IBS-FODMAP Research, Overtraining & Acne, & Treating Alopecia Areata
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RHR: New IBS-FODMAP Research, Overtraining and Acne, and Treating Alopecia Areata

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Another (mostly) Q&A episode. Enjoy!

In this episode, we cover:

6:38 What Chris ate for breakfast
9:30 Surprising new IBS-FODMAP research
21:33 Food allergies and testing for inflammation
27:04 What to do about chronically chapped lips after taking Accutane
33:01 When is cholesterol too low?
37:44 Does over-training cause acne?
48:22 Naturally overcoming alopecia areata

Links We Discuss

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Full Text Transcript:

Steve Wright:  Hey, everyone.  Welcome to another episode of the Revolution Health Radio Show.  This show is brought to you by ChrisKresser.com, and I’m your host, Steve Wright.  My website is SCDLifestyle.com, but we’re both here to talk to integrative medical practitioner and healthy skeptic Chris Kresser.  So, Chris, how is your day going?

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

Steve Wright:  I’m pretty excited, Chris.  I’m in my last week of being an engineer and about to be doing SCD Lifestyle full time, so I’m pretty excited.

Chris Kresser:  Wow.  Congratulations.

Steve Wright:  Thank you.

Chris Kresser:  Big changes.

Steve Wright:  Yeah, it’s exciting.  Obviously walking away from the conventional route of taking a paycheck and good insurance and stuff to be a full-time entrepreneur is risky in some regards, according to some people, but I’m ready for the challenge.

Chris Kresser:  Yeah.  I think you’re up to it.

Steve Wright:  Awesome.  So what’s been going on with you?

Chris Kresser:  Well, busy-busy, as usual.  I’m excited about the book, and I was hoping to be able to make an announcement this time, but it looks like I’m going to have to put it off until the next time again.  I can’t announce it until the publisher announces it, and there have been a couple holdups that have prevented that from happening, but I think pretty soon I’ll be able to.  Meanwhile, I’m writing away because the manuscript is due in June.  I’m probably 90% finished, which feels really good.  The end is definitely in sight.  And I’m having a blast writing it.  I really love the creative process of building something from scratch, and it’s been a really good opportunity for me to kind of get all of my foundational views on nutrition and lifestyle and supplements in one place, which I’ve never really done before, and to do a lot of new research and update some of my views as well.  We talked about vitamin D last time, so that’s one example, but there are a lot of examples where I went back to the scientific literature and had a chance to read some of the newer studies in certain areas and update some of my recommendations, which I really feel is important.  I want to continue learning and continue evolving and growing my own knowledge, and the book has been a really great opportunity to do that.  What I can tell you is that the publication date is going to be either in late December or early January, so right around the “New Year, new you” time period, which I think is good.

Steve Wright:  Uh-oh.  Lots of competition.

Chris Kresser:  Good for a health book, and yeah, I’m really excited not only about writing the book, but all the fun stuff we’re going to do around the book leading up to the publication, and I have some great ideas for really cool bundles to create.  It just feels like a natural next step for me, and I’m looking forward to it.

Steve Wright:  Well, that’s super cool.  I definitely understand, though, when you have to actually crystallize your thoughts into one place into writing – I guess we both do that through blog posts all the time, but to do it on an immense scale in a book, that’s an awesome piece of work.

Chris Kresser:  Yeah, for me actually the challenge has been figuring out what won’t go in the book because I think I’m pretty close to about 550 pages right now of writing, and I think it goes without saying that the book’s not going to be 550 pages!  And even that, I was like:  Oh, man.  I have to leave this out?!  There are so many things I could say.  There’s going to be a part of the book that deals with customizing paleo to treat 11 different common health conditions from digestive disorders to autoimmune disease to thyroid problems to skin issues.  And of course, each of those chapters could be a book in its own right, and maybe they will be eventually, but it’s really difficult to condense my thoughts about how to treat thyroid disorders, for example, into a 10- or 15-page chapter.  I think it’s going to be really super valuable for people, anyway.  I’m really kind of focusing on the top tips, but I just had to come to terms with the fact that I’m not going to be able to download my entire clinical understanding and approach in one single book.  But that’s all right.

Steve Wright:  Yeah, you have plenty of time.

Chris Kresser:  Yeah, exactly.  And I don’t want this to be such a beast that people are intimidated by it and don’t pick it up or read it because it weighs 14 pounds!

Steve Wright:  And just use it as a highchair for their kids?

Chris Kresser:  A doorstop.  Yeah, exactly.  But we’re recording this at the end of May.  I’m pretty sure by the next time hopefully the publisher will have made the announcement and I’ll be able to tell you a little bit more about it.  It’s on track.  That’s the main thing.

Steve Wright:  Awesome.  Well, good to hear an update.  I think we’re going to answer a lot of questions today, so why don’t you go ahead and take a second to review those questions, and I’m going to let everybody know about Beyond Paleo.  So if you’re new to this podcast, if you’re new to the paleo diet, or you’re just someone who’s interested in optimizing your health, you’re going to want to check out what over 30,000 other people have already signed up for.  It’s a free 13-part email series called Beyond Paleo, and it’s Chris’ best tips and tricks for burning fat, boosting energy, and preventing and reversing disease without drugs.  To get this right now, go over to ChrisKresser.com, look for the big red box, and go ahead and put your name and email in that box, and Chris will start sending you those emails right away.

So, Chris, I think just because we’re in this flow right now, I think we should know about what you ate this morning.

What Chris Ate for Breakfast

Chris Kresser:  Yeah.  OK, so I did something a little different this morning, not too different, but I had some rabbit crepinettes.  It seems like every time we record a podcast the last few weeks I’ve been having crepinettes for breakfast.  I don’t do that all the time, but for whatever reason, that’s how it works out.  These ones were rabbit, which was really great.  And sometimes I’ll do plantains fried in ghee or coconut oil that are somewhat ripe, but this time I used a completely green plantain, and I peeled it and then I cut it into 2-inch rounds, and then I boiled it in water for about 15 minutes.  I got this idea, by the way, from the folks at Health-Bent whom I really love.  I love their recipes.  If you haven’t checked out their site, it’s Health-Bent.com, and they just published a new cookbook, actually, via Primal Blueprint Publishing, Mark Sisson’s outfit, which I really recommend.  We’re going to be reviewing it on the site soon.  Anyhow, they, like me, enjoy plantains, and they have a lot of good recipes for green plantains and how to use them in their book.  One of them is plantain fritters, which I’ve been making for a while, but I wanted to try their particular take on it.  So you cut them up into 2-inch rounds and then boil them until they’re soft enough to kind of moosh down.  And you take them out, let them cool a little bit, and then use a plate or some other flat instrument to squash them into fritter shapes.  Then you put a little bit of salt on them, and then you fry them in either duck fat or lard or coconut oil or ghee or whatever.  I used coconut oil this time.  And then I had some leftover steamed broccoli from last night, and then I had half a glass of beet kvass to wash it all down.

Steve Wright:  Sounds pretty gourmet.  I’m coming over.

Chris Kresser:  It was good.

Steve Wright:  I swear I’m coming over!

Chris Kresser:  Yeah, it was good.  The plantain fritters were a particularly big hit with Sylvie, actually.  She really liked them.  If it passes her test, it’s good with me.

Steve Wright:  Then you know it’s going to be a staple on the family menu for a while probably.

Chris Kresser:  That’s right.  It might even make it into the meal plan in my book.

Steve Wright:  Oh, man.  All right, well, did you have some studies that we were going to talk about today before we get to questions?

Surprising New IBS-FODMAP Research

Chris Kresser:  Yeah.  I promise I won’t take up the whole episode talking about studies this time, but there are a couple studies that came out right around the same time that were complementary and kind of interesting, I thought, so I was wanted to go through those quickly, and then we’ll get to questions.

So the first one was a study about the gluten-free diet and how it improves irritable bowel syndrome, diarrhea-predominant irritable bowel syndrome.  There are two different types of irritable bowel syndrome.  There’s constipation predominant and diarrhea predominant.  In this study, they took a bunch of people with diarrhea-predominant IBS, and they didn’t select them on the basis of prior self-reported gluten intolerance, which is good because some studies have done that and it kind of biases the results.  So it was just a random sample of patients with diarrhea-predominant IBS, and they put them on a gluten-free diet.  And they found that the people who followed a gluten-free diet had decreased stool frequency, so their diarrhea improved.  And they also had less gut permeability, so their guts weren’t as leaky.  And they had increased expression of tight-junction proteins that regulate the intestinal barrier, so again that’s another way of saying that the gut barrier integrity improved.  And these effects were greater in people with the HLA-DQ2 and DQ8, which is the genotype that is associated with gluten intolerance and celiac disease.  That’s not the first study that showed that, but it was another study that showed that a gluten-free diet can improve IBS.

This other study, though, showed that a gluten-free diet, while it does help with IBS, it doesn’t help IBS patients that are already on a low-FODMAP diet.  They took a bunch of patients, put them on a low-FODMAP diet, which we’ve talked about before.  FODMAP stands for “Fermentable Oligosaccharide, Disaccharide, Monosaccharide, And Polyols,” and they’re basically specific types of carbohydrates or sugars that are not well absorbed in the digestive tract, and then they can linger around and become food for pathogenic gut bacteria, and if SIBO is present, small intestine bacterial overgrowth, which is one of the causes of FODMAP intolerance, eating a lot of FODMAPs can make it worse, and then studies have shown that removing or greatly restricting FODMAP intake can have a profound effect on IBS.  In fact, I think some studies have shown up to 75% to 80% of patients improve, which is way, way better than any drug treatment for IBS.

So they were randomly assigned to groups, and they were all on a low-FODMAP diet.  But then there was one group that was placed on a high-gluten diet with 16 grams of gluten per day.  And there was another group that was on a low-gluten diet, and that was 2 grams of gluten per day and 14 grams of whey protein a day.  And then there was another group on a control diet with 16 grams of whey protein a day.  And then they assessed different markers of intestinal inflammation and immune activation and then different ways of measuring fatigue.  And this was a crossover study, so 22 of the patients then crossed over and ended up in a different group, so the patients that were on the low-gluten group went into the high-gluten group and vice versa.  And that’s a good way of doing a study like this.  It just strengthens the results.  If you find, for example, that patients in each case that were on the low-gluten diet did better rather than just one group of patients, it strengthens the results.

As suspected, the low-FODMAP diet universally reduced symptoms in everybody, regardless of whether they were eating gluten or not eating gluten.  But reintroducing gluten once FODMAPs were already really restricted didn’t cause any problems in this particular study group.  So there was no difference in symptoms in people on a low-FODMAP diet who were taking supplemental gluten and people that were on a low-FODMAP diet and weren’t taking gluten.

This is certainly interesting.  I mean, does this mean that we should eat gluten?  I don’t think so – you may not be surprised to hear me say that – for a few reasons:  Number one, these results actually directly contradict a previous study that the same researchers did.  It was a placebo-controlled study where they gave patients capsules, some with gluten and some with a placebo powder that didn’t have any gluten in it.  And these patients were also already on a fairly low-FODMAP diet, and they did that to kind of reduce any background noise because these researchers knew that FODMAPs can trigger or exacerbate IBS symptoms.  And in that study, the patients who did receive gluten had more symptoms and were worse off than the patients who didn’t.  So there are two completely different results there.

Steve Wright:  I haven’t seen this study, but do you think that in this new study they just measured the wrong variables or they measured the wrong things?

Chris Kresser:  I don’t know.  I mean, one thing that’s interesting is that they used whey as a control.  And certainly some patients with IBS would be sensitive to whey, in my experience.

Steve Wright:  Oh, yeah.

Chris Kresser:  So I don’t know if that’s an adequate control.  That’s maybe one possibility.  But in a practical sense, most people when they eat gluten, they’re not taking it in capsules, right?  I don’t know anyone who takes gluten supplements.

Steve Wright:  Can you get that on Amazon?  I don’t know.

Chris Kresser:  Yeah, they’re eating wheat, right?  Or other gluten-containing grains.  And wheat is actually a FODMAP.  So patients in the real world, if they’re removing wheat, they’re going to be removing gluten unless they’re eating other… I mean, rye is also a FODMAP, which is another gluten-containing grain.  So from a practical perspective, most of the time, a low-FODMAP diet is probably going to end up being a gluten-free diet.  It certainly is when we talk about it, anyway.  And then there are other studies that show that gluten may be harmful for people who already have disturbed gut function.  So I think this is interesting and definitely worth thinking about, but I wouldn’t really change any of my recommendations.

Steve Wright:  Well, it’s also interesting to think about what you just hit on there, which is that there are lots of other substances in wheat.  We know that gluten is an issue for a certain percentage of people, there are also WGA and lots of other protein compounds that could be very reactive to these people.  They just tested gluten, which might be good or bad, but they definitely didn’t test the entire compound of wheat.

Chris Kresser:  That’s right.  That’s a great point.  Actually in the first article of the Beyond Paleo series, which you always mention at the beginning of the show, I talk about all those different compounds, proteins in wheat and how many people can be sensitive to wheat germ agglutinin or other agglutinins or other types of gliadin that aren’t typically measured, so definitely that could be one issue.  But like I said, from a practical perspective and a clinical perspective, most of my patients with gut issues not only do better without gluten-containing grains, they just do better without grains altogether.  Some of my patients do fine with properly prepared grains, like in the Weston A. Price tradition, but I would say the vast majority of my patients with gut issues can’t even tolerate those very well, and they just seem to make the gut inflammation worse.  There aren’t a lot of comparative studies on patients with gut issues that are doing properly prepared soaked and fermented grains versus typical processed grains or even whole grains that aren’t soaked and prepared that way, and there probably never will be, and that’s where we rely on clinical experience and even anecdotal reports.

Steve Wright:  Yeah, I would add in about another 10 to 20 thousand reports from my experience over the last four years talking with people with gut issues.

Chris Kresser:  Yeah.  But as always, my recommendation is to go a period of time without any of that stuff, and then if you really want to try it and add it back in, go for it and see how it works.  And like Steve and I are saying, in most cases it doesn’t work very well, but if you’re one of those few cases where you can tolerate it, then there isn’t a ton of research that shows that eating soaked and fermented whole grains is going to really contribute to any diseases.  There just isn’t a lot of research that implicates those foods in modern disease.  Certainly in populations that are eating a large portion of their calories from grains, as happened in the early transition to agriculture from hunter-gatherer societies in some parts of the world, that’s going to be a big problem because grains are much less nutrient dense than animal products and vegetables and fruits and nuts and seeds.  And so if you are eating the majority of your calories from grains, you’re going to end up being nutrient deficient, and that’s what happened with a lot of those populations.  But if you’re eating a small amount of properly prepared soaked, fermented grains, which breaks down the phytic acid, which is what inhibits some of the absorption of the nutrients in grains, in the context of an overall very nutrient-dense diet, like a paleo diet, there’s little evidence that suggests that would be harmful in terms of promoting disease.  Like I’ve said, my clinical experience suggests that people with gut issues and also autoimmune disease who already have chronic diseases do better even without those foods, but that doesn’t mean that they contribute to the modern disease epidemic.  I think that’s a bit of a stretch, people who have made those claims.

Steve Wright:  All right.  Well, we should probably stop talking right now and go to questions because you promised the listeners.

Chris Kresser:  I know.  Let’s do it.  Let’s go.

Steve Wright:  No, but thank you for walking through those new studies, and I think that just keeping the listeners up to date on this new research is huge.

Chris Kresser:  All right, we’ll keep it up.

Food Allergies and Testing for Inflammation

Steve Wright:  Cool.  Well, this first question comes from Michael.  Chris, he would like to know:  “Regarding food allergies and intolerances, specifically casein and coconut and using ghee and coconut oil.  Although I’m allergic to the proteins in both dairy and coconuts, I’ve been using both ghee from Pure Indian Foods brand and coconut oil without any noticeable problems.  I would like to include them in my diet for obvious health benefits.  However, I question whether or not they might be causing some low-level inflammation and/or immune problems, basically doing more harm than good.  I’ve done an elimination diet for other foods, but I think it’s too hard to objectively tell if these are causing a problem.  Am I better off just avoiding these foods altogether?  Is there a test that can be done for low-level inflammation and immune markers?”  What do you think?

Chris Kresser:  I think it’s really unlikely that, Michael, you’re reacting to casein and any of the proteins in those products because, number one, ghee is basically casein and lactose free.  It can be classified that way when it’s sold.  I think they’re even allowed to put “casein and lactose free” on ghee because it has such a small amount that it’s going to be negligible except for people who have the most intense kind of allergy – not an intolerance.  I’m talking about a real casein allergy where they would have a significant IgE-mediated response.  And if you had one of those types of allergies, you’d probably know it already.  And if you didn’t know it, you would have a noticeable reaction when you ate it.  And it sounds like you don’t, which leads me to believe that these are probably perfectly fine for you.  The same with coconut oil:  The fat is likely to have a negligible amount of protein, and since you don’t have any noticeable problems and since these are indeed very healthy, nourishing fats, I think there’s no reason not to include them in your diet, and I don’t think any testing would be helpful or necessary in this case.  Given that you’re not reacting and given that it seems that you don’t have any particular issue with these foods, I think it’s highly unlikely that there would be any result on any test that you would do.

Steve Wright:  And if someone did want to test for just inflammation markers, do you have any thoughts there?

Chris Kresser:  Well, there isn’t really any perfect way to do that.  I mean, C-reactive protein is a systemic inflammatory marker.  That can be elevated in some cases, but not all.  I’ve had patients with raging gut inflammation, Crohn’s disease type of problems with normal C-reactive protein, so it’s not always reliable that way.  If it is elevated, it does suggest that there’s some kind of inflammatory process happening, but it can be elevated even by a virus, like a common cold.  It’s a helpful marker.  It can be useful.  You just have to understand its limitations.  And you have to get tested at least twice and preferably three times to really have a sense of what it is because there’s so much intraindividual variation, which means it can change a lot from reading to reading in a given person, in part because of the factors that I just mentioned.  So C-reactive protein is one possibility.

Interleukin-6 is another general systemic inflammatory marker.  I will sometimes run that on patients.  Ferritin, which is the long-term storage form of iron, can also be elevated in the inflammatory response because it’s an acute phase reactant, just like C-reactive protein, which means it’s a type of protein that’s elevated in the inflammatory response.  So if I see a patient that has high ferritin but other iron levels are normal, I’ll usually suspect that there’s some inflammatory process happening.  You can also do CD4 and CD8 immune panels, which measure the ratio of certain white blood cells and can be indicative of inflammation.  You can do a sed rate, erythrocyte sedimentation rate, or ESR, which is another way of measuring inflammation, but this should all really be done, especially those last tests should be done under the supervision of a healthcare practitioner who knows what they’re doing because some of it can be difficult to interpret.

All of that said, in most cases, inflammation is kind of one of those things that, with the exception of cardiovascular inflammation, which isn’t symptomatic, most other types of inflammation is symptomatic and you kind of know when you’re inflamed, and the tests are just there to confirm that and maybe track the results of the treatment.

Steve Wright:  That makes a lot of sense.  And when you’re talking about C-reactive protein, do you typically test highly sensitive C-reactive protein, or do you find that the regular CRP is good enough?

Chris Kresser:  I typically do high sensitivity.  That’s called hs-CRP, high-sensitivity CRP.  That’s a better marker.

What to Do about Chronically Chapped Lips after Taking Accutane

Steve Wright:  Gotcha.  Awesome.  Well, hopefully that helps him out, and we’ll move on to the next question now.  This question comes from Jim.  “Hi.  I’m a 29-year-old male, and I took Accutane back in high school about 10 to 11 years ago.  As expected, soon after I started taking Accutane, I began to experience dry eyes, lips, and skin, which my dermatologist told me was only temporary.  Once I stopped taking Accutane, these symptoms would definitely go away, she assured me, nothing to worry about.  I also started experiencing indigestion for the first time in my life.  So right at the end of my senior year of high school I stopped taking Accutane, and I was looking forward to seeing these symptoms go away, but they did not.  I had to stop wearing contacts because my eyes became too sensitive to handle them.  For several years after I stopped taking Accutane I had redeye and inflammation in my eyes that was very uncomfortable.  For many years, I also experienced fatigue after eating a meal.  I reckon there was some mild depression in the mix, too.  After adopting a paleo diet with digestive enzymes a couple years ago, the health of my eyes improved by about 95%.  I still can’t wear contacts, but my eyes feel good again.  That nightmare is over.  My energy and mood have been great ever since going paleo, and I no longer experience the post-meal lethargy.  But one symptom remains all these years later:  chronic chapped lips.  I have to carry lip balm with me wherever I go and apply it regularly throughout the day.  I reckon this is related to something along the lines of a virus, fungus, candida, etc., something to do with a compromised gut caused by or exacerbated by my Accutane use.  Chris, what do you think the culprits may be?”

Chris Kresser:  Well, I’m sorry, Jim, you had to go through that.  Accutane is probably one of the most toxic and dangerous drugs there is.  You might be aware that there have been class action lawsuits against the manufacturer of Accutane with claims that it causes Crohn’s disease, and there’s some evidence to back that up.  I actually have a few patients who developed Crohn’s disease after taking Accutane when they were in high school and several other patients with pretty similar symptoms to what Jim is experiencing.  So anyone out there who is listening to this and is considering Accutane or knows somebody that is considering Accutane, I would strongly, strongly urge you not to do it and to look into alternatives.  I know when you’re a teenager and you have acne, you’re willing to do just about anything to get rid of it, but as Jim has pointed out here, the consequences of that can be lifelong.

I’m not exactly sure what’s happening here in terms of the ongoing chapped lips.  I think Jim’s theory is probably as reasonable as what I would come up in this situation.  It certainly seems to be gut mediated, and like I said, because Accutane is associated with Crohn’s disease, it seems reasonable to assume that there are some significant changes that happen in the gut after taking it.  The testing that might be helpful in this situation could be an organic acids dysbiosis profile from Metametrix to look for SIBO or dysbiosis, a stool test from Metametrix or BioHealth or both to look for a fungal infection or opportunistic or pathogenic bacteria or parasites.

Not that this has anything in particular to do with Accutane, and I’m not sure if there is any mechanism that would explain how Accutane would disrupt essential fatty acid metabolism, there may be, but I wonder about DHA and EPA and the long-chain omega-3 fats from cold-water fish or fish oil or cod liver oil.  I’m not sure if you’re already doing that and you’ve tried that, but that might be something to try as well.  But I think focusing on the gut is probably a good place to start.  In Chinese medicine there’s actually a connection between the gut and the mouth and the lips, and again, I don’t know how to explain that in conventional terms, but I’ve actually seen in many cases that acne, especially around the mouth, and chapped lips and things like that often do have some relationship to gut health.  We’ve talked a lot about the gut-skin connection in general, but I find that in particular that area right around the mouth seems to be related.

Steve Wright:  Well, just my two cents, but being a ChapStick baby all the way through growing up and never being without a ChapStick in my pocket, over the last four years as I’ve conquered most of my health concerns, I no longer use ChapStick.  I don’t need it anymore.  And I used to have ridiculous chapped lips.  I think the two things that really helped me were, one, I learned that through being chronically sick I hardly ever breathed through my nose, and so I’ve had to slowly retrain my processes of having my mouth closed and breathe through my nose.  Otherwise, if I get a head cold or something, my lips begin to get chapped again because they’re open all the time.  So I think just healing up through the gut as well as in my case I think there was at least some manual breathing stuff that I’m still working on.

Chris Kresser:  Yeah, I think that makes sense, too.

When Is Cholesterol Too Low?

Steve Wright:  All right.  This next question comes from Judy.  “Hi, Chris.  I’m a 52-year-old who has been overweight all my life.  I have greatly moved away from the standard American diet in the past two years by reducing sugars and grains and eating more whole foods.  But even back when I ate everything in the book, my cholesterol levels were always low.  Total cholesterol over the years has been in the 130s and 140s with the highest ever being at 162 back in 2011.  My HDL is always higher than my LDL, and triglycerides mostly nonexistent in the 20s and 30s.  The traditional lipid panel is what I have access to through my primary care doctor.  My most recent numbers in December 2012 show a 138 total, 53 LDL, 79 HDL, and a cholesterol/HDL ratio of 1.7 with triglycerides of 31.”  Chris, do you have anything that you can help her with there?  She really wants to know about how low is too low.

Chris Kresser:  Well, in the scientific literature, you start to see an uptick in depression, suicidal ideation, aggressive behavior, some cancers, etc., when cholesterol drops below 150, but we always have to remember that those are observational studies and they suffer from the same potential confounding factors that the early observational studies that suggested that high cholesterol was the cause of disease suffered from.  There are certainly plenty of mechanisms that could explain why low cholesterol would contribute to disease because cholesterol plays so many important roles in the body and especially in the brain, so it’s very plausible that cholesterol levels under 150 might be problematic, but there’s not a ton of direct evidence about that.  And there’s also some suggestion that different cholesterols in different people will have different effects.  So maybe 135 or 140 is fairly normal for Judy, but if another person’s cholesterol was that low, it would be problematic.

One thing to investigate is liver function.  Poor liver function can lead to low cholesterol.  Dietary intake of cholesterol may or may not help because it’s sort of the other side of the coin here.  We’ve talked a lot about how eating dietary cholesterol doesn’t raise cholesterol levels, and that means that if you’re worried about high cholesterol, you don’t have to worry too much about eating a few eggs a day, for example.  But it also means that if you have low cholesterol, eating a significant amount of dietary cholesterol may not solve the problem.  Now, it often does if people were on a low-cholesterol diet.  So if they’ve been on a vegan diet or a vegetarian diet without any eggs and they start eating cholesterol and more saturated fat, usually I see an increase in cholesterol in those people.  But if someone’s already eating a paleo type of diet with eggs and a fair amount of cholesterol-containing foods, then eating more cholesterol may or may not have that effect.  But you could try adding a substantial amount of coconut oil to your diet, maybe 2 to 4 tablespoons a day, and you could also try adding some more cholesterol-rich foods, like egg yolks, to see if that has any significant impact.

Given that the cholesterol level has been steady over a long period of time across lots of, it sounds like, different dietary approaches, I probably wouldn’t worry about it.  And assuming you’re healthy and feel good, I’m not sure that I would worry about it too much.  The Maasai, I think, had average cholesterol levels of about 140 to 150, and they were free of modern disease, so that’s not too far off from where they are.

Does Over-Training Cause Acne?

Steve Wright:  OK.  Well, hopefully she’ll be able to play around with that and get some more tests in maybe to find out if the numbers go up and she feels better.  OK, this next question comes from Anonymous, but I think that a lot of listeners will be able to relate to it.  It says:  “Hi.  I’m 28 years old.  I’ve been training for about 2-1/2 years, and for the last 1-1/2 years I’ve been eating a paleo-style diet.  For about 10 years I suffered from acne until I got isotretinoin.  That was about 4 years ago now.  Since then I’ve turned my training frequency up to about seven times per week, and my acne has returned.  Is there a possible connection between training frequency and acne?  In other words, do heavy workouts equal inflammation which equals hormonal disturbance?”

Chris Kresser:  Absolutely, there is a connection.  Last year I did a talk at the Weston A. Price conference, Nourishing Traditions, on the gut-brain-skin connection, and I did a similar talk at PaleoFX this year, a kind of shorter version of it.  The skin is a remarkably sensitive organ.  It presents the largest interface with our environment.  It’s exposed to a wider range of stressors than any other organ, and this exposure happens pretty much 24/7 throughout our entire life.  It’s really well innervated and sends a large volume of signals to the sensory cortex in the brain, and then a lot of neuropeptides in the skin share a common embryonic origin with neuropeptides that are produced in the brain.  There are numerous skin conditions that are associated with stress, including psoriasis, dermatitis, alopecia, urticaria, vitiligo, and acne among others, and we know that the skin is influenced by neuropeptides and hormones like corticotropin-releasing hormone, adrenocorticotropic hormone (ACTH), cortisol, catecholamines like epinephrine and norepinephrine, substance P, and nerve growth factor.  And many of these are part of the stress response, particularly CRH, ACTH, cortisol, and the catecholamines.

So certainly a scenario where you’re overtraining, that basically triggers a stress response because training is a form of stress and it can be hormetic in moderate amounts, meaning it induces a positive adaptation, but when you do too much of it, it can become a chronic stressor, a negative stressor just like any other type of negative stress.  And in that situation, the body will respond just as it responds to any other type of negative stress, and those hormones that are produced by the hypothalamic-pituitary axis, or the HP axis, in response to stress can even be mirrored locally in the skin.  This is pretty fascinating, actually.  The skin contains a microcosmic or holographic stress response.  CRH, corticotropin-releasing hormone, which is produced by the hypothalamus during the stress response, is also expressed in the skin, and stress triggers a release not only of CRH, but also ACTH and cortisol in the skin.  And then other studies have shown that the skin has CRH receptors, and that can lead to the stress-induced exacerbation of skin conditions.

This also, as a side note, affects the hair, and the hair follicles have a similar microcosmic kind of HP axis going on there.  The hair follicle turns out to be one of the most hormone sensitive tissues in all of mammalian biology, and of course, that doesn’t exclude humans!  And the follicle is especially sensitive to some of the key stress hormones that we’ve been talking about, which can act as hair-growth modulators.  So hair falling out in men or women can often be a sign of stress and inflammation.

I think there are plenty of clear mechanisms whereby too much stress in the form of overtraining could lead to skin conditions and hair loss, so I would definitely suggest scaling back on the workout frequency and intensity and resting more, making sure you’re getting plenty of sleep, reducing your exposure to artificial light at night, making sure you get some bright light on your eyeballs in the morning to help reset the circadian clock, making sure you’re eating enough because if you’re training at that level, another common problem is that people aren’t actually getting enough calories to support their activity level.  Maybe eat some extra protein to help with muscle recovery, and take it easy for a while because your skin seems to be your barometer.

A lot of us have a particular trouble issue, trouble spot, or maybe more than one trouble spot, and if we’re open to it, that can become our teacher.  For this guy, it sounds like it’s his skin, and if the skin starts to break out and that happens persistently, then that’s the body telling you it’s too much and something’s not right.  For other people, it’s their gut.  For other people, it might be insomnia.  And these are the barometers that we can use.  If we’re open to and we’re aware, we can use it as a way of making adjustments in our diet and lifestyle and supplement regimen to promote better health.

Steve Wright:  Yeah, I think it’s pretty fascinating.  Like you said, I think most people, if they look at things like acne or hair loss as a nonspecific symptom of just your general health, they can track their health pretty well without getting tests done.

Chris Kresser:  That’s right.  One of the blessings of a chronic illness, if you’re willing to look at it this way, is that it can be a powerful teacher.  For me, when I was sick for all those years, it became my spiritual practice, essentially.  My body was so sensitive to changes in my life and my diet and my emotional and psychological state, that I would get instant feedback on what I was doing, what I was thinking, how I was relating to myself, and how I was relating to other people.  And it was a pain in the ass and it was oftentimes where I wasn’t interested in receiving that feedback, but it came anyway and often would come pretty intensely.  And I think at some point when I stopped struggling against that and stopped wishing that it wasn’t that way and stopped being bitter that it was that way, which took a while, I began to really be open to listening on a deeper level and using those symptoms and signs as a really potent reminder that I’m off track.  Even now, years later, when I’m not in the place that I was before, I’m probably more sensitive than a lot of people who didn’t go through something like I went through because it just so profoundly changed my system.  So if I start to get off track and if I’m doing too much work and not doing my stress management and not spending enough time having fun and outdoors and things like that, then I’ll start to notice some weirdness in my gut or I’ll start to develop some muscle fatigue or maybe some difficulty sleeping, and that’s that instant kind of reminder that I need to come back to the place that I know works for me.

Steve Wright:  Yeah.  I think it kind of happens to all of us.  I actually just got a recent reminder of that.  I’ve been pushing pretty hard for the last few months to do SCD Lifestyle full time, and two months ago, right before PaleoFX, I had about three weeks of the worst GI issues I’ve had in a long time.  My old symptoms from before I started any work on recovering my health kind of came back, and it was just because I was working 14 or 16 hours, 6 or 7 days a week, and just wasn’t doing the things that I needed to do.  It was a really good kick in the butt for me.

Chris Kresser:  It does happen to most of us who have dealt with chronic disease, but there are actually a lot of people out there who appear to be able to get away with a lot.  In other words, they don’t have the blessing or the curse, depending on how you’re looking at it, of this kind of chronic illness type of symptom presentation, and so the feedback is not as immediate for them.  They might be able to get away with months or even years of that kind of behavior, and then they have a heart attack and die.  It can manifest in a really different way in different people, and that’s why I do actually sometimes see the sensitivity that some people with illness have developed as a blessing.  It’s a little bit like the canary in the coalmine because I’m sure we all know these people who seem to be relatively healthy in spite of a really poor diet and hard lifestyle, and then all of a sudden, something relatively tragic happens.  Either they didn’t get the signs or the signs were coming but they were subtle enough that they could be ignored.  So I think if you have one of these things that can be extremely irritating and irksome, learn to use it as a guide and as a teacher and a reminder because there’s actually, believe it or not, some good fortune that can come from that.

Steve Wright:  I think that’s 100% how you have to think of it.  I think that’s the only way you get through to the other side.

Chris Kresser:  Exactly.

Naturally Overcoming Alopecia Areata

Steve Wright:  I don’t think you can do it any other way.  OK, let’s roll on to this next question from Brian.  “About three months ago, I looked at my scalp in the mirror, and I noticed a large bald spot on the top of my head that essentially came out of nowhere.  I made an appointment with my dermatologist and was diagnosed with alopecia areata and was given a topical cream called Elidel.  Over the subsequent three months, the spot has gotten bigger and I’ve developed two additional bald spots.  I’m perplexed as to why this is happening since I have been strict about my diet.  Sure, I ‘cheat’ now and then, but my typical diet consists of two pastured eggs in the morning with bone broth, a fruit and vegetable smoothie, a large salad with a piece of lean meat for lunch, and usually a piece of grass-finished beef with vegetables for dinner.  I’ve also started adding coconut oil and sea salt to most of my meals since I heard that they might help, too.  On top of this, I’m taking many of the supplements recommended in your ‘Supplement Wisely’ post in addition to a probiotic to help my gut.  Still the problem continues to get worse.”

Chris Kresser:  Yeah, so for those of you that don’t know – I imagine Brian does – alopecia areata is an autoimmune disease, so it generally involves hair loss, patchy areas around the body.  It typically starts on the scalp, but in rare circumstances, which is called alopecia areata totalis, it can affect the entire body to the point where there’s not a single hair to be found on the body anywhere.  In fact, Moises Velasquez-Manoff, who came on the show recently to discuss the hygiene hypothesis and old friends, has alopecia areata totalis, and that’s one of the things that led him to want to try helminth therapy.

I know I’ve discussed this before on the show, but there’s no question that a good diet is the cornerstone of health, and wise supplementation and getting plenty of sleep and getting enough exercise and spending time outdoors and connecting with other people – all of that is really important to good health.  But unfortunately, it’s not a guaranteed protection against disease.  It would be lovely if that were the case.  Don’t we all wish that that was the case?  But the reality is there are a lot of factors that affect our susceptibility to disease that we have no control over, at least in our adult lives.  For example, if we were born via C-section, that can increase the risk of disease, and of course, we didn’t have any say in that.  If we weren’t breastfed, that can increase the risk of disease.  We didn’t have any say in that.  If we weren’t exposed to these old friends… More and more research now suggests that early exposure to saprophytic mycobacteria, like bacteria that we would find in the soil and mud in cowsheds on farms, exposure to helminths like hookworm or whipworm, there’s a lot of evidence that our immune system actually requires these things to function properly, which, I know, is just kind of a head-spinner if you haven’t been following along with some of the stuff we’ve talking about recently.  Most of us didn’t have any control over that.  If you were raised in the Western sanitized, hygienic world where hookworm has pretty much been eradicated, if you grew up in an urban area and not on a farm, if you didn’t have pets or you didn’t have siblings, all of those things can lead to a higher risk of autoimmune disease, allergies, asthma, and things like that.

And then there are genetic predispositions.  The genetic predisposition isn’t enough to trigger the disease on its own because these genetic predispositions have been around for a long time, including times where these diseases were rare, if not nonexistent, so clearly it’s some combination of genetic predisposition and a lack of old friends, poor diet, exposure to environmental toxins, not enough sleep – all of the things that characterize the modern lifestyle.  So it’s very possible that Brian is doing everything right, and unfortunately because of some combination of genetic predisposition and some of the factors that we’ve been talking about, he has developed this autoimmune condition.  And that’s really a bummer.  There’s no other way to put it.

So the question now is, what can he do to treat this and to try to slow the progression?  Certainly all the things that he mentioned are an excellent start, and I think he’ll fare much better than people who have alopecia who aren’t doing those things, but there are some additional things to consider that could have a beneficial immunoregulatory effect.  We’ve talked about low-dose naltrexone several times on the show before.  There are no studies about LDN, or low-dose naltrexone, in alopecia that I’m aware of, but most of the mechanisms of autoimmune disease are the same and they just affect different tissues in the body.  In this case, it’s the hair follicles.  So I think looking into that would be wise.  Ensuring optimal glutathione levels because glutathione stimulates T regulatory cells, and the T regulatory cells are often malfunctioning in autoimmune disease, so either using some grass-fed, non-denatured, bioactive whey protein, like about a quarter of a gram per pound of bodyweight per day, to boost glutathione levels.  You can take glutathione precursors, like formulas that have alpha-lipoic acid, and things that improve glutathione recycling, like milk thistle.  And there’s a new form of glutathione, which we discussed on a previous show, called S-acetyl glutathione, which unlike most other forms of oral glutathione supplements, this actually gets glutathione inside of the cell, which is where it needs to get to have its beneficial effect.

Those are some things to do, and maybe someday helminth therapy might be an option.  It didn’t actually help Moises with his alopecia, but he has one of the most extreme cases that you can have, and it’s possible that helminth therapy could arrest the progression of a more mild case of alopecia.  If you want to learn more about that, you should read his book called An Epidemic of Absence, which is a fantastic book.  In science right now, in the research community, they’re basically trying to find ways of mimicking the effects of helminths without actually infecting people with helminths, which I think is a good goal, but I’m not even sure how necessary that is because helminth infection has been shown to be overwhelmingly benign in people that are well nourished.  It can cause symptoms in people that are undernourished and rarely in people that are well nourished, but it’s remarkably safe, and there are still 2 billion people around the world infected by helminths, many of whom don’t have any symptoms.  Up until the 1930s and ’40s in Western Europe, I think something like 40% of 45% of the population was infected by helminths, and then in the US, up until the turn of the 20th century, a large percentage of the population was infected.  So these are organisms that have been a part of our GI tracts for as long as we’ve been human, and they’ve actually been colonizing mammals for over 250 million years and all the way back to some primitive tetrapods 650 million years ago.  There’s some evidence that certain parts of our immune system, the Th2 arm of our immune system, actually evolved in response to these helminths.  And as I said before, if you follow that to the logical conclusion, it means that we could of outsourced certain aspects of immunity to these organisms, not just helminths, but the soil and mud bacteria and other beneficial organisms, pseudo-commensals, like probiotics that we find in fermented food, and that when you remove these from the gut environment, our immune system can’t function properly.

So yeah, I think the LDN, the glutathione, and optimizing vitamin D levels, because vitamin D also stimulates T regulatory cells, would be the first place to start.  And I think finding a practitioner that’s skilled in working with autoimmune conditions would be a really good idea at this point.

Steve Wright:  Yeah, I mean, we obviously don’t know Brian’s history, but it seems like he could definitely benefit from some basic hormone testing.  After talking with lots of clients and lots of people, it seems like anyone that tells me that their autoimmune condition is worsening, there’s usually a lifestyle factor that the stress is kind of creeping in one way or the other, whether it’s emotional or physical or something.  And so I think it might be a really good idea for him, a low-cost way, of starting to commit to a meditation practice or yoga practice to help slow that down as well.

Chris Kresser:  In my book, I feel like I’m a broken record because in just about every chapter I’m talking about the correlation between whatever I’m writing about and stress.  It’s mind boggling when you really look at the literature.  I think chronic stress is probably one of the most important risk factors for disease, and it gets a lot of lip service, but I think it’s really underappreciated as a risk factor.  And we’ve talked about this before, but in my patient population, I often will talk to patients and say:  OK, so have you been doing your stress management?  And they’ll kind of go:  Um… kind of.  And they feel guilty, and I’m like:  Look.  I’m not saying this to make you feel guilty or bad.  I’m just trying to share my experience both in my own healing process and in all the work I’ve done with my patients how crucial this really is.  People are gung-ho about changing their diet and taking supplements, but stress management is often the first thing to fall away and the last thing that gets adopted.  And in many cases, I think actually adopting a stress management program could even have a greater impact than making the last 10% tweaks on the diet or switching the supplement regimen around.

Steve Wright:  I would say that for the longest time I’ve been a part of that group of your patient population that can’t seem to commit to a daily stress-reducing program, but I’m still working on it!

Chris Kresser:  Yeah.  Well, it’s always a work in progress.  For myself, it’s a lesson I’ve learned so many time that I’m relatively good about it, but I’m human and I go through periods where I get really busy and it falls away a little bit, and I suffer the consequences.  Certainly the most challenging time for me, I think, was Sylvie’s first year, first year and a half.  Up until then, I had an extremely consistent sitting practice, meditation practice since I was 17.  I basically sat every day for 20 years before she was born, and all of a sudden when she was born, my world turned upside down in all of the most blissful and beautiful ways, but it was very difficult for me to maintain that in the midst of doing everything else that I’m doing as well, like my practice really growing and thriving and book writing and all that stuff.

The goal is just to keep trying, like you said, Steve, and not to beat yourself up if you’re not doing it because that just, of course, psychologically make it less likely that you’re going to do it.  And as we’ve discussed before, a little can go a long way.  I think a lot of people make the mistake of trying to commit to too much at first.  They say:  OK, I’m going to meditate for an hour every day!  And that’s great, but especially if you’re starting out, that’s probably too much to commit to, and you’d be a lot better off just saying:  I’m going to do it for 5 minutes.  And then as you start to experience the benefits, you can extend the time, and that’s just a generally more successful, effective way of making a lifestyle change.

Steve Wright:  I can say that I have fully learned that lesson.  Yeah, don’t try to change everything at once.

Chris Kresser:  Yeah, that’s usually a recipe for a lot of starting and stopping and on-the-wagon, off-the-wagon type of thing.  Just start with a few minutes a day.  And I recommend setting an alarm if you’re going to do meditation.  You sit down and set the alarm for whatever it is, 4 minutes, 5 minutes.  And when the alarm goes off, you stop.  Even if you’re feeling good and you want to keep going, just stop.  Because if you keep going when you feel good, then the corollary of that is that you’ll stop when you don’t feel good.  Just set the alarm and stick with that.  And then the next week or whenever you decide to increase the time, set the alarm and stick with that, and then just gradually increase, and before you know it, it’ll be like brushing your teeth.

Steve Wright:  Awesome.  I might have to give it a go and then report back in a few shows.

Chris Kresser:  Please do.

Steve Wright:  All right.  Well, I think that’s a wrap for today.

Chris Kresser:  That’s a wrap.

Steve Wright:  Great.  Well, if listeners want to get more from you in between shows, they can go over to Facebook.com/ChrisKresserLAc and Twitter.com/ChrisKresser.  Is there anywhere else they can connect with you?

Chris Kresser:  I think that’s pretty much it right now.  Of course, there’s the website, ChrisKresser.com, if you haven’t already been there.  It’s really amazing to see how the community has grown.  The comments now, unfortunately I don’t have time to regularly respond, and if I did, that would be all that I did because there’s such a great thriving, growing community of people that are on there leaving comments and discussing different posts and stuff, so make sure to check that out if you haven’t already.

Steve Wright:  Great, and we want to thank everyone for sending in your questions to make these podcasts happen.  And I want to let you know that I still have all your questions, and we’re going to continue to keep going through them.  If you’d like to send your question and this is the first time you’ve listened to this, go over to ChrisKresser.com and there’s a link called the podcast submission link.  Go ahead and click on that and send your question in there.  And if you enjoyed listening to the show, please head over to iTunes and leave us a review.

All right, Chris, I will talk to you on the next podcast.

Chris Kresser:  Sounds good.  Enjoy your first few weeks of freedom!

Steve Wright:  Thank you!

  1. I gotta say Chris you are amazing. Thank you so much for everything you do. I know the chronic disease was hard in the beginning but I think you have far exceeded anything possible. You are an inspiration to me. Thanks again!!!
    Heidi Savage BSc, R.H.N
    Registered Holistic Nutritionist in British Columbia

  2. Regards over-training and acne, I agree with you, there is a direct connection between two. I think over-training may cause a lot of health problems, not only acne. The question is what do you mean “over-training”? If you’re training for every day but you have enough time to rest and sleep, I think it’s ok. But if you don’t sleep enough and feel tired, it’s not good. At night our body is making reboot and also our skin. Very important to have enough time to sleep.

  3. To Jim who had the question about chapped lips… You may find it helps to remove mint, camphor, menthol and other “cooling” ingredients. I use Blistex Silk and Shine. I feel that I don’t get so “addicted” to it. Good luck!

  4. With regard to the question on low cholesterol. I have a liver disease and have had historically LOW total cholesterol numbers as well, even when eating every sad food in the books. If I remember correctly, the last physical I had was about 7 years ago and my total cholesterol was 98, HDL was around 36 and Triglycerides were around 50.
    I found out about eating clean and have followed a pretty strict Paleo template for 2 years and 5 months, high in saturated fats from good sources. Finally had a standard preventative medicine physical a few weeks ago and was pleasantly surprised at my total cholesterol number of 174! HDL – 72; LDL – 92; VLDL – 10; Triglycerides – 50; T. Cholesterol/HDL ratio – 2.4. Other markers such as vitamin D, Hemoglobin (which used to be high 15+), Calcium, Proteins, etc were all within normal ranges. Urinalysis was also CLEAN! Liver enzymes were of course elevated, but no more than usual (AST – 69 and ALT 65), those numbers have been as high as 100x normal in the past.
    I wanted to let you know that yes, eating very clean can improve cholesterol numbers that might be considered too low…

  5. What about white rice congee (a super simple carb) for those with gut problems as your only grain?

  6. Chris, for the question about the chapped lips…what about the balm he is using? If there is mineral oil in the balm, it has the effect of furthering the drying of the lips. Simple, but I think it is worth a try to switch to something with natural oils, if that is not being used.

  7. Ok, so where to go next? Gluten free 16 mos, Dx micro colitis, diarrhea 6-8 times a day. No improvement with paleo, gluten free, lactose free diet. No improvement with prednisone or budesnonide, pepto, asacol. GI docs want me to increase steroids that have not worked in past. Tried chiecken broth diet, FODMAPS, no improvements. what now? Ideas???

    • cc,

      That sucks, I’m really sorry to hear that! Have you had a stool test done? I think the Metametrix GI Effects stool test is pretty good, and it would tell you if you have any parasites or bacteria that might be contributing to your problems. Have you experimented with different probiotics and fermented foods? VSL#3 is supposed to be pretty powerful, but it’s ridiculously expensive because it’s been studied (and found effective) in UC patients. And I’ve heard good things about soil-based organisms…I think the brand is Prescript Assist? If I were you, though, I’d really try to get the stool test done first, because then you’ll know (to some extent) what your gut flora is doing, and be able to better judge what sort of antimicrobial/probiotic therapy you want to try.

      Diet wise, have you tried a super low fiber diet? But then you’ll be missing out on prebiotics, which is less than ideal. Also, are you very low carb Paleo? You need enough glucose to produce mucus which protects your gut, so if you aren’t getting enough through ‘safe starches’ it might be worth adding some. But it sounds like you’ll probably need more than just dietary changes to heal your gut.

      Hopefully something in there will be helpful! I really hope you can figure it out and don’t end up needing the steroids. They’re no fun.

  8. with regards to the acne+training – I’m thinking there other possible links
    1. Right after training your gut is more permeable than at other times – if you take in post workout nutrition maybe things (like whey protein) that would normally not be a problem are more readily absorbed?

    2. training promotes IGF 1, which can promote acne

  9. Hi,

    That was very interesting. Since I also have alopecia areata I have a question.

    For me, and it seems many people, the greatest issue is emotional stress. But I wonder if low carb dieting can exagerrate the symptoms. Do you have any thoughts?

    Also there seems to be some signs that zinc supplements may be useful in some cases, what do you think of that?
    http://www.ncbi.nlm.nih.gov/pubmed/1971470

  10. Chris,

    This comment is not related to this podcast. Thanks for your sexy back summit topic on adrenal fatique. I was able o purchase all the supplements you recommended. Do u also recommend progesterone replacement ? I’m a f 28 yrs old was diagnosed with 2 nd stage af. I eat paleo x 1 year. I have lots of Pms symptoms after ovulation all the way till the end of my period, pretty miserable, mainly swelling and muscle cramps. Progesteone relieves my symptoms greatly but I gain weight from it. Any thoughts ?
    sorry for bugging you about this, I have seen 2 naturopaths and have not had any relief with their treatments. I simply can’t just wait on your wait list too miserable. Thanks a lot.

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