Foundations of Functional Medicine: Episode 3

In this episode, Dr. Hartman continues the discussion of the first pillar of functional medicine, Diet and Nutrition. This episode continues where episode 2 left off and looks more deeply into specific diets trending today. If you’ve wondered what is the difference between Paleo, Autoimmune Protocol (AIP), Nutritional Ketosis (or Keto), Grain-free vs. Gluten-free, Vegetarian or Vegan as well as which diet may be the right one to choose to support your own health goals, this episode will be both accessible and informative.

Foundations of Functional Medicine – Episode 003

In this episode, Dr. Hartman continues the discussion of the first pillar of functional medicine, Diet and Nutrition. This episode continues where episode 2 left off and looks more deeply into specific diets trending today. If you’ve wondered what is the difference between Paleo, Autoimmune Protocol (AIP), Nutritional Ketosis (or Keto), Grain-free vs.

Transcript

Host [00:00:39] Welcome to Foundations of Functional Medicine with Aaron Hartman, M.D. This is a podcast of Richmond Integrative and Functional Medicine. This podcast seeks to motivate individuals to reclaim their health through education, encouragement, and empowerment by reviewing the basic tenets of Functional and Integrative medicine, as well as discussing new advances shaping the future of healthcare in our country. To learn more about us and keep up to date on other important health-related topics, visit us at www.richmondfunctionalmedicine.com. 

Host [00:00:57] The following discussion is for educational purposes only and is not intended to diagnose or treat any disease or disease process. You should always discuss any medical treatments or interventions, as well as changes in your health, with your personal physician.

Dr. Hartman [00:00:59] In episode two, I began discussing some of the concepts of diet, lifestyle, nutrition. This episode is a continuation of that topic. If you haven’t already listened to Episode 2, I would encourage you to go back and listen to that episode first. When you finish, please come back here for Episode 3. In this episode, I would like to talk about food trends or fads. Armed with the idea of how you get high-quality food on your plate, you’ll be equipped to evaluate these critically. There will always be food fads. There will always be food trends. We know that is true from the last hundred years of our history. Hopefully in this episode where a review in the most popular current trends and fads, you’ll have additional tools to help you evaluate these better, and assist your own needs based on your type of diet. And, of course, enable you to personalize your own diet. I would like to start with the ketogenic diet. This diet is wildly popular right now, and this is largely due to the work of multiple researchers. This includes pioneers like Dr. Jeff Volek [and Stephen D. Phinney, MD, PhD] and his book, “The Art and Science of Low Carbohydrate Living”. This is a little bit of a technical work on low carbohydrate diets and ketogenic diets, but it is likely the best research in a single source if you want to learn about low carbohydrate and ketogenic diets. Dr. Volek is a major researcher who has been working [in] this field for 20 to 30 years. He’s less well known, however, then maybe some other people like Dr. Terry Wahls. Dr. Wahls is a well-known researcher at the University of Iowa who has used a ketogenic diet to treat her own multiple sclerosis. And then there is Dr. Dale Bredesen over at the UCLA Buck Institute, who was a pioneer in Alzheimer’s research and is using a ketogenic-type diet as the basis for his nutritional treatment of Alzheimer’s disease. So, what is so amazing about the ketogenic diet? Well, a lot of things. The ketogenic diet actually helps improve mitochondrial function. The mitochondria are the energy, or powerhouses, of the cell. When in ketosis, think about it as burning clean. When you burn energy in ketosis, it’s like burning clean fuel. You burn clean, you burn fast and efficient. Cells prefer this. And when you burn clean, you produce less smoke residue, or smut, in the air. So, what happens in your cells is that the energy is used in a much cleaner and more efficient fashion. This is in contrast to when you burn sugar or carbs. That is a very dirty kind of fuel. Think about the big truck in front of you that doesn’t have a good diesel system that is leaving that smoky smell in the air where the particles you smell in the air compared to a car with a well-functioning catalytic converter. That is like the difference between ketogenic versus carbohydrate-based diets. So the first concept is this, that ketogenic diets burn very clean. The second thing is a clean-burning ketogenic-type diet improves detoxification. While you sleep at night in a ketogenic state, detoxification of your neurons is improved. You actually have less sugar fluctuations. Your gut repairs and rests and your liver detoxifies better. The third thing about a ketogenic diet, is that it improves insulin sensitivity and thus how efficiently insulin works in our bodies. Insulin sensitivity is a big, big deal. Elevated insulin levels are associated with metabolic diseases, diabetes, cardiovascular diseases, and a whole host of other things. In ketosis, you actually maximize and improve insulin sensitivity as your sugar levels come down and you switch from a carbohydrate metabolism to a ketone metabolism. Insulin sensitivity improves, your body starts using fat for energy and you also get less adipose cell, or fat cell, inflammation. Your fat cells in your body are probably the largest endocrine, or hormone-producing, organ in your body. Think about how much fat you have in your body. That is an endocrine organ that produces cytokines, or inflammatory hormone-like molecules. When in ketosis, fat cells work better. So, there are multiple reasons why ketogenic diets are great. And this is one of the reasons for the popularity of interval fasting, which I’ll talk about in just a bit. But there are some downsides to the ketogenic diet, and the biggest one is the effect on your microbiome. The microbiome, or bacteria in your gut, are a very big field of research right now. If you’re familiar with any of this research, you’re familiar with the data on the microbiome affecting your risk for diabetes. There are now actually probiotics being researched that treat diabetes. We’re looking at a research study right now at my research company on a probiotic to treat C-diff colitis. Other studies are being done on probiotics to treat obesity. The microbiome is a really important part of your immune and metabolic system. And the ketogenic diet, by definition, is a low carbohydrate diet, which means you don’t get enough food for your microbiome. For some people, this can be very detrimental. If you don’t have the right microbiome or your microbiome is disrupted, a ketogenic diet can make things worse. The other problem with a ketogenic diet is that if you have a microbiome that is disrupted, and you have an overabundance of E-coli which are gram-negative rod, these bacteria have something called endotoxins or lipopolysaccharides for short. This is a toxin that surrounds bacteria. There are tons of bacteria in your gut, but as long as it stays in your GI tract, it’s not an issue. Medium-chain triglycerides or MCT’s, which plenty of people consume from coconut oil or palm oil to make you go into ketosis, will actually drag these endotoxins across your GI tract and into your blood and lymph systems. If you have a lot of these in your GI tract, the ketogenic diet can actually make you quite sick. Sometimes when people get a “keto flu”, that is what’s making them feel sick. It’s these large scale endotoxemia or these endotoxins in the blood. So there are advantages to the ketogenic diet and disadvantages. I tend to use interval fasting with my patients, like those who want to lose weight, to maximize their health, and particularly with my diabetic patients. There are different kinds of interval fasting, whether it’s the 12-12 ketogenic diet where you don’t eat twelve hours a day, say between 6 o’clock at night and 6 o’clock in the morning, and you wake up in a state of ketosis or Dr. Bredesen’s 16-8 Keto Flex where you condense your eating time daily into an 8-hour window. If you have a gene defect called the APOE gene mutation, this makes you more prone to inflammation and Alzheimer’s. And Dr. Bredesen’s research, he has patients with the APOE4 gene do what he refers to as the 16-8 Keto Flex diet, which is where you fast for 16 hours per day and eat for eight hours per day. So, for example, this would have your dinner at 6 o’clock at night and then you’re not eating until 10 o’clock the next day, getting a 16 hour fast every day, or something similar to this. Individuals with the APOE4 mutation require a long, daily fasting period to obtain an adequate therapeutic ketosis. During the fasting time, you’re able to drink plenty of water, herbal teas, green teas, et cetera. There are a lot of advantages to ketogenic diet, whether it’s improved energy production, improved brain health, reduced vascular inflammation, or improved BDNF or brain-derived neurotrophic factor, which improves new neuron formation.

Dr. Hartman [00:07:23] The next diet I’d like to discuss is a vegan diet. Probably one of the biggest proponents of this diet was Dean Ornish with his research out of California. He’s known for the research putting cardiovascular patients, patients with heart disease and blockages in their arteries, on a vegan diet for a year. What he saw was amazing. His group showed using vascular ultrasound of the carotid arteries, that the plaques in the carotid arteries would get smaller. Amazing diet. One thing that is not emphasized in the reports on his trials is that there were three parts to the Dean Ornish Plan. First, it consisted of a vegan diet. Second, daily meditation, and third, exercise. So, one of the questions I always had with his research is, which was the most important one? Was it the vegan diet? Was it the meditation daily for stress reduction? Was it the exercise? Was it the combination of all three? Who knows? But again, a very powerful diet. A vegan diet does a lot of good things for your metabolism. Large amounts of plants and vegetables help improve detoxification. I tend to think about the vegan diet as a fast. A fast from processed foods, a fast from animal products, and it allows your liver and other organs time for detoxification to work a little better. One of the downsides of a vegan diet is that people tend to eat a lot of processed grains. Rice cakes, quinoa, and other grain products, and even though they are vegan, they’re absolutely terrible for you. Many also eat a lot of highly processed plant-based meat replacement products, which are also not a health-promoting option and other factors related to processing. The other issue with the vegan diet is that it’s difficult to get enough protein. Phase two of detoxification requires a lot of amino acids; glycine, taurine, cysteine, malic acid. These are all important amino acids that are deficient in the typical vegan diet and they’re required for your liver to detoxify. And without these, it’s difficult to detoxify properly. For me, it’s really hard to get 60 to 80 grams of protein a day on a normal diet. Remove animal products, and it’s even more difficult. The other thing is, certain kinds of sulfur-rich amino acids like methionine and cysteine only come from animal sources. There are no plant source alternatives. If you do fermented foods, you can get these amino acids. But again, how many people with a vegan diet are eating fermented foods? For this reason, I tend to think about the vegan diet more as a construct, like you’re doing a fast from processed foods or a short-term detox type diet, not as a lifestyle. I feel like this is the best and safest way to utilize this diet. The analogy I like to give patients is this: I do not know, in the history of the world, a culture or society where vegan grandmothers had vegan mothers and vegan mothers had vegan grand children. So, are we going to start now? Often people use the term vegetarian diet. This can still include some animal products. More specifically, an ovo-vegetarian will eat plants plus eggs. A pescatarian, vegetables plus fish. The simple term vegetarian, only means that someone’s diet consists mainly of plant life, but doesn’t describe the source of protein whether meat or eggs or fish. Vegan excludes all animal products.

Dr. Hartman [00:10:12] The next diet is a gluten-free diet. This has been touted as a fix-all for just about everything that ails you. I’ll spend a little time with the gluten-free diet because I feel like it’s a really important kind of diet. Why is a gluten-free diet so powerful? One reason is likely because we just do so much in the processing of gluten that makes it toxic and inflammatory to your body. And we use gluten as a filler in so many processed foods. I try to remind patients that we have historical records dating back to 8000 B.C. in the tablets of Sumer, showing bread and bread grains used as food and even as a form of money. Have you ever heard the phrase “the bread of life”? There is a reason that that phrase could be used two thousand years ago and have an impact on the hearers. But what we’ve done to bread in the last 150 years has been nothing short of life-changing in a different sort of way. As discussed previously, first we separate all the constituent parts of the wheat berry, leaving only the carbohydrate-containing elements of the grain, which consist of a large amount of gluten, and very little vitamins and minerals. But even before this part of the process, we hybridize wheat (it’s actually not a genetically modified food) to the extent that it’s fourfold more productive than the wild-type plant. This plant only grows eight inches tall in nature, not like in the generations past where we used to have the four feet tall plant that the Star-Spangled Banner described in its “amber waves of grain”. This does not exist anymore. Well, these 18-inch plants can’t survive in nature and are overgrown by weeds. In my field, some of the weeds grow several feet tall. The answer to this is spraying the crops with glyphosate, or the brand name Roundup. On a side note, the hybridization process also enables the wheat plants to survive high doses of Roundup. Roundup received its initial patent as an anti-microbial. It kills bacteria in the soil and in your GI tract. At the end of the season, in order to be able to reap large tracts of land, thousands of acres of wheat have one super large dose of Roundup applied to kill even the wheat. It browns quickly, in a controlled manner, and then the entire tract of land is harvested. After the processing of wheat, it has to be turned into bread. Emulsifiers and other chemicals are added to the grain to ensure that the sticky, doughy batter doesn’t stick to the machine parts, and to ensure that the final products all look pretty and uniform on the store shelf. These emulsifiers also emulsifier the mucous lining of your GI tract. Some of these emulsifiers have been associated with inflammatory bowel disease, and it’s no wonder. They literally partially dissolve the protective lining of your GI tract. Even the fermentation process has been changed. Typically it takes 24 hours for bread to rise. Due to the modernized techniques, we can get it to rise in three hours. So how does all this change food chemistry? I think you get the point by now. Just removing this one thing from your diet actually is removing a whole host of food chemicals and nutrient deficient food-like substances.

Dr. Hartman [00:12:47] I’ve mentioned briefly today a detox-type diet and I even did a whole blog series on detoxification. So let’s discuss this diet next. Detoxification is something our bodies do on a daily basis and the cells in our body do on a continual basis. We either have to remove the waste products of metabolism, made in our bodies, or remove the toxicants to which we are exposed from our environment. The detox diet attempts to remove all toxicants and chemicals to which we are exposed from our foods and beverages, plus eat foods that maximize our body’s ability to detoxify. I won’t spend too much time here talking about it today since I already did a full blog series on detoxification, but what I’d like to say briefly is that every diet either is improving our body’s ability to remove toxins and toxicants or increasing our exposures. There’s no way around this. So everyone, no matter what your diet is and how you eat, you should use these constructs in food sourcing. For example, if you’re using a keto diet, you want to make sure all the oils you use are 100 percent clean, the butter you consume is from grass-fed cows, the oils you use are cold-pressed or traditionally produced, etc. If you’re doing a vegetarian/vegan diet, you want to make sure all the vegetables are non-sprayed, non-GMO. The second thing which makes the detox diet unique is that it focuses on foods that especially improve your body’s detoxification processes. Some of these foods include the cruciferous vegetables like broccoli, cauliflower, arugula, some sulfur-rich foods like onions and garlic and fermented foods like sauerkraut and kimchi. The entire detox food plan from the Institute for Functional Medicine is available as a free download on our website and will be linked in the Show Notes. So if you want more information on this diet, you can download it under the nutrition tab.

Dr. Hartman [00:14:23] The last diet I’d like to discuss, and probably the most important diet right now, is the paleo diet. This diet includes the [Paleo Autoimmune Protocol] diet (AIP) and Whole 30 as well as the so-called Caveman Diet. The diet itself is a grain-free, dairy-free, soy and other legume-free, processed food-free diet. In some ways, it’s very similar to an elimination diet. The strength of the paleo diet is all the resources available due to its popularity. There are websites that will put up an entire meal plan together for you, multiple cookbooks with really great recipes, and even Facebook groups to help with implementation. Whole 30 itself is a type of paleo diet, but it’s meant as a 30-day plan, and not a lifestyle change. This is usually used of a type of restart and is very similar to an elimination diet. However, if you’re doing an elimination diet for gut issues, allergies or other GI problems, I’d recommend an official elimination diet. Again, there are many resources to help implement this diet. Neither the Whole 30 nor a straight paleo diet are medical nor medicinal diets per se. What this implies, is that these diets were not designed primarily to be implemented in certain disease states, but due to the degree of similarity between this and say, an Autoimmune Paleo diet, there are definitely some therapeutic results in people depending on their food triggers. Whole 30 focuses on whole, unprocessed foods and removes the following: all grains, grain replacements like coconut flour as a replacement for regular pancakes, legumes, dairy, food chemicals, processed baked foods. The paleo diet restricts the following: grains, sugar, dairy, processed foods, artificial sweeteners, and potatoes. As you can see, the diets are quite similar and differ mainly in their implementation. There are really no downsides to either of these diet approaches and around 60-70 percent of my patients do really well on a paleo-type diet. The focus is really unprocessed food with the avoidance of so-called staples that are associated with most of the inflammation and most allergies in our country. Additionally, removing dairy, wheat, eggs, soy, corn, peanuts alone account for 80 to 90 percent of all food reactions and allergies. Just think about that for a second. What makes these five foods so special that they alone account for almost all of the food reactions in our country today? One simple word: processing.

Dr. Hartman [00:16:27] I’m going to take a few minutes here to talk specifically about these foods and how they are processed just to give you a glimpse into how this can affect your health. So for dairy, the process of homogenization and pasteurization change the chemical structures of dairy. In homogenization, the fat in the dairy is mixed with the water and the two come together. Water and oil are not supposed to mix where they do in homogenization. This changes how dairy is absorbed and even can increase your risk of developing things like gout. Pasteurization, which is supposed to help decrease the risk for infections from dairy does do that, but it also changes the protein structure of the dairy. But even before that, we have to remember that these cows are being fed grains, cows fed grains ferment the grains in their GI tract. The result being, they produce alcohol. Well, that is not good and it results in fatty liver disease and pre-diabetic cows. So now we’re drinking milk and eating milk products from pre-diabetic, metabolic diseased cows fed grains. We must remember that the cows are herbivores. They ferment food. They’re supposed to ferment grass, not grains. And so that changes the food chemistry reactions within the cow, which then affect the quality of the milk that then comes to us. Wheat—I’ve already discussed wheat, how it is hybridized, how glyphosate is used in it, and how it’s fermented. So, I won’t go into this too much, but it’s one of the top three altered foods. Eggs are another interesting food. Eggs are a superfood or they’re toxic. It depends on how the egg is processed. So eggs typically are irradiated, which is kind of crazy if you think about it, to kill all the bacteria on the eggshells. They’re also bleached. Now, if that wasn’t bad enough, the eggs are actually filled full of soy and other grain products. Well, how do those things get there? Well, the chickens are largely fed grains, they’re not allowed to go around, look for bugs and forage. And so what happens is you get the byproducts of grain, soy, corn into the eggs. And then when you eat the eggs, it gets into you. Corn has been genetically modified to produce a toxin called the B.T. toxin. So corn produces its own pesticide, and it’s also sprayed with glyphosate, but that’s just on the side note—results in large amounts of mold on the corn. So those who have mold issues or things like chronic fatigue and fibromyalgia tend not to do well with corn due to the mold content in the corn itself. Soy is very similar to the above. The difference with soy is that here in America soy is not fermented like it is in Japan or in Asia. Typically, they will ferment soy there from one to three years, here that’s not the case. Of course, soy is genetically modified. Of course, it’s sprayed with large amounts of glyphosate, and it’s also processed similarly to wheat. But the biggest issue here is the genetic modification, it not being fermented, and then how we process it. Now these five foods, but basically everything we eat. They’re everywhere. Even the animals we eat are exposed to these things. So how these foods are modified and processed, even if you don’t eat them, is going to work its way into ultimately the foods you’re exposed to and eat.

Dr. Hartman [00:19:10] Now, there are several medicinal or therapeutic diets I’d like to briefly discuss. These are by definition diets that have been studied with specific disease states and have researched data on their therapeutic effects. We’ll start with the Six Food Elimination Diet. This diet alone has a 70 percent remission rate for the condition eosinophilic esophagitis, or EOE for short. In this diet, you remove wheat, milk, eggs, nuts, soy, fish, and shellfish. The typical medical treatment for EOE is steroids. So just ponder this—just removing these six foods prevents 70 percent of individuals with this disease from needing any type of prescription treatment. This is compelling. The Autoimmune Paleo diet has been popularized by Dr. Terry Wahls and her multiple sclerosis research and lupus research. She has even gotten an NIH-sponsored grant to use these diets and study their effects on these two diseases. On the West Coast, Dr. Dale Bredesen is using the same type of diet in his treatment protocol for Alzheimer’s patients. To learn more, you can read Dr. Wahls book titled “The Wahls Protocol” or Dr. Bredesen’s book entitled “The End of Alzheimer’s”. I also have a resource in my reading list on the website that focuses on the Autoimmune Paleo diet and it’s uses entitled, “The Autoimmune Paleo Plan”. SIBO is something I see quite routinely in my office. Small Intestinal Bacterial Overgrowth is a condition of the colonic bacteria refluxing into the small bowels. This agitates the immune system and causes symptoms such as gas, bloating, constipation, anxiety, and flushing just to mention a few. Typically it’s treated with antibiotics like Xifaxin and neomycin, but a SIBO diet can also be used to resolve these issues. A great resource for this particular diet can be found at www.siboinfo.com. Here Dr. Allison Siebecker gives great resources on the causes and dietary treatment for SIBO. There are also several other therapeutic diets I want to briefly mention. These are the Anti-Candida Diet, FODMAP diet, and GAPS diet. I could do a full podcast episode on each one of these, so I’ll be super brief here. The Anti-Candida Diet is a restrictive sugar-free, carb-, grain-free diet that seeks to decrease the population of Candida in the GI tract. Typically it’s used for those with severe sugar cravings, “hangry” episodes that resolve with consumption of sugars or carbs, or those with candida overgrowth syndrome. The FODMAP Diet, or fermentable oligosaccharide, disaccharide, monosaccharide and polyphenol diet, is used to treat irritable bowel syndrome. Even some have used it as the preferred diet in inflammatory bowel disease. There is detailed information on these two diets on our website under the Nutrition tab. We will link to these in our Show Notes. The GAPS Diet, or Gut and Psychology Syndrome Diet, is primarily used in the world of Autism. It attempts to reset the microbiome of the GI tract, which is where 90 percent of serotonin and 50 percent of dopamine are produced. Natasha Campbell-McBride, who was a practicing neurologist and neurosurgeon in Russia, developed this diet to treat her autistic child. Her website www.GAPS.me has a full compendium of resources for this plan. We’ve come a long way from my days in medical school where I was told diet didn’t matter. Now researchers are using diet to treat Alzheimer’s, cardiovascular disease, multiple sclerosis, and inflammatory bowel disease, just to mention a few. My hope is that this two-part series on diet and nutrition was helpful and that, armed with the basic information, you can begin to individualize your own nutritional plan. In the Show Notes, we will provide a place to sign up to receive my complete food sourcing guide with help on how to find local and seasonally-sourced foods, which also includes a food sourcing guide specific to Central Virginia region as well as resources available throughout the country. We’ll also link any of these resources or the websites I mentioned earlier in the episode. The foundational diets from Institute for Functional Medicine are also featured on our website. Listeners can go there and read through each of these diets and then choose the nutritional plan that either resonates best with them or their health needs. As always, it’s best to work with a healthcare practitioner whenever starting any new health plan or dietary plan to make sure it’s the right one for you.

Host [00:23:41] We hope you found today’s episode useful and informative. Please see the show notes on our website at www.richmondfunctionalmedicine.com in addition to many other resources and educational materials, we’d also like to invite you to subscribe to our podcast to keep up to date with new episodes. You can find us on Apple podcasts or wherever you listen to podcasts. Please also consider giving us a five-star rating in review so that others can gain access to this information. You can also find Richmond Integrative and Functional Medicine on Facebook and Instagram. [We can also now be found on Twitter and LinkedIn as well]

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