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Hello gut check project fans and KB MD health family I hope that you're having a great day. It's now time for episode number 60. Soon to be joined with my awesome co host Dr. Kenneth brown board certified gastroenterologist and we are digging in to my colony Yes, kicking it off to fun guys talking about fun Gus so let's get straight to it. I think that you will really like the series which we are about to kick off So with no further waiting let's get into the people that pay the bills are trying to get your daily polyphenols and artron to go to love my tummy.com slash KB MD. Get your very own polyphenols from artron to love my tummy calm today. Second, of course go and feel like great food. Don't forget that you can always head over to unrefined bakery calm or you paleo eater. You can't tolerate gluten you want just some great bread but you're worried about the way there's gonna make you feel unrefined a bakery, take 20% off your entire first order it unrefined bakery.com use code gut check and save 20% for your entire first order unrefined bakery.com And last but not least, head over to KB m d health.com. For your very own Dr. Brown signature packages artron teal CBD from KB MD health as well as the only professional curcumin added to broccoli. That's right so if you're feigns for you, your health use code GCP for 20% off of any order a short intro because we're kicking off an awesome series here no guest today so we're going to get straight to the to the information for about mycology and fungus. There's over a million different types of mushrooms which you may or may not be aware of, however, does tune in Episode 16 starting now.Hello KBMD health family and gut check project fans. It's time now for Episode Number 60 with my awesome co host here, Dr. Kenneth Brown. I'm Eric Rieger. Dr. Brown, I think with this episode number 60 we must be a couple of fun guys.that's a that's a pretty good pun. Because today we're talking fun guy.We are talking aboutmushrooms. So we're it's pretty exciting. I was watching on Netflix of a show called fantasticfungi. logs. It was talking about that.Yeah. And so a lot of people if you get a chance go and take a look at this. Paul Stamets I learned about this pre COVID when Paul Stamets went on Joe Rogan. And at that time he was talking about it and they're trying to raise money. So I rent or I purchased the movie, sure through Amazon Prime or one of those and watched it. Because they're supposed to go to various locations and show it at theaters like yeah, like in like in really cool locations, and outdoor theaters and stuff like that COVID hit, didn't get a chance to do it. And now it's on Netflix so you can see it. It's great. But what it does show is just how complex fungi are and the whole kingdom of fungi, which includes the mushrooms, which everybody thinks of them as mushrooms, and we're gonna get into that a little bit. But today we're gonna talk about that and not just kind of what they talked about. I mean, there's a lot of stuff in the medium right now about magic mushrooms and different things like that. But we're gonna talk the nutritional aspect, because an article just came out recently and I think you're gonna start seeing a big push of people discussing Well, how do we use this as a functional food, and that's what I want to get into today.That's huge and interesting, because growing up, I think that my only exposure to mushrooms were if they happen to come in a soup or if it was a you know, a portabello or a baby Bella or just a traditionally a white Texas mushroom and really didn't know much else than if they grew in the yard. And of course your mom was like, don't touch those are probably poisonous. So I I think it's kind of amazing how people kind of transitioned on this is actually something that can be very, very beneficial given the right circumstance.Absolutely. It's so cool. There's so much science with it. And you're right like it could be poisonous. Unfortunately, a good friend of ours, Dr. Rusev, Ron, a gastroenterologist in San Antonio, if you're anywhere in that area, make an appointment with him. He's amazing. His chocolate lab ate a skullcap I believe in cause liver failure. And his poor dog is really close to his dog and so that happened to our pig.Oh, that's right. Snoop hoggy, hoggy,hoggy hog you have pig wedid and Snoop Doggy hog a to death cap and it's very sad but it literally followed the the timeline of what happens when a mammaleats exists. skullcap or death tap is a call to death camp.I was assuming skullcap was another one I didn't really know butI'm barely getting into the one You can eat, let alone a boy,but you're not supposed to. So they, I think the death caps, at least in Texas, they'll follow the tree roots of oaks or post Oaks. And we've got a lot of okay. And so we're where we lived at that time. And so he was kind of lethargic for a day or two. And then there was about three days where he was really energetic and hyperactive. And I hated to see it, but it's almost like there's this turn, it's about a six to seven day rule. There's not a lot he knew.Regardless, I was just sitting there this morning, actually, this morning, I was doing the like news feeds. And of course, something always makes it up on Reddit. There's a woman in Taiwan where her landlord won't fix the leaks. And she was showing pictures of her bedroom, where the leaks are coming down to the wall. It's becoming a whole wall. It's a mushroom growing apartment, Natalie. Yeah. And she was just showing it's just like strips of mushrooms. And you know, it was getting a lot of comments, like if you you know, is that this will, if that's that, then you can eat it. And that's good news. And other people are like you're just breathing in spores. Pretty sure. Not the best place to have mushrooms all over your bedroom, but it is part of it.I don't know if it is or if itisn't. We'll get into all of this about the beneficial aspect of mushrooms. This is not a show about what what mushrooms can kill you. We're going to talk about how you can utilize mushrooms for your overall health benefit. And I was blown away by how healthy these are like people aren't talking about it. I always thought mushrooms were just something to add texture. And she didn't really think much about it. No. Now, this is really cool, because we're going to even sample a mushroom dish that has the nutritional value of this is pretty cool.Yeah, I'm excited to sample it again.Speaking of cool, yeah. I want to give a shout out to the wonderful Dr. Christian mill vilem you're that's how you sayOh, yeah, last guess. Yeah,yeah. Kristin. Well, she did something really cool about this now, and she sent us signed copies biohack your brain your Eric says right there dear Eric, left a little message for you. biohack your brain on our last episode Episode 59. Dr. Kristen, it's it's spelled Willem here. It's pronounced the villa Muir, PhD super smart, fantastic woman she sent us both signed copies of biohack your brain. And I think she's gonna end up coming out with addition to after she hears this episode, because I think we can help even biohack your brain more with these mushrooms.They are amazing. Thank you, Kristen, this is this is a very, very nice gift. And I mean, the feedback from that episode alone is really kind of amazing and ongoing. And people are are wanting to learn from her book because we referenced it. But yeah, she'sa smart cookie. And a study just came out today, sort of verifying everything she has in this book study just came out with a huge, huge number of people that showed those people that eat flavonoids, which she discusses correct in her book, significantly decreased dementia later in life. Oh, we talked about polyphenols all the time. But today we're going to come off the whole polyphenol thing and talk a little about mushrooms because I'm just excited. I feel like we're kind of pulling the lid off of this whole mushroom thing, the way that we did with polyphenols, and we keep getting deeper and deeper. Let'sdo it. I'm ready to learn.Yeah. Let's go ahead and jump in. Before we jump in really quick. I was just thinking about this. I I have not seen Mac or Murray around. And just it's odd not to see them or they did everything going okay with Mark and Murray. They are alive. Okay. And they are not in the countrywasn't as in the United States. They are in a country. So everyone is I mean, everyone's susceptible, I guess. And as a family, we took a trip to Panama the country onaverage on the news, those vacation trips look amazing, man, thatis great trip. I mean, it really wasn't wonderful family vacation. And we, we we weren't trying to go around crowds. Unfortunately, we we did have to go through an airport. So I'm assuming that possibly that's where the infection took place. But I don't I don't know. No one knows. But all four of us flew in to Panama City, we immediately get to a rental car. And we drove five and a half hours deep into the jungle down to this whale peninsula. There we served had a great time. And then we set up a test for us to be tested outside of the Panamanian International Airport at the tocumen Airport and we were advised that Be sure and do it outside of the air. Because if someone happens to be positive, you can then quarantine yourself, and then schedule your own subsequent tests to come back. So we did that. The other problem was is when they called to give us our results, we were already in the airport, we didn't realize that there was that caveat. So when informed that Mac was positive on his antigen swab coach that I said, well, do we need to leave? And they basically, we were informed Well, you're already on camera. And you're there. You got to stay. So essentially, Mac was was COVID positive, the pain could have any symptoms. 00 nada, no, no fever doesn't doesn't feel bad. But he and since he's only 17, and not 18, that meant that a parent had to stay. Fortunately for us, Murray does all of her work digitally, almost. And she's able to stay with him. But they are in a hotel room until the end of this week.Did they get to choose their hotel room that sounds neat wasn't necessarily a choice.Wasn't a choice at all. And they are only in the room and Reid and Mack both deserve huge credit because they've kept a great attitude. I don't think I could have pulled it off. But she she took some funny videos when they first got there because when they get their meals, they either flash the lights in the room or they buzz their room and tell them that they can go down the hallway. And this is a this is a very nice hotel. The hotel is not old at all. It's very brand new. It's brand new.It's so it's a Panamanian, COVID Hotel, that's where their quarantine all visitsare seven nice hotels that are quarantine for visitors currently. And they they didn't have to walk down the hallway and then an unmanned elevator appears with their food Emory took a picture of is a very Stephen King. Yeah,it sounds like a horror film. Yeah. They're waiting for two little girls and tricepsto shine. And I think I think if only for you know, five days, it would be kind of funny. As we're approaching 14 days, no one's really laughing much. You come home,I say on the news, because all my employees I showed up to work and they're like, Hey, we saw Eric's family. And like you didn't see the whole family.Yeah, just just just half. But does read it and re gave him pictures. She was contacted from a local affiliate, because I think it could be wrong, but I think she has a client who has a connection. They reached out to them and, and Mac and Maria, both good sports. And they went along with it. And I want to say just like they did, the Panamanian people, wonderful, this is very little to do with them. We're not above anybody's protocol, we went with exactly it happened. We thought we were being cautious. And, you know, we're we're still going to enjoy ourselves as a family. That's what this is the risk that we took.I think it's and I think that's great. I think the lesson here is if you're when you come into a country, you have to be COVID negative, and we're all getting used to taking those tests before we go. And then when you leave at least do it a day or two before so that you don't have to be part of the governmental process. Yeah,it's there's a couple of lessons certainly in there about the way to handle it, just simply because of the the way the bureaucratic rules are. And it's it's no one's fault, who's who's necessarily down in Panama. However, that being said, you know, would we have traded in the vacation in the time that we guys are family to tonight ever have those experiences? I still say no. Yeah.And so when that those, those pictures were amazing. The Panama just looked absolutely beautiful.Yeah, it was nice.anything going on with you personally, sides spending all your time trying to figure out how to get stuff to them inPanama. Oh, man, that was not very much fun. Everything is kind of pales into comparison. where lots of work and that's enough. Self well, because you got something coming up with you got a young one that travels.So this is relevant. So Lucas had a really good showing at one of the largest tournaments of the year called the qaiser tournament in Kalamazoo, Michigan. him and his partner, Nico godsick won the doubles. Awesome. And then he made it to the finals unfortunately didn't pull it off because the winner gets to go to the US Open. So didn't quite but still huge bracket 250 some kids the best in the country. And he made it to the finals. So super proud of him.But your son also overcame in the semi finals, a six one loss in the first to come back and win the next two. Correct?Correct Yeah, so in the semi finals, he came out a little but it just shows the caliber of play that's out there. If you don't have your game face on, you can or if you're just not firing on all cylinders, and you know he's playing two matches a day, every day for whatever seven days in a row. pretty wild and really cool to see that that level. We'll play they streamed it online. So I was able to watch these matches and you know, and love that my son was able to give a very gracious and appropriate loss post loss speech afterwards where they kind of hand the mic to you and you kind of get the you understand what it's like when you you miss out on something you want so bad, they're like, okay, that's great. Hey, what do you think about that? Put a mic in front of it, I think if the Naomi osaki stuff that's going on, and how the media stuff but so super proud of him. And we'll see what what goes on. He's gonna be doing some international traveling. And so we had a long talk about what makin Maria going through and how we're going to do the testing now and how to make sure that you cover your bases and how to prepare that if you have to stay for an extra two weeks,I will say gauge when we when the news broke that, that some people were going to have to stay because of quarantine gage was obviously negative. And he looked at us and he said, Well, I'm getting on the plane. So he is back at his back and luck attack and getting ready for the fall semester. He's looking forward to just having a fall semester where they actually go to classlike it like a real college experience. Yeah, yeah, totally. super proud. Carla's taking tennis, serious enough that now she's going to do online school. So she's joined the what I guess the more competitive group at the legs where they practice in the morning stuff. And so she's doing some fun fitness. This is the only thing she came home. And she was like, yeah, that had this fitness guy. And he's talking about fast twitch muscles in doing this and explosive power. And we're doing all the exercises that you make me do. I'm like, I'm telling you. Yeah. You guys think I don't read? I mean, I'm not telling you. Just because I'm a country, but doctor doesn't mean I can't at least read some stuff on sports performance. Yeah, I'mlearning that parents don't always get the same credence design.So Well, I think Dan is up to speed here. That's been an interesting week that you've had. Yeah. Yeah. Yeah. So let's talk mushrooms that. Alright, so I want to talk a bit about the nutritional value of mushrooms and the effects on the microbiota. We always talk about the microbiota and I had no idea that mushrooms and factories very little in the literature about this, about the effect on our gastrointestinal health, okay, through mushrooms, we'll eventually get to that. Before we do that, we got to talk the mushrooms, the beautiful mushroom that everybody thinks about which is the fungi. The actual thing is, this right here is the cap. Mm hmm. Underneath the cap, you've got these gills underneath that you've turned a mushroom over and seeing the little lines that are there. And then below that is the is the basically the stock or the stem. And then beneath that you have the mycelium. What you'll learn if you watch fantastic fungi is that it's all about the mycelium, this that we eat that we think are mushrooms. This is basically a sexual origin, as they call it, fruiting fruiting. It's the fruiting body. underneath those gills right through here is where all the spores are made. And I remember what was his name that we had in the podcast that knew everything about mushrooms. Oh,that was early on.Cooper Reed Cooper read, talked about it like it just flowed off his tongue and I was like, what's he talking about? He used the word gills spores mycelium and I'm like what? Well, the mycelium is fascinating because that's basically without the mycelium. We don't exist. The mycelium is it's so cool, just watch fantastic fungi. But we're going to talk about the fruiting body right here. Because this is what we know more about mushrooms about what's going on. underneath here are the spores. They release trillions and trillions of spores, you actually breathe them in. Whether you know it or not all the time. We live in harmony with this organism. It's not a plant. It's not an animal somewhere in between. and we exist because of this. Yep. And I had no idea that this fruiting body is so good for you in so many different ways. So that's what I want to talk about.Let's do it.Alright, from a nutritional standpoint, you were we were working today and you're like you know, I hear all this stuff people throw out names and you hear things and gnocchi should tacky and you know, criminy and oyster and all these other names of mushrooms are some really cool names also Reishi Reishi lion's mane, but then there's like, I mean, just really wild ones. If you watch the Netflix special, he just starts rattling off purple headed dragons and things like that. It's there's over, I'm gonna get it wrong. I'm gonna get all this wrong, but 1.5 million different species that we've identified.I do not know that. It'slike some crazy number like way more than plants and everything. So from a nutritional standpoint, that's what I want to talk about today. And because we don't want to have a few other experts on to discuss some of these other aspects, but I've always kind of viewed mushrooms as just this filler that you just put into soups. Yeah. Or Whatever it is you want to do salads, it just adds a little bit of texture to things. So I pulled the nutritional facts of a few mushrooms very, very common ones, brown mushrooms, also known as crimini mushrooms. total fat is zero, total cholesterol is zero. Total carbohydrates is four grams. Protein is two grams. And the fiber content is point five grams, which is 2%. So four grams carbohydrates, but point five of it is fiber. Then you go to pataky mushrooms, which you'll find in Asian food all the time. And same thing about cholesterol and fat. That's the same process. This one also has two grams of fiber 12 grams of carbohydrates. And then oysters, oyster mushrooms, it's got two grams of fiber as well protein three grams. Now the aspect which I was unaware of, is the incredible micronutrients in it, it's one of the only ways to get vitamin D. Outside of Sunlight, sunlight, wow, it has a significant amount of selenium. In fact, a small serving of crimini mushrooms which would be like five small mushrooms is 31% of your daily Selenium that you need. And we have a hard time getting Selenium in our diets. That's actually why I eat like a Brazil nut three times a week just a pecans, yeah, to try and get that in. And then other nutrients like copper that you don't think of zinc, potassium, thymine. All of these things, and even iron are in slightly different, very slightly different concentrations of these different mushrooms, they're all slightly off. But the micronutrient component of this is incredible. Copper is one that I don't really pay much attention to. But then I realized, well, it's part of a cofactor in a lot of different things in your body it is. And so that is the mushroom content, or some of the nutritional values of some of the more common mushrooms. So if you're going to take these mushrooms, make a stir fry or a soup out of it, all you got to do is put five of these mushrooms, five of each kind into whatever it is. And what you're going to end up with is a total of 100 calories, no fat or cholesterol 4.5 grams of fiber. So that's 70% of the fiber that you need in a in in your whole day. six grams of protein. So for me 200 pounds, somewhere around point eight grams per kilogram, so slightly north of 70 grams of protein, I get six grams just in the mushrooms nice. And that's kind of what I aim for is around 72. But the real key to these are the micronutrients. It's like 64% of your daily Selenium 64% of your daily selenium, a ton of vitamin D and a lot of B vitamins that I didn't talk about before, along with copper, like we're talking about. Okay. So learning about this. We had a little bit before we started the show we Diego couldn't resist honestly, what we did is we made a basically it's kind of I don't know what would you call it a saute of. Number one, ittastes incredible.So with this in this, let's let's call the stir fry. In this stir fry, there is half a pound of grass fed grass finished meat, we have half a bag of spinach. There's those mushrooms that we discussed in those ratios. And what this comes out to is that with the grass fed meat, the spinach, and this doesn't include the nutrients from the onions and the other things to add a little bit of flavor onion, garlic, the zucchini, you're going to end up with 30 grams of protein, you're going to have 6.3 grams of fiber. Well I should break it down the meat is 30 grams of protein, you add the spinach, that's 6.3 grams of fiber, eight grams of protein and 50% of your potassium. So you put the mushrooms end with this and this little bowl here, which we're gonna take a bite of altogether is the bowl with a little bit bigger when we started. It's 500 calories, 11 grams of fiber 45 grams of protein and like 90% of the micronutrients that you would need in a day. Mushrooms, spinach meat, so take a little bite here.It is quite tasty. I'm gonna let him bite so that you're not just sitting in silence while we chop. But kids has a little bit of hot sauce on the top which I had some earlier with it and it's also delicious. But all I can say is it's fantastic. And I'm a creature of habit I can easily see myself doing thisevery day. So I would like to take credit for this. All I did is add the mushrooms but there are this is kind of a Kind of a staple in the bodybuilding world I didn't realize I started reading about this is what people will do this is they'll put spinach and meat. And they will use this for the whole week because then you add the mushrooms and now you've got the micronutrients. This is essentially a two bowls of this and you're done with all the protein that you need, all the micronutrients that you need and all the fiber that you actually need.So and to be fair, I would say for some eating mushrooms sometimes is an acquired taste. And I don't I don't know that feeling because I don't remember a time of not liking mushrooms. But I would say that this is this is a dish that I would say is not heavy and mushroom flavor. When you when you agree like the way that it's kind of salted and put together definitelyit's almost hard to distinguish what is mushroom? Because they're so finely chopped. What is mushroom? And what is me every minute. You asked meto kind of describe what are the and then you throughout the stir fry. But it's almost kind of like a super healthy stroganoff. It's kind of like a beef. stroganoff taste. Yeah, without strong mushroom tastes at all. AndI mean, I don't know, I think it's delicious. If I were to sit there if you're trying to watch your weight, and want to make sure that you eat healthy or even if people with intestinal problems. A lot of people can't handle gluten and a lot of people can't handle some some starches, which can result because of what we work in CBOE IVs. That can make it worse. This can be a very tolerable thing. And one of the things I really like about it is that you can get your body used to a certain thing every day. Yeah. And then you can start expanding your diet a little bit.Yeah, I mean, it's really good. It's very, very clean. Like it's the the fullness that you get just from the the natural fat and protein that's in there is is noticeable. So you, you probably won't overeat it, you'll feel satisfied, and you won't have a letdown because there's not a bunch of high carb sugar content inside.So let's talk about that. Why is this so satiating? Well, in on the Huberman lab, he talks about how your body your vagus nerve, actually sends an immediate signal that when it has reached a appropriate fat and amino acid content, that's the key here. So when you have a food that has a high amino acid content, and then in addition to the micronutrients, there is a immediate signal that sends to your brain and it turns on a hormone called leptin, leptin tells you that you're full, it's the exact opposite that happens in the food industry, which very highly processed packaged foods, they purposely make it with the emulsifiers, that it actually with the most fibers that make it shelf stable, but the emulsifiers actually do micro damage to that nerve. And that signal gets lost. So instead of turning on the unfold hormone, it turns on the I'm not getting enough nutrients called ghrelin, and you get hungrier, which is why you can eat a whole bag of Fritos or whatever your whatever, your crappy chip crappy chips or anything. Yeah, they the food industry hires PhDs, to figure out how to make it so that you will eat more of what they're making. If you're still hungry, you're still buying more products, because you're rifling through whatever they just sold you. So really simple way if you're fighting, I'm not gonna get so far as saying you're fighting food addiction, because I think that's a whole separate deal. But if you are somebody that fights cravings, a really good idea is to have something like this on hand, eat a cup of it, and then wait 15 minutes, then open up whatever device that you feel necessary that you have to do, because you're gonna end up eating less of it, because you've already turned on this hormone that says we've had enough.Yeah, I agree. It makes sense. I mean, quite honestly, when I was much younger and coming out of college, I didn't have the best eating habits. I would say I was I was falling into the pattern of being an overeater because I wasn't satiated. What wasthat crap that you would you would eat like a Yoo hoo. WhenI was in college, yeah, it was called a milk jug. milk jug and a fried pie. I can't believemill, chugging fried pie and now we're talkingabout chugging a five pie or sometimes I get a package ding dongs. Was that was the pinnacle health.So the package ding dongs are there to make you eat more ding dongs that is for sure. And the nutritional value is essentially that's that So today, we were you were like we're gonna talk mushrooms. I'm like yeah, I want to talk mushrooms. let's get let's get into this. And first thing you said is you know, I hear these names, but I don't Is there any science on this? Or is this just people saying oh, you should eat Reishi or Lion's Mane or, or whatever. I think Chagos is another one that people always talk about in all these different ones. corta seps as one.Sure. And how are we quantifying how I quote Find what we're measuring, and how do we qualify that the data is real. And it's we do that a lot.So it fit in perfect. I'm so glad that you asked that today, because one of the reasons why I wanted to do this particular topic is because a study just came out not too long ago, like a few weeks ago, on in the Journal of functional foods, and the title of the study is the role of dietary edible mushrooms in the modulation of gut microbiota, right in our wheelhouse. Definitely. So how do these mushrooms affect your gastrointestinal tract? And how do they affect your microbiome? So that's what we're going to cover today. And it's really cool, because I learned a lot. They they're so powerful. And I mentioned earlier how we pulled the lid off of polyphenols. There are so many similarities in a different lane. Nice. So we talked so much, we've got so many episodes where we talk about the innate immune system, we talked about the adaptive immune system. In relation to polyphenols, we talked about the how the polyphenols will increase the diversity of your microbiome, how polyphenols get broken down into post biotic, anti inflammatory, anti aging products. And this is all based on the science of these PhDs who've shared with us their brilliant work, right? This is when I started reading this, I'm like, Oh my gosh, they're saying something so similar by a different mechanism. So let's just jump right in. This is a super sciency article. So I'm, if I get too weird with it, you know, dumb it down and come back because it's, it's really complex. It's equally complex as the first time we were discussing the policy and also Yeah, if you look back, we did an episode with Sylvia, Sylvia Molino, and her research was just insane. It talked about how she took these complex polyphenols that are in our trunk to the kabocha in the horse chestnut, and she showed that they get broken down into smaller phenolic compounds like ecgc, which is green tea extract and light course attend and these different things. They didn't get into how the mushrooms do this, but I suspect it would be something quite similar. Yeah, through a different arm because these aren't polyphenolic compounds, the same ones that we're talking we'd have to find a fungus Silvia, we would have to find a fungal equivalent of Silvia correct. So it's very sciency. I'm gonna try to cover just some highlights of certain types of mushrooms, some of the more common ones that you may have heard of, and they're it's very complex, but these mushrooms have a wide range of constituents like things called glycoproteins polysaccharides phenolic compounds, and tri terpenes. Okay, so we're talking about terpenes when we're talking about CBD and cannabis and things. Yeah. Alright, so the first one that they covered was Reishi. Now Reishi has been well known for its anti inflammatory, anti tumor, something I didn't know acetylcholine esterase inhibition. So we talked about that when we looked at the the the episode with Angie, what was the title of that one? Anyways, when we talk about dysautonomia, acetylcholine has a big role. If you read biohack your brain she's got supplements to increase your acetylcholine, they do that by decreasing acetylcholine, esterase. And ratio has significant anti allergic properties. So what these team of scientists did, and this is out of China, where mushrooms have been used for ever, so it's it's more widely accepted that that is a functional food. These guys summarize that Reishi influences the gut microbiota by improving the intestinal barrier, okay, improving the intestinal barrier function, increasing microbial diversity. And it does a shift where it reverses bad bacteria and increases good bacteria very specifically, Reishi consistently would decrease bacteroides and increase from from from acuities for MC teas anyways, for me, Curtis, remember, I'm gonna mispronounce it might get all over me for doing the the reservatrol versus resveratrol. So let's just assume that I mispronounce a few things once in a while. Alright. So what it does, by doing that is that significantly increases the short chain fatty acids and anti inflammatory post biotics. They don't describe it as that what they do describe is molecules are then converted from the polysaccharides into anti inflammatory constituents also, they're describing post biotics while using the term. So all of these things in the literature has been shown to help with sugar control, lipid control, weight management and immune regulation. So when you said earlier, is there any data on these guys that's what they did in this article, they summarize the data on Reishi and showed this is what it's used for. This is how it does that. And this is why it helps with sugar weight management lift an immune regulation.Now well, I mean, you can even stop with this it'll Coleen be able to increase by stopping acetylcholine esterase. And that would be a benefit even by itself.So that's Reishi. Lion's Mane is another super common one that you'll find in supplements. It's one of the more popular supplements for mushrooms. And it's mostly due to lion's mane. Some studies were shown, I think it was in the 90s. That Lion's Mane can actually help with nerve regeneration. So it's been used a lot in the neurology world. And the reason is, is they believe that the beta glucans that are in lion's mane, show an anti aging and neuronal regeneration property, the prebiotic component of the lion's mane has been shown to have a positive influence in changing the pH in the colon, which increases the ability of other bacteria to produce butyrate. And in inflammatory bowel disease models, ulcerative colitis and Crohn's disease. It decreased the inflammatory cytokines intraluminal, that have been shown to cause the damage and we've talked a lot about cytokines and a ton about cytokines. While once again, it improves the microbial diversity. And specifically, it has been shown to control the amount of Clostridium difficile that has been produced c diff is something really bad. If you don't know what it is good. If you know what it is. I'm sorry, you probably had it. That usually takes place when your microbial diversity gets shrunk down due to antibiotics. And then the C diff takes off unchecked. Now studies also show that Lion's Mane proteins are similar to immunoglobulins, like ag G. So structurally, these proteins look a lot like well, you might know it as SBI or colostrum. That's the immunoglobulins. And so those are the things that your body produces to help fight infections. Correct. So it looks like that. And this can result in this anti allergy anti tumor effect. And so there's so many studies going on with Lion's Mane right now. Not so much in the Western world. But there's a lot of studies going on in the Eastern medicine world looking at that. I mentioned shittaka earlier, do you have something to say about life? I wasgonna say I mean, we've all young gone in to and both from Reishi to lion's mane, there's a little crossover. And when you mentioned neurogenesis possible neurogenesis with lion's mane, it reminds me there's there are other mushrooms, too, that we're not going to cover today.Oh, no, no, no, we're gonna cover all of them. We only have 1 million for a really long episode. But it's cool though, just like just like traditional plants that we that we're that we're used to talking about, there's going to be some crossover and benefit from the way that certain fungi performs. I guess what I'm trying to say because there are other neurogenic or Yeah, neurogenic properties of other mushrooms or other acetylcholine boosters and other mushrooms. Anyway, I just kind of point that out there. There's absolutely complimentary aspect. And they kind of get into that in the fantastic fungi about how there's this symbiotic, sometimes competing, depending on what needs to be done. Some mushrooms will augment each other, some mushrooms will repel others. And this is kind of what it's showing that from a nutritional value these things do kind of the same thing in a slightly different way. Yeah, well, they're all kind of doing it. Like for instance, shotoku mushroom in colon studies, is a potent anti inflammatory specifically, the studies that they referenced, it showed that it decreased interleukin six, TNF alpha inducible nitric oxide, and we know that these are all things we've talked about in prior episodes, usually related to polyphenols and Cox two, while it increases the anti inflammatory cytokine called interleukin 10. Very similar to what the polyphenols have been shown to do, they've just been studied a little bit more over here.So Cox two just as a reference, if you've ever taken aspirin or anything similar to aspirin, you're, you're you're basically blocking coxy with that this is a this is nature's way of at least injecting itself into stopping that kind of inflammatory process.Exactly. So she Taki also, what's really cool about photography is that the studies have focused on its effect on the brain. More specifically, multiple studies have shown that it can help with anxiety and depression. Now this is through something that you're very familiar with. It increases BDNF brain derived neurotrophic factor. Yeah, brain derived neurotrophic factor and decreases something else. You're very familiar with. Nf Kappa beta?Oh, yeah. Are you talking about those two?So these so NF Kappa beta is like the first domino that starts a whole process of inflammation. And if that's always being tipped, that's chronic inflammation. BDNF is a Protein mood says it's a factor. So let's just call it a protein. Yeah. So it's a protein that crosses the blood blood brain barrier, and helps decrease inflammation in the brain and helps clear out toxic aspects of it. So BDNF is one of the reasons that have been shown that eating a diet high in polyphenols increases your BDNF. Now we've got a shotoku mushroom here that actually has been shown to do something similar. That's super cool. It's really wild. Now as well, it increases nerve growth factor. So Dr. philomela will love this because she has a whole section in her book about nerve growth factor, and increases neurogenesis in the hippocampus. In biohack. Your brain she explains what the hippocampus does, and how important it is and how relevant it is to memory. And how you can regrow these nerves and people didn't think that we could forever I was taught in med school once you once a nerve dies, you're done.So what are we dealing with today with our aging population increase in incidence of dementia? So possibly an early intervention with shotoku mushrooms could be could be something that could be arming your body to help that.Yeah. The one another one that they discussed, which I'm unfamiliar with, but it was listed in this nutritional roundup that I found on mushrooms, it's called my Taki. Otherwise known as hen of the woods. You've heard of Yeah,all of the time. My dad often talked about my turkey. And I always knew he was talking about his hand that was always stuckin the woods. While he named his hand, my talkie.Yeah, well, he didn't want it to be your talking. So yeah, something like that. Terrible, stupid joke. Really, youknow what? It's okay. You don't have Mac around to listen to your bad dad jokes. It's okay. You can call me out mostly just by complete disinterest. So in other words, your dad's talkie. Yeah, show that it was it's it's Richard and phenolic compounds. So it actually has some of these problems. Not the ones we talked about ones that I've never heard of, but they're phenolic compounds nonetheless. And it has high levels of these beta glucans, which are very unique to cell walls, but it's the beta glucans that make these mushrooms functional foods. Studies have shown that has an increased and profound effect on increasing anti inflammatory microbial species. So basically, they show that it will increase the species of your microbiome, which will keep bad bacteria in check, right? It's kind of that whole yin and yang type thing. And increases short chain fatty acids producing species of bacteria. So it was really cool about the my Taki is that it seems to focus more on the surrounding environment of bacteria, so that these other mushrooms can let those bacteria break them down into good things. So it's all about signaling and getting the bacteria to grow, kind of like we talked about with spore based biotics, where they signal to have more of these less of these, it's it's trying to manipulate this stuff after after we get further and further into it, trying to say, oh, we're going to turn this into a drug. So it does this one thing, you start realizing this is way more complex than we could ever single handedly manipulate 100%. So basically, it still works as a prebiotic, and it helps produce all these other beneficial bacteria. So we're not actually going to cover the other 1,000,499 94 or whatever we did. But to summarize, these were the only ones that they actually looked at in this article, because the articles thick and they went into tremendous detail in each one. But to summarize it, edible mushrooms like this have a very positive effect on regulating dysbiosis. So your microbiome, maintaining the balance of good to bad bacteria ratios, increasing short chain fatty acids, specifically butyrate. The searching fatty acids result in all kinds of benefits across your body, including blood sugar control, blood pressure control, weight management, and brain health all of this together. So now, if you think about this, these mushrooms work different than the large stable polyphenols, like I was saying, but there's a lot of overlap.Sure. So it's a compliment. It's a compliment.I'm starting to see this beautiful Venn diagram. So our food right here, amino acids in the meat. We've got a bunch of polyphenols, colorful plate being in there with the spinach and the zucchini and then all those mushrooms are in here. That is a Super Bowl.Yeah. And it's it's super good. Period.So that is our first take on mushrooms. We've never done a mushroom episode.Now we haven't and I'm just gonna go ahead and reveal it. We've got a series of some pretty awesome guests lined up to come in and really kind of school us on some really cool deep aspects of mushrooms, the applications, how to find out what to look for If you're utilizing mushrooms to improve gut health are similar.So this whole mycology world is really neat once you start showing a little interest. There were, I mean, we've got people were emailing people right now like I would love to come on the show, can we talk about this? I'm like, wow, that's wild loved fun, eventually work our way through to whatever. And if you guys have any things you want to find out, like, you know, talk about what the How would you go about? What's the best way to things? I'm thinking about? What's the best way to learn how to find mushrooms in the wild, what's the best way? What are the best supplements that would, you know, augment if I'm trying to achieve certain things? What are the side effects? Yeah, so we've got a great natural path, who's dealt with this a lot uses mushrooms as a consultant. And he goes, I would really like to talk about some of the cons because all you hear is, you know, the pros. And that's great. Also, I want to get into that we've got all kinds of stuff. I thinkit's really cool that we're catching up on this subject matter, too, because actually, when we did have Cooper on it was fascinating. And at the same time, I felt just really inadequate to keep up on the subject matter because he was he was a completely different country. And we were stuck here going, I'm not sure I'm following every single thing that he's saying. Butall the way just from him saying, remember, it's the mycelium. It's the mycelium, and I know we're alive at the time. So it's likeyeah, it was it was like that. And since that time, we've we've actually were inspired by Cooper to kind of really start digging in deep, and it's paid off. And it's, I'm excited to have the next two, maybe even three guests. Join us here.I mean, eventually, if I can talk you into it, I want you to get another pig and we're gonna go truffle hunting.Oh, can we truffle hunt here? I don't know. That that's what we're gonna have. We're gonna have a truffle expert. Join our Yeah, I don't really I don't know enough aboutI mean, the way I see it, if you're if you're thinking about this, you're like, Okay, I've never really thought about mushrooms. If you're like me, never really thought about mushrooms. Now I'm realizing, if I've got my poly phenol ring here, and I know quite a bit about the endocannabinoid system over here, you need to fill that in. And now we're going to bring into third circle to form this Venn diagram kind of feels like they all augment each other in different ways in synergistic ways.Definitely, yeah, no, it makes sense. The The proof is in the pudding. I think that the choosing the right things to complement what you eat and how you live your lifestyle, of course, still getting good sleep. But what's crazy is when you eat right, you select the right kinds of foods to eat, sleep actually becomes easier. functioning throughout the day, becoming more productive becomes easier,for sure. And even when we've met with other experts, like the owners of four sigmatic and stuff, I didn't know what to ask. Yeah,yeah, that actually that's that was really funny also, because we, we had just had Cooper on the show by the time we met Marcus. And I can remember I sit there Go, man, this is fantastic. What do we say to him?Well, because we've heard we've heard all these people like like for SIG Matic for SIG Matic did a great job of advertising on different podcasts.Yeah. But then, but they brought valuein doing it. Yes. 100%. And then I'll even hear Rogen talk about different, you know, defenders, there's mushroom coffees, and all this other stuff. This is the stuff I want to know. Yeah. Like they want to, like this is the stuff that you say, just go Do you want to improve your microbial diversity? Do you want to decrease inflammatory markers? That's not making a claim? Now, that's referencing studies that have been done? And I'm like, Well, yeah, I do. Yeah. So that makes sense. I'm going to start using so grass fed meat. Bag of fresh spinach, some spices, onion, zucchini, garlic, zucchini. And then really, every any mushroom you can get your hands on. Yeah, it adds bulk and adds micronutrients and picks that up and you got yourself several meals,maybe pretty soon and I don't think we'll have it in time for production. We should throw the the recipe of and one of the show notes or something like that. Just to get some feedback on what people think of it.Yeah, and you know what we'll do we'll hit up Gabrielle Lyon. Who, who's she's a great, brilliant doctor. I heard her on cell dinos podcast, and then her and I were talking one time where I was like, Hey, man, I heard you talk about that. She does this but without the mushroomsnow okay. She's a bodybuilder.She's bodybuilder in great shape. And yeah, so yeah, if I can just take the time to do this. It's just a just I love it. It tastes so good.It does taste very good.And it's got the fiber in it and it's got the protein content and the micronutrients once again the fiber fiber fiber we do not get enough fiber in our dietsnow now and this this is an easy way to make italmost like a sneaky way to make it happen. It's like the anti food industry meals like Haha, yeah, you think it tastes good? You're not getting anything out of it.You don't have to keep buying anything from you. Yeah. Well, that's gonna be it for that's going To be all for episode number 60. Be sure and tune in for our follow ups like and shared kin, anything to add.Yeah, so we're really gaining some traction right now and having some fun, it would really mean a lot. If everyone just go to iTunes and like it, share it. Make some watches on YouTube because that getting some traction, there's a big deal. At Spotify, we're having some great guests lined up. And it's because we're getting a little attraction and I learned a lot from this. I love the questions that we get. So fire him our way, and we can help out. I know somebody is gonna ask, Well, wait a minute, I thought you're gonna talk about mushrooms. You didn't say anything about hallucinations or anything like that? No, no,they are some of the 1.5 million that we haven't gotten to. Yeah,just one of the 1.5 million. That's all y'all Great Day.We'll see y'all soon. Have a great one episode60 stay safe.

There are countless ways that MS can MesS with your life. But one of the most infuriating, most common, and most difficult to talk about, is sexual dysfunction. Obviously, this is something that can affect anyone. But a shocking 80% of people with MS report having sexual concerns or issues. The symptoms can include loss of sensation to an inability to climax, and the causes can run the whole gamut from depression, poor body image, and medications to treat your MS and associated conditions.So Dr. Fred Foley is here to help you bring your sexy back!Dr. Foley is Professor of Psychology at Yeshiva University, in the Bronx, NY, and the Director of Neuropsychology and Psychosocial Research at the Multiple Sclerosis Center at Holy Name Medical Center in Teaneck, NJ. The most important thing to learn from this podcast is that there are lots of ways you can still get busy and get happy! But the key is communication - with your partner, your doctor, and healthcare professionals. So Dr. Fred also offers guidance on how to do that.Full show notes and resources at https://fumsnow.com/fums087See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Immunotherapy is transforming the treatment landscape for triple-negative breast cancer. Through patient cases, Drs. Ruth O'Regan (medical oncologist, University of Rochester) and Jacob Kettle (Pharmacist, University of Missouri) discuss the application of novel treatment options. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 8/18/2021   TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. RUTH O'REGAN: Hello and welcome to ASCO's Education Podcast episode, focused on new therapies for triple negative breast cancer. My name is Ruth O'Regan. I'm a medical oncologist and the Chair of Medicine at the University of Rochester. JACOB KETTLE: And I'm Dr. Jacob Kettle. I'm an oncology clinical pharmacy specialist and pharmacy manager at University of Missouri Health Care's Ellis Fischel Cancer Center. We'll start our discussion today with a patient case. So let's say we have a 64-year-old female diagnosed with stage two triple-negative breast cancer three years ago. She received neoadjuvant AC-T and then underwent mastectomy, followed by adjuvant capecitabine. One year after completing therapy, she presented with new neck masts. Imaging demonstrated cervical nodes, probable liver metastases, and lymph node biopsy confirmed suspicion of recurrence, and now metastatic triple-negative breast cancer that is PDL1 positive. So Dr. Regan, what, in this patient, would you be considering for therapy for her. RUTH O'REGAN: Yeah, so I think unfortunately this is a pretty typical history of a patient with triple-negative breast cancer having this recurrence within two to three years of diagnosis. So her cancer is PDL1 positive, so obviously that would mean that we would consider immunotherapy for this patient. And there are two options with regard to this. We can either use atezolizumab or pembrolizumab plus chemotherapy, which could be paclitaxel, nab-paclitaxel, or, indeed, gemcitabine and carboplatin. So just to very briefly review the trials-- so the IMpassion 130 trial randomized patients in the first-line setting with metastatic triple-negative breast cancer to nab-paclitaxel weekly with or without atezolizumab, and it showed a benefit and progression-free survival of about two months in patients whose cancers were PDL1 positive, and also an overall survival advantage that was quite meaningful at about seven months in the patients who received the immunotherapy plus nab-paclitaxel compared to the control arm. So that obviously would be a very reasonable option for this patient. The KEYNOTE-355 trial evaluated chemotherapy, which could be paclitaxel, nab-paclitaxel gemcitabine, carboplatin, with or without pembrolizumab, again in the first-line setting for metastatic triple-negative breast cancer. And so really, very similar results to the IMpassion study with about a two month improvement in progression-free survival in patients whose cancers were PDL1 positive. What we'll talk about later on is how we define PDL1 positivity in this patient population. JACOB KETTLE: Yeah, I think that's an important distinction. RUTH O'REGAN: Yeah, I think we can talk about that, because I think most of us now are actually doing both of the assays. But on the face of it, in somebody who has a cancer that's PDL1 positive, I'm not sure that there's a huge difference. Obviously you can't do cross-trial comparisons. I tend to use atezolizumab plus nab-paclitaxel because that was the first one that was approved. But I also think, in a patient who's had a recent taxane, using pembrolizumab plus gem/carbo would also be very reasonable. The other trial I was just going to mention was the IMpassion 131 trial. JACOB KETTLE: Yeah, absolutely. It's a game changer. RUTH O'REGAN: It really is, because in that study they use paclitaxel with or without atezolizumab and actually didn't see an advantage for the immunotherapy, even in patients with PDL1 positive cancers. We really don't know why that is, but it's definitely an interesting finding. JACOB KETTLE: I mean, I think that really speaks to the importance of sticking with what we know from the trials. RUTH O'REGAN: Absolutely JACOB KETTLE: I think there's a tendency, especially with pembro's FDA approval, says chemo. Just-- that's it, chemo. But the trial, as you mentioned, limits it to paclitaxel, nab-paclitaxel, or the combination of carbo and gemcitabine, but really to extrapolate that to other chemo regimens, other drugs, I think that's a little bit of a stretch. Because, again, we saw an IMpassion 131, maybe it's not, across the board, efficacious. There may be some subtle differences there. I'm glad you brought that up, because I think that's an important distinction. RUTH O'REGAN: It's all about following the data. I think that's a key thing. So Jake, just in your role as a pharmacist, I think will be very interesting for you to talk a little bit about toxicity of these agents, and if there's any difference in the safety profile between these agents. JACOB KETTLE: Yeah, I think what we've seen is pretty consistent as really all our experiences. We've started combining immunotherapy with chemotherapies that really it's not this new emergence of unexpected toxicity or an unacceptable level of toxicity. It's just what we would expect with chemotherapy agents and what we've already known with immune therapy agents. So there's nothing new and emergent or difficult to deal with. And from the IO toxicity profile, it's all the same stuff we're used to. Derm toxicities, GI, pulmonary, endocrinopathies for the most part. We are comparing to PD1 inhibitor in pembrolizumab to PDL1 inhibitor in atezolizumab, so maybe there are some subtle differences. I think some of the things I've read have suggested maybe endocrinopathies are potentially more likely with PD 1 inhibitors. But these are all subtle things, very nuanced-- I don't think anything that would really dictate a difference in choice of therapy. So I think from the side effect profile, fairly interchangeable, at least from the immunotherapy perspective. Obviously, we're talking about the biggest difference is the chemo backbone, and that's going to be a key driver in what regimen you pick. Again atezolizumab-- very limited to the nab-paclitaxel backbone, which is great drug. Like you said, it was the first out. And I think another important caveat is that is the only trial in this space where we have overall survival data. We don't see that yet in KEYNOTE-355. Although, as you pointed out, PFS looks very similar between the two. So we anticipate-- don't extrapolate too much, but anticipate those are, efficacy-wise, pretty interchangeable. But the chemo backbone-- big difference between the two. Again, you have a little bit of flexibility of pembrolizumab to use paclitaxel, nab-paclitaxel. Or I think, again, for those patients that have recently exposed to paclitaxel-- it kind of fits with our case. This patient-- relatively early relapse, pretty early recently exposed to taxanes in the neoadjuvant or adjuvant space, you may want to use a different regimen. Carboplatin and gemcitabine-- a great commonly used triple-negative backbone, especially again, if you have those folks with more disease burden, visceral disease, where you want to get that bigger punch up front. I think that's another potential role there. But one other thing is to talk about logistics. These kind of regimens are very different because of how the immunotherapy is dosed. So when we use atezolizumab with nab-paclitaxel, that aligns very nicely with a 28-day cycle. Atezolizumab on day 1 and 15, nab-paclitaxel on day 1, 8, and 15. An off day at 22 that flows really nicely. Pembrolizumab, when you combine it with carbo and gemcitabine, that aligns really nicely with the 21-day cycle. Again, pembrolizumab on day 1, carbo, gem, day 1 and 8 and off day of 15. The regimen that gets a little funky, for lack of a better word, is when you try to combine pembrolizumab with the taxane, because the taxanes kind of line up on a 28-day cycle, days 1, 8, and 15. And pembrolizumab is a 21-day cycle. So that could become a little bit cumbersome to navigate those waters and get those doses the right days. So you can just, from a logistical perspective, I think there's some differences there. And the challenge really is, how do we kind of get this nice balance of finding the treatment regimen that's compatible with the patient's lifestyle, the monitoring frequency, and just your clinical operations to make sure all those things align? And we do want to have some flexibility. I think that's one of the great gifts in modern oncology, is we have all these good choices, but both are really important. You also want to have some consistency. So anyway, that's a really long-winded answer to side effects. I don't think there's much difference, in terms of side effects. RUTH O'REGAN: I think your point is very important. Because this is all about the patient, of course. Because we've got metastatic triple negative breast cancer. So I think making it as painless as possible for them to come in, as far as their scheduling, I think, obviously, is very important. Now, I think one of the issues with the immunotherapy is that I don't think we got great biomarkers. So we use PD-L1, but really, it's imperfect. And as we kind of alluded to earlier in the IMPASSION study, they used PD-L1 on the immune cells as a marker, and about 40% of the cancers in that study were determined to be positive. And that's where the benefit was seen. In contrast, in the KEYNOTE study, they used what I think a lot of, outside the breast cancer world, is being used a lot, is this CPS, or Combined Positive Score, that basically looks at the PD-L1 positive tumor cells and immune cells and basically looks at them compared to the overall number of tumor cells. So at this point, we're kind of in a situation where we have to kind of check for both. The interesting thing that's been shown is that there's not complete overlap. It's only about 75%. So it is possible that you could have a cancer that was PD-L1 positive by one of the assays, but not by the other. And I guess that might help us decide which agent to use, although I've never seen that myself in my practice. But I don't know what your experience with that is. It would be nice to have a better biomarker, I think. JACOB KETTLE: Yeah, I'm glad you brought that up. Because I would be in the same boat. I haven't seen a case, but obviously it's possible to have some discordance. And we're looking at PD-L1 expression, whether you're looking at the tumor, or you're looking at expression in a combined positive score, regardless of the assay, it's on a scale. It's not a yes or no question. And little, subtle differences can be the make or break between determining whether someone's PD-L1 positive. I've heard-- and I don't want to comment too much-- but there could be discordance whether you're testing archived tissue, whether you're testing metastatic tissue, maybe some differences between what site the metastatic disease was found in. Did you find it in the liver? Did you do the biopsy from the lymph node? Again, that all speaks, it goes back to the imperfection of PD-L1 as a biomarker. It's just kind of this dynamically unstable marker that's not as predictable and not as viable as some of the other biomarkers we use. And we want to take advantage of it as much as we can, and find as many unique treatment options for patients, but also don't want to leave-- we don't want to leave anything on the table. RUTH O'REGAN: And I think the other interesting thing that we'll talk about later is that PD-L1 doesn't appear to be a biomarker at all in the earlier stage setting, which is, I think, very interesting. I think one of the things that's worth mentioning is that, of course, some patients do incredibly well with immunotherapy and have very, very prolonged responses. So trying to work out who those patients are, I think, would be just incredibly valuable. I have a couple of patients that actually came off the immunotherapies because of immune toxicity, but have remained, really, in remission for years after that, even though they actually weren't even receiving the drug. So it's really fascinating. I think the other thing, though, is unfortunately, the majority of patients do not have cancers that are PD-L1 positive. And I guess the question is, what would we do for those patients? And the only really standard is chemotherapy. And I guess I'd be interested in your thoughts on, is there a preference first-line chemotherapy that would be used in your practice, or what are your thoughts on that? JACOB KETTLE: I'd more defer to you on answering that. As far as our practice, you kind of have the whole mix of what you can pick from. You've got taxanes. You've got anthracyclines. You've got gemcitabines. We've got capecitabines of the world. Eribulin is a fantastic drug. Again, a lot of that goes back to what's best for the patient. And I think that is, again, the miracle. It's a challenge, because we all of a sudden have all these options, but it's the great blessing in practicing in oncology today, is there is this wealth of options, and we have the potential to really guide therapy to what's preferential to the patient. RUTH O'REGAN: Yeah, I completely agree with that. And my thought always has been-- and I think this is very much in keeping with the NCCN guidelines-- is that there isn't a huge difference, in terms of efficacy. So I actually quite often use capecitabine in these patients, even though there was some data at one point saying that maybe capecitabine wasn't as effective in ER-negative breast cancer. I think we know that's not true in actual fact. So I think that's a great option. If they haven't had a taxane, either paclitaxel or nab-paclitaxel is a good option. And then I think if somebody's got a large burden of disease, using a doublet like gemcitabine and carboplatin is totally reasonable, as well. Obviously, thinking about clinical trials, and particularly once you get past the first line setting for these patients is very important. And I think one of the complexities about triple-negative breast cancer is the fact that there's at least four different subtypes that probably do require slightly different approaches. But at this point, that's not really standard of care. We kind of just manage them all the same way. But I think that's what's kind of on the horizon, as far as selecting at the best option for patients. I think one very interesting subset is the subset that expresses androgen receptor, and which I think initially, we were super excited about. And I still think it's very interesting, but so far the data looking at antiandrogens in these cancers has not been that impressive, although there are some patients that benefit. JACOB KETTLE: Well, I do think, too, the immunotherapy story, we kind of got talking about biomarkers. Even if you're not PD-L1 positive, even if the tumor doesn't express PD-L1, that's not necessarily the end of the role of immunotherapy in breast cancer. KEYNOTE 119 showed that pembrolizumab monotherapy later on didn't work, but we still need to be assessing for tumor mutation burden, microsatellite instability or mismatch repair. Those are other avenues by which we do have some good data to support that there is a role for immunotherapy in breast cancer, these triple-negative breast cancer patients. Like you said, only about 40% are going to be PD-L1 positive. So that leaves 60%, more than half the pie, that are going to not have a route for immunotherapy. So I do think it's important that we always explore tumor mutation burden and microsatellite instability. Because again-- and you've alluded to this-- the great promise of immunotherapy is this potential for really long, sustained responses. And until we have really good predictive tools to find exactly what patients are going to be that, I think we should be striving to at least offer that glimmer of hope, that potential opportunity to as many patients as we can. But I think it's another important part of breast cancer is that, again, immunotherapy doesn't start with PD-L1. That's just a sliver of the useful biomarkers here. RUTH O'REGAN: I completely agree with that. I think for our patients, it's important to consider sending tumor genomics, for sure, for exactly the reason that you said. I'm obviously also doing genetic testing to see if they've got a BRCA1 or BRCA2 mutation, or indeed a PALB2 mutation. Now there's some data suggesting that PARP inhibitors might actually be effective with those germline mutations as well. So I think definitely, sending that off makes sense. Unfortunately, as we know, in triple negative breast cancer, we don't very often see actionable mutations. We see them, I think, more commonly in ER-positive breast cancers. But certainly we're ascending, I would think. JACOB KETTLE: Excellent. I think that was a great discussion. Let's shift gears and do a second case and talk a little bit about this emergence of immunotherapy in the upfront setting, in the neoadjuvant setting. We'll talk about that a little bit, and then what are some additional later-line options? So we'll do our second case. This will be a 45-year-old female presents with relapsed/refractory triple-negative breast cancer, metastatic disease in the bones and liver. Her initial therapy consisted of neoadjuvant chemotherapy combined with immunotherapy. And that would be what was discussed in the KEYNOTE 522 trial. So before talking about choice of therapy for this patient, let's dive in a little bit about and talk about KEYNOTE 522. What are your thoughts of up-front immunotherapy in triple-negative disease? RUTH O'REGAN: So KEYNOTE 522 took patients with earlier stage triple-negative breast cancer and basically randomized into the standard anthracycline taxane-based chemotherapy with or without pembrolizumab, and actually showed pretty impressive pathologic complete response rate in the immunotherapy arm. It's about 65%, and it was quite a bit higher than the control arm, where it was about 50% or so. And they actually have some data as well looking at event-free survival showing a benefit for the addition of pembrolizumab. It's not FDA approved yet. And obviously, you have to take into account toxicity, which I'd certainly like to get your thoughts on. But I think we know that pathologic complete response is very important, a prognostic factor in triple-negative breast cancer, at least in most subtypes. So getting a pathologic complete response rate that high, I think, is very important. And I have to say, I tend to reserve this approach for patients who have clinically node-positive breast cancers or locally-advanced breast cancers. Because-- I should have said this earlier-- because in KEYNOTE 522, all the patients got carboplatin as well. And that's one of the problems, I think, because it's hard to add carboplatin with paclitaxel. Just to mention that we also, at ASCO, just heard a follow-up of the GeparNuevo study that looked at durvalumab with a slight, somewhat similar anthracycline taxane-based regimen. They saw a higher pathologic complete response rate in the durvalumab arm. But actually, we're showing data, now, on longer-term outcomes, and again showing a benefit for the immunotherapy. So it is interesting. I think you're always weighing up longer-term toxicities with the efficacy seen here. But I think with a pathologic complete response rate that high, I think in a patient who has more higher-stage triple-negative breast cancer, I would consider adding pembrolizumab for that patient in this setting. But I guess I'd like to hear your thoughts on weighing up toxicity. It's a little bit different in this scenario versus the metastatic setting, I think. JACOB KETTLE: I completely agree with you. That PCR rate is supremely promising. Obviously, we need time for the data to mature. But I think there's definitely a subset of patients that I think we're going to find this, hopefully, to be very beneficial. And triple-negative disease is problematic, so any additional tool is useful. But again, it's a very intense chemotherapy backbone. Four cycles of carbo-paclitaxel, and then four cycles of an anthracycline and cyclophosphamide base with pembrolizumab throughout the whole cycle, that's not going to be something that all patients are going to be able to tolerate. So again, as the data matures, my hope is that we can really narrow in on the subset of patients that this is most likely to really deliver a lot of benefit to. And I've probably said this three or four times already, but I really didn't feel like this is the great promise. But again, the great challenge of oncology practice today is, we're going to end up with four or five different great options for up-front therapy in neoadjuvant or adjuvant treatment, and it's really going to be up to us to really tailor therapy and find this ideal balance of risk and benefit ratio to meet patients' needs, and what they value. And so some patients may have, they want to avoid the severe toxicities at all costs. And that's maybe how we pursue, is to get the best benefit with that in mind. And then you'll have patients that will say, I'll go through anything. I want my risk of relapse be absolutely as low as possible, and I'll take all the chemo you're willing to throw. And trying to figure out how to walk that line, I think, is our challenge. So with that in mind, remember back to our case, our second case here, we're going to assume that this patient's relapsed after immunotherapy in the front line. And I think that is another thing we'll explore, as the years go by, is learning, what do we do when we start seeing these therapies early in treatment, whether it's breast cancer or other tumor types? But what would your approach be, if they did relapse after initial immunotherapy? RUTH O'REGAN: Well, I think this is a data-free area. And I should have said when I was talking about the earlier phase studies that PD-L1 is not a biomarker in that scenario. So if we assume this patient has PD-L1 positive cancer, I guess it would really depend on how long it was since she got the neoadjuvant chemotherapy. But I could envision if she was a couple of years out, I might think about rechallenging her, particularly with a different PD-L1 or checkpoint inhibitor. But I think that's not the likely scenario, because most of these patients will have pretty high-stage disease when they present, and they probably relapse pretty quickly. So I guess we're kind of back to the case we talked about earlier, where you're really looking at the different chemotherapy options. So I think there is a potential for rechallenging with immunotherapy. I don't know-- and you may know this-- if there's any data outside of breast cancer, like lung cancer, where this has been done, for example. I'm just not aware of that data. JACOB KETTLE: Yeah. I'm not aware of any really solid evidence. I think you can find anecdotal reports or some retrospective studies that do suggest maybe it's beneficial. And I think, especially like you mentioned, for someone with a nice long response, good, strong tolerability, all those kind of things, may be worth considering. But again, the challenge with immunotherapy, it doesn't work quickly. So you always have that component. And like you said, these are aggressive, rapid relapses. That may not be something you can lean on too heavily. So I think it all speaks back to, we're very confident in pathological complete response as a very strong surrogate marker for long-term benefit. But again, we're using it in a slightly new space. And until that data is very mature, and we have the overall survival data, what we don't know is, how does this all translate to the whole picture for the patient? If we burn out of immunotherapy up front, I don't know. Does that mean it's not useful, and we've lost lines of therapy in the relapse/refractory setting? I don't know. Those are some of the big questions we have. RUTH O'REGAN: And I think it also speaks to what you said earlier, that the whole immuno milieu of the cancer may change, depending on what setting you're looking at. So there could be very good rationale for rechallenging with immunotherapy. But again, I think this is an area where we really would need some data for sure. JACOB KETTLE: Yeah, absolutely. Very tricky. So let's play out the scenario just a little bit more. Let's say we started carboplatin and gemcitabine, for instance, in this patient. She got about nine months of therapy, and then progressed again. What other, maybe, newer options are lingering out there for sort of later-line triple-negative metastatic disease? RUTH O'REGAN: So unfortunately, of course, that's typically what you see. They usually, patients usuallt experience disease progression within six to nine months. And so obviously, alternative chemo options would be on the table, a taxane, if she hasn't had one recently, capecitabine, if she hasn't had that. However, I think for a patient like this, I would strongly consider sacituzumab, which is a relatively new antibody drug conjugate that targets Trop-2. The data from the ASCENT study, which looked at patients with triple-negative breast cancer who'd had at least two prior lines of treatment were randomized to sacituzumab or to physician's choice of chemotherapy, and the data was pretty striking. And the progression-free survival, it was less than two months in the control arm, versus six months in the sacituzumab arm. But the overall survival was doubled from six months to 12 months by using sacituzumab. So that's pretty impressive in this scenario. And it appears that, although most triple-negative breast cancers do express Trop-2, there doesn't appear to be a definitive correlation between Trop-2 expression and benefit from this drug. So there appears to be some kind of a bystander effect from this antibody drug conjugate. I think it's a really interesting drug, and maybe you can talk a little bit about the tolerability of it. JACOB KETTLE: Yeah. So again, like you said, it's a Trop-2 target. That's the antibody component. And Trop-2 is a transmembrane glycoprotein. It's upregulated in a lot of tumor types. So this is not something that you necessarily would do additional testing for. It's not unique to breast cancer. And sacituzumab-govitecan has an approval now in bladder cancer as well. So I think we're going to start seeing more emergence and utilization of Trop-2. And then like you said, it's kind of an enriching biomarker. You might see a slightly higher response rate for those overexpressors. But again, low expressors still respond. But I think when it comes to the side effect profile-wise, it was all driven by the chemo payload. And that's Govitecan, or SN-38. This is the active metabolite of irinotecan. And so a couple of things make this really exciting to utilize in breast cancer. One is, we're all probably fairly familiar with managing the common side effects of irinotecan, predominantly neutropenia and diarrhea. So we don't have to relearn or come up with a new kind of management profile, side effect-wise. But I think part of why we see such a robust response is this is a mechanism of action. Govitecan, it's a topoisomerase inhibitor that almost, I'd say, the vast, vast majority of breast cancer patients have not been exposed to that mechanism at any point in their treatment journey. So you take advantage of that new option. And I think, all things considered, this is why we've seen this kind of recent-- it's not brand new technology-- but we've seen this recent emergence of a lot of antibody-derived conjugates. Because it really does allow you to take advantage of antineoplastic agents that may otherwise be too toxic, but we find a way to deliver it in a very sophisticated, precise manner. And by doing so, again, we're able to take advantage of chemotherapeutic agents that otherwise would be on the shelf. But we can deliver it in a very precise way. And so that's a really exciting piece of the promise for this drug. And again, just to ask you, do you any anecdotal experience or insights with the drug? RUTH O'REGAN: Yeah. I've used it a little bit. I actually started a patient on it today. But overall, I think it's well tolerated. It's unfortunate it causes alopecia, obviously. But I think most patients with the results of the ASCENT trial, they're OK with that, I think. And the tolerability seems to be very reasonable. JACOB KETTLE: I mean, a six-month OS improvement at this stage of the game is pretty clinically meaningful. RUTH O'REGAN: I don't think we've really seen that before, actually, and so it definitely is. I agree with you completely. I think antibody drug conjugates are really the way forward, because they're so much more tailored to the cancer than regular chemotherapy. The other drug, I think, that will be interesting to see in triple-negative breast cancer is trastuzumab-deruxtecan, which obviously is approved for HER2-positive breast cancer, but again, also has a bystander effect. And there's some data from one of the DESTINY studies basically showing activity in cancers that have low expression of HER2. So I think that's going to be very exciting. So I think there's a lot of exciting things happening in triple-negative breast cancer. There's a lot that I think we have to learn. I mean, biomarkers are going to be very important, particularly for immunotherapy. Do you have any other thoughts on other agents you're excited about in this setting? JACOB KETTLE: I'm always fascinated by precision oncology. And like you said, I haven't really found a lot of great targets for triple-negative breast cancer. It's tended to hold out its negativity. It doesn't have-- not as if we're finding a bunch of things. So I hold out hope, just that we come across a good marker, something else targetable for these folks. I share with you the enthusiasm about trastuzumab-deruxtecan, and how it might play a role in HER2 low. Interestingly enough, that's also a topoisomerase inhibitor type, very similar backbone, chemo-wise. But also just watching the IO story continue to play out, I think it was interesting just that breast cancer, really, especially the most common cancers, was really one of the last disease states to really see indications for immunotherapy. So just excited to see that story continue to unfold. And hopeful, always remain hopeful that we continue to push the needle forward, bit by bit, day by day. RUTH O'REGAN: I completely agree, and that was a great discussion. So that's all we have for today. I want to thank you, Dr. Kettle, for a great conversation. And thank you so much to all our listeners tuning into this episode of the ASCO Education Podcast. SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning Weekly Podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

Are you familiar with adrenal fatigue and how that can ruin your energy and motivation along with screwing with your hormone levels? It turns out that is actually a myth and adrenal fatigue does not exist! Dr. Carrie Jones, today's guest on The Red Light Report, explains why adrenal fatigue is misunderstood and clarifies what is actually going on with the adrenals and what we can do about. She is also a bonafide hormone expert and is obsessed with mitochondrial health, both topics of which are thoroughly discussed in this episode!   Dr. Carrie Jones is a Naturopathic Physician who is board certified in Naturopathic Endocrinology (FABNE) with a Master's in Public Health (MPH) having over 15 years in the field of functional and integrative medicine. As former Adjunct Faculty for the National University of Natural Medicine (NUNM), she has taught courses in both Gynecology and Advanced Endocrinology.Dr. Jones has been the Medical Director for two large integrative clinics in Portland, Oregon and is currently the Medical Director for Precision Analytical Inc, creators of the most cutting edge hormone test on the market, the DUTCH Test. As a result, she has been honored to lecture all over the world on the topic of hormones and has had the privilege to consult with the premier health care practitioners on the hormone status of their patients.Understanding adrenal and sex hormones can be a complicated topic. So Dr. Jones has taken full advantage of her spunky and keen personality to create fun, educational content on her Instagram page - @dr.carriejones  - where she nurtures a nonjudgemental environment and aims to educate and empower anyone wanting to learn.Enjoy listening and learning from one of the best! - Dr. Mike Belkowski and Dr. Carrie Jones discuss the following: How she got into hormone therapy The biggest culprits to hormone balance caused by modern technology How the female body naturally prepares itself for fertility Cortisol and its affect on our adrenal glands and our body How mitochondria and cortisol interacts Key indicators of an overabundance of cortisol How we can control cortisol levels with our environment How the system works to protect you Her approach at assessing patients Circadian rhythm and its importance to healthy cortisol and melatonin levels Testosterone and how men produce it during sleep Sleep deprivation and its short-term benefits vs long-term effects Blue light blockers and changing your screen's light Biohacking and how it shouldn't be a crutch to replace good habits The keto diet, how it affects estrogen levels, and how it affects women vs men The Mitochondria and its role in hormone production Biogenesis and how our mitochondria fuse together and have evolved over time How the mitochondria are environmental “sensors” Red light therapy and the results she has seen from it Research on red light therapy and pain reduction Red light therapy recommendations for people on the fence Daily habits you can do to improve your health, wellness, and longevity - Watch the YouTube video of this episode here: https://youtu.be/2tgP4Gc9AYQ - Works cited: Skin adhesive low-level light therapy for dysmenorrhoea: a randomized, double-blind, placebo-controlled, pilot trial - Follow her on Instagram: @dr.carriejones   Visit her websites: http://www.drcarriejones.com/ www.dutchtest.com     - Don't forget to check out these health-related recommendations from previous podcast guests! - To learn more about red light therapy and shop for the highest-quality red light therapy products, visit www.biolight.shop Stay up-to-date on social media: Instagram YouTube Facebook

An interview with Dr. Valeria Mercadante from University College London, Dr. Siri Beier Jensen from Aarhus University, and Dr. Douglas Peterson from UConn Health, authors on “Salivary Gland Hypofunction and/or Xerostomia Induced by Non-Surgical Cancer Therapies: ISOO/MASCC/ASCO Guideline.” This guideline provides evidence-based recommendations for interventions to prevent, minimize, and manage salivary gland hypofunction and xerostomia in patients receiving nonsurgical cancer therapy. Read the full guideline at www.asco.org/supportive-care-guidelines. Suggest a topic for guideline development at www.surveymonkey.com/r/ascoguidelinesurvey.   TRANSCRIPT [MUSIC PLAYING]   SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING]   BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines Podcast Series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcasts.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. Valeria Mercadante from University College London and University College London Hospitals Trust in London, United Kingdom, Dr. Siri Beier Jensen from Aarhus University in Aarhus, Denmark, and Dr. Douglas Peterson from the School of Dental Medicine and Neag Comprehensive Cancer Center UConn Health in Farmington, Connecticut, authors on salivary gland hypofunction and/or xerostomia induced by non-surgical cancer therapies, International Society of Oral Oncology, Multinational Association of Supportive Care in Cancer, and American Society of Clinical Oncology Guideline. Thank you for being here, Dr. Mercadante, Dr. Beier Jensen, and Dr. Petersen. VALERIA MERCADANTE: Thank you. It's a pleasure to be here. DOUGLAS PETERSON: Thank you. SIRI BEIER JENSEN: Thank you. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Mercadante, do you have any relevant disclosures that are directly related to this guideline topic? VALERIA MERCADANTE: No, I do not have any relevant disclosure. BRITTANY HARVEY: Thank you. And Dr. Beier Jensen, do you have any relevant disclosures that are directly related to this guideline? SIRI BEIER JENSEN: No, I have no conflicts to declare related to this guideline topic. BRITTANY HARVEY: Thank you. And finally, Dr. Peterson, do you have any relevant disclosures that are related to this guideline topic? DOUGLAS PETERSON: No. No related conflicts to declare. BRITTANY HARVEY: Thank you. Then let's delve into some of the content of the guideline. First, Dr. Mercadante, can you give us an overview of this guideline's scope and purpose? VALERIA MERCADANTE: Of course. These clinical practice guidelines focus on the prevention and management of salivary gland hypofunction and xerostomia due to non-surgical cancer therapies. This is something we are deeply passionate about because nonsurgical cancer therapies, including all type of radiation regimens, chemotherapy, and biological cancer therapy, can damage the glands in our mouth that produce saliva, resulting in xerostomia, which we define as patient-reported subjective sensation of dryness and salivary gland hypofunction, which we define as reduced salivary flow rate as measured objectively. And this condition may last for several months or may become permanent. And because saliva serves so many important function, xerostomia may lead to a range of other symptoms that can impact patient quality of life. And therefore, ASCO, MASCC, and ISOO decided to update the findings of their two previous systematic reviews published in 2010 and provide a practical, evidence-based approach in a multidisciplinary testing to address this important topic. BRITTANY HARVEY: Great. Thank you for that background. So then I'd like to review the key recommendations of this guideline. This guideline covers two clinical questions, one on prevention and one on management. So Dr. Peterson, starting with prevention, what are the key recommendations regarding pharmacologic and non-pharmacologic interventions for the prevention of salivary gland hypofunction and/or xerostomia induced by non-surgical cancer therapies? DOUGLAS PETERSON: Thank you, Brittany. As you've noted, the guideline is framed in the context of two clinical questions, prevention and then followed by the management once the condition has occurred. Relative to prevention, there were eight recommendations, all of which were directed to reducing the risk of salivary gland hypofunction and/or xerostomia in patients with head and neck cancer. And as with other ASCO guidelines, each of these recommendations was in turn supported by text directed to literature review and analysis and clinical interpretation. So let me just briefly highlight the eight recommendations on prevention. Recommendation 1.1 was that intensity-modulated radiation therapy, IMRT, should be used to spare major and minor salivary glands from a higher dose of radiation. This was a very strong, well-evidenced recommendation. The evidence quality was high. The strength of the recommendation was strong. Recommendation 1.2 is that other radiation modalities that limit cumulative dose to an irradiated volume of major and minor salivary glands as one or more effectively than IMRT may be offered. Recommendation 1.3 reads that acupuncture may be offered during radiation therapy for head and neck cancer to reduce the risk of developing the symptom of xerostomia. Recommendation 1.4, systemic administration of the sialogogue bethanechol may be offered during radiation therapy for head and neck cancer. Recommendation 1.5-- and this is an important different type of recommendation-- vitamin E or other antioxidants should not be used to reduce the risk of chemoradiation-induced salivary gland hypofunction and xerostomia. And this is because of the potential adverse impact of these antioxidants on cancer-related outcomes and the lack of evidence of benefit. In addition to those five recommendations, there were three recommendations for which the evidence was insufficient. In the panel's view, it was important to delineate these three recommendations in the context of current clinical practice as well as opportunities for future research that we'll talk about in a little bit. The three recommendations for which there was insufficient evidence are 1.6. The panel was unable to make a recommendation for or against the use of submandibular gland transfer administered before head and neck cancer treatment. This limitation is due to the current amount of evidence associated with this surgical intervention, submandibular gland transfer, in relation to ever-evolving contemporary radiation modalities. Recommendation 1.7-- evidence remains insufficient for a recommendation for or against use of the following three interventions during radiotherapy for head and neck cancer. The three interventions are oral pilocarpine, amifostine in association with contemporary radiation modalities, and low-level laser therapy. And then, finally, recommendation 1.8-- the evidence remains insufficient for or against the use of several interventions, including selected radiation technology, for example, boost radiation or hyper or hypofractionated radiation therapy, Transcutaneous Electrical Nerve Stimulation or TENS, human epidermal growth factor, and selected complementary medicines. And again, the evidence is insufficient in the panel's view for a recommendation for or against these and several other interventions that are listed in the guideline. So I'll now turn the microphone back to Brittany. BRITTANY HARVEY: Great. Thank you for reviewing those prevention recommendations and explaining the evidence that supported those as well. That's very helpful. So following that, Dr. Beier Jensen, what are the key recommendations on pharmacologic and non-pharmacologic interventions for the management of salivary gland hypofunction and/or xerostomia induced by non-surgical cancer therapies? SIRI BEIER JENSEN: The key recommendations for the management of salivary gland hypofunction and xerostomia induced by cancer therapies are based on the principles of stimulation of the salivary reflex and lubrication of the oral tissues of, say, the mucosa and the teeth. The recommendations 2.2, 2.3, 2.4, and 2.5 address this stimulatory approach. If there is residual secretory capacity of the salivary glands, stimulation of natural saliva secretion may be provided by chewing or taste stimuli. This can be regular use of sugar-free lozenges, sugar-free candies, or sugar-free non-acidic chewing gum. In patients who has their natural teeth, it's important to be aware that if acidic candies are used to stimulate saliva secretion, then it should be a special nonerosive preparation for dentate patients that will say that they do not dissolve the tooth substance. Pharmacological stimulation is also an option by prescription medication such as oral pilocarpine and cevimeline in countries where this is available. This may result in systemic adverse effects that limit use in some patients. So the gustatory and masticatory salivary reflex stimulation, recommendation 2.2, the evidence-based quality was intermediate, and the strength of the recommendation was moderate. And for the pharmacological stimulation by pilocarpine and cevimeline, it was evidence-based, high-quality, and strong recommendation strength. For patients who have salivary gland hypofunction or xerostomia induced by radiation therapy for head and neck cancer, stimulation of saliva secretion may also be provided by acupuncture, transcutaneous electricity stimulation, or acupuncture-like transcutaneous electricity stimulation, although the evidence base here is less strong than for the other stimulatory management options mentioned. This is addressed in recommendation 2.4 and 2.5. If the residual secretory capacity of the salivary glands is low or maybe even nonexistent, then regular lubrication of the oral mucosa and teeth is of relevance. This is addressed in recommendation 2.1. Such lubrication may be provided by topical application of mucosal lubricants and saliva substitutes, which are agents directed at ameliorating xerostomia and other salivary gland hypofunction-related symptoms. It is important to notice that available stimulatory and lubricating options all provide transitory increased salivary flow rates and transitory relief from xerostomia. If you would like to review the specific recommendations, they can be found in the manuscript. BRITTANY HARVEY: Great. Thank you for reviewing those recommendations on the management of salivary gland hypofunction and/or xerostomia. So Dr. Peterson, you mentioned this earlier, but there are some cases in the guideline in which evidence was insufficient to make recommendations. And you went through a few of these areas. So what areas of future research did the panel discuss? DOUGLAS PETERSON: Thanks, Brittany. The panel worked very carefully to relate the quality of evidence to strength of each of the recommendations. In addition to providing important context regarding clinical prevention and treatment of xerostomia salivary hypofunction, novel directions for future research were therefore identified. And I'll just briefly delineate these future directions. Studies directed to the continued, rapidly-evolving radiation technology such as proton therapy and volumetric modulated art therapy or VMAT, as well as the length of time after this treatment is completed, for example, one to five years after completion of treatment, these studies are needed to assess the relationship of this rapidly-evolving technology to the long-term adverse oral events such as salivary gland hypofunction and xerostomia as well as advanced dental disease and osteoradionecrosis as well. Importantly, and the panel spent quite a bit of time deliberating this, ethical considerations must continue to be paramount in the study designs. And this is pertinent relative to this guideline. An important issue is that implementation of randomized clinical trials comparing current and novel radiation therapy modalities is typically precluded for ethical reasons. So this is a barrier to address, and the panel wanted to call attention to the scientific and clinical community. In addition to the radiation technology itself, two additional future research directions also represent potential strategic advances in the field as well. First, radiosensitivity of parotid gland stem cells. For example, it has been recently shown that not all constituents of the parotid gland are equally radiosensitive because of an unequal distribution of the stem cells within the gland. This and related biologic concepts should be incorporated in future randomized controlled trials of head and neck cancer patients. Secondly, novel regenerative medicine options may be used to spare, optimize, or restore salivary gland function after treatment. The guideline addresses these innovative treatment approaches in the context of both the current state of the science as well as opportunities for future research. I'll turn the microphone back to Brittany. BRITTANY HARVEY: Great. Thank you, Dr. Peterson, for reviewing those areas where additional research would be helpful. So next, in your view, Dr. Mercadante, what is this guideline's importance and how will it affect clinicians? VALERIA MERCADANTE: Thank you for this question. We believe these guidelines offers an opportunity for any clinician involved in non-surgical cancer therapies-- oncologists, dentists, dental specialist, dental hygienists, oncology nurses, clinical researchers, advanced practitioner. We all have an essential role in supporting our patient for the entire journey by optimizing symptoms management and improve our patient quality of life. These guidelines thus suggest a preventative and treatment course, but we've also delineated what we feel is common practice between expert and what areas would need further research to provide, as Dr. Peterson beautifully described, an ethical framework for future studies in this field. BRITTANY HARVEY: Great. Thank you so much. So finally, Dr. Beier Jensen, how will these guideline recommendations impact patients? SIRI BEIER JENSEN: Well, for patients who live with these complications during cancer treatment or as [INAUDIBLE] of cancer therapies, these guideline recommendations on prevention and management of salivary gland hypofunction and xerostomia will enable them evidence-based and with the help of professional health care providers to support the natural functions of saliva and promote their oral comfort and health. BRITTANY HARVEY: Great. Well, thank you all, Dr. Mercadante, Dr. Beier Jensen, and Dr. Peterson for taking the time to work on this guideline and produce evidence-based recommendations for clinicians and patients. And thank you for taking the time to speak with me today. VALERIA MERCADANTE: Thank you. DOUGLAS PETERSON: Thank you. BRITTANY HARVEY: And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/supportive care guidelines. Additionally, our annual survey for guideline topics is open for submissions. Suggest a topic for guideline development at SurveyMonkey.com /r/ascoguidelinesurvey by August 1st. The link is also available in the episode notes of this podcast. If you've enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]

The question was asked, "what are your thoughts on Mental Health and Religion?" and the results were eye-opening. It has become pretty clear that mental health has been a source of tension for what we know of as the "church." Even more interesting is that as a people, we have new understandings in this realm, but we lack the conversations needed to provide movement in a healthy direction. We need to talk about this more!!! So Dr. J. Duncan and Just_Z set out to gather feedback and start this conversation with you! Join in as we share the responses to our questions and engage you in the conversation. Be sure to share and subscribe to our podcast. Also check out our Website: www.mindsunltd.com Contact our Hosts with questions, comments, and ideas at: email: jduncan@mindsunltd.com Instagram: @mindsunltd, @doctor_j.duncan, @_Just_z_ Check out our Merchandise at Mindsunltd.com/merch Support our Patreon at: Minds Unltd we are growing thanks to listeners like you!!!Thank you for over 3K listens!!!

Dr. David Freyer, professor of clinical pediatrics at the University of Southern California; Dr. Michael Roth, director of the AYA Program and Childhood Cancer Survivorship Program at The University of Texas MD Anderson Cancer Center; and onco-fertility expert Dr. Leslie Appiah, associate professor of Obstetrics and Gynaecology at the University of Colorado Anschutz, weigh in on the challenges and advances in care for adolescents and young adults with cancer and survivors. Transcript ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. On today's episode, we'll discuss the unique challenges facing adolescents and young adults with cancer. I'm delighted to welcome three experts for this discussion. Dr. David Freyer is a professor of clinical pediatrics, medicine, and preventive medicine at the University of Southern California's Keck School of Medicine. Dr. Michael Roth is director of the AYA Program and Childhood Cancer Survivorship Program at The MD Anderson Cancer Center. And Dr. Leslie Appiah is associate professor of obstetrics and gynecology and director of the Fertility Preservation and Reproductive Late Effects Program at the University of Colorado and Children's Hospital Colorado. My guests report no conflicts of interest relating to our discussion today, and full disclosures relating to all episodes of the podcast are available on our transcripts at ASCO.org/podcasts. Dr. Freyer, Dr. Appiah, and Dr. Roth, it's great to have you on the podcast today. Dr. David Freyer: Thanks, Geraldine. It's really great to be here. Dr. Leslie Appiah: Thank you for having us. It's our pleasure. Dr. Michael Roth: Yeah, really great to be here. ASCO Daily News: So today we're highlighting some of the issues and strategies you all presented during the ASCO Annual Meeting that addressed equity issues and strategies to improve outcomes for AYAs. Our listeners will find a link to the presentation in the transcript of this episode. Dr. Freyer, there are approximately 89,000 AYA patients diagnosed with cancer in this country each year. Tell us about the challenges they confront and why they're so vulnerable to health care disparities. Dr. David Freyer: Absolutely. I'd like to say, first of all, thanks, Geraldine, for the opportunity for us to participate in this podcast. I think, as your question points out, AYAs who developed cancer are in a sort of double jeopardy, because not only of the challenges of cancer, but also their life stage where there's so much change and vulnerability. Normal changes for AYA life stage differ across the spectrum. 15 to 39 years is a very broad range. And at the younger age, I would say in the 15 to 21-year-old group, these challenges commonly involve education. It's finishing high school, possibly education or trade school, pursuing a career or vocation, expanding and reorienting their social network from their nuclear family, experiencing serious relationships for the first time, and then starting to explore intimacy and sexuality. For that younger group, self-image and physical appearance is very, very important. And there's overall a move toward greater personal autonomy and independence. When you get into the middle years, roughly [ages] 22 to 29, I would say that the issues begin to take on a financial character. It's becoming financially independent, paying for housing, starting or maintaining their own health insurance, maybe having their first meaningful employment. And a great many in this group are saddled with substantial debt from previous education. And then in this age group, they're starting to identify significant partners for the first time. And then finally, in the later years, roughly [ages] 30 to 39, the concerns really begin to focus on career advancement, maintaining a home life, starting or building families, raising children, taking on new financial obligations of adulthood like owning a home. And interestingly and importantly, some in that latter phase, we're seeing more and more, are beginning to feel the pinch from above as they're beginning to take care of unwell or older dependent parents who also need the financial support of this normally productive age group. So there's this developmental continuum. And to add cancer on top of all of that is, to say the least, highly disruptive. So even the experience of being treated for AYA cancers that have a good prognosis, and many do nowadays, it still interrupts education, delays career starts and return to work, upends their social networks, [and] undercuts their independence. They revert to being dependent on their nuclear family, and they have enormous financial burden. And then on top of all of that, of course, many of these patients are dealing with long-term health problems, because they have late effects from their treatment. And so to get your point about why this is an equity issue, I think that this session is perfect for this 2021 ASCO meeting actually, because AYAs, it's a cancer population that's defined by age. It's characterized by life stage dependent challenges. And so for that reason, they're systematically disadvantaged in ways that other cancer populations are not. And that's the definition of health care disparity. So they need special support in all these areas. And as a final note, I would say that AYAs who represent other disadvantaged cancer populations, such as low income or racial and ethnic minorities, I mean, they're actually in triple jeopardy, because they're at the intersection of their age, cancer, and also their background social status. ASCO Daily News: Absolutely. AYAs confront a host of disparities. AYAs frequently identify fertility threat as a major concern, and many patients have suffered fertility loss due to the effects of treatment. Thankfully, there continues to be much progress in fertility preservation, but not everyone has access to this care. Dr. Appiah, you've done a lot of work in onco-fertility and have even engaged with legislators to help pass bills mandating insurance coverage of fertility preservation for patients with cancer. Can you tell us about best practices in fertility preservation and your concerns that not all patients and survivors have access to available technologies? Dr. Leslie Appiah: Thank you, Geraldine, for that question. As you stated, with 80,000 plus AYA patients being diagnosed a year, we know that there are approximately 100,000 survivors. And so survivors are living longer. Up to 75% of them will experience at least one adverse event or late effect of their cancer therapy. Infertility, as you stated, is the most prevalent, one of the most discussed reproductive late effects in the literature, affecting up to 12% and 66% of female and childhood cancer survivors respectively. And then in addition to the infertility or fertility-related effects, there are other reproductive late effects that cancer survivors experience. And so as in many aspects of adolescence and young adult care, disparities also exist in onco-fertility or fertility preservation. The governing bodies of our societies--so the American Society for Reproductive Medicine, the American Society of Clinical Oncology--have all put out consensus statements describing how we should be caring for this population and how we should be providing equal care to these patients (DOI: 10.1200/JCO.2018.78.1914). And all of the societies or the guidelines recommend that physicians inform every patient of reproductive age about the risk of therapies to fertility and the options for fertility preservation. And by reproductive age, we mean from birth through, typically, for women age 42 and our male counterparts can be fertile much later into 50s and 60s. And so all of these patients should be counseled about the risks and then referred or offered the opportunity to see a reproductive specialist for further counseling, and that this really should occur before any treatment is provided. We know that once patients receive any cancer therapies that our options are limited in terms of what we can provide them for fertility preservation. So this conversation should occur regardless of the patient's age, gender, culture, socioeconomic status, or health care team bias. And these discussions should continue into survivorship, because even at the end of therapy, there may be some options for these patients. Despite recommendations, however, less than 50% of patients ever recall having these discussions with their providers, and then less than 30% of patients go on to use fertility preservation therapies. This disparity is sometimes due to information overload. Many times the patients don't recall the discussion, even though the discussion was had. But really when we look at the data, many times they are not being offered this information. We know that in terms of disparities, men are more often referred for counseling and referred for fertility preservation therapies because of the idea that it's easier to bank. And for those men who are feeling well and are of age, sperm banking can be a simple process. But many of these patients are very ill, and so extracting sperm becomes an issue for them and it becomes very challenging. We know that patients with fewer financial resources are less likely to be offered fertility preservation counseling. So our patients in the lower socioeconomic statuses, these patients are less likely to be referred. And again, that's not providing equitable care. There are many resources available for patients that can provide some financial resources. And so these patients really should be given the opportunity to have a discussion and seek resources, or we can provide options for them. And then lastly, I'll say that in terms of disparities, cultural biases play a huge part in this. Our providers come with their own biases as to how many children they feel that a family should have, and that can be a bias. Sometimes prognosis can be a form of bias. If the patients have a poor prognosis, then perhaps the provider is uncomfortable referring them for fertility preservation therapy. But there are some options for patients if they should succumb to their cancer diagnosis, there are some posthumous reproductive options that our young adults can participate in or agree to. And it requires a lot of legal discussion and documentation and contracts, but there are options. And we really should be providing our patients the opportunity to decline these options. And in that way, we can really address the disparities in fertility preservation for our patients. And then lastly, I will say cost is a factor, but there are I think now 13 states with insurance mandates for fertility preservation. And these mandates are starting to occur more and more often. And so we need to continue to push our legislatures to move the needle forward in this way. ASCO Daily News: Can you highlight some of the new technologies in fertility preservation that oncologists should be aware of? Dr. Leslie Appiah: Absolutely. I think two of the very important aspects of this is that we are able to provide fertility preservation for adolescents in terms of egg freezing. So until recently, we limited this option for girls who were 18 and older or late adolescents, but we now can provide egg freezing for girls once they reach puberty, and especially once they are monarchal or have achieved menses. And so that is something that we really want our oncology colleagues to know. It's also important for our colleagues to understand that we can start for egg freezing at any point in the patient's menstrual cycle. Historically, the patient needed to be on their cycle in order to stimulate, but now we have random start protocols. So if we see a patient today, we can start stimulating tomorrow or the next day. And the average number of days to stimulate the ovaries to be able to grow eggs to freeze is about 10 to 12 days. And so we really can intervene for these patients if we are informed of their diagnosis very early. And in that way, there will be no delay in their cancer therapies. And then lastly, we are very excited to share that ovarian tissue freezing is no longer experimental. As of December 2019, the experimental ban was lifted by the American Society for Reproductive Medicine and ASCO. And so patients from birth through age 40 can have an ovary removed, or part of an over removed, and frozen for their future fertility. And this is considered clinical care. We're able to put this through the insurance, and therefore alleviate the financial burden on many of our families. ASCO Daily News: That's great, Dr. Appiah. Thanks for highlighting these positive developments in fertility preservation. Managing the care of AYA patients and survivors as they age and deal with toxicities from treatment and other physical and mental health issues requires collaboration between providers. Dr. Roth, can you share some strategies to address the unique challenges of AYAs and the providers who care for them through various phases of their lives? Dr. Michael Roth: Thank you, Geraldine, for that important question. As Dr. Appiah and Dr. Freyer clearly noted, AYAs face many unique challenges both during and after cancer treatment. And it really is essential that, as medical providers, we seek to meet and treat these challenges. Unfortunately, the system as it's currently set up is really not well suited to care for some of these unique needs. Specifically, many of our younger AYAs who deal with cancer such as leukemias and lymphomas, they're treated within the pediatric oncology department. And often, the approach to their care is focused on the care of younger children. On the flip side, many patients in their 30s with breast cancer, colorectal cancer, these AYAs are treated within the medical oncology community and are often seen in clinics with many older adults. So most of the care across the country is not specifically tailored to the unique needs of AYAs, and that's really where collaboration comes specifically into play. We know that there are many opportunities to address these psychosocial needs, the education and work needs, the onco-fertility needs, the genetic counseling needs of our AYAs, but it really takes a champion, or a number of champions, at each site to ensure that AYAs needs are prioritized. Recently, there has been a large growth in the number of AYA programs. And what a number of institutions have done is they've brought medical oncology together with pediatric oncology to centralize these specific AYA resources under one house. Some of these AYA programs are treatment-based programs. For example, some sites have an AYA heme-malignancy program, where they will provide both the cancer care, as well as the supportive care required for their AYA patients with leukemias and lymphomas. Other AYA programs are purely supportive care-based programs, where patients will be referred to them for their onco-fertility needs, for their psychosocial health needs, for their education and work needs as well. At the end of the day, we really just need to do what's right for our patients. And we've learned over many, many years that just treating our AYAs the same as we treat our younger children, or just treating our AYAs the same as we treat our older adults, doesn't cut it. And we really need tailored, focused approaches to make sure that we both optimize cure rates, as well as to optimize health-related quality of life for these patients both during and long after treatment. ASCO Daily News: Right. So Dr. Roth, what will it take to improve collaboration between providers? Dr. Michael Roth: Cancer care is traditionally very siloed. And these silos do decrease the rate of progress in which we can make within cancer care. But specifically within AYA oncology, historically, pediatric oncologists did not interact much with medical oncologist. By having AYA tumor boards, by having more multidisciplinary clinics, essentially you're taking down those barriers. You're breaking down those walls. And being face to face, or now in the virtual world, being able to connect and to collaborate, it really allows the optimization of care for our AYAs. It's not possible to know everything about every AYA oncology diagnosis. And when you're in a large academic center, you often have many subspecialists within each of the different cancer types. When you're in a smaller community setting, oftentimes you have more generalists who take care of all patients with a large number of diagnoses. And often in the community settings, there aren't many specialists who focus on AYAs with breast cancer or young adults with colorectal cancer. And oftentimes, it really takes teamwork and a real consensus and an approach within a team setting to make sure that both the cancer-directed care is appropriate and is the most appropriate treatment approach, but also there's a need to focus on that health-related quality of life, and specifically that often gets lost for many of our patients during their treatment. Dr. Leslie Appiah: We are also finding that when we incorporate our fertility preservation colleagues, our experts, into the multidisciplinary oncology meetings that were also able to break down those silos and help educate our colleagues about fertility options for patients as they are diagnosed. And that really does expedite the care that we provide to these patients. We also want to look at leveraging technology to improve how we incorporate fertility preservation into oncology care and using our best practice advisories within our Epic systems, as well as using the Epic referral process to really expedite the referrals of patients. And by that I mean, there are ways to do an opt-out referral system where the referral is automatic, unless the oncologist opts out of that referral. And in order to opt-out, the oncologists will have the discussion with the patient about their fertility risk and then recommend consultation. And the patient can then decline, and that's when the provider would opt-out of that consult. So utilizing technology that we have already can really expedite the care for these patients and break down some of those barriers. ASCO Daily News: Absolutely. Well, there's a huge need for more research on AYAs. Dr. Freyer, how does clinical trial accrual among AYAs compare to older patients? Are there any innovative strategies that could improve trial accrual among this patient population? Dr. David Freyer: This is a really important issue, and I'm glad you raised it, Geraldine. So clearly, to continue advancement of AYA oncology and really every realm, whether it's survival or supportive care, more epidemiology studies, studies on basic biology questions about cancer types in this age group, long-term outcomes, and so forth, we can't make any advancements in AYA or any other age without conducting the research. Clinical trials for many years have been sort of the heart and soul of clinical oncology science, because it's actually testing new questions, new therapies, and following in an organized way the outcomes of the patients who are enrolled in clinical trials. The problem is that the proportion of AYA patients who are enrolled in clinical trials is exceedingly low. The gold standard, I think, or benchmark for clinical trial enrollment actually tends to be children, pediatric oncology, which for decades has been very, very successful at enrolling patients on clinical trials. And they have improved survival and improved knowledge around cancer to show for that effort. So most studies--there's a little bit of variation--but most studies indicate that about 20% to 40%, at any given time, of children enroll on a clinical trial if they're newly diagnosed with cancer. For AYAs, that number is less than 10%, usually more around 5%. And that's actually similar to older adults. The drop off occurs sometime between 15 and 20 years of age in terms of enrollment on clinical trials. So the question is, how can AYA patients--how can the picture be shifted to look more like that of younger children? And it turns out, I think it's really a complicated scenario. There's multiple levels to this problem. Part of the challenge is having the right kinds of trials available for the diseases that occur in adolescents and young adults. And then another layer is getting those trials that are developed by the, say, the National--the NCTN Oncology groups getting those opened up at the sites where the AYA patients are being treated. There are a lot of barriers that institutions need to overcome in order to get those trials opened up. And if they can be opened up, then they're available to the AYA patients. But it doesn't stop there. Then the next step is that you've got to get those trials presented to the AYA patients. So the pediatric or medical oncologist that's taking care of the children--or excuse me, the AYA patients--need to be aware of these trials. They need to have access to research infrastructure that can make it feasible to offer these and enroll the patients. And then finally, of course, the AYA patient himself or herself needs to be convinced that this is the right thing for them to do and to go ahead an enroll on the clinical trial. So there's multiple steps to this. And clearly, addressing any single step won't ensure that more AYAs are being enrolled into clinical trials. So it requires a multi-level, multipronged approach. I think, in terms of innovative strategies, again, it's all of these things at one time. So on the national level, there's a good deal of work being done to try to increase the collaboration across the different NCTN groups--the National Cancer Institute (NCI) National Clinical Trials Network groups, the adult groups, and children's oncology group--to increase collaboration across those groups. So that there are more trials being opened that are appropriate for that entire spectrum of 15 to 39 years of age, which, as Dr. Roth pointed out earlier, cannot be addressed without collaboration between the pediatric and the medical oncology groups. So trying to pull those together. And then on the delivery end to the patient, trying to find better ways to support our oncologists and to make the information about clinical trials more digestible, more maybe less threatening, more understandable to AYA patients, so that they can make a good, well-informed decision for themselves. Perhaps the least exciting for most of us, but in some ways maybe the most crucial and the most overlooked, is that middle stage of getting these trials opened at the sites. That requires resources to get these passed through the IRBs at the institutions. It takes resources to have clinical research coordinators there to shepherd them through the regulatory processes and then to make those readily available to the practicing oncologists. I think at the local level, that's where some of the greatest challenges are. And I think one of the factors that sort of feeds and aggravates or exacerbates the health disparities issue for AYA patients is where these patients are being treated. There are a number of studies that show that AYAs tend to be treated at community sites rather than traditional academic centers. And that's wonderful in terms of making health care accessible to these patients in their home communities. There's a lot to be said for that actually. But one of the features of that treatment setting that may undercut the clinical trial question at least is that some sites, many of them, don't necessarily participate in a regular way or have fewer resources to participate in the clinical trial enterprise. So those patients, if they're treated in the convenience of their home community, they may not have access to the same sorts of clinical trials of those who are treated in academic centers. We need to figure out a way to overcome those kinds of challenges. It's not easy. ASCO Daily News: Right. Dr. Roth, what are your thoughts on clinical trials for AYAs? Dr. Michael Roth: So a couple of the layers that Dr. Freyer addressed in terms of barriers to enrolling more AYAs in clinical trials, I do think at the national level, we've made a lot of progress over the past decade with these collaborations within the NCTN network groups. Currently, we have a record number of truly AYA collaborative trials open and available for our sites to be able to have available for their local patient population. And like Dr. Freyer said, a lot of these trials, they're really getting stuck at the local level because, in many ways, there's not an incentive to open the AYA trials when you have limited resources, because it's easier to enroll many more patients on the prostate cancer trial or the older adult breast cancer trial just due to patient numbers. So we really do need to overcome that large barrier of when we have trials available at the national level, they need to be opened up at all sites really across the board to make sure that our AYAs have access. The other point on the local level is to address the challenges we have in lack of knowledge on disparities in AYA enrollment and care. And we've tried to overcome that by having local AYA site champions, having folks on the ground really spreading knowledge. These folks typically are investigators, sometimes they work in the research office. And their goal is to help prioritize the opening, activation, and enrollment on AYA specific trials. There's still a lot of work to be done. It's a complex situation, but I do believe we are chipping away at many of these issues. ASCO Daily News: Great. I'd just like to wrap up with a final question about models of survivorship care delivery. So AYA patients who complete treatment need to be supported. They need appropriate follow up to monitor treatment-related health problems and psychosocial support. Dr. Freyer, what are the models of survivorship care delivery that can successfully address these needs? Dr. David Freyer: I think, again, similar to the clinical trial situation that we just discussed, I think that survivorship care for this population--in other words, patients treated during the 15 to 39-year-old age group--is in a process of emerging and growing and taking many of its leads from the pediatric oncology experience. Survivorship care in pediatric oncology is well established. It's been now decades in the development. And there's been a huge amount of research, really high quality research, done to map out the spectrum of late effects of cancer treatment, both medical and psychosocial, for patients who are treated. Those children then grow up into adulthood and they become AYA patients, but they were treated as younger children. So that landscape is pretty well mapped out, and there are excellent models of care in place around the country. That has now become the standard of care in pediatric oncology for comprehensive holistic care of these patients long term. That situation is emerging in AYA oncology--in other words, for patients treated in the 15 to 39-year-old age group. Of course, part of what drove that in pediatrics is that survival rates improved so dramatically that these issues were staring oncologists in the face. And it was absolutely necessary to deal with it. It's taken a little bit longer for survival to come up to those levels in AYA and older adults, but we're there in many cases. And with the high survival now that we're seeing in the AYA age group, the same question is begging itself as was in pediatric oncology, which is now we've got these patients who have completed treatment with all of the problems that you just mentioned. I mean, many do very, very well. And it's important not to paint a more negative picture than is warranted, but I think the data are beginning to show that many long-term survivors of AYA cancer also deal with health problems that are getting superimposed on the normal problems of aging that all human beings develop over time. Now how to deliver that, again, the experience is just emerging. I think that different centers have developed programs that sort of play to their own strengths and overcome their own challenges, just like Dr. Roth said with AYA programs and I'm sure Dr. Appiah could say about fertility preservation programs. Every place has its own experience of one. And while there are some common themes, there are some things that need to be addressed that are individual. I think probably the basic requirements for a survivorship care model for AYA patients is having somebody, a champion, who has some expertise in this area, commitment on the part of the facility to put together at least the basic resources to begin to bring these patients together. There are different kinds of models. The models can be doing survivorship care in the context of each disease team. Breast cancer may have their own survivorship focus, colorectal cancer, leukemias and lymphoma, and so forth. And they may be delivered within the context of the diseases or another model is, I would say, more the classic pediatric model, which is to have a survivorship clinic that can meet the needs across these different diagnoses. And it's important for each program to determine these for themselves. I'll put one final closing pitch in for the clinical research, which is needed in this area as well. Just as clinical trials are needed to improve survival with treatment and also our understanding of these diseases and the cancer hosts that the AYA [patients] represents, there's also a need for research in the long-term as well. And the best way to do that is in the context of survivorship efforts that are organized and have resources like databases and participation in larger cohort studies, so that we can begin to amass the data in the same way that we've done for children. Dr. Michael Roth: So, I completely agree with Dr. Freyer. I think AYA survivorship is still in its infancy. And we're really only learning now about what happens to our patients diagnosed as AYAs with cancer in 15 years, 20 years. What are some of the cardiovascular events that are happening in these patients as they age into their 50s, early 60s? I think there's a real need for standardization of how we care for our AYAs post-treatment based on exposures, based on cancer diagnoses. And currently, with the models in place for survivorship within some of the large institutions, there's a lack of standardization across departments, and then across institutions as well. There really are no set guidelines as to how do we monitor for cardiotoxicity. What should we be doing in terms of monitoring for psychosocial health concerns? And I worry even more, as you go into the community setting, that many of these sites don't have the resources to offer expert survivorship care. As Dr. Freyer mentioned, this is really a plug, a call to action, to focus more attention on our patients' lives, not just during treatment but well beyond treatment. We know that 5-year overall survival for AYAs is approximately 85%. So the majority of our AYAs diagnosed with cancer will live long and well past beyond their cancer diagnosis. And it really is essential that we help them live long, healthy, and happy and productive lives. Dr. Leslie Appiah: And I will add one final word to that. So the U.S. news and World Report reporting system has now started to include fertility preservation as a marker of providing excellent care in the children's hospitals. And of course, that's going to go into the adolescent population as well. So I think that's one impetus for our colleagues and our institutions to really make this a priority. Additionally, as Dr. Roth stated, using national databases, where we can really bring together all of the information so that we can standardize how we care for this population, is really important. And the University of Colorado is developing a national database in fertility preservation as a data coordinating center for the Oncofertility Consortium and will be including various sites across the country, so that we can start to look at this data longitudinally. And then lastly, I would say, again, leveraging technology. I don't think that, in medicine, we utilize technology the way that we should. And I think using our electronic medical record to signal to us, as fertility specialists, when a patient has completed their treatment and they are in survivorship, this is a time for us to intervene again into this patient's care and to make sure we've really addressed all of their fertility and reproductive and gynecologic/urologic needs that they are going to experience. So those are the ways that I think we can incorporate better fertility preservation care into the survivorship care model. ASCO Daily News: Excellent. Thank you, Dr. Appiah. And thank you, Dr. Roth and Dr. Freyer as well, for highlighting the challenges facing AYAs and approaches in care for this patient population. Dr. David Freyer: Thank you, Geraldine. Dr. Leslie Appiah: Thank you for having us. It's been a pleasure. Dr. Michael Roth: Thank you so much. ASCO Daily News: And thank you to our listeners for joining us today. If you've enjoyed this episode, please take a moment to rate, review, and subscribe wherever you get your podcasts.     Disclosures: Dr. Michael Roth Research Funding: Eisai, Pfizer Dr. David Freyer: None disclosed.  Dr. Leslie Appiah: None disclosed. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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Eric Rieger  0:00  Hello gut check project fans and KB MD health family. I hope you're having a great day. It is now time for episode number 58. And of course we got an awesome guest. It's Dr. Sabine Hasan, who is she a world renowned research gastroenterologist, she is based in California, and she is an expert in faecal microbial transplants, FMT trusted it fast. I couldn't do it. Anyhow FMT. So essentially you're taking healthy poop from a healthy person, and using that microbiome that's inside of there to be transplanted into somebody else who may not be doing so well and could have all kinds of disease etc. Regardless, she's at the forefront of finding real solutions that can be accepted by our bodies to make us better make us well even help you lose weight. That's right. Could poop because somebody else's poop Have you lose weight, and earmuffs in case you have any young kids in the car, but she wrote a book and it's called let's talk shit, although the AI is upside down like a exclamation point. So regardless, let's get to her interview. And well first got to pay the bills though of course brought to you by artron to artron to get your daily polyphenols that are Tron teal.com or just go to love my tummy calm get your daily polyphenols. That's right. Developed by my partner, Dr. Kenneth Brown, gastroenterologist, these polyphenols are terrific for you. Whether you having digestive issues, maybe you have symptoms that are similar to those of IBS. 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Dr. Sabine HasanKen Brown  3:03  Hey, what's up everybody? Welcome to Episode 58 of the gut check project. Ooh, today's a really, really cool one. We have Dr. Sabine Hasan, who will be our very first gastroenterologist as a guest. So I'm a gastroenterologist, but she's way smarter than I am and does all kinds of really cool stuff on read. What's that? Cool stuff? Yes. Cool stuff. Indeed. It's awesome. So I put together a quick little bio for you. I apologise that I don't have your probably standard bio. So I hope I get some of this stuff, right. This is Oh, and you'll notice there's an empty seat here where my co host, Dr. Eric riegert crna, who's usually here on time. Don't do that. It'll make it blurry. It'll make it blurry. It'll get us out of focus. He almost photo bombed us. Dr. Hayes in this is Eric reser. We've already been talking and we practically had a whole podcast before this podcast. You missed it. Sorry. Oh, that'sEric Rieger  4:05  okay. Another topic that I'd like to talk about is promptness, and being on time, that's another thing that really well, apparently I wasn't very good at today.Ken Brown  4:14  So I'm really surprised. You know, what is what's interesting, and I hope it's something that we can comment later is that Eric got a round of antibiotics. And ever since then, it's so weird. He's just always late for everything, and I'm blaming it on the microbiomeUnknown Speaker  4:26  100% I think we should test this microbiome. I'll send you a kit. That's the first thing I do.Ken Brown  4:34  Alright, so Dr. Sabine Hasan is a Board Certified gastroenterologist and avid researcher. She has a thriving practice in Ventura, California, and she started her own clinical trial company 16 years ago called Ventura clinical trials, and has been principal investigator and sub investigator in over 150 clinical trials. Now you say that number but I'm in like, For, and it was exhausting. So 150 Holy cow. Alright, so during this period, she became an expert in the microbiome with an interest in cdiff. Clostridium difficile. So through this process, she became one of the world's leaders in faecal microbial transplant. And through her research and expert, and through research and experience, she realised the unmet need to dive deeper into the microbiome. And she founded progenitor biome. So she is the founder of her own company, progenitor biome. And most recently, she published a fun, easy to read book for the lay person called let's talk shit. And I got it, and I read it and I laughed a lot. And it's really good. Written in a great lay, lay person point of view. And I loved it. So Dr. Hayes, you want to talk some shit? Talk?Unknown Speaker  5:57  Let's talk shit, for sure. Oh, at least finally a podcast that's like willing to go there? Like, oh, I don't think we should talk about it. Or we should say another word. And I'm like, Are you kidding me? I've seen half the books that are out there. The Art of not giving a f EU Oh, that's number one bestseller. But let's talk shit. We can't even say the word shit. Since when is the F word more acceptable than the shit? Come on?Ken Brown  6:28  This is true. Unfortunately, I think I use the words quite frequently, both of them often. So I really do not discriminate.Unknown Speaker  6:36  I named it that way. Because too often, you know, we sugarcoat microbiome, right? We made it pretty. But I think we're entering in a world of microbiome, we got to tell the public and the consumer what it's all about. And that's why I wanted it. First of all, I thought it was funny. I mean, this is like a tough topic, right? People come to us as gi doctors, bloated, gassy symptoms of you know, bowel changes, etc. And so we hope to, we have to explain to them and how do you explain a topic like the microbiome, without, you know, a little bit of humour to digest it a little bit better? My opinion, that's what I that's why I named it. So to give it full transparency. And then the other thing was to, essentially, you know, make people smile, because there's so many jokes you could say about it.Ken Brown  7:30  I heard you on another podcast where you're exactly right. As gastroenterologist, we have no problem talking about it. But I have the same issue with patients. They're like it was so embarrassing. I don't want to discuss this. I'm like, we have to discuss this. And then that goes from that to Okay, well, as long as you're comfortable with it. Here's some pictures.Eric Rieger  7:49  Not all the time, like no pictures, please. Okay, sometimes randomly the nurses they showed up with the bag.Unknown Speaker  7:58  Field great. I mean, you know, you probably know Neil Stallman, right? Yeah. So Neil, when I was a fellow at University of Florida, and I was presenting my research on visceral hyperalgesia, which was super clean, would come to me and say, You better start getting your hands dirty, because we're going into the ship business. I said, No, please, they call me Gucci girl in the GI lab, because if it's dirty, if the colonoscopy was not clean, I was out of there. I'm like, sorry, we do the prep, come back next week. I'm not cleaning the patient, right. And then the mere mention of having to actually play with tools and putting it in there was just something I never ever thought that would even happen to me. And, um, you know, when a patient is about to die from C diff, and you tried everything from, you know, antibodies after antibiotics to, you know, clinical trials, and that was my, my path, right? I was doing clinical trials, and Neil was doing people transplants. And we met when I was doing a clinical trial on faecal material in a capsule because every time I would do a clinical trial for pharma, if the pharmaceutical product didn't work, I would do faecal transplant, because I would say, Well, you know, the patient trusted me to heal them. And whether they got placebo or the drug didn't work, it's my obligation to make sure they're fine. So I would do people transform them. And then I discovered all these things. And of course, I you know, I blame Neil in a way for stepping into this because I've stepped in fully and every day I play with it, I can tell you the first time I I was, you know, looking at collecting stools, I think I almost passed out. But then you develop you know, that survivor or that, you know, warrior mentality that you're like, I can do this, I can do this. I went into gi I'm tough and blameless goes I can do this. And that's what happened.Ken Brown  9:59  So I'm really curious about your history. Can you just give us a little background about like your family and where you came from who you're married because I find it all really interesting. Your, your past is fantastic to where you are right nowUnknown Speaker  10:13  increasing the volume. So I'm I was born in Morocco. My parents, you know, my background is pretty much a mud like Spanish background German, you name it. It's all mixed in Italian, I was happy to see on 23andme I have some Italian blood and Greek. So I'm a mutt. And essentially, my parents immigrated to Montreal, I was raised in Montreal, went to medical school in Nova Scotia. My siblings all went to McGill and wanted the McGill route. And I went down housing because I didn't want to, you know, in my family, you had to live at home if you're going to college in Montreal, but if you go to college elsewhere, then that's the only exception to moving out of the house. So I said, Okay, I'm going to Dalhousie and Dalhousie was, was fun because it was you got into the rotations of, of medicine right off. You know, from day one, you were seeing patients. So that was kind of fun for me. And then I was gonna go back to Montreal, and I had a cold and I was interviewing for positions for internal medicine and gi for internal medicine, I don't even think I was going to be a GI at the time. And I got an interview a University of Miami Jackson Memorial Hospital, and they paid for my plane tickets, because they love Canadians back then. And they paid for my hotel. So I said, Oh, free trip to Miami. And then I show up in Miami, and I'm interviewing, I'm doing the interview. And they're telling, they're showing me like a room of 10 CAT scans, and you know, just like beautiful hot. I mean, you've been I don't know, if you've been to Miami Jackson Memorial, it's it's a city in itself. And back then, I mean, we had one CAT scan and the whole country of Canada, I mean, show up in my app, and you've got like 10 CAT scans in the room, and it's like, and then they sell you on Miami, and they're like, Oh, you could live in, you know, on the beach. And then you could go to the hospital, like, I'm there. I'm coming. So I showed up. And that was during the, the world of HIV. You know, that's when HIV was really, you know, really starting and all right, I remember here I am this, you know, kid that my parents kept like in a, you know, protected and clean environment. And then I'm the move, I'm moving to Miami, and I'm dealing with, you know, HIV, like 12 HIV patients a night and patients are like throwing blood all over the walls. And you remember the, I don't know, you're probably much younger than I am. But, you know, this was this was war, right? And so, me and Neil and my colleagues from Miami, we we trained under those circumstances of patients coming and crashing from HIV, kind of what we're seeing with COVID. Right?Ken Brown  13:04  It does have some and yes, I did have that we had our aids Ward where you would have to rotate, and then you have to make sure because their CD forecasts are so low that you you know, so you didn't want to give them any microbes that could hurt them. We just didn't know back thatUnknown Speaker  13:20  you didn't know. And we were so scared, right? We were if we got pricked by a needle, we, you know, you'd hear the residents like chopping their fingers. You know, going into a room of a patient that was altered mental status and being dressed like an astronaut going into space. And I met my husband, by the way, in Jackson Memorial first day of internship. And we became best friends because we were on call together. And it wasn't like scrubs or er, although kind of, but it was kind of fun. We were together we like work hard and do call and then we'd go party after on South Beach. So we met under this circumstances, and I think some of my best friends and you know, I've been married to my husband almost 30 years. So I think that really that environment really, you know, bonded us forever The memories, my colleagues because it was really survival. And he used to joke because he used to say, you look like an astronaut going into space. Going to see these spaces are like I'm not coming because we had TB resistant TB and HIV. We had all sorts of infections in that hospital. So it was really Warzone. And at the same time, you're treating these patients that are swallowing bags of cocaine, and in condoms, right and you have to like wash the bag evacuated. So it was really it was intense. I mean, we were I was taking care of your HIV patients criminals. I mean, it was just it was a interesting times but it forms you and makes you you know, a top doctor that you can do survive, you know, helping people no matter who they are. Right. So I think that that was it was great for me. It was a great education. It was great. And then in Miami and residency, some guys said, because we were, my husband wanted to go into cardiology, and I said, Well, maybe I'll go into cardiology. And then some guy said to me, you know, we don't take an eye and I said, how's gi his gi a good feeling looks kind of fun. I mean, it's like surgery but without doing surgeries, and he said, we don't take women in gi so don't bother well. That's all it took.Ken Brown  15:40  In there on challenge taking you ripped off your space suit room is roomful of AIDS people vomiting blood me like I'm gonna do giEric Rieger  15:52  the lion You sound like you're talking shit. Let's talk shit.Unknown Speaker  15:56  So basically, yeah, and back then gi and it was actually a miracle because back then gi was like the the flexible StG where you're like, touching your like, baby, you train with that. You were still you were probably kaleidoscope. IKen Brown  16:12  am actually a few years older than you. And so I went through everything you're saying I'm 100% dead. But I will say this, you've got way more guests than I did. I interviewed at Miami. And I went I looked at the volume and what was wrong because Miami had that they had more than a bigger HIV population, tonnes of age, lots of trauma, all that stuff. And I'm like, I like the warp. So I was training in Nebraska and I just got sick of the cold. And so I just moved south, I just drew a line from California, Arizona, across and it basically Texas is like Midwest but south. So I just but Miami I was I remember thinking, Oh my gosh, if I do residency here, you're just you're just not gonna sleep.Unknown Speaker  16:53  And actually, I was sleeping because I came out. So I was a Canadian train. So we trained with like physical exams, right? you examine the patient, you actually say, oh, gallbladder problem just by doing, you know, Toby's face and percussion, etc. So, you know, it was much faster for me to take care of patients. So me and my husband used to have like, gone, you know, he would, he would come in the column. He's like, you're sleeping, I didn't sleep. And I'm like, Oh, you know, and then we would have this competition of who would discharge the patient and treat the patient the fastest. So there'd be a board. And it'd be like Hasan and Steinberg and HIV patients and I'd be like, I'm giving them this, this, this, that and that. Okay, they're fine out of the hospital one day, and then it'd be like zero. He's in 20, Steinberg and thenKen Brown  17:42  eventually he just made everybody DNR and just flowing out.Unknown Speaker  17:48  He was it was a you know, it was it. We do things for challenges, right. I mean, we do things. Why do you go into medicine? Otherwise, if it's not the treat, that's what bothered me with this whole COVID is like, was the idea of doing nothing. I the patient's having shortness of breath, oxygen, the SATs and you do nothing? I couldn't understand that mentality because you have to try.Ken Brown  18:12  So I have a feeling that this we're just going to go all over the map here. So I'm going to get right off because there's something I was super impressed that you did, you gave a lecture on COVID and ivermectin way back. So now ivermectin, now, all these things were being said, are now coming to light and going, what the heck, why don't we? Yeah. How did you realise ivermectin fairly early.Unknown Speaker  18:36  So it was I started the protocol with the hydroxychloroquine, which went completely political. And my idea was, well, makes sense, right? That's kind of like what we do with H. pylori, multiple drug combo. So I thought, well, hydroxychloroquine azithromycin would be killing the virus and then vitamin C, D and zinc would boost the microbiome, right? So in other words, you kill but you boost right? So you we we bring the balance. And so Dr. Berg when hydroxy glow. At the same time, Dr. Brody said you know what, I think ivermectin is a better solution, because he was investigating himself. And you know, Dr. Brody is the man we all follow for his leadership on faecal transplant, but also he was the one the brain behind H. pylori and triple therapy. So he was the one that said combination therapy, and he's big on combination therapy. I mean, he's used combination therapy for two patients in Parkinson's, he published on that. So, basically, for me, it was following his direction. And he said to me, you know, what we need to do ivermectin, doxycycline zinc. And I said, Yeah, but you got to add the vitamin C and vitamin D. Nothing should be done without vitamin C, and D because you're killing the virus. And in fact, the microbiome is going to tell the story, and it's going to be amazing, because I showed the data to Dr. Ayman quickly, and you know, Dr. COVID,Ken Brown  20:02  right. The Godfather of probiotics,Unknown Speaker  20:05  yes. And and by the way, he was like fantastic data. Fantastic. And he's on my paper that's coming out. So yeah. So I got I got Dr. bozkurt from Turkey. I got Dr. Brody, of course in the paper and even quickly, so and it's basically blank, blank, blank susceptible marker for COVID-19. And we know we're going to show in the microbiome why ivermectin is working. Oh, that's cool.Ken Brown  20:39  So both Eric and I are big fans of the podcast. Brett Weinstein the Dark Horse podcast. Yes. And he had the critical care doctor from New York, pa Corey. Yeah, up here. And I was just floored because, you know, like all of us. We, we there's only so many hours in the day and we do quite a bit of research and I'm and ivermectin caught me off guard. I went, I was like I was, I was behind the curve on that one. I looked back and went. How did I miss that? How did I miss ivermectin? That's why I was so impressed that you were on it right away.Unknown Speaker  21:09  Yeah. And by the way, when you see what is doing to the microbiome, it's going to be as clear as life because what happened is because I have a CR O, and I'm able to put these protocols through pipelines through the FDA. And by the way, I did it because I had enough of pharma. You know, I had enough of putting these products and then you saw with the Alzheimer study, this Alzheimer drug goes into market, and the benefits are like, you know, what's going on there. So I said, we need to have doctors lead the path for pharma. In other words, doctors come up with these solutions, and bring them to the FDA. And so I kind of started this with COVID was more of a lead to show it Look, I'm taking combination therapy, and I'm putting them through a pipeline, I wrote the protocol and I submitted to the FDA and the FDA approved it right off the bat. Then the FDA then had second thought, because they said, Well, you need to have a placebo, and I said a placebo and COVID in the middle of a pandemic. I'm like, that's like. And I said, we're in the middle of a pandemic. Rome is burning. Are you asking me to use a bucket that doesn't have water? On the fire?Ken Brown  22:30  Okay, the house is on fire. I'm going to give you a bucket. Yeah. And you're gonna get a bucket. Now go put it out. Yeah. And then walk one of those bucket was gonna have water and one's gonna have nothing makes gasoline. More than anything, because we're talking about COVID here. I mean, it's like giving a placebo is like giving gasoline.Eric Rieger  22:48  Okay, so some burning Sinan fire truck. And over here sim school bus?Unknown Speaker  22:52  Yeah. So that's basically what happened. And then I started, when I submitted these protocols, I said, Okay, find the, the placebo is going to be a vitamin. So we did vitamin versus the other thing. But what we discovered is when we started looking at the microbiome and looking at we found COVID, in the stools, whole genome sequencing presented at an american college of gastro and then it got published, took six months to get published on gut pathogen, because they couldn't believe it. Right? They were, what is this real, we had to like submit, it was sent to the who I mean, it was just too ridiculous, you know, long term time to get that paper published. And so when we started looking at the microbiome, we discovered something in the microbiome. And we discovered something in the microbiome of those that were super sick, compared to those that were not so sick, compared to those who never got COVID to begin with. But yet we're exposed to patients with COVID. So we said, Wow, if this is a susceptible marker, so it was so basically became like a susceptibility marker, right. And so we determined that if we don't know the baseline of the microbiome in a patient, and we're giving them placebo, and that person has those microbes are super high. In other words, where's your immunity in your gut, right? And your immunity at baseline is super high, and I'm giving you a sugar pill? Well, of course, it doesn't matter because you already have like super strong microbiome to survive. COVID So is it fair to compare a placebo to a person, you know, that doesn't have a good microbiome? You know, you're comparing like an athlete running a marathon to a person on a wheelchair. Unless you know, the microbiome, you're really doing placebo controlled trials useless and COVID in mind,Ken Brown  24:47  you're bringing up something that is, I mean, could be a complete game changer in how pharma would do and type of research in the future. Yes, because what we're saying what you're saying is, if You do not have. And we've discussed this kind of stuff on the on other podcasts. If you do not have a diverse microbiome, are you able to take full advantage of these medications that we believe are helping because the FDA determined that there's a safety profile on it, therefore, it goes to the second trial. And then just like you said, in phase three and four trials, you're 6% better than placebo. So because of that, it's now a $14 billion drug that got bought by a bigger company.Unknown Speaker  25:26  Yes, absolutely. And we are entering into a world of research now, that is no longer research. In my opinion, medicine is no longer an art, it's a business. And that's scary to me, because that's not why I went into medicine. I'm sure that's not why you went into medicine. We're all individuals, we should all have an individual treatment. We have the technology now, especially with what we do with Regina biome, to understand with precision, these microbes of the individual, and the future is beautiful, because it's going to be a readjustment of microbes to attain that precision medicine. We need to get there, we can't be stopped, because roadblocks is what stops innovations and stops answers. And we got to keep asking questions and say, is this is this correct? Is this safe? Why are we doing this? Why are we not? The moment we stop asking questions, we stop science, we stop research, we stop finding answers. And then in my opinion, humanity is lost. I mean, you're talking about diversity. Look at the diversity of microbes. Over the last 100 years, we've gone from diverse microbiome to now an diverse look at 1980 the rate of autism was one in 2000. Now it's one in 20. In New Jersey, something is happening in the microbiome that we have to pay attention to and is it the herbs we're giving? Is it these vitamins that are over the counter and supposedly have the vitamins right? Or is it the probiotics? Is it the right probiotics, the wrong probiotics? So I think all that we need to fine tune a little bit more.Ken Brown  27:06  fine tune is an understatement thatUnknown Speaker  27:09  sure, like people come to you and say, Doc, I want I'm on this probiotic. And you're looking at this bottle and you're shaking your head, right. Probably. Dr. Hasan,Ken Brown  27:21  have you met Kiran Krishnan from microbiome labs? Yes, yeah. Very, very, very smart microbiologist. We had him on the podcast and we discussed this exact thing about the fact do you know if it's alive, do you know that you can get a a railcar, you know, like one of those big giant crates for like $2,000. From who knows where and then anyways, we went into the whole aspect of probiotics and how easy it is to make your own probiotic. Yes, put your label on it, but you have no idea if it's gonna do that, you know, you have no idea if there's data it's gonna survive. So absolutely on the same page. bacteria in the gut that's live is dangerous, in my opinion. Yeah. And that's in your book, your offices. It's funny, because in your book, you you had a brief segment about how people in the desert when they would get I don't know, dysentery, they would eat Kagame. And Kiran brought up that exact same thing. oil based, soil based people figured out early on that somebody got sick, they would eat the camel dung, and they would get better. Yes. And you brought it up there, which was fascinating.Unknown Speaker  28:27  To the soldiers were stuck. I forget where but they they had Calera and that's how, you know, the Bedouins told them. Just eat the apples from the camel, which is really the poop from the camel, and they cure the colour all of a sudden.Ken Brown  28:45  Isn't that crazy?Unknown Speaker  28:46  I know. We're not going to go into that because I don't think people want to eat that. But I think we can understand the microbes that are play. Right. So that was my thing is we're heading up.Ken Brown  28:58  I just saw Eric trying to order a camel off Amazon. No,Eric Rieger  29:02  no, no, I've got a coupon for camel apples. Oh, that's what it is.Unknown Speaker  29:05  I already trademarked sisters of Camelot. I was in Jordan with my sisters. And we were on camels. And of course, you know, they're pooping all over. And it came to me. I said, I need to analyse the stools. So of course, I took my eye because I did bring some kids with me. And I'm taking it. I took it home and looked at it. So I said, Okay, we're starting sisters of Camelot. But we're not going to start that because I'm my plan not to make people eat pizza becauseKen Brown  29:36  of you. You're the reason why when I'm coming back from a from a country and in customs, they're like, Did you bring any animals? Do you have any food? Do you have any camel dung on you? And I'm like, why would I have Canada? No.Unknown Speaker  29:50  It was me. It was me. Actually one time my husband brought in an apple to an island and actually we got fine. I think they got the memo. They were like Dr. Hasan's come in, there's probably some microbes in there, stay away. $200 fine.Ken Brown  30:07  Alright, so we got so many things I would love to talk about. But I do want to really hone in on progen ibiam for several different reasons. Number one, I am also trying to run a different company and you know, have all this stuff, you've got a lot of stuff going on, we got a lot of similarities and how your enthusiasm and your need to keep your curiosity forces you to start other companies to sort of meet the need that you're trying to find. So can you please tell everybody what progetto biome is?Unknown Speaker  30:36  So progenitor biome is a genetic sequencing lab, what does that mean? It basically looks at the microbes, the genetics of the microbes, so the fingerprint of your microbiome, kind of like your DNA, but the DNA of all your microbes that co exist and cohabitate in your gut. It's so when I explain this, we have a choice. When we look at the microbiome to look superficially, it's kind of like scuba diving and being at the ocean, in the top of the ocean and seeing guppies or going super deep into the ocean and seeing the life and so we go super deep with every patients. So we can look superficially and do a lot of patients with that cartridge. So when we do genetic sequencing, you have to take that stool sample, which is the size of a fingernail, and then we have to tag it and do library preps are called and then we put them on these cartridges, and then essentially the cartridge we have a we have a choice, we can use the cartridge and do multiple development and see the surface. Or we can go deep, deep and use that same cartridge into the depth. So we go into the depth of the microbiome, to look at the microbes a species because that's what we want. We want species of microbes because we as doctors understand species, you know, to the rest of the for the forever the world of microbiome has been from acuities bacteroides. Right? But that's very superficial. So if you remember microbiology you go phylum class, order family, genus, species. I don't want to be at the phylum phylum is like looking at Planet Earth, right? I don't want to be at the class. That's like looking at London. I want to be almost at the family to say Mr. And Mrs. Jones, but I really want to see the species to see the kid of Mr. And Mrs. Jones, who has autism, the species tells the story, right? Because when you see mycoplasma for the first time, which is a cellular doesn't have a cell wall, and you see 40,000 sequences or 40,000 mycoplasma shapes into the microbiome. You say this kid has mycoplasma, and that's the cause of his problem. Maybe, right? Because then the next step would be, well, what is mycoplasma succeeding, and is mycoplasma. So creating something and therefore active in that patient, or it's just a dead organism? But even if it's a dead organism, why does that kid have so much relative abundance of that? So really, it's looking at the species and understanding the species yesterday, I was excited because I had a Crohn's patients. So remember, for Crohn's, I'm always looking for mycobacterium tuberculosis, right? Because that was Dr. Brody's idea. That map is the cause of Crohn's. Right? But when, but other scientists have come in and says said, well, you're sending your your sindhya and turistica is the cause of Crohn's. And then others have said, malice sees your firfer. And so you look at all that and you go Well, which one is it is a mouse, he's your first and your semi analytic as a map. So it's important to look at the species. And when you look at the species, you start going, Wow, this patient has a lot of eco lie a lot of Shigella, a lot of demopolis. There's definitely a dysbiosis there, right, because we know that these microbes have been the culprit of problems E. coli, chronic urinary tract infections, you know, Shigella, you know, all these bugs. So when you look at the species, and you see the species, and you can kind of make a correlation, it helps in the diagnosis and helps guide you with the patient. And so, to me, that's what it was basically. So that's why I started 42 clinical trials, we're actually up to 59. Now on every diseases, because it was that look, every time a patient comes in with Crohn's, we would say, Crohn's database going there, but what we discovered from the beginning with progetto biome when we looked at everyone, and that was something that made me think, you know, what's out there like you biome is not legit, because they're comparing individuals to others, but we're all different. How can we be compared? So what we so the first thing we discovered Regina biome is we're all different, which, you know, I know, you know, by common sense, right? We all have different fingerprints. How can we have the same microbiome? and Why would my microbiome that was in Jordan, B compared to someone that lives in Greece, right? Completely different microbiome. But why am I healthy with this microbiome? And this person is not healthy with down microbiome, right? That's the million dollar question. So we started noticing, well, if we are all different, how do we compare? How do we understand the microbiome, so the only thing that you can compare is really within the family. And then the other thing that you can compare is within the individual. So whenever you have a product that you want to give it, you have a patient with Crohn's, and you attain a cure. And that was my thing that I would speak about at conferences, attain a cure, understand the microbiome, right? Because if you attain a cure on the same patient, and you see the microbiome before and after the cure, you know that something changed in the microbiome, and what was it that changed that obtain the cure. And so that's basically my bath is, is looking at families. And then from there, once you have like a group of microbes that you've identified and said, Okay, well, that makes sense. This is the bugs, these are the bugs that are related with Alzheimer's, because I've improved the patient's memory. And now these bugs have disappeared. Now, let me look at other groups and see if those bugs are in those patients with Alzheimer's, and let's come up with an essay. That's a formula. So ideally, what I want is the dictionary of all the bugs with diseases.Ken Brown  36:43  Let me back that up just a little bit. First of all, it's super fascinating. And there's a lot going on here. But as the as gastroenterologist, and I know that my colleagues get this, I get second opinions. And so they'll come in, and they'll just hand me this pile. And in evitable, II, there's some sort of stool analysis. And then somebody will circle things and then say, you need to take this supplement for this, this supplement for this this supplement. And I've always just flipped it over and said, I'm sorry, just because we can analyse it doesn't necessarily mean that we need to make recommendations on this or that we can manipulate it. You're saying, just to clarify is that progen A biome your company is doing a much deeper dive and making the association with diseases, yes, with the person that comes in so that you can at least develop a trend and start to predict how or what I need to do for it.Unknown Speaker  37:43  And the other thing we did is basically we created an assay that we felt were the 25 actually 15 most important microbes for disease. And we validated that. So what does that mean? We took microbes that were cultured, we bought them, and we put them through the pipeline. And lo and behold, see this was seeded because we had the microbe. So that's validation process, right? The second thing we did is we verified the validation process. In other words, let me repeat that to sample Am I getting the same value? And then let's reproduce it right. So let's reproduce it at month one that's reproduce it by someone else, another technician takes on the same standard operating procedure of how we develop this asset. And basically, we produces the asset. So I was very vague at the beginning. And I hired a genetic sequencer, PhD physician, who is actually behind the bracket gene. And his genius, who developed the essay for me with me. And I said to him from the beginning, I said, Listen, I want to be able to give you a stool sample, and I want you to be able to reproduce the same thing. In other words, I give you my stool sample today, tomorrow, next year, it should be the same fingerprint, the same exact colours. Because if you I'm giving you a stool sample today, and in a month, I'm giving you another sample, but it's no longer the same colours, and the same fingerprint while you're comparing apples and oranges. And that was the whole problem with all these sequencing lab because I remember and again, you'll see them and I would call them because like you I was getting patients that would bring me Sue samples, and I would say what does that mean? I mean, like bacteroides in your gut, what does that mean? And I would call I would call Neon is like nothing, it's all bogus. And I know there's a whole holistic path out there that has looked into this, but you know, they have their vision but unfortunately, you know, we need to bring the holistic and we the idea that holistic healers have achieved and bring in into gi to understand it with the microbiome In my opinion, right. Bring everything that's out there and say, Okay, well, we all see this from this guy and this from this guy. Let's put it all together to say, yes, this is accurate information. This is valid, verified and reproducible data, because everything in science, you have to reproduce it right? If I do faecal transplant on a patient that's has alopecia areata, and my patient grows hair like Dr. Colleen Kelly. Then I've just reproduced Dr. Colleen Kelly's data. And I can say, Well, I did this ABCD like Dr. Kelly, and I got ABCD the same thing and my patient blue hair, right. So reproduction of validation, verification, and reproduction of data is very important in research. But, you know, the problem is just too many we live in a world where people want to just fast, fast development of products fast sell, you know, like sell a probiotic, sell this sell that. And we've stopped the research because it takes time to do research, but it doesn't have to take time to do research.Ken Brown  41:06  Where you're gonna say something? Yeah,Eric Rieger  41:07  I had a quick question is, so you've talked about the microbiome. And obviously, you've been able to look at different diseases and then figure out where they match up. And whether the same somebody it's kind of interesting to me, though, is that locally, that makeup of that microbiome, of course, is at the local level in the colon. But they've all looked at the second level and tried to map out that it also matches not just in the makeup of the microbiome, but what those post biotic metabolites would look like. So that the systemic responses are also the same to mimic what what the makeup isUnknown Speaker  41:44  absolutely an excellent point. There's so the microbiome is different at every location in the coalmine, that what we're doing is really a beginning of seeing what it's looking like at a deep level. The next step that we're going to do, and we're going to be working with a company that developed a capsule that is guided that takes a sample of Seoul, from every different locations, where we can show with precision that the stomach microbiome looks like this, the small bowel microbiome looks like this, the seachem looks like this, the transverse colon. So that's going to be coming because that with that technology, hopefully we can deliver precision microbes to those areas to achieve cures in the future. And, you know, capsule endoscopy, I was the first one Well, one of the first doctors to start using it. And that was the first time that we saw that I saw myself a parasite floating in the small bowel. That was a revelation, right? When you look at the, the sequencing of the microbiome, and you see all these microbes, and I said that I found c diff in my gut, um, you start going, Wow, this there's a mystery there that needs to be figured out. Yeah. Because the microbiome is everything. You're you're born with a lot of good microbes, you die with very little good microbes, right? You live, and then the microbes consume your body and put you back into the earth. So from the earth to the earth. I mean, we're proving that with the microbiome. So even on a and I think for me, the biggest lesson about the microbiome is really that diversity is key to life, key to health. And I was just speaking on the microbiome at a farm polyface Farm that's really big on regenerative farming. And so they believe in diversity of farming, they believe in, you know, coconut, you can't just put like avocado trees, you got to put the avocados with the blueberry trees with the tomatoes with everything. And it's the diversity that creates the beauty of the soil and the amazing, you know, matrix of microbes underneath the ground that feeds us really.Eric Rieger  43:55  So yeah, they they try to discourage monocropping now, because it will destroy the soil. They wanted, they want to switch it up. Yeah, right.Unknown Speaker  44:04  Well, you see, Amazon jungle, they tried to do that they tried to utilise things from the Amazon jungle.Ken Brown  44:11  So one more time in your book, you're you're not discussing the examples that you have in the book. But I was just thinking you had that great section on we should be doing green burials because what we're not doing is giving our microbiomes back we have micro biomes are trillions of microbiome we should give them back to the soil so that then other you know, it'll fertilise plants. We shouldn't be embalming ourselves. We shouldn't. We should be green burying and let that happen.Unknown Speaker  44:42  We should, we should. So that's what we should be doing. I have someone at the door but I'm gonna ignore them. You can go get him. You can.Eric Rieger  44:49  I am on bring him on.Ken Brown  44:51  Let's listen, we have some reach. Maybe Dr. Brody saw this and said I'm gonna fly over there and see Right or Yeah, that would be great. Do you have one quick question about progetto biome and then IUnknown Speaker  45:12  talked to Dr. Brody like every day two to three times a day times on love the man will have toKen Brown  45:19  genius I've never personally met him obviously read tonnes of his tonnes of his work even quickly I've met a tonne of times and you know he's just so nice and so approachable and everything. Quick question for you not for Dr. Hasan but to Sabine is it Sunday now you're sitting clean, it's fine. So being the how I built this aspect. So as a as somebody that built presented by him, how did you think about organising like that stuff? That's that was really intimidating to me. How do you how do you build a business?Unknown Speaker  45:51  You know, I built it basically, I just my attitude with everything in life is I just jump in, and I just expect, you know, to find something. So I basically jumped into it. I saw, you know, it was it was during the Woolsey fire, the whole backyard burned. And I was in communications with Dr. Feingold, who was the father of bacteria in anaerobic bacteria in the gut, he actually wrote the book anaerobic infections. And I was in communications with him because earlier on, I had done a faecal transplant on a patient who had Alzheimer's and he remembered his daughter's Date of Birth six months later. So to me, that was one of those, you know, and Dr. Brody likes to call it Martians. It's one of those Martians that comes in your front door and you say, wow, there's life on Mars. And so I called Dr. Feingold. And so what am I seeing? When I change the mind? Which microbe Am I seeing when I changed the microbiome in a patient with Alzheimer, and he remembers his daughter's date of birth. And Dr. Feingold said, You're seeing this bacteria that I cultured for so many years, nobody wanted to take on the study and to support it. So I'm giving you the protocol. Get yourself a next generation sequencer machine gets yourself alive, a scientist, and he showed me the path, right? He was 97 years old. And he showed me the path he gave me the paper. And then he put I put it in my Sage because I said, Well, I'm not going to start a genetic lab that's like, you know, at least a couple million. And so what happened is he passed away during the Woolsey fire, my whole backyard burns. And the family calls me and they go, Dr. Hayes, and we want to give you like all the books of our dad, and he signed all his books. So I had like, I have about 1000 books in my I picked up I took a pickup truck, and I picked up the books. My husband thought I was crazy. It's like, our house is burning. And I said, Don't worry about the house. I don't care. This is more important that this is like a seat. This is his work. I wanted to take it on. And I felt like and I felt like it was like tag you're it right. And about a month later, I started communicating with Dr. Brody because Neil had introduced us at ACG and said, oh, by the way, Sabine also cured Crohn's disease with faecal transplant. And he said, what he took my card, and then called me in December, and I said, By the way, I got the paperwork from, I got everything. And I found a couple of patents with you and Dr. feigl. You guys were communicating together those wonderful man, wonderful scientists, brilliant mind. And I said, Well, we got to continue this. And then he said, by the way, I'm working with Dr. Adams, who's publishing a data on autistic children post faecal transplant. So I said, he said, Be ready. You're gonna have the flood. This is Dr. Brody. I'm autism, I don't even know anything about autism. No way. And then next thing, you know, I start my lab. And I told my husband, I said, we're not rebuilding the backyard. I don't care about the house. I'm building a genetic sequencing lab. So he goes Sure, honey, and my if you know, my husband, my husband's a great guys, cardiologist. You know, hi, doctor. Amazing. And he's like, yeah, sure money, do whatever you want. You want to analyse shit, go for it.Unknown Speaker  49:15  I said, Okay, I'm buying a machine. So, and it was kind of at that point in my life where, you know, my, you know, you your kids are growing up and you've done the raising and they're blooming on their own and you're, you know, at that point where you say, Okay, well, what is my life mean? I'm no longer a mom. Okay, great. I'm a GI doctor, I do research for pharma. But now farmers getting into the shed business, and we don't even understand it. So I saw this light and I just said, I think this is my path. And then lo and behold, everything was just opened up. I mean, my first case of faecal transplant was a patient with metastatic melanoma. That I submitted the protocol to the FDA, the FDA thought I was crazy for wanting to put stools in a woman's body Hold on who was dying, but her haemoglobin was seven. She wasn't eating anything. She was dying. I had to fight with them to let me do it. And I saw her starting to crave chicken nuggets after the faecal transplant, the same cravings that her grandson had. So that was an open an eye opener for me. She ended up living a lot more months than she was supposed to, to to begin where she should have died within the month. But I think the faecal transplant really helped her and I think we're seeing that with, you know, MD Anderson's work with faecal transplants, and chemo, etc. So I think that was the path. I didn't really think of money because people always ask me, Well, how do you support it? How do you venture and I said, Well, let me create a nonprofit. So I created a nonprofit. And then next thing, you know, I wrote the book was shali. And, and everything, like even Shelley came to me in my office, it was just like divine intervention.Ken Brown  50:56  Shelley? Who is Shelly, I don't know her.Unknown Speaker  50:58  So Shelly is an author, she writes, you know, she writes books. And she, her husband, was a friend of mine. And we started talking, he's a pilot. And he said, you know, and I said, I need to write this book. And he goes, one is why don't you have Shelly, I'll pay you. And she puts it in the book. And she wrote, I helped Dr. Hayes and get her shit together. Because this is what happened. I gave her all my stack of papers. I said, this is chapter one. Let's start chapter one. And then she started. So as she was building, and we were building dog book. And then Dr. Brody, of course, every time we had a chapter, we're like, what do you think is that said, it's like, I like the quotes I like, you know, because he's very much into, you know, quotes and old quotes from, you know, people in the past. So we started, you know, writing. And then at the same time, I started building these protocols. And I had a team of writers that I basically, I had my, my, my main writer that I said, you know, let's start writing these protocols. And little by little, it was built, and I and Andrea showed me from day one, a patient with Crohn's disease. And he showed me the microbiome, and I changed the microbiome, I played with it with certain products like you that I believed could change the gut. And I was able to reach a cure in this kid, and I was able to see the cure in the microbiome. So before and after. And so when I saw that, I said, I have something. And then I saw see this in 17, the first 17 patients, I saw c diff, and all of them. So I said, you know, maybe we're wrong about C. diff May, and I and I actually challenged the industry, the infectious disease doctors, because I said, maybe we all have C diff, and maybe it's what we give our gut that kills off all the microbes, the diversity, that causes c diff to start succeeding, it's toxin, right? And so, you know, infectious diseases are very pragmatic. They're like, well, if you didn't call to it, then it's not there. And I can't say, Well, how do you culture a dead bacteria? How do you take a tree that's dead and expect to plant it? It doesn't work. I mean, you almost have to culture it anaerobically, right. And so I said, well, but the next generation sequencing shows the whole genetic sequence of the microbe, right? And then when we did RNA pipeline, which is the you know, so we have a bunch of pipelines when we look at microbes, right? So we actually can do a DNA pipeline that looks at our bacteria, or we can do an RNA pipeline, which looks at the bacteria reproducing. So if you see a microbe is reproducing, and you see it high in the messenger RNA pipeline, then you know that this microbe is active.Ken Brown  53:48  That that's that's a game changer. That's awesome. Yes. Nobody showed it. Nobody. Nobody's ever said that before. Because I remember mark, you know who Mark Pimentel is and cedars? Yes, I know, Mark. So I remember Mark was describing Well, when we're doing these stool studies, where basically it's like going into a neighbourhood and looking at the trash, and then making these assumptions about what's going on inside. That that's just trash is what you're looking at. Oh, the mRNA that's huge. That's big fish.Unknown Speaker  54:18  Yes. And then the metabolomes is the next step, right? Are those microbes to creating something like the sofa Vibrio in the gut, right, then we know that sofab embryo was linked with autism from Dr. Feingold. So he thought that the sofa Vibrio or Clostridium perfringens could play a role with autism. Well, when you see the sofa Vibrio in a family in one kid that has autism, and the rest of the family doesn't have autism, and don't have it, but the kid has 40% relative abundance of the sofa of embryo you don't even need to do metabolomic studies on that because you know, that there's that The problem most likely, and then that good faecal transplant would be a solution. Oh, that's, that's so cool.Ken Brown  55:06  I talk to my patients that, especially people with certain food cravings are battling their weight and stuff. And I'm like, well, it could be that you're not really it's not really you and controlled your microbiome, would you discuss briefly your two daughters? In your experience?Unknown Speaker  55:20  Yeah. So. So I took antibiotics, my young, my old, my oldest also, and, you know, I have a hard time I used to eat like, in Miami, I used to eat the whole tuna subway, and you know, would not gain a pound naito cucumber, and I get a pile. And my little one eats 5000 10,000 calories. Sometimes she'll eat like a one o'clock in the morning, the whole pizza, and then an apple pie doesn't gain weight. She's a toothpick, right. And so we looked at the family microbiome, and actually, there was a group of microbes that is potentially the obesity marker. There's also a group of markers that are potentially the cholesterol. And so this is a new world, right that we're entering. So even with Alzheimer's, we're seeing similarities in the microbiome. So we need to understand, but more important, I think, then understanding the microbes isn't is understanding the environment of the microbes. Because you saw studies when they do so we know that when we do faecal transplants, we are achieving improvement in patients, right. But you saw the studies where they remove the faecal material and they just had the liquid then they implanted it and they still got improvement, right? So something in the substance, something in the environment, the substances, I think, make a big, big difference. It's all gonna make sense to you. When you read the paper with ivermectin.Ken Brown  56:44  I'm so excited. I just I'm literally like thrilled.Unknown Speaker  56:49  Vitamin C and vitamin D, because I'm going to be writing Linus Pauling was right.Ken Brown  56:54  That's coming. I agree. With everything you said. I have a couple quick comments. Number one, your doorbell rang. And he did tell you that emotion would show up on your front doorstep that could have been, and Oh, well. And then I got a I have a I have a quick story for you. Yes, that we were interviewing a fellow. He was from Yale. And this is gonna be about eight to 10 years ago. So before faecal microbial transplant FMT was being discussed. We're out to dinner with them. I've took them to a nice steak restaurant here in here in my city. And I was asking him about his research. And he goes, Well, what we're showing is and he's talking, and the waitress was there, and she was like, This is interesting. And she was listening. And she was a little bit obese. And he goes, Well, we're taking stool from skinny mice and giving it to fat mice. And those fat mice are losing weight. And then vice versa. Right, like, no, that's so cool. Because like the first time I'd ever heard of it, he was doing the original research on this. And then the funniest thing happened. She was once again I said she was a little overweight. She looks over at this busboy who's all about six for 120 pounds. She was Bill, you are the sexiest person in this restaurant, right? Cuz he went on to say that if you live with somebody, you end up sharing the microbiome. Yeah, and she yells to this poor guy was probably like, 17. She's like, you want to move in? You want to move in? A little premature, but I don't know. Maybe she wasn't. SoUnknown Speaker  58:25  hey, you know what I do every day as a routine. I take my little one my 17 and I rub my face to her. I'm like, I want some of that microbiome on my skin. That's the best lotion right there. I mean, I don't need to put lotion on my face.Ken Brown  58:38  Your I'm scared that I'll ruin my kid's Mojo by giving them my kids,Unknown Speaker  58:46  my little one who actually is a hyper metabolizer. That's what I call her. I asked her to donate stools from me. I said, you know, your skills could be worth a lot of money, because that could cure for obesity. And I said $1,000 for one sample Scarlet. She's like, Nope, not giving it I'm not going to grab it. She's like, I'm not going to be a rat lab. Mom, she gave me one sample. That's it. That was all.Ken Brown  59:10  That's it. And this is this is not hyperbole. In your book you discuss about how the marathon runner they took his store he gave it to mice, and the mice immediately with no extra training could run 13% moreEric Rieger  59:21  than they could before. Before we publish this episode we need we need to get shit studying calm. have it ready to go?Ken Brown  59:31  Well, I will give you credit. A lot of the things that come across you do trademark it's like you'll just like call your trademark attorney and they're just trademarking everything.Unknown Speaker  59:41  Yeah. Because so yes, it's it's kind of funny because I, you know, in medicine and you know, you come up with an idea. A businessman takes an AI takes your idea and make something out of it. And then you're like, wait a minute, that was my idea how many doctors have I seen over the course of my career that have come up with cures, and a businessman came, took that cure and made it a business and the doctor now, you know, Dr. Feingold, his book is the beginning of so many pharmaceutical companies, because that was without his book. Without that foundation, none of these pharmaceutical companies, you know, existed. And, you know, the fact that he had to struggle to get money for his research and keep putting all his money into his work. It was just not okay. And so when I started this, and I started the company, I said to myself, first of all, I'm trademarking everything. And I learned from the best Dr. Brody, because he said, patent everything, trademark everything, because they will always say, somebody will take your idea and try to make something out of it. So the man is genius on multiple level. Yeah.Ken Brown  1:00:57  And the fact that you actually are doing what people don't realise is that you're going down this microbial path, a speaker microbial path. And to get these studies done, you have to file these nd eyes, these new drug sounds like that. Yes, I end that's it. Yeah, I end in Yeah. And that's, it's super expensive. And they make it they make it difficult, or maybe they do on purpose or not, I don't know. I mean, obviously, as as an investigator, where we have to deal with that a little bit with our supplement, we kind of skirt the FDA, but we still have to walk such a careful line, you want to talk science, but if you start talking too much science, then you have to file that ind andUnknown Speaker  1:01:40  and I think, you know, it's not hard to file it's not hard to do it. I think this is where doctors need to join forces because really, um, you know, we lose when we don't work together when we were in residency and internship we were collaborating together to fix you know, what happened with COVID was really sad to me because the collaboration disappeared. All of a sudden, the media is telling you how to take care of your patients, and the politicians and the whole time it was like, wait a minute, the moment the politician can tell me what the Latina does in COVID, or Rosa Yuria or fasula, bacterium, press neiti let alone they should probably spell fasula bacterium proxy, never mind what it's doing. The moment a politician can tell me that, then I will respect what they're saying or immediate person. But the reality is we're entering a world of microbes, I think we should let the people that are in the microbiome world, lead that path and lead the treatment. At the end of the day, achieve success listen to the people that achieve success. You know, those doctors on the front line that realise different methods to to meet, forget ivermectin, let's talk about others, right. kosha seen, you know, cheap solutions be that cyanide, you know, eliquis all these I think those were hints right? When when I have a patient that's oxygen saturation 73%. And I'm freaking out because the patient doesn't want to go to the hospital, but I know he's gonna die on my shift. And I don't want him to die. I'm going to do everything in my power. So I'm going to give him everything I know. And then I'm going to call, you know, my buddies. You know, Brian Tyson say, Brian, what did you do with this? And then he would say, you know what, I've this. And then Peter McCollum. What did you do on this? And so I think this is where the collaboration of physician comes into play. Because we are the ones on the front line, taking care of patients. And at the end of the day, who do you trust with your life? The doctors that guided you this way? Right. I trusted with my life. Tom perrotti. Let me Yeah,Ken Brown  1:03:50  I just want to ask a quick question on this, because I saw that you have done presentations you have submitted for different trials. You've done this, have you? A lot of the doctors that have had the guts to do this have had backlash. Did you receive any backlash from social media, from the media from anything?Unknown Speaker  1:04:07  So I'm because I'm working with the FDA oversight. And right now we're doing actually clinical trials with the Department of Defence sponsoring it, which is another product altogether? I've not had the backlash as much, I'm sure I've had backlash when I tried to advertise to get patients. You know, definitely my there were criticisms and you know, and I always try to stay under the radar as much as possible talking about treatment. I'm more the microbiome girl and I don't think anybody really knows about the microbiome and if they want to go one on one with me and start trashing me, bring it on the ship is going to be caught starting. And I call the book and in January because let's talk shit because I said Look, I couldn't be full shade or I could know my shit. But I think I know my shiftKen Brown  1:05:02  to that is awesome.Unknown Speaker  1:05:04  So we'll see. I mean, it's a it's a path. It's a, it's a discovery path. It's, it's, it needs to be done. And I think I say to people, if you stop the innovation, you're going to be the patient coming for an innovation that's not going to be happening. You know, right now we get how many patients do get probably as much as me that wants faecal transplant for Alzheimer's, for Parkinson's, for autism, etc. You can't offer it. We're not there yet.Ken Brown  1:05:31  So let me ask you this. So you've got your lab set up to do a really good job. We were doing it heavily. A guest standing for this podcast, Dr. Stuart Ackerman, him and I did a few of these super intelligent doctor, my colleague who trained in New York, we were lucky enough to steal him and bring him over about five years ago, he jumped all in on the on the faecal transplant, and he signed up, he did everything. And then like overnight, he said, Well, this was like, in between the FDA saying it's a drug and this and then he was able to get the frozen capsules. And then it was like overnight, it became cost prohibitory because something happened with the lab. And we just quit doing it because we couldn't get it approved insurance wouldn't pay it suddenly, it was super expensive. Right?Unknown Speaker  1:06:17  So that's the peer pressure and the lobbying power, right? of lobbyists that basically, and I'm gonna say it out there because I think it needs to be told, you know, there is a lobbying movement that is basically stopping these, these drugs, these, these cheap solutions. And I think we need to stop that we need to fight as physicians for that because the moment we stop, you know, trying to do what was right for the patient, faecal transplant being one of them. I think all of us that were doing faecal transplant join forces in the microbiome meeting, the Malibu microbiome meeting that you probably saw, because of the fact that we saw that our ability to help patients were being cut. We were doing, we were helping patients we were doing using a bank that was good. And that ability was cut. I think, you know, the onus is to go from that product that was sold of open biome to go to Finch, right, which is now a pharmaceutical product, then, you know, that's fine, as long as you know, the data shows that it's working, etc. But I think you know, stopping the right to try and doctors from doing faecal transplant or scaring them, you know, I still do faecal transplant, you know, who's gonna stop me? I mean, the the FDA, you know, has said you can do faecal transplant for C diff, provided you do all these things. And even if you want to do it for autism, you have to submit an ind, well, I just have to write the ind, I have to follow the protocol and follow the guidelines. Nobody's gonna stop you if you're doing things the right way.Ken Brown  1:08:03  So you don't have to wait for them to approve the ind. JustUnknown Speaker  1:08:07  wait for them to approve the ID. But for C diff, you can do faecal transplant. You just have to f

In the second of ASCO Education's two-part episode, Todd Pickard, MMSc, PA-C (MD Anderson Cancer Center) continues the conversation with Drs. Daniel McFarland (Northwell Cancer Institute), Sayeh Lavasani (City of Hope), and Fay Hlubocky (University of Chicago) about individual and institutional interventions to prevent and address burnout among oncology professionals. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 6/30/2021   TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] TODD PICKARD: Hello, and welcome to the second ASCO eLearning podcast episode focused on burnout in oncology. In the previous episode, our guest speakers discussed what burnout is, its warning signs, risk factors, preventative measures, and talked about their own personal experiences with burnout. My name is Todd Pickard, and I'm an oncology physician assistant at the MD Anderson Cancer Center. I'm pleased to introduce our three guest speakers as we continue our conversation on the prevalence of burnout and its implications for personal well-being and professional satisfaction. Dr. Fay Hlubocky is a clinical health psychologist and research ethicist at the University of Chicago Medicine. She's also co-chair of the ASCO Oncology Clinician Well-being Task Force and has extensive research experience in burnout. We're also joined by Dr. Daniel McFarland, a medical oncologist and consult liaison psychiatrist specializing in head and neck thoracic malignancies and psycho-oncology at Northwell Health Lenox Hill Hospital. He has conducted research on empathy, resilience, and distress in trainees and edited an upcoming Springer book publication entitled, Depression, Burnout, and Suicide in Physicians. And finally, we are also joined by Dr. Sayeh Lavasani, a medical oncologist specializing in breast cancer and an assistant clinical professor in the department of medical oncology and therapeutic research at City of Hope. Dr. McFarland, you mentioned that you've been involved in research on burnout. So tell us, how prevalent is burnout in oncologists? And is it getting better or worse? DANIEL MCFARLAND: Thanks, Todd. Yeah, good question. The research that I did was more on empathy, resilience, and distress, not burnout. I didn't actually measure burnout. But the latter part of your question, I'll tell you that some data indicate that it is increasing. In general, oncologists are in the middle of the pack in terms of medical specialties and where they fall in terms of how burnt out they are. And it really speaks to the drivers of burnout being not always what you think that they might be. As a specialty, we see a lot of the patients at the end of life. But as has been mentioned, these are really more systemic, administrative of issues, although it can be communication. And again, it's just everyone is a little different in that regard. So whether it's actually increasing or we're just having more attention to it is probably a good question. But either way, it's there, it has been there, it's a problem, and we should do something about it. TODD PICKARD: So Dr. McFarland, I really like the fact that you just said we should do something about it, and that leads to my next question. Is there any evidence-based interventions that we can use to prevent burnout? DANIEL MCFARLAND: Absolutely. There are several good meta-analyses in fact. So people have been looking at this across the board. The caveat is that they're not always specific for the setting. And I don't think there is a way to make that necessarily possible, given the multitude of settings. But in general, across the board, doing something seems to be better than nothing. The issue is, well, are they durable responses? And what exactly are you measuring? So if you have a drop in burnout by two points, is that enough? It looks like actually even a few points-- and I think it's around four points on the Maslach scale, MBI, Maslach Burnout Index. Fay can correct me on that, I guess. But if there's just even a small drop, then that has been shown to be a meaningful change, which is wonderful. Now in sub-analyses in these meta-analyses, they've shown that the kinds of interventions that are most effective are organizational interventions. And most of those types of interventions are things like work hour restrictions and workflow modification. But the big caveat there is a lot of those were done in trainees, where they would have work hour restrictions. So again, you have to sort of take the data for what they are. And if it's applicable, then great. If it's not, maybe try something else. So the take-home message is that the organizational type interventions are not only more efficacious but seem to be longer lasting in their efficacy. But that doesn't mean that individual interventions don't work, because they do. They also work. And I would say from the sub-analyses that I've seen, if the interventions incorporate mindfulness or some part of CBT-- that's Cognitive Behavioral Therapy-- those interventions seem to work the best. The combination would be ideal of organizational changes with individual types of changes. And a lot of this comes down to sort of system-based changes. I think of adaptive trial designs, that's essentially what's needed. One thing's going to work in this setting, another thing will work in another setting. Each field has its own drivers of burnout. I'll tell you, for example, totally outside of oncology, that with psychiatrists, who, again, don't have the highest rates of burnout for probably the reasons that we talked about, but actually violence. A lot of psychiatrists have been hit by a patient or had violence thrust upon them. And it's a real cause of burnout. I just would have never exactly put that together. So the point is that for each discipline, there are specific things, and then there are general drivers of burnout. I think we all work with the electronic medical record. We all have bosses and administration that we work for. And so it's a matter of putting these things together. TODD PICKARD: Yeah, it resonates with me that there's a lot of things that we hear about, but then there's a difference between understanding what's out in the literature, what you hear articulated, but then how do you turn that into practical methods. Dr. Hlubocky, how can our listeners adopt some practical methods for preventing burnout that's easy to implement? FAY HLUBOCKY: Thank you. Awareness and education is key, truly being aware, truly being motivated. We talked about self-assessment. That was actually one of the first strategies that we described in our educational book in 2016 with Dr. Back and [INAUDIBLE] of really doing, as Dr. McFarland talked about, really doing that self-assessment. 1 to 10-- how irritable, how sad, what am I? Rating that, and not just rating yourself multiple times a day, having a barometer. And again, asking that trusted observer, maybe it's your wife, maybe it's your colleague. And then, of course, to seek support if that is needed if it does become too extreme. But clearly, we know awareness and education is key-- education. So some of the early internal medicine work showed that a simple one hour educational talk on burnout, on well-being not just informed the attendees but also compelled them to practice preventative behaviors. What was that? Exercise, getting better sleep, trying to leave work on time if they were able to, better nutrition. It is these simple things. I work with oncology fellows and teach them communication. And we have a formal burnout and compassion fatigue course. And that is what we did in one study was just do an education, a little didactic, six months later evaluated them using the protocol and the MBI. And similarly, they changed their behaviors. They changed their practices, even the qualitative responses told us. So education is so key. And I motivate leaders so much to simply have a one hour [INAUDIBLE] grand rounds on burnout. Get some CMEs, so it motivates the docs to come in and to attend and to learn, because it is only through education do we know what to look for and what to address. Self-care is critical. I cannot emphasize that enough. Yes, burnout is an occupational phenomenon, without a doubt. But in order to find meaning and joy and purpose in your work again, to find, to research, to rekindle that joy that you have, you have to practice some techniques. So again, it's these preventative behaviors, again just basic needs of sleep and nutrition and exercise, but it's also things like writing a narrative. When you had a patient case that maybe went a little bit south, write a little narrative about what happened so you can be self-reflective of that. Journaling, talking about that patient's story, that patient's story that went well, that patient's story that went really bad. Gratitude-- gratitude is kind of a newer phenomenon coming out, but we teach docs to just name three things that you're grateful for in the morning, in the afternoon, and before you go to bed. It's a way of seeking self-compassion and kindness where you haven't been. Mindfulness-- Dr. McFarland talked about mindfulness. My conflict of interest is that I am a mindful teacher. I teach this with patients and with my colleagues and students. It is intentional, purposeful. It's not about sitting in the corner and doing some yoga and breathing, but truly teaching the docs, teaching my colleagues to do some breath work before they start their EMR, right? Mindful handwashing techniques of really taking the time when we're washing our hands, a real contemplative practice to be able to recharge and refresh during that course of the day. Although self-care is critical, and I view it very much as it being your life preserver, sometimes when colleagues say it's my organization that's really beat me down, it's not my fault I'm burnout, my analogy is, gosh, if you're on a sinking ship, won't you use your life preserver? That's what self-care is. But equally important is for the organization to please provide that support, to empower the oncology clinician to use the team. So many times I encourage the colleagues to use your team members. We're all in it together, but to truly work together as a community, because it's only as a community we'll be able to address this issue in that. So truly, self-care is vital without a doubt, can't say more than enough about it. TODD PICKARD: So many things that you just said resonate so strongly with me, that sense of community where you feel like the stress and everything that you're going through is shared and that sense of gratitude. Just thinking about a few things that are going right, it just lowers the threshold. It lowers the stress. So let's stick with stress for a second. Dr. Lavasani, in your experience, what are the effective strategies that you've used or experienced to mitigate stress level that are helpful? SAYEH LAVASANI: When I experienced burnout, then I decided to learn how to cope with it and to reduce my stress level. I realized that situation was not sustainable and I needed to take some action. So what I do is that I usually set aside one hour every night for myself to do things that I enjoy. It's like my me time. So this could be cooking or reading a book one night, or watching my favorite show on TV or Netflix the other night. And also one way that I relax is by listening to music. When I'm tired of doing my administrative work or days that I'm in office, I just listen to my favorite song. It's just three to four minutes, but it makes me feel better, and then I go back to my work. It's also, I think, it's very important to set aside some time to do exercise. If it's not possible every day, but a few times per week. And our nutrition is also very important as you know. Fay was mentioning as well. Initially when I started working as an attending, I was always skipping lunch in clinic. But then I learned that actually taking that half an hour break to have lunch helps me to feel better and to recharge, and then I can go back to my clinical duties. And also, I try to stay organized and complete my tasks on time. It helps me to avoid procrastination. That really increases my anxiety level, because then I feel like I have unfinished things to do and just that it increases my stress. So I try to really be organized and to be on time for everything. And this is something that is very difficult-- I'm learning to do that-- And that's basically to say no to unrealistic demands. Medical oncologists, like other physicians, we have learned to say yes to all expectations. This is something that we need to work towards unlearning. The expectations and demands on us is really high. And we feel like we always must serve others and their needs, including our institution's administration. We have turned into passive individuals, that we agree to whatever that is thrown on us. Unfortunately, in a lot of practices, there is a disconnect between administration and physicians. And so it is very important to engage the administration to recognize burnout. And it can really affect productivity, and they need to come up with an action plan to help physicians to do things that will make our lives easier. And definitely getting support from other team members, from our colleagues is very important. Our peers, they play a very important role in helping us and supporting us. And we always believe you are stronger if we stick together. So definitely, this is also very important to have that support system at fort. TODD PICKARD: It's really important that when there is that disconnect between your practice, your institution, the administrators, and what the individual providers need, they've got to have a resource. And that brings me to my next question. This is where ASCO has actually something that might help. So Dr. Hlubocky, you're serving as co-chair for the ASCO Oncology Clinical Well-being Task Force. Can you walk us through the work this task force is doing? What kinds of tools and resources are being developed and offered? FAY HLUBOCKY: Oh, thank you. It's such a privilege to introduce our membership to this wonderful task force that's in our infancy, and it's an honor to serve as co-chair with Piyush Srivastava. It was a collaborative effort between both the ethics committee and the clinical practice committee to gather a group of folks that are experts, including, for example, Dr. McFarland is one of our tasks force members, where we could actually focus on the oncology clinician well-being. And how have we defined well-being is it's been adapted from the National Academy of Medicine's definition that it's this integrative concept that characterizes the quality of life that encompasses that individual's work-related activities, the personal, the health, the environmental, and the psychosocial factors as well. And our mission is to improve that quality, the safety, and the value of cancer care by enhancing oncologist's well-being and the sustainability of the practice as well. We have a five-year plan. Our task force has a five-year charter and road map. The aim is really to promote well-being across the ASCO activities, diversifying resources to promote and identify the needs through research activities, to identify the needs of that individual clinician to improve the practice as well. So ultimately, our vision is across ASCO to create programs and strategies that can really help the clinician, as well as I think the cancer organization as well. As I said, many leaders come to us wanting to implement interventions and not really knowing how to. So although we are in our infancy, we have been quite busy and we have developed a research page that all members can access that has empirical research on there and also some tools that could be used, multiple resources on there. We also had a webinar to introduce the task force to the members-- of course the purposes and the charter. We also recently published an editorial in the JCO JOP talking about the impact of COVID on burnout, moral distress, and the emotional well-being of the oncologists. And that actually has multiple useful interventions that the organization might consider as well. And we just conducted a focus group study that is currently under peer review of the oncologist experience, both the personal and occupational experiences during the COVID pandemic, what is that oncologist going through. So very busy. Again, in our infancy, we have lots of plans to hope and look forward to all of these endeavors, and of course, your feedback on it. We are here to help and serve you, and we are very grateful to ASCO leadership for giving us this opportunity to advocate for the oncology team. DANIEL MCFARLAND: Can I just say one other thought that I had? When we were talking about the interventions, I was just going to say that one way that I think about the interventions that might be helpful is that there are some interventions that are sort of pulling the clinician away from the work environment, whereas others are having the clinician kind of engage more strongly with the work environment or in a different way. And the latter seemed, obviously, to be a little bit more effective or makes sense, because we've all had that feeling of being on vacation and you go back and it's the same thing. And so I just wanted to add that that's just another way of looking at the interventions. I always talk about this study that was done in Oregon like 20 years ago, because it was so genius that what they did was they basically-- it's a group of five different community oncology practices. They got together and they said, OK listen, burnout's a problem. We're measuring it. You guys figure it out, and we're going to remeasure it. And the beauty of it was that it addressed what some of the problems of burnout are-- feeling like you're in control, and then kind of having that engagement part where you're engaging with whatever you're creating to mitigate the burnout. And thirdly, it brought the oncologists together. So they had to figure it out in their own way and what made sense for them. And in my mind, that's the perfect solution. And it does help bring administration and clinicians together, because ultimately, we do all care about the same thing. FAY HLUBOCKY: It's a great example of peer support, Daniel. We always talk about peer support. And I think a lot of folks say, what does that look like? Is that a group thing? And exactly that study of getting everyone together to talk about it-- how can we make change, how can we improve burnout at our organization-- is critical. That's why it really-- it can't just be leadership alone, and we need physician champions. We need lots of folks involved in the process to ultimately improve the quality of cancer care at that institution, and I think honestly nationally and globally. That's kind of what I think even our task force is about. TODD PICKARD: Oncology is a team sport. We're all in it together. [INTERPOSING VOICES] TODD PICKARD: Exactly. If we're taking the patient's care in all of our hands, well then we all have a responsibility for preventing burnout and backing each other up and talking about this and being that trusted person to be that barometer. So it's a team sport. No person stands alone. FAY HLUBOCKY: Yeah, and the oncology clinician is the most compassionate clinician, I think, out there. Truly. Of course, I have a little bit of bias there. But truly, my colleagues are the most compassionate, kindest people, people I just love being around. But it's so tough to show self-compassion isn't? We're great at giving compassion to others, to the suffering, but to self that tends to be a little bit more difficult. So that's why we have to help all one another, as you said. TODD PICKARD: Well, this has been a terrific conversation. So thank you Dr. Lavasani, thank you Dr. Hlubocky, thank you Dr. McFarland for your engagement and conversation today. That is all the time we have. But we thank all of our listeners today for listening to this episode of the ASCO e-Learning podcast. To keep up to date with the latest episodes, please click to subscribe and let us know what you think about the podcast, leave us a review, or email us at elearning@ASCO.org. Thanks so much, everybody. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

An interview with Dr. Zeba Aziz from Hameed Latif Hospital in Lahore, Pakistan, Dr. William Burke from Stony Brook University Hospital in Stony Brook, NY, and Dr. Keiichi Fujiwara from Saitama Medical University International Medical Center in Saitama, Japan, authors on "Assessment of Adult Women with Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource Stratified Guideline." This guideline provides recommendations in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer. Read the full guideline at www.asco.org/resource-stratified-guideline.   TRANSCRIPT ASCO: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org. My name is Brittany Harvey, and today, I'm interviewing Dr. Zeba Aziz from Hameed Latif Hospital in Lahore, Pakistan, Dr. William Burke from Stony Brook University Hospital in Stony Brook, New York, and Dr. Keiichi Fujiwara from Saitama Medical University International Medical Center in Saitama, Japan, authors on Assessment of Adult Women with Ovarian Masses in Treatment of Epithelial Ovarian Cancer: ASCO Resource Stratified Guideline. Thank you for being here, Doctors Aziz, Burke, and Fujiwara. First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline and the Journal of Clinical Oncology, Global Oncology. Dr. Burke, do you have any relevant disclosures that are directly related to this guideline topic? DR. WILLIAM BURKE: I do not. BRITTANY HARVEY: And Dr. Fujiwara, do you have any relevant disclosures that are related to this guideline topic? DR. KEIICHI FUJIWARA: Yes. I have the consultancy for the PARP inhibitors development. BRITTANY HARVEY: Thank you. And then Dr. Aziz, do you have any relevant disclosures that are related to this guideline? DR. ZEBA AZIZ: No, I don't. BRITTANY HARVEY: Thank you. OK, so first, Dr. Burke, can you give us a general overview of what this guideline covers? DR. WILLIAM BURKE: Sure, Brittany. The purpose of this guideline is to provide expert guidance in treatment of adult women 18 years and older with epithelial ovarian cancer, including fallopian tube and primary peritoneal cancer, to clinicians, public health leaders, patients, and policymakers in a resource-constrained setting. To do this, ASCO has established a process for development of resource stratified guidelines, which includes a mixed methods of evidence-based guideline development, adaptation of the clinical practice guidelines to other organizations, and formal expert consensus. This guideline summarizes the results of this process and presents resource-stratified recommendations. The recommendation of this guideline centers around the four key clinical questions pertaining to the care of women with ovarian cancer. BRITTANY HARVEY: Great. And then, as you just mentioned, this is a resource-stratified guideline. So Dr. Fujiwara, can you tell our listeners about the four-tier resource stratification used for the development of this guideline? DR. KEIICHI FUJIWARA: Oh, yes. So we have the four tiers resource stratification, which were basic, limited, enhanced, and maximum. So for the basic, it's the core resources or fundamental services that are absolutely necessary for any public health or primary health care systems to function. So the basic levels of this typically are applied in our single clinical interactions. For the limited, so this is the second tier resources or services that are intended to produce major improvements in outcomes such as, for instance, cost-effectiveness, and are attainable with a limited financial means and modest infrastructures. So the limited level of service may involve single or multiple interactions. And the third  tier is enhanced. The third tier resources or services that are optional, that are important, enhance the level of resources should produce further improvements in the outcome and to increase the number of the quality of options in the individual choices. Lastly, the fourth tier is a maximal, so high-level or state of the art resources, or services that may be used or are available in some high-resource countries, and/or may be recommended for the high resource setting guidelines that do not adapt to resource constraints, but that nonetheless should be considered for a lower priority than those resources or services listed in the other categories on the basis of extreme cost and/or impracticality for the broad use of the resource-limited environment. BRITTANY HARVEY: Great. Thank you for going over those. So next, I'd like to review the key recommendations of this guideline. This guideline addresses four overarching clinical questions. So first, Dr. Aziz, what are the key diagnostic and staging recommendations for patients with symptoms of epithelial ovarian cancer? DR. ZEBA AZIZ: Thanks, Brittany. Basically, as pointed out, we have three levels. The basic level usually involves one or two encounters, and at the basic level, the doctor makes a clinical assessment of a suspected ovarian mass, takes a good history and physical, and the family history is also important at the same time. At the basic level, one can do a chest X-ray and an ultrasound to confirm the suspicion, and then the doctor should ideally send the patient to a limited or an enhanced level-- wherever the patient can go. At the limited and enhanced level, again, you have to do diagnostics, which include a CT scan and an MRI if it's available and feasible. You can do the biomarker studies for CA125 and CEA level, and to make a diagnosis, you can do a CT-guided biopsy. You can also do a cell cytology and if a cell block preparation can be made through cell block. Very rarely, if need be, and if you think that you need to make a diagnosis and you can't do anything else, laparoscopy can be done. Once the diagnosis is made, you then go for staging. And the staging is usually done when you're doing a CT scan and you do an abdominal and pelvic CT scan. You do a CT scan of the chest if you think it's needed. Otherwise, a chest ray will suffice. And then you go forward and get a diagnostic workup done and send it to the surgeon for either and decide on a multidisciplinary with a neoadjuvant or surgical assessment testing. BRITTANY HARVEY: Great. Then so next, Dr. Fujiwara, what are the overarching recommendations for surgery with women with stage one to four epithelial ovarian cancer? DR. KEIICHI FUJIWARA: Yes. So the purpose of the surgery is to diagnose, stage, and/or for treatment. So we strongly recommended the ovarian cancer surgery should be performed by trained gynecological oncologists or surgeons with oncologists' surgical expertise. If it is not suitable, we strongly recommend to refer those patients to the highest-resourced level center with an oncology surgical care capacity. For the staging purpose, where the feasible patients with a presumed early stage ovarian cancer should undergo surgical staging by train surgeons. In basic setting, surgical staging is not feasible. Thus, it is not recommended. For the treatment purpose of the women with advanced ovarian cancer, which is a stage three or four, should receive optimal surgical debulking to remove all visible disease to improve overall survival by trained surgeons. BRITTANY HARVEY: Great. And then Dr. Burke, what are the key recommendations for optimal adjuvant and systemic therapy for patients with stage one to four epithelial ovarian cancer? DR. WILLIAM BURKE: Sure. Well, one of the most important things is that access to appropriate evidence-based chemotherapy agents, contraindications to chemotherapy, and potential side effects of chemotherapy should be evaluated and managed in every patient. Basic resource settings that most likely lack the capacity to provide safe administration of chemotherapy should refer patients to a higher level center for evaluation. Limited settings without skilled capacity should refer patients to settings with access to specialized care. Some other notes include that clinicians should be able to document pathology and stage to determine eligibility for adjuvant chemotherapy. If pathology confirmation is not possible due to patient or resource limitation, alternatives can be discussed. Clinicians should not administer systemic treatment, adjuvant chemotherapy, to patients with ovarian low malignant potential tumors or early stage, microinvasive borderline tumors, independent of stage. Combination chemotherapy with paclitaxel and carboplatin is the standard of care for adjuvant therapy in ovarian cancer. However, single agent carboplatin may be utilized due to resource limitation or patient characteristics. Only in enhanced settings, highly selected cases can be assessed for appropriate evidence based intraperitoneal chemotherapy following optimal debulking, where there are resources and expertise to manage the toxicities. BRITTANY HARVEY: Great. And then the last overarching clinical question-- Dr. Aziz, what is recommended for patients with recurrent epithelial ovarian cancer? DR. ZEBA AZIZ: You know, with recurrent ovarian epithelial cancer is a tough option, especially in patients residing in the low-middle income countries. Supportive care treatment should be started together with whatever we have to do. So there are three options. There's one patient who presents with a rising CA125 with no evidence of disease and asymptomatic. We can elect to follow these patients, and it's easier to follow them until they become symptomatic or they have evidence of disease. If you have small volume disease which is resectable, you send them to an enhanced level setting, ideally where surgery can be done. Then you also look at patients and divide them into platinum resistant or platinum sensitive. If they're platinum sensitive, you can give a platinum-containing regimen, but if they're platinum resistant, you can put them on a non-platinum chemotherapy-- a single agent or whatever-- but these patients are tough to manage in that part of the world. BRITTANY HARVEY: Definitely. Well, thank you all for reviewing each of those key recommendations. The full recommendations are available in the guideline, but those are some important highlights. Thank you very much. So Dr. Burke, in your view, what is the importance of this guideline, and how will it change practice? DR. WILLIAM BURKE: Sure. Well, I think the importance of this guideline is that it globally targets health care providers, including gynecologic oncologists, surgeons, nurses, and palliative care clinicians, as well as non-medical community members, including patients, caregivers, and members of advocacy groups, providing them with resource-stratified clinical guidelines, recommendations that can be implemented across many health settings. The guideline will hopefully raise awareness among frontline practitioners, and provide guidance to provide adequate services in the face of varied and sometimes limited resources we see throughout the world. BRITTANY HARVEY: Great. And Dr. Aziz, how do you envision that these guidelines can be applied in low and middle income regions? DR. ZEBA AZIZ: These are extremely important guidelines for our part of the world. Remember that there are about 70 low-middle income countries, and all these countries-- and within each country-- there's marked variability in training of physicians who encounter cancer patients. There's also difficulty by the patients in accessing a few tertiary care centers, cancer care centers which are present, and most of all, financial implications, because you have to go there, you have to stay there, you have to get your chemotherapy, and this is true for the marginalized population. You also have to remember that more than 50% of our patients are treated in a limited resource setting, and the availability of enhanced resources are very difficult for them. And these limited settings are in public sector hospitals, where the doctors-- some of the doctors are very good, but the physicians or surgeons are overworked. They have resources ranging from minimal to moderate, depending on the funds available. And because they're overworked and there are few working hours, detailed counseling of the patient is infrequent because there are a large number of patients there. And the majority of surgeries, which is the cornerstone of ovarian cancer, is done by the postgraduate fellows who are there. Sometimes the senior consultants do surgeries, but most of the time, it is done by them. First time chemotherapy is easier to deliver because it does not have any expensive medicines. There are a lot of generics for carboplatin and taxanes regimen available, so it's not a major problem. But treating the side effects, again, becomes very expensive, and the patients have to come back and forth. The relapsed disease is very difficult to treat because we don't have too many options there and it is expensive. We've also seen that patients who are treated at an enhanced level do much better. Their survival outcomes are better, the supportive care treatment is better, and the progression-free survival is also better. BRITTANY HARVEY: Great. Thank you for reviewing that information. And then finally, Dr. Fujiwara, Dr. Aziz touched on this a bit on how it impacts patients, but how else do you view that these guideline recommendations will affect patients? DR. KEIICHI FUJIWARA: Yes. As Dr. Aziz said and Dr. Burke said, this guideline is written for the patients around the world in a different medical environment. So I think that it is very useful resource of information for patients to receive the best ovarian cancer treatment that suits the actual situation of each country or regions. BRITTANY HARVEY: Great. Well, thank you all for your work on these important guidelines. It sounds like they're going to have a real impact globally, and so I really appreciate both all of your work on these guidelines, and also for taking the time to speak with me today, Dr. Aziz, Dr. Burke, and Dr. Fujiwara. DR. ZEBA AZIZ: Thank you, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast Series. To read the full guideline, go to www.asco.org/resource-stratified-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines available on iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.

TEG, also known as thromboelastography is gaining popularity. So Dr. Elizabeth Beierle talked about the basics at our 2019 Pediatric Surgery Update Course. Mark your calendars for the next one on August 27, 2021. Host: Rodrigo Gerardo

An interview with Dr. Jennifer Griggs from University of Michigan and Dr. Gary Lyman from Fred Hutchinson Cancer Research Center & University of Washington, co-chairs on “Appropriate Systemic Therapy Dosing for Obese Adult Patients with Cancer: ASCO Guideline Update.” This guideline updates recommendations on appropriate dosing of systemic antineoplastic agents – including cytotoxic chemotherapy, checkpoint inhibitors, and targeted therapies – for obese adults with cancer. Read the full guideline at www.asco.org/supportive-care-guidelines.   TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one at podcasts.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. Jennifer Griggs from the University of Michigan and Dr. Gary Lyman from Fred Hutchinson Cancer Research Center and University of Washington, co-chairs on appropriate systemic therapy dosing for obese adult patients with cancer ASCO guideline update. Thank you for being here, Dr. Griggs and Dr. Lyman.   DR. GARY LYMAN: Thank you, Brittany.   DR. JENNIFER GRIGGS: Thanks for having us.   BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Griggs, do you have any relevant disclosures that are directly related to this guideline topic?   DR. JENNIFER GRIGGS: No, I don't.   BRITTANY HARVEY: And Dr. Lyman, do you have any relevant disclosures related to this guideline?   DR. GARY LYMAN: I have no relevant disclosures to this guideline.   BRITTANY HARVEY: Great. Thank you, both. Then let's get into the substance of this guideline update.   So Dr. Lyman, can you explain what prompted an update to this guideline on appropriate dosing for obese adult patients with cancer last published in 2012, and what is the scope of this update?   DR. GARY LYMAN: Thank you, Brittany. Yes, this is an update of a previous guideline, several years old, that was prompted by evidence that there was wide variation in how chemotherapies at that time were being dosed, particularly in the overweight and obese population. Some were capping the dose, some were giving the full weight-based dosing, and all sorts of permutations in between. So that guideline was greeted, I think quite favorably, and, in fact, led to changes in clinical practice in many institutions and I believe also in the cooperative group research networks.   Since that time, however, a whole array of new therapies have come along. These, we'll talk about briefly in this podcast, include the novel targeted therapies based on molecular targets, as well as the new checkpoint inhibitors, and other monoclonal antibody therapies, where the dosing issues, in general, are different for many of these agents. And specifically for patients who are overweight and obese, we thought it was important that we update this guideline, review the evidence in total appropriate to the dosing of these new agents in overweight and obese patients, and make updated recommendations that would be more relevant to that practice of oncology in 2021.   BRITTANY HARVEY: Great. Thank you for explaining the previous version of the guideline and for explaining the expanded scope. So given that, I'd like to review those key recommendations made in this guideline. So Dr. Griggs, what are the recommendations regarding dosing of cytotoxic chemotherapy in obese adults with cancer?   DR. JENNIFER GRIGGS: With rare exception, we recommend, and the evidence supports, using actual body weight when we calculate doses. So whether it's just per kilogram, milligrams per kilogram for example, or per meter squared, using body surface area, we recommend that the actual body weight of the patient be used with no compromise or capping, no maximizing the dose as if it were calculated using 2 meter squared for example. There's no evidence that that's necessary to avoid side effects, and, in fact, there's increasing evidence that doing so, that limiting the doses in patients, is associated with decreased benefit of the treatment.   Since the original guideline came out, there's been no convincing evidence that has made us change our recommendation. So again, in brief, we recommend that actual body weight be used in calculating the target dose for cytotoxic chemotherapy.   BRITTANY HARVEY: Great. Thank you. That's very clear for clinicians. So Dr. Lyman, you mentioned this in your introduction to the scope of this guideline, what are the recommendations for dosing of checkpoint inhibitors and targeted therapy in obese adults with cancer?   DR. GARY LYMAN: Well, Brittany, these are the new agents that I referred to in the introduction that have appeared in broad usage in oncology and other disciplines since our 2012 guideline recommendation. Many of these are monoclonal antibodies, and they just generally have a wider therapeutic index and distribute an extracellular fluid and plasma with less correlation with body size descriptors, such as weight or body surface area. They may be, in fact, in some cases are amenable to fixed dosing schedules.   So this has all led to a whole array of new agents approved by the FDA for cancer therapies that are being dosed on a wide variety of means, some based on dosing like we have done for classical chemotherapy that Dr. Griggs discussed using body surface area, in some cases body weight, and then some being dosed base on fixed dosing-- fixed size regardless of the body size that the patient represents. So it gets a little complicated, because currently the monoclonal antibodies and many of these therapies are dosed in different ways, versus fixed dosing is recommended for some of the immunotherapies, alemtuzumab, afatinib, as well as targeted therapies like pertuzumab, which are relatively recent.   And then weight-based dosing, milligram per kilogram, is used for other checkpoint inhibitors, like ipilumumab, as well as other monoclonals like bevacizumab and trastuzumab among others. And then again some were still dosing based on body surface area, such as rituximab and cetuximab. So the bottom line is these agents will be dosed and the approved dosing by the FDA will generally be based on the schedule and dosing that was used in the pivotal clinical trials. And different companies in different disease areas have chosen different ways of dosing these.   So for us, with this guideline, and this is true of overweight and obese patients in particular, we recommend dosing these agents based on the FDA approved dose and schedule for that agent. But be aware, as I indicated, that it will vary from agent to agent and category of agent from one to the other. Because of the convenience and perhaps some safety issues related to fixed dosing, additional data has been submitted to the FDA for some agents, nivolumab, for instance, and pembrolizumab, to suggest that a different dosing schema, fixed dose schema can be used, and that has led to a modification in those dosing recommendations.   So even if you think you know, if you're not using these agents day in and day out, you really should check and make sure you're using the currently recommended dosing. And final point is, in the overweight and obese patient, any dose modification because of adverse events or scheduling changes should be applied independent of the patient's obesity or overweight status. In other words, any dose modification that you would apply a healthy weight patient is the same type of dose modification you should apply in the overweight and obese patient and not modify solely based on the patient's weight or obesity status.   BRITTANY HARVEY: Definitely. Great. That was actually going to be my next question. So Dr. Griggs, do you have anything to add about for obese adult patients with cancer who experience high grade toxicity-- should clinicians modify dosing and schedules differently than they would for non obese patients?   DR. JENNIFER GRIGGS: Well, as Dr. Lyman says, the same with checkpoint inhibitors and targeted therapies, we don't recommend and the evidence doesn't support making changes in a different way. That is, there's no interaction between obesity status and the recommendation through dose modification. So in a patient who has severe toxicity related to chemotherapy as well as the targeted agents and checkpoint inhibitors, we recommend that standard dose modifications be made, and moreover that if the patient does better that one consider dose escalation again, if there were for example another concurrent illness that might have contributed in part to the toxicity. So if that other factor resolves, let the dose be increased again to try to maintain that relative intensity dose over time that we consider ideal.   BRITTANY HARVEY: Great. Thank you for reviewing that for the cytotoxic agents in addition to the immune checkpoint inhibitors and targeted therapies. So then, Dr. Lyman, the last clinical question of this guideline-- how should body surface area be calculated?   DR. GARY LYMAN: Well, this is the issue alluding to when I mentioned that there could be safety concerns with these complex calculations. And we tried to make it simple in the guidelines. There are multiple BSA-- Body Surface Area-- calculators out there. You can search them on the web, you can go to textbooks, and there's a whole range of them.   And we actually looked at this. This goes back to the original guideline, and it holds true today, that if you compare that the dose calculated by these different calculators, it's very close to one another. So our bottom line recommendation-- if you're going to use body surface area for calculating the dose of conventional cytotoxic therapy or any of these other agents where that dosing approach is recommended, any of these calculators are going to give you a safe and hopefully effective dose of the therapy. And we don't prefer or recommend one over the other.   Again, there are many on the web. Many institutions have their preferred and may even have embedded the calculator within the EMR or computer order entry system. Many prefer the Mosteller, the Du Bois, the Boyd, there's a whole variety of these, but all of them will generally yield very similar calculations. We haven't mentioned, and just to point out, as most oncologist know certainly, is one drug group, a specific agent, carboplatin is dosed differently. And for carboplatin, we calculate the dose based on a target area under the curve and GFR, so that the Calvert formula calculates the dose differently for carboplatin. And that's for historical as well as pharmacologic reasons.   So again, as Dr. Griggs mentioned, for classical chemotherapy, body surface area is the most common one. But any of the approved calculators or available calculators will give you essentially the same dosing recommendation. And I would follow what's recommended by your institution.   BRITTANY HARVEY: OK. Well, thank you both for reviewing the key recommendations in this guideline update. So finally, Dr. Griggs, in your view, why is this guideline update important, and how will it impact both clinicians and patients with cancer?   DR. JENNIFER GRIGGS: Dr. Lyman and I have viewed this as a really important guideline and guideline update. Because, as we know, the prevalence of obesity is increasing and obesity is associated with an increase in the risk of cancer-- many cancers, not all. And moreover, people who are obese tend to have worse outcomes. And so to try to level out and keep people from systematically what we consider underdosing people who are obese with chemotherapy is very likely to improve outcomes for an important group of our patients.   In addition, the update, because it's been updated now since 2012, we have more evidence that what we're recommending, what the evidence has supported thus far historically and in trials, is actually safe. There's been no signals, in other words, that the original guideline needed to be altered for certain patients or drugs. And now, with this update, we're pretty confident, based on what we know from the FDA and clinical trials, that using actual body weight is not just appropriate, but it's also recommended. So it's an important issue for the population and for our patients, and it's important for clinicians to have the confidence to use actual body weight when calculating anticancer drug doses.   BRITTANY HARVEY: Great. Thank you, both, for all the work you did to update this evidence-based guideline and thank you for taking the time today to speak with me on the podcast, Dr. Griggs and Dr. Lyman.   DR. GARY LYMAN: Thank you, Brittany.   DR. JENNIFER GRIGGS: Thanks, Brittany. We want to thank our co-authors on the guidelines, as well as the ASCO staff for their tremendous work.   DR. GARY LYMAN: Yes, we couldn't do it without all of them, and it's a tremendous team effort.   BRITTANY HARVEY: Definitely. We thank them all as well. And thank you to all of our listeners for tuning into the ASCO Guidelines Podcast series. To read the full guideline, go to www.asco.org/supportive-care-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available on iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.   [MUSIC PLAYING]

PROSTATE PROS Series Finale On the last episode of the PROSTATE PROS podcast, Dr. Scholz and Liz recap important themes and talk about what’s new in prostate cancer, including Lutetium-177 and Orgovyx. Dr. Scholz: [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz. Liz: [00:09] And I’m your cohost, Liz Graves. Dr. Scholz: [00:13] Welcome to the PROSTATE PROS podcast. Liz: [00:15] We have a bit of a sad announcement to make, as this will be the last episode of the PROSTATE PROS podcast. Dr. Scholz and I have really enjoyed working on this project and we’ve covered so many important topics surrounding prostate cancer and men’s health. So for this last episode, we’re going to recap some important themes and talk about some promising new therapies. So Dr. Scholz, on our very first episode, we talked about how important it is to find the right treatment team. This is something that’s come up again and again and again. What are some tips you have for newly diagnosed men trying to find their doctors? Dr. Scholz: [00:53] I think what’s confusing is how much of the responsibility falls on the shoulders of patients. The prostate industry is a very powerful multi-billion dollar industry, and there is a lot happening really fast. When patients are diagnosed, they’re not in a thoughtful perspective, they’re in an action mode, they’re frightened. It is hard to sort out who to listen to and who to stay away from. This process can be aided by family members, primary care doctors, oncologists, and of course, online resources and books. I try to provide some of that information in the book, The Key to Prostate Cancer, but the process, if it was easy, we could give you one simple answer. It is not a simple process. Liz: [01:46] One thing that we’ve talked about is to get a quarterback. So this is a doctor that isn’t the treating doctor necessarily, but it’s someone that will oversee the treatment and work with the other teams of doctors. This is something I hear you doing Dr. Scholz, you’re always talking to other doctors about patients and kind of networking with them to make sure that the patient is getting the best care, even when they’re not in our office. Dr. Scholz: [02:12] I think the issue that you’re relating to is that many of these physicians have a conflict of interest. You’re asking them, what should I do? But they’re a surgeon or they’re a radiation doctor. And as a medical oncologist, I’m neither of the above. This is somewhat uncommon, but you can recruit your urologist or your radiation doctor to help you by explaining at the outset that, “you, sir, will not be my treating doctor, but I definitely need your aid and your assistance in picking the right doctor.” Liz: [02:43] Now you may be thinking that you have cancer and you don’t have time to see all these people, but as we’ve mentioned, prostate cancer is slow growing. So really taking that time to find the right doctor for you is crucial. Dr. Scholz: [02:56] Just yesterday, I saw a very sophisticated new patient who was feeling the rush job, the sense that the clock is ticking, and he did have a Gleason 9. We consider that the High-Risk category of prostate cancer. But, the idea that you have to make a decision within days or weeks is never substantiated by the literature and the science. Patients can take several months to sort out what they want to do. This sort of careful thoughtful process pays off in the long-term with better results. Liz: [03:29] So patients really need to take it under their control. One of the things is to educate themselves. In the past couple of years, there’s been a huge shift towards imaging. So we’ve had the approval of the PSMA PET scan and using 3T MP MRIs and color Doppler to help men diagnose their prostate cancer and watch it. Dr. Scholz: [03:51] What Elizabeth is referring to is that if you don’t have a clear picture of where the cancer is and whether it’s spread outside the gland, what part of the gland it’s located in, it’s not feasible to tailor treatment to the specific needs of the individual. Some men are fortunate enough to have prostate cancers residing on one side of their gland. This opens the door to something called focal therapy, enabling men to undergo treatment with less risk of erectile dysfunction. There were a lot of things we could have covered in this last podcast and the reminder that quality imaging and not only MRI and PSMA PET scans, but scans done at centers of excellence that are read by experts are going to help men be light years ahead in their selection of treatment, because they’ll have a clear picture of what they’re really treating. Liz: [04:43] So we’ve actually gotten emails from people all across the country saying, you know, my doctor’s never heard of the PSMA PET scan or my doctor doesn’t do 3T imaging. So it is really important that you take the time to educate yourself and bring these questions to your doctors. Finding the right treatment team and doing your due diligence to make sure you’re choosing the right treatment is all important because of where the prostate is located. Treatment related side effects can have damaging effects on quality of life. Because prostate cancer is so slow growing, hopefully you’ll have a very long life, so it’s important that that can be lived to the best of your ability. Dr. Scholz: [05:25] That’s so, so important. And these functions, sexual, urinary functions are something that people face every day of their life. In the hustle bustle to get treatment quickly, the fact that if the treatment is not done in an ideal way, that men can be left with permanent issues unnecessarily, certainly if there was no other option, we would live with these negative consequences. But, in most cases now with skillful care, these things can be avoided. Liz: [05:58] Over the past two years, Dr. Scholz and I have covered all the treatment options from active surveillance to surgery, radiation chemotherapy. These episodes will still be available even after the podcast ends, you can go back and re-listen and keep sharing with friends and educating yourself. Dr. Scholz: [06:16] One thing about this information provided in the podcast is not only the idea of which treatment is best and what kind of things to look out for, but the step by step process, the thinking process, the procedures, and how you can come to get the right doctors and the right treatment is implicit in the whole podcast system that we have provided. So you can also just learn from the thought process that leads to successful outcomes. Liz: [06:49] While there are a lot of challenges that newly diagnosed patients face, patients with advanced prostate cancer also are missing out on some tools like Xgeva and Prolia. Dr. Scholz: [07:01] These medicines are to help compensate for men who have disease that’s spread to their bones or men who’ve been on hormone treatment and the calcium is leaching out, a process called osteoporosis. The number of times this is overlooked and people coming to us for second opinions is really quite surprising, as they are FDA approved to help compensate for these problems. So simple second opinions can be so valuable for men, even if they have advanced disease. Liz: [07:35] As we segue into what’s coming up and what’s new in prostate cancer, we wanted to quickly mention that there are a lot of new drugs and things being tested for FDA approval through clinical trials. Clinical trials are a great way to get access to these new medications, if you have a specialist on your team who is constantly looking out for these and keeping tabs on what’s coming up. Dr. Scholz: [08:03] Every new medicine or treatment goes through a process of being researched. Once it’s validated as a treatment, it gets FDA approved. And then after that, it becomes commercialized and broadly available across the country. The things that succeed through that process are very valuable. And we’ll be talking about a Lutetium-177 and a new pill called Orgovyx. These medicines have been available, but now are commercially available. If your physician is not staying abreast of all the new developments, men who could benefit from these treatments will be denied access simply through unawareness. Liz: [08:43] Lutetium-177 is something that we’ve talked about on past podcasts. And it’s not even FDA approved yet, but you’ve actually had some patients who have had it, is that correct? Dr. Scholz: [08:57] Lutetium-177 a was purchased by a Novartis pharmaceuticals for $2 billion prior to all the testing being completed because all the preliminary data looks so favorable recently, they released the code for the large clinical trial that was performed confirming that it does prolong survival. This is a medicine that was evaluated in men with very advanced prostate cancer who had already had chemotherapy who had been on other powerful hormone treatments and they’d stopped working. The man who got treated with Lutetium-177 lived longer, statistically significantly longer, than the men who got an alternative, placebo-type approach. This medicine is well tolerated. It can cause some dryness of people’s mouths. It can lower blood counts a little bit, but it’s a simple injection every six weeks. And it is a potent treatment for men with advanced disease. It may even be a useful treatment for men with earlier stage disease. This will probably be commercially available within a year. Liz:  [10:05] To learn more about this medicine, we covered it in Episode 10, Don’t Reject Radiation.  So you can go back and listen to that.  At the end of 2020, there was a new FDA approval Orgovyx.  This is an oral anti-androgen, so it works kind of like a Lupron, but instead of it being an injection, it’s just a daily pill.  Dr. Scholz: [10:28] So how much do we really need a new pill? When if you could take an injection that lasts three to six months, and you don’t have to remember taking pills every day, but Orgovyx may have some other advantages when compared to head to head with Lupron and the other medicines like Lupron, such as Firmagon and Trelstar, Eligard, and Zoladex. These medicines all work by shutting down the production of testosterone in a man’s testicles. Orgovyx is interesting for two reasons. One is that the recovery of testosterone when treatment is stopped, seems to be much more predictable and consistent medicines like Lupron, and the others that I mentioned, can have a very protracted and prolonged effect even after they’re stopped, and it’s hard to predict when testosterone is going to return. Another thing that came out in Orgovyx trials was a lower incidence of cardiovascular complications. For years, I’ve made a strong argument that Lupron and other drugs do not cause cardiovascular problems directly, but indirectly in men who have a lot of weight gain, blood pressure goes up, blood sugars start to go out of control. Of course these things can lead to cardiovascular problems, but for some reason, in that randomized trial Orgovyx had a lower incidence of cardiovascular related issues. This is certainly an interesting and potential advantage for this medication. Liz:  [11:56] Technology and medicine around prostate cancer is improving almost daily.  And one of the things that’s really promising is immunotherapy.  We talked about this on Episode 9, The Intelligence of Immunotherapy, and we cover all sorts of different things that will benefit men with prostate cancer, like KEYTRUDA and OPDIVO YERVOY.  So if you’re interested in learning more about immunotherapy Episode 9 is a great place to start.  Making this podcast has been such a rewarding experience for Dr. Scholz and I, and we really hope that it’s helped you on your prostate cancer journey.  And we’ve left you with a little more education and knowledge and empowered you to take control of your prostate cancer diagnosis and spend time really learning about it and understanding, so you can have your medicine personalized to you.  You can find the right doctors, seek second opinions, and then take everything you’ve learned to spread awareness about prostate cancer.  Remember prostate cancer is a silent disease and it affects so many men and families and loved ones.  This really needs to be something that people are comfortable talking about.  So we hope our podcast has helped give you some points to talk about with your friends and family members and help them make those treatment decisions.   Dr. Scholz: [13:26] So Kaili, my business manager and myself are very grateful to Liz for all the hard work she’s done in compiling these episodes and helping us reach the things that really count. It’s been quite a bit of work along the way, which has been a delight to participate in for me. Liz, can you just share a couple of sentences of where you think you’re going to be going with your own professional career as you’re moving on? Liz: [13:51] Yes.  I am actually pursuing higher education to become a professional writer.  I am looking forward to it, but I’m definitely sad that I won’t be working with you and bringing this podcast to everyone.  I know I’ve had so much fun learning about prostate cancer and hopefully being able to help all of our listeners navigate this subject.  Again, these episodes have been archived, so you can go back and listen to all twenty-four of them on podcast.prostateoncology.com, or Apple Podcasts, SoundCloud, wherever you like to listen.  Another good tip is that the PCRI’s YouTube videos come out every week.  These are awesome videos that talk all about prostate cancer.  Dr. Scholz is a very frequent guest on there, so I would highly recommend you check that out.  You can find them at youtube.com/thePCRI.  Thank you for listening and supporting us.

An interview with Jessica Geiger, MD, from Cleveland Clinic and Patrick Ha, MD, from the University of California, San Francisco, co-chairs on “Management of Salivary Gland Malignancy: ASCO Guideline.” This guideline provides recommendations for preoperative evaluation, surgical procedures, radiotherapy techniques, the role of systemic therapy, and follow-up evaluations for patients with salivary gland malignancies. Read the full guideline at www.asco.org/head-neck-cancer-guidelines.   TRANSCRIPT SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines Podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. Jessica Geiger from Cleveland Clinic and Dr. Patrick Ha from the University of California San Francisco, co-chairs of management of salivary gland malignancy ASCO guideline. Thank you for being here, Dr. Geiger and Dr. Ha.   DR. PATRICK HA: Thank you, Brittany.   DR. JESSICA GEIGER: Thank you.   BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Geiger, do you have any relevant disclosures that are directly related to this guideline?   DR. JESSICA GEIGER: No, I don't.   BRITTANY HARVEY: And Dr. Ha, do you have any relevant disclosures that are related to this guideline?   DR. PATRICK HA: No, I do not.   BRITTANY HARVEY: Thank you both. Then let's talk about some of the content of this guideline. So first, Dr. Geiger, can you give us a general overview of the purpose and the scope of this evidence-based guideline on the management of salivary gland malignancy?   DR. JESSICA GEIGER: Sure. So salivary gland cancers-- they're relatively rare, and they encompass a wide variety of both histologies, but also biologic behaviors of cancers. This is a very multidisciplinary tumor, so surgeons, radiation oncologists, pathologists, medical oncologists-- they all play an integral role in treating these patients. And the purpose of this guideline was to bring all of these disciplines together and to develop an as strong as possible, evidence-based way of approaching the diagnosis of such cancers and then approaching it from all modalities of therapy-- surgical, radiotherapy, systemic therapy-- in a very evidence-based and organized fashion.   BRITTANY HARVEY: Great, then as you just mentioned, this is a multidisciplinary guideline, and it covers six different subtopics on the management of salivary gland malignancy-- preoperative evaluation, surgical management, radiotherapy, systemic therapy, follow up, and treatment options for recurrent and metastatic disease. I'd like to go through and review the key recommendations from each of those sections for our listeners.   So first, Dr. Ha, what is the guideline recommend regarding preoperative evaluation for patients with salivary gland malignancy?   DR. PATRICK HA: Great, so I'd first like to start off by saying that we were focusing on salivary gland malignancy. So again, these are tumors where we may not know the diagnosis, but we're suspicious of this being cancer as opposed to a benign tumor.   So along those lines, there are many different imaging recommendations-- first off, that some sort of imaging would be helpful if there's a suspicion of cancer, and then drilling down a little bit more specifically if there is concern about bone involvement. And then CT scan was recommended if it was more of a concern about the soft tissue or perineural invasion or skull-based invasion, then MRI was suggested. And we did spend some time focusing on the strength of and the importance of tissue biopsies, either with fine needle aspiration biopsy or core needle biopsy as a real helpful tool to help clinicians determine what sort of procedures and care this patient might need.   Additionally, with the onset of more understanding of the pathology in the markers, it was felt that using these biopsies-- these FNAs or core biopsies-- to perform either molecular or immunohistochemical studies could further help clarify what the diagnosis would be and thus lead to sort of more specific and defined treatment subsequently.   BRITTANY HARVEY: And then following those evaluation and imaging and biopsy recommendations, what are the key surgical recommendations?   DR. PATRICK HA: Yeah, so again this is probably known to most people-- that when it is considered resectable, the surgery is really the mainstay upfront management option for these patients. We spent some time looking at the different types of surgeries and felt that it was a bit up to the discretion of the surgeon, but it depends on the location as to what type of surgery exactly needs to be done. But the idea is obviously we would want a complete resection of it and margins where possible.   And then we address the nodes and the ability for these cancers to sometimes spread regionally. And basically, if these are high risk or high grade cancers, specifically if there are things like the grade of the tumor itself-- the type-- and then whether there were other concerning features about it, than a neck dissection electively would be offered.   If there were N positive disease, then the neck dissection definitely should be performed. And then there was discussion as well about the facial nerve and how to manage that, wherein the evidence mostly reported trying to preserve the facial nerve whenever possible.   And then we did talk a little bit about the possibility of palliative resection, which can occur sometimes in the presence of distant metastatic disease upon presentation. And it was felt again that there is a palliative component to surgery if the metastatic disease didn't seem to be rapidly progressive or imminently lethal. So these are all the difficult decisions that we discussed regarding surgery.   BRITTANY HARVEY: OK, thank you. Then Dr. Geiger, how does this guideline address radiotherapy for patients with salivary gland malignancy?   DR. JESSICA GEIGER: Well, as Dr. Ha mentioned, this is primarily a surgical disease. So most of the recommendations regarding radiotherapy involve the post-operative setting. But if you look at the guideline, we have actually laid out 10 recommendations regarding radiation, and they're dependent on various factors with each cancer, so the histology of the disease, other tumor pathologic factors, such as T-stage, vascular, lymphatic invasion, margin status, perineural invasion-- all of that goes into the recommendation here. There's also considerations for what nodal basins to cover, based on where the tumor is, and even the type of radiation, and, of course, the timing of radiation. All of that is important to be considered, and all of those specific features are mentioned within the recommendations.   BRITTANY HARVEY: Great. And then in addition to those radiotherapy recommendations, what's the role of systemic therapy for patients with salivary gland malignancy?   DR. JESSICA GEIGER: Well, unlike the radiation section, where I said we have 10 specific recommendations, we're limited with the evidence for the use of systemic therapy in the curative setting of these diseases. So one point that I will make is, again, we're very limited based on evidence, and this is what is driving such a guideline-- is evidence, evidence, evidence. And we just don't have it.   There are several large studies that are ongoing, but until those results flesh out, we were limited. And so our recommendations are based on the lack thereof, and often are considered low quality or moderate strength of recommendation at best, based on our expert panel.   Basically, outside of a clinical trial, we're not recommending the addition of radiosensitizing chemotherapy with post-op radiotherapy. Again, that can be contentious, especially in the clinical realm, where there's a wide variety of biologic behavior. So some of the more aggressive diseases, we know that oncologists are advocating for the use of chemotherapy. But again, the evidence is not there yet, and so we weren't able to make that informative within this guideline.   And then we also addressed tumors that are expressing different markers, like androgen receptor, HER2, and make a recommendation for the use of targeted therapy, again noting a lack of evidence for it outside of a clinical trial currently.   BRITTANY HARVEY: OK, thank you for explaining the reasoning and the evidence behind those particular recommendations. So then for patients who have then completed treatment for salivary gland malignancy, Dr. Ha, what are the timelines and recommendations for follow up for these patients?   DR. PATRICK HA: Well, so again, this is where the data are really not strong. And so you'll notice that pretty much all of these recommendations were informal in consensus. But similar to the NCCN guidelines for general cancer follow up was believed by the panel that early follow up more frequently and just sort of spaced out over time was important.   And then there was an emphasis on some form of imaging often, whether that be CT or MRI, it's sort of up to the practitioner. And then perhaps for a couple of years after treatment, that might be important.   It was also felt that, as everyone probably knows, that one of the areas where this may spread to distantly is in the lung. So getting some sort of chest imaging between years 2 and 5 would be important as well, just in case one can detect an asymptomatic yet potentially treatable metastasis.   So again, a lot of informal consensus. The idea is that we feel it's important to continue to follow these patients to look for signs of recurrence, whether that's with imaging or physical exam. We thought that either would be an option.   BRITTANY HARVEY: Definitely. And the last section of recommendations for this guideline is on recurrent or metastatic salivary gland malignancies. So what are those treatment options, Dr. Geiger?   DR. JESSICA GEIGER: Well like before, when we're talking about systemic therapy, again, informal consensus is sort of driving the majority of these recommendations, again highlighting lack of strong evidence. That said, there are several different clinical situations that we address within these recommendations.   So whether a patient presents with diffusely metastatic disease with a large tumor burden or oligometastatic disease, where maybe just one or two local or regional areas have recurred. And so in that latter case, you could discuss with the patient is it worthwhile to do some locally ablative therapy, such as SBRT, or possibly a resection versus, for more widely metastatic disease, starting systemic therapy.   Now, there's also a recommendation specifically for the histology adenoid cystic carcinoma. And that is based on studies that have been done with tyrosine kinase inhibitors. And so there's some evidence for that outside of cytotoxic chemotherapy.   And then we also make a mention, which is very important, again on checkpoint inhibitors, but also on some of the targeted therapies-- doing next generation sequencing, looking for molecular markers that drive the progression of these diseases, and then in subsequent targeted therapies for this.   So we really try to encompass any and all particular situations that an oncologist may encounter with these diseases and offer some guidelines and recommendations regarding the appropriate management.   BRITTANY HARVEY: Great. Thank you both for reviewing those key points of the recommendations. This guideline goes through a lot of content, and so it's interesting to hear more about what kind of those details are for each section. So Dr. Ha, in your view, what is the importance of this guideline, and how will it impact clinicians?   DR. PATRICK HA: Well, I think that we realized we had a lot to cover in just a short amount of time. And I think that we felt that while the data may not be as strong with-- full of randomized clinical trials as perhaps other disease subgroups, we felt it was important to organize what the current state of the data are, because these are rare cancers, and there are some nuances between some of the histologies even that it may be difficult to keep up to date all the time. So organizing it into one document where it we have clearly delineated what areas we feel are common practice amongst experts and what areas actually do have some studies and perhaps some deeper level of understanding and depth of studies would be important, so that clinicians understood where it was that they have to be a little more creative and areas where they felt like hey, we feel like this is important to do.   So I think that that would be useful for clinicians. And I think also it provides a framework for future studies, meaning that we hope that whenever these get updated and 5 or 10 years that there will be more studies. But it also does, I think, help for those of us who are in the field to organize where those gaps are so you can look at the guidelines and really understand OK, these are the areas that we need better understanding of how to treat patients.   BRITTANY HARVEY: Definitely. It's helpful to understand both where there is evidence and where there is no evidence and where informal consensus takes rule. So then finally, Dr. Geiger, how will these guideline recommendations affect patients?   DR. JESSICA GEIGER: Well, when it comes to cancer treatment, there is a lot of fear in the unknown. And I feel that patients are always asking am I doing the right things? Am I looking to make sure that I'm getting the best of care? And I think with any guideline-- this one included-- patients can rest assured that they don't have to make the trip and travel to a large academic center necessarily-- that they can feel comfortable knowing that their providers are following the data and following such guidelines that have been brought forth in one single document. Even though the patients aren't going to necessarily have this document at hand, they can have confidence within their oncology team.   And then I think they'll also benefit from, as Dr. Ha was saying, as medical professionals being able to identify gaps and bring forth clinical trials. That's the only way that we're going to be able to move this field forward, particularly in such a rare disease that many histologies as salivary gland malignancies. And so while being treated in a regional oncology office or a community oncology office, maybe their provider will then recommend clinical trials that are open and have that additional opportunity for patients, if they so desire. So knowing that they're getting great standard of care based on evidence, but then also the opportunity to create new evidence for us to better treat patients in the future.   BRITTANY HARVEY: Definitely. Well, I want to thank you both so much for your work on developing these evidence-based guidelines and for taking the time to speak with me today on the podcast, Dr. Geiger and Dr. Ha.   DR. JESSICA GEIGER: Thanks.   DR. PATRICK HA: Thank you.   BRITTANY HARVEY: And thank you to all of our listeners for tuning into the ASCO Guidelines Podcast series. To read the full guideline, go to www.asco.org/head-neck-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available on iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.

Have you ever thought that you could become a better version of yourself using numerology? Do you feel that you’re capable of living way more through spirituality? You’re doing a lot, but nothing seems to work out. People like living the same monotonous life and choose mediocrity every day. But you realize you can do way more and are capable of achieving greater heights? Here’s the hard truth: you need to set in place things that you believe in and focus on them rigorously. In this episode, we are joined by Craig Wright where he talks about his experience with numerology and spirituality. Tune in to this episode to learn more about this whole new array of things and how to get your hands-on it. Here are three reasons why you should listen to the full episode: Understand the different ways numerology can have an effect in your lives. Discover the importance of spirituality and numerology in ones life. Learn the significance of numerology in daily lives. Episode Highlights [01:41] Freewill & The Self · Each of us has a contract with our creator, which consists of the gifts that we receive and the promise that we make. ● Craig talks about numerology and free will and how it leads to different things. ● Everyone knows what it is like to be numero uno but every number has a meaning of its own. [08:11] The Start ● Craig talks about how his journey began and explains his ‘Wake Up Call.’ ● He also talks about his set of realizations from when his best friend died and how he found himself. ● “Why am I here?”, “What is the meaning of life?” are some of the many questions he began asking himself after the demise of his Best Man. ● He talks about the book “In search of the third eye” and his journey of discovery from there. [17:53] Levels of Acceptance ● After Craig discovered himself, he became his first client. ● Craig talks about how he ditched being a pilot and get out on this spiritual journey which further expanded into numerology. ● Craig discusses his analogy of the number four. [29:09] The Journey ● Craig talks about how things didn’t work out for him in the beginning but everything started to fall in place once he started reading. ● He talks about how he started receiving information from the universe and the hints to help people out. ● Talks about how he ventured viral and started as a numerologist. [35:00] Making a living ● Talks about how he started his services out as a labor of love and used to give seminars where no one showed up. ● Today, he successfully runs workshops, teaches at a local community college, and creates curriculums. [42:50] Cultivating Yourself ● The mind is very eager to see and the universe puts things in place for you. Powerful Quotes from the Episode “There is a difference between figures and numbers.” About Craig Craig Wright is a native of Baltimore, Maryland where he studied religion and philosophy in his youth as a member of the Baltimore Ethical Society. He holds degrees in Psychology and Metaphysics. He is an Ordained Metaphysical Minister and a Certified Metaphysical Practitioner. It was the tragic death of a friend in the summer of 1972 that prompted Craig to search for the meaning of life. This began his study of NUMEROLOGY. After many years of personal research, Craig went public in 1988. This was the year he met Rev. Hazell Cassell and was invited to be a guest on her radio program. Craig's presentation on Numerology generated so much excitement that people began to ask him to share his knowledge about this fascinating science. The momentum has continued to grow. Craig's services have been sought nationally and internationally. He has served as a resource to several Human Service Agencies by conducting seminars and workshops. He has a wide array of clientele who consult with him regularly on personal as well as business matters. Connect with Craig here: http://www.craigewright.com Enjoy this Podcast? It’s easy to show the side of ourselves we’re proud of. But true change and self-love come with being able to accept all of you—even the sides you’re afraid to show the world. If you enjoyed today's episode of Spiritual Dope Podcast, then hit subscribe and share it with your friends! Post a review and share it! If you enjoyed tuning into this podcast, then do not hesitate to write a review. You can also share this with your family and friends so they can take a big hit of spiritual dope! Transcript auto generated by otter.ai Brandon Handley 0:00 All right, well, let's get on that. And 54321 Unknown Speaker 0:07 Hey, there's Brandon Handley 0:07 spiritual dope. I'm on today with Dr. Craig. He right. He's a native of Baltimore, Maryland, where he studied religion and philosophy in his youth. As a member of the Baltimore ethical society. He holds degrees in psychology, and metaphysics. He's an ordained metaphysical minister and a certified metaphysical practitioner, we're going to talk a little bit about a story is how you got there. So I'm gonna leave that out. But one of the big things that we're gonna be talking about is numerology kind of how you went public with your story, you know, the radio show that you were on for quite some time. And just unless we're gonna talk about, you know, the, the journey. So Dr. Craig Wright, thank you so much for being on here today, how I like to start these off is with the idea that you and I are here, connecting, and sources, you know, kind of put us in this time in this place in this space, so that a message can flow through you to somebody in the audience today. What does that message just come through, you Unknown Speaker 1:12 know, that message would be, each of us has a contract with our Creator with source doesn't matter what name you use, God has 1000s of names depending on the culture you're from. But each of us has a contract with source, and that we are giving gifts. And we make a promise, the contract has come out composed of gifts that we received, and a promise that we make, and that information is is available, because it shows up in the numbers and our birthday, in the letters in our lay. Brandon Handley 1:53 That's powerful. So it's interesting to me. And of course, the first thing that comes to my mind is we were talking you know, we connected online and you mentioned like this show to be on the show. And one of the first things that kind of comes into my mind though about numerology that i i think that you know, some of the naysayers, right would say, Well, if it's all in the numbers, is it all predetermined? Right, or, you know, what happens after? You know, you give me the some numbers? Is it fatalistic? Is it something else? Unknown Speaker 2:30 Well, no numerology does not rob us of our free will. For example, if you're born on the first of any month, one of your gifts is leadership. Everybody knows that number one. So you could be an engineer, you could be a pilot, you could be a fashion designer. But whatever you decide to be using your free will, you're going to be the cutting edge, and you're going to be the best at it. So the number one will reveal your creativity that you're here to be an originator, not an imitator, you're here to lead not to follow. And more than likely, if you're born on the first 10th 19th or 28th of any month, you're going to have opportunities to become self employed. Those are the number ones. If I may, at this point, it's important that we realize there's a difference between figures and numbers. If I hold up a pin, and I say I have one pin, that would be a quantity. In this case, number one, this is a figure a quantity. But if I look a little closer, and I say big pins are number one. Now I'm no longer talking about a quantity, but a quality, at least in my opinion of being the best. So everybody knows what it means to be numero uno, but every number has a meaning or every number reveals a spiritual quality, a spiritual quality. So getting back to your question. No, it's not fatalistic. For example, it'll tell you, hey, it's springtime, time to plant but you can plant that is tomatoes, okra, corn, whatever you choose. But you don't want to plant in January. What is freezing? So that's the benefit of numerology. Brandon Handley 4:25 I gotcha. I gotcha. That makes sense. So I want to I definitely want to talk a little bit about your journey into this space. You know, it kind of happened, right? You got a new tragic death of a friend, your best man for your wedding, if I recall correctly. Yeah. And and yeah, let's just talk about an area. You know, let's talk about kind of how that hits you. And what you did, how that how that kind of spurned your journey. Unknown Speaker 4:54 That was my that was my wake up call, if you will, for my call. to spirituality. I showed a propensity for math and science when in seventh grade, my parents decided they were going to have an engineer in the fam. My mother was a schoolteacher. So I was never out of school, math, science, every program, summer school, anything having to do with math and science. I was there. I was preparing to become a jet pilot. I wanted to fly jets with the Navy. By the seventh grade, I knew every jet they own. I knew what what armament they had, what caliber machine guns, they had, oh, I was prepared to become a technocrat. I didn't I wasn't a believer. At that time. If you couldn't measure it, quantify it. I was able to, to we say figures, not numbers at that. But when my best friend was from a drug overdose, Brandon and I didn't even know he was using. So they told me a lot about myself. I was too self absorbed. I wasn't paying attention to anything around me. And it also told me that it started my search for life, I began to ask those tough questions. Why am I here? What's the meaning of life is going to be this arbitrary? Take me now I don't want this pain anymore. And I gotta tell you, that happened when I was 21 years old. And I've never really had a allow myself to get that close to another individual since then. But what did happen was, I begin to pray for the very first time, and I begin to ask the universe, why am I here? What's the meaning of life? And the answer came back to me in a form that I would understand. I just was in a state of of yearning and wanting to know, and I heard a song that was on our radios, it was called in search of the Third Eye by a man who just play some of his music won won the Super Bowl this year. Roy airs. So this song mystify me search for the third eye, what's that all about? The lyrics were sequence of numbers can be found secrets of wisdom can be found. So this was before Amazon and Google, it took me two years to get a copy of that book. After both are bought the album, read the cover, took me two years to get the book. But once I got my hands on it, it was called in search of the Third Eye by various family order. And this was a book the artists read, who compose the song. So I'm reading the book now, on one from the song to the artists to the book, in the book was talking about the secrets of numbers. And I discovered, I was a number seven. And that the purpose of my life was to study the meaning of life and share it with others. I was like, oh, my goodness, that's what I'm doing. So I realized that there is no greater love that a friend has this is how I rationalized his passing. Because Scripture says there's no greater love than a friend later in his life. So I said, Okay, I'm gonna change because of his passing. And I started going to the Library of Congress, reading everything I could get my hands on, about the sequence of numbers. Now you can go to the library and find 20 books on the shelf. There's even a there's even a numerologist for Dummies. But back in 1972, if you want to read about numerology, you had to go to the Library of Congress and study the journeys of Protagoras, how he went to the Mystery Schools in Egypt and study with the Masters there, who taught using the oral tradition. And then he came back and shared what he learned. And the Greeks became famous. Brandon Handley 8:56 And I love that as it's, um, you know, one of the one of the quotes that you one of the things you're referencing already was something that I believe you found from Pythagoras, right? was the idea that there's a difference between figures and numbers, right? Yes. Unknown Speaker 9:12 And Brandon Handley 9:14 I know you've already kind of illustrated so yeah, absolutely. Right right now on touch touch of the finger, you know, you know, you sent me your book and an email right, I was able to read like numerology information, touch of a finger. I can go to Amazon and I've got something on Kindle instantaneously. Yes, I go download like these great, you know, these great mysteries and, you know, moments as soon as soon as it comes to my mind, but what I think is interesting so far, right? Is that here's this, you know, arbitrary song that plays, right, this strikes a chord for you, and sets you on your path. Unknown Speaker 9:54 Yeah, amazing, right? sequence of numbers. This The only way I could have, I could have even accepted the concept that there was a higher being and that it was influenced my life in any way. And it was a tremendous wake up call, you know, and it came to me, not from some guy up on the pulpit in a in a yellow suit. Gallery, right. It came to me through my own research. In a call a discovery, no one else knew what I was doing, or what I was, when I was pursuing. It spoke to me, it fed me in a manner that I was ready to receive through numbers. It was the only way in for me. Brandon Handley 10:49 Yeah, no doubt, no doubt, right? No, I also gotta imagine like Baltimore. You grew up in Baltimore. Was it the city proper? Or was it the suburbs? Yeah, I Unknown Speaker 11:00 grew up in Baltimore City. Brandon Handley 11:01 Yeah, yes. I mean, you know, city city proper. It's no doubt like, especially in that time to that. It's really a good idea to run around and talk about being spiritual, right? Especially as a male, right, and it's right, and in that city environment. And then, you know, the scientist, you're not even just spirituality or things, you know, easy. Or, then now you're throwing in numerology tonight, you're like, Well, does not just spiritual, but like, let's, let's, let's do numbers, too, right. And I think that that can be, you know, that can that can throw people off to I imagine, just Unknown Speaker 11:39 did Brandon Handley 11:40 levels of acceptance, right, you know, what, what people are willing to accept? And and, you know, so Unknown Speaker 11:46 very true. That's very true. Brandon Handley 11:48 So when did you become a pilot? Unknown Speaker 11:53 No, after my, my discovery, after my friend passed, and I discovered numerology, I became my first client. And I began to, instead of going to the Air Force is setting engineering, I went to seminary, I went to the seminary. I thought that was my calling. But what happened was, once I got into seminary, I discovered, there really wasn't a search for God there. They had already done the surgeon and everything figured out, they wanted to make sure you were saying the right things before you could get their degree. Brandon Handley 12:34 Yeah, that's I think that's the challenge to have spirituality slash religion, right. I mean, that's, I think, one of the one of the reasons for spiritual dope, right, the podcasts? Because, like, let's, let's have a conversation about spirituality that isn't previously dictated to us as whether or not this is acceptable or not. Right. Exactly. And so you found you found that they were just trying to dictate to you, you know, here's the right way to say it. Right. Is that is that kind of what exactly, Unknown Speaker 13:05 that's exactly right. I was getting good grades, because, technically, my, my writing skills and my, my research was spot on, they, they could not deny what I was saying, I was finding evidence of reincarnation, I was finding evidence of numerology how every time the number 40 shows up, for stands for order, and zero is a symbol for God. So every time a number 40 show up, God was establishing a new order, 40 days and 40 nights of rain, 40 years of wandering in the desert. And each time that number precipitated a tick or change, that God was bringing a new order, so that I was getting good grades, but I was very uncomfortable there. Because it was like swimming upstream. So Brandon Handley 13:56 one second real quick there, cuz I've been, I've been on the number 40 for like, years now. I'm like, what, because it's always showing up, just like he said, I'm like, there's gotta be something, right. Like, there's got to be something because there's 40 days, 40 nights, there's, you know, the, the whatever, but I also call it to age, like, when we turn 40 like, there's a massive shift, right? Like, you know, there's a massive shift and kind of who, you know, a lot of us are and and i think that you know, 40 is illustrated in my take on 40 has always been like, you know, these are the signals like it doesn't always have to be the ages and years but also kind of what you know what you're saying there's numerology, numerology there, but in my mind the most well, that's just like the signal like age 40. Like, you know, you're gonna ask, I'm really serious, right? Yeah, something's gonna change in 40 days and 40 nights, you know, be ready, you know. So that's really interesting. Thanks for thanks for sharing that. It's been on my mind for literally a few years now. So thank you. Unknown Speaker 15:00 So my body was I called a picture. That's right. That's spirit, isn't it? That's it. That's it. So for us, they asked for order. If you think in terms of Adam being one is being too with one or two fit together, there's tears, there's three, right? So you can't have a kid crawling around. So you put them inside the playpen, so forth sided figure. So you have some order you get your work done. Unknown Speaker 15:24 is great. Brandon Handley 15:25 Yeah, I love you know, so one of the things I love about, you know, finding and establishing a pattern order, and you're doing it with like numbers, you you, you begin to, you begin to apply it anywhere, right, you get a you get a certain kind of set of knowledge, and now you're able to apply it and in so many different facets, that without any of that knowledge, you can't, right. So you know, that's Unknown Speaker 15:48 exactly right. Yeah, especially that number for the 40 minutes, when it comes to a home, fixing, mending and repairing. So whenever my clients contact me with an address, like 2102, number 1921, apartment B, I always tell them to avoid a house with the number four, unless they're prepared to do a lot of work on it. And a lot of renovating it, keeping it a Brandon Handley 16:16 you know, keeping it a casino because it's a good one to keep in mind as I'm in moving to my next place here shortly. So I'll keep in mind that to keep the number four out of the equation. For sure. So, you, you know, you took this kind of, um, you know, even at the age of 21, coming out of Baltimore, young excited, man, I gotta imagine, like, you know, even spirituality, right, like, that's still tough grab. And so you follow through seminary and into what just trying to follow the journey? Unknown Speaker 16:51 Well, seminary didn't work out too well, for me, I just, I was just there one semester kereta a 3.7. But um, after that, I started going to the Library of Congress and studying on my own, studying the information that I was being called to. It was just fascinating. He was like, it was food it was, it was the answer. It was what I was looking at before. And it was telling me all the questions I had while I was here, what I was supposed to do, and I was studying it and learning from it. And after a while I started getting clues from source to share. I will be in a checkout line. And I will see someone's name on their on their name tag. And I will hear information. If I read in a computer, I will hear information about I can't hear you information about it. I'm gonna share a little later, but this is how it started to happen. And and I wouldn't, I didn't know what it was, I was afraid. So literally, I heard a voice tell me you have the gift of discernment do not wish I had to go look it up. I didn't know what this tournament meant. So I had to go look that up and say, Okay, I'm going to be getting some information from from what I've been studying now. Now I've reached a certain level, now the university is going to start using me. So my heart's pounding a little heavier. Yeah, because it's not only about me, I'm being asked to share information. So eventually build up enough confidence to start doing that. I would tell someone Whoa, I know, you've been waiting for money a long time it's gonna be it's gonna be in your mailbox. You know, things like that, you know, in the checkout line, or whatever, way fast so nobody would know who I was or anything like that. But I had to come back the next day was to buy some milk, but it was Hey, how did you know that? You arrived I was there. So that's how the birth started getting about this guy knows about now but so people started contacting me. And I didn't I didn't know what to do. I didn't have any services, anything like that. I just share information with you. So Brandon Handley 18:54 so you know that two things. Two things there right? Well for I love the idea, right? Hey, universe is gonna start using me right? Like I mean, just so you set yourself up as a as a vessel, right? You set yourself up as a conduit and we talk a lot about like, you know, receiving we talk a lot about tuning in and all that kind of thing, but it sounds to me like you just you know you you allowed right and and you let it he let it coarser you so I think that's pretty cool. And you know, second part, like you're talking about right now, just thinking you didn't we didn't have what we've got right now. You couldn't you know, your credit, you couldn't go back there and spin out spiritual dope back then. Right? Because you had like a street corner like maybe unspiritual dope was that corner that block, you know, so? Yeah, tell me a little more about the time. Unknown Speaker 19:52 So I'm continuing to listen to the radio station. It was it was a College Station Morgan State University. Radio where I heard the song in search of the third. So I'm continuing to listen to the station. And a lady comes on the station a Reverend Hazel caselle. And she has a radio show. So he is teaching classes about spirituality. I said, Oh, I needed to learn some more about this. So I went to visit her. And I'm talking to her about a class. So I'm getting ready to leave her office. And she says, aren't you going to tell me about your gift? I didn't say anything to this lady about numerology or any special gift. But she has psychic abilities. And she says, I'm seeing numbers around you. You haven't said anything to me about it. So I gradually came back to the opposite said to and I started sharing with her what it happened, what my experiences was. So see if I knew her or her radio show. So okay, I'll come on your show talk about numbers. So people calling in giving their name and their birthday, I'm doing readings over the over the over the air. And at the end of the show, she gives out my phone number. Well, I guess I was kind of naive. Now I expect to give out my number and my website. But not this first show. I'm just sharing my gifts. And she gave out my number brand. And people started calling me my phone off the hook. I had to go back home and create services. Well, this will be a reading and I'll call this a forecast and to meet the demand that that that people wanted to know. And that's how I got started. Yay, a numerologist I did not plan it. I had never heard of it. It just happened and I really feel like it was my calling. And and that is why I'm here to be of service to God to share information about about these numbers man is so fascinating. And so complex yet it's it's all around us. Right? It's like we come with a owner's manual. Like when you buy you buy a new gift or you get a any type of product. You open it up it says here's the owner's manual read this first name on our birthday. We're totally blind to it, you know? Sure. Brandon Handley 22:05 No, no, it's Yeah, that's you know, he was always walk around be like, well, we didn't come with an owner's manual. Now you're telling us that we do. So they have to dig into that. Right? Well, I was asked to dig into that. So, you know, you've been able to sustain through numerology is my question, then, you know, have you been able to kind of like make make make your living out of out of this practice? Unknown Speaker 22:30 It's interesting. It started off there were no, okay. No, it was a labor of love. Like I said, I didn't reach out to start a business. It was only people contacting me for my services, and my hallways was was doing something else with this was sort of like a vocation. But as time has gone on, when I was 21, I eventually I ended up having a show on sa radio show that I would say radio station, I was listening to doing a numerology report. So over time, I would give classes announced workshops, nobody would show up. Nobody will show relevance place. Zero. But now, yes, workshops. been teaching at the local community college. One of the people heard my show in a radio was a program director at a community college in Baltimore County in the asked me to create a curriculum to teach numerology and make it available. That's true. Things have really changed his math, t 72. Brandon Handley 23:49 A couple things, a couple things have changed, for sure. Things have changed. Unknown Speaker 23:57 I love how you say things like that. I told you, I was picking up things for you too. And what I picking up is global, a global impact. That's what I'm picking out that. I don't know if you can translate your show into other languages. But I'm picking up your impact is is going to be global. And people from different cultures from all around the world are going to start tuning in to your show. And and what you write new habits. I know you didn't tell me you were an author or writer. But I'm showing up and picking up your writer is something you write has a potential to go to the big screen. Brandon Handley 24:36 Mm hmm. Well, I don't know what I'd write that would go to the big screen. But you know, there's still plenty of time. You know, I love the idea though. And thanks, man. It's really interesting. I was just talking to talking to somebody this weekend in New Zealand to get connected with somebody else who's you know, got some global initiatives and here's the thing Being able to have that conversation. So, you know, yeah, like, I got like little goose bumps and like, my hair is rising up over here. So on the different cultures, right, that's what this is about. It's, it's, it's not about, um, it is about is exactly what it's about those different cultures if you look at if you look at the graphics for spiritual dope, you see, you know, Jesus figure there you see Buddha there, and my original one had a, you know, Shiva on there, right. So it's just kind of like, you know, we're all saying the same things we've all got, you know, how do we light this fear up within us? How do we how do we, how do we honor it? Right? I think that's one of the first how do we recognize it? How do we honor it and how do we allow for it to bloom right, what do we do to cultivate ourselves? Right and and nurture that and and share it, but now so so thanks, man. That's it. So is that is that done through numbers or just straight vibing? Unknown Speaker 26:02 Well, I think straight vibing led me to numerology. I'm listening to the song doing the research on pursuing holding a my consciousness because I believe the mind is so opposed to see. And what we're co creators with the universe. sparks from the big flame, if you will. And by holding it in my mind, it just manifested that book. That book showed up in a bookstore in house and there was only a business for a year and a half. Unknown Speaker 26:32 That's crazy. Unknown Speaker 26:34 Okay, universe put that stood there for me, right. But yeah, I think i vi, to numerology, but after that, I just began to study it and apply my skills, my technical abilities. So there's so much they give me their birthday. And I can edit out real quickly, because I'm used to formulas and things like that. So math does math doesn't frighten me. So I can look at an a tag editor, convert the letters to numbers and give someone a reading within seconds just because of you know, the, the pathways, the mental pathways I created by studying math and science. I didn't know I'd be applying it this way. Yeah. Yeah. Brandon Handley 27:19 You never you never know how it's gonna strike. Right? So real. If this is okay, you know, so it's my wife's birthday. Next week. Can we can we do her? Do her numbers? Yeah. So. So what do you need the whole year, month, date and year? So March 16 1974. Unknown Speaker 27:43 Okay, Okay, awesome. Eat number in the birthday represents a gift. Okay. Then if you add it all up, you have like the ultimate gift. So I like to think of it as a contract with creator in these closets. The first clause is the number three. And the three is a symbol for expression, and you singing, painting, dancing, writing, anything artistic, decorative, colorful, is also a symbol for abundance, because the story of the Christ is about the number three, he was taught by three wise men. And there's a lot of other references, but we know he arose on the third day. That's Easter, I left a lot of about for the sake of time. But when asked Massa, why are you here, he says, I'm here to have life and have it abundantly. So the three stands for abundance. So your wife gift is to always appear younger than she is. If he's in a room and children are there, they will be drawn to her like a magnet. She's extremely creative, in terms of her artistic talent and ability. And you may have channels getting a word and once he starts to communicate, because threes are expressive, okay. Now, I'm going to skip her day for a moment because her year is also a three. If you add one plus nine plus seven plus four, it adds up to 20 119 is 1074 is 1110 1011 is 21. Are you with me? Unknown Speaker 29:25 Because I'm tracking? Unknown Speaker 29:27 Absolutely Did you add two plus one, that's also with Ray. So he's got a double dose if everything that I shared with you about the number three, full abundance, social activity, mixing, working with children, being an artist creative, seeing the penny dancing, writing a double dose of that. Now her date of birth is a seven, one plus six is seven. That's the number of face. On the seventh day God rested. So as social as she is There's going to be times she's going to be by herself. It's almost like what happened? Did the cloud come over to set on? Where she go? Right? What what? Because it's the exact opposite of the number three, which makes her social. So her rhythm will be to introspect, and then to project to interest, fat, and then to project because the seven makes her a minister, does it matter? She goes to school, where's the row? Seven is the number of faith. So she's a mountain mover. Okay? She's a researcher. That's my number. The number seven so sees a researcher and analyst or thinker, does he take things at face value? Oh, she goes deep. She is the reason why you are walking that straight line. If I write about the man, Maria, number seven female, okay, you don't have to worry about being going astray or doing anything wrong, because she'll sense it before even comes to your mind. My wife was a number seven. So I can't even dream about doing anything. I mentioned you might be a writer, your wife is definitely around this. About the book, hobby. Okay? hobby, okay, this is your second letter as a two, oh is a six because the 51 five or six, that as the 14, a K is to the left of ladder. One plus one is two. So the word book vibrates to the 16. So when you see the 16 Not only is he a researcher, but she has the ability to communicate it. So she's writing has a potential to write lecture travel a share her expertise. I don't know what her expertise is, okay, numerology does it, box her in. But that seven tells me whatever she does, she's the expert, a people will seek her out for her expertise. It also tells me she's so creative. Her main challenge is to follow through. To follow through completing projects is going to be a task. Because her creativity, so delegating is important. Now let's add it all. Okay, so that those are the clauses in her contract. Craig, real quick, Brandon Handley 32:32 I lost her picture. Can I get you to come back? Oh, sure. Sure. I Unknown Speaker 32:36 don't know what happened here. These are the gifts that God gave her. Okay, that I just shared with you, the creativity, the mental ability to analyze. So if we add it all up, is three plus 16 is 90, which tells me as a numerologist. She left the house as a child, she got out of the house as fast as she could. It was quit out of there, man. And it was someone in their family who tried to keep their keeper under their thumb. But she said find them because that spot her originality and her leadership that brought it up. But I digress. If we add 19 to her a year, which is a 21 guess what 19 to 21 add up to Brandon Brandon Handley 33:23 Is that right? Unknown Speaker 33:28 42? The number 40 see Unknown Speaker 33:31 that crazy number, right? Well, Unknown Speaker 33:33 you're right, plus 16 plus 21. Three plus 16 plus 40. So your her death is the orderliness of God. So he embodies it to wherever she goes. That's the energy that she's taking with her. So people are going to call her mean stubborn and strict. Brandon Handley 34:00 I mean, I don't know if they would say to her face, Unknown Speaker 34:04 probably a bad idea. Unknown Speaker 34:07 Also, as a number 40, when you guys have entertainer has gas, after they leave, you will find her going around the house, putting things back in their place where they belong. So orderliness is very important to the number 40. As his eyes are numbers, he's probably extremely good with numbers. Well, she Brandon Handley 34:28 will tell you, she's not but most you probably, you know, it's one of those things right? It's what you tell yourself. It's what you tell yourself, right? Unknown Speaker 34:36 That's the number four. The fourth book in scriptures is called numbers. So people four is always concerned with measurements and things like that. So you get involved with numbers when you do research and studies and things like that. So right. And I will also share with her that this year was as a 223 is going to be a year of said numbers. 1923 is 42. This is a number six year for her. And number six year, so she's going to have a chance to use her creative talents, skills and abilities this year, she couldn't have a chance to join with others in some goodwill projects, they're going to be reaching out for her to to work together in a goodwill project. And a lot of people do get a new home in a number six year, so the focus is on the home, and the six year domesticity the whole community, in your relationship Brandon Handley 35:46 towards fun, right, that's a lot of fun. That's, that's great. So thanks. Thanks for doing that. Unknown Speaker 35:50 It is a love vibration. Brandon Handley 35:54 Well, that's awesome. So you know, so you kept at it, and you feel like, you know, what was it like, I guess and you know, kind of communicating this as your primary path to like your friends and family? And how long did it take you? So how long did it take you? You know, to? To even feel confident to do that? And were you scared to do it? Unknown Speaker 36:17 Well, with my immediate friends, I went to right away after losing my friend to that drug overdose. I wasn't taking any chances on quoted back any information that I now have revealed to me about them, because I knew that he burned things. So I started sharing information with them. Many of them were receptive. But some of them ran away, they became afraid not because the info meishan wasn't accurate. But because the information was accurate, on and they felt. And now before they were invisible, now I knew everything about them. So people started running away from me, not because it wasn't true, accurate, but because they didn't want to stand in front of an X ray machine. Sure. For sure, but then there was also the other side of the coin. And people thought I just lost, I thought I just lost my mind and flipped out. And that what I was doing was actually something demonic and evil. So I took that this spirit said, what do you what do you have me doing here? Look him, he told me this. This is where I'm supposed to be doing. I'm trying to share it. So spirit told me I wasn't ready yet. I was, you know, going off too quickly. That to continue the study. And when the time was right. God told me he would bring his leaders to me. So it wasn't a type of thing where I could get on a hit a brass, hit the symbol and advertise and put it up in the lights come to me Come to me. I had to be patient and wait in study and to be prepare to prepare myself for the time when God was going to start sending people to me. So that's what I did. I just zipped it up, it started studying. And the people who found out about me found their way to me. I had prepared my services now. And it wasn't a a wide stream of clients. But when they came I was I was ready for them. And I knew they were leaders, right? That they were leaders and it hasn't changed. You are a global leader. The name brand is a number 32. And that's America's birthday, July the fourth 1776. And the number 32 shows up in all of America's leaders in George Washington's bow total. And Barack Obama has showed me showing up in your first name. The number 32 is called the ruler of all nations and people. And because I studied that, that's how I know you're going to have a global impact. Hmm. So this is why you're starting to meet people from other countries. And sooner or later you will have a network all around the world because that's that's what you came here. That was your contract. Promise creator that you would impact the planet. So you may not be telling other people that's your goal. But that's that's pretty much what the universe has planned for you. Your last name Handley the valtos a number 13. So I want to talk about that people are so afraid of the 13 branded, they won't come outside on Friday the 13 people are terrified, for sure and for good reason. The 13 is all in Nothing is an all or nothing type vibration. And what it stands for is change, release and transformation. So it does mean death, but not how we think of it. Because we are spiritual beings here for a temporary spell, what we call it death is simply returning back to our original state. Sure, is the transformation. So the 13 stands for change, release a transformation. And when it shows up in your name the way it does for you, it means you came here to be part of the transformation that's taking place. We've heard songs about the Age of Aquarius. Well, by golly, we're in it. Brandon Handley 40:46 Where are you? Yeah, and you know, I'll throw it out there too. I am an Aquarius to say, Unknown Speaker 40:50 wow, you Brandon Handley 40:52 know, I'm all in right? Like, I mean, do I need any other signs? There's something that I'm missing. Change, Unknown Speaker 41:02 right? It's transition. So when people meet you, they'll be transformed. The 13 is represented by the butterfly star. So calling around is that with wings fly, save energy save manager now, but also the Phoenix that goes down in flames and then rises from the ashes. So people should never count you out. Brandon Handley 41:33 That's I mean, it's great. Right? I love I love both of those. Both those symbols, right? We always we always look at you know, the caterpillar. And then you know, going into its cocoon, and just totally eradicating what it was before getting into a big new mass of goo. And then coming out like this beautiful thing, right? So always love that. And same thing with the same Yeah, Phoenix is always a great story to write down to the ashes and reborn again, and into something more beautiful than it was before. And you know, as they say, powerful, but you know, powerful than more, you know, but maybe, maybe, you know, it's funny, I just shared the quote, that, uh, that kind of speaks to how I felt like upon like, my awakening, if it were as it were, right. I was like, I don't know what this power is. But I know that I'll figure it out. Right, I'll work towards figuring understanding it right. And that's me, just kind of right. The the Phoenix has probably always been that capable, but it wasn't until it was down and out that it's got to strike forward and search for it and, and come into its own power. Unknown Speaker 42:45 Awesome. Awesome, man. Awesome. So most people, most people give up at that point. Most people, they, they check, you know, they turn to different escapism where they just hold on and go through that pain. You know, it's it's the old Coke is the old say, but no pain, no gain, you know, is this what you grew up? A farmer has to break up the soil before we could plant a seed. Brandon Handley 43:18 No, hey. Yeah, absolutely. Absolutely. And I see that 100% the other thought, you know, and this is recent, recent one, the mean just just a quick exchange of of, you know, quotes and whatnot and thoughts on this. But there was, um, there's a lady that I listened to system or her meditations and, and just talking about pain as as a as a gateway to the divine, right. Unless we unless we allow ourselves to actually feel that pain and said that we continue to most of us shove shove pain away, right though I don't want to touch it, it hurts to keep that away. But if we go ahead and accept that pain, and feel into it, and we realize the power that's within that pain, and I don't know if you transform it or just feel it right and be okay with it, but a pain is also a gateway to the divine. And so I recently just kind of you know, that did it hit me. So what are your lines here and Craig, this has been awesome. I'm really enjoying it. And I know that you know, the audience will as well. But I love the line that you've got on on your website says I use my gifts to help I use my gifts. I use my gifts to help my clients understand themselves as spirit by journeying within we can discover a higher self higher purpose and divine well. Now is that from scriptures, that's something that you kind of came up with on your own just a curiosity there. I love it. Unknown Speaker 44:39 I notice that something I came up on my own just over over time over the years people asked me the question, you know, we do was was it about was it four? Right? So that's, that's what I came up with. I realized that, you know, the body is a temple of the spirit and we're We're not physical beings, we have an occasional spiritual experience, the awakening is oh my goodness, we're spirit inside this this vessel by hand. So with numerology, I'm able to enable to share with people who they are in terms of spirit in terms of energy, so they can see themselves that way. because very few people will come up to you and talk to you in those terms. You know, they're talking about What school did you go to what car you drive when you work, you know, how much money do you make, but not what's your contract with God? What do you do earn your body to when you book your trip? Brandon Handley 45:41 No, no, that's absolutely, absolutely. And so, you know, one of the things that, actually, so I mean, it's almost like, here's a UPC code on everybody that walks by, right, you got like, you got a scanner, they listen, let me tell you about you. First of all, these these ingredients are, you know, anyways, the idea is that to you know, in your book, you spell it out a little bit. It's not just to learn kind of numerology to figure out who you are, and just your kind of divine contract in your book, you also illustrate how you can determine relationships that, you know, beneficial in you know, you know, in matchmaking for sure, and like, you know, kind of find my next significant other, as well as you know, how things will work out at jobs or what what are good job fits, maybe give me like one or two scenarios, I know you listed out for my wife, Meg, you know, the number three, or was it number 16? Number, the book and being able to be a writer? What's like, Unknown Speaker 46:49 like, what's your date of birth? Brandon Handley 46:51 My date of birth is 125 1976. Unknown Speaker 46:56 Okay, so you're also a seven, your wife is born to 61 plus six is seven. You're the 25th to plus. And it just so happens. This is crazy. You are both savage in compatibility. In my book starts on page 77. By case you Unknown Speaker 47:29 I'm going to share with you what it means when two sevens, okay? to service. Now, this is in your day of birth sector and the day of birth and the compatibility report. Is the canvas for the relationship. No, it's not. It's not a it's the weakest energy really, when you're doing compatibility. Like if you go look at two artists, you go to a museum, look at a painting, you know, but the canvas is important, right? Canvas is important. Unknown Speaker 47:56 So Unknown Speaker 47:57 here's number seven, and number seven compatibility, and my book is on page 102 sevens. Silence is so much peace exists with this combo. On the seventh day God rested. So there's silence, there's peace, there's non verbal communication, there's no way without even speaking, okay, Unknown Speaker 48:19 we're definitely there. Unknown Speaker 48:24 This could be a couple who miss as hermits, or older friends or civilization and blissful solitude surrounded by nature, she herself is likely to be away from it all. Very spiritually inclined to sevens. But who's going to pay the bills, if both are lost in the world of thought, see that we got Unknown Speaker 48:51 that we got that from Unknown Speaker 48:55 very eccentric unit, with each being absorbed in their mental interests. So that's a couple of sevens there, right? When added up your wife's month, day and year, it added up to the number four. Now that's the most important number in a compatibility chart, the sum of the month, day and year. So for you, it was 125. There as of the 26th. So your gift is leadership. The number one, everybody knows that. I talked about faith aspect of, of spirituality being a researcher and analyst or thinker your year as up to 23 1976 is a 23. Okay, this happens a lot. I start I have one in kitchen and spirit kicks in. I don't know why the camera keeps going up. Spirit is telling me to share this with you on you're going to have a business and have an opportunity to hire your family. That's showing up family entrepreneur. vibration shows up in your chart. But I digress. This happens a lot. I have an intention, but something come in from the Brandon Handley 50:09 universe. Where does that where does that where does that come from? Is that coming from a number or is that coming from a vibration? Unknown Speaker 50:15 It's coming from the number, your month is a one in your year is a 23. Okay as up to 24. And that's called the family entrepreneur vibration. Okay? The family entrepreneur vibration, of course, is showing up in your chart, starting your business and hiring your family. So as I said, I digress it off, this happens in the house, I have an intention, the universe will say okay, while you're open, share this. I wanted to share that with you. So your mother today is 2424 25 is 49. So not only do your your birthdays match, but he's a 44 plus years for your 44 plus nine is 30. There's a 13 again, right one plus three is four. So you match not only do your days match, but when I have your muffin here that matches man when you when you took one look at her the earth must have shook Unknown Speaker 51:26 there's no doubt in your mind because you guys. So for for for what does that mean? I share seven seven nonverbal communication. Two fours both are very fixed in your point of view, and somewhat stubborn for us. Okay. Okay, realized material conference and business success. This is a workaholic combo that might put too much energy into working in building. Unknown Speaker 52:09 Right not have fun. Yeah. any conflicts will be around budget or time issues. Because four is orderly. So there's budget and time issues. Here, he should have their own bank account. This is a great business combination. So if you come to me seeking advice, as a couple, that's what I'll be telling you. Right. Now other when it comes to time, and budgets, because it was about keeping the trains in order, making sure everything is growing. I'll tell you about the number four. You see when a plant a new tree brand, and they put spikes in the ground with that Robert wanted to hold it in place. Yes, sir. Before energy. Right. To the left, but it gets a good root set. Right? goes up tremendously. Education, pending it without those bikes, right. The tree is saying you're stubborn, you're me. You're strict, even though you're saving the tree lives, right? When people are complaining about you being stubborn, or mean or strict, that's when you know you're on your job. Brandon Handley 53:43 I'm here, I'm here, sir. And I'm doing my contract. I gotta Unknown Speaker 53:47 make sure whatever gets off the ground. It manifests because God created Earth on the fourth day on phase commit the physical manifestation under your energy, Brandon. So were other people have ideas and dreams. You had the ability to make your dreams reality. Brandon Handley 54:11 Well, thank you, man. That's, that's, that's awesome. That's awesome. That's a ton of fun. It really is. And I know you do so much more to I didn't even go over all your credentials for the audience putting out just just so everybody understands this, you know? You've got Reverend Dr. Craig he right PhD, right PhD in metaphysical counseling metaphysical science metaphysical science. You know, Minister, metaphysical practitioner, so, you know, this isn't obviously it's not news to you, right? And you've actually taken the time to go and and to an actual school and get, you know, educated in this material, whereas you probably you know, you probably didn't need to you probably found out most of the stuff or a lot of it on your own But you, you put forth a lot of extra effort. So I really appreciate you reaching out to me and being here today on the podcast sharing just a small amount of what it is that you do. And even this, this whole conversation has been very impactful for me. And it's been a lot of fun. So, you know, if somebody else wanted to reach out to you to get this kind of service, where could I send them to, to connect with you? Unknown Speaker 55:27 Well, they could visit my website, and they could see all the services that are available to them. And that website is www dot. Craig he right that, that c r AIGEW rI ght.com. Brandon Handley 55:48 Awesome, Craig, thanks for being with us today. Unknown Speaker 55:50 Thank you, Brandon. Transcribed by https://otter.ai

In this episode, Associate Professor in the Doctoral Program of Physical Therapy at Rutgers, Dr. Ellen Anderson, talks to Dr. Stephanie Weyrauch about burnout in physical therapy. Today, Ellen talks about her dissertation on burnout, the distinction between normal stress and burnout, and how these markers of burnout fit into the anecdotal accounts of burnout seen in blogs and magazines. Why is data so limited on burnout in physical therapy? Which settings within physical therapy experience the highest rate of burnout? Hear about the many factors impacting the number of therapists affected by burnout, how Covid-19 has affected recent graduates and students, and the causes of burnout, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “When people work with people who are in crisis, there are a lot of demands placed on them - very different than in other kinds of work, for example.” There are 3 categories in burnout: Emotional exhaustion. Depersonalisation. Personal Accomplishment. “When we think about just being stressed out, it’s hard to know what that means because everyone’s stressors are different.” “If a physical therapist has high perceived stress, that’s correlated with emotional exhaustion, which is a part of burnout, but not the full definition of burnout.” Researchers have suggested that there’s 2 ways to look at burnout: The Personal Approach. Make the person resilient, and they will be able to handle any kind of environment. The Work Environment. Make a nurturing environment that’s conducive to good work, and supporting people who are in crisis, then you’re supporting the workers and you’ll have less burnout. “Younger physicians have higher rates of burnout than do older practitioners.” “When people in healthcare feel as though they don’t have control of the situation, or they cannot contribute to good patient care, effectiveness, and efficiencies, that the burnout rates are higher.” “There needs to be an understanding on how stressful and difficult it is to work with people who are at risk and people who are in crisis.” “We need to be thinking about ways in which physical therapists can have some participation in systems that supports everyone in that work environment.” “One of the things that’s very detrimental when people share thoughts and ideas, is that the first response they get is ‘we cant’ or ‘no’ without any kind of real honest investigation into the suggestion or recommendation.” “Breathing practices and meditation are two strategies which help people be able to manage their stress effectively. The idea is that you practice those things so that when you need it, you can use it.”   More about Stephanie Weyrauch Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company’s workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation.   More about Ellen Anderson [caption id="attachment_9555" align="alignleft" width="150"] Rutgers School of Health Professions in Newark. 11/7/16 Photo by John O’Boyle[/caption] Ellen Zambo Anderson, PT, PhD is an Associate Professor in the Doctoral Program of Physical Therapy at Rutgers, The State University of New Jersey where her primary teaching responsibilities are in Therapeutic Exercise, Development Across the Lifespan and Clinical Inquiry. Dr. Anderson, a Board Certified Geriatric Clinical Specialist, earned a BS in Physical Therapy from West Virginia University, an MA in Motor Learning and Control from Columbia University and a PhD in Health Sciences from Rutgers University. She is the Assistant Director of the Rutgers Community Participatory Physical Therapy Clinic, a student-run, pro-bono clinic in Newark, NJ, and serves as the Special Olympics Global Advisor for Young Athletes. Dr. Anderson is the co-author of the textbook, Complementary Therapies for Physical Therapy: A Clinical Decision-Making Approach and has spoken internationally on physical activity, mental health, and complementary health practices. She is also co-owner of YogiAnatomy, a company that provides continuing education for rehabilitation professions on topics related to complementary approaches for managing well-being, health and function.   Suggested Keywords Physiotherapy, Research, PT, Health, Therapy, Healthcare, Education, Training, Stress, Burnout, Wellbeing, Mental Health, Stressors, Support, Covid-19, Exhaustion, Depersonalisation, Accomplishment, Environment,   To learn more, follow Ellen and Stephanie at: Website:          https://stephaniesandvickweyrauch.academia.edu                         https://ptsmc.com/stephanie-weyrauch                         https://www.yogianatomy.com Facebook:       Stephanie Sandvick Weyrauch Instagram:       @thesteph21 Twitter:            @thesteph21 LinkedIn:         Stephanie Weyrauch                         YogiAnatomy   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript:  Speaker 1 (00:07): Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Hey everybody. Speaker 2 (00:37): Welcome back to the podcast. I am your host, Karen Litzy and today's episode. We have our good friend of the podcast back, Dr. Stephanie Y rock, and she is interviewing Dr. Ellen Anderson all about burnout in the physical therapy profession. I'm not going to go into Dr. Anderson's bio because Stephanie reads that in the beginning of the podcast. We don't need to double up on that, but what you're about to hear, I'll give you some highlights is they talk about the three categories of burnout and does the research definition of burnout jive with the anecdotal accounts of burnout that we see on blogs and podcasts and things like that. They also talk about the difference between stress and burnout or perceived stress and burnout. The main causes of burnout in physical therapy, how COVID is affecting burnout. And Dr. Anderson talks about some things that perhaps you can do as an individual to help with your perceived stress. Speaker 2 (01:41): And she hypothesizes on some things that perhaps some businesses, some physical therapy businesses can do to help their employees with stress and burnout. So thanks to doctors why rock and Anderson and everyone enjoy today's episode. Hello everyone, and welcome to the healthy, wealthy and smart podcast. I'm your guest host today, Dr. Stephanie, why rock and, or once again, going to partner with the American physical therapy association, private practice section to discuss a topic that has been in the forefront in healthcare and that's burnout. This is an especially relevant topic. I think as COVID-19 pandemic continues to rage on, and I've actually been asked to write an article for PPS impact magazine on this. And so when I went to do some research on this topic, I of course found a lot of blog posts and opinion articles by physical therapists throughout the profession on this topic, but was really surprised to find that there's really not a lot of research in physical therapy on burnout. Speaker 2 (02:50): And I was surprised by that because it's so frequently discussed in our profession. So eventually my literature review led me to our guest today, Dr. Ellen Anderson. So Dr. Ellen Zombot Anderson is an associate professor in the doctoral program of physical therapy at Rutgers university in New Jersey where her primary teaching responsibilities are in therapeutic exercise development across the lifespan and clinical inquiry. Dr. Anderson is a board certified geriatric clinical specialist and earned a BS in physical therapy from West Virginia university, an ma in motor learning and control from Columbia university and a PhD in health sciences from Rutgers university. She is the assistant director of the Rutgers community participatory physical therapy clinic, which is a student run pro bono clinic in Newark, New Jersey, and serves as the special Olympics global advisor for young athletes. She's the coauthor of the textbook complimentary therapies for physical therapy, a clinical decision-making approach, and has spoken internationally on physical activity, mental health and complimentary health practices. She's co-owner of yoga, Yogi anatomy, a company that provides continuing education for rehabilitation professions on topics related to complimentary approaches for managing wellbeing, health, and function. So thank you so much Dr. Anderson for joining us today on our podcast. And again, I read your dissertation and I've, I found it really interesting that you decided to tackle burnout for your PhD dissertation. So maybe summarize your dissertation a little bit, tell our listeners a little bit about yourself and how you became interested in this area of research. Speaker 3 (04:38): Okay, great. Yes. It's a pleasure to be with you, Stephanie. Thank you very much. Initially I became very interested in complimentary therapies and through the work that I do with my colleague, Judy Deutsche, where we published a textbook in that area, I was interested in the application, the safety and the efficacy of complimentary therapies for patient populations. And that got me to realize, or helped me realize that there is a fair amount of data that suggests these complementary therapies can be useful for our patients, particularly in the areas of mood reduction of stress, as well as reduction of pain. And so that got me thinking about using approaches such as Reiki or yoga, meditation, breathing practices for self care as well as patient care from that point. However it was determined that we really didn't know what stress was in physical therapists or what burnout is in physical therapist, because as you've identified, a lot of people are talking about it, but there hasn't been a lot of research in that area. Speaker 3 (05:57): And so I started to embark on trying to get a handle on what is the stress and burnout in physical therapists. My focus took me to burn out. And the reason for that is because burnout was defined by fruit and burger back in 1975. And it was based on his observations in working with healthcare providers. And what he observed is that when people work with people who are in crisis, there are a lot of demands placed on them, very different than in other kinds of work, for example. And he began to categorize some behaviors that he saw in people who were becoming more and more stressed. And then it was Nass latch who developed the mass latch burnout inventory. And so what mass latch did was kind of support the observations of fruit and Berg by saying there are three categories that we need to look at in this thing called burnout, that there's emotional exhaustion, there's depersonalization and there's personal accomplishment. Speaker 3 (07:16): And so when we think about just being stressed out, it's hard to know what that means because everyone's stressors are different. So what stresses you out is different than what stresses me out, you know, when you kind of come to your work with a certain constitution about what keeps you even keel and what are your triggers? The burnout goes a little bit further because it's not just emotional responses. And in this case, emotional exhaustion is that sort of physical, mental exhaustion that many people might be feeling. That's just one part of burnout. So the next part of burnout is this deep personalization. And what that means is that you kind of begin to separate yourself out from your patients. And there's this phenomenon of, of I'm sick of thinking that the patient is to blame for their problems. You know, so they brought it on themselves and some psychologists and researchers suggest that perhaps this deep personalization is really kind of a protective mechanism because you're dealing with people in crisis all the time. And then you have the personal accomplishment and that's where you feel like your, a rat in a, in a maze or in a wheel. And you just keep going round and around and you ask yourself, finally, what am I doing this for? Am I really making a difference? So the, the, the curiosity for me is, was understanding the D the difference between just job stress and burnout, and that physical therapist in fact, would fall into a category of people working with people who are in crisis most of the time. Speaker 2 (09:28): I think that that's really interesting that, you know, we have a defined a true research definition of burnout. I'm wondering what your opinion is on how this definition fits with these anecdotal accounts of burnout that we're seeing in some of these blog posts that people post or that TA magazine has been posting about regularly. Speaker 3 (09:50): It doesn't really jive a very well, to be honest with you. So when, when I see comments about burnout, I just say to myself, well, people are stressed out and, and we should honor and respect the fact that people are very stressed out. That burnout technically from a research standpoint has a different definition. And what I found through my research is I did study and survey physical therapists, both using the mass latch burnout inventory, which has the three part, but I also included the perceived stress scale. And so the perceived stress scale, I think, is a very valuable tool because as I mentioned, previously, stressors for you are different than stressors for me. And the perceived stress scale has been used in thousands of studies. And it's looked to be sort of a gold standard if you will, to get a finger on the pulse of people's stress, because it is about perception of your stress. Speaker 3 (11:04): And, and so what I found in my, in my dissertation was that all, although physical therapist had better perceived stress scores than the national sample that I compared it to, there was a relationship between a high perceived stress score and burnout especially in the category of the emotional exhaustion piece. And so what we, what we saw was that if therapist had high emotional exhaustion, they were seven, seven times more likely to actually have burnout. So let me tell you what burnout is. According to those three parts is if you do the burnout scale, and you're very high where you're high in emotional exhaustion and you're high in deep personalization, and then you have low professional accomplishment, you fall into the category of burnout. And so what I found was that 29% of PTs are high in emotional exhaustion, and that is consistent with what people are talking about in the blogs related to being stressed. Speaker 3 (12:27): Okay. The other thing that I want to know is that in a lot of studies that are being done with physicians and nurses with burnout, sometimes the headline is 50% of physicians have burnout. And what they did was that they used the burnout scale, but they focus their, their headline on the fact that it was emotional exhaustion. And so there was recently a systematic review that looked at just that is the reporting of burnout and how it's a little bit of a mixed bag now where it traditionally had been the high score in exhaustion depersonalization on a low score in professional accomplishment. But now people are reporting even just on the emotional exhaustion. So when we think about PTs and what I found was that 29% had emotional exhaustion and then 12% had actual burnout. And so that's, that's really a concern because we're talking that we have a vulnerable PT workforce out there when it comes to stress and when it comes to burnout. Speaker 2 (13:56): So if somebody has, if a physical therapist has high perceived stress, that's correlated with this emotional exhaustion, which is a part of burnout, but not the full definition of burnout. Speaker 3 (14:09): You got it, it's perfectly stated. Speaker 2 (14:11): So do you think that we, that our research needs to maybe reassess the definition of burnout? Or do you think that people, that we just need to get the word out there about what burnout actually is and educate people that, you know, you're not quite burned out yet? You're, you're emotionally exhausted. Here are the steps that you can take to decrease this high emotional exhaustion to prevent burnout, or what, what's your kind of opinion on that? Speaker 3 (14:39): Well, it would be a wonderful thing if it was so simple. But the reason why it's not simple is because people have looked at well, what comes first is an emotional exhaustion, and that leads to depersonalization followed by lower professional accomplishment. And the answer is not clear. So there are different models that have been proposed and tested to show that it can be multi-directional. And so it's not easy to say that if we manage stress, as we know stress, the perceived stress that we will have made a dramatic effect on burnout, because if depersonalization is what drives emotional exhaustion or low self-efficacy kind of low personal accomplishment, low self-esteem that type of thing in your workplace, if that drives burnout, then managing stress may not have as dramatic effect on those areas. So I, I think it's, I think it is behooves us to think about the complexities of stress and that mirrors the complexities of burnout. Speaker 3 (16:04): But I think that the first step is to be thinking about what are those stressors in the workplace because researchers have suggested that there's two ways to look at burnout, and that is the personal approach, so that you're more resilient to that stress, to that emotional exhaustion. And then the other area of focus should be on the work environment and the, the experiences that a person has at work. So we see that there's both sort of schools of thought that you, you make a person resilient and they will be able to handle any kind of environment. And then the, and then the counter is that if you make a nurturing, caring environment, that's conducive to good work and supporting people who are in crisis, then by that you were supporting the workers and you'll have less burnout. Speaker 2 (17:14): I think that those are some very interesting points. You know, this is obviously a very popular topic in our profession. Why do you think there's then we had, we've talked about that. There's not a lot of data for this. And just so our listeners know, like there's maybe a few studies, including Al including Dr. Anderson's recent dissertation, which was published in 2014, there's a couple of articles that have been published since then, but most of the research has been, was done in like the eighties and the nineties. So it's like over 20 years old. Right. So why do you think that data regarding burnout is so limited in our profession? And is there really any research going on in this area right now in our profession today? Speaker 3 (18:00): Yeah, I I've thought about that quite a bit, and I'm not sure why there hasn't been much, much research in the area. You can imagine that when I was working on my dissertation, I was shocked that there wasn't anything that was substantial. Everything was very old, as you had mentioned. And it was done in very discrete populations. So one was in rehab inpatient facilities in Massachusetts. Another wasn't a head injury unit in the Pacific Northwest. So very specific, nothing quite as broad as a national sample. Why, I don't know. I, in general, though, the efforts in looking at burnout has been focused on nursing and in physicians and MDs. And the only thing that I could come up with is there's a difference in the way we think and do things if you're medicine versus when you're rehabilitation. And I think that in comparing some of my findings in, especially in the areas of deep personalization and personal accomplishment, is that PTs typically were scoring much lower than nurses and physicians in those two categories. Speaker 3 (19:24): And I speculate that perhaps it's because of the kind of relationships that we have with our patients, that because we spend more time with our patients, we get to know our patients, families, and a lot of instances that it's very hard for us to depersonalize when you really spend a lot of time with someone. And that may also contribute to the fact that PTs score better than people in medicine, in the area of personal accomplishment, because although things may be crazy in your, in your practice setting, the fact that you can see a difference in the individual clients and patients that you see may in fact be reinforcing for that personal accomplishment. Speaker 2 (20:16): So is your belief then based off of what you found in your research, that kind of the difference between say physical therapists and nurses and physicians, which are more studied than what our profession is that we have better really, you know, longer lasting relationships with our patients and get because of that, we get a lot more accomplishment. Whereas physicians and nurses are more short term relationships with their patients. And so kind of those better scores and deep personalization and in personal accomplishment kind of help us save us from being burnt out. Like maybe our physician and nursing colleagues is that a, Speaker 3 (20:57): That is my hypothesis, but I haven't tested it. But that in looking at some of the publications in physicians of, of all different practice settings they are scoring typically higher, interestingly, except for those in mental health fields. So that may be a situation, two fold. Number one, is that a person working in mental health may actually have more skills to deal with their own stress and burdens. But they also may be spending more time with their patients because of the kind of therapeutic relationship that would occur in, in mental health. Speaker 2 (21:44): I think that your hypothesis is a very logical one, because if you think about, so if we, if we look at those studies from 20 years ago, obviously our profession has changed a lot. I mean, healthcare in general is just always changing. So, you know, right now student loan is at an all student loan debt is at an all time high wages for physical therapists are basically the same as what they were in the nineties. And the two thousands, we continue to experience decreases in payment. We have rising productivity expectations in order to maintain that bottom line. And so a lot of these factors are kind of cutting into our ability to form these relationships, so to maintain those good scores and depersonalization, and to have that personal accomplishment. But I'm interested in potentially knowing your opinion on how you think these factors have impacted the number of physical therapists affected by burnout. Speaker 3 (22:43): Yeah, I think that it has one of the, one of the findings that I observed in my research and that others have observed in medical populations is that younger therapists, younger physicians have higher rates of burnout than do older practitioners. And it's speculated that it's because the more seasoned therapist or physician has learned how to manage, right. They've learned how to manage sort of the, the game, if you will. They've also learned strategies for self preservation. So that gets us into that twofold area again, right. The personal, you know, wellbeing, and then the institution as something separate, I think it be worth it to take a look now, even compared to five years ago, with all the things that you've described, they were occurring five years ago when I did my dissertation, but then along comes higher expectations for productivity. Speaker 3 (24:01): And now, you know, let's throw in a worldwide pandemic onto that. Right. And so I think that what we've, what we'll, what we will see is that institutional changes that people may not have been able to keep up with because it's happened so rapidly over time, or it's sorry, that's weird. It's happened so rapidly within a short period of time that I think it would be worth looking into what changes have occurred in perceived stress or burnout. Within the past couple of years in physical therapy, because I would predict that those numbers would be greater than they were back in 2014. Speaker 2 (24:51): Well, I mean, that leads me beautifully to my next question is how do you think COVID-19 has contributed to burnout in physical therapy amongst physical therapists? Speaker 3 (25:01): Right. So when, so, although I didn't ask the question in my survey about what's causing you to be burned out or, you know, identify things that are stressors in your life. What I know, what I know from the literature is that when people in healthcare feel as though they don't have control of the situation, or they cannot contribute to good patient care effectiveness and efficiencies that the burnout rates are higher. So there is something to be said about this time in COVID where in our physical therapy world, we went from non essential to essential. We went from, you know, not doing rehab to doing nursing care. I colleagues of mine who were sent to the Mork colleagues of mine who worked security desks because in order for them to keep their job, they needed to say I would do assigned duties. So if we know that having little say about your work environment, little, say about how much time you spend with patients or what your responsibilities are, or what responsibilities you can delegate to other people, we know that that's contributing to burnout then hello, because that's exactly what happened to the physical therapy profession during COVID. Speaker 2 (26:39): So you teach at Rutgers what types of what types of instances of burnout or stress have you experienced amongst your students who are now like fresh into our profession and the students that are maybe still in PT school? How have they reacted to this COVID-19 pandemic in relationship to burnout or perceived stress? Speaker 3 (27:04): Right. So I think that we, we probably have cooked two cohort of students, the ones that graduated in 2020, who did a big sigh of relief because, because of in our program, the amount of weeks and hours they had got in for clinical experiences was complete by the time that they started to be pulled out of their clinical rotations. So all of our students were able to reach a level of competency and entry level so that everyone graduated in 2020. So they were like, just so relieved the group that is scheduled to graduate in 2021 have been dealing with the stresses, the traumas that come with changing responsibilities and different expectations because of COVID. But I think that by and large, they've had excellent clinical instructors, so kudos to the physical therapy profession and that they have been able to take the challenges in stride in part, because of the support from the institutions and their clinical instructors. Speaker 3 (28:30): I think that the students that are engaged in academic work, their stressors come from the fact that they know that they are in a program that's delivering information very different than the previous year and their hands-on experience has been truncated. And, and that, despite the efforts of the faculty to give them all the experiences that they normally would have in person that we are limited by the COVID restrictions of our university. So what we've, what we've attempted to do is to speak about the virtues of tele-health. We have some testing opportunities for students to engage in tele-health and improve their skills with communication and observation. Also giving directions watching movement from like you and I are right now from across the screen. And I do think that that is something that many therapists are learning. There's many courses and, and many workshops that you can do for best practices in doing telemedicine. So I think some of our students will be better equipped coming out because they have had some work in that area. Speaker 2 (30:09): So we've talked a lot about some of the different stressors that potentially could lead to burnout, but do you think are the main causes of burnout amongst physical therapists? Speaker 3 (30:19): Yeah, I think number one, I think autonomy is, and, you know, we got out from under the physician prescription. But if you think about autonomy from many practices in which the productivity demands is so high that you feel as though you've lost some sense of autonomy, and that comes from not being able to perhaps schedule your patients based on their needs. So, you know, if 30 minutes session versus 45 versus an hour so that contributes to a decrease in, in autonomy, which we know is that, which is a stressor when it comes to burnout. The other thing that is a big factor is redundancy. And it can be primarily in documentation where, you know, we've all experienced that you fill out one form, then you fill out another, then you have to do this chart and so on and so forth. Speaker 3 (31:20): You have this information in four or five different places, and that contributes to burnout because what happens is you feel as though you've imparted your professional opinion and you've made your professional observations, and that should be good enough. And you know what, Stephanie, it probably should be good enough. The fact that we have to, you know, regurgitate it in three different ways for different purposes is, you know, sucking the life out of people. All right. So the other thing that happens is that acknowledgement of credentials and continuing education and bettering yourself when that is not honored and respected by an employer or by a setting that contributes to burnout. And so in the physician world, they talk about having their board certifications. And we could also think about that in physical therapy as well. So even if you've got staff that have qualified or are now OCS is, or sports, clinical specialists is they need time to maintain that expertise. Speaker 3 (32:35): They need to do continuing education. They need to see the right patient caseload. They need time to do some outcome measures so that they can maintain that level, that high level of expertise, and that needs to be respected and time needs to be given to those professionals. Otherwise you can see an erosion of professional accomplishment. So it, it's not from my, my work, but from the readings that I've done in other professions, you know, predominantly medicine and nursing, these are the institutional things that contribute to burnout. And I can see that how that can they can have a big role in physical therapy as well. Speaker 2 (33:23): So I recently did a very unreliable and bias social media study pool on this topic asking you know, what, which physical therapy setting is burnout most prevalent. And I had 147, a sample size of 147 on, and I was kind of surprised by the results, but here were the results. 48% said private practice, 23% said, hospitals, 24% said skilled nursing facilities, and 5% said home health agencies. Do you think based on kind of what your research showed and based off of what you've read and potentially what your alumni have said, do you think that there is a higher rate of burnout amongst physical therapists in certain settings? And if so, what settings do you hypothesize put people most at risk for burnout and how can leaders within those settings decrease the rate of burnout amongst their employees? Speaker 3 (34:25): Okay. So I don't have to hypothesize because I actually have the data that was not part of my dissertation. So I will share that with you now. All right. So the winner in the burnout rate is skilled nursing facilities at 24%. Okay. followed by home a home care at 14% closely followed by the hospital outpatient department at 13% and private outpatient at 12%. So 12, 13, 14%, you know, sort of in the ballpark, but the standard, our skilled nursing facilities. And in, in a statistical analysis that I even still don't remember or can explain the one that stands out is truly statistically significant difference are those people who practice in skilled nursing facilities. And I mean, I would have to say that that number is probably in a higher, I mean, look what our colleagues in skilled nursing facilities had to deal with with COVID. Speaker 3 (35:39): You know, people were not being able to have visitation by family members, right. Trainings for going home sometimes were done via zoom sometimes in person for maybe five minutes. But think about that, think about all of the subacute rehab, people who didn't have family support when they're, you know, they're following surgery. They've never been in that kind of situation before, and they had to do that totally alone. And the demands that were placed on the rehabilitation staff and the nursing staff to keep moving forward with subacute care, nevermind all of those residents in long-term care that needed attention. So it, it back several years ago, it was still ranking pretty high as a stressful burnout written place to be long-term care. And I think it's still gonna sort of be at that level if not higher, what can they do? Speaker 3 (36:50): I still, I still have to go back to having compassionate supervisory support that there needs to be an understanding on how stressful and difficult it is to work with people who are at risk and people who are in crisis. And with that compassionate understanding supervisor comes a system that optimizes the physical therapist clinical decision-making professional opinion and allows therapists to continue to impact people's lives as positively as we do and not be burdened or, you know block or have a blockade set up through unreasonable demands and expectations. I think that the other the other idea that I didn't speak about earlier also is this sense of fairness and justice, and that comes from also the supervisor and, and the institution, and that it appears that when there's good transparency by knowing what everyone's case load is by knowing what the expectations are and that everyone is contributing to a a great unit or a great facility and that there's rewards and acknowledgements. Speaker 3 (38:37): And sometimes it doesn't have to be an actual bonus or reward. Those are nice, but sometimes it's just the acknowledgement. And at the same time that there shouldn't be any kind of punitive action on people who are not able to accomplish the same benchmarks. So I'll give you an example of something that happens in medicine quite a bit is that physicians who work in clinics are, have their appointments, you know, done by a scheduler, and they will have an income based on bonus based on how many people that they see. But what happens is when people cancel, they don't see anyone and there's no one there to fill in that spot. So physicians are, who are in that situation, feel like I'm not pulling my weight, but it's no fault of my own. And now I'm also being penalized because I don't have that slots filled. So I can't generate a ticket if you will, in order for a charge to go in, and yet it's by no fault of their own. And so we need to be thinking about ways in which physical therapists can have some participation in systems that supports everyone in that work environment. Speaker 2 (40:17): Do you have any advice on any of those systems or any thoughts behind developing those systems? Speaker 3 (40:24): I don't actually, I think that those are for, for different minds than mine right now. And I bet that there's plenty of people in the private practice section who have looked into different types of systems that include participatory type management strategies. Speaker 2 (40:48): I think you're probably correct on that statement, Dr. Anderson and, you know, most physical therapy facilities, including private practice, we're moving towards using data to make decisions. So how, what advice would you give to private practice owners? How can they use data to measure burnout amongst their employees? Speaker 3 (41:09): Yeah, I mean, I think, I think one of the the easiest tools to use is actually the perceived stress scale. It's by Cohen, it's free, you know, there's plenty of places where you can find it online and know how to score it. And one of the reasons why I, this is because I've done the perceived stress scale with groups of therapists who take continuing education courses with my partner and me and they are often surprised at what their score is. So some who thought they would score really high on this perceived stress scale, realize that no, they really didn't. And those who thought, you know, they were getting along pretty okay. When they went through those questions, they're like, Oh, I didn't think I would score that high. And so it, it leads to a conversation about that personal side, right? So what are you think that your stress, but your perceived stress scale kind of comes out a little bit low. Speaker 3 (42:22): So what are you doing in your life? How do you approach your day? What are the things that you do to manage your health and wellbeing? And I think that facilities that make that part of the culture will do really well with being able to use some of that information from the perceived stress scale, not where they're collecting the data, but they're increasing the awareness of their employees and the people that work together. And it opens up the opportunity to have a conversation about the stressors at work, the stressors at home, and how people can support each other and how people are coping with their stressors. Speaker 2 (43:09): What advice or solutions do you have for private practice owners or any, or organizational leadership on managing burnout amongst their employees once they kind of figure out some of the data points that you mentioned previously? Speaker 3 (43:23): Yeah, I, I think that one of the things that has come out in some of the literature is the fact that when you're working with highly intelligent people. And so remember that burnout came from people who were working in healthcare, right? They, they are licensed healthcare providers. They often have advanced degrees. They often have specialties. One of the keys is to give people a voice regularly. And then what is also been found is that when people are given a voice and suggestions are made for changing in the environment or something that could help greater efficiency, that the response from the administration is that I will look into that and then come back with information to either support that idea or to say at this time, and in this situation, that idea won't work. And here are the reasons why, but one of the things that's very detrimental is when people share thoughts and ideas, is that the first response they get is we can't, or no, without any kind of real honest investigation into the suggestion or recommendation. And so I think that that's a very sound place to start and trying to have a clinic or a facility that is going to be resilient against all of these forces that are going on in healthcare and have a happy and healthier staff. Speaker 2 (45:23): What about employees? What type of advice do you have for employees who are maybe close to, or are experiencing burnout? Speaker 3 (45:32): Yeah. institutional change takes a very long time, and sometimes it can be really frustrating, particularly if you don't have those empathic caring supervisors who are going to sort of beat the drum for you. And so you have the chance to turn to yourself. And what we know from some work site studies that have focused on healthcare providers is that breathing practices and meditation are two strategies, which help people be able to manage their stress effectively. And the idea is that you practice those things so that when you need it, you can use it. So, you know, you could always think, well, like when I get really anxious or whatever, I just stop and I take some deep breaths. Oh, okay. That's great. But when do you, do you always have an opportunity to like, just stop, pause and like take your deep breaths? No, you, you have to anticipate that this is happening and you have to be really good at pulling that up very quickly. And that comes from a regular practice. And I think that in general, we know those practices are really good for managing the balance of the sympathetic and parasympathetic nervous system. We know that those practices help increase heart rate variability, decreased blood pressure, decreased heart rate. And so it's not, those are strategies that are not just great for managing stress, but they're also great for managing your overall health. Speaker 2 (47:27): Well, Dr. Anderson, this been a great conversation. I know that I have learned a lot and I'm really looking forward to using some of this information to write my article. One last question that I want to ask you, that we ask everybody on this podcast is knowing where you are now in your life and in your career. What advice would you give to your younger self? Speaker 3 (47:53): Huh. I think, I think to my younger self, well, Hmm. Okay. There's two, there's two sides to this sword. One is that if I wanted to be more accomplished, I would say in my career I would have focused earlier on, on a line of inquiry or a line of research. However, not having done that. I can't say that I have a lot of regrets and I have dabbled in a lot of things so that you, you saw from my bio, that I have a lot of different interests and I don't do anything with a half effort. So, you know, a lot of research went into the book. A lot of research went into my being the advisor for young athletes for special Olympics. You know, there's, there's, I haven't really ever fallen into anything. I feel as though I've put a lot of effort into that and, and all of those parts of who I am. I enjoy immensely and I wouldn't want to give anything up. So my advice is if I had a clear career trajectory, I should have focused more on one area. But I don't know if that was really me to begin with. Speaker 2 (49:34): Yeah, don't we all want to have one area that we want to focus on and have a very clear trajectory. I think of 2020 has taught me anything. It is, that is not something that's going to happen most of the time. Well, I want to thank you so much, Dr. Anderson for joining us today on the podcast, and thank you so much for your time. Thank you to our, thank you to our listeners for listening to another episode of healthy, wealthy, and smart, and hopefully you will stay healthy, wealthy, and smart. Speaker 1 (50:10): Thank you for listening. And please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.

From our physical appearance to our body's mechanical functions, our whole being is encoded into our genes and kept in each cell that makes us. These basic biological units have their system to keep everything functioning and our body alive and moving. They have housekeeping functions: cells perform autophagy to get rid of accumulated waste materials. Maximising the effects of these processes can help in increasing your longevity. When the autophagic processes fail, it can damage important parts of the cell such as the DNA and accelerate ageing. In this episode, Dr Elena Seranova explains the science behind autophagy and how it connects to NAD and sirtuin genes. She also shares her own experience and research on using this knowledge to live a longer, fuller life. Join us in this episode to learn more about autophagy and how this process is useful in increasing your longevity and giving you a boost in life.   Get Customised Guidance for Your Genetic Make-Up For our epigenetics health program that is all about optimising your fitness, lifestyle, nutrition and mind performance to your particular genes, go to https://www.lisatamati.com/page/epigenetics-and-health-coaching/. You can also join our free live webinar on epigenetics.   Online Coaching for Runners Go to www.runninghotcoaching.com for our online run training coaching.   Consult with Me If you would like to work with me one to one on anything from your mindset, to head injuries, to biohacking your health, to optimal performance or executive coaching, please book a consultation here: https://shop.lisatamati.com/collections/consultations.    Order My Books My latest book Relentless chronicles the inspiring journey about how my mother and I defied the odds after an aneurysm left my mum Isobel with massive brain damage at age 74. The medical professionals told me there was absolutely no hope of any quality of life again, but I used every mindset tool, years of research, and incredible tenacity to prove them wrong and bring my mother back to full health within 3 years. Get your copy here: http://relentlessbook.lisatamati.com/  For my other two best-selling books Running Hot and Running to Extremes, chronicling my ultrarunning adventures and expeditions all around the world, go to https://shop.lisatamati.com/collections/books.    Here are three reasons why you should listen to the full episode: Discover how cells stay healthy. Find out Dr Elena's tips and advice in increasing your longevity by activating autophagy. Learn more about the science behind NMN supplements and their revitalising effect.   Resources Read about Dave Asprey’s work around the keto diet. Lifespan by Dr David Sinclair Pushing the Limits Ep 170: The Search for the Perfect Protein with Dr David Minkoff Visit NMNBio if you want to learn more about NMN supplements in New Zealand.   Episode Highlights [04:33] Getting to Know Dr Elena Seranova Dr Elena Seranova is an interdisciplinary scientist.  She holds a degree in Psychology, MSc Translational Neuroscience, and a PhD focusing on autophagy and cell biology. With her expertise in her field, she co-founded a biotech startup and is now the the founder of NMN Bio in the United Kingdom.  [06:06] What Is Autophagy? Autophagy is a catabolic pathway that degrades unwanted materials within the cell. The cell needs to avoid the build-up of unnecessary materials. There are different pathways for activation like mTOR (mammalian target of rapamycin) and PI3K (Phosphoinositide 3-kinase). Impairments at various stages of autophagy lead to its failure and cell death. Once autophagy fails, apoptosis, or programmed cell death, can activate. [11:25] NAD as Fuel for Sirtuin and PARP PARP and sirtuin are different classes of enzymes that use NAD for multiple vital processes, including DNA repair (both) and gene expression (sirtuin). Sirtuin 1 is one of the pathways that can initiate autophagy. initiates the autophagic process. When DNA is damaged, PARP activates and depletes NAD stores. The decrease in NAD levels inhibits sirtuin's ability to carry out its functions, including autophagy, accelerating a cell's death. [15:34] What Is NAD? Nicotinamide adenine dinucleotide or NAD is a substrate for enzymes. It plays a vital role in different reactions within the cell. You can supplement NAD levels using boosters such as nicotinamide mononucleotide (NMN). [18:44] mTOR-Independent Pathways Activation of autophagy using Sirtuin 1 is an mTOR-independent pathway. It is essential not to activate autophagy through mTOR pathways. mTOR is responsible for cell growth and translation. [25:04] How to Activate mTOR-Independent Autophagy Autophagy is dependent on nutrient starvation. Intermittent fasting can activate it. A generally healthy lifestyle includes supplement intake, proper sleep, and healthy foods. Avoid too much sunlight because it damages the skin and DNA. It activates PARP enzymes. Take a tablespoon of extra virgin olive oil which contains oleic acid. This good fat has the same effects as resveratrol. Induce artificial stress through cryotherapy, saunas, and exercise to activate sirtuin 1.  [33:22] Why Did Dr Elena Decide to Bring NMN to the Market? She came across NAD and NMN during her doctorate studies and saw their importance. Her own experiences showed better focus and energy levels after taking NMN supplements. There are not enough reliable suppliers that offer good regulation and quality control. She wanted to provide the best for herself and her family. NMN Bio has complete transparency on suppliers and quality regulation [38:28] Can Weight Loss Occur from Taking NMN? Lisa Tamati's experience in taking NMN shows fat loss but no muscle loss. Dr Elena's mice studies show evidence that NMN can improve insulin sensitivity and lipid metabolism. [40:42] Do NMN Supplements Have Any Downsides? They found no side effects in studies with mice despite an increase in dosage. Current studies are still ongoing to determine the ideal dosage for humans. Most people take 500mg to 1g. Doubling this still shows good tolerance. Take supplements in the morning as NAD affects the circadian rhythm. [53:57] How Do Autophagy, NAD and Sirtuin Genes Fit Together? Autophagy recycles various damaged organelles. Sirtuin 1 genes activate autophagy and mitophagy. NAD functions as a substrate for sirtuin enzymes to work. NMN supplements can increase NAD levels. Listen to the episode for the full explanation of how these three work together. [58:43] Can NMN be Taken as an Infusion? This is not something that Dr Elena has studied in-depth and she is curious as well about how viable this procedure will be.  There is a low concentration of energy in intravenous injections, but it's present. Oral administration is more reliable in giving boosts and it costs cheaper. [01:00:01] Do Antioxidants Help in Increasing Your Longevity? Studies have shown that antioxidants don't suppress ageing. Lifestyle intervention and autophagy activation are proven ways to slow ageing.   7 Powerful Quotes  ‘Lysosome is another acidic organelle that contains acid hydrolases that are able to digest this cargo...and if it doesn't work, well, the cell is basically in trouble because you have all this garbage floating around, and there is nothing to remove them. So this is why autophagy is important. ‘When things are preserved across species, then that gives a scientist an indication that this is probably a very important biological function’. ‘I think that in order for your body to function properly, you really need to have a kind of a healthy routine in general’. ‘So I think that when it comes to being healthy, and activating your autophagy levels, and having a healthy lifestyle in general, you need to start with the basics first.’ ‘Another small tip that I can give is to actually avoid sunlight, which is something that people don't really consider. What happens when we're exposed to sunlight, when our skin is exposed to sunlight for prolonged periods of time, we start getting the DNA damage’. “The important part is not to just increase your age, it’s to increase your healthspan.”  ‘And if you have if your mitochondria are not healthy, and they're dying, and you're not having enough mitochondria in your cells, then you are going to be sick.’   About Dr Elena Seranova Dr Elena Seranova is a scientist, serial entrepreneur and business mentor who has founded multiple innovative biotechnological businesses. She first studied at the University of Ioannina with a major in Psychology. She started a private practice before developing an interest in neuroscience. She continued her studies and earned her Master’s Degree in Translational Neuroscience at the University of Sheffield. She now also holds a Doctorate Degree in Stem Cell Biology and Autophagy from the University of Birmingham. Her expertise in these fields has led her to become the co-founder of a biotech start-up, SkyLab Bio. She has written a number of peer-reviewed articles and multiple research articles on autophagy throughout her career. Aside from these accomplishments, she started her own business, NMN Bio. Her own experiences with the use of supplements have inspired her to expand the market to supply the public with cutting-edge anti-ageing supplements. NMN Bio reaches New Zealand, UK, and Europe.  Dr Elena found her passion for drug discovery and autophagy. She has endeavoured to share this with the public through her research and work as an entrepreneur.  To learn more about Dr Elena and her work, visit her website.    Enjoyed This Podcast? If you did, be sure to subscribe and share it with your friends! Post a review and share it! If you enjoyed tuning in, then leave us a review. You can also share this with your family and friends, especially those interested in increasing their longevity, so that they can practice the activation of autophagy in their lifestyle. Have any questions? You can contact me through email (support@lisatamati.com) or find me on Facebook, Twitter, Instagram and YouTube. For more episode updates, visit my website. You may also tune in on Apple Podcasts. To pushing the limits, Lisa   Transcript Of The Podcast Welcome to Pushing the Limits, the show that helps you reach your full potential, with your host Lisa Tamati, brought to you by lisatamati.com. Lisa Tamati: Well, hi everyone and welcome back to Pushing the Limits. This week I have Dr. Elena Seranova, who has already been a guest on the show. And today, we're talking about autophagy and NAD, and the interplay between these two. Now that might sound extremely boring, but it isn't. It's all about longevity and anti-aging. So, we're going to be talking about the science between about NAD precursors and the sirtuin genes, and how to upregulate the sirtuin genes, and all about autophagy, which is really the recycling of old and damaged parts and proteins of a cell that need to be gotten rid of. So, it's a bit like having a good garbage disposal unit happening. And there are many ways to activate autophagy, which we go into in this episode. We talk about intermittent fasting, we talk about cold and hot and hormetic stressors like exercise and yes, of course fasting. But also, mTOR independent pathways to activate autophagy, it'll all be revealed in this interview.  Now this does get a little bit technical in the first 20 minutes or so. But hang in there and listen to this a couple of times. Because if you want to slow down aging, if you want to slow down the generative decline of your body and you want to have a long and healthy lifestyle, then this stuff is really, really worth paying attention to and trying to understand.  We talk about NMN, which is nicotinamide mononucleotide, which is a supplement that is now available, is a longevity compound to upregulate the sirtuin genes. And we're really lucky to check that out. You can go and find that supplement, which has been made and produced by Dr. Elena Seranova and her company, NMN Bio. So if you head hop over to nmnbio.nz, we're now importing this into the country. So, this is one way that you can really fight aging and degenerative decline that we all fear and don't want.  And when you listen to this episode and really listen to it a couple of times, you'll understand some of the incredible anti-aging things that are coming down. This is not pseudoscience. Dr. Elena is one of the most amazing neuroscientists out there. So please listen to this episode, enjoy it, get a lot out of it and get the takeaway. So, if you don't understand some of the terminology, don't worry, keep going. And by the end, you'll start to pick up certain bits and pieces. And if you listen to it again, you'll be able to pick up a little bit more and a little bit more. And at the end of the day, it's about the takeaways, what can you do to slow aging down and all that information is in there. So, I hope you enjoy this episode with Dr. Elena.  Before we go over to that we are all about health optimisation, high performance, athletic performance. So, if you need any help with any of those areas of your life, please reach out to us, Support at lisatamati.com. Go and check out our website, lisatamati.com. You'll find all our programs, our Epigenetics Programs, our online run training system that's customised and personalised totally to you, and check out what we do. We love helping you be the best version of yourself that you can be. Now over to the show with Dr. Elena Servanova.  Lisa: Well, hi everyone. Lisa Tamati here and very excited to have you hopefully join us this morning. It's 7:30am in the morning here in New Zealand. And where Dr. Elena Seranova is, it's very late at night. How are you doing, Dr. Elena?   Dr Elena Seranova: Good, good. How are you? Happy to be here again. Lisa: Yeah, very excited for today's topic. So, we're going to be doing a discussion around autophagy and NAD boosters and sirtuin genes. So it’s going to be a really interesting discussion that is really beneficial for you if you want to know how to live longer, live healthier, and optimise your body and your mind and your potential. So, Dr. Elena, can you just tell us briefly a little bit about yourself?  Dr Elena: Sure. So, I started my journey as a psychologist. So I'm an interdisciplinary scientist. I majored in psychology at first and then I had my own private practise for five years which turned out to be a successful wellness centre. And I really got fascinated by neuroscience and the brain. And for this reason, at first I started studying the brain myself and then I found an amazing master's degree at the University of Sheffield in Translational Neuroscience, which basically combined the research and neurodegeneration with applications that could translate into therapeutics. So, this is what translational neuroscience means, is basically the combination and the outcome of the research—the hardcore biology research that can be utilised for therapeutic approaches and patients.  I really enjoyed that. So that was quite cool, being in the lab and doing molecular biology experiments and so on. So, I kind of fell in love with the lab, and I decided to do a PhD as well. I continued my studies in autophagy and stem cell biology and it was quite challenging, but at the same time, I really enjoyed it. And I can definitely say that science is a big part of my life. Lisa: Definitely your thing. Okay, so autophagy and stem cells. So in relation to neurodegenerative diseases in that case? Okay, but what is autophagy? Because a lot of people will be listening to it and go, ‘What the heck is that big word, autophagy’? It's sort of big word in biohacking circles, but perhaps not in the general public. Can you explain what autophagy is exactly?  Dr Elena: Yes, sure. So, autophagy is a catabolic pathway that degrades dysfunctional organelles in the cell or protein pro aggregates. So, any material that is basically unwanted in the cell, autophagy can degrade. It's like the stomach of the cell.  Lisa: So, it’s like eating it? It's eating, sort of...  Dr Elena: Yeah, exactly. And what happens when autophagy is activated, we actually have the formation of the so-called phagophore, which is a membrane structure that basically engulfs different organelles and materials that need to be degraded to form the so called autophagosome, which is a round organelle that basically has this cargo that needs to be digested. That eventually fuses with lysosome.  And lysosome is another acidic organelle that contains acidic hydrolases that are able to digest this cargo. And this process is very essential for the cell, it’s very vital. It's evolutionary conserved in all species, from yeast to models. And if it doesn't work well, the cell is basically in trouble because you have all this garbage... Lisa: Floating around.  Dr Elena: ...floating around and there is nothing to remove them. So, this is why autophagy is important. And we have different pathways that autophagy can be activated through as well. So, one of those pathways is mTOR, mechanistic target of rapamycin. And then we have other pathways that can activate this process such as AMPK, GSK3, and so on.  Lisa: So is this like, sorry to interrupt, but like because I know that people out there might be like, ‘Wow, that's a lot of big words and a lot of information’. So, is it like that the cell has to do a housecleaning, and it's got stuff inside the cell that is not working optimally, and needs to be gotten rid of, or is it the whole cell? So, it's not apoptosis. So it's not where the host is disintegrating? Dr Elena: No. Yeah, it's actually a—it's a pre-apoptotic pathway. So, before apoptosis is activated, we have autophagy. And if autophagy fails in what it needs to do, then we have activation of some apoptotic pathways. So, it's one step before that. And if everything goes well, and autophagy is functional—and by the way, in different diseases, we might be having different autophagy impairments at different stages of autophagy. So, it's either the initial phagophore formation, for instance, that it's not working well, and it can’t engulf the cargo, or it's insulator stages of autophagy, such as the acidic hydrolysis and the lysosomes that are actually not that acidic. So their pH is not acidic enough to digest the cargo. So, we might be having different defects in the autophagy pathway in different diseases. Lisa: That leads to apoptosis. Am I right?  Dr Elena: And yeah, if autophagy is not doing its work correctly, then eventually we will have apoptosis. And actually, this is what we're seeing in in vitro models of neurodegenerative diseases as well. So, for instance, if autophagy is not working well.  And we have, let's say, dysfunctional organelles, such as mitochondria—dysfunctional mitochondria that are not working well. Let's say they are depolarised. And there is an excess production of reactive oxygen species going on. Now, if nothing can degrade these dysfunctional mitochondria, you'll keep on having this accumulation of reactive oxygen species, which eventually will lead to DNA damage and deactivation of PARPs. And it's basically a death spiral that will keep on leading the cell towards death.  Lisa: Okay, so what is a PARP? You mentioned PARP there. And just for the listeners, too. So, apoptosis is basically cell death, programmed cell death. So, this is not—what's the other one necrotic or something?  Dr Elena: Necrosis?  Lisa: Yeah, necrosis, where the cell dies for—necrosis. But this is sort of a natural programmed cell death. But we only want that if we're actually renewing the cells and we are wanting new stuff. So, before that, the body tries to do this autophagy process, is that how it works? And then what so what is PARP? What is PARP, because that’s the word again... Dr Elena: PARPs are a class of enzymes, and in order for them to function, they need a molecule called NAD, so nicotinamide adenine dinucleotide. And they're actually competing for NAD in the cell. And whenever we have increased DNA damage, we would have the PARP activation as well. And this would lead to NAD depletion, which kind of brings me to my next point about what other enzymes consume NAD. And one of those enzymes are sirtuins, which are the so-called longevity genes that are basically responsible for multiple processes in the cell, including epigenetic regulation of gene expression.  So, they do—because sirtuins are a class of enzymes that are also dependent on NAD, and they're all the deacetylase enzymes, meaning that they remove acetyl groups from the DNA. And as a result, they control which genes will be expressed in which tissues, which is very crucial for the cellular identity and for the proper function of different cells.  So, sirtuins in a healthy cell, so sirtuin should be upregulated and they should be having this housekeeping gene—housekeeping function where they basically control what's going on with the DNA repair and also with the gene expression as well. And if we do have—when we do start having impaired autophagy, and let's say there is increased reactive oxygen species, because there are increased dysfunctional mitochondria in the cell, you will have in more activation of PARPs, and all of the NAD will start being drained from... And sirtuin will not have enough energy to function. So, those are actually quite an elegant interplay between autophagy and NAD and sirtuins.  Lisa: Okay. Okay, can I just want to like put that back to you, so that we can slow down because we are going technical quite fast. And I think a lot of people might be like, ‘What the heck are they talking about’? So, the sirtuin genes, basically longevity genes, and then one of the jobs is DNA repair. And another of the jobs is to say which genes are actually being activated right now. And these sirtuin genes are also responsible, I think, for cell replication, is that correct? Dr Elena: The sirtuins are responsible for multiple functions, directly or indirectly. So, for instance, the sirtuin 3 gene is also responsible for mitochondrial biogenesis. And it's implicated in the amount of mitochondria that are being produced by the cell, which is related to cell replication eventually, because you do need to have enough ATP levels to replicate. Lisa: Right. Yeah. So, this has definitely to do with ATP production as well and mitochondrial health. So, these are doing all of these jobs, the sirtuin genes, they're very, very crucial genes in our genome. And these are preserved across every species, I believe? Every species on the planet?  Dr Elena: Yeah. Also from yeast to humans, it's also—sirtuin genes are preserved very well. Lisa: And when things are preserved across species, then that gives a scientist an indication that this is probably a very important biological function and we need to have a look at this one because it's—from what I understand.  Okay, so when you have activated PARP because you're not doing autophagy well and there's things going wrong, it's taking the NAD. So NAD is basically like a fuel source that both the sirtuin genes. And when PARP is activated, it's using to fuel its job. And so, this is competition for competing fuel sources. So, like if you imagine, you've only got one tank of fuel for your car, but you've got to go in two different directions and do two different jobs. You go, ‘How am I going to divide up my energy’? So, then it becomes important as to how much NAD we have in the body? So, what is NAD again? That says nicotinamide adenine dinucleotide? But what is that and how does it work?  Dr Elena: Yeah, it does serve as a substrate for all of these enzymes, including sirtuins and PARPS and is basically a master regulator of metabolism. So, it's a very important molecule and it serves as—without NAD, the cell is not able to function properly just because this crucial molecule is implicated in so many different reactions. So, NAD is found in all living cells and organisms. This is also evolutionary conserved across species. And it exists in two forms, NADH and NAD+, which is the reduced and the oxidised form, respectively. And both of them are important. And both of them are implicated in multiple cellular reactions.  Lisa: Is it going backwards and forwards in a cycle, NADH, NAD+, by donating electrons back and forth, sort of thing?  Dr Elena: Yeah. Through electron transport chain in the mitochondria, yeah. So, this is why it's so important. And so, what we're seeing now in the latest advancements in longevity research is that we actually can supplement with different precursors of NAD, such as nicotinamide mononucleotide, for instance, NMN. And this is the supplement that my company...  Lisa: See, you've now got that available on the market because this is such a crucial thing. Dr Elena: Exactly. And I think that it's really interesting to also say that when it comes to the interaction between autophagy and sirtuins, there is also another regulation of autophagy there. So sirtuin 1 is actually responsible for activating some transcription factors such as TFEB and FoxO3 that have to do with initiation of the autophagy process.  So, for this reason, when we do have dropping levels of NAD, decreasing levels of NAD, and there is not enough NAD for sirtuins to do their job. And let's say again—let's talk about that previous example in neurodegeneration when you have increased reactive oxygen species, and you have increased the level of stress and oxidative stress and decreased activity of sirtuins.  And not only the situation is already bad, but because sirtuin 1 doesn't have enough energy to function and to activate the TFEB and the FoxO3 transcription factors to initiate autophagy, now you have all of this dysfunctional mitochondria floating around and autophagy starts being impaired as well because we activated enough. So, it's a negative feedback loop which actually accelerates the scenario where the cell is going towards cell death, basically. Lisa: So that means like, if you don't have enough NAD, then your sirtuin 1 gene is not going to be able to initiate autophagy and clean up the cell and you're going to have dysfunctional mitochondria. Is that independent of the mTOR pathway? Or is that—am I getting confused?  Dr Elena: So, okay. So, good question. So, what happens is there are some molecules that activates sirtuins. So, for instance, sirtuin 1 is activated by resveratrol, and this is something that has been demonstrated many years ago. So, when you have sirtuin 1 dependent activation of autophagy, you will be having it through an mTOR independent pathway. Lisa: So it's a fasting mimetic resveratrol.  Dr Elena: Yeah, yeah. Yeah, absolutely. So, because we now know that the mTOR activity is not affected by intake of resveratrol. And this is quite crucial because actually, even if we want to activate autophagy, we shouldn’t do it through the mTOR pathway, this is not the preferred way, because mTOR is also responsible for growth and translation in the cell. So, this is not—it's also quite a key player in the cell. So it's a serine threonine kinase, and you actually don't want it to be activated at all times because this may lead other conditions. So, what we're focusing on at the moment is to find molecules that can activate autophagy in an mTOR independent manner. Lisa: Okay, so. So if the mTOR—cause MTOR is usually what's for growth it’s anabolic, it's causing growth. So for example, a bodybuilder goes to the gym, they're in an anabolic state, they are in an mTOR growth state. And when you have autophagy, that's sort of the opposite. So, it's a catabolic state where it's starting to eat itself. So, it’s mTOR, most people like do fasting for that reason to activate autophagy? Dr Elena: Yeah, this is another good point there. So, when we're fasting, and there is actually conflicting evidence out there as to when autophagy is fully activated. Usually, people say that around 24 hours, you start having the autophagy activation. There are others that swear by the ketogenic diet, and say that if you don't consume any carbs, you will get autophagy activation anyway. However, from what other researchers have found is that, if you are in a ketogenic diet, and you do consume meat, it depends on what kind of meat you consume that will either activate autophagy or not. And it all has to do with levels of different amino acids in the cell because autophagy is quite sensitive to nutrients and to nutrient starvation to be activated. If you have an abundance of amino acids, again, it will not be activated.  So, for instance, one amino acid that activates autophagy very well is leucine. And if you're eating certain meat that are rich in leucine, this is probably not good for your autophagic state. Something else to keep in mind, and I've heard, I think it was Dave Asprey saying that if you can manage to be on under 15 grams of protein per day, you will probably keep the autophagy going.  Lisa: Because a lot of people on keto think I can eat a lot of protein, which is a mistake, really. It isn't about having—that's interesting, because I had Dr. David Minkoff on my podcast, Pushing the Limits a while ago, and he has a product called PerfectAmino, which is really a 99% usable form of amino acids and combination. And I was interested, ‘Well hang on, if I'm heading there, which is going a lot of good things in the body. But is that going to inhibit my mTOR, or autophagy’? Sorry, because I've got too much leucine in there? Dr Elena: This is a very good point for all of this process food as well. So, for instance, there are some ready meals you can get or some protein bars that claim to have all the low carb and everything. And then they slam a badge on their pack saying that it's vegan as well. But then, why is it vegan if it has all the amino acids because that's one of the selling points when you're actually on a vegan diet, or you have some days where you are on a vegan diet. You want to get yourself in a state of partial amino acid depletion to get this beneficial effect of enhanced autophagy. And on intercellular toxins and so on.  Lisa: Right, so for certain periods of time, you want to do this, and it's a cycling thing, you don't want to be completely deficient of aminos for too long because then your body will start to break down. Dr Elena: This is what I do personally as well. So, during the week, so I am a fan of cattle/carnivore diet. So, this diet is quite comfortable for me and I enjoyed it quite a lot. But then during my week I try to have some days where I'm either vegetarian or vegan, just because I want to have those benefits.  Lisa: Yeah. Up and down. And then this seems to be a theme in biology all the time is that it's not one thing. It's not staying on keto for ever and ever, amen. It's about doing cyclic keto or cyclic vegan and it’s cyclic. And our body loves this push and pull—when there’s recovery and there’s growth and then clean up phase, growth clean up. So autophagy can be activated through fasting. It can also be active through having resveratrol and upregulating the sirtuin 1 gene, how else can we activate autophagy? Dr Elena: So there are different ways, there are different things you can really implement in order to activate autophagy. And I think that it all has to do with how you build your lifestyle in general. So, I think that in order for your body to function properly, you really need to have a kind of a healthy routine in general. And an analogy that I can give you there is that there are people that would buy a couple of supplements, and then they would be so proud of it. And then they would say, ‘Oh, yeah, but I'm taking those supplements now, and I'm so healthy’. And then their biorhythms are all off. They sleep at 5am every day. And they're eating crappy foods or super processed foods.  Lisa: Yeah, it’s not going to work.  Dr Elena: It’s all good. So, I think that when it comes to being healthy and activating your autophagy levels and having a healthy lifestyle in general, you need to start with the basics first.  So, the intermittent fasting is definitely the first step to take in order to become a bit healthier. And from the research that I'm reading, and from the things that I'm implementing, I definitely believe that both anecdotal and scientific evidence point towards the fact that intermittent fasting is actually the way to go. I mean, there are conflicting opinions out there and there are pros and cons in every diet, and so on. And I get that. But I personally believe that with intermittent fasting, if you try to narrow down the window where you're uptaking food, this is very, very good for you. So, this is step number one.  But then again, so either you're trying to raise your NAD levels, or you're trying to activate your autophagy, because those pathways are quite intertwined. And what you eventually want to do is you want to have increased levels of sirtuin, and sirtuin 1 in particular, and sirtuin 3, of course, and so on. And for this reason, in order to preserve this pool of NAD that is available for the sirtuin 1 to activate itself and activate the autophagy pathway.  Another small tip that I can give is to actually avoid sunlight, which is something that people don't really consider. But what happens when we're exposed to sunlight, when our skin is exposed to sunlight for prolonged periods of time, we start getting the DNA damage. And when you get the DNA damage, you have PARP activation, and then again, you NAD pool... Lisa: Wow. I never connected those dots. That's really interesting. So, because—I mean, we need sun. We need sun for vitamin D and for our mood and all that sort of stuff. So, you're not saying don't have any sun.  Dr Elena: Yeah, sure.  Lisa: But because the sun is causing DNA damage, it's going to cause more PARP activation, it’s going to have the sirtuin genes going to repair the DNA, that's going to use up the body's resources is what you're saying.  Okay, wow, that makes sense. Makes sense. And then by the same token, like things like smoking that breaks DNA, like no tomorrow. This is why smoking ages you is because of all the DNA breaks. And this is why, when you're in the sun for hours every day, you get wrinkly skin and you get collagen lost and all the rest of the things that are happening. So, anything that's going to be causing DNA breaks is going to cause you to age quicker.  Dr Elena: Exactly.  Lisa: Using up the resources basically. Wow, okay. Dr Elena: So it's obviously—you don't have to become a vampire and dissipate walk in the sun when you want to go somewhere. But sunbathing for hours is definitely not something you want to do with—to get your body go through, basically. So that's another tip.  And then something else, really, really simple that can be implemented on a daily basis in order to maintain your sirtuin levels, and as a result, your autophagy levels, and your NAD levels is also to take a tablespoon of extra virgin olive oil, which contains oleic acid. And it basically does the same job as resveratrol. And it's interesting—I think that there's been a recent research article out that shows that like oleic acid might even be more efficient than resveratrol, in terms of activating sirtuin 1, which I think it's really, really cool.  Lisa: So yeah. Well, combine the two. I do. Dr Elena: Yeah, absolutely. You can do that. And then, you need to make sure that the extra virgin olive oil is actually of a very good quality because there is a bunch of...  Lisa: There is a bunch of rubbish out there. So, make sure it's from an orchard that you know, it's cold pressed, it's all those extra virgin, it's all that sort of good stuff. And not—how do they do it with solvents and stuff? Or that it's come from multiple orchards and being cut with other oils. It's a really, really important point. And then oleic acid does so much good things in the body. But isn’t that fat, Elena? Like lots of people are like, in their minds are going, ‘But oil is fat. It’s the same with MCT oil. Isn’t that going to make you fat when you eat fat’? Just going to put that around.  Dr Elena: There are good fats and there are bad fats. So, olive oil is good fat. MCT oil is a good fat. Avocado is a good fat. So, not all thoughts are made equal. So, this is definitely something important to keep in mind, especially with a good quality extra virgin olive oil.  Lisa: Because each one of our cells is a membrane that has a phospholipid, isn't it? So we need that,  actually, this building of ourselves into the integrity. Dr Elena: We have a phospholipid layer in the brain as well. And this is why we actually supplement with omega 3 fatty acids, because this is what it does. So, this is what omega 3 fatty acids do. They go into the phospholipid membrane, and then they basically... Lisa: Make the integrity of that membrane better. Dr Elena: Yeah, they contribute to the healthy phospholipid layer in the brain.  Lisa: So that's why it's very important for neurodegeneration to have omega 3s going in and again, people get quality omega 3s. Not your cheap supermarket ones that are perhaps oxidised and have been sitting on the shelves for six months. So really important to get a reputable source here. And omega 3 is of course in fishes as well, and krill, and so on.  Okay, so but is there a downside to fat? Because I studied epigenetics and a lot of people's profiles come back with don't have too many fats. And it's been one of those things in my head is like ‘Why would some people not come back with you shouldn't have too much fat’? I mean, there are things like gall bladders been removed. That's a pretty specific thing. But is there a genetic component? And probably not your wheelhouse, really, but is there a genetic component to your ability to process fat? Dr Elena: There is a genetic component, and I've actually seen this with a family that has a history of very problematic digestion of fat, and so on. Absolutely. But yeah, again, not all fats are made the same. And when you cut off the bad fats from your life, things change and everything changes really. Lisa: Yeah, it really is very satiating, too to have a little bit of fat and that can really help with cravings and blood sugar spikes—we're getting off topic.  So you have a company, NMN Bio, which produces nicotinamide mononucleotide supplement. And you've got a whole range of other stuff coming as well. Why did you decide like, you need to get this out there on the market? Based on your research and your knowledge around this area, why is it important that people take NMN if they're serious about slowing aging? Dr Elena: So first of all, I came across the biology of NAD and NMN during my PhD studies and my research kind of led me into this field because I was studying autophagy neurodegeneration. And actually, I still cannot disclose my research.  Lisa: Yeah, it’s not published yet.  Dr Elena: My research paper from my PhD is not published yet, but hopefully soon, so we're about to submit it quite soon actually. So for this reason, I started studying the biology of NAD and I actually saw how important and how crucial NAD is to the cell and what happens when we have a lack of NAD and depletion of NAD pools in the cell. And I've been supplementing with different kinds of vitamins and supplements my whole life really. So, I was watching closely this space for a while, and I was taking different supplements myself for a while.  And so, when I came across NMN and I realised that actually there is this strategy where we can supplement with a precursor in order to increase our energy levels, I found it really, really interesting. And I thought to give it a go myself and try it out and see the results. And then what shocked me was that the immediate effect of the supplement—so within a few days, you can already feel a difference in your energy levels and your focus. And this comes from the fact that sirtuins are responsible for so many molecular processes in the cell. And this is why you have this effect, including the mitochondrial biogenesis, which gives you basically increased ATP, consequently.  Lisa: You get actually more mitochondria. So, like, if you got heart disease...  Dr Elena: The production of more mitochondria, and then they produce more ATP as a result. And then you have this magic energy, yeah. This is why I thought to bring this product into the market. And the other reason was that there was not enough reliable suppliers on the market, which is crazy, because it's actually quite a popular supplement. It's been on the rise, the interest was rising for the past couple of years, but what we're seeing is there is a lot of white labelling companies that don't offer any certificates of analysis and so on. And also, you have even big companies not offering proper certificates of analysis, which was me like, it was…  Yeah, I don't understand. You have a big company, and you have just the purity report from like, 18 months ago, and you don't have any other analysis, such as heavy metals, or pH or microorganisms. So, the consumer is actually not confident in buying from you. And I wanted to deliver the best quality for myself and my family. And then I said, ‘Wait a minute. This is not done, right’. And this is why I launched the company because I wanted a company that was completely transparent. And I even say it on the website, that if you're interested in finding out who our suppliers are, and so on, and have any questions about our supply chain, just feel free to reach out to me. And I would be happy to disclose all of those things. There are other companies that you can't find any registration number, or who the founder is, and so on. And it's quite confusing, really, because like you— you don't know who you deal with.  Lisa: This is the same with the whole supplement industry. On the one hand, it's good that it's not regulated by the FDA, and whoever else, there are authorities around the world. Because like, then—they are turned into the pharmaceutical industry, which don't get me started. But on the other hand, there's not enough regulation around the quality control.  And one of the things when I was searching for NMNs, searching the world for it, I had to go overseas and import it to friends in America and get it out of there. And this is why I like—was super excited to discover your work. And then, we've since now made it available down here. So, we're going to branch down here in New Zealand for New Zealand, Australia. And I wanted someone who I could trust, who has all the scientific knowledge behind it, there's all lab tests, etc. And that was really important for me for quality.  Just on a side note. So I've been taking NMN now for—I think—so five, close to six months. I've had a massive weight loss and so as my mum. Why would that be? Like, I didn't take it for weight loss. I wasn't overweight, per se. But I had a couple of kilos that I was quite clear to get rid of. And what I've noticed—because I'm an athlete, that's my background—I haven't lost an ounce of muscle, which has been really awesome because most people are struggling to keep muscle mass, lose fat mass. My mum has lost 11 kilos. And she is of a genetic body type that really struggles with weight loss. She's conservation metabolism, from a genetic point of view, very, very hard for her to lose weight. So, I've never seen this in the history of her entire life, since I've been around. The weights just dropped off her.  Is this some sort of upregulation in the metabolic pathways? Is it improving the insulin resistance? What's it doing there to cause such weight loss without muscle loss? Dr Elena: Well, in my study so far, there's definitely evidence that it does improve insulin sensitivity, and it also improves the lipid metabolism profile. So those two are very important. And unfortunately, we don't have those studies in humans yet. But more clinical studies are on the way, and hopefully we'll have very good results this year with the NMN besides the safety studies that we already have in humans.  So in mice, what we're seeing is that there is basically a reverse of type two diabetes, which is really impressive. And if you want to correlate this data into humans somehow, I would say that, obviously, I'm not a medical doctor, and this is not a medical advice, but I would say that it does have to do something with the metabolism, and it basically improves the way your body metabolises everything. And...  Lisa: Worth trying and there's no downside to NMN. There's no, it's a vitamin B derivative, well then you will say to me, ‘Well, can I just take B3 and be done’? and it's like, no, it doesn't work like that, which should be a lot cheaper. Dr Elena: That’s the other impressive thing about this compound is that it actually doesn't have, if any, side effects at all. So even in studies with mice, where the dosage that they use in mice is actually much higher than it is in the one that we usually have in humans. So, for instance, if someone would take 500 mg, or one gram of NMN per day in humans. And then in mice studies, they use something like 200 mg per kilogram of weight, which is much, much more, and it still doesn't have any side effects. Lisa: Does it mean that we need higher dosages? Like in the human, or has it only been tested to one gram and why has it not been tested higher, if that's the case?  Dr Elena: No, I think that there are studies underway for this as well. So eventually, we will find what is the ideal dosage for humans. I think that from anecdotal evidence, people can already see results from 500 mg or one gram and so on. There are people that take more. So, some biohackers say that they take two grams or four grams, and is still very well tolerated. But yeah, so far, it does not produce any side effects in terms of… Lisa: Any downside. Dr Elena: Basically. And, for instance, for myself, my stomach is quite sensitive. So, when I'm on an empty stomach, I can't take vitamin C or caffeine and I get nauseous and so on. And this is not the case with an NMN. So, I can take it first. It is very well tolerated on an empty stomach, very mild. I really love it. There’s so many reasons to love it.  Lisa: Yeah, yeah, yeah, I have my morning and night. So, I'm on a gram a day. And is there any reason not to take it at night? So I split the dose—reasoning, thinking, keeping the levels up?  Dr Elena: I mean, I would probably take it all in the morning, I think. There's been a study out that it can affect the circadian rhythms as well. And interestingly, it actually affects NMN—sorry—NAD levels affects the circadian rhythm. But it's not the other way around. So, NAD actually dictates the circadian rhythm in the body. So, for this reason, I would suggest to take it in the morning because then your whole body synchronise, then you wake up and you tell to your body that look, it's the morning now, and we're going to have increased NAD level. Lisa: Increase. Ohh okay. So, okay, I got that wrong. I haven't noticed that I've had worse sleep or anything like that, or any rhythm has been out. But I would definitely swap to doing—my thinking process around that was keeping the tissue saturated over a 24-hour period, as opposed to all at once and then perhaps dropping, but I don't know. What is the half-life of it? Do you know? Is there any sort of evidence around that? Dr Elena: I actually, not sure. No, no.  Lisa: There’s no evidence yet. And so yeah, there's a ton of studies still being done that are currently, like this year, like going to be coming out, which is going to be really exciting. So that we're going to get more evidence. I mean, there's this stuff that I've been reading around fertility in animal studies, and they're starting to do human studies, which I personally am very interested in, in reversing aging of the ovaries and even with... I mean, the mice study was incredible around fertility, where the mice were postmenopausal, they actually knocked off any existing eggs with chemotherapy. And then gave them NMN and the mice went on to have babies. And there was a whole study. Dr Elena: This is why I get so excited about NMN and this is why it's my first product because frankly speaking as a scientist, I've never seen results like that with a natural compound.  Lisa: No? Dr Elena: Because there is a bunch of natural compounds out there, there is a bunch of other supplements. And what we're talking about spermidine the other day...  Lisa: Yeah, yeah, it's interesting.  Dr Elena: ...another autophagy activator. Quite an interesting supplement, yes. By the way, it's also an mTOR, independent autophagy activator, which is good. Lisa: Another very good reason to take that as well. And we were looking into that aren’t we, Elena about adding that?  Dr Elena: Yeah, absolutely. We will look into this, but again, you don't see results, like the ones that you see with NMN in multiple studies from other compounds, it's really fascinating. Lisa: Wow, so yeah, so there are other products that are going to... And this is a super exciting thing, like were our grandparents or our parents even didn't get the chance, like, with aging was aging, and there was nothing that you really could do to influence how fast you aged. They weren't aware of it. And later on, it's become well, if you eat better and you exercise a little bit more and you stop smoking and, and stuff, you’ll age slower. But now we're taking exponential leaps in our knowledge. I mean, I fell into this realm when I was reading Dr David Sinclair's book, who is a very prominent scientist at Harvard Medical School, and made his book, Lifespan, which I totally recommend people reading. I was just like, ‘Oh my gosh, if I can stay healthy now’, because I'm 52, ‘if I can stay like, really, in top shape for another 10 years, by then we're going to have stuff that will help me live really long’. And that really excites me. And not just live long, but live healthier.  Dr Elena: That’s the important part. The important part is not to just increase your age, it’s to increase your health span. So, the time that you're spending being healthy. And what you're referring to is actually called the aging escape velocity, where basically we’ll have more advanced research coming in every year of our lives. And this will eventually expand our lifespan, which is amazing. And I also think that if we preserve ourselves well, we might as well see this in our lifetimes, which will be amazing.  Lisa: Absolutely. And I want another few decades, please. Listening to Dave Asprey, who by far, got... Dr Elena: I want another like, few hundreds.  Lisa: Yeah, well, I mean, I know it sounds ridiculous right now. But if you listen to Dave Asprey saying conservatively, and Dr. David Sinclair, too, like, conservatively, we could live to 150, 180, and beyond. Then once they crack the code, and they're actually able to turn the cells back to which they are working on right now. And which they can actually go in the petri dish, from what I understand like with skin cells and make them immortal. And they can't do it in humans because it's too risky, they could turn you into a tumour and stuff. But with the Yamanaka factors that were discovered a decade or so ago, they're actually able to turn the clock back to the point of you being a 20-year-old again. And this is like, ‘Wow, this is pretty exciting. Being able to regrow nerves, spinal injuries, people who have gone blind from macular degeneration’ — all of these things are coming down the line. This is very, very exciting.  Dr Elena: There are several advancements in this field. So, as I said, my PhD is also in stem cell biology. So, I was working with human embryonic stem cells in the lab, and what they can do on a dish is just mind blowing. Because what I was able to do was to take human embryonic stem cells, and then dictate their fate, basically, with different growth factors, and then differentiate them into neural precursors at first. And then to push them further in order to become terminally differentiated neurons. And like four weeks later, you basically have a human brain in a dish and it's a primary human cells. And it's an amazing, physiological irrelevant human platform as well to study disease. And this is what I was doing during my PhD.  So, I’ve seen it with my own eyes. And every time I would do, I would go through this process, I would differentiate the human embryonic stem cells into neurons. It would be as exciting as the first time because of what it represents, because it does represent the progress that we've made so far. And I personally started human embryonic stem cells for the sake of drug discovery. So, I wasn't interested—my project was not focusing on different therapeutic applications. However, I know that there are many advancements in this field as well. So, we do have clinics in America, where you can have a total body rejuvenation, stem cells, and so on. And this technology is definitely advancing.  And I've been actually thinking about the application of this for myself. So as you know, I recently had a dental injury. This is something to keep in mind for the future. So perhaps in the near future, I can just inject myself with a bit of a stem cells there...  Lisa: And that’s already happening to a degree. I mean, I've got a doctor friend up north, who's doing stem cell replacement for joints, and so on, for degenerative joints. Because stem cells, basically, for people who don't understand why this is important. The stem cell is the original like cell, but before it decides, ‘Am I going to become a skin cell, or a neuron or a liver cell’, it differentiates. So, it's a pluripotent stem cell, it can become anything. And so, in the lab setting, you're going to be able to say, ‘Well I want your cell to become a liver cell’. Will we eventually be able to grow organs that can be used for transplantation? Is that sort of one of the end goals?  Dr Elena: Absolutely. And it's already been done with some organs. So for instance, I've heard that there is a research group that basically 3D-printed a functional thyroid gland from stem cells.  Lisa: Wow. 3D-printed. So, the printer gets these differentiated cells somehow, and then makes it into a functioning organ that they will eventually—they're going to be able to actually transplant this into people and save the whole organ donation, horrific troubles that we have currently.  Dr Elena: Yeah, exactly and I think that we're not too far away from this from whole organs being recreated in the lab. We already are able to actually do a 3D culture in the lab and create the so called organoids. So for instance, from stem cells, you can do a brain organoid, where you have a liposphere and it basically consists of different kinds of cells that you see in the brain. So it would have neurons, it would have glial, it will have astrocytes, and then it would have this brain organoid and then you can study it.  So, we're already getting there. We’re close, we’re much closer than we thought we were 20 years ago. And I think that we're not far away from having different kinds of organs being grown in the lab for transplants and so on.  Lisa: Hopefully not our brains because it's the seed of who we are. Honestly reading Dr Sinclair's book, I was like, ‘Am I in a Star Trek movie or something’? because it is pretty, pretty amazing. But when you do this, you also ask that to understand the whole process and how the whole thing functions, and then you can actually really slow down neurodegeneration and optimise things.  And so the NMN that we're talking about right now is the beginning of this really exciting road, which we're going to be staying abreast of. And hopefully adding to what we have available to the consumer right now for prices that are not moon money, that it's out of anybody's reach, but actually what you can do today so that you can preserve your health. So that in 10 years’ time, when the real crazy stuff starts coming on line, you'll be able to live longer and healthier lives. And that's the whole goal of it.  So before we just wrap up, I just wanted to reiterate again, so how is autophagy—can you just put that—how is autophagy related to NAD and sirtuin genes? Can you just put that two pieces together again, just repeat that a little bit? Dr Elena: Sure. So basically, what happens is that you do need autophagy to recycle different damaged organelles in the cell when something goes wrong. So, and this is quite prominent in neurodegeneration because the reason we have—let's say, aggregate from proteins in neurons and dysfunctional mitochondria and so on is because neurons are terminally differentiated cells. This means that they don't divide anymore. So, they rely on autophagy in order to have their housekeeping function because they can't divide the junk away. Okay. So that's the reason why autophagy is important in terminally differentiated cells such as neurons.  Lisa: So there's no hay flick limit for a neuron. There is just only one—when a neuron becomes a neuron, that's a neuron. Okay. Dr Elena: Yeah, yeah. And then that's it. And what happens with the activation of autophagy, one of the signals is—comes through sirtuin 1, which basically can activate the transcription factors that are related to autophagy activation, which is the TFEB transcription factor, EB and FOXO, which are basically influenced the activation of autophagy. And more specifically, the mitophagy as well. So, mitophagy is the arm of autophagy that is responsible for the mitochondrial clearance in the cell. Lisa: Yep, so mitochondria, just for people, are the powerhouses of the cell. This is where a lot of—so all of the energy is produced, if you like. And so, this is why mitophagy, as opposed to autophagy, so mitophagy is doing the same process, but within the mitochondria to keep your mitochondria healthy. And if your mitochondria are not healthy, and they're dying, and you're not having enough mitochondria in your cells, then you are going to be sick. And that could be heart disease, it could be neurodegeneration, that could be anything. So, keeping your mitochondria healthy is the basis of all bloody disease, blatantly.  Dr Elena: Yeah, exactly. So then, if you have impaired autophagy in the cell, and then you also have some sort of DNA damage going on, such as the one from reactive oxygen species, for example. And then what you have is the activation of the PARP enzymes. And PARP enzymes heavily rely on NAD levels in the cell in order to function. And NAD is also a substrate for the sirtuin genes that are responsible for also regulating a bunch of very healthy, a bunch of processes in the healthy cell. And for this reason, if you do have increased activation of PARPS, you will eventually get this NAD drain out of the cell. And this will not be enough in order for the sirtuins to function properly. And this will also deplete your autophagy. So, both NAD levels and autophagy are important to the cell. And fortunately for us, we can actually replenish the levels of NAD by supplementing with an ad precursor such as an NMN. Lisa: Okay, and so NMN has been proven to be by most of our bio available, because there's also like nicotinamide riboside which is used in a number of supplement companies that I know have nicotinamide riboside, but not many, there are some now, but have nicotinamide mononucleotide. Nicotinamide riboside is also a great molecule, but it's two steps away from becoming NAD. As long as it’s available.  Dr Elena: Yeah, so nicotinamide riboside needs to be phosphorylated and fast converted to nicotinamide mononucleotide first. And then this will enter the cell and then this will increase the levels of NAD in the cell. And for this reason—so first, this area of research was focusing on the NR molecule, the nicotinamide riboside. But then when they started studying NMN, they actually saw that there is increased bioavailability and there is increased levels of energy that come after supplementation with NMN. Lisa: Can you take—because NAD is a molecule, you cannot just take it as a capsule, and then it's all good to go. Can you take it as an infusion because I have heard of NAD infusions. I mean, it’s not available here.  Dr Elena: Well, and I'm curious myself about this, and I haven't done it, I haven't tested it. And from what I've seen—so the concentration of NAD in those intravenous injections is quite low. And I think that the same way that we have many opportunistic companies in the supplement field, we also have many opportunistic clinics that offer this kind of treatments. So, again, this is not something that I have studied in depth, and I actually don't know how much will it help. But yeah, I mean, this is another way to boost NAD, I guess, and you can try it out.  But with oral administration of NMN, we do have evidence that it can boost the levels of NAD in the tissue and in liver tissue and muscle tissue, and so on. And also, it's much easier to do and it's obviously much cheaper because those injections cost a lot. Lisa: Yes, yeah. Just one last question in relation to antioxidants, because I mean 10 years ago or so we used to think our reactive oxygen species ,oxidative stress happens through the electron transport chain. When we're metabolising, and so on, we get all these oxidative stresses and free radicals running around. And if we take antioxidants, we're going to be counterbalancing that. Does supplementing with antioxidants, like vitamin D, like glutathione, like vitamin C, and so on, alpha lipoic acid, is that going to contribute, too, to the slowing of aging, because it's going to down regulate the PARP enzymes? Dr Elena: People were very optimistic about antioxidants, something like 20 years ago. And everyone was talking about it and so on. But actually, the big studies that have been done, have shown that by taking antioxidants, you actually do not suppress aging. And there are some biomarkers that might have changed in those studies. But most of the biomarkers that they measure stay the same. Basically, saying that antioxidant is not the... Lisa: Not the holy grail. Dr Elena: ...that everyone was thinking about.  Lisa: Was hoping, yeah. Not to say that antioxidants don't have their place because they definitely do. Especially if you have a lot of oxidative stress, and you need to, like with vitamin C, if you're infected, or—I've done a whole series on vitamin C. But then it's not the holy grail for stopping the aging process, but it probably does help with not having so much PARP activation. I don't know, as a non-scientific brain, I'm just connecting dots.  Okay, so I think it's probably we've— so from a lifestyle intervention, apart from taking NMN and resveratrol, and oleic acid or olive oil, intermittent fasting, is there anything else that we can add to our anti-aging regime on a lifestyle intervention side?  Dr Elena: Intermittent fasting, and then avoid exposure to sunlight, as we said. And sirtuin genes are being activated from any kind of stress. And what we can do is we can also induce some sort of an artificial stress, which could be done, let's say with cryotherapy. This is what cryotherapy does. When you're exposed to cold, you also have this stress signal that activates sirtuins, or the other way around, so you can try out a sauna. And this will also have the same effect. So, I think this is also something to keep in mind.  Lisa: Breathing, breathing. So, sort of tumour breathing, or, like what one half does all of that sort of stuff. So, there’s hormetic stressors, there’s exercise obviously, that cause a cascade of changes and make you stronger. And yeah, it's sort of a balancing act. You don't want to be doing exercise for Africa or really freezing yourself to death, but you just want to have a little stress to cause a change in the body. So these hormetic stressors can be very, very helpful.  Okay, well, I think we've covered a very, very, very complex topic and I hope we didn't lose everybody on the way. But at the end of the day, take NMN, take resveratrol, take olive oil, do your exercise, get in the sauna, if you have a chance to do cold therapy, do that as well. Get your exercise, get your antioxidants in there as well, to a certain degree and you're going to be able to live long enough but until other things come online, and you'll be able to improve everything.  Dr Elena: Sounds good.  Lisa: Brilliant. So Dr. Elena, thank you very much. Dr. Elena has been on the show, NMN Bio. So we have nmnbio.co.uk in UK and in Europe, and nmnbio.nz if you're down at this end of the world. We'd love to help you over the air. If you've got any other questions, please reach out to us. And thanks very much for being here today. It's been really exciting. Dr Elena: Thank you, Lisa, thank you so much for having me. That's it this week for Pushing the Limits. Be sure to

We all want good health and a long life. That's why we subscribe to health fads that offer promising benefits to our bodies. But, for this same reason, we tend to neglect foundational health principles. While these are easily accessible to us, there is still so much we can learn and get from them. By going back to the basics, we can take better care of our health, prevent diseases and boost longevity. Dr Elizabeth Yurth joins us in this episode to talk about the importance of cellular health in longevity. She gives an overview of the benefits of foundational health principles in the disease process. Dr Yurth delves deeper into fasting, autophagy and the specifics of spermidine. If you want to know more about slowing the ageing process and boosting longevity, this episode is for you.   Get Customised Guidance for Your Genetic Make-Up For our epigenetics health program all about optimising your fitness, lifestyle, nutrition and mind performance to your particular genes, go to  https://www.lisatamati.com/page/epigenetics-and-health-coaching/. You can also join their free live webinar on epigenetics.   Online Coaching for Runners Go to www.runninghotcoaching.com for our online run training coaching.   Consult with Me If you would like to work with me one to one on anything from your mindset, to head injuries,  to biohacking your health, to optimal performance or executive coaching, please book a consultation here: https://shop.lisatamati.com/collections/consultations   Order My Books My latest book Relentless chronicles the inspiring journey about how my mother and I defied the odds after an aneurysm left my mum Isobel with massive brain damage at age 74. The medical professionals told me there was absolutely no hope of any quality of life again, but I used every mindset tool, years of research and incredible tenacity to prove them wrong and bring my mother back to full health within 3 years. Get your copy here: http://relentlessbook.lisatamati.com/ For my other two best-selling books Running Hot and Running to Extremes chronicling my ultrarunning adventures and expeditions all around the world, go to https://shop.lisatamati.com/collections/books.   My Jewellery Collection For my gorgeous and inspiring sports jewellery collection ‘Fierce’, go to https://shop.lisatamati.com/collections/lisa-tamati-bespoke-jewellery-collection.   Here are Three Reasons Why You Should Listen to the Full Episode: Find out the importance of hormone metabolisation and cell fixing in preventing and addressing diseases. Learn the importance of going back and forth between different health routines. Discover the benefits of spermidine in improving health.   Resources Pushing the Limits Episode 181: Genetic Predisposition and Understanding Your Hormones Join the Human Optimization Academy for FREE at Boulder Longevity Institute! Bulletproof Radio Abundance 360 Low Protein Intake is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population PubMed Seed Scientific Research and Performance Boulder Longevity Institute’s Facebook page       Episode Highlights [01:54] Dr Yurth’s Practise and Boulder Longevity Institute Dr Yurth has been practising orthopaedic medicine for 30 years. Fifteen years into her career, she became frustrated with the band-aid solution process in orthopaedics. She started looking at the way to stop this downhill decline. She did a fellowship in functional and regenerative medicine and incorporated it into her practice.  However, short consultation sessions for such proved to be inefficient, so they opened the Boulder Longevity Institute. They started the Human Optimization Academy to educate people about orthopaedic regenerative care. Every single disease comes down to the mitochondrial level that requires systemic treatment. [07:16] Foundational Health Principles There are a lot of cool fads on taking care of your health. However, we have to start with the basic principles. Metabolising the hormones is very important. A urine metabolite test determines the pathways where hormones are going. Simple lab studies, including CBC and CMP, can give an estimation of longevity comparable with telomere length testing and DNA methylation. Looking at albumin can predict longevity. Listen to the full episode to have an in-depth look at how albumin works! You have to train people to go back to understanding these foundational principles. [21:33] An Overview on Cellular Health Every organ system comes back to cellular dysfunction. When you have damaged mitochondria, the cells are in an altered state of energy. Senescent cells are cells that sit in the body without doing anything. Zombie cells become toxic to the cells around them. To heal any disease, we have to clean out the bad cells. They use fasting in the disease process because it causes autophagy. The biggest mistake people make is to try to have many antioxidants and NAD in the body. To clear out the bad stuff, Dr Yurth and her team use rapamycin and spermidine. Tune in to the full show to know more about these cell-restoring methods! [27:45] Fasting and Autophagy Mimetics There’s a lot of questions about fasting that even experts have no answer to. Autophagy is self-eating. You can have autophagy without being in ketosis. One of the benefits of fasting is oxidative stress. Taking resveratrol reduces this benefit because it has a potent antioxidant. You don’t want to be doing any protocol and patterns continuously. You have to go back and forth between different things. A balance between mTOR and NPK keeps things in a homeostatic state. [35:08] Muscle Building and Longevity Muscle building is not the key to good health and longevity. The genes that stayed in our body’s genetic evolution are those that will help us survive famines. While research has shown that low IGF people live long, they don’t have good energy. It's about repeatedly bringing IGF levels down and building it up. The cells need a push and pull for them to become healthier. [38:36] All About Spermidine Spermidine is present in every single living organism. It is prominent in our guts and in some food, with the richest source being wheat germ extract. The major research of spermidine is its benefit in cardiovascular diseases. Myeloperoxidase is an inflammatory cardiovascular marker, of which they have seen high levels in post-COVID patients.  Research has also found that spermidine can lower Lp(a). Immune system support is another place where spermidine has been studied. Spermidine, along with the peptide thymosin alpha 1, can improve lymphocytes. The early studies in spermidines are on hair growth. It affects the body's overall regeneration process. [46:29] Using Spermidine Starting from a low level, it takes a while for spermidine to make you feel better. One of the things Dr Yurth did when she started spermidine was to monitor her heart rate variability (HRV) and her Oura ring. HRV is predictive of almost every disease state. Getting a higher dose of spermidine comes at a great cost. But it's putting your health at a priority. [50:35] Why You Should Trust the Research Fixing the cells at the very base level takes time. Dr Yurth is part of the Seed Scientific Research and Performance along with 25 mastermind doctors. Through this, they weed out what works and what doesn’t. If you want to learn more about how Dr Yurth applies her practise, listen to the full episode! There are a lot of inexpensive things you can do that are effective. If it doesn’t respond, that’s the time to pull up the bigger stakes. The Boulder Longevity Institute bridges the gap between research to save lives.   7 Powerful Quotes from This Episode ‘It is not that you run too much; you wear your knees. It's that there is a disease process going on in your body that is now making your joints wear out, and so you have to treat it systemically, or you're not going to make any progress’. ‘The cool stuff is cool, and there's a place for it in all of us. But you still got to start at the basic stuff’. ‘There's so much information in these really simple lab studies that you've gotten from your primary care doctor’. ‘I think even the functional medicine space sort of went beyond the step of looking at some very basic things that are inherent to life’. ‘You're never going to train doctors; you've got to train people’. ‘There's not really anybody who has one disease that does not have something else wrong; it's just impacted lots of times in different ways’. ‘We want to go back and forth between different things. And we want to make sure we're cycling. Any of you are staying on the same patterns all the time, that's not serving you’.   About Dr Elizabeth Dr Elizabeth Yurth is the co-founder of the Medical Director of the Boulder Longevity Institute.  She is a faculty member and a mastermind physician fellow in Seeds Scientific Research and Performance (SSRP). She specialises in Sports, Spine, and Regenerative Medicine and has double board-certification in Physical Medicine & Rehabilitation and Anti-Aging/Regenerative Medicine. She has a dual-Fellowship in Anti-Aging, Regenerative and Functional Medicine (FAARFM) and Anti-Aging and Regenerative Medicine (FAARM). Dr Yurth is also an active athlete and has worked with numerous sports teams at collegiate and professional levels. She does consultations with high-level athletes to optimise performance and aid recovery. If you wish to connect with Dr Yurth, you may visit her Instagram.   Enjoyed This Podcast? If you did, be sure to subscribe and share it with your friends! Post a review and share it! If you enjoyed tuning in, then leave us a review. You can also share this with your family and friends so they can include more amino acids in protein in their diet. Have any questions? You can contact me through email (support@lisatamati.com) or find me on Facebook, Twitter, Instagram and YouTube. For more episode updates, visit my website. You may also tune in on Apple Podcasts. To pushing the limits, Lisa   Full Transcript of The Podcast Welcome to Pushing The Limits, the show that helps you reach your full potential with your host Lisa Tamati. Brought to you by lisatamati.com. You’re listening to Pushing The Limits with Lisa Tamati. Fantastic to have you guys back with me again. I hope you're ready and buckled down for another great interview. I really do get some amazing people and this lady is no exception. So today I have Dr. Elizabeth Yurth, who I originally heard on the Bulletproof Radio Podcast with Dave Asprey, who I love and follow. And she is a longevity expert. But Dr. Yurth is also a medical director of the Boulder Longevity Institute, which she founded in 2006. And she's double board certified in physical medicine and rehabilitation and anti-ageing and regenerative medicine. So she's a specialist in sports, spine and regenerative medicine.  She's an orthopaedic surgeon, and she's also heavily into the whole regenerative stuff. So from stem cells to different supplements to working with the latest and technologies that are available to help us slow down the ageing process and to help people regain function. So it was a really super exciting episode and I'm going to have Dr. Elizabeth on a couple of times. She's also a faculty member of the 25 mastermind physicians fellows at the Seeds Scientific Research & Performance group, which allows you to stay abreast and teach others in the emerging cellular medicine field. She's also been an athlete herself and works with numerous sports teams and both of the collegiate and professional levels. She's a wonderful person and I'm really excited to share this interview with her.  Before we head over to talk to Dr. Yurth, I just want to let you know about my new anti-ageing supplement. Now this has been designed and developed by Dr. Elena Seranova, who is a molecular biologist who is also coming on the podcast very shortly. And this is an NMN. It has nicotinamide mononucleotide. I recently read the book Lifespan by Dr. David Sinclair, who's a Harvard Medical School researcher in longevity and anti-ageing. And he's been in this field for the last 30 years. And his book was an absolute mind blowing, real look into the future of what we're going to be able to do to stop ourselves ageing to slow the ageing process down. And very importantly, increase, not only our lifespan, but our health span so that we know we stay healthy for as long as possible and don't have this horrific decline into old age that most of us expect to have.  So Dr. Sinclair in this book talks about what he takes and one of these things is an NAD precursor called nicotinamide mononucleotide. I searched all over the place for this. I couldn't get it in New Zealand when I was searching for it. And so I went and found Dr. Elena Seranova, who has developed this product and I'm now importing that into New Zealand. So if you want to find out all the science behind it, please head on head over to nmnbio.nz. That's N-M-N bio dot N - Z and all the information is on there. And you can always reach out to me lisa@lisatamati.com, if you've got questions around that.  We've also updated our running coaching system. So the way that we are offering our online run training system is now on a complete new look. We are doing fully personalised, customised training plans for runners of all levels and abilities. So we will program you for your next goal doing a video analysis of the way you're running, improve your running form through drills and exercises. Build your plan out for you. You get a one-on-one consult time with me as well. And just really help you optimise your running performance and achieve those big goals that you've got. So head on over to runninghotcoaching.com to check that out. Right now over to the show with Dr Elizabeth Yurth in Boulder, Colorado.  Lisa Tamati: Well, hi, everyone, and welcome back to Pushing The Limits. Today, I have Dr. Elizabeth Yurth with me from Colorado—Boulder, Colorado, and she is a longevity and anti-ageing expert. She's an orthopaedic surgeon. She's a real overachiever. And I'm just super excited to have her on because I have been diving into Dr. Yurth’s world for the last couple of weeks since I heard about her on the Bulletproof radio show. So Dr. Yurth has kindly given up an hour of her time to come and share her great knowledge. I know we're only going to skim the surface, Dr. Yurth, but it would be fantastic if we can gain some amazing insights on how the heck do we slow down this ageing process. So, Dr. Yurth, welcome to the show.  Dr. Elizabeth Yurth: Thank you so much, Lisa. I've been actually stalking you ever since you asked me to do this. And I've been fascinated with all the things you've been doing and teaching and I love it. I love that there's people like you out there who are now getting the masses involved in this and interested in this because doctors aren't doing it and so it has to be that educate the public. And people like you are paramount to that, so thank you. Lisa: Thank you very much. Yes, I think, yes, this is the beauty of podcasts and such things and will in the internet whenever we can go direct to the best minds on the planet, get the information direct to the consumer, cutting out all the middle people, so to speak, and really get this information out there. Because what I've found in my research in the last few years is that there is so much amazing, great science out there that has never seen the light of day and certainly not in local clinical practice being utilized.  So Dr. Yurth, can you tell us a little bit about the Boulder Longevity centre before we get underway and what your work there is all about and your background? Dr. Elizabeth: Sure, I'd love to. So basically, I've been in the orthopaedic medicine world for 30 years. And about 15 years ago, I actually became very frustrated because I saw people coming in and they would get injured or just have arthritis, chronic pain and we would sort of patch them a little bit and nothing ever really got better, and then something else will get hurt. And it really was just this downhill process from square one. I mean, I tore my first anterior cruciate ligament in my knee at the age of 18 and subsequently, had torn two or three more times between the two knees, had four more surgeries and then it was just a downhill decline.  And so, we started looking at is there a way to stop this, because you don't learn it in medical school, and you don't learn in orthopaedic medicine. And when I started looking into—and this was a very early time in the whole functional medicine space, it was really early, there wasn't a lot. And so I went back to American Academy of Anti-ageing Medicine, which is really the only thing available at that time, and did a fellowship in functional medicine and regenerative medicine and tried to incorporate that into my orthopaedic practice as much as I could. But it's difficult in 10 to 15 minute appointments to do that. So we realized that you can't really do good medicine in that model, and so we opened Boulder Longevity Institute about 15 years ago now. And I really sidelined did both practices, because what I found is that people are still looking for that insurance-based practice, and I try as much as I could to educate them there. And then some of them would transition over to here and over time for 15 years, Boulder Longevity Institute has really grown and developed, and subsequently is now my full-time practice. But we do a lot of orthopaedic regenerative care here, the targeting, taking care of people and getting them healthier in that realm.  But much like you, our focus is very much now on education and we have a whole, what we call, Human Optimization Academy. We're trying to bring the just like you said, the research to the people. Peter Diamandis, who runs Abundance360—is very well known, you probably know him — he has a great quote where he says, ‘Researchers don't do medicine. And doctors don't do the research and learn the research and use on their patients’. And so, there's a lag of about 15 to 20 years since when something is available to us that will make us better and ever getting to us.  Lisa: Exactly. I had the exact same conversation with another doctor, Dr. Berry Fowler and we were talking about intravenous vitamin C and I said, ‘Why is it taking so long and critical care to get this in?’ And he said ‘because it's like turning a supertanker’. He says, ‘It's just so slow’. And so people are not getting the benefit of the latest research. And for an orthopaedic surgeon to go down this anti-ageing functional medicine route is a very rare thing, or at least in my country, it would be a very rare thing. Dr. Elizabeth: Yes, orthopaedics does not cross over this line at all. And ultimately, it's one of the reasons I had to leave my other practices because my partners were very much like, ‘Stop talking about medicine. That's not what we do here’. And you have to—even arthritis is a disease. It is not that you ran too much and wore out your knees. There is a disease process going on in your body that is now making your joints wear out. And so you have to systemically treat it or you're not going to make any progress. Lisa: Oh man, people so need to hear that because it is an inflammatory process that's coming like out of the immune system. And I've heard you say a couple of times on some of your lectures, I listened to one on mitochondria. And mitochondria is sort of the basis of where a lot of other things are coming from, isn't it, and diseases are probably...  Dr. Elizabeth: Everything. Honestly, I think what we're going to find is that every single diseases—every single disease is going to come down to mitochondrial level. In fact, I was just reading a new research article on autism and mitochondrial dysfunction, that they're actually linking this mitochondrial dysregulation in even autism. I don't think that we're going to find any disease that is not linked first to mitochondrial dysfunction, which is fascinating because mitochondria are fascinating. So it's really my passion is, is how do we repair mitochondria. But that you start looking at—you can pretty much do that. You guys go out there and Google mitochondria and any disease you can think of and you will find research to support it.  So, in arthritis it is exactly the same, right, Lisa? You're right. It's damage to now the mitochondria and the chondrocytes. And that damage—you get these damage from chondrocytes, which then are actually spewing these reactive species that are damaging the next cell and the next cell. And simply sticking steroids in that joint is not going to help it.  Lisa: Wow. So we want to talk a little bit today, like we talked about our foundational health—a few foundational health principles so that we can then get on to some of the cooler, more sexier stuff that I want to talk about, like things like spermidine and peptides and NAD precursors, perhaps, and all of these sort of really cool things.  But what are you seeing in your practice—like you're seeing a lot of people who are becoming aware of their health, they're looking at everybody knows the basics about nutrition now, I think. Like, fried foods are not good for us, sugar is not good for us—the basics. But what are you seeing as missing in that foundational side of things? Dr. Elizabeth: So I think this is the biggest thing I've seen over the past—probably a year. And as I've done more podcasts, and I've listened to more podcasts, and now you have all the bio hacker groups and the peptide group, so everybody is doing all this cool thing. So now, like, ‘Oh, I got to go do my hyperbaric and I have to go take my growth hormone, peptides’. And they come in to me, and I was just telling you about a patient I saw who literally had a worksheet, spreadsheet of all the things he was doing. And I said, ‘Well, are you taking testosterone’? And he was 56 years old, I said, ‘Are you taking testosterone’? ‘No’. And I said, ‘Have you ever looked at your nutrient pound’? ‘Nope’.  So, what I really want to encourage your listeners is the cool stuff is cool, and there's a place for it in all of us, but you still got to start at the basic stuff. So, when we look at people we have to go through and we have to fix—so we look at all the hormones and you just did a great podcast looking at hormone metabolism, right? Because people are so scared of hormones and they’re terrified that these hormones are going to cause cancer. And we know that's not true. It's how you metabolize the hormones that's important, which has genetic and environmental. You just gave an incredible podcast with your guests the other day on that. Lisa: With Dr. Mansoor; he's wonderful.  Dr. Elizabeth: Right. And your epigenetic background, that the key is how these hormones are processed. So when we look at hormones, we actually do a urine metabolite test. So we know exactly where those hormones are going, and are they going down bad pathways or good pathways? So you've got to repair all that, first, fix all the pathways, which you do, and you know your CYP genes and all that kind of stuff. How do you alter it? There's nutrients that you can use to do that. There's tons of things, exercise. So, fix all the hormones first. Men and women all need hormones. I think testosterone’s neglected in women all the time, right? They're on estrogen, progesterone, and I'm like, ‘You’re not on testosterone’? Like, ‘No’. And so even within the realm of our type of medicine, we are neglected in that realm. Right?  Testosterone is huge for women. If you want muscle, you need testosterone.  Lisa: I basically got good muscles. Dr. Elizabeth:  Right, that’s right. So, you've got your testosterone on board, and it has to be not alternating into estrogen—all that has to be involved. So you've got to fix that. And then, there's so much information in these really simple lab studies that you've gotten from your primary care doctor. So, a complete blood count, a CBC, a CMP. Everybody has them, and everybody's doctor looks at and goes, ‘Yep, looks good. There's no reds in there, everything's perfect’. You can actually take that—and Dr. Levine, anti-ageing expert, did a whole algorithm that just taking some of these blood work give you very comparable estimation of longevity as doing telomere length or doing methylation.  So, we have all these expensive tests to look at DNA methylation and telomere to look at age, and you could come up very close to the same number, simply by feeding some of these parameters, like your albumin level and your metabolic calculator that would... Lisa: Wow! Is that available publicly, that calculator?  Dr. Elizabeth: I'm not sure how publicly available it is. We actually have access, and we utilize that in our patients to follow it. But it's great, because these other tests are expensive. And if I want to put you on a protocol and then see if I'm making headway, how do I follow that? So, I don't think people know that, for instance, what is one of the most valuable numbers on your CBC? It’s actually the size of your cells, the mean cell volume, and the rest of distribution?  Lisa: Yes, I'm just studying cell distribution. Dr. Elizabeth: Isn’t that fascinating?  Lisa: We are completely unaware.  Dr. Elizabeth: And have any of your listeners have had the doctor ever mentioned what their MCV is? Or their RDW is? And those are very, very important. So is albumin. So albumin alone, which is not just dietary. There's a great study that you could predict who is going to get out of the hospital alive based on their albumin levels. And so simply looking at things like that. So if your albumin levels are low, maybe it's because you're not eating enough protein, but that doesn't—it tends to be something else wrong. Lisa: Liver not doing something.  Dr. Elizabeth: Definitely. And sometimes that's the need for more beta carotene. Sometimes it's need for more copper. Copper has to help carry the albumin and copper deficiencies are super low. Nobody measures copper. So, you can look at a low albumin and try putting somebody on a little copper, it’s quite GHK copper as a peptide, I might get to the fancy stuff. Using copper as a peptide is an amazing peptide. It's very longevity promoting because copper is super vital to our health. And so sometimes just putting people on two milligrams of copper can markedly improve their health.  Lisa: But isn’t there copper’s also a toxicity problem? Isn't that quite a lot of people have high copper levels?  Dr. Elizabeth: Less than you think. So it's gotten a lot of market to that, right? It has to be that zinc copper balance has to be imbalanced. So that's one of the things. But actually, copper toxicity is pretty easy to tell. When people become copper—toxic on copper, you'll see the lunula, the fingernails start turning, a little discoloured, a little bluish in colour. So it is a little harder to get toxic in copper than people think. I use it a lot for wound healing in my patients. So, it really helps with wound healing. It's why it's in all skin, expensive skin creams, copper peptides are because it's so good for collagen function, it’s so good for wounds. So I think we may scare people a little bit from copper. But it actually has some value. And a lot of times, it's not so much that you have too much coppers, you don't have enough zinc and that balance is not there. It has to be balanced between zinc and copper. So those are simple things that you can actually look at and measure. And you can—I don't have to do it on everybody.  So I see somebody who has a low albumin, I might say, ‘Hmm, we better look at your zinc and copper level’. So we take the CBC and CMP. And how about simply creatinine? If your creatinine is above point eight, that is not good for longevity. So, why is that?  Well, maybe you're eating way too much protein, right? We will erase any high protein diets, super high protein, the kidneys can only process so much protein and your kidneys depend on your genetics, maybe less. So that's all things I think you have to go back when you talk about foundational health.  I spend literally 30 minutes going through a CBC and a CMP with people. They’re so valuable, and those are $12 tests. Not these big, fancy, expensive tests, they don't cost $500 or $600. And by the end of that test, I can give them, this is what your biological age, your pheno age, this is where we really need to target and start with them some very basic, inexpensive things.  Lisa: Crikey dex, that's amazing. I didn't know we can get to that. I mean, I've only been studying blood chemistry for a couple of months and like it's a big topic isn't it?  Dr. Elizabeth: It has some really cool value to it that you can actually look at. Some ranges that—we have all gone from the normal range, right? All your listeners now know this the normal range, there's an optimal stage. Within that optimal range, right, there's one number above that you'll see you start to see a change in ageing. The curve on your projected longevity, you look at  albumin levels, and you look at the curve on your projected longevity. If your albumin levels are less than 4.6, your projected longevity is five to 10 years less than somebody who's above 4.6. Lisa: Crikey. No one's ever told me any of these things and I’ve been studying blood chemistry and from functional doctors, like that's all news to me. Dr. Elizabeth: Yes, I think that that's the problem. I think even the functional medicine space sort of went beyond the step of looking at some very, very basic things that are inherent to life. And now start focusing, ‘Oh, let's look at hormones, right? Let's look at the gut microbiome’. All super important, but all going to be messed up, if the other stuffs messed up, right?  Lisa: You’re basically not in the right place. Dr. Elizabeth: And so I—that's where I get a little frustrated. So now we're targeting back to that whole cellular health, it all comes back down to the cell, fix the cell. As the cell gets fixed, the mitochondria get fixed, everything else falls. So once you've refined that now, we can look at gut microbiomes, if the person is not doing well. We can look at things like micronutrient profiles, and I love micronutrient profiles because I don't know if how much vitamin D you need or how much vitamin B12 you need. Micronutrient profiles, particularly one that gives me intracellular and serum levels, as you know genetics plays a huge role in your micronutrients.  Lisa: Yes, vitamin D, for example. I mean, I know I have bad vitamin D genetics, so I need to supplement with vitamin D. Right?  Dr. Elizabeth: And B12, you've got the SUV people of B12. I’m one of those who need a lot of B12. It's all very genetically based. So, you can predict it from genetics. But then are you accomplishing your goal? I think you need some… Lisa: Measurements. And this is where the combination of what I'm—like the combination of doing your genes and finding out your innate pathways and what they do, and then seeing actually where you are, getting that snapshot of ‘Okay, we are actually in their hormones and stuff’. And it's quite complicated.  And this is the problem is that you go to your local doctor, at least here where I live, and none of this is offered. And none of this is—and so you left as a lay person trying to work this stuff out yourself. And that's quite frustrating and quite difficult. Dr. Elizabeth: It's hard. And it gets caught up again, in the glitz and glamour. I'm going to be attracted to my podcast that's talking all about the coolest, newest thing, it's just our nature is to want the coolest, newest thing. And we just talked about that. We want that cool new thing, because that is on the forefront. And we use those cool new things to help fix the basics. But you still got to know where you are in that standing, and that's really now become, I think, one of my frustrations as I'm seeing more and more people walk in my door, who are doing everything they’re thinking of.  And so we are trying to teach people this. We're trying to teach people how do you interpret your own blood work? How do you look at every one of those parameters and say, ‘What should my albumin be? Okay, it's too high, it's too low. What can I do to fix that’? Whereas, if my MCV is, mean cell volume. If your mean cell volume, and you look at your own. As we age, I look at my 19 year old son, he has a mean cell volume of 83. If I look at your average person who's in their 50s, and 60s, who's our age, it's going to be 97, 98. So the higher that number goes, the more your stem cells are wearing out, the more your bone marrow is wearing out, the more that whatever you're doing isn't working.  So we can use those things, like you can use your infrared, you can do all those great things. Me, I infrared, I cryo, I do all that. But I will tell you some very basic stuff that sometimes has been the things that made changes in those numbers. I want people to know, that's them that, honestly, is why we decided you're never going to train doctors, you've got to train people. But we've also got to get people back to understanding that you've got to sort of learn these things and kind of a fashion of can learn this, learn this, learn this. When I understand everything about how hyperbaric oxygen improves my cell function, have I really learned how to just look at the cell at that molecular level from looking at basic labs? And that's what we're trying to teach people. Start there, and then we give them tools.  Lisa: Fantastic. So people can join Dr Yurth, and get us some of this education. And I've started delving into it and I can't wait to see what else comes along because I mean, this sort of stuff, I'm like already going, ‘Oh my god, I didn't know that’. So I've learned something today already as well. And I'm very definitely guilty of going after the shiny object and love it. Dr. Elizabeth: It’s human nature. That’s human nature.  Lisa: Yes. And so people can go to the Boulder Longevity website and I'll put the links in the show notes and there is a Human Optimization Academy, join up for that and it's actually free at the moment, isn't it, Dr. Yurth?  Dr. Elizabeth: Right. Right now, it's free. And we'll start putting together—so right before COVID hit, we actually had an in-person course. We're actually going to teach how to look at your own CBC and CMP. And COVID hit, and it all sort of fell apart. But we'll be putting that back into sort of a virtual course with people so you can actually get your bloods run. We will walk you through. So, here's how to interpret every one of those little numbers you see on there because I will tell you, every one of those little numbers is important. Everybody just looks at it as a piece of paper, and there's no red marks highs or lows, they sort of discard it. And we'll show you how to look at that and give huge value.  And just from those simple things, you can now say, ‘Maybe I better get a micronutrient panel’, or at least test a copper or zinc or a B12, or D based on some of those numbers that you see being off. And then take the tool, now fix the basics. ‘That's not working? Okay, now, maybe I need to add this, this, this’. Lisa: And then now we can get fancy. Well sign me up for that course because I need it. And I'm already up on some of it, but I wasn't that familiar with some of the things you've just said. So like, that's just like, well. Okay, so we're looking at foundational stuff. Now let's go and look at cellular health, per se, because it all comes down to the cell. The more I look into things, the more everything seems to be about mitochondria in the cell, and what they're doing. and when we're made up of what? 10 trillion cells or something ridiculous. So cellular health, can you give us a bit of a view—it's a big topic, isn't it? But where should we start? Dr. Elizabeth: Yes, well, I'm going to start with first kind of explaining what that means. So, functional medicines, we went from a disease-focused medicine, right? And then we all got very savvy—well, not the doctors—but the rest of the world who got very savvy said, ‘Oh, this isn't working. It's making somebody money, but it's not working to make anybody happy’.  So we went to a functional medicine part. Let's look at organ systems and let's start. So then we went to the organ system, let's look at the adrenal glands and let's look at the liver in this and let's now fix the organ system that's dysfunctional. we got to fix the thyroid, we got to fix the endocrine organs and we have to do all that.  And then now, and this is really super recent, we're realizing that every organ system comes back to a cellular dysfunction. And there's not really anybody who has one disease that is not have something else wrong. It's just impacted lots of times in different ways. So if I have osteoarthritis. So if you have osteoarthritis, your risk of dementia is about fivefold higher. So why is that? Right? Osteoarthritis... because I ran 800 miles a day. But that's not the case, I have patients who run 800 miles and they're fine.  Lisa: Oh, I'm fine. Like, my joints are fine, and I haven't got any osteo. Dr. Elizabeth: And then you have people who are like, ‘Oh, yes, I just wore myself out because I ran too much’. No, not the case. So, there's something wrong. So now we have to go back and look at what is wrong in the cell. So if you think about what power, what is the cell all about? It is the mitochondria. Mitochondria, what gives the cell energy, right? And so as we start getting damaged to our mitochondria with time and life and environment and genetics, and we start getting damage at the mitochondrial level. So, now have these damaged mitochondria. And now we start getting these cells that are in this altered state of energy. And that's when you start getting that senescent cell—cells that are basically sitting there… Dr. Elizabeth: They’re zombie cells.  Lisa: And there's zombie cells, right? And they're producing these reactive oxygen species. And that's why they're called zombie cells, it's because the things that are being spewed out, are now toxic to the cells around them and then toxic to those cells. And so, it truly is like a zombie takeover.  So that's where we look at when we're going back to a cell level. First thing we have to do to try and heal any disease is clean out the bad cells. Clean up the zombie cells. That’s why fasting has been utilized for years in every disease process because we know that fasting causes autophagy, causes bad cells to go away, and now we can rebuild. I think one of the biggest mistakes people make is that if I start throwing a lot of rebuilding things into my network, tons of NAD and I'm trying to always be in this state where I've got a lot of antioxidants going. I'm throwing a lot of NAD and well then, I'm actually contributing to that cell senescent state. I've got to get rid of that first.  Clear out the bad stuff and do that periodically. And we use things like rapamycin, you can use it for fasting. And most recently what my go-to has been this spermidine for that talk. And I fell in love with spermidine a few years ago, actually and couldn't get it here in the US. That basically—it came onto my radar because there it worked at a very sort of primal level. Every single organism has spermidine. Anything that every organism has, is vital to life. And so we know that—and then all these studies that show that well, if you have higher level spermidine, you live longer, so. And it was only available in—I don't know if you guys could get it—but it was available in Europe.  Lisa: I’ve just got my first order on its way. But I had to get it via Colorado, and I've actually being in contact with the guys in Austria. So, working on that one, I'm getting it down here. Dr. Elizabeth: We couldn't get it. And like six months or so ago, we finally could get it here in the US. And it works as an autophagy inducing agent. It basically tells the cells to get rid of the bad stuff, it helps to restore the good parts of the cell. And really, at a baseline level is probably the one supplement that I know of, and probably the only one I know of, that is going to be actually balancing cell health continuously. Lisa: So it's homeostasis as opposed to... Dr. Elizabeth:  The homeostatic state. Right.  Lisa: So like, just to backtrack a little bit there because we covered a heck of a lot of ground in a very short time there. So, fasting, I mean, we've heard, like fasting and intermittent fasting and longer fasts are very, very good for us and all that. While a lot of us don't want to do it because it's not very nice... I do intermittent fasting, but I must admit, I don't enjoy it. And I certainly—when it comes to doing longer fasts, I struggle. So I'm always like, fasting mimetics, how can I get some fasting mimetics going? Because like you say, if I'm going to put in the antioxidants, the precursors, which I do as well, which are very important piece of the puzzle, but just that is not enough. So, this is like we've looked at in the past, like resveratrol as being a possible fasting mimetic. And wouldn't it be great if spermidine turns out, and it looks like it is going to be another fasting mimetic that's actually even more powerful. So, I know you do a lot of fasting, you're very disciplined, unlike myself. Dr. Elizabeth: No extra weight, I still have extra weight so fasting’s easier for me. Lisa: But yes, it is a difficult thing to do. So intermittent fasting is probably for me is the easiest go-to because I can sort of coke for it.  Dr. Elizabeth: Time-restricted eating. Really, yes, more doing a 16, 8, kind of thing as opposed to the longer fast. And there's a lot of questions, we don't really know, do you need to long fast? We actually don't know the answer to that. There's a lot of people who say, ‘Oh, you've got to be hit the 48 to 72 hours to really get the full autophagy phase’. There's not a lot of data that actually really says that. You may still be able to get the same benefits from doing time-restricted eating. So we don't know the answer to all these questions.  Lisa: But so what we're targeting with fasting is autophagy. So, autophagy, just to define what autophagy is, is getting rid of the bad stuff, basically. The bad proteins that are damaged, the mitochondria, or mitophagy, in that case. And recycling the parts that we can reuse and getting rid of it. Does the body sort of lock at it when you're fasting, and you haven't got anything coming and going up, ‘I've got no fuel supply, I better start recycling the old stuff’.  Dr. Elizabeth: Yes, exactly. Yes, autophagy is self-eating. And so basically, the cell basically says, ‘Oh, I need to preserve. I'm going to take the good things from the cell, get rid of the bad stuff I don't need. It’s a waste of energy. Getting rid of cells that shouldn't be utilizing my energy’. So and then really by going into a ketotic state, and that's, not utilizing glucose has a huge benefit. Lisa: So ketosis and autophagy, are they hand in hand? Are they part of the same thing? Can you have autophagy without being in ketosis, or are they very much married together? Dr. Elizabeth: No, you can actually have autophagy without being in ketosis. And you can basically be in ketosis and not necessarily have autophagy. So that all kind of depends on the cell, the state the cells in.  One of the problems with resveratrol as a fasting mimetic, you mentioned taking resveratrol continuously, is there's also very potent antioxidant. Remember, one of the benefits of fasting is oxidative stress. So, I want oxidative stress while I'm fasting. If I'm taking resveratrol, for instance, while I'm fasting, I'm actually not getting as much of the oxidative stress. So, it's working a little different level. That's why I like spermidine a little bit better as it doesn't have that same effect to sort of negate the oxidative stress. Lisa: And for how long for people to get their heads around? I know because I mean, I've been struggling with this one, like the antioxidants sort of paradox. Yes, sorry, you carry on. Dr. Elizabeth: I think the key to remember is you really don't want to be doing any protocol continuously. I was just talking to a guy and he said, ‘What do you do to look like you do’? because I have more muscle. And I said, ‘I don't do anything continuously’. There's nothing—workout, nothing continuously. My food, my eating is never continuously, my supplements are never continuously.  And I think it's a problem as people get in these patterns where they are taking all these antioxidants continuously. I always am going through build-up, breakdown phases. So there's only a few supplements that I will continuously take. One is, I will take spermidine at a baseline level. But if I'm doing a sort of a fast autophagy phase, where I really want to do a big tie up off of everything, I want a very high dose spermidine, much higher dose than just until that time of day.  Lisa: Because spermidine works at a level lower if you like, at the base level. So, when we're talking about antioxidants, what the job is in the cell is to basically scavenge and donate electrons to where you got oxidative stress, and reactive oxygen species and to get rid of it there. But we're actually going a step back and actually stopping the reactive oxygen species, or oxidative stress from happening in the first place. And this is why spermidine at that base level, seems to be one that you can take continuously. And it even builds up to some degree, perhaps in your body or upregulates some of the bacteria in the microbiome. And whereas, antioxidants, we want to sort of cycle in and out. It's like exercise, isn't it? Like when I go to the gym, I'm not going to have my vitamin C right next to when I go to the gym, because that's going to mitigate that cascade of effects that vitamin C has. Yes.  So I'm doing things. I'm taking my vitamin C away from that. And so there's, none of this is good or bad, it's cycling. And I think the more I've looked into things, the body likes this push and pull. It likes a medic stress. It likes to be cold. It likes to be hot. It likes to be pleasant, but it likes to be fasted. It likes to have a good amount of food. It's this whole—because that's how we've evolved, isn't it? Dr. Elizabeth: That's the way life for it was, yes. Lisa: We didn't come from this neutral environment where the temperature is the same all the time. And we're sitting on comfy couches, and we're not exercising and we're not cold, or we're not hungry, and we're not hot, and we're not not anything, and we've got an abundance of everything. And therefore, if we look at our evolution, and how we've come about that sort of a push and pull seems to go right through nature. Dr. Elizabeth: Yes, you're exactly right. Remember, there's that balance between mTOR and AMPK, right? We know that AMPK is breakdown. And we know that when we block mTOR, our lives are longer, but we also don't build as much muscle and we don't have as much energy. And what you do is go through phases, build up mTOR, build up AMPK, build up and do that balance, so that you keep things in a very homeostatic state. And you said exactly right, there's great benefits to being hot. You have all the, how great being cold is and doing our cold showers in our cryo and everything. But there's a study that came out recently, I think I quote it in some podcasts I was in recently, that showed that in hotter environments, bone density is much better. So why is it that?  Lisa: Yes, I heard that.  Dr. Elizabeth: There's some effects from the warmth on our body too. So you're exactly right. We want to go back and forth between different things and we want to make sure we're cycling. Any of you who are staying on the same patterns all the time, that's not serving you. Your body needs to have this back-and-forth balance. And you're right, that is—whenever you give the quote of well, ‘That's how cavemen lived’. You're like, ‘Well, but cavemen died in 18 whatever’.  So how our evolution occurred, right? It's still what, what got us to survive. And it really is how our world is designed, and it's how our cells are designed. So I think that the use of thinking about your body as ‘Okay, I'm going to go through a fast, autophagy phase, and then I'm going to build up and I’m going to build my muscles’. You can build muscle while you're in a fasted state, but it's not nearly as easy as it is when you're eating a lot of food.  Lisa: Yes. And but we're wanting to keep everything in balance so that it doesn't get just mTOR because, if we're in a state of like, activated mTOR all the time, then we are growing, but we were possibly growing things like cancer cells and things like. Dr. Elizabeth: And we know that mTOR activation all the time is closer to death. Lisa: But isn’t it weird, like there's nothing simple about...  Dr. Elizabeth: It actually, honestly, it makes very little sense to me, right? The things—the mTOR, everything's muscle building. Super high IGF all the time and it is muscle building. You would think it would be kind of pro longevity, right, and healthy, and yet, it's not. And the only way I can really—in my mind, reason that out is that if the zombie apocalypse hits, you're better designed to be able to survive without any food and without any—nothing just huddled away in your little house, right? And so maybe the evolution of our body that's for longevity, the genes have kind of stayed there are the ones that really make us survive through famine, right? And yet, that's probably not where we all want to be. We don't want to be huddled in the back of our houses not moving.  And so yes, if you look at Valter Longo and his research on—really low IGF people live longer, they don't have cancer. Yes but they actually don't necessarily feel great. And they don't necessarily see low IGF people all the time, who are fatigued, who don't have good energy, who can't build muscle, who don't exercise. So I think that the thing here is build your IGF, bring it back down, build it up, bring it back down. So, I think that that's where we really need to look at things, as this kind of waxing and waning of everything we do.  In our cellular medicine fellowship program, it's one of the things we're really, really focused on is that's what the cell needs, is a push and pull to it, to really help it become a healthier entity. And I think if we start doing that, we're going to start seeing that that's really where we're going to see that big focus to health and longevity occurrence. It's not going to be ‘Everybody eat this diet’.  Lisa: No, no. And this is like, even as a coach of athletes and stuff. And I did this in my athletic career where I didn't know all this stuff. I ran long, because that's what I do, it was ultra-marathon running. And that's all I did. I didn't train at the gym. I didn't do—and I was not fit. And I was not healthy. I could run long because I've trained that specific thing, but I wasn't healthy. I was overweight. I was hormonally imbalanced. I ended up with hypothyroid. I couldn't have sat on the couch and ate chips all day and probably come out better than I did. Because I'd been doing one thing and one thing that was actually not suited to my genetics either, ideally. And so understanding all of this is not as simple as well, ‘I'll go and do the same old thing, same old and then we'll be good’. I want to sort of flip now and go a bit of a deep dive into spermidine because I think spermidine is the one thing that, this is going right down to the base level of before. Because we want anti-ageing. I mean. We compared ages before this podcast and I mean, I won't share your age, but I was shocked. You look amazing. And I'm like, ‘I want a piece of that’. What is it that you're doing? So spermidine is a part of your—that is one of the things you do take on a pretty much a daily basis. Can you dive into the research? There’s 10 years behind the spermidine and it's only just becoming available. Guys in New Zealand, it's not here yet. I'm working on it. Give me time, I'm getting, I'm working on it. Dr. Elizabeth: So, what we know is as we talked about spermidine is on every single living organism. So, we know it's critical to life, it's what's called a polyamine. It's what a three poly means is spermidine, spermine, and putrescine. And they all have some value. Putrescine is what's in rotting meat. You're probably not going to go eat rotting meat. But there's actually some value to putrescine in our bodies, too. Spermidine appears to have—spermidine is converted typically this into spermidine. Spermidine is innately in our gut. So, it's made by our gut bacteria but it's also in some foods. It's in some a lot of fermented foods, in wheat germ extracts. It's in some peas and mushrooms. It's in some algae.  Probably the richest source of it is a specific type of wheat germ extract. It's apparently very difficult to extract, it's only a certain type of wheat germ that has it's difficult to extract a pure form of it. And so, there is companies that make it from algae as well. But you have to take—actually before we could get spermidine from spermidine life which is wheat germ extract, we actually bought an algae extract one. You really had to take 40 of these little green pills. I mean your hands are green, your teeth are green all the time. 40 of them, I mean, I did that because I wanted it but once we got spermidine.  I get the question all the time about well, it's wheat germ extract. Interestingly, I've celiac patients on spermidine and even though it's not advised for celiac patients, it probably actually is perfectly safe because it's actually working on one of the pathways, that's what makes the gluten exactly unsafe those patients. So, it's probably even if you're—I'm very gluten sensitive, I don't do gluten. I have no problems in spermidine. So, it tends to be pretty well-tolerated in those people. Lisa: Yes, but I've got a brother who’s recently examined and she said, ‘Yes, I can’. Dr. Elizabeth: Yes, I have two celiac patients on who've done fine. And again, the bio says not to take it if you're celiac, but I think cautiously, there is some research that supports it actually may be useful in treating some of the celiac patients.  So basically, the study is now—there's so many studies on it. In terms of preventing almost every disease in the book, and that's where you and I come back to that whole, is mitochondria the answer to everything? Because we've seen spermidine—you can Google spermidine. I do this. I mean, Google ‘spermidine and Alzheimer’, Google ‘spermidine and cancer’, there's not a disease that we don't have a study on where you can find some connection to higher or lower levels of spermidine being better.  Some of the major research has been on cardiovascular and its benefits and cardiovascular disease. It's one of the things we've been using when we see high inflammatory cardiovascular markers in our patients. We measure what's called myeloperoxidase, which is an inflammatory cardiovascular marker. It's interesting, we've seen it very high in our lot of our post-COVID patients. So patients who have had COVID recovered, coming for labs, we're seeing very high levels of myeloperoxidase. So, we think that's probably from some of the vascular damage that COVID seems to create in some people with certain genetics. And that’s very hard to bring it back down, and spermidine has been one of the things that's been really helpful there for us.  So, it's also any of your patients who have a high Lp little a. Yes, so by Lipoprotein little a, you'll know is basically genetic. Lisa: Yes. And there's not much you can do.  Dr. Elizabeth: Nothing much you can do about it. You use high-dose niacin, but it's hard to take, the liver toxic. Spermidine actually has some research to support it in lowering Lp little a and we've seen that in our practice, it's one of the things we lower Lp little a. So the other place that's been really studied is an immune system support. So we've seen improvements in lymphocytes. So, one of the other labs that you want—when you're looking at that CBC is looking at your neutrophil-lymphocyte ratio.  Lisa: Yes, I've just like I've got a problem with my brother at the moment, lymphocytes, neutrophils down. No, sorry, your neutrophils down, lymphocytes, high.  Dr. Elizabeth: That's a little uncommon, that might indicate some kind of viral illness going on. Typically, what happens as we age is, we start to see the lymphocyte number go down and the neutrophil number go up. So that ratio, which should be around 1.3:1, 1:1, 1.3:1, starts climbing. If you look at the typical person our age is, 3:1. And so, it's hard to get—how do you get back lymphocyte function? You don't have thymus glands anymore. And so the two things that we've been able to utilize to really restore lymphocyte function in our patients who have ageing immune systems is spermidine. And then the other one is a peptide, thymosin alpha-1, which is a thymic peptide.  What our thymus gland does is it takes those two lymphocytes, it tells them what to do and, and once—your best immune function is at puberty. After that, your thymus gland starts getting smaller. And by the time you're 60, you don't really have much thymus gland. And so your immune system starts going a little haywire, it doesn't know what to do. And so what we can do, because really crazy people are trying to transplant thymus glands, or eat sweetbreads, which doesn't work. They do it in France, maybe they taste good, but I don't think it replaces your thyroid function. But you can get thymic peptides. So, two of the things that the thymus gland really makes is thymosin alpha-1 and thymosin beta-4. And thymosin alpha-1 is a very immune modulating peptide, and it really helps to restore normal immune function. So, the combination of spermidine and thymosin alpha-1 and your people who have immune dysregulation, autoimmune diseases. You could start normalising the immune function. So instead of attacking self they start attacking viruses.  Lisa: Wow. And autoimmune is just like, a huge, huge problem. I mean, it's just epidemic levels now.  Dr. Elizabeth: It is epidemic.  Lisa: Sorry, so this would help with that. Oh, my God. Okay. So that's another reason to take spermidine and the peptides. I mean, peptides are harder to get hold of like… Dr. Elizabeth: It’s still harder to get hold of. Your people who are in Europe, thymosin alpha-1 is actually a drug. It's called Zadaxin. We can't get it here as a drug. We've made us a peptide but it actually is a drug. They use it in their chemotherapy patients in Europe and Asia. And so oddly, it's available as approved drug. Probably pricey. Lisa: Most of these drugs are for some unknown reason. Dr. Elizabeth: Yes. Spermidine—someone's early studies and where it actually sort of panned out, as people went after it initially was actually hair growth. And again, if you think about, the tissues, we're talking about, like cardiac here, those are all fast-growing tissues. And that's where spermidine sort of had its nice effect and sort of that whole regeneration process. And so even in guys with thinning hair, spermidine has huge benefits. Just taking on like a milligram a day dose will start the thickening of hair. I noticed when I first started, my nails grew really fast means, I mean, super fast. And so even in those basic things, like hair growth, nail growth, spermidine has some really marked effects. Lisa: Fantastic. We’ve got to get it here.  Dr. Elizabeth: Yes, it is amazing. I mean, honestly, I feel a little—whenever I see my patients now and I see something wrong. I'm like, ‘Well, spermidine, oh’. Lisa: Yes, yes, yes, yes. And this is all to confirm because it's such a wide panacea, and it works at base level of the ageing and pathologies and things… Dr. Elizabeth: It’s too good to be true.  Lisa: It's too good to be true, but actually now, it makes sense. And so, it’s fantastic if we find something that is a panacea for many, many things. And also, I've got my first shipment coming from the States, and I'm super excited. Dr. Elizabeth: One of the hard things in what we do, right, is it takes you awhile to feel better, and just starting from a low level, right. Or if you're like us, and you're at a high level, then making this little extra. And so, what I tell people to monitor, because one things I noticed was, when I started spermidine was a pretty—I don't sleep enough, I study too much. But I use my Oura ring, and I monitor my HRV. And so, I know a lot of your listeners have the Oura ring and HRV is very fluctuating. And so it's one of those things, it's very easy to see a change.  So, if I do something like start taking spermidine, I can say no, and you can look at the trend on your Oura ring. And you can say, you can take—started spermidine here, and I had about a 15 point jump in my HRV, which I won't say what it is because it’s just from starting spermidine. So I know it's doing something at a very basic level because HRV is predictive of almost every disease state; so low HRV, you know you have a higher incidence of all Alzheimer, we know we have a higher incidence of cancer. So I know if I'm affecting my HRV, I'm positively affecting my health.  So something really simple that you can do to say, okay, I started this here, and then look back in two weeks, go to your little trends thing and see ‘Wow, look, my trend is going this direction’. Lisa: Wow, I can't wait to see that because yes, I mean, I haven't been able to move the needle on my HRV really. Dr. Elizabeth: Yes, me neither. And mine's not good.  Lisa: Yes, and mine isn't great either.  Dr. Elizabeth: Yes, the downside of sometimes what we do is we're reading all the time and staying all the time and trying to do too much and… Lisa: Brain doesn’t turn off.  Dr. Elizabeth: And that's not so good.  Lisa: Adrenaline driven. Dr. Elizabeth: Yes, so it is really, honestly one of the first things I did that really made a dramatic change. Lisa: Wow, I will let you know how I go.  Dr. Elizabeth: Yes, let me know. Lisa: When mine comes, whether my HRV is now turning up.  Dr. Elizabeth: I will say sometimes you need a higher dose which gets pricey. Lisa: And this is the problem with everything, it's the same with the deep precursors and all the stuff that's fantastic, it does cost. But you know what? I don't have money to burn but I would rather go without a fancy car, go without fancy clothes, go without cosmetics, go without all that to have supplements that work or to have biohacking technologies that work because that's my priority, it’s my health. Because what good does it do me if I have a fancy car, but I'm sick?  Dr. Elizabeth: I know. And it is funny, I was giving this lecture and this woman came in, she asked how much this program we do cost? And she said, ‘Well maybe when I pay off my Lexus, I'll be able to do that’. And I'm like, ‘You’re really willing to spend a lot of money, a $1,000 on an iPhone and’...  Lisa: Priorities.  Dr. Elizabeth: …and car and we just still have to keep putting this focus on your priority, absolutely has to be this your health? And it’s so hard to convince people of that. Lisa: And I'm constantly shocked at people who expect to like, they take a supplement and they don't see anything change for three days and then they're like, ‘It didn't work’. And I'm like, ‘You've got to be kidding’. Like you know your hair is growing, right? But do you see it growing every day? No.  But if you keep going—and with my listeners have heard me rabbit on about my story with my mum and bringing her back from a mess of aneurysm. The reason I have been successful with her is, is not any one particular thing. I mean, yes, hyperbaric, yes, all of these things were a big part of the puzzle. But it was the fact that I keep going when there was no signs of improvement. And I keep going every single day for five years, and I still go. And that is the key is that persistence. And that just keep doing it and prioritizing this, even when you see no results. And that's a really hard sell because people want to see, how long will it take for this to kick in? Dr. Elizabeth: I think it's one of the hardest things about our jobs is—listen, it is very hard. But this is stuff that I'm looking at a future that's 10 years, 20 years, 30 years, 40 years down the road, I know these things—I know that they do, they've been proven. So to say they're not working for you is why in every study did they work and oddly, they don't work for you? It just doesn'

Taking birth control pills can be a drag. It's so easy to forget, take it at the wrong time, and realize days later you messed up. And then re-upping your prescription can only be done in most case s in a short 7-day window.   Taking birth control pills can be a drag. It's so easy to forget, take it at the wrong time, and realize days later you messed up. And then re-upping your prescription can only be done in most case s in a short 7-day window. So Dr. Sophia Yen created an innovative approach to birth control: shipping it to you each month until YOU want it to stop. Dr. Sophia Yen is Board Certified in Adolescent Medicine with 20+ years of experience in medicine. She graduated from MIT, UCSF Medical School, and UC Berkeley with an MPH in Maternal Child Health. She serves as a Clinical Associate Professor of Pediatrics in the Division of Adolescent Medicine at Stanford Medical School. Dr. Yen co-founded Pandia Health and enjoys educating the public and other physicians about birth control, acne, weight management, and other adolescent health issues. Dr. Yen is a true badass and this interview only solidifies that - she talks about how she founded her company Pandia Health, destigmatizing birth control (and whatever it's used to help), the battle to get men interested in this business, and her crusade to help all people with uteri take control of their health.

Taking birth control pills can be a drag. It's so easy to forget, take it at the wrong time, and realize days later you messed up. And then re-upping your prescription can only be done in most case s in a short 7-day window.   Taking birth control pills can be a drag. It's so easy to forget, take it at the wrong time, and realize days later you messed up. And then re-upping your prescription can only be done in most case s in a short 7-day window. So Dr. Sophia Yen created an innovative approach to birth control: shipping it to you each month until YOU want it to stop. Dr. Sophia Yen is Board Certified in Adolescent Medicine with 20+ years of experience in medicine. She graduated from MIT, UCSF Medical School, and UC Berkeley with an MPH in Maternal Child Health. She serves as a Clinical Associate Professor of Pediatrics in the Division of Adolescent Medicine at Stanford Medical School. Dr. Yen co-founded Pandia Health and enjoys educating the public and other physicians about birth control, acne, weight management, and other adolescent health issues. Dr. Yen is a true badass and this interview only solidifies that - she talks about how she founded her company Pandia Health, destigmatizing birth control (and whatever it's used to help), the battle to get men interested in this business, and her crusade to help all people with uteri take control of their health.

If you enjoy this podcast consider supporting my work in any of the following ways:  Become a member of our community here: www.coffinnation.com Send us a donation: www.patrickcoffin.media/donate +++++++++++++++++++++++++++++++++++++++++++++++ It’s not easy standing up to the very industry you belong to. But some crises are too urgent and some stakes are too high to sit there and do nothing. So Dr. Patrick Phillips, MD of Englehart, Ontario, decided last fall that the data were not supporting the MSM narrative about Covid-19.  So he spoke up against the lockdowns, the mask army, and the misinformation being sold by the nexus of Big Media and Big Government (both are big “Bigs” in Canada). Listen in to this brave emergency and family care physician go against the grain on behalf of his patients and anyone who will listen.   Watch this episode on our website here:  https://www.patrickcoffin.media/brave-canadian-d…-vs-the-lockdown/  

The Ben Joravsky Show has been a podcast for two years. So Dr. D though it would be fun to have a few of our favorite guests show up on google meeting to surprise Ben and celebrate.

Professor Esme Fuller-Thomson is cross-appointed to the Faculties of Social Work, Medicine and Nursing at the University of Toronto. She is also Director of the Institute for Life Course & Aging.  She has published more than 150 articles in peer-reviewed journals including the New England Journal of Medicine, The Lancet, and Cancer. Her research examines ADHD and mental health, the association between early adversities and adult physical and health outcomes, and disparities in health. Her work has widely cited in the media including the New York Times, Wall Street Journal, Time Magazine and CNN. We’re talking about why the number of Women with ADHD are underreported, about the dark side of ADHD, depression, how to lookout for warning signs in your child, and strategies for making a positive difference. Enjoy-   ***CORONA VIRUS EDITION***   In this episode Peter & Dr. Fullerton-Thompson discuss: 1:12-  Intro and welcome Esme!!  1:53-  Is it true that there is a big difference between males with ADHD and females with ADHD?  Ref: (requires log-in) https://onlinelibrary.wiley.com/doi/abs/10.1111/cch.12380 3:07:  Ref: More Play, Less Problems?? Episode with Dr. Debbie Rhea. LINK Project 3:10-  How ADHD is looked at differently between males vs females and how they act and react with it? 5:38-  Without strategies to manage your ADHD things can go terribly wrong; women with ADHD have substantially higher odds for things to go wrong than men. How do we address this from early-on in a child’s life? 9:00-  On the need of structure and how it’s a key component of managing your ADHD 10:15-  Ref article: The Dark Side of ADHD: Factors Associated With Suicide Attempts Among Those With ADHD in a National Representative Canadian Sample 11:45-  As numbers of suicide are higher than before, what can parents, teachers, doctors do to be aware/on the lookout for signs, and how to move forward once diagnosed? 13:14-  On addiction and depression.  15:18- Ref: Cognitive Behavioral Therapy  Impulse Control 16:35-  Dr. Thompson, how can people find more of your studies of your research? Just type in Fuller-Thompson + ADHD, HERE on Google Scholar, or via https://socialwork.utoronto.ca/profiles/esme-fuller-thomson/ 17:40-  Thank you Dr. Fullerton-Thompson! And thank YOU for subscribing, reviewing and listening. Your reviews are working! Even if you’ve reviewed us before, would you please write even a short one for this episode? Each review that you post helps to ensure that word will continue to spread, and that we will all be able to reach & help more people! You can always reach me via peter@shankman.com or @petershankman on all of the socials. You can also find us at @FasterThanNormal on all of the socials. 18:02-  Faster Than Normal Podcast info & credits! As always, leave us a comment below and please drop us a review on iTunes and of course, subscribe to the podcast if you haven’t already! As you know, the more reviews we get, the more people we can reach. Help us to show the world that ADHD is a gift, not a curse! Do you know of anyone you think should be on the FTN podcast? Shoot us a note, we’d love to hear!   TRANSCRIPT:  Hey everyone, happy day, Peter Shankman here, welcome to another episode of Faster Than Normal, I'm thrilled that you're here, as I always am.  We are going to touch on a subject today, we're going to talk about ADHD, um, it's not as happy-go-lucky as my normal episodes, but that's okay because sometimes they can't all be happy-go-lucky., and sometimes you’ve got to talk about stuff that is, um, a little disturbing to sort of get along and to make sure that people understand all aspects of ADHD, I highlight the good points all the time.  But you know, it's, there are times where they're not so good, and I think we all know that, and so I am thrilled today to be talking to Professor Esme Fuller Thompson.  Um, she's cross-appointed to the faculties of social work medicine and nursing at the University of Toronto, and she's also Director of the Institute for Life Course & Aging. She's published more than 150 articles in peer reviewed journals, including New England Journal of Medicine, at The Lancet and Cancer, her research…. examines ADHD and mental health, the association between early adversities and adult physical and health outcomes and disparities in health.  She's been quoted in New York Times, Wall Street Journal,  Time Magazine, CNN… whole bunch of others. And I'm, I'm, I'm really, I'm honored that you took the time to come in today professor. Thank you so much.  Thank you so much for having me, I'm delighted to be here.  So what I found... you, because there was an interesting article, um, that came to my attention and I think,, there were a couple of them.  One of them was in child health care, uh, development, and that was attention deficit hyperactivity disorder, casts a long shadow findings from a population based study of adult women with self-reported ADHD. We don't talk about gender breakdowns that much, um, I, I think no one does really…. does, um, in the ADHD/ADD world, but there is a big difference between, uh, males with ADHD and females with ADHD. Well, I think women with ADHD tend to be under the radar screen. Most teachers and health professionals are not really thinking about women and ADHD, and you may present a little bit different, uh, in a different way, so the majority of people with an ADHD diagnosis are males, and for sure it is higher in the... among men, but I think because women often present more, um, distractible rather than the hyperactive, they're… they really don't get noticed enough, and our research is indicating that the women with the diagnosis of ADHD are quite vulnerable with respect to a variety of mental health concerns.  Yeah, I, and I believe that, you know, we had a professor [Episode with Dr. Debbie Rhea] from the  University of Texas on the podcast who, uh, spent a semester in a junior high school, um, giving I think elementary school or a junior high school, can’t remember which one,  giving, um, they changed the, the workout schedule, the recess schedule from 20 minutes a day to 60 minutes a day. And they changed the lunch, the lunch, uh, options from, uh, primarily carb-based to primarily protein based, and they saw a drastic, not only decrease in ADHD outbursts from boys, but addressing increase in, um, girls who were willing to participate in class.  And that, that struck me, that's always stuck with me, you know, we don't, we don't look at ADHD as the same thing. And, and there are a lot of differences between... between male and female, boys and girls and how they, and how they act and react with it.  Absolutely. So, I mean, there's two things. One possibility is that women with ADHD are doing more or doing less well, which is what our data seems to indicate, but it could also be that if anybody, there's a whole spectrum to ADHD, like there's a spectrum to everything… and it might be that the, only the women who are at the far, far upper end of the spectrum with the most symptoms, are the people that are being actually diagnosed. So these negative outcomes may be more true for men who are at the upper end, but it's just that men along the whole spectrum may have been diagnosed.  Um, the other piece of what you raised that… isn't particularly, um, from my data, but other research exercise,  is so key exercise structure, organization, it just makes life more livable for sure, for people who have, um, impulse control issues and, and, and disorganization, personal coaches, there's all kinds of positive things that can really make a difference because I think these mental health outcomes that we're looking at, are partly because there's a cascade of negative, um, outcomes, relationships, uh, income, uh, that all of these things, if you can't get yourself completely organized. So, um, being physically active, having lots of structure, having some, maybe some personal coaching, there's all kinds of strategies to minimize the negative, um, outcomes related to ADHD and also to be able to maximize the positives, which I know is your major emphasis on this podcast.  Right. And it really is a question of getting those strategies in place. I mean, you know, there was, there was a study that showed that, um, a much, much higher number, and I wrote about it in, this, in the book a much, much higher number of incarcerated males have ADHD that are just not diagnosed.  And, you know, if you look at that from the, the bigger, the 50,000 foot perspective sure. You know, they do something wrong, they get in trouble, you know,  they, they, they forget about their court date. Well, now there's a warrant out for their arrest, they get arrested, they can't afford a lawyer, you know, and it just, it just goes on and on.  And so.. so looking at the concept of ADHD, um, you know, from things that we don't often notice, right, and, and ADD and ADHD do things we don't often notice is, is huge. And you know, this, the kind of research you're doing is, is, is so needed. Um, I want to read something that, that, uh, from the results on your, on your, uh, study about, uh, adult women, self reported ADHD, women with ADHD had tripled the prevalence of insomnia, chronic pain, suicidal ideation, childhood sexual abuse, and generalized anxiety disorder and double the prevalence of substance abuse, current smoking depressive disorders, severe poverty and childhood physical abuse in comparison with women without ADHD, even after adjustments for age, race, education, and income, women with ADHD had substantially higher odds of a wide range of problems. What does that tell you, uh, that we need to do? How do we start addressing this um, from the perspective of, of at a, at a younger age, teachers and, you know, moving forward.  Well, I mean, our finding is that there was a very high link between childhood sexual abuse, childhood physical abuse,  and ADHD, both in men and women.  It's just that women were much even more vulnerable than the men. Um, certainly says at a minimum, we need to be protecting these children. So it, that ...that abuse may not have happened inside the household, but children, who are…  have impulse control issues, tend to be a little more vulnerable in the community as well.  They may not be quite as thoughtful about, um, you know, where they're at, what time they're out, those types of things. So there's a lot of concerns even right at step one about keeping children safe with respect to, um, almost all of these outcomes, if the young adult has made it through university or college, they're much less likely to be suicidal, to be depressed, to have anxiety disorders.  So anything we can do to provide an infrastructure, to keep children in school and, and, and, or, you know, in the trades or something, but getting something, um, post high school that gets them a good job because not my research, but others have indicated that the serious debt is associated with suicidality and those with ADHD as well.  So how do we, help people manage their funds, learn... learn basic financial management and organizational skills around that.  So basically from child on up, keeping them in school, having them actually get lots of exercise, um, to kind of keep them saying, providing as much structure as possible, personal coaching, uh, there's all kinds of ways to make life more livable and therefore allow people's strengths to come through. That's a phenomenal point. I find a lot, almost always, it has to come back and focus on structure... it’s so much, I mean, this is the one thing I realized more and more, the more research I do on this. And again, you know, I'm not a doctor, you are, but the more research I've done on this and the more,...and the more I read and read studies like yours, you know, structure is just such a key component.  And, and I remember when I got diagnosed, I spent the next several years trying to figure out exactly what it meant, you know, I can put most of the times where I went to a bad place or a dark place or, or, or a period of time where it was, where I look at it upon that now as negative, all, a lot of which had to do with, I didn't have any structure.  I didn't have, um, you know, I wasn't focusing my days, it wasn't scheduled. It wasn't organized, it was, it was just, you know, things happen. And, and I guess there's something that, you know,  better scientific way to put this, but when you're ADHD, you know, it tends to be, uh, you tend to find things to do that most of the time or a good portion of the time aren't necessarily beneficial right, and, you know, it's, it's the joke I always make about, I won't do this and it's true. I won't do a speech in Vegas where I have to stay overnight, uh, because I don't, I don't want to be, um, I don't want to be unstructured for 12 hours in Las Vegas. Nothing good is going to come of that, and let’s move a little...  you recently published a study that came out in... I believe the end of December., uh, yeah, December 21st, 2020, um, the dark side of ADHD factors associated with suicide attempts among those with ADHD and a national representative Canadian sample and the results... ADHD, adults with ADHD were much, much more likely to have attempted suicide than those without. 14% versus 2.7%  That's a huge number….. That's a huge,    It’s unbelievably distressing information. And when we divided it by gender again, what you started with as well, we need to think about women in particular, the women, 24%, one, almost one in four women with ADHD had attempted suicide. Now our previous research has shown almost 50% had thought about it, but luckily likely most people would think about it and never attempt.  So, this is a really very vulnerable population., among men, it was about 9% who had attempted, so we're very concerned. Um, you know, that's that, that's why we called it the dark side, but, um, I I, before we go on, I just want to say... flip that, remember that the vast majority of men, like 90% of that, of the men with ADHD never attempted suicide and 3/4 of women have never attempted, so it's not inevitable at all. I'm just coming at it as a social worker saying, what kind of interventions can we do to make these numbers go down dramatically?  I mean, I mean, it is, you know, granted 75%, you know, of the, of the, of the population is not {indistinguishable}  There's just not looking at suicide, but it's, it's still, you know, a much higher number than, than those without ADHD, and I wonder as we move, you know, as you look backwards on that, is, is there, I mean, I know that that when I was a kid, I say this all the time, I wasn't diagnosed because it didn't exist, right?  I was diagnosed with sit down/you're disrupting the class disease and, um, you know, I remember some really difficult times for me in high school and I, it, it, never came to it... came close to it, but it never came to that.  And I wonder, are there, what can, what can parents, teachers, doctors do to be better on the lookout for this? And, and I mean, even to be aware of this, right? So say, oh your child might have ADHD. That should start a, a, a, a chain that says, let's look at these things.  So, um, I think with both women and men, but perhaps even more with young girls, um, part of the problem with ADHD as it can make social relations difficult, right?  It's harder to fit in. There's more likely to be social rejection, and that is very tough, but particularly in your younger years, as people are trying to make their way in life., so the social rejections, so, um, you know, ADHD medication can help calm the symptoms down, but you, but there has to be a lot of guidance and training around social skills, opportunities to socialize and healthy socialization starting at a young age can make a difference.  Um, the other two factors that we found were pretty important, uh, with respect to risk for having had an a, um, an attempted suicide were addictions and depression. So as a parent, uh, uh, you know, as a parent of somebody with ADHD really cau… um, thoughtful and cautious approaches to minimize, um, substance abuse is really key because once people are involved in substance dependence or substance abuse, there is a cascade of negative, negative outcomes of social academic career, life, everything.  So, and then from that, uh, comes depression and suicide, so I think addictions, uh, or avoiding addictions, um, avoiding substance dependence is really key and parents doing whatever they can on that front to help, and as an adult, um, you know, not some people can drink or use substances in moderation and some people can't, and I'm guessing most people with ADHD are on the all or nothing kind of level about it.   No question about it.   And the other piece is depression. So the rates of depression were very, very high  um, among women, um, just looking at my numbers, but I, you know, it was well over a third, had... almost 40%...  had major depressive disorder and lots of anxiety. So they're really good interventions for everybody, not just those with ADHD. Cognitive behavioral therapy is a calming talk therapy, but it's really designed to help you catch those dysfunctional thoughts.  You know, if you're, if you're giving yourself subliminal messages that I'm useless, I can't do this sort of really negative messages. Nothing that, uh, is going to change that until you start catching those thoughts and reprogramming your brain basically. So it's a very simple, straight forward, uh, intervention.  It can be given in a group setting and it is very effective basically, um, in the general population for every three or four people who take it., and it's eight to 12 weeks, not a big thing. One person moves from depression to, uh, to recovers from depression that wouldn't have otherwise. It is a solid investment of your time and energy.  So cognitive behavioral therapy is one particular type in general that short, and can work with depression and anxiety.  So obviously depression and anxiety are key risk factors for suicidality. The other piece, of course, is impulse control. So if you have a negative thought, which we all do or, uh, would in many people be a fleeting thought, uh, I just want to end it all kind of thing, you know, somebody with ADHD, they may not be able to put that aside, go on and see something better the next day, that.,,,,,,, that's where the impulse control issues come into play.  No question about it. Um, I want to be, be mindful of your time. Um, doctor, how can people find more of your studies of your research? If, if they, if they're curious, I'm sure they're gonna want to read more.  So I typically, uh, release sort of media releases on the information. So you can kind of get it all in one page, which works well for most people, including those with ADHD…  So if you just type in Fuller Thompson and ADHD, probably it'll all pop up. Um, we've covered a lot of the research I've done in this discussion with respect to early adversities, with respect to women in particular and suicide, and I have several more papers underway looking at anxiety disorders and also looking at resilience. So it turns out a lot of people with ADHD aren't just free of mental illness, they're actually happy and satisfied with their life. We're trying to figure out the flip of this who's doing well and why, and how can we help more people get there  What a phenomenal way to end the conversation, because there's no question that we're going to have you back on to discuss that once that research is done.  So Dr. Fuller Thompson, thank you so much for taking the time today, I really appreciate it.  My pleasure, thank you for having me.  Guys, you’re listening to Faster Than Normal love that you're here. Tune in next week for a brand new episode. If you like what you heard, feel free to leave us a review on iTunes, GooglePlay, Spotify, wherever you listen to your, your podcasts. We will see you next week with a brand new episode on ADHD and neuro-diversity as a whole.  Stay safe. Credits: You've been listening to the Faster Than Normal podcast. We're available on iTunes, Stitcher and Google play and of course at www.FasterThanNormal.com I'm your host, Peter Shankman and you can find me at petershankman.com and @petershankman on all of the socials. If you like what you've heard, why not head over to your favorite podcast platform of choice and leave us a review, come more people who leave positive reviews, the more the podcast has shown, and the more people we can help understand that ADHD is a gift, not a curse. Opening and closing themes were performed by Steven Byrom and the opening introduction was recorded by Bernie Wagenblast. Thank you so much for listening. We'll see you next week. 

An interview with Dr. David Hui from MD Anderson Cancer Center and Dr. Margaret L. Campbell from Wayne State University, co-chairs on “Management of Dyspnea in Advanced Cancer: ASCO Guideline.” This guideline outlines a hierarchical approach to dyspnea management, beginning with identifying and managing potentially reversible causes, followed by the use of non-pharmacologic interventions, and then pharmacologic interventions. Read the full guideline at www.asco.org/supportive-care-guidelines TRANSCRIPT SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines Podcast Series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. David Hui from MD Anderson Cancer Center in Houston, Texas, and Dr. Margaret Campbell from Wayne State University in Detroit, Michigan, co-chairs on "Management of Dyspnea in Advanced Cancer: ASCO Guideline." Thank you for being here, Dr. Hui and Dr. Campbell. DR. DAVID HUI: Thank you. It's wonderful to be here. DR. MARGARET CAMPBELL: Yeah, it's my pleasure. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Hui, do you have any relevant disclosures that are directly related to this guideline topic? DR. DAVID HUI: I have no relevant disclosures. BRITTANY HARVEY: Thank you. And Dr. Campbell, do you have any relevant disclosures that are related to this guideline topic? DR. MARGARET CAMPBELL: No, I do not have any relevant disclosures. BRITTANY HARVEY: Thank you. Then let's get into some of the guideline content. So first, Dr. Hui, can you give us a general overview of the purpose of this clinical practice guideline? DR. DAVID HUI: Yeah. This clinical practice guideline is on dyspnea in patients with advanced cancer. And this symptom of shortness of breath, or dyspnea, is very common in our patients and extremely distressing. And the evidence base is rapidly evolving, so the purpose of this guideline is then to summarize the up-to-date information and provide some recommendations for clinical practice to help alleviate this very challenging symptom. BRITTANY HARVEY: Great. Then let's review some of those key recommendations of this guideline. So Dr. Campbell, what is recommended for screening and assessment of dyspnea in patients with advanced cancer? DR. MARGARET CAMPBELL: Well, as David mentioned, this is a highly prevalent symptom. But we know that in clinical practice, sometimes patients won't disclose their symptom unless they're asked. And it gives us an opportunity to be certain that we don't overlook the symptom, particularly when it's in the early stages, mild or moderate stages, where we can intervene rapidly. So in order to treat a symptom, we have to know that the symptom exists. So in the guideline, we recommend at every clinical encounter that there be an assessment for dyspnea. So every clinical encounter could be every time the patient presents in the outpatient clinic, or it could be every day if the patient is an inpatient. Every day on rounds, or every time vital signs are obtained, there would be an assessment of the patient's dyspnea. BRITTANY HARVEY: Great. Then, reading through this guideline, it takes a hierarchical approach to the management of dyspnea, addressing first potentially reversible causes, then the use of non-pharmacologic interventions, and finally pharmacologic interventions. So first, what does the guideline state regarding addressing those potentially reversible causes of dyspnea? DR. DAVID HUI: Yeah, well, this is a very important aspect that you highlighted is that we really want clinicians to remember that it's not just about treating this symptom. It's ideally identifying what are the causes of shortness of breath that we could reverse. And in many patients, there may be multiple factors contributing to the shortness of breath. Some patients may have some effusion, perifusion contributing to it. They may also have underlying emphysema. And other times they may have some complications, such as blood clots. And so it's important to kind of identify the issues that may be at stake. And some of them are very treatable, and patients may have significant improvement in their shortness of breath right away. So I think it's a combination of identifying the complications and comorbidities in those patients. And of course that along with treating the cancer if the cancer is the cause of the dyspnea as well. BRITTANY HARVEY: Great. Then so after addressing those potentially reversible causes, Dr. Campbell, what are the recommended non-pharmacologic interventions? DR. MARGARET CAMPBELL: Well, in the case of a patient whose dyspnea is not severe but is a difficult to tolerate symptom, we propose that the clinician begin with a hierarchical approach from the easiest, simplest interventions that are non-pharmacologic that may actually help improve the symptom experience. So that might be as simple as changing the patient's position. And depending on where their cancer is located, they may find that they are more comfortable sitting up straight propped with pillows, for example. In addition, circulating air around the face has a fairly strong evidence base. And that can be accomplished, weather permitting, by putting the patient's chair near an open window. Or it can be accomplished with a small handheld fan blowing on the face. For some patients whose blood oxygen levels are low, then the application of supplemental oxygen may be helpful to correct the low blood oxygen. Those are the major interventions that we would suggest, but there could be others. If the patient is still ambulatory, then perhaps a walking aid, avoiding stairs. And some of that comes back to our comprehensive assessment. If we could determine what triggers the patient's shortness of breath, then perhaps we can suggest interventions to minimize that, like pacing activity. So similarly, if the patient's in the hospital but has dyspnea, we would want to pace their clinical activity. We wouldn't want them to have their bed, bath, their breakfast, their linen change, their physical therapy all in the same short period of time. We would want to see those interventions staggered through the day. BRITTANY HARVEY: Definitely. That makes a lot of sense. So then, Dr. Hui, what pharmacologic interventions are recommended for patients with advanced cancer and dyspnea? DR. DAVID HUI: Yeah, and so building on Dr. Campbell's discussion of the non-pharmacologic interventions, sometimes patients will continue to have quite a bit of shortness of breath. Or it's a very acute or severe presentation, such as in the hospital setting, then we do recommend some pharmacologic interventions. So the front line measure for that would be systemic opioids. And I recognize that, nowadays, opioids, there's still a lot of stigma around the use of it and concerns. But it is after careful review by the committee and based on the existing evidence that we do recommend this as the main pharmacologic agent. For patients, of course, the use of opioids need to be carefully monitored, and patients should be educated very carefully on how to use them properly for shortness of breath. There are a number of other pharmacologic agents that may be considered for selected populations, other than opioids. So if patients have a higher level of anxiety, then a short-acting benzodiazepine may be considered for those individuals. And for patients with more structural causes of shortness of breath, such as airway obstruction, systemic corticosteroids may be considered. And for patients with airway obstruction, then bronchodilators may be helpful as well, although the evidence around that is still on the weaker side. And there are some patients who, despite very active intervention with many of these non-pharmacologic and pharmacologic measures, who continue to have very severe shortness of breath. And for those who are, let's say, in a palliative care unit setting and have refractory dyspnea, palliative sedation is mentioned as an option for patients as a last resort. BRITTANY HARVEY: OK, thank you both for reviewing those interventions for patients. So Dr. Campbell, in your view, why is this guideline important? And how will it change practice? DR. MARGARET CAMPBELL: Well, for a busy oncologic clinician who may not have a lot of time to search the literature because of a busy practice, what this puts in one place is an opportunity to do a quick guideline that could suggest a treatment course. For a palliative care provider, who may have more experience with non-cancer diagnoses, this guideline focuses on the patient with advanced cancer. So I think there's an opportunity for clinicians in both of those fields who would be taking care of advanced cancer patients to find a benefit. BRITTANY HARVEY: Definitely. And then finally, Dr. Hui, how will these guideline recommendations impact patients with advanced cancer? DR. DAVID HUI: Yeah, well, I'd like to echo what Dr. Campbell said. I would also say that perhaps one of the strongest recommendations of this guideline is actually for patients with dyspnea and advanced cancer to be referred to palliative care. Because dyspnea is such a multi-dimensional symptom and often just the tip of the iceberg in terms of what patients are going through. So just the very presence of it really highlights that there is likely a high supportive care burden, and it would be a good idea for a team specializing in relieving of this symptom to be there to work with the oncology team to help patients. So we hope that with this guideline, that there will be more patients who will have access to palliative care teams. And I think that will be one important impact. And there is a lot of evidence that palliative care can help our patients. And other, maybe, impacts, I think, down the road for maybe future patients would be that we highlighted that more research is really needed in this field. The guideline clearly highlighted some areas we need to work on for further research. And it is not easy to do research in dyspnea and cancer patients because these patients are so sick. And yet these are the very patients who need to have better interventions. And so with this guideline, we hope that it can stimulate further research and to support some patients in the future as well. BRITTANY HARVEY: Great. Well, it definitely sounds like these will have a positive impact for both researchers and for patients with advanced cancer. So I want to thank you both for your work on these guidelines. And thank you for taking the time to talk with me today, Dr. Campbell, and Dr. Hui. DR. DAVID HUI: It's my pleasure. DR. MARGARET CAMPBELL: Mine also. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/supportive-care-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast. And be sure to subscribe so you never miss an episode.

An interview with Dr. Natasha Leighl, Dr. Andrew Robinson, and Dr. Gregory Riely on “Therapy for Stage IV Non-Small Cell Lung Cancer with Driver Alterations: ASCO and OH (CCO) Guideline Update.” This guideline provides recommendations on systemic therapy for patients with stage IV NSCLC whose cancer has driver alterations, focusing on seven targets - EGFR, ALK, ROS-1, BRAF V600e, RET, MET exon 14 skipping mutations, and NTRK. Read the full guideline at asco.org.   TRANSCRIPT PRESENTER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcasts.asco.org. My name is Brittany Harvey, and today, I'm interviewing Dr. Natasha Leighl from Princess Margaret Cancer Center in Toronto, Ontario, Dr. Andrew Robinson from Queen's University in Kingston, Ontario, and Dr. Gregory Riely from Memorial Sloan Kettering Cancer Center in New York, New York, authors on Therapy for Stage IV Non-Small-Cell Lung Cancer with Driver Alterations: American Society of Clinical Oncology and Ontario Health (Cancer Care Ontario) Guideline Update. Thank you for joining me today, Drs. Leighl, Robinson, Riely. DR. ANDREW ROBINSON: Thank you for having us. DR. NATASHA LEIGHL: Thanks for having us, Brittany. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Leighl, do you have any relevant disclosures that are related to this guideline topic? DR. NATASHA LEIGHL: I don't have relevant disclosures, but I do have institutional research funding from a number of companies, including Amgen, ARRAY, AstraZeneca, EMD Serono, Guardant Health, Eli Lilly, Merck, Pfizer, Roche, and Takeda, and personal fees from Bristol-Myers and MSD, which are unrelated. Thanks. BRITTANY HARVEY: Thank you. And Dr. Robinson, do you have any relevant disclosures that are related to this guideline? DR. ANDREW ROBINSON: I do not have any relevant disclosures related to this guideline. My institutional list of research funding is not as extensive as Dr. Leighl's, but is still fairly extensive and includes many of those companies. BRITTANY HARVEY: And Dr. Riely, do you have any relevant disclosures? DR. GREGORY RIELY: I receive institutional research funding from Novartis, Roche, Genentech, GlaxoSmithKline, Pfizer, Moradi, Merck, and Takeda. But those are my only disclosures. BRITTANY HARVEY: Thank you all. Then let's get into some of the content of this guideline update. So this guideline is an update of an earlier ASCO guideline on the systemic treatment of patients with stage IV non-small cell lung cancer, which was then divided into two companion guidelines, one on systemic therapy treatment options for patients without driver alterations, which was published in 2020, and then this one for patients whose cancer has driver alterations. So Dr. Robinson, can you give us a general overview of what this particular guideline covers? DR. ANDREW ROBINSON: Thank you, Brittany. It was a great experience to be part of this important guideline and an honor. As you mentioned, this guideline is on treatment of stage IV non-small cell lung cancer patients with driver mutations. And it's a companion guideline to the earlier guideline published on treatment of stage IV non-small-cell lung cancer without driver mutations. The guideline followed a robust evidence gathering and evaluation process as a standard for ASCO-Ontario Health guidelines. In this case, we ended up reviewing several phase III trials, as well as many earlier phase studies and specific driver mutation groups. If we look back to 2017, there were four driver mutation group recommendations included in the guideline. We now have recommendations for seven different oncogenes, as well as some recommendations that are specific not only for the oncogene involved, but also the specific mutation within that gene. The non-driver mutation guideline is referenced as well frequently in this guideline, as many of the treatment options that are recommended in that guideline are also appropriate for patients with driver mutations, with the exception of a couple of key mutation groups such as EGFR. Recommendations in the guideline are qualified as weak, moderate, or strong, and the level of evidence for each recommendation is given. For many of these novel agents, the evidence is relatively low in comparison to what we are used to with recommendations based on phase II trials without comparator arms, and with surrogate endpoints for patient benefits such as response rates and duration of response, as opposed to quality of life and overall survival. Nonetheless, it was felt appropriate to include many of these agents in the recommendations, with the caveat that the level of evidence is weak or non-evidence-based. One of the recommendations in the introduction to these guidelines is to continue with studies such as phase III clinical trials in many of these settings, in order to move from an informal consensus-based recommendation, to a recommendation based on moderate to high quality evidence. We hope oncologists and their patients will find these guidelines useful. BRITTANY HARVEY: Great. Then, as you just mentioned, this guideline focuses on seven targets, EGFR, ALK, ROS1, BRAF, RET, MET, and NTRK. I'd like to review those key recommendations for each of those targets. So first, Dr. Robinson, what is recommended for patients with stage IV non-small-cell lung cancer and an epidermal growth factor receptor mutation? DR. ANDREW ROBINSON: Thank you. In terms of stage IV EGFR mutation positive lung cancer, the recommendations in the 2017 guidelines were to use tyrosine kinase inhibitors upfront, such as gefitinib, afatinib, or erlotinib, and to follow that with osimertinib if a mutation was found in T790M, or chemotherapy depending on what was available. In the current treatment guideline, we have recommendations not only for first and second line treatment, but also some acknowledgment and recommendations for treatment of patients with EGFR mutations other than the classical exon 19 deletion mutation or LA58R. For patients with a classical EGFR mutation, several strategies have been shown to be superior to first generation tyrosine kinase inhibitors in the first line setting. And the panel strongly recommended osimertinib to be used as first line therapy with a high level of evidence, based on the FLAURA clinical trial. This demonstrated not only an overall survival benefit, but a quality-of-life benefit. Other strategies that have been shown to benefit include dacomitinib as first line therapy, gefitinib plus chemotherapy as first line therapy. Erlotinib/bevacizumab and erlotinib/ramucirumab are also options with a lower level of evidence, as they have not been shown yet to be associated with improved overall survival. But they are associated with improved progression-free survival. Most of the recommendations, other than osimertinib, are really recommendations for what to pursue if osimertinib is not available. If we move to patients with sensitizing but non-classical EGFR mutations, the evidence is certainly much more sparse, as are these patients. And the recommendation was for afatinib first line or osimertinib was also considered an option based on phase II data. For patients with EGFR exon 20 insertion mutations, recommendation at this time was not to use a targeted agent first line, but to default to the non-driver mutation guidelines. For second line therapy, after tyrosine kinase inhibition stops benefiting, the recommendation was to use doublet platinum chemotherapy with or without bevacizumab. The atezolizumab/bevacizumab/carboplatin/paclitaxel combination was acknowledged as an option based on an exploratory analysis of the phase III EMPOWER trial, but this was considered exploratory and this regimen was not strongly recommended until further evidence accrues. BRITTANY HARVEY: OK, thank you. Then Dr. Leighl, what is recommended for patients with stage IV non-small-cell lung cancer and ALK rearrangement? DR. NATASHA LEIGHL: So for patients with ALK rearranged stage IV lung cancer, in the first line setting, next generation ALK inhibitors alectinib or brigatinib should be offered to patients. This is based on randomized trials comparing these to first generation inhibitors, crizotinib specifically, demonstrating better outcomes including progression-free survival and better intracranial activity. If you live in a region where alectinib and brigatinib are not available, earlier inhibitors like crizotinib or ceritinib should be offered again based on high quality evidence randomized trials demonstrating that these are better than chemotherapy. In the second line setting, if your patient has received alectinib or brigatinib first line, lorlatinib may be offered. If your patient received an earlier generation inhibitor crizotinib, they should be offered alectinib, brigatinib, or ceritinib, again based on randomized trials. And later, lorlatinib third line may be offered. It's also important to remember that in this group of patients, chemotherapy, especially pemetrexed-based chemotherapy, is very active. And we would refer you to the ASCO-Ontario Health non-driver mutation guidelines for chemotherapy recommendations when targeted therapy is no longer an option. I should also note that when we drafted these guidelines, we did not yet have results of the first line lorlatinib study, the CROWN study, where we found that lorlatinib was also superior to crizotinib, the first generation inhibitor. This is currently under review by the US FDA. So while it's not recommended in our guideline, we may see this added to future guidelines in our next guideline update. BRITTANY HARVEY: Great. Thank you. And then, what is recommended for patients with ROS1 rearrangement? DR. NATASHA LEIGHL: So for patients with ROS1 rearranged stage IV lung cancer, in the first line setting, specific ROS1 inhibitors, crizotinib or entrectinib may be offered. Because this is based on very impressive response rates and prolonged duration of response and patient benefit, in single arm studies, we have to recognize that alternatives may also include standard treatment based on the ASCO non-driver mutation guidelines, as well as other target agents, such as ceritinib or lorlatinib, that may be offered. If, though, your patient has progressive disease and previously received non-targeted therapy, targeted therapy with crizotinib, ceritinib, or entrectinib, can certainly be offered. Also, if your patient has received ROS1 targeted therapy in the first line setting, standard treatment based on the ASCO non-driver mutation guidelines should be offered also with consideration of clinical trials. BRITTANY HARVEY: And then additionally, what is recommended for patients with stage IV non-small-cell lung cancer and an NTRK fusion? DR. NATASHA LEIGHL: Thanks, Brittany. For patients with stage IV disease and an activating NTRK fusion, entrectinib or larotrectinib may be offered in the first line setting based on single arm studies, including patients with lung cancer and very dramatic response rates and prolonged duration of response. However, standard treatment based on the non-driver mutation guideline chemotherapy-based may also be offered in the second line setting. If NTRK targeted therapy was given first line, standard treatment with chemotherapy-based options may be offered second line based on the non-driver mutation guideline. If NTRK targeted therapy, though, was not given in the first line setting, entrectinib or larotrectinib may be offered to your patient. And I think at this point, we really don't know what the optimal sequence is for these patients. But I think it's very clear from the data that we do have, that we want to try and identify this target and get patients on targeted therapy as soon as possible in the course of their disease. BRITTANY HARVEY: Great. Then Dr. Riely, can you review what the guideline recommends for patients with stage IV non-small cell lung cancer and a BRAF mutation? DR. GREGORY RIELY: Thank you, Brittany. I'll highlight that the BRAF mutation guideline pertains specifically to those patients with BRAF V600E mutations. The other BRAF mutations that we observed, we don't have sufficient data to make recommendations. But for those patients with BRAF V600E alterations, again, based on the quality of the data and the type of data available, the guidelines recommend consideration of first line use of dabrafenib with trametinib. This is a consideration rather than a should recommendation, given the absence of randomized clinical trial evidence. But nonetheless, we recommend that they be considered in the first line setting. If, in fact, you choose to use a non-targeted approach in the first line setting, then the guidelines do recommend consideration of dabrafenib with trametinib in the second line setting. So it's, again, the first line setting, dabrafenib/trametinib combination. Or, if not used in the first line setting, then recommendation dabrafenib/trametinib in the second line setting. BRITTANY HARVEY: OK, then, what is recommended for patients with stage IV non-small-cell lung cancer and a MET mutation? DR. GREGORY RIELY: Again, specific for MET, we're talking about MET exon 14 alterations rather than MET amplification with other mutations, which we might call emerging targets. So for patients with metastatic exon 14 altered non-small cell lung cancer, the recommendation is for the use of capmatinib or tepotinib. These are newer MET inhibitors that have recently been approved. And again, the guidelines recommend that they should be considered in the first line setting. If, however, you choose to use non-targeted therapies in the first line setting, then MET directed therapy such as capmatinib or tepotinib should be considered in the second line setting. BRITTANY HARVEY: And then the final target addressed in this guideline, what is recommended for patients with stage IV non-small cell lung cancer and RET rearrangement? DR. GREGORY RIELY: RET rearrangements are relatively uncommon, but important in a subset of patients with non-small cell lung cancer. And we have MET targeted agents that are available. The current guidelines recommend that in the first line setting, we consider the use of selpercatinib. And in the second line setting, if patients have not previously received a RET inhibitor, one should consider selpercatinib in that context. Patients who have received a targeted therapy in the first line then conventional chemotherapy with or without immunotherapy or bevacizumab should be considered. I will note that the guidelines were finalized prior to the approval of pralsetinib, and pralsetinib is another RET inhibitor with similar data in this context. BRITTANY HARVEY: Great. Thank you all for reviewing those recommendations. So Dr. Robinson alluded to this earlier, but Dr. Riely, could you describe what emerging targets the panel reviewed but were unable to make recommendations for at this time? DR. GREGORY RIELY: The development of treatments in patients with non-small cell lung cancer has really proceeded at a breakneck pace over the past 10 years. We've seen newer alterations identified, new drugs tested in those populations, and new drugs approved in relatively rapid succession. We have a number of targets that are currently being studied with new drugs, but we don't quite have enough data yet and the drugs aren't yet approved, so they can't be included in the guidelines. Some of these targets include KRAS G12C, recently seen a number of direct KRAS inhibitors that have been developed and seem to have activity in that group of patients. And that's a hot area to look forward to. We've also seen that patients with EGFR exon 20 insertions don't seem to benefit from currently available EGFR TKIs at the standard recommended dose. And so we don't have recommendations for their utilization here, but there are new drugs that are being developed to target this group of patients. Similarly, patients with HER2 mutations seem to not benefit from available therapies, but there are drugs that are being developed, and we look forward to seeing more data in that context. Finally, patients with NRG1 fusions are another emerging target, but we don't have good recommendations yet or good drugs yet. BRITTANY HARVEY: Great. Understood. So then, Dr. Robinson, in your view, why is this guideline important, and how will it impact clinical practice? DR. ANDREW ROBINSON: Well, this guideline is important because it's taking a problem that we see in the real world, which is patients with lung cancer with an ever-expanding number of driver mutations, and trying to give recommendations for the integration of new therapies with standard clinical practice. It's important that I've highlighted that for most of these mutations, without phase III evidence, the recommendations were to consider the targeted agent as first line therapy. But also, if it's not given first line, to use it in subsequent lines. And I think we need to recognize that these targeted agents, it's most important that patients get these drugs at some point in their care, even if we don't know exactly what the optimal point in their care is. The guideline was sort of the first one in lung cancer, where we've taken a number of these rare mutations and examined the phase II data, and will likely be the template for what is going forward with an ever-expanding number of medications. So hopefully, we get a bit of standardization out of it. Hopefully, we've highlighted some of the areas that are still unclear and can be a template for the next round of targeted therapy guidelines. BRITTANY HARVEY: Definitely, it's an ever-changing landscape. So finally, Dr. Leighl, what do these updated guideline recommendations mean for patients with stage IV non-small-cell lung cancer? DR. NATASHA LEIGHL: So this is really great news. And as Dr. Riely and Dr. Robinson have highlighted, in just a very short number of years since 2017, we've made tremendous progress. We have at least three new targets, many new treatments for almost every class of targeted therapy indication in lung cancer. And most of these new targets are their oral therapies or pills. And many of them should now be offered to patients as first or second line treatment instead of chemotherapy. So for patients, this really means many more will be able to enjoy a chemotherapy-free world, or at least a chemotherapy-free period for a time. I think it's really important for patients and the oncology team to remember that genomic testing is essential. And it's an essential part of the stage IV non-squamous, non-small-cell lung cancer diagnostic process, and in some places, you know, any non-small-cell lung cancer. And this may be a very important part of the process. And it really doesn't depend on clinical factors like smoking. It's really about your pathologic diagnosis or in your tumor sample. So it's really key that we make sure that patients get their samples tested as soon as possible in their lung cancer journey, preferably with comprehensive profiling so we can identify any of these targets, if our patients have them, and then get them onto the right treatment as fast as possible. If there isn't enough tissue for testing, liquid biopsy has emerged as a potential alternative. And I think it's so important for patients and oncology professionals to remember that PD-L1 expression, which is an important marker for immune therapy, is not enough. At least a quarter of our patients with PD-L1 expression that suggests immunotherapy should be an option, in fact, have these actionable genomic targets. And we do know that in these patients, targeted therapy should come first. So again, tremendous progress, many exciting opportunities for our patients to be chemo-free for much longer. And again, important to get the right test as soon as possible so we can get you onto the right treatment as soon as possible. BRITTANY HARVEY: Great. Well, thank you all for reviewing the extensive literature associated with this guideline and developing these recommendations, and for taking the time to speak with me today, Dr. Leighl, Dr. Riely, and Dr. Robinson. DR. GREGORY RIELY: Thank you. DR. ANDREW ROBINSON: You're welcome, and thanks a lot to the ASCO staff for doing all of the work in sort of herding the cats that are oncologists, as well as getting all the references and the deep literature searches for us. DR. NATASHA LEIGHL: Agreed. Thanks so much. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.

Our hormones affect almost every aspect of your body. Mood, metabolism and many physical processes are all governed by hormones. However, you might not recognise just how unique you are genetically. Our genetic profile and predisposition to certain hormones impact our daily lives more than we think it does. Learning more about ourselves can drastically improve our quality of life and allow us to make informed and empowered decisions. Dr Mansoor Mohammed joins us in this episode to explain the importance of understanding our genetic predisposition and the hormone cascade. He also talks about women's hormones. Finally, he explains why we should take our genetic profile into account before experimenting with pharmaceutical treatments and different types of therapy. If you want to know more about the science behind your genetics and hormones, this episode is for you. Hormone Report with The DNA Company If you would like to have your hormone test done, understand your genetics in regards to your hormones and would like to then have these interpreted by Lisa, please go to this link to get the test done. Lisa will then contact you once the DNA has been processed to have a consultation. Please note the consultation will take an hour and will cost $190, which is extra to the actual report. The Report can be purchased here: https://www.mydnacompany.com/products/lisa-tamati-and-the-dna-company-female-hormone-profile Please note The DNA Company is based in Canada and this price is in Canadian dollars. It may take up to 6 weeks depending on where you are located in the world for your results to get back to you. For any questions, please email lisa@lisatamati.com.   Get Customised Guidance for Your Genetic Make-Up For our epigenetics health program all about optimising your fitness, lifestyle, nutrition and mind performance to your particular genes, go to  https://www.lisatamati.com/page/epigenetics-and-health-coaching/. You can also join our free live webinar on epigenetics. Online Coaching for Runners Go to www.runninghotcoaching.com for our online run training coaching. Consult with Me If you would like to work with me one to one on anything from your mindset, to head injuries,  to biohacking your health, to optimal performance or executive coaching, please book a consultation here: https://shop.lisatamati.com/collections/consultations Order My Books My latest book Relentless chronicles the inspiring journey about how my mother and I defied the odds after an aneurysm left my mum Isobel with massive brain damage at age 74. The medical professionals told me there was absolutely no hope of any quality of life again, but I used every mindset tool, years of research and incredible tenacity to prove them wrong and bring my mother back to full health within 3 years. Get your copy here: http://relentlessbook.lisatamati.com/ For my other two best-selling books Running Hot and Running to Extremes chronicling my ultrarunning adventures and expeditions all around the world, go to https://shop.lisatamati.com/collections/books.   Here are three reasons why you should listen to the full episode: Understand why it is essential to learn about the nuances of the menstrual cycle.  Discover your individuality as a person going through hormonal cascades. Learn more about the effect of estrogen and why being on the pill fundamentally changes you up to the cellular level. Resources Your DNA Company Female Hormone Profile Report In the FLO by Alisa Vitti The DNA Company The DNA Company on Facebook Episode Highlights [06:47] The Journey Going Through Hormones Menarche is the first menstrual cycle, which is when a female enters young womanhood. After menarche comes pre-menopause, perimenopause and then post-menopause. Our sex hormones are fundamental at a holistic, physiological and phenotypic level, as they affect functions at the cellular level. Hormones have a circadian nature, which affects metabolism, oxidative stress and other physiological processes. Some of the top female athletes in the world are still unaware of their menstrual cycles’ health and how it affects them. The phases of the menstrual cycle and variety of hormones affect ligament flexibility, likelihood of injury and exercise response, among others. [12:45] The Circadian Rhythm of Hormones The nuances of your hormonal circadian rhythm rely heavily upon your genetic predisposition. Women have different mental, emotional and physical responses, depending on where they are in their cycle. We should focus on the individuality of women when it comes to the genetic traits of their hormonal circadian rhythms. Females need to listen to their bodies and be wary of one-size-fits-all approaches to hormones such as birth control. The pill can either be a saving grace or bring complications. [18:39] Understanding Hormones, Treatment and Therapies Even without the extremes such as hormonally-related cancers, daily issues such as migraines, fatigue, weight gain, and nutrient deficiencies can occur. Knowing your innate tendencies is essential to feeling healthy and optimal. Most women enter womanhood without clearly understanding their innate patterns. This lack of understanding forces them to accept the routine or resort to pharmaceutical treatment. Symptoms of what was thought of as supposedly lyme disease and other complications vanish when women enter pregnancy. Some hydroxy-dominant women have a genetic predisposition to inflammation and oxidative stress due to hormones, regardless of their diet. [29:44] Estrogen and Testosterone Estrogen is essentially aromatised testosterone. Four hydroxy estrogen metabolites in men contribute to prostate enlargement, leading to inflammation. Men who have a genetic predisposition to aggressively convert estrogen into metabolites are more likely to experience benign prostatic hyperplasia. Both men and women will benefit from understanding their tendencies when it comes to converting metabolites. [35:57] Athleticism, Menstrual Health and Birth Control Some women can eat the same food and do the same exercises but can never achieve the same musculature. World-class athletes need to understand their monthly cycle thoroughly to be in an optimal state. Being on the pill makes you estrogenised for 21 days instead of the usual five days, which can be wonderful or detrimental for you depending on your genetic makeup. Estrogen binding to its receptors radically changes gene expression. Being on the pill fundamentally changes you on a cellular level. The pill can be right or wrong for you; taking it is not a trivial matter. Women aren't designed to be estrogenised continuously in the long-term, as it affects mitochondrial efficiency. [47:46] The Effect of Having a Proclivity to Produce 4-Hydroxy and Being on the Pill Being on the pill exacerbates the effects of having a genetic predisposition to inflammatory and oxidative traits in hormones. Women who already have a disadvantageous genetic profile expose themselves to greater toxicity if they estrogenise themselves non-stop. Estrogen isn't evil, and it keeps us young. However, we have to find a balance. Listen to the full episode to understand the entire process and the chemical processes and genetic pathways involved! [53:32] The Importance of Cellular Balance Cells have other receptors, and there has to be a proper balance and circadian rhythms to have healthy processes. Optimal health comes when the presence of hormones come in optimal waves. There are many nutraceutical or nutritional intake and environmental exposures that can further slow down essential processes. An example is a glass of red wine. If you know your genetic predispositions, you can improve your quality of life. This knowledge empowers us to make choices to either live a healthier life or at least mitigate negative consequences and know our genetic limits. [1:03:57] Hormonal Implications for Men Older men can erroneously assume testosterone is the magic fix to declining sex drive and athletic performance due to aging. However, the reality is that you may have a genetic predisposition to convert testosterone into estrogen and become more estrogenised. These have implications with undergoing testosterone replacement therapy and can undermine your goals. 7 Powerful Quotes from This Episode ‘Your listeners have to understand that the way in which their bodies respond to these hormones define and contribute every aspect of cellular function’. ‘Few aspects of medicine are as boldly innately different as the nuances and the individuality of a young woman's innate genetic control of the circadian rhythm’. ‘It defines why she can eat the same foods, exercise the same as her mate, in fact, exercise more than her mate and be fit and be beautiful and be strong, but never get that cut or that sort of musculature’. ‘When you are naturally menstruating, there's only a window of about five to seven days, give or take, in your 28- or 30-day or thereabouts, where you are in your unit, but recycle that your body is actively producing estrogens. Those estrogens are actively circulating in your bloodstream. And the cells of your body are actively responding to that estrogen’. ‘It's about the balance... A healthy female cell is one that is having, it's a traffic system, and it's one that is being trafficked into it at the proper ratios at the proper circadian pulses and rhythms’. ‘If you do not know these things, you're going to be at risk of using a one size fits all approach that will be beneficial for 10%, 20%, 50% of women, but that most certainly equally can be deleterious for a group of young women, unwittingly’. ‘This is about empowerment, it is the empowerment of being informed — being informed about your unique predisposition. What is your operating manual, making your more normative choices, if you will, of these cascades? And then how do you optimise the things that you want to do and the things you don't want to do’? About Dr Mansoor Dr Mansoor Mohammed is the President and CSO of The DNA Company, a leading and innovative provider of comprehensive Functional Genomics testing, consulting and personalised health solutions. He is widely regarded as a pioneer in medical genomics and has been the recipient of multiple academic and industry awards. He is the holder of several patents in the general fields of molecular diagnostics and genomics research and is one of the most sought-after national and international conference speakers in the genre of personalised medicine. Prior to his role at The DNA Company, Dr Mansoor was also the former Founder and President of ManaGene, CEO of Combimatrix, Director of Genomics at Quest Diagnostics and Director of Research and Development at Spectral Genomics. He continuously maintains an active clinical practice as a genomics consultant to some of the leading executive health clinics in Canada and abroad, has served on the Canadian Board of Autistic Research and is a consultant to the world-renowned Toronto Center of Applied Genomics. If you want to learn more about Dr Mansoor and his work on genetics, you may visit his website. Alternatively, you can check out his Facebook and Twitter. Enjoyed This Podcast? If you did, be sure to subscribe and share it with your friends! Post a review and share it! If you enjoyed tuning in, then leave us a review. You can also share this with your family and friends so they can understand themselves more through learning about their genetic predisposition and hormones. Have any questions? You can contact me through email (support@lisatamati.com) or find me on Facebook, Twitter, Instagram and YouTube. For more episode updates, visit my website. You may also tune in on Apple Podcasts. To pushing the limits, Lisa Full Transcript of The Podcast! Welcome to Pushing The Limits, the show that helps you reach your full potential with your host Lisa Tamati, brought to you by lisatamati.com. Lisa Tamati: Well, everyone and welcome back to Pushing The Limits this week. I have a really super duper interview coming up. I know we say that but are some of the people I have just blown me away. And this is Dr. Mansoor Mohammed who is coming on the show today, that name may ring a bell because documents or has been on the show, I think three times previous to this occasion. And he is one of my great mentors and teachers. And he's one of the world's leading geneticists, and functional genomic scientists. And it's really, really exciting to be able to work with a caliber of men, like Dr. Mansoor. Now, today's subject that Dr. Mansoor is going to be talking about is hormones, hormones and your genetic profile in regards to your hormones. We're specifically looking at the female hormone situation today. But what I do want you to know is that the hormones cascade is exactly the same for me. So a lot—while we’re specifically focusing in on the woman today, and we'll probably focus in on the men on another episode. A lot of what we're saying here will be relevant to men too. And just understanding that you need to know about these pathways, the genetic pathways, before you go mucking around with anything hormonal. And also some of the nutriceuticals that you may or may be taking can also interfere with this pathway too. So this information that's going to be coming out to you today is absolute game changer. Really important for me. I'm on bioidentical hormone replacement therapy, and because I'm going through the menopausal change at the moment, just being transparent. So this information for me has been absolutely crucial because I can tailor my own hormone prescription to my specific genetic needs. And then layering that on with understanding where my bloods are at as well. So it's really really key information.  If you're a woman who is on the pill, if you're a woman who's got endometriosis, or PCOS. Or if you're a male who's got prostate problems, or if you're a male who's thinking of going on testosterone replacement, all of these things are really, really pertinent to this conversation today. So I don't want you to miss out. Now do stick around to the end of the conversation because Dr. Mansoor has a company called the DNA, a company which actually has DNA reports. So you can get your DNA tested. If after listening to this session, you are curious about what the heck your hormone pathway is, and how to optimise it, then you can—you know, stick around to the end and check out the show notes as all the links will be in there as well. Before we head over to Dr. Mansoor, I just want to remind you, we have a new system now in Running Hot Coaching, my online run training academy. We have fully personalised, customised run training plans based specifically on your goals and where you're headed. If you want to join us in our company, we would love you to come along. You're going to get a session with me to discuss all your goals and your objectives, to answer any questions around running. And then you would also get a fully—after that consultation has been done, you'll get a video analysis so we can actually look at you running and analyse your running style and help you optimise that. And then you're going to get a fully customised training plan for your specific next goal. Whether that's a 10K or 5K, a marathon, a half marathon, it doesn't matter. We will provide the plan for you which will also include all your mobility work, your strength work, as well as your run sessions. And also guidance around nutrition and electrolytes and mindset, which are very, very important pieces of the puzzle as well. So if you want to check that out, head on over to runninghotcoaching.com. And you can find out all about it or if you've got any questions reach out to me support@lisatamati.com.  Also wanted to remind you my latest book, Relentless is available for sale. You can grab that on my website at lisatamati.com along with my other two books Running Hot and Running to Extremes. I'd love you to check those out. If you love some of the content that's been on this podcast, then these books will definitely be up your alley. My latest book is a bit different to the first two, which were my running adventures and all the highs and lows and disasters and successes that I had racing the world's most extreme events on the planet. The third one is really the journey I took with my mum over the last—how many—nearly five years now. After her aneurysm and bringing her back and rehabilitating her. But it's not just a book about rehabilitation. It's about mindsets about overcoming the odds. It's about the mental strength to be able to carry on when everybody's telling you there's no chance and there's no tomorrow. It's a book that will empower, inspire and have some very, very important messages that I'm really, really keen to get out in the world. So please make sure you check that out as well, Relentless. You can find all of those on lisatamati.com. Right now over to the show with Dr. Mansoor Mohammed.  Well, hi, everybody, and welcome back. I am super excited once again to have Dr. Mansoor Mohammed on the show today. And Dr. Mansoor is a real repeat offender on the show. I think this is the fourth podcast. You're the only person who's been on here four times, Dr Mansoor so welcome to the show again. It's fantastic to have you back. Dr Mansoor: It's an absolute pleasure. I'm not sure does that mean I have to repeat myself to be understood? Lisa: No, you've got so much knowledge that we have to share with everybody. That's why. Dr Mansoor: Absolute honor. Lisa: So Dr Mansoor, so today, we are going to be focusing everybody on genetics and hormones in particular. And we're going to be focusing in a bit on the ladies, although this is very relevant for the men out there too. So don't turn off if you're a guy and just go ‘Well, this is for one for the ladies’. This is also aimed at men.  But Dr. Mansoor is a world leading functional genomic scientist. And we're going to be talking today about the hormone cascade and understanding our genetic pathways that we take with our hormones and why we need to understand this and how important it is for us. So Dr. Mansoor where shall we start with this journey of going through the hormones. Dr Mansoor: I think the first thing we want our listeners to understand and it's not lost in any young woman, post menarche. And so let's just define just two quick terms menarche, the time in which a young woman begins a monthly cycle and she enters into young womanhood all the way through menopause, pre menopause, perimenopause and then postmenopausal. But in all of these wonderful stages of a young woman's life, that there's what we call sex hormones, the steroid hormones, the progesterone, the androgens, most notably testosterone, estrogens and their respective metabolites. They influence the human body at a cellular and at a holistic level, in the most fundamental of ways. Okay, so that's the first thing. Just to emphasise the importance of these sex hormones. The second is to clarify that with this importance, it's not just about external female characteristics of breast developmental, hip flare or thigh developmental, bum developmental, factor position. It's not just “about the obvious phenotypic or physiologic manifestations” of these hormones. We have to understand that sex hormones impact every aspect of cellular behaviour. These hormones when produced—and by definition, hormones are messenger molecules that are produced in one part of the body. In this case, for example, the ovaries. They then enter into the bloodstream, circulate throughout the body, and then impact every cell in that cellular behaviour. So the second more important point is our listeners have to understand that the way in which their bodies respond to these hormones define and contribute to every aspect of cellular function, every aspect of cellular function. Now, if we can appreciate that. The third thing we've got to appreciate and the young woman’S body, okay, is that there's a circadian rhythm or circadian, generally speaking, that there's a circadian nature to these hormones. In other words, it strikes me and I attended a remarkable conference a bit over a year ago. It was with the Red Bull team of super athletes and their clinicians. And one of the clinicians, she is from the UK. She specialises in treating female athletes. That's her series dealing with female athletes. And in her presentation, we were all presenting at this conference. She said something that was alarming, heart wrenching, but almost not surprising all at once. And what was she said, she would run a survey on these female athletes. These are like Top of the World female athletes, one of which just to begin with was one of the top—if not the top—female soccer teams in the world. And she said, not a single one of these athletes, female athletes were ever asked or made aware of the health of their monthly cycle. Lisa: Wow. Yes. And these are the top people let alone the other...  Dr Mansoor: Yes, and so she was beside herself as a scientist and the clinician, that for something as fundamentally impactful to the human body, as those sex hormones. So for example, as she illustrated, depending on whether a woman is in her follicular phase or her luteal phase of her menstrual cycle, proclivities to injuries change, the flexibility of the ligaments, and the body changes, the response to the body to different types of motifs of exercises, changes. When is the female body—can we speak in here, at first, in generalities of the average female going through a monthly cycle, not yet on the pill, we're going to talk about the pills as a separate factor. But just is part of the normative circadian rhythm of the female body. The female body morphs physiologically, cellular metabolically at day seven of the monthly cycle is completely different. And that's speaking a little bit extreme as to the body when it's on day 15, as to the body when it's on day 20. And so you've got individuals demanding the very best from their body optimal performance. And they have not yet even come to terms with the baseline changes to the body between these stages. And as you pointed out, so many injuries due to training in these athletes, and again, we're speaking of athletes, but we can, we can juxtapose that. Like you said the average female trying to simply be the best version of herself, could be avoided. If the young woman only knew what stage in her monthly cycle she was at. If the young woman only knew the oxidative stresses that are different during different times of the monthly cycle. So if I told you Lisa, that at a point in your menstruating cycle, you innately, naturally have surplus, oxidative stress. It really doesn't take a lot further to grow to understand in those times and days, the last thing you want to do is go—there you go. You don't want to put even more oxidative stress at that point in the body. And so on, and so on, and so forth.  So in this third category, as you said, to establish the baseline that we're speaking of, we've got to understand the importance of hormones, we've got to understand that it's beyond just the outward superficial physiology of the body. And in this case, speaking of young women, we've got to understand that there is a circadian rhythm to these hormones.  Now, once we understand these three bases, these three points,then we have to appreciate that part, a significant part of what controls, that's the circadian rhythm. And then within that circadian rhythm, what controls the nuances of one young woman versus the other relies upon their genetics. Lisa: The genetics, yes. Dr Mansoor: And so once we understand the functionality of the circadian rhythm of the female cycle, Lipson, once we understand the gears that are going through those 28, approximate dates, once we understand that rhythm, we understand the genes that control or significantly contribute to that rhythm. We understand that each individual potentially has variations in those genes that controls that rhythm. We begin to understand the nuances. We begin to understand the individuality of Paula versus Lisa versus Joanne versus Isabel. And so we begin to understand that one aspect of every aspect of intelligent medicine. But few aspects of medicine are as boldly innately different as the nuances and the individuality of a young woman's innate genetic control of the circadian rhythm. And one week we will talk about this, we need to appreciate this.  And the most abhorrent of complications that occur, if you do not understand this individuality, one young woman to the next, and then you take that birth control pill, I am not, of course, I have no place to be anti birth control, but I'm a man. I'm not a young woman. Now. So this is not about being controlling. No, not at all. But it's the fate. The simplest thing that we think that you can take 1000 university young woman, you know, first year university students, girls, young woman. And somehow put them on the same birth control, literally the same birth control. And somehow expect that they're getting to be the same effect, and somehow minimalise and even criticise a young woman who comes back and says, ‘I find that I'm gaining weight. I find that I'm—my mood is not the same, I find a’.. And then because five other young women don't have those issues, the doctor says ‘No, that's not because of the pill’, and they are dismissed. And they're not even appreciated as to the uniqueness of their body's response to something. Again, sometimes the pill is a saving grace for a young woman. But what we're speaking of here is in these three pillars, the fourth pillar is the individuality of the genetics of that young woman. And all of the remarkable insights that a young woman can gain from this. Before I go any further, it's not a plug in the least I hope I'm not, you know, going against any regulation of your podcast, but there’s a brilliant book called In the FLO. Lisa: In the FLO. We’ll put the link in the show notes. Dr Mansoor: I have no association with the author. But it's just she did an amazing job. And I'm trying to get the name as I'm speaking about. I'll remember the name. She did an amazing job, without the genetics, of showing how radically important a young woman understanding her circadian rhythm, how different points of her month, her body responds to different foods differently, her brain response, her emotive response. She's really done a beautiful job of highlighting the awesome, holistic cellular changes that go through a young woman's body in these waves of human rhythms every 28 days. So this sets the stage Lisa, everything that we might want to talk about, is predicated on this understanding. And then the genetics that explains this.  Lisa: That’s a beautiful entry into this whole actual looking at the mechanics, if you like, of the genetic pathways that I do want to get into. Because in other words, every single woman is individual. And this is the beauty of genetics in general, is that we can actually personalise once we understand their own genetic pathways. And you know, we do this both in our profession is to understand what our genes are doing and how they're expressing and how we can optimise these genetic pathways, if you like, in this case, with our hormonal pathways.  And this has a real implication when it comes to things like the birth control pill, when it comes to—In my case, bioidentical hormone replacement therapy on the other end of the scale going through the menopausal years. Because this has implications whereas, you know, if I take biological hormone replacement therapy, and we've actually talked briefly on one of their podcasts about some of my hormonal which I'm happy to share as well.  I'm on a hormone replacement therapy. But I understand my genes, and I understand where my problems may lie. And therefore I can keep an eye by from a blood perspective, you know, keep an eye on my hormone levels, but I understand my own cascade. And I can mitigate the chances for example of developing estrogen-based cancers or, you know, like breast cancers or cervical cancers. Whereas another person, if we put them on the same regime may run into trouble. Dr Mansoor: Indeed, even without the—shall we say, more extreme outcomes or concerns, such as hormonally-related cancers, but really just even the day to day well being of the body. You know, the risk of peripheral neuropathy is, the risk of migraines or lack before resolving them fatigue, weight gain, things that are—the way your body responds to nutrients. Again, understanding where your body innately, your your innate tendency is, as per explained by your genes. And we'll get into some profound examples of this.  And then making sure that you act in accordance because we have choices. And some of the choices we can make. And sometimes there are, you know, I think there are many times we speak about human optimisation.There are certain voices, and they have a point that can say, ‘Look, but there are universal truisms’. They're just things that we should all know, are either healthy or unhealthy. And there are a few of these things...  But what is remarkable here is, especially when it comes to female hormones, there are things that you might deem to be universally healthy, but actually can be either unhealthy or certainly not optimal for some young woman versus others. So we’re really in the realm here of not just talking about universal truisms that are relevant with or without genetics. We're speaking of nuances that are so radically important.   And may I say with that, if it's okay with you. I'd like to then set the stage of some of—just set the stage for themes, themes that your audience, your listeners. And then I'm going to say a few things. And my hope, and my goal is, for many of the listeners out there, at least a few of these things should resonate. For example, how many young women out there find that their introduction and their experience to cyclical migraines kick in post puberty?    In other words, here she is, she's living in the same home, same nutrition, healthy, or whatever version of lifestyle, and the day comes where she enters into your womanhood and break there after, right there after. Not directly related to her flow as per what she could physically and visually manifest. But this concept of now dealing with migraines, a concept of dealing with a circadian rhythm to her mood, and to her what she might find trouble for those first few years until she becomes an adult woman. And she's got life experiences, but she's always found that she's having a hard time to express, that she literally feels that her emotional resilience, that ability, that barometer to what tips are over that scale of resilience changes. And she's never—and no one has even asked her by the way. ‘Do you see that it comes in patterns? Do you find that it happens? And kicks in three to five days prior to your cycle? Do you find that that's when you see some of these changes in the month? Do you find that it kicks in a day before ovulation? Do you even know when ovulation is happening’? None of these conversations are going to happen.  So that these apparently unrelated just symptomologies of ‘Well, there's some anxiety’, or you know, ‘I get migraine’. They just brushed under the growing list of things that ‘Will you just take a pill for it’? Meaning a pharmaceutical treatment. Or they're minimised and somehow they're accepted as just a routine part of all, that's what it is to life. Okay. Or how many young women out there have dealt with some of the symptoms of migraines or pain, Fibromyalgia-like pain, debilitating fatigue. And then something miraculous happens. When they become pregnant for nine months, most of all, have their symptoms resolved. How many young women have said to me, I can't tell you, Lisa. Again, I know that being in New Zealand, I'm not sure if you have to deal with the plague of Lyme disease. It's something that we have here more in Eastern America. Lisa: Yes, more overseas. Dr Mansoor: But yes, but it's a bacterial tick borne disease that ruins lives. And there are, interestingly, a preponderance of women who present with Lyme disease-like symptoms. Now, we worked, I worked in a clinic and I was one of the first to describe this phenomenon. And I had to say not trivialising the horridness of disease, I said to a patient, I said, ‘You know, those ticks don't like women more than men’. Lisa: Then why more women are presenting with these symptoms? Dr Mansoor: Presenting with the symptoms. Unless women were more likely to go trekking and hiking and be exposed to, you know. But here's the point. It was that there was a significant—in one of the clinics that we did the study in. There were a significant number of women who presented with classically, what outwardly seemed as Lyme disease symptomologies of debilitating fatigue, almost concussion-like presentations, mental malaise, muscle aches and pains, as I mentioned, Fibromyalgia-like presentations, and they were convinced that they had Lyme disease, convinced that they had Lyme disease. And because it's such a polymorphic disease, yet many doctors were going ahead and treating them with massive antibiotics, even if they couldn't confirm the Lyme disease.  Because many doctors, almost agreeably have had to say because so many, so many true Lyme patients are being under cared for, right that there are some really good doctors wanting to do the right thing, who were treating the symptom and the presentation, per se. But amongst individuals were a preponderance of women who were not testing positive for Lyme disease. So what was going on here? And what we did when we studied these young women was, we looked at a significant number who then went ahead and became pregnant during their proposed Lyme disease. And for the nine months of pregnancy, all of their symptoms resolved. And I had to say to both the doctors and the patients I said, ‘Your Borealis, the burgdorferi Borrelia bacteria, the bacteria that causes—that doesn't just take a hike during pregnancy’. Lisa: It doesn't just go away. Dr Mansoor: It doesn’t just go away. It's not that. So what else is at play here? Well, how many young women understand that during their menstruating months and years, the primary estrogen in their body is estradiol? During pregnancy, your primary estrogen is estriol. Estriol is not metabolised into the same byproducts as estradiol. Estradiol can be metabolised. Every young woman metabolises this estradiol into three byproducts, 2-hydroxy estradiol, 4-hydroxy estradiol,  16alpha-hydroxy estradiol. Now every young woman produces all three. But genetically, you are predisposed to producing more of one or the other depending on your genetics.  And if you happen to be the young woman who was predisposed to producing in the ratio, more than 4-hydroxy or even the  16alpha-hydroxy, and God forbid more of the following 16 hydroxy as compared to the 2-hydroxy, the 4-hydroxy. And to a degree, the  16alpha-hydroxy metabolites are particularly inflammatory. They're literally inflammatory metabolites that the body has been designed to get rid of.  But if you were that young woman that genetically, was predisposed to producing more of these naughty metabolites, as opposed to the much, much less inflammatory two hydroxide. Then just innately, you the young woman that recycles the body, when it comes around to the body metabolising, those estradiol, your primary estrogen when you're menstruating. When that estradiol is metabolised for a period of two, three to five days, depending on your particulars, your body, literally, regardless of whether you were eating organic and living organic and breathing the best hair in the world, normally, you are producing an internal inflammogen. An internal thing that is causing both inflammation and oxidative stress. Now, during pregnancy, when you become estriol dominant..  Lisa: You're not getting it.  Dr Mansoor: You don't get these metabolised. And so when a young woman gets pregnant, and she complains prior to pregnancy, of these malaise and the symptomologies and then comes pregnancy and the only thing that has changed, and I've had young women cry in my office saying ‘Dr. Mansoor, how did you know to ask me if I felt better during pregnancy’? Because usually it's quite the opposite. People think, ‘Oh, my gosh, I'm gonna get morning sickness. And I'm gonna’...  These young women were better off. And they would say, ‘You know Mansoor, wish I could stay ‘pregnant. Those were the months where I actually had a relief from symptoms’. So this is Lisa... Lisa: Yes. Sorry Dr. Mansoor. So these 4-hydroxy in the  16alpha-hydroxy to a lesser degree, because it's a rarer situation. And this is in relation to the Cyp19a1 gene, the aromatase gene, turning our testosterones into estrogens. Is there any—so when we go on that—if we put on the pill, which is got estrogen in it. And you're one of those women who have—and this goes for me too. My husband has a 4-hydroxy dominance for example, which is a problem. He is—are we exasperating the problem when we take the pill without knowing it? Dr Mansoor: So just to clarify and add a layer of clarity. So estrogen and the estrogen molecule and the estrogen hormone is actually nothing other than aromatised testosterone. So a lot of young women don't appreciate that, you know, they self identify with estrogen. You know, women tend to self-identify their estrogens, and men tend to “self identify with testosterone”.  In fact, I had one of these absurd pop ups on—I was watching a food vlog which is my guilty pleasure, especially doing COVID. I like watching it, you know, foods being prepared and you've got these annoying YouTube ads that come up. And what if it was this buffed, you know, male trainer and he comes on the screen on the ad and he goes, ‘Well, testosterone is what makes a man, a man’. Not quite.  But the point is, men need to understand that we too, make estrogens. And women need to understand that the very estrogens that they may or may not self identify with are really simply testosterone molecules that had been aromatised. Okay, so there is a gene, a specific gene, one gene Cyp19a1, as you have mentioned. And in fact, the parlance, the more common name for the Cyp19a1 gene is aromatase. And this gene with its enzyme chemically changes testosterone into estrogen, i.e. estradiol, estriol, as the case might be, okay. But then once you make your estrogen, your estradiol, let's just fix it at that. Then there are other genes that make other enzymes, that make the two or the four or the 16 byproducts. So specifically, there's a gene known as the CYP1B1, CYP1—Bravo—1. This is the gene that makes the self named enzyme that takes some of your estrogen and turns it into the naughty, 4-hydroxy estrogen metabolite. Now, the point here is different women and different men—and just to clarify for the male listeners out there, if you would think that estrogen was a female issue, and if you would think that 4-hydroxy estrogen was a female issue, think again. And we now understand that 4-hydroxy estrogen metabolites in men contributes to prostate enlargement, contributes to the inflammation of the prostate for many years. In fact, for the last two to three decades, all of the research on benign prostate hyperplasia in men has focused on a testosterone metabolite, known as DHT.  So DHT, dihydrotestosterone is the product, it is the metabolite of testosterone produced by the steroid five alpha reductase to the SRD5A2 gene with its enzyme produces that metabolite. And it is true, the DHT, one molecule of DHT has the potency to bind androgen receptors as six molecules of testosterone. It's a much more potent, super testosterone. Super, right.  So here's the thing. DHT is to testosterone. As 4-hydroxy, estrogen is to estrogen. DHT is the testosterone metabolite that interacts with the androgen receptor, much in the same way as the 4-hydroxy metabolite of estrogen. 4-hydroxy overproduction and men, we have now discovered is a significant contributor to the etiology and the progression of prostate and benign prostate hyperplasia. Lisa: I thought it was just a SRD, the DHT so I need to know. Yes, okay, I need to go and check that with my husband.  Dr Mansoor: Now for the last couple of years. Some of the actual pharmaceutical clinical trials to treat benign prostate hyperplasia has switched everything, all of our propecia and finasteride, these medications that we currently... And just for the male listeners out there, it is unsurprising that the very medications that are often used for benign prostate hyperplasia, were found or would then use for balding. It has the same DHT that promotes male pattern balding is the same testosterone metabolites that over inflames the prostate. But now we understand that the males who have the 4-hydroxy estrogen preponderance genetically, why? Because they had a version of the CYP1B1 gene that made a version of the CYP1B1 enzyme that is more aggressive at converting estrogen into this metabolite. So men, this discussion is equally important to you.  But coming back to the females very quickly, then Lisa. You see a young woman who does not know who's going about her, you know, her life and her teenage years and her 20s not even knowing ‘what is the degree—what is what is my innate tendency within which I convert my progesterone to testosterone? What is my innate tendency to convert testosterone to DHT? That more virulent testosterone? What is my innate tendency to convert testosterone into estrogen? And by the way, once I make the estrogens? What is my innate tendency and converting it into the twos and the fours and the 16 metabolites’? Because you see, if a young woman were to understand this right off the bat looser, it defines why and how easily she develops lean muscle mass. It defines why she can eat the same foods, exercise the same as her mate, in fact, exercise more than her mate, and be fit and be beautiful and be strong, but never get that cut or that sort of musculature. As for not saying that that's what she wants to know. But so many women are going ‘I work so hard. I trained my bum off but I'm not seeing that type of’, this is going to be intimately described by the woman who is making less DHT from the testosterone, making more estrogens from making more 4-hydroxy estrogens from her estrogen from her testosterone. This is a young woman whose cellular level is estro dominant and estro toxic. And she cannot until and unless she appreciates this.  And until and unless she takes steps to reduce. And of course, that's the million dollar question, ‘Can we take us to 37:00 reduce it easily’? And the overwhelming answer is, ‘Yes, we can’. Okay. But she's even unaware of this to take the steps in the first place. So let me come back to those super athletic young females for whom their doctor, when they did the research. Here they were, no one ever even asked them what their monthly cycle health was. ‘Are you having a monthly cycle? Is it irregular? How do you feel with the cycle? Are you on the pill’? So now I answer your question, you see Lisa, if you didn't know where you were innately on that cascade. Remember, young woman out there, all of the ladies out there, in a ‘normal’, in your natural monthly cycle, without the pill. You know, just you're 16, you're 26, you're 36 you're menstruating. How many of you realise that that estrogen that you self identify with isn't produced 24/7, 30 days a month?  Lisa: Exactly. It is when you put on the pill work. Dr Mansoor: That's the difference isn't it? The very point that I'm trying to make is, in your natural monthly cycle, your body is only estrogenised, it is only under the influence of this hormone. And I'm going to stop beside and make a couple more points on this. But I'll finish my point here. When you are naturally menstruating, there's only a window of about five to seven days, give or take in your 28 or 30 day or thereabouts, where you are in your unique monthly cycle, that your body is actively producing estrogens. Those estrogens are actively circulating in your bloodstream. And the cells of your body are actively responding to that estrogen. Compare and contrast that to being on the pill, where have for 21 days of a 28 day cycle, not five to seven days, 21 days, your body is under the influence of testosterone. Here's the thing Lisa, that I have to admit. And again, let me be clear, all of Lisa's amazing listeners, this is not about anti-pill. The pill is absolutely—it is your right. It is something that you control. It is absolutely a godsend for different times of your life and for different young women. But you've got to ask, Where are you in the spectrum of young woman? And how will your body respond to this differently? And you would at least need to understand that your body was not estrogen eyes for 21 days in your normal cycle.  And here's the newest thing, Lisa. That I must admit, this gives me indigestion. Again, I have no say over the matter, but down the practice of actually having no bleed, how many women are now being put on constant pill without even a bleed through? So now you go from a normal physiology of every month, say seven days of estrogenisation to 365 days of estrogenisation.  Lisa: Disaster. Dr Mansoor: So now, Lisa I'm—and we would be remiss if I don't quickly emphasise to our listeners, what is estrogen? ‘What is this thing that you—okay, well, it's stopping me from getting pregnant. My hair is luscious, my skin might look really wonderful. So after all, shouldn't be a problem’. What you have to understand, and our listeners out there in the female body—and I can speak of the male and female body, I'm just going to focus on the female body for the time being. In the female body, Lisa, every single cell produces these receptors for estrogen. So if this is your cell, you have an estrogen receptor. And when that estrogen is produced, or it is taken as a pill, or as whatever the— even certain neutra estrogen analog or xenoestrogens and plastics, these molecules enter your body, they bind to these receptors on your cells, okay? Because by the way, estrogen doesn't do what it does in the body by just being produced and floating in the bloodstream. No. Estrogens do what they do in the body by being produced by then binding to these receptors. And what happens, this is the important point. What happens when estrogen binds to its receptor? What happens is the DNA expression, your genes in that cell, gene expression is radically altered? Literally, the genes, the instructions within your cellular operating manual changes when estrogen enters the cells. When there's no estrogen in the cell changes. So now let's come back, the female body.. Lisa: Apologies for the phone call people in the background. Dr Mansoor: The female body in its normative circadian rhythm experiences a gene expression shift, change in gene expression for the days in which your estrogen was elevated. And yet, of course, it comes back down in the normal cycle. What happens when you force yourself to go into a gene expression shift to 365.. Lisa: Constantly. Dr Mansoor:  ...days a year without change.  Lisa: And we're talking like hundreds of genes, hundreds of thousands of genes that have been changed, turned on and off, turned on, and wow.  Dr Mansoor: These genes impact the metabolic efficiency of your cells. Well, the thyroid function, which is why how many times we see a competitive joint problem between hypothyroidism, hyperinsulinemia—your body's response to insulin, and estrogen dominance. Wow. And when these three things come together, we euphemistically call it metabolic syndrome. You know, there's a read, there's a point behind, there's an impact behind it.  And the point here that I want to make is, we often just think of the sometimes and arguably beneficial outcomes, outward outcomes of being on the pill. Okay. And I emphasise for the umpteenth time, please, this is not about not being on the pill. The pill can be what is right for you at certain points in your life. But it's about being educated, that taking this hormone is not something as trivial as stopping your ovaries from producing an egg. That's not what that hormone is doing only. This hormone is interacting with every cell in your body and it is changing the way your genes express in every cell of your body.  Now, the point here is, if we were to do—I like to call it a heat map. If you took a young woman, and you colour code her body, from white to red, according to which cells in her body have had more estrogen receptors. What you will do is the whole body isn't going to be white, the whole body isn't going to be red, it's going to be shades of white and pink and red. And of course, unsurprisingly, the region of the breast tissue will be somewhat the reddest, because those cells and the breast tissue are some of the most sensitive to estrogen. So what does this mean? It means that when estrogen is present in the bloodstream, the cells of the breast tissue are some of the most able to absorb that estrogen. But what happens when it absorbs the estrogen? Gene expression happens, gene expression changes happens. And the cells were designed to account for a circadian rhythm to their gene expression change. Not 21 days, repeatedly, repeatedly, or 28 days, for that matter, repeatedly, repeatedly. Again, I stress not for the young woman who is seeking birth control maybe for a few months, or periods in our life. We're speaking of the travesty of the young woman that had been on the pill since they were 14. And here they are 32. Lisa: Unable to conceive and or cancers, or weight gain, or cellulitis, or all of these implications. Dr Mansoor: The very metabolic machinery of that cell, you're very mitochondrial efficient efficiency of the cell is impacted during—and this brings me back to the brilliant comment by the brilliant female scientists that I was speaking of earlier, where a young woman should understand that in her natural, healthy 28 day rhythm, metabolic efficiency, mitochondrial efficiency, changes in response to the ratios and the waves and thrusts of progesterone versus testosterone versus estrogen.  Think what happens when you put a blanket of estrogen over everything, 24/7, 28 days, 30 days a month, 365 days a year.  Now, the point here, Lisa is coming back to even more finesse point in your question is, well, that is what I what we've just explained happens in every young woman that goes into pill, every young woman that goes into pill. But what happens when you didn't realise that you had the proclivity of making more of the 4-hydroxy estrogens? What happens when you didn't realise that your ability to then neutralise the 4-hydroxy estrogen that inflammatory estrogen metabolic, which by the way, you know, not realising that you were making more of it. You were producing—when you introduce X amount of estrogen molecules more if it was going down the 4-hydroxy pathway than the healthier 2-hydroxy pathway? If you were not aware of this, and you were doubly unaware of the molecular mechanisms that neutralise? So what is the gene? — Let's take a look at this. What is the gene that neutralises 4-hydroxy estrogen? What is that gene? The gene that neutralises, is COMT, catechol-O-methyltransferase. This is the gene, the gene that is—makes an enzyme. The same name, that's COMT enzyme. And the job one of the jobs of this enzyme is that it recognises the production of 4-hydroxy estrogen, which is inflammatory, which is pro-oxidative, pro-inflammatory, pro-estrogen. Indeed. Because here's what happens, that 4-hydroxy estrogen—think about it, Lisa and all of the listeners—you took estrogen, which was binding to its receptor, and causing all of those estrogenised changes that we spoke of. So of course, what the body wants to do is it wants to limit the duration by which estrogen can bind to its receptor.  So it's good to metabolise the estrogen. But ironically, when you metabolise your estrogen into 4-hydroxy, estrogen, ironically it's still doing—in fact, not only is it still binding to the estrogen receptor. Some studies indicate it can bind to the estrogen receptor actually with greater proclivity within greater binding efficiency than its original estrogen. And it can induce that altered gene expression 2-hydroxy estrogen does not do it near as much, which is why we consider the 2-hydroxy estrogen prefer—to be the best pathway.  Well, the point here is COMT converts that full hydroxy estrogen into 4-methoxy estrogen. Now, 4-methoxy estrogen dramatically loses its ability to bind to the estrogen receptor. So 4-methoxy estrogen is what we can now say it's no longer estrogenising. Okay? The other thing of the 4-hydroxy, going back now to the 4-hydroxy, estrogen, if you're not removing it, if you are not converting it by methylation into the methoxy, estrogen, 4-hydroxy estrogen, it decomposes into these nasty little molecules called quinolones. Horrible, not very nice things. And quinolones decomposed into oxidants. So the whole stagnation if—let's let's clarify the statement now. Now, if as a young woman, you did not know that you have the predisposition, when ever your body sees estrogens, whether they are internally made, or externally introduced, when ever your body sees estrogen molecules, if you did not know that you A) tend to metabolise those estrogens into 4-hydroxy by products more than we would like and B) you will not as efficient at neutralising the 4-hydroxy estrogen by virtue of COMT, what you are unaware of is you are unaware of this thing called an estro dominant burden with estro toxicity. You are unaware that in your normal cycle for five to seven-ish days, your body is under the strain of an internal inflammatory production, internal oxidative stress more than your female companions. And will you to then take that normal exposure, but then by going day in day out on an estrogen source, think of what you're doing to the body. Lisa: And by the same take of the bio identical hormone replacement on the other end of the scale with the menarche, the menopause. And we want like, just just to clarify, estrogens are not evil things we want. The body needs estrogens and like it keeps us younger. I mean being on—this is the dilemma that I've been facing. The biological hormone placement keeps me—my bone density good, keeps me—you know, being able to hold my muscle, my skin is better. I'm not aging as quickly the inability or cells of my vessels are better, etc, etc. However, I need to keep those in a balance so that I don't get too many chicks estrogens going in or I need to keep my progesterone up and I need to make sure I know where my testosterone is. Yeah, so that. Dr Mansoor: Because it's about the balance. It's about finding—and so here's that final point. You know how we spoke about the cells, Lisa having these estrogen receptors? Well, your cells have androgen receptors as well. And they have progesterone receptors as well. So think now, we can almost visualise a healthy soul, a healthy female soul is one that is having—it's a traffic system. And it's one that is being trafficked into it at the proper ratios at the proper circadian pulses and rhythms.  Sometimes estrogens are getting in, altering gene expression in an estrogenised manner. Sometimes androgens are getting in altering the gene expression in an androgenised manner. Sometimes progesterones are getting it, altering the gene expression and the progesterone alised manner. And it is optimal health and optimal youthfulness and responsiveness to yourself is when we get that circadian rhythm allowing the cell and allowing its operating manual, its genes to go through this rhythm of when are the—the genes that are controlled, and that are going to be expressed because of the presence of estrogen. The genes that are going to be controlled and expressed because of the presence of testosterone, because of the presence of progesterone, these waves and rhythms of gene expression, optimal health is when these waves happen in the optimal full manner, okay? And we can replace that optimality and we can extend the optimality and therein lies the brilliance of hormone replacement, of which it absolutely is something that you know, other knowledge can afford. But unfortunately, when we do this, without the appreciation of the individuality of these ebb and flow waves, and we push the system, without appreciating what was the a priori tendency of that young woman. Was this young woman a priori andro dominant? Was she a priori estro dominant? Was she estro toxic? Was she estro dominant and estro toxic? If you do not know these things, you're going to be guilty of—you're going to be at risk of using a one size fits all approach that will be beneficial for 10%, 20%, 50% of woman, but that most certainly equally can be deleterious for a group of young woman, unwittingly. Lisa: And this is what shocks me is that we have done this human experiment, like 85% of the population of woman on the planet who are in their menstrual years have been on or are on the pill, including myself, who was on it for 25, 30 years, I don't even know and ended up with fibroids, ended up with endometriosis, even though I don't have the 4-hydroxy dominance. Yes, and because I was constantly on these things, and so now with these genetics—and this is the point. We are able to tweak into change. For example, I'm on organic black seed oil, which upregulates my Cyp18a1 genes, which helps me create more 2-hydroxy because I'm 57:15 red-lighted if you like for that one as well. I take them so that I can slow down the aromatase of testosterone. I have a very quick Cyp17a1. So I need a bit more progesterone support, because I'm making my testosterones very quickly. But without this knowledge, we just like throwing mud against the wall and hoping it sticks in the right places and doing so many people and injustice. Dr Mansoor: Think about this, Lisa, that COMT, that all important—that is that is methylating those metabolites including the naughty 4-hydroxy estrogen. Well, Lisa and listeners out there, there's a variation of very, very, very well studied variation of that come to genome. For those of you who are dabbling with a little bit of genetics, this is the rs4680 variation. So you can actually go look at the code of the variation. And these variations have coding qualifications. This is the rs4680 variation. And this variation is defined by two alleles, two versions of the gene. One is a G version, G as in George, the other is the A as in apple version. Okay? Now, the G version of this gene produces a version of the enzyme that is faster, it is kinetically more efficient at doing its job. But what is it one of its jobs? Neutralising 4-hydroxy estrogen. So much so that if you were a GG, both copies of your comt with the fast versions, the genes and versus if you were AA, both versions were slow. The AA COMT individuals, the people that have to have the slow versions of the gene, their COMT is working at 70% to 75% slower than the person that is... We're not talking trivialities, we're not talking 5% to 10%. We're saying that if you're an AA, your enzyme is doing the job. It's doing its job. It's just doing it 70% slower than if you were a GG. Now, here's the point. If you were a COMT A and you had the fast version of Cyp1B1 making more 4-hydroxy estrogen from whatever estrogens your body is seeing. Now you’re not getting rid of it.  And here's the final point. There are a number of nutraceutical nutritional intake things environmental exposures that can further epigenetically slow down COMT. So here's one of them. Several of the molecules, the phenolics, in red wine, which we could talk about whether red wine is good for you one glass, we can… But the phenolics in red wine epigenetically slows down COMT further. If you were in AA COMT, already dealing with a pump enzyme, it is doing its job. And then you will drink something like red wine that another person might have had, you know, perfectly fine having a glass of wine, or whatever the case might be helpfully. You don't even realise that you're doing something that is actually now nutraceutically—from a nutrition perspective, working against something in you that you were even unaware of. Lisa: Wow. And then if you layer on that, that you don't have optimal B 12 levels and folate levels and your methylation process is slow. Dr. Monsoor: Now we're really putting in—you're really putting fuel on the fire. So those listeners out there... Lisa: Yes, this leads to things like cancer. Dr. Monsoor: It leads to cancer, it leads to—again, I keep saying, you know, even before we get to cancers, it leads to a quality of life, that can be so radically either improved if we knew or simply a quality of life, where we're simply being told ‘Well, you know, that's just of the things… That's the way it is’.   Lisa: Wow, Dr.Mansoor, I know you've got another appointment coming up, and we have to jump off the call. And I don't really feel like we've finished this conversation. So again, I'm going to have to have you back. And we have to go over the men’s male hormone report too, because everything that we've seen today is also valid for the men in different races, same cascade.  And what I want to get across though, Dr. Mansoor is that you have the power now to be able to understand these genetics. So you and the DNA company have a hormone report, which I'm going to link to in the show notes that people can go and order. The only reason I'm doing this is because I want people to get this report. I want them to understand the genetics and I want them to optimise the genetics and make informed decisions around their hormone replacement or their pill or their what nutraceuticals to take, whether you should take them with you should take black organic seed oil, goodness knows what—all of these things that we can do to optimise our pathway. So I'm going to be linking to that in the show notes that Dr. Mansoor's company has this report now. And you can find out exactly what you should do and how to optimise your your actual personal hormone situation.  Dr. Mansoor, is there anything you wanted to add there?  Dr Mansoor: Well, Lisa, shortly, the short answer, no. A little longer than the short answer is to emphasise what you've just said. This is about empowerment. It is the empowerment of being informed, being informed about your unique predisposition. What is your operating manual, making your more normative choices, if you will, of these cascades? And then how do you optimise the things that you want to do and the things you don't want to do. And it is this empowerment that we really want. It's not about negating any choices you have. It is rather simply about empowering you to either make healthier choices, or when you make certain choices, you make them informed about the limitations of those choices, and then you do your best to mitigate any consequences or implications thereof. And then I will end with one very quick note. As you've said, you know, we've emphasised the ladies here and the woman viewing this, but it is as important to the men and I will give you a very quick example. How many men are going through that man no pause period. I'm 48. I can tell you a thing or two about that. But how many men have come to me having felt that they were declining in their muscle mass and declining in their performance in, you know, both in the bedroom and out of the bedroom and everything else? And they thought that testosterone was the magic fix. And what they did was they went and they were prescribed in good meaning testosterone, only to find that upon taking the testosterone, they were becoming more and more estrogenised. Right. Because remember, even when you take testosterone that same Cyp19a1, that same aromatase is going to convert some of that testosterone into estrogen.  And men that Cyp19a1 gene comes in three different versions. A version that is going to convert your testosterone into estrogen, much faster, medium speed and slower. And so if you don't know which version of Cyp19a1 you have, you do not know what is your body's natural tendency to convert testosterone into estrogen, which can have so many implications on the choices you make, per going into hormone replacement. Lisa: Yes. And that's a thing that I'm discussing with my husband and my brothers at the moment, you know, like the implications of testosterone therapy. And it's not—it's a very simplified thing, ‘I'll just take testosterone, and I'll take a heck of a lot of it because I want more muscles’. It's not. And there are a lot of men doing that. And it works for some, and it doesn't work for others because of this very intricate knowledge that we need to have before we make these decisions.  So Dr.Mansoor, I thin

An interview from Dr. Larissa A. Korde from the National Cancer Institute and Dr. Dawn L. Hershman from Columbia University on “Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline.” This guideline covers the optimal use of neoadjuvant therapy for women with invasive, non-metastatic breast cancer. Read the full guideline at www.asco.org/breast-cancer-guidelines. Transcript ASCO: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one podcast.asco.org. My name is Brittany Harvey, and today I am joined by Dr. Larissa Korde from the clinical investigations Branch of the Cancer Therapy Evaluation Program in the Division of Cancer Treatment and Diagnosis of the National Cancer Institute in Bethesda, Maryland, and Dr. Dawn Hershman from the Herbert Irving Comprehensive Cancer Center at Columbia University in New York, New York, co-chairs on Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. Thank you for being here Dr. Korde and Dr. Hershman. DR. LARISSA KORDE: Thank you for having us. DR. DAWN HERSHMAN: Yes, thank you. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines in ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available on-line with the publication of the guideline in the Journal of Clinical Oncology. Dr. Korde, do you have any relevant disclosures that are related to this guideline topic? DR. LARISSA KORDE: I do not. BRITTANY HARVEY: And Dr. Hershman, do you have any relevant disclosures that are related to this guideline topic? DR. DAWN HERSHMAN: No, I do not. BRITTANY HARVEY: Great, thank you both. Then, Dr. Hershman, to kick off the content of the guideline, first, can you give us a general overview of the scope and the purpose of this guideline? DR. DAWN HERSHMAN: Yeah, sure. In breast cancer, we have seen a plethora of studies looking at neoadjuvant therapy for breast cancer. And as we've learned over time, that neoadjuvant therapy has focused on the role of, really, response as a predictive marker and whether or not the improvement in a pathologic complete response rate translates into benefit in terms of long-term outcome. And the fact that several studies have shown that has really increased our interest in looking at pathologic complete response rate and its predictive value. So part of the guideline is really to help us really elucidate as the understanding of biology of breast cancer has evolved over time, what scenarios where neoadjuvant therapy is the best choice for patients, and what the real purpose of neoadjuvant therapy is. So the guidelines' purpose is really to help us develop recommendations concerning the optimal use of neoadjuvant therapy, whether it be chemotherapy, endocrine therapy, or targeted therapy for a variety of different biologic subtypes. And I think the overarching principle is that the expert panel strongly advocated for a multidisciplinary team in the management of these patients. Specific guidelines really go into details about each of the scenarios where we would use this therapy. BRITTANY HARVEY: Great. Then I'd like to review some of those key recommendations that you just mentioned for our listeners. So Dr. Korde, which patients with breast cancer are appropriate candidates for neoadjuvant systemic therapy? DR. LARISSA KORDE: So when we sat down to write this guideline, we thought through this question in many different ways. But we basically ended up sort of dividing patients by breast cancer subtype and then coming up with recommendations separately for each subtype. So broadly speaking for triple negative breast cancer patients and for HER2-positive breast cancer patients, we felt that the kind of most important triage point is that in both those diseases, there are effective treatments that can be used in the adjuvant setting in patients who do not have a pathologic complete response to neoadjuvant therapy. And so broadly speaking, it's those patients where there would be an adjuvant therapy decision point, or recommendation in whom the neoadjuvant response is important. Those would be the patients in whom we would most strongly recommend neoadjuvant chemotherapy. In ER-positive disease, we looked at both chemotherapy and endocrine therapy in the neoadjuvant setting. And we know that both of these can improve response. Pathologic complete response is less common in patients with ER-positive disease. But there are also benefits to neoadjuvant treatment in those patients in terms of being able to reduce the size of the surgery, reduce potentially morbidity from surgery, and then also in terms of being able to convert patients who were not lumpectomy candidates from mastectomy to lumpectomy. And so in the guideline we outline the scenarios for ER-positive patients in which neoadjuvant therapy would be recommended as well. BRITTANY HARVEY: Great, got it. Then Dr. Hershman, what do the guidelines say about how clinicians should measure response in patients receiving neoadjuvant chemotherapy? DR. DAWN HERSHMAN: Yes, so patients undergoing neoadjuvant therapy should really be monitored by their provider at each visit with a clinical examination at regular intervals. And we really felt that the role of breast imaging was really for patients where there was some clinical suspicion of progression during that therapy to ensure that patients were not progressing during treatment. And ultimately, the best modality for imaging was the modality that was most effective at the point of diagnosis, whether it be mammogram, ultrasound, or MRI, that should be the imaging modality used at follow up. We did not feel that there were any specific blood markers or tissue based markers at this time that should be used for monitoring patients undergoing neoadjuvant therapy. Much of that is done for clinical trial purposes, but not so much in the clinic. And that when patients had completed their treatment, pathologic complete response rate is the most important outcome and would be really assessed at the time of surgery as the absence of any invasive disease in either the breast or the lymph nodes. But in order for that to be good for clinical decision making, it's really imperative that the clinician and the surgeons make sure that the tissue is removed that is suspect to begin with, so to make sure that the clips that defined where the tumor was evaluated and that the tumor bed is clear of any evidence of disease. BRITTANY HARVEY: Great, that's helpful information. So then, Dr. Korde, you mentioned that the recommendations are divided up by biologic subtypes. So what are those neoadjuvant systemic therapy regimens recommended for the following patient population-- so first, those with triple negative breast cancer, second, those with HER2-negative hormone receptor positive breast cancer, and then finally, for those with HER2-positive disease? DR. LARISSA KORDE: So maybe we can divide this up a little. Let's start with the triple negatives. For triple negative breast cancer patients who are embarking on neoadjuvant chemotherapy, and that would be patients with clinically node positive disease, and/or at least T1C disease, and again, with the thought that the goal is really to think about whether adjuvant therapy recommendations would be altered based on PAP CR. But in that setting, we recommended that patients be offered an anthracyclines and taxane containing regimen. We also found data supporting the use of carboplatin with neoadjuvant therapy for the purpose of increasing the likelihood of PCR. So we noted that while there is good data showing that PCRs increase with carboplatin, there is more conflicting data regarding the effect of carboplatin on long-term outcomes. Although, hopefully, new clinical trials that are ongoing now or that are in follow up may clarify this question a little bit more. We felt at the time that we wrote the guideline, and certainly, this is potentially an evolving topic. But at this point, we felt that there was insufficient evidence to recommend routinely adding immune checkpoint inhibitors to neoadjuvant chemotherapy in patients with early stage breast cancer. And again, there may be more data on this upcoming in the next few years. So maybe Dawn can take the next category, the HER2-negative hormone receptor positive patients. BRITTANY HARVEY: Yeah, that would be great. DR. DAWN HERSHMAN: Absolutely. So we felt for this population of patients that neoadjuvant chemotherapy could be used instead of adjuvant chemotherapy in any patient where the chemotherapy decision could be made without the benefit of having the results from the surgical pathology data, or any results from the specific genomic testing. So if the decision was made that the patient was going to need chemotherapy regardless, that would be a patient that could get it neoadjuvantly. We felt that for postmenopausal patients with hormone receptor positive HER2 negative breast cancer that neoadjuvant endocrine therapy with an aromatase inhibitor could be offered to either increase local regional treatment options, if there was no intent for surgery, endocrine therapy could be used for Disease Control. So in a patient where they really were not a good surgical candidate, we could offer this therapy to try to control their disease. For premenopausal patients with hormone receptor positive HER2-negative disease, we did really not feel that neoadjuvant endocrine therapy should be routinely offered outside of a clinical trial. Because in this scenario, there really wasn't enough evidence to offer this approach. BRITTANY HARVEY: And then Dr. Korde, do want to finally address those patients with HER2-positive disease? DR. LARISSA KORDE: Absolutely. So in patients with HER2-positive disease that is either node positive or high risk node negative, we felt it would be appropriate to offer neoadjuvant therapy with either an anthracycline and taxane containing regimen, or a non-anthracycline-based regimen in combination with targeted therapy. And we did feel that targeted therapy should include trastuzumab and may also include pertuzumab. For patients with smaller tumors, really those in whom it's unclear whether the more aggressive for on-chemotherapy regimens or even any chemotherapy at all is needed, for example, those with very small tumors, T1A and T1B, we did not feel that neoadjuvant should be routinely offered. And we did note that in those patients with smaller tumors, an alternative regimen, the APT regimen of paclitaxel and Trastuzumab is something that has been studied in the adjuvant setting. But again those patients with these very small node negative tumors, in general, would not be routinely offered neoadjuvant chemotherapy. BRITTANY HARVEY: Great, thank you both for reviewing those neoadjuvant systemic therapy approaches for those specific patient populations. So Dr. Hershman, in your view, what is the importance of this guideline? And how will it impact clinical practice? DR. DAWN HERSHMAN: Yeah, that's an excellent question. I think as our data has shown more and more studies where there's a benefit to giving adjuvant treatment based on the response of patients in the neoadjuvant setting to get additional benefit long-term amongst patients with residual disease, I think that these guidelines really can help clinicians to understand those scenarios where we know we can maximize treatment. I think ultimately the goal of neoadjuvant therapy is that it gives us opportunities to both escalate treatment in patients that are at high risk that don't have great responses, and de-escalate therapy in patients that have outstanding responses. And so I think this will help clinicians understand what those benefits are. BRITTANY HARVEY: Definitely. It seems like it will provide some clarity for those scenarios. So finally, Dr. Korde, how do you envision that these guideline recommendations will affect patients with non-metastatic breast cancer? DR. LARISSA KORDE: Well, I think building on Dr. Hershman's answer to the previous question, really, the key here is to be able to personalize or tailor the therapy for individual patients. So in those patients whose disease is very high risk, or did not respond to initial therapy, patients can be given appropriate escalation of treatment. And for patients who have an excellent response to treatment in the neoadjuvant setting can potentially be spared other treatments. And so I think that the main use of neoadjuvant treatment and the use of this guideline in terms of how it affects patients is being able to offer the most appropriate therapy for each patient. BRITTANY HARVEY: Great, well, thank you both for your work on this guideline on neoadjuvant chemotherapy, endocrine therapy, and targeted therapy for breast cancer. Appreciate your leadership on this guideline. And I want to thank you also for taking the time to speak with me today, Dr. Korde and Dr. Hershman. DR. DAWN HERSHMAN: Thank you. DR. LARISSA KORDE: Happy to be here. Thanks so much. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/breast-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.

On today's episode of JIMMY RANTS on the LLVLC Show, Jimmy takes a deep dive into a new study by Dr. David Ludwig. “I’ve heard all my career that a low-carb diet is just another version of a low-calorie diet.”  - Jimmy Moore When I first got into the nutritional health community, I remember hearing people who were advocating for the Atkins low-carb diet talking about it providing a metabolic advantage over other diets. What exactly was the advantage? There was an increased total energy expenditure (TEE)—the number of calories burned—of about 150-200 calories a day when you eat a carbohydrate-restricted diet. Flash forward to 2020, now we have a new meta-analysis research paper that confirms it. ⁣ ⁣ In this episode of JIMMY RANTS on The LLVLC Show, I read from a study conducted by Boston Children’s Hospital obesity researcher Dr. David Ludwig and his team published in the December 3, 2020 issue of The Journal of Nutrition. It’s a response paper to another meta-analysis that claimed low-carb diets decrease TEE. But the average duration of the low-carb diets in those studies used in that meta-analysis was just four days. ⁣ ⁣ So Dr. Ludwig reanalyzed the numbers while adding in some longer duration studies of low-carb diets on TEE. What he discovered in his research was an important factor for people attempting to eat low-carb on why they work. Get the full details about what was found in the study in today’s episode! ⁣

Functional Medicine with Dr. Carol Shwery Dr. Carol Shwery (DrCarolShwery.com) has been a dedicated healthcare practitioner for more than 40 years. She is deeply committed to helping people who struggle with feeling sick, tired, and in pain, find the root causes of their health challenges. She helps them reset their body and health so they can wake up feeling vibrant, full of energy, and ready for each day, no matter their age. Through targeted lab testing, Dr. Shwery can assess how each system is working and design an individualized program to rebalance your body. Creating an individualized diet plan, a scientifically based supplement program, stress reduction, and exercise, a person’s health can improve dramatically – not only physically, but emotionally. With an ongoing wellness plan, many health problems can be avoided, such as diabetes, cardiovascular disease, arthritis, female, adrenal, thyroid, and insulin hormone imbalances. Her clients are finding a vitality that has given them a new lease on life! Her personal goal is to transform our broken health care system as well as our broken health and empower people to achieve optimal health so they experience the joy and freedom of a life without limits. www.drcarolshwery.com www.feedingfatty.com   Full Transcript Below Roy - Feeding Fatty (00:03): Hello, and welcome to another episode of feeding fatty. I'm Roy I'm, Terry Terry, I'm going to let you introduce our guests today. Terry - Feeding Fatty (00:12): So we are so excited to have Dr. Carol Shwery. She is a dedicated healthcare professional professional, and has been doing that for 40 years. She's deeply committed to helping people who struggle with feeling sick, tired, and in pain. Find the root causes of their health challenges and to find their root causes of their health challenges. She helps them reset their body and health so they can wake up feeling vibrant, full of energy and ready for each day. No matter what age through lab target or targeted lab testing, Dr. Sherry can access, assess how each system is working and design an individualized program to rebalance your body, creating an individualized diet plan, a scientifically based supplement program, stress reduction and exercise. A person's health can improve dramatically, not only physically, but emotionally with ongoing wellness plan with an ongoing wellness plan. Many health problems can be avoided such as diabetes, cardiovascular disease, arthritis, female adrenal, thyroid, and insulin hormone imbalances. Her clients are finding a vitality. There's given them a new lease on life. Her personal goal is to transform our broken healthcare system, as well as our broken health and empower people to achieve optimal health so they can experience the joy and freedom of a life without limits. Dr. Carol, thank you so much for joining us. We're just thrilled to have you here. Thank you so much Roy - Feeding Fatty (01:51): Nicotine time too. I am was not feeling too hot this morning when I got up. So yeah, it is very timely subject. Yeah. Terry - Feeding Fatty (02:07): So tell us, so tell us more about your history, how you got started, what you started in the healthcare profession 40 years ago. Dr. Carol (02:18): Yeah, so I wasn't spring chicken back then. Roy - Feeding Fatty (02:21): You still are, Dr. Carol (02:24): Well, the numbers say differently and you look great. Well, I, um, I got interested in health at a very early age and, um, I was directed by some of my mentors to go to Google to actually get a degree. And so I did that and I, I expanded my, I went to chiropractic school back then. And since then, I've, um, in the last 40 years I've gotten many different degrees, but, uh, at that time, uh, in, and for the first 20 years of my practice, I was just, uh, you know, don't go and gangbusters, everything was fantastic. And then about, um, about when I was 49 years old, um, my health started to all of a sudden deteriorate before I was, you know, everything was great. You know, I could do anything and everything. And did, um, I tended to pride myself on being a mom, great multitasker and stress was my friend. Dr. Carol (03:27): It really motivated. Um, but then, uh, at that 49th year, everything started to dismantle and I spent about five years trying to figure out what was wrong with me as my health just started to go down, down, down, down, down. And I will, I went from doctor to doctor, whether it be conventional or alternative, nothing was making sense. And, um, people were telling me things that I knew were not true. They were diagnosing me. And I said, you're not hearing. And so ultimately, um, it's a long, long five-year long story. I found out I had a brain tumor. Wow, gosh. And I'm a big, bad one. And, um, I ended up and it was killing me and I was slowly deteriorating in many different directions. So I ended up in a 14 hour surgery, um, came out and, um, was in a coma and then came out paramedics. Dr. Carol (04:28): Um, like why, um, why I tell this story? It's a big story, but we all have our stories. We all have stories. And ultimately I call myself a warrior because I said, this, I'm not, I'm not Lee, I'm this, I'm not letting this stop. And, um, I spent a long time, well, actually a short time and written in real terms for months clawing my way back to being able to go back to practice. I was in a wheelchair, but I learned everything over again. I still have partial paralysis in one leg, but it's, you know, I'm here and I'm back to being the ever anybody. And the reason why it's probably this is because we a, we do have our stories, but also I now have a sense of understanding and compassion for people and what their needs are. Whereas before I could give information, but I didn't have the personal experience. Terry - Feeding Fatty (05:27): So you having that, um, that, uh, brain tumor and, and having to go through all of the therapy and that you're just clawing your way back and being paralyzed and all of that, just, you think that made you a better practitioner? Dr. Carol (05:45): It made me a better physician. Yeah, totally. Because now a I can listen to people in a brand new way. Right. And then I can be empathetic and I can empower people in a new way that I simply could not prior to this moment. So I'm grateful that I had that experience. What I wish it on anybody else? No, but it happened. Right. And so I do feel I'm a better doctor because yeah, yeah, Speaker 4 (06:14): Yeah. Sometimes we have to go through that to, to actually, uh, you know, it can be transformative. Once we come out on the other side of a traumatic experience, like Dr. Carol (06:24): That's right. And it made me, you know, it empowered me to be, have more of a belief. What I needed to do to get back to the place I'm at now is alternative medicine. Conventional medicine took the majority of that tumor out, but alternative or functional medicine got me to where I am. So it was the blend lovely blend. Speaker 4 (06:46): That was one. Oh, I'm sorry. That was one question I was going to ask you was the, uh, you know, what is the difference between the functional and the traditional? Dr. Carol (06:54): Yes. Conventional medicine, um, is an expert in diagnosis, surgery, medication. We need these things. If we're in a crisis situation, there's nothing like conventional medicine. That's going to help us. We need that, but these things can behave like band-aids. And so it doesn't get down. It's like going from the top down, conventional medicine is looking at the top of symptoms. And then it's saying, this is how we're going to treat those symptoms. Functional medicine is going underneath. We're trying to look at the root causes of why people get sick. So it's completely different approach, more holistic and taking in to account all aspects of a person that you may actually think is unrelated. So we're, it's really looking from top down or bottom up. And that's really the essential difference than we know that our health in this country particularly is going down in our healthcare system and the model for it is broken. Um, and we're, we're not doing well from a health point of view in this culture. So this is trying to take the wisdom natural of natural medicine from the ages mixed with science of nutrition and medicine and blend them to come and figure out root causes, then give personalized treatments to each individual. Cause it's not what anybody gets. One, one picture, right? She has to be customized. That's right. Speaker 4 (08:32): So a couple of questions don't want to get too far out ahead of you, but, uh, two things that just came to mind while you were talking were number one. Do you feel that traditional medicine or Conventional, do you feel like there is a difference between prescribing medications does traditional, uh, uh, does, Oh, now I'm confused. Does that, does the, uh, Terry - Feeding Fatty (09:01): Conventional medicine go, are there, are they more apt to prescribe the medication first and foremost? Or Dr. Carol (09:11): I guess it just depends what versus what, as opposed to trying Speaker 4 (09:16): The traditional versus the conventional, you know, the, I guess the mainstream, like we have today, my opinion only, but it seems like if you go in and say, Hey, I've got this, it's like, yeah, we got some pills that we need you to take. That's going to fix that. And so I, the, Terry - Feeding Fatty (09:32): The functional medicine medicine is more looking at the whole, Dr. Carol (09:36): Well, let's say, why do you have that thing? Right. That's the difference here? Let me give you something for the pain without understanding. Why did that pain occur in the first place? Right. That's the essential difference between the two things. Okay. Here, I'll give you something, but I don't really know. What's why it's happening. This is going to get rid of the symptoms, right. Maybe right. Terry - Feeding Fatty (10:01): If somebody were wanting a functional, wanting somebody to look at, you know, at a functional medical professional, how would they go about searching for that? Dr. Carol (10:16): Uh, well, I know you guys are in Texas. I know, I know there are functional medicine doctors in Texas. I mean, I totally know that you can find, you know, somebody like me, there are you look, you clump in functional medicine. Yeah. And then people and people will show up. You can find me, I treat, I read virtual all over the country. Everybody's virtual. Now you have, yes, you have in actually it's been a service been, um, because people can get what they need and not necessarily be locked into their immediate environment. Right. Community and wants something outside. Speaker 4 (11:01): Well, not only that, but you know, like I had a falling out with my longtime doctor because it was like, you know, you go there and wait an hour in the waiting room. Then you go back to the exam room and wait another 30 or 40 minutes. And you know, nobody, you know, I know that scheduling tight is how they make money. But on the other hand, it's like, you know, with this virtual medicine, I think that it probably puts the patient a lot more ease being to be staying at home in their own environment, but not going to be in that waiting game. And then also not mixing with the people in the waiting rooms, especially with COVID. But even before that, I mean, you never know what people have sitting next to you. Dr. Carol (11:43): That's true. Well, there's also sort of a standard of care in medicine, which is a, uh, you know, you have a window of time and it's a short window of time. You have to be rapid. You have to, so they can put a lot more, you know, they put a lot more people in where is in functional medicine because we're really looking at a larger complexity of situation. We're going to take a longer time. I didn't turn into a cattle call. That's right. Different. Speaker 4 (12:08): So you mentioned diet, uh, earlier, that was the second question I had is so, uh, you know, from your experience, have you found that diet is a big component of our illnesses or when things go wrong, can it be traced back to that? Dr. Carol (12:26): Well, I'm going to, I want to talk a little bit about something called what I call the essential eight. We have what I call foundation of health and they're essentially eight different foundations. And if they're like pillars, okay. So if you have any of those pillars is been knocked out of balance, the building on top, which is your organs are not going to be able to function correctly. So there's eight of them. And I'll just say, um, it's sort of like, these are the basics. Okay. And if you don't take care of the basics, whether it's, whether you're worried about COVID or you have a mental health issue, or you have a chronic health condition or an acute one, if you don't deal with these essential aid, your something's going to be out of whack. Let me just tell you what I believe they are. Okay. So nutrition, hydration, that's one, that's an essential core piece of health sleep. If we don't get the proper sleep, we're not going to function like Speaker 4 (13:31): We've been dealing with that lately. Dr. Carol (13:34): This is a huge people are having trouble sleeping right now because they're, so one of the other things, stress stresses them, stress management, another pillar, another foundation, um, physical activity. How many people have been sitting in front of their computer for eight or 10 hours a day and not getting up to move, right? We are, we are locked. My hips are locked. I mean, I've never set them up to my believable. Um, the environment, whether it's the water, the air, we are surrounded by 85,000 potential chemicals every week. You 5,000 that's that's toxicity in the environment. And then another problem is social connection. There's no much distress because we are at this time. So isolated and social connection at any time is one of these essentials. And then, um, fun, pleasure, joy getting out in nature. If people are unhappy, that is one of the pillars. And then the nervous system, if our nervous system isn't functioning, right? Any one of these, or if you have more than one or just one, they can knock your system out. So nutrition key, right? That'd be eight. I hope that's a long winded way of answering. Speaker 4 (14:53): It's good. I was taking notes here because, uh, you know, that's kinda, uh, I don't think I've given it quite that much thought, but you know, kind of what we always talk about between us as our pillars, I guess, are, you know, the sleep diet, exercise and the hydration, because I feel like I've begun to feel like, uh, you know, sleep is, uh, kind of, uh, what sends me off on the wrong paths. And, you know, I've been working a lot the last few days and getting little sleep and, you know, then all of a sudden I feel like I have to eat more, um, eat, you know, like a vacuum, I'll be eating anything. I could get my hands on to try to get me some energy to, you know, boost me up for a couple minutes and then diet Cokes, no water. You know, it just seemed like it is a downhill from, Dr. Carol (15:43): Sorry. No, no, you're fine. You're fine. So the truth is you're tired and you're trying to use nutrition or the lack thereof to boost energy in the two really have nothing to do with each other. But that is a really common situation. Yeah. Speaker 4 (15:58): Oh, and I forgot exercise was the other, which that has gone, you know, that goes by the wayside too. When you get busy, no exercise, no sleep eating by, you know, drink, not drinking water. Dr. Carol (16:11): Do you have a cell phone? Yes. You got your little cell phone. Yeah, I have every, every hour I have my cell phone. I like, I'm a dog person, so I have my cell phone bark every hour. And instead of get up off your tush and do something a few minutes. Right. Okay. Okay. So we need, we need some ways. Yeah. The other thing is, um, you know, I, I say this a lot, especially during this time of lockdown, we are not social distancing from the refrigerator. No. Okay. Speaker 4 (16:46): No, we've become, we've become very close. I should probably have a six foot from it. Got a tunnel. Dr. Carol (16:57): Yeah. It's definitely a thing. Yes. Speaker 4 (17:03): It's so important because you know, I'm just looking at these that, you know, you've talked about and it seems like that, you know, going through this pandemic, especially all of these eight are, are out of whack in some way for just about everybody, you know? Cause I know, you know, and we've been lucky. Uh, I'll say I'll speak for me. I think Terry too, but we've been lucky we have thrived through this and you know, I kind of tell some people that I feel like I may have a little survivor's guilt because you know, being at home, it's been, I've been a lot more focused, been able to get a lot more done, but unfortunately it kind of leads into that. Staying in the chair longer, not getting up, not getting out and getting the exercise. You know, you just, it, I don't know. You just cannot Terry - Feeding Fatty (17:51): Leave in, not leaving your seat there. Cause you're working, we work and all the time feeling like you need to work when you, and so many things going through your head. Dr. Carol (18:00): I know my desk here is just covered. You know how that is, but the good news is the two of you work together. And so you can push each other to go, okay, we need three minutes. Let's get up. Let's go outside. Let's do something. Right. Um, that's the good news if you utilize it, right? Speaker 4 (18:22): Yeah, no, she tries to keep me on track. I have to give her that much. He works very hard to make sure, to make me stop for dinner and you know, do all the right things. But you know, I guess what another point is where we are, we are some of the lucky ones because we have each other and we have things to do around here where we can get outside or I can get outside and get my exercise and work. But you know, there's so many people that can't get out and the, the social isolation I'm sure. Especially for like, you know, our parents that, um, seniors. Yeah. I just know when we go over there, we, we went by to drop something off on a Sunday and you know, ended up staying for three hours just because, you know, they were just, uh, Terry - Feeding Fatty (19:09): Starved for any kind of human interaction whatsoever. Dr. Carol (19:13): Well, well the stats on seniors actually, um, there's the loneliness of creating and social isolation is creating a more chronic disease manifesting. Terry - Feeding Fatty (19:26): Wow. And depression. I bet Dr. Carol (19:27): It could be found that it's not, it's not a pretty picture. No. Speaker 4 (19:31): Yeah. And it's a vicious cycle because even if they have a medical condition, then they get scared to go to the doctor or go to the hospital and then it just kind of snowballs from there. So yeah. Dr. Carol (19:45): Yeah. That's right. So it's, it's just important that we do as much as we can for ourselves and the people who love you within the limits that we now have. Right, right, right. Um, to, to help, to help. Um, so I did want to talk and tell me if this is okay, because you kind of hit on something and what you said. Okay. Um, we're, you know, we're probably all super pandemic fatigue. Like it's hard to even say it. It's like, Oh my God. So that's always thought about for, you know, eight months. Right, right, right. But the thing is that what you said? Um, there are non-infectious pandemics that are going on all the time. They're not infectious, but they're not infectious. And I wanted to talk about three of them. Cause what you said. I can't remember exactly, but it's triggered me wanting to speak a bit. Yeah. There are three non-infectious pandemics and I wanted to talk about, and it relates to how this essential aid, if they're off kilter, then how your body functions isn't going to work. So I wanted to talk about the first one, which is, have you ever heard of metabolic syndrome? Yes, but I don't remember. Okay. Dr. Carol (21:07): Um, you've heard, we all know that these, uh, when they talk about co-morbidities as being a problems, well, three of the comorbidities, hypertension, obesity, and diabetes all make up, uh, can, uh, be manifestation of something called metabolic syndrome, which is your blood sugar. Uh, you have high blood pressure, high blood sugar, excess body fat around the waist, high cholesterol. These are all things I see your face. These are all things that, Speaker 5 (21:38): Um, is he over there rolling his eyes? I just hit the triple crown on that one there. I think I've got all of them. Here's the problem. Dr. Carol (21:48): I mean, this is just, we're just hitting on a few things very briefly. We can spend hours looking into this, but if you have this problem, it lowers, it causes inflammation in your body. We've all heard that cytokine storm. This is inflammation. Okay. And then it lowers our immune function. Okay. So if we are hitting, uh, sugars and carbs, um, that is going to alter our ability to handle blood sugar correctly, then metabolic syndrome can take place. Now your immune system starts coming down. It doesn't work. Yeah. Okay. So I wanted people to understand in terms of understanding root causes, it's not just me. All I have to do is put a mask on in social distance. No. How is the body function so that we can try and maximize our immunity by not doing things that are going to be problematic. Right. So I wanted people to talk about that. And one of the things I do with patients is ask them to test their blood sugar throughout the day, many times a day. So we find out what is your blood sugar? And this is something that you can do at home, um, to give us this information. Um, once something else I, uh, stop me at any time. Speaker 5 (23:11): Yeah, no, you're good. You're good. This is all, you're a dream Dr. Carol (23:15): Big 90% of all our illnesses are due to lifestyle and 90% of illnesses can be fixed with lifestyle. Okay? So this, these beans are really relevant. I don't care what we're talking about. Right. It could be immunity or anything else, but here's this other thing. And I wanted people to really get this we're sitting around and we are suppressed to the men. Most of us, uh, well, there's these glands called the adrenal glands. Have you guys heard of them? They sit right on top of the kidneys and they are our first line of defense against stress. Now, if they are struggling, they might be pumping up too many of these hormones that they produce. Or maybe not enough if we're really, really stressed, the body goes, I can't take this anymore. And they stopped supporting these hormones. Guess what happens to your immune system? It goes down. Dr. Carol (24:10): Yeah. Yeah. Yeah. So that's important that we can find out are our adrenal glands suffering. Um, and so we talked about the essential aid. If our stress management is not working well, the adrenals may suffer. So in functional medicine, we talk about, um, tests don't guess. Okay. So we do, um, for people who, I think this is an important piece and it may not be for everyone. I would have them do a salivary test to find out what, what is going on with your was so that we could find out a personalized approach to whether they need to have that handle in order to boost their immune. Speaker 4 (24:57): Okay. Yeah. And you know, I can attest to that back in, uh, LA, it hasn't happened lately, but this was back in my younger days when I had a pretty high stress corporate job is that, um, exp you know, before I would go on vacation the last, the week before vacation would be so stressed, trying to make sure everything was handled and in line. And my people knew what to do that week and that I would literally get off on Friday night, go home and wake up sick Saturday. Yeah. I would be, I'd be sick for three days because you know, it was like once that's, once the stress had, once the stress had relieved, once I got home and it left my body, it's like my immune system must have been so weak that, you know, I just got, I got sick. And so my vacations were usually marred by two or three days of, you know, flu like symptoms. Not, not really bad, but just being fever and, uh, all of that. Dr. Carol (25:56): I am right there with you. Yeah. And you're going away Terry for two weeks. I am, let's see, Oh my gosh, I've been running around. Speaker 4 (26:05): I think people are, people have got a pool going on. Who's going to survive me or the dogs when she comes back. Dr. Carol (26:13): I mean, for two weeks, I'll be gone two weeks and there you're going to be sorely missed. I think I wanted to talk about one other thing because people, I really want people to see the connection. And that is, um, where do you think 70 to 80% of your immune system lives in your body, Speaker 4 (26:39): On your skin or underneath? Just underneath your skin? Yeah, yeah. Speaker 5 (26:44): Yeah. Okay. I'm done drop the mic. Dr. Carol (26:50): If you're, you've heard the term microbiome, have you heard that your gut, the floor in your gut, the good, the bad and the ugly, if that is imbalanced, is there is a problem with, and these are terms may or may not know if there's a problem with the permeability and we've got meaning there's holes and bad guys are bidding in and affecting the body. If that, if your gut is not running smoothly and your microbiome is off and given it 70 to 80% of all our immune system is living down there, your guts, not good. Guess what happens? Your immune system is thinking. So these are actual pandemics. These things are happening everywhere with everybody, but nobody's thinking about all that interaction, that infectious pandemic and these noninfectious pandemics, this is a recipe for disaster. And so we want to find out well, is that relate to you have that issue? Um, so we might, if, if I think, you know, somebody has that issue, I might want to test that, test your guts in, in what we call functional testing. Speaker 4 (28:01): So what is, uh, what is a test that you would run to test somebody's gut? Dr. Carol (28:08): If I felt it was important for that person? Uh, well, I call them poop tests, but they are, Speaker 5 (28:17): Oh, now we're always going to start turning red. And we talk about anything, Dr. Carol (28:23): You know, fecal tests, but, and they're, they're done over a couple of days. You get a sample from each day and it tells us many things. It tells us, uh, what you are able to digest, what you're not able to digest. Do you have creatures down there that are, um, parasitic or fungal or bacteria that are not supposed to be there? Um, it gives us a whole huge array. Are you, if you have inflammation in your gut that we, that you couldn't see, you would not be able to see if you went for a colonoscopy, this is the functioning of the gut. So it tells us lots of information, um, of which then we can design something based on that information. Speaker 4 (29:08): I guess you could say, I stepped into that one. Speaker 5 (29:12): [inaudible] yeah. Speaker 4 (29:14): Those are good things to understand, because it is, um, now that you, when you said that I did, I do realize now that I've heard that before, that that's where a lot of our immunity lives is in our gut health. Dr. Carol (29:29): Right. So I just liked people to step back and go. The first line is the social responsibility of what we are being told what to do, but then we want to go deeper. Right. So that we actually have impact. We are so that I'm, I'm fortified. So as to be Roy - Feeding Fatty (29:54): Out. Okay. Yeah. We just kind of, you kind of bleeped out on us that last word there, I think, yeah. Dr. Carol (30:02): The internet. Do you, can you hear me? Cause my internet, just, Roy - Feeding Fatty (30:05): You blanked out after, um, you said at the, at the people being empowered, Dr. Carol (30:12): Empowered to take responsibilities and really do something for their kids. Um, and I don't know. I mean, I can give little, uh, little things for people to do right now today. You know, what can you do right now? Roy - Feeding Fatty (30:28): Okay. That'd be good. Yes. Yeah. I'm taking notes. Dr. Carol (30:31): All right. Cool. Okay. So, um, I wanted to say, obviously you said something about drinking water. You want to drink, if you can, for an average adult drink, I'm sorry. I see your face. There is Roy - Feeding Fatty (30:44): Water. Dr. Carol (30:46): Okay. You need to try and drink, um, about around 64 ounces a day. And so, um, you'll see, you know, I've got my cup here. You got to figure out how to do that. Now coffee does not count. Okay. Roy - Feeding Fatty (31:01): Wait, say that again, please. Liquids Dr. Carol (31:04): Are not the same as water. Okay. So unfortunately, so you can also, everybody agrees that fruits and vegetables are really important, right? Everybody is in agreement of that. There's lots of things in alternative medicine that people don't agree with them when it comes to diet. But we all agree that having fruits and vegetables and having a large plant-based diet is super important. So what that means, and even the CDC believes it's if we could have like nine to 11 servings of fruits and vegetables a day. So I often talk about drinking your fruits and vegetables, making a drink, uh, should be a smoothie, is so that you, you can put big handfuls of stuff in there and you don't have to stress. If you had nine to 11 servings, that's about to dinner plate full of vegetables or two pounds. But if you drink your vegetables or fruits, then you minimize that, Oh my God, are you kidding me? Dr. Carol (32:10): Um, sort of feeling right. So that's something you can do because that will give you lots of important vitamins and minerals. Anti-oxidants all these things that are going to fortify your system. Okay. Um, and then for, um, uh, for, uh, de-stressing okay. You could do two simple things. Well, first of all, do you meditate? Do you find moments of peace? Do you pray? How do you, how do you get into that calmer state of being that's going to really help your adrenals? Okay. Um, okay. So that's one thing you can take a couple of vitamins that really help your adrenal glands, a B five B6 and vitamin C. Okay. There are formulas that I have that are, you can get that are specific for adrenal de-stressing and they generally always have B five, B, six, and C. Okay. Okay. And then a simple protocol for your guts is, do you guys have, I don't know, where are you in Texas? Did you, after you told me, okay, I'm assuming there is called booths there. Yes, Speaker 5 (33:31): We do have that. Dr. Carol (33:34): Yeah. Um, but you know, do you know what kimchi is? Speaker 5 (33:38): Yes. And you know, I don't think I've ever tried it, but I've been very curious for a long time Dr. Carol (33:43): Kimchi and sauerkraut, organic, raw, both of them. Um, they taste great. You have to kind of, you have to, you know, you might have to acquire a taste for it, but I love them. They have natural probiotics in them. Okay. So you can fortify with the proper bacteria by eating these foods or taking a multi-screen probiotic. And you go to the health, food store is your weight to say, Oh, I'm going to support is, you know, support my guns, Speaker 5 (34:16): But you said raw sauerkraut and, Dr. Carol (34:19): Um, rock, rock, rock him. [inaudible]. Speaker 4 (34:23): So let me ask you about that because I think that's where, um, you know, somebody like me, that's tried to, you know, I've kind of played at being healthy for a long time, but there's so much information and probiotics and not trying to put you on the spot, but just trying to get your opinion on this is that, um, at one point, you know, I was taking a probiotic and, um, I don't know, 25 million deals or whatever, you know, it was pretty good strength, Dr. Carol (34:55): 5 million billion, Speaker 4 (34:57): Maybe billion maybe. Yeah. But then I started reading some material, not, I didn't seek it out. It's just stuff that came across to me that it said that there's this natural occurrence in our stomach. And so when we take a probiotic every day, we were actually counteracting it. And I guess this guy or person was saying that maybe you need to do it once a week or once a month, every once. Every two weeks. So what, what is the thought on that? Dr. Carol (35:28): Well, I've never personally seen that, but I want to comment on it anyway. Um, Speaker 5 (35:37): You have to find Dr. Carol (35:38): Out whether you need the probiotics or not. Okay. That I just want to say, I do feel that taking a multi-screen probiotic because the research indicates there's so many positive value. There's so much positivity to it. Okay. Um, I don't know what he was. He or she was thinking about some mechanism that this is going to hurt. I don't, honestly, I didn't have to hear the whole thing. Just trying to really understand, but probiotics, like anything are not all made equal and they need part of the, part of the thing about probiotics is not all probiotics can make it through the, through the gallbladder, the secretions. So you have, you have to know about what you're getting, because if you, you know, the most expensive supplement is the one that doesn't work. Right. Okay. So not everything is made equal, but again, um, I do think that taking probiotics is, uh, in, uh, in, um, sort of a preventative way can be valuable. Speaker 4 (36:43): Okay. Okay. No, thanks for answering that. Cause I, you know, the thing is I heard it, I don't know their credentials. Don't really, and it's been a year, a few years ago, but I think like you said, the key is probably, you know, doing the test to see if it's even necessary or if it's what's right. Dr. Carol (37:00): Well, the other that brings up this whole thing, I read it, I read this, I read that you go to Dr. Google. Yeah. Okay. And you know, Dr. Google is going to make him crazy because there's so much conflicting information. So in my opinion, um, I love to research, you know, and lots of people do. Um, but you need some, some way to decipher whether this is information that actually is valid. Right. Um, and, um, I think it's helpful to have somebody in your corner who has, uh, studied enough, who has enough, uh, years under their belt to go yay, Nate, or let's think about this Navy, you know, so you just don't go, I'm going to buy every, I have a pitch that she has. She came in with bags and bands of supplements, just everything she reads on Dr. Google, she, the slides, that's it? This is it. Speaker 4 (38:02): Yeah. Well, you know, and I, this is a long time ago. I had, you know, an unhealthy diet. I knew I did, and I wasn't eating fruits or vegetables. Mostly. It was, you know, restaurant food at every meal. So, uh, you know, I, I am that person. I started, you know, taking one and then I read something, it took more, you know, and it morphed into a whole bag full. And of course I took it to my doctor and let him look over him. And there was, there's one he threw out and wine. He added, I think K three was one that he wanted me to take. But then, you know, one thing we did, um, you know, when we started this show was we got the Krono meter. You know, we started monitoring our Mac, our micronutrients as well. And when, when we eat good, like we're supposed to, we were getting most of everything, you know, that we needed. I know there's some like the, the ones that you were talking about, the be five and six and see that you may need a boost to, uh, you know, help you with what you were talking about. But, um, I basically got off of most everything that I was taking and kind of pared it down to a few that I knew we were struggling with. Dr. Carol (39:17): That's a good, that's good. Um, because really what you're wanting to say at this point for our health, the best defense is a good offense, right? So you want to take, you want to, you know, strengthen your body as much as you can, given what your particular personal needs are. So you, you know, you want to, you want to put yourself in, uh, in that, uh, position of taking responsibility with the proper information. Right. Which I think is really important. Yeah. Speaker 4 (39:51): Yeah. Yeah. And so, so what can people do today if they're feeling overwhelmed, trying to figure all this stuff out all the time? Dr. Carol (39:59): Well, first of all, um, I wanted, I put, I have my notes somewhere. So the first, um, first thing is I would stop. I would consider like minimizing your doctor, Dr. Google. But, um, you have to figure out, you know, when you're feeling overwhelmed, you know, what's your personal, why, what do you, why do you want to be healthy? Do you want to be healthy to play with your kids, your grandkids, do you want to go to Hawaii and hike in the volcano? Um, you know, what is it that you're, what is your goals? You figure that out. Okay. So you can go as, is, is this important to me? What do I want to do? And then you try it. We were part of, in a situation where we want to, we really want to survive and thrive. So we're calling that thrival, we want to do that. Dr. Carol (40:55): So, um, we come up with, we find a mentor, if that's your choice, not everybody likes that who can support and figure out what's going on with you and support it. Um, also my website, I have a book, an ebook that I've written called this the essential aid, and it gives you a guide to those essential foundations. And you can go to my website, it's free. You can just click it. That's something you can do right now to get, and I can give you my website. Um, I can spell it out for you. Okay. Um, it's Dr. Dr. Carol C R O L S H w E R y.com. So Dr. Carol square.com, no period or anything you can go and you can go to, uh, go there and you can get my ebook. Okay. Okay. That's certainly one thing you can do. And did he decide that, um, you really want to investigate this further? Dr. Carol (41:53): You know, you want to go, she, I really want to be healthy. Um, I am offering your, your listeners today, a gift, and that is if you would like to talk to me and have me hear what's going on with you, um, what, what your health concerns are. If you have health concerns, what is driving you to say, I'm going to spend 15 minutes, a complimentary discovery consultation with me, 15 minutes on the phone, uh, where we talk about your health challenges, or we talk about the kind of, uh, programs that I provide and see if, what I have to offer you in terms of information, education, and a plan might be of service to you. I'm happy to do that for your listeners. Roy - Feeding Fatty (42:45): Very nice. Yes. Yeah. I may be the first one. I was going to say we have to Duke it out. Dr. Carol (42:54): Uh, but it's, it's nice to have for me, I'm the kind of person that wants to go to somebody who has years of experience that can go, Oh, I hear you. Or I see, like I've been watching cause you sort of your wear it on your face. That's a bad Speaker 4 (43:12): Thing about doing video now, Roy - Feeding Fatty (43:17): Whose idea was it to do video? Speaker 4 (43:20): You know, for so much of my life, it was, you know, it's meat, potatoes, and the only two vegetables that I like are, you know, potatoes and corn, probably the two worst ones, Dr. Carol (43:31): By the way, just why, I guess what those turn into in your body, those two, those two things, what have they turned into Speaker 4 (43:40): Carbs sugars. Dr. Carol (43:42): Totally. That's it? Yeah. That's all I do. So is that going to affect your blood sugar potentially? Yeah. Yeah, yeah. Speaker 4 (43:52): And the other thing is the quickness and, you know, that's one thing that we, we were on a good path. We were cooking in the kitchen and doing everything right. And then, you know, uh, Terry's mother had had a spell. And so we kind of, she had been out, you know, kind of in and out for two or three weeks, kinda got off track, but you know, it, it became easy, the easy path. And I think that's, uh, Roy - Feeding Fatty (44:19): Just grabbing something already, you know, some pre-packaged something just that you can eat and you don't have to prepare and then just go back to your work and, you know, yeah. I mean, I'm not just saying you no, but that's, Speaker 4 (44:32): That's the way it is. It's hurry up and eat so we can sit back down and get back to work. And I guess it's a bigger picture is take the break, eat the good meal, take, go for a walk, get away and get out of the chair. Dr. Carol (44:44): I say, it's, um, these basics they're fundamental. Are they sexy? Meaning, uh, you know, is it like, Hey, this, this has been real easy, really? You know, it's going to be, well, these are the day-to-day ins and outs that are not so exciting. Right. But they will keep us moving and alive better and longer if we do them, but it can be like the drudgery. So we have to figure out how to make that better. Speaker 4 (45:14): It's funny. That's the other thing I think it's funny you mentioned is that, um, I guess at some point I got wrapped up in that food is fun. And so, you know, it'd be like, when she'll tell me, Oh, I got some broccoli. I'd be like, Oh, Speaker 5 (45:32): Uh, shoulders, did you get me a snack? I sure did. Rugeley Speaker 4 (45:40): Yeah. So you know it, and it, we talk about it and I can say the words, it's harder to put into practice that we need to eat to live. We don't need to live to eat. And it, you know, we, while we can make it a social event, as far as us setting down, talking about our day, talking about tomorrow, you know, that shouldn't be where we gain our, shouldn't be what we look forward to for our fun, I guess. Dr. Carol (46:05): Well, I'm going to have a slight disagreement with you because food can and should be fun. I think that that is one of the basic enjoyments in life. It's that our taste buds have been programmed to think only certain things taste fun. Yes. But if we can retrain them. Okay. So I D I think food is a foundational piece of, you know, of enjoyment and we should, you know, and so I think we can alter that so that you can, anybody can change and make it fun. Even if it's not fun with, I don't know what you loved most, except I do know you love potato. Right. Um, but it can't be fun. Speaker 4 (47:00): Yeah. I'm going to have to really give that some more. Speaker 5 (47:03): I'll see what I'm working with here. This is hard. This is really hard. Dr. Carol (47:09): Uh, I'm gonna keep doing it. Speaker 4 (47:11): No. And I give her a lot of credit. I mean, she jazzes things up and re you know, trying stuff out, which it it's, it's more delightful. It's just, it's not my thing. You know, I'd read that, uh, the vegetable part I'm, I'm like, wait a minute, Dr. Carol (47:31): You might be a great candidate for drinking your drink and your veggies. Roy - Feeding Fatty (47:35): Right. Yeah. And you went down a little. Speaker 4 (47:39): Yeah, I did that a little. I bought a, it was like a green mix, some kind of green powder that had all the vegetables wrapped up in it. And, you know, I had gotten pretty good about making some smoothies, uh, with that in it. So we, I may have to revisit that or look at making, uh, making some with fresh vegetables too. We haven't really tried juicing. Dr. Carol (47:59): Good. Did you guys have a, I don't know. Do you guys have, um, Costco in Texas? Okay. So Costco, at least where I am, uh, they have, uh, bags of organic grew, dark leafy greens. And the reason I say called Costco is there's so much cheaper than if you go to the store. So you can get a big old bag of dark leafy greens, organic at Costco for a few bucks. And you can, I mean, you can just dig your hand in there and really make it make a great trick. I did want to say too, what I like to do to make the drink, uh, more palatable is I have these things called medical foods. So if somebody let's say has an influence, if inflammation is one of their big problems, I have medical, uh, powder, which has vitamins, minerals, nutrients, and also supplements in it for inflammation. You mix that in with your drink, or if somebody's blood sugar, if that's their big issue, I have powders for that. So you can combine getting your nutrients and supplements in with your drink so that it becomes multipurpose. Right. Roy - Feeding Fatty (49:12): That'd be ideal right there. All right. Dr. Carol (49:15): Yeah. I mean, that's how I start my morning. Um, and I just feel like for, I mean, it's hard to get that stuff in and if you, if you're sitting there going Rockley Roy - Feeding Fatty (49:27): Squash is a really big one. You don't like squash. I think, I think it's the word squash, maybe. I don't know, but none of it, I mean, pretty much none there's spaghetti squash, you like that. All right. Dr. Carol (49:41): You don't like to Keenis you don't like Sakina maybe just don't fix them. Speaker 4 (49:46): No carrots, no squash, no com I like, you know, catch up, but I don't like tomatoes raw. I mean, it's really just meat potatoes and some corn Roy - Feeding Fatty (49:57): And bread and bread. Oh, well, Speaker 4 (50:07): Um, I guess we'll, uh, we'll call it, uh, you give me some things to work on, so we'll, let me get started. What we need to do is we need to make an appointment to, uh, you know, get you back on the show, continue this, because like you said, we could, we could talk about it for hours and hours. It's very interesting to me because I want to learn. I want to do better. I really do. I just have to find that, you know, I think I just have to find the path for me is just the no, Dr. Carol (50:36): That's right. And you know, one of the things, you know, like when somebody becomes a client, um, I ask them, you know, we have a very long consultation, so I can try and understand the root causes of what may be going on or not going on with somebody. Plus I have about 30 pages of questionnaires. Oh, wow. Okay. Yeah, because that way, well, yeah, because I don't care how long I talk. I'm never going to remember all the things I need. It's just not going to happen. So, so that way we really get down to the meat and potatoes [inaudible] so that's what I do. And I know if you guys, or any of your peeps on the show are interested in doing this, I'm going to give you my phone number, call my office and set up a time. Okay. So if you call them, I want you to say, you know, I was on your show. And so that they know, you know, what the connection is. My number is (831) 476-6906. Speaker 4 (51:50): Okay. And we'll be sure and put that in the show notes as well. But before we go, before we start wrapping up too much, let me ask you about, uh, is there a tool that you use in your, your daily life, a tool, habit, ritual, professional, personal, something that you do every day that you just couldn't do without? Dr. Carol (52:11): Yes. Okay. Um, I've been a meditator for 40 years, but I decided I needed some help in that area. So there's a group that just happens to be located in my County. And the group is called heart math. Have you heard of them? No. Art man. You can go to their website, heartmap.org, I believe. Speaker 4 (52:36): Is it M a T H like math, Dr. Carol (52:39): Math, hard math. Yeah. One word, one word. And, um, they have a device called inner balance. It's $129, or it might be for, I have an iPhone. It works with the iPhone for 129. Uh, and then I think for, uh, Android, it might be, or for Bluetooth, which I did not want. Um, it may be one 49, but it's a way for a person to learn how to use their breath and learn how to, um, go into their heart, uh, and find a level of gratefulness that causes, uh, what we call a heart, the heart rate, variability. It just is a term that talks about what's your heart is doing. And it represents a level of calm. There's a great deal of research on this. They've been, they've been at this for about 40 years, but it has brought great calm to me and my patients. Okay. And I feel like we're living in times where we need to find methods to have that calmness. Right. And I encourage people to go to that website. Cause it's, it's powerful. Speaker 4 (53:59): Speaking of breathing that that's one of the other big things that used to be on my list with the, uh, with the water and the sleep is I had it's like breathe, remember to breathe because I am the world's worst about holding my breath. And, you know, I had gone to one of these painting parties once, you know, and the lady was walking around, checking our workout. She's like, it's okay if you take a breath every now and then, cause I was just like so intense and it's just, but uh, you know, I've done a little bit of yoga before and it's just amazing what we can control with our breath if we just be mindful of that. So definitely something worth checking out for sure. Yeah. Dr. Carol (54:40): Yeah. I'm just trying to think of this. I wasn't old Yogi for many years and then I decided to become paralyzed instead stuff, Terry - Feeding Fatty (54:50): You know, I have never tried yoga. Isn't that terrible. Yeah. Yeah. Dr. Carol (54:56): You get addicted to it. Yeah. Yeah. It's very, one of the beauties of yoga is that you lose, you have to stay very present or are you going to fall down? Okay. You need to just be in your body. And yoga is not easy. No, Terry - Feeding Fatty (55:16): I mean, I've, I've done certain aspects of it, you know, but not ever really sat through a whole class, you know, and I need it. Dr. Carol (55:24): Well, I encourage you to, um, to do it. And I have a friend, uh, uh, one of my oldest friends from high school, she teaches yoga and she's teaching it online. She lives in New York. And now that I cannot think of her website, but I could certainly get that to you because she's teaching five days a week online and she's teaching for beginners. Terry - Feeding Fatty (55:49): Oh, that's what I need. Definitely. Yeah. Okay. Dr. Carol (55:51): So that's the beauty of it. Yeah. What it, Speaker 4 (55:55): A lot of people don't understand that. Um, I have, uh, a DVD of a lady. She has like an am and a PM routine. And she was good about the modifications because it's tough. I mean, if you try to start out doing what these instructors do, I mean, you'll give up are, I'd give up in a minute because it's number one, it's difficult with the flexibility. But number two, it takes a lot of body strength. I mean, they have to have a lot of body control. Dr. Carol (56:24): Well, there's two aspects to, um, yoga strength and stretch, right? Some people are quite strength oriented and other people are quite stretched or either I was the ladder. I was extremely flexible, but I actually, I utilized, I did not utilize my body correctly because I wasn't strong enough. So I did a lot of work that ended up hurting my joints because I was always using my joints rather than the muscular strength. Yeah. So you need somebody, one of the beauties of have going to a live class is that they watch you, even when you're virtual, they go, okay, Terry, I want you to do this. Yeah. And adjust accordingly. That's fine. Yep. Right. And men are more, clearly not as flexible for the most part. So you guys use your strength, but you don't have that stretch, which makes it equally difficult. Right. Speaker 4 (57:21): Right. Well, Dr. Carol, thank you so much for taking time out of your day to be with us. And, uh, we definitely will, uh, you know, set up another time. It's been enjoyable talking to you. I feel like we've gained so much information. I have learned so much. So, uh, if you don't mind again, I know you gave us the phone number, but tell us the website again, how people can, Dr. Carol (57:42): Should I just spell it? Yeah, I'll just spell it. www.drcarolshwery.com. Speaker 4 (57:54): Okay. And we will con uh, we will put that in the phone number in the show notes as well. So they will be there for everybody to look again. Thanks a lot. Uh, thank you so much. Dr. Carol (58:07): Thank you. This was really fun. All right. Speaker 4 (58:11): Well, we won't thank our listeners for being here. Of course, we're on all the major platforms, iTunes, Google play, Stitcher, Spotify. We've just been added to a few more of the Pandora, Amazon, and, uh, uh, another big one. I can't think about which one anyway, if we're not on one that you listened to, if you're not on, if we're, if we're not a one you'd listen to let us know we'll get added to it, but you can find us at www dot feeding, fatty.com. We're also on, uh, Facebook, Instagram, Twitter, um, look us up. We'd be glad if you are professional. I'm sorry if you are a professional. Uh, okay. Yeah, if you are a professional, uh, we'd love to hear from you and hear your insight if you had, uh, if you're somebody that's had some success with, uh, getting healthy weight, loss, exercise, things like that. We'd love to hear from you as well until next time I am Roy on Terry. www.drcarolshwery.com www.feedingfatty.com    

So Dr. Miami is Advertising a $600 Dick Enlargement Surgery, and (like a bunch of other things) The Thousandaires predicted the trend years ago... ・・・ “If you catch me On Instagram, Wearing Grey Sweatpants 7 days a Week, You Know I Got The Surgery....” —— Shortso Great ・・・

Edward W. Pearson, MD began practicing as a primary care physician, but he was not happy with what he saw in conventional medicine. So Dr. Pearson set out on his own to find the education that would teach him how to truly heal people and prevent the epidemics of chronic illness. In 2007 he founded the New Medicine Foundation, which has a global mission 'To Elevate the Health and Health Education of Humanity.’ Dr. Pearson works with medical marijuana and psychedelics to treat his patients.

Dr. Potter's background and current roleSleep's effects on the brainREM sleep for motor learningLucid dreamingPTSD, trauma, TBI, and sleepCreatine supplementation, sleep, and healthOther supplement science and recommendationsBe careful when choosing your supplementsWhere to find Dr. Greg Potter:Resilient Nutrition Co-founder and Chief Science Officer, Resilient NutritionInstagram | Twitter | LinkedinGreg Potter PhDThe Flex Diet Podcast is brought to you by the Flex Diet Certification. Go to flexdiet.com for 8 interventions on nutrition and recovery. Join the waitlist, which puts you on the daily newsletter, and you’ll be the first to be notified when the certification opens again.TranscriptSpeaker 1 (00:00:01):Hey, welcome back to the flex diet podcast today. I've got a great interview with Dr. Greg Potter, and we talked all about resiliency, a lot of stuff on sleep, like certain things about the best dose of melatonin. Rather, there are other supplements that can help with sleep such as [inaudible] and even range across the board into some pathologies like PTSD or traumatic brain injury. My ran my crazy kiteboarding supplement routine past him in case I get dropped on my head out of the sky and just really fascinating interview. I think you'll really enjoy this. So Dr. Greg Potter is an expert on circadian rhythms and how they interact with nutrition and sleep. He was formerly a content director over at human OS, their good friend, Dr. Dan party. And now Greg is helping with some nutrition consulting and has his own nutrition company, a resilient nutrition.Speaker 1 (00:01:13):When we talk about that also, I talked briefly about his background. He worked at the university of, of Leeds and his background is actually in exercise physiology, which is awesome. So the beginning part, it takes a little little while for us to get into it, but kind of wide ranging topics here, the overall arching theme related to resilience and the role of sleep. So enjoy this podcast, coming up with the Dr. Greg Potter as always. This is brought to you by the flux diet certification, go to flux diet.com F L E X, D I E t.com. And the certification we'll be opening up again in early January, 2021. So go to the notifications list at the top to get on the waitlist. I'll put you on the list where you'll get access before everybody else, and I'll probably have another cool bonus for you there and flex diet.com. Sign up there, get on the newsletter and enjoy this podcast from Dr. Greg Potter.Speaker 2 (00:02:32):Hey, what's goingSpeaker 1 (00:02:32):On? And it's Dr. Maxine Alison here on the flex diet podcast, and we are back talking about resilience and many other topics today with Dr. Greg Potter. Welcome to the show doctor.Speaker 2 (00:02:46):Hey Mike, thanks very much for having me.Speaker 1 (00:02:49):Thank you. And you're hanging out in London right now, so hopefully everything is going okay for you.Speaker 2 (00:02:57):Christmas is approaching, so I've got no complaints and there's lots of tasty food around suits me. Absolutely fine.Speaker 1 (00:03:05):Yeah, that's always good. So how for listeners who may be under a rock or not familiar with you, give us a, just a little bit more info on your background and then how you got interested in the topic of resilience.Speaker 2 (00:03:21):I think most of this is probably not familiar with me and my background is largely in exercise science. So I studied exercise science for my undergrad and my master's degree. And in between those, I also worked briefly in professional rugby at the rugby football union. And as I was going through that process, I recognized the biological rhythms and sleep are very important and went on to do a PhD at the university of Leeds, which focused on the intersection between biological rhythms, sleep nutrition and metabolic health. But I did those degrees because I've always been fascinated by how lifestyle in general affects our performance and also our long-term health. And since then I've been involved in a few different projects, but right now I am chief science officer and co-founder of the company based in the UK named resilient nutrition. And in that role, I spend most of my time working on product formulation, but I also work with some athletes athletes who represents our brand. So they're primarily ultra endurance athletes. And I really enjoy that side of the job too, because coaching is something that I've done for about 13 years now.Speaker 1 (00:04:44):Nice. Yeah. Very cool. Very cool. What made you go into exercise science? That's what I did my PhD in so great topic. Of course,Speaker 2 (00:04:56):I think it came down to teenage insecurity. Let's be honest. I was playing rugby when I was 12 and hurt my back. And that was right around the time I became interested in girls too. And off the back of that injury, I started going to the gym, became increasingly interested in nutrition, spent far too long, reading things like men's health, but slowly found better sources of information. And when I was going through what a cool GCSE and A-level was over here. So my education around the ages of 15 to 18, I was a lot of my free time reading, elite FTS, and several other related websites, and also became interested in science in general. And I had a place at university to study English literature and recognize that if I were spending all of my free time, finding out about performance, nutrition and strength, training and related topics, then I was probably on the wrong trajectory.Speaker 1 (00:06:04):Got it. And how did you get interested in sleep? Because you've published areas in the sleep and obviously have more formal education in there. It sounds like it was more of the intersection and coming at it from a performance angle.Speaker 2 (00:06:20):It wasn't really, I think I first became interested when I heard a couple of people speak about sleep on some podcasts, probably around 2010 or so. And then off the back of that, I started reading some books and I just found the whole thing. Fascinating. And to this day, it's a subject that the more that I find out about it, the more intriguing it becomes because there are so many unsolved mysteries within the field of sleep research. And I think that that field is in its infancy too, which is true, the exercise science research while too. But I think that sleep is such a fundamental human behavior and it's not quite such a nice subject niche subject is excise science that it's surprising that the research into it has only been going on for a relatively short period of time.Speaker 1 (00:07:20):Yeah, I've always been, I'm not very, I'd say up-to-date on a lot of the sleep research, but to me it's always been fascinating that at a base level, I believe the human body is survival orientated. And the fact that will literally entirely shut down, which I know is an oversimplification, but we have to take a good third of our day to be not really cognizant of what's going on potentially at a risk of being eaten by a lion or something similar would give us the data that there has to be super important reasons for sleep. But yet if you ask a very, which I would ask you this question, like why, why is it that we sleep? I mean, it's, we have some data, but it still seems like a lot of it is a big mystery and the unknown.Speaker 2 (00:08:14):Yeah. And this is something that people go back and forth about a lot. And I don't think that there's a unified theory of why we sleep, but that said, I think that there are plenty of things that we can point to that show the importance of sleep and some of the functions that it fulfilled. And I think that it's probable, but it has some different functions in some different species. If you look across species, then no one thing seems to strongly predict how much sleep a species needs. But there are a few factors that do relate to that, including things like the type of thought they can seem to whether that carnivorous or I'm never saw, however, social dynamics, how complex their nervous systems are. And then of course there are some things that are common to species. So I think that sleep is a period of adaptive inactivity.Speaker 2 (00:09:15):So it optimizes when we're active and for how long, and one of the functions, or probably fulfills is energy conservation, but that's probably a very small function, but I think a lot of the functions of sleep relate to its effects on the brain. And there are various relevant theories, but one of them relates to the activity in our signups seas. And as we're awake during the day, exploring our environments, the strength in inverted commas of various signups is in our brains increases. And when we sleep, it's a period in which that is a selective downregulation of the strength of some of those signups, so that we only hold onto the most pertinent information. And then there are some other factors at play too, like physical restoration and so on. And I think that it doesn't make sense to think about sleep without contrasting it with wakefulness. And fundamentally, I think that sleep is the price that we pay for wasteful behavior and it's therefore really to prevent malfunction during week. But the fact that sleep deprivation has been used as a form of torture in many countries, eons tells us a lot.Speaker 1 (00:10:39):Yeah. I always think of what happens when you do the opposite, right? So what happens with loss of function? Do you get and where two different functions drop off once someone is more on the sleep deprived scale and correct me if I'm wrong, but I think some of the processes you talked about with different synopses is that a lot of the learning more or less takes place during sleep. So we have kind of the stimulation, different synopsis kind of get marked with different chemical messengers during the day. And then at night, it's kind of like this housecleaning effect where, Ooh, we need to get rid of this guy. Ooh, this is a good one. We did a lot of stuff over here. Let's just make sure this is nice and robust and Oop don't need this one anymore. And then when we kind of impair that process of sleep, no matter how high quality of work we did or what we did during the day, we see sort of a diminished result from that because we're kind of skipping over at very best diminishing that process during sleep.Speaker 2 (00:11:43):I think there are a couple of things you mentioned there that it worth picking up on one is this idea of housekeeping and in the last seven years or so, there's been a lot of in the glymphatic system, which is a bit like the brain's waste disposal system. And during sleep, we have these large slow waves during the deepest stage of sleep. And those seem to influence cerebral blood flow and thereby the flow of fluid through the glymphatic system. And during this stage of sleep, the spaces in the system open up and that flow of fluid helps wash the debris. That's accumulated with metabolic activity during wakefulness out of those spaces, clearing out toxic waste that could otherwise be detrimental. So that's one thing. And then you're also touching on the roles of sleep and learning and memory in relation to signups at homeostasis. One thing that does seem apparent is that sleep does free space, your real estate, if you like to learn new things.Speaker 2 (00:12:50):So even a brief nap during the middle of the day will help with subsequent learning for instance, but then sleep is also important to things like the consolidation of memories and arrange of information too, in different stages of sleep, probably differentially important to this. So for example, during stage two non REM sleep and the deepest stage of sleep that is transfer of information from the short-term limited storage Depot in the hippocampus to regions of the neocortex, which are more like a long-term volt for information. And then during REM sleep that stage in which we dream a skeletal muscles are mostly paralyzed, not essential muscles like respiratory muscles and cardiac muscle, but because of that, our brains have free rein to explore different motor patterns, for instance, without risk of us acting those out. And so that stage of sleep is probably very important to things like motor learning, but it's probably important to creativity and evolution of intelligence too. And that there is that free space in which to try out different things and creates a virtual model of the world. If you'd like to try and better understand how we interact within it.Speaker 1 (00:14:09):Yeah. That's one thing I tried for a while, but I eventually gave up on it because the practice was, it was kind of a pain, but is my thought was okay if I can learn to, you know, wake up during my dreams and control my dreams, could I practice new motor patterns like kiteboarding doing jumps or heavier deadlifts, and then go back to sleep the rest of the night and reconsolidate those patterns. But in essence, I could do it without any fear response or worry of damage, quote, unquote to the system. But I wonder would that even if it did work, which I honestly gave up after about eight weeks, cause it was a monster pain in the, my life I always wonder what did even transfer to real life because it, it is so different, but any thoughts on that? Yeah.Speaker 2 (00:15:10):A few thoughts. So one is the REM sleep, that particular stage of sleep in which we do most of our dreaming, not all of our dreaming does seem to be important to most of learning in general, but what you're touching on is lucid dreaming, right? And that is when we're conscious during our dreams. And during those dreams, we often have some control over the contents of the dreams too, although that's probably not an essential parts of lucid dreaming per se. And about half of people will experience at least one lucid dream over the course of their lifespan that they remember, but it does seem that it's somewhat trainable. And in recent years there's been a resurgence of interest into dreams and into whether lucid dreaming training has some potential therapeutic applications. And there's been some fascinating research published very recently by people like Jason Ellis showing for instance, that you can take adults who have insomnia and some related psychiatric issues, anxiety, and depression, and you can put them through a short term intensive lucid dreaming training program lasting only a couple of weeks and quite dramatically improve their insomnia severity as well as some of the anxiety and depression symptomatology, which is fascinating.Speaker 2 (00:16:34):And the strategies that people use are probably some of those that you tried Mike, but they include things like keeping a dream diary. And then within those dream diaries, by identifying unusual elements within dreams, and then you're using a technique named autosuggestion in which you take that element. And if you recognize it within a dream, you use that as a trigger to cue lucid dreaming. But then there are some other strategies that people will try out too. So some people for instance, will use an alarm to wake themselves up during certain stages of dreaming, which they think that they might be particularly likely to be lucid dreaming at that time. There also reality checks that people will do over the course of the day. So colon one is just to look at your hand and ask yourself whether you are awake and in daily life, or if you are in fact dreaming and people in that particular study, I think set a timer on their phone every hour to remind themselves to do that.Speaker 2 (00:17:38):And the point is that those people could increase their frequency of lucid dreaming, and it does have some other potential applications too. So for example, it might be helpful in PTSD. One of the problems that arises in PTSD is that people experienced nightmares that relate to stressful experiences. And what will happen is that that nightmares will be so distressing that they will spontaneously awake from them. And if we return to the idea of rapid eye movement, sleep, being a safe place in which to explore previous experiences and try and make sense of the world, then it's as if their mind is like a broken record. They keep waking up from this particular stage in the record, and they never quite managed to process it and get to the end of the track. But if they can lose a dream, then they can take control over their dreams.Speaker 2 (00:18:32):They can reduce some of that negativity within the dream and thereby, potentially have some positive effects on their symptoms and their daytime function. But going to your particular example, Mike, and whether it's possible to practice motor skills during lucid dreaming in a way that facilitates you improve those mode skills and the rest of your life. I don't know if that's been studied it hasn't to my knowledge, but it is something which is definitely why the, of exploration. And I think that it makes some mechanistic sense and it wouldn't surprise me at all if it was proven to be beneficial.Speaker 1 (00:19:11):Yeah. Cause if anyone's ever had a lucid dream when you're doing it, or even just dreams in general, I mean, you are absolutely convinced that it's real when it's going on. Which to me is fascinating. And then I don't know if there's any research on this too. You talked about someone looking at their hands. So one of the cues I tried to use was looking at clocks or watches, so I'd wear a watch. And so I tried to train myself every 15 minutes when I was awake to look at the watch and ask myself, am I dreaming or awake? Or what time is it? And I noticed that in dreams, again, this could just be me that you can't really get a sense of time. Like even looking. I remember having a lucid dream looking at the clock and I couldn't figure out what time it was. And then I was like, Oh, I'm dreaming.Speaker 2 (00:20:09):And, and that is a common experience. There's a complete distortion of time. And I think people often wake up from their dreams feelings if they've been stuck in that dream for days. And the bouts of dreaming might've actually lasted several minutes,Speaker 1 (00:20:25):Is that related to areas of the brain that basically are helping with our perception of time, right. That gets into, you know, different flow States and how you may have a dilation or a compression of time. And, you know, at the end of the day, time is basically kind of a, I don't want to say a neural construct, but it's not as static as what we think it is. It's more of a, I guess almost a perception per se,Speaker 2 (00:20:56):I don't know is the short answer, but that certainly makes sense. So it wouldn't surprise me whatsoever if that was the case.Speaker 1 (00:21:04):Yeah. That's something I've been interested into related to the PTSD. I just read some of the research on it and I've been kind of fascinated for several years now about how someone can have a very, you know, traumatic type experience. And there's also a post-traumatic growth that can potentially happen from it. There's also PTSD that can happen. And sometimes there's not that much of a change and there's some preliminary research that I think you touched on that quality of sleep after an event may predispose one person to one direction or the other. But the theory is if you had a traumatic event and your sleep is disrupted for the next two nights, you can't enter that REM stage are missing out on some of that processing that as you mentioned, the record just gets kind of stuck there, where if you can get high quality sleep, maybe post one, two nights, I'm not sure the duration that you can then process that information and kind of reach the completion in the end. And then you may end up with a more positive result than a quote unquote negative result from a similar traumatic event.Speaker 2 (00:22:23):Yeah. And I don't know much about PTSD, but I've heard that too. And that makes complete sense to me in the context of how thief influences responses to a variety of stresses. So in the case of vaccines, for example, if you take a salient example, then if people sleep well around the time of the inoculation, then that antibody titers are likely to become much higher in response to the vaccination. If they sleep well, pre vaccinations, Leif is somewhat predictive of those responses. So different stressor in this case, a psychological one, I'm sure that sleep would influence how we respond to that. And we also know something about sleep being predictive of some other related problems, such as traumatic brain injury. If somebody has a concussion that will likely disrupt their sleep, but in turn, how they sleep in the following nights will influence the time course of their symptoms and their recovery from the trauma.Speaker 1 (00:23:27):Interesting. So the theory there being, if you get kind of locked in the head, if you get better sleep for the next couple of nights, your symptomology would be a little bit better.Speaker 2 (00:23:38):Yeah. I think people would probably be less likely to experience some of the negative consequences that come TBI. So that, that might be anxiety, for example, will low mood.Speaker 1 (00:23:52):No, that's fascinating. I just finished up creating a course for the Kerrigan Institute and they do clinical neuroscience. So I worked with them and looking at the ketogenic diet and traumatic brain injury. And so on my little again, this is what I do for myself, my checklist of stuff. If I'm out kiteboarding and get dropped 20, 30 feet out of the sky on my head and have kind of a bad injury, I have ketone esters in my bag to put myself in a state of ketosis. I'll use a CBD with a small amount of THC beforehand, just like an over-the-counter supplement high dose creatine, high dose fish oil. And then on the list I have is I would probably just not ride any more that day to risk any more injury and then just go to bed as soon as possible. Does that sound somewhat sane or is that just batshit crazy?Speaker 2 (00:24:50):Well, I think, I think that will sound very seen to me again, I'm no expert in this stuff, but certainly in terms of brain energy metabolism, the exogenous ketone supplementation makes sense the importance of EPA and DHA to formation of the brain during early life and the possible effects of those and that ratio to some Amiga. And Amiga six fats that also makes sense creates an it's particularly interesting to me because of its potential effects on sleep, which I think probably massively underappreciated because it's an under studied subject. But when people think about things that affect their sleep, they often immediately think of nicotine, alcohol and caffeine. And the most relevant of these is caffeine. Caffeine is an antagonist that all of the adenosine receptors and the longer that you've been awake, the greater the accumulation of adenosine in the extracellular fluid in the brain, which then acts on its receptors to promote sleepiness.Speaker 2 (00:25:59):So caffeine blocks this interaction there by reducing that sleepiness signal. If you think about creates a hydrate there, when people supplement with creatine, they boost their phosphate creates installs and they do so in their brain to the degree to which creates in supplementation, supplementation does that. And humans is likely lower than how much it does that in rodents. For example, however, it probably still does that. And as a result of that, that free adenosine can be more readily recycled to ATP offsetting the accumulation of that sleepiness a signal. And there was a fascinating paper published three years ago by Marcus Boruch, who I think is no longer in research by belief has a paper coming out on next year, showing something similar. And what he showed was that when you add, create some on a hydrates, the chow of rats for I think four or five weeks, you quite dramatically affect their sleep architecture.Speaker 2 (00:26:56):So specifically their sleep is shortened. They spend less time in the deepest stage of sleep. The intensity of the deepest stages of sleep is lower and then their rebounds sleep in response to sleep deprivation is also lower. So it creates, and it's clearly very strongly affecting sleep homeostasis. And what is fascinating to me about creating is that if creating shortened sleep and I'm almost certain it does in humans too. And I think the markets for Apple show you this in the paper next year, then you'd expect it to have negative consequences on the basis of all the literature on sleep restriction is the deprivation, right? However, if you look at all the research on creating one, a hybrid supplementation, then it's good across the board. Think about its effects on athletic performance. It boosts adaptations to strengthen power training. It might also do so for cardio respiratory fitness too.Speaker 2 (00:27:51):It improves Thermo regulation. During exercise has positive effects on brain function, particularly during sleep deprivation. There've been interesting studies on rugby skills, for example, but also on cognition. It can have some positive effects on mood and people have treatment resistant depression when used as an adjunct therapy, at least. And it also has some favorable effects on cardio metabolic health T. So CLICO regulation for instance, and homocysteine. So if it's affecting sleep, then it doesn't come with the attendant negative effects of less sleep. So if there's ever a situation in which he can't get enough sleep, there's one supplement you go for should be creatine monohydrate. And we don't know what the optimal dose is or anything like that. But I suspect that it's higher than the dose that you would use for exercise performance. So if you think about creatine people commonly either have a loading phase in which they might consume five grams, four times a day or something, or they take three to five gramsSpeaker 1 (00:28:54):Every day, maybeSpeaker 2 (00:28:57):During TBI, something more like theSpeaker 1 (00:28:59):Loading phase isSpeaker 2 (00:29:01):Closer to optimal. We don't know, but if you go for one of those high doses, you want to split up your intake just because it does have quite strong osmotic properties. So if you consume lots of it at once, then you probably draw a bunch of fluid into your GI tract and cause some bloating and other related problems too. But Mike Long story short, I think you're doing things in a really smart way. And there are potentially a couple of other things that might be helpful. I'll defer to your expertise here, but other things such as Citicoline potentially on the Aerie, they have some neuroprotective properties. So they might be useful.Speaker 1 (00:29:38):Yeah. I'm a huge fan of CDP Coleen. It's I've used it for quite a while. And even just a couple of supplements, I helped formulate it. I recommended it and now it's becoming pretty popular again. I mean the patent still exists on it and the company does enforce the patent. So it does tend to be a pricier ingredient. So what I've seen in some of the new ones, at least in the U S is it's being touted as the next kind of greatest supplement. And there's a lot of very positive research on it. And Renshaw was one of the main researchers and then they just chronically underdose it? Cause they're too cheap to put a legit like dose the product. So it's like, yeah, you got part of it. Right. But didn't quite in quite yet.Speaker 2 (00:30:24):It's, it's frustrating. There were so many nootropics on the market or purported nootropics, at least that contained a hundred milligrams of Citicoline. Whereas if you look at the research, then in healthy adults, slightly lower doses seem to be beneficial in some context. So there's a study of adolescents and a study of healthy women, both of which use 250 milligrams, but in the context of brain injury and vascular dementia and some other neurodegenerative problems, higher doses seem to be preferable. It's like maybe half a gram to a grammar Placer to the sweet spot.Speaker 1 (00:31:02):Yeah. No, that's fascinating. That's super interesting about creating too, because I'm very similar to you. I've I've just recommended it as a general health supplement for probably four or five years now, which two athletic populations, not really shocking, but when people ask you like, Oh, what's, you know, kind of your top supplement recommendations, like, eh, some protein, maybe a good multivitamin fish oil. And I'm like Korea team. They're always like crazy. And what are you talking about? I'm like, there's just every time we turn around, there's more benefits associated with it. And I can add, you know, some very interesting sleep stuff thanks to you to that list. And we have like so much data, just show that there's very little to almost no downsides. You know, even in, I talked to Dr. Tommy wood and he was describing an elderly population where I think they were using 10 or 20 grams a day and you just saw a little bit of GI upset and a few people Tarnopolsky did a study with 20 grams a day looking at, I don't remember if it was Parkinson's or ALS, but extremely well tolerated for like many, many months, you know?Speaker 1 (00:32:15):So there's almost like a node downside to it. So even if it doesn't have the next latest, greatest potential for whatever yeah. We know it's pretty about as safe as you're going to find anything too.Speaker 2 (00:32:30):Yeah. And I think that, that those of 30 grams or so has been studied out to three years plus. Yeah. So no safety crimes whatsoever, but if your sleep is very shallow and you've been taking creatine for a long time, then hopefully light bulb, might've just gone.Speaker 1 (00:32:51):So in that case, what would you, what would you do? I have an idea, but would you opt to dose then to try to change the sleep architecture?Speaker 2 (00:33:03):It depends what the person wants. So if the person's sleep as a result of taking creates and supplementation is slightly shorter and slightly less steep, so maybe they're marginally more prone to waking up during the night, but there's no obvious negative outcome that relates to that. So they don't feel like their daytime functions and pad, they don't feel fatigued. They don't feel like they have difficulty concentrating and that performing well in the gym and that cardio-metabolic health seems to be good. Then I wouldn't worry about it. If however, you are somebody who has anxiety because of the fact that you don't feel your sleep is very well consolidated and you've been taking creatine then doing away with it for a period of time while reducing your caffeine intake or eliminating it entirely will likely positively affect your sleep architecture. So at least that would put your mind at rest.Speaker 1 (00:34:04):Could you go the other direction and do a higher dose to see if it kind of changes, sleep the other direction then? So there's like a directionality associated with it.Speaker 2 (00:34:17):What I think would happen is the creates supplementation. So if the person has been using creatine for a long period of time, it probably more or less saturated that brain phosphate creates instincts. So going to higher dose wouldn't top up those stores anymore, if full and they therefore wouldn't experience any additional benefits or effects on mass leap in response to that higher dose, for somebody who is using it acutely, they can probably saturate those stores faster with higher doses. There is also a related metabolite named [inaudible] acid, which is probably better boosting brain phosphate creates in the stores. And it has actually been compared head to head with creating insights and context. It's used to feed animals and make them gain weight faster. And it's very anabolic at lower doses than creatine, but it does come with some potential side effects that creates and doesn't really, so for example, it might boost homocysteine. I'd be fascinated though, to see a study comparing guanos Dino seeds and creating for their effects on brain phospho creates in stores and sleep architecture. But the research on GAA is relatively scam right now.Speaker 1 (00:35:35):Yeah. I remember looking that years ago. I think it was my buddy, Dave BARR pointed it out to me and I've just kind of followed it and it'll kind of, you know, in esoteric bodybuilding forums and stuff here and there, you'll see it kind of pop up as the latest, greatest thing. And I don't know, every time I check into it, similar to you, like there might be something there, cause it does hint that there's some potential, but I remember being a little bit kind of shied away by some of the potential downsides and just not that much data that I could find at least in humans. Unless you've seen a lot of data in humans,Speaker 2 (00:36:12):There've been a few studies that have come out recently, mostly by the Serbian guy and his lab, which very intriguing, but that haven't been enough studies that I'd be comfortable to take it. And I certainly wouldn't recommend taking it. I suspect that it's relatively benign, but if you're somebody who already has a health profile that would contraindicate it, then I certainly wouldn't touch it. Of course. And my guess is that it's probably not more efficacious than creating enhancing adaptations to exercise, but its affects on creating stores in the brain are interesting and it wouldn't surprise me if they do boost those possible creates in stores more than creatine monohydrate alone.Speaker 1 (00:37:00):Very cool. Do you think some of the other intermediate may be beneficial? I remember talking to, you know, Dr. Roger Harris about beta Elene years ago and he was saying there's, you know, newer data coming out on that. And there's a couple of pieces of data. Now since then have shown it, you know, may have similar benefits kind of to create a novel it's obviously operating on a different effect. So it kind of any of those bioenergetic intermediate that we've kind of classically used for exercise physiology may hold potential for brain metabolism. AlsoSpeaker 2 (00:37:41):The short answer is, I don't know, and I haven't seen that research on beets or alanine specifically, I'm guessing that it relates to its actions as a buffer.Speaker 1 (00:37:53):Yeah. Buffer intermediate. Yeah. Similar, similar mechanisms as muscle, just well as best we understand it.Speaker 2 (00:38:01):Sure. Yeah. But in, in terms of other products that have historically been used in the context of sport science and whether they have applications to brain health, I think ketone esters are up there. Of course. And there certainly are plenty of overlapping areas that relate to both brain health and to exercise performance. So for example, agents that improve blood flow are often conducive to vascular function in the periphery and in the brain take cocoa flavanols if you get a high quality cocoa product. And there are few of those, I think in the UK there's Acticoat cocoa powder, which is made by Barry Callow bough and in the States, I know that Mars has a very pure extract. I believe it's called cocoa via if you consume 500 milligrams, 2000 milligrams of those on a regular basis, then you'll like the enhance your endothelial function and possibly also improve angiogenesis.Speaker 2 (00:39:13):And specifically in certain parts of the brain that are important to things like memory. So hippocampus for instance, and there've been studies of elderly adults showing that when they consume high dose flavonols for a period of several weeks, they experience improvements to various aspects of cognitive function, improving memory. And similarly, the have been studies looking at exercise performance and Coco showing that it might have some small beneficial effects on endurance exercise performance and vascular function during set exercise. And the same is likely true of beet tree beetroot too, which of course relates to its effects on nitric oxide, metabolism and thereby blood flow. One thing that I find very interesting is how these different things interact because typically and completely understandably, these things are studied in isolation, right? When they're studied together, you might expect them to have additive effects, but that doesn't necessarily seem to be the case. And Louise buck wrote a very thoughtful essay on that few years ago. And it's really difficult thing to study, but obviously in reality, most people who are supplementing with one of these agents are taking others too. And right now we just don't understand how those different things affect one another. Do they synergize? Do they cancel each other out? We don't really know.Speaker 1 (00:40:41):Yeah, no, that's a great point because in the supplement world, everything is advertised as synergistic effects, right? So for the listeners who already know this, you know, one plus one would normally equal to, well, if it's a synergistic effect, one plus one is four or five or seven, it's crazy. You know, you need to take them together and are 17 individual products all in one. And man, you look in the literature and there's, there's not a ton of literature on combinations really from what I've seen. Hadn't if you even see an additive effect, that's pretty cool. I, I can't even think of one like legit study. I would say that there was a dramatic synergistic effect.Speaker 2 (00:41:29):I think the only example that comes to mind is the combination of Corinne and [inaudible]Speaker 1 (00:41:35):Okay. Yeah, I would, yeah. I would give you that one. Yeah. Yeah.Speaker 2 (00:41:38):Cause the, the bioavailability of most forms of curcumin are so poor. Right? And if you take piperine, which is a polyphenol in black pepper and cumin at the same time then because of its effects on various enzymes that are involved in liver metabolism, you can dramatically improve the uptake of curcumin. Although in recent years there have been new forms of Kakuma and developed that seem to be much more bioavailable. One of them is named [inaudible] and one of them is named hydro Kirk Theracurmin is probably the best study of them. It just contains very, very small particles of curcumin and an interestingly because of that seems to probably permeate the blood-brain barrier and might going back to your kite surfing concussion example, Theracurmin is probably one of those agents that would benefit you in that context. And one thing that acumen seems to consistently do is boost BDNF and something that you want to support.Speaker 2 (00:42:43):That there's been a Metro analysis showing that in recent years and something that he wants for obviously in the context of brain injury is neurogenesis. And while BDNF expression is only a proxy of that, it's certainly an encouraging one. And based on the limited number of studies today, human does seem to boost brain health in general, at least in people who have impaired baseline brain health. And that's an important distinction because there are many instances in which something that helps people who are in the States of chronic disease or impaired function, the compound might not benefit people who are otherwise healthy. And I think this is very much true of nootropics. If you're undergoing some sort of duress, which reduces your function below baseline, that's when nootropics really come into their own. So take the context of sleep loss. Creatine seems to enhance cognition during sleep loss. If you take somebody as well, rested creates and doesn't really seem to affect their cognition. And that's probably true of many of these things that you've discussed.Speaker 1 (00:43:51):Yeah, no, that's a great point because our brains are wired to think linearly. So like the old example I use at the assets all the time is just zinc. It's like, yeah, if you were very deficient in zinc and you take it, you could see your testosterone go up. But if you're sufficient in zinc taking more, your testosterone is not going to go up anymore, which we could argue testosterone going up or down is debatable in terms of performance, depends on where you land on the scale, but within physiologic range. And if you keep taking more and more zinc, now you're going to start having issues with copper depletion and other things going on. But the standard media line, especially with supplement sales is, Oh, look at this study done in, you know, hypogonadal rats that were depleted on zinc and we gave him zinc and it went up like 400%. This is amazing.Speaker 2 (00:44:47):I think, I think we've all fallen for those at some point.Speaker 1 (00:44:50):Yeah. And I mean, I remember taking ZMA back in the day and having crazy dreams from it and I've tried it again. And do you think it's the, the zinc, the magnesium, or I think it's actually the B6 for some reason or is it just, we've all been anchored with the Ronal thought of, Oh, whenever you take CMA, you just get crazy dreams. So that just kind of happens.Speaker 2 (00:45:20):Yeah. It's so interesting that you use that example because I remember buying a fitness magazine when I was a teen and it came with a free sample of Zetta may when it was all the, which was probably around the time of BALCO scandal. And I of course expected to have crazy dreams. And I did have the most vivid dreams that night when I took it. And if you look at the research on it, however, then the Zetta Mae combination hasn't really been well studied, certainly not in the context of sleep. Right? If you look at the research on zinc supplementation and sleep health, then it doesn't seem to do much some of the cross-sectional research points towards some weak effect on sleep. But the actual intervention trials in which people are supplemented with zinc, don't tend to show much B vitamins. Likewise, theoretically, they can be important things like supporting melatonin synthesis, which you might expect to have some bearing on sleep, but they don't seem to do much high doses of one of them might increase the salience of dreams, but that's been shown by one study.Speaker 2 (00:46:31):And then magnesium is the most interesting of them. Magnesium is not in the same category as creating for me, but if they're a supplements that I regularly recommend taking the magnesium is one of them. If you look at the, you look at us adults than something like 68%, don't get enough magnesium on a regular basis. And the nice thing about magnesium is that if you take too much of it, it will probably just cause you some GI distress, which is it. It's not the end of the world. But when you take people who have poor cardio metabolic health, then magnesium can actually quite potently improve some of those aspects of health, blood pressure, regulation, glucose regulation, so on. So I think magnesium taken as big as glycinate or three and eight. If you want, the brain benefits can be helpful. There's only one study to my knowledge on magnesium three and eight and sleep showing that it might some positive effects in an elderly population, but there are reasons to think that magnesium could enhance sleep.Speaker 2 (00:47:36):It does seem to have some general relaxation effects. If you look at brain ion balance, it has a clear circadian rhythm and the concentration of magnesium in some brain cells is substantially higher during the sleep period. Hmm. So taking it late in the day probably makes sense because you might better support that process. And some of those restorative processes that take place during sleep, but compared to some of the other sleep supplements that are out there, I'm not sure that it's a particularly strong sleep aid with that said not many sleep AIDS seem to be that helpful for many people, none of them have very strong effects on things like sleep duration or sleep latency or sleep consolidation of the different supplements that have been studied, the best evidences for melatonin. You look at Metro analyses on melatonin. Then when people take it, they tend to fall asleep faster and have slightly higher sleep efficiency, which is just the proportion of time that someone's in bed.Speaker 2 (00:48:41):They're actually asleep and they might feel subjectively like their sleep quality is slightly higher too. And the right dose for most people is probably somewhere between 300 micrograms and five milligrams, depending on what you're after in the context of jet lag, it's probably around one milligram. If you want the potential effects of melatonin on oxidative stress and cardio-metabolic health. So it might have some blood pressure lowering effects and some glucose lowering effects too. And people with metabolic syndrome, then the higher dose might be preferable, maybe five milligrams. And there's also a time release version. The patient version of that is named Circadin, but there's also an over-the-counter form named micro active two to three milligrams of that might be better at helping people sleep through the night and maintaining sleep. And then there are a couple of other supplements, which I think are helpful in some instances, one of which is pea, which is an analog of an endo-cannabinoid Palmer toil, Espanola MIDE.Speaker 2 (00:49:51):There's a very bioavailable form that was made recently showing that, and this particular form seems to help sleep and people have neuropathic pain. So specifically there was a study of patients with carpal tunnel tunnel syndrome showing that when they supplement 600 milligrams of it twice a day, they reduce their pain and thereby improve their sleep. And then some other agents that have some anxiety, agentic and anxiety, lytic effects such as our theming might be helpful and ashwaganda healthy. And in the right doses, probably something like 200 to 400 milligrams. And the best studies on ashwaganda generally supplement 300 milligrams of KSM 66, twice a day. So I think those are some of the sleep supplements that are more helpful for most people, but it always depends on the context. And I think that people often look at sleep supplements. They think, Oh, that's something that will help my sleep.Speaker 2 (00:50:49):And it might help some people with their sleep depending on the source of their sleep issues. But for someone else, the supplements support, their sleep will be completely different. So just as an example of this, there's a sleep disorder named restless leg syndrome, which used to be thought to be idiopathic. So people thought that it didn't influence risk of health outcomes later on, but we now know that it's strongly influences risk of disorders and diseases such as Parkinson's dementia with Lewy bodies. And interestingly, for many RLS patients, it seems to be a disorder of iron metabolism in the brain. And when they supplement with iron, they can dramatically improve their restless leg syndrome. But if you are, I might take high dose iron, then we would be very unlikely to experience any improvements to our sleep.Speaker 1 (00:51:43):Hmm. Potentially risk high oxidation at some point since we're both male.Speaker 2 (00:51:47):Absolutely. Yeah. We probably want to go and give blood straight afterwards.Speaker 1 (00:51:50):Yeah. Well that's super cool. That's super fascinating. Do, what are your thoughts on a phenom Butte as a sleep supplement? Cause I know that's been on the FDA at least in the U S kind of the gray area for many years now. And I'd have to look up again to see what the status was. I heard it's kind of on the naughty list now again, but who knows?Speaker 2 (00:52:15):Yeah, I believe it is. And I haven't looked at it since 2018, but I remember briefly looking at the literature then, and it wasn't at all convincing that it was a helpful sleep aid. And like you say, I believe it's now regulated. It's certainly regulated over here in the European union. We are still part of the next few weeks. So I wouldn't recommend it. And another consideration here is the veracity of product claims. The supplement industry is so poorly regulated, but if you buy something, especially by something which has a bit gray market, then the likelihood of you buying something that contains what it claims to might not be that high. There was a study published within the last couple of years on melatonin supplements, showing the amounts of melatonin in them varied from less than a hundred percent to more than 400% of the product label claim.Speaker 2 (00:53:13):Some of them also contain things like serotonin, which is part of the same pathway in the brain. So you need to be careful when sourcing your supplements. And fortunately there are a third party testing company. So one of them is consumer lab that do go out, take products off the shelves and check them for the presence of banned substances and other contaminants too. So you're not part of the membership site of consumer lab and you're interested in sourcing good supplements. Then that is one route that you might want to explore. But just as a general tip, thorn and life, extension supplements always seem to fare very well on their site. And I say that as somebody who is co-founder of a food product company, but for that, for the products that we don't make ourselves by generally default to life extension, because they always seem to contain what they claim to. And they also have a very large product range.Speaker 1 (00:54:21):Yeah. The whole, there's only like a handful of supplements. I recommend, you know, thorn is one of them just because trying to stay up to date on that is very difficult. And even, you know, places like with I've toured, you know, Charlotte's web who makes CBD and other products. And that was a couple of years ago. That was great. You know, I signed an NDA, I got to see all the facilities spend two days with them. It was great. Everything about it is awesome. They have traceability, but the end of the day, I'm not there every day, no matter what the place or the manufacturer is. And you get into, especially smaller companies I get really nervous about because they just don't have a lot to lose. You know, if you're generally a bigger company and you've been around for quite a while. Yeah. If something goes wrong or your testing doesn't look so good on consumer labs and you don't fix it, you have a lot of business to lose. If you're some fly by night company that starts up and sells, God knows whatever in a capsule. And we find out it's just bad or non-existent, or potentially toxic or heavy metal Laden, whatever. We'll just file bankruptcy, disappear to some Island in the Caymans. Good luck. Trying to find usSpeaker 2 (00:55:38):Bowel Chestnut bowel Chestnut. What is that? Oh, that's probably a British thing. Just, just ignore me.Speaker 1 (00:55:47):Oh, you just said follow Chestnut. Is that right?Speaker 2 (00:55:49):No, I know that that old Chestnut, Oh, people have been doing that stuff forever.Speaker 1 (00:55:58):Unfortunately. Yes. So he has to tell us more about the supplements that you're helped co-founded right now and working with them.Speaker 2 (00:56:08):Sure. So the website is resilient, nutrition.com and we launched it earlier this year, off the back of some work that we did helping two guys get ready to row the Atlantic last year. So w one of the things that I do is help prepare people for certain athletic events and help them also with health and performance in general. And I was helping my friend Allie, get max Thorpe and Dave Spellman ready, helping them specifically with their nutrition and also their sleep. And as you can imagine, when you've got two guys who are over a hundred kilos who are going to be rowing for several weeks on end, they need a lot of calories. And they spent most of their time growing into our shifts two hours on two hours off. So we estimated that they'd be burning more than 10,000 calories a day, at least initially.Speaker 2 (00:57:05):And they therefore needed easy to digest energy, dense nutrition that would support that performance, but also be usable in those conditions. They don't have a fridge or anything on board, so it has to be stable. And what we did is we started playing around with different versions of nut butters, and we came up with a suite of them, for the guys and they used them during the event, love them. We ourselves use them in different contexts, too, including things like knowledge work, but also some other athletic events. And while we take no credit for this, they did really well. They broke the world record at the start of this year. And so we thought was there a way that we can scale this? And we since then spent time refining the formulations. And now there are four versions of our first product, which is named long range fuel, and the versions are better suited at different times of day.Speaker 2 (00:58:06):That is so-called energized version that contains caffeine and Elfie and IIN. And going back to that discussion about things that have been studied together, caffeine and Althea painting is one of those rack combinations that seems to have some additive effects on cognition. And that's, well-suited being taken at the start of the day before knowledge work and also to support wakefulness if you have to be up during the night. So if you're a night shift worker, for instance, then we have bomb versions, which contain the dose of ashwaganda, which is that's generally been used in research. So they contain 600 milligrams of KSM 66 ashwaganda per pouch, which is 100 grams. And ashwaganda is so-called at that gen that helps people better cope with stress. It tends to reduce people's subjective feelings of stress, but also some related stress hormones. But interestingly, when people regularly take it, they tend to boost their cardiorespiratory fitness.Speaker 2 (00:59:09):There was a matter analysis published recently, looking at the effects of ashwaganda in take on VO two max showing that it does have a small effect on improving VO two max. And there've been a couple of studies too, looking at ashwaganda intake and adaptations to strengthen power exercise, showing that when people take it every day for several weeks, they gain muscle mass and strength slightly faster, LinkedIn CME ashwaganda. So it's not only good for brain health, but it also seems to support exercise performance. And then both of those energizing conversions are available. And so called rebuild versions, which just contain added whey protein, isolate, and L leucine. And that makes them a particularly good meal replacement. We add the L leucine because it's the one amino acid that seems to independently quite strongly trigger the synthesis of new proteins and skeletal muscle. But it also seems to have some appetite regulation enhancing effects.Speaker 2 (01:00:15):And in some contexts, it can be useful for some other aspects of metabolic health too. And that all nut butters that are all based on tree, nuts, not peanuts or anything like that. So they contain things like almonds and hazelnuts. And obviously I'm very biased, but they're really, really tasty too. So that's long range fuel. And right now I'm working on formulating our next products, which will hopefully launch early next year, which I'm really looking forward to. And it's also a project that we, we try and give back whether it's not just about trying to sell products, but we, for example, give 1% of our sales to a charity that works with governments and communities and tropical countries to protect their rainforests. And given my background, I also try and create useful educational content. So I recently wrote a free ebook about nutrition, which people can download from the website and we'll have lots of more content coming out too in the coming months. So that's resilient nutrition in a four minute nutshellSpeaker 1 (01:01:23):Nutshell. I like it. Very good nutshell. Not a Chestnut or whatever, any hints on the, on the new product or is it top secret, top secret, right. Okay. I had to ask, you know,Speaker 2 (01:01:41):Unfortunately, but hopefully at some point next year we might be over in the U S and if that's the base, then I'll have to get some over to you to try.Speaker 1 (01:01:49):Yeah. That was my other question. Do you ship a worldwide or is it just mainly in the UK right now?Speaker 2 (01:01:55):Right now, it's in the UK in the next few weeks. It will be in Europe too. So we'll be on Amazon over here shortly. And then hopefully next year, we'll transition to North America too. And then ultimately we'd love to be in the Asia Pacific region. So 2021 fingers crossed in North America, but right now it's, it's just over the side of the pond. Cool.Speaker 1 (01:02:20):Awesome. Well, thank you very much. I know we talked about sort of a subset of resilience related to sleep and other supplements and things that are useful, which I think is always beneficial for a lot of people. So where can people, what's the best way for them to find out more about you and about resilient, nutrition,Speaker 2 (01:02:41):Resilient, nutrition, it's resilient, nutrition.com. And we're also on Instagram at resilient nuts. And I have my own social media, which is at Greg Potter PhD, which sounds ridiculously self-indulgent. But at Greg Potter was taken, I don't post there that much, but I'm going to probably start posting more regularly in a few reach out to me on there and send me a message. Then at some point I will get back to you.Speaker 1 (01:03:09):Awesome. Yeah, I know. That's always, sometimes you get interesting emails from people it's like, why do you have to put doctor on everything? It's like, well, sometimes the normal name was taken and it's just the easiest way to get the next normal semi looking name.Speaker 2 (01:03:27):I actually, I hate being called doctor. Just if it feels wrong, I always say, I'm not a real doctor. I'm just a PhD.Speaker 1 (01:03:35):Yeah. I had that one. So when I checked into a hotel, my assistant made the booking. It was a couple of years ago and she goes, Oh, and how was your stay? Oh, Dr. Nelson. I said, Oh, it was good. She's like, Oh, what kind of doctor are you? I said, well, actually I did a PhD in exercise physiology. She goes, Oh, you don't cut people open. I'm like, no, I'm not, not a surgeon. She's like, Oh, well have a good stay there. Mr. Nelson,Speaker 2 (01:04:04):Did you take any muscle biopsies during your PhD?Speaker 1 (01:04:07):No, I didn't. We, our lab was weird that we were an exercise physical lab, but to get to do any bloods, we had to go to the what's called the clinical research center and to get IRB approval process was completely separate. And then because of the way the budgets were set up, the GCRC charged us, literally an arm and a leg just for us to walk into their building. So we did everything unfortunately possible to avoid that, just due to the sheer cost of it. We did do some stuff over there. We did some stuff with like nitroglycerin and some other stuff related to flow me to dilation and to seal function for doing it as a chemical in part of the studies. But unfortunately, no, that's one of those weird things I always wanted to do. Or in some, I dunno, weird way have done to me, but I haven't. It's a masochistic way. Yeah. Yeah. Yourself.Speaker 2 (01:05:10):Although my undergraduate thesis was looking at the association between quadriceps muscle isoform composition and sprinting jump performance and untrained young men looking at, yeah, we were looking at where the fast Twitch fibers associate with performance, but that's, that's the closest I've come and I've, I've never, I've never been stabbed in the leg in the interest of science.Speaker 1 (01:05:36):I know. I, my good buddy, Dr. Andy Galpin, I'm sure. He's like, well, we can do it here. Unfortunately all their studies due to the recent COVID stuff are all, all on hold. So I talked to me their data. I said, well, what are you actually really doing? It's like, well, not really a lot, because you can do virtual biopsies like, Oh yeah, that would be pretty hard. So, yeah. Awesome. Well, thank you so much for all your time today. I really appreciate it.Speaker 2 (01:06:07):Thanks, Mike.Speaker 1 (01:06:09):Thank you so much for listening to the podcast greatly. Appreciate it. Big, thanks to Dr. Greg Potter for coming on and sharing all of his knowledge with all of us today. Super insightful and again, a lot of good practical knowledge that you can take forward if you were in the UK, make sure to check out his nutrition company, resilient nutrition, even if you're not in the UK, still check out all the great information that he's put out over many years. I always enjoy listening to him on other podcasts and reading his work. So this show is brought to you by the flux diet certification, learn eight different interventions on how to get better body composition and performance without wrecking your health via nutrition and recovery interventions certification goes through the top eight related to protein fats, carbohydrates, ketogenic diets, fasting, neat exercise, sleep, and more.Speaker 1 (01:07:15):Each module has a big picture. We'll be talking about the overall concept of the flex diet, which is a mashup between metabolic flexibility and flexible dieting. And then each one has about an hour technical primer. So everything you wanted to know about protein metabolism, how does it work? What is the role of branch chain amino acids? The leucine terms you may have heard Uber geeks throw around like muscle protein, synthetic response all broken down into a language. You can understand everything is fully referenced. And then each intervention has five very specific action items. So as a coach, you know what to do with clients, and this is all in a complete system where I show you how to use each one, where to start and how to know what action item is going to be best for each client at that time.Speaker 1 (01:08:13):So it allows you a complete, but it's done in a very flexible approach. And we also have a ton of expert interviews everything from Dr. Dan party, Dr. Stu Phillips talking about protein metabolism from McMaster, Dr. Jose Antonio talking about protein overfeeding. And what happens when you feed people too much protein, Dr. Eric Helms discussing flexible dieting, Dr. Hunter Waldmann talking about changes in metabolic flexibility and insulin dynamics and many other expert interviews there also. So that's all in the flux diet. It will open up again January of 2021. I would love for you to be a part of it and get onto the wait list right now, go over to flux diet.com F L E X, D I E t.com. That'll put you onto the daily newsletter and you will be the first people notified. So thank you again for listening to the podcast greatly appreciate it. Always feel free to leave any comments, feedback, or reviews for us in your favorite podcast player. Thank you so much.Speaker 2 (01:09:35):Cool. Cool. Sounds good. And how are you, how are things your end how's how's business being given the context?Speaker 1 (01:09:42):You know, it's actually been pretty good. I mean, in all honesty, like income wise this year was better than last year. Although I've worked probably twice as much just cause I haven't been traveling really at all. So since we got back from Costa Rica in March, like everything just got like the whole year just got wiped out in terms of presentations and even academic stuff. So I'm like, well, whatever, we drove out to visit some of my wife's family in July when kiteboarding and hood river. And then we did a five, six weeks trip, just drove down to Texas, did some kiteboarding down there and October, November. And yeah, I got freaked out because all my clients are mostly online trainers. So I'm like if their gym closes, why are they going to pay me to do their training? So in like April and June, I just said yes to every online product thingy known demand because everyone in their brother's like, Oh, you need someone to do online stuff.Speaker 1 (01:10:40):Who's that, Hey, you we've done this before. And eh, you know, some of them were okay. Some of them were just when they actually released it's I sold three, you know, so somewhere just a complete disaster, maybe they'll sell more next year or whatever. So it's, you know, overall it's been good, just interesting with all the variability in the, you know, projects that we started, you signed the contract, everything's good. You get 40% done. And then they're like, I dunno, we just can't do this. Like, you know, some something happened family wise or you don't know and then just cancel it. So that goes away and yeah. So it's been interesting to say the least, but it's, it's been okay. Which is good.Speaker 2 (01:11:25):It's cardboard and a great love of yours. I can see your board there in the background. Yeah.Speaker 1 (01:11:29):Well, it's my surfboard. I'm like, have you ever watched the show Seinfeld where he had the Cannondale bike in the back? So I'm like secretly wondering if like Slingshot a lover, watch my videos and be like, Oh, there's a Slingshot surfboard in the back. So yeah, I've done it backwards. I'm actually trying to teach myself how to surf using a kite first and then go back the other way. Which I don't know everyone else, like, that's the stupidest thing I've ever heard of. I'm like probably, but it's like, I can, I'm okay with the kite and yes, I'm using that to hide like every flaw with the board, but the amou

The holiday season is a busy, and often an anxious time, for a lot of us. So Dr. Maggie is getting straight to the heart of how to overcome an anxiety disorder and OCD with these 5 core principles. In this short lecture series, you’ll learn how to adopt an attitude of willing acceptance, go toward an anxious moment instead of withdrawing, embrace uncertainty, avoid your avoidances, and increase your awareness of opportunities to practice your emotional freedom toolset. Disclaimer: Please consult your doctor or therapist before attempting any strategies shared. 1:36 - Anxiety state vs. anxiety disorder 2:28 - Panic disorder 2:38 - Social anxiety 4:26 - Exposure and response prevention 9:44 - External triggers 10:13 - Internal triggers 11:49 - Feeling hopeless, helpless, or worthless 13:25 - Why it’s worth it to go toward the anxious moment 14:32 - Anticipatory anxiety 15:35 - Situational anxiety 16:15 - Post-event processing 18:11 - Fearful anticipation of uncertainty 20:02 - Behavioral strategies for handling uncertainty 23:44 - How not to undermine yourself 25:01 - Re-interpreting anxiety as excitement 28:38 - Commit to the process, not the outcome 32:02 - Be as patient with yourself as you would with a child 35:57 - Self-criticism 36:53 - Numbing out 37:51 - Helpful & compassionate self-talk around anxiety & OCD Connect with Dr Maggie Perry and TMWYPO: Visit the TMWYPO Website: http://TellMeWhatYoureProudOf.com/ Follow TMWYPO on Instagram: https://www.instagram.com/TellMeWhatYoureProudOf Follow Dr Maggie Perry on Instagram: https://www.instagram.com/drmaggieperry Subscribe on YouTube: https://www.youtube.com/channel/UCY4kQLJ55Upy3RxoZBWIp2w Like TMWYPO on Facebook: https://www.facebook.com/tellmewhatyoureproudof Follow TMWYPO on Twitter: https://twitter.com/whaturproudof Follow Dr Maggie Perry on Twitter: https://twitter.com/drmaggieperry --- Send in a voice message: https://anchor.fm/tmwypo/message

The music industry is a fascinating setting to understand the power of pop culture AND political economy. (Yup, like that Karl Marx kinda of political economy!) So Dr. David Arditi joins us to explore how power and institutions influence the music we listen to, and the art that musicians create. We discuss self-censorship, Soundcloud, commercialization, Bhad Bhabie, and more! Tune in here, and go check out Dr. Arditi's book ‘Getting Signed: Record Contracts, Musicians, and Power in Society'!

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Narjust Duma, MD, moderates a discussion with ASCO CEO, Clifford A. Hudis, MD, FACP, FASCO and Sybil R. Green, JD, RPh, MHA, Director of Strategic Initiatives in ASCO’s Policy and Advocacy Department, on what ASCO is doing as a professional society to address equity as part of its mission.  Subscribe: Apple Podcasts, Google Play | Additional resources: elearning.asco.org | Contact Us   Transcript: PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. NARJUST DUMA: Welcome, everybody, to the second episode of ASCO's Social Determinants of Health series. My name is Dr. Narjust Duma. I am an assistant professor at the University of Wisconsin and also a thoracic oncologist. Today I'm joined by ASCO's CEO, Dr. Cliff Hudis, and Sybil Green, Director of Strategic Initiatives in the policy and advocacy department for ASCO. This series is a new initiative proposed by ASCO president, Dr. Lori Pierce. It focuses on increasing oncologists' awareness about the social determinants of health through the cancer care and how impacts our patients' outcome, including modifiable risk factors. This series is inspired by Dr. Pierce's presidential team of equity, every day, every patient, everywhere. In this episode, we look at what ASCO is doing as a professional society to improve health equity and cancer care. Welcome, Dr. Hudis. Welcome, Mrs. Green. First I would like to us what is ASCO doing as an organization in the matter of health equity and cancer care? CLIFF HUDIS: So I guess I'll start here. Thank you very much for spending some time with us on this. If you look at ASCO's mission, it is conquering cancer through research, education, and the promotion of the highest quality and equitable cancer care. So the idea of equity and our responsibility to address disparities is really in our organizational DNA. I have to point out something that many people may not realize. But when ASCO was founded in 1964, one of the seven founders was a black woman, Jane C. Wright. Dr. Wright died in February of 2013. But her father was among the first African-American graduates of the Harvard Medical School. His father was also a physician. And he was educated at what became Meharry. So I remind everybody of this as often as I can, to make the point that not only do we have an opportunity to advance equity and to deal with disparities in health care, but it's my perspective as a leader of ASCO that we have a special obligation and responsibility to do all of that. So we can talk more about it. But I'll just introduce maybe the answer by saying there are really two broad themes at work for us at ASCO. One is externally facing. And one is internally facing. The externally-facing work includes a range of projects and output that we can talk about a little more, but for example our position papers describing disparities and then identifying potential steps to take to address and solve them. But it also includes support for targeted research that is meant to narrow those gaps. It includes our educational efforts, both for our members and for legislators, advocacy for policy, and so on. And then on the internal side-- and here I'll ask Sybil to talk a little bit-- I think we've recently recognized our opportunity, and again responsibility, to think about the workplace itself and to think about our staff and to think about the activities and actions we can take and the roles we can model to create a better world. So I know I've been high level in my initial answer here. But the two domains again are external and internal. And then we can talk about some of the specific projects as we go on. NARJUST DUMA: Mrs. Green, I think it's very important to share about these internal aspects of ASCO because many of us are now aware as members, we see the surface. But ASCO is a large organization with many staff and members. So it would be great that you can share that with us. SYBIL GREEN: Absolutely. And thank you for allowing us to share that. I think Dr. Hudis pointed out some of what we've done since ASCO's establishments and really charging everyone on staff to really live out that obligation of equity, diversity, and inclusion. And so through our programs, our staff have to do their work, make sure that we are creating equitable opportunities for patients and physicians, but it starts at home. And so we have to make sure that internally, we are offering those same opportunities for our staff to engage because what we know is that when staff are engaged, and they have the opportunity to bring their true selves to work every day, they bring their personalities. They bring their lived experiences. And that all plays out in the work that we're doing on behalf of members, in their patients, but also for staff. I think if I were sum up where our program is going, similar to what Dr. Hudis has done, the three components are really enabling staff success. We ought to be able to do that for our staff internally. Every day we ought to provide opportunities for them to succeed. And then making sure that our partnerships-- those that we work with, whether it's in our publications, our meetings-- making sure that our partners goals and ideals align with ASCO's values and ideals. And all of this, of course, is in support of the greater ASCO enterprise, which is our members and the patients and of course, ASCO staff. NARJUST DUMA: And I think that it's really important-- I had the pleasure of interacting with several staff members with diverse backgrounds. And I think as we develop the mentorship program and other things, their input is diverse. It means we also are able to cover the trainees needs because every trainee's needs are different. And because I cannot give a talk or do a podcast without mentioning my grandma, [INAUDIBLE], I have to say that it's important to clean your house first before you go and try to clean other people's houses. I do promise it's beautiful in a Spanish. But I think it's important that everybody knows that internally ASCO is doing a lot of work. And I think it's important to talk about the grants in health equity. And I'm mentioning this because I haven't been doing health equity since I was a med student. And sometimes you find yourself not having enough grant opportunities. Now there is an increase. But when you compare it to other areas of oncology, you may be more competitive because there are less grants. And I think it would be great to hear from the both of you about the new health equity grants, the breast cancer disparity grant, and beyond. CLIFF HUDIS: Well I would just point out something to build on your comment, first of all. Since we were founded in 1964 til now-- so just over 55 years-- we've made unbelievable advances, I think, in oncology in general. Indeed the reason I as an old man chose to go into an oncology in the 1970s was that the vision ahead was that this was going to be an exciting field. And it has not disappointed. However there's a dark that I think we should acknowledge. The advances have not been fairly or evenly distributed. And indeed in some cases when we make massive improvements in outcomes in terms of what's possible with state-of-the-art care, we increase disparities because not every group catches up. And I say all that because it's important to understand that this is not about abstraction. These grants that address that gap are as or more important than the basic science grants that actually advance the biology and understanding in the first place. One without the other is incomplete. So I can't agree more that this is important. And actually from an investment or return on investment point of view, in some ways, these grants are an even better deal because we can rest many of these gaps in care delivery and in knowledge pretty quickly and narrow the gap. And we've seen it. I'm going to give you some examples in a moment. Whereas funding basic science, honestly, is a much higher risk proposition, if you think about it. So I don't mean to set up a false competition here. But I want to point out that there's a big reward. So here's an example. The plenary session abstract at ASCO two years ago now-- abstract number one, if you recall, was no moral less than an analysis of the impact of Medicaid expansion. And what did it show? It showed that with Medicaid expansion, those states that implemented it quickly narrowed the gap in time to initiation of therapy for curable colon cancer. It's a simple take-home point. I care passionately about this personally because these are differences in outcome that have been labeled as associated with race for many years or other specific ethnic facts. But really what they're about is nothing except unfair, uneven access to care in the first place on the basis of race. And it's something that we can address. So we are building out programs to address this through a number of granting mechanisms. For 2020 alone, there are going to be two Young investigator awards that are earmarked for underrepresented populations. And there's a career development award and another YIA, Young Investigator Award, in health disparities specifically. But this is just, I think, part of the issue. The other issue for us-- and actually a commitment going back for years-- is to do something about the workforce itself. And I don't have to tell you, but of course, there is a huge disparity playing out when we look at makeup of medical students in America. And it gets accentuated to the extreme when we look at black men. They are the most disproportionately underrepresented group right now. So how are we going to address that? And we're really proud this year to be launching a program that is aimed at newly-matriculating medical students building on a successful program in Boston that's been running for a couple of years already with Bob Mayer is the founder. And our goal is to the interest of specifically targeted populations, not just in medicine but specifically in oncology. NARJUST DUMA: Mrs. Green, you would like to add something about the grant and what is happening to support health disparities various research at ASCO? SYBIL GREEN: I'll just add the importance of any grant opportunity in any program being one to two. So it's one thing to be able to address bringing in the right medical students to be able to mirror the populations that they serve. It's something else to continue to support them along the way, and so not just stopping at the students, not just stopping at the research, but also making sure that was they're in practice they're supported. And a couple of grants that we've had for some time focus on quality, not just in ensuring that quality services are delivered, but actually helping practices to determine how to identify gaps in [INAUDIBLE] populations that are underserved because we may not be able to identify those same gaps that we would identify in majority populations. And so by giving them the tools to some of the other programs that ASCO has to be able to identify those gaps and then to support them along the way is really important. NARJUST DUMA: And I want to add to what Dr. Hudis mentioned about workforce diversity because this is one of my areas of research and passion. And it's extremely important to have a diverse workforce to represent the patients we're caring for. It's not only having a diverse workforce, but having a workforce that practices cultural humility. We cannot assume that we are proficient or we are competent in somebody's culture. I'm a Latina. And there are so many Latinos in so many different backgrounds that I cannot learn them all. And I think it's important that early interventions are-- because when you get exposed to a specialty early on during the training, that would change your pathway. I'm the daughter of two surgeons. I'm supposed to be a plastic surgeon. But a patient with cancer changed my life and my pathway. So we're able to support those students that have less resources and less access-- and that also includes rural students-- they may don't be black or Latino, they may be white, but they come from rural areas with limited resources-- we are sure that we meet the patient needs because there are aspects I don't understand. Like I'm in Wisconsin, and there are some aspects to farming I didn't know. Now I know when harvest is. And all of that allows us to plan appropriately. So I can see how important it is. And there's a task force that is run by Dr. Winfield, which I'm lucky to be part, that focuses on the workforce diversity. Along those lines, as a minority in medicine, I have seen up and downs of the interest in workforce diversity and health equity. I think many events in 2020 helped a lot of people open their eyes or be more conscious like, oh, that's not isolated. That happens in my back yard. It happened in Kenosha, Wisconsin. But we want to hear how is ASCO making these things long term, how the internal and external changes are going to be long term? And I will start with Mrs. Green and then go to Dr. Hudis. SYBIL GREEN: So in terms of making it long term, it can't be one and done. I think quite often when we focus on equity and diversity issues, we always look at diversity first. And so whether it's workforce or whether it's increasing opportunities for access, you can't just look at the numbers. You have to also think a little bit deeper. You have to think about culture. And so culture with humility, like you mentioned, Dr. Duma, is important, but making sure that attitudes are changing along the way. And that happens through self-awareness. That happens through understanding. And I think that ASCO plays a real role in making sure that our members understand what the issues are and how to dig past those things and provide them with the tools to be able to [INAUDIBLE]. ASCO I think, is not unique. And the idea that this is all new to us has gotten a lot of attention because of some of the social and racial injustice. But what that means is that our members now are probably more interested in ensuring equity than ever before. But we have to teach them how to do it. We have to teach them how to speak the language. We have to teach them how to be more aware, both in their own organizations, at ASCO internally, and for their patients. And so it's a cultural change. It's not going to happen overnight. It's gradual understanding of the dynamics, gradual understanding of different peoples goals, and meeting them where they are, so that we can help them to move along, so that we can come to a more equitable and just [INAUDIBLE]. CLIFF HUDIS: I think one of the things Sybil and I spoke about this summer is we launched our internal EDI effort-- relates to this. And that is this is not about identifying a leaky pipe and patching it and saying, well, we're done now. This is actually, in my view, a permanent change in the way we see work and the way we see our growth. So the goal is to reach a specific landmark. The goal is to change how we think about our work and how we think about our role in the world, so that we're constantly improving. And it's a journey, not a destination, I think, which sounds trite. But that's the spirit of it. And it gets to your question about how we make sure that the commitment is continuous and not just while it's [INAUDIBLE] and exciting. And I think we are committed and dedicated to that. I do want to present a related challenge because it's something you said really sparked this thought for me. As a physician, when did you know that you wanted to be a physician? How old were you? NARJUST DUMA: I was 5. CLIFF HUDIS: And, Sybil, when did you know what your career path was going to be? SYBIL GREEN: I was 9. CLIFF HUDIS: That doesn't support my thesis [LAUGHS] [INAUDIBLE]. So here's the issue. The issue of burnout in medicine right now is getting a lot of attention. And one of the reasons for it, frequently given, is that doctors on average decide to commit to their careers a decade younger than most people on average commit to other careers. You're an exception, Sybil, so I should have pretested the question. But the issue is we're not here to talk about burnout today, even though that's really important. The issue is this. In order to ultimately address the makeup of the population of physicians, we need to reach deeper and further into precollege communities. And we need to show people that they could have lives in science and health care and in medicine and maybe specifically oncology. And I'm just pointing out to you that that's a daunting challenge for a professional society like ASCO. That's not our audience. We don't have a natural connection there. And one of the things that we're working on right now is identifying programs that have worked, that exposed high school students from previously excluded populations or communities to medicine, so that we can spark that passion before college, not during college, and therefore have the commitment that it takes to go far into medicine. And I'll just close by saying something that you hinted at but needs to be said. The reason to have diversity in our workforce is not that an Asian patient needs an Asian doctor. It's that an Asian patient needs a practice that has Asian doctors in it, so that the practice as a whole is able to be culturally sensitive and able to relate and communicate and support them because I think sometimes this issue gets oversimplified as well. SYBIL GREEN: So Dr. Hudis, your theory is not completely [INAUDIBLE] I think it's relevant to this conversation because while I knew what I wanted to do at 9, what I didn't have was the representatives in the community. I didn't have the mentor. Interestingly enough, I had more mentors in pharmacy than I had in law because I saw pharmacists who looked like me. I happened to live in a town where there was a historically black college with [INAUDIBLE]. And so I saw people look like me. And it made it a lot easier for me to reach out to them, for them to mentor me, for them to start talking to me about what equity in health care looked like. That really wasn't until I was in college. But the truth of the matter is for most diverse students, most minority students, that doesn't exist. And I think that that's where ASCO's mentoring programs are really rich. You have the opportunity to do that. NARJUST DUMA: And I think this is important because you can do what you can see. And that has been proven over and over again. We unfortunately are running out of time. But I want to ask the final question. Like a manuscript, like a study, everything has limitations. And I think it's important that we talk about the limitations of ASCO doing this work because realistic expectations are helpful so we don't get disappointed when we have big expectations that may not be met. So Dr. Hudis, what are some of the limitations of ASCO to help equity work now? CLIFF HUDIS: You're right, it's a huge issue. If you think about where our scientific focus is, we can measure the disparities or the difference in outcomes. And we can write a paper about that but when you really get to addressing the reasons for it, it extends far beyond what we can do. So I guess our limit is we can call attention and rally colleagues and collaborate across the House of Medicine and broadly into Congress, where we can make a difference-- or to the United Nations and World Health Organization. But we can't do this heavy lift alone. We need other colleagues who agree who are willing to invest time and money to make the change. SYBIL GREEN: And I would add partnerships because as much as we're talking about social determinants of health, we recognize that all social determinants of health are not health related. They're not [INAUDIBLE]. And many of them live and operate outside of the realm of health care. But what we can do is bring our expertise to the table about the impact of those things, so that our partners stand in their own world, in education, in criminal justice, in financial assistance, how that can help really change the outcomes for patients. I think at ASCO, we've got that expertise. And we can do that. NARJUST DUMA: Thank both of you for your time. Thank you, everybody, for joining us for the second episode of ASCO Social Determinants of Health series. Please keep up with us. You can subscribe. You can see this on Facebook, YouTube-- when it becomes available. We'll continue to explore the social determinants of health and cancer care. You can leave feedback or emails, any questions to the professional development, at asco.org. And I thank you for your time. And have a wonderful week. PRESENTER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning center at elearning.asco.org.

Truth Strikes CNNIt’s first Tuesday of the month SO Dr. Everett Piper joining meCensoring Witnesses & Abetting Election Fraud 2020Covid Kills Football?ACWT Soon on RumbleFollow Debbie Georgatos!WEBSITE: http://americacanwetalk.orgFACEBOOK: https://www.facebook.com/AmericaCanWe...America Can We Talk is a show with a mission — to speak up for the extraordinary and unique greatness of America. I talk about the top issues of the day facing America, often with insightful guests, always from the perspective of furthering that mission, and with the goal to inspire listeners to celebrate and embrace the liberty on which America was founded.

This episode of PROSTATE PROS reviews and summarizes the year’s advancements in prostate cancer as well as looks forward to future updates. Beyond prostate cancer, the episode examines how COVID-19 has impacted the healthcare landscape and discusses news of the vaccine. Catch up on the latest and stay tuned for an exciting announcement. Liz:  [00:00] We have an exciting prostate cancer update.  Since recording this episode, the FDA recently approved the PSMA PET scan.  Keep that in mind when listening to the episode.  If you’d like further information, visit fda.gov. Dr. Scholz: [00:18] We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz. Liz: [00:24] And I’m your cohost, Liz Graves. Dr. Scholz: [00:28] Welcome to the PROSTATE PROS podcast. Liz: [00:31] A lot has happened this year and we’ve covered many topics on the podcast. This episode we wanted to highlight a couple of exciting advancements and talk about some updates. Dr. Scholz: [00:44] The elephant in the living room of course, is the COVID situation. That’s impacted the way we do business. It’s impacted our patients. It’s impacted all of you dramatically. I thought I’d give a little update on what’s happened in our over 2000 clients. As you know, we serve a population of men between fifty and ninety plus our oldest patient just turned one hundred. This is a high risk group. Men are at higher risk for COVID complications and as we get older, particularly over 80, the complication rate goes up and the mortality rate goes up. We’ve actually lost one patient to COVID in our whole practice in 2020. It was an unfortunate individual that was traveling in Egypt in the January, February timeframe and when he came back to the United States he was ill. This was before people were really clear of what was going on, went to the hospital with pneumonia, and unfortunately passed away. We’ve had other patients, perhaps a dozen or so that have caught the COVID. They’re sort of evenly divided between men who really report that it wasn’t much of anything at all and others, the other half, they got pretty darn sick, a really bad flu. None of them fortunately had to go to the hospital. They all recovered. This is rather remarkable considering our vulnerable demographic. It shows that if people are careful and they isolate, they wash their hands, keep their hands off their face, most people aren’t going to catch this. Of course, when I talk to patients, I’m impressed by how much isolation is going on out there, how much care they are taking. Many men have come to the office and said that I am the first out of the house experience that they’ve had in 2020. So people are being very careful and clearly being careful does work. Liz: [02:49] Yeah. I remember early on in the pandemic, our office had way less traffic and was almost empty. Now it seems like things are picking back up and people are checking back in on their health. Dr. Scholz: [03:01] We’ve had a bunch of people come to the office who maybe had some cold symptoms, everyone’s on edge, and we’ve tested them for the COVID antibody to see if they did indeed have previous exposure. These tests are almost always coming back negative. We’re told by the scientists that these tests are probably 80% to 90% accurate. They’re not 100% accurate when you do the antibody test. That’s the test to determine if you’ve had previous exposure to COVID. We believe, and some people disagree, that if you’ve had previous exposure and your antibody test is positive, that it’s as if you’ve had a vaccination and you can’t catch COVID and you can’t transmit it. That of course would be good news. We’ve tested several hundred people now and almost all of them are negative. The ones that are positive are the ones that told us previously that they knew they had COVID. These antibody tests confirm it. This is a different test than the nasal swab, where doctors are trying to determine if you actively have the COVID virus. Those tests are more accurate, perhaps approaching 99% accurate. Patients who think that they have symptoms need to find a place to get tested, to rule in or rule out whether they are infectious. After they’ve been sick, they want to be tested again, to make sure that the infection risk has gone away. Liz: [4:38] We’ve had inquiries about where to get tested. We usually just send whoever across the street to Cedar Sinai, and they’ll do it there. The turnaround on these test is quick enough that people can just wait for their results and they should know within an hour. All right, Dr. Scholz, I think the biggest information about COVID right now is news of a vaccine. I think one thing a lot of people are concerned about is how quickly this has developed vaccines usually take years, if not a decade to get developed. This has happened within a year, which is pretty incredible. Do you think it will be safe? Dr. Scholz: [05:15] So there’s been debates, everyone’s heard them, that will the vaccine work, will it have durability? At this point, the preliminary science suggests that it will work and it will have durability. There’s three different companies that are putting forth a new product. The hope is that by the end of the year we will be having people getting vaccinated. Of course, there’ll be selective preference for the elderly people in healthcare. How this is all going to roll out is a big question. But it seems at this point, there’s no doubt that by early 2021 a vaccine is to be available and it will be effective. Liz: [06:00] It is changing really quickly. I know we were just talking about this last week and when I went back to review, I almost had to research it all again. So it’s important to stay up to date on this. Dr. Scholz: [06:14] Yeah everything that we do in the oncology realm and in this realm as well is predicated on what we call a risk-benefit ratio. We give dangerous medicine sometimes in oncology, but we are treating life-threatening cancers and sometimes rolling the dice and taking a chance with a treatment makes a lot of sense if the disease is much worse and very dangerous. So it’s going to be different for different people, for myself as a physician, meeting people all day long and basically in a high-risk situation, it seems to me that I’ll be lining up early for the vaccination. For those of you out there that are comfortable in your isolated state and are willing to sustain that, 2020 showed us that people can remain pretty safe if they’re very careful, but the social isolation is taking a big cost in our patients’ mentalities, their lifestyles, their social lives. It’s been painful and difficult when people have to make a personal choice as to whether the relatively small risk of getting a vaccine is too great to consider as opposed to continuing in their existing lifestyle. We’ll have more information every month as this vaccine rolls out as to how dangerous or how many risks there’ll be associated with it. That is unknown at this point. But as a lot of people are going to be getting this vaccine, we should have very good information within a few months. I think one last thing to emphasize is that we’ve learned that the COVID virus complication rate goes up astronomically in men over 80. Men over 80 and the elderly are at the very highest risk and mortality rates start to become very significant in this group. It would seem to me that these elderly men are going to want to try and get a vaccine, even if there are some risks associated with the vaccine, because the virus for them is very dangerous. Liz: [08:22] So another paradigm shift that occurred this year was the shift towards telehealth. It seems like about half of our visits now are being conducted over the phone or via FaceTime or Skype. Dr. Scholz: [08:36] This has been a really big change. In trying to understand it and wrap my brain around it, it seems that it’s a radical shift in accessibility. In the past, phone visits were discouraged because the impetus was to get people into the office and be able to bill for your services. Now, both private and Medicare insurance has essentially mandated insurance coverage for telehealth. This has rapidly been accepted by patients due to the accessibility, the ease of communication. It’s even been nice to be able to take off my face mask and see the body language of my patients and communicate non-verbally with Skype and FaceTime. In the office employees, patients alike are all wearing masks and we’re making eyes at each other, using our voices and trying to overcome the muffled communication that has become routine now in our lives. Liz: [09:44] I think something else that the telehealth has brought is connection. Right now people are feeling kind of anxious and separated. If they are skipping doctor’s appointments to avoid waiting rooms and being close to other people, it’s such a great way to catch up on the latest in prostate cancer and catch up with you. Your face appears in their living rooms and it’s like they’re right in your office. Dr. Scholz: [10:10] Yeah it is very personal. It’s as you all have experienced now, your face fills the screen and it’s not as disconnected as people might think. The risk to patients with telehealth is obviously reduced. But one component of the way we do medicine, of course, is blood tests, injections, and treatments, and certain in office visits are still unavoidable. If patients go to a remote facility for blood testing, they’re still going to have some contact. But so far as has been demonstrated, the COVID infection rate for our patients has been very low, whatever precautions people are taking seem to be working quite well. One thing about telehealth is it appears to be here to stay. I’ve talked to high-level insurance people about the future of telehealth asking, will it go away once the COVID risk disappears? The general consensus is that there’s no going back. This increased accessibility seems to be the future of medicine. Liz: [11:19] So even big topics that are maybe a little more involved or confusing are easily addressed over Skype or FaceTime or a phone appointment. Let’s start talking about a couple of those that are new developments for 2020. Dr. Scholz: [11:34] We already covered PARP inhibitors but they, being brand new treatments for advanced prostate cancer, merit a quick review. PARP is an enzyme that helps repair DNA. About 10% to 15% of men with advanced prostate cancer have a mutation that causes their DNA repaired to work less efficiently. One application of this mutation, which is called BRCA, is that there’s a little higher risk of getting prostate cancer. The men who get prostate cancer that have BRCA tend to have a more aggressive form. The PARP inhibitors exploit this mutation and men that have this mutation respond much, much better to PARP inhibitors. PARP inhibitors are pills that make it even more difficult to replicate or duplicate DNA. These already impaired cancer cells then die more easily and more quickly than your normal cells of your body. We’re always looking for a differential effect with cancer treatments, a treatment that focuses more on the cancer, then your cells killing cancer without causing a lot of side effects. So the medicines we’re talking about are Olaparib and Rucaparib two new pills that help men with BRCA mutated cancer and are now FDA approved. Liz: [13:01] These two approvals really highlight how important using genetic testing is. This will help men with prostate cancer find treatments that may have only been FDA approved for another cancer. Doing genetic testing is very easy. It can be accomplished with a mouth swab or a blood test, and it’s almost always covered by insurance. So we briefly covered some updates and genetic testing. Let’s review the PSMA PET scan really quick. Dr. Scholz: [13:32] We did a whole podcast on this because it’s a big breakthrough. Most of you have heard of it by now, but for the first time we can accurately locate the prostate cancer wherever it is in the body and the prostate and the lymph nodes in the bones with one single scan. This scan may be five times more accurate, ten times more accurate than any previous scan that was available. What a wonderful addition to our diagnostic armamentarium. This is going to have an impact for people with early stage disease, late stage disease. Unfortunately, the FDA has not yet approved it, but we’re anticipating approval within the next six months or so. In that situation, it will be covered by insurance and it will be very popular. Liz: [14:18] Some companies are investigating using PSMA as a therapeutic target rather than just a diagnostic target. Dr. Scholz: [14:28] Exactly. So the diagnostic scanning is incredibly useful reconnaissance for figuring out where the cancer is and helping design a treatment protocol. But if we’re able to accurately locate the cancer with these scans, wouldn’t it be possible to use this same target, to make therapies stick to the surface of the cancer cells? There are two very exciting types of treatment. One we’ve talked about before uses an antibody to stick to PSMA and draw a high energy radioactive molecule right next to the cancer cell and kill the cancer cell. This is called Lutetium- 177. The phase three trials in prostate cancer have been completed. We’ve had patients on trial or outside the country, get this treatment with very nice responses. We’re talking about a treatment for men that have already had chemotherapy, become hormone resistant to Zytiga and Xtandi, and who perhaps have limited treatment options getting nice PSA declines with relatively little, if any, toxicity. There is a PSMA antibody on the salivary glands, so some people get a little bit of a dry mouth. Some people with radiation, it can cause some lowering of blood counts, but for the most part, there’s practically no side effects with dramatic responses to Lutetium-177. The phase three trials are completed and they’re waiting for them to mature to validate that there is a survival advantage. Once that happens and the study results are released, the FDA has six months to approve or disapprove the treatment for broad spectrum dispersal amongst the population for therapy and insurance coverage. Liz: [16:14] So it seems like there’s a lot to look forward to with PSMA being used as a diagnostic test as well as its role in therapeutics, especially for men with advanced prostate cancer. There are a couple immunotherapies that are exciting on the horizon. Can we talk a little bit about those? Dr. Scholz: [16:36] Amgen has developed a connector molecule that instead of linking a radioactive moiety to the antibody that clips to PSMA, it’s sort of like a pheromone tag that draws in your T-cells. I don’t know how many of you are familiar with how the immune system works, but the soldier cells of the immune system are called the T-cells and the T-cells are the component of your immune system to go in and attack the cancer cells and kill them directly. Theoretically, if you can get the T-cells in close approximation with the cancer cells, they will attack and kill them. There is new technology from Amgen, a very large pharmaceutical company, that has developed this and is doing phase two testing in men with advanced prostate cancer and responses are indeed occurring. So the patients are injected with a substance that clips onto PSMA i.e. the surface of the cancer cells and draws the patient’s immune system close to the cancer cells so that it will attack it. Liz: [17:49] As you can see, there’s so much information about prostate cancer this year alone, we’ve covered focal therapy, brachytherapy, radiation, immunotherapy, chemotherapy; the list goes on and on. So looking forward, it’s important to always stay in touch and stay up to date and keep sharing and keep listening. You might find it useful to go back and review old episodes of PROSTATE PROS. You can find us on your favorite player. So Dr. Scholz, another exciting thing 2020 was the 10th anniversary of your first book Invasion of the Prostate Snatchers. Something you may not know is that this year, Dr. Scholz and I have been working hard to update his first book Invasion of the Prostate Snatchers. So about 10 years ago, when the first edition was published, it was really the first introduction to active surveillance. I think Dr. Scholz received a little flak from that, and now it’s more widely accepted, but with that, there’s still a lot of the industry that patients need to be careful of. That includes over-treatment. That includes dangers of surgery and random biopsies. So we’re really looking to restart the conversation, and get patients to be their own advocates. Dr. Scholz: [19:16] There’s a theme in the prostate cancer world that you have to educate yourself. I hope that both of my books encourage people to do their own research, to take responsibility for their health and to double check the information, rather than just accepting the first pitch you hear from a doctor. Prostate cancer is big business. It’s a multi-billion dollar world, and people are trying to make a profit. Ethically, no doubt, there’s so many gray areas in the prostate cancer world. You need to double-check and you need to find the original, basic information that leads you to the truth. Liz:  [19:59] So this new completely rewritten second edition of Invasion of the Prostate Snatchers will be out in 2021.  We’re really excited to share it with you.  Telehealth has really connected us this year, and we’re looking forward to staying connected in 2021.  Remember to tune into the podcast and share with your friends.  If you have any topics you want us to cover in the upcoming year, you can email us at podcast@prostateoncology.com.

Eric Rieger  0:00  All right, everyone, it is now Episode Number 45 Hello KB MD health family and GCP gut check project fans. I'm Eric here with my co host, Dr. Kenneth Brown. We've got an incredible show today. And well, this guy's always referred to a special secret weapon and I'm gonna let him unveil it here in just a moment. But I'm gonna go ahead before he talks about why this secret weapon is a secret weapon. Let's just talk that here in just a moment. Angie cook is a registered nurse. She has some issues such as dysautonomia, miles Ehlers danlos, colonic inertia, severe constipation, all of these different things that she's got experience with that she could actually share a personal story. So, Ken, what brought us here? All right, soKen Brown  0:53  this is what Alright, so this episode is very dear to my heart. And people that don't experience this, you're going to go out? That's kind of an odd topic. But I'm telling you, you want to listen to this. Because we know that there's a connection between digestive health, gut inflammation and the possibility of developing other symptoms, other issues, like dysautonomia, and before you just turn it off? You're like, what's that? Like? Whoa, that's what Angie is going to tell us about today. So Angie, I've always referred to her as my secret weapon on the podcast, you can go back to almost one of the first episodes that we've ever done one, Episode 45. And first of all, Angie, thank you so much for your incredible diligence to researching and backing everything by science. So I get emails from all over the world. And people say, Hey, can you help me with this? And I will email you and say, is there any chance that you could find this article, and then you find me 50 articles related to that, and we sift through them. So one of the most impressive things is that you're a patient of mine, that has gone from having some symptoms, to learning so much about it, that you've actually gotten your master's in nutrition. And you realize that part of this process is that you and I are now a team. And I've gotten to the point where I'm relying on you for information. And this is my exposition of us saying, look, you know so much more than me about this, we need to get this out to the public. And this is what I want to do. I did Chris kresser, his podcast a couple months ago. And immediately him and I ran to the same conclusion. It's not about the bacteria. It's not about this, it's about the motility. What do we do about that? What is it and so what we're going to talk about today is the motility about everything. And your history is incredible. Because if you're somebody who's ever felt frustrated, by the lack of attention that maybe you've gotten in medical community, if you're somebody who's felt frustrated that you're being blown off or anything like that, this is what we're gonna do. We're gonna go from Angie's story about what she has gone through. And then we're gonna geek out on a level that I am so impressed by. So if you're shavon Sarna and you're the CBOE summit person, you're gonna want to listen to this one if you're Chris kresser. I got an email from Ben Greenfield just today or yesterday. Yeah, today asking about what different help with some CBOE people I feel like and what I feel like because this hasn't been done is because you sent me 30 pages of that, I know that you figured this out. This is like the first time ever, these puzzle pieces have been put together. And I'm so excited. So I want to say first of all, I'm honored to be your doctor. Secondly, I'm disappointed I didn't figure it out. And I have not figured it out yet. Thirdly, I'm super proud of your resilience, of your drive and of your determination to not only help yourself, but ultimately share it with other people. So I'm thrilled about this podcast, we have Angie cook on the podcast, Rn, a nutrition Master's in nutrition and just beginning her road to helping lots of people I know this and I know that you're gonna end up writing a book and I know that you're gonna be the motility expert, and that's what we're gonna talk about today. So, welcome.Angie Cook  4:42  Thank you, no pressure there.Eric Rieger  4:46  I just want to say that was the most detailed introduction we've ever done for anybodyAngie Cook  4:54  i know i kind of want to run into the other room and hide under a coverEric Rieger  4:59  in Episode 46 sakes, what are we talking about the stuff that we just did in the introduction.Ken Brown  5:04  But in all sincerity, it's that important to me. And it's that important that you help me. You teach me so that I can help other people. That's why we're doing this. Definitely.Angie Cook  5:16  Thank you. Thank you for having me.Ken Brown  5:18  Absolutely. So I'm gonna throw it back at Eric and let him kind of lead. And I'm just going to try and pop in occasionally, because I'm a huge superfan of you. So I'm going to try not to interrupt every 30 seconds.Eric Rieger  5:31  Not a problem, not a problem. So Angie, whenever we are dealing with issues of motility, not everyone necessarily understands what the problem is. So when you began to experience problems, and not really even knowing that it was a motility issue, what did you first experience? And then who did you go to to try to find out answers? And then also you take it from there,Angie Cook  5:55  right. So I'm to share a little bit about my story. My problems started about eight years ago. And so what happened was at that time, I was actually pretty healthy. I didn't have any kind of diagnoses, I didn't have any medications, I didn't see a doctor on a regular basis for any kind of ongoing reasons. And over a very short period of time, I had sort of what I described as the perfect storm of things happening, and they sort of seemed a little bit unrelated. But the first thing that happened was I started having abdominal pain. And I did have a little bit of trouble with the bowel movements. But my main issue was I just started having really severe pain. So I started by seeing my gynecologist, and I went to him and they found a very large ovarian cyst. So I had surgery right away to get that taken care of. But I still had problems, I still had pain. So then he sent me to another doctor who was a surgeon. And they thought maybe I had appendicitis. So I ended up I did have a problem with my appendix and they removed it. But after that surgery, which was just 30 days after the first so I had two surgeries within 30 days. Both my gynecologist and my surgeon said, Well, we think you're just constipated. And I was shocked. I was like, What do you mean, I'm constipated. I've never had a problem with bowel movements. I've never taken any kind of medication. It's never been anything that has been an issue. For me, it's always been a non issue. Even though I've been having a little bit of trouble, I didn't really consider it constipation. And so I found out very quickly that I did have constipation, and that the pain was relieved when I took medication. But the problem was that I needed a lot of medication. It wasn't just like a normal laxative over the counter, I needed very high doses. And it took my body a very long time to do anything once I took the medication. So they told me to go find a gastroenterologist. And that's when it came to you, Dr. Brown. And all of this happened within about six or eight weeks from where I thought I was fine to where I was severely incapacitated.Eric Rieger  8:10  So in that, at that point, when you when you end up going to obviously see Ken and you go to his clinic, I've gotten to know a little bit more about your story, just simply because not only do you experienced this issue and do a lot of research on it, you do tons of research for for both of us on various topics. So we we've exchanged quite a bit. I've seen you though, as you've moved through and and hit roadblocks and challenges. So this isn't just as if you went to Ken's office, and then Oh, you've got constipation, allama gi, this must be pretty easy to fix. In fact, you've probably encountered a much different scenario what wasAngie Cook  8:49  right. So when I first started, started seeing Dr. Brown, we did all kinds of tests. And you know, I mean, Dr. Brown, you've been amazing, because a lot of patients with motility issues when well let me back up. So what we ended up finding out was that I was diagnosed with colonic inertia. So basically that is a diagnosis that is very similar to constipation, but it's the most severe type of constipation you can imagine. So basically, what happens is your colon just becomes paralyzed and nothing moves and it causes severe pain. Severe bloating, can cause nausea and vomiting. And it can be even a really dangerous issue because if you can't move anything, you're at risk for obstructions and other complications and things like that. So early on, I knew that my problem was really severe. I started seeing Dr. Brown we went through all the usual tests, and then I got this diagnosis. What's interesting though, is that I found later on that I didn't realize it at the time, but I had some things going on with my neck. So about a year or two after I was diagnosed We realized my neck problems had progressed, I actually had several spinal cord at several discs on my spinal cord that were herniated, but I had one that was actually herniated, and it was pressed into my spinal cord. So it was causing severe myelopathy. So I really think that that probably triggered some of my problem and contributed a lot to trigger this kalinic ownership, you know, starting so.Ken Brown  10:25  So Angie, let me just stop right there when you say it caused myelopathy, which is different than when if somebody's listening, they're like, well, I had a bulging disc, I didn't have constipation. Yeah, explain briefly what you mean by that.Angie Cook  10:37  So I actually had three discs that were a problem, my see four or five disc, the five, six and the six, seven. So the way I found out about it was I had a lot of left upper extremity pain, numbness, it was just I felt like maybe I had torn my rotator cuff. But I was also having all these gi issues. And I even thought maybe I had a mess because I couldn't feel my legs very well. So what happens is normally when a disc herniated it herniates to one side or the other, and that's what causes Radiculopathy. And you can have that in your upper extremities or your lower extremities. And that's when you get that pain and the numbness and tingling and all that. But my disc at the top does the C four or five discs actually herniated back instead of to the side. So it was pressed halfway through the spinal cord. And when I ended up having surgery, The surgeon said it was very bad that anything like a simple slip or fall, that disc could have fallen or could have been pushed all the way through the cord, there would have been no forgiveness that could have been paralyzed. And he said that it had been pressed into the spinal cord for so long and so hard that when he removed the disc, and actually there was a hole on the spinal cord, it started gushing spinal fluid everywhere. So it was more than just like a simple disc that it's herniated to the side causing problems. That was the problem with the two disc below. And that's kind of what alerted me. Something's going on. I need to see a doctor. But the main problem was the desk that was pressed into the spinal cord.Eric Rieger  12:10  And so you feel like this was probably a catalyst that ended up resulting in, right.Angie Cook  12:15  I mean, once this happened, I could look back and see that there were several warning signs, I didn't have an injury or anything like that. Probably what happened is I had very severe osteophytes, which are bone spurs, and they started pushing the disk out of alignment. And I was having headaches, I was having migraines, I had started noticing that I couldn't really feel things. Like if I was shaving my legs and I cut myself I couldn't feel it. I didn't know it until I saw myself bleeding. But by the time that I realized that it was a problem, and I was having all the other symptoms it had progressed to the point I was actually having trouble walking. And I couldn't feel anything below my waist. And I was actually having the fecal incontinence at night in my sleep. So it was very severe.Eric Rieger  12:59  Man, I am so sorry that you had to go through really any of it. Just Yeah,Angie Cook  13:04  so I'm sure that that probably contributed to the colonic inertia. But really, at the time that this happened, I didn't know much about any of this. I was a nurse. I'd been a nurse for a long time, I'd never heard of it. I when I got the diagnosis, I started going on Google to try to read and I just got very frustrated and hopeless. I felt depressed because there really wasn't a lot of information out there. And every time I asked someone Why did this happen? You know, no one could really explain it. They just kind of said, Well, we know motility issues happen, we just don't always understand why. So it was it was very hard. But since then I have joined several discussion groups and support groups online and met a lot of people and when I read stories, one thing that I do see is that generally people with motility issues have one of two scenarios. They either have always had motility issues that just progressed to the point where now they're severe, or they are like me where several things happened. And it could be different things, not necessarily the same things that happened to me, but several things happened with their health. And somehow those issues are issues that we know can create intestinal inflammation or increased permeability, and that that probably caused the dysmotility.Eric Rieger  14:25  So with this, basically a physical manifestation is what we're talking about. And it's very mechanical, we have a disc herniation. And then you're saying that it's do your best estimation that ended up leading to the GI issues. And we haven't talked about it yet, but I bet you that you're probably going to talk a little bit about maybe food selections and different things like that was a was a road that you went down to see if you could correct constipation. It's a very natural thing for people to do. Do you feel like that you were able to get anywhere and maybe why you weren't and I'll let you take it from there.Angie Cook  15:00  Yeah, so the one thing about colonic inertia is that it isn't the same as constipation. A lot of times people have constipation. You can have them maybe increased their fiber in their diet or, you know, people have CBOE they'll they'll try all kinds of different diets. But colonic inertia doesn't really respond to any of that, in fact, if you try to increase your fiber is severely exacerbates the pain and the problems I mean, even to this day, I can't eat as much fiber as I would like, I have to be very careful, even if I'm making a smoothie or juicing something where it's still liquid, but it has a lot of fiber, that's going to mess me up. And that's very common. People with colonic inertia, or gastroparesis, which I also have developed, will will say the same thing.Ken Brown  15:48  So let me interrupt you right there, because of the path that we were going down when I was doing my research on SIBO, small intestinal bacterial overgrowth of bacteria grown where it shouldn't be. And that was a recurring thing between you. And I'm like, why are you not responding to anything? Yeah, this is like, I'm crushing it with my other patients, they think I'm amazing. And you're like, nothing. And that's where we kept going. And so this led to you not giving up me not giving up and then saying, Okay, what else is going on? So when we talk about colonic inertia, you're saying the word over and over, but what do you really mean by that?Angie Cook  16:31  So again, it's like a very severe form of constipation, it basically means that your colon is paralyzed, it's not moving. So what happens is, when you eat, your food goes to your stomach and your small intestine, so you can digest and absorb it, but when it gets to the colon, it stops moving. So you have this buildup of waste. And if if you can't do something to get that to move, then you're going to end up with an obstruction or something like that. And that's very common with patients like this. They get in very dire situations, I can say, one of the best things that you told me in the very beginning, the best advice I received was to always take what I needed to take to make sure that I was going every day. And I took that advice to heart. And that was sort of my, you know, my guiding principle that I used. And I learned very quickly, what was normal output. And if anything changed, then I knew I needed to change, I needed to stop eating, go on a liquid diet, increase my medications, I needed to do something right away to get that corrected. And unfortunately, I see a lot of patients that you know, and of course, this isn't to their fault, because this is a very, very hard problem to manage. But it is not uncommon for patients to go a week, two weeks, three weeks, a month, and they have not had a bowel movement.Ken Brown  17:55  We talked about this that my wife loida is she's on sabbatical now for 16 years. But it's she's a rehab doctor. And so they deal with spinal cord injuries, one of the first things that they address when somebody has a spinal cord injury, which essentially is what you're describing you had a spinal cord injury because it herniated into the desk, which is you need to stay and you need to essentially make sure that your patients have bowel movements, because the nerves are not telling you. So colonic inertia is essentially a nerve issue where you're not having the peristalsis. Angie Cook  18:33  So Exactly. In fact, I actually worked in a rehab when I was in nursing school, and I worked on the spinal cord injury floor. So I helped patients every night with their bowel program. So it's very familiar with that. And patients who do have spinal cord injuries, they have a bowel program where they will have some sort of regimen that they follow. It's usually either every night or every other night, but it's all about doing some kind of intervention to make things move so that that's a regular, you know, just a regular regimen they follow. And basically, I had to do the same thing, I had to go on a lot of different medications, very high doses. And for me, because I work during the day, I made the decision that I came home from work, I took all my medications, and then I was in and out of the bathroom all night long. And sometimes, you know, all evening as well as all night long. I did sleep a lot. And I did that for about seven years. And then unfortunately, when people have colonic inertia, it's so severe that when you fail all the medications, the only option is to remove the colon and that's what ended up happening to me is that even though I was trying very hard to manage it, I got to the point where the medications were not as effective. I was having a lot of side effects. I was having a lot of electrolyte issues with low potassium, which is pretty serious if that continues. And so about a year ago, I ended up I did have my colon removed.Ken Brown  20:01  So I just want to clarify this for anybody who is dealing with even constipation, just simple constipation, and they don't want to talk to their friends about it, they want to do anything you mentioned a couple things we've, we've packaged a lot right in there. One of those is support groups that you do online forums and things like that. But it shows that how important it is that digestion is not just the absorption of calories, it's also the elimination of waste, which is a necessary process. So when I talk to my patients, it's like look breathing out co2, you know, if you want to think that, that pooping is embarrassing, or whatever, guess what happens when you can't, you can actually die from it. And what what we were dealing with during that period was oh, my gosh, this is crazy. We're throwing everything in the kitchen sink, and your colon is not working. So if anybody's listening to it, and they're maybe blown off by their doctor and such This is it's a very real thing, which is why I was so excited to have you on and tell your story. It's really,Angie Cook  21:07  it's really hard and you feel very alone, it's not socially acceptable to talk about your bowel habits, it's always considered taboo and you know, too much information kind of thing. And so no one can really understand this unless you've actually been in that desperate situation. So you feel very isolated and alone and affects your quality of life. And every way imaginable. I know that for me, personally, my social life was greatly affected. You know, anytime that I wanted to do anything, like meet a friend for lunch, or, you know, go out to dinner, I actually would plan ahead, I would fast for, you know, two or three meals. So then I could go to a restaurant with someone and actually eat a meal, and then come home and then fast again. So I mean, the impact on your quality of life, you just you can't describe it. It's very isolating.Eric Rieger  22:00  You find yourself just basically planning life around regular life. It soundsAngie Cook  22:05  Oh, absolutely.Eric Rieger  22:06  Yeah, that sounds that sounds not ideal. So not too fast forward. But what I feel like that you've really done an excellent job at summarizing is that the traditional way for you to try to find relief for constipation, which would be increasing fiber making certain that you've had enough fluids and, and the normal things that we would tell most people, if they're having a constipation issue, you just choose better food, essentially, it obviously wasn't working for you. And so we're now going into a situation where you talked about basically it's a it's a paralyzed movement, or lack of movement of a food bolus, especially by the time it enters into the colon. So talk a little bit about that. Once you discovered that your situation wasn't going to have an easy remedy. And it really is more or less going to be affected by a mechanical structure, nerves. It really changes probably the landscape on what you Angie we're going to do for yourself to figure out, okay, the ballgame is different. I'm not just not eating fiber, I'm not just not selecting the best foods, my body essentially is not responding the right way when there is something in the colon. So what did that do for you when you kind of found out or discovered?Angie Cook  23:29  Well, definitely, when I started realizing that this was my new baseline that, you know, I wasn't going to ever go back to the way things were that at some point, I was going to have to manage this in some way for the rest of my life. And that's when I really started getting interested in gut health and doing research, I became a complete nerd started spending a lot of my free time, you know, reading journal articles and trying to learn to educate myself, I had heard that, you know, all gut, all health begins in the gut. And I wanted to understand more, what did that mean, specifically, and I knew that this was something I was going to have to manage. So I knew there wasn't a lot of great answers. And I just figured that there was it, it just figured that I needed to understand it as much as I could myself to help myself because nobody else had that much motivation. So it really kind of made me turn into this nerd. And then of course, I got interested in nutrition and that's why I went to get my masters. But it was all because I knew that this was going to be my baseline that I had to learn somehow to live with it.Eric Rieger  24:30  Okay. And then knowing that you had to find this new place to live in what what did you find that the deficits were now you know, it's not fiber lack and and and you've prepared yourself on how do I support myself and others like me with nutrition? kind of walk us through what you began to discover on like, what the issue actually was, where it wasn't, it wasn't just a lack of focus. I'm sorry. Ken Brown  24:55  Well, yeah, let me just clarify this because you mentioned something in passing. You had your colon taken out. Hello, yeah. Since we had my colectomy so I mean, that's pretty big. I would like to like read probably on the podcast now because then you were cured, right?Angie Cook  25:07  No, no. Ken Brown  25:08  Uh ohAngie Cook  25:09  yeah. So um, you know even that that was my first symptom somewhere along the way. I did start developing other problems. I don't have all the problems that you listed at the beginning of the podcast. Yeah,Eric Rieger  25:21  may have misspoken in there. But yeah, that's our shot of time together. ButKen Brown  25:24  But your because of your research, what I really want is anybody who has CBOE or pots, or Ehlers danlos, Ehlers danlos, or mast cell activation syndrome or malls. And if you're like, I don't know what any of those are. Don't worry, if you don't know, consider yourself lucky. Because if you do know, you know, you're suffering. And so we're gonna eventually get to the science of where everything you did, I believe has found this puzzle piece to get there. But I just want everyone to know that you had the surgery, but you weren't completely fixed.Angie Cook  25:59  Yeah, no, I'm not. So at some point, during the years, I did start developing symptoms of gastroparesis, which is basically the same thing that I was describing with the colon, but it's with the stomach. So your stomach becomes kind of paralyzed, where anytime you eat food, or you drink anything, it just stays in your stomach for much longer than it needs to. And it doesn't move and it causes a lot of pain, it can cause nausea, it can cause vomiting. So I developed that and actually for the last several years, the problem with that is, it's aggravated by position, so it has prevented me from eating later in the day. I usually try to eat everything I'm going to eat by the middle of the afternoon. If I eat like a dinner, then I'm taking a chance that when I go to bed at night, I may wake up no 234 hours later in pain or even vomiting. So like the last several years, I've actually kept a bowl next to the bed, because I'll wake up and I'll already be starting to vomit. So I develop gastroparesis. I also developed several symptoms of dysautonomia, which have come and gone throughout the years. It's not something I deal with every day, but I'll have flare ups where I'll have a lot of symptoms and then and a little while, kind of get better and then it'll kind of come back again. So I have dealt with quite a bit of that. And when I had my colon, I sort of just lumped it all together that Okay, my colon doesn't work. So I know I have all these other problems but it's all just kind of related. And then when I had my colon out, obviously that part got better because now I don't have a colon. I don't have to take as much medication I'm not you know, having to do the things that I did before. But I still have the gastroparesis. I still have some overall slow motility in my stomach and my small bowel and I've had issues with dysautonomia off and on this year, I've learned more about dysautonomia and really recognize that there are some symptoms I've had that I never recognized beforeKen Brown  28:03  can you define dysautonomia,Angie Cook  28:04  dysautonomia basically, your autonomic nervous system does everything in your body that you don't have to think about. So it controls like breathing heart rate, your digestion actually, gastroparesis is considered a symptom of dysautonomia. But when you have that, one of the things that can happen is I've had pots type symptoms. So the definition of pots is basically postural orthostatic tachycardia syndrome, which all that really means is that when you stand up, your heart rate goes way high. But it's really more complicated than that what happens. And what it's like for me is I can be sitting here where I'm at right now working doing my job, and I have a little Pulse ox, I'll check my my heart rate, it'll be in the 60s. And when I'm having a flare up, I can get up and I can walk to another room in my house, get a drink of water, come back. And I will have felt like I had just ran a marathon. When I checked my heart right now it's gone from 60 to like 131-140. And you just feel like you're swimming underwater, and it'll stay high for maybe 30-45 minutes. Another symptom is heat intolerance, which I've also had for several years, but at several episodes this year, where it's not just been that I'm uncomfortable when it's hot, but my temperature actually will raise it'll go higher several degrees and then I can't, my body can't cool itself off. So another problem that goes along with that is people with dysautonomia will lose the ability to sweat. So when I realized that I'm thinking back, I don't remember the last time I sweat. So that kind of goes with the heat intolerance. When you get hot, your body can't cool itself off and you know my face look at Red and my temperature will go up, but my body can't cool itself back down to normal temperature and things like dry eyes. Dry mouth, dry skin, I have all of those almost every day. And those are all because the autonomic nervous system controls all your glands and the way that it functions. And when you have decided Nami, you can have problems with that.Ken Brown  30:14  Is there any people with dysautonomia that have worse symptoms that are life threatening?Angie Cook  30:20  Oh, absolutely, you can progress, it can be very severe because you can't regulate your heart rate, or your breathing. So there are people who have it much worse than I do. The other part of Potts is that there are people who struggle with dehydration on a daily basis and require IV hydration every single day. Along with that, you can also have symptoms just taking a shower can be overwhelming to your system and take a long time to recover from. So yes, it can progress to where it's life threatening.Eric Rieger  30:53  So just by description, and a little bit more technical, the symptoms that that he is describing that you're describing Angie is just it, it allows me to think of on the autonomic nervous system, we're really talking about one side that's really becoming deficient, there would be the parasympathetic side. Yeah, the autonomic nervous system. So of course, we got fight or flight, and we have rest and digest, we really depend so much on rest and digest really, more for better function throughout the rest of the day, when that is not being I guess, in tuned, if you will, for the better part of the day, we can suffer like this, and our glands don't work. And we don't, we don't sweat when necessary. And our heart rate does raise so yeah, it. Unfortunately, it does seem like it all comes back to one side. And from all the notes that you sent over, it seems like that's what you spent a lot of time drawing the parallels and tying it back to, to one specific source, do you want to kind of go down that road?Angie Cook  32:02  Sure. So, um, like I said, I had my colon removed about a year ago, and then when that when I had that done, and then I started realizing I still had problems, that's when I started thinking, Okay, these problems are continuing, I need to start figuring them out. So I started researching different areas. And I'm going to kind of say, it's almost like an onion. So like, when you start peeling back one layer, then there's another layer, and it just kind of keeps going. But um, the first thing I started looking at was small intestine dysmotility. And I actually found several studies, where the researchers use the model of a post operative alias, to study what small intestine dysmotility is all about. So when you have surgeries, particularly an abdominal surgery, the intestines are manipulated. And if you're having intestine surgery, then of course, they're cut, and your body perceives all of that as an injury, and it creates inflammation. So what I learned was that in all these different studies, I looked at that inflammation always causes pro inflammatory cytokines to be released, which you want your body to do that whenever there's inflammation. But specifically, what I found is that, even though there was a number of different cytokines that were released, that were creating inflammation, that all of them seem to down regulate acetylcholine, which when you're talking about the parasympathetic nervous system, that of course is controlled by the vagus nerve. And you need acetylcholine for the parasympathetic nervous system to function. And so as a result of all those cytokines down regulating acetylcholine, then the person developed an alias, which is basically your small intestine is going to freeze up, it's not going to move and you have dysmotility. But then in all the studies I read, what I found is that the researchers were looking for a way to reverse that. And so they were using different medications. And all of the medications they used, reversed the alias. And even though I found like three or four different studies, and the medications were all different, the common thread was that all of the medications had a mechanism of action that actually increased acetylcholine. So that kind of was an aha moment for me because I realized there's a connection between inflammation driving these pro inflammatory cytokines, which can cause dysmotility and down regulate acetylcholine. But if you can replace this, either citicoline or you can somehow increase that, then your motility can be restored.Ken Brown  34:42  So this is where I, I feel like I may have failed you eight years ago when your inflammation started. If we describe it as a nerve thing from your neck, and you change the motility of your intestines, then it is quite possible that Let's say a bacterial overgrowth acebo creates low level inflammation. And so your cells that protect us go, That's not right, they start sending out what you're calling inflammatory cytokines, which just mean your immune system has a very complex process where it says, we need to recruit more cells, we need to do this and they start sending out these different cytokines like TNF alpha, which, that's tumor necrosis factor, which is good if you're fighting a virus or a bacteria or you're doing things, but it actually, you found some great studies on how some of these cytokines have a direct effect on acetylcholine. Can you get into that?Angie Cook  35:52  Yeah, so um, well, first, let me explain another part of this that I found that's really interesting and that adds really some important information is that when I was looking at gastroparesis, I found a couple of different studies that were describing how gastroparesis and let me back up for a moment. So gastroparesis is basically when your stomach is not functioning, and it's a nerve problem, but most doctors identify gastroparesis as being a complication of diabetes, because in diabetes, what happens is that you can have nerve damage and so a lot of people who have diabetes and have nerve damage will develop gastroparesis, and it's actually a barrier or a problem that a lot of gastroenterologist don't realize that you can have gastroparesis and not be diabetic because I'm not diabetic, but I have, I have it. So, what I found is that in people who have idiopathic gastroparesis, like mine, where, you know, I don't really know why I developed it, that and those people who also seem to also have dissident naamyaa, because gastroparesis is considered a symptom of dysautonomia. So it's really highly likely you're going to have other symptoms as well, that in those people, what they were finding is that they could trace it back to where those people had had either some type of virus, like epstein barr virus, Lyme CMV, or maybe they had gastroenteritis, and we don't really know what caused that that could be. Usually it's viral, but it could be bacteria, too, that they had some sort of illness that preceded the development of the gastroparesis and the dysautonomia, and that when they ended up treating them, they would treat them with different kinds of medications to help reverse that immune process, things like ibig. And I think one study I saw it was a very, very small study, I will admit, they used intera gam, which is a medical food but it's I GG, but when they did something that helped the immune system recover, then that actually improved gastroparesis and dysautonomia. So that was kind of another aha moment that, okay, so when you have these things develop, it could be that there's some sort of pathogen that actually started this inflammation, that the inflammation is just continuing. So it's driving the symptoms, and until you're able to control the inflammation and deal with it, then you're going to continue to have problems. But if you can deal with it, then you might resolve the symptoms. Ken Brown  38:25  This is well, this is so interesting, because we talk about all these people that certainly seek out functional functional medicine doctors, because they get so frustrated, it's the chronic Lyme person. And the reality is the chronic Lyme person has the fatigue, they've got the gut issues, and they get told, you know, no, you don't have the Lyme titers, you're not there. But what we're saying is that a virus can start the inflammatory cascade and doesn't quite get turned off. And now we've got an inflammatory cascade and an acetylcholine imbalance that came with this, Angie Cook  38:57  right. And actually, so the next part was I started looking a little bit more specifically into the macrophage. So there's a lot of research right now about how the macrophage can drive a lot of intestinal inflammation and other problems in the intestine. So what I learned is that the macrophage actually comes from a type of white blood cell called the monocyte. And what happens is that when that monocyte enters the tissue or the Oregon and there's some kind of pathogen, it then becomes the macrophage. And it's a cell that its job is to try to help you attack or defend yourself against some sort of pathogen or inflammation or whatever might be going on. So what I found out is that one of the main cytokines that the macrophage releases is that TNF alpha, which can cause inflammation anywhere in the body, but specifically an intestine. It's a really big problem. So Dr. Brown, I know you treat a lot of patients with IBD and That's sort of like the model of the most extreme severe type of inflammation you can find in the intestine. And one of the types of medications they use for patients like that are TNF alpha inhibitors. So they're specifically targeting TNF alpha to try to lower that cytokine, because that's what's driving the inflammation. So then when I started reading about this, I also read some articles that were telling me that TNF alpha specifically can cause to sudden naamyaa. So I thought that was really interesting. And then when I started getting further into it, what I found was that TNF alpha and acetylcholine have sort of this really interesting relationship where they oppose each other. So TNF alpha will lower acetylcholine, but then acetylcholine also lowers TNF alpha. So I was a little confused, because it's sort of like what came first the chicken or the egg? And if one is opposing the other, then why do we have a problem. But what I was learning is that when you have too much TNF alpha, then it actually down regulates to see the coaling enough to where you don't really have acetylcholine, and then that, in turn, allows the TNF alpha to to remain and persist and continue to cause all these issues. And the really interesting part of this, it's kind of getting a little bit more into the geeky science, is that when I started studying how this works with the vagus nerve, so we talked about the vagus nerve, and one of the most important functions is that it helps regulate the autonomic nervous system.Eric Rieger  41:31  I just want to say something really quick. Because we've mentioned the vagus nerve. But I think, just to clarify that Vegus nerve is the biggest nerve it's going to be releasing as you're pulling, correct. Okay, I just wanted to clarify.Angie Cook  41:45  Well, it's the biggest, longest nerve in the body. And it is it does need to citicoline. Correct.Ken Brown  41:52  Okay. So just just to clarify that vagus nerve 10th, cranial nerve comes out, and actually innervates it's the grand highway. So innervates all the organs when your vagal nerve doesn't have its nutrients. So it responds to acetylcholine. Am I correct? In that words, need to see to Coleen to conduct itself. So,Angie Cook  42:13  right, right. So it's the the nerve that connects that whole gut brain pathway, no.Ken Brown  42:25  Brain all day long.Angie Cook  42:28  So what's interesting about the Okay, so what's interesting about the vagus nerve is that not only does it help to regulate the autonomic nervous system, but it also has a huge anti inflammatory component. So there's something called the colon nergic, anti inflammatory pathway. So started, yeah, so I started reading studies about this. And basically, what the research is explaining is that in the model of sepsis, which is when your whole body is fighting an inflammation and infection, that typically the spleen is the one where the macrophages in the spleen are releasing all these cytokines. And that if you were able to stimulate the vagus nerve, that, that acetylcholine will help lower that inflammation. So like they've done some studies with sepsis, where they've tried to treat it with Vegus nerve stimulation, and it's helped to control the inflammation, reverse the sepsis and, and, and help the patient get better. In fact, there's actually studies right now on COVID that they're doing that is along the same lines. So then we also I found out that it's not just the spleen and the vagus nerve that have this colon ergic anti inflammatory pathway, but you can have it between the intestines and the vagus nerve as well. So this part is where it gets a little geeky, I'm gonna try to explain it, I'm gonna do my best. But basically, the macrophage releases the TNF alpha, which, of course is going to can be communicated to the vagus nerve through that gut brain connection.Ken Brown  44:08  Let me just clarify one thing, the macrophage the way that it works, is it is it phagocytosis. In other words, it's it eats and goes, Oh, my gosh, we have an invader. And so it just goes help help help. And it sends out this signal, which is TNF alpha. Right? Oh, my gosh, oh, my gosh, help, help help. I'm holding this guy. We've got a burglar, we need help. And that's the start of it. Okay.Angie Cook  44:34  Right. So this is where it gets a little geeky. And I'm going to admit, I'm not a Vegas nerve expert. But there's something called the preganglionic pathway. And that's basically when you have that signal coming from the gut to the vagus nerve, and that's when you can have that TNF alpha being communicated to the vagus nerve. But then you have the vagus nerve that is going to try to send a signal to say, Hey, we want to release acetylcholine and as you It turns out the macrophage specifically has a receptor and it has a really long name. It's the alpha seven nicotinic ganglionic receptor or acetylcholine receptor, something like that. It's very long name. But basically what it is, is that it has a receptor that specifically is sensitive to see the cooling. So if I see the calling is released, and if it is, so that postganglionic nerve is going to be really close to the Oregon and really close to the macrophage, if it's going to release acetylcholine and it lands on that receptor, then it's going to tell that macrophage, Okay, stop with the TNF alpha. Everything's okay, lower the inflammation be okay now.Ken Brown  45:40  So a negative feedback loop where the vagus nerve tells the macrophage chill out, we got this handled is basically what it's saying, right through this anti inflammatory acetylcholine receptor likes inhibitor thing or whatever, right?Angie Cook  45:59  So what's really interesting, though, that is, if you don't, if you have too much TNF alpha, then you don't have enough acetylcholine to oppose that. So then you can continue having all this inflammationKen Brown  46:13  for chronic inflammation begets more inflammation, yeah.Angie Cook  46:16  Right. So if you have too much TNF alpha, then then all of a sudden, there's not enough acetylcholine to fight that. And then that's where the inflammation can persist.Eric Rieger  46:29  So then, you're good.Angie Cook  46:31  So then the goal is that you want to somehow help the vagus nerve or help help support acetylcholine in order to where it will help decrease that inflammation, and then it restores that parasympathetic function. So like, for example, this was a big aha moment for me. So TNF alpha is a direct inhibitor of intestinal motility. So, if you have too much TNF alpha, you're basically lowering acetylcholine. But if you take pro kinetics, which most pro kinetics, the mechanism of action is going to do something to increase acetylcholine, then that helps restore the motility. So that was kind of an aha moment for me because if you think about CBOE experts, they're always preaching will even after you clear the CBOE, you need to stay on a pro kinetic. And now to me that I understand why that makes sense.Ken Brown  47:27  How does that affect the migrating motor complex?Angie Cook  47:31  Okay, that's something completely differentKen Brown  47:37  talk to us about the meaning of life and what you get usAngie Cook  47:45  all about motilin and all of that, but there is something called Tributyrin. That will help that. And as a matter of fact, before I forget, I want to give a shout out to a friend of mine in a discussion group. Her name is Rachel. And she and I have been going back and forth on a lot of this issue. So she's been helping me and find ideas of what to research. Well, thankEric Rieger  48:05  you, Rachel.Ken Brown  48:06  Yeah, right on Rachel.Eric Rieger  48:07  That's actually really awesome. Well, that is I mean, it. I'm just impressed that honestly, that you've pieced together so much about the dependence that we have specifically on this Vegas nerve. The acetylcholine that essentially there are lots of yin and yang opportunities. Biologically, we talked recently about oxytocin and vasopressin. I mean, there's lots of different opportunities there where biologically, we have things that go back and forth. SoKen Brown  48:41  yeah, this is what's interesting. Clearly the body has its checks and balances everywhere. And the common theme that I'm hearing is that when you have too much chronic inflammation, acute inflammation, we've got these things built up to protect us from acute invader. What happens is when we end up in this chronic inflammatory state, then things get out of whack. And what you're describing is this Eliot model from Well, in my world from CBOE to dysautonomia through acetylcholine in the vagus nerve, am I right overgeneralizing that?Angie Cook  49:18  No. And so there's one other part that I'll just throw in there, if you'll be okay with that,Eric Rieger  49:23  go for it like that.Angie Cook  49:24  So,Ken Brown  49:26  I mean, you're joined as a vampire, I love it.Angie Cook  49:31  Okay, so another thing that I learned this year that I had never heard of, um, well, let me back up. So I had heard I had heard a few years ago, that there are some doctors that are now recognizing that when you have dysmotility, that this is an autoimmune issue. Like you can have autoimmune gi dysmotility. And personally, I never really thought about it or wanted genders and not that I didn't want to understand it, but didn't try to understand it, because I didn't really see that that was going to apply to me I kind of figured I knew why develop dysmotility. But I learned about a condition this year and it's called autoimmune. autonomic ganglia. Obviously, I'm going to have to refer to my notes. But it's that's a really big word. And it's a big mouthful. And it actually you can just abbreviate it by ag. But it's an autoimmune condition. And what was really interesting to me is that it can actually be, it can actually happen after an event it can happen after a virus after an illness after surgery. It's not something that you necessarily have to have your whole life it actually can develop it can be acquired, and typically there so I'm going to just read you the list of symptoms. The symptoms include dysautonomia, as well as extra autonomic or outside of the autonomic nervous system manifestations. It can include diffuse gi dysmotility, which includes both gastroparesis and colonic inertia, orthostatic, hypotension, pots, dry mouth, dry eyes, dry skin, urinary retention, or some type of difficulty voiding, difficulty regulating your temperature. And you can also have CNS symptoms, which are those of like the brain symptoms like things like anxiety, depression, cognitive difficulties, which we call brain fog, sometimes. And it's also usually can co exist with other autoimmune conditions, including fibromyalgia, and hashimotos, which is a thyroid. So I thought that was really interesting, because I hit on a lot of those. And so they're actually antibodies that you can test for, it's a blood test, and it's was initially developed by the Mayo Clinic, but you can now get it through other labs, and they will test for the antibodies. But the interesting part is that only about 50% of the people who they consider to have this will actually test positive for the antibodies. So when they when you have this condition, the way they treat it, is things like ibig, steroids, there are some immunosuppressants they do plasma exchange, it's kind of some pretty heavy duty stuff. But it's all to target the immune system. And the reason the antibodies matter is because even if you don't test positive, if you're considered sero, negative and you don't have the antibodies, you can still they show that you can still have improvement if you do the same treatment.Eric Rieger  52:31  So just because it's done to take doesn't mean they may not have that problem.Angie Cook  52:34  Correct. So what's really interesting, and this is something that my friend Rachel had taught me about is that her theory is that maybe because she's, she's aware that there have been cases where people will test positive for the antibodies, and then later they'll test negative. And so it's very inconsistent. And so her theory is maybe the antibodies are detected only when you're at your worst, or when you're having some sort of like, major flare up. I don't know, we're just speculating, we're just wondering,Ken Brown  53:07  that's a super interesting theory. But yeah, let's liken that to celiac gliadin, my seal TTG antibodies, when you're eating a lot, your antibodies go out, when you back off, your antibodies go way down. So if you're having a lot of ganglionic acetylcholine receptor antibodies, which are detected in the blood, for whatever reason, due to inflammation due to the trigger, I mean, what were this onion that I think you're starting to peel back, Angie, and you're doing an amazing job explaining this is, this is so high level, that as we're peeling this back, we may end up getting to record where there could be a trigger that we could avoid. So that this doesn't have that,Angie Cook  53:50  thank you for mentioning that because I forgot to mention that the antibody that they're testing for is an antibody to the acetylcholine receptor, the ganglionic acetylcholine receptor comingKen Brown  53:59  back to your original thought that it all comes down to a super colon effect in the vagus nerve, the inner balance between TNF alpha and acetylcholine, and now we're talking about people developing antibodies to prevent the acetylcholine that's floating around to even attaching to that receptor.Angie Cook  54:17  Right. And it actually made sense to me, because when you go back, so when I was reading about aiag, so you know, basically, you've got somebody with gi dysmotility, and obviously saw the dysautonamia and and all the other things that we know sometimes go along with it, and they're treating it by things like ibig, or plasma or, you know, some sort of immunosuppressants. It kind of went along and was consistent with the studies I found on gastroparesis, where they're saying that this is triggered after a viral or possibly bacterial illness, and that it triggers the gastroparesis and the dysautonomia, but the way they treated that was also with IBIG, and things like interrogate anything that was going to help reverse that immune response. So like, if you're getting to where you're actually thinking, Okay, this sounds like something I could have, then to me, there's two ways to think about it. You can actually support this either coaling by doing some things like pro kinetics, and there's certain supplements, but thought,Ken Brown  55:17  after the restroom really quick, we're going to talk about treatment, you guys are gonna recap that aspect and make it palatable. And I'll just be,Eric Rieger  55:24  we're gonna recap this aspect to make it palatable. So,Angie Cook  55:29  okay,Eric Rieger  55:30  how do we what kind of salt and sugar do we put on this thing to make this more palatable that he he leaves and laughs at me as he or no,Angie Cook  55:39  right?Eric Rieger  55:44  No, no joke, though. Angie is, as Kim was pointing out this amount of research and really pacing and building, he says, peeling the onion back, but we had to put this onion together. I mean, there's linking all these things together, as is I find very, very interesting. And actually quite, I don't know, built on common sense the Vegas nerve is, is I think Vagus is vag us and is Latin for wandering, is not such a big as it basically means it's everywhere. Our parasympathetic nervous system is essentially run by that 10th cranial nerve to basically keep everything in check for us. So you piecing this together, and finding all of the common pathways back to how it relates to your situation. And yeah, it is a gut paralysis issue. But it seems like that we've simply just lost the the autonomic function of one very delicate, yet incredibly important nerve, which services, everything throughout the body. And you've been able to not show us that. Yeah, these are symptoms of something that's failed. But this is what's happening. And this is how we can actually overcome it. Because no one's ever talked about, how do we build back kind of this wall that's fallen down lots of times, I think people just are just kind of shoved to the side because you don't always have somebody in your corner to help out and work through that problem with you there.Angie Cook  57:20  Right? Exactly.Eric Rieger  57:22  So,Ken Brown  57:23  so palatable, was the wrong word. Did you guys choose salt? Lawrys? would you do it?Eric Rieger  57:27  It tasted great. While you're gone? The conversation?Ken Brown  57:30  I can't talk about parasympathetic this long without my bladder going on parasympathetic. Okay, so the really cool part is you put a lot of thought into potentially helping this process, what are your thoughts on this and you're not being held to it because this is all in, there's not enough research out there, which is probably something that we got to figure out as a team, what to do. So what are some different things that you have found to try and help increase the acetylcholine?Angie Cook  58:02  So I think first of all, pro kinetics, and I know there's a lot of functional practitioners that want to hear about what kinds of things to try but all of the prescription pro kinetics actually work by increasing acetylcholine with the exception, I think of a rethrow myosin, which is the MMC. But I think that's important because that'll help promote the motility and now that I understand kind of why acetylcholine is important for motility, and then how it can be impacted by things like inflammation, then that makes me understand even more that those pro kinetics are important. I actually also found a supplement this year called huperzine. So I've been taking that and that's an a colon esterase inhibitor. So it basically prevents the enzyme that's going to break down acetylcholine, which also helps the port having those levels something like vitamin B five, I think that supports I think some of there's some other ones be one also might I think they're in the pathway of synthesis seratonin I actually read or actually five HTP rather,Eric Rieger  59:15  which that's the building block to build serotonin right? is five ht I'm sorry, that's the building block that our bodies use or can use to to build more serotonin correct. I kind of like a precursor, right.Angie Cook  59:28  So I'm losing my notes, but I do remember so serotonin, our five HTP helps to build serotonin. And then so your five ht four receptors, we haven't talked about that, but five ht four receptors are in the gut, and that's the target for the pro kinetics. But five HTP will also target the those receptors and those receptors once they're activated. That helps promote us. See the colon as well. So it's a long winded way to say that five HTP can help. Um, but the other thing that's really interesting is that's all to try to help promote acetylcholine. But maybe there needs to be some more work on getting that inflammation down to begin with. So maybe, you know, I don't know something like entera gam, or there's some over the counter versions that I think are similar, SPI and things like that. Maybe we talkKen Brown  1:00:32  a little bit greater on that. So there's what you're talking about is taking in colostrum, IGA, G, things like that, that we might experience using some of those things in gut health has not been very successful in the sense that I think it's you need to hit it from a multi angle approach and decrease in the inflammatory aspect. Your situation is a little bit different in that you, I think you had a neurologic event which led to this whole cascade, but we have so many people that eat a very pro inflammatory diet. And if you're listening to this and you're waiting in line in a fast food restaurant and a drive thru or something, please understand that when you have that high fructose corn syrup, or you have those poly unsaturated fatty acids, like corn oil and soybean oil, right, that is a pro inflammatory thing that could potentially lead to some intestinal inflammation, which then leads to a macrophage getting turned on, which then leads to TNF alpha being spread around which then leads to acetylcholine dropping and Oh wow, Angie just figured out how intestinal inflammation can lead to pots dysautonomia, which is something I treat so many patients with this, and I share patients with a well known doctor here in town, Dr. Suman who treats pots we share these patients. I'm like, why am I sharing patience? With this cardiologist? I think you just figured it out. I think you did an incredible job of walking from A to k. And I think we can go from cadence. Yeah.Angie Cook  1:02:10  But it has been very eye opening.Ken Brown  1:02:13  It's incredibleEric Rieger  1:02:15  what a bit it just simply makes sense. We've been talking and he you've helped us with with the research on some of the other shows we've pieced together, but high fructose corn syrup, soybean oil, Saffron, safflower, safflower oil, all of those different ingredients. Unfortunately, they get subsidized, which means that they are in everything we see, we've seen these numbers of people who have dealt with just various gi issues. And unfortunately for Angie, hers is definitely one of the more extreme circumstances but it just comes down to where is all of this new information coming from Why is the American Western diets such a culprit. And it's not just because people just want to eat these substances inherently, could just be bad and perpetuating this inflammation that you're trying to run from. And if you can't recognize, just like you said, Angie, we need to find out what's causing the inflammation, because we can keep trying to patch it up. But if the flood keeps coming in, it's going toAngie Cook  1:03:19  be looking at TNF alpha one thing. I'm not an expert, but I know that there's a lot of research about toxins in our environment, and how they can impact you. So like just something simple, like BPA, I found an article that says that can increase TNF alpha. Yeah, so you know, I mean, I'm guilty of it. I drink water bottles all day long. But you know, maybe that's something I should rethink, I don't know.Ken Brown  1:03:43  Well, this is gonna be a moving target. And there's a couple things I want to make sure that we get out there. First of all, thank you so much for coming on the show and talking about this. I believe that this is just a high level introduction to a lot of things that I'm trying to wrap my brain around and I can only imagine that it's it's a lot of information for people to try and grasp what's going on. But for those people who are struggling, this is a huge, huge opportunity to at least start heading down a different path. Which means and that path I'm talking about is many of my own colleagues gastroenterologist. I get second opinions all the time where they go to a doctor and they say, I don't believe in CBOE, here's an antidepressant. Now, we're going to go one step further. We're going to go I believe that if we don't fix your CBOE, your intestinal inflammation, your diet, then you can end up in this situation and right now, I've got so many people with pots and malls and you know, and we didn't even touch on the Ehlers danlos epi genetic phenomenon, all that that is next podcast, so you have a week. To learn.Angie Cook  1:04:57  Add I will just quickly add a no master list. Something that is also really common with all of these symptoms. So I didn't really have an opportunity to I haven't gone deep into that. But it was interesting to me what I did learn is that so typically when you think of mast cell, you think the mast cells releasing histamine. mast cells actually also released a high amount of TNF alpha. And then the macrophage, you know, we're talking about how it releases TNF alpha, it actually also releases a high amount of histamine, histamine. So it kind of is like adding fuel to the fire. I mean, it's all it's not just one cell and once one inflammatory cytokine. It's kind of like that whole generalized and immune response.Ken Brown  1:05:40  So I want to encourage anybody who's listening to this, that even if it didn't quite fall into your wheelhouse about what you have, but if you have know anybody who has bloating or digestive issues, or autoimmune issues, or anything related to pots, dysautonomia, or CBOE, share it with them, because this is a community that Angie, you're involved in multiple support groups, and you're crushing it right now. And I feel like your life struggles are going to make a difference in hundreds of thousands of lives. And I appreciate you not giving up I appreciate you saying, I'm going to learn more about this, even though I got a bucket next to me for the last seven years that I vomit in, when I don't time things right. Because these nerves don't work. I think that's number one very brave of you really cool. And then you've become you kept saying, I'm not an expert, you sound like a dang expert to me,Eric Rieger  1:06:41  I would definitely defer to you. I can't thank you enough. Thank you for coming on. It's just so much information. But it's it's all so relative can be used immediately by by many and something else that crossed my mind. Whenever you were talking about what do you do to avoid inflammation we, for decades ago, we talked about the dangers of smoking, right? We talked about you shouldn't smoke, you should inhale because it's going to cause these elasticity issues with lungs and people could you know, one to one, everyone can admit that smoking is bad. Well, not understanding the dangers of the things that are coming into our food and causing the tops of long term inflammation. That's that's the new problems of like smoking, because now what he is doing is showing us that you have to get the triggers that are causing your chronic inflammation under control. Or just like you said, Can someone who has IBS or CBOE if you don't address it, and we don't find out what it is while we're trying to get your acetylcholine back into balance. And you continue to have these these inflammatory episodes, you may find yourself with a much much more severe situation.Ken Brown  1:07:56  Yeah, I guess that's the thing I want everybody to take away here is that just because a doctor pat's, you on the head and says, you'll be fine,

Jeanny Aragon-Ching, MD, FACP, a medical oncologist and clinical program director of genitourinary (GU) cancers at the Inova Schar Cancer Institute, shares her concerns over the decline in the screening, diagnosis, and treatment of prostate and other GU cancers amid the COVID-19 pandemic, and highlights promising clinical trials underway to advance the fields of prostate, bladder, and kidney cancers. Transcript ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. Joining me today is Dr. Jeanny Aragon-Ching, a medical oncologist who serves as the clinical program director of Genitourinary Cancers at the Inova Schar Cancer Institute in Virginia. She joins me to discuss the worrying decline in screenings for prostate cancer due to the COVID-19 pandemic. Dr. Aragon-Ching also highlights clinical trials underway to advance the treatment of prostate, bladder, and kidney cancers. Dr. Aragon-Ching reports no conflicts of interest relating to the issues discussed in this podcast. And full disclosure relating to old episodes of the Daily News podcast are available on our transcripts at ASCO.org/podcasts. Dr. Aragon-Ching, it's great to have you on the podcast today. Dr. Jeanny Aragon-Ching: Thank you so much, Geraldine, for having me here. ASCO Daily News: Well, screening for prostate cancer is vitally important. What are your concerns about the long-term impact of delayed screenings, diagnosis, and treatment in this setting? Dr. Jeanny Aragon-Ching: Yes. So generally there have been already reports actually of observed decline in the common screening and diagnostic procedures and practices reflecting the impact of the COVID-19 pandemic on cancer prevention and early detection, signaling possible downstream effects on the timing and staging of future cancer diagnosis. Now, the issue is there has been no major guidelines or guidance regarding recommendations for screening during the pandemic. Now, one closely aligned guidance, if you will, from the NCCN, actually it's more for management, it suggests that patients with known low risk or certainly very low-risk prostate cancer may actually defer staging active surveillance or even testing for treatment until conditions are deemed safe. Therefore, determination of who really needs to be absolutely screened and certainly diagnosed, I think, is key. So especially since the subject of screening in prostate cancer has always actually been controversial even while the U.S. Preventive Services Task Force set forth the D recommendation, which is recommendation against PSA screening except for those target ages, let's say, between 55 and 69 years of age, they had a C recommendation, which involves individualized decision-making. And that means for us, we always have to have that dialogue with the patients in order to weigh the pros and cons of screening, especially during these times. So therefore, I mean, there's really no current standards that are set forth. A lot of it I think would be tailored to each individualized person and patient as well as physicians in practice during these times of pandemic. ASCO Daily News: Right. Well, COVID-19 will continue to be a threat for some time. So, how is the oncology care community to fill the gap in diagnostic services? Should cancer screenings, biopsies, and surgeries press on? If you see a patient that really needs treatment now, you, I assume, will proceed, correct? Dr. Jeanny Aragon-Ching: Correct. Yeah. Now, I do think the gaps in diagnostic services is really actually being remedied by performing other alternative services, if you will. So, for instance, remote telehealth services have gotten and gained ground since the COVID-19pandemic. And my general recommendation is, and the thinking really is minimal harm is really expected with delays in care certainly for certain types of risk of prostate cancer, or even bladder cancer or kidney cancers. If one were to delay the treatment for, let's say, 3 months, especially when we weigh the risk of mortality or morbidity from being exposed to COVID-19, I think those are the critical issues. Now, I would say that diagnosis and treatment for patients with GU cancers really require prioritization, adjustments for, let's say, screening biopsies, as well as individualized tailored approach to the diagnosis and treatment. The oncologic community, the GU community as a whole I think quickly filled that gap, as I mentioned earlier, by restricting non-urgent, in-person clinic visits, as well as adopting more remote telehealth visits to continue care that the physicians provide. So in terms of prioritization of the goals, patients, let's say, who need to undergo immediate diagnostic procedures and biopsies to make a diagnosis would be a priority. So especially for those who are deemed to have high-risk disease, for those who are likely to have high-grade disease, let's say, muscle-invasive bladder cancer, or let's say, big tumors that are seen on abdominal imaging for a renal cell cancer because we don't typically biopsy, let's say, renal masses to diagnose renal cell carcinoma. And as a general rule of thumb, procedures and treatments that are curative in intent would be considered high priority, whereas benefits of care from treatments certainly has to be weighed against a potential risk for infections and morbidity from COVID-19. Identifying the risks are important as well. So, for instance, treatment may be safely deferred for patients with low risk or certainly even intermediate-risk patients, whereas surgery may be delayed in most high-risk patients or alternative treatments, let's say, a neoadjuvant hormone therapy, coupled with external beam radiation, may be a treatment of choice with regard to the pandemic, and then may be a feasible alternative. So there's a lot of changes that are being set forth. Now with regard to radiation, there's also some concern, for instance, for lymphopenia, for those who undergo radiation. So actually identifying the patients who really would benefit from upfront treatment is key. So for patients with bladder cancer, let's say, who have muscle-invasive bladder cancer, they undergo surgery. We call it TURBT. And they undergo intravesical treatment. So a lot of it highly depends on the goal of the therapy. Is it curative in intent? Certainly if they undergo neoadjuvant chemotherapy, that adds to the layer of complexity for these patients because they are now being exposed to chemotherapy. But on the other hand, it is an important treatment with the goal of curative intent. And there's also something to be said about the varying institutional procedures. For instance, each institution has in place their own safeguards to screen, let's say, or treat patients with COVID-19. So in our institution, for instance, doing rapid COVID-19 tests to assess prior to performing these procedures, anesthesia or procedures that are high-risk for aerosolizing like respiratory secretions, would be of paramount importance. So I think there's a lot of institutional guidance also that comes into play in this day and age of COVID-19 in the treatment of our patients who have a diagnosis of GU cancers. ASCO Daily News: Absolutely. What can you tell us about new developments in diagnostics in the prostate cancer space which have truly advanced the field, resulting in fewer unnecessary biopsies and hopefully making men a little less reluctant to actually take care of their prostate health? Dr. Jeanny Aragon-Ching: Yes, that's a great question. And emerging data suggests that targeting using a combined MRI and an ultrasound fusion approach may perhaps increase the detection of significant high-risk prostate cancer, which, after all, is really the clinically significant and meaningful cancers that we need to treat, and therefore lead to perhaps lower detection of the lower risk prostate cancer that may not need to be treated. Now, it's important to recognize also that a negative MRI does not necessarily exclude the possibility of cancer. And therefore, biomarkers have been in place to be also helpful to perhaps avoid a biopsy in someone, let's say, who has a negative result. Now, there are numerous tests or biomarkers out there available. I always have said that a lot of times it is dealer's choice. It's highly dependent on what physicians are comfortable using, [and] what the availability is within their own institutions. And what the payers or insurance would pay for or cover. But there are several promising ones out there that help further predict if a patient has a high-risk of having a diagnosis of clinically significant prostate cancer. So, for instance, there was a urine base marker, it's called IntelliScore, so it looks at three different genes that would be able to discriminate a higher grade group of cancer versus a lower grade group. And that would help physicians and providers to help further define who needs to be biopsied, especially in this day and age, again, of COVID-19, so that they would be able to predict the likelihood of higher risk prostate cancer that ultimately needs to be treated. And that's not the only one out there that's currently available. There's other things like blood work or blood tests, like 4Kscore, which combines different parameters like free PSA, total PSA, intact PSA, that will help further predict high-grade prostate cancer. And the bottom line is all of these tests would help the physicians, the urologist hopefully to decide who they need to biopsy and prioritize versus those who can safely wait based on just an elevated PSA alone. ASCO Daily News: Well, African American men are at a significantly greater risk of getting prostate cancer. Can you talk about the health disparities that exist in this setting? And do you think the field is doing enough to address this? Dr. Jeanny Aragon-Ching: Mm-hmm. Yeah, so prostate cancer disparities actually constitutes one of the most complex issues in cancer today. So it is known that African American men unfortunately do have disproportionately higher incidence of prostate cancer, easily about 60% to 70% higher compared to Caucasian men counterparts. And they also have a higher 2-fold increased risk of prostate cancer death. So these are very relevant in the practice of prostate cancer in the field. African American men are also more likely to be diagnosed at a younger age. They tend to have more advanced and aggressive disease. And African genetic ancestry is really unfortunately not a modifiable risk factor, so when we talk about genetics...so there are potential reasons why this is so, why African American men may have a higher incidence or mortality. One potential explanation could be genetics. So it has been found that several genetic variants may be a little bit more common in African-American men. So, for instance, like 8q24 mutation in a tumor suppressor gene, there's differences in microRNA regulation, and they tend to, unfortunately, present with more aggressive tumors. And certain gene mutations also can lead to poor outcomes, let's say, P53 mutations, CDK M18, which is more commonly seen in African American men. Now, I would say that there are also possible issues with screening. So you may all recall that when US Preventive Services Task Force, which is felt to be the most influential in making recommendations for a PSA screening, gave a D recommendation in their most recent iteration of PSA screening, and that is that PSA screening is not recommended for the average person, especially for the older individuals, there was no real recommendation for men of African descent, or African American men. And they are really the ones who are underrepresented in these studies. So in one study, for instance, that looked at rigorous modeling, when they look at these trials, they suggested that PSA screening can actually yield greater mortality benefits for high-risk groups. And that includes men of African American descent. So one other big issue with this is probably access or utilization of health care, which would be a key factor in racial or ethnic disparities. And we know that standard prostate biopsies are still really the gold standard for diagnosis. And whenever we talk about better tools for making diagnosis, and we mentioned earlier about MRIs, for instance, MRIs may be less utilized in patients with lower, let's say, socioeconomic status. So there are a lot of reasons why we are seeing these disparities in men with African American descent. ASCO Daily News: So speaking of research, I'd love to ask you about your current research. You treat patients with bladder, kidney, prostate, and testicular cancers. Is there anything you'd like to highlight today? Dr. Jeanny Aragon-Ching: Yes. So, for instance, we are looking carefully at prostate cancer. And we are very much in tuned with the fact that a lot of men with prostate cancer have genetic variants and genetic and hereditary mutations. So we are looking carefully at the differences between men who present with de novo metastatic disease, and that means at the very first presentation to the medical or health professionals, they already have metastatic disease, versus those who were treated with curative intent treatment and then later on down the line present, unfortunately, with metastatic disease because they were not cured. We would like to further define what the differences is between these two population of patients because the former seems to, unfortunately, do worse. So those are the things that we are highlighting. In bladder cancer, we are very closely following what the outcomes would be for patients who have muscle-invasive bladder cancer. For the longest time, we've known that neoadjuvant chemotherapy followed by cystectomy is one of the gold standards of care for treatment of these patients. So the additional role of immunotherapy in addition to neoadjuvant chemotherapy, that is a key improvement perhaps in the field, especially now that we know that avelumab maintenance has been shown to improve survival for a lot of metastatic bladder cancer patients. And for kidney cancer, one of the key things that we would like to further highlight and improve upon the care is for patients who have high-risk, high-stage kidney cancers. So the standard of care remains to be surgery, but we know that a proportion of them would unfortunately recur with metastatic disease or have disease that comes back later on. So the idea is, can we improve upon these odds by giving them adjuvant therapy? So we have an adjuvant immunotherapy trial that seeks to answer this question of improvement in the [INAUDIBLE], in the metastases or recurrence for these patients who have or are deemed to have high risk disease (NCT03138512). ASCO Daily News: And what is the name of that trial? Dr. Jeanny Aragon-Ching: So this is actually CheckMate 914. This is the neoadjuvant immunotherapy nivolumab and ipilimumab versus a placebo. It's a placebo-controlled trial. ASCO Daily News: Excellent. So Dr. Aragon-Ching, is there anything else on your mind that you'd like to address today before we wrap up the podcast? Dr. Jeanny Aragon-Ching: Yeah. I really just think that the changes in practice brought on by the COVID-19 pandemic has us rethinking and reorganizing as an oncologic community the practice that we do. I believe that some are likely here to stay. So, for instance, the changes in the landscape and practices of treatment, we are really thinking about how long the duration of treatment are we providing. Even clinical trials, since the start of the pandemic, of course, the key issue here is some trials have closed their doors on enrollment. And I think we're starting to pick up on those. Some have limited its enrollment. And I think once we get institutional practices streamlined, and people are in general a little bit more comfortable about exposures because they see that everything is safe, I think we'll be getting back to our routine. But I don't think things are going to go back to the way they were. I think telehealth visits, for instance, are here to stay. We're creating a lot of guidance and guidelines on who are the patients who are best fit for these telehealth monitoring visits, or who are the patients who still need to come in person in order to get their care? ASCO Daily News: Absolutely. Well, Dr. Aragon-Ching, thank you so much for sharing your valuable insight with us today on the ASCO Daily News Podcast. Dr. Jeanny Aragon-Ching: Yeah. Thank you so much, too, Geraldine for having me and for sharing the insights with you all. ASCO Daily News: And thank you to our listeners for joining us today. If you're enjoying the content on the podcast, please take a moment to rate and review us wherever you get your podcasts.   Disclosures: Dr. Jeanny Aragon-Ching Paid Honoraria: Bristol-Myers Squibb, EMD Serono, and Astellas Scientific and Medical Affairs Inc. Consulting or Advisory Role: Algeta/Bayer, Dendreon, AstraZeneca, Janssen Biotech, Sanofi, EMD Serono, AstraZeneca/MedImmune, Bayer, Merck, Seattle Genetics, and Pfizer Speakers’ Bureau: Astellas Pharma, Janssen-Ortho, Bristol-Myers Squibb, and Astellas/Seattle Genetics Travel Paid or Reimbursed: Dendreon, Algeta/Bayer, Bristol Myers Squibb, and EMD Serono Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

It is no exaggeration to say that Jennifer Temel, MD, has helped change how cancer care is practiced. Through her research, she has shown that integrating palliative care and oncology care from the time of cancer diagnosis improves patient outcomes. This early integrated care model is now the standard of care in the United States and many other countries. Now, however, because it’s the standard of care, demand for early palliative care is so great that the palliative care workforce is unable to meet every patient’s needs. So Dr. Temel is now working to use novel healthcare technologies—such as telehealth and mobile apps—to deliver patient-centered palliative care to cancer patients and their families everywhere. Jennifer Temel, MD, is an American Cancer Society Clinical Research Professor. She is Professor of Medicine at Harvard Medical School and Director of the Cancer Outcomes Research Program at the Massachusetts General Hospital Cancer Center. 2:17 – On what motivated her to become an oncologist 3:20 – What is palliative care? How can palliative care differ from the care provided by an oncology clinician? 4:48 – On the importance of early palliative care for patients with serious cancers 7:06 – On her seminal research findings showing that integrating palliative care with oncology care leads to better outcomes 8:32 – How cancer caregivers are impacted by palliative care 10:21 – On how palliative care is typically offered, drawbacks to the current delivery system, and communicating well with patients and their families 16:30 – On being named an ACS Clinical Research Professor 17:40 – On the goals of her ACS-funded work: using healthcare technology to better support and inform cancer patients… 21:25 – …and the three technologies she’s focused on 28:35 – How the pandemic has impacted the need to be innovative in how palliative care is provided 32:49 – How ACS and the cancer community at large can help scale her findings 35:46 – A message she’d like to share with cancer patients and caregivers

Eric Rieger  0:00  All right, we are here at gut check project. Welcome KBMD health fans and family. We are on location in Conroe, Texas at Southern star brewery with my co host, Dr. Kenneth Brown. I'm Eric Rieger Dr. Brown. It's Episode 42. And this does not look like our set.Ken Brown  0:19  This is not our set. And this is very special. First of all, shout out to Southern Star Brewery, or letting us do this. Now we're here for a reason, a very special reason we are. This is going to be a really cool episode where we're going to talk about something really important and how it impacts the health and the future of everyone living in the United States. We're gonna talk about high fructose corn syrup. And there's a reason for that, because the next episode, oh, man, Eric Rieger  0:42  It's huge if we won't give it all away. But if you're tuning in for this episode, you're missing out. If you're not watching the one that comes right after this, we've got a special guest. And it's the whole reason that we're here in Conroe, Texas, Southern Star brewery just north of Houston, you can hear the sound in the background, the music's going crazy, but it's all worth it.Ken Brown  1:01  And the really cool thing is Southern Star Brewery, I just spoke with their brew masters, they do not use high fructose corn syrup. So we are in a perfect place to do that Eric Rieger  1:09  We are in a perfect place to do this. So Dr. Brown this particular episode, we're going to really get down to the meat and potatoes we normally don't do, quote unquote short episodes, even though we try to do that. But today, we have a topic that we really kind of discussed that we needed to cover before we had our special guest on. And this is an election cycle also. So of course, the next guest the next episode is definitely I would say political when you say it is definitely political, but also like minded, very like minded and really much very interested in your health. So let's get straight to it. high fructose corn syrup. That's what's on the table today. Why don't you kind of steer us where we're gonna go.Ken Brown  1:52  So we were planning on doing high fructose corn syrup, regardless. And then yesterday, a patient of mine sent me an article said, Hey, check this out. And an article just got published out of the University of Colorado, okay, where they looked at the lows. Yeah. And they, they were able to associate that symptoms, ADHD, aggressive behavior, and bipolar disease can actually be linked to high fructose corn syrup, not just Oh, if you drink this, this happens, scientists figured out that the reason why is that when you take in high fructose corn syrup, you are actually starving your brain. Your brain thinks it's starving, while your body's getting fat. And so because of that, your brain goes into what is called a foraging mode. It actually turns on remember when we talked about orexin and things like that when when you go into a forest? Yeah, guess what your brain is going Yo, we got to get some food here. Even though you're drinking mountain dews. And you're opening up, you know hohos and stuff and you are morbidly obese on the outside, your brain is starving for energy. And they're attributing that this could actually be the the reason why you have hyperactivity, creating ADHD, aggressive behavior, and bipolar disease. When you have foraging mentality, your brain tells you to go out and do something. So you end up with impulsivity, aggressiveness, and reactiveness. And I just want, there's no way a patient just sent me this article. It came out yesterday. And we were already planning on talking about this beautiful timing. So this is just one article. I mean, that just showed up yesterday. So that is, if you are interested in high fructose corn syrup, and you happen to be somebody who suffers from anxiety, ADHD, or impulsivity, listen,Eric Rieger  3:41  well, another thing to take away here is where do you find high fructose corn syrup? Oh, I don't know, almost everything that's processed with sodas, breads, treats. It is a sweetener, per se. And a lot of people have even told me I remember when I was younger, that it was just like sugar. Well, it's sweet. And that's pretty much where it ends. We've already talked about the dangers of just even sugar exposure. Believe it or not, it's worse. It's truly worse. We're gonna get into it today, but Coke's, Pepsi's sodas, if they're sweetened. And I mentioned breads and treats. But in sometimes you'll find high fructose corn syrup and things that you don't even perceive as sweet. Which is the problem Ken Brown  4:23  100% we're gonna get into that. Now, one of the things we do here on the gut check project is we want to bridge the gap. A lot of people always say, Oh, yeah, I've heard the same on high fructose corn syrup. And in this climate right now, it feels like everything could be politicized. Yes. And I feel like even bringing this up could turn into some sort of political argument. That's not what we do here. We're just gonna talk science. Let's, let's talk objective data. So I'm gonna throw this at you. You're better at the historical aspects of things. Let's just briefly go over how did we end up with high fructose corn syrup in everything.Eric Rieger  4:57  I think if I recall the story, somebody What correctly, we needed number one to have sugar or sweeteners available, we wanted to see if we we mass produced products that the shelf life could be extended. And in doing so we also had farmers that had grown a lot of corn. And so you have the I think it's the Corn Growers Association or corn refiners Association, CRA that essentially functions as a lobbying agency for corn growers. And what they found is they could compete in the sweeteners market by mass producing high fructose corn syrup. And this process was, I don't know if it was discovered accidentally or on purpose. But ultimately, it's a two step process, which one phase of it is somewhat, I guess, naturally occurring if you force it, but it's not a natural thing to have.Ken Brown  5:52  It sounds like you're describing a Labradoodle?Eric Rieger  5:54  sorta a Labradoodle of sugar.Ken Brown  6:00  Kind of natural, but it was forced. Yeah.Eric Rieger  6:02  It's kind of like a liger. You're not supposed to have them.Ken Brown  6:08  Did you ever see Dan Cummings? Chocolate squirrel doodle?Eric Rieger  6:13  Oh, the comedian.Ken Brown  6:15  He does a whole set on this exact topic. Yeah, mixing animals that shouldn't be missed. Anyways, off topic already, wow, are are super fast episode. on time, DeRay. A lot of the time. Everything you're saying is true. Let's just put a little historical context into it. So basically, since the 1920s, there have been farm subsidies. So the US government has said, okay, we need to help out. We've got a great depression going on, let's make sure we have enough food for everybody. And then, through a series of events, which I'm not an economist, but basically the 1960s. During the Nixon administration, there was a series of events like a couple bad harvest years, and then we made a bad decision to sell millions of tons of grains to the Soviet Union. And all of a sudden, we ended up with a shortage. This shortage, of course, led to the overcorrection, which happens in government at the federal level a lot. It's like driving down an icy road, you turn a little bit here and go well, and then you overcorrect and now you're spinning out of control. Yeah. So in the 1960s, they started this subsidies program where they were going to subsidize farmers and ultimately, the most abundant crops were wheat, corn and soy. Okay. So then this was started, because through a lot of different reasons, those were the ones that were subsidized the most. And then in 1996, it was discovered, oh, we've way over corrected, we've got way too much of this stuff. So the federal government put in new mandates, which then said, Okay, we're not going to subsidize this anymore. But since we were doing it for so long, everybody that was subsidized gets grandfathered in, at the rate that we've been doing. And since the major crops were corn, wheat and soybean, they got subsidized. And they were grandfathered in whether or not they grew, the crops paid did not grow anything Hey, did not grow. And guess who wasn't getting paid at all. The farmers that were growing fruits and vegetables, they got squeezed out immediately. So, so now you've got these farmers that are being paid with our tax dollars to make more of a grain that we don't even know what to do it.Eric Rieger  8:20  I know we're gonna get into it. But you're telling me that essentially, we have a food additive that is being subsidized. So now it's already somewhat less expensive for not only a producer of foods, but even the consumer to get its hands on now. Right? So we've reducing the threshold of normal people to get their hands on the substance. Surely, since we weren't doing that with fruits and vegetables, it must be better for us, right?Ken Brown  8:47  So what happened was, we have all this corn. And some Japanese scientists in the late 90s figured out that when you add a couple chemicals, natural enzymatic chemicals, you produce this high fructose corn syrup, since we're already subsidizing it. And it's really easy to make, then it's 70% cheaper than standard sugar cane or standard cane sugar. So automatically, you've got a 70% advantage. So then they realized oh my gosh, it's also two times as sweet as sugar. And look, it works as a food preservative. We just found the holy grail of the food industry. So it just exploded. And in fact, since then, or since it was discovered how to make high fructose corn syrup 1,000% increase in our consumption has taken place. It's ridiculous thousand percent. So our ancestors would normally take in. I don't remember the exact numbers let's but I think it's somewhere around 20 grams of sugar in a year.Eric Rieger  9:53  Now we're in a bit just just to categorize that's not including just fruits and stuff. You're talking about just raw sugar and and another Think just for context, today's standard is just try to consume less than 22 grams of sugar a day aKen Brown  10:08  day. So in other words, right now, without even trying, most of us are consuming what our ancestors did in a year, in a day. So you said, Surely it must be better for us. It's not and quit calling me surely I don't know how many times we've talked aboutEric Rieger  10:25  airplane.Ken Brown  10:28  Alright, so real briefly, we're gonna get a little sciency, then we're gonna do a quick deep dive and then come right back out. So just hang in there. But the whole point of this is we don't want to make it political. But it is impossible to not discuss some of the political aspects of it, because it's because of the subsidies that we're here on. Let's be clear, and if you identify as either right or left, believe me, both sides are involved. This is not exonerated either side whatsoever. All right. So why do you even care about fruit dose? Well, glucose, which is the sugar that we always talk about, right? table sugar is sucrose and glucose combined, and then all of a sudden we start throwing then it's fructose right about now a bunch of people are just going that's too many else's, like I agree with you. So let's focus on the one else. fructose. fructose is the only sugar which is metabolized in the liver, it does not need insulin to drive it into the cell. Glucose is used by every cell in your body, fructose goes straight to the liver, right. And it's when it goes to the liver, that it has to be broken down and then metabolized. That doesn't happen with that. So we've got this very cheap sugar that is metabolized in an unnatural way, right. And it's not used for energy. And we're going to come full circle here. But basically, we now know that fructose consumption has epidemiologically been connected directly to the diabesity epidemic that we have. And now I can tell you in a little bit on a cellular level, how it actually does that. But we've already mentioned that you said it lasts longer. So if you're going to go out, and you've got a granola bar or an apple, and you go Oh, the granola bar is healthy. That's nature made set it is that commercial showed hikers there and sure the commercial doesn't show somebody pulling an apple out of the backpack because an Apple has a shelf life, right? The granola bar can sit there forever, and it sits forever because they hide the sugars in it. Right? You don't even think of that now. And then we talk about other foods that are there. So when we're sitting there taking this for people that are like, Oh, I like this food better. I like this bread better. I don't know if you saw that, that an Ireland, they they won't allow subway to call in a sandwich. They can't call it.Eric Rieger  12:37  I don't think they can call it aKen Brown  12:38  brandy. They can't call it a bread because the sugar content is five times higher than what bread should be.Eric Rieger  12:43  Yeah. I mean, that's that's alarming. Like, it's not like, Oh, I can't believe they don't let us call us bread. Well, they can't call it bread because it's not bread. Yeah.Ken Brown  12:51  Um, the interesting thing is that it is actually extremely addictive because it is two times sweeter than sugar. So you condition your body to watch that sweetness. Sure. And then we can get into exactly why all this is going on. The irony of it all is that actually makes people hungry right? Now I just told you about an article where you have ADHD because your brain cells are starving. Sure. Now, we know that when you take this, what does that mean? Tell me one benefit, other than it's cheap, and you can sell more products, but you get no nutritional value out of it. And you actually cause damage as you take it. Like it's like if you start with that they wouldn't allow it to be made ever.Eric Rieger  13:34  I mean, quite honestly, it sounds to me like every advantage is somewhat sinister. It's it's there is no advantage about this. There's not a direct advantage that I'm aware of, for the person that's consuming it. And I think that's that's really what we need to be concerned about. Because we're consumers weKen Brown  13:51  Yeah, we do. And fortunately, we're consumers that are doing a podcast that a microbrewery that uses all natural ingredients, and they're very conscious about not doing that. We're consumers that are in the health field. Correct. And unfortunately, the burden of diabetes high blood pressure and death in the poorer socio economic areas is much higher than the general population. Yes. And then when you start reading about it, they consume they being people in poor social economic neighborhoods and in cities, they may not have access, they may not have the money nor access for healthy foods. I don't mean healthy. I mean just something that isn't fast food or in a packageEric Rieger  14:35  right and most fast food is going to be made with high fructose corn syrup and other additives don't don't get me wrong. There's others out there. It's not by itself, but we're talking specifically about high fructose corn syrup today. And you're you're correct. The subsidy has made it to where that's what is obtainable. That's what they can eat because it's cheaper for the producers to Make it because it's a subsidized product because it serves as commodity. It doesn't make sense. We are making it easier for taxpayers to subsidize people who don't have money to get sick and stay sick. And they have this anxiety. It's a horrific cycle. Because if they're trying to climb out of poverty, guess what? They don't feel normal. They're not thinking, like they should beKen Brown  15:21  that article that discuss the impulsivity. Yeah, that really got me thinking, right? I mean, we always blame we try and blame so many things on different aspects. Oh, we're obese because we're not getting enough exercise. And I can get into a whole different aspect of this where the Corn Growers Association hired scientists to put out public statements that basically said, high fructose corn syrup is really good for you. You're just not working out enough.Eric Rieger  15:49  Yeah, it's ridiculous.Ken Brown  15:50  And then we're looking at this, you're like, wait a minute, areas that have the highest burden of obesity, and have high blood pressure and diabetes, which lead to this huge cost burden in the United States have the highest consumption of high fructose corn syrup. Yet, there's people out there saying, Oh, it's not related. They're just not getting out there jogging enough. Now, that is, I'm going to give you cellular reasons why this is wrong. But if you don't care about it, and I know that we're going to talk some politics on the next episode, if you look at the pure numbers, since high fructose corn syrup came on the market, Eric Rieger  16:26  right. Ken Brown  16:27  And we're taking 1000 times more than we used to, it is estimated that right now, 60% of the adult population is overweight. The prevalence of insulin dependent type two diabetes, that means diabetes that didn't respond to medications, and you eventually have to go to insulin is 9.3% of the population. Pre diabetics is through the roof, they're estimated that about 30% of the US population right now is pre diabetic. It's sad. 60%. It's, it's sad. It's also really expensive. Yeah, I'm gonna put you on the spot. How much do you think the burden of this cost the US annually? Thank you for putting me on the spot. And I will say eleventy billion dollars, because I don't know the number that is very close to 327 billion, because it's, it's encompassing the health care costs of this, that's ridiculous. If we could fix one thing if we could fix obesity and diabetes. Sure, if you take out diabetes, just the causes, just the morbidity of obesity Sure, is like 192 billion. And if you look at diabetes, 327 billion, that includes loss of work when people get sick, and you know, all the other weird numbers they put in there. 320. Okay, so imagine if we could sit there and get roughly 527 billion off the tax records off of our tax burden. And all we got to do is take one food subsidies. So we're paying taxes that are now going and making peopleEric Rieger  17:56  sicker. And it's by it's by design, if you just step back and look atKen Brown  18:00  and then right now in 2021 of the hottest topics and always is every election year is healthcare. What do we do with health care? We need Medicare for All we need this. We need that. Now. How about taking one thing that we're already paying for his tax dollars, converting it to something that the European nation is actively trying to ban 100% they're out, they're gone. We don't want to do this. And then what's really sad is when you introduce high fructose corn syrup, and I'm not trying to pick on anybody, but it's a soda company that ends in Ola. Ah, Mmm hmm. It's couple of them. Yep. You pick which Ola you want. Alright, so they've so they've looked at this, and one of the older companies did a real big campaign paid for their own studies, and got it introduced in Mexico. And now Mexico is almost caught up to us and diabetes, and obesity. And somehow, same thing happened in China. I mean, China says, FU to everything whenever they want, but somehow one of the older companies got in there, if you want to learn about that watch Patriot Act, because Minaj Hassan did a whole thing on this where he was like, How in the world can we not negotiate with China, but the older company just went in and said, pow do it. And now they're running into the exact same problems. He showed different commercials that they're running. And they had they, they gave them articles which show the same thing. Coca Cola has their own research institute, and they come out with things that say high fructose corn syrup is actually good for you. And you just need to exercise more. exercise more.Eric Rieger  19:37  Yeah, I mean, it's ridiculous. If if you wanted to make certain that your bank was secure, it would be a bad idea or policy to get the robbers who are going to heist you later to check your security system, because that's exactly what's happening here. It doesn't make sense to take the data from somebody who is wanting to sell you what they're telling you is safe just on the other side. Yeah. They're the only ones who have the data that show that. Think about it. If you're hearing that high fructose corn syrup is okay for you, who is putting together study? And what did they study? Interesting? Is there a study? Or is it just a kind of a? We feel like it's, it's okay, was there actual data that showed a reproducible, less than 0.5 p value?Ken Brown  20:26  I went down a little journal searching rabbit hole, because I did that thing you're not supposed to do when you read the whole thing. And at the end was, there's no way that studies so I started going through our Mendeley account and stuff, and then it said unpublished data,Eric Rieger  20:41  so they don't believe in it.Ken Brown  20:43  So they brought a PhD to stand up and go, it's good for you. We did a study on that. Trust me, it's right there. Right there in my brain. didn't even get it published.Eric Rieger  20:53  Yeah. I mean, if you come home and your newspapers torn up and the trash is out, and you ask the dog, did he do it? And they go, No, he did it. The dog did it. It's the same thing. They did. The the study is not real. They're just saying it.Ken Brown  21:07  Yeah. That happened to me when I was a kid once and I yelled at our dog, it actually was a raccoon.Eric Rieger  21:12  couldn't believe he didn't call me up or dog saying no.Ken Brown  21:17  All right. So even if you're sitting here, and if one of those scientists is listening to this, and he's like, no, I looked at the data. It's there. That's fine. Let's back off all that. Let's back off speculation. I want to talk about an article that was just published about two weeks ago. The title of the article is the negative and detrimental effects of high fructose on the liver with special reference to metabolic disorders published in the Journal of diabetes and metabolic syndrome. It's a lot, we got to teach these guys how to write their name. Because I got tired Listen, just kind of reading through the title. But what I just I'm gonna just go over the key points to this. Yeah. And then you make your own conclusion about this. So what this article looks at is let's talk about the cellular mechanisms. This isn't speculation anymore. This isn't taught let's just look exactly what's going on on a cellular level. Okay. So what actually happens is, we may have to put the nerd glasses on, I always carry him around in case it gets too nerdy when you go, you need to back off,Eric Rieger  22:11  Clark.Ken Brown  22:12  so got the nerd glasses on. Basically, you already know that fructose is metabolized in the liver. So I'm going to go through a five step process, okay, have a two part reason why high fructose corn syrup is messing you up. Okay. Okay. So we know since it's metabolized by the liver, step one, the liver tries to metabolize all this fructose that it's getting in, and it quickly cannot do it. So the liver converts it to triglycerides, or fat that so you start having these fat depositions in your liver, step two, the fat starts accumulating, and we call this fatty liver disease, right, the fat starts accumulating, and as a result of this, fructose becomes harder to metabolize. So in other words, the fructose is going, Hey, I'm here, I need to be metabolized. And these fat cells are just going like, man, we don't know what to do. Sure, because we're not built to do this, right. So then you end up with this snowball effect. And then that fructose that's sitting around starts impairing other processes, one of them being something called a beta oxidation process, where if you're a medical student, they go, Oh, that's how you break down fat. So you impair the ability to break down fat. So you impair the ability to break it down. And what that means is, is that it can't metabolize fat, so it leads to fat just sitting there, and it starts creating other problems. So step three, is a decrease in ATP, adenosine triphosphate. That is the energy that our cells you, you have to have it, I'm going to throw it back to the article that my patients sent me yesterday. So what happens is you get a decrease in ATP, which is the energy for mitochondria, that's the powerhouse in the cell. When this happens, the body increases and expression of an enzyme which I'd never heard of, and nobody's ever taught me this. So it almost feels like a cover up called fructokinase C. Okay, fructokinase C. So when fruto kinase c starts ramping up to get rid of the fat, all this other thing, it actually destroys more ATP, as it turns out, fructokinase C is a bad thing for around in your body. Sure. So it actually starts breaking down what little ATP you're making. And then this increases something called uric acid, which leads to a very vicious cycle of the fat not being able to metabolize, and then more fat comes up and then you start decreasing the cellular energy and now you've produced uric acid. And this vicious cycle actually creates severe stress on the cell, which leads to reactive oxygen species. I don't know if you Remember a few episodes back we talked about how one of the leading causes of obesity is oxidative stress. Yeah.Eric Rieger  25:05  RsKen Brown  25:07  Rs right there. And then guess what's happening. There's this battle going on, fat is just showing up because they don't really care. The body's trying to get rid of that. ATP is being used to try and offset this fructokinase C. And then you've got a mitochondria that are sitting there going, yo, we have no energy here, right? I've got no energy. And the brain cells go we have no energy. I'm gonna go forage. impulsivity, ADHD bipolar. So not only are you actually putting on weight, but you're starving, like there isn't. There's it's a lose, lose lose situation. Right. Does that make sense? Can Can you summarize that really quick? Because I feel like I got a little too deep in the woods.Eric Rieger  25:50  Sure. I think while we have someone here, briefly announcing this behind. Not really announcing us behind this makes no, it makes no sense. It's even throwing me off. But I do think that I could somewhat summarize what we're talking about.Ken Brown  26:04  I, I'll tell you what, I've been listening to what he's saying. He's like, Listen, everybody, if you're, if you're if you're here. Now, I just learned a lot about high fructose corn syrup. I want everybody here in the audience, too. And so I love that, that he's actually doing that for us. Thank you. I mean, I like it when we make that big of a difference that quick.Eric Rieger  26:20  Yeah, everybody's on board now. Yeah. So I what I do, when I hear is they bring in high fructose corn syrup, we don't know how to metabolize it, or our cells don't know how to metabolize it is now giving us too much uric acid, which I actually made me think of. There's a close association between high fructose corn syrup consumption and gout.Ken Brown  26:38  Yes, exactly. Yeah, yeah. AndEric Rieger  26:41  beyond that, when your body doesn't know how to handle this, you're just going to keep storing fat. And when it didn't have the energy, because you're destroying adenosine triphosphate, where you can't break it down to ADP, your cells can't, then essentially, it's going to keep looking for food. While you keep packing on fat. You're going to keep looking for food. While you're packing on fat, consume more high fructose corn syrup, pack on fat, keep looking for food, because you're not feeding yourself. You're not gonna keep burning the brain because the brain needs what it's not getting.Ken Brown  27:13  Yeah. So now part two of this vicious little cycle that's just going on in the liver. So as it turns out, the liver in its attempt to get rid of the fructose just produces tons of this Fructokinace C. Oh, can I see that then floats around and goes to my special origin, the small intestine? Oh, yeah. Where What does it do it inactive. It makes the cells insulin resistant. So this made total sense to me where that study that we've talked about before I've talked about with my patients, where people that drink diet, cokes, have a higher propensity to develop diabetes right? Now that makes sense. They're taking in high fructose corn syrup, even if it is in the form of some artificial sweetener and things like that. I'm always always like, man, how's that happening? Well, bacteria break it down. And ultimately, you end up with fructose and the liver has to, you know, do this insulin resistance, the fructokinase c creates insulin resistance through a process called glute five, and all those other imacon get as nerdy as you want on this. Because I don't want it to be an opinion piece. I want it to be like, Look, this is what's happening. Sure level. So then fructokinase C gets into the small bow where data causes leaky gut.Eric Rieger  28:29  It just is a never ending cycle. I have not heard one of the redeeming qualities. You told me you were going to tell me about high fructose corn syrup.Ken Brown  28:36  I thought we were just gonna do the usual Oh, it looks like it's associated with this. And I found this article where they're like, no, it actually does this little tiny thing here that leads to this that leads to this that leads to this. So now, I mean, we always talk about how bacterial overgrowth can cause leaky gut or intestinal permeability. We talked about how glyphosate does it. Now, if you're taking in high fructose corn syrup, you're developing intestinal permeability, which allows the endotoxins to actually get absorbed directly, which then go to the brain. leaky gut, leaky brain. That's right. So one of the things that I always tell my patients, we want to avoid gluten, I want you to avoid products with glyphosate. I actually mistakenly have not been saying the most important thing to take out of your diet is high fructose corn syrup. I've been harping on certain molecules. Now I realize oh my gosh, this could be the root cause of a lot of the problems. Okay,Eric Rieger  29:31  so this is a this is an important intersection, I think right here. And I think it's it goes for everybody go it went for me. It's not your fault. It's not your fault. We weren't told that because we weren't meant to find out about it. This was something I mean, our own federal government does subsidize corn. And the corn refiners Association presses hard every year they they compete with the Archer Daniels Midland. It's Edra, who run the sugar lobby, they, they fight over who gets the sweetener lobby money. I mean, and then they they're strange bedfellows they work together in, in in advocating sweeteners in certain foods. But the moment it comes down to which sweetener is going to go into your food, trust me, they fight over that. And Archer Daniels Midland who represents and Cargill who represent lots of sugar cane growers, they fight with the corn refiners Association. And I hate to say it, but in this instance, I sided with sugar, because at least it's somewhat natural, and our bodies, at least know what to do with it.Ken Brown  30:37  So imagine if I'm producing this, and I'm selling this to a large corporation, I came up with a molecule. When you eat sugar. You need insulin to drive it into the cell, right? When you have insulin in your body, it gives you the sensation of being full. How does it do it? Because when insulin is there, a hormone called leptin. Yep, a hormone called leptin goes up and says, yo, we've had enough to eat. So if you're somebody that really struggles with your weight, and you're over there going, I'm trying I do not know. And people talk about sugar addictions. And yes, we know that sugar can have the same effects as cocaine and things like that high fructose corn syrup will, will do the exact same thing. Oh, icing on the cake, high fructose corn syrup, blunts the leptin response. Yeah,Eric Rieger  31:30  well, I mean, it's already blocking what insulin does? Yes. So it now you're giving me a sweetener that doesn't let me know that I've technically had enough food, even though it didn't give me any calories that I needed in the first place. Exactly.Ken Brown  31:43  And so you've got the situation where it is the perfect storm, if you're a corn grower, or if you manufacture high fructose corn syrup. Or if you are a manufacturer of something that is processed foods, right? Or if you're an insurance company, or a hospital, or anybody that benefits with the detriment of health. It's crazy. It's like you cannot, it's all it's almost like a biological weapon.Eric Rieger  32:13  pretend for a moment, you're a junk food manufacturer, I'm going to come to you and I'm going to tell you, okay, Listen, I've got an ingredient, it's going to replace that sugar that you're putting in your foods. And at first, you're like, Well, why would I want to do it, because it's going to give you a longer shelf life, it's going to keep people coming back, they're probably going to consume three to five times as much as they normally would. And on top of that, it's inexpensive, because the government is is paying down the cost. Sold right sold because you don't care about the person who's buying it, you're just wanting to sell it. That's what they've done to you. That's what they've done to the public.Ken Brown  32:52  If you eat any fast food, high fructose corn syrup, if you're opening a package, high fructose corn syrup,Eric Rieger  32:59  go to you know, the other day, we're talking about ketchup, and we need to give credit where credit's due. Okay, so Heinz 57, ketchup and see it and all the grocery stores. If you go and look in most shelves, now they actually offer a natural, or organic Heinz ketchup now. And if you look closely there, it says, advertises no high fructose corn syrup, it's regular sugar. There's a reason behind that because the word is getting out. And if you want more choices like that, then make the correct choice for yourself. So with this show, we want to arm you with the information. This isn't really a joke, look at a picture of people gathered on the streets hanging out in the 60s and 70s. Again, just simply compared to today, I won't tell you what you're looking at, just look at a group of people. And then look at a group of people today. It does not look the same. And you can't blame it on laziness. I wasn't wanting to say this to laziness, there have been lazy people around for generations for centuries. They're lazy people that existed back in the 70s that have way worked out or whatever else. We still didn't look like this. It doesn't make sense.Ken Brown  34:05  I think we just gave a pretty compelling argument of so much of it is not your fault, right? And I hear that from my patients. They're try and then even well intentioned people going well, I meeting mine, I don't want to I have not done the due diligence to look, but let's just pretend like it's a Lean Cuisine or something. The fact that it's got a shelf life probably means it's got some high fructose corn syrup. Yeah. And if it's got some high fructose corn syrup, all this stuff is happening to you. And at the very top, it's you're not going to get full, because you don't have a hormone that says you're full, and then it just starts dripping down. Oh, your brain is going to be starving. So you're going to be more anxious, you're going to have anxiety, you're going to have impulsivity, oh, and then all of a sudden, you're getting fatter, your liver can't process it. Now you've got intestinal permeability. And then the one thing that is my passion, that probably is the least relevant to everybody out there, it affects the microbiome, you decrease your microbial diversity. It's not. It's literally poison.Eric Rieger  35:09  It's poison. And I did challenge yourself. So you'll notice they're like, I don't mind giving these guys a shout out, Justin, Justin's little peanut butter chocolate.Ken Brown  35:19  Yeah.Eric Rieger  35:20  So what makes Justin's unique if you pay attention to it, they are made with real sugar. And so all of the different flavors of Justin's peanut if they have something sweetened, because they also have just like nut butters and things like that. But they're Almond Butter Cups, peanut butter cups, a walnut Butter Cups, or cashews, whatever it is, but they're all made with regular sugar. And then they may be slightly more expensive, but just go and compare that to your standard gas station candy aisle. I'm not gonna have to say any names. Just go look, the first ingredient is going to be high fructose corn syrup. It's cheaper, they don't care. And of course you want it. You want it because your brains been programmed to want it. That urge just make the leap and start fun. I'm not I'm not at this point. I'm saying avoid sugar, just pick the right time. And it will at least start allowing your body to react appropriately to the sweetener.Ken Brown  36:13  Absolutely, you can you can retrain, you can do this. We, I feel like I tilt at windmills, you know, the Don Quixote style, I feel like I tilt at various windmills. I just I don't know how I missed this. It's, it's like it. It's been camouflaged. Yeah, out there. And I'm like, that's the truth thing that we need to make our mantra here.Eric Rieger  36:36  Another thing to think of to kids, if you're making your kids lunch, check the bread. In our I purposefully went through the grocery store that we have close to our house here recently, and just checked all the different breads, there's a I think I counted, there was a 47 different kinds of breads and bread brands to, to mass produce bread brands had a line, not even all of the lines had a line that didn't have high fructose corn syrup. And like their wheat bread, for instance, the rest of them do,Ken Brown  37:10  don't buy that. Well. And then the other thing, they're catching on to this. So I started looking at labels. Also, it goes by a bunch of different names. Oh, almost made up names by the food industry, where they and I wrote them down someplace because I was like, so annoyed by it. It's like they when you look it up, you're like, Ah, that's high fructose corn syrup. And they call it like something else, like whatever. And other countries are starting to do this now where they'll name at different things. So it's like, okay, to avoid it, try not to open packages, refined foods, try and eat those whole foods on the outside of the grocery aisle where they really want you to walk in, go down that middle aisle, they want you to hit those cookies right away. Because that's it's cheap for the grocery store. They know that you're going to buy them it's hard to not buy it that go on the outside, get some whole food first. And then really try to because once you start that path, it's it's super, it's super hard. So I don't know, I it opened my eyes to be honest. I mean, one of the reasons why I love doing the show is that we I get the opportunity to take a few moments to look at something where I normally wouldn't. This is one of them.Eric Rieger  38:16  Yeah. And I love the show because we get to get into subject matter that just like you said, it's it's bringing something to your attention. I think that this is a topic that maybe I've kicked around with family members or friends but I even at times, I don't know how seriously I took it until I decided to do the research myself I my last soda, my last sugared high fructose corn syrup soda was several years ago, but that was buying. That was on purpose. It was by design, I wanted to stop consuming that stuff. It wasn't easy, but doing it, I feel better doing it. And I want I just really want everybody else to have the same opportunity, same information. There's no reason for us to keep in this crazy cycle. We only live once of feeling sick, not feeling our best. I want you to enjoy your life. There'sKen Brown  39:06  no reason to do this, the idea that on a federal level, we're paying taxes to produce this to make us sicker. I mean, if I were a politician, if I were in charge, I'd be like, subsidies are now shifted to fruits and vegetables, corn, you've had your run. No more grandfathered in subsidies. You can't just have excess corn you don't know what to do with. So you're gonna, you're gonna convert it to high fructose corn syrup. We're going to feed it to our animals. We're going to do this. I know that there's a role for it. I also know that it's, oh my gosh, I was trying to do some research on this. And I discovered a Netflix video called corn or something like that. Okay, this is this is wild. It was in Iowa. These guys from Boston, found out that they had relatives generations before and they wanted to see what it's like to farm corn. So they got a one acre plot and then they kind of lived in this little Iowa town. I'm about halfway through it, but it's really this is really awesome. So they planted their corn, and then weeds started coming up weeds. And the guy pulls it up. And it's hemp. Oh, wow. It's hemp. That's how much hemp is wants to grow. It's like I want to be here. Yeah. And then what do they do? Very good, glyphosate, whatever thing and they just kill everything in between the corn. And then all of a sudden, you're taking high fructose corn syrup, and you're adding glyphosate and chemicals and stuff to it. And so we're taking poison, I'm going to give you arsenic, and then you're going to mix it in gasoline and drink it.Eric Rieger  40:35  It's funny the same as getting gasoline, because they also make ethanol and all that excess corn. Hey, yeah. I mean, just, I don't know, this episode is a great, a great introduction for our next show.Ken Brown  40:48  Absolutely. That's the whole purpose of doing this, that we understand that, you know, this is a lot to be thrown at you. But just take a second to look at it. And look at least look at the various names are calledEric Rieger  40:58  One last thing I wanted to call back on a recent but previous episode, we had one two shows ago, I believe might have been three, where we talked about the increase in gi cancer in people. There is another study that we can't get to today, it's very, very in depth. Well, it's not just one size, there's several. But there's one that really ties together our current day food additives, including high fructose corn syrup and the increasing incidence of gi cancer. It's not a joke. It's not something that we're just trying to say, Oh, don't eat sugar to not get But no, in fact, eat real sugar. If you have to have a sweet tooth, the studyKen Brown  41:35  results were pretty simple. The equivalent of one can of soda a day resulted in increased cancer in mice.Eric Rieger  41:42  Yeah. It's It's not good to say it's and it's horrific that our that our government subsidizes it and you mentioned it earlier, you can change the name of how you see them the label, you know how hard it is to to put an all natural product and what it is on a box. It's actually good for you. The FDA is really hard on this.Ken Brown  42:02  Yeah. So in case your Eric's now holding up a box of atrantil no high fructose corn syrup, and I'll turn to no so no additives, no additives, so it'sEric Rieger  42:11  a little annoying. Well, regardless, I'm prettyKen Brown  42:13  pumped about our next show coming up.Eric Rieger  42:15  I am too so be certain to check out 42 right. This is 42 next one's gonna be 43. Thank you. Paul Rogers went on the road with us by the way. Yeah,Ken Brown  42:24  this is a special thanks once again to Southern Star All natural brewery. Southern Star here,Eric Rieger  42:33  the whole thing. But seriously, so Episode 42. I think it's gonna do it for today's show, or for thisKen Brown  42:38  particular show. Yeah, I'm proud of us in so many levels. This is the shortest show we've ever done. How manyEric Rieger  42:43  minutes is that? We're at like, 42. We're only 12 minutes over. Well, thank you so much. This Eric Rieger with my co host, Kenneth Brown. that's gonna do it for episode number 42. Be sure and check out the show notes. We've got information on getting in touch with Southern Star brewery as well as a think we may end up adding after we published some information on where we can find some of the studies specifically on high fructose corn syrup, and it's dangerous to you.Ken Brown  43:10  Yeah, absolutely. Thank you so much for tuning in and definitely tune into the next one.Eric Rieger  43:15  All right, see y'all then

  Dr. David Graham returns again this week to discuss his newly published book, From Killer to Common Cold. The book touches upon the topics we have discussed on this show for a few months now. The central theme of the book is how SARS-CoV-2 will transition from the pandemic killer COVID-19 to a common cold coronavirus. Dr. Graham expertly lays out his case in a short book that is easy to digest in just a few hours of reading. He sets a background of what viruses are, basic physiology and epidemiology, and history. He discusses what features make this coronavirus like the others that currently circulate freely amongst humans and how it is different. Most persuasively, he makes the case for how one of the current endemic viruses, OC43, went from pandemic to endemic some time in the late 1800s. His argument is persuasive and is playing out before our eyes. Efforts to prevent the spread of the virus have proven mostly ineffective or temporizing. Even those countries that have managed to contain its spread find that as soon as they give even a tiny glimmer of an opening, the virus finds its way into the population. So Dr. Graham argues that containment is essentially hopeless we need to figure out where we will eventually end up and how we will learn to live with this virus. He states that if it is similar to other coronaviruses we won't be able to vaccinate it away or find effective treatments. Probably, humans will develop partial immunity to the virus and after multiple exposures will experience only mild cold symptoms. After all, it seems as if the worst elements of the virus are not the virus' effects as much as our own bodies' immune responses. Dr. David Graham is an infectious disease specialist in Billings, MT. He is also the author of the FIPhysician.com website. show notes @FiPhysician: Twitter for Dr. Graham. FIPhysician.com: Dr. Graham's blog and website where he blogs about finances and pandemics. Episode 101: Today's show Episode 096: From Pandemic to Endemic Episode 095: Is Herd Immunity Here? Episode 091: COVID and Back to School Episode 087: Deception on the Coronavirus from our leaders. Episode 086: How the Coronavirus epidemic ends Samaritans Health Sharing Ministry: This is the ministry we use. Feel free to mention my name if you sign up - not sure if that helps you or not. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

In this episode of Functional Medicine Research, I interview naturopathic physician Dr. Ilana Gurevich on overcoming inflammatory bowel disease.  We had a deep discussion about testing and treatment options for inflammatory bowel diseases including Crohn's disease and ulcerative colitis.  We covered diagnostic testing, the pros and cons of stool test markers, probiotics, fiber, digestive enzymes and hydrochloric acid, gut healing nutrients, diets like the Specific Carbohydrate Diet, helminths, and much more.  It was a pleasure to have Dr. Gurevich's expertise on inflammatory bowel disease. Below is a transcript on How to Overcome Inflammatory Bowel Disease with Dr. Ilana Gurevich Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research" I'm Dr. Hedberg, really looking forward to my conversation today with Dr. Ilana Gurevich. She is a naturopathic physician and acupuncturist. She graduated from the National University of Natural Medicine in 2007, with her doctorate in naturopathic medicine, and in 2008, with her masters of Oriental medicine. She is currently co-owner of two large integrated medical clinics, one in Northwest Portland and one in Northeast Portland. She runs a very busy practice specializing in treating inflammatory bowel disease, which we'll be talking about today, as well as IBS, SIBO and other functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for gastrointestinal conditions, including inflammatory bowel disease, SIBO, and IBS. She's one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. Dr. Gurevich also acts as a mentor in the naturopathic community, educating and consulting with physicians about GI disorders. She supervises residents and consults with doctors about their most difficult GI cases. She was nominated as one of Portland's top docs by the Portland Monthly in 2014, 2016 and 2020. So Dr. Gurevich, thanks for coming on the show. Dr. Gurevich: Thank you so much for having me. Dr. Hedberg: Yeah. So this is gonna be really interesting. I've heard you talk before and I wanted to have you on because you're extremely a research-based, you know, scientifically sound. And of course, you have tremendous experience in inflammatory bowel and SIBO and IBS. So why don't we just lay some groundwork? And if you could just talk a little bit about what have you found to be the real causes, the triggers of inflammatory bowel in your patients? Dr. Gurevich: You know, it is such a multifactorial disease. So with inflammatory bowel disease, there are these two peaks of when people generally get diagnosed. The first is, you know, adolescence, right around puberty to like the mid-30s or 40s. And then the second is menopause, andropause in your 60s, 70s, 80s. And those patients tend to get found a lot just on their basic screening colonoscopy. And so, you know, because there are these bi-modal peaks of diagnosis, it really makes me think that one of the issues is hormonal changes that happen. And, you know, we're learning more and more recently about how hormones affect the GI, mainly using the estrobolome as an example, and then how the estrobolome affects how you conjugate or process your hormones. And so there's definitely a hormonal component. Research is also exceptionally clear that diet is a huge component. You know, in parts of the world where they don't really see inflammatory bowel disease like Africa, like Asia, when people from those countries move to a Western civilization, they start getting diagnosed with inflammatory bowel disease equal to people of the West, which means that the way that we're eating is definitively changing our microbiome, which is then causing onset of inflammatory bowel disease. What's interesting is the opposite now is also happening as we introduce the Western diet into more diverse countries that in the past were, you know,

Eric Rieger  0:00  Hello It is now time for the gut check project KBMD health fans and those at the Ken Brown clinic. I'm here with my guest host, Dr. Kenneth Brown. We've got an incredible special guest with us here today Dr. Tom O'Brien joins the show. Like and share of course, Dr. Brown once you take it away and introduce our awesome guests. Ken Brown  0:19  Well, I'm so excited because Dr. Tom, you and I have been running in similar circles. And every time I bump into somebody including different lab companies, including different mindshare people, everybody's like, Hey, you and Dr. Tom need to hang out. I'm like, I keep missing him. I'll go on a summit and he'll be like before me or after me. And then I'm just like, Oh, this is awesome. So we finally got you, wrangled in, you've got so much stuff going on. You're an author, you're a doctor, you obviously do some incredible deep dives. And what I love about you is everything that I've seen you on a webinar on a summit is science backed and that's exactly what we do. So I'm just thrilled I I have no agenda for this. You got a ton of information. If we ended up talking about something that I need to learn about, I'm just going to peel off and say, Wait, explain that. And that's, that's for me. So I'm not trying to question you, but like, sure, where I've read some of your stuff. And it's pretty cool. We're talking the same stuff, fix your brain through your gut, that kind of thing. That's all about us. So, welcome. So excited. Dr. Tom O'Brian  1:18  Thank you. Thank you so much. And I'm thinking a place to start if I may. The Alzheimer's Association came out last year and said one out of three elders dies with Alzheimer's or another dementia. So that means between the three of us, one of us is going down in our brain function, and it ain't gonna be me. Ken Brown  1:42  It's gonna be Eric. It's gonna be Eric.Eric Rieger  1:43   This is unfair.Dr. Tom O'Brian  1:44   I feel like I understand. But that's a reality check. And with a reality check like that, whether we like it or nobody likes to talk about brain function, no one does. You know, we all know someone that had a heart attack and survived. They changed their diet, they started exercising, they lost 25 pounds, they look better than they've looked in years. Most of us know someone diagnosed with cancer that went through the recommended protocols. And they're doing better than they've done in years. No one knows anyone diagnosed with a brain deterioration disease that's doing good. It terrifies us. And so we avoid the topic. So I want to talk about first the reality check that our healthcare system is not quite working the way we want it to and more people are getting sicker, especially if we talk about the brain and kids with autism and the numbers are skyrocketing and all that, but how can we look at our health care if our bodies aren't working the way we want them to right now? What's the big picture view of that? How do I get a big picture and I want to suggest this concept because I have found that this works really well. When I moved from Chicago to Southern California in 2010 I needed a map. How do you get from Chicago to San Diego? You need a map, you know, and I may know how to get to Denver cuz you just get on I 80 in Chicago, it takes you to Denver, right? You know, I may or it actually doesn't, it takes you close and you have to go up and 94. But I don't know how to get to San Diego, you need a map. When your body is not working the way you want it to you need a map. You can't just look for a better form of vitamin C, or what brain nutrient Can I take to help my brain function better? We have to have the map and what is the map in healthcare. The map is understanding at a layman's level, how I got to where I am and if we don't. To understand how we got to where we are right now, we are just like a dog chasing its tail trying to get somewhere else. So the question about brain dysfunction, or the question about auto immunity is, why is the immune system attacking my own tissue? Why is my brain not functioning the way it's supposed to, and you have to do a deep dive. And you don't need to be a geek and know the science because there's lots of information out there now. But we have to be willing to be uncomfortable for a little bit of time in being overwhelmed with knowledge. And we take it just one step at a time. That's why the subtitle of my most recent book, you can fix your brain. The subtitle is just one hour a week to the best memory, productivity and sleep you've ever had. And it's not cutesy subtitle It is the only way to be successful at changing the direction your brains going. Because as you learn more and more about the things that you didn't know, you mean that little bit of mold on my shower curtain there, it secretes spores into the air every time I take a shower, and I'm inhaling those spores and they go right up to my brain. And the number one type of Alzheimer's of the five types is called inhalation Alzheimer's, meaning what you're inhaling is causing the inflammation in your brain killing off brain cells. Yes, change shower curtain, you know, or whatever the trigger is. People don't know what the trigger triggers are. So they don't know what to do and they're hoping for a magic pill. You need the map. How did I get to where I am, so you then can make the corrections over six months to a year that turn your health in a new direction.Eric Rieger  6:00  I agree with that. I think that with where you're where you're beginning here in our discussion, many of the things you listed there, there's a lot to unpack, but many of the things that you listed there are, I think some huge tenants that that we discussed here on the go check project. One of those is that gut brain access, Dr. Brown talks quite a bit about the relationship for brain health and how it begins really with systemic health, which obviously originates in the gut. And then you're talking about issues of, of nerves and obviously the brain is a bundle of nerves but neural health and so what is it specifically that we need to do to protect our bodies from I would assume you're getting to long term inflammation what what the caveats are there that are initiating those inflammatory responses? So is there something that you wanted to kind of peek at there were Ken Brown  6:51  Yeah, so love where you're going with this. I'm um, as a gastroenterologist what I'm seeing is an exponential growth of autoimmune disease, Crohn's all sort of colitis are those celiac disease. Those are the ones that I deal with. And we're seeing this huge exponential growth. What you're describing is one in three people getting Alzheimers, we are seeing that autism is increasing. there's a there's a common theme here. And it's this upward hockey stick that's going on with chronic diseases. I love everywhere you're going and you I'm my bandwidth is only so large, where I have to kind of focus on how do I improve your gut to improve your brain and now you're talking other aspects. I want to get into that, but I want to know more about the guy. I'm a real big fan of how I built this. So I want to know more about the guy, the doctor Tom, how did you end up deciding that you were going to go down this path? I've heard a lot of your lectures so I know that you're super smart. I know you're very well read, but I don't know you. So let's talk about you for a moment. Dr. Tom O'Brian  7:52  Sure, sure. When I began my medical education in chiropractic school, very first week, the very first week I knew absolutely nothing. You know, we're working on a cadaver. I've just seen a dead body for the first time learning how to work with cadavers and genetics classes. There was a sign Dr. Sheldon Deal. Mr. Arizona was coming on campus to give a talk on Wednesday night. My very first week. This was the first week of January 1978. And I thought I'll go listen to this guy, Mr. Arizona bodybuilder, he's going to be a healthy guy. So I go to the talk. He has a color television on a stand in the room and back then color televisions were pretty new. And so to see all those colors, you know, he had the television on but the volume offand he walked over to a desk opened his briefcase to pick out a bar man, an iPhone, walked up to the color Television holding the iPhone like a flashlight you know policeman holds a flashlight up Hi, walks up to the color television with this bar magnet, the picture turns upside down and walks away. It goes right side up and walks towards it goes upside down. walks away it goes. Right? In attic pollution does to your brain and your nervous system. It's called neurological switching. These are people that say right, when they mean left, they write the number three backwards. they they they just are confused. And it was the first evidence in my mind the first introduction to electromagnetic pollution Ken Brown  9:51  1978 he was talking about in 1978. That's crazy.Dr. Tom O'Brian  9:55   Yes, because he he was talking he was talking about batteries in a watch and because they were fairly new, and when you put a battery next year body and this was a watch that it can for sensitive people, not for everyone but for sensitive people. It can be the straw that breaks the camel's back. And it impacts on their neurological organization, and how their their brain and their nervous system functions. Nowadays, we take it for granted Of course, we wear watches with batteries, and we put ear pods and our years we put batteries next to our brain. And, you know, we're using headphones that are remote wireless, so more batteries next to the brain. You know, I'm a strong advocate that we never put a cell phone next to our head. You either use the speaker or you use a corded earphones so that you're not putting especially for children whose skulls are thinner and these electric magnetic waves penetrate through a thinner skull of a child. And now there are so many studies on that. That's why in the book, you can fix your brain. I talked about the pyramid of health. Remember, we're still looking for a map here. How did I get to where I am? So in a pyramid, we think there's three sides to a pyramid. No, there's four. There's also a base. So the base is structure. That's the home of chiropractic and osteopathy, and massage and pillows and orthotics in your shoes and is your car seat tilted back. So you're driving like this all the time. That's, that's structured the base, then there's the biochemistry, the one that we all know about. And that's what we eat and drink the air we breathe. Then there's the spiritual or emotional and then there's the electromagnetic. So whenever you have a health concern, you have to look at all four venues to see, where are the triggers that are contributing to my body not functioning the way it should. So that was my introduction in January of 1978, to healthcare. And from that, I started looking in the literature and I found some children living within a quarter mile of high power tension wires had higher incidences of leukemia. That was 1979. I think I found that first study. And by the early 80s, mid 80s, there are many studies coming out about high power tension wires, and people's health if they live near that. So that validated for me, that for some people, electromagnetic pollution was a problem. Not for everybody, but for some people. And the same is true about structure. For some people. That's the problem. For some people, it's stinking thinking, the emotional or spiritual side and You can see the studies on stress hormones inflaming or triggering type one diabetes and triggering autoimmune diseases was what we think that or how we respond to stress and the hormones we make that set that up. For some people. That's the trigger. It's all about finding the map. So my entire career has been based on always asking my first mentor, no, my second mentor. My second mentor was Dr. George Goodheart, the founder of applied kinesiology, the muscle testing that some doctors have seen. Practice night have hundreds and hundreds of hours with Dr. George and he would always every weekend in our seminars, and usually they were at the Marriott Hotel at the airport in Detroit. So people fly in from all over the world to listen to Dr. George and the the podium that he's stood on was a wood podium. And he would do this all the time. He would say, lift up his right knee and his right arm and go, Why doctor and slam his foot down really hard. So we all kind of jumped in our seats now, because that would stage would just like bounce a little bit. Why do they have what they have? Why is your patient complaining of dot dot dot? And he would consistently drill into us Why? So my entire career has been based on why is that happening? You know, for example, why is it? We've all heard that it takes 20 minutes before the hormones in your gut. Tell your brain that you've eaten enough? How come you don't feel full right away with the volume of food you take in? How come you have you eat a little bit more and they say, Oh, I'm really full. How come that messaging is delay. I don't really know. But doctor Ken , you might, you know, we could have some discussion about this. I just made this up. But I think it's because we have the same body as our ancestors thousands and thousands of years ago, bodies function exactly the same. And a primary concern for our ancestors was getting enough food. They didn't get three meals a day, they ate when they found food. So even when they're full, maybe they should eat a little bit more because they might not get it next time. And so they get an extra few 15-20 minutes of eating the berries or eating the nuts or a little more meat on a harvest they made because they might not get a meal for a day or two. And I'm just making it up as to why I've never seen anyone write about why that is that that happens. But that's that was my thought about it, but always why. So I've been asking why my entire career.Ken Brown  16:01  So the why this is really interesting. So the when was 1978? The How is these mentors that have come to you? And then the Why is how do I do this? So then the how I built this, where did you go from? Okay? I am learning a lot from these experts, I have decided to shift my career focus and put in you've put a ton of time into developing summits into writing books into I mean, your your website is just got blogs that are just stacks and stacks deep. So when did you make this decision to go, I'm going to really commit to this aspect. And I'm going to become a thought leader and a teacher about these kind of things. Because clearly, you're passionate. But the as, as a physician myself, it's finding that time it's saying I'm going to take this, this leap off this dock, say I'm going to commit to this. I feel so strongly about it that I'm willing to put myself out there.Dr. Tom O'Brian  17:01  My third mentor was Dr. Jeffrey Bland. Who I heard Dr. Bland first talk in Chicago in 1978. And he is the Science Guy. Ken Brown  17:15  78 was a big year for you.Dr. Tom O'Brian  17:16   It was a big year. It was a very big year, married in 77. Went to school graduate school in 78. met these incredible mentors. You know, I think my angels just guided me to these guys. It was unbelievable. And but Dr. bland would say now this doctor in the New England Journal of Medicine said this and oh here three years ago, in the British Medical Journal, they said this and right here last week in the Journal of American Medical Association, they've said this, do you see how these pieces come together? And Dr. bland has always been about asking why and understanding at a deeper level why things can occur from a science level. So Dr. Goodhart was all about clinicians and being a clinician and finding out how things work. And sometimes he made up the reasons because he wasn't as much of a science guy, as Dr. bland. so bland is talking why from the science goodheart is talking why from the results. And so what happened? Was I just with every patient, I just kept looking to see, why is that happening? Or if they're not getting the results that I think they should have gotten? Why is that not happening? What am I missing here? What am I missing? And so I kept I keep looking and looking and looking. I'm not content when they feel better. And I mean this with the greatest of respect, I don't really care how they feel. They don't come. They come to me because of how they feel. But they're really coming to me to have their bodies function better so they live a long and vital life and how they feel is transient. So whether I get them feeling better right away is secondary to identifying the mechanism behind why their body's not functioning properly, Ken Brown  19:11  love how you said that, so that how they feel is transient. And the first thing I thought of is how many people come to me. And they're on multiple anxiolytics and multiple antidepressants, right? And I read the notes from the other doctors and they're like patient reports of feeling less anxious. Plus, check. Beautiful, there it is. But now I'm dealing with side effects of eight different drugs. And so I like how you said that how you feel is transient. I need to know why. I love Dr. Tom O'Brian  19:38  Yeah, yeah, and of course, all of these drugs, the antidepressants, the anti anxiolytics. They're all approved and designed to be used for a short period of time. None of them are approved for the rest of your life. But they're given to people so they continue to feel less symptoms. Ken Brown  19:56  They're approved to be given for short periods of time, but the pharmaceutical and I'm not passing the pharmaceutical industry. Many of these drugs if you try and get off of them create a tremendous amount of their own side effects. So knowing that, so Eric Eric's former life, the way that he paid for his crna school was actually as a drug Rep. So he's got some pretty interesting stories about how to make sure that you move some product.Eric Rieger  20:19   Yeah, no comment, but I don't work there anymore. So that's probably the most important takeaway. No, but I do agree with that. And I do think Dr. Tom, one of the biggest issues that I never liked about certain aspects of pharmaceuticals, which were intended for short term, to become long term is they're missing a very, very important piece. Once I've taken this to alleviate whatever the symptom or the feel, as you put it, there's no exit strategy. There's no way for me to break this dependency that I've now formulated to make me now feel this new normal. And that's, that's something to fear. I would, I think, to engage long term with a pharmaceutical that's just simply going to function as a feeling band aid. is taking care of the issue.Dr. Tom O'Brian  21:02  You're absolutely right. You know, and we've got so many cases of people on high blood pressure medication or on antidepressants. And we always say at the very beginning, now look, here's what's going to happen. There are some side effects to the medications you're taking. And you may have heard some, but I'm just want to make sure you know, these are the potential side effects. But we're going to address why your body has high blood pressure right now. So it's great to be taking these medications. You absolutely take them when you need them, and you need them right now. But as we address the underlying why your need for those medications is likely to go down, which means you're going to stand up and you're going to start getting dizzy because your blood pressure is too low, because you've got too much medication now. So I want you to call your cardiologist or the doctor who put you on that medication as soon as you start noticing any symptoms like this, this, this or this and say, Hey, I'd like to come in, and you come in and you say, you know, I'm getting a little lightheaded when I stand up now, and I never did before, but I've changed my diet. I'm exercising, I think I need less medication. Can you monitor me and we meet down when you think it's appropriate and safe. But just gradually wean me down so that I don't have any complications as my body's getting healthier. And every doctor is willing to do that every doctor and if they're not find a new doctor to monitor your medications.Ken Brown  22:36  So I'll stop you right there. And this is more for teaching me and with your style of practice. You have somebody that comes in you know that they've got the diabesity triad or whatever. And you look at them you go Okay, we need to start someplace. Do you start diet do you start environmental toxin do you start sleep, because I think those are kind of the three pillars might leave least knowledgeable aspect of that is environmental toxin because it's just something that I've not gotten into yet. And when you mentioned the breathing in the spores, I'm like, Yeah, I've got a lot of patients that got really sick when they moved into an older home and they renovated and then they've never been right. Since I've definitely believe that mold has a big role, but it's just the amount of time. So when you look at this, I'm challenging you to say this is where I start first, where is it? Dr. Tom O'Brian  23:25  Really easy, really easy. There is a great program that's been developed called the living matrix. And the living matrix is a, I don't know 30-40 page questionnaires. And it's going to take you, Mrs. patient, it's going to take you a day or two to fill this out. You'll come back to it and fill out some more of it. Someone's going to say how is the health of your mother during your pregnant pregnancy with you? And he will say, Oh, I don't know my mother passed. That's all right. Call your aunts. Call your aunts and find out. Did mom take any medications during the pregnancy with me, you get as much information as you can, and when you have a completed living matrix, this is the computer model, the program sets it off into eight different categories. And it becomes obvious which categories are the most out of balance. And that's usually the place that you start. And we'll start with maybe two or three of those categories, depending on the individual. Some people, it's clear, their auto immunity happened within three months of their divorce, or within three months of being sexually abused. And it's clear, they've got to deal with that energy. And so that person needs to include in their protocol, a therapist that they feel really good working with about this particular topic, because that's not my category. But if it's not address, it's going to thwart the progress radically. Ken Brown  24:59  That is so interesting. That's that insult to injury that I have to have that discussion with so many patients where I have somebody that comes to see me and they're like, yeah, it's unfortunate. I went to this horrible divorce. And then I started bleeding out my rectum and then I diagnosed them with raging ulcerative colitis. So like, what is the bad luck? I'm like, I hate to attribute it to bad luck. I attribute it to a sequence of events. Dr. Tom O'Brian  25:22  Yeah, exactly. Right. I agree. Yeah, that is totally agree fully agree. And and the tool called the living matrix of every patient fills that out. I have lots of people, you know, we we did a docu series called betrayal, the autoimmune disease solution. They're not telling you is that out yet? Okay. It is it is. And we've actually had over 600,000 people watch it. When I make the living matrix available to people and I think probably four to 6000 people have filled it out. You know, it's great because it's hard to read until you understand how it works, but it gives you a lot of information. And all of our patients fill it out before I'll ever see them if they don't fill it out, or they fill it out halfway. I don't see them. If I if I see that it's only half done. I call my staff because I'm virtual now, you know, so I do virtual consultations. But as I'm looking at the results here, and I'm looking at the screen and living matrix, you know, if it's not filled out, I call my staff and I say rescheduled or they put the time and I'm not putting the time in until they do if they do it half ass, I'm not going to do it half ass, and so cancel them, and don't charge them just cancel them. And if they want to come back, do it right. You know, you just don't put up with that. And I talk on stage all the time to doctors. You can't put up with someone who's putting their toe in the water. They're either going to do a deep dive with you, whatever your skill set is or they're not and in our practice, we represent that our goal is to help them see the map of what's happened to them. And so if they can't, they can't see the map. If I don't know the history, it's not possible.Eric Rieger  27:16  Well, that's actually pretty, pretty impressive because in a different in a different way when we've had patients who've come through the clinic, and then we've, we've prepped them to, to scope and I'm addressing anesthesia and of course, Dr. Ken over here is discussing with them what to expect as they continue on their journey. Something I've heard him address is, it doesn't matter necessarily what led to where you are right now, whether it be your fault and all of them or none of them. But it is your responsibility to engage with the change that's going to make you better. And you've had that conversation with with plenty of patients and it really just doesn't matter what to this point we can identify the triggers, which of course helps finding the solution. But ultimately, there's going to be self responsibility for one's own health. And you've got to be able to commit to whatever that change happens to be. And I would say that really the the gut check project that this whole the whole reason for this podcast was, we felt that there are better solutions than just taking the old didactics from the pharmaceutical industry and antiquated medic medical school iidx to solve problems. Mother Nature has lots and lots and lots of tools that we don't all, you know, use which are free available. And if you just have the discipline to stick with it for your own interest, you'll find in most cases, a better health, healthy living style, I guess you could say, Dr. Tom O'Brian  28:48  well, you guys are in a unique situation that you have to do the tests to identify where they're currently at. You've got to be able to clearly say you've got ulcerative colitis, it's at this stage and it's in this area of your colon and Okay, so we need to calm down this fire, calm down this inflammation while we look to see where it came from. So you you guys have both areas that you have to address and I do this on stage a lot and you know doctors laugh at it, but I've had a number of people come back to me years later and thanked me that they implemented this. When I I tell patients that my favorite patients are the ones that say I've been to Mayo Clinic and they don't know what's wrong. And I'll say that's great. Congratulations. And they look at me kind of startled. You know, they heard I'm a nutcase. But Congratulations, that means you don't have a disease. Because if you've got a disease, Mayo Clinic would find it. You've got dysfunction, something's not functioning right. So the test we're going to do or not the same test that we're looking for disease, we're going to do functional tests. And I hope that we find some functional tests, and people will and sometimes their insurance won't pay for it. And then some patients will say, Well, I can't afford that. And I say, Okay. Oh, okay. And then I write down in their file. Patient refuses this recommended test due to finances? And please sign this. Well, why? Why would I sign that? Because you're asking me to work with one hand behind my back. And I'm going to do everything I can to be of service to you. I will do my very best, but I'm not responsible anymore. If a problem occurs that I miss something, because well, no, no, that's okay, Doc, I'll sign it. Okay. Or no, no, no, I'll do the test. I'll do the test. Okay, good. Because I've seen so many people that say I can afford it. And two months later, I see him in the shopping they've got a deep tan because they just spent three weeks in Mexico, on vacation. It's just a priority thing. And if someone really can't afford what they need, well, our services will always reduce our services for finances if it's true, but we need patients to take ownership and responsibility to be actively involved with us. as we're going through this process. Ken Brown  31:28  When you started this, you open with Alzheimer's and it's funny because I kind of do that with my patients where you said that one in three people will now develop Alzheimer's. And then you tell me Alzheimers Association says that Alzheimers Association, so and then you talk about a patient that cannot afford to do X, Y and Z but you see them with a deep tan. So I use the let's fix your gut to protect your brain later in life. Because I'm I personally and I try and teach my kids this. I've got a 15 year old, a 13 year old. And my wife and I are on the same page where I personally prefer to purchase memories, as opposed to things. So I'm perfectly willing to take us on a trip, have some incredible meals, have some great pictures that we'll revisit. And rather than purchase something else, and what I mean by that is what is that memory worth? That memory is worth so much more than that object to me. And then if you were to say that I'm going to take away all those memories, meaning I'm going to take away your life, that's the panic moment with me, that's when I want to sit there and say, I want you to change your diet, I want you to change your lifestyle, not even so much is it so much a physical thing. It's not so much so that you can have the Beachbody, it's not so much you can do this. It's so that we protect your brain later. It's so that the same concept of osteoporosis prevention in your 30s so that we're not dealing with it and you're 60 so you're not busting a hip in your late 60s. And then now thing, what you're talking about, it's so true that you, it's hard to get people to think big picture like that. But you've always done this. So 1978 you have these mentors that do this. When did you decide to really say I'm going to be part of the movement? And I'm going to develop this website? I'm going to spend, I mean, you've been prolific. You've written books, you lectured you do some crazy summits. Man, you're gluten summit. Some of the people you have on that are like my heroes. I mean, Alessio Fasano, I mean, I've been following that cat since you know, early on in his career and a lot of you get some some pretty heavy hitters. That's pretty impressive. How did you go from, I now need to make a difference. On a greater scale, I guess is what I'm saying. You've mentioned multiple stages and stuff like that. When did you go it's less from one to one it's more from one to many.Dr. Tom O'Brian  33:53  January 2013 my friend, I think our friend I believe, you know, JJ Virgin. I've known JJ for many, many years. And she used to call me or I'd see her and she said, I just went to this weekend seminar was fabulous. You know, they're talking about this marketing concept of how to get information out to people in sales. He she said, You should come and say, Oh, yeah, thanks. Thanks. And then she hired a consultant, Allie, and he called me and said, I just signed the contract and I'm working with Allie. I'm gonna learn how to do this at a bigger scale. Come do it with me. Yeah, how much? $10,000 it ain't happening here. It ain't happening. Right. And then JJ grew and she grew. She applied to Princeton. Ken Brown  34:45  JJ is pretty convincing. when she gets passionate predicaments. Dr. Tom O'Brian  34:49  Yeah. And then she called me and said, Look, I'm having a seminar. I'm having I'm hosting a seminar, you're going to be there. I'm going to hire somebody to come grab you by the nape of your neck and bring okay, okay. Okay, welcome. So this is January 2013, dropped my jaw to hear how the participants there would do one thing that they prepare a webinar or something. And they would have 200 people attend, or 400 people attend just drop my jaw of the impact factor that was magnified by learning how to use the internet. And so I made a declaration that weekend. I said, you know, I'm a geek, and I just read a lot of science and I know these guys are I've been in their seminars where I've seen them at symposiums. I'm going to interview a number of geeks from around the world. And I'm going to put it online. Would you everyone here in the audience helps support me in this by send out announcements. And they all said yes. So my first interview, you'll really appreciate this Dr. Ken. My very first interview ever was Professor Michael Marsh, and our the marsh Godfather, the Godfather, celiac Marsh one Marsh to Marsh three, the Godfather, and he and no one had ever interviewed him. He was 74 no one had ever interviewed and he took me by the arm and walked me around Oxford and said, Tom, that's, that's right, right where I stood, and that and I received my medical degree in 1962. So that's great professor or took me down in the bowels of the library from the 1800s and that's where he sat to study every day. And you know, so Marsh, the Godfather and Professor Fasano, Harvard and so many others from around the world. Umberto Volta chairs the celiac Society of Italy. And I interviewed all these people. And everyone who's a JJ's event, sent announcements out to their people. We had 118,000 people attend Luton summit in November of 2013. It was the first online. The first online health summit ever was the gluten summit. And we made it up. Ken Brown  37:25  And that was when 2000 what? Dr. Tom O'Brian  37:27  November 2013. Ken Brown  37:30  I mean, thousand of those people were still doing dial up. Yeah.Dr. Tom O'Brian  37:35  That's right, you know, and the weekend I came back from making that declaration, I mean, I was fired up. I get a message. And this guy emails me and says, Hi, my name is Bob Roth. I am the social media director for the University of Chicago celiac center, and I'm out in California. I'm wondering if you did have time for breakfast, and I said, You i'm sure so we had breakfast and Bob said, you know, Dr. O'Brien, everyone's University Chicago thinks you're a nutcase. You talk about you talk about gluten sensitivity outside of celiac disease. And but I watched one of your presentations was recorded, and you're just talking science. I said, Yes. You said, you're actually correct. And I said, I know. I know. He's and I said, Listen, Bob, I just made this declaration. I'm going to do this thing. I'm going to travel the world. I'm going to interview these guys. I know who to interview. And I'm going to interview them. We're going to put it together and we're going to do this thing online. Come join us. So Bob left the University of Chicago celiac center, and came to Southern California and was our social media person. And then we found a guy to who knew how to run this program I learned about in jjs weekend called InfusionSoft, which puts puts all the data together into one package and sends it online. And we hired Bobby from Tennessee. And we put on the gluten summit. And the next day, I mean, so many of my friends call him said, How did you do that? What did you do people like Deanna Minik and Mark Hyman and so many other my friends, how did you do that? And I said, Well, my friends helped me here. And they said, Oh, can can are my staff and we just made it up. When there was a problem. We made it up. And they said, can I talk to your staff. And I said, Sure. Then my staff came to me and said, Hey, Doc, they they want us to do this for them. We should start a company to do this. And I know man, that's not my thing. That's not my passion. You guys go ahead if you want to. That was the formation of health talks online which is hosted 10s of millions of people in the last seven years in different summits all over the world, they of course, that's where it came from.Eric Rieger  40:09  Sorry about that. I didn't mean to talk over you. But of course, you wanted to have people that were interested in what it was that you were offering. You also find some inspiration in the fact that there were that many like minded people who were essentially as you probably assumed, but now you confirm they're kind of starved for that information.Dr. Tom O'Brian  40:27  Oh, I knew I knew from the day I opened my practice about the frequency of weed related disorders outside of celiac disease. I knew it. The testing was just not accurate enough at the time to confirm it. But I put people on gluten free diets and they get better again and again and again. But it was a component of a treatment program, not just gluten free diet, but it was a prerequisite you have to do that. Sure, guys, I see that the battery on my computer's at 5%. I have to run into the other room and get the charger So I'm going to come right back to you. SoKen Brown  41:04  we're gonna love this. I love this conversation. So what's really cool about Dr. Tom is just how honest he's being. He's just like, Hey, I met this guy. He taught me something. I met this other guy. He taught me something, I met this, JJ comes up to me and says, Hey, come over and do this, and just pulls the trigger and says, I have a message that I interview out there. And the digital marketing era was really in full swing. Right then.Eric Rieger  41:30  the thing I felt the reason why I asked Darshan that last question was, to me it was it was eye opening, even when we met JJ is just seeing how many people were now gaining access to topics that simply were not being addressed when when we were young, or going through school, etc. And basically what I feel like Dr. Tom just illustrated here is technology has allowed us to take what has been either ignored or hidden messages out to the masses and then helping people where they couldn't find help before. Ken Brown  41:59  Yeah. Are you back with a Tom?Dr. Tom O'Brian  42:02  I'm back with you. And as, as, as you were talking about technology absolutely correct, you know, for years and years that they thought I was a nutcase because I would talk about wheat related disorders outside of celiac. And now we have the testing available that's very, very accurate 97 to 99%, sensitive and specific. And so with those kinds of tests, the test is called the wheat Zoomer, could you zoom in on problem? And with those kinds of testing, people see for themselves that their immune system is trying to protect them, whether they get sick when they eat it or not.Ken Brown  42:43  So you've said this three times now, which means that it has clearly been a part of your career you said they said I'm a nutcase. They said I'm a nutcase. They knew I was a nutcase. So you've stuck by this, but will you explain a little bit when you say that, they say I was a nutcase. That meant that as a chiropractor discussing these other aspects infringing on people's territory, was it that you were just so far ahead of the curve that nobody was discussing? I want to know why you feel why you Dr. Tom feels that other people viewed you as a nutcase?Dr. Tom O'Brian  43:20  Oh, it was obvious. It was spoken about. But the the point in that is, you know, when when you know, that science is on your side, but technology just hasn't caught up yet to confirm it. And you know, it's on your side, because you see the results again, and again, and again and again, and you keep seeing the results, but you the technology just hadn't caught up yet. Then either you go by the status quo, with all of these unexplained applications, and people Don't get well, they're the way they're supposed to, or are you willing to break new ground and say, you know, oh, no, as is negative, when they give up wheat, they feel so much better. Why don't you try it for three weeks, and let's see what happens. Well then, and they get better. Their their child's attention deficit gets better. And the teacher say the new drug, you've given your child's working really well. And it was just a gluten free diet. The other parents say, Oh, we, we didn't give them any drugs. So he's on a gluten free diet. And you see that again and again and again. I can't let what other people think of me get in the way of the service that I can do for my patients.Ken Brown  44:50  Because you took a really bold let's, let's dissect what you just set about that. You knew that certain people in health care, we're not saying the nicest things about you. And then you dove in when you said I don't want to treat a patient that just sticks their toe in the water, you dove into a digital marketing world where keyboard warriors love to play also. So you went from I know that some people are going to say not nice things, too, I'm going to embrace it on a level that nobody ever has. And I'm gonna teach online, which is a very, very bold thing, because not a lot of people have the guts to do that right. To be pushing the envelope. I mean, it's, you know, I mean, you talk about I've been talking about zonulin for years before we test it. And you said we'd Zoomer and that's how I got involved with vibrant wellness. I was like, Ah, you guys figured out how to check zonulin? Yes,Dr. Tom O'Brian  45:49  yes, yes.Ken Brown  45:51  Yeah. And when I talked to my colleagues, I mean, even when I talked to gastroenterologists, they looked at me like you're What are you? Are you one of those? nutjobs talking leaky gut. You're one of those weirdos talking gluten sensitivity. Um, you know, fortunately, I fortunately did not discover the internet early enough so I didn't have to put myself out there and have a successful career writing books and doing stuff like that. Fortunately, I still have to stick my finger in people's butts to make a living and occasionally interview somebody who's smarter than me that decided to put it out there on the internet and do things and do summit so that's a but it takes guts to do that. So are you there. Dr. Tom?Eric Rieger  46:35  Did he freezeDr. Tom O'Brian  46:37  sn Ken Brown  46:38  you froze there for a little bit.Eric Rieger  46:41  We can hear you. Okay. You guys go. How about that?Ken Brown  46:45  Okay. There we go. Okay, back now.Dr. Tom O'Brian  46:47  Okay. Yeah, sorry. Yeah, you're absolutely right. You know, you asked me why and how did I do this? A home that I have in every one of treatment rooms. Can Can you hear me? Okay?Ken Brown  47:13  Yeah, you're going in and out a little bit, but I think it's all right. Oh, we should go ahead and muscle through it. That's right.Dr. Tom O'Brian  47:19  Okay, okay. There's a poem that I when I read it I just resonated deep deep in my being. It's by George Bernard Shaw. This is the true joy in life, being used for purpose recognized as the Mighty One. The being a force of nature. Instead of a selfish, feverish little clod of ailments and grievances complaining The world will not devote itself to making you happy. I am of the opinion that my life belongs to the whole and it is my privilege to do for whatever I can, life is no brief candle to me. It's sort of a splendid torch that I have a hold up for the moment and want to make burn as brightly as possible before passing it on to future generations. So that's my creed.Ken Brown  48:18  I love it. I love it. It's awesome.Dr. Tom O'Brian  48:20  And and from that place, if you know about zonulin, and you know about leaky gut and you think a patient's got it and you don't address it, because of what our peers may think, in my mind, it's Shame on you. And I do that on stage with doctors all the time, who cares what your peers think? I'll give you an example of that one, and you'll appreciate this one 1986 Australia. gastroenterologist says, You know, I think that sometimes ulcers are caused by a batch said you are a nutcase. Everybody knows ulcers are caused by too much acid and you have to give antacids so what did this guy do? He does an endoscopy, puts a camera down into his stomach takes pictures of the healthy pink tissue of his stomach. And then he drinks a beaker of beaker of a bacteria called Helio backer pylori. waits for days until he's as sick as can be, does another endoscopy takes pictures of the many ulcers that are starting in his stomach, and then he takes the antibiotics to kill the bacteria waits about a week until he's feeling better, does another picture of the healing of the ulcers. Then he publishes that paper, then everybody knows he's a nutcase. But he proved the under shadow of a doubt sometimes, ulcers are caused by a bacteria and the World Health or I thought that was so important. They sent that paper to every medical society on the planet. Why? Because at that time, stomach cancer was the number one cancer killing people. And it often comes from a helium backdoor infection. So, this guy didn't care. You know, he didn't care. He done his work, and he still was kind of thought of as a weirdo out there. Dr. Barry Marshall. 21 years later, he wins a Nobel Prize in Physiology. And the Nobel committee says and this is the exact quote, who with tenacity, and a prepared mind challenged prevailing dogma and that's what every one of our patients needs.Ken Brown  50:49  a prepared mind. I like that exact word mind if you if you're tenacious, but you do your homework, you burn the midnight oil, the prepared mind with tenacity is an unstoppable force. That's awesome. That's love thatDr. Tom O'Brian  51:05  is just one hour a week. That's tenacity every Tuesday night after dinner every Sunday morning after services whenever it is, but every week, you're going to spend one hour learning more about reading the map of how you got to where you are just one hour a week. And in six months, you've changed the way you think you change the way you live your life. You challenge prevailing dogma, and your health is the benefit that you get from it.Eric Rieger  51:34  I love that. Ken Brown  51:35  I love it. IEric Rieger  51:36  mean, it's interesting that you use Marsh as that example, because when this guy sitting to the right of me developed Atrantil and went on to talk about why polyphenols are so incredibly important. I guess we're going on six years ago now. He used that example. And that it's okay to think outside of the box which is essentially what he was saying to challenge dogma is to go outside of this box that we have built around ourselves. If it weren't for someone venturing outside, we never would have made innovation. Ken Brown  52:08  And the beauty of the technology that has allowed you to have this stage where 600,000 people sign up for summon at one time, also allows us to share globally information in a way that we couldn't before. So when I sit there and meet with some of my colleagues, and they're like, oh, there's no science on that. I'm like, Oh, really, let me pull up my Mendeley account. Really, here's 8000 articles on what we're talking about. Why don't you start reading that and when in my world traditional medicine world especially in Texas, I think that different states a little more progressive, like California has always been a little more open to the functional medicine side but Texas, not so much coming around. But when the drug rep to my left over here when doctors say there's no science on that what they're saying is somebody is not brought me lunch with a detailed piece explaining what I'm supposed to say. That's really what I'm saying. And we're all really busy. And that is what it is. But it just happens to be just like you. You go, um, you know, I'm tenacious, but I'm armed with science, therefore, I can walk into this battlefield and hold down, even if they even if they call me crazy.Dr. Tom O'Brian  53:17  Yeah, cuz that's exactly right. Last week I did an interview for a neuro psychiatric psychiatry group. And the doctor who coordinated the interview, she said, you know, Dr. Brian, I heard you speak three years ago at our conference, and you yelled at us on stage. No one's ever yelled,at us on stage before your neuropsychiatrist they're the cream of the crop in their own mind. You know, they're legends in their own mind. Right. AndKen Brown  53:48  voices in their heads.Dr. Tom O'Brian  53:50  Yes, right. Good, catch. Good, good. But what I said to them if you aren't spending one hour a week, reading the current literature Cutting Edge literature in your field of expertise, shame on you. You're outdated, one hour a week. And nobody's got time for any of this. But if you don't do that you're outdated within a year. Yeah. And, and she thanked me. She said, You know, I took what you said to heart because it made sense. I didn't like how you said it, but I liked what you said. And the result is I've completely changed my practice in three years. Thank you so much. I really want to acknowledge you here on the microphone in front of all of my colleagues, that was such an excellent recommendation to us and i and i say that to everyone. Whether you're a general public, or a health care practitioner, one hour a week. That's what it takes to have 10 that's tenacity and then prepare your mind to challenge the way you think so that you can read the map of what's happened to your body so far,Eric Rieger  54:58  don't you one of the reasons why really enjoy doing our show is that I'm a better doctor because of it because I prepare for different things because I have to research a lot of stuff. When we talk about topics. You're the exact same way you have gone. You started with the gluten and the you went to the brain. You're looking at this now you've got different you've got the whole erm. Dr. Tom O'Brian  55:20  bottle immunityKen Brown  55:21  Yeah, but what's the name of the of the program again?Eric Rieger  55:25  betrayal, Ken Brown  55:26  betrayal, betrayal. Yeah, I was I was trying to think of that. So when you do that you automatically your passion will have you read this. So I'm going to ask for your help. Maybe it's not you. Maybe it's some other people that you meet, but we're running into something. So when I say my Mandalay account, I have a graduate student that I work with and she finds everything If you need anything, let me know just email me She will find it and get the articles and so we can sit there and look at some of this but I'm seeing something and I think that you're probably seeing it also and it is This weird it becomes down to a nerve, dysautonomia motility type situation that can be the underlying cause of a lot of gastrointestinal issues which then lead to neuro inflammation. And now we're getting to the vagus nerve and we're talking about this I've got some really sick people that come to me and they're they've all been to the Mayo Clinic they've all been to the Cleveland Clinic and they all have been told that it's functional this and that, that it's in their head and they all say you should start taking Prozac but these are really intelligent people really type a people that had very successful their attorneys or accountants and this and that. I'm seeing a trend here that the chronic disease is affecting the nerves that is it acetylcholine Do we need to start working on the you know, the, the vagus nerve, I don't know. But I it just feels like more and more people are showing up there. They're really trying what's your what's your take on that? Because if we can figure this out. That's it.Dr. Tom O'Brian  57:00  This is this is a PhD discussion that we're now getting into that is at the core of the answer to your question. Arguably the number one journal in the English language for children's health is the journal Pediatrics put out by the American Academy of Pediatrics. They published a policy statement, which means it's not an author, you know, if I were to get an article published in pediatrics as an author, I've scored top tier difficult journal to get into I've really scored but this is a policy statement. That means it came from the board of the Academy of the American Academy of Pediatrics, and they said the toxic substance Control Act failed miserably to protect our children and princes and adults. And it is The governing legislation at the federal level for all chemicals introduced into our environment. This was passed in 1976. It's still the regulating guidelines for all chemicals introduced into our environment. It the the guidelines are so cumbersome, that in 40 years, they've only regulated five chemicals or classes of chemicals in 40 years. Because the lobbyists were so successful in paying off the senators and the representatives to pass this legislation that has no teeth. The legislation says you have to show that the amount of whatever chemical a person is exposed to is toxic to them. When you pump gas and fill your tank with gas, can you sometimes smell the gas? Sure, of course. you're smelling benzene,Ken Brown  59:09  right? Oh, yes.Dr. Tom O'Brian  59:10  Benzene going up your olfactory nerves right into the brain triggering inflammation killing off brain cells right now. Right? It's killing brain cells. But there's no evidence that the amount of benzene it's inhaled while pumping gas is toxic to humans. There's no evidence you can't. There's no evidence that it causes a problem. But give me 30 years of smelling benzene once a week and how many millions of cells you've killed off. I'm warming up now. 2017. papers published that came out of Chicago 346 pregnant women and the eighth month of pregnancy They did urine analysis they measured Phthalates five Phthalates Phthalates are chemicals used to mold plastic. Most of us have heard of Bisphenol A or BPA Corona is one of the chemicals. They measured five chemicals. There are hundreds of chemicals but they just measured five. they categorize the results into quartiles, the lowest, the next, the third and the highest quartile. They then follow the offspring of those pregnancies for seven years. When the kids turned seven years old, they did Wechsler IQ tests on the official IQ test. There's not much in medicine, that's all or every This was every every child whose mother was in the highest quartile of Phthalates eats and urine and pregnancy compared to the children in the lowest quartile of Phthalates and urine and pregnancy. Every child in the highest score tile, their IQ was seven points lower than the kids in The lowest quartile of Phthalates seven points. That doesn't mean anything to anyone until you understand one point difference is noticeable. A seven point difference is a difference between a child working really hard getting straight A's, and a child working really hard, getting straight C's, right this kid in hell because his brain never developed properly. And then just go to Google and type in Phthalates and neurogenesis, nerve growth. Here come all the studies, how balades inhibit nerve growth. And you see this and you wonder why Autism is going up and attention deficit is going up. You see this and then you go back to the pediatrics article and you read that is 247 pounds of chemicals manufactured or imported into the US United States every day for every person in America 247 pounds, that's 27 trillion pounds a year, take the population of the US multiplied by 247 times 365 days, it's 27 trillion pounds.Every newborn child in America has at least 200 chemicals in their bloodstream at birth that aren't supposed to be there. Many of them are neurotoxins, brain time. You wonder why we're seeing this increase in disease. We all are walking sewage dumps, excuse me, but we are we all are because it's in the air. You if you sit in a room and you can see the sunlight coming through the window, sometimes the right time of day the angle and you see little dust in the air. That's what you're breathing. That dust is the family lychee From the plastic lines in the windows, they leach out family chemicals into the air for years. It's the scotch guard on the sofa, leaching out those chemicals into the air for years. It's the formaldehyde in the kitchen cabinets. If they're not solid wood, they're pressboard. They're soaked in formaldehyde, and the bathroom cabinets leaching out into the air for years. And we were exposed to all of this, all of that and we're walking sewage dumps. You wonder why degenerative diseases are going, why Alzheimer's and the number one type of Alzheimer's is inhalational Alzheimer's, it's what's your breathing. This is so overwhelming for people. When you get when you look at this map. When you see what's happening. It is so overwhelming. That's why you have to operate from the platform of one hour a week. Yes, because and so one week When you learn that the leftover chicken from dinner, you put it in a plastic storage container in the refrigerator. The next day the chickens got phalates in it from the plastic. When you learn that one week, you take that hour you go into my book and there's the three URLs to order glass storage containers, and you go to miles, kimball.com and Amazon, whatever the third was, Oh, I like those. And yours three round ones in two square ones and one for the eyes. You pay with your credit card, you hit send, it took an hour, you're done for the week. Like that. Never again, will you poison your family with minute amounts of foul aids from leftover food in a plastic storage container. Now, there's no evidence that the amount of families that leach out of plastic storage containers is toxic to humans. That's how they get away with that crap it is. That's how they've gotten away with it. And it's the it's the The indoor and just read the science indoor air pollution is much worse than outdoor air pollution in most areas of the country. Because we don't think about our homes we don't think about the formaldehyde, the benzene, trichloroethylene that we're inhaling, then you go to my book and there's the study with the graph that the study from NASA that shows to six inch house plants, and there's the list of all the house plants that do it to six inch house plants and a 10 by 10 room absorbs up to 70% of the toxic chemicals in the air.Ken Brown  1:05:37  warmer times. This is the front so now you're scaring the snot out of me, but now you're giving me a solution. So you're saying when your book can gotDr. Tom O'Brian  1:05:43  a Kleenex, hand him a Kleenex to get the snot and to six inch houseplants, and there's about 12 or 14 different types of houseplans six inch houseplants absorbable To 70% of the toxins in the air in a 10 by 10 room, they're absorbed through the leaves, they go down into the roots, the microbiome of the soil breaks that stuff down. They produce oxygen and put oxygen into the air to 10 by 10 to six inch houseplants for a 10. By 10 roomEric Rieger  1:06:17  solution.Ken Brown  1:06:18  Yeah, it's a solution I'm all about so and so your book is not just teaching people what to worry about, but you're like, this is the solution. So the one hour a week is I'm going to give you one hour a week solution. And if you continually do that, by the end, you're going to be a healthier person.Dr. Tom O'Brian  1:06:35  You know, everybody wants solutions. Nobody wants to hear about the problem. But there's no way you will have the tenacity to do this. And at a pace that you can do it and not be overwhelmed. That's why it's one hour a week understanding. You are going to be overwhelmed, but you're going to do bite sized pieces pieces of this. And in six months. You've got it. You've changed your life. Your husband Using the Tupperware containers to store nails in the garage, right? I mean, you've got all the the dishwasher, you'd never run the dishwasher during the day. Because the toxic chemicals that come out of the dishwashing detergent, when they get heated up to 160 - 170 degrees, they leach out of dishwashers are not airtight. They're watertight, they're not airtight, and those chemicals are in the air, you're sucking those fumes. You only run the dishwasher at night when everybody's sleeping. And you've got to learn all these little things because the paradigm that we've accepted the prevailing dogma that we've accepted about the way to live life and about our homes is killing us. It's slowly killing us. This is why your patients are coming in with more confusing results is because they're loaded full of all of these toxic chemicals. How many of us have been watching the chem trails? For years to say, Oh, that's really something you know that that's too bad. Yeah, I wonder what that stuff is. And we've never done anything about it. We're sucking the fumes of all those heavy metals that were being spewed into the air.Eric Rieger  1:08:12  Yeah, well, I do want to add something here. I know that we've been it didn't seem like until just looked. But we've been talking for a good while. And I need to also give you some praise since you were the first to utilize the digital internet to reach so many people. You also have one of the most kick ass URLs I've ever seen. Yeah, so what is it? We do? SoKen Brown  1:08:34  we haven't ever joked about this? I was like, how in the heck did that guy get that URL?Dr. Tom O'Brian  1:08:39  1996Eric Rieger  1:08:42  the URL to link up with this very Dr. Tom O'Brien is the doctor.com and I want to say that one more time the doctor.com but you have the Dr. Yeah, I'm sorry. Yeah, you're the Dr. calm. So Dr. Bri ER doctor abbreviated v dr.com. dr.com will connect you with Dr. Tom O'Brien. But you also also have two specific programs for our listeners. One is to do that with a / betrayal to get on to the train of exactly the training that you're talking about and the other one, and I'll put, I'll put this in show notes, everyone, but the other one is thedoctor.com/kickstart. And if you want to do a quick rundown on exactly what kickstart is, that way, everyone in our universe can hop over and learn a little bit more from that from that with from you. Just tell us a little about thedoctor.com/kickstart.Dr. Tom O'Brian  1:09:36  You bet that Thank you. The kickstart is a number of handouts for you. They're going to talk about how to detox your house, how to reduce electromagnetic pollution in your house. What are the house plants that will suck up toxins? There's there's a handout for the kitchen there's a handout for the bathroom. There's a handout for the bedroom, all a number of different handouts so that you've got Steps to implement right away and you take them at your own pace, you'll get the plastic storage containers out of there, order glass storage containers, things like that.Ken Brown  1:10:10  Dr. Tom, I want to interrupt you real quick because you've hit a nerve with me here this is I just don't have the I'm always I spent a lot more than just an hour a week. But I spent an hours a week looking at the stuff that I'm interested in. And I have a blind eye to what you're talking about. And what you just said is I'm going to give you solutions. You can put a handout up, you're just going to go do this, this and this, because I believe you and I, I don't want to read a whole book about why I should get rid of my plastic just Just tell me how to how to fix it. That's what I like. kickstart seems like a really cool program for that.Dr. Tom O'Brian  1:10:46  Oh, thank you very much. And if you were my patient, I'd be all over you. That you can't do that because it's wanting solutions that has gotten us into trouble. Oh, gotta understand. All of you. The map of what happensKen Brown  1:11:01  this where you start yelling at me like you did on stage.Dr. Tom O'Brian  1:11:06  Because if you don't understand that mold can be a huge problem for Mrs. patient. When you go on vacation for a week or two, when you come home, you have to open the windows to air the house out. Oh, yeah, you got mold. You have to have the house remediated, you have to have a professional come Well, I don't have a problem. When I'm here. I don't feel anything. It doesn't matter if you feel it or not. If you're inhaling it, it's going up to your brain. And it's the number one trigger for the development of Alzheimer's is in halation, Alzheimer's, it's what you're breathing. So if your brain ain't cooking the way it should be, it's cooking in the wrong direction, you're too much on fire. You have to identify where it's coming from so you can get all the house plants you want. But if you still got mold in your bathroom, well it's not too bad on the tiles there. You know, it's just on the grout in between the tile that's not too bad. We'll Put that on your tombstone. It wasn't too bad. You know, it's critically important that we change our paradigm so that we understand what our individual map is, what has gotten us to where we are, because that map is going to change, you're going to get better because you implement the things in the handouts. That's great, you're going to get better. But a year from now, two years from no

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michael Greiwe on the show to discuss telemedicine.  Dr. Michael Greiwe is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. In this episode, we discuss: -The benefits of telemedicine for both the patient and provider -Choosing the right telemedicine platform for your practice -How to meet patient privacy and compliance requirements -Practical tips for a seamless telehealth visit -And so much more!   Resources: Ortho Live Website Michael Greiwe LinkedIn Michael Greiwe Twitter Email: mikegreiwe@ortholive.com   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.    For more information on Dr. Greiwe: Dr. Michael Greiwe, M.D., is a surgeon by day and tech guru by night. He is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. Dr. Greiwe is a nationally recognized expert on how telemedicine technology is changing the practice of medicine. TV news stations and podcasts across America have interviewed him about the future of telemedicine and how to use it to improve the patient experience. He attended the University of Notre Dame, where he won the prestigious Knute Rockne Award for excellence in academics and athletics. He completed his Founder and CEO of OrthoLive orthopaedic surgery training at the University of Cincinnati Department of and SpringHealthLive Orthopaedic Surgery and Sports Medicine. In 2010, Dr. Greiwe completed his fellowship in shoulder, elbow and sports medicine at Columbia University, training with the head team physician for the New York Yankees, Dr. Christopher Ahmad.   Read the full transcript below: Karen Litzy (00:01): Hey Dr. Greiwe, welcome to the podcast. I am so happy to have you on today to talk all about telemedicine. Michael Greiwe (00:08): Oh, thanks so much, Karen. I'm glad to be here. I really appreciate you having me on the show. Karen Litzy (00:11): Yeah. So for any of the long time listeners of this podcast, you know that back in March and April, when the covid pandemic hit, we talked a lot about tele-health. But I think it's great to sort of revisit that now that we're a couple of months in and perhaps more people are using telehealth at this time, then were back then. But what I want to know is Dr. Greiwe, did you just start using telehealth when the pandemic hit or were you more of an early adopter? Michael Greiwe (00:42): Yeah, thanks for the question. I kind of carrying out with sort of like an early adopter. You know, I started using telemedicine back when it really wasn't cool, I guess. It was like back in the 2016 time period. And I knew it was great for my patients cause they live pretty far away. I had patients that live like two or three hours away and they would drive and try to meet me. And then you know, I'd only see them for 15 minutes. I felt really bad about that. So I started using telemedicine and it's been a great thing for my practice. And then of course, you know, recent things changed everything and it's now exploded. Karen Litzy (01:16): Right. And like I said, in your bio is that you're an orthopedic surgeon. So one question that I think is probably good that you probably get asked all the time is how in the heck do you see someone for an orthopedic condition when you can't put your hands on them and kind of feel what's going on? Michael Greiwe (01:37): Yeah, that's a great question. I get it all the time. And it's one of those things where, you know, for me, and I'm sure for you as a physical therapist, you know, so much when you hear about the history of that patient. So like the history gives you probably 80 to 90% of what you need. And then the rest is sort of verifying things through, you know, a physical exam and there's certain things on video that you can kind of catch. So like if I have somebody with the rotator cuff problem, I can watch their arm move. And I just know that the rotator cuff is bothering them. And then I'll maybe order like an MRI or something along those lines sort of confirm. But ultimately for me, it's more about like, you know, I may have to see this patient in the office at a certain point in time, but I don't always have to do that. It's kind of like depends on what the history gives me. Karen Litzy (02:22): Yeah. And I agreed from a physical therapy standpoint. I get that question all the time is, well, how can you do physical therapy on someone if you can't, if you're not in the same room. And again, it comes down to listening to the patient. Like they will tell you everything you need to help treat them to help diagnose them. If you just listen in the beginning and then you can tailor your program accordingly. Now of course, like you said, there are times where you have to see the person in person, right. And sometimes that's the same with PT. So I think oftentimes when people think about tele-health, they just paint with a very broad stroke and they think, well, how can you do that? So what do you say to people who sort of have that mentality of all or nothing? Michael Greiwe (03:13): Yeah. I think if they experience it for their, you know, themselves, they can sort of see that, okay. You know, this really works and it works because, you know, if you have somebody on the other side that's engaging you and asking the right questions, you're going to eventually come to the right answer. You know, I've had patients with a frozen shoulder and I'm sure you've treated patients with frozen shoulder. It sort of have classic signs and symptoms. Sometimes the history isn't like exactly, they're just sort of out, well, you know, my shoulder has been hurting and it kind of came on over the last several months and now I can't really move my arm as well as I used to. Or maybe you might not hear that. You just hear like, well, it hurts all over all the time, but if you kind of ask some leading questions, you have the right examiner, you can find out the answer. And so I think that's really, the key is having the right person on the other side of the screen, you know, asking the right questions. I'm sure you do the same in your practice with physical therapy. Karen Litzy (04:06): Yeah, absolutely. And you know, when we're talking about our different practices and our businesses because of the COVID pandemic, a lot of places had to shut down there in person I'm in New York city. So talk about being shut down. So we were shut down quite early. Now other parts of the country are flaring up and there's a lot of uncertainty here. So when it comes to tele-health and our business, how can tele-health help our practices grow and help our businesses grow? Michael Greiwe (04:41): That's a great question. I think it's something that people are sort of finding out more and more about right now. I mean, there's so many ways to be able to utilize telemedicine in our practices to help it grow. I mean, first of all right now as an orthopedic surgeon, I see patients from around my area because of COVID in the situation we're in right now, they don't want to come into the office, you know, so they're looking online and they find, Oh, Dr. Greiwe has got an open slot to be able to be seen via telemedicine. So we're kind of advertising that at ortho Cinc, where I practice to say, Hey, anybody that might want to come in for telemedicine appointment, you can. And it just gives me access a lot better than it normally would to be able to see patients. And then I think there's other ways too. Michael Greiwe (05:25): So for instance you know, for physical therapists, you might work with employers for instance, or workplaces that need a physical therapist and you put like an iPad there to say, if you need a physical therapist, here's how I can help you, you know, call me or whatever through this device. And so there's just so many ways for us to do that inside ortho, specifically postoperative recheck appointments, they open up slots of time that, you know, you typically wouldn't have because it's a lot more efficient to see someone via telemedicine than it is in person. And you know, also there's a lot of downtime kind of between surgeries for us too, so that downtime can be utilized for telemedicine too. So there's a lot of ways we can sort of generate you know, revenue through that and kind of open up our practice a little bit more. Karen Litzy (06:13): And, what I found is I can actually help more people. Michael Greiwe (06:17): Oh yeah, absolutely. Because you could probably have group visits too. Right. You could have you know, on those group visits or are you talking about just sort of more you know, area? Yeah. Karen Litzy (06:29): Like you were saying before we went on is sometimes you have people have to drive two to three hours to see you. Right. You know, that's really, that can be really difficult. So imagine if you have, you know, this really aching shoulder pain and you have to drive two hours. Michael Greiwe (06:45): Right. Absolutely. You're absolutely right. I think what helps, what helps you is, you know, with telemedicine, you've got the reach to be able to see somebody that's five hours away or even across the country that's heard about you or, you know, maybe they know that you have certain techniques that they like. I sort of developed like a posterior shoulder replacement where it's kind of a muscle sparing approach to the shoulder. And so I have people come from like California, Texas, Montana, you know, and now I can kind of see them postoperatively and preoperatively with telemedicine. So it's a really nice, it's a nice tool from that standpoint too. Karen Litzy (07:19): Yeah. That's great. Yeah. So you could see them preoperatively, if they're across the country, they come in, you do the surgery and then you can then see them postoperative. So they don't have to stick around by you for six weeks. Michael Greiwe (07:33): Right. So I'll have him stay for the first week and then we'll have the incision to make sure everything's looking good. Take x-rays and then they'll go back home and then I'll check in with them every four or five weeks, they'll be doing physical therapy kind of in their local area. Or of course I could refer them to you to remote therapy, but yeah. So that's how they do it currently is they go back home, they work and they get their motion back. And then we'll check in again, virtual. Karen Litzy (07:57): Now how about prescribing medications? Is that something that you can do via tele? How does that work? Michael Greiwe (08:03): Yeah, it still works pretty well via telemedicine, but I don't really do any like schedule three narcotics, you know, things like that. We don't do, but you know, anti-inflammatories, you know you know, if somebody has had some nausea like Zofran or, you know, things of that nature are pretty easy to prescribe and we still prescribe and have the same prescribing practice that we do in person, it's just, I get a little bit more wary and I think it's prudent to be more wary about, you know, narcotic prescriptions and things like that, especially in the world that we live in right now. We've gotta be very careful about that. So, we're super careful with that, but I think most of the other prescriptions are totally they're okay to do. Karen Litzy (08:46): And how about this is a question that I get sometimes is what about privacy and compliance and making sure that meeting all those standards. So how can we ensure that we're doing that as a healthcare practitioner on tele-health? Michael Greiwe (09:04): That's a great question. I think, you know, it is very important, obviously. So HIPAA compliance is what it's sort of called as you know, and it's what everybody's sort of, doesn't like to have to worry about, but it's very important for our patients, right? I mean, it's, people are very much in tune with their privacy. Data privacy is becoming like a really big thing right now, but really people's healthcare privacy and their you know, their medical privacy is very, very important. So the telehealth platform that you choose, you have to make sure that that is HIPAA compliant. And that means end to end encryption. That means like the data that starts out, you know, it's carried through the internet and it's encrypted and then wherever it's housed, it's also encrypted there too, so that no one can sort of get to that information. I think that's really critical, very important for our patients and most of the platforms they will advertise whether or not they're HIPAA compliant. And you want to know kind of how many you know, what type of bit encryption they are and things like that when you look at platforms. Karen Litzy (10:06): What was that last thing you said? Michael Greiwe (10:09): Yeah, it's sort of like, as the information is traveling across the internet there's sort of, you know, bytes of information, right? And so the amount of encryption can be sort of leveled up so that, you know, basically you can have like 64 bit encryption, or you could have 264 bit encryption there's certain levels. And so it takes, it's like a string of numbers. And so that string of numbers is how much it would take to crack the code essentially. So 256 bit encryption is like, you know, a massive amount of code breaking has to happen to catch that while it's traveling through, you know, the inner web. Karen Litzy (10:50): Well, no, that's really good because I think that's something that if people are choosing a platform, it's definitely something that as a provider you want to be looking at. Michael Greiwe (11:00): Absolutely. It's very important, you know, and most providers are pretty in tune with that, but right now, like, you know, they're allowing telemedicine to occur on FaceTime and some other platforms. Karen Litzy (11:12): Now FaceTime is not HIPAA compliant. Michael Greiwe (11:17): Yeah. So we don't want to really be using that right now. And there are some providers out there that are doing it, maybe just for ease of use and because the pandemic it's happened. But ultimately what we really need to make sure is that we don't use those platforms. Those platforms are not safe, not secure. Karen Litzy (11:35): Are there any other sort of things that you want to watch out for when you're let's say, well, first we'll start with looking at different tele-health platforms. So what are the things that you want to be looking for? And if you have any advice on a do's and don'ts, while you're actually in your tele-health session, I know some of them seem like, should be common sense, but you never know. So let's go with, what should you look at first? What should you be looking at in your telehealth platform? Michael Greiwe (12:11): It's a great question. I think the first thing that's really important for patients is making sure that, you know, the HIPAA compliance there, we covered that, right? So HIPAA compliance, probably number one, number two is, does this platform allow you to, you know, keep a schedule? So one of the most frustrating things as a provider of telemedicine is, and this is what I found out many, many years ago is that there is no schedule. You know, you have to send the invitation to the patient. The patient sort of says, yes, I'd like to do this. And then, you know, they link up eventually, but what you really want us to be able to schedule the appointments, that way you can move from one person to the next, and you're not really leaving a screen and trying to come back and forth just from an efficiency standpoint. Michael Greiwe (12:53): It's not very efficient to do that. Another thing that's important, I think is being able to chat with your patient. Sometimes it's important to be able to have a conversation. And it's also important to answer questions. And so being able to have kind of a text based chat that's secure as well, that might be, you know, maybe they can send you a picture. Maybe you can send them a video. Maybe you can send them sort of a document that gives them some exercises or what have you. And that's really important too. But I think one of the other things I was gonna mention is consenting. A lot of platforms don't have consent and of course that's part of the law. You have to consent that patient for telemedicine before you have a visit in most of the States, I think 45 of the States, you have to have a consent. So very important for the consent process to happen also. And that allows you to have a legal telemedicine appointment. Karen Litzy (13:44): And that consent process. Can that be in your initial paperwork? So if you're onboarding someone and, you have, I mean, we've all been to the doctor's office, you have to fill out a million different forms, right? So same thing with PT. So can that consent to tele-health be in that onboarding or does it have to be every time you connect for a telehealth visit, do they have to consent every single time? Michael Greiwe (14:11): That's a great question. And it's really just a onetime consent, so it doesn't have to be, you know, every time. So if they just come to your office first time, you're going to maybe have him sign some paperwork that says consent to telemedicine, and that's fine. You're good to go. But in the case where you have a new patient, it's very important to make sure that you have that consent process. And so for us and what we do at ortho live and spring health live, we just have them sign off one time that they agree to telemedicine. And then we assume every time they visit the platform, they know what they're doing and they've already agreed to it. Karen Litzy (14:44): Yeah. Yeah. Cause I have woo. You just gave me a little sigh of relief cause I have it again as part of my onboarding paperwork that people are consenting to their telehealth visits, but I don't do it every single time for each visit. Michael Greiwe (15:00): Right. Then I think it's just sorta like the billing practices in your practice too. And that people sign off that they're okay with billing and that they just do it once they're not signing it every time that they come back, it applies similarly to telemedicine. Karen Litzy (15:12): Got it. Got it. Okay. So those are the things you want to look at when you're kind of shopping around for a platform. Now let's talk about some things that you want to have in mind as the healthcare practitioner during your telehealth visit with your patient on the other end. Michael Greiwe (15:30): Yeah. It's a really good question. So the first thing is if you're going to use a phone, you know, and sometimes you're using a phone because you might be on the go or maybe your platform only allows you to have a phone it's really important to make sure that you don't like hold the phone, like right underneath your nose. Because it sort of gives you like kind of the up the nose shot a little bit. So I always tell people, you know, prop your phone up in front of you, like on your keyboard, maybe that's a really good place for it. Or if you're using a laptop, obviously like your face is kind of directly in front of that camera. And it just gives you more of a conversational type of appearance to your patient rather than you're not like talking straight down to them. Michael Greiwe (16:06): I think that's important. The other thing to sort of test out is just make sure that like, you know, when you move your right arm, like your right arm is like going up in the correct location in the camera. So you're not off to the side, you know of the camera when you're trying to show them kind of what you expect, I imagine for physical therapy and you can answer this, you know, too, I imagine for physical therapy that you may have to be seen, like your full body may need to be seen at some point in time. Karen Litzy (16:33): Yeah. Yeah. You definitely need like a decent amount of space so that you can lay down on the ground. You can come up to kneeling, you're standing you're so yeah, for physical therapy, you do need a good amount of space. So it comes down to finding those spaces, whether it's in your home or your office, where you can kind of get the right angle and good lighting. Michael Greiwe (16:54): Right. That's great. I think that's really important. You know, for your listeners on the physical therapy and for us, it's also being able to screen share too. If you can screen share, then you can show x-rays MRIs, things like that. And just getting tests sent out. Like I know for my practice, you know, we had a lot of physicians go live as soon as COVID hit and nobody had practiced. And so it was disaster on the first day, it was like, you know, it was like Groundhog day. And like no one knew what they were doing. And I was running around different pods trying to help everybody. But it's important to practice just like we would never go to surgery, not practicing what we're doing, you know, you practice to on your side to make sure that everything's working properly, your camera, your audio and all of that. Karen Litzy (17:36): Yeah. Do a couple dry runs with friends and family, make sure it's working well. Yeah, that's excellent advice. And now what do let's say, physicians or therapists what do they need to do now to kind of quickly adapt to this telehealth? Because from like, I look at, it's such old hat now, but I've been doing it since March. So now you have other parts of the country who are sort of trailed behind New York city. So they're in lockdown maybe for the first time and they really need to start adapting quickly. So what advice do you give to those practitioners? Michael Greiwe (18:12): Well, you know, providers of medical services always have a hard time with change, right? I think that's like one of the tenants of being a type a personality, the personality that ends up getting into medical practices or, you know, we're very particular. So we don't like to change. That's the first thing to recognize. And, and so there's going to be bumps in the road and they're just going to be hurdles. And I think it's really important to just understand like, Hey, you got to sort of roll with the punches a little bit, understand is not usually too difficult. We just need to kind of figure out what your plan of attack is going to be. Are you going to see tele-health patients in the morning and then see your regular, you know business in the afternoon, if you're completely shut down, how are you going to adapt to that? How are you going to get the word out? Are you going to be able to market this really, really important for you to make sure you kind of figure all that out on paper before just sorta like saying, yeah, I'm going to buy this telehealth cloud from when we get rolling, you know, it's like let's plan an attack and how we're going to be seen and how we're going to be able to see patients. I think that's really, really important. Karen Litzy (19:12): Yeah. Makes sense. And now let's talk about the platforms. Let's talk about the platforms that you're involved with and how you got involved. So there's ortho live and spring health live, right? So how are you an orthopedic surgeon with all of the work that surrounds that and then sort of this tech person entrepreneur on the side. So you must have some spectacular time management skills. Michael Greiwe (19:44): Well, I've got a very forgiving wife. I know that that's number one. But you know, it is like a it's a wonderful thing for me because I really enjoy doing kind of creative things. Things that might help my patients and telemedicine was one of those things I think really was, was a great thing for my patients ultimately. But for me, telemedicine was a way for my patients to be helped in a way that we couldn't really help them through anything else. And so there wasn't a great solution. So I decided to found ortho live about three years ago, that was 2016. And it was only because I was looking around to try to find a solution for patients and for providers that was really efficient and that worked really smoothly. But what I found was that really didn't exist and it was really hard to find the right solution. Michael Greiwe (20:32): And so I decided to create it after speaking with a CEO of a telemedicine company out in the California area, he kind of runs a lot of the video for MD live and some of the other larger companies. And he said, Mike, you know, this is a great idea. You ought to kind of through on your vision to do this for orthopedics. And so I did that with ortho live and it's been really successful and I kind of knew what we needed. We just, you know, we didn't have the efficiency in a way to be able to see patients in a streamlined fashion. So we created that within orthopedics, which I knew very well. And then we kind of branched out and now we're offering services to other specialties and subspecialties as well with spring health live. Karen Litzy (21:11): And within these platforms, do you have ways to do objective measurements within these platforms? Cause I know some do some don't so how does this, how does this work let's say from an orthopedic standpoint. Michael Greiwe (21:27): Yeah. So I mean, if you want true objective measurements we have to kind of integrate with braces and things like that. So, you know, we're like a smartphone application. And so we do have API APIs that can integrate and take in information like that. It's not something that, you know, orthopedic surgeons really use on a daily basis. I would see that more for physical therapists. So we kind of have the ability to integrate with you know, applications that give you range of motion and actual discrete data. I think that's really important because it does give you some actual feedback on a day to day basis, how a patient's doing. But from an ortho standpoint, we don't really need those, like the discrete data points we just sorta need to see, okay, well, how was that patient performing? Michael Greiwe (22:09): Are they having difficulties still, you know, moving their knee, let's see you bend your knee. And if it's not really going as well as we want, we know we need to up the physical therapy, we need some more intensity there. And it's more of a good stall for us. Less on the discrete hard numbers, but with therapy, I feel like it is really important to have that feedback to say on a day to day basis that patient's not doing well, how can we help them? Do we need to intervene sooner? So maybe that's what you're getting at, but, but yeah, we have the ability to kind of feed that information back into our platform. Karen Litzy (22:39): Yeah. Yeah. That's cool. Because a lot of times it's, you know, you could say, well, if 180 degrees of shoulder elevation is considered full, it looks like maybe they're at 75% or they're at 50%. So, but it's hard to get those, like you said, very discrete numbers because we can't measure it. Right. So having the ability to kind of integrate applications to be able to do that, I think is it can be really helpful. Although I, yeah, I guess sort of postsurgical when the patient is perhaps limited to X amount of degrees of movement, I think is where that comes in really handy. Michael Greiwe (23:21): Right. Right. And we have them sort of stand kind of at the side and like watch for inflection and things like that. So I think we get, you know, to within probably five to 10 degrees, but if you're looking for exact degrees, that's where those programs, which, you know, you can strap like an iPhone to your leg now and like move your knee. And it measures range of motion through like some little track pads and things like that. And there's ways to, to really effectively get that, that motion and understand what's happening with the patient and recovery, which is nice. And so we've allowed the ability to integrate those types of applications to our platform, which is cool. Karen Litzy (23:56): Yeah. That's really cool. I was working with some developers based in Israel who have an app for gait. And so you put it in your pocket and what it does is it can tell you the excursion of your hip range of motion from flexion through extension pairing side to side, your stance time steps per minute all sorts of stuff. I think there's up to like seven or eight discrete measurements, which is super cool. So again, in times like this, this is where the technology 10 years ago didn't exist. Michael Greiwe (24:33): Yes. A hundred percent. Karen Litzy (24:36): Having that now is allowing healthcare professionals to continue to help their patients during this pandemic. Michael Greiwe (24:46): No question. I was speaking with a group that has some special socks that like will measure stride length and things like that. So they know when a person may be like, you know, unsteady with their gait when they might be a fall risk which I think is a great, it's a great thing. And so, you know, understanding when patients may need some therapy to try to help with balance is critical. I mean, falls are a multibillion dollar issue in the United States today. And if we kind of cut down on falls, it's a great, great opportunity. And so we're, I think we're leveraging little things like, you know, from a data standpoint to be able to improve population health. I think it's great. Yeah. Karen Litzy (25:26): And where do you see telemedicine moving in the future? The pandemics over is everybody just gonna wrap it up and call it quits? Or what, where do you see that moving towards in the future? Michael Greiwe (25:39): No, I think telemedicine is here to stay Karen, I think you know, so-called genies out of the bottle, you know, there's a lot of great things that have happened with telemedicine recently. I think it's here to stay. We're gonna end up seeing telemedicine continue to spike. It was on the rise. Even before the pandemic, we were seeing multi millions of patients that were being seen every year. It was doubling every year. And now it's like, I mean, I think it's gone up by 10 X. So there's going to be a lot more telemedicine, I think, in people's future. Karen Litzy (26:10): Yeah. And as we were discussing before we came on the air hopefully the providers of insurance will also agree with that and say, we are going to continue paying for these because look at the advantages it's giving look at the money we're saving because of this. Cause like you said, if you can have a telemedicine visit with someone and it prevents a fall, which is a multibillion dollar industry, would you rather pay the $2-300? Whatever it, I don't know how much it is or have that person hospitalized for hundreds of thousands. Michael Greiwe (26:48): You're absolutely right. And so if there's any, you know, any of the insurance industry listening is very, very critical that we continue with telemedicine for their patients. And it's so beneficial, not only in protecting them during this time period, you know, we definitely don't want to let them go out of the house or 70 year old patients that are potentially sick and I'll really you know, it's for their safety and it's also for the benefit of the patient. I mean, it's way more convenient for them. And so I think without a doubt, it is so important to make sure that our legislature continues to support telemedicine and telemedicine billing. Karen Litzy (27:25): Absolutely fingers crossed fingers crossed that that happened. So I'm with you on that. Alright. Now, before we start to wrap things up, is there anything that we didn't cover or anything that you want the listeners to sort of walk away with from our discussion on telemedicine? Michael Greiwe (27:43): Oh, I think the main thing is, is that, you know, there's a lot of great people out there trying to provide health care. And many of them are trying this, you know, as a new you know, thing for them in their practices. And I think supporting them in that is important. I think everybody inside their local community is really trying to do things via telemedicine now and they weren't doing that before. And so being flexible, I think with those providers, I think is important, but I also think that telemedicine is here to stay. It's one of these things where there's so much benefit on both the provider and the patient's end that it'll just continue to be here and be a part of society and medical care going forward. Karen Litzy (28:20): Yeah, absolutely. And now I have one question left and it's a question I ask everyone, and that's given where you are now in your life and in your career. What advice would you give to yourself as a fresh medical school graduate? Michael Greiwe (28:36): That's a good question. I love this question. I think for me, I was such a you know, a worrier, like I was, I was always worried about, you know, what was I going to be good enough? Was I going to be smart enough? And you know, I always knew that I believed in myself, but I didn't trust myself back in those days enough to know that I was going to be okay. And I think the thing to remember is like, you know, you went into this medical profession for a reason you want to take good care of patients. You got to believe that, you know, you're a hard worker and you're going to continue to do as best you can to take good care of people. And you're not, you know, even a few fail it's okay. I think failure is it's okay to fail. I think that's another thing that I would tell myself to, because I was so worried about failing that I wasn't willing to like branch out and take risks. But I've learned that now. And I think if I could go back, I'd tell myself, don't worry about failure. Just you're gonna be fine. Just keep working hard. Karen Litzy (29:36): Great, excellent advice. And now where can people find out more about you more about ortho and spring health live? Michael Greiwe (29:43): Great. Yeah. Well, they can actually look at our website. So our website is www.ortholive.com and then www.springhealthlive.com. So for me, I can be reached at mikegreiwe@ortholive.com. That's my email address and I'll be happy to respond. Karen Litzy (30:08): Perfect. And just so everyone knows, we'll have all of those links in the show notes under this episode at podcast.healthywealthysmart.com. So Dr. Greiwe, we thank you so much for coming on. And, and like I said, I've spoken about tele-health before, but it was way back when this started. So it's great to get more information out there for people to know that it's not just something that we're doing during the COVID pandemic, but that this is something that can be incorporated into your practice. It can help your business, help your patients. So thank you so much. Michael Greiwe (30:43): Oh, thank you, Karen. I was glad to be here. Appreciate it Karen Litzy (30:45): Anytime. And everyone. Thanks so much for tuning in, have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Our Ask Us Anything brought a great question that needed some further discussion. So Dr. Jonathan Katz, Mental Health Advisor and Performance Coach for Behind The Racquet, joins us to answer this question from Jack Wichtendahl: How do you stay motivated for something you’re not sure is going to come back, and even it does, you know it’s not going to be the same because of the coronavirus? Learn more about your ad choices. Visit megaphone.fm/adchoices

The Therapy for Black Girls Podcast is a weekly conversation with Dr. Joy Harden Bradford, a Licensed Psychologist in Atlanta, Georgia, about all things mental health, personal development, and all the small decisions we can make to become the best possible version of ourselves. Parenting through the past couple of months has been nothing short of stressful. So Dr. Ann-Louise Lockhart joins us again to help us through it. Dr. Lockhart and I chatted about the benefits of routines and structure right now, managing your own and your child’s anxiety about cities re-opening, what kinds of things we should be considering about school in the fall, and how to have conversations with our kids and our schools about racism and racial trauma. Resources Mentioned Visit our Amazon Store for all the books mentioned on the podcast! Where to Find Dr. Lockhart https://www.anewdaysa.com/ Dr. Lockhart's Course on Racism, Prejudice, & Microagressions Instagram: @dr.annlouise.lockhart Facebook: @dr.annlouise.lockhart Listen to Dr.  Lockhart discuss helping children regulate their emotions on Session 120 of the podcast. If you're looking for a therapist in your area, check out the directory at https://www.therapyforblackgirls.com/directory. Take the info from the podcast to the next level by joining us in The Yellow Couch Collective, therapyforblackgirls.com/ycc Grab your copy of our guided affirmation and other TBG Merch at therapyforblackgirls.com/shop. If you have questions or would like to discuss podcast sponsorship, email us at podcast@therapyforblackgirls.com. The hashtag for the podcast is #TBGinSession. Make sure to follow us on social media: Twitter: @therapy4bgirls Instagram: @therapyforblackgirls Facebook: @therapyforblackgirls

Zach welcomes Dr. Janice Gassam, Ph.D. back to the podcast to talk about the concept of centering Black experiences. She and Zach discuss the tremendous impact of enduring continuous emotional labor and implore any and all aspiring allies and/or white executives to compensate Black people when they're asked to speak about their feelings, and Dr. Gassam also shares a bit about both her podcast and new book, both titled "Dirty Diversity" - check the show notes if you'd like to find out more!Learn more about (and buy!) Dr. Gassam's book "Dirty Diversity" on Amazon or Audible.Interested in the Dirty Diversity podcast? Check it out on her website.Read Dr. Gassam's "Dear Companies: Your BLM Posts Are Cute But We Want To See Policy Change" piece on Forbes.Connect with Dr. Gassam on LinkedIn, Twitter, and Instagram.Visit our website.TRANSCRIPTZach: What's up, y'all? It's Zach with Living Corporate, and look, you know, you know what we do. We have real talk in a corporate world, and we do that by centering marginalized voices so that we can actually amplify and center marginalized experiences at work, right? And so we're having these conversations with thought leaders, with educators, with writers, with executives, with entrepreneurs and social influencers and activists and elected officials - anybody, really - all around, again, centering and amplifying the most marginalized voices in the workplace, and so today we have a returning guest - frankly, a friend of the show, you know what I mean? Dr. Janice Gassam. Dr. Janice Gassam is an educator, public speaker, a consultant, and a senior contributor with Forbes. Dr. Gassam, how's it going?Dr. Gassam: It is going well. Thank you so much, Zach. I really appreciate you amplifying my voice and consistently amplifying my work. I love that we, like, you know, have built this support system, and I think that's so important, that we are, as quote-unquote marginalized people, we're supporting each other.Zach: Well, I mean, it's not--you make it very easy. You do great work, and your work really is what needs to be centered and focused on right now. I'm really curious, you know, as white folks are apparently learning what racism is for the first time, how have your--what does it look like in your field? Like, are you getting more requests right now? I know last time you were on the podcast we talked about the fact that a lot of folks would ask you not to talk about race. You know, what does it look like when you have clients reach out to you with requests?Dr. Gassam: Wow, that's a great question, and things have blown up and have exploded as far as I've been getting so many requests for racial equity workshops, and that's--you know, I'm partial to those workshops. Those are my favorite, but it's just so ironic because even, you know, less than a year or so ago I would have these discovery calls with clients, you know, who want me to come in and do a workshop or a training, and they have specifically said, "Do not talk about white privilege. Do not talk about race." They preferred me talking about the safe subjects like emotional intelligence, which I'm fine with talking about that, but I think that it's limiting in that if you're not willing to engage in the conversation nothing is going to change. So I'm very--I'm cautiously optimistic, and I hope that the momentum is still here after the summer is over. And I try to impress upon these leaders that, like, one workshop is not gonna change anything. Whether it's me or somebody else, you need to be bringing people in to facilitate to these continuous conversations. I think that that is really important, and people seem like they're starting to get it, so, you know, I'm just excited about this moment in time right now. I've never been busy like this before since my career started. So I think it's an exciting moment, and I'm trying to take advantage of it.Zach: And so let's talk about that. So, like, you know, again, in the past people would say, "Don't talk about white privilege, don't talk about Black experiences, Black female experiences. Talk about gender, but don't intersect that at all with ethnicity (or) race." What does it look like now when people hit you up? Like, what are they actually saying?Dr. Gassam: So, you know, I get emails primarily, and they're like, "Hey, my company wants to--" And what's funny, Zach, is that, like, there's such a sense of urgency now, you know? These same companies that--I'm gonna be [?]. I'm gonna keep it 100,000% real. Some of the same companies that didn't have money once COVID hit magically found the budget. You know, I had things lined up. And I get it, you know? They came back to me in March and April and said, "We don't have the budget." Cool. So now in June y'all found the budget, I guess. You know? Which I'm like, "Obviously you're realizing diversity, equity and inclusion is a priority." So it's usually--you know, the requests come in the form of an email. I appreciate that people have really been sharing my content on social media. So people often find me either through LinkedIn or through Instagram and they say, "Hey, I saw you talk about race, and we need this at our company. So when can you find a time to speak? How much do you charge for a workshop? What do your workshops entail?" So that's pretty much what it seems like, but with some of these requests it seems like there's such a sense of urgency, and that worries me a little bit because I think that it's not, like, a quick Band-Aid. You know, I'm happy to do the workshop. I've been doing these workshops. I've done many workshops, and I already know the structure and everything. However, I think that you have to have long-term objectives, and I don't know if a lot of these organizations have long-term objectives. It just seems like they want to do something so it looks like they're not doing nothing.Zach: Right, right. What is concerning about that, anxiety-inducing for me transparently, right, is it's very reactionary, and it reminds me of Martin Luther King's Letter from a Birmingham Jail. Like, that portion where he talks about the white moderate and, like, how they're more concerned about false peace [than] with an absence of justice. And so even now in this moment I'm like, "Okay, are y'all just trying to mobilize something really quick just to say that y'all did something so that you don't have uprisings within your companies, or are you really looking to create equitable and inclusive working environments, not just for the next couple of days but for, like, the foreseeable future as your company moves forward in this new normal?" Like, that to me continues to be, like, my ongoing question. I mean, I've had people reach out talking about, "Can you come in and do some unconscious bias?" No.Dr. Gassam: And that is the worst. I don't think unconscious bias trainings are trash by any means. I think that most companies are not doing them effectively. That's, like, a nice way to say it, 'cause I think unconscious bias training doesn't do a lot. "Hey, I go through this training and I find out I have a bias against Black people." You might take an [?] association test and see, "Hey, I have a bias toward or against women, so what do I do now?" It's like, "Cool, now I recognize my biases," but if there's systems in the organization that allow bias to persist, it doesn't matter that now I know how to not say micro-aggressive statements, because there's, like, bias entrenched and baked into the fabric of the company. Like, in the way that they hire employees, that they're using a referral--many of these consulting companies, it's all referrals, it's all Jim knows Bob who knows John, and that's how you get jobs. It's primarily who you know and not what you know, and I think that there is benefits to referral hiring programs and systems, but I think that the way they're currently being done is just, like, creating this echo chamber of the same types of people. So I always encourage organizations to look at their systems and say, like, "Are Black people being promoted at the same rates as other people?" Because it's cool for you to say, "Look, no, no, no, we have a lot of Black people," but they're all in lower-level positions in the organization, but are they in senior-level positions, and if they are, how long are they staying? Because a lot of these tech companies, I love that they're being transparent and putting out these diversity reports, but they're not telling us how many of those Black people or those Latinx people or those women are staying in those roles, 'cause they're like, "Look, 13% of our population is Black [?]. Yay! That went up 1% from last year. Yay!" Like, but it's like, are those the same Black people, or did you just hire a bunch of new ones, and then those same ones with quit next--you know? So I think, like, looking at why there's this revolving door, particularly of Black people, you know, like, in the tech industry and all of these industries. The fact of the matter is that, like, Black people, a lot of us are not staying in companies, and part of the reason--a large part I would say--is because of the hostile work environments that we're working in. Zach: 100%. I mean, so Living Corporate, we've put out a couple of whitepapers, but, like, there's a few different reports, but they're, like, very rare, that talk about, like, turnover percentages. So I've yet to see anything that explicitly says "The turnover for this group is this." I've seen, and we've cited, sources that'll talk about the fact that Black and brown turnover is, like, two or three times higher than their white counterparts, but you're right. Like, there's no annual reporting that shows, "Hey, you know, our Black employees are four times more likely to leave within their first two years than their white counterparts." Like, that's not anything--those rates are never discussed. But you're absolutely right.Dr. Gassam: I think it's important, I mean, because these companies tout that they're so diverse, and I think that that's something important, that not just--we focus so much on the diversity piece. That is important to say, "Hey, look, we actually have diverse representation," but also, like, are they staying? Because if you're using stock images with Black people that look diverse that make your company look diverse but then I get there and I'm like, "Hm." I'm, like, the only Black person. That's, like, false advertising, and there's a lot of that going around, you know? I know the new buzzword is, like, performative allyship, and there's a lot of that going around with a lot of different companies that shall rename nameless, but yeah, I'm glad to see people are really calling them out, these companies out, and saying, "You posted Black Lives Matter, but you asked us not to wear Black Lives Matter stuff." Or "You have no Black people in senior positions," or "You have a hostile work environment where Black people don't feel comfortable." So, like, it's cute to--I wrote an article, like, "It's cute to post Black Lives Matter, but we want to see, like, policy changes." That's nice and fine and dandy, and I appreciate your statement because, you know, that's better than your silence, but I want to see more, and I'm glad that people are demanding more of their company.Zach: I wonder... I still don't think that organizations--and your piece was incredible, and we're gonna make sure that we link it in the show notes for those who didn't see it, but what I don't think organizations understand is that, like, if they come out here really loud externally about all these things they're gonna do to combat racism and inequity and things of that nature, but then, like, internally their policies and their cultures, their practices, their behaviors don't change, like, that's going to create more resistance, higher turnover, higher disengagement, than they had in the first place.Dr. Gassam: Mm-hmm, and as an employee, if I worked in that company, I would just be looking like, "Okay, y'all are, like, not really about that life." And I'm not about, like, exposing the company that I work for unless I feel like I've been completely mistreated--and I've definitely felt like that in workplaces, but my industry is very small, so I just silently exit a company, and I might speak of it but not give specifics and names and things like that. But I think that you're opening your company up to that type of negative publicity from employees if you're not, like, authentic in the things that you do, and I mentioned this before in a few speaking engagements I've done, but I have a friend that works at a very well-known consulting firm. She's been there for four years, and she said that--she belongs to a marginalized group. She's considered brown, and she said that since--her company has a diverse referral program, but she said since she's been working at the company for the last four years, they've never hired anyone from that diverse referral program. But it's just, like--I call it cosmetic diversity, where you have something in place just to look like you're doing something, look like you're actually about that life that a lot of these companies are not about [that life]. So I think that that's just not a good look. If you're gonna like the talk, you have to also be doing things that show that you're actually putting your words and your intentions into action.Zach: I agree. And to your point around, like, negative press or attention, it's--I think also, and all of this generational, because even I--you know, as someone... I'm 30, right? So, like, I'm not young-young, but I'm not older. I'm not old. So I think I probably still don't fully appreciate how easy it is--like, for something to go viral, especially as something negative, but it's, like, really, really easy. Like, there's so many avenues and mechanisms to, like, share your voice now, and I just don't know if organizations appreciate that AND the fact that, you know, doing that today, like, airing things out, putting people on blast, is not an automatic career ender like it might have been, like, five or six years ago. Like, if you put somebody on blast now, like, that doesn't mean that your career is over. It means you just--like, you may be actually heralded as a hero depending on how you do it, right? Dr. Gassam: Yeah, you're absolutely right, and just like a lot of these racists who say and do things after a year or so and the public forgets and they're able to go and get jobs, the same I think could be said for employees that put their companies on blast, because so many things are happening in our lives that we forget. Like, I don't remember all of these people's names. Are we still gonna remember Amy Cooper? Well, I guess there's a law now with her name, but are we gonna remember all of the Barbecue Beckys? Like, what their actual names are? Probably not. So I do think that you're absolutely right in that companies I don't think quite appreciate and understand how easy it is for people to get information out and just share their story and just share, "This company has a crappy environment." And you actually shared with me last year that internal memo, that Medium article, that those Facebook, those Black--I believe they were all Black, or some were Latinx--Facebook employees wrote about the toxic work culture and, you know, there's so many avenues to write anonymous memos and things like that about your company, and so that's not the type of press and reputation that you want. So I'm really happy that people are like, "We need to change. We are really--" Like, I've been getting requests, Zach, from, like, the most fascinating, like, industries that I never even expected, like, this person is reaching out and that person is reaching out. A fitness company reached out to me and said that they wanted me to do a webinar. A jewelry company reached out to me, and I was just like, "Wow." So, like, it's every industry. It's industry-wide. So, you know, I think that has really been interesting to me, that everyone is waking up and saying, "Whatever industry we're in, this is a problem that is, like, not specific to our industry. Everyone is having these issues and needs to figure out how we create an environment that is inclusive to Black people specifically," because I think that a lot of times the conversation gets watered down and we talk about other groups but we don't focus specifically on Black people and Black liberation and things like that, and I think that that's a huge part of the reason we're here, that we have more ease with talking about LGBTQ+ issues or gender issues than we do racial issues.Zach: You're absolutely right, and I think a large reason for that is because white people can be women and white people can be gay, but white people can't be Black. So it's like what does it look like to really shift and, like, have authentic conversations that center marginalized people? And it's interesting. I was talking to some colleagues a little while ago and was talking about the concept of, like, decentering whiteness, and they were like, "What do you mean?" And I was like, "A large way that we center whiteness is just in our language, right?" Like, a lot of the terms and things that we've created, we create those terms to avoid Blackness and to avoid the reality of harm. So it's like, we'll have these conversations and we'll talk about--you know, we'll say bias when it's like--and bias is, it fits technically, but what you're also talking about is, like, white supremacy or just racism, right? Like, we're not talking about--this isn't, like--like, bias softens it sometimes. In certain ways, bias softens it in the same way that, like, you know, it's not like I have a bias towards Coca-Cola versus RC Cola. Like, no, I genuinely think this person is less than me and, by relation, because of that, I treat this person differently. Like, that's different. And, you know, even--yeah, so anyway, not to go on a rant. So I do think this segues well though into your podcast, Dirty Diversity.Dr. Gassam: Yes. Yeah, so I actually started the podcast during Black History Month, and it was important for me to not only start it during Black History Month, but, like, the first episode was ironically, like, why your Black employees are leaving, because I don't think that we're talking about these things, and I think that we conflate people [of color?] with Black people, and we lump everyone together, I think for the sake of, like, conversation, it's easier to just say "Black and brown people," and it is, because a lot of these--your closeness to Blackness will impact your experiences, you know? And there's Latinx people who are stopped as much as us when they're driving, who experience racism just like us and things like that. So, you know, I think it's easy to say that, but I think it's important to put a particular focus on the unique experiences of Black people, and I don't think we do that enough, and when I'm asked to do these trainings there isn't a focus on--when that is the problem, Zach, it's that you're not able to retain Black employees. They're leaving, but you want me to come in and do inclusion training. Your problem is not inclusion. The problem is you're not creating an environment where Black people feel like they're valued and they matter, so we need to focus on that specific problem, and I think that watering it down is what we've been doing for so long, and that hasn't produced positive results or changes, so we have to just be bold and call it out for what it is. And I'm so excited, because I feel like I have been censoring myself--I censor myself on social media a lot because my colleagues follow me, so I can't be like, "White supremacy--" I can't be using that language a lot because, you know, my colleagues [?] me and all of these things, and I know in my field that's gonna get you--that sort of thing is not gonna sit well with... but now I feel like I can say what I really want to say, especially in the workshops, and I think that that's gonna make people [uncomfortable,] but for me, my goal isn't to make people feel happy. My goal is to help you change and help you create better organizations, and the way to do that is I'm gonna have to say things that are uncomfortable and you're gonna have to evaluate your role and how you've contributed to inequitable systems and oppression and things like that. And for a lot of people this is the first time that they've ever taken a look in the mirror, and just with speaking with different white women, they've said--and they're millennials, you know? Like, they're young, and they're like, "This is the first time I've really taken an honest look at myself, and even though I have Black friends and, you know, I dated a Black guy, you know, maybe I have white supremacist views," and it's like, "Yes, you do." Every white person who's born and raised in the U.S. have internalized white supremacist views, and a lot of it is just baked into our American fabric, so it's, like, recognizing that and using your privilege and your power to impact change.Zach: And, you know, I think that really leads us well into the book that you recently--I think by the time this airs it'll be published, so, like, let's talk about the book.Dr. Gassam: Yeah, and thank you again for the opportunity to just share my work with your audience. You know, I was--it was important to create the book, but now I'm already [thinking about] book #2 and how it needs to focus specifically on race. So I wrote "Dirty Diversity" as, like, a very simple, practical guide [for] implementable ways that you can create more inclusion and equity into your workplace. The thing that I've learned in the years that I've been--I've been in consulting now for, like, two years or so, and I've learned so much. When I started doing these diversity workshops, I knew nothing. I didn't know anyone personally that was close to me that did any sort of--I didn't know consultants like that, you know? Just people I went to school with who work at large consulting firms, but I didn't know independent consultants, so I had to figure a lot of things out on my own. I had to bump my head multiple times. So the book is written in three different sections, and the first section is for managers, and it's things that are so simple and easy to implement into your workplace you might say, "Why didn't we think about this?" Or "Why haven't we been doing this?" But it's simple ways to create more inclusion in your workplace. The next section is for people who do diversity, equity and inclusion consulting and things that I've learned from creating workshops and ways that you can improve the effectiveness of the workshops, but one of the things that I emphasize is that one workshop or one training is not gonna make a change. You have to encourage the organizational leaders to do multiple trainings and multiple workshops. And then the third section is written for employees and just, like, simple ways and simple things you can include in your workplace to create more inclusion as an employee, 'cause I get that question a lot where people say, "How do I get my manager to care about diversity? And how do I get my manager to--" And I think that it's not just get managers to care and to--it's understanding the value of what this can bring into your workplace, but there are things that you can do yourself. Like, you know, I talk about an employee book club, and that's something, like, super easy, and maybe petitioning your employee to sponsor an Audible membership--because everybody doesn't read. For me, most of my books I consume them now on Audible. So, like, if you have an Audible membership, you don't have an excuse now to say, "Oh, I didn't have time to read." You could, like, take a [?] minute walk and listen to a chapter of a book. It's very easy now to me to, like--for things as an employee that you can implement into your workplace. So I felt like this book was really necessary, and I didn't--I had no idea all of these events would be transpiring right now, so I feel like it's even more relevant. And there's so many--in the book I talk about some really simple things, low cost or no cost things, that you can implement to create more inclusion, and I think that there's a perception that you have to spend a lot of money--which I do think you should be adequately compensating your consultants that come in, and a lot of times people ask me to come in and they expect it to be free, so I think that is part of the problem, but there are things you can do, like having a panel in your workplace. That's something that is a really simple way to create inclusion that you probably didn't think about. Inviting someone like you, Zach, to come in to speak with employees on a panel just about equity and inclusion and different things like that is just, like, an event your company can host, and often times on panels people are donating time or, you know, giving up their time for free. So, like, there's so many simple ways. It doesn't have to be this, like, extravagant sort of, like, training program that could help you to create equity and inclusion. So that's pretty much, like, the goal. It's a simple read. It's, like, a little over 100 pages, and I think it's just filled with things that you can do and can easily implement into your workplace to create more equity and inclusion. I mean, I'm excited to--I've already got a copy, okay? So we're gonna--Dr. Gassam: Thank you so much, Zach.Zach: No, no, thank you, and so we're gonna make sure we put a link in the show notes for everybody to get a copy as well. And the book's title though--is the book's title "Dirty Diversity?"Dr. Gassam: Yes. So same title as the podcast. The reason I titled is "Dirty Diversity" is because diversity has definitely become a dirty word. People are not into having diversity trainings. There's a misconception about what diversity is, what it brings to an organization. There's still diversity resistance and pushback. So when you say, "We're gonna have a diversity training," people in their minds have an idea of what that is. There's a lot of research that indicates diversity trainings are not effective. So I really was kind of focused on, like, what are some things, in addition to workshops and trainings, that you can--what are some ways you can create more inclusion? Because I kind of resent the fact that--I've seen this meme going around, and I disagree--I think it's cute and it's funny, but it's like, "The revolution will not be in diversity and inclusion training," and I disagree with that. [both laugh] Have you seen that meme before? Zach: I have. I don't--I hear you though.Dr. Gassam: I was like--I don't agree fully. I think when done effectively workshops--if you're having workshops every month in addition to a multitude of other things like mentorship programs, I think they can be effective.Zach: I think authentic, intentional workshops paired with other systemic solutions are effective. I think most people when they think about these workshops, they're not talking about the type of work that you do or the type of work that, like, Dr. Erin Thomas at Upwork, that she does, thinking more about the--you know, the very white comfort-centered diversity of thought -type workshops. Those are not gonna lead us to no revolution, but I agree with you about, you know, intentional, intelligent, competent workshops along with other things are very effective.Dr. Gassam: Yeah, yeah, and that's--you know, that was my thought. You know, everybody's kind of--you know, and I try not to curse, but everyone's kind of, like, crapping on diversity and inclusion trainings, and I do think that in itself one training is not gonna change anything, but the problem is those companies don't even have ongoing trainings or workshops. They have one once a year if that. A lot of them have never had any sort of training, yet every year they have sexual harassment training, which I find to be interesting, you know? Zach: Well, it's typically to check a box, right, from, like, a legal perspective. Like, that's typically what they're doing so they can at least say, "Well, we do this, and we do it regularly," you know? It's not really about any type of behavioral change.Dr. Gassam: Exactly. Yeah, so it's like to check a box. So really, like, how to overcome this idea that diversity has become a dirty word. What are some really simple things? And I'm telling you, it's such a practical, simple--I'm not using any, like, jargon that you wouldn't be able to understand. It's very, like, a simple guide. You open it, you read it and say, "Oh, this is something, like, so simple. Why aren't we already doing this in our company?" But you'd be surprised. To me, like, something, like, a blind resume system. When people tell me they can't find Black candidates, can't find Black engineers, I'm like, "Do you have a blind resume system?" And they're like, "No, what's that?" And that to me is something that I think is so simple but a lot of people just don't know. So that's really, like, what the purpose of me writing this book was. Like, simple things that you think a lot of people know but they might not, and it's just, like, so simple to implement into your workplace. It's not complicated at all outside of just workshops that you can do to create more inclusion.Zach: Man, this has been super dope. What else do we need to talk about, Dr. Gassam? 'Cause I want to make sure I give you your space. So we talked about--Dr. Gassam: So much! Thank you. [both laugh] You know, there's so much. All of the performative allyship, all of the--Zach: Oh, yeah. Let's go in on that real quick actually. Yeah, no, this is good. So side note, y'all, for those who are kind of behind the scenes. Typically I send out, like, these very detailed questions before each podcast, but, you know, for people that like--you know, we kick it or, like, we kind of get each other's style or energy, we kind of freestyle. So this is actually a freestyle, y'all. That's why we're, like, actively trying to think about what we talk about next. We have a little bit more time. Dr. Gassam: And I really appreciate that, and we'll talk about how to support each other after we get into the performative allyship.Zach: Yo, let's do that. Okay, so this performative allyship stuff is crazy, right? Like, I'm so tired of these people--and you know what's really wild? It's like--what we don't talk about is, like, just... we don't talk about this enough I think just, like, culturally, the importance of authenticity, right? So, like, I've had people who have harmed me with their racist behaviors hit me up now talking about, "Hey, just thinking about you." Like, what are you talking about? Why are you talking to me, and why would the first thing when you reach out to me not about the harm that you caused, that you KNOW you caused? These are, like, [?], right? Like, these are things that, like, you gravely harmed me personally and professionally, right? It's not like you walked by, you touched my hair and said, "Oh, this is like my little pet lamb's hair back in my Meemaw's house." Like, no. This is "You harmed me." And so it's wild, like, that we have--how members of the majority... go ahead.Dr. Gassam: I know. It's just like--I'm getting a lot of people hitting me up, like, that are--you know those people that are in the periphery of your life? They're not in your life, but they're just, like, there watching from the--I get a lot of those, and there are people who have actively done things to prevent me from being successful, and they reach out to me, or on the other end people are asking of me, and I won't get into too many details, just, you know, to protect myself, but there are people who are actively asking things of me without consideration of the events that transpired. You're asking for projects from me and things like that, and I'm like, "Well, I'm not in a mental state--" And I've had to send emails like that where I'm like, "I'm not in the mental state to produce what you're asking me to produce because there are Black people being killed and slaughtered, videos," you know? And I just--and it's "Oh, my gosh! You're so right! I didn't even realize it! Oh, my gosh. Like, it's all because of Trump. This would have never happened if Obama was president!" [Zach sighs] And it's like... I mean, it did happen when Obama was president.Zach: It happened a lot [?] though.Dr. Gassam: I was just like... "Okay, but thanks." So I get those, where people are completely, like, oblivious to what's going on and what's happening and how maybe the Black [people] you know are impacted by this, so maybe I shouldn't be asking for X, Y and Z, and I've had to let people know, but I've also seen, yeah, like you said, people who have actively caused harm to you, "Hey, how are you?" Without any acknowledgement of what was done, what was said, your role in how you contributed. Lots of snakes in the grass.Zach: A lot of snakes in the grass! I think also just, like, the psychological--and, like, I don't even think, like, even just considering the additional mental and emotional toll you put on that other person when you do that. So, like, now, as the person who's receiving your random message after a year or after six months or however long, now I have to do the mental calculus if I'm gonna even gonna respond and then make a decision if I respond, "How vulnerable do I want to make myself in responding to you?" Knowing that if I respond to you and you get upset it could harm me even more. So it's just so... so that alone is, like, ugh, such a rant. Such a rant-worthy topic. I do think that it's, like, when we talk about allyship and--I just wonder, are people--I'm not curious about it. This is my belief. I don't believe that members of the majority have the capacity to, like, really deal with being explicitly anti-racist for more than, like... like, for a sustained amount of time, right? Like, you're already seeing on Twitter, people are getting burnt out. Like, "Ugh, I know that you guys are probably tired, but here are some tips that you can--" [Dr. Gassam laughs] "Make sure you drink your [?] tea."Dr. Gassam: You're absolutely right, and it's exhausting in that--and I know a lot of white people are confused, because in one breath we say, "You should be checking on your Black friends," but in another breath it's like we're getting binged and pinged and all of this, like, left and right, and then you have to keep having to revisit the conversation of, like, you know, "Why aren't you answering my text messages? I hit you up to check on you." 'Cause I don't want to keep talking about the same--like, I appreciate that you reached out. I don't--I'm not in the mental state. I want to go on a bike ride and just have the sun on my face and just not think about Black people being killed. I just want to listen to a podcast while riding a bike. Sometimes you just don't want to keep talking about, keep talking about it, and what I've found is that--it's interesting, companies want to give us space to talk about without asking us if this is something we want to take part in. A close friend of mine worked in a healthcare system, and she said her company was like, "Hey, can you be on this panel? It's all Black people talking about their families," and it's like, "I don't want--like, why do I gotta--you don't even--" Like, it's really like, "Hey, we want you to be part of this panel." "No, I don't want to." I had another friend who was asked to talk about white privilege, and she was like, "This isn't even my scope or my domain. I'm in PR. Why are you asking me to talk about white privilege? This isn't even, like--what, just because I'm a Black woman you want, "Oh, yeah, have her talk about--"" She was like, "What?" And I had to send out an email to somebody that asked me to a part of a panel, and I didn't want to be mean, but I was like, "When you're asking me to regurgitate and keep repeating why I feel bad as a Black person living in America, like, you should be paying me," you know what I'm saying? And I know that sounds like--it's not a matter of being all about the money, but it's a matter of, like, this is emotional labor, and this takes an emotional toll on me to be on 80 million eleven panels talking about why, what I feel as a Black person and all of this, and it's just like--the idea of paying a Black person doesn't often cross these people's minds who are organizing these events, and I'm just like--at this point, like, my mind [?] so busy with these workshops--and also I teach as well, so it's like with teaching and doing the workshops and promoting the book, like, I'm not gonna just be on a panel talking about how sad I am and my experiences as a Black person. There's so many thinkpieces online with people giving this information to you already. You don't need me on a panel to talk about what it feels like to be Black. And I hope I'm not being too raw, but it's just that's how I've been feeling lately.Zach: No, you're not being too raw at all. I see where you're going and I will meet you there. So look, folks who are asking--please stop asking us to talk about our feelings for free. I need y'all to stop. Many of you listen to the podcast, right? And, like, when I say you I mean aspiring allies and white executives. Stop. Now, look, especially--like, not to be classist, but especially don't be asking a bunch of degreed people to be doing it. Like, that's crazy. You have people out here who have whole doctorates in sociology and psychology and you're asking them to come on these panels for free. It's like, "No." Like, "I have the Western colonized expertise from an actual [?] institution, and couple that with the expertise of my lived experience, when you ask me for my time, I need you to pay me. Don't even ask." I've had people ask me for my time to do things and I'm like, "First of all, do you understand how much--" Like, I'm gonna feel drained after this, because I'm gonna talk about all these things and no one's gonna come back to me with, like, any tangible resources or support. It's just gonna be me, like, giving out.Dr. Gassam: And it's like--you have a podcast where you talk about all these things. You invite people to talk. You have--and then it's, like, on top of that you write about these things, on top of that you work full-time, on top of that you're a father and you have a wife. It's just, like, y'all gotta think about all of these things. It's like, "Hey, can you explain to me, like--" No, I can't. I'm sorry.Zach: No, I can't. And shameless plug, like, Living Corporate, it's not like we're just, like, a random podcast. Like, you can go on our website and type in anything and a bunch of stuff will pop up. Like, we have a whole database, so you can educate yourself, and, like, there's other free resources. I think it's so inappropriate during this time, like, going back to what you said earlier about organizations and, like, predominantly white leadership who have, like, either intentionally or unintentionally been the cause for people to exit their places of work are now, like, sending out these emails with a bunch of different options to have quote-unquote "real talk sessions," and, like, who made you a luminary on the subject one, but then two, like, why do you just presume that I even want to do this? But the challenge, Dr. Gassam, is, like, there's also the reality--which we don't talk about enough, and, like, shout-out to Brittany J. Harris of The Winters Group. I see you. She talked about it, like, explicitly--this was some months ago--about the fact that, like, power is, like, the silent "P" in DE&I, right? It's like--we don't talk about the fact that, like, yo, if a senior executive sends out something to talk, have one of these conversations, there's gonna be a certain percentage of marginalized people who feel pressured to join it simply because the person who sent out the invite is in power, right? Like, there's a power dynamic that we don't want to address, and also when you ask people to do things--like, nine times out of ten the Black and brown folks you ask to do this type of work or, like, to randomly jump in this and it's not even their expertise, they're gonna feel pressured to say yes because you're in charge, and then when they show up to do whatever you want them to talk about, white privilege, their own lived experience, whatever, they're going to be pressured to not be as honest as they would even like to be because they know that they might get fired or they may be opportunities withheld from them if they say the wrong thing.Dr. Gassam: Exactly, exactly, and I'm actually doing a workshop tomorrow, and the two individuals who reached out to me to do the workshop, they had told me they don't want to be part of the facilitation because there are--there's 500 people who are a part of this workshop, and they're worried because in their industry it's, of course, not what you know it's who you know, and I sympathized with them 100,000% because I'm still--you know, I work in an institution, and I can't fully say--I can't go out and jump on a limb and say everything that I would want to say because of that power piece and because I know that there's still many people who are uncomfortable when you're speaking the truth and when you're trying to--so it's like you can only say but so much, and unfortunately it's like--we need the raw, and we need it to the point, and I'm glad people are more open to that right now, but it's still, like, a concern for us and for people who do this work and, you know, even you as a--not only as an employee but as someone in the podcast space, I'm sure there's topics that you can venture into but not too, too much because you don't--Zach: Oh, Dr. Gassam. Ooooh, bay-bay. [laughs]Dr. Gassam: You know? 'Cause it's like, "I know my audience." You know, there's stuff--I'm sure there's a lot of stuff you want to say but you just--one day [I'ma?] have a tell-all.Zach: Listen, one day--no, I literally tweeted this the other day, I said, "One day I'ma let these @s fly." Like, I'ma really talk to y'all. But no, you're absolutely right, the power dynamic, it dictates, like, literally everything. So, like, you know, I talk differently now because I work--I have a 9-to-5 job. Like, the day that I do Living Corporate full-time, I'm still not gonna be able to talk as free because I'm gonna have clients, and my clients need to know and respect the fact that, you know, I won't air them out one day, you know what I mean? So, like, the only time that I think you ever really hear, like, Black people speak the truth, like, unabashed truth is when they have a lot of money, right? So you think about--you know, you think about, like, the Will Smiths and Kevin Harts and Dave Chappelles and Eddie Murphys of the world, the people who just--or people who just don't care at all, and those voices are needed, but it's just, like, I can't shame people for not being 100,000% raw all of the time when, like, our survival is predicated on some degree of white comfort. It just is. We can't just say--we can't speak the truth like we want to. Like, I believe I speak the truth pretty consistently, don't get me wrong, but there are certainly--like, I'm halfway joking, but there are things that I would like to be much more explicit about, but I can't, you know? Especially [because] I have a daughter, you know what I mean? You have to be careful. So let's talk about this. Let's talk about supporting each other during this time. So we're talking about, like, the emotional labor that we sometimes get pressured into performing or just the increased emotional labor during this time, but also just the general amount of labor just in being Black and brown in majority white spaces. When you asked or when you kind of suggested talking about supporting one another, like, what comes to mind for you?Dr. Gassam: So many things. You know, I think that besides the Candice Owens and some of these people out here that maybe don't [?]--Zach: Oh, my gosh. Please don't ever say her name again. Nope.Dr. Gassam: [laughing] I'm sorry. Some of these people, you know, these people, I think for the most part we got us, and the community that we're building and that we've built and the support that I feel from my fellow Black people just makes me really proud to be Black, and I have to say that in a lot of the--in April I was offering these complimentary workshops because I was transitioning from in-person trainings and workshops to online and I was acclimating and getting myself used to Zoom. So I was like, "You know, if your company wants a complimentary workshop just reach out." And let me tell you, I did 7 complementary workshops that month, and all of the people that reached out to me were Black women. I love that Black women are always, always at the forefront of putting other--we're always... I feel like we have such big hearts and we're always trying to, like, save the world, and people need to listen to us more, but I just think that in a moment like this, the support and the camaraderie that I'm seeing among Black people but particularly among Black women is just what, like, warms my heart and reminds me why, despite all of the B.S. and what we're going through, I'm so proud to be a Black person and to be a Black woman. So I think that just supporting each other, supporting Black businesses and things like that, just reaching out to your Black friends, I think--one of the many things that I love about us is, like, we're gonna have fun and find entertainment in anything, and I've been like--we've been crying a lot, but I just find that we just make anything into, like, something funny, into a joke. Like, after the Verzuz of Beenie Man and Bounty Killer, I was just, like, so entertained by the memes and the gifs, and I was just like, "I love us." Like, we are just so funny, and we're just like--so that's, I think, like, the fact that us coming together and just laughing and doing things that bring us joy and just, you know, the community I think right now is we're building that and we're creating these groups, and so I think that we should all be doing one thing that makes us feel joy, and whether that's, like, meeting up with a friend, grabbing some ice cream, riding a bike, I've been trying to do that more and more. And just, like, [supporting] each other. I have friends that reach out to me and say, "Hey, I want to bring you into my company," and it's like, just that support of, like, "I see you, I see the work that you're doing and I'm trying to put you on," is I think what we need more of and what I've been seeing a lot, and I just love that.Zach: Man, I love it too, and, you know, with that being said, if you haven't yet, make sure that you get a copy of "Dirty Diversity," Dr. Gassam's--it's your first published book, right?Dr. Gassam: Thank you so much, Zach. Yes, my very first published book, so I'm awaiting--it is gonna be available Juneteenth, on June 19th, and both the e-book and the paperback will be available on Amazon, but I'm also awaiting Audible approval because I recorded the audiobook, so I'm just waiting on that process now. Hopefully it'll all be good by June 19th, but I think by the time this episode drops it'll be available via Audible as well.Zach: Well, that's dope, and yeah, we'll make sure that we signal boost any of the promotions and advertising for it on Juneteenth, and then we'll also make sure that y'all check out Dr. Gassam's Dirty Diversity podcast. So Dr. Gassam, you know what I'm saying, she's way more fancy than me, so her guests--I mean, we have great guests, don't get me wrong. We have amazing guests, so let me not play, but I'm just saying, like, she's--Dr. Gassam: Yeah, you guys have amazing, amazing guests.Zach: We have dope guests, but I'm saying your guests are nothing to sniff at, you know what I'm saying? So make sure y'all check out Dr. Gassam, you know?Dr. Gassam: Thank you so much, Zach. I really appreciate it. Thank you for amplifying our voices and trying to use our platform to put more of us on. I think that that's an inspiration to me, and that's what I think we should all be doing, using our platforms and our power to put other people on, you know, other, our people on. But thank you so much, Zach, and I hope you have a wonderful rest of your weekend.Zach: Yo, same to you. Listen, y'all, this has been Zach with Living Corporate. You know what we do. We're having these conversations weekly. So again, this might be your first time listening to Living Corporate, so as a reminder or as an FYI, we have Real Talk Tuesdays--that's when we have these, like, you know, 1-on-1 conversations. We then have Tristan's Tips on Thursdays, and then we have The Link Up with Latesha or See It to Be It with Amy C. Waninger on Saturdays. Like, those kind of interchange, and so we have essentially three different series a week, so make sure you reach out. We're all over Beyonce's internet, you know? Just type in Living Corporate, we're gonna pop up. And then yeah, you've been listening to Dr. Janice Gassam, public speaker, entrepreneur, educator, consultant, podcaster, and writer of "Dirty Diversity." That's also the podcast. Make sure y'all check out all the links in the show notes. 'Til next time. Peace.

After seeing five different doctors, Dr. Becky Campbell, a Functional Medicine practitioner specializing in thyroid health and histamine intolerances, was diagnosed with thyroid issues. Despite this diagnosis and treating it, many other symptoms still remained. So Dr. Campbell kept digging to uncover the root cause of these issues. She discovered a histamine intolerance was to blame. In this podcast episode, Dr. Campbell shares her journey along with what a histamine intolerance is and why so many people could unknowingly be affected by it. You’ll also hear more about the symptoms of an over or underactive thyroid, histamine intolerance symptoms to watch out for, and how to test yourself at home. If you’re not familiar with Dr. Campbell’s work, she’s the author of The 30-Day Thyroid Reset Plan and The 4-Phase Histamine Reset Plan. Dr. Campbell is also a board certified doctor of natural medicine (DNM) and she has her doctorate in chiropractic medicine. She’s also trained under Chris Kesser. Tune in now to learn more about thyroid issues and to see if a histamine intolerance could be causing your unexplained symptoms!