling it, sticking on that for seven to ten days, and then proceeding to increase from there.  The other thing is that — and I just wrote a blog article about this today, the day that we’re recording this show — is that a lot of studies show that selenium can protect against the potentially negative impacts of iodine supplementation for people who have autoimmune thyroid disease.  So, if you do have Hashimoto’s or Graves’ or something like that and you’re considering taking iodine, you want to make sure that you’re getting at least 200 mcg of selenium combined from food and supplements each day.

Steve Wright:  So, Chris, do you have a preferred form of selenium?

Chris Kresser:  I like the Super Selenium Complex from Life Extension, and it has four different forms of selenium in there.  It’s got selenomethionine, sodium selenate, selenodiglutathione, and Se-Methyl L-Selenocysteine.  Some studies I’ve seen, Chris, and you’re probably familiar with this work — in fact, somebody just sent me a study this morning on type 2 diabetics, the effects of long-term selenium supplementation.  They were interested in seeing if selenium could help treat diabetes, but what they found was that 200 mcg a day of selenium actually increased the risk of type 2 diabetes in their study population versus placebo.  So, there’s some evidence that certain populations who take too much selenium or too much of one form of selenium, that that can be problematic, which is why I recommend taking multiple forms.  What are your thoughts on that, Chris?

Chris Masterjohn:  Well, I have a bias that has very little evidence behind it that selenocysteine is probably preferable over selenomethionine because that’s the form that’s incorporated into our proteins.  That’s why it’s the form that’s found in animal foods.  But I’ve had a similar suspicion as you that in those studies the form might be part of it and interactions with other nutrients might be part of it, but I guess we’ll have to wait and see for some clinical tests of that idea.

Chris Kresser:  But, I mean, in general, it’s always the better idea if possible to get as much of your nutrients from food, and that helps avoid this kind of thing, because there’s a lot we still don’t know about nutrient supplementation or augmentation. 

Chris Masterjohn:  Right.  And in a normal diet, you would get that mix because plants have selenomethionine and animal foods have selenocysteine. 

Chris Kresser:  Right.  And Brazil nuts, for those of you that don’t know, are a very rich source of selenium.  They’re also very high in omega-6, but I don’t think that’s necessarily a problem because you only really need to eat two or three Brazil nuts, depending on the source, to get 200 mcg of selenium.

Steve Wright:  Do either of you take iodine?

Chris Kresser:  I’ve experimented with it in the past.  I don’t have a thyroid issue, and I eat a lot of seafood and some sea vegetables, so I get it in my diet; but I have experimented with it just because I do that a lot on myself, and if I’m recommending stuff to my patients, I often will do it myself to, you know, just see what it feels like.  I’ve gone up to 25 mg of iodine without really noticing any difference personally. 

Chris Masterjohn:  I don’t supplement iodine right now, but I have plans in the future to see if I can use it to detoxify fluoride that I suspect I have in my system, but I’ll write about that when I get around to it.

Chris Kresser:  Yeah, keep us posted.

Steve Wright:  Yeah, I’m looking forward!

Chris Masterjohn:  OK, so shall we move on to carbohydrate?

Chris Kresser:  Yeah, sounds good.

The telltale Thyroid-Cholesterol signs you need more carbs

Chris Masterjohn:  All right, so there are a number of studies that have shown that carbohydrate restriction or fasting or calorie restriction can decrease thyroid function, and they tend to show a decrease in T3 in the serum and an increase in reverse T3.  T3 is the active hormone, and reverse T3 is kind of an antithyroid hormone.  And many of your listeners probably have seen the correspondence between Paul Jaminet’s blog and his guest blogger and Anthony Colpo last year, where these studies were debated quite extensively.  And I think when we look at these studies in the context of some of the biochemistry that has been studied regarding insulin’s interaction with thyroid hormone, then I think what we are seeing is a definite effect of the level of carbohydrate in the diet.  And I know that there are some confounders in some of these studies, especially when they compared it to fat; a lot of the fat was really low-quality fat, like corn oil.  But if we look at what insulin does, we find that there is evidence from humans, from cells, and from rats that insulin cooperates with thyroid-stimulating hormone, or TSH, to increase the production of the enzymes and proteins involved in making thyroid hormone, and we find that it contributes to the enzymes that activate thyroid hormone from T4 into T3, the active form.  So, I think what we’re seeing here is when we have insulin operating in its optimal conditions, then insulin is again sort of acting as a messenger that the body is in a state of abundance, and it’s contributing to the production of thyroid hormone and to its activation into T3.  And if you prevent the activation into T3, then the T4 — There isn’t very evidence that insulin actively prevents the production of reverse T3, but by promoting the conversion into the active form, that in itself tends to prevent T4 from being converted into the inactive form, reverse T3.  So, I think we’re looking at a definite effect of effective carbohydrate here, and I think the best way to test for this is to look for a decreased ratio of T3 to reverse T3.  From the clinical studies, that seems to be the most likely marker to look for to see if this is what’s happening, to see if this is why cholesterol has gone up.  I think that if you find that T3 or reverse T3 are out of whack, probably the best way to address that is to try increasing the carbohydrate intake — not necessarily meaning you have to go on a high-carbohydrate diet, but, you know, like, Paul Jaminet had sort of concluded at the end of that series that he still advocates a low-carbohydrate diet, but it’s possible to go too low for some people, and that’s when you might get deficiency in thyroid signaling.

Chris Kresser:  And I definitely see this, Chris, in my practice, and this is purely anecdotal, but I often get people who come to me who have been on a low-carb Paleo Diet, not for any particular reason, just because that was their understanding of the Paleo Diet, you know, as a low-carb approach.  And then they’re suffering from the classic hypothyroid symptoms:  Their hair is falling out, and their hands and feet are cold, outer third of the eyebrows thinning, you know, low metabolic symptoms.  And then they start eating some more starch and starchy tubers and fruit and increase their carbohydrate intake; and in almost all cases, their symptoms improve significantly.  The challenge clinically with that is the patient population who is on a low-carb diet because if they start to reintegrate carbohydrates, their blood sugars go up and they gain weight and they experience all of the metabolic issues that can be associated with that if they have metabolic syndrome, so it’s a little more challenging in those folks to just add the carbohydrates back unless you address the other mechanisms that are causing carbohydrate intolerance, whether they be metabolic issues or gut issues.  You know, some people with small bowel bacterial overgrowth can’t really tolerate a lot of carbohydrate.  So, it gets a little more complicated, of course, but I think that, at least in my experience, the phenomenon that you’re describing with low-carb diet contributing to hypothyroid and increasing carbohydrate intake improving thyroid function is definitely real.

Chris Masterjohn:  Yeah, and I think you highlighted something important there that there are a lot of classic symptoms that go beyond the blood tests, and you know, I think even if you don’t see the changes in T3 and reverse T3, there are other mechanisms.  For example, if you have increased liberation of free fatty acids beyond what you’re able to utilize, there is some evidence that the free fatty acids will accumulate in the nucleus of the cell at a high enough concentration to inhibit thyroid binding to its receptor, and that will cause all of these symptoms of the metabolic effects, including the high cholesterol, but it might not show up as changes in thyroid hormones in the blood.  So, I think if you see those classics symptoms, if you see high cholesterol and low sex hormones, for example, I think those are good clues in addition to T3 and reverse T3 that might signify that an increase in carbohydrate intake might be needed, but I have an anecdote that I think is pretty interesting to share from Nutrition and Physical Degeneration, Weston Price’s book.

Chris Kresser:  Yeah, let’s hear it.

Chris Masterjohn:  He says:  “For the Indians of the far North this reinforcement” — he’s talking about reinforcement of nutrition for pregnancy — “was accomplished by supplying special feedings of organs of animals.  Among the Indians in the moose country near the Arctic circle a larger percentage of the children were born in June than in any other month.  This was accomplished, I was told, by both parents eating liberally of the thyroid glands of the male moose as they came down from the high mountain areas for the mating season, at which time the large protuberances carrying the thyroids under the throat were greatly enlarged.”  So, what he’s saying is when the moose were about to reproduce, they naturally went into a kind of hyperthyroid state where their thyroids were enlarged, and the people there would harvest the thyroid glands so that they could reproduce, and as a consequence, most of their children were born nine months after the moose mating season.

Chris Kresser:  Wow.

Chris Masterjohn:  And what the indicates to me is — I mean, it’s difficult to interpret it because he doesn’t go into great detail, but I think what we might be seeing here is up in the Arctic circle — and these are the inland people, they’re not seacoast, so they probably don’t have a lot of iodine in the diet, they certainly don’t have a lot of carbohydrate in the diet.  It seems like they, as part of their natural adaptation to their environment, they supplemented with thyroid hormone so that they could convert their cholesterol to sex hormones so that they could increase their fertility, and I think what we’re witnessing is perhaps a natural acknowledgement that under those certain conditions where you have an extremely carbohydrate-restricted diet, you may need supplemental thyroid hormone in order to maintain that fertility. 

Chris Kresser:  Yeah, I mean, that’s so fascinating.  In The Healthy Baby Code, of course, I talk a lot about anecdotes like that and traditional populations and their approaches, like in the Masai culture in Africa.  And maybe you can correct me if I’m wrong on this, Chris, because I know you’ve studied them a lot, but something I read a while back where when people are trying to get pregnant or thinking about doing that, then they’ll consume dairy from cows that have been grazing on grass during the particularly lush seasons of the year to increase their fertility.

Chris Masterjohn:  Yeah, well, the Masai definitely have an association between animal fat and fertility not only in the diet but in many of their rituals.  Animal fat is always associated in that way.  And they also have very strong associations between lactation in the cow and sort of the principle of female fertility, so I don’t remember the specifics of their fertility diets in great detail, but that definitely sounds characteristic of the Masai. 

Chris Kresser:  OK, so we gotta wrap it up.  We could go on, and we probably will.  I think we’ll have to have you back, Chris.  We’ll make it a regular thing, because this is an issue that’s on a lot of people’s minds, and even with all that we’ve learned about it and, you know, a lot of people, like I said before, have been exposed to the idea that cholesterol isn’t necessarily bad and we don’t need to do everything we can to just lower it indiscriminately.  I think, just speaking personally from the comments I get on my blog and the people I see in my practice, there’s still quite a bit of concern about it, and in some cases rightfully so, as we’ve learned in this 3-part series.  So, I want to thank you, Chris, for coming back, and like I said, we’ll have you back.  Maybe we’ll do some case studies.  I’m actually speaking at the PaleoFX conference in Austin, and the topic of my talk is gonna be what to do, if anything, about high cholesterol, and I’m gonna present a practical framework in kind of a flowchart format for what you do if, let’s say, you get a cholesterol reading that comes back above 250 and kind of a step-by-step process for how you can investigate that.  And I imagine those presentations will be available after the conference is over, so if anyone is interested in some more kind of really down and dirty, practical info on how to deal with this stuff, you can check that out.  And, Chris, when are we gonna meet?  Are you gonna be at AHS this year? 

Chris Masterjohn:  Yes, I will be at AHS this year.

Chris Kresser:  Cool.  So, I’ll see you there if not before and then, I’m sure, at the Weston A. Price Conference in November, as well.

Chris Masterjohn:  Yeah, I look forward to it!

Chris Kresser:  Yeah.  So, Steve, thanks for shepherding us through this again, and we’ll see everybody a couple weeks from now.

Steve Wright:  Yeah.  It was a great show.  Thanks again, Master J, for being on, and it sounds like we’ll hear again soon from you.  

If you’re confused about what to eat, check out the Personal Paleo Code.  It’s a 3-step process designed to help you discover your own ideal diet and create highly customized meal plans with a few clicks of a button.  Visit PersonalPaleoCode.com to learn more.  And if you’re trying to get pregnant or are already pregnant or nursing, don’t miss The Healthy Baby Code.  It guides you through the essential steps to naturally boost fertility and promote lifelong health for you and your baby.  Find out more at HealthyBabyCode.com.

Please keep sending us your questions at ChrisKresser.com using the podcast submission link.  And if you enjoyed listening to the show, head over to iTunes and leave us a review.  Thanks.

 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.

**Special announcement: you’ll notice we’re now providing a full transcript for each new episode of the show.  Special thanks to Lindsey Gosling from our community for volunteering to do this.  She’s my hero.

One of the most hotly debated subjects in the Paleo-sphere over the last several months has been the causes and treatment of obesity and overweight.  Some claim that it’s simply a matter of “calories in, calories out”, and weight loss is just a question of “eating less, and exercising more”.  Others claim that it’s all about macronutrients (fat, carbs & protein), and calories don’t make a difference at all.

Over the last two decades a more sophisticated theory of weight regulation has emerged that encompasses the seeming contradictions in the prevailing paradigms.  This theory holds that the brain is the primary driver of weight gain and loss, and that environmental and genetic factors that influence this neurobiological system are what account for the alarming rise in obesity we’ve seen in the Western world since the early 80s.

2:57 Why it’s so hard to lose weight and keep it off
8:00 The truth about food reward, calories in vs. calories out, and “the metabolic advantage”
13:32 The Body Fat Setpoint making you “gain the all weight back”
21:06 Why leptin is the master fat hormone and what happens when you’re leptin resistant
26:05 The link between inflammation and obesity
31:00 Are modern foods engineered to make us fat?
49:48 The one thing any successful weight loss intervention must have

Links We Discuss:

• Stephan Guyenet: Author of The Whole Health Source Blog
• Stephan Guyenet: Body Fat Setpoint Series
• “The End of Overeating”

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, Chris?

Chris Kresser:  I’m pretty good.  I have to confess to being quite sleep deprived.  Sylvie is usually a pretty good sleeper actually, but the last several nights she has been — I don’t know what’s happening, maybe a growth spurt or something, but she has just been squirrelling around the bed like a little monkey all night.  Yeah, so if I start slurring my speech or just have large pauses or gaps, you’ll know what’s going on.  How are you doing, Steve?

Steve Wright:  We’ll be a pretty good tag team today then, because I’m working one-handed here, so I can basically only talk.  I had shoulder surgery nine days ago, and everything went well.  It appears to be good.  I had a labrum tear, but I do have an arm in a sling for four weeks, so that kinda slows down life.

Chris Kresser:  Oh, wow.  Well, all right, so we’re injured and impaired, but we’re still here.

Steve Wright:  That’s right.  We can still talk!

Chris Kresser:  Yeah, thank God for the radio show!  So, let’s see, we have one announcement to make before we get started.  Some people are already aware of this, I’m sure, but we now have full transcripts for all of the Revolution Health Radio and previous Healthy Skeptic podcasts in the works, which is really exciting.  We loved you so much that we just decided that we were finally gonna do it, and we have a volunteer from the community, Lindsey, who is helping us with this on an ongoing basis, and we’re really grateful to her.  She’s doing an awesome job, and so we’ve already put some of the transcripts up on the website, on the actual episode posts, and some of the older ones are in progress right now, and we’ll be adding them as we get them done.  But in the future, I think we’re gonna be able to have the transcript up there right as the podcast or the radio show goes live, so that’s really exciting, and I hope you enjoy the transcripts, all of those who have been asking for them.  I hope you enjoy it!

Steve Wright:  Yeah, it will make things much easier to find with the Ctrl+F function.

Chris Kresser:  Yeah, definitely.

Why is it so hard to lose weight and keep it off?

Chris Kresser:  So, today I decided to review a study that was recently published by a friend of mine who I’m sure many of you know and a colleague, Stephan Guyenet, from Whole Health Source, one of my favorite blogs, and if you don’t know his work, I would highly recommend checking it out.  I think it’s WholeHealthSource.blogspot.com.  And Stephan published this paper with his mentor, Michael Schwartz.  Both of them are at the University of Washington School of Medicine.  And Stephan is an obesity researcher.  He has spent his career studying the mechanisms involved in particularly the neurobiology of weight regulation, and he just published a paper called Regulation of Food Intake, Energy Balance, and Body Fat Mass:  Implications for the Pathogenesis and Treatment of Obesity.  And we’ll put a link to the paper in the show notes.  Unfortunately the full text is not available for free, but the abstract is, and if you’re really interested you can cough up the, I think, 30 bucks or 35 bucks for the full text.  I want to talk about it because Stephan’s been on the show twice already to discuss obesity and all the various factors involved in obesity, but I wanted to take another opportunity to revisit this because I think it’s much misunderstood.  I think our understanding of it is continually evolving, and this paper, I thought, was the most concise and thorough synopsis of all of the various mechanisms that are supported in the scientific literature in terms of what causes weight gain and what might cause weight loss and keeping the weight off, because as everybody knows, losing weight is hard and keeping it off is even harder, and I want to explain in some detail why that is because, again, I think there is a lot of misunderstanding about that.  So, we’re gonna spend quite a bit of time talking about this.  It might even take the whole show.  If we have a chance, we’ll answer some questions at the end, and I’m sure we’ll come back to this again.  I’m not gonna get too far into what this means in terms of practical mechanisms because we’ll probably devote another show to that later, so this is just gonna be more of the background theory.

Steve Wright:  Sounds good.

Chris Kresser:  OK, shall we do it?

Steve Wright:  Yeah, are you gonna start with a high-level overview or just dive right in?

Chris Kresser:  Yeah, I’m gonna do a high-level overview, and so I’ll just give you kind of the basics of what we’re gonna be talking about, and then we’ll get into more detail about each point.  The high-level overview, I’ve written about this on my blog as well, and as most of you know, I think, obesity is a multifactorial disease, and I think pretty much anybody who researches it seriously agrees with that.  Anybody who says obesity is as simple as, you know, too much fat or too much carbohydrate or something like that is either misinformed or is intentionally misleading you.  It’s far more complex than that, but I can boil it down into one simple phrase, which is modern lifestyle + genetic predisposition = obesity.  And this is supported by the fact that obesity is virtually unheard of in populations that still follow their traditional diet and lifestyle.  In modern hunter-gatherer societies, it is basically nonexistent.  And then on the other hand, we know that there must be some genetic predisposition because not everyone who adopts a modern lifestyle becomes obese.  I mean, surely we all have friends or family members that eat like crap and they’re still really lean, so there are obviously some genetic and epigenetic factors, as well.

Steve Wright:  And lifestyle is food, stress, environment, everything?

Chris Kresser:  Yeah, exactly, so everything from the food we eat to our — I mean, actually it starts even before that.  It starts with our mother’s diet while she was pregnant with us, and it’s our gut flora particularly at the time of birth, whether we were breastfed.  So, that’s maybe kind of depressing news for some people because we obviously didn’t have any control over that, but it turns out that those things can have a very significant impact on our risk for obesity as we get older.

The truth about food reward, calories in vs. calories out, and “the metabolic advantage”

Chris Kresser:  One thing I want to talk about right up front is this whole — many of you who follow the Paleo blogs and are involved in this kind of thing have been aware of this debate that has been going on about food reward and calories in / calories out vs. the metabolic advantage or the idea that carbohydrates in particular predispose people to weight gain.  You know, on one end of the spectrum you have people say that calories don’t matter at all; it’s more a matter of carbohydrate density and the type of carbohydrates that you eat, and if you eat a low-carb diet, for example, you can eat as many calories as you want and you won’t gain weight.  And then you have on the other end of the spectrum people that say it’s all about calories, and as long as you’re in a negative energy balance, meaning as long as you expend more calories than you eat, then you will lose weight, and if you have an energy balance where you eat and expend about the same amount of calories, then you’ll maintain your weight.  That’s a little bit of a false dichotomy, and I’ll explain why in a second, but I just want to say for the record that I think that calories do matter, and I think the research definitely supports the idea that calories matter.  If you look at per capital energy intake — there’s actually a great graph in this study — in the U.S. it has increased about 20% since 1980, and that increase in energy intake or food intake over that period has closely paralleled the rapid rise we’ve seen over this past 30 years in obesity.  I think where people get confused about this is that they mistake the idea that calories matter with the idea that eating less and exercising more is effective weight loss advice; and it’s not.  And, you know, I absolutely agree with that.  That’s been a monumental failure.  The idea that you can just tell somebody to eat less and exercise more to lose weight is ridiculous and doesn’t work in the vast majority of cases, and we’re gonna talk a lot about why that is in the show today.  But that doesn’t mean that calories aren’t a factor and that some interventions that reduce caloric intake wouldn’t contribute to long-term weight loss.  This will be more clear as we get into it.  I’m already kind of ignoring my own top-line review thing here.

Steve Wright:  Hey, Chris, what was the 20%?  Was that 300 extra calories a day or 400?

Chris Kresser:  I don’t know the exact number, actually.  Let me look here.  I don’t know the exact number.  I’d have to look it up.  I just the percentage.

Steve Wright:  OK.

Chris Kresser:  So, another thing that we’re gonna focus on here is that over the last 20 years or so, research has shown that food intake and body fat regulation are primarily orchestrated by the brain.  And of course, the brain gets input from another of other body systems, but it turns out that the hypothalamus in particular, and other regions of the brain play a really essential role in regulating weight and body fat mass and that obesity involves the biological defense of an elevated body fat mass, or another way of putting that is an increased setpoint, and we’ll talk more about this.  And the increase in the setpoint, in turn, is mediated by interactions between the hedonic or pleasure/reward-seeking system and the homeostatic or energy-regulating system.  And these, in turn, are influenced by inflammation, both peripherally, like in the gut and other parts of the body, and then in the brain, by leptin resistance and by other mechanisms that impair the function of the hypothalamus or those other parts of the brain that are involved in regulating weight.  So, that’s the birds-eye view of what we’re gonna talk about, and it unfortunately gets a little bit complex in certain areas, so bear with me, and I hope it’s not overwhelming in those parts, but since we do have a transcript, you can go back and read it if it gets to be too much.  So, all clear, Steve?  Shall we go on?

Steve Wright:  Yeah, I think one more time really fast do that crescendo of the various parts.

Chris Kresser:  Well, basically obesity = modern lifestyle + genetic predisposition, and one of the ways that that is mediated, and the primary focus that we’re gonna talk about today, is the interaction between the hedonic and the homeostatic weight regulation mechanisms, and those are governed primarily by the brain.  So, that’s kind of the gist of what we’re gonna get to today.

Steve Wright:  OK, and then a bunch of things, like inflammation, affect the brain.

Chris Kresser:  Yeah.

Steve Wright:  Gotcha.  Cool.

The Body Fat Setpoint making you “gain all the weight back”

Chris Kresser:  OK, so let’s talk about the body fat setpoint.  I mean, I don’t know if anyone has thought about this, but if you’ve wondered how most lean people stay the exact same weight or within a couple of pounds for years or maybe their whole life without counting calories or weighing what they eat, it’s actually a pretty remarkable system if you think about it.  I mean, if it is true that the amount of calories you take in and the amount of calories you expend is what determines your weight, then it’s a pretty exquisitely regulated system to be able to maintain a range of weight within this 1 or 2 pounds without the person even thinking about it at all.  So, this happens because survival in a natural environment is threatened by either too little or too much fat.  If we have too little fat, we can’t survive periods of food scarcity and we starve; and if we have too much fat and we become obese, then we aren’t as fit to hunt and gather food and evade predators and survive.  So, the body has a system for maintaining a level of fat that’s appropriate for the human ecological niche, and this is called the energy homeostasis system or the homeostatic regulation of weight, and it’s this system that’s one of the main reasons it’s so hard to keep weight off once you lose it, because the homeostatic system responds to any reduction in fat.  Like if you lose 20 pounds, let’s say, this homeostatic system will increase hunger, it will decrease your resting energy expenditure, so even when you’re just sitting down the number of calories that you’ll burn will be lower, and it extract more calories from the food that you eat, so your metabolic efficiency goes up.  So, it has all of these mechanisms that are basically working against you when you lose weight to get you back to that body fat setpoint or what it thinks is the ideal weight for you.  On the other hand, if you were to gain 10 or 15 pounds, the body responds in the opposite way.  It would decrease hunger, it would increase your resting energy expenditure, so you burn more calories just sitting there, and it would extract fewer calories from the food that you eat, and by doing that your weight would also fall back down to the setpoint.  And so, a good analogy for this setpoint is a thermostat, and everyone knows how a thermostat works.  Let’s say the thermostat is set at 70 degrees, and that’s the setpoint for the temperature in the house.  And, you know, overnight the temperature drops down to 60 degrees, the heating system kicks in, and it brings it back up to 70 degrees.  And then during the day the sun comes out, maybe the temperature goes up to 80 degrees, and then the air conditioner kicks in and brings it back down to 70 degrees.  So, likewise, that’s how the body fat setpoint regulates our weight.  That’s what happens in a normal-weight person, but what happens in obesity is that the thermostat, or the body fat setpoint, gets thrown off and the body defends a higher setpoint, which corresponds to a higher fat mass.  And then when that person tries to lose weight, all of their efforts to reduce the fat mass are fought pretty strenuously by the body in the same way that a lean person maintains their normal weight.  So, it’s an extremely effective system, and anyone who has tried to lose weight and keep it off knows exactly what I’m talking about.  It’s really an up-hill battle, and that’s the depressing part about weight loss, and it’s probably why after all these years nobody has come up with the magic bullet.  You know, weight loss is a billion dollar industry, it’s still a huge hot topic in the research literature, and really it still hasn’t been cracked, and that’s because we’re talking about some very old, very powerful, innate evolutionary mechanisms that are working against us, and any time we’re up against mechanisms like that, you know, that are mediated by our brain and not in our conscious control, it’s a challenge.

Steve Wright:  So, when it comes to the setpoint, do we know anything about, like, how long it takes to slowly reset?  Because there are a lot a people who do lose the weight.  I’m not sure how many.  There are people who lose the weight and keep it off, and then there are definitely plenty of people who lose the same amount of weight but then gain half of it back, so is it more of a time-based thing, do you think?

Chris Kresser:  There are a number of factors that control what dysregulates the setpoint, which we’re gonna talk about, and as you say, there are some people who seem to be able to lose weight and keep it off, but statistically speaking, there is only really one treatment that we know of that reliably and substantially and durably lowers the setpoint in pretty much everybody that tries the treatment, or a vast majority of the people, and we’ll talk about that towards the end of the show.  But in answer to your question, I don’t think that it’s an easy formula and certainly not black or white, and it depends on so many factors, beginning with genetics, you know, gene mutations, single gene mutations, which are relatively minor, and then epigenetic and developmental factors like I just was talking about, maternal status, maternal weight, birth weight, exposure to initial bacteria, gut flora, breast feeding, food, environmental toxins.  I mean it’s so vastly complex that I don’t think there will ever be an easy, straightforward answer to that question.

Steve Wright:  OK, and then did you say that the homeostatic system basically will also stimulate more hunger, as well?

Chris Kresser:  Yeah, if you lose weight and you’re below what your setpoint is, then you’ll get hungrier.  And that’s one of the ways that the homeostatic system regulates energy balance.  You know, it’s one of the ways it tries to get you back to what it considers to be your normal weight.  And that’s fine, that’s exactly how it should work in a lean person, but the problem in obesity is that the setpoint has become too high, and so the weight that the body is defending is inappropriate, and that’s again, of course, why weight loss and keeping it off is so difficult.

Why leptin is the master fat hormone and what happens when you have too much

Chris Kresser:  So let’s talk about leptin because, as I’m sure most people have heard by now, leptin is really the master control hormone in this process.  It is made by fat cells in proportion to body fat mass, so more body fat means you’ll be producing more leptin.  And leptin basically informs the brain of changes in energy balance and the amount of energy stored as fat, so it’s a communication system where leptin signals to the brain how much energy is stored as fat, how much fat mass you have.  And that leptin signal acts primarily on the hypothalamus in the brain.  The hypothalamus is a little, pea-shaped gland kind of right between your eyes; if you were to extend back beyond that, that’s about where it would be.  But there are also other more specific areas like the arcuate nucleus; the paraventricular nucleus; the ventromedial hypothalamic nucleus; and the lateral hypothalamic area, which is often referred to as the LHA; and then other parts of the brain that are leptin sensitive.  So, clearly we know now from the last 20 years that leptin acts on several different areas of the brain, and that’s probably the main nexus of where leptin acts.  So, in a normal-weight person, here’s what happens:  When fat mass increases — if you go through a period of overfeeding or overeating, for example — leptin goes up, and then the brain gets the message to constrain the fat mass by reducing food intake and increasing energy expenditure, all of those mechanisms that we already talked about.  And then, on the other hand, when fat mass decreases, leptin will go down, and then the brain will stimulate mechanisms that increase food intake and reduce energy expenditure and cause body fat accumulation.  And so that’s how leptin regulates that homeostatic system.  But in obesity, what we see is an increase of fat mass and a corresponding increase then in circulating leptin, but the appropriate response of reducing food intake and increasing energy expenditure doesn’t happen, and this suggests a state of leptin resistance, where increasing amounts of leptin are required to overcome the insensitivity to leptin in the brain.  For people have heard of insulin resistance, and that’s a condition where the liver or the fat cells or the muscles cells become resistant to insulin, and the pancreas has to just continue to make more insulin in order to have the same response, in order to perform the functions that insulin should perform, because it’s basically like somebody is knocking on the door and nobody is answering, and so then they have to knock louder and louder or you have to get a couple more people to knock on the door before the person inside can actually hear it and open the door.  So, that’s possible with the pancreas and insulin resistance because the pancreas can just make more insulin, right?  But what happens with leptin resistance and in obesity, because leptin is produced by body fat, when there’s leptin resistance in the brain, the only way for the message to get through is for the body to increase fat stores, and that’s what will lead to a higher amount of leptin so that the message can finally get through.  So, this is how leptin resistance promotes the defense of a higher setpoint for body fat mass, and we see this borne out in studies that show the genetic interventions that prevent leptin resistance in the hypothalamus will also prevent obesity, diet-induced obesity.  We see this in rat studies, and we also have seen that leptin resistance precedes weight gain, so for example it can be detected in the brain even after relatively short periods of overfeeding, which suggests that it’s the leptin resistance that comes first, not the obesity.

Steve Wright:  So, once you’re obese then, you don’t want to focus on more leptin, you want to focus on the leptin resistance and making new receptors.

Chris Kresser:  Yeah, decreasing the factors that cause leptin resistance — and inflammation is a big one, improving leptin sensitivity, and decreasing fat mass because that’s part of what caused the problem in the first place.

The link between inflammation and obesity

Chris Kresser:  Let’s talk about what causes leptin resistance then, because we just touched on it.  So, one of the main causes is inflammation, and Stephan has written some good articles about this on his blog.  Maybe we can link to them, as well, in the show notes.  But we know that proinflammatory cytokines inhibit leptin signalling in a whole bunch of different cell types, so leptin is getting to the brain, again, but the hypothalamus can’t hear it, and then the fat mass has to increase to produce more leptin.  This inflammation can be caused by a lot of different factors.  There are, of course, a lot of foods that promote inflammation:  processed and refined foods in particular and sugar and some unprocessed, improperly prepared grains.  Gut infections that produce an increase in endotoxins like lipopolysaccharide and then intestinal permeability, which allows those endotoxins to get out of the gut and into the blood stream, that promotes inflammation and has been implicated in hypothalamic leptin resistance.  Then certain micronutrient deficiencies and fatty acid imbalances can also promote inflammation and leptin resistance in the brain.  And finally, another cause of leptin resistance is injury to the neurons that is, in turn, caused by accumulation of free fatty acids in the brain, and this has been shown in experiments with rodents, where researchers overfeed them, you know, they feed them a purified, which means processed, high-fat diet, and then they observe the damage to the neurons prior to the onset of obesity.  So, just like leptin resistance seems to precede obesity, then the damage to the neurons also precedes obesity.  So, let’s talk about now what else increases the body fat setpoint.  We just discussed inflammation, and inflammation is a pretty broad term that can include causes like gut infections and intestinal permeability and environmental toxins and food toxins and micronutrient deficiencies, etc.; but there’s another main cause, I think, and this is one that Stephan has really spent a lot of time and energy highlighting on his blog, and he has taken a lot of flack for it, which I don’t really understand why.  I mean, I understand people’s reaction, but I think he has presented really solid evidence supporting this.  I mentioned before that the modern lifestyle is one of the primary causes of obesity, and one aspect of that lifestyle that affects weight regulation is the availability of highly energy-dense and palatable and rewarding foods.  So, again, we have two systems that interact to regulate fat mass, and one is the hedonic or pleasure-seeking system and the other is the homeostatic system.  And we’ve talked a bit about the homeostatic system, but the hedonic system evolved to help our hunter-gatherer ancestors seek out and take advantage of any highly palatable, energy-dense foods they happened to come upon, and its job is to make it hard to resist those foods because they’ve been so rare for most of evolutionary history.  You know, having a 7-Eleven on the corner and being able to access extremely calorie-dense, rewarding, palatable foods is a very recent development on the overall scale of human history, so the hedonic system evolved at a time where that wasn’t the case, and it was to our survival advantage to be naturally drawn to those energy-dense foods and eat pretty much as much as we could of them and then store them because inevitably there were would be times where those foods were scarce and possibly even most of the time.

Are modern foods engineered to make us fat?

Chris Kresser:  But, like I said, over the last 50 years in particular, there has been a huge increase in the availability of these foods and actually a systematic effort by food manufacturers to increase the reward value of food, and there’s a book that’s all about this that Stephan referenced in one of his blog posts.  I can’t remember the title off the top of my head, but the book covers the intentional effort on the part of food manufacturers who hire scientists, people who really understand all of these mechanisms in depth, and they purposely engineer the food to be highly rewarding.  And reward in this context is actually a term borrowed from psychology literature, which means that it reinforces a particular behavior in response to a stimuli; in this case, eating.  So, eating a rewarding food makes you want to eat more of it, and there are a number of factors that influence the reward value of food — and believe me, the processed food industry has, like I said, teams of scientists that study these factors — and they include caloric density, the texture of food, the content of fat and starch and simple sugar and salt and free glutamate.  They talk about it with terms like ‘mouth feel,’ like when you put a food into your mouth, how it feels in the mouth; and they study the neurobiology of it, like what centers in the brain are stimulated when you eat that particular food.  It’s really quite insidious, and if you study it and become aware of how much effort has gone into this, it starts to become obvious, at least from this perspective, why there is such a dramatic increase in obesity.

Steve Wright:  Is that book The End of Overeating?

Chris Kresser:  It might be.  Is it?  Have you read it?

Steve Wright:  I think it is.  I’ve read that one.  There’s also Mindful Eating, I believe.

Chris Kresser:  I don’t think it’s Mindful Eating.  It could be The End of Overeating.  We’ll look it up and put it in the show notes.

Steve Wright:  Yeah, if it’s that book, that book just literally blew my mind.  It talks all about that, about the chemistry and the various — I think they have five variables that they rate food on.

Chris Kresser:  Right, so this is a highly developed science, right?  I mean, they talk about that in the book.

Steve Wright:  Yeah.  I think they talk about — I think it’s over a billion dollars that is kind of spent in R&D, or it’s some astronomical number that’s spent in R&D just to make us like the food, and they call it a craveability.  So, they want to create foods that just — like, for some people maybe it’s a Dorito, like the Cool Ranch Doritos, or something — and they’re only looking to promote foods that are craveable.  In a capitalistic, you know, consumer marketplace, that’s the only thing that’s gonna survive is that one food where you’re like, “Man, I just want some of that Cool Ranch,” or something like that.

Chris Kresser:  Yeah, exactly.  So, like I said, it’s an insidious and very highly developed industry.  Well, we know from many animal and human studies that the reward value of a food has repeatedly been shown to influence food intake and body fatness in both animals and humans; whereas, palatability, on the other hand, is defined as the pleasure or the hedonic value associated with a food.  So, when Stephan was writing this series, people got reward and palatability really confused, so let’s say again reward value reinforces a particular behavior; in this case, eating more of it; so eating a rewarding food makes you want to eat more.  Whereas, a palatable food is just one that tastes good, and you know, of course, they often are related.  Like, a highly palatable food might be one that is highly rewarding, in that since it tastes so good, you want to eat more of it.  But it’s not necessarily to the same degree.  A good example of this is steak.  Steak, in my opinion, is a pretty palatable food.  It tastes great.  I love it.  But how often do you hear somebody say, “I’m really addicted to steak.  I can’t get enough steak”?  People like it, they eat it, but it doesn’t tend to stimulate addictive eating behavior, right?  But you do often hear people say that about chocolate or ice cream or chips and crackers.  I mean, the whole Pringles thing, right?  What was their slogan?  “I bet you can’t eat just one.”

Steve Wright:  Perfect.

Chris Kresser:  Yeah!  There’s a reason for that, because the scientists have designed it that way, and their marketing department is even making a baldfaced bet against you in their advertising slogan.  They’re betting that your hedonic system’s evolutionary effectiveness is gonna override any willpower that you might have and that you won’t be able to eat just one, and so they’re doing everything they can to make sure that’s possible, and they’re capitalizing on our innate, you know, our evolutionary mechanism here that was designed from the beginning to be a survival advantage, but in an obesogenic environment where you have access to all these super-energy-dense, palatable, rewarding foods, that system kind of backfires.

Steve Wright:  So, let me repeat that back really quick.  So, palatability is just all about the food in itself and our judgement of whether it tastes good.

Chris Kresser:  Right.  It’s the pleasure and taste.  If you find a food to be palatable, that means you like it and it tastes good.

Steve Wright:  And then the reward that we’re talking about is multilevel — it’s a chemical in the brain, it’s psychological in our actions, and it potentially is also driven from, like, our ancestors in a deeper lizard brain as far as seeking certain nutrients, as well?

Chris Kresser:  Well, I think they’re both driven by neurobiological mechanisms, which we’re gonna talk about a little bit more.  I think that the easiest way to simplify it is that palatability doesn’t necessarily imply a change in behavior.  It just means that it tastes good and you like it and you get pleasure from eating it.  Whereas, food that’s rewarding will make you want to eat more, so it will actually influence your behavior.  And I think, again, the really good way to piece that out in your mind is just to think of certain foods that you like the taste of but you don’t have any kind of addictive relationship with them, like steak or something.  And those would tend to be foods that taste good and they’re probably part of our evolutionary history in terms of eating them, you know, like a plain sweet potato.  I think most people would think a plain sweet potato tastes pretty good.  It’s sweet and it’s pleasurable to eat, but how many people, again, do you know that just would go crazy eating plain sweet potatoes?  It just doesn’t really happen.  On the other hand, chips that have fat and salt and a particular mouth feel all engineered to stimulate the centers in your brain that motivate a particular behavior, that’s gonna have a really high reward value.  Does that make sense?

Steve Wright:  Yeah, it totally makes sense, and I think a lot of people listening probably in the Paleo crowd or the Specific Carbohydrate Diet crowd will relate, because I know that previously if I ate mashed potatoes or sweet potatoes I never thought of them as particularly intensely flavorful, and I think that’s just because I was eating that other stuff.  Then once you drop off and you eat something that has some more carbs in it like that, you can definitely taste the sweetness and it’s much more subtle.

Chris Kresser:  You got it, and I’m glad you brought that up, because one of the reasons I love this overarching theory is that it can explain why both low-carb and low-fat diets can be effective for weight loss and why when people tend to start adding carbs back if they have been on a low-carb diet or they start adding fat back when they’ve been on a low-fat diet that they tend to gain the weight back, and that’s because carbohydrates and fat have reward value on their own.  And so, when you remove or really limit a whole entire class of macronutrients, that reduces the reward value of that diet.  And then when you bring them back in, that increases the reward value and it tends to make you want to eat more of that.  So, in your example that you just used, if you’re on a low-carb diet, which the SCD and GAPS typically are, and then you start eating carbohydrates, you’re adding reward value back to your diet, and if you had a weight problem before and the setpoint hadn’t been actually adjusted, then the chances are that you’ll gain weight back.  We’re gonna talk a litte bit more about that in a moment here.  So, one of the best examples of how reward and palatability affect weight regulation is something called the cafeteria diet model of rodent obesity, and this is where they give rats a bunch of human junk food, so you know, just chips, crackers, candy — it’s all human, processed food — and then they also give them an unlimited amount of the standard rat chow, which compared to the human junk food is pretty boring.  And what do you suppose happens?  I mean, you can probably guess.  They over consume the junk food, and they don’t even touch the rat chow.  And the rats that are genetically susceptible become obese, and how addicted do they get to the junk food?  Well, the rats that are put on this cafeteria diet will voluntarily endure foot shocks and extreme cold just to obtain the cafeteria diet, even when the standard rat chow is freely available.

Steve Wright:  That’s how good those researchers are.

Chris Kresser:  Exactly!  So, I mean, it’s pretty amazing, and it works the other way around, and again, we’re gonna talk about that in a second, but before we do that, I want to back up a little bit and talk at least a little about how food reward and the central nervous system interact and the regions of the brain that are involved in this, because I thinks it’s important to have a basic understanding of it.  So, there are a lot of regions of the brain involved in evaluating and reinforcing the reward value of food, including the corticolimbic system, the hypothalamic system, and parts of the midbrain, and we know that signalling of dopamine and opioid peptides is especially important in the reward and hedonic value.  And this kind of gets at what you were asking before, Steve.  Dopamine signalling is thought to contribute particularly to reward, to the wanting of food and to the motivation to obtain food, and this is supported by the observation that changes in dopamine signalling are associated with other kinds of addictive behavior like drugs and alcohol and other substance abuse.  There are lots of studies showing in drug addicts or alcoholics that there is a problem in the dopamine signalling system.  We also know that interventions that alter dopamine signalling in the central nervous system have been shown to powerfully influence food intake and body fat mass, and we know that inherited or acquired reduction of dopamine signalling favors the accumulation of body fat.  And one theory on this is that overexposure to these highly palatable, rewarding, and energy-dense foods desensitizes the dopamine circuits, although there is some controversy about that.  Now on the other hand, opioids are connected to the liking or the hedonic value or palatability of food, and studies have shown that opioid receptor agonists — an agonist is a substance that mimics the action of a natural substance, so an opioid receptor agonist would be something that increases the effect of opioids.  They strongly increase intake of palatable food in rats, so if you stimulate the opioid receptors, rats will really go crazy for palatable food.  Whereas, on the other hand, opioid antagonists have the opposite effect.  So, we’ve talked a lot about low-dose naltrexone on the show, but full-dose naltrexone at 50 mg is an opioid antagonist, so it completely blocks the opioid receptors, and that’s why it was used for opiate and heroin and alcohol withdrawal, because if a heroin addict, for example, is on 50 mg of naltrexone and they shoot heroin they’ll feel absolutely nothing.  So, the naltrexone has been shown in clinical trials to reduce body weight because when people are taking it, they’re not inclined to eat as much palatable food, so that’s more evidence that these parts of the brain are involved.

Steve Wright:  I was just going to repeat that back:  So, dopamine is the craving, it’s the wanting, and then opioids are the high?

Chris Kresser:  Opioids are the liking.  Yeah, the hedonic — it goes to palatability.  So, dopamine is connected to reward and the motivation and the behavior, and opioids are connected to the liking or the experience of pleasure or the high, yeah, if you want to put it that way.  Definitely.

Steve Wright:  So, that’s how LDN works, is by taking away the high, then all you’re left with is craving, and you could eat a case of chocolate and –

Chris Kresser:  Well, that’s how full-dose naltrexone would work, but the problem with that is that it also, I mean, opioids are what regulate our sense of pleasure overall, so if you’re taking 50 mg of naltrexone, yeah, you won’t experience pleasure when you shoot heroin, and you won’t experience pleasure when you eat that bowl of ice cream, but you’re not going to experience much pleasure any other time.  So, there are pretty obvious problems with that.

Steve Wright:  Yeah.

Chris Kresser:  And then a third neurochemical that’s involved in this whole process are the endocannabinoids.  These are involved in the brain reward area, and of course, they earn their name after it was discovered that marijuana acts primarily through the CB1 endocannabinoid receptor.  Stimulating that receptor selectively increases the consumption of highly palatable foods, and this explains, of course, why people get the munchies when they smoke pot.  So, if they smoke pot and then those endocannabinoid receptors are activated, then they’re gonna want to increase palatable foods, and when people get the munchies they’re seeking out particularly palatable foods, right?  They’re usually not getting the munchies for, I don’t know, brussels sprouts.  I mean some people find them to be palatable.  I actually like them, but it’s not the food that people tend to eat when they get the munchies, right?  They’re going for the more palatable and probably more rewarding foods, as well.  On the other hand, just like naltrexone, drugs that block the endocannabinoid receptors have been shown to cause weight loss and selectively suppress the consumption of highly palatable foods in rodents.  So, that means it didn’t suppress consumption of all food across the board; it just selectively suppressed the consumption of the highly palatable foods.  But, again, there are some problems with using this as a treatment for human obesity because these drugs are known to have psychiatric side effects including an increased risk of suicide because the endocannabinoid system probably, again, plays a role in our overall experience of pleasure and enjoyment or life.  So, you have a drug that blocks those receptors, it does serve the goal of reducing consumption of palatable food, but it also, you know, really screws up people’s mood.  And, of course, that’s often the problem with drugs is they suppress function.  So, they suppress symptoms, but they also suppress functions, and that means that in solving one problem, they end up causing several others, because the receptors and proteins and things that drugs affect in the body don’t tend to have just one effect; they tend to have several different effects.  And so, when you suppress something, you’re not just suppressing the one effect that you want to get rid of.  You’re suppressing multiple effects, many of which are beneficial.  So, when you put all of this together, it suggests that in an environment where humans are exposed to food that’s way more palatable and way more rewarding than what we’re adapted to, that’s when you get obesity.  And I just want to reiterate that I don’t think that food reward and palatability is the only environmental factor involved in the obesity epidemic by a long shot.  We’ve already talked about other factors like food environmental toxins and genetics and micronutrient deficiencies and gut flora and birth weight, etc.  But I do think that reward and palatability is definitely a factor, and I think the research pretty clearly supports that it is.

The one thing any successful weight loss intervention must have

Chris Kresser:  So, let’s wrap all of this up and talk a little bit about what it means for people who are trying to lose weight, and as I said in the beginning, we’re not gonna — you know, we’re already getting to the end of the show here, so we’re not gonna have time to cover this in detail, but we will revisit it later.  At the simplest level, what it means is that any successful weight loss intervention has to involve lowering the setpoint.  And if it doesn’t lower the setpoint, the effect is just flat-out not gonna work at all or it’s gonna work for a short period of time and then the weight will come back, and of course, that explains why something like over 90% of people who go on calorie-restricted diets end up gaining the weight back at some point, and oftentimes they gain more weight back than they lost in the first place.  There is some evidence that low-carb diets and Mediterranean diets have been shown to induce moderate fat loss over the long term, and I think Paleo Diets can do that, too.  There are a few studies that suggest that, but we don’t have any long-term Paleo Diet studies yet on weight loss.  I certainly, you know, anecdotally in my practice have seen that, and I’m sure a lot of other people have had that experience, as well.  But on the other hand, I have a lot of patients in my practice who come to me for weight loss, and they’ve been on a Paleo Diet, they lost weight to begin with, sometimes quite a bit of weight, and then they either plateau and can’t lose the last 10 or 15 pounds or they start gaining the weight back and eventually gain it all back.  So, even though the Paleo Diet, I think, helps a lot of people and in some cases is the only thing that people need to lose weight and keep it off, there are clearly a lot of people whom that’s not enough for, and that’s one of the reasons I wanted to do this show, is I wanted to explain some of the mechanisms involved and help people appreciate how deeply rooted those mechanisms are, that they’re evolutionary in nature and that it’s not a failure of willpower, it’s not your fault that these systems are in place and that they work so strenuously against our efforts to lose weight.  So, getting back to the setpoint, right now, as I mentioned earlier in the show, the only intervention that we know that substantially and consistently and durably, meaning in a lasting way, reduces the defended level of body fat or the setpoint is bariatric surgery or gastric bypass.  So, this is a surgery where they divide the stomach into a small upper pouch and a much larger lower remnant pouch, and then they rearrange the small intestine to connect to both of these chambers.  In the most popular variation of this, the small intestine is divided about 18 inches below the lower stomach outlet, and then it is rearranged into a Y-configuration, and that enables outflow of food from the small upper stomach, and what it does is it causes a rapid onset of satiation, which is feeling full.  So, people who have had this surgery will feel full very quickly after they start eating, and then that is followed by growing satiety, which is an indifference to food or a lack of appetite after you’ve started eating.  So, people who have had gastric bypass, on average, they lose about 60% of the excess body weight that they were carrying — at least, morbidly obese people do, and those are the ones who generally have this surgery.  And in contrast to calorie restriction and other weight loss programs, the bariatric surgery causes a reduction in hunger and reduced cravings for energy-dense foods, and it doesn’t cause any change in circulating thyroid hormones that would suggest a compensatory homeostatic response to fat loss.  In other words, the body doesn’t respond to this surgery in the same way that it responds to caloric restriction that I described earlier by increasing hunger and decreasing resting energy expenditure and decreasing the conversion of T4 to T3 and all of those things.  And then we have studies that suggest that gastric bypass alters food reward processing in the brain, and so it’s changing the food reward system in some way, but those mechanisms aren’t entirely clear at this point.  So, at this point, it may seem like I’m recommending gastric bypass, and –

Steve Wright:  Are you?

Chris Kresser:  I’m not really.  I think it has some use in people who are extremely obese and who have tried every other way of losing weight and haven’t been able to because morbid obesity along with extreme, you know, metabolic syndrome is a real significant risk factor for a number of different diseases that can kill you.  So, in those situations, gastric bypass might actually be a valid alternative, but I’m not bringing it up to suggest it for people who are just trying to lose a little bit of weight or are even 10, 20, 30, 40, 50 pounds overweight.  I don’t think it’s a viable alternative in that situation.  There are risks, of course, associated with any invasive procedure like that, and you know, I’m more talking about this as a way of, first of all, just sharing what this surgery and what happens after it can tell us about the setpoint and other interventions that might help to lower the setpoint, because at this point that’s not altogether clear.  And that’s the million dollar question, really.  I talked earlier about how we just haven’t cracked the nut yet in this whole weight loss thing, and whoever figures out what nonsurgical method can reliably lower the setpoint is gonna get the Nobel Prize and be a multi-billionaire — if there even is such a, I mean, I frankly don’t think that there is gonna be just one thing and that it’s that simple because this is so complex.

Steve Wright:  Yeah, I think you made it pretty clear that this is pretty complex, and any thought that a surgery could just magically turn things around — because I think there is a lot of new stuff coming out now about long-term studies with the bypass surgeries, and they’re having onset of other diseases because of lack of nutrients now and that kind of thing.

Chris Kresser:  Absolutely.  Those are the complications that I was referring to, so there’s no magic bullet.  It does work for weight loss, that’s for sure, but as you pointed out, there are a lot of other problems that the surgery causes, and there is a lot more to health than weight.  There are some other interventions, though, that might lower the setpoint that research supports, and Stephan, again, of course, has written about this.  Just as increased food reward and palatability can increase the setpoint, there are studies that suggest that decreased reward and palatability lowers it in both rodents and humans.  And Stephan blogged about a really great 1965 paper that was published in the Annals of the New York Academy of Sciences, and in this study researchers developed a machine that basically dispenses bland liquid food through a tube at the push of a button, and it was kind of like sci-fi, if you look at the picture; it’s pretty funny.  And the formula was 50% carbohydrate, 20% protein, and 30% fat.  So, at first they fed two lean people with no weight problems for 16 and 9 days, respectively, and both people maintained their typical caloric intake and weight eating this really bland liquid food.  And then they fed morbidly obese volunteers, and over the first 18 days, one obese volunteer ate only 275 calories a day, and the second volunteer ate even less, 144 calories a day over 12 days, and that person lost 23 pounds in 12 days.  The first volunteer continued eating from the machine for 70 more days in the ward and lost 70 pounds total in that 70 days, and then he was sent home with the formula and instructed to eat about 400 calories a day with it for another 185 days, and he ended up losing 200 pounds in that 185-day period and, remarkably, never complained of hunger or GI discomfort.  So, some people might say, yeah, big deal; of course you’re gonna eat less food when it’s not palatable or rewarding.  But that doesn’t explain why the lean people maintained their weight and their caloric intake on that diet, because if both lean and obese people ate less of it, then you would expect the lean people to lose weight, but they ate the same amount of it, and they maintained their weight over that period of time.  And then there was another study in 1976 that confirmed that reducing food reward by feeding bland food lowers the body fat setpoint in humans.  So, all of this implies that, of course, highly rewarding food can increase the body fat setpoint in certain susceptible people, not in everybody, and that food with few rewarding properties can allow them to return to a lean state, and that doesn’t happen necessarily with everybody either.  And there’s also some evidence that suggests another technique called the protein sparing modified fast may reset the setpoint, but we’re out of time here, so we can’t talk about that in any detail.  Before we close, I just want to say a brief word about genetics.  There’s absolutely no doubt, as I’ve said a few times already, that genetics play a role in fat gain and fat loss, but how much is the question.  We know that heritable factors, when you combine genetics and epigenetics, are estimated to account for somewhere between 45% and 75% of body mass index variability.  But we also know that monogenic disorders, which mean mutations of one single gene, account for less than 5% of obesity, and some estimates say it’s even less than 2%.  So, this means, of course, that obesity is a polygenic trait, which means that it involves both developmental and epigenetic factors, as well as genetics, and we’ve talked about some of those before.  Things like low birth weight and maternal obesity and maternal overnutrition can increase subsequent obesity risk.  And likewise, prepregnancy fat loss, like women who have had the bariatric surgery before they get pregnant, tends to reduce the future risk of obesity.  So, this suggests that genetics do play a role, but that role is pretty small on its own but pretty large when you combine genes with environmental and developmental factors.  So, again, it’s the interaction of the genes and the environment that really makes a difference.  OK, I think that’s it!

Steve Wright:  Yeah, that’s pretty powerful!  So, the moral of the story is that you could have been set up from the beginning, unbeknownst to you, from genetics.  And there are a bunch of scientists and a large, billion dollar industry that are trying to set you up on the corner, and so you definitely need to get some help, right?

Chris Kresser:  That’s it!  I hope that the effect of this — one interpretation of this is to get really depressed and say, “Wow!  It’s just pointless to even try to lose weight.”  But I hope that’s not the result of this.  My intention was that people who have been having a hard time might be able to find some more compassion for themselves, because if you think about the forces you’re up against — as you pointed out, so you’ve got genetics, genetic predisposition.  Then you’ve got epigenetic factors that start from before you were even born.  I mean they basically start at conception or even before conception with your mom’s nutritional status during her pregnancy and then your birth and the manner of your birth and whether you were breastfed and your early exposure to all of these environmental factors.  And then you encounter the food industry, which, like you said, is on every corner, trying to get you to eat these highly energy-dense, palatable foods, and that is interacting with all kinds of neurobiological mechanisms, opioids, endocannabinoids, dopamine, and the whole hedonic, pleasure-seeking system that we’ve had as part of our wiring for millions of years.  So, when you put all that together, I hope it leads to just an appreciation of the difficulty of the task and maybe some compassion for yourself if you’re struggling with this for why it is so difficult, and hopefully in the future we’ll get a chance to dive more into what can be done about it, and I will frankly say that weight loss is difficult.  It’s one of the hardest things for me to treat in my practice.  I’m experimenting with some different programs designed to reduce the body fat setpoint, and sometimes they’re successful and sometimes they’re not.  And I’d be really suspicious of anybody who claims to have a program that works for everybody.

Steve Wright:  Yeah, I hope this isn’t depressing either.  I hope this is eye-opening, as you said, and I think it should be eye-opening in the fact that there is no magic pill.  There’s not a magic pill that’s even in testing that could come, and the appreciation that it’s a multifaceted problem, which means that the answer is likely multifaceted.  So, it’s a food problem; therefore, there’s gonna be a food answer.  It’s potentially a psychological problem; there might be a psychological component. It’s a chemical problem; there’s probably a chemical answer.  And altogether, I think it should be encouraging to take multiple steps in every area.

Chris Kresser:  Yeah, that’s very well said, and the takeaway is that it’s extremely individual, and it’s really important to first identify what all the mechanisms are in each individual case and then address those one by one, and that’s, of course, why there is, again, no magic bullet that works for everybody in the same way.  OK, so thanks everybody for listening, and we’ll see you next time!

Steve Wright:  Yeah, it’s been a great show!  OK, so if you’re confused about what to eat, which, after the show, you might be, check out the PersonalPaleoCode.  It’s a 3-step program designed to help you discover your own ideal diet and create highly customized meal plans with a few clicks of a button.  You can visit PersonalPaleoCode.com to learn more.  And if you’re trying to get pregnant or are already pregnant or nursing, don’t miss out on The Healthy Baby Code.  It guides you through the essential steps to naturally boost fertility and promote lifelong health for you and your baby.  Find out more at HealthyBabyCode.com.

Thanks for listening, and keep sending us your questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show, 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.

The human body has an elaborate system for managing and regulating the amount of key trace metals such as zinc, copper, iron, manganese, chromium.  One of the most common malfunctions of this system is an excess of copper and deficiency of zinc (copper-zinc imbalance), which can lead to hyperactivity, attention deficit disorders, behavior disorders, depression, acne, eczema, sensitive skin, sunburn, headaches, poor immune function and much more.

In this episode of Revolution Health Radio, we cover:

3:07 Can someone without a gallbladder eat a Paleo Diet?
6:39 How to tell if you should avoid coffee, green tea, and caffeine
13:52 If you have this Copper-Zinc imbalance your body could be starving for oxygen…
21:52 Get these tests done if you have nervousness, anxiety, or mood swings
27:43 What to do – and not do – if your copper levels are high
33:46 Is 5-HTP safer than SSRI’s for anxiety and depression?
42:54 Why anti-depressants could permanently alter your brain chemistry… in a bad way
45:37 The surprising cause of depression (and no, it’s not low serotonin)
48:40 Are chocolate cravings related to magnesium deficiency?
53:22 How to get your Vitamin A and D ratio within healthy ranges

Links We Discuss:

• The Depression Series
• Light Therapy Machine for Depression
• Chris Masterjohn’s Vitamin A Article
• Recipes for liver (at the bottom)

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 today, Chris?

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

Steve Wright:  I’m doing well, as well.  I’m recovering from a chest cold over the holidays that I had, but today has probably been my best day so far, so I’m hoping it’s behind me.

Chris Kresser:  Glad to hear it.  Did you have a good holiday season other than that?

Steve Wright:  Yeah, it was great.  Lots of family time, lots of relaxing, and other than the stress of trying to hit a party every other day, it was great.

Chris Kresser:  Wow.  I kinda remember that, vaguely.

Steve Wright:  How was Canada?

Chris Kresser:  Dark and cold.  No, it was actually not that cold compared to last time; I think I mentioned it was 40 below when we went to visit Elanne’s parents, but this time it was a balmy 25 or 30 degrees, which was not that bad.

Steve Wright:  You could almost wear shorts!

Chris Kresser:  Yeah, right.  It’s interesting because I’m such a daylight person myself.  I’m not a night person.  I’m a day person.  I love being outside during the day and being really active, and up there at this time of year, it doesn’t really even get light until, you know, 8:30 or 9 in the morning, and then it’s already getting dark at 4, so the days are really short, and the good part of that is I ended up resting a lot, you know, and just really doing a lot of nothing, which is not my usual MO, and so it’s nice to have a little bit of time like that.

Steve Wright:  Yeah, that’s good.  Sort of a forced outage.

Chris Kresser:  Um-hum, exactly.  And from a sort of Paleo lifestyle perspective, that’s what the winter is supposed to be like, you know?  I mean our ancestors had a natural rhythm and flow throughout the year.  Certainly the spring and the summer were more active times, and the fall, late fall, and winter were times of contemplation and rest, and a lot of us aren’t really in tune with those natural rhythms anymore because of electric light and, you know, there’s often nothing that’s really that different about our lives in the winter and the summer in terms of our work schedule or something else that we’re doing, so it’s always nice for me to get back in touch with those natural rhythms.

Steve Wright:  Yeah, and the added sleep, I think, is a big bonus for me.

Chris Kresser:  Definitely.  Cool.  Well, we have some interesting questions.  Let’s dive in.

Can someone without a gallbladder eat a Paleo Diet?

Steve Wright:  Yeah, thanks everyone for sending in your questions, and let’s start with Angela’s first.  She’s curious how someone without a gallbladder does Paleo.

Chris Kresser:  Well, the common bile duct, which still remains after the gallbladder is removed, actually assumes a lot of the function of the gallbladder once it’s taken out, and that’s why it’s possible to take out the gallbladder and not have somebody just completely fall apart and be unable to digest any fat at all.  So, a lot of people do really well on Paleo without a gallbladder.  Some people may need to moderate their fat intake to some degree, although a lot of people don’t.  The type of fat seems to matter.  Coconut oil is a very good fat for people without a gallbladder because it doesn’t require bile acids for absorption, so it’s rapidly absorbed in the upper part of the small intestine, and it’s transported directly to the liver via the portal vein.  These are medium-chain triglycerides that I’m talking about, and in fact, they’re used in hospital tube-feeding formulas, you know, for people who have had surgery on their intestine or have had parts of their intestine removed because they’re so easy to digest and absorb.  So, coconut oil is definitely your friend if you’re lacking a gallbladder.  Then there are some other things that can be done to improve that function of the bile duct and help emulsify and break down fats.  Dandelion is a very commonly used herb in the Western pharmacopoeia.  It’s bitter and it’s a cholagogue, which means it helps with bile synthesis.  Ox bile can be used if you’re having trouble digesting fats.  You know, that won’t address the underlying cause of the problem, but it will help symptomatically.  It’s a similar approach to using hydrochloric acid when you have low stomach acid, but you’re actually using bile itself in this case.  So, that can be useful for people who don’t have a gallbladder or for anybody who is having trouble digesting fat, because that’s often one of the biggest difficulties that I see when somebody moves from a lower-fat diet to a higher-fat Paleo Diet is if they haven’t been in the habit of eating fat and producing bile that you need to break it down, they can often experience some difficulty with the high fat content, and so ox bile or dandelion root or ginger can all be helpful in breaking down the fat.

Steve Wright:  Well, what about lipase?  Would someone want to take an enzyme like lipase for this?

Chris Kresser:  Sure, that can work too.  You know, we talked before about how I generally prefer HCl to correct the problem at the top, and if the food in the stomach is properly acidified, then the pancreas should secrete all of the necessary enzymes, but the NOW Super Enzymes are a good choice at least temporarily while you’re resolving the underlying issues.  That can be helpful too.

How to tell if you should avoid coffee, green tea, and caffeine 

Steve Wright:  All right, great.  Let’s move on to question #2 from Jeff, and it is, “What is your take on coffee, green tea, and caffeine consumption in general?  Robb Wolf and his cohort seem fine with it, but Mat ‘The Kraken’ Lalonde is against it.”

Chris Kresser:  Well, everyone is probably tired of hearing me say, “It depends,” for questions like this, but I’m gonna have to say it again because I do think it depends.  Caffeine is subject to individual tolerance, just like dairy products and starches, white rice, things like that.  Certainly I don’t think that anyone benefits from drinking, you know, three to five-plus cups of coffee a day and drinking three or four Red Bulls.  That’s not gonna help anybody out, but a single cup of coffee, for example, or a couple of cups of green tea, at least according to the scientific literature, may have health benefit, but it really depends on how somebody responds and what their current circumstances are.  So, let’s just use a couple examples.  Let’s say somebody sleeps well, their energy levels are fine, they don’t have any problems with blood sugar regulation, no adrenal fatigue issues, they’re generally healthy, and they have a cup of coffee each morning.  Is that a problem?  I don’t think so.  I mean there’s no research that shows that that’s a problem really, and if they’re not suffering from it, then I don’t think it’s an issue.  On the other hand, take somebody who is sleeping very poorly, they crash in the afternoon, they have wild blood sugar fluctuations, they feel jittery and agitated, they crave sugar, they’re dealing with depression or anxiety or mood swings, or any number of psychological issues like that.  That person, even one cup of coffee could be a big problem.  It could really prevent them from getting the rest that they need to heal, prevent their adrenals from recovering; and in some cases, even green tea would be too stimulating for them, but they should be able to determine that by going completely caffeine-free for a period of time.  If I was their healthcare practitioner, that’s what I would recommend if we were doing an adrenal protocol.  We’d take them off caffeine completely, with the possible exception of something like kukicha, or twig tea, which is made from the branch of the green tea plant instead of the leaf, and it’s really, really, really low in caffeine.  It provides just a mind-clarifying kind of effect, but it’s rarely stimulating enough to make a difference, so I might allow that.  But if we take them completely off caffeine for a period of time and then they add it back in, they often find that when they get that kind of space from it, it becomes pretty obvious that it’s too much for them to tolerate.  So, it’s really an individual issue.  There are other circumstances to be considered.  Like green tea has shown some benefit, and caffeine in general has shown some benefits, for weight loss, but I’m hesitant to recommend it for weight loss because, in my experience, a lot of people are having difficulty with weight partly because of adrenal issues.  You know, their cortisol is too high or too low or it’s fluctuating inappropriately, and if those people do a caffeine stack for weight loss, it could actually worsen some of those underlying mechanisms.

Steve Wright:  OK, so what about the middle road?  What about the average Paleo person who is on the diet?  They’re doing their best to get some sleep, but they really love, you know, one to three cups of coffee in the morning.  Are they going to be all right on that, or should they take some time off and see what happens?

Chris Kresser:  Yeah, I think everybody benefits from taking some time off and seeing what happens, and that’s true with any other gray-area foods, and I talk about this in the PersonalPaleoCode.  You know, there are a number of foods that are just pretty much safe for most people, and those are what are included in the 30-day Reset, but then there are a bunch of foods that are gray area, which means that they are really subject to individual tolerance.  So, that could be dairy products, it could be starches and then white rice or soured buckwheat, could be caffeine, chocolate, nightshades, eggs, FODMAPs, a lot of the stuff we’ve talked about on the show, and I think nearly everybody would benefit from taking a period of time and going without caffeine.  Now, that can be difficult, of course, as anybody knows who is drinking a lot of caffeine and tries to stop, and I actually don’t recommend that you do it cold turkey because that can be problematic.  You would titrate off of it slowly to make it not as dramatic and difficult.  I don’t think someone who is dealing with potential adrenal issues should be drinking three cups of coffee a day.  One cup, you know, that’s arguable, and maybe if you stop it for a period of time and you add it back in and you really don’t notice that much of a difference, you can make an argument for continuing, but I think most people who are struggling with anything that could be construed as adrenal fatigue should stay away from coffee and should maybe stick with lower-caffeine green teas, green tea that is only steeped for a short period of time so it’s not as strong in caffeine as, you know, a green tea that was steeped for a longer period of time.  Or, if you’re gonna do coffee, maybe doing half decaf and half caffeinated or something like that.

Steve Wright:  OK.  Another thing I want to throw in there is Tim Ferriss, in his book The 4-Hour Body, likes to recommend taking green tea extract that has been decaffeinated, so if someone is looking to stack something for weight loss, that might be a potential avenue to look at.

Chris Kresser:  Um-hum.  Yeah, definitely, although part of the benefit theoretically is the caffeine for weight loss, but I think you’re right.  You get the benefit without the potential downside just by doing the green tea extract.  And there are a lot of other benefits with green tea extract, as well, beyond weight loss in terms of reducing oxidative damage and some other neat stuff.

Steve Wright:  All right, so green tea over coffee, and keep it before noon.

Chris Kresser:  Sounds good.

If you have this Copper-Zinc imbalance, your body could be starving for oxygen…

Steve Wright:  Let’s roll on.  This question is from Allison.  She would love to hear your thoughts about the copper-zinc balance and whether you’ve heard of pyroluria.  What sort of presentations do you see?

Chris Kresser:  Pyroluria.  I wish they would rename that.

Steve Wright:  Me too.

Chris Kresser:  It always sounds funny to say it.  So, let’s talk about this first because I think a lot of people haven’t heard of it, so I need to give a little background about the condition, and then we’ll come back to the copper-zinc ratio and how that relates to pyroluria.  And then we’ll talk about more specifics about copper-zinc imbalance and what to do about it if you’re suffering from it, and how to identify it in the first place.  So, pyroluria is a genetically determined chemical imbalance that involves a defect in hemoglobin synthesis, and hemoglobin is the protein, as I’m sure some of you know, that holds iron in the red blood cell and is responsible for delivering oxygen to the tissues.  So, every cell and tissue in the body needs oxygen and glucose to function properly, and if you’re not getting oxygen to the tissues, as is the case with anemia, nothing is gonna work right.  None of your cells are going to work right.  It’s one of the first things that I look at when I do a case review and I run a comprehensive blood panel on my patients is oxygen deliverability and blood sugar regulation because those two are what I call deal-breaker issues, meaning if they’re are out of whack, nothing else that we do is gonna be very effective until we get those two systems working properly, so it’s really important and this is why pyroluria can be a really challenging condition to experience and to work with.

Steve Wright:  Would I know that I had that from birth, or would I have to get some sort of genetic test?

Chris Kresser:  Well, you have to get a test.  I can’t remember the name.  I think it’s the mauve something or rather.  So, people who have this condition produce too much of a byproduct of hemoglobin synthesis called kryptopyrrole, and kryptopyrrole has no known function in the body, and it is largely excreted in the urine, so the test that you get tests for the levels of kryptopyrrole, and if it’s too high, then that’s a sign that you have pyroluria.  So, kryptopyrrole binds to vitamin B6 and zinc and makes them unavailable as co-factors in the enzymatic and metabolic processes that they participate in.  And then excess kryptopyrrole also leads to a deficiency of arachidonic acid, or AA, which is an important fatty acid in the tissues.  So, a lot of people with pyroluria will exhibit mild to moderate signs of B6 to zinc deficiency, and so that’s usually what happens.  You know, they go to the doctor and they might be experiencing poor stress control, nervousness, anxiety, mood swings, just a lot of psychological symptoms like feeling really tense, or episodic anger is one of the kind of classic signs, like explosive temper, poor short-term memory, and depression because they can’t create serotonin well.  Serotonin, of course, is a neurotransmitter that reduces anxiety and depression, and vitamin B6 is a rate-limiting factor; it’s an important factor in that last step of the synthesis of serotonin.  So, if you don’t have vitamin B6, you can’t make serotonin properly, and people who have pyroluria don’t have enough B6 usually.  So, let’s get back to the copper-zinc ratio and show how this relates to pyroluria.  So, the body has a pretty elaborate system for managing and regulating the amount of trace minerals like zinc, copper, iron, manganese, and chromium in the blood, and what happens is if blood levels of any of these trace minerals are depleted, then we have a system for absorbing them from the diet, and then they are transported from the blood into cells if the cellular levels are inadequate, or they’re excreted from the body if blood and cell levels are sufficient or overloaded.  That’s the way the system is supposed to work, but in various cases of either genetic diseases or diseases that have environmental causes, that system breaks down, so you get people either absorbing too much of a particular trace mineral more than they need, like with hemochromatosis, which we’ve talked about, or you get people that have deficiency of some of these key minerals, like zinc deficiency with pyroluria.  One of the most common and important imbalances that we see in clinical practice with trace minerals is excess copper and deficient zinc.  So, the ideal ratio between these two, if copper is in the numerator and zinc is in the denominator, would be 0.7 to 1, which means anywhere from 70% as much copper as zinc to even amounts of each.  And one of the ways that you can recognize this or when you might suspect this, and this will tie into a future question that we’re gonna talk about a little bit later in the show, is that copper and zinc are not only minerals, but they’re also regarded as neurotransmitters in the brain.  They have some of the functions of a neurotransmitter, so an imbalance in copper and zinc will lead to things like hyperactivity, ADHD, other kinds of behavioral disorders, and depression; and in fact, a lot of people who are labeled with autism and even paranoid schizophrenia, when they test their copper levels, they find out that they’re elevated.  Then high copper can cause severe PMS.  That’s another red flag for me where I’ll consider it.  It can cause estrogen intolerance, and it can cause skin issues, so people with excess copper have a high incidence of acne or eczema, psoriasis, just sensitive skin in general, sunburn, people who are really apt to get sunburned even if they’re only out for a short period of time, headaches, poor immune function.  Another characteristic sign is white spots under the fingernails, excess copper and deficient zinc, that can happen.  And then elevated copper is a special problem for people with low blood histamine levels and overmethylators, and that can lead to anxiety and even panic disorders and paranoia and, in severe cases, hallucinations.  So, as you can see, most of the effects are nervous system related, nervous and endocrine system, I would say, with particular impact on the brain and behavioral health.  So, those are the things to look for when you’re considering copper-zinc imbalance as a potential issue.

Get these tests done if you have nervousness, anxiety, or mood swings

Steve Wright:  It seems pretty serious, so how would I go about testing for it?

Chris Kresser:  Oh, yeah, it’s definitely serious.  I mean, there’s a syndrome called Wilson’s syndrome that’s a severe excess copper problem.  Actually you’ll see low copper in the blood, but you’ll see very high copper with a 24-hour urine test, and that can cause severe brain damage and difficulties.  I have a friend who had Wilson’s syndrome, and when she first figured out, or when people around her first figured out what was going on, she had lost the ability to speak, and when she gained the ability to speak again, her voice was very slow and deliberate, and it was difficult to understand her, and she’s made a lot of progress and is feeling a lot better and is getting back to normal, but it was a pretty scary thing, and she ended up at the Mayo Clinic.  So, yeah, this is definitely something to pay attention to.

Steve Wright:  Yeah, I’m glad she’s getting better.  You called it Wilson’s disease.  Is that something that can onset in anyone?

Chris Kresser:  Well, there’s a strong genetic predisposition for that, but we don’t fully understand, you know, what all the factors are.  In her case, there was probably a genetic predisposition plus an excess of copper in the diet or copper from other sources, which we’re gonna talk about here in a second.  But Wilson’s is different than just standard copper-zinc imbalance.  They’re not the same thing.  They don’t present in the same way, so I’m not suggesting that copper-zinc imbalance will lead to Wilson’s.  I was just pointing out, using Wilson’s as a way of explaining how serious excess copper can be.  These metals, the trace minerals are potentially lethal.  It’s the same with hemochromatosis, as we talked about before.  That can cause really, really serious problems, including death eventually, so not harmless, for sure.  So, testing for copper and zinc, I use blood tests, just serum testing of copper and zinc.  There is hair mineral analysis, urine testing, other forms of testing.  You know, to be honest, the jury, for me, is still out with hair mineral analysis.  I’ve seen some studies suggesting that it might be accurate in the case of certain nutrients especially, and then I’ve seen a lot of other research indicating that it’s not reliable.  If you look in the mainstream scientific literature, you know, it’s mostly dismissed as not being reliable.  If you search on the Internet, you’ll find lots of kind of random websites saying that it is, but being a little bit of a skeptic myself, I’m not yet convinced that it’s reliable, so I do serum copper and zinc testing and use the ratio above that I just mentioned of 0.7 to 1.

Steve Wright:  I’ve read a lot, or I’ve heard a lot, that zinc serum tests don’t represent the correct number and that you should do, like, a Zinc Tally taste test.

Chris Kresser:  Yeah, I’m not convinced about that either.  I mean if someone has some good, peer-reviewed, placebo-controlled research, if you do, Steve, send it to me.  I’d like to take a look at it, but most of that sort of stuff that I’ve read has been not in the peer-reviewed literature.  It’s just been on, you know, random websites and stuff, so I’m still waiting to see that evidence.

Steve Wright:  OK.

Chris Kresser:  Have you seen it?

Steve Wright:  It’s been a while since I’ve looked into this issue, but I swear it was like one doctor, and my guess is he didn’t publish in a peer-reviewed journal, but he published his own study about it.  So, I’ll try to dig it up and send it to you, but I do know from my own experience that I tried the Zinc Tally taste test, and Thorne Research makes one that you can buy, and I bought the solution, and I put myself through it and I didn’t taste anything.  And then I put several of my family members and friends through it just to see what would happen, and I would say 60% of them right away would, like, spit it out and say, “Ugh, this is gross.”  However, when I put it in my mouth, I was like, “Eh, this tastes like water,” and I supplemented with a lot of zinc over a period of six weeks or eight weeks, and I gradually got that flavor back to the point where it tasted pretty awful.  So, you know, that doesn’t make it right or wrong as far as tests go, but that’s my experience.

Chris Kresser:  Yeah, well, I’ve had patients who have used the Tally, a couple, and one who had no problem with it and the other who absolutely couldn’t handle it at all; it was just revolting immediately, and she was zinc deficient and he wasn’t, according to the blood tests.  So, there was a concordance there, but I’d be curious to see more evidence of how they correlate, those two ways of testing.

What to do — and not do — if your copper levels are high

Chris Kresser:  In any event, people who are eating–well, let me back up.  We’ll talk first about the main sources of copper because if you have excess copper, you’re gonna want to reduce your intake of copper from food, and you’re gonna want to reduce your exposure to copper in the environment.  So, copper is mostly found in vegetarian or plant proteins like nuts and beans and seeds and grains, and meats do contain copper, but they’re balanced by zinc, which competes for the absorption of copper, so a Paleo, Weston A. Price type of diet that’s high in animal protein, it’s unlikely you would develop a copper-zinc ratio just from eating that way because the zinc competes with absorption for copper in those foods.  Chocolate is high in copper, and actually, in some cases, when people are really craving chocolate, you often hear that they’re craving magnesium, and that may be the case, but they may also be craving copper.  Drinking water that is in copper pipes can have copper in it, so if you test high in copper and you’re living in a house with copper pipes, that may be something you want to look into.  There’s copper cookware, which I don’t recommend using.  Some dental materials have copper in them.  Certain vitamins have copper.  If you like multi’s, you want to check and make sure your multi doesn’t have it if you have excess copper.  Fungicides and pesticides have copper residue, and then IUDs and birth control pills have copper, as well.  So, those are the primary sources of copper in the environment and food, and then there are some things that deplete zinc levels, like stress, for example.  Any disturbance of homeostasis or oxidative stress will deplete zinc levels over time.  So, it’s important to manage your stress if you’re dealing with copper imbalance.  One of the first things I would do with patients like this is order a SpectraCell micronutrient analysis, which tests micronutrient levels within the white blood cell, and that can help determine if there are deficiencies of other micronutrients that help reduce copper buildup.  So, these are things like vitamin B1, B3, B6, folate, inositol, and choline, and those are all antagonistic to copper, and then there are some minerals that are antagonistic to copper, like zinc, of course, which we’ve been talking about, manganese, iron, sulfur, and molybdenum.  You want to be careful with the iron, though, of course, because if you are iron-loaded, you have too much iron, and you take iron to reduce copper, that may help solve one problem and cause another, or exacerbate another.  And then there are some studies I’ve seen that suggest that copper might be excreted by binding with glutathione, so yet another reason to maintain healthy glutathione levels; and glutathione levels are often depleted in cases of chronic illness and stress, so that’s another thing to pay attention to.  Then you want to improve the detox function of the liver and the skin.  You can do things like sweats and saunas.  And then, of course, you want to do a diet that is based on animal proteins and lower in the plant proteins that tend to be rich in copper, like the nuts and beans and seeds and grains, like I mentioned earlier.  So, those are the basic steps.

Steve Wright:  To summarize those, it’s basically look for any environmental triggers that are adding a lot of copper to your diet, cut out the high-copper foods, and then look to possibly supplement with any other micronutrient imbalances you might have?

Chris Kresser:  Exactly.  And on top of that, improving glutathione levels, improving the detox function of the liver, and improving adrenal function, and managing any form of stress, whether it’s dealing with inflammation or oxidative damage or psychological stress and adrenal stress.

Steve Wright:  OK, so let’s say that I find out that I have high copper and low zinc.  Do I start supplementing with zinc right away?

Chris Kresser:  It’s probably best to get some help from someone who has some experience dealing with this, because it can get a little bit complex, depending on the status of other micronutrients, and you know, I mentioned Wilson’s disease before.  That wouldn’t present with high serum copper.  It usually presents with low serum copper, so they’re not often confused that way, but depending on how you tested for elevated copper, it may be something that you want to rule out, Wilson’s.  But, in general, just following the steps that I outlined for a lot of people should be sufficient.  Zinc is definitely one of the things you would supplement with, especially if the zinc is deficient.  So, it’s important not just to test copper.  You would test copper and zinc at the same time, and if zinc is low, then you definitely would want to bring it back up.

Steve Wright:  OK, so to wrap it up, it’s something you should definitely get tested if you’re exhibiting any of the problems that Chris was mentioning, and I think we’re gonna move on to the next question, unless you have anything, Chris?

Chris Kresser:  No, I think that’s it.

Steve Wright:  OK, copper and zinc.  Got it done.

Is 5-HTP safer than SSRIs for anxiety and depression?

Steve Wright:  All right, this one’s from Breaking All Illusions.  “What do you think about the use of 5-HTP as a natural supplement for anxiety and depression?  Do you consider it safer or more effective than SSRIs?  And do you consider it safe/effective at all?  If so, how would you recommend using it?”

Chris Kresser:  OK, so 5-HTP is an intermediate in the conversion of tryptophan to serotonin, so tryptophan gets converted to 5-HTP, and then 5-HTP gets converted to serotonin.  As I’m sure many people know, some people who are depressed have issues with serotonin synthesis or metabolism, and that can cause depression, and in those cases, 5-HTP might be helpful.  There is some research that’s fairly promising, but I think the jury is still out on it.  But as I pointed out, I wrote an entire series on depression, ChrisKresser.com/depression.  Hopefully that will be updated soon because there’s a lot that I’ve learned since I wrote that.  It’s all still completely valid, but I want to add some information about the inflammatory cytokine model of depression, which I’m gonna talk about in a minute.  But in that series, I pointed out that not all depression is as simple as being a serotonin deficiency, and that is really just a convenient fiction that’s been manufactured by drug companies to sell more antidepressants.  Doctors in 2009 wrote 235 million prescriptions for antidepressants, which is just a mind-boggling number.  It’s a 14 billion dollar market for antidepressant drugs, so it’s a huge business, and the drug companies know that if they create a really simple model for depression, which is basically depression equals serotonin deficiency; therefore, if you take a drug that raises serotonin, that will cure and treat depression.  But the reality is a lot more complex than that, as anybody who works with depression knows or who has experienced it knows, and the drug trials on antidepressants, when you really look at them and you look at careful meta-analyses that have been performed by Kirsch and colleagues and others, you see that for mild to moderate depression and even fairly severe depression, antidepressants are often no more effective than placebo.  And a lot of the natural treatments, which we’re gonna talk about here in a second, are just as effective as antidepressants, with far fewer side effects.  So, 5-HTP may be one of those, but it doesn’t have the research behind it that some of these other natural therapies do.  So, if you’re gonna try 5-HTP, I would recommend starting with a pretty low dose, which would be maybe 20 mg in the morning, and it’s important to take it on an empty stomach.  And then you can continue to increase your dose every few days up to 100 mg, and I wouldn’t go above 100 mg.  Some people out there, some of the studies recommend 200 or 300 mg, but I don’t recommend that for a number of reasons.  So, somewhere between 20 and 100 mg.  If you take it before bed, it can sometimes help with sleep, so that’s another possibility, but I’ve found with patients that it’s more effective for depression if you take it in the morning.  But that’s not the first thing I would try with depression, and in fact, these days I’m looking at it much more as an inflammatory condition, which again I’ll come back to in a moment.  I wanna talk a little bit about some of the natural treatments that have been proven to be effective.  Psychotherapy is, of course, one of them, and it’s often left out when we talk about natural treatments for depression because I think a lot of times we’re thinking of, you know, nutrients or herbs or pills or things that we can take, but psychotherapy, particularly cognitive behavioral therapy, which is a specific type of psychotherapy, has compared favorably with antidepressant drugs in a lot of trials, especially in the short term, even when the depression is severe, and over the long term, it actually appears to be superior to medications.  And then some studies have looked at medication plus psychotherapy versus just medication alone, and of course, that’s almost always more effective, so that’s something to certainly consider, and I would definitely recommend it as part of a protocol for depression in any case.

Steve Wright:  When you say medication, are you talking about SSRIs and SNRIs?

Chris Kresser:  I’m talking, yeah, about both, but primarily SSRIs.  They’re the bigger drug class by far still even though there has been more of a trend to SNRIs lately, but a lot of the research that has been done in the comparisons has been more with SSRIs.  Exercise is at least as effective as antidepressants in treating depression, according to the research literature, and the good news about exercise is the only side effects of exercise are usually other health benefits and reducing your risk for a number of other diseases.  Light therapy, and there was a study in 2005 in The American Journal of Psychiatry that found that it was just as effective as antidepressants.  One of the arguments about that study was that it could have been placebo, and that’s true, but if that’s the case, you know, who cares?  If there’s no negative impact other than spending the 75 bucks or whatever on the machine, actually maybe we can put that in the show notes.  There’s a machine that I recommend on Amazon; I think it’s about 75 bucks.  You know, the only thing you might lose is a little bit of time in the morning and a little bit of money to buy the machine, but there really aren’t any significant side effects associated with it.  St. John’s wort, which I’m sure a number of people have heard of, it’s probably the most popular treatment for depression in Europe.  It’s just as effective as antidepressants in clinical studies, but it has 10 times fewer side effects.  One important thing to keep in kind with St. John’s wort is that it takes several weeks often for the effect to come on fully, so it’s not something that you just start taking and you feel the benefit right away.  It takes about three to four weeks to really get the effect.  Another thing I’ll mention is not to mix these treatments together with drugs.  I mean, exercise and psychotherapy, of course, is fine, and even light therapy, but I would not recommend combining St. John’s wort with antidepressants without supervision.  That can be dangerous.  And the same with 5-HTP and any other nutrient-based or herbal-based remedy.  Acupuncture has been shown to be pretty effective for depression.  In fact, there was a Cochrane review, Cochrane being one of the prestigious group that does meta-analyses of available research on a particular subject.  They found, “There is no evidence that medication was better than acupuncture in reducing the severity of depression.”  And again, just like exercise, acupuncture has very few side effects except feeling better in other ways.  So, those are a number of options for someone who is dealing with depression and doesn’t want to take the drugs or eventually wants to get off the drugs.  Again, it’s really, really important if you are taking a medication for depression not to stop taking it abruptly and to do it under the supervision of someone who is experienced in getting people off SSRIs and other forms of antidepressants, because stopping them cold turkey can really wreak havoc with your brain chemistry, and the problems with suicide that are associated with antidepressants most often occur when people are just starting the medication or just coming off of it.  So, it’s not something to play around with, and it’s really important to find someone who has experience getting people off of those drugs, if you choose to come off of it.

Why antidepressants could permanently alter your brain chemistry… in a bad way

Steve Wright:  Is there also a long-term consequence of staying on the drugs for a number of years?

Chris Kresser:  I think there is, and I wrote about this in my series.  There’s a lot of pretty disturbing research that shows that SSRIs can cause permanent changes in brain chemistry, and it’s difficult to talk about this because, you know, a lot of people are on antidepressants, and some people are helped by them.  Even though the research is pretty equivocal, you have to consider that research is about averages.  You know, when you do a study and statistically at the end of the study there was no difference between placebo and the intervention, in this case an antidepressant, it doesn’t mean that there weren’t some people that benefited from the antidepressant in the study.  It just means that on average, when you take all the results together, there was no statistically significant difference between the two treatments.  I know people that have taken antidepressants and that have benefited from them, and of course, I know people that haven’t, so I’m not saying they never work.  I’m just saying that statistically speaking, from a research perspective, they are not better than other treatments, in general, except in the cases of very severe depression.  So, I’m not making any judgements of anyone who chooses to take antidepressants, and it’s a little bit scary to tell someone that a drug that they’re taking can cause permanent changes in brain chemistry, but I also feel it’s important to get the word out about this so that people think really carefully about going on these drugs before they choose to do so.  So, the research shows essentially that those changes that are made in the brain can basically predispose you to depression more for the rest of your life.  So, they create changes in the brain that make it more likely that you’ll need to be on an antidepressant or have some other kind of treatment for depression indefinitely, and that’s what scares me the most about these drugs, and unfortunately that is not, you know, very few patients are told that before they go on a drug.  I think very few doctors even know about that research, but I wrote about it pretty extensively in the Depression Series.  There are a lot of references there, and there are some great books that I linked to as well, where you can read all about that research if you’re interested in it.

The surprising cause of depression (and no, it’s not low serotonin)

Chris Kresser:  So, before we finish up with this question, I want to talk a little bit about a newer perspective on depression that we discussed in an earlier show.  We talked about it in the gut-brain axis program, and this is known as the inflammatory cytokine model of depression, and the theory essentially is that inflammation, which often originates from the gut, produces inflammatory cytokines, and these cytokines travel through the blood, they cross the blood-brain barrier, and then they suppress activity in the frontal cortex, and then that, of course, causes depression, the frontal cortex being responsible for some of the higher brain function.  So, one of the most important things you can do if you’re dealing with depression, if you haven’t already done this, is eat an anti-inflammatory diet and fix your gut.  Anti-inflammatory diet being a Paleo-ish diet, a Personal Paleo Code-ish type of diet, and then all of the steps that we have discussed lots of different times towards healing your gut, and I think that those are kind of the first steps that should be done when somebody is dealing with depression, and then if you eat that diet and you fix the gut and deal with any other potential sources of inflammation like a chronic infection; for example, a viral infection or a bacterial infection that may not be in the gut but outside of the gut.  So, if you deal with all of those sources of inflammation and you’re still experiencing depression, that’s when I would turn to some of these other natural remedies.

Steve Wright:  So, when you start fixing the gut, it’s not necessarily advisable to look towards trying to replace any neurotransmitter losses in the dopamine or serotonin areas?

Chris Kresser:  That’s kind of the last step, maybe.  You know, it’s like fix the gut, reduce inflammation, any other sources of inflammation, then consider some of these other natural treatments that we just talked about that would indirectly regulate brain chemistry:  psychotherapy, acupuncture, St. John’s wort, light therapy, exercise, possibly 5-HTP.  And then there are some products that I might use that improve serotonin or dopamine or acetylcholine or GABA synthesis and metabolism, but even then, they’re a milder, safer, and more natural approach than SSRIs or SNRIs.  I consider those drugs to be a last resort.

Are chocolate cravings related to magnesium deficiency?

Steve Wright:  All right.  Well, let’s roll on here.  You mentioned it earlier in the show, but chocolate cravings — both Martin and Evan were asking about magnesium, and so here’s Evan’s question:  “What are your thoughts about chocolate cravings being related to magnesium deficiency?  As a raw vegan, I didn’t touch chocolate for two years probably, and now I can’t get enough of it.  I’m way beyond your recommendation of a piece about the size of a silver dollar.  A full bar or more is reasonable,” and I think that’s on a daily basis, so he would like to know more about the topic of magnesium, chocolate, and magnesium oil applied topically.

Chris Kresser:  Yeah, OK, so one of the easiest ways to figure that out is just start doing some fairly high-dose magnesium glycinate or malate supplementation.  So, you know, take 600 mg a day for three or four weeks, and if the craving for chocolate disappears, then you could suspect that it had something to do with magnesium deficiency.  But if you’re still eating that full bar of chocolate every day after a month of that kind of magnesium supplementation, then I have a feeling that it has something more to do with something else in the chocolate, maybe the sugar or the caffeine or, you know, some other substance or combination of substances.  Perhaps copper.  I mean, we mentioned that earlier, although copper deficiency is fairly rare in people who are eating a — I just don’t see copper deficiency very often, but you can check for it.  Transdermal magnesium oil — it’s another one that I’m a little bit uncertain about, and when you look in the scientific literature, there are no studies other than studies that are done by companies that sell magnesium oil that show that it’s an effective way of delivering magnesium.  However, I have patients who have not experienced any benefit from taking even the chelated forms of magnesium, like glycinate and malate, but have experienced a fairly dramatic change after using transdermal magnesium oil.  So, I don’t see how it could do any harm, and if you try it and it helps improve your symptoms, then maybe it does work.  And, you know, lack of proof is not necessarily proof against, so it’s possible that we just don’t have the research on this yet.  I remember trying it a while back, and I didn’t really notice that much of a difference, but I don’t think that I was significantly magnesium deficient either, so I’m probably not the best test case.

Steve Wright:  Were you eating a bar of chocolate a day?

Chris Kresser:  No, I wasn’t.  You know, I’m irritating to some people in my discipline around those things.  It’s not even discipline.  I just don’t crave it.  I have sometimes a little piece that size after a meal, and that’s all I really need to satisfy the craving, so I’m no hero of discipline.  I just, for whatever reason, don’t have that kind of relationship with it.

Steve Wright:  It’s interesting.  So, with the magnesium supplementation, would you recommend that before bed?  Is there a certain time there?

Chris Kresser:  Yeah, two times a day usually, so in the morning and then in the evening.  If people are using it for constipation and they want to promote a healthy bowel movement in the morning, you could take two times the dose in the evening and maybe a smaller dose in the morning.  Or, you could even take it all in the evening, maybe with dinner as a good approach.  If you’re using it for muscle pain, muscle fatigue, and just general health, it doesn’t really matter as much when you take it.

Steve Wright:  OK, and with magnesium glycinate, just to remind everyone that there is gonna be an upper level for them at which they’ll start to cause loose stools probably, right?

Chris Kresser:  Yeah, it’s a higher upper level than with oxide or citrate, which is one of the reasons I recommend it, but one approach is dosing intolerance, just like you do with vitamin C.  So, you can keep increasing the dose until you hit the loose stools, and then you can go back a little bit, but I find that for most people, unless they’re severely magnesium deficient, a dose of somewhere between 400 and 600 mg a day will be sufficient.

Steve Wright:  OK.

How to get your Vitamin A and D ratio within healthy ranges

Chris Kresser:  So, I think we have time for one more short one.  How about the vitamin A-D ratio question?

Steve Wright:  Sure.  This comes from Michel, and he or she, I’m sorry, is asking about the ideal ratio between vitamin A and vitamin D.  Should one be higher than the other, and by how much?  They’re worried that vitamin D is being hyped so much that people are going to tend to consume too D and not enough A.

Chris Kresser:  Yeah, I think that’s a valid concern, and one of the reasons that I like the Weston A. Price Foundation approach is they put a lot of emphasis on the importance of fat-soluble vitamins, and that’s not something that’s really discussed in the Paleo world very often.  Fat-soluble vitamins — we’re talking about A, D, K2, and E — they play so many crucial roles in health, and they’re difficult to obtain from food in most cases, particularly K2 and A, you know, and D, if you’re not eating seafood.  But there has been a lot of hype about vitamin D, and then there’s been a lot of hype in the other direction about the danger of vitamin A, particularly for pregnant women or women who are trying to get pregnant; they’re really freaked out, unfortunately, about vitamin A because it’s a crucial nutrient for healthy development of the fetus, which I talk about in The Healthy Baby Code.  The important thing to understand about these fat-soluble vitamins is they exist in a synergistic relationship, and when you have problems with toxicity of one of them, it’s almost always contributed to by, or even only possible in the face of, a deficiency of one of the others.  So, for example, all of the problems with vitamin A toxicity that people are afraid of are only really possible in the presence of concurrent vitamin D deficiency, and Chris Masterjohn has done some great work on this.  I think there’s an article on the Weston A. Price website that he wrote called — I think if you search for vitamin A / osteoporosis in the search engine on their site, you’ll find it, but he talks about a study, and I mention this in The Health Baby Code, too, where when people are supplementing with vitamin D or they have adequate vitamin D levels, the toxicity threshold for vitamin A goes up to like 200,000 IU a day, which is an absurd amount of vitamin A.  Like to put that in perspective, 3 ounces of liver have about 27,000 IU of vitamin A, so you’d have to eat 30 ounces of liver every day to exceed the toxicity threshold, and I don’t know anybody who is eating 30 ounces of liver a day, so that’s just not going to happen.  And likewise, vitamin D toxicity will happen at a lower level if vitamin A and vitamin K2 are deficient, because vitamin A and K2 protect against vitamin D toxicity.  So, as I’ve said on the show before, I think an ideal range for vitamin D is somewhere between 35 ng/mL and maybe 60 or 65 ng/mL.  I don’t see any reason to go higher than that.  I don’t agree with, you know, some of the people pushing vitamin D levels above 100 ng/mL.  Studies show that you’re at risk for hypercalcemia because vitamin D regulates calcium metabolism, so you start to get issues with kidney stones and stiffer arteries, which, of course, increases the risk of cardiovascular disease.  Whereas, vitamin K2, which also has an effect on calcium metabolism, it makes sure that the calcium ends up in the bones and teeth and the hard tissues, and not in the soft tissues.  So, the key thing here is balance and making sure that you have enough of these fat-soluble vitamins.  Vitamin A is only really found in significant amounts in organ meats and cod liver oil.  It’s found to a lesser extent in grass-fed dairy, and that’s why I’m always talking about cod liver oil, especially for people who are on a strict Paleo diet and who aren’t eating grass-fed dairy or organ meats, like liver.  So, getting back to the question, which I’ve kind of gone off on a tangent from, there’s not a lot of research on the ideal ratio between vitamin A and vitamin D, but there was a recent paper by Dr. Holick that suggested that ratios between 4 and 8 times as much vitamin A as D would be ideal, and then the lead author on that paper, Dr. Linda Linday, had used cod liver oil with a ratio in that range to successfully protect against upper respiratory infections, and then there was some other research showing that that range of ratios is ideal in chickens.  I don’t know how applicable that is to humans, but if you look at the amount of vitamin A and D in foods like cod liver oil, then it’s a roughly similar ratio, and that’s, I think, a good ratio to shoot for, and if you eat liver, 2 to 3 ounces of liver once or twice a week, or you’re taking cod liver oil on a daily basis, and then you’re getting exposure to sunlight and maybe taking some supplemental D in the winter, then that’s probably where you’ll end up.  Vitamin K2 you can get from butter oil or ghee and smaller amounts from all grass-fed dairy.  Cheese is actually a particularly high source of vitamin K2, hard cheeses, and goose liver, which is I don’t think a very commonly eaten food, which again, if you’re on a Paleo diet and you’re not eating dairy and you’re not eating goose liver or natto, it’s probably a good idea to supplement with K2.

Steve Wright:  I usually eat natto and goose liver every night.

Chris Kresser:  I bet.  Natto is one of the nastiest things I’ve ever tasted.  Have you tried it?

Steve Wright:  No.  It’s on my list for 2012 to explore.

Chris Kresser:  Oh, God!  Yeah, it’s wrong.  But it’s one of those things where people either like it or absolutely can’t stand it, and that’s kind of what liver is, I think, too.  You know, either people were raised on it and they have a taste for it, or they weren’t and they can’t stand it.

Steve Wright:  Yeah, I think there’s a lot of things you can do to liver to make it taste pretty good.  I started off being a little squeamish with it, and now I actually enjoy it.

Chris Kresser:  Incidentally, I just published an article today, I mean, you won’t hear this podcast for a little while longer, so on Friday, the 6th, about why you should eat more cholesterol, and the article is about choline and the importance of choline, but at the end of the article there are several recipes for liver from some great blogs.  So, check that out if you want to get some more liver in your diet and you’re wondering about some ways to make it more palatable.  There are some good recipes there on that blog post.

Steve Wright:  So, the biggest takeaway of this A-D conversation is that if you’re just taking a D3 pill, you need to look at adding some liver or some cod liver oil to your diet?

Chris Kresser:  Yep, that’s it, and K2 also, if you’re not doing that.

Steve Wright:  All right.  Well, I think that brings us to the end here.

Chris Kresser:  Yeah, great show!

Steve Wright:  Yeah, this was good.  We dived into a lot of topics I’ve never even heard about.

Chris Kresser:  Cool.

Steve Wright:  OK, so if you’re confused about what to eat, check out the PersonalPaleoCode.  It’s a 3-step program designed to help you discover your own ideal idea and create highly customized meal plans with a few clicks of a button.  Visit PersonalPaleoCode.com to learn more.  And if you’re trying to get pregnant or are already pregnant or nursing, don’t miss The Healthy Baby Code.  It guides you through the essential steps to naturally boost fertility and promote lifelong health for you and your baby.  Find out more at HealthyBabyCode.com.

Chris and I would like to thank you for sending in your questions, and invite you to send in more questions at ChrisKresser.com using the podcast submission link.  If you enjoyed listening to the show today, 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.

We’ve talked a lot about the “gut-brain” axis.  But did you know there’s also a “gut-skin” axis?  And did you know that researchers have been aware of this connection for more than 100 years?  Of course, this early work was forgotten for about 90 years, and it has only received increasing attention in the last decade.  It’s an exciting area of study, and it gives us new strategies for naturally treating skin conditions like acne (vulgaris and rosacea), psoriasis, eczema, dermatitis and others.

And in this episode of Revolution Health Radio, we cover:

2:24  Does the Gut-Brain-Skin Axis hold the secret to naturally get rid of acne?
8:23  The latest study validating 100 year-old research connecting stress, leaky gut, and acne
12:20  Why these ancient gut remedies also treat skin conditions
17:59  Could leaky gut be the hidden cause of acne?
20:55  How to break the vicious constipation-acne cycle
26:00  Why rush-hour traffic can cause low stomach acid, gas, and bloating
29:40  “The first place I look when someone comes to my practice with skin conditions”
34:48  The specific Gut Healing Protocol to naturally eliminate skin problems… for good
40:00  What foods to eat – and not eat – to get rid of migraines (and clear your skin)
44:12  The telltale signs you have low stomach acid… and what to do about it

Links We Discuss

• The Gut-Brain-Skin Axis – Back to the Future? (Full Text Study)
• The HCL Challenge Instructions

Full Text Transcript:

Steve Wright:  Hello 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, man?

Chris Kresser:  I’m pretty good.  I’m a little tired.  It’s been a long weekend, and we’re getting ready to go up to the Great White North at the end of next week.  My wife is Canadian, and she’s from a town in northern British Columbia called Prince George.  So, every other year we go up there; we trade off with my family for Christmas, and so it’s our Prince George year this year, and it’s probably gonna be 30 or 40 below.

Steve Wright:  Woo!

Chris Kresser:  That’s what it usually is when we go there, which is no joke!  I’m just like why do they put a city here, you know, at 40 below?  Just keep going south!  I don’t get it.  Yeah, so it’s actually nice to be up there because it’s pretty low key, and it feels like I’m far away from everything else in my life, so I look forward to it.  I get along really well with her family.  Yeah, so that’s what’s happening for me.  What about you, Steve?

Steve Wright:  It’s been a busy weekend for me as well.  Lots of Christmas parties going on right now, and just trying to wrap up all the gift buying and make sure I’m all set for the big coming week right now.  I won’t be going anywhere where it’s 40 below, so I’m feeling actually pretty good about that!

Chris Kresser:  Ha-ha!  Yeah, well, it’s not gonna be warm and balmy in Michigan, but not 40 below, huh?

Steve Wright:  No.  We don’t even have any snow, though, which is crazy for us.  We might not even have a white Christmas.

Chris Kresser:  Right.  Weird.  That’s like California, huh?

Steve Wright:  Weird.

Does the Gut-Brain-Skin Axis hold the secret to naturally get rid of acne?

Chris Kresser:  So, we’ve talked about the gut-brain axis on a previous show, and I’ve written about that on my blog, and today we’re gonna talk about the gut-brain-skin axis, or the gut-skin axis.  I get a lot of questions about how to treat skin issues or how I look at skin issues, and I’m actually gonna write a special report about this.  I know I keep saying I’m gonna write all these special reports, and I will eventually, but I think the next one will be either iron overload or the gut-skin connection, because skin issues are pretty common.  I see them a lot in my practice, and I think they’re misunderstood, so we’re gonna take some time and talk about that today, and there are some pretty interesting studies I want to cover, and if we have some time, we might get to a few questions, but probably not, just looking at all the stuff we have to cover.

Steve Wright:  Well, I’m pretty excited, because as somebody who has had some lifelong skin battles, I’m ready to listen, ready to hear it.

Chris Kresser:  Cool, and I mean, this is n = 1, but you’ve also, of course, had gut issues, so that’s really common.  I’m still waiting to find a patient with skin issues that has no gut issues and no history of gut issues.  I haven’t seen that yet.  I’m not saying they don’t exist, but so far everybody I’ve treated with a skin issue has a gut issue.  It doesn’t necessarily work the other way around, where someone who has a gut issue absolutely has a skin issue, but it does seem to be pretty consistent with the skin.  So, this connection between the skin and gut health and mental health has been known for a long time, and in recent years there are actually two new fields of study called psychodermatology and neurodermatology, entirely new fields of study dedicated to looking at this stuff.

Steve Wright:  Sounds like a lot of school.

Chris Kresser:  Yeah, ha-ha, no doubt about that!  And we know that acne is more common with depression and anxiety and other psychological conditions, and likewise, we know that depression and other mental health disorders are more common with acne.  And lately researchers have been paying a lot more attention to the gut-skin connection.  There’s one study of, I think, 13,000 adolescents that found that those with acne were more likely to have constipation; halitosis, which is the fancy name for bad breath; and acid reflux.  And bloating, interestingly enough, was especially correlated with acne, with about 37% of kids with acne experiencing bloating.  So, in my practice, as I said, I see this all the time.  Regardless of the skin condition, it could be acne vulgaris or acne rosacea or dermatitis or psoriasis or eczema — any number of different skin conditions — they’re often connected to a gut problem, as I mentioned.  And I will often use a gut-healing protocol to treat skin conditions, and we’ll talk a little bit more about that towards the end of the show.

Steve Wright:  Are you gonna dive into if the vulgaris and all the different versions of this — Are they all kinda the same pathology?  Are we gonna talk about that?

Chris Kresser:  I wasn’t planning to talk about that in detail, but it’s a good question, and generally I would say that they share some similar pathological characteristics, but the pathology, of course, is not identical because then they would look the same.  If everything was identical about them, they wouldn’t be different conditions.  That said, some of the mechanisms that we’re gonna talk about, like low stomach acid and small intestinal bacterial overgrowth and leaky gut and dysregulated gut microbiota or gut flora — You can find these in all of those conditions that I just mentioned, psoriasis, eczema, rosacea, acne, dermatitis, and a lot of other ones that we’re not even gonna have time to discuss.  So, the answer to that is, yes, they share similar characteristics, and I think from a practical perspective, you know, from a treatment perspective, I do tend to look at them in a similar way and treat them in a similar way.  The exceptions would be psoriasis and eczema, which I and a lot of other researchers consider to be autoimmune conditions, and of course, we know about the connection between leaky gut and autoimmunity, so there’s still a very strong gut connection, but there’s maybe an additional immune dysregulation happening there that may not be happening with acne and some of the other skin conditions, although maybe it is and we just don’t know at this point.

Steve Wright:  So, at a lot of the base levels, it’s probably the same, but as it goes deeper, they branch off as far as the pathologies, basically?

Chris Kresser:  Yeah, I think so, and maybe that’s a question of genetics and what one person’s predisposition is.  It’s really interesting.  You know, like, two people get a leaky gut.  One person develops type 1 diabetes, the other person develops an autoimmune thyroid condition, and they both have a leaky gut, but they develop completely different manifestations of that underlying pathology, and I think it’s probably impossible to determine why, but my guess is it has something to do with genetics, it has something to do with environmental influences and personal background and any number of other factors that we don’t totally understand yet.

Steve Wright:  OK.

The latest study validating 100-year-old research connecting stress, leaky gut, and acne

Chris Kresser:  So, I want to talk about my new heroes, Stokes and Pillsbury.  The gut-brain-skin axis idea has been around for a long time, and these two guys whom I just learned about recently, they were talking about it as far back as 1909, so over a hundred years ago.  And they had connected emotional states like worry and depression and anxiety with altered gut function.  They knew that changes in the microbial flora promote local and systemic inflammation that can manifest in the skin.  I mean, this is crazy!  If you went into a dermatologist’s office today and you started talking about this, they’d look at you like you were nuts, and they’d call it some kind of alternative quackery.

Steve Wright:  Ha-ha, I’ve been there!

Chris Kresser:  Ha-ha, right!  But there’s a difference between being skeptical and conservative and just being uninformed.  I mean, this is in the scientific literature.  If you go and you search on PubMed for intestinal permeability and psoriasis, you’ll see several papers.  If you search for SIBO and acne, you’ll see several papers.  So, it’s interesting to me how when people encounter something that they don’t understand or that seems strange or foreign to them, they dismiss it as being irrelevant or quackery, but in the medical literature, which is supposed to guide clinical practice, it’s right there and it’s been there for over a hundred years.  Yeah, side note!

Steve Wright:  It’s sort of like a reoccurring theme with all these things when it comes to the different diet approaches that we’re seeing and various supplementation with vitamins, you know, your vitamin X, K2 type of thing.

Chris Kresser:  Yeah, K2.  Yeah, you’re right.

Steve Wright:  The people that lived in the 1900s to, like, 1920, man, they were on it!

Chris Kresser:  They were, and we have this idea that all things that are new are better, and if research was done in the early 20th century, it must be out of date and not worth paying attention to, but these guys were decades ahead of their time, even a century ahead of their time.  So, here’s a quote from the paper.  This is 1909.  They said:  “There is an important linkage of emotion with cutaneous outbreaks of erythema, urticaria, and dermatitis by way of the physiology and bacteriology of the gastrointestinal tract.”  That was a little wordy.

Steve Wright:  So, what does that mean?

Chris Kresser:  Basically they were aware of the gut-brain-skin axis in 1909.  That’s what they said.  That quote was there’s a link between the gut and the skin, and what mediates that link is the physiology of the gut, like whether it’s permeable or not, and the bacteriology of the gut, meaning our gut flora.  So, they also cited other research that showed that 40% of those with acne had hypochlorhydria, which is the medical term for low stomach acid, and low stomach acid, as a lot of you know, because I’ve discussed it on my blog and on this podcast, is what sets the stage for the migration of bacteria from the colon, where it belongs, to the small intestine, where it doesn’t belong, and that condition is called small intestinal bacterial overgrowth or SIBO, which of course, you guys talk a lot about on your blog, Steve.

Steve Wright:  Yep.

Chris Kresser:  So, Stokes and Pillsbury also knew that stress-induced changes in the gut microbiota lead to intestinal permeability and leaky gut, so back in 1909, they were already talking about the stress-gut connection and how stress can cause a leaky gut.  And they knew that leaky gut causes both local and systemic inflammation that can then manifest in the skin.

Why these ancient gut remedies also treat skin conditions

Chris Kresser:  But it gets better.  The remedies they talked about to break this cycle included “direct introduction of acidophil organisms in cultures such as those of Bacillus acidophilus,” aka probiotics.

Steve Wright:  Wow.

Chris Kresser:  They also advocated cod liver oil, which is a rich source of omega-3’s we know now and plays an antiinflammatory role.  They didn’t know that then.  So, they were basically prescribing cod liver oil and probiotics for skin conditions because they were aware of the gut-skin axis.  I mean, it’s incredible, really.

Steve Wright:  That’s fascinating!

Chris Kresser:  Ha-ha, I’m such a dork to get so excited about this, but it’s really amazing.  It’s really cool to see this in the scientific literature.  So, their theories, though — This was, like we said, over a hundred years ago, and it’s been largely forgotten, and it’s only in the last 10 years that they’ve really been vindicated, because we know now that low stomach acid is a significant risk factor for SIBO, small intestinal bacterial overgrowth, and I talked about that in the GERD series.  In fact, my theory for — it’s not just my theory — but my perspective on what causes GERD and heartburn is not too much stomach acid as a lot of people and conventional medical establishment sometimes assumes, but not enough stomach acid, which then causes bacterial overgrowth and gas pressing up against the lower esophageal sphincter, and then that opens that sphincter and acid gets in from the stomach back into the throat.

Steve Wright:  Yes, stomach acid really is the gatekeeper.  It’s fascinating.

Chris Kresser:  Yeah, so we know that studies show that 50% of patients on long-term PPIs, proton pump inhibitors, or antacid drugs have SIBO.  That’s a crazy statistic!  One in two patients who are taking PPIs over the long term have small intestinal bacterial overgrowth.  And since we know that SIBO is associated with leaky gut, and we know that leaky gut is the gateway — talk about a gateway — to autoimmune conditions and all kinds of other issues like skin problems, that’s reason alone not to take antacid drugs.  We know that SIBO is also correlated with functional syndromes like fibromyalgia and chronic fatigue, which suggests an inflammatory link.  It suggests that SIBO causes some of kind of systemic inflammation that can manifest as these functional conditions.  We know that SIBO has recently been shown to be associated with increased intestinal permeability, and we know that antimicrobial treatment helps restore the normal intestinal barrier, so when you get rid of SIBO, the intestinal barrier heals and starts to do its job of keeping things out of the bloodstream that don’t belong and keeping them in the gut.  And then we’ve also seen other studies recently that show that psychological stress can decrease transit time, meaning can cause constipation, it can cause SIBO, and it can make the gut barrier permeable, and that SIBO is strongly correlated with both depression and anxiety, while eradication of SIBO improves emotional symptoms and feelings of well-being.  So, I think this is a remarkable area of study, and I’ve said this before, but I think if antibiotics were the medicine of the 20th century, I think probiotics or at least just modulating the gut flora not just with probiotics but with a gut-friendly diet and other strategies that we probably haven’t even considered yet of replacing and restoring healthy gut microbiota is really gonna be the focus of medicine in the 21st century, as it was even thousands of years ago.  Way back, you know, 2500 years ago, this was talked about when people in Western medical literature at that time were still talking about humors and bleeding.  It was even then recognized that the gut was a major factor in health.  So, things are coming around again, and it’s probably gonna take a while to penetrate into the mainstream consciousness, but I think at least in the research literature it’s already starting to happen.

Steve Wright:  Yeah, there are more links and more studies coming out by the day — it’s really amazing — with the SIBO / leaky gut connection, so I think you’re right on.

Chris Kresser:  Yeah, and you guys, I know you’ve interviewed a lot of people.  It seems like there are a lot more doctors who are aware of it and talking about it, and I notice when people come, patients in my practice now when I say SIBO, they don’t look at me like:  What the heck are you talking about?  A lot of people seem to know more about it at this point.

Steve Wright:  Yeah, I think it’s definitely spreading.  People are contacting us on our site that are aware of it and they’re looking for different ways to treat it or improve the gut, anyway, via diet and supplements, so I think it’s really encouraging.

Could leaky gut be the hidden cause of acne?

Chris Kresser:  Yeah, so the specific connection between acne and leaky gut hasn’t been studied directly, but there are a lot of mechanistic studies that suggest a link.  So, for example, one study showed that acne patients are more likely to show an increased reactivity to bacterial strains that are isolated from stool.  Sixty-six percent of the 57 patients in this study with acne showed a positive reactivity to stool bacteria compared to 0% of the controls.  And then in another study, patients showed the presence of and higher reactivity to lipopolysaccharide endotoxins in the blood.  None of the controls in the study reacted to the lipopolysaccharide endotoxin, while 65% of acne patients did have a positive reaction.  I know that was a lot of jargon there, so I’m gonna explain that.  Basically what those two studies suggested is that the patients with acne were having strong reactions to things that should still be in the gut but had escaped the gut into the bloodstream, so that, in turn, suggests that the gut is leaky in those patients and things like lipopolysaccharide endotoxin are getting out of the gut and into the blood, and then the patients are mounting an immune response to that, and then that’s causing inflammation, which manifests as acne.

Steve Wright:  Hey, Chris, real quick for everyone, what is a lipopolysaccharide, an LPS?  What is that?

Chris Kresser:  It’s an endotoxin that’s produced by certain bacteria.  It’s a very potent toxin, so when it gets into the bloodstream, it can cause an immune reaction.  Any immune reaction is basically inflammation, so that inflammatory response, as I say, can manifest in a number of different ways, depending on people’s genetics, background, their basic physiology, who knows, but in this case, it’s manifesting as acne, but it can also manifest as an immune response mounted against the joints, like in rheumatoid arthritis, or the thyroid in autoimmune thyroid disease.  The important point here is that all of this stuff is supposed to stay in the gut, and the fact that the patients with acne are reacting to it suggests that it’s leaving the gut and getting into the bloodstream.

Steve Wright:  So, a normal person is still gonna have LPS toxins, it’s just not getting into the blood?

Chris Kresser:  Yeah, but if your gut flora is healthy, you’re not gonna have the same amount of LPS as you would if you have an overgrowth of pathogenic gut flora.

Steve Wright:  OK.

How to break the vicious constipation-acne cycle

Chris Kresser:  Then you have other studies that have found a link between constipation and acne, and that’s probably mediated via changes in the gut flora too, because research has shown consistently that people with constipation have compromised gut flora, and this is definitely my clinical experience.  In fact, I think in pretty much all cases of constipation, the long-term way that it needs to be treated is by restoring healthy gut flora.  In the short term, other interventions are often necessary to just get the bowels moving because it’s one of those vicious cycle things, where if you’re constipated, that messes up your gut flora.  And then if you have messed-up gut flora, you’re gonna be constipated.  So, you have to do something to get the bowels moving just to get out of that vicious cycle, but then over the long term, you’ve got to restore normal gut flora.

Steve Wright:  Do you have a go-to method to get them started right away?

Chris Kresser:  I often will use magnesium glycinate in fairly high doses.  That’s a chelated form of magnesium that’s easier to absorb, and it doesn’t affect the gut in the same way that magnesium citrate and oxide do.  Those tend to draw more water into the bowel, and they cause either diarrhea or loose stools or what I refer to as “constirrhea.”

Steve Wright:  Ha-ha.

Chris Kresser:  And those of you who have ever experienced that will know exactly what I’m talking about!  Whereas, magnesium glycinate is better absorbed, and it’s a smooth muscle relaxant.  It promotes intestinal motility, but it’s not habit forming.  It doesn’t have a stimulant laxative effect like senna or rhubarb or any of those more potent laxatives.  So, that’s a good starting place, and it works for most people.  And then we start addressing the gut flora, and over time that’s, as I said, the main thing because 70% to 80% of the dry weight of stool is bacteria, so if you don’t have sufficient good bacteria in your gut, you’re not gonna be able to form a normal stool, and then that will decrease the intestinal motility.  So, we know, as I said, that people with constipation have compromised gut flora, and we know that chronic constipation is associated with intestinal permeability, and that’s because when someone is constipated, LPS and other endotoxins that would normally just keep moving and be cleared, they damage the gut lining and make it permeable.  We also know, and I’ve mentioned this a couple times, that there is a connection between stress and altered gut flora and leaky gut, which in turn, suggests a connection between stress and skin issues.  And there are a lot of experimental studies and human studies that have shown that a variety of psychological and physiological stressors can impair the normal gut flora and cause intestinal permeability.  I talk about stress a lot and the importance of stress management a lot, and I think there are so many different ways to look at it, but the connection between stress and gut health, especially, is so important to understand.  The gut is basically one big nerve plexus, one big nervous system tissue.  In fact, some doctors refer to it as the second brain, and there’s way, way more serotonin, which is a neurotransmitter that most people associate with the brain, in the gut than there is in the brain, and there is 400 times more melatonin in the gut than there is in the pineal gland, where melatonin is produced.  So, the gut is extremely sensitive to stress, and most people already know this very directly.  If anyone’s ever had to give a public speech or perform and you get those butterflies in your stomach, that’s an immediate connection between the gut and the nervous system, and I think everyone has experienced that to some degree or another.  But it’s maybe a little bit more difficult to get a sense of how that works over time, that over time if you continue to have activation of the sympathetic nervous system, the fight-or-flight response, even if it’s at a low level, that that will break down that intestinal barrier and cause leaky gut and cause changes in the intestinal microflora, so it would predispose you towards less good bacteria and more opportunistic or bad bacteria.

Why rush-hour traffic can cause low stomach acid, gas, and bloating

Steve Wright:  Is it also true that to actually start secreting stomach acid, or at least hydrochloric acid, you need to have the parasympathetic stimulated?

Chris Kresser:  That’s right.  Parasympathetic is rest and digest.  Everyone’s heard of fight or flight, which is the sympathetic nervous system, but parasympathetic, the catchphrase for that is rest and digest, and that’s exactly why, because when you’re in a sympathetic nervous system response, your body prioritizes everything that is required for immediate survival.  So, the blood pumps to your skeletal muscles and your lungs so you can get oxygen and run away or fight, and all of the resources are devoted to only what will help you fight or flee.  And all of the long-term mechanisms important for long-term survival, like reproductive function, digestion, endocrine function, hormone metabolism and synthesis, all of those things the body could care less about if your life is at stake and whether or not you live or die is gonna be determined in the next moment.  And people might be listening to this and go:  Well, yeah, how often is my life really at stake, though?  Well, the thing is your body doesn’t really differentiate between a real threat to your life, like from an evolutionary perspective, getting chased by a predator like a lion or being in a fight, and something like driving in traffic and getting cut off.  The activation of the sympathetic nervous system happens in both of those cases, and even though in one case your life may not really be in danger at all, that’s the way that the nervous system responds.  So, most people in the modern world, most of us are in this chronic state of low level sympathetic nervous system activation, and you can’t really be in both at the same time.  Either your sympathetic nervous system is activated or your parasympathetic is activated.  So, if you’re in that chronic fight-or-flight response and you never do anything to activate the parasympathetic response, then there’s gonna be a range of symptoms like you just alluded to, Steve, low stomach acid because as part of the rest-and-digest response that’s what happens.  You produce stomach acid, the peristaltic wave begins, and you produce pancreatic enzymes, and that’s, of course, one of the reasons why it’s recommended not to eat when you’re really stressed out and why a lot of people won’t even feel hungry when they’re really stressed out, because none of those mechanisms are working, and you just naturally get the sense that it’s not the right time to eat, and if you do eat when you’re really stressed out, food just sits there like a rock because your digestive system is not functioning.  So, let’s see here.  There’s a lot more we could talk about, and I’m gonna write more.  I’ll probably write some articles about the specific skin conditions and how each mechanism contributes.  I’m not sure how I’m gonna divide this series yet.

“The first place I look when someone comes to my practice with skin conditions”

Chris Kresser:  But why don’t we talk a little bit about my clinical experience with this stuff and how I approach these things and maybe just a few ideas for things that people can do at home?  As you’ve probably gathered by now, the first thing I look at if someone comes in and says they have a skin issue, the first thing that’s on my mind is their gut.  And what’s interesting about this is that about 30% of people with leaky gut have no gut symptoms at all.

Steve Wright:  Really?  Did they do that in study?

Chris Kresser:  Yeah.  I mean, it’s extrapolation, of course, but they took people and measured for leaky gut using probably a lactulose/mannitol challenge, and then they compared those results with people who actually have gut symptoms, and they found that 30% of people with leaky gut don’t have any gut symptoms.  And I have a patient who came to me with psoriasis, and they had no gut symptoms at all, perfect — well, unless they were not telling the truth — but according to them, perfect digestion, never had any gut problems in their whole life, still didn’t have any gut problems but had pretty bad psoriasis, and I suggested a pretty strict gut-healing protocol, and they were pretty resistant to that at first because they didn’t really get how that could be connected or why that would make sense for them.  So, we tried it, and within three weeks there was a significant improvement, and within probably three months it was, I would say, 85% to 90% resolved.  And he was obviously thrilled and pretty surprised, but he continues to follow the protocol, and it’s sometimes a little difficult because he doesn’t get the immediate feedback with the gut.  Some people when they eat certain foods, they have an immediate reaction digestively, and that’s a reminder that they can’t eat those foods.  For him, it’s more like if he starts eating those foods, he has a few days of free pass and then, sure enough, the skin starts to erupt again.

Steve Wright:  So, is that kind of like the toxins just start to accumulate?

Chris Kresser:  I don’t know.  It’s probably more that if the gut barrier is relatively healed, it takes a few days, you know, if he starts eating foods that damage the gut barrier, it takes a few days for it to really get permeable and for the inflammatory process to kick in and, yeah, maybe the endotoxins to slip through.  But one of the great things about the gut is that the enterocytes and the cells inside the intestine regenerate about every three days, so the gut has the potential of healing pretty quickly if you get all the conditions right.  That said, there seems to be a kind of reverberation effect, and the analogy that I sometimes use when I talk about this with patients is that it’s like a bell; it’s like ringing a bell.  So, if you ring a bell with a mallet, you strike it, and then you take the mallet away, you’re gonna hear the sound for quite a while afterwards even though the mallet isn’t touching the bell anymore.  And if we consider that the mallet is like a parasite or a gut infection or a really stressful event or something that dysregulates the gut, even when you remove that trigger, you’re still gonna have this kind of reverberation effect for a period of time afterwards in most cases, so it’s a little paradoxical in the sense that the gut can heal very quickly because of that quick cellular turnover, but at the same time there seems to be pretty long-lasting effects from some of the triggers that can cause gut problems in the first place.  So anyhow, getting back to the clinical side, when someone comes in and they have a skin problem, we’ll talk about their gut.  Very often they have a digestive condition, and they may or may not be aware of the connection, so that’s where we start focus.

The specific Gut-Healing Protocol to naturally eliminate skin problems… for good

Chris Kresser:  I’m kind of always tweaking my gut-healing diet.  I mean, there are a number of gut-healing diets out there:  the Specific Carbohydrate Diet, of course, the GAPS Diet, and there are a whole bunch of other ones that we don’t have time to cover, but what I generally start with these days is a modified version of the Paleo Diet.  It’s similar to the autoimmune Paleo Diet, so it’s a Paleo Diet that removes dairy, except ghee is usually really well tolerated because it doesn’t have casein or lactose in it, and then we also remove nightshades because they have glycoalkaloids and a lot of other compounds that can be inflammatory for the gut when people are susceptible, and depending on the patient, we may also remove eggs.  Then we also would take out FODMAPs, and I talk about this in the Personal Paleo Code, and we’ve talked about it on the show as well.  These are foods with excess fructose or fructans, also sugar alcohols, polyols, and disaccharides and oligosaccharides, so longer-chain sugars.  So, you can search for FODMAPs on Google, and you’ll get a list of these foods.  So, it is fairly restrictive.  Oh, and the other thing I’ll do is often limit the amount of insoluble fiber because insoluble fiber, there’s nothing wrong with it, but it can be really rough on an inflamed gut.  It’s kind of like rubbing a wire brush over an open wound.  This is the way that I think about it.

Steve Wright:  That would be things like greens and stuff like that?

Chris Kresser:  Yeah, there are two kinds of fiber.  There’s soluble fiber and insoluble fiber, and the main difference between the two is that soluble fiber can be fermented by good gut bacteria, and so it promotes healthy gut flora.  Insoluble fiber cannot be fermented by good gut bacteria, and just mechanically is indigestible, so it passes through the intestine without really being digested, and it has a mechanical effect of pushing stool through the intestine, but because of the texture of it, it can be just pretty rough on an inflamed gut, as I said.  So, that would be broccoli, cauliflower, the winter greens, the skins of the fruits and vegetables.  Things like blueberries have a fair amount of insoluble fiber.  Whereas, soluble fiber is found more in things like bananas and the winter squashes, the inside, not in the peels, or sweet potatoes, not the peels, but the flesh.  So, we have them focus more on soluble fiber and eat less insoluble fiber.  And then we also will do probiotics, and sometimes that’s fermented foods, sometimes that’s other commercial probiotics, sometimes that’s probiotic implants rectally for people who can’t tolerate them orally.  And then we might do some antimicrobial treatment to rebalance the gut flora for people who have a gut infection or have an overgrowth of pathogenic gut flora.  We’ll do bone broth and glycine-rich foods because that is what provides the fuel or the raw material to help rebuild the gut barrier.  And then I’ll often use supplements and botanical medicine that helps restore a healthy gut barrier, things like MSM, slippery elm, marshmallow root, glutamine, and licorice.  And then, of course, hydrochloric acid, betaine HCl, to replace stomach acid for people that have low stomach acid, which is a pretty large percentage of folks who have gut issues, not everybody, but a pretty large percentage.  And that’s a lot.  It’s definitely a comprehensive protocol, but I find that for most people when they follow this kind of approach, they experience an improvement in both their digestive health and their skin.  For some people who have really recalcitrant conditions, I might also use a custom herbal formula that has some anti-inflammatory and skin-clearing herbs in it, but in general, the basic approach is pretty effective.

What foods to eat — and not eat — to get rid of migraines (and clear your skin)

Chris Kresser:  And one other interesting note:  In the Personal Paleo Code, there’s an antimigraine diet in there that I talk about how to address migraines with food, and it’s a low tyramine, histamine, and arginine diet.  And just kind of by accident, I noticed because I had a few patients with migraines and skin conditions, and I put them on the migraine diet, and it helped with their migraines, but then they came back to me and said:  Wow, my skin is clearer than it’s been in years.  And so, I started to think, Oh, that’s interesting.  So, now I’ll often use that diet, the low tyramine, histamine, arginine approach for people with skin issues that don’t respond to the basic protocol.  And maybe we can talk more about that at some point.

Steve Wright:  Well, what are the biggest foods that you would cut out, that that diet cuts out?

Chris Kresser:  Oddly enough, fermented foods are one of the biggest categories of foods that contain both histamines and tyramines, which is, of course, ironic because fermented foods have a lot of probiotic organisms, and that’s one of the keys to getting well.  And then those patients, if they don’t do well with fermented foods, they we use a commercial probiotic supplement to help rebuild the gut flora.  We do probiotic implants.  So, like just sauerkraut and fermented vegetables, but also smelly cheeses and wine and vinegars, those are the foods that tend to be high in tyramine, and then histamine kind of also includes those fermented foods but in addition includes some random fruits and vegetables that there’s no obvious connection between them, like strawberries, for example.  Again, usually if you just do a little Google research, there are some lists of these foods online.

Steve Wright:  Interesting.  So, when someone comes in exhibiting, because we talked a lot in the beginning about SIBO, do you ever do any SIBO testing for someone who comes in with digestive problems or skin problems?

Chris Kresser:  I don’t often.  If I suspect they have SIBO, I’ll usually just treat them as if they do and see how they respond, because the treatment that I do is often similar whether it’s leaky gut or SIBO or some other gut issue, but sometimes I do test.  I’ll use a breath test to see if they have SIBO, and then that will help focus the treatment a little bit more.  I’m kind of going back and forth on that right now because so far I haven’t noticed that it really changes the outcome of the treatment very much, and my standard for whether to run a test is whether it’s gonna change what we do in the treatment, and a second consideration would be whether it can provide some clarity or answer a burning question for a patient.  For example, I don’t necessarily think gluten intolerance testing is all that helpful if somebody is convinced that gluten is inflammatory and they’re just not going to eat it, but for someone who really wants a smoking gun and just really wants the clarity of knowing that they’re gluten intolerant so that they have the commitment or the motivation to completely avoid it, then I think it’s a useful test in that circumstance.  And I don’t know whether SIBO fits that guideline because it doesn’t lead to avoiding something in the diet as clear as gluten, but I’m kind of keeping an open mind about that testing, and we’ll see how that plays out.

The telltail signs you have low stomach acid… and what to do about it

Steve Wright:  OK, well what about the stomach acid?  How would I know if I have low stomach acid?

Chris Kresser:  That’s mostly symptomatic.  I mean, you can get stomach acid tested by a gastroenterologist.  They could do, like, a 24-hour stomach acid test, but they’re really reluctant to run them.  I’ve only ever had a few patients that have had that done.  So, if you have a lot of symptoms after a meal, right after a meal, like upper GI bloating and belching and just a feeling of discomfort, bad breath, and then especially with proteins, like, if you have trouble digesting proteins, those are all signs of low stomach acid.  Also I do a lot of blood testing for patients when they first come to see me, and if they’re low in a lot of vitamins and minerals, then I’ll suspect low stomach acid because one of the main purposes of stomach acid is to help digest and absorb those vitamins and minerals.  So, if somebody comes in and they’re low in B12, they’re low in phosphorus and magnesium and iron and a number of other things, and they’re eating a diet with animal products, that’s gonna be one of the first things that I suspect because they shouldn’t be low in those nutrients if they’re eating a nutrient-dense diet unless there’s some problem with absorption, and that would probably be caused at least in part by low stomach acid.

Steve Wright:  I’m glad you hit on the meat trend there, because I see so many women who will come and email us and say:  You know, I just don’t do well with meat.  I can’t switch to something like a Paleo or SCD or GAPS.  And that, to me, is just a giant red flag that right away that have a stomach acid issue.

Chris Kresser:  Right.  That’s exactly the way I approach it too, and it’s unfortunate because a lot of people stop eating it because they think:  I just don’t digest it well.  Well, that may be true, but that doesn’t mean that that’s a stopping place.  That’s a sign, as you’re suggesting, that there’s some work to be done.  So, yeah, that’s a really good diagnostic piece of information there.  And then, let’s see, the other thing you can do is the HCl challenge, which I’ve talked about.  I have really explicit instructions for how to do that if you go to ChrisKresser.com/heartburn.  The last couple articles are how to treat GERD from a nutritional perspective, and it lays out the whole HCl protocol.  But it basically involves starting with a single HCl capsule just before a meal, and then you gradually increase the dose until you feel a mild burning sensation.  And most people with adequate stomach acid will feel some burning even with one capsule, maybe two or three capsules, but I’ve had patients go up to 10 capsules and not feel a thing, and that’s definitely an indicator that stomach acid is low.  And fortunately for most people after a period of time of taking betaine HCl, their own stomach acid production will kick in again.  In some cases with patients who have been on PPIs, acid-suppressing drugs, for like 15 years or more, I have seen in those situations where they may need to continue to take HCl for the rest of their lives or indefinitely, but it’s way better for them to take HCl indefinitely than it is for them to continue taking a PPI in light of all of the things that we know about PPIs do to you over the long term.

Steve Wright:  Can I ask from a skeptical patient or a skeptical client perspective, when I feel that mild burning, because we know that supplementing with betaine HCl is not an exact science, and when I feel that mild burning, does that mean I’m doing damage or is it just a one-time indicator and it’s not a big deal, nothing to worry about?

Chris Kresser:  You mean as you’re building up the dose?

Steve Wright:  Yeah, because I know that I talk with a lot of people who are trying to handle this part of their health, and they might get to four pills and they’re really, really worried about five pills because it just seems like a lot, and they’re also worried:  Well, if I start this supplementation and I feel this burning, then I already know my stomach is hurt.  Aren’t I just injuring it more?

Chris Kresser:  Right.  Yeah, if it’s just a one-time thing, I don’t think it’s a problem, and it’s a way to figure out how to get to the next phase, which is feeling better.  And a single episode of feeling a little mild burning isn’t gonna cause any long-term damage.  If somebody is doing that repeatedly, I wouldn’t recommend it, but that’s not really necessary as part of the protocol of figuring out what you need.  Also I don’t think that it’s even necessary, I mean, everyone has to find their own dose.  Like, some people, even though they build up to 10 capsules, that doesn’t mean they won’t get the same benefit at five capsules or seven capsules that they get at 10.  In other words, just because you don’t feel burning until you get to 10 or 12 capsules, it doesn’t necessarily mean that you need to take 10 or 12 capsules each time.  That make sense?

Steve Wright:  Yeah, I think so.  That’s probably definitely true, depending on the protein load of the food, of the meal.

Chris Kresser:  Yeah, it really differs.  And it is a kind of trial-and-error process, and it isn’t an exact science.  That’s definitely true.

Steve Wright:  I would encourage everyone, just as someone who uses the betaine supplementation on an everyday level even though it is a bit of a pain to figure out your correct dosage, it was night and day for me, and I know it still is night and day if I miss by a couple pills or something just because I want to test something.  So, what we’re talking about shouldn’t deter you from testing this right away, because it will make the difference.

Chris Kresser:  Yeah, it’s safe.  I’ve done this with hundreds of patients, and I hear from people.  If you look at the comment section in the heartburn articles, you’ll see people who were suffering from GERD and heartburn for 20, 25, 30 years.  They were on PPIs for all that time, and they’re now completely symptom-free just from following this protocol.  So, people from all over the world, all different backgrounds and histories, so it works, it’s really powerful, but it does take some time, and like you said, Steve, it’s kind of a hassle to have to always be carrying these capsules around and take them every time you eat, but for most people, it’s worth it.  So, I think that’s all I’ve got for now.  We’re gonna come back and talk about this a little bit more maybe in the future.  And like I said, I’m gonna write a little bit more about it.  Sorry we didn’t have time for questions this time.  We’ll do a Q&A episode where we answer a lot of the questions that have been coming in sometime soon.

Steve Wright:  OK, well, it’s been a great show, and if you’re confused about what to eat, check out the Personal Paleo Code.  It’s a 3-step program designed to help you discover your own ideal diet and create a highly customized meal plan with a few clicks of a button.  Visit PersonalPaleoCode.com to learn more.  And if you’re trying to get pregnant or are already pregnant or nursing, don’t miss The Healthy Baby Code.  It guides you through the essential steps to naturally boost fertility and promote lifelong health for you and your baby.  Find out more at HealthyBabyCode.com.

Keep sending us your questions at ChrisKresser.com using the podcast submission link.  And if you enjoyed listening to the show, head over to iTunes and leave us a review.

Well, Chris, it’s been a great episode.

Chris Kresser:  Yeah, I’ve enjoyed it.  I hope everybody learned something useful, and I’m looking forward to writing and talking about this more in the future.  If I don’t talk to you, Steve, have happy holidays, and I should probably mention this will be our last show until January, so everybody enjoy the holidays, whatever it is that you celebrate, and I look forward to seeing all of you in 2012.

Steve Wright:  Yeah, have a happy New Year’s party, and be safe up there in that -40 degree weather.

Chris Kresser:  Ha-ha, yeah.  Thanks.  Take care.

Steve Wright:  See ya.

The podcast is back! Only now it’s not a podcast, it’s a radio show (Revolution Health Radio), and we have a new host: Steve Wright. Everyone say “hi” to Steve!

We had a few growing pains on this first episode, so the audio is not quite as good as it normally is. We’ve got it ironed out now, though, so expect studio quality sound from here on out.

In the first episode of Revolution Health Radio (RHR), we cover:

• 1:17 How Steve, the new RHR host, came to be here
• 5:13 The latest study showing the concrete connection between chronic stress and the immune system
• 10:38 Can arguing with your significant other trigger inflammation and cause disease?
• 16:51 Recommendations for benchmarking your inflammation from chronic stress
• 21:18 The latest Fasano paper: could healing the gut prevent and cure autoimmune disease?
• 27:02 Why fixing leaky gut can stop and reverse autoimmunity
• 36:59 Will the latest intestinal permeability drug trial lead to Celiac’s eating gluten again?
• 44:12 How to overcome IgG food sensitivity to eggs and milk
• 54:07 The 3-step process for figuring out the right diet changes that work for you and your body… once and for all

Links We Discuss:

1. Study: Chronic Stress, Immune Dysregulation, and Health
2. Study: Leaky Gut and Autoimmune Diseases
3. Diabesity: The #1 Cause Of Death And Disease
4. 9 Steps To Perfect Health: Manage Your Stress

Full Text Transcript:

Steve Wright: Hello, 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’s it going today, Chris?

Chris Kresser:  Well, to be honest, I’m a little bit sick for the first time in a long time and this will be a good segue into one of the papers we’re going to talk about which is Effect of Stress on the Immune System but Sylvie’s been teething, she started teething pretty early. She’s only four months old but she is starting to get a tooth and for those of you who have kids, you probably what that means. I’m not sleeping very much. She’s just really kind of out of sorts during the night.

And then, my family was out visiting. I have like nieces and nephews and three or four of them were sick so both Sylvie and I got sick because I’ve been really run down and not sleeping and so I’m a good case study for this stress paper we’re going to talk about. Steve, why don’t you introduce yourself, tell everyone where you’re coming from, how you came to be here on this show and just let everyone get to know you a little bit.

How Steve, the new RHR host, came to be here

Steve:  First off, again, I want to thank you Chris for allowing me to have this chance to be your host. I think it’s going to be a great friendship that we’re going to build here and a great show. A little background on me, my friend, Jordan and I, we run a blog, scdlifestyle.com and the blog is dedicated to digestive problems and people who suffer with them.

Everything from bowel disorders, IBS, celiac disease, all those types of things. Jordan had celiac disease and I used to have IBS and we used a specific carbohydrate diet and supplements to really turn our lives around and our health around. And we feel really passionate about this subject and helping people and so we went ahead and created an E-book about how we did it and how people like us could turn their health around as fast as possible using this specific carbohydrate diet.

Chris:  Right. Let me jump in and say, for those of you, actually one of my patients the other complained to me that we throw all these acronyms around and talk about these diets and we just kind of assume that everyone knows what they are and a lot of people do but for those of you who don’t know, some of you may be familiar with the GAPS diet and the GAPS diet is very similar to the specific carbohydrate diet but they’re, they’re like Paleo but they completely remove starches so you wouldn’t eat sweet potatoes or plantains or things like that and there is more of an emphasis on fermented foods and bone broth particularly in the GAPS diet. So how long have you been doing that for, Steve?

Steve:  I started in January 2010 and previous to that I’ve been sick for five or six years. So since then, like you said, the GAPS diet and the SCD diet are very similar and Jordan and I have found out that along with Paleo and the starches that like you prescribe too, there’s no one diet for all. And so our take on the SCD diet really goes to the next level we think where we embrace the different things that the GAPS people have an emphasis on as well as some things like we’re not poopooing, no pun intended, starches or anything like that. But that we take the opinion that everyone needs to find their own diet. They need to test all foods and that everything should be subject to a test.

Chris:  Yeah, great. So we’re glad to have you, Steve and Jordan is our behind the scenes genius helping with producing the show and making sure everything’s running smoothly and so I’m really glad to have you both on my team. So why don’t we dive in? We’ve got some interesting stuff to talk about today. Actually, one of the studies we’re going to cover is related to the gut as most of my listeners know; it’s one of my favorite subjects, too.

So I’m going to talk about the stress paper that I mentioned especially because it’s front and center on my mind right now. The connection between stress and the immune system and then we’ll talk about the new leaky gut paper by Alessio Fasano who is one of my favorite researchers and real pioneer in the field intestinal permeability in autoimmune disease research. And if we have any time after that, we’ll get to some questions. I know I did a Facebook post listing questions but I decided that I really want to talk about these two studies. If we don’t get to some of the questions, we’ll get to them on a future episode. Sound good?

Steve:  Sounds great, man. I can’t wait to hear what you think about these studies.

The latest study showing the concrete connection between chronic stress and the immune system

Chris:  Alright. So let’s talk about this paper, the title is Chronic Stress, Immune Dysregulation and Health. I can’t remember where I came across, somebody sent it to me. Last week is all kind of a blur. Let’s start with the definition of stress. That’s actually the first line of this paper and I really like their definition of stress. I think it will people understand what I mean when I talk about stress because I mentioned it several times on my blog and the Nine Steps to Perfect Health series on the podcast.

I’m really trying to encourage people to take a broader view of what stress is because most people hear of stress and they think of psychological and emotional stress like financial problems or problems in a relationship or anything like that and of course, that is stress but stress is actually much more inclusive. The definition these researchers used was, “stress occurs when environmental demands exceed the individual’s capacity to cope.” So from that perspective, anything that throws the body out of its natural balance or homeostasis being the more technical term is a stressor. So an injury could be a stress, a chronic gut infection could be stress. You know, over training especially the wrong kind of training can be a stressor on the body which means you could have no cares, you could be independently wealthy and laying on a beach in Thailand with absolutely no psychological or emotional stress whatsoever but if you have a gut infection, you’re under stress. And I think that’s really important to understand when we talk about addressing stress.

The other thing is when you look at it from this perspective; there are two different types of stress. One is called eustress and the other is called distress. Eustress is the kind of stress that is actually beneficial which is the stress that encourages an adaptive response. So an example of that would be exercise if it’s done properly. Like if you go and you lift weights, that weightlifting tears down your muscles. But when your muscles grow back, they grow back a little bit bigger so that they can handle the next challenge and that’s an adaptive evolutionary mechanism. So that kind of stress can be beneficial because it helps us to grow and expand our capacities.

Distress is often chronic stress and this is the type of stress that directly affects our immune function via neuroendocrine and sympathetic pathways and over time, consistent activation of those systems can cause wear and tear on the body that researchers refer to as allostatic load. So you know often mild acute stress especially when it’s adaptive like with exercise is beneficial but it’s that chronic stress that can be so harmful to the body.

And in the paper, they review a number of impacts of chronic stress but one of the main impacts is inflammation. And that’s something of course that we talk about a lot as well but studies have shown that even acute psychological stress can reliably increase interleukin 6 levels, that’s a type of inflammatory cytokine and C-reactive protein which is an acute phase reactant, a type of protein that’s elevated in the inflammatory response and it’s pretty well known and pretty well established in the literature now that chronic stress is associated with chronic low-grade inflammation and that’s the type of inflammation that’s associated with nearly every modern disease like cancer, cardiovascular disease, diabetes, autoimmunity, obesity, etc.

And one of the best models for studying this, one of the most frequently used models in the literature is they look at caregivers. You know, people who are taking care of a partner who have Alzheimer’s or dementia or other degenerative disease because that’s just so, so stressful. And when they study the caregiving population, they find that they have often double or even triple the risk of mortality than age-matched non caregivers. And you know, they’ll study circulating inflammatory markers and find that they’re higher. Their CRP is often higher and this is just more evidence of the toll that chronic stress takes on the body.

Can arguing with your significant other trigger inflammation and cause disease?

There was an interesting section in the paper where they were talking about conflict and even arguing with your spouse or partner can wreak havoc on your immune system and there was this study on couples who engage in frequent hostile negative interaction, that’s the way they put it. These couples had much higher levels of interleukin 6 that inflammatory cytokine than less hostile couples.

And then another study showed that people with a frequency of interpersonal conflict in their daily life had higher levels of interleukin 6 and higher levels of CRP. So you know, the lesson there of course is be nice to your partner. You know, the interpersonal conflict which can affect us emotionally is affecting us physiologically. And most people know this already intuitively, right. It doesn’t feel good in your body when you’re angry or really upset but I think it’s helpful to have the mechanisms pointed out where people can make a concrete connection between emotional and psychological stress and real physiological mechanisms that are affected by that and that was kind of the point of this paper.

Because a lot of times when I talk to people about stress, I think what happens, everyone has kind of an idea and a real direct experience that stress causes physiological problems you know even just on a simple level, if someone has a fear of public speaking or even if they don’t and they have to you know get out in front of a group of people, they’re going to probably notice some kind of fluttering in their belly, you know. Some people actually experience pretty severe gastrointestinal symptoms if they have to speak publicly. There’s a really strong clear connection so people aren’t really surprised by this.

But I think now that we have a better understanding of the actual mechanisms involved and people can really understand what those mechanisms are, I mean, personally I’ve found that that’s helped me to take stress more seriously and to really pay attention to it and really elevate it to the same level and sometimes in some cases even higher than nutrition and a lot of the other things that we talk about because it’s really difficult in the modern world to work with it and it’s a lot easier to change the diet and to take supplements I think for most people than it is to really address these stress mechanisms.

So there were a couple of interesting things about this paper. We’ve talked previously on the show I think when we did gut-brain access podcast about the connection between chronic inflammation and depression and in fact, some researchers now think that there is a model of depression or study of depression called the inflammatory cytokine model of depression and some researchers really believe that depression is primarily mediated by inflammation.

But this paper was saying that there’s also evidence that it work the other way around that depression can cause chronic inflammation which in turn leads to immune dysregulation and the evidence for that is that among clinically depressed patients, treatment leads to a reduction of circulating inflammatory markers and then initial levels of depression like when they do prospective studies of people with depression, people who start out in those studies depressed end up having higher levels of circulating inflammatory markers.

And you know, prospective studies are observational in nature and they can’t really prove anything but it’s an interesting correlation and when you put it together with the fact that treating depression reduces inflammatory markers, there’s quite a lot of evidence to support that connection.

And then the last thing I want to talk about in this paper is that most of you know, I think, that cortisol is one of the main antiinflammatory hormones in the body. It’s part of the fight or flight distress response. When we’re under stress, the body makes cortisol and cortisol suppresses inflammation. That’s how it’s supposed to work, at least but studies have show recently that persistent exposure to high levels of cortisol during chronic stress actually down regulates cortisol receptors on cells. So this leads to cortisol resistance where the immune cells become nonresponsive to the antiinflammatory effects of cortisol. In a way, this is just like insulin resistance only it’s working with cortisol.

So the takeaway is that when somebody is under chronic stress, they’re almost certainly going to be chronically inflamed and if someone is chronically inflamed, they’re almost certainly going to have a poorly functioning immune system and that can manifest as increased susceptibility to infectious disease like cold and flu, case in point for me this week. Or it could manifest as autoimmunity which we’re of course seeing a huge rise in over the past couple of decades and there are a lot of reasons for that. I think nutrition certainly plays a strong role but we’d be kidding ourselves if we didn’t acknowledge the role that I think increasing stress of modern life plays in the rising incidence of autoimmune disease.

Recommendations for benchmarking your inflammation from chronic stress

Steve:  So Chris, I’m guessing as someone who wants to try to maximize their health, you wouldn’t want us to be rushing out and getting our IL-6 or CRP test that we should just assume then based on this paper that we all have some stress if we’re living in a modern world that we should probably be taking some steps.

Chris:  Yeah. Maybe you’re hearing Sylvie’s sound effects in the background there. She’s having a rough morning with this tooth coming in. Yeah. I think, I mean getting CRP measured can be useful. IL-6 is not very often tested in the clinical setting. You might have a hard time getting your doctor to order it. But CRP can be useful if anything else as a benchmark, you know, to see where you’re at. But if you’re under chronic stress, you can pretty much assume that you’re dealing with some inflammation and for all the reasons that I just mentioned. I don’t think it’s necessary to get a test to confirm that and yeah, I think it’s just a question of taking some steps to reduce the amount of stress that you have in your life if possible. It’s not always possible but there are some things you can do, even if you can’t really change the circumstances of your life, you can change the way you relate to those circumstances and that has a net effect of reducing stress.

And then you can also do things to increase your stress tolerance so that the stress that you are experiencing in your life doesn’t impact your body in the same way. And I outlined several of these things in the article on managing stress in the Nine Steps to Perfect Health series so if you go to chriskresser.com/perfecthealth, there is an index of all those articles and it’s the one titled, Manage Your Stress and there are several recommendations in that article for some of the things that you can do.

But interestingly enough, one of the most negative impacts of chronic stress and this is in the literature as well is that people who are under chronic stress will tend to adopt behaviors that can be damaging to their health or discontinue behaviors that could have protective health effect. So it’s one of those chicken and egg things or vicious cycles really where in someone who’s really stressed out says, “I’m too stressed out to do stress reduction.” No. or I’m sure you’ve all had the experience of we’re like really, really stressed or really upset, we might have craving for food that we wouldn’t normally eat or our diet kind of falls apart or whatever but that’s another reason why taking specific steps to manage that stress can be helpful because it puts us back in a kind of upward spiral instead of the downward spiral that chronic stress can often involve.

So I think that’s it unless there’s anything else you want to say about that, Steve.

Steve:  No, I would say that I know from personal experience that if I spend too long outside of the gym that I can almost feel that anxiety kind of creep back into my life and that I’ve also tried your recommendations and I really like the rest and digest program. I use some of those exercises on like a daily basis, like you know, five minutes here or there during the day and that seems to really help so…

Chris:  Yeah, I like that too. I think that you’re referring to the Rest Assured program, right?

Steve:  Oh yeah, the Rest Assured program.

Chris:  Yeah. Rest and digest might be a better name now, I like it. Yeah, so the Rest Assured program, you can get it at soundersleep.com, you can download the mp3s and it is really helpful. One of the things I like about it, in particular is that, like you said there are some techniques that can be done and as little as four or five minutes throughout the day and that really can just help keep the edge off even if you’re busy. Most people can find a few minutes during the day to do that.

Steve:  Four or five minutes? I only do it for two and I feel it.

The latest Fasano paper: could healing the gut prevent and cure autoimmune disease?

Chris:  So there you go, there you go. Well, cool. Let’s talk about, let’s dive into the Fasano paper. Yeah, like I said, he’s really one of my favorite researchers. I’ve read, I think, everything that he’s published and I was really excited to see a new paper come out, it just came out, I don’t know, 23^rd of November, I think. It’s called, “Leaky Gut and Autoimmune Diseases” and it was the clinical review of allergy and immunology. I just posted a link to it on Twitter, twitter.com/chriskresser this morning because I tweeted about it yesterday.

But, as I said before, Fasano is a bit of a pioneer in the field of leaky gut and autoimmune disease. He’s the one who’s really established in the scientific literature, at least, this connection between leaky gut and autoimmunity. And we’re going to talk about this more in more detail but I also wrote about this in my series on diabesity and the connection between the gut and diabetes and obesity.

But his view is actually that you can even develop autoimmune disease without a leaky gut and I’ll explain more about that in a second but first, I want to talk about some of the more conventional theories about autoimmunity or maybe I should say more traditional or recent views on autoimmunity because I don’t know that they’re actually conventional.

But early on after autoimmune disease was discovered, most people thought that they were associated with viral and bacterial infections and in fact there is a school of thought still today that believes that there is no such thing as autoimmunity and that all autoimmune diseases are actually infectious disease and infections that we may not be able to detect with our methods of testing it at this point.

Yeah, so there’s a whole group of people who believe that autoimmune disease does not exist and that all autoimmune diseases are actually infectious diseases and they may be infections that we can’t detect with our current method of testing. I think there’s a microbiologist named, Paul Ewald, I might be getting his first name wrong but I think that’s what he believes and there are a number of different groups that believe that.

But the connection between a non self antigen like bacteria or virus and autoimmune disease is often explained by a mechanism called molecular mimicry and it works like this, a microbial like virus or bacteria or a food antigen like gluten enters the body and then the immune system mounts an attack against it and produce antibodies but since the chemical structure of those non self antigens can be similar to proteins found in various tissues in the body, you get a cross reaction where as the body is attacking those non self antigens, it also starts attacking itself and it can attack the thyroid like in Hashimoto’s or Graves or it can attack the joints in rheumatoid arthritis or the myelin sheath in multiple sclerosis or the gut in inflammatory bowel disease and animal studies have confirmed that molecular mimicry is part of the autoimmune process.

But here’s the interesting thing, in human studies, it appears that molecular mimicry might be the effect rather than the cause of autoimmunity. So in other words, that molecular mimicry process that I just described is only a factor in the progression of preexisting autoimmune diseases. So that’s one theory, the molecular mimicry theory. And I would say that’s probably the most popular theory at this point.

Another theory of autoimmunity is called the bystander effect and it’s just similar to molecular mimicry. In this model, those non self antigens like bacteria or viruses directly damage the tissue in the body and the exposed parts of the tissue that shouldn’t otherwise be exposed and then the body attacks those parts of itself, of the tissue as if they were not self.

So I think the important thing to understand about both of those theories, the bystander effect and the molecular mimicry is that the idea is if you, even if you remove the trigger which could be a bacteria or virus or gluten, according to those theories, the autoimmune process will continue because the antibodies have already been produced and the body’s has already started attacking its own tissue and because of the way the immune system works, once the body starts producing antibodies then it won’t ever stop and that benefits us because for the most part, like if you get exposed to chicken pox when you’re a kid and you get exposed to that virus again later in life, you’re not going to get it.

And there could be 30, 40 or 50 years that pass but the body always remembers. But according to molecular mimicry model, that backfires on us when we’re dealing with this autoimmune process. But Fasano is proposing an entirely different theory of autoimmunity that involves leaky gut as a crucial element and he says that three preconditions have to be present for autoimmunity to develop and I covered this again in that article on the connection between the gut and diabesity.

Why fixing leaky gut can stop and reverse autoimmunity

Number one is that you have to have a genetic predisposition to autoimmunity. So some people have asked me, why my friend eats a really crappy diet even worse than I ever ate and doesn’t really exercise and is really stressed and he doesn’t have autoimmune disease but I have three autoimmune diseases, you know, what’s that about? That’s probably about genetics. There is a genetic predisposition to almost every autoimmune disease that has been studied.

Number two, there has to be an environmental trigger. So even if you have the genes, the genetic predisposition to autoimmune disease, without an environmental trigger, it won’t get activated and that’s, that can explain why even though our genes haven’t changed that much in the last 100 years, very little if any, there’s been this explosion of autoimmune disease. that’s because even though the genes haven’t changed that much, the environment has changed quite a lot and the environmental triggers now are happening all around us both in food and then in air and water, you know, by chemical toxins and those are triggering these genetic tendencies in the way that didn’t happen 100 even 150 years ago.

And then number three and maybe most important in Fasano’s model is that, you have to have a permeable intestine or a leaky gut or more specifically abnormal function of the tight junctions. So the tight junctions or TJs as they’re called, if you take your hands and you interlace your fingers, that’s what kind of what the tight junctions look like. I mean on a much smaller level. then if you open and close your hands so that you can create a little bit of space between your interlaced fingers and then you close so that’s there’s no space and nothing can get through, that’s kind of how the tight junctions are supposed to work. They selectively allow molecules to pass into the bloodstream that should be in the bloodstream like nutrients that we need and then they’re supposed to selectively prevent things from entering the bloodstream that we don’t want in our body like antigens, pathogens or large molecules that would provoke an immune response.

But what happens with leaky gut is that those tight junctions stop being able to make that distinction and they just permanently become a little bit open so things start passing through the gut like a sieve and that’s a big problem because one of the main purpose of the gut is to serve as a barrier that keeps things outside of the body that shouldn’t be in the body and lets things in that should be in.

So Fasano introduced us this trinity a while back and a lot of research supports it. we know that celiac disease and type 1 diabetes, MS, rheumatoid arthritis, Crohn’s and several other autoimmune diseases have all been associated with leaky gut that allows the passage of these antigens from the intestinal flora into the bloodstream and this then challenges the immune system to produce a response that can target any organ or tissue in people that are genetically predisposed. So the significance of this is pretty huge because if it turns out to be right, it implies that contrary to those popular theories of autoimmune disease like molecular mimicry and bystander effect, the autoimmune response can theoretically be stopped and then even reversed if the interplay between genes and environmental triggers is eliminated.

Let me use an example to explain what I mean. Celiac disease is actually a perfect example of this because we know what the genetic factors are, the HLA-DQ genotype. We know what the environmental trigger is which is gluten and its many subfractions and then we know that celiac is characterized by a leaky gut. So I just mentioned gluten and its subfractions.

I want to take a little side tangent for a second and talk about that. one of the sections in the paper that really stood out to me and I talked about this in my first article in the Nine Steps to Perfect Health Series, Don’t Eat Toxins but you know, it used to be thought that it was just pretty much gluten that caused problems and now we know that the repertoire of gluten peptides that are involved in disease is a lot bigger than we previously thought and in this latest paper, Fasano says there are at least 50 different toxic epitopes in gluten peptides that have been shown to destroy cells, dysregulate the immune system and cause leaky gut.

So when we’re talking about the proteins in wheat, we can talk about gluten, gliadin, deamidated gliadin and then even with gliadin, there are different epitopes like alpha, beta, gamma and then we have wheat germ agglutinin or WGA. There are just a number of proteins that can cause problems like destroying cells and destroying tissue in the gut.

So back to what we were talking about before, zonulin is a protein that was recently discovered. It regulates the tight junctions and Fasano has talked a lot about this in his research. And we know that zonulin is overexpressed in people with autoimmune diseases like celiac so the more zonulin they have, the more leaky their gut is.

It basically works likes this, if someone with celiac eats gluten or gluten intolerance and then they get an increase in zonulin production and then that increases inflammation, inflammatory cytokine production and then tight junctions in the gut open, you know like those interlaced fingers open and allow passage of antigens from the gut into the blood and then the body mounts an immune response and then you get an inflammation in the gut and everywhere else.

But as Fasano explained, this process can be completely reversed in people with celiac if you remove gluten from the diet. So when you take out the environmental trigger which is gluten, you see a decrease in zonulin levels, you see that the intestinal barrier function which is supposed to keep things out and let the right things in is restored. Antibodies drop and the whole autoimmune process shuts off and then even after that, the intestinal damage, if you take away gluten for long enough, repairs itself completely.

It kind of leads to the question, is this a cure? Does this mean that autoimmune disease can be cured? I guess the answer to that depends on what you mean by cure. It doesn’t mean that a person with celiac can go eat you know a pizza and get away with it but it does mean they can live a normal healthy life if they order that interplay of genes and environmental triggers.

Unfortunately, in the case of other autoimmune diseases, the trigger isn’t quite as clear. We know that gluten can exacerbate and even trigger other autoimmune diseases by making the gut permeable in that framework that we’re talking about. If you have a genetic predisposition, environmental trigger like gluten and then leaky gut, you can develop autoimmune disease and not just celiac, a bunch of the other ones that I mentioned.

But, what I can say, you know, in my practice, in my experience working with patients is that removing gluten often helps but it doesn’t always completely resolve the condition as it would in celiac, you know, where you see that decrease in antibodies and repair of tissue and everything else. And in some cases like in Crohn’s, the trigger is not something that can just be easily removed because the trigger in Crohn’s is thought by a lot of people to be the commensal gut flora or the normal gut flora and the body is essentially mounting an autoimmune response to its own gut flora and it’s pretty hard to remove that since it’s a normal part of the body. You can’t really fully sterilize your gut unless you live on antibiotics and there are obviously a lot of reasons not to do that.

Will the latest intestinal permeability drug trial lead to Celiac’s eating gluten again?

But one interesting thing in this paper and I’m always naturally skeptical of drugs until I really see research that shows that their safe because do no harm is always the first principle of medicine even though that’s often forgotten but there’s a drug that they’re trialing right now. It’s in phase 2 clinical trials, it’s called larazotide and this is a zonulin inhibitor so, you know, zonulin as I mentioned is the protein or the substance that interferes with tight junction function.

So larazotide, they’ve done a proof of concept inpatient study. It was double blind, placebo controlled. It took two groups of patients with celiac and they gave them gluten. I mean, I’m wondering who signed up for this study, like, I have a lot of celiacs and man, when they eat gluten, it’s painful to watch what happens and the reaction can go on for a long time. So bravo to whoever signed up for this in the name of science or maybe they gave them a good financial reward or something.

But they took these two groups and they gave them gluten and one group was on a placebo and the other group was given larazotide. And in the control group, as you would expect, there was a 70% increase in intestinal permeability with the exposure to gluten so no big surprise, right? You give a celiac gluten and they get a leaky gut. But the big surprise was that in the larazotide group there was absolutely no change at all in intestinal permeability.

So they fed these celiacs gluten and the people that were taking larazotide did not develop leaky gut and furthermore, although they had some GI symptoms from eating the gluten, they were a lot less than the control group that was taking placebo. So you know my philosophy on medicine is whatever works and causes the least harm and in most cases that’s not a drug but in some cases like low-dose naltrexone which I’ve talked about a lot and thyroid hormone medication that can sometimes be, it can sometimes be a drug and perhaps larazotide will be that for autoimmune disease, I don’t know. It’s certainly worth following and I’ll be following it over the next couple of years.

I don’t think it will be, if they’re only in phase 2 trials, it’s probably going to be a few years before that medication would make it to the market and there have been a lot of drugs that have never made it out of phase 2 or phase 3 trials because of unanticipated side effects because you’re messing with function of the body that we don’t completely understand. We still don’t really fully understand zonulin and what it does and how it does what it does. So it’s still to me a little bit scary to be taking a drug that inhibits zonulin production without fully understanding that but I will mention that in the study, there were no adverse effects compared to placebo in the larazotide group. So it seems to be well tolerated at least in the very small study.

It was, I think, where is the sample size? I don’t remember the exact sample size but it was small, I think 14 patients or something like that. So we definitely would need to see a bigger study that was powered to better detect whether there would be adverse effects versus placebo and whether the drug effect was real or just, you know, consequence of chance.

Steve:  That’s really encouraging. I just feel bad for the people who are going to be involved in the next phase of the, 200 to 300 people that are on the placebo.

Chris:  Right. I mean, it certainly does present an ethical problem. I mean, it’s not as serious as some of the studies that were done in the past, you know, where they, and even recently where you had studies continuing where you know part of the drug treatment arm is you know, they’re dying at a much faster rate but yeah, that’s some serious discomfort. I don’t have celiac but I have a lot of patients that do and I guess you would know, Steve, that that’s not fun.

Steve:  Yeah. From the people I’ve talked to, you’d have a hard time signing up anybody who’s lived in a symptom-free life to try that study so…

Chris:  Yeah. So I guess there are people that probably haven’t found the GAPS study or the specific carbohydrate diet and they’re probably pretty desperate.

Steve:  Do we know anything yet as far as what increases or decreases zonulin like stress or supplements or anything?

Chris:  I mean gluten certainly increases it but, no, not that I know of at least. And I think probably inflammation is likely to do it. I mean, we know that inflammation causes a leaky, contributes to leaky gut and that chronic stress contributes to a leaky gut and we know that zonulin mediates the tight junction function so we could surmise that chronic stress and inflammation probably have an effect on zonulin which in turn causes the intestinal permeability but I’m not aware of any papers that have directly studied that. Nor do I know about any supplements that have an effect on zonulin one way or the other.

But interesting line of thinking, I have to look into the larazotide and what exactly it is and what it does and it will be interesting to think about other ways of accomplishing the same thing without using a drug.

But certainly, the basics that we always talk about are the starting place. Take out the toxins from your diet, eat nutrient-dense food, manage your stress, you know, make sure you’re doing all the things you need to do for a healthy gut like eating fermented food and possibly taking probiotics if you need and then making sure you’re getting enough sleep and you’re exercising and you’re having a good time in your life. That’s always the starting place, you know, and this stuff that we’re talking about here is for the people who’ve already done all that stuff and they’re still struggling and the same is true for low-dose naltrexone when we talk about that. I never suggest that someone just goes right to low-dose naltrexone and without doing all the other stuff that we’ve been taking about first.

So I think that’s it. It didn’t take quite as long as I thought so we may have time for a couple of questions.

Steve:  Well, I’m looking at a question here that I think might really follow up those studies well and give you a chance to talk for a little bit longer if you want to go into one of those.

Chris:  Let’s dive in.

How to overcome IgG food sensitivity to eggs and milk

Steve:  This one comes from Lana from Facebook and it’s, “how can one overcome IgG allergies, for example, eggs and milk? Thank you.”

Chris:  Yeah, I think this is related for sure. First of all, I think a lot of people who have been listening to this show for a while know what my opinion is about IgG food allergy testing. I think it’s not ready for prime time. It’s been shown in experiments like my colleagues and I drawing our blood, labeling two different vials with two different bogus names and sending them to the same lab and getting completely different results. If you look into the scientific literature, there’s not really any support for IgG food allergy testing.

However, if you have an IgG food allergy and it says you’re allergic to eggs and you eat eggs and you feel horrible, well, that’s, you know, I’m not going to debate that but I’m more into paying attention to the symptom that you have when you eat eggs. Let’s just assume that someone has, well, let me step back again. I assume by IgG allergy they mean intolerance because if it’s a true allergy where, you know, you eat eggs and you have an immediate hypersensitivity reaction or anaphylaxis or something like that or the type of allergy that you can have to shellfish or peanuts or strawberries in certain people, I’m not sure that there’s that much that can be done about that.

If we’re talking about food intolerances where you eat eggs and you feel bad but you’re not like headed to the hospital, you know, with your life at stake, then I think this really falls into what we’ve been talking about all along. I think most food sensitivities are caused by leaky gut. That’s why I’m always a fan, an advocate of healing the gut and instead of, you know, continually removing more and more foods from your diet until there’s nothing left to eat because that’s just dealing with the symptom. The symptom is the intolerance to these particular foods but the cause is the leaky gut or the gut dysbiosis or gut infection or some combination of all three of those which is usually the case.

So, milk is a little, it’s a little more complicated because are we talking about pasteurized milk or raw milk? Are we talking about actual milk or are we talking about fermented dairy? Are we talking about full-fat dairy like cream or butter or ghee? As I talk about in the Personal Paleo Code, there’s a really, really big difference in all of those dairy products and if someone is sensitive to dairy, you have to ask are they sensitive to the casein which is the protein or are they sensitive to the lactose which is the sugar or are they sensitive to both?

If they’re only sensitive to the lactose then they should be able to tolerate dairy products that have very little lactose like ghee has no detectable lactose. Butter has very, very little lactose and if the ratio of fat to protein and sugar and butter is like 80 to 1. And then if you do homemade fermented dairy like they recommend in the specific carbohydrate diet and in GAPS where you ferment your own yogurt for 24 hours, you can pretty much get rid of the lactose in it. If you make kefir, you ferment for long enough, you can get rid of the lactose almost entirely so even people who are lactose intolerant can often deal with long fermented dairy and some of the full fat dairy products.

If someone is sensitive to casein, the casein protein then they’re going to have problems with nearly all dairy except for maybe ghee because ghee in theory doesn’t have much detectable casein either and whether somebody can overcome that or not, I would say that depends. Some of the most recent research about the effect of probiotics suggests that the real benefit does not come from restoring or repleting the number of probiotic organisms in our gut because really, most orally consumed probiotics are only putting a tiny little dent in the total number of probiotic organisms that we have in our gut.

But the recent thinking is that the probiotics are modulating the microbiota, the intestinal flora and they actually change the milieu in such a way that we can begin to digest foods better and we can even begin to digest certain foods that we haven’t been able to digest before and that explains why, and so our gut flora is somewhat adaptive and like for example we know that people who live in coastal areas in Japan, they have different gut flora than people who live maybe in the mountains in Europe. And they have different gut flora because they eat different foods and they require different bacteria to break down those foods.

So for example, there’s a type of bacteria that’s really helpful in breaking down the nutrients in seaweeds that the people in coastal Japan eat a lot so they’re bound to have a lot more of that bacteria and maybe if you took someone who is living in the mountains in Europe and they went in coastal Japan and tried that much seaweed, they wouldn’t be adapted to eat it. They wouldn’t be able to process it as well as someone who has that genotype or that, in this case, the intestinal microbiota to handle that.

Art Ayers who writes a blog called Cooling Inflammation has posted some interesting research in the past and theorized that some people who eat fermented dairy can cure themselves of lactose intolerance over time because they can change the gut flora in such a way that they become able to process fermented dairy or just dairy in general. But I don’t know if that works the same way with casein. Most people in my practice who are casein intolerant pretty much stay casein intolerant. You know, maybe other people have had other experiences but that’s just been my experience so far.

Steve:  I know that I used to have a big problem because I tried making the SCD yogurt, the 24-hour fermented yogurt when I first started the diet and I did it with goat’s and cow’s and either of those were raw milk. They’re just store bought organic stuff. And it took me a really long time. I had this postnasal drip for a really long time and it wasn’t until I had seen an allergy specialist who was like, have you ever tried just not doing any dairy for seven days or something like that?

And so it turned out that’s what it was and so doing that. And then I did have a Candida infection that I got rid of but after that, I am able to eat dairy again including, you know, even the crappy kind, not the raw stuff.

Chris:  Right, right. So I mean, it’s hard to say what you’re reacting at that point but I definitely think that that’s possible and I think that that’s probably mediated to some extent by the way that the bacteria in the dairy are modulating your own intestinal microbiota. And I do see that a lot. I mean that’s true in my experience, too. When I first started the GAPS diet way back, I’m not doing it anymore, but this is during my more therapeutic phase, I could only tolerate like a half a teaspoon of kefir and I would notice it, I would really feel it. And then it was a teaspoon. And now I could drink two pints of it and feel great and not noticing any negative effect at all. So there’s definitely some change that happens in the gut with that but usually you have to go, start really with a very small dose and proceed really slowly over time.

And it’s still optional. It’s only if you want to eat dairy. I think it’s a healthy food when it’s well tolerated and it’s got a lot of, you know, fat-soluble vitamins and things that can be hard to come by otherwise but there’s certainly no rule that you have to eat dairy. If you’re happy without eating dairy then proceed.

Yeah. I think we’ll stop there. There are several more questions but I’m going to give my voice a little bit of a break this week and we can come back to these questions in another episode.

The 3-step process for figuring out the right diet changes that work for you and your body… once and for all

Steve:  Okay. Well that brings us to the end of this week’s show, Chris. Do you want to tell us a little bit more about the Personal Paleo Code launch and how that’s been received?

Chris:  Oh yeah, sure. So I finally got that out. I see it was a couple of weeks ago now. Personal Paleo Code, for those of you who don’t know about it is a program designed to help you discover your own ideal diet instead of following a canned approach, you know, this is designed for everybody. And it was borne out of my experience working with patients, most of whom were totally confused about diet and even within the context of the Paleo community; there are a lot of disagreements. I don’t think they’re big disagreements but you know, Robb Walsh might say this and I might say that and Mark Sisson says that and you know, somebody else says a different thing.

The whole premise of the Paleo Code is just to stop listening to all of us and follow this three-step process that I use with my patients in my practice to figure out what works for you and your body once and for all so you don’t have to spend your evenings with Paleo hacks trying to figure it out anymore.

You can go to personalpaleocode.com. It’s been really well received. I had a lot of great feedback which of course feels good because I worked really hard on it. The meal plan generator in particular has been really popular. That’s a web app that allows you to generate highly customized meal plans using only the ingredients that you want. So for example, if you’re on the GAPS diet, you can just hit a button and it will bring back only GAPS recipes or if you’re on autoimmune Paleo diet, you can exclude nightshades and dairy and eggs and get a meal plan that only has recipes that don’t contain those ingredients.

It’s been a lot of fun and yeah, if you’re interested, go check it out, personalpaleocode.com.

Steve:  Alright. I want to thank everyone for listening this week. Keep sending us your questions at chriskresser.com and you can use the podcast submission link to do that. If you enjoyed listening to the show, head over to iTunes and leave us a review.

I’m very sad to say this is Danny Roddy’s last show. The next episode will have a new host, and a new name – we’re finally switching over to Revolution Health Radio.

In this “Goodbye Danny Roddy” episode we discuss:

• Is it possible to be healthy if you don’t eat a Paleo diet?
• What might cause gastritis after starting a Paleo diet?
• How can I reduce iron overload without drugs?
• Is there any evidence to support “food combining” principles?
• Should a Paleo diet cure rheumatoid arthritis?
• What’s a good alternative protein source for people who can’t afford grass-fed animal products?
• Is adrenal fatigue real?

Full Podcast Transcript:

Danny Roddy: Hello everyone and welcome to the Healthy Skeptic Podcast. I am Danny Roddy of DannyRoddy.com and with me is Chris Kresser, health detective and owner of ChrisKresser.com. Chris, I am sad to say but this is my last podcast with you ever.

Chris Kresser: Danny! Say it ain’t so! Yeah, we’re gonna miss you.

Danny Roddy: It’s been real. I’ve enjoyed every second it. But yeah, I think it’s time for me to move on from the popular Paleo paradigm.

Chris Kresser: You only really care about hair.

Danny Roddy: For the listeners, if anybody has ever been to my website they’ll quickly realize that I am obsessed with hair loss. So I just feel like, you know, I am short-chaining the show and I am not so interested at what Paleo men ate and I know you aren’t either, Chris. I am not even interested in looking at nutrition from an angle anymore. I am really just interested at what diet provides relief from hair loss and if that diet includes tree bark then it includes tree bark.

Chris Kresser: Hmm, yummy! When is your big book coming out? You are going to give us a real date this time, right?

Danny Roddy: I am super excited to announce that it will be out November 28th.

Chris Kresser: Wow, just in time for the holidays. Grow your hair back. Good timing.

Danny Roddy: Exactly.

Chris Kresser: Well, we’re going to miss you, Danny. I know a lot of people wrote in to say they are sad that you are leaving. I am definitely sad you are leaving. I wish you luck in your endeavors. We are all waiting for “Hair like a Fox”with bated breath. So, how about sending me a free copy? Do I get some kind of benefits like that at least?

Danny Roddy: I am going to send you a signed digital copy.

Chris Kresser: Ok. Piracy-free.

Why are some people finding success eating non-Paleo?

Danny Roddy: Ok, that kind of leads us into your first question. Let me bring it up for a second. This one is from Darius and he asks “Chris, everyone wants to know your thoughts on why some people are finding success with non-Paleo eating such as Don Matesz and Ray Peat?”What do you think about that, Chris?

Chris Kresser: I am not surprised that people find success with non-Paleo eating. I have a lot of friends who are really healthy and don’t eat a Paleo diet. Could they be healthier if they ate Paleo? Maybe, it’s hard to say unless they actually did. I am not so myopic in my approach to think that the Paleo diet is the only way that somebody can be healthy, the only approach to nutrition that`s valid. I just think that in my experience it happens to be the best starting place for most people. That’s really, you know I hope I have not given the impression that I am really, really dogmatic about the Paleo diet, because what I advocate is not even technically Paleo. I think dairy, particularly grass-fed, fermented, full-fat dairy is really healthy when it is well tolerated. I think white rice is pretty well tolerated by a lot of people, sourdough buckwheat, you know that recipe for those buckwheat pancakes, which I eat a couple of times a week. I am not technically on a Paleo diet, but Paleo is just a convenient term for describing the template or the basic set of guidelines that I think are an appropriate starting place for most people. It does not surprise me at all that other people follow other approaches and are healthy. I think there is a lot more to health than diet as I have tried to communicate on my blog in the 9 Steps to Perfect Health series, we often talk about that on the show, things like stress management and pleasure and movement and exercise, spending time outdoors, taking care of your gut health, a lot of this stuff is in some cases just as significant as a contributor to health and in some cases even more. I think we talked about the beer and pizza story a while back.

Danny Roddy: Good story!

Chris Kresser: So, great! I am all for Don for doing whatever diet works for him. I might take issue with some of the kind of anti-Paleo posts he has been doing lately. Not because I feel offended by it, but because I don’t agree with his interpretation of some of the research that he has presented. I don’t really take part in those debates, because I think it’s a waste of time. Generally, I am just happy that Don has found a way that works for him. Anybody that finds something that makes them feel good and works for them, that’s great. I will add one caveat though, which is time will tell, you know, how this goes for Don. You know I was a vegan at one point and I felt great for a little while until everything just went off the rails. So who knows, who knows?

Danny Roddy: So you are not going to take issue with my tree bark diet?

Chris Kresser: Tree bark and low-fat ice cream and OJ? As long as you wash it down with OJ and low-fat ice cream, I won’t take issue with it.

Gastritis after starting a Paleo diet?

Danny Roddy: So do you want to go to the next question?

Chris Kresser: Sure. Let’s start from the top.

Danny Roddy: Ok, this one is from anonymous. Gastritis after starting a Paleo diet. And that’s what, irritation to the gut lining?

Chris Kresser: Yeah this was a question that we said we answered in a previous podcast, but neglected to. Or at least I put it in the show notes and I guess we did not get to it and there has been a few requests to talk about it. So any -itis is inflammation, right? So anytime you see -itis after a root that we’re talking about inflammation of that part and –gast, G-A-S-T, we are talking about the stomach. So the basic interpretation of that, it is a generalized term and it is often used very generally but it means inflammation of the stomach, inflammation of the stomach mucosa, often associated with ulcer, but not always.

So the question as I recall was “Why would someone get gastritis after starting a Paleo diet when they did not have it before?”There are a few possibilities; I just give you my impression. The most honest answer is I don’t know for sure. It’s a case-by-case basis. Some of the things that I would think about and look for would include stomach acid deficiency. If you don’t have enough stomach acid and you eat a lot of protein, like people do on a Paleo diet, especially if they are switching over from like a vegetarian diet, which a lot of people do. A lot of my patients that I talk to, it’s a very familiar story that someone was a vegetarian or a vegan and they switch to a Paleo diet. So you take someone who has been eating almost no animal protein, certainly no meat for a significant period of time, their stomach acid production might decline, because stomach acid is required to digest protein and if they are not eating a lot of protein and things that require stomach acid production, perhaps their stomach acid will decline and then they start eating those things and those proteins don’t get digested well in the stomach and they putrefy. God, I love that word. And that putrefaction can potentially irritate the stomach lining and cause gastritis. So that’s one possibility. Similar possibility would be people who have issues with fat digestion. Maybe a sluggish gall bladder and they are not breaking down fats as well as they should be and again this is common for people who are coming from a low-fat, whole grain “heart-healthy”approach and they start eating a Paleo diet with loads and loads of fat and then they get stomachache and feel terrible. That often to me can be a sign of problems with fat digestion. Of course one way to test that out is to just for a few days eat a higher carb, lower fat Paleo diet, with a lot of starchy tubers and more fruit and less fat and see how you feel. Another potential issue depending on what kind of Paleo diet somebody is eating, one thing that seems to be gaining in popularity is raw food Paleo, where people are eating a lot of raw meat. The truth is there is a risk to eating raw meat. There is a risk to eating any food, but eating raw meat there is a risk of getting a pathogen, especially if your gut flora is already compromised in some way, or your stomach acid is low and you are not able to defend against pathogens like that. So those are three possibilities, they are the most likely ones but there are others too.

Donny Roddy: I ate some two-month-old raw eggs and I had to go home from work.

Chris Kresser: Ouch!

Danny Roddy: I broke them into the glass like I do every morning and they smelled really weird.

Chris Kresser: So why the heck did you eat those things?

Danny Roddy: They were pastured so I did not want to waste them. I was like Ajonis does this every day, you can do it one day. And I did. I got to work and I felt really, really loopy.

Chris Kresser: Oops. Yeah, there are consequences to our actions.

How do I handle iron overload without taking drugs?

Danny Roddy: Ok, that was good stuff. Ok, This next one is from Felix. This is a Facebook question. “I would like to know about handling iron overload without taking drugs.”We have already talked about this a little bit but why don’t you expand on that, Chris?

Chris Kresser: Yeah, I am just getting fascinated with this topic. I know I am moving a little more slowly than normal on the blog series. I am going to write about this a big series, because I am involuntarily becoming somewhat of an expert in it, just simply because I see it all the time. This week, for example, I had three patients with probable hemochromatosis. That seems really high. You know, I see patients for twenty hours a week, which is a lot less than other practioners, because I want to have time for research and writing and doing this podcast and, you know, continuing to stay current with the scientific literature. But three patients in a week with this genetic disease and that’s kind of an average for me. I am surprised if I go a week where I don’t see it and in the vast majority of cases people don’t know that they have it. And they are often relieved to find out, because they are suffering from a lot of different problems and nobody has been able to figure out why and they feel like they are going crazy. Even though it’s no fun to learn that you have a genetic disease it is at least a treatable one and it gives you somewhere to focus your attention and there is some explanation to make sense of how you have been feeling. So, I will write a lot more about it, but I will just answer this question briefly. The only two ways to get rid of excess iron are bleeding and chelation. So chelation involves taking substances that bind to iron and other minerals and carry them out of the body. So with bleeding you really only have one practical option. I suppose you could do a more low-tech approach but I would not recommend it. You donate blood and if you don’t have a diagnosis of hemochromatosis then you’ll have to just do it through the normal channels like Red Cross. You can only donate blood every 56 days and that’s a precaution to keep people from bloodletting themselves to death or making themselves anemic by doing it too frequently. So most people who don’t have aggressive iron storage condition like hemochromatosis if they donate blood they will lose between 50 and 100 units of ferritin. So if your ferritin is 300 and you are trying to get it down to 50, for example, usually that will take, depending on the person, maybe three blood draws over a period of time. The second route, which is chelation, I don’t really recommend especially not without medical supervision. The drugs that are used for chelation are actually some of the more toxic and risky drugs there are. They are definitely not desirable. There are some natural substances that can be used to chelate iron like lactoferrin and our good friend phytic acid. So here’s another case where something that we talk a lot about minimizing in the diet can actually be helpful in a therapeutic situation. But that needs to be managed too, because if you take things like that without doing it right you run the risk of eliminating several other minerals that are important to your health in addition to iron. But there are a couple other things to be done from a nutritional or dietary perspective, there are some substances that increase the absorption of iron and some things that decrease the absorption of iron. So the things that increase iron absorption are alcohol. Bad news for people with iron overload. Alcohol does it quite significantly. Supplemental Vitamin C. So the amount of Vitamin C in foods is in most cases negligible, so you don’t have to worry too much about that, but taking Vitamin C capsules or pills will increase iron absorption. And HCL, stomach acid, betaine HCL (hydrochloric acid) that pretty dramatically increases iron absorption. So if you have iron overload, you want to avoid those things.

And the things the decrease iron absorption are tannins, so coffee and tea, black tea, particularly the ones, the teas that are higher in tannins. So if you are eating red meat, if you are someone who has a gradual tendency to accumulate iron and you want to mitigate that somewhat you can drink coffee or black tea with meals that contain more iron, like red meat. And then there is phytic acid. Phytic acid is in as many of you know grains and nuts and seeds, but it’s also pretty high in certain greens, leafy greens. So if you don’t want to eat grains, which can cause other problems that are not related to their phytic acid content, you might want to just stick with a supplemental form of phytic acid, but again I recommend doing that with supervision so you avoid other mineral deficiencies that that could cause. So that’s basically it. Yeah, I just want to caution people not to go overboard here, it is probably best to work with someone on this stuff. There are a lot of different considerations. We talked about this last time. Elevated ferritin doesn’t necessarily mean excess iron. It can mean systemic inflammation. You want to make sure not to get your ferritin too low, because then you are running the risk of anemia. So just exercise caution, folks!

Danny Roddy: I have a mini story about this. So, my ferritin was about 150. I had it measured about a year ago. And I went about four times and we won’t talk about how I was able to do it that many times.

Chris Kresser: Please do not!

Danny Roddy: Yeah, do not do that. But now my level is 30. So that means each time I went, it reduced my iron status by 30ng/dl.

Chris Kresser: So what did you notice in that whole process if anything?

Danny Roddy: Absolutely nothing. I can’t say I have seriously noticed anything.

Chris Kresser: Yeah, so that’s a good example. I mean, before everybody runs out and starts going to different Red Cross offices and trying to donate blood. Ferritin at 150 is very borderline, meaning it very well could not be a problem at all. There is no guarantee that getting it down to 30 is going to do anything significant for you, especially if you did not have any symptoms of glucose intolerance or any problems with that before, which I don’t think you did.

Danny Roddy: No.

Chris Kresser: All right, let’s move on.

Any science to food combining?

Danny Roddy: Next question. This one is from another anonymous. “Food combining –any science to it”

Chris Kresser: Well, they weren’t anonymous to begin with, but I forgot who they were, so now they are anonymous.

Food combining –any science to it? In a word, no. Does that mean there is nothing to it at all? I don’t think so. I mean I have some patients who have difficulties eating fruit after meals. They find that, you know, maybe the digestion of protein takes a bit longer than the digestion of fruit. So if they eat fruit on top of a heavy meat meal, they experience some gas and bloating. So as with everything the key is to experiment and see if you notice any difference, but I have looked several times over the years for any evidence that would support the food combining principles that are often talked about and I have never really seen any. Have you?

Danny Roddy: I have never, oddly enough, in the long time I have been doing this gotten into food combining.  I feel like some foods have a natural synergy with other foods, like what we were talking about, like Vitamin C will increase iron absorption. So you will probably not want to eat oysters and fruit together.

Chris Kresser: Big glass of OJ.

Danny Roddy: So stuff like that makes sense to me, but I don’t know in other contexts, I guess. Like meat and fruit. I don’t do that normally.

Chris Kresser: They are talking about, I mean that’s another issue, there are lot of different theories on food combining. Some of the main ones are don’t eat carbohydrates and protein together.

Danny Roddy: Oh ok.

Chris Kresser: So if you are going to have a meal, I guess you would just have protein and fat separately and carbohydrates in a different meal. That sort of thing. I have never seen anything to support that and number two it does not make a lot of sense, because most foods have some combination of fat, carbohydrate and protein in them, right? So why would we lack the capability of digesting those macronutrients together if they are present in nearly all foods? That to me is the most damning argument to that whole theory.

Danny Roddy: And fat increases the absorption of all the other nutrients?

Chris Kresser: Absolutely! All right.

Will I ever get off meds on Paleo?

Danny Roddy: Coolio. This one is from Kathy, this is another Facebook question. “Sometimes I feel like a failure in the Paleo community when I hear about folks getting off meds with rheumatoid arthritis. Even with strict Paleo, good sleep, exercise, low stress, and meds my joints hurt. Is it as easy to get off meds as it appears?”

Chris Kresser: Sometimes and sometimes not. Again, this is a really personal thing. I feel like a broken record often times on these podcasts and I think that’s ok, because obviously this is a messages that really needs to get repeated and to sink in. A disease like rheumatoid arthritis, even though it has a name there is a risk there of saying “Oh, ok I have got rheumatoid arthritis. That means I am in the same exact situation as somebody else is that has rheumatoid arthritis.”The reality is there is a lot of variability from person to person with even the same autoimmune disease name; I mean each person has different genetics, they have different constitution, different life history, different life circumstances. The list goes on and on. There are a lot of key differences and the way that even the same disease will manifest in different people is really different. I mean, Crohn`s disease in some people produces fulminant diarrhea, like fifteen watery, bloody bowel movements a day to the point where these people have to be hospitalized and get a section of their intestine removed. On the other hand, some people with Crohn`s disease have no diarrhea, never have had diarrhea and actually have constipation and their symptoms are very mild. They have never been to a hospital for it, they don’t even take medication and, you know, maybe in those two cases there is not even a real big difference between what they eat. So diseases really are heterogeneous and it differs a lot from person to person. So it’s impossible to compare oneself to somebody else and say, “Yeah, I am doing all this stuff right and I still am struggling while someone else is doing all that and they are able to get off their meds.”It’s not your fault when that’s the case. It just means that you have a more intense or difficult expression of that disease in many cases.
So, some things that Kathy could consider, one would be low dose Naltrexon. We’ve talked about it on the show a lot. It’s amazingly effective for many autoimmune diseases. It promotes T regulatory cell function, which has an immune balancing effect and especially if you have tried all of this other stuff and you are not getting any results, I would seriously consider that. There are a lot of other things you can do to support T-reg cell function nutritionally with supplements and botanical medicine. Probably at this point it’s a good idea to get some help with someone who is experienced with this sort of thing so that you can make some more progress. But it’s definitely not your fault. There are a lot of different ways that these conditions manifest and it’s really not helpful to compare yourself to other people in that regard.

Danny Roddy: This kind of illustrates how I felt sometimes. If Kathy feels like a failure in the Paleo community, I am sure she is strict with her diet, she says she is strict with her diet, I mean just for comparison and I am not saying for anybody with arthritis to go do this, but like Pete loves aspirin or pure aspirin for arthritis conditions.

Chris Kresser: Yeah, I know where you are coming from. I have my own issues with aspirin over the long term, it’s one of the most toxic drugs to the liver, but what you are saying is by sort of carrying the belief that Paleo diet is the end-all be-all that heals everything magically, then maybe she is not considering other options that would be helpful. And I agree and I have tried to stress that before, the Paleo diet can be magic in a lot of cases in the sense that people who go on it, some people experience a seemingly miraculous improvement in a lot of their symptoms. But that does not always happen. I have a practice full of patients that proves that it does not always happen, because the vast majority of people who come see me are already on a Paleo diet. My patients are people who read my blog and listen to my podcast, they are already following a lot of the recommendations that I make in those venues. So it’s not your typical Standard American Diet people coming to me, they are already on a Paleo diet and yet they are still having a lot of problems. So the existence of my practice is proof that the Paleo diet is not a panacea. So the sooner people ditch that idea, the better. Again that doesn’t mean it can’t be magical for some people, but if you find yourself doing it and you are not getting the results that you would expect then it does absolutely make sense to do further investigation.
Is that like the anti-Paleo episode, huh?

Danny Roddy: So we both agree that aspirin is a great thing to take? Just kidding.

Chris Kresser: Gobble it down.

What’s a low-budget alternative to Grass-Fed Beef, Fowl, Fish, and Eggs?

Danny Roddy: Next question is from Monika. “What do you consider a good alternative protein source for people who are on a budget and cannot afford grass-fed meat, fowl, fish and eggs every time? What about quinoa that has been rinsed, soaked and cooked properly?”What do you think Chris?

Chris Kresser: Well the first thing I would say is that although I think grass-fed and pastured meat and animal products are superior to conventionally raised animal products for a number of different reasons, I don’t believe that it’s either grass-fed or pastured or nothing at all. I guess it depends on what you are basing that decision on. Some people for political, economical, social reasons won’t buy conventionally raised animal products and ethical reasons and I can certainly understand that and sympathize with that. But if you are purely basing this on nutritional factors, conventional animal products would be the best alternative to grass-fed animal products and particularly if you know how to cook and prepare cheaper cuts of meat, you can get really nourishing protein and fat sources without spending a lot of money. So for example even grass-fed, pastured organ meats tend to be very cheap. Grass-fed liver around here, even at Whole Paycheck, is four bucks a pound.  That’s Whole Foods by the way for anyone who does not know. Four bucks a pound, which is pretty darn affordable. Then you have oxtail and brisket and some of the cheaper cuts of beef. You can get chicken parts and make broth, you can get beef bones and make broth, you can get fish heads and make fish head soup. Those are all really, really deeply nourishing foods and they are pretty cheap. So with some creativity and learning how to prepare the cheaper cuts of meat, which tend to be tougher and require longer cooking methods, you can still eat animal products without breaking the bank.
Quinoa does have some of the food toxins that we are trying to minimize by not eating grains. It is not technically a grain; it is one of the pseudograins.

Danny Roddy: It’s a superfood, Chris!

Chris Kresser: It’s a superfood, right. I have just noticed that a lot of people, particularly with gut issues, have problems with quinoa. It’s very fibrous and it seems to irritate the gut even when it’s prepared properly. If you do well with quinoa and you have tested it, you have tried doing without it and added it back in and you do really well and you feel good, then go for it!

Danny Roddy: I don’t digest that stuff at all.

Chris Kresser: No, I don’t do well with it either and a lot of my patients don’t. So I would definitely urge you to pay attention to that if you are testing it out and as I said the protein that you get from even conventionally raised animal products will be superior in terms of its digestibility and assimilability and amino acid profile to what you get from quinoa.

Is Adrenal Fatigue Real?

Danny Roddy: Cool. This next question is from Arnbor from Facebook. He asks or she asks “Is adrenal fatigue real?”And I am assuming they are talking about low cortisol.

Chris Kresser: Yeah, so you hear adrenal fatigue, adrenal stress, adrenal insufficiency.

One of the best ways to be the target of scorn is to go into your doctor and tell them that you have adrenal fatigue. They will look at you like you are some crazy whack job and they will try to start leaving the room as soon as possible. The truth is whatever you want to call it, it is real. If you look into the scientific literature, for example, the adrenal stress hormone profile that you can get from Diagnostix and BioHealth and some other labs where you test your cortisol rhythm throughout the day, that is now being used by specialists who treat Alzheimer’s and dementia as a prognostic tool to determine how quickly they expect somebody to degenerate. So the extent to which the cortisol rhythm is off, is predictive of how quickly someone’s hippocampus is going to fall apart and the reason that is, is because the hippocampus is responsible for regulating the circadian rhythm, the cortisol/ melatonin rhythm. This is actually being used by high-level clinicians that are kind of on the forefront of treating Alzheimer’s and dementia.
Cortisol is a really important hormone. Danny’s buddy Ray Peat talks a lot about the importance of this hormone. I have talked a lot about it. I see cortisol dysregulation a lot in my practice. I see people suffering from it and when we take steps to fix that and we fix it, people feel better. That’s enough for me to be convinced that it’s real and like I said there is plenty of research supporting this. I think a lot of doctors just are not aware of this research just like they are not aware of the research that shows that cholesterol alone is not the cause of heart disease. There are a lot of people who self-diagnose with adrenal fatigue and it’s pretty easy to do that because a lot of the symptoms are non-specific and they may have adrenal fatigue but they may have something else. There is a little bit of a gray area, but it’s absolutely real and it’s absolutely something that needs to be treated.f

Danny Roddy: How many of your patients are completely flatlined? Do you see that often, like not just their circadian rhythm is off but if it’s just low across the board?

Chris Kresser: Low? No, I don’t see that that often actually. I way more often see problems with rhythm than I see absolute low or absolute high production of cortisol and I do this test pretty regularly, so I see a lot of them. The rhythm seems to me more important and more sensitive to problems than the adrenal production of cortisol and that’s interesting, because as I said the rhythm is controlled by the brain not by the adrenals themselves. So technically you could say that that is not an adrenal problem, it’s a brain problem. A lot of the conventional approaches to treating adrenal fatigue ignore the brain and the importance of addressing the brain and that may be why they are not as successful as some would like.

Danny Roddy: Do you find that, I heard this on Robb Wolf’s podcast a long time ago and I don’t know why I never thought about it, but even like food allergies can cause major adrenal stress, just because if you are consuming an allergen you are going to secrete a lot of cortisol to face the inflammation.

Chris Kresser: Absolutely, anything that promotes inflammation will cause a decline in adrenal function and the list of those things is very long.  So really kind of anything that throws the body out of homeostasis can affect the adrenals, which means that anybody who has any kind of long-term chronic illness or like you said allergies, food allergies, anything that is throwing the homeostasis off is affecting the adrenals. So I think and in my experience adrenal issues are very, very often secondary to other problems, meaning they are not the underlying cause of those other problems, they came second but once adrenals get involved, then there is a vicious cycle where adrenal fatigue will make all of those other problems worse and then all of those other problems getting worse will worsen the adrenal fatigue.

Danny Roddy: Cyclical.

Chris Kresser:  Yeah.

Danny Roddy: Ok Chris, that’s going to bring us to the end of this week’s episode. Where can we find more of your work on the Internet this week?

Chris Kresser: Oh man. That’s is the end?

Danny Roddy: This is the end of the road.

Chris Kresser: Only the beginning Danny…of your new chapter.

Danny Roddy: …of a better life for you.

Chris Kresser: Yeah, I am hoping it should be ready on actually the day that this podcast goes live or close to it. Sure you guys have heard me talk about it if you have been listening the last few podcasts. It’s called the Personal Paleo Code. It was born out of a lot of the discussion that we have had on the show, Danny, about the fact that there just really is no one size fits all approach when it comes to diet. My work with patients over the last several years, I’ve developed a process for helping people to figure out their own ideal diet instead of just relying on a canned approach, no matter how good that canned approach is, how good a starting place that approach is. So it’s a three-step process. The book or the program is me guiding you through that process in the same way that I do with patients in my clinic. I have also included tons of resources to make it really easy for you to figure this out and implement these changes. I have got over ten guides, special guides, on subjects like bone broths, nuts and seeds, fats and oils, even kitchen equipment that you might need, how to make salad dressings, you know there is a lot of schwaggy ingredients in commercial salad dressings, Paleo friendly sauces and condiments. I have got a progress-tracking app because that’s really important as you move through these various steps. When you move from one step to the next is predicated on how you are progressing. So you use the progress-tracking app, which has a questionnaire that you fill out each week on all kinds of symptoms that you are trying to deal with and it automatically plots your progress on a chart so that you can see it visually, which is really cool. One of the things I am most excited about is the meal plan generator, which is a web app that you get access to as part of your purchase of the Personal Paleo Code; you get a 60-day free trial to this meal plan generator. It’s really cool.
My wife and I have been using it a lot, the beta versions. So you log in and you can decide exactly what foods you are including or excluding. Let’s say that you are trying an autoimmune Paleo diet and you want to exclude nightshades, eggs and dairy. It can be really frustrating and hard to find good recipes for that because, you know, obviously not everyone is doing that. So you have to either know how to modify the recipes yourself or just be always doing a lot of research to find those recipes. So what you can do with this tool is you just check off the foods that you want to exclude and then you hit a button that says generate a meal plan for either a single meal or one day or a week and it will query the database, we have got over 450 recipes in there, all Paleo type recipes and it will bring back only the recipes that don’t include the ingredients that you have chosen to exclude. So you can exclude dairy, you can exclude nightshades, eggs, concentrated sweeteners. There is a ton of different criteria. Then there are these quick plans where if you just want to generate a plan that is commonly followed, like there is one for strict Paleo, there is one for GAPS-friendly, there is one for a 30-day challenge like Whole 30 type of program. Once the meal plan shows up, you can print the meal plan, you can click on the individual recipes and go the recipe page and print them out, you can print a shopping list, you can save the recipes to your favorite section. I am super excited about that, like I said my wife and I have been using it a lot. It’s been really cool, like last night we had some ground beef and we were kind of tired of the ways we have been normally cooking it. So we went in there and we just searched for beef and we got, like nine or ten recipes showed up for ground beef, different ways to prepare it. So we had a little, I forget the name of it, it’s an Indian dish, it’s like ground beef with a particular Indian spice mixture. It was really yummy.

Danny Roddy: Does the product ever glitch out and tell you to drink orange juice with collagen?

Chris Kresser: Yeah, I’ve got the Danny Roddy quick plan in there actually. It says…Breakfast: low-fat ice cream and OJ. Lunch: crushed eggs shells and wait, what else is in there for lunch?

Danny Roddy: Oh, Gummy bears too.

Chris Kresser: You got to help me out with it, because I wasn’t sure.
So anyways, this is going to be ready, you can check it out PersonalPaleoCode.com. We are doing a special deal for podcast listeners and blog readers and people in my very cool inner circle. So make sure to take advantage of that if you like saving money.
I think that’s it, Danny.

Danny Roddy: That’s it? Let me go through my spiel. Keep sending us your questions at ChrisKresser.com using the podcast submission link. If you enjoy listening to the podcast, head over to iTunes and leave us a review.
Chris, it’s been amazing, thank you for everything, thank you to all the listeners. I’ve had so much fun doing this and you’re the man. I appreciate everything. I ‘ll miss you and everybody.

Chris Kresser: Danny, we’ll miss you. You have been a great co-host. I appreciate all the free work you have done on this show and helping us build it up to the audience. Numbers are growing and growing; I think you had a lot to do with that. We are going to miss you for sure, hope you stay in touch with us. Come back and heck less about fructose and orange juice and stay in touch!

Danny Roddy: Thank you, Chris.

In this episode I answer frequently asked questions about digestion, covering topics like parasites, stomach acid, the GAPS diet, SIBO and more.

Questions include:

• How to differentiate between a gut infection and food sensitivities?
• How to boost your HCL production
• Can strengthening the immune system take care of parasites?
• When to call it quits on the GAPS diet
• Is FODMAP sensitivity permanent, or can it be treated?
• What causes digestive reactions to carbohydrates?

The next podcast will be our last with Danny. We’ll make it a good one!

In this episode we discuss the following topics:

• A recent study demonstrating that low cholesterol is associated with higher risk of death in women
• What truly normal blood sugar levels during pregnancy are, and cut-offs for pre-diabetic and diabetic women during pregnancy
• Whether there’s any science behind breaking weight loss plateaus by adding carbs back in the diet
• Best practices for people with Hashimoto’s
• Why there has been such an explosion in food sensitivities, celiac disease and leaky gut
• The connection between diet and body odor
• Recommendations for moderate to severe ulcerative colitis

Please note that in the next few weeks, the name of the show will be changing. It will be called “Revolution Health Radio”, with Chris Kresser. There’s nothing you need to do. You’ll just notice that the graphic and show name are different at some point.

In this “Grab Bag Q&A” episode of the podcast, I discuss the role of nutrition in healing, obstacles to optimal health, macronutrient ratios and more.

Questions include:

• Do you feel with the right nutrition the body is capable of healing itself?
• In your practice, what do you find to be the biggest barrier stopping people from reaching their optimal health?
• Should I eat low-carb, low-fat, or do macronutrient ratios not matter?
• Do you have anything you could teach on the problem of developing gastritis AFTER going paleo?
• Does the food combining theory have any scientific merit?

As part of the recent re-branding of the site from The Healthy Skeptic toward Chris Kresser, I will also be changing the name of the podcast soon. I haven’t settled on a name yet, but keep an eye out for the change.

This week we’re glad to welcome Chris Masterjohn back to the show. Chris joined us on Episode 11 to discuss the role of cholesterol in heart disease, and to dispel the many myths associated with those subjects. There was so much to cover, we had to have Chris back for part 2 (and in fact, we still didn’t cover all of the material so he’s going to come back for part 3 in the future!)

In this episode, we discuss (among other things):

• what is a “normal” cholesterol? what can anthropological studies tell us about this?
• are lipoprotein particle size tests accurate? what’s the best way of determining particle size?
• why do some people have high cholesterol (TC & LDL) after adopting a Paleo/WAPF diet? is this something to be concerned about?

Enjoy the show!

In this episode Dr. Paul Jaminet answers reader questions, including:

• Thoughts on the role of chronic infections in disease?
• How to distinguish between fungal and bacterial infections?
• What causes depression and how to treat it?
• Are essential fatty acids actually essential?
• How to treat acne when diet isn’t helping?
• What to do if you don’t tolerate coconut oil?

We loved having Paul on the show and I’m sure you’ll enjoy the interview.

In other exciting news, one of our listeners, Jeff Rothschild, has generously agreed to transcribe the podcast! He has already completed a few, and I’ll be adding them to the show notes soon as PDF files. So make sure to check back every now and then if you’re interested!

In this episode, we discuss the diagnosis and treatment of andropause (a.k.a. “manopause”) from a holistic perspective.

Topics include:

• Basic physiology and pathology of andropause
• Can vasectomies contribute to early onset of andropause?
• The best non-pharmaceutical approaches to preventing andropause?
• Blood and saliva markers for andropause
• What role libido/erections play in determining health?
• Should andropause be accepted as a normal physiological process in aging males?
• Is a “beer belly” and are “man boobs” signs of andropause?

Full Text Transcript:

Danny Roddy: Hello everyone and welcome to the Healthy Skeptic podcast. My name is Danny Roddy and with me is Chris Kresser, health detective and creator of thehealthyskeptic.org, a blog challenging mainstream myths about nutrition and health. Chris, I missed you  last week, how are you doin buddy?

Chris Kresser: Yeah we missed you Danny, I don’t know if you had a chance to listen to it but it was a lot of fun.

DANNY RODDY: I did Emily is truly amazing I really enjoyed the episode.

CHRIS KRESSER: Yeah she is a popular guest too, we got a lot of comments saying best podcast ever so, we’ll have to have her back for sure.

DANNY RODDY: Awesome how’s the lady? how’s the forthcoming baby?

CHRIS KRESSER: Both good as far as I can tell, there’s a fully formed baby in there, so it could be any day, could be today. Could be two weeks from now we really don’t know but we’re sort of making predictions just cause it’s fun. And my prediction is two or three days before the due date which would be like the 14th or the 15th, but it’s just a wild guess I have no idea.

DANNY RODDY: It could be during this podcast.

CHRIS KRESSER: Who knows? Stranger things have happened; you’ll forgive me if I have to stop in the middle of it. How about you, what’s happening?

DANNY RODDY: Nothing new as I told you I just moved, but really keeping busy with summer school, and that’s pretty much it.

CHRIS KRESSER: That’s biology now?

DANNY RODDY: Yeah biology, taking some general ed classes like english and communications. I’m really lucky I get to take these accelerated classes which are in my opinion way easier, so I’m getting it all done super fast since I didn’t do it when I was doin the whole band thing.

CHRIS KRESSER: Nice, glad you got out of that stupid nutrition program.

DANNY RODDY: Yeah that was, well I sat in the back and didn’t raise my hand anymore and that kinda solved the issue.

CHRIS KRESSER: Right. Alright so today’s topic is everybody’s favorite topic man-o-pause.

DANNY RODDY: Man-o-pause, best topic ever.

CHRIS KRESSER: Otherwise known as male menopause or andropause, if we wanna get technical.

When does Andropause (a.k.a. “manopause”, male menopause) strike?

DANNY RODDY: Chris, beginning question does this hit men at any age? A certain age? Or do you see men all across the board with this?

CHRIS KRESSER: It certainly can happen earlier rather than later, it’s not typical to see it in the early twenties  but it can, and we’re gonna cover why that is. Man-o-pause, just to back up a little bit in case some of our listeners don’t know what man-opause or andropause is, it’s basically a slow, usually a slow but steady reduction of the production of testosterone and dihydrotestosterone, which are the main androgens, or male hormones. And then the consequences of that reduction, which is usually associated with a decrease in leydig cells in the testicles. So man-opause, as you hinted is a little bit different than menopause in this way… In the case of menopause there’s usually a pretty dramatic and abrupt shift that happens in female hormone levels. Any woman that’s gone through menopause and experienced it in this way will tell you how abrupt and dramatic it could be. But the changes that happen in make reproductive hormones are often but not always more subtle. And they tend to occur more gradually through life. But as with menopause these changes can have pretty serious implications. For example, I know we talked about this before but the ten most common causes of death in males are heart disease, cancer, accidents (or unintentional injury), stroke, lower respiratory diseases, diabetes, fluid pneumonia, suicide, kidney disease, and Alzheimer’s. And when you look at those ten causes it’s pretty clear that andropause can play a role in nearly all of them if not all of them. So it’s definitely a serious problem and I haven’t seen any solid data on this but just anecdotally, having been in practice for a while and even back into my student days, it seems to me that I’m seeing more men with these complaints. What do you think? I know because of the work with hair loss and since that’s a major symptom of it you must see some of this too.

DANNY RODDY: Totally,  I think it really becomes apparent when people at work I’m like known as the health guy, and as you know I think people are really willing to share information with you that they wouldn’t otherwise. So people always say I have digestive issues or I have  no libido, and I don’t know if I’m just privied to that information but it’s definitely something that happens commonly.

CHRIS KRESSER: And I’m seeing it more in younger guys at this point too. In their thirties and forties, and even some in their twenties. We’ll talk a little bit more about how that could be possible and it will make a lot of sense once we get into the patterns. But before we do that I wanna talk a little but about basic male hormone physiology, because it’s important to understand how that works in order to really get the mechanisms that occur when things go wrong.

The basic physiology and pathology of Andropause

So, male hormone production and any hormone production, male or female, involves the hypothalamus in the brain and the pituitary, and in the case of males involves the testicles and in females it involves the ovaries, and too a lesser degree in both the adrenals. So the whole process starts with gonadotropin releasing hormone or GnRH, which is produced in the hypothalamus. And then at the level of the pituitary GnRH stimulates the release of FSH, follicle stimulating hormone and LH which is luteinizing hormone. And then it kinda breaks off in two different directions. LH acts on the leydig cells in the testicles which produce testosterone. And then that testosterone is converted into dihydrotestosterone which is a downstream metabolite of testosterone that’s about ten times more metabolically active. The enzyme 5-alpha-reductase is involved in that conversion and we’ll come back to that late because one of the pathologies of man-opause involves that enzyme. In the other pathway FSH acts on the sertoli cells in the testicles which produce sperm. So keep in mind that the production of testosterone depends on precursor hormones like 17-hydroxyprogesterone, pregnenolone and DHEA, all of which can be depleted in the stress response and diverted into cortisol production. So for example if you’ve got too much stress, that can deplete these testosterone precursor hormones and lead to lower levels of testosterone and we’ll talk more about that later too.

It’s also important to understand how hormone regulation works in general in the body. It’s a negative feedback system so  one analogy I like to use is, you can think of the pituitary gland as a control tower and it basically sits up in the brain monitoring hormone levels in the blood. And if a hormone level is low, for example if testosterone is low, then the pituitary will pick up on that and it will increase the production of the stimulating hormone, in this case LH that acts on the leydig cells to produce more testosterone. On the other hand if testosterone were high then you would see a decrease in LH, so that the testicles would produce less. And that’s basically how it works with any hormone in the body and it’s a really exquisitely controlled and regulated system and there are still parts of it that we don’t really understand that well. So it’s important to keep that in mind because when we talk about things like testosterone replacement therapy or hormone replacement therapy, one of the issues with it is that it disrupts that carefully orchestrated natural regulation and the negative feedback system and we’ll talk more about that as well.

DANNY RODDY: Chris are you saying I can’t balance the delicate symphony that is the hormonal system with testosterone cream?

CHRIS KRESSER: That is what I’m saying, we’re gonna talk a lot about this but I do also wanna say that there are some cases where testosterone replacement is helpful and so I’m not saying there’s no place for it and it’s never beneficial, I’m just saying it certainly should not be the first thing that somebody tries and I’m also suggesting that it really depends on the mechanism. You need to figure out why testosterone levels are low and then address the particular mechanism, otherwise it’s just a band-aid solution and of course as you’re implying and we’ve already talked about you can end up causing more problems than you’re trying to fix.

So let’s about five main patterns of man-opause, so these are like five, at least as far as I’ve seen in my practice and in the literature these are five typical presentations of man-opause. So number one would be over-conversion of testosterone into estrogen via aromatization. As you know, males should be androgen dominant, or testosterone dominant, and if a lot of testosterone gets converted into estrogen then all kinds of problems ensue. One interesting thing is that in males, testosterone is actually protective against heart disease, whereas in females estrogen is protective against heart disease. So in males when they become estrogen dominant, they become more susceptible to heart disease. And I think that’s actually one thing that’s not really talked about very often in terms of these increasing rates of heart disease is this pattern of man-opause and how that is contributing to the increased risk of heart disease. And women it’s the opposite, when women convert too much estrogen into testosterone which is common with PCOS and caused by insulin resistance, then their risk for heart disease goes up.

DANNY RODDY: Is  there a known mechanism for how testosterone protects the heart?

CHRIS KRESSER: There probably is but I can’t tell you what it is. My sense of it is just that, again there’s such a delicate balance of hormones in the system and hormones regulate so many different processes and if that goes out of whack then pretty much everything can go out of whack along with it.

So number two would be increased production of sex hormone binding globulin which then leads to low levels of free testosterone. So in order to get this we need to explain a little more about how hormone regulation works in the body. Generally when hormones are produced by the gland that produces them, they are attached to a carrier protein. That’s because hormones are not water soluble or soluble in the blood they’re fat soluble. So in order to be transported through the blood they need to be attached to a protein carrier. In the case of thyroid that carrier is thyroid binding globulin, but in the case of sex hormones it’s sex hormone binding globulin. However in order for the hormone to become biologically active and act on the tissue or the cell it needs to be cleaved from that carrier protein. Once it becomes cleaved from that carrier protein it’s then referred to as free hormone. Once testosterone is cleaved from sex hormone binding globulin it becomes free testosterone. So this is why you hear people emphasize the importance of testing free hormone levels rather than just the protein bound hormones. Because protein bound hormones, it’s still important to test that because that’s what tells you how the gland is functioning. Protein bound hormone levels tell you how much of a hormone that the gland is actually producing. But it’s also important to test the free levels because that tells you how much of the hormone is actually biologically active. So in this pattern that we’re talking about here you get an increased production of the carrier protein sex hormone binding globulin which if you follow, the more carrier proteins you have the less free testosterone will be left over to act on the tissue.

DANNY RODDY: Bad news.

CHRIS KRESSER: Bad news, no fun. So pattern number three is leydig cell failure, so the leydig cells that produce the testosterone have failed or are not functioning properly, and then you’ll get an elevated level of LH because of that negative feedback system we described earlier where leydig cells are not producing testosterone, the levels of testosterone are low as a result, and then the pituitary picks up on that and it cranks up the level of luteinizing hormone in order to stimulate more testosterone production. But because the leydig cells aren’t working well they don’t get that memo, or they become insensitive to it in the same way that cells can become insulin resistant. So the pituitary is shouting at the testicles and the leydig cells telling it to produce more, but it can’t hear that message. So, that’s usually secondary to inflammation, which we’re gonna talk a lot more about.

Pattern number four would be up-regulation of 5-alphareductase which is the enzyme that coverts testosterone into dihydrotestosterone. And that can lead to an increase production of dihydrotestosterone which can cause problems like benign prostate hyperplasia, BPH, and as of course you will know Danny, it can cause hair loss.

There’s another pattern which would be a down-regulation of 5-alphareductase which is less common where you see elevated levels of testosterone or elevated or normal testosterone but low levels of DHT. And since DHT is so much more potent than testosterone in its metabolic effects, low levels of DHT can lead to some of the symptoms of hypogonadism or andropause.

DANNY RODDY: Chris, this is a wild guess but is it true that the more DHT one has the more beard and auxiliary hair they usually have? To my understanding DHT is responsible for a lot of male characteristics like beard growth.

CHRIS KRESSER: Yeah I think so. I mean we probably all have that guy who we grew up with who got a beard when he was in fifth grade. I won’t name any names but if anyone here we went to school with is listening to this show they’ll know who I’m talking about. Poor guy got a pretty hard time but seriously he could go into a liquor store and buy beers when he was in sixth grade. But yeah I think he had some extra DHT floating around in his system.

So pattern number five is chronic stress, which depresses pituitary function. Depressing pituitary function can leads to decreased levels of LH and FSH which of course are the stimulating hormones that tell the leydig cells and the sertoli cells to produce testosterone and sperm. So this is one of the mechanisms by which stress can not only cause andropause but can cause infertility because if you a decrease in sperm production that’s obviously not gonna increase your chances of conception.

So now let’s talk a little bit, those are the five main patterns but the obvious question is what causes those patterns to happen, what are the main mechanisms that lead to those patterns and this of course is gonna inform how we deal with them. So the first one is insulin resistance and keep in mind as we talk about each of these mechanisms, in most cases each mechanism contributes to most, if not all of the five patterns we just talked about. And it’s sort of a cycle, so the mechanism, like insulin resistance, will cause one of the patterns and then one of those patterns contributes to some of the other patterns and then you get into that whole downward spiral thing. So insulin resistance and low testosterone have been shown in several different studies to occur together in diabetic men, they were associated, because insulin up-regulates the production of aromatase. We talked about this in that first pattern the over-conversion of testosterone into estrogen via aromatization. So aromatase is the enzyme that converts testosterone into estrogen. So what happens is when you have elevated insulin, or insulin resistance, you get an increase in that enzyme aromatase and then you get an increased conversion of testosterone into estrogen. Now elevated estrogen levels increase the production of sex hormone binding globulin. And as we just discussed that will decrease the level of free testosterone. And a third way that insulin resistance mucks everything up is that it of course contributes to weight gain. And we know now that adipocytes, or fat cells from body fat, release interleukin-6 which is an inflammatory cytokine that contributes to man-opause in several different ways and we’re gonna talk about that next when we talk about inflammation. And then finally insulin resistance also triggers the release of GnRH and so hypogonadism could be the result of insulin resistance that’s occurring at the level of the hypothalamus.

Okay so now let’s move on to the next mechanism which is inflammation. Interesting thing about this, as I said, is all of these things start to interrelate and it becomes a really nasty viscous cycle so if you’ve read my series on di-obesity you know that insulin resistance can contribute to inflammation and inflammation can contribute to insulin resistance so keep that in mind as we talk about this stuff. So inflammation can reduce testosterone production several different ways. Inflammatory cytokines can alter the growth and differentiation of leydig cells. And it can also inhibit the production of testosterone by leydig cells at the transcriptional level of the steroidogenic enzymes. I know that was a mouthful… So in other words inflammation suppresses the transcription  of enzymes which are needed to produce testosterone. And then inflammation can cause testicular resistance to LH, which is what we were just talking about before when I was saying how the pituitary is shouting at the testicles to produce more sperm or testosterone but the testicles can’t hear because they’re resistant to LH. It’s the same phenomenon as insulin resistance or thyroid hormone resistance.

The third main mechanism is stress. And again, stress can lead to elevated cortisol levels we’ve talked about this ad naseum, lots of different times. Cortisol levels when they’re elevated disrupt blood sugar regulation, and that can lead to insulin resistance. We know that calorie restriction, like long term dieting, and poor sleep have both been shown to alter the secretion of GnRH and LH, which in turn would decrease testosterone levels. I saw a study where daytime testosterone levels were decreased by 10-15% in young men who were otherwise healthy who underwent a week, just a week, of sleep restriction to five hours per night. So that’s a condition that 15% of the U.S. working population experiences, is either working the night shift or working a late shift so they can only get five or six hours of sleep per night and in just one week of that testosterone levels were decreased by 10-15%. Now compare that to a decrease in testosterone levels of 1-2% per year which is associated with normal aging, that’s a pretty big difference. And these men, the symptoms we’re talking about here are things like low energy, reduced libido, poor concentration, increased sleepiness, and then more significant stuff like increased risk of heart disease, increased risks for dementia and alzheimer’s which we’ll talk about in a second, and pretty much all of the major causes of death that we talked about before.

So the last thing I wanna talk about before we get into prevention and treatment and some of the questions, is testosterone and the brain, and the relationship between the two. So in addition to the stuff that we just covered, low testosterone can also alter mood and memory and the ability to concentrate. And this is why loss of testosterone is associated with dementia and Alzheimer’s. On the other hand, when you have decreased blood flow to the brain and activation of the microglia which are the immune cells in the brain, and microglia activation of the brain equals inflammation of the brain. That can in turn suppress the function of the hypothalamus and the pituitary and lead to low testosterone levels. We know that long term elevations of LH which occur in testicular resistance, which is again secondary to inflammation, can promote degeneration of the hippocampus and the hippocampus is the part of the brain affected, and degenerated in alzheimer’s and dementia. The hippocampus also controls cortisol rhythm and so this is another viscous cycle that you get into where you get an elevation of LH that degenerate the hippocampus, the hippocampus controls cortisol rhythm so then you get a disturbed cortisol rhythm which causes more stress and more inflammation which leads to further degeneration of the hippocampus and we’re off to the races.

One interesting too, is that a lot of recent research suggests that erectile disfunction in men is generally not an endocrine problem, it’s not a problem with hormone regulation as much as it’s a vascular and neurologic problem. So what’s happening is there’s not enough blood flow to the peripheries and that’s what’s causing the erectile disfunction rather than a hormone imbalance. And a couple recent studies that I saw suggested that erectile disfunction may actually be the first sign of systemic vascular disease, or cardiovascular problems in other words erectile disfunction might be an early indicator or early warning of future cardiovascular complications because of the relationship with blood flow there.

Okay so let’s just talk a little bit in a general sense about prevention and treatment because that’s all we can really do without, I always harp on this but it’s really different for every individual because each individual is gonna have a different presentation with different mechanisms, different patterns, and it’s really important to identify what those patterns are to create the most effective treatment. And that’s why I’m never comfortable just saying go out and take tribulus, or gymnema or this because it’s kind of a shotgun approach that might work if you happen to be one of the people where your LH is decreased and that’s the mechanism and tribulus increases it you get lucky but if you’re not it’s not gonna help and at worse it can cause harm.

The best non-pharmaceutical approaches to preventing Andropause?

Let’s talk a little bit, I know we’ve already covered this but let’s talk again about why testosterone replacement isn’t the best place to start. We talked about the whole negative feedback system earlier in the podcast, and what happens then if you take a testosterone cream, you rub it on your skin, there’s a few things there. Number one, I explained earlier that the body has a really complicated way of determining hormone balance. And beyond that, it decides in a way that we don’t fully understand yet, when to cleave the free hormone from its protein carrier and make it active to the tissues. So the body orchestrates that process in a way that we don’t understand and what happens when you take testosterone cream is that’s free testosterone in that cream. So it goes right into your blood, into your tissues and into your bloodstream as free testosterone. So the body has no ability to regulate how much free testosterone is available to the tissues when you take the cream because it just enters the tissues in the free form. The body has no choice about cleaving it from a protein carrier.

So that’s problem number one. Problem number two, which is the more general problem is that as the levels of testosterone rise in the tissue, because of the negative feedback system the pituitary will produce less LH and FSH to try to compensate. But because it’s not the glands that are producing that excess hormone it’s coming from outside of the body, the decrease in LH and FSH doesn’t really have any affect. And you often see a further decrease in LH and FSH as the body scrambles to compensate for the increased testosterone levels. Now that means of course that you’ll have decreased internal production of testosterone, and then what happens in any case where there’s excess hormone floating around is that the cellular receptor sites for that hormone will become down-regulated. It’s a smart way that the body has of protecting itself from too much hormone exposure. So not only do the receptor sites become less sensitive to that hormone, like testosterone in this case, you’ll actually see a decrease in the overall number of receptor sites on the cell. And then what happens at that point is that you’ll need to take more testosterone cream to get the same effect, because you have fewer receptors and the receptors you do have are less sensitive. And then the LH and FSH continue to decrease which means you’re producing internally less and less testosterone and so over time a guy who’s on the cream might need to take more and more to have the same effect, keep increasing the dose and then at some point they just might give up, it’s not working anymore, and then they stop the cream. What do you suppose happens then?

DANNY RODDY: A world of hurt.

CHRIS KRESSER: Exactly. Because when they stop the cream they have fewer receptors, the receptors they do have are totally insensitive, and their LH and FSH are completely depressed from all of the time on the cream so they’re not producing any of their own hormone. And when I see this in my practice I tell people honestly this is gonna suck. You’re gonna be in a world of hurt for a few months as we deal with the situation and there’s no way around it unfortunately. I actually don’t take people off cold turkey because of this, I usually try to titrate them off over time. But inevitably there’s a period where we remove the external support and the internal production is not caught up yet. But the good news is that receptor sites can come back, so once the body figures out that there isn’t any excess in the tissues anymore then the LH and FSH will start to come back and the internal production of the hormone will start to come back and then the number of receptor sites will increase and the sensitivity of the receptor sites that exist will increase. So it is reversible in many cases.

DANNY RODDY: Would you put a number on that for how long that takes for a gentlemen?

CHRIS KRESSER: I definitely would not.

DANNY RODDY: I know it’s different for everybody but a couple of months? or…

CHRIS KRESSER: Months yeah. Months, it’s a function of how long they’ve been on the cream of course, and then how down-regulated their receptors and LH and FSH are. But in general I would say that the transition period is at least two months and maybe somewhere between two to four months. It’s not like there’s nothing changing during that time there’s a gradual shift happening but it can be difficult for those couple of months for sure.

So what else can be done? If not TRT, or testosterone replacement therapy, what can we do? Of course the answer depends on first identifying the underlying mechanism that’s always more than half the battle. Which pattern is it? Is it aromatization? Over conversion of testosterone into estrogen? Is it inflammation, is it stress, all of the above? And then of course once you figure out what that pattern is you’ve gotta address it at that root level. If it’s insulin resistance you’ve got address glucose tolerance and blood sugar regulation, insulin sensitivity. If it’s inflammation you need to look first of course at diet, are there food toxins in the diet that are contributing to inflammation, is there over-training happening, is there some other cause of inflammation like a chronic infection that hasn’t been identified. You’ve gotta look at stress and sleep, which I think in seriously probably 90% or maybe 95% of cases of andropause stress and sleep deprivation is running the show. It’s the thing that people have the most trouble focusing on, especially men it seems. And it’s one of the hardest things to focus on as we’ve talked about a lot. It’s a lot easier to take tribulus or some other supplement than it is to radically change one’s lifestyle. If adrenal stress is the primary driver, which it often is then stress management programs like mindfulness based stress reduction or the rest assured program which you can get at soundersleep.com, we’ve talked about these before. Herbal adaptogens can be helpful, things like ginseng, rhodiola, ashwagandha, eleutherococcus, these are botanicals that can increase cortisol when it’s low and decrease it when it’s high, which is the definition of an adaptogen it’s a pretty neat thing that plant medicine can do that drugs can’t do generally. Then there’s phosphatidylserine which protects the integrity of the hippocampus, helps regulate the cortisol rhythm, helps with cognitive function overall. Those are some basic ideas. And of course if there’s insulin sensitivity you’ve gotta take of the diet, but if you’ve already taken care of the diet and you still are dealing with glucose intolerance or insulin sensitivity things like gymnema which is an herb that’s been used in Ayurvedic tradition in India for hundreds of thousands of years to decrease sugar cravings and improve insulin sensitivity and glucose tolerance. Magnesium is really good for that, green tea extract and alpha lipoic acid can be helpful. Then there’s chrysin which has come up before, chrysin is one of the few compounds that we know of that inhibits aromatization, which is that over-conversion of testosterone to estrogen so if that pattern is present in addition to of course doing everything you can to decrease insulin resistance, chrysin might be helpful. And then maca and tribulus increase LH production and of course these are the two supplements that you see on the internet recommended all the time, like if you have low testosterone take tribulus and maca. It’s not that simple but consider this possibility, let’s say the mechanism is testicular resistance and you actually have high LH. Taking maca and tribulus is not gonna help that problem and arguably it could make it worse by increasing the testicular resistance. But if you do have decreased LH production, and this is what we’d suspect for a guy who’s been on testosterone replacement therapy and is coming off of it, we would expect their LH and FSH production to be low, and I’ve found in these circumstances that maca and tribulus can be helpful in bringing LH production back up to a normal level.

DANNY RODDY: I was gonna throw in working with somebody like yourself might be the key to getting these herbs to actually function correctly.

CHRIS KRESSER: Yeah or finding anybody who has this kind of perspective, a functional perspective who’s looking at the underlying mechanism, doing the appropriate testing to determine what that mechanism is and then creating a treatment plan that’s based on that data. Rather than just prescribing an herb for a symptom.

DANNY RODDY: Because herbs can be equated to medication almost.

CHRIS KRESSER: Yeah absolutely, they’re very potent. And a lot of people don’t understand that. There’s a sad story, I haven’t talked to this guy in a while. He is a patient and I might be screwing up the details but he took an herbal formula, it was something he got off the internet. It was for andropause, he had borderline low levels of testosterone and it had an herb in it. I can’t remember the name of the herb right now but it’s one of the herbs that you see recommended a lot for increasing testosterone not a lot it was kind of a lesser known one actually. And he had complete, irreversible at least up until now, impotence after taking this product formula. It changed something really significantly and I only spoke to him once I think we did an initial consult and he told me about it and then I didn’t talk to him I’m not sure what he ended up doing.

DANNY RODDY: Did you guys ever end up doing blood work or anything?

CHRIS KRESSER: No he didn’t follow through, I’m not sure what he ended up deciding to do but that’s rare. It’s not like you hear about that often but it does underscore the importance of finding some help with this sort of thing, because one of the thing things about herbs is that they’re not regulated by the FDA and in some ways I think that’s a good thing because I certainly don’t want the FDA deciding what herbs I can prescribe or not but the downside of that is that there’s a lot of variation in quality out there. Being an herbalist I’ve studied this in depth and I can tell you first hand that there’s a huge, huge difference in the quality of herbal products out there. The typical Chinese herb product has been harvested ten years ago, it then sits in a warehouse in these big open bins in China for four or five years more than that, before it finally makes its way over to the US or gets included in a product. The herbs that I use in my practice are sourced in a really different way. One of the companies I use is in Marin county and they try to use as many fresh, organic, wild crafted, local, herbs as they can. And the herbs that they do get from China they get from the number one supplier that complies with all of the regulations and they’ve been over to visit the factory. Obviously you’re gonna pay more for those kind of herbs but for me it’s worth it because I know that they work and they’re way more potent than herbs that have ben out of the ground for ten years and sitting in a bin in a factory, and they’re also safer.

DANNY RODDY: That Natural Calm news you posted was sobering.

CHRIS KRESSER: Yeah and to be fair there were a lot of good comments and responses to that, I think that article that I came across was a little bit old, like two years old, and the founder of the company has responded to it and said that they comply with the regulations and so there is confusion about that too. Sometimes there can be scares that people make more of a big deal of something than should actually be made. But certainly it does highlight the importance of going with a brand that’s really trustworthy or with the case of herbs I think it’s generally fairly safe to use single herbs in relatively low doses depending on the herb, but when you start getting into formulas and when you start getting into using herbs for therapeutic purposes it’s really best to find an herbalist to work with because you absolutely can cause problems and damage with herbs.

So let’s get into some questions.

Can vasectomies can contribute to early onset Andropause?

DANNY RODDY: Cool, okay this one’s from Andrew this is off your Facebook page, he asks if vasectomies can contribute to early onset andropause.

CHRIS KRESSER: That’s a great question actually, and I did a little bit of research on this and I guess what we can say is the jury’s not out, but there is enough research to give me pause, if that was something I’m considering, which I’m not obviously. First of all let’s step back a little bit, I mean the idea that the vasectomy is totally safe is not quite accurate. As any man will testify the testicles are very delicate and sensitive structures. They’re complex organs with a really rich nerve and blood and lymph supply, and they’re under this intricate hormonal control that we’ve already talked about during the show. And also intricate temperature control that regulates sperm and testosterone because sperm has to be produced in a pretty narrow temperature range. And another thing is that the sperm is really tightly isolated from the rest of the body so that the man doesn’t produce antibodies to his own sperm, which as far as the rest of the body is concerned sperm is a foreign protein. So there are these defenses that keep the sperm isolated from the immune system. Now all of that, that intricate hormonal and temperature control, the defenses that keep sperm isolated, the delicate physiological structures can be disrupted even when the vasectomy seems to have gone well. And there can be short and long term complications which can be serious. So there’s a clinic, the Harley Street Clinic which is a place where they specialize in treating andropause and some of their own internal research, this isn’t double blind placebo controlled stuff it’s anecdotal but in their experience over the past ten years 25% of men who have come in for treatment for andropause have had a vasectomy. And that’s about twice the level in the general population. And in some of the surveys they’ve done, 35% of men who have filled out this andropause checklist and had andropause have reported a vasectomy in the past and some sister impotence clinics in Australia that they work with have reported a rate as high as 45%. So we don’t know for sure what the mechanism is there but one of the theories is autoimmunity related to sperm released into the tissues after the vasectomy. In other words that defensive structure that keeps the sperm away from the immune system is disrupted and then the immune system becomes aware of the sperm and treats it like a foreign protein, starts producing antibodies to it and then that becomes sort of an immunological time bomb. So to summarize, we don’t know for absolute sure that a vasectomy can increase the risk of andropause but there certainly is some evidence suggesting that it does and there are some clinical studies above and beyond the anecdotal studies that I mentioned that have shown increase in anti-sperm antibodies shortly after a vasectomy in animal studies and there’s been a couple studies that have shown an increase in LH levels after a vasectomy which could indicate a compromised ability to produce testosterone. And then there’s been some other studies about general increase in autoimmunity after that surgery. Anytime you have a surgery like that there’s a risk, and so I think it’s real, but what the likelihood of something happening is not entirely clear.

DANNY RODDY: Yeah I won’t be getting a vasectomy any time soon.

CHRIS KRESSER: Some people, I have no judgement for the choice that people make in that regard but just be aware that there is some risk.

The blood and saliva markers for Andropause

DANNY RODDY: Totally. This one’s from Martin I think we kinda went over this but if you could give the quick, dirty rundown of the blood markers that you look for, that you’re concerned with, with regards to andropause.

CHRIS KRESSER: Well actually I prefer saliva testing for hormones because it’s cheaper to test the free hormone levels that way and you know we mentioned before that you can test either the protein bound hormones to see what’s happening with the glandular production or you can test the free hormones to see what’s actually active in the tissues. With blood testing you can test both free and protein bound hormones but the free hormone testing with blood is quite expensive. And saliva hormone you test free hormones only and it’s much more affordable so I use a saliva hormone panel in my practice. There are a couple different labs that offer it, there’s Biohealth diagnostics and Diagnostechs so I test for the steroid hormones, the sex hormones like testosterone, dihydrotestosterone, I always test for estrogen in men too, to see if they’re over converting, that can tell us about aromatization. I test for androsteindione which is a precursor hormone so it’s important to know about that. And then when I’m doing a male hormone panel I always run cortisol and DHEA because those are the primary stress hormones and DHEA being a precursor hormone to the stress hormones and sex hormones. We can find out more about what’s happening with the adrenals and how much stress is contributing to the picture, so I usually do a complete hormone panel. Of course in terms of blood work and basic stuff you can test your blood sugar, so you can test fasting glucose, a1c, and fructosamine. And then you can also do post meal blood sugar testing with a glucometer to determine whether insulin resistance is an issue. Uric acid’s another kind of surrogate marker of insulin resistance and blood sugar regulation. And then in terms of inflammation you can test for acute phase reactants like ferratin and c-reactive protein. And in terms of autoimmunity I might look at a CBC, look at a white blood cell count. And you can look for anti-sperm antibodies if there’s evidence that might be happening.

DANNY RODDY: That should definitely get the whole picture, doing all of those.

CHRIS KRESSER: Exactly.

What role libido/erections play in determining health?

DANNY RODDY: This one’s from Darius, if/when the body is healing what role does libido/erections play in determining health. When/how does the body divert sexual and reproductive energy into healing? Are andropause ever a good sign? And just to emphasize what do you think, is morning erections a good sign of testosterone production?

CHRIS KRESSER: I don’t actually know, do you?

DANNY RODDY: I mean from personal experience I know libido is always higher when that phenomenon is happening. I used to talk to this anti-aging doctor and he was super hot on that being a positive sign.

CHRIS KRESSER: It makes sense but I’ve just never seen any studies about morning erections being a marker for testosterone, I haven’t looked that carefully either. I think I understand what he’s asking, which is essentially will the body divert resources that would otherwise go into production of male hormones into healing in a chronic illness state.

DANNY RODDY: Probably pretty hard to tell.

CHRIS KRESSER: Yeah I think it probably does though, because you’ve got like I mentioned before the precursors pregnenolone, 17-hydroxytprogesterone and DHEA, and there’s something called the pregnenolone steal, where pregnenolone is diverted into cortisol production and away from the sex hormone pathway which would go into DHEA and down through the rest of the sex hormones that way. So what you see often in a lab panel in the pregnenolone steal is high levels of cortisol and low levels of DHEA and low levels of the sex hormones and cortisol is one of the major anti-inflammatory hormones. So let’s say you’ve got some kind of chronic illness going that involves an inflammatory component which almost all chronic illness does, then you might see increased production of cortisol in order to deal with that inflammation and that would divert precursor material and pregnenolone into that pathway and away from the male reproductive pathway. Conceivably also if you have blood sugar issues like hypoglycemia or reactive hypoglycemia that then cause chronic cortisol secretions to bring blood sugar back up, that could conceivably divert pregnenolone into that cortisol pathway rather than the male reproductive pathway so yeah I think it’s definitely possible. In terms of whether andropause symptoms are a good sign of healing I don’t know if we could go that far. I think it’s more of a sign that the body is in a state that is where it doesn’t have enough resources for both the stress tolerance and the production of male hormones so I would  interpret it more as a sign of being in a healing state, and needing more healing rather than being a good sign of healing.

Should Andropause be accepted as part of normal, physiological decline of males?

DANNY RODDY: Okay the next question is from Greg, should andropause be accepted as part of normal, physiological decline of males, or do our lifestyle choices influence this to any great degree positively or negatively.

CHRIS KRESSER: I do think that there is almost certainly a normal, slight decline in testosterone production as we age, but andropause implies to me kind of a pathological acceleration of that process. So I don’t think andropause is necessarily normal, but I do think that some decline in testosterone production as we age is normal. In terms of the second part of the question I absolutely think that lifestyle choices influence to a great degree and I think we’ve covered that extensively. Things like stress management, making sure you get enough sleep, reducing inflammation, improving your glucose tolerance and insulin sensitivity, are all definitely lifestyle related. And so that can play a really significant role in how we age and whether we experience andropause or not as men.

Is a “beer belly” and are “man boobs” signs of Andropause?

DANNY RODDY: I like this next question, I have a friend who is approaching 50, he has a beer belly, or a gluten belly, and what he refers to as man boobs. He is a major workaholic stress monster and fears his mortality and fears the loss of the use of his manhood. I’ve heard it said that belly and boobs are indicators of too much estrogen. Is he bringing on his andropause at an alarming rate by not treating himself better? Where should he start to repair what he has done to himself? Perhaps he needs to stop by your office.

CHRIS KRESSER: Yes. Beer belly, wheat belly, gluten belly, and man boobs can all be signs of estrogen dominance in a male particularly the man boobs. Wheat belly or beer belly could be a sign of visceral fat accumulation due to increased cortisol levels or insulin resistance or both. But man boobs are pretty sure characteristic sign of estrogen dominance.

DANNY RODDY: I think hyperprolactinemia also causes that?

CHRIS KRESSER: Yeah that’s another potential cause for sure. But hyperprolactinemia can cause hypergonadism, which would cause estrogen dominance so yeah. He is probably bringing on andropause by not treating himself better.  I would say a food toxin free diet like a paleo template type of approach making sure to reduce processed and refined grains, and seed oils and soy and eating plenty of healthy saturated fat, we’re not gonna talk about macronutrient ratio because we know by now that there are many different macronutrient ratios for different people right? And then probably stress reduction is gonna be the major factor for this guy, workaholic stress monster does not seem like a good…

DANNY RODDY: What about fears mortality and the use of his manhood.

CHRIS KRESSER: So certainly stress management. I work pretty hard and I work a lot right now, but I do make an effort to, I’m still able to fit it in and even if it’s five or ten minutes a day that can have a really profound effect. Being too busy is not an excuse, it’s not one that really holds water anyways. Or put another way yeah, fine if you say you’re too busy for stress reduction then you’re just gonna have to deal with the consequences of it. And I don’t say that without compassion I just day you gotta make time for it. I think everyone can find five or ten extra minutes in a day and I still haven’t found anyone that’s so, so busy that there aren’t five or ten minutes that they spend extra on facebook or twitter, something else that they couldn’t spend just sitting in a chair closing their eyes and doing five or ten minutes of stress reduction.

DANNY RODDY: But now they’re all gonna be google +ing.

CHRIS KRESSER: Anybody have an invite? Please, please. That’s all I need is a whole other thing like that. Anyways who knows maybe Google + will be the best thing since sliced bread and I’ll be all over it but I doubt it. So that’s it I think that’s the last of our questions huh.

DANNY RODDY: Yeah great episode, awesome. I really enjoyed it.

CHRIS KRESSER: Yeah it was fun, and we always love to hear your feedback and questions so you can post them when we post this blog post, in the comments section. I’ll probably be changing dirty diapers at that point in the middle of the night so I may not be able to answer immediately but eventually I’ll try to get to them.

DANNY RODDY: Chris where can we find more of your work on the internet this week?

CHRIS KRESSER: Thehealthyskeptic.org, I’m in the middle of a series on natural child birth, just wrote the first article which looked at the mistaken idea that hospital birth is safer than home birth and I’ve got a few other articles planned in that series which I may get to the next one before the baby comes or I may not. Also healthybabycode.com if you’re interested in nutrition for fertility, pregnancy, and breastfeeding, and that’s about it.

DANNY RODDY: You can find all my work at Dannyroddy.com. Keep sending us your questions at thehealthyskeptic.org using the podcast submission link. If you enjoy listening to this podcast head over to itunes and leave us a review. Thanks for listening guys.

CHRIS KRESSER: Thanks everybody.

Dr. Emily Deans’ Evolutionary Psychiatry blog has quickly become one of my favorites over the past year. It’s rare to find a psychiatrist that acknowledges the role of nutrition in mental and behavioral health at all, much less one that approaches these topics from an evolutionary perspective.

This week Dr. Deans joins us on the podcast to discuss the role of Paleo nutrition in mental health. Topics covered include:

• The link between diet and Alzheimer’s
• Can nutritional changes effect depression?
• Does gastric bypass surgery lead to mental health issues?
• Can gluten intolerance induce mental disorders?
• What role does the “modern lifestyle” play in the increasing prevalence of mental health problems?
• How does an individual’s mental state influence his/her biology?
• Does iron deficiency anemia contribute to mental health problems?

Episode 12 is a grab-bag super special! Topics covered include:

• Thyroid glandulars
• Raw milk vs. colostrum
• Testosterone and other hormone replacement
• Magnesium & potassium for constipation
• Hair thinning and decreased libido in men
• Iodine, thyroid meds and hypothyroidism
• Protein shakes. Good or bad?

Full Text Transcript: 

DANNY RODDY: Hello everyone and welcome to the Healthy Skeptic podcast. My name is Danny Roddy and with me is Chris Kresser, health detective and creator of thehealthyskeptic.org, a blog challenging mainstream myths about nutrition and health. Chris, we’re on round two how are you doin buddy?

CHRIS KRESSER: Forty five minutes of the best material ever and it’s gone. You’ll never ever hear it you’ll just hear Danny’s side of it nodding his head, so hopefully my voice doesn’t completely go out since this is gonna end up being a very long period of me just blabbing away.

DANNY RODDY: We have a random grab bag episode but before we start how is your lady and how is the forthcoming child?

CHRIS KRESSER: She’s great and baby is great. I haven’t had the chance to really verify that but it seems good. The first time around we’re doin a birth unplugged we haven’t had an ultrasound, have not interacted with the medical establishment at all. We have a midwife, we’re having a home birth so all we know is that we’re having a baby some point in the next several weeks. Don’t know who that baby is, boy, girl, which is pretty cool I think people miss out when they find out what it is in advance because one of the things that’s been really interesting is I’ve had no opportunity to project a whole identity onto this child. I’m not imagining playing catch, all the things that I would do with a boy or all the things I would do with a girl, it’s just this big mystery right now and I’m enjoying it a lot because I feel like I’m really open to whoever is gonna come out of there.

DANNY RODDY: That’s so cool yeah, so you haven’t purchased the catcher’s mit yet?

CHRIS KRESSER: No catcher’s mit no blue nursery walls or pink nursery walls we have this hodge-podge of clothes, I have six nieces and nephews so my brothers and sisters in law have been setting us up as well as all of our friends so we’ve got a little androgynous wardrobe going. Our baby will be a cross-dresser one way or the other.

DANNY RODDY: Awesome.

CHRIS KRESSER: How’s it going for you?

DANNY RODDY: Good, can’t complain waiting for school to start. I’ve purchased some new sweet soft star Vibram fivefinger-like shoes and I’m wearing them around town.

CHRIS KRESSER: The paper bags on your feet.

DANNY RODDY: Yeah the running joke at my work is that I’m wearing static bags, which is always a good laugh.

CHRIS KRESSER: Sweet, alright so shall we dive into the grab bag-o-rama?

DANNY RODDY: Grab bag super special.

CHRIS KRESSER: Right, sorry.

Thyroid Glandulars

DANNY RODDY: Okay the first question is from my buddy who lives super close to here Bill Milan, Chris what are your thoughts on thyroid glandulars? Can you comment on the quality, consistency compared to Armour, Westhyroid, and Naturethroid? And then also thoughts on raw milk vs. colostrum? Is colostrum more or less tolerated and what are your thoughts on colostrum for leaky gut?

CHRIS KRESSER: Okay I do use thyroid glandulars but I tend to use them in more mild thyroid hypo-function cases where it doesn’t seems as important to control the consistency, like you would have more control with Armour, or Westhyroid, or Naturethroid. That is an issue, Armour is a very specific ratio of T4 to T3 its 4.22 to 1 I think, I could be slightly off on that but I think it’s pretty close. Whereas the thyroid glandulars you’re just taking glandular extracts, so you’re taking actual thyroid gland from usually a bovine source. So that can be helpful but there’s just less control of the dosing. Something I’ve mentioned in my thyroid series on the blog, on the healthyskeptic, is that the key, and this is true for treating any condition but it’s certainly true with thyroid is figuring out the nature of the problem. The exact nature of the disharmony or the problem and addressing it at that level because if you don’t then the results are gonna be limited. Te perfect example of that is I see a lot of mostly women but sometimes men in my practice who have quote hypothyroidism and their doctors put them on levothyroxine because that’s just what they do, it’s the popular one to use and it’s what a lot of doctors use. In a lot of cases these people have never even had their T3 tested they’ve just had their TSH and their T4, their total T4. And when I run my labs and test their total T3 we see that their T4 is actually fairly normal, that it’s been brought up from the levothyroxine but their T3 is still in the toilet. Many people who listen to this will probably know that T4 is the inactive form of thyroid hormone and it needs to be converted into T3 which is the active form in order to have its physiologic effect on the tissues and the cells. So you could have fairly normal TSH, normal T4, but low T3 and you would still experience all the signs and symptoms of hypothyroidism. And if you give that person T4 then the outcome is gonna be not that great because their problem is that they’re over-converting T4 into reverse T3 or put another way they’re under-converting T4 into active T3. So this is really common I’d say probably 70% of my thyroid patients have this T4-T3 conversion problem and it’s because inflammation causes it and almost everyone who comes to see me has some level of inflammation. So again it’s important to figure out what the mechanism is and then address that cause and in most cases with Hashimoto’s which is the number one cause of thyroid disease I think it’s probably necessary to be on thyroid hormone replacement. If iodine deficiency is an issue than that needs to be addressed as well. Sometimes just repleting iodine levels can be enough and make it so that thyroid hormone replacement isn’t necessary.

Raw milk vs. colostrum

So the raw milk and colostrum question, truthfully I haven’t had a lot of success with colostrum both personally and in my practice, I’ve tried it on and off for years with patients and I’ve tried it myself several times and I just haven’t seen much benefit from it. I know the theories about why it should work and I know that it’s crucial and important for newborns and that’s one of the reasons breastfeeding right after birth is so important  because it’s mostly colostrum that they’re getting, but I just haven’t seen a lot of benefit.

DANNY RODDY: Agreed I tried raw milk and colostrum both and I never could tell a difference between either one.

CHRIS KRESSER: Raw milk of course there’s whole other issues about what people might react to in raw milk, we’ve talked about that a lot so we won’t beat a dead horse we can move on to the next one. Especially since we just talked about it about twenty minutes ago.

Testosterone and other hormone replacement therapy

DANNY RODDY: This one is from Brandon Freese, what do you recommend for low hormone levels of thyroid and testosterone? What are your thoughts on HRT (hormone replacement therapy)?

CHRIS KRESSER: I went into a whole long thing about man-o-pause which was so fun we’ll have to do it again, we’ll do a whole show on it I promise because it’s a big issue and although no man likes to admit that they are in man-o-pause, cause it’s not very manly, it’s a pretty common phenomenon I think and it’s happening prematurely more and more and it’s a big issue so I definitely wanna talk about it at some point. I’ll answer the question more directly here, we just talked about thyroid and it’s kind of impossible to say what you should do for low levels of thyroid hormone because the answer to that question depends on why thyroid hormone levels are low. Are they low because T4 is not being converted into T3? Are they low because the person has hashimoto’s and there’s this uncontrolled autoimmune destruction of the thyroid gland? Are they low because a person’s iodine deficient? Are they low because the person has inflammation and the inflammatory cytokines are depressing pituitary function and then the pituitary can’t secrete enough TSH to stimulate T4 and T3 production? You get the picture, so I can’t answer a question of what to do with low thyroid hormones because it completely depends on why thyroid hormone is low and I’ve covered that on the blog in detail, if you haven’t seen it go to healthyskeptic.org/thyroid there’s probably 12 articles on it in a lot of detail so check that out if you haven’t.

Testosterone I haven’t talked about much and as I said I’m planning to do a series on it maybe some time after I get out of the intensive diaper changing phase. So it probably won’t be in the near future but it’s an important thing for men’s health because men should be naturally androgen dominant just like women should be naturally estrogen dominant. For a male testosterone has a protective effect, it protects against cardiovascular disease, cancer, diabetes, really all of the top 10 causes of death for men you can argue that testosterone plays a role in each of them. For example alzheimer’s I think is the number 10 cause of death for men and it’s growing every year, and low testosterone has been linked with alzheimer’s and cognitive decline and memory loss. It’s also been linked with depression and anxiety, I think suicide and depression I think is number 7 on the list of top 10 causes of death for men. And that’s probably via inflammation which we’re gonna talk a little bit more about in a second because low testosterone is associated with increased LH levels, luteinizing hormone, and luteinizing hormone has been shown to promote degeneration of the hippocampus which is the part of the brain that degenerates in alzheimer’s and dementia. So getting back to the importance of addressing the underlying cause, just like I can’t say what do you do for low thyroid hormone, I can’t say what do you do for low testosterone without knowing what the causes are. There are some basic patterns for man-o-pause that we’ll talk about when we do an episode on this in the future but in general I can kind of break it down into two things. That the main causes of low testosterone and increased estrogen levels and inflammation. Once again inflammation rears its ugly head. Show me a disease and I’ll show you inflammation. Just to give you an idea of how this works, like most processes in the body it’s cyclical and it’s a chicken and egg downward spiral type of thing where you get elevation of inflammatory cytokines and insulin resistance. Both promote each other so inflammation promotes insulin resistance and insulin resistance promotes inflammation. Both of those both cause and are caused by leaky gut, systemic inflammation in the body, which both cause and are caused by obesity and neurodegeneration which both are caused and caused by vascular degeneration like cardiovascular disease, and if you draw this out in a schematic with all of those factors I just mentioned you see just a bunch of arrows with double ends pointing to each other. It just becomes a tangle of causality and everything just promoting everything, it’s ugly when you see it actually diagrammed out and so that’s the viscous cycle that we can get into that becomes a downward spiral. As inflammatory cytokine surges happen and insulin resistance happens then that increases body fat, and as body fat increases that causes more inflammation and more insulin resistance, and all of that together upregulates an enzyme called aromatase which converts testosterone into estrogen, and  that’s when you get things like man boobs. And the accumulation of fat around the middle. When you see someone who’s got that going that is usually excess estrogen and probably also excess cortisol. This aromatization is kind of the core of the problem in a lot of cases. You don’t want that as a man, in addition to the undesirable appearance of man boobs that’s a sign that you are not androgen dominant or you have too much estradiol and of course that can predispose you to heart disease and strokes and alzheimer’s and diabetes and all kinds of other fun stuff.

Now let’s get to the second part of the question which I think was what do you think about hormone replacement therapy, right? Okay so in order to fully explain what I think about this I need to give you some basic physiology in terms of how hormone regulation works in the body. It works on a negative feedback system, and the pituitary gland sits up in the brain and you can think of it as a control tower for hormones. It monitors levels of hormones in the bloodstream and when hormone levels are low, the pituitary will send a message to the particular gland that produces that hormone to increase production. And that message is in the form of stimulating hormone so you have thyroid stimulating hormone, you have follicle stimulating hormone or FSH, you have luteinizing hormone which is LH. Those are the relevant ones in testosterone production it’s luteinizing hormone that acts on the leydig cells in the testes. Okay the way this would work is if testosterone levels are low, the pituitary notices that and then will produce more luteinizing hormone so that that luteinizing hormone will stimulate the leydig cells to produce more testosterone. Does that make sense? Okay so likewise if testosterone levels are high, then you would expect the pituitary to produce less LH so that less stimulation of the leydig cells happens and less testosterone gets produced. So that’s a negative feedback system and it’s amazingly complex. We know a lot about it we’ve learned a lot but there’s still aspects of it that we don’t fully understand. For example all of the hormones that are produced in the body are produced bound to a protein. This is because hormones are fat soluble and they can’t be transported throughout the bloodstream unless they’re bound to a protein. So in the case of thyroid hormone it’s secreted attached to thyroid binding globulin, which is the protein, and in the case of sex hormones like testosterone they’re secreted attached to sex hormone binding globulin. And those protein bound hormones are inactive, so they can’t have any effect on the tissues or cells, and in order for them to have an effect they have to be cleaved from that protein carrier and we don’t understand how the body knows when to do that, or how exactly that that happens. So there’s a lot that we don’t understand about the body and as much as we like to think we do, there’s a lot that we don’t. And so here’s how this all comes into play with hormone replacement therapy.

So let’s say somebody has low testosterone, because they have low levels of luteinizing hormone which is as I just said what stimulates testosterone production. And the reason they have low levels of luteinizing hormone might be because they’ve got inflammation that is suppressing pituitary function. What happens if that person takes testosterone? Well a few things are gonna happen, number one it’s not gonna address the underlying cause of low testosterone which in this case is inflammation. It’s just like putting a band-aid over the problem it doesn’t address the underlying cause. The second thing that’s gonna happen is that it’s gonna completely bypass the body’s natural regulatory feedback mechanism which I just described. And that’s not good because we don’t know how to operate that system like the body knows how to do it. When you take testosterone what’s gonna happen is the pituitary gland’s gonna go, oh great we;ve got plenty of testosterone. And it’s gonna reduce further the production of LH and of course that’s gonna mean that even less internal testosterone will be produced, which means the person taking testosterone will have to increase their dose, and guess what happens when they increase their dose? It further suppresses LH, which further reduces the amount of testosterone that the body produces. Now it’s kinda funny when we think about it and talk about it but it’s also kind of sad because I see a lot of patients in my practice, both women and men, who’ve been on supplemental hormones for a long time and the ones that are especially a problem are the creams, because the cream is usually in the free fraction state. So they are absorbed directly through the skin into the bloodstream in the free state so they’re available immediately to act on the tissues. The difference there if you take oral hormones are usually in their protein bound state and so the body still has some control, as I described it can still describe when it cleaves those protein bound hormones and makes them free and available to the tissues, but that’s not true with hormone creams. I’ve seen men who’ve been on testosterone creams, they get on the cream they feel fantastic for the first week, they’re just like oh I’m a new person, new personal records in the gym, I’m just gettin the chicks… they’re like way into it, but then a couple weeks later they start feeling bad again. Their libido’s decreased, plateaued at the gym, they just feel terrible and so what happens, they increase their dose and then they feel good again they’re back on the ball, everything’s working and then usually in less time this time around they feel bad and then they increase the dose again. At some point they’ve really screwed up their system because what happens is the body, in its wisdom in spite of our often stupidity, and that’s not directed at anyone that’s taking hormone replacement it’s just a general comment about human ‘monkey-mindness’ I guess I would call it, where we’re always trying to mess around  with things that we don’t understand and getting ourself in trouble in the process.

So what happens is the body is smart, and the body will do everything it can to protect itself from this excess testosterone exposure. One of the way it does that is by a), downregulating receptor site sensitivity, so that the receptors for thyroid hormone on the cells will become less sensitive to testosterone just in insulin resistance. And number two the body will actually downregulate the number of receptor sites on the cell for testosterone. And that’s its smart, intelligent way of protecting itself from too much free testosterone hanging around in the blood. So it’s doing everything it can to stay well in spite of us, while we’re taking the excess hormone. Over time that just becomes more and pronounced and so the big problem is that when we stop the hormone, we’re kind of in a bad way because (let’s use testosterone  as an example) not only is LH completely suppressed because of the external supplementation, which means that there will be very little internal production of testosterone, the cells have not only few receptors but the receptors they do are insensitive to testosterone. So you take somebody off testosterone hormone that’s been on it for a long time like that it’s literally like pulling the rug out from under them and there’s gonna be a period of weeks where they are very unhappy. Because it’s gonna take a while for the receptor site function to upregulate and for the cells to express more receptors and for the LH production to increase. And that’s assuming that the underlying cause is being addressed, which often would be inflammation and/or insulin resistance.

DANNY RODDY: Been there, done that.

CHRIS KRESSER: Right, so this is where you the people like the bodybuilder folks, I know you used to hang out in some of those forums where they just dig their selves deep into a whole and  it gets worse and worse.

DANNY RODDY: The deepest holes it was never ending. Do you know who you can write a letter to to thank for all this trans-dermal hormone usage, Chris?

CHRIS KRESSER: About 500 practitioners on the web that have an entire practice based on hormone replacement creams? Who are you thinking about?

DANNY RODDY: Suzanne Somers.

CHRIS KRESSER: Oh right, the sugar blues and the hormone replacement. She got one part of that right.

DANNY RODDY: Awesome, I could not agree any more with what you just said.

CHRIS KRESSER: I feel bad now, I feel like I might have been a little harsh on people taking hormone creams, it’s actually more directed at people who are prescribing the hormone creams and even then I think most people are doing their best and trying to help other people and that’s what they believe will help. I’m just kind of frustrated at the lack of education around this issue and why more people don’t understand this phenomenon that I just described. Because if you understand the physiology it’s perfectly clear how that would be a bad idea but I guess the other thing is it’s a lot easier to prescribe and take a hormone cream then it is to make the necessary diet and lifestyle changes that would be required to address the underlying mechanisms.

DANNY RODDY: Chris real quickly, man-o-pause, what age range do you think that is? Is there any different protocol for a younger gentlemen?

CHRIS KRESSER: I think man-o-pause is man-o-pause, but you can enter in to it prematurely any time if you start getting really inflamed and insulin resistant. So I don’t really necessarily treat them differently other than there may be effects like neurodegeneration that are more common later on in simply life because there’s been more of a chance for that to happen. It’s fairly rare to see severe neurodegeneration for a 21 year old male but it can happen if there’s enough inflammation, gut problems, and blood sugar irregularities.

DANNY RODDY: In a world of Four Loko I could see neurodegeneration happening, quite rapidly.

CHRIS KRESSER: Right, some people might argue there’s a lot of neurodegenerating in young men out there but that’s maybe a different cause, a different story.

Magnesium & potassium for constipation

DANNY RODDY: This next question, a completely different question, this is from Kara De Leon, my question is regarding magnesium and potassium for those who suffer with constipation. How much of both of these supplements should one take to help the situation? I already eat paleo and I’m currently pulling nightshades and eggs out of my diet. What do you think Chris?

CHRIS KRESSER: It depends? No it’s a good question and of course the answer is not the same for everybody, it depends. I test people’s magnesium levels and even though that’s not a super accurate test, if someone comes back below 2.0, in 99% of cases they’re gonna really benefit from magnesium supplementation.

DANNY RODDY: Do you just do serum magnesium?

CHRIS KRESSER: I do serum, red blood cell magnesium is more accurate, and there’s one lab in the country that does intra-cellular magnesium and claims that that’s more accurate than red blood cell magnesium. Those tests are pretty expensive, they’re more expensive, and I’ve just found that magnesium is one of the nutrients that I think many people should be supplementing with because it’s hard to find in the diet, even a healthy diet. Nuts are the biggest source, and dark chocolate I think is a pretty good source but nuts and chocolate have phytates and in the case of nuts a significant amounts of omega 6. So I don’t necessarily like to see people gobble down a huge amount of nuts to get their magnesium and I definitely wouldn’t want to see someone gobbling huge huge amounts of chocolate for that reason either. Although they might enjoy that. So typically if somebody is magnesium deficient I’ll put them on 600-800 mg of magnesium glycinate. The form is important. Most supplements have magnesium citrate or magnesium oxide and those are not really well absorbed. They have some effect for constipation but they tend to bring a lot of water into the bowel and cause loose stools or what I sometimes call contsorrhea, which I’m sure you can figure out for yourself what that is. The chelated forms of magnesium, magnesium glycinate and malate tend to be much better absorbed and I have a lot more success with them so I would say 600-800 mg of magnesium glycinate. Potassium I don’t use as much for constipation, there is a product  called ageless Hydro-C, which I sometimes give to my patients. It’s got a blend of a highly absorbable form of vitamin C, calcium, magnesium, and potassium. The amount of potassium is pretty small, it’s 40 mg which is like 1% of the RDA, and then the vitamin C can also have an effect on bowel regularity so you can take a gram or 2 grams or up to 3 grams of vitamin C per day, really up to bowel tolerance but if you take too much vitamin C that will also create often diarrhea or loose stools so you gotta be careful there.

DANNY RODDY: Do you think the constipation is a result of a magnesium deficiency or is this another thing that you kind of have to do some investigative work on finding the root cause of the constipation?

CHRIS KRESSER: Ding ding ding…Yeah. Well certainly a magnesium deficiency can cause constipation, and magnesium can help even if there’s another cause. But, you’re right, you definitely have to look and see what the underlying cause is and in my experience, constipation is 99% of the time due to gut dysbiosis. Because something like 70-80% of the dry weight of stool is dead bacteria, and so if you’re not producing a lot of good healthy gut flora you’re gonna have problems forming bulky stool and you’re gonna have problems with intestinal motility. So the long term solution to constipation is almost always addressing the gut flora, but magnesium can be really helpful in the short term, especially if there’s a deficiency.

Hair thinning and decreased libido in men

DANNY RODDY: Awesome. Okay bear with me this one’s kinda long. This one’s from Robbie Garfinkle, I’ve been doing paleo, low fat moderate protein, carbs range from 20-50g/day of citrus, buckwheat, yams, and green veggies since January. So far I went from 164 to 152lbs. I’m a male, 41 years old and my hair seems to be thinning since I’m 19 but so far I’m not completely bald. About 3 months into paleo I noticed some thinning and dismissed it but now it’s definitely obvious. My hair seems to thin quite rapidly even after only a few weeks, I will soon be completely bald up top if this keeps up. Is this a coincidence? Or something to do with my diet and current state of health? More information, I’ve had borderline high blood pressure for a few years recently this has gone from the 140s to 160s, my libido has suddenly gone downhill as well. I know the liver is involved in a lot I was a moderate-heavy social drinker for about 10 years, I’ve cut down drastically when I started paleo. He says his liver enzymes show up just fine. He also says that stress is fairly high and he’s worried about money, job, and he has sleep apnea as well.

CHRIS KRESSER: Okay, one of the first thoughts I have is he’s on a very low carb diet, 20-50 g is extremely low in my opinion, and I know that can be helpful in weight loss for some people, it certainly seems like it’s worked for Robbie, however there is some at least anecdotal evidence I don’t know about actual studies that show this but that low carb diets, I certainly see it in my practice I know other practitioners have reported it, Chris Masterjohn talks about it, that low carb diets can have an adverse effect on thyroid function. One of the primary symptoms of hypothyroidism or low thyroid function is hair loss. So that’s one thought, that this low carb diet is adversely affecting Robbie’s thyroid function and that is causing some of the hair loss and could even be contributing to the low libido as well, and another thought is that there’s some kind of inflammatory process  going on that could be stress related and cortisol related. Like cortisol disregulation from all of the stress that he’s been through recently and that is causing some kind of inflammation that is in turn promoting hair loss. Danny, you are the hair loss expert so I would love to hear your opinion on this question.

DANNY RODDY: Hardly, I’m gonna align right with you I think his very low carbing, that might be a major stressor, so the thing that comes to mind is telogen effluvium, which is the medical name for rapid hair loss if you’re in the state of malnutrition or you’re dieting really badly. He doesn’t say that he’s restricting calories but I wouldn’t be surprised if he was.

CHRIS KRESSER: Yeah that tends to happen spontaneously on a diet that low in carbs.

DANNY RODDY: Exactly, because male pattern baldness isn’t a rapid thing that happens all in a couple months, it happens over a long period of time so anytime it’s happening very fast it’s probably a major stressor like you said. And the only other thing I would throw in that I’m glad he mentioned was he had high blood pressure, so Chris I’m gonna need your help on this but I know aldosterone is part of the renin-angiotensin system, and aldosterone is, in all my research correlated with premature hair loss. So if he was willing to go to the doctor, and you can help me on this again, is there a test to measure aldosterone?

CHRIS KRESSER: Well the question still would be what’s causing the elevation in the aldosterone and the elevated blood pressure, but if it’s always been high, or no what did he say for a few years?

DANNY RODDY: I had borderline high blood pressure for a few years.

CHRIS KRESSER: I’m thinking that stress is probably the major player here in addition to the low carb diet because the stress can raise the blood pressure, it can cause inflammation, it can promote the hair loss. And the cortisol disregulation is also associated with sleep apnea.

DANNY RODDY: Totally, that’s exactly where I was going I was just gonna throw in, I have an article on my site and I remember digging up some research on pubmed suggesting that aldosterone can be reduced oddly enough with salt. I know that a salt-restricted diet can increase synthesis of aldosterone.

CHRIS KRESSER: Yeah, which a lot of paleo people are doing either intentionally or unintentionally. The original version of the paleo diet suggested salt restriction, right?

DANNY RODDY: Exactly, and then another thing to look into, vitamin D deficiency can also increase the renin-angiotensin system, increasing aldosterone. But like you said he’d have to find the root cause of the stress which can be so many thing it will make your head spin.

CHRIS KRESSER: Yeah, and to manage it, which we talked about this before but I didn’t say eliminate because most of us can’t do that but there are a lot of things we can do to manage stress and mitigate the impact that it has on us. I’ve written about some of those things in the 9 steps to perfect health series on my blog. I can’t remember what step it was maybe 7 or 8 or something but go check that out and there’s some recommendations there for how you can improve your stress tolerance. That’s probably the best way of saying it.

Iodine, thyroid medication, and hypothyroidism

DANNY RODDY: Awesome, okay our next question is from Barbara, she hails from Boston… I am hypothyroid, on armour, and a small dose of synthroid with pretty good results. I took ioderol for a few months and initially felt fabulous. Good energy, better aerobic capacity when cycling, and all over good effects. It did not make my TSH level go up nor make me hyperthyroid however it did give me a runny nose to the point of causing a weeping rash at the bottom of my nose. Does it seem that I am allergic? I took it for a few months and started it again at a very small dose but the same thing happened. Any ideas?

CHRIS KRESSER: Yes I do have an idea actually. Some people with iodine deficiency, which it sounds like she has based on her response to it, also have bromide toxicity. Bromide is a halide which is capable of binding the iodine receptor and blocking uptake of iodine. It’s found naturally in seaweed and seafood in saltwater, in low to moderate amounts. I suppose you could induce bromide toxicity I think I’ve seen some studies of Japanese coastal people who have bromide toxicity from eating tons and tons of seaweed and seafood. But the main exposure to it in our part of the world is that it’s used in a lot of plastic products including computers, and it’s also a flame retardant, it’s found in carpet and clothing, mattresses and a lot of other consumer goods. Also bromide is now added to baked goods, I’m assuming that Barbara is not eating a lot of baked goods but if she did some point in her life that could be part of the exposure. It used to be that iodine is added to baked goods but now they use bromide. And guess what one of the main effects of bromide toxicity is, it’s actually called bromaderma. Which is an acne like papular raised eruption of the face and hands, but it can also cause the more macular non raised rash, particularly on the face. So my guess is that this is, and the way that you detox bromide is by taking iodine. So iodine will help clear excess bromide from the body and so what I suspect is happening is she takes iodine and that starts detoxing the bromide and then she gets this rash, so my suggestion would be to take less iodine and go really slowly, and just try to see if you can manage it in such a way that you don’t get the rash or that if you get it it’s mild and you can work through it. With iodine you really need to move slowly when you’re taking it, I think probably starting off at a small dose a milligram or even less maybe for people who are sensitive and doubling it every 10 days to 2 weeks. So it could take months to build up to a higher dose like 12.5 mg or more, which some people recommend more. And then make sure you’re taking enough selenium when you’re taking iodine because particularly if you have hashimoto’s if you take iodine and you’re selenium deficient that can trigger or flare an autoimmune response. I have learned a lot recently in the last six months from my patients and also looking at the scientific literature and then a guy called Mario who left some comments on my blog a while back when I wrote the thyroid series and just wrote a two article series on the perfect health diet about using iodine in people with hashimoto’s and what the literature seems to suggest, and some of my patients experience, is that iodine only causes problems in hashimoto’s in the presence of selenium deficiency which is quite common unfortunately and so that’s why you see a lot of reactions to iodine in people with hashimoto’s. But it appears that if you take enough selenium or if you’re selenium sufficient then iodine can actually benefit people with hashimoto’s especially those with concurrent iodine deficiency. So that’s what I’d recommend for Barbara, I’m not sure that’s what’s happening but it seems it’s the most likely scenario.

DANNY RODDY: Yeah is there any given time for how long it would take one to detoxify from bromide?  Is there any literature on that?

CHRIS KRESSER: I don’t think there’s any literature but there are guys like Dr. Brownstein and Dr. Abraham who’ve been treating patients with iodine for a really long time and from what I’ve read of their materials in some cases it can take six months or over a year in the more sever cases so it’s unfortunately something you really have to be patient with and go slowly with, just listen to you body and see what kind of response you’re having. It just requires a lot of patience.

Are protein shakes good or bad?

DANNY RODDY: Just keeping your nose clean. Okay let’s go to Blake Smith’s question. I have a question about protein shakes. I supplement them for the protein and the calories, specifically BSN syntha 6, muscle milk cookies and cream, optimum nutrition casein protein, these are all the same ones that you take Chris, which is amazing. Are there any on the market that you’d recommend or would you suggest making your own? Have any recipes? ‘m at the gym 3-4x/week weightlifting to build muscle. He’s not a huge runner, regular diet is pretty clean, besides the occasional indulgence in ice cream and restaurants. What do you think Chris?

CHRIS KRESSER: I’m not a fan of protein shakes or bars, as most of you probably know by now. They’re extremely processed in most cases, they contain a lot of isolated synthetic nutrients. I generally don’t think people need to be on a high protein diet. Our need for protein, like 15% of calories is generally enough, it doesn’t sound like he’s doing tons of bodybuilding but even if he was he could bump that up to 20 or even 25% which is pretty high in my opinion and I think that would provide all of the protein that’s necessary for building muscle without any powders. The powders are like I said highly processed and I don’t see a need for them in the context of a healthy paleo plus raw dairy, whatever you wanna call it real food kind of diet. Fat is the structural part of all cells it’s the preferred storage form of energy for the body and I think a higher fat, moderate protein, moderate carbohydrate diet is a better choice and I don’t really see any need for protein powders.

DANNY RODDY: If he wanted to get jacked would you be opposed to the old school methods of raw eggs and raw milk or something like that? We’re not really bodybuilders though.

CHRIS KRESSER: No, so I’m probably not the best person to ask about that, but yeah the Rocky Balboa crack a few raw eggs but he did it wrong though because you can’t eat raw egg whites, well you can but it’s not a good idea because they contain trypsin inhibitors that contain avidin which inhibits the digestion of trypsin and if you cook egg whites that avidin gets at least partially destroyed but not so in the raw egg whites. You can eat raw egg yolks especially if you get them from pasture raised chickens and the yolks contain most of the protein nutrients anyways or most of the good nutrients so certainly raw egg yolks and raw milk or if you don’t tolerate raw milk, kefir for example make a shake with kefir and several raw egg yolks and some melted coconut oil and that’s like the best shake you could have. And gnaw on some liver while you’re at it and that’s the real superfood shake. If you can take it. Probably won’t taste as good as muscle milk cookies and cream though. With the liver in it, it would without the liver. So anyways I’m not a fan of the powders, they seem overly processed and I don’t think they’re necessary. But I’m not a bodybuilder so there’s a caveat.

DANNY RODDY: That’s gonna bring us to the end of this week’s episode. You can find all of Chris’ work at thehealthyskeptic.org. You can find me at Dannyroddy.com. Keep sending us your questions at thehealthyskeptic.org using the podcast submission link. If you enjoy listening to this podcast head over to itunes and leave us a review. Thank you for listening and thank you for your support.

This week we’re glad to welcome Chris Masterjohn to the show. Chris is currently pursuing a PhD in Nutritional Sciences with a concentration in Biochemical and Molecular Nutrition at the University of Connecticut. He writes a blog called The Daily Lipid and is also a frequent contributor on the Weston A. Price Foundation’s blog.

I consider Chris to be one of the foremost experts on the topic of cholesterol and its relationship to heart disease. In this episode, we discuss (among other things):

• the history of the cholesterol-heart disease connection
• misconceptions around diet vs. lipid hypothesis
• finding middle ground between cholesterol skeptics and proponents of the lipid hypothesis
• the LDL receptor and familial hypercholesterolemia and what they can tell us about cholesterol and CHD in normal populations

We didn’t get to any questions this time around, but Chris has graciously offered to come back and do an entire episode devoted to Q&A in the future – so look out for that!

This week we’re happy to have Stephan Guyenet from Whole Health Source back to discuss the body fat set point and food reward theories of obesity and weight regulation.

Questions covered include:

• How does the food reward system work? Why did it evolve?
• Why do certain flavors we don’t initially like become appealing over time?
• How does industrially processed food affect the food reward system?
• What’s the most effective diet used to make rats obese in a research setting? What does this tell us about human diet and weight regulation?
• Do we know why highly rewarding food increases the set point in some people but not in others?
• How does the food reward theory explain the effectiveness of popular fat loss diets?
• Does the food reward theory tell us anything about why traditional cultures are generally lean?
• What does this all mean from a practical perspective? How can these theories be applied to regulate weight and improve metabolism?

Click here to read all of Stephan’s recent posts on the food reward concept.

In this episode we discuss the gut-brain axis: the relationship between digestive health and cognitive function, memory, depression, anxiety and other mental and behavioral health issues. We cover:

• the basic physiology involved
• how inflammation in the gut affects the brain
• how decreased brain activity compromises gut function
• how to recognize the signs and symptoms of gut-brain axis dysfunction
• studies demonstrating gut-brain dysfunction and its effects on health
• dietary and lifestyle modifications to improve gut-brain function.

I think the gut-brain axis is one of the most important and least recognized factors in human health. If you follow a good diet (Paleo, Primal, Perfect Health Diet, etc.) and you’re still experiencing gut symptoms, it’s likely you have a gut-brain axis issue.

Full Text Transcript:

DANNY RODDY: Hello everyone and welcome to the Healthy Skeptic podcast. My name is Danny Roddy and with me is Chris Kresser, health detective and creator of thehealthyskeptic.org, a blog challenging mainstream myths about nutrition and health. Chris, how are you doin buddy?

CHRIS KRESSER: I’m pretty good Danny, how bout you?

DANNY RODDY: I’m doing really great, but when I walked into my garage, my podcasting studio, I forgot to plug in my deep freezer from two weeks ago, so there was spoiled beef fat that smelled absolutely terrible.

CHRIS KRESSER: You’re bringing this whole garage band thing to a new level huh.

DANNY RODDY: Cleaning out the deep freezer was one of the worst moments of my life, also because it was a ton of expensive spoiled meat.

CHRIS KRESSER: Yeah that’s what I was gonna say.

DANNY RODDY: But the smell, oh my God.

CHRIS KRESSER: That would be catastrophic for us, we buy like, a quarter of a cow at a time, it’s like $500-600 bucks of meat, if that happened I would be really really upset.

DANNY RODDY: Every single time we podcast I tell myself, you need to like make a note because you’re totally gonna forget and I forgot.

CHRIS KRESSER: Maybe we need the Danny Roddy grass-fed beef fund.

DANNY RODDY: It’s okay I’ll get by. It was mostly fat, which I’m more happy about, cause I think it’s like, way less expensive.

CHRIS KRESSER: Yeah, definitely. Good.

DANNY RODDY: What’s new with you?

CHRIS KRESSER: Um, ya know just slowly getting settled in to our new place, and when I say slowly I mean it. My office probably still has probably 14 unpacked boxes that I’m surrounded by. I’ve just been too busy to unpack em and it’s gonna stay like that for the next couple weeks until we get the healthy baby product out, which, I’ll talk a little bit about at the end, cause it’s coming up. I’m pretty excited about that. Yeah otherwise I’m happy to see the spring here it’s a beautiful, sunny, windy, crisp day in the bay area, I like that kinda day, so I’m good.

DANNY RODDY: That’s exactly how it is down here too. Awesome so this week’s episode is gonna specialize in the gut-brain axis. Do you wanna tell us a little more about it?

The basic Gut-Brain Axis physiology involved

CHRIS KRESSER: The gut-brain axis, the axis of evil. Sounds kind of sci-fi, but actually it’s probably one of the most important and most often ignored aspects of health and I think the more I see patients and the more I get into this research, the more important I’m seeing it and the more significant I think it is, especially in people who are doing all the right things in terms of gut health and they’re not improving. And that’s actually a significant percentage of the patients I see, fall into that category, so it’s one of the reasons I’ve been pursuing this as an avenue of research.

DANNY RODDY: It seems like it’s kind of a black box mysterious thing to treat, I hear everybody talking about but it seems very up in the air, is it just because it’s so new, do you think?

CHRIS KRESSER: Um, I think that’s partly it but I actually think that it’s related to what we’ve been talking about a lot that some of the treatments for it are, involve lifestyle changes that are a lot more difficult to make than just switching up your supplement regime or the percentage of carbohydrates you eat every day.  I know people are probably getting tired of hearing me say this but, the whole stress management piece is so crucial and yet I think it’s the hardest thing we can do in terms of making changes in our health. We’ll talk about that at the end when we talk about how to work with gut-brain axis issues.

I’ll talk a little bit generally about what I mean when I say the gut-brain axis cause it’s complex but it’s also completely simple. It’s probably obvious but I’ll say it anyways, everything we’ve ever done in life, or everything we ever will do depends on the brain. Anything from our capacity to taste food or appreciate art or music or smell, to feel the sun or the wind on our skin. To enjoy activities, to read, to record a podcast, it depends on our brain. And if the brain’s not functioning well, nothing else in the body will function well, period. And that’s so important to get. It’s one of those really obvious things that’s so obvious maybe that we overlook it.

DANNY RODDY: Is it the chicken or the egg syndrome though, because I feel like foods I eat specifically make me happy or sad, or is that a mental thing? Do you know which comes first?

CHRIS KRESSER: I think the sooner we get rid of this idea of linear causality in the body the better. One of the coolest things about Chinese medicine (and Chinese philosophy in general) is that they don’t really tend to see things in linear fashion. They see things in a cyclical way. And they way they look at the body, they would never say ‘this causes that’, like from A to B. It’s always ‘this and that’. Or, ‘and both’. For example, they’ve always recognized that the emotions, psychology, and physiology are one in the same. In fact they don’t even really have a separate word for emotions, like in the medical sense. Of course they do in language, but they look at systems of the body. The liver system, or the lung system, or the heart system. Each system includes both physical symptoms and also emotional and psychological and even psycho-spiritual aspects. So it’s a pretty cool way of looking at the body and I think in that sense it’s more advanced than our way of looking at it, which is ya know, like a car, with a bunch of separate parts. We understand that they’re related but we still talk about them as being and distinct. But the truth is, you can’t really talk about emotion without talking about physiology. And you can’t talk about physiology without talking about emotion. They’re not connected, they’re  the same system. So I think that’s important to understand and it kinda makes the chicken and egg thing a moot point. In the sense that it’s really difficult, if it’s all part of the same system it’s really difficult to say which came first and which followed. Once you’re in the cycle you’re in the cycle. So, that’s good news, bad news because it means that when it comes to treating it, you don’t have to figure out which one. You do both and both will improve. But you can figure out which one you havn’t been focusing on, which in most cases for most people is the brain. And so you might get more milage by focusing on one area because you’ve been neglecting it.

DANNY RODDY: I like that cyclical thing, I’ve never heard that before.

CHRIS KRESSER: Yeah Chinese medicine, they’re amazingly far, far ahead of they’re time. They figured this stuff out 2500, 3000 years ago. While we were still thinking about things in terms of phlegm and bile, western medicine was just a totally archaic understanding the body.

DANNY RODDY: Phrenology?

CHRIS KRESSER: Yeah, you were a phlegm type, or a bile type, and you know even up until the middle ages we were bleeding buckets full of blood from people to make them better. Ya know George Washington was killed by his physician who just kept bleeding him and bleeding him. He was sick but he just kept bleeding him til he died. Anyways I don’t know where the heck we’re going with this, but lemme get back on track here.. the brain.

How inflammation in the gut affects the brain

When the brain’s not functioning well nothing else in the body functions well. So you have to also remember that neurons are post-mitotic which means they don’t go through  cell division, they don’t regenerate. They’re like heart tissue in that respect which is the only other post-mitotic tissue in the body. So when neurons die that’s it. You don’t get new ones, game over. So for example by the time you finish listening to this podcast you’ll probably have lost about 7,000 neurons. Sorry to say, it depends what you’re doing while you’re listening too but, and the day that we’re born we have more neurons than we’ll ever have in our life. So that’s the bad news but the good news is that the neurons can develop plasticity, which means that when you lose neurons, other neurons can adapt to communicate with each other so you can form these new connections that can take the place in some cases of the loss of neurons.

What all this means is that protecting the brain from neuro-degeneration, which is happening for all of us all the time, and when I say protecting I don’t mean stopping cause you can’t, at least we don’t know how to yet. I mean slowing it down as much as possible. This is one of the most important and again overlooked steps we can take in protecting our health.

So let’s talk a little bit more specifically about the brain-gut axis and how it all works. The 50,000 foot overview, which somebody on the facebook page asked for, is this… 90% of our brain’s output goes into something called the pontomedullary area, it’s the lower two-thirds of the brain stem, and that goes into the vagus, or the pneumogastric nerve, which innervates the digestive tract. Now one of the earliest signs of the brain not firing well is poor vagal activity, which will manifest as decreased pancreatic enzyme secretion, poor gallbladder function, and poor gut function overall. And it basically works like this, you have decreased activity in the brain, and we’re gonna talk about how that can happen in a second, and that decreases the activation of the vagal motor nuclei, which in turns suppresses the intestinal immune system and decreases intestinal blood flow. And when that happens you get an increased growth in pathogenic yeast and bacteria, that cause intestinal permeability or leaky gut, which we’ve talked about a lot, and leaky gut causes a state of chronic low grade inflammation. Then the inflammatory cytokines produced in the gut travel through the blood and they cross the blood-brain barrier. One of the problems with inflammation is that it makes the blood-brain barrier leaky so you get leaky brain. And then those inflammatory cytokines once they get into the brain activate the microglial cells, which are the second type of cell in the brain. You have neurons and then you have microglial cells. The microglial cells are the immune cells of the brain and once they’re activated by these inflammatory cytokines this is basically inflammation of the brain. So your brain gets inflamed, you get a leaky brain and then you get inflamed brain. And that’s no fun, definitely. Cause one of the problems is that unlike the rest of the immune system in the body that has T-regulatory cells that can turn off inflammation in the brain, the microglial cells don’t get turned off. So, when you’ve got an inflamed brain it can be really tricky to reduce that inflammation without some outside help. So, you’ve got an inflamed brain and the inflammation in the brain decreases nerve conductance and that in turn causes depression and reduced activity of the vagal motor nuclei, and of course then we’re back where we started. That reduced activity of the brain reduces the output into the vagus, and that causes more digestive problems, more inflammation in the gut, more inflammatory cytokines to be in the bloodstream and up into the brain and we’re stuck in this really viscous cycle.

DANNY RODDY: Cyclical

CHRIS KRESSER: Cyclical, exactly, more cycles, it’s all cycles baby! So, this is also why digestive symptoms are typically the main symptom of brain issues. I don’t know if you’ve ever thought about this, but two of the populations that most commonly have gut symptoms are seniors and autistic kids. I mean, show me an autistic kid and I’ll show you someone that’s got a screwed up gut. As Datis Kharazzian likes to say. And seniors typically have problems chewing, they have hypochloridia or atrophic gastritis where they don’t produce stomach acid, they’re constipated. It’s very very common to see digestive problems in seniors and it’s not a coincidence, it’s not, there’s a mechanism here and that mechanism is neurodegeneration and neuroinflammation. The other thing that’s important to recognize about all this, which we already alluded to, is that when gut symptoms persist even in the context of a healthy diet, like let’s say you’ve done the 30-day challenge or your on a paleo diet and you’re still having a lot of symptoms, that could indicate a brain-gut axis problem. It may also indicate a parasite or something like that, but let’s say you’ve been tested for a parasite and you don’t have any but you’re still having all these gut symptoms, that’s the brain-gut axis or the gut-brain axis right there.

DANNY RODDY: Could  heavy metals be another factor?

CHRIS KRESSER: Sure,  I mean any kind of environmental toxin, including metals, could be a factor in terms of agitating the gut and causing inflammation. And also, I think as you’re suggesting, causing issues in the brain. But, the body is equipped to deal with some level of metal toxicity and of course there certainly are people who have more exposure to toxic metals than they can handle, but I think heavy metal toxicity is also one of these diagnoses that fall into that sort of like, candida, chronic fatigue, lime disease category.

DANNY RODDY: I couldn’t agree more, just because the amount of people with amalgams in their mouth and that are unaffected by them is huge so it’s like some people it affects really badly and then other people it’s like totally okay.

CHRIS KRESSER: Right so my mantra lately is ‘it’s the environment stupid’. Which is like, we’re always trying to find the answer for everybody, but the truth is, and I was just talking to a patient about this yesterday, there is no answer for everybody because everyone’s internal environment is different. So for example, you take one person and they have Blastocystis hominis, which is the most common parasite in humans and they have no symptoms, they’re completely healthy, completely symptom free. Take another person and they have blasto and they’re totally sick. They’re like on death’s door. So is Blastocystis pathogenic or not? Well yes and no, it depends on what’s happening in the host. Depends on the internal environment of the gut, and the innate immunity of that person. As usual it’s a lot more gray than we’d like it to be.

Just a little personal story here, lately I’ve been overworking. Between my very full practice, and the blog, and facebook and twitter, and I’m spending a lot of time on this healthy baby product which I’m really excited about, it’s gonna be ready soon. I’m just like, I’m working too much, there’s no other way to put it, not taking my own advice. I have been exercising, doing my sitting practice, those pretty much are bulletproof, they never go away, but  a lot of the other things I usually do to keep my brain functioning well, like just resting, surfing, going out in the sun, listening to music, doing yoga and other stress management stuff, having fun, watching a funny TV show or movie or something like that. I havn’t been doing that stuff.

DANNY RODDY: You better watch out cause Durian Rider is gonna write a post about you like he did Robb. Did you see that?

CHRIS KRESSER: No I don’t pay attention to that stuff.

DANNY RODDY: Well no doubt he’s crazy but he wrote a really mean article about Robb and then Robb responded with something really funny but I don’t remember what it was.

CHRIS KRESSER: I try to take the high road with that stuff, I don’t even have time to bother with those people. So anyways I was noticing a flare up in gut symptoms, ya know I have this history of digestive issues from when I got parasites and amoebas and a bunch of other stuff in Asia a long time ago, some of you know that story. I was starting to have gut symptoms, I hadn’t made a single change in my diet, a single change in the supplement regime (which is pretty minimal anyways), nothing else had changed except for the level of work I was doing and the amount of time I was spending taking care of myself so I switched some things up over the past week or ten days and even in that short period of time I’ve noticed huge differences, I feel like I’m back on my normal track again, so just a little cautionary tale.

How to recognize the signs and symptoms of gut-brain axis dysfunction

Okay so what are the symptoms of a brain-gut axis problem? Well, fatigue and brain fog are a big indicator. We’ve talked about chronic digestive problems and especially those that don’t respond to dietary changes. Then we have things like progressive cognitive decline or memory problems, which we see in the elderly of course, but also an increasingly large number of twenty-five year olds. I have so many people in their twenties and thirties who are losing brain function, which is just kinda scary. It’s something that you don’t want to be happening when you’re twenty five years old. Anxiety, depression, ADHD, autism spectrum disorder, behavioral problems, and then here’s an interesting one, cold hands and feet. Especially if you have toenail fungus, because what’s happening there is that you’ve got reduced blood flow, reduced circulation to your peripheral tissues and the brain when you think about it is a peripheral organ. So, cold hands and feet, and toenail fungus can be an indicator of a brain-gut axis problem. I see that a lot actually, in my practice.

DANNY RODDY: Does it have anything to do with the thyroid? and the brain down-regulating things?

CHRIS KRESSER: It could, it could also just be a simple result of reduced blood flow. And that can happen in all kinds of inflammatory processes. So the basic physiology here is that in the brain the key players (in this gut-brain axis) are the frontal cortex, the insular cortex, the vagal motor nuclei (which I’ve already talked about) and the hypothalamus. The frontal cortex basically stimulates the vagal nuclei to activate gut motility (intestinal peristalsis), which is what moves the contents of our gut through the digestive tract and out the other end, and enzyme secretion. The insular cortex contains the somatotopic map, which is basically what lets the brain know where the gut is. And then the vagal motor nuclei activate intestinal motility, and they modulate blood flow, which we just talked about, but in this case to the gut. And then the activate the release of hydrochloric acid  and digestive enzymes. The brain primarily communicates with the gut via neuronal projections and then hormones that are secreted via the hypothalamus.  But in the gut the key players are the enteric nervous system, the intestinal immune system, which is the gut-associated lymphoid tissue and the gut flora, and then the intestinal microglia.

The enteric nervous system is really interesting actually, the gut is basically one big nervous tissue. In fact it’s been referred to as the second brain. There’s a book by that title by Dr. Michael Gershon that’s kind of interesting, it has some flaws but it’s worth reading. The enteric nervous system also generates intestinal motility and enzyme release and then it provides incoming input to the vagus nerve. Someone asked about serotonin in the questions and how much serotonin is in the gut, well 80% of total serotonin in the body is located in the enterochromaffin cells in the gut and this is used primarily to regulate peristalsis and motility. So this is why constipation and depression so often tend to go together. And then the remaining 20% is synthesized in serotonergic

neurons in the central nervous system that regulate mood and appetite, sleep, and muscle contraction, and a whole bunch of other stuff. So the gut communicates with the brain via cytokines and gut opiates and gut peptides like neurotensin and substance-P. Whew. Okay. Everyone who just zoned out for the last five minutes staring out the window while your driving or whatever you can come back now cause we’re gonna talk about some practical applications but I feel like it’s important to understand the basic physiology so that what we’re gonna talk about next makes more sense. Any questions Danny? How you doin?

DANNY RODDY: I’m good.

CHRIS KRESSER: You’re still with us, in your rotten meat smelling garage?

DANNY RODDY: Luckily the smell has subsided, it was bad man.

How decreased brain activity compromises gut function

CHRIS KRESSER: Good. Okay so, how does the brain affect the gut. Well I know everybody’s experienced this in a very personal way, we have  phrases like ‘butterflies in the stomach’ and ‘gut feeling’ that of course suggests the connections have been known for a long time. Maybe we all know somebody that has lost complete bowel control in a state of extreme fear or stress, certainly that’s in the movies and we hear about that sort of thing. But what are some of the mechanisms here. Well, in the intestinal mucosa there are blood vessels that are influenced by the autonomic nervous system. The intestinal mucosa also is infiltrated by the myenteric plexus which is a network of nerve fibers and neuron cell bodies that are in turn influenced by the brain. So as I said before the gut’s basically one big nervous tissue. I think I mentioned this study in a previous podcast or in an article but it was a really interesting study where they induced traumatic brain injury in mice, which is not too nice, but these mice developed leaky gut in less than six hours after having this brain injury. Even more interestingly if the researches stimulated the vagus nerve, which mimics increasing the brain output into the vagus, that actually prevented the leaky gut from developing.

DANNY RODDY: When they did that to the mice, is the root cause like, the brain injury causes stress?

CHRIS KRESSER: It causes decreased output into the vagus, cause remember I said before 90% of the output of the brain goes into the pontomedullary area and then into the vagus. A traumatic brain injury is gonna reduce that output and then they showed that by just stimulating the vagus, which mimics increasing the output, they were able to prevent a leaky gut. So they basically showed, proved that connection between the brain and the vagus and the gut.

Then you have other studies that show that neurotransmitters like serotonin and acetylcholine are involved in preventing or promoting ulcers in the digestive tract. And that alterations in the brain can cause abnormal gastric enzyme secretion. So I wanna talk about a few different studies that I have found over the last couple of years that I think are pretty interesting.

Studies demonstrating gut-brain dysfunction and its effects on health

There was one published last year in the National Review of Gastroenterology & Hepatology and I’ll quote from the conclusion. It said “IBS is thought to be the result of disturbed neural function along the gut-brain axis.” So that makes it pretty clear.

DANNY RODDY: That’s big news.

CHRIS KRESSER: Yeah, there’s an interesting thing here where for a lot of years doctors told people with IBS it was all in their head. And that’s really not a nice thing to say, but it’s true. The thing is it’s not true in the way that the doctors meant it. You know what I’m saying? They meant you just need to get over this, or you’re just imagining it is what they meant.  But what is true is that it is in your head, cause that’s where your brain is. And if the gut is malfunctioning then the brain is involved, and vice-versa. So it is all in our head but not in the sense that we’re to blame for it or we’re just making it up.

Another study in 2005 found that IBS patients have increased activation of pain circuits and decreased activation of pain inhibition circuits. So this is interesting cause, I don’t know if you remember this but when we had Kurt Harris on we were talking about fructose malabsorption and the gas that produces, and the difference  in the way that’s experienced with people with IBS and people without IBS. And they found in that study that people with IBS and without IBS had the same amount of gas produced with fructose malabsorption, but it didn’t even bother the people who didn’t have IBS. It only was painful and uncomfortable in people with IBS. And so that’s what this is about here, people with IBS have a decreased pain threshold, increased activation of pain circuits and then decreased ability to turn off the pain circuits.

DANNY RODDY: So they’re just in a hyper-sensitive state?

CHRIS KRESSER: Exactly. Yeah, so it’s not even necessarily the amount of gas that’s produced, it’s how they experience it. And again it’s not their fault, it’s not something that they are imagining it’s a real neuro-physiological pathway. Journal of Clinical Psychiatry 2001, this is crazy, 50-90% of IBS patients seeking treatment have a psychiatric disorder. Woah. This includes panic disorder, anxiety, social phobia, PTSD or a major depressive disorder. I mean, if that doesn’t sum it all up, give you some strong evidence for an association between the gut-brain connection I don’t know what does.

DANNY RODDY: I hate to put you on the spot here but is there a figure for how many Americans suffer from IBS? It seems pretty common, at least among my peers.

CHRIS KRESSER: The only figure that stuck in my mind about that it’s now the second leading cause of people missing work, behind the common cold. That stuck in me more than whatever the number of millions of people are that have it. It’s causing serious debility and morbidity in the population. It’s right up there with depression in terms of how common it is and how debilitating it is.

DANNY RODDY: And then the third cause just being a normal hangover?

CHRIS KRESSER: And hating their jobs. Okay Biological Psychiatry 2009 they again not very nicely exposed rats to stress by separating them from their mothers early on in their life, and then they challenge them with lipopolysaccharide which is a bacterial endoxtoxin. And the rats that were exposed to the early life stress had increased pain and alteration in their gut flora compared to controls and the conclusion by the researchers was that early life stress alters the gut-brain axis, and in a permanent way, and causes depression, IBD, and IBS. I mean permanent I don’t know, they were suggesting that it’s something that wasn’t passing, it didn’t just last for the early part of the life for these rats, it persisted throughout their life. Whether that’s permanent for humans or can be reversed that’s a whole other question.

DANNY RODDY: Because mice, their lives are so much shorter could they say that it wouldn’t be transferable over to humans because we live so much longer? Would that have anything to do with it?

CHRIS KRESSER: Yeah I dunno, I think this all sort of, fairly gray territory in terms of earlier on it was thought that certain neurological conditions were irreversible and certain neural-pathways once developed couldn’t be undeveloped, but now more recent research suggests there is a lot more plasticity in the brain and in the nervous system than we thought there was, which means that it’s possible to form new connections and for those new connections to take over in terms of importance in the brain and nervous system. My sense is, that significant trauma early on in life probably would predispose somebody for life to certain, to maybe having a sensitive gut-brain axis. And maybe that sensitivity wouldn’t be reversible but by learning strategies for how to cope with it and things to do that manage it they can live a perfectly healthy, happy, normal life. That’s my sense but there’s nothing particularly scientific about that.

Journal of Neurotrauma in 2009 they found that traumatic brain injury can cause gastrointestinal disfunction, we already talked about this, and leaky gut. And then a study in Lancet found that patients with inflammatory bowel disease, which includes chron’s and ulcerative colitis, had focal white matter lesions which are these small areas of dead cells in the brain, with almost the same frequency as patients with multiple sclerosis. So how’s that. Once again extremely clear connection between brain issues and gut issues.

Now we’re gonna talk a little bit about how the gut affects the brain. There’s a lot of different mechanisms here and we only have time to review a couple of the main ones. Our friend Mat Lalonde actually sent me me a study a couple weeks ago that was just published that the gut flora influences the development of behavior and causes neurochemical changes in the brain. So again from the conclusion they said “we conclude that the presence or absence of conventional intestinal microbiota influences the development of behavior and is accompanied by neurochemical changes in the brain.” And they point out that even sub-clinical doses, small doses of pathogenic bacteria infused into the gut of mice can produce anxiety without any overt gut inflammation. So what they’re saying here basically is that the gut flora can not only affect how we digest food and whether our gut lining is permeable, but can actually influence the development of our behavior and one can even argue personality.

DANNY RODDY: I think it was Gershon that said have you ever met somebody with IBS that’s not anxiety prone. I think he said if you were a changed to a toilet you probably wouldn’t be in the best spirits either.

CHRIS KRESSER: That’s a vivid example for sure. Yeah, it reminds me of the fact that bacteria outnumber human cells in the body by 10 to 1. We have a hundred trillion bacteria in our gut that’s 1014, it’s just like an incomprehensible number. And so if you look at it that way you could say that we’re more bacterial than we are human. When you consider it that way it’s not that surprising that the composition of the gut flora can have so many effects on everything from our metabolism to our behavior. So another study by Lee, et al. found that changes in gut bacteria induced by feeding different types of food to mice altered their memory and learning. So they fed half the mice standard rat chow, and then the other lucky half of the mice got a 50-50 blend of rat chow and ground beef. And then they measured the diversity of the gut flora and the mice that ate the beef had significantly more diverse gut flora and significantly higher learning and memory scores. So now we’re talking about healthy gut flora making you more intelligent, essentially.

DANNY RODDY: Like serotonin in the gut, does acetylcholine, could that have somehow been involved? I mean I know we don’t have all the answers…

CHRIS KRESSER: I don’t know the answer to that Danny, actually where the majority of acetylcholine is produced. I don’t think it’s in the gut but I’m not sure.

One of the most interesting examples of how the gut affects the brain is this immune inflammatory cytokine model of depression, and I wanna get Dr. Emily Deans to come on the show and talk about this cause she writes a lot about it and she probably knows a ton more about it than I do. But I’m gonna give you my understanding of it. I like it because it’s the only model of depression that bridges the gap between physical and mental. We talked about this before, in Chinese medicine they don’t see depression as a mental problem they see it as a whole body problem. Mental, emotional, psycho-spiritual, physiological problem. But the immune inflammatory cytokine model from this perspective depression isn’t so much a disease as it is a sign of chronic immune system activation. And that chronic immune activation produces inflammatory cytokines that in turn produce depression I explained that back at the beginning of the show how that works. And this was discovered back in the 80s, that inflammatory cytokines have a huge effect on mood and behavior and you would have thought this would have had a gigantic impact cause it completely changes the way we look at depression. But it didn’t receive much attention at all in the mainstream press or the conventional medical world I suspect because there were no drugs available for treating it in this particular way. But the inflammatory cytokines that are associated with depression include interferon-alpha,   tumor necrosis factor, interleukin-1 and 2, and it’s important to note that elevated cytokines don’t produce depression in everybody and why some people are susceptible and others aren’t isn’t really known. But we do know that inflammatory cytokines produce symptoms of depression in some people. And the best example of this is patients given interferon treatment for hepatitis. I don’t know if you’ve ever heard about this Danny, but interferon is a nasty, nasty drug and basically the idea is to increase the inflammatory response so that the body can deal with the hepatitis and most of the patients who take this drug, they report severe fatigue, complete lack of interest in life, lack of concentration, and just debilitating depression. And suicide rates are higher on interferon than any other drug. In fact one study 65% of patients taking interferon became psychiatric patients during the study.

DANNY RODDY: Holy smokes.

CHRIS KRESSER: Yeah. And the depression didn’t stop immediately after stopping the treatment. So definitely a strong connection between inflammatory cytokines and depression. We also know that depressed people secrete greater quantities of inflammatory cytokines than normal people and this has been extensively studied by… Dr. Michael Maes and his colleagues in Belgium, and they’ve published like 40 papers demonstrating that chronic immune activation and the associated increase in cytokine production is characteristic of depression. So you have all those different ways that the gut can affect the brain and particularly inflammation in the gut can cause inflammation in the brain. So the takeaway here is that anxiety and stress and IBS and IBD, the gut and the brain, they’re all part of the same axis, they always go together. Every stressful event that we experience in life increases the plasticity of stress pathways in the brain which means it makes the brain essentially more efficient at running stress pathways. And there’s a saying in functional medicine, fire in the gut, fire in the brain. Which sums it up pretty well. Digestive function will start to fail immediately after the brain starts to fail, and the inter intestinal gut mucosa in the brain themselves don’t have any pain fibers which is why brain-gut, you don’t see people coming into the clinic going my brain hurts. My brain feels really inflamed can you help me? They come in saying I can’t eat any foods, I’ve got gas and bloating, I can’t remember anything, I used to be able to concentrate for long periods and now I can’t, I’ve got cold hands and feet, and I’ve got this toenail fungus and it won’t go away, this is what people say when they’ve got a gut-brain issue. And as a patient or a clinician if you ignore the role of the brain in addressing gut issues, success is definitely gonna be limited. Probiotics, and HCL, and diet are all very important of course. But it’s possible to do all of that right and still have gut symptoms as I’ve experienced directly myself, and as a lot of my patient’s have experienced. So this is one of the reasons that I’m always harping on the importance of sleep, and stress management, and cultivating pleasure, because these are all things that we can do to help our brain function better.

So let’s talk a little bit more about that. You have a question?

DANNY RODDY: No, I liked your conclusion.

Dietary and lifestyle modifications to improve gut-brain function.

CHRIS KRESSER: Okay, good. So there’s three things that the brain needs, essentially. Glucose, oxygen, and stimulation. As far as stimulation goes that’s why people that stay mentally active as they get older tend to age better. And do a lot better than people who don’t, you know who just sit on the couch and eat jellybeans and watch TV. And this is another reason why blood sugar regulation is so important. When people come to see me in the clinic, the first things that I’m looking for are oxygen deliverability and blood sugar regulation, those are like, the two deal breakers. Once again here as we talk about the brain we see glucose and oxygen being two of the main things that it needs. Alzheimer’s and parkinson’s and other neurological conditions have been called diabetes of the brain, that’s one of the newer theories about it and of course this also illustrates why stress management is so important. Studies show that cortisol rhythm maintains blood sugar stability, so if cortisol doesn’t go down you get insulin resistance and if it goes too low and can’t come up you get hypoglycemia, which is a total disaster for the brain. And then we know that elevated cortisol also damages the hippocampus. And that chronic stress atrophies the brain, it literally atrophies the brain. And this is also why blood flow to the brain is so crucial because blood carries oxygen and glucose and everything else we need to the brain. You could almost say that blood flow equals function.

So two of the best ways to increase blood flow to the brain are exercise and acupuncture. And actually I wrote a whole series about, I believe that one of the main reasons that acupuncture works is that it increases blood flow. That’s kind of a western understanding of how it works but there’s a lot of support for that. And it’s been proven to increase blood flow to the brain. And so anyone with a brain-gut axis issue should definitely be trying acupuncture on a pretty regular basis. And then there are certain nutrients and botanicals like feverfew, ginko, cayenne, and then some limited research suggests that vinpocetine from periwinkle can increase blood flow to the brain. And then you of course would have to deal with any anemias that are present, which of course is compromised oxygen deliverability. The impaired ability of hemoglobin to deliver oxygen to the tissues including the brain. I think anemia is one of the most under diagnosed and misdiagnosed conditions there is, cause I see anemias in 30-40% of my patients and they’re almost all unaware that they have it, and their doctors havn’t told them anything about having it. If they see low hemoglobin they just give them iron, even if iron deficiency is not the cause of anemia but that’s a whole other issue. And then stress management, stress management, stress management. It just keeps coming back to this. Things like mindfulness based stress reduction, Jon Kabot-Zinn’s programs, Feldenkrais, yoga, qi gong or tai chi, whatever it is for you. Different people have different things that work for them. It’s super important to integrate this into your life. You notice that I’m not staying stress reduction, or stress elimination because in the modern world most of us don’t have that luxury or option. Stress management is the key.

Regarding the gut we’ve talked more about this in other podcasts, but a gut-healing protocol might include the GAPS diet, glycine rich bone broths, probiotics, prebiotic foods like sweet potatoes, jerusalem artichokes, stuff like that. And then you’ve got botanicals like marshmallow root, and slippery elm, and chamomile, and spanish moss can be helpful. And if there’s a pathogen you should address that. But really at least in terms of this episode I’m focusing more on the brain because I think that’s the part that people are missing more. There’s a lot out there on how to heal the gut but not that much on how to heal the brain.

And I mentioned before that when the microglial cells become activated it’s hard to turn them off. There are some nutrients that have been demonstrated to do that including curcumins like turmeric, skullcap, green tea extract. In terms of healing the blood-brain barrier you’ve got alpha-lipoic acid, glutathione, which you need to take things that help glutathione synthesis, you can’t take just oral glutathione it’s not effective. And then the omega 6:omega 3 balance is absolutely crucial in blood-brain barrier integrity. Don’t go out and just buy all this stuff and come home with a shopping bag of supplements, try to find someone who can help with this and focus your efforts. It’s definitely worth doing because it’s a really important pattern to manage.

DANNY RODDY: Like Spectracell will actually measure the amount of glutathione in your blood correct?

CHRIS KRESSER: I don’t know about that test.

DANNY RODDY: I don’t know if it’s totally bunk or not, but I remember receiving it, and they didn’t tell me that it measured it but I got it back and it was cool.

CHRIS KRESSER: I’m always naturally skeptical, as you might imagine, of those kind of tests. but anyways I don’t know anything about it so I can’t really say. So let’s take a couple questions, I know we had a long episode last time I don’t wanna go too far this time, but let’s take a few questions and then I have a couple things to end with.

DANNY RODDY: Alright cool, this one I believe was on your facebook page, from Stephanie Alexander. I would like to understand the connection between acute emotional stress and the onset of gut issues, and the progression to additional health issues.

CHRIS KRESSER: Okay well I think probably we’ve covered that mostly but early studies suggested that a stressful evert would trigger hormonal and neuronal reflexes in the brain that influence the gut, and that does happen but recent reports have also shown that the gut produces the same stress peptides that are present in the brain and the central nervous system. These peptides regulate intestinal motility which is the rate at which digested material passes through the intestines. So we’re getting back to that extreme fear stress event that causes diarrhea. During a stressful event the normal amount of those peptides gets totally thrown out of whack and that affects digestion and motility. And when that happens repeatedly over time it can evolve into a gut-brain axis disorder like IBS or IBD.

DANNY RODDY: Awesome, the next question, kind of a two-pronged question from Lisa Rose. I would love to hear your take on probiotics. Should everyone be taking them? or can it do more harm for some. Which brands do you recommend? And the roll enzymes play to help digest food while the gut heals, also highlighting the power of foods for a healthy gut, like fermented foods. What other foods help? And then an additional question from Laura that’s kind of in the same vain, should people with healthy gut digestion take probiotics? What happens if you take too much? How do you determine the right amount?

CHRIS KRESSER: I don’t see any need for healthy people to take probiotic supplements but I think incorporating fermented foods into your diet is a good idea for everybody. Number one it tends to help with digestion, number two it can just help normalize the gut flora and protect us against overgrowth of pathogenic bacteria or parasites that we might take in through food, and number three they’re tasty and I like them. Number four they tend actually to have even more microorganisms in them than a lot of the commercially available probiotics. Number five I think some common sense and maybe studies suggest that they are more likely to survive the stomach acid and make it to the colon which is where they’re needed. So, I don’t typically recommend probiotic supplements as a matter of course, I do recommend probiotic foods so we’re talking about dairy ferments like kefir, yogurt, and creme fraiche, fermented cream which basically is creme fraiche but there are different ways to do it. And then you’ve got fermented vegetables like kimchee and sauerkraut, and saueruben and fermented beverages like beet kvass. There’s a great book called Wild Fermentation by Sandor Katz that has like, every possible fermented food you can imagine and how to make it. Full Moon Feast by Jessica Prentice is really great for that too, as is Nourishing Traditions by Sally Fallon from the Weston A. Price Foundation.

DANNY RODDY: Yeah food not pills.

CHRIS KRESSER: Yeah but I use probiotics and prebiotics therapeutically in my practice for sure, because for some people the food doesn’t seem to be enough.

DANNY RODDY: Totally. Okay the next one’s gonna be from Mike Zemrose, please discuss psychosomatic reactions to food and how this complicates diagnosis of gut related problems.

CHRIS KRESSER: I’m not totally sure what he means by psychosomatic reactions to food but I’ll take a guess. The Chinese have a great saying, I think I mentioned this before when I wrote the article on the 80/20 rule, which is that it’s better to eat the wrong food with the right attitude than the right food with the wrong attitude. And of course it’s best to eat the right food with the right attitude, but that’s not always possible or it doesn’t always happen that way. And this is in part why I do suggest an 80/20 rule or 90/10 rule for most people and for those of you who don’t know what that is, that means that 80 or 90% of the time you eat a paleo plus raw dairy type of diet, or whatever you wanna call it, Perfect Health Diet, Paleo 2.0. And then the other 10-20% of the time you eat whatever you want. And for a lot of people whatever they want still just is the paleo type of diet, but some people might have a food that they really associate with happy times, when they were a kid, or they’re out with friends and they wanna get some ice cream, or whatever. And the pleasure that that experience can create, and the stress and feeling of deprivation and stuff that that can prevent will actually, according to this Chinese saying is actually better, will have a more beneficial effect on the body. So I think that’s a good rule to follow if you’re generally healthy. If you’re gluten intolerant or celiac for example you don’t get the 80/20 rule with gluten, with bread. It’s 100%/0, you never get to have it. Anyways back to the question, there was an interesting study where they hypnotized patients and put them into four different emotional states. Relaxation, anger, happiness, or excitement. And then they observed the gut after they ate. Relaxation and happiness increased the distension volume required to produce discomfort meaning that, going back to what we were talking about IBS and hypersensitivity that when people are relaxed and happy they’re less likely to experience discomfort while eating. And then when the patients were angry it decreased the distension volume that was required to produced discomfort. So I don’t think this is a surprise to anybody that when you’re happy and relaxed you’re gonna digest your food better, when you’re angry you’re not. But it’s definitely in the scientific literature.

How we feel when we eat alters the secretion of hormones and peptides and neurotransmitters, and that effects not only our digestive function but also things like cardiovascular function. Dr. Malcolm Kendrick talks about this and he points to some studies in his book The Cholesterol Con, that postprandial or after meal stress is one of the most significant risk factors for heart attack. So those French that have those leisurely two hour meals, they know what they’re doing. Whereas here we eat, and we’re eating in front of the computer, or we’re chomping down an egg mcmuffin while we’re changing lanes on the freeway or whatever. That’s kind of a disaster.

DANNY RODDY: Well speaking of the French, our next question is from Pierre Brode. His question is I’m interested in how stress eating throws off the physiology/ body chemistry and how the brain-gut axis amplifies it, and what are some ways of resetting it caught in the cycle. Big question.

CHRIS KRESSER: I think we’ve hopefully covered this during the podcast, but I’ll just mention a few… stress eating we havn’t talked about particularly. Sugar and carbs and fat can mitigate the effects of stress via increasing opiates and dopamine, other neurotransmitters like serotonin that make us feel good, feel like life’s okay and everything’s gonna be fine. But if you do this regularly during times of stress you can cause adaptations in those pathways that can lead to overeating. Other studies have shown that food reward and sensitivity is decreased during stress, which leads to overeating. In other words when you’re really stressed out you don’t actually enjoy the food that you’re eating as much as you do when you’re not. And then you keep eating because you’re not getting that food reward that you’re expecting. And then, I don’t know if you saw this but Stephan Guyenet over at Whole Health Source wrote a post today about food reward. It showed that mice eating chocolate ensure but not vanilla or strawberry ensure, these are these elemental diet drinks that they give people that are just disgusting I can’t believe that mice would even eat them at all, it’s surprising to me. But the mice eating the chocolate ensure could overeat and become obese, whereas the ones eating strawberry and vanilla didn’t. So what this suggested was that the flavor of food actually influences body fat and body fat set point. And then the last thing is, I guess we talked about this before but elevated cortisol can lead to increased food intake. That’s an evolutionary mechanism probably designed to make sure that we get enough food to fuel our metabolic needs during times of stress or maybe when a food shortage is on the way or something like that. So the way to deal with this, is as I said to take steps to manage stress throughout the day and throughout the week and to find other ways of coping with stress when it becomes overwhelming aside from eating. That’s a topic beyond the scope, we can’t cover that in significant detail right now at the end of the show. But I think the key is to manage stress regularly so that you don’t get to that place where you’re just so overwhelmed that the only solution is a half of a chocolate cake.

DANNY RODDY: Cool Chris, do you have anything else to throw in about the gut-brain axis?

CHRIS KRESSER: I don’t think so, did I miss anything? I’m sure I did.

DANNY RODDY: No I thought it was fantastic, you covered everything.

CHRIS KRESSER: Well I wanna talk a little bit about this healthy baby home study course that’s coming out soon. I’m super excited about it, we actually renamed it it’s now called the Healthy Baby Code. Very secret code.

DANNY RODDY: That makes me think of the History Channel’s Bible Code that I used to watch in high school.

CHRIS KRESSER: The Da Vinici code? No it doesn’t have anything to do with that. It’s based on, I was giving these live presentations, for those of you who aren’t aware of this, on nutrition for fertility, and pregnancy and breastfeeding. And they sold out, there was huge demand for them locally, and a lot of people on my blog and facebook and twitter were asking if I could make it available to people who didn’t live locally here in the bay area. It’s a super important topic, I feel really passionate about getting the information out there so what I did is I turned the presentation, which was about three hours, into this home study course. I actually expanded it considerably, and there’s gonna be six video modules that are like screencasts from the presentation, covering things like the basics on how proper nutrition contributes to the lifelong health of your baby, which I just wrote a blogpost on called the developmental origins theory. The sacred fertility foods that have been used by traditional cultures around the world. And then module two we talk about macronutrients, protein, fat and carbohydrate. Not necessarily how much of each but what type of each which I wrote about in my 9 steps series and Kurt’s talked about a lot.  Find out which types of fat and carbohydrate and protein are best for you and your baby. And we talk about micronutrients, essential vitamins and minerals, which ones are critical during the developmental period, during pregnancy, and also for fertility. Where to find them in foods and when it’s necessary to supplement and what dosage of each you might need to supplement with. And then in module four we talk about food toxins, we learn about the four neolithic agents of disease which I’m sure many of you are already familiar with. Cereal grains, industrial seed oils, excess fructose and soy, modern processed soy. And then in module five we talk about breastfeeding and first foods, which a lot of people have questions about. How long should you breastfeed, when should you introduce foods, and how do you introduce them safely to try to minimize the risk of food allergies and reactions, autoimmune conditions and stuff like that. And then in module six we kind of put everything together and into a focused strategy for really supercharging your fertility and promoting healthy pregnancy and then raising a vibrant, healthy, beautiful baby. Of course this is very, my personal motivation for doing this too because my wife is six months pregnant, we’re expecting a baby in july and we had kind of a long road, difficulty conceiving at first. My wife has autoimmune thyroid disease and a lot of doctors just told us not even to bother. Of course that didn’t sit well with me so, I did tons and tons of research in my typical obsessive compulsive way, into what nutrients were really necessary to support a healthy pregnancy and the magic happened last october and we conceived so I’m really excited to share this with people. In addition to the video modules which are by the way gonna be transcribed into pdf’s cause I know some people don’t like video and they learn better by reading, I happen to be one of them. And then there’ll also be MP3 recordings of each module so if you drive a lot and you wanna listen to them in the car you can do that.

And then I’ve added a whole bunch of bonus stuff which we’re excited about. There will be quick reference charts, an easy to follow nutrient chart that lists all the essential nutrients and what foods they’re in and what dose to supplement with if you need to. There’ll be a two week meal plan, which both my wife and I worked pretty hard on from collecting recipes from places like health bent and the cheese slave and the paleo diet lifestyle, a lot of great recipes on the web and then our own recipes, we’re not too shabby cooks ourselves. And then there’s gonna be an interview, of frequently asked questions with me, some of the most frequently asked questions about nutrition for fertility, pregnancy and breastfeeding. There’s gonna be a list of recommended supplement brands, dosages. And then of course it wouldn’t be complete without come stress management, because that’s obviously a huge factor for women trying to get pregnant and women who are pregnant. My wife, Elanne is a Feldenkrais practitioner and has also done a lot of somatic experiencing training which is a particular approach to dealing with stress and trauma. So she is recording some stress management audio programs for women who are trying to get pregnant and men for that matter, and women who are pregnant and breastfeeding. So that’s the whole kit, and now you can see why I’ve been working so hard.

DANNY RODDY: No doubt.

CHRIS KRESSER: So that’s gonna hopefully be available in like, I want it to be available in two weeks but maybe more realistically three weeks and please don’t shoot me if it’s the end of may. I’m working as hard as I can to get it out there. So if you’re not already on the list for this you should go to growahealthybaby.com that’s the old name for it but that’s where the sign up list is and I know it’s a little but confusing, it’s kind of in transition to the new name but if you go to growahealthybaby.com  you can sign up to be on the email list, be notified when it’s released, and one reason to be on that list is that I’m gonna be making a special offer to people that are on that list. We’re gonna do kinda like a beta launch, a smaller launch just to that list. Kick the tires a little bit, and in exchange for people’s feedback I’m gonna offer some pretty cool stuff to people on that list so make sure to join that if you’re interested in this and pass the word on to folks that you think might be interested.

DANNY RODDY: Awesome you can find all my insanity at Dannyroddy.com, keep sending us your questions at thehealthyskeptic.org using the podcast submission link. Chris, what a great episode, thanks.

CHRIS KRESSER: Yeah I had fun, thanks everyone we’ll talk to you next week? are we doing, is it Stephan?

DANNY RODDY: May 20th is Masterjohn.

CHRIS KRESSER: We’ve got some exciting episodes coming up we’ve got Chris Masterjohn, we’re gonna bring cholesterol into the 21st century finally. It’s gonna be like the fully up to date, integrated understanding of cholesterol, all the latest research and cut through the hype and the confusion and you’re finally gonna understand this whole cholesterol thing. And then Stephan Guyenet is gonna come back and make a second appearance, we kicked the whole podcast off with him talking about obesity and he has some very interesting, newly developed theories about obesity and weight regulation that he is gonna share with us which I’m super excited about so, looking forward to that.

DANNY RODDY: Awesome, cool. That brings us to the end of the episode, take care guys.

CHRIS KRESSER: Alright, see ya later, take care of your brain-gut!

Bring on the Paleo-Nerd-A-Thon! In this week’s episode paleo nerds Robb Wolf and Mat LaLonde (a.k.a. “The Kraken”) join me to discuss some of the finer points of the paleo/primal approach to nutrition. We answer cover the following topics:

• Why weight loss often plateaus or even reverses on low- or zero-carb diets, and why increasing carbohydrate intake can often jump-start weight loss again
• Whether ketones or glucose are a better source of fuel in particular circumstances
• Whether it’s important to eat glycine-rich foods like bone broths as well as methionine rich foods like muscle meats and eggs – and what the consequences may be of too little glycine and too much methionine
• How to increase testosterone and libido without testosterone creams
• Whether elevated LDL after adopting a paleo diet is caused by micronutrient deficiencies
• The complete lack of evidence supporting “metabolic typing”
• The potential causes of excessive bloating
• The myth that a paleo diet is bad for the kidneys
• What a paleo diet can – and can’t – do for type 2 diabetes

Since we’re all nerds that like to talk, the episode is longer than usual – 90 minutes. But we had a great time and we’re thinking of making it a quarterly event. Let us know what you think!

P.S. You’ll notice the theme song is different this week. We pulled it from Release the Kraken.

This week’s episode is all about nutrition for fertility, pregnancy and breastfeeding. I answer common questions like:

• What do you see as the biggest factor keeping women from getting pregnant these days? What one factor, if optimized, has the biggest effect on fertility?
• How important is the father’s nutritional status pre-conception?  What should a man be eating to improve the chances of conception?
• Do you recommend significantly different diets during the times a couple is trying to get pregnant versus after she becomes pregnant?
• Can I continue my paleo/low-carb lifestyle if I fall pregnant? Is it safe to practice a paleo diet while pregnant? Most doctor’s say it isn’t.
• When I was pregnant in the past, I had TERRIBLE morning sickness. How can I maintain a healthy eating plan and deal with food aversions/ morning sickness/ sheer exhaustion?
• What prenatal vitamin (with DHA?) would you recommend? Are generic supplements targeted at pregnant woman worth taking?

We also discuss appropriate weight gain during pregnancy, how to avoid gestational diabetes, how long to breastfeed and how to ensure adequate milk supply.

At the end of the podcast I talk a little bit about the Grow a Healthy Baby Home Study Course, which will be available online by the end of this month or early next month. If you’d like to be notified when it becomes available, click here to join the mailing list. Note that I’ll be making a special offer to people on that list, so sign up so you don’t miss out!

In this week’s show we interview the illustrious Kurt Harris, M.D. from PaNu.

Topics discussed include:

• Orthorexia
• Meditation practice
• Whether anyone should care about their lipid measurements
• Are their hormetic benefits from fructose, wheat and seed oils?
• A lot more…

We had a great time recording it, and I think you’ll enjoy it.

In this week’s show we discuss the similarities and differences between the Paleo, GAPS and Weston A. Price approaches to nutrition. Specifically, we explore:

• The health of traditional cultures studied by Weston A. Price
• Raw dairy, IGF-1 and cancer
• Signs and symptoms of raw dairy intolerance
• Properly prepared grains – worth the trouble?
• How to reintroduce and test your tolerance for dairy
• A1 vs. A2 milk: significant difference or bogus theory?
• Which is best: Paleo, GAPS or WAPF?

We covered a lot of ground, so the show’s a bit longer than usual (1 hour, 15 minutes).

Make sure to tune in next week – Kurt Harris will be our guest! More to follow soon about that.

Here we go with another episode of the podcast! I finally got myself a decent mic so I don’t sound like I’m talking in a tin can. Also, we’ve decided to group questions together into 1-2 distinct themes for each show, instead of doing a random grab bag of questions. This will allow me to go into more depth on topics, and it will allow you to quickly see whether the subject of the podcast is of interest to you.

We’ve received some great feedback on the show. If you have a moment, we’d be grateful if you could head over to iTunes and leave us a review. It seems the so-called “skeptics” from the sciencebasedmedicine.org cabal have showed up to proclaim in their typical myopic and ignorant fashion that anything challenging the dominant paradigm is not factual, accusing me of sharing “anecdotal” evidence and making “unsubstantiated” claims. Obviously they’ve neither listened to the show nor read my blog – but that doesn’t stop them from feeling qualified to write a review! A few people have already responded to their nonsense, including a physician who listens to the podcast, and I’d be grateful if you’d do the same.

This week’s show is focused on hypothyroidism/Hashimoto’s, leaky gut and autoimmune disease. Specific topics covered include:

• Do plant goitrogens influence the thyroid?
• Why do I continually need higher doses of my thyroid medication?
• Kelp’s affect on the thyroid
• Synthroid vs. Armour, what is the best thyroid medication?
• Can antibiotics cause autoimmune disease?
• What is the best diet to heal the gut?

And remember, keep those questions coming in!

The podcast is back! After a long hiatus, I’ve decided to start it up again and continue on a regular (bi-weekly, for now) basis with my new co-host, Danny Roddy.

It will be a Q&A format, so make sure to send us your burning questions. We’ll also have special guests on occasionally. Stephan Guyenet, Kurt Harris and Paul Jaminet are already lined up. If you’ve got ideas for people you’d like us to have on the show, let us know.

In this episode we cover:

• The Blood Type Diet
• Anemia, ferritin & supplemental iron
• Polycystic ovarian syndrome (PCOS) & pregnancy
• Statins & cardiovascular disease
• Vitamin A toxicity (or lack thereof)
• Side-effects when cutting carbs

In this second podcast episode I cover the basics of essential fatty acids, discuss the importance of reducing intake of omega-6 and increasing intake of omega-3, and compare the relative benefits of fish vs. fish oil as sources of omega-3.

I go through most of the material I’ve written about in my special report on essential fatty acids, fish and fish oil, but there is some additional material in the podcast that isn’t in the written series.

I’ve also answered a few of the most common questions that came up in the comments section, or were emailed to me by readers.

Topics include:

• Why flax oil isn’t an adequate source of omega-3 fats
• The importance of reducing omega-6 consumption
• How much omega-3 is enough to prevent disease and promote health
• The advantages and disadvantages of fish vs. fish oil as sources of omega-3
• Criteria for choosing a fish oil
• Is vitamin A safe in cod liver oil?
• Is EPA or DHA more important in human health?

Click here to subscribe to and download the podcast in iTunes. (For those of you already subscribed to the podcast in iTunes, keep in mind that it sometimes takes up to a day for the feed to update.)

Click here to listen to an MP3 of the podcast, or right-click to download the MP3 to your computer.

Welcome to the first episode of The Healthy Skeptic Podcast! To listen to this podcast and subscribe to future episodes in iTunes, click here or click the new iTunes podcast button in the sidebar to the right.

If you don’t use iTunes, you can listen to the file by clicking this link. If you’d like to download it, just right-click the link and download it to your computer. If you’re an Android user or prefer subscribing to an RSS feed of the podcast and blog together, click here.

We’re kicking things off with an interview with Dr. Stephan Guyenet, Ph.D. on obesity, body fat regulation, and weight loss. Stephan is a researcher at the University of Washington studying the neurobiology of fat regulation. He also writes one of my favorite blogs on nutrition and health, Whole Health Source.

Topics covered include:

• The little known causes of the obesity epidemic
• Why the common weight loss advice to “eat less and exercise more” isn’t effective
• The long-term results of various weight loss diets (low-carb, low-fat, etc.)
• The body-fat setpoint and its relevance to weight regulation
• The importance of gut flora in weight regulation
• The role of industrial seed oils in the obesity epidemic
• Obesity as immunological and inflammatory disease
• Strategies for preventing weight gain and promoting weight loss

It’s a bit long at 1:20, but I think you’ll enjoy it if you’re interested in this topic.

Please let me know what you think!

I was interviewed last week on Joanne Unleashed about the recent series of articles I wrote on heartburn and GERD. We cover the following subjects:

• Why acids leave the stomach and enter the esophagus
• The harmful effects of taking antacids and acid stopping drugs
• How antacids perpetuate heartburn and actually make it worse over time
• The role of stomach acid in digestion
• The bacterial component in acid reflux
• Why you get gas and belch
• Which nutritional deficiencies are common with acid reflux
• The association between acid reflux and IBS, Crohn’s, and other intestinal diseases
• Which inexpensive supplement will help reduce indigestion
• Which foods cause heartburn
• Which foods you should eat to heal the gut

Click here to listen to the MP3 file, or right-click to download it.