In this episode, we discuss:  

  • Robert Biswas-Diener’s journey from psychologist to coach
  • What is positive psychology?
  • Combining positive psychology and coaching
  • The fundamentals of health coaching
  • How health coaching differs from an expert or authority approach
  • How asking powerful questions shifts the dialogue
  • Framework for coaches just getting started
  • What an aspiring health coach should look for in a training program

Show Notes:

[smart_track_player url="http://traffic.libsyn.com/thehealthyskeptic/Harnessing_the_Power_of_Positive_Psychology_in_Health_Coachingwith_Robert_Biswas-Diener.mp3" title="RHR Podcast: Harnessing the Power of Positive Psychology in Health Coaching - with Robert Biswas-Diener" artist="Chris Kresser" ]

RHR Podcast: Harnessing the Power of Positive Psychology —with Robert Biswas Diener - YouTube

Chris Kresser:  Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Today I am very excited to welcome Robert Biswas-Diener as a guest. Robert is the foremost authority on positive psychology coaching and has consulted with a wide range of international organizations on performance management and talent development. He conducts trainings on coaching, strengths, positivity, courage, and appreciative inquiry with organizations and businesses around the world and through his own coaching school, Positive Acorn.

Robert has trained professionals in North America, Europe, Asia, Africa, Australia, South America, and the Middle East. He has a doctorate in social psychology and a master’s degree in clinical psychology and is an ICF Professional Certified Coach. He’s the author of Practicing Positive Psychology Coaching, The Courage Quotient, and The Upside of Your Dark Side, among other books. Robert is also on the faculty of the ADAPT Health Coach Training Program, which is launching in June, where he has created and is going to be delivering the content on developing core coaching skills.

So I’m really excited to talk to Robert about positive psychology and especially its application in a health coaching context—why it’s so important, what the most important skills and competencies somebody needs to be successful as a health coach are, and how effective health coaching can help stem the rising tide of chronic disease. So let’s dive in. Robert, thank you so much for joining us. I’ve been really looking forward to this conversation.

Robert Biswas-Diener:  Thank you so much for having me. I appreciate the opportunity.

Robert Biswas-Diener’s journey from psychologist to coach

Chris Kresser:  So let's start by talking a little bit about your background, like, how you came to this work, how you came to positive psychology, and then how you ended up working primarily as a coach. Because you have a background in psychology and you chose, at least from my understanding, not to work as a clinical psychologist. So I'm just curious to hear more about your journey.

Robert Biswas-Diener:  Certainly. Yeah, it’s a good question. I think, like most people, I come from a family entirely populated by psychologists. Both my parents are psychologists, my older sisters, who are twins, are psychologists, so I was the fifth person in my family to get a degree in psychology. Our parents were very liberal and understanding and open-minded. They said, “You can go into any subfield of psychology you want.”

Health coaching isn’t just providing information or advice, it’s about becoming a “change agent”—helping your clients to discover their own motivation and strategies for change. Positive psychology is a powerful tool in this process. 

Chris Kresser:  It's amazing that you're so normal, Robert, with all those psychologists around.

Robert Biswas-Diener:  Well I don’t make any claims about my normalcy. But I can definitely tell you that psychology was the air we breathed growing up. My father had all these sort of psychometric and psychological measurement devices around. We had a little sort of stuffed bunny that we pet, but it had a meter attached to it to measure how aggressively you were petting it. That’s the kind of thing you were exposed to as his kids. I know this makes my father sound a bit like a sadist, but he would have my sisters and I clean his office as quickly as possible. And whichever of us did the best job could have the thumb of our non-dominant hand shocked in a shock machine.

Chris Kresser:  Totally normal, totally normal childhood.

Robert Biswas-Diener:  Absolutely. See, we just grew up thinking that people and the study of people is totally fascinating. And more interesting still, my father is one of the people who pioneered happiness studies. So it wasn't just looking at depression or the darker elements of human nature, but we grew up thinking happiness is something worth studying, something you can define and measure. And that's really what attracted me to psychology in general. I, as you mentioned, pursued a doctorate in clinical psychology.

But I knew by the time I got my master’s that I didn't want to be a full-time therapist. I think therapy is great, noble work, but I just knew it wasn't for me, sitting across from one individual helping one person at a time. And I made the tough choice to leave and go study, do research with my father, and I spent about five years traveling the world and studying happiness, which was a pretty blissful five years of my life. And I had the opportunities to visit some pretty extraordinary places, work with extraordinary people. But I did, while doing research, missed that one-on-one connection, that sense that I was doing more than creating knowledge. I wanted to help people make a difference in individual lives. That's when I discovered coaching. This was sort of right around 2002. And I was able to leverage my expertise in positive psychology and my training and coaching into a decent career that allowed me both to continue researching and satisfy my quest for knowledge, while also helping people, to satisfy that aspect of my mission.

Chris Kresser:  So what was it about coaching that you decided that you didn't want to work as a clinical psychologist in that one-on-one capacity? But what was it about coaching that drew you to it where the practice of clinical psychology did not?

Robert Biswas-Diener:  There a few things. And again, I certainly like clinical psychology, but my sister, my mother, they’re both clinical psychologists and good people. But there’s something weighty about it. The sense of responsibility you have when you sit across from someone who's in psychological distress, that you have to keep your heart pretty open to them, you have to be empathic, compassionate to them, and you're often dealing with trauma, with suicidality, with pretty high-stakes concerns. I'm glad that there are people doing that, but the risk for burnout is high in that function.

Chris Kresser:  Right

Robert Biswas-Diener:  And coaching, by contrast, just really to me seemed somehow more playful, a little bit more goal focused, that we could be light about it, take it less seriously. People were coming to me because they'd always wanted to write a novel and they'd put it on the back burner their whole life, and they just hit midlife, had their crisis, and they finally wanted to get going with it or they wanted just to establish better work/life balance. Or they wanted to improve their health or they wanted to be a better manager. They had just gotten promoted and they felt like an imposter. And these are not clinical concerns, and it just felt like, wow, this is a bit … the stakes are high here, but they're not life-or-death stakes. And we can kind of have fun, the people who came in felt healthy and resourceful. It didn't drag me down at the end of the day, I guess.

What is positive psychology?

Chris Kresser:  Right, and perhaps more compatible with your interests in happiness and positive psychology, which I want to talk to you a little bit more about. Because some of our listeners are probably not that familiar with positive psychology, and it was really, at least from my perspective looking in from the outside, fairly radical. Psychology historically was more focused on the past and what's wrong, perhaps. And here comes a new way of approaching it that is really more focused on what's right and the present. So I'm just curious to hear more about, you know, how you got involved in positive psychology. It sounds like through your family, but tell us a little bit more about the evolution of this approach. Because I think that's an interesting story in itself.

Robert Biswas-Diener:  Yeah, absolutely. So sort of the nutshell version of the history of psychology is a long time ago psychologists were either philosophers or medical doctors. And they were just trying to puzzle out, why are people doing the things they're doing? And the medical doctors were doing things like, how does the nervous system work? How does the brain work? And the philosophers were asking questions like, what is morality? What is our duty? What's our best potential? And for a long time, even up until sort of the year 1900, psychology did have a lot of emphasis on positive topics like morality, companionship, friendship, support, and athletic performance, even. Winning. And it was really only after World War II and at least in the United States with the creation of the Veterans Administration, that there was a pivot towards a clinical focus. Because clinical issues are pressing, and folks coming back from war time were experiencing what then was called shell shock, we now know as PTSD. And rates of depression and later on anxiety were growing at epidemic rates.

So about half of the psychologists in the United States now are clinicians, and that's a pretty overwhelming amount. But around the turn of the century, that is 1980 or 1998, 99, 2000, there was sort of this reinvigoration that, yeah, it's okay to focus on these pressing psychological ills, but that really it’s only half, or one portion, of human nature. What about people who are generous? What about people who are funny? What about people who are great learners or great teachers? Shouldn't we also be looking at those types of topics? Optimism, savoring, and happiness. And so a group of researchers and practitioners got together and sort of established this new approach. It was an old way of thinking, but it came under a new umbrella called positive psychology.

Chris Kresser:  And when positive psychology first was introduced, was it well received amongst conventional psychologists? Was it controversial? What happened?

Robert Biswas-Diener:  Yeah, it's a really great question and I think that anyone who has probably opened a blog in the last five years has probably come across at least some study suggesting that X makes you happy, whether that's a glass of wine or a little workout or a piece of chocolate or spending more time with friends, whatever it is. So it is part of the zeitgeist, I guess, that just sort of this idea that happiness research is out there, I think, is widely accepted now. But really, there are a lot of stereotypes about positive psychology. There are many skeptics, many critics of it.

Many of the most common sort of complaints, if you will, are folks who think that positive psychology is pollyanna, it's just this naïve science where we only focus on the positive and we would never talk about anxiety or depression or divorce or child abuse or any of these social ills. And say, “Ah but we should all be happy all the time anyway.” And that's not true, actually. There are no researchers that actually believe that. We're just trying to say, “Hey, let's study all of human experience, not just the darker half. And then some folks also criticize it a little bit as sort of a middle-class movement. They say, “Hey, there's folks living in poverty, there’s real injustice going on, and you’ve got these middle-class people attending happiness seminars.” There might be a seed of truth to that, but I don't know that that's necessarily wrong for middle-class people to want to be happier. And nor do I think it's exclusive to the middle class. I think that upper-class and lower-class people, I think across the economic spectrum, folks are interested in happiness.

Chris Kresser:  Yeah, so I mean that pollyanna critique is one that I've heard, and I've seen people conflate positive psychology with things like affirmations. Just repeating the outcome that you want to see or the beliefs or thoughts about yourself, over and over again. But there's really actually quite a bit of research supporting positive psychology, isn’t there?

Robert Biswas-Diener:  Yeah, at the heart, really, it is a robust science. It’s largely happening in universities you've heard of. Places like Stanford and Harvard, as well as others. Very solid researchers using sophisticated statistics, sophisticated measurements and methods, and it's a lot less New Age-y, I guess, than many people might assume. It’s not, let's just reframe every bad thing like, “Oh, I'm so happy I got cancer because this is going to be an extraordinary lesson for me.”

Chris Kresser:  Look at the bright side.

Robert Biswas-Diener:  Yeah, that’s really not what this is about. Really, we’re interested in saying things like, like, just take a concept like savoring that is taking a positive or pleasant moment and extending it mentally. So it’s sort of like, who does this? Are women, are men more likely to do it? Young people or old people? When do they do it? Are they more likely to do it when they are together or when they're alone? Do we do it in different ways? For example, when you get together with your buddies and you tell these kinda good times that happened to you collectively long ago—that's a form of savoring. You’re taking that pleasant moment from the past and dragging it into the present. When you talk about a meal as you sit across from someone and say, “Oh you should try this. It’s really good,” that’s a form of savoring. And so we’re really just kind of interested in kind of describing like, what's going on with these fascinating phenomena.

Chris Kresser:  So there's the application of positive psychology in a psychotherapeutic context, like in a clinical context where a client is coming to see a psychologist for anxiety or depression, or any number of other complaints. But then there’s how positive psychology is applied in a coaching context where the focus is more on behavior change. And that might include things like focusing on strengths and leveraging those strengths instead of trying to fix things that are broken or not working as well. So tell us a little bit more about that, how you've combined positive psychology and coaching practice.

Combining positive psychology and coaching

Robert Biswas-Diener:  Okay, so, so it's interesting. Some people who have just a passing familiarity with positive psychology will recognize some of these sort of artificial interventions that are often trumpeted as happiness-producing. There are things like, you should write down three things for which you’re grateful each day, and if you do that, that will yield good happiness dividends for you. In positive psychology coaching, we don't really do that because coaching isn't prescriptive. I'm, as a coach, not going to say here's what you should do. I'm not giving a lot of advice. A lot of the positive psychology and positive psychology coaching is invisible to the client. And just to give you a couple examples of this.

One, you already mentioned, is strengths, that we’re interested in clients identifying their strengths, seeing those strengths as actually being strengths, not just dismissing them as ordinary, and using them optimally. So that might be “use your strengths more,” but it might also be “use your strengths less,” or “use them more judiciously” with a certain type of person for whom the strength doesn't make sense. So imagine someone who's great at humor, they might want to use humor with some people but not others. And the coaching process would be reflecting on when this strength, when does this strength of humor go well? How should you best employ it? And through that process, you would be more effective at using your strength.

And another thing we would do in positive psychology coaching would be just to invite people to focus on solutions rather than problems. And I think this is kind of an artful way of thinking because it's a little bit tough. Because people want to complain, and you can't invalidate them by saying no, no, no, let's not talk about your complaints, right? So you let them talk about their complaints, you just don't invite them to do so more than they normally would. Instead, you invite them to focus on solutions. The simple question is, “Wow, that complaint sounds awful. What would you prefer instead?” And it's so, so much of the positive psychology in the coaching is very subtle and it just comes out in the form of very natural questions.

Chris Kresser:  So let's talk a little bit more about coaching because this, as I've, we’ve been preparing to launch our ADAPT Health Coach Training Program, have been talking to a lot of people about coaching, both people who identify as coaches and people who are wanting to learn to become coaches, people who are experts in the coaching world. And it turns out there are a lot of different definitions of coaching and a lot of different conceptions of what a coach should do. I mean, certainly for some who might not be very familiar with health coaching or life coaching or executive coaching, they might think about, like, a sport coach, you know, like someone with a whistle around their neck, blowing it and yelling at them. And that’s what they think of as coaching. But what is coaching from your perspective? What defines coaching?

Robert Biswas-Diener:  Sure, it's a great question and I think you're right, there are a lot of stereotypes around it, right? Sort of this New Age life coaching kinda stereotype, just like, “Hey, if we could look at your past lives, which of those would you want to use?” And I think that there is some of that in coaching, and there's folks that do coaching that have no training in it, and I think that's a little bit dangerous. This is a profession. It's not just something that you can kinda shoot from the hip. So I believe that coaching fundamentally is a professional relationship where the coach acts as a facilitator. And in the capacity as a facilitator, they work with their client to help the client achieve personally important goals, and they do so primarily through some broad mechanisms.

One, they support the client and they act as a yes-man or yes-woman, kind of saying like, “Yeah, that's interesting. Yeah, what would it take for you to try that?” They also provide accountability. “So you want to make this big behavioral change. Great. I'm going to hold you to that. You're gonna let me know exactly the progress you're making and I'm going to hold your feet to the fire if you fall short of that.” They also do a lot of exploration. That makes up the, sort of the lion’s share of a coaching session. And that just comes in the form of questions where you probe the client's life. You have them take stock of his or her identity and resources, challenges, hopes, help them articulate goals. And then the last thing, I think, is just a little bit of challenge too. You mentioned the sports coach with a whistle, and while I wouldn't whistle or yell at my clients, I don't mind occasionally needling them or prodding them, or doing a little bit of that just to improve motivation as well.

The fundamentals of health coaching

Chris Kresser:  Right. We’ll come back to that, because I think it’s important to emphasize that there are different styles of coaching and not necessarily a right or wrong way to do it. And I know you're a big believer in authenticity in coaching. So I do want to cover that. But before we dive in there, let’s shift our focus a little bit toward health coaching because that’s something that I’m interested in. And something that I’ve noticed as I’ve gone around having these conversations is that some people have the impression that a health coach is someone who requires a lot of expertise and information about things like nutrition and lifestyle, like sleep and exercise. And then their primary role is to deliver that information and expertise to the clients that come to them. What is the problem with that understanding?

Robert Biswas-Diener:  The problem with that understanding is that it’s not what health coaching is fundamentally. That is like being an educator, that's a health educator or health consultant, perhaps. That’s saying, “Look, I've got the solution for you. I know it's gonna work. And if only you follow my plan, magically, things are going to go right for you.” But again, going back to that kind of sports analogy, the sports coach doesn't run out on the field and grab the ball away from the players and try and score with it. That is, they’re not playing the game. They recognize the players play the game and they're just there to motivate, encourage, help them see the big picture, help them improve their strategy, help them train. And that's really a better model for a health coach.

So the health coach can go in with a client that wants to make some type of health change, anything from “I want to quit smoking,” to “I need to get into the gym.” And they help the client tease out his or her own solutions that make sense in the context of his or her own life. Because I think we all understand X amount of exercise is pretty good for people and that you can look at exercise in terms of mobility and strength building and flexibility and all these sort of subcomponents of it. But what about the client in front of you? What about this single mom who's stressed out, has a preteen, and a teen kid, is trying to balance work and home life, doesn't have a huge amount of time or money for a gym membership? What's the solution for that person?

And that person gets to be the..

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The trillions of microbes in our gut play incredibly important and complex roles in our health. I’ve written several articles on the gut microbiome and its connections to:

Because the health of our gut microbiome is so important, I’ve also extensively discussed why we should think twice about taking antibiotics. Thanks to more widespread appreciation of the gut microbiome, more and more patients and doctors understand the potential negative impacts of antibiotics on normal healthy bacteria. But a study published in March of this year suggests that many non-antibiotic drugs can also affect the microbiome. In this article, I’ll break down the findings of this study and discuss whether this is truly cause for concern.

Drug–microbe interactions

The interaction of drugs and the microbiome is not a new concept. It’s been known for quite some time that microbes influence the efficacy and toxicity of drugs, and several studies had previously found that metformin (1), PPIs (2), NSAIDs (3), and atypical antipsychotics (4) can all alter the composition of the microbiota.

Antibiotics can have adverse effects on the gut microbiome, but did you know that nearly a quarter of non-antibiotic drugs can as well? Learn which of your prescriptions might be influencing your gut microbiome – for better or for worse 

However, the effects of many other non-antibiotic drugs on the microbiome had never been assessed, even though many have known gastrointestinal side effects. The goal of this study, therefore, was to systematically profile interactions between drugs and individual gut microbes. It was titled “Extensive impact of non-antibiotic drugs on human gut bacteria” and published in the journal Nature.

For the study, the authors monitored the growth of 40 human gut isolates comprising 38 different bacterial species, which were grown in an anaerobic medium that largely “recapitulates the species relative abundance in human gut microbiomes.” The species were chosen based on their prevalence and abundance in the healthy human gut microbiota and their phylogenetic diversity. Most strains were commensal, or normal, gut flora, but the set also included four potential pathogens, including Clostridium difficile and the probiotic strain Lactobacillus paracasei.

They tested 1,079 pharmaceuticals that are commonly administered to humans, including:

  • 835 with targets in human cells
  • 156 with antibacterial activity (144 antibiotics and 12 antiseptics)
  • 88 with antifungal, antiviral, or antiparasitic activity
Drugs have widespread activity against beneficial microbes

Unsurprisingly, many of the antibacterials tested had broad-spectrum activity, meaning that they inhibited pathogenic bacteria but also inhibited normal commensal bacteria. Of the 156 antibacterials tested, 78 percent were active against at least one commensal species, and most had activity against many potentially beneficial microbes. Additionally, 47 of the 88 antifungals, antivirals, and antiparasitics had anti-commensal activity.

The most novel finding, though, was that 203 out of the 835 human-targeted non-antibiotic drugs showed activity against normal gut microbes. That’s almost a quarter (24 percent) of non-antibiotic drugs having a significant effect on the gut microbiome. Most of these drugs only inhibited the growth of a few strains, but 40 drugs affected at least 10 strains!

The effects weren’t limited by drug class, either. Almost every type of drug tested showed some activity against normal gut flora. I’ve listed the categories below, along with the specific names of drugs that affected more than 10 microbial strains:

  • Cancer therapies: 8-azaguanine, 5-fluorouracil, floxuridine, tamoxifen citrate, amethopterin, etoposide, doxorubicin hydrochloride, streptozotocin, aprepitant
  • Anti-inflammatories: diacerein, anthralin, auranofin, methotrexate, zafirlukast
  • Antihistamines: loratadine (Claritin), terfenadine, clemizole, astemizole
  • Antidiabetic drugs: troglitazone
  • GI disorder drugs: pinaverium bromide, oxethazaine
  • NSAIDs: tolfenamic acid
  • Antipsychotics: methiothepin maleate, thioridazine hydrochloride
  • Antihypertensives: felodipine
  • Antiarrhythmics: amiodarone hydrochloride
  • Anticoagulants: dicumarol
  • Hormones or hormone modulators: estradiol valerate, diethylstilbestrol, diestrol, tiratricol (thyroid hormone analogue), clomiphene citrate
The microbes affected

Microbial responses varied by drug, but the abundance of key commensals Roseburia intestinalis, Eubacterium rectale, and Bacteroides vulgatus were among the most sensitive. R. intestinalis and E. rectale are known producers of the beneficial microbial metabolite butyrate, a key promoter of gut barrier integrity, while B. vulgatus is an important producer of the metabolite propionate, which stimulates the release of gut satiety peptides and has been shown to help prevent weight gain (5). The authors write:

Overall, species with higher relative abundance across healthy individuals were significantly more susceptible to human-targeted drugs. This suggests that human-targeted drugs have an even larger impact on the gut microbiome, with key species related to healthy status […] being relatively more affected. (6

They also stressed that the doses used in the study to probe drug–microbe interactions were well within physiologically relevant concentrations and that their data are likely to underestimate the impact of human-targeted drugs on gut bacteria.

Lastly, there was a strong overlap between resistance against antibiotics and resistant against non-antibiotic drugs, suggesting that consuming non-antibiotic drugs could potentially increase the risk of acquiring antibiotic resistance.

On-target or off-target effects?

I want to stress that there is still much we don’t understand here. For instance, is an altered gut microbiome an on-target or off-target effect of the drug? As the lead author on the study, Dr. Peer Bork, pointed out in a press release, “This shift in the composition of our gut bacteria contributes to drug side-effects, but might also be part of the drugs’ beneficial action” (7).

In other words, your prescription might only be working because it is changing your gut microbiome. For example, metformin, a drug commonly used to treat diabetes, has been shown to alter the gut microbiome, increasing abundance of the beneficial microbes Akkermansia muciniphila, Butyrivibrio, and Bifidobacterium bifidum (8). Transplanting fecal material from humans receiving metformin into germ-free mice has been shown to improve glucose intolerance, suggesting that the microbiome is responsible for the therapeutic effects (9).

All that being said, metformin seems to be the exception, not the rule—it’s clear that many of these drugs are negatively impacting microbial composition. These off-target effects on the microbiome suggest that treating one disease with a pill could potentially be causing another disease down the road. In other words, taking a proton pump inhibitor might help control your acid reflux in the short term, but it will also cause a shift in your gut microbiome that predisposes you to irritable bowel syndrome (10), gut infections (11), liver disease (12), and other conditions.

While pharmaceuticals can be a valuable tool in the management of disease, this study further supports the notion that if we can address the root cause of disease and support a healthy gut microbiome, we’re much more likely to achieve lasting, long-term health.

Now I’d like to hear from you. Did you know about the effects of non-antibiotic drugs on the gut microbiome? Start the discussion in the comments below!

The post The Effects of Non-Antibiotic Drugs on the Microbiome appeared first on Chris Kresser.

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In this episode, we discuss:

  • Introduction and background of Dr. Rangan Chatterjee
  • WNL: We’re not looking
  • Raising public awareness of functional and progressive medicine through the mainstream media
  • The impact of the show Doctor in the House among colleagues and across the UK
  • Changing the expectation among medical professionals to a more collaborative care method
  • Chatterjee’s new book, How to Make Disease Disappear, and the 4 Pillar Plan
  • Communication is the biggest skill for healthcare professionals
  • Small changes tend to make the biggest impact

Show notes:

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RHR: Bringing Functional Medicine to the Masses—with Dr Rangan Chatterjee - YouTube

Chris Kresser: Rangan Chatterjee, it's such a pleasure to have you on the show. I'm really looking forward to this.

Dr. Rangan Chatterjee: Chris, the pleasure is mine. Thanks very much for inviting me.

Chris: We met when I came over to the UK last year, I think that was. It’s all such a blur.

Dr. Chatterjee: Yeah, someone said we need to speak, so we went out for a lovely dinner, actually.

Chris: Yes. I really enjoyed that. Mark Hyman introduced us via email before we came over and said, “Hey, you guys should know each other,” and he was definitely right. We hit it off immediately, in large part because we share not only a passion for reinventing healthcare and the future of medicine, but also a pretty similar perspective on how we should go about doing that. That's what I'd love to dive into today, and I want to start by talking maybe a little bit about just your background, how you came to Functional Medicine, and this perspective that we share on reinventing healthcare and medicine, and then I want to talk a little bit about your experience with the TV show, because here in the US we don't have access to it. And so while that's a pretty well-known show and people have had a lot of exposure to it in the UK, some of my US listeners might not be as familiar with what's going on. I think it's a really interesting portal to how Functional Medicine can get a wider adoption and exposure.

Introduction and background of Dr. Rangan Chatterjee

Dr. Chatterjee: Yes. Well, Chris, first of all, just a bit of background and a sense of my journey and how I've got to where I am today in terms of my perspective. I've been seeing patients now as a medical doctor for almost pretty much 17 years, actually, and my career has gone through various evolutions during that time, because the reality is, you leave medical school and you think that you have been given all the tools that you need to get your patients better. That's ultimately why you end up at medical school, is to how to do that way, and it's not so obvious, but when I reflect back on my career, I think there was a discontentment in the way that I'd been taught to practice medicine. It was probably there right from the start, so I don't think I quite realized it because I start off in the acute medical setting, so I was training in hospitals dealing with a lot of emergencies. I remember running the cardiac arrest team for the hospital for a period of time and doing all the things that you think modern medicine is with the defib and all that kind of crazy stuff which you see on television. As a young guy in their 20s, I think, “This is medicine,” right?

The biggest skill for a healthcare professional may not actually be scientific knowledge, but how they connect and communicate with the person in front of them. Every patient wants to be as healthy as they can. They don't want to struggle. They want to live their life!

Chris: Right.

Dr. Chatterjee: I went through my training, I was going to be a specialist, so I got my exams. Certainly in the UK, we call it the MRCP, Member of the Royal College of Physicians, a very tough set of exams to certify in internal medicine, and I was planning to do nephrology, or kidney medicine. I just started to get a little bit frustrated, month on month, sort of year on year, I was getting a little bit frustrated. It's the sort of thing that I don’t really want to spend the rest of my career just seeing kidneys and kidney problems. I thought that I'm going to move to general practice. To put this in perspective, I come from a medical family, and my dad was a consultant in genitourinary medicine. I think he was a bit flabbergasted that his son was going to leave the hallowed turf of being a specialist to become a generalist. But I really had this calling from inside me saying, “Look, I want to see everything. I want to see how everything interacts with everything else.” That's why I moved to general practice. I did my exams, and then I started working and I loved it, but a few years in, I honestly sat back at the end of the day and I thought, “How many people have I really helped today?” I came up with a figure, 20 percent. I thought, 82 percent of the people that had come in, I wasn't convinced I'd actually done that much for them. Sure I may have given them a prescription, a pill to suppress their symptoms, but I really didn't feel that I had actually helped them understand what was going on. I don't think I knew what was going on in terms of what was driving their ailments. I think the difficulty is, Chris, I'm sure you’ve heard this before from people, it's very hard to know what to do with that. You know, all your training, your whole career, everything is shaped around the system the way it currently is. And then for me, as many people have an experience with illness either in themselves or with a family member, that really changes everything. For me it was when my son, who is now seven years old, but he was six months old at the time … My wife and I, we went on holiday, it was just past Christmas, it was around 27th of December. I remember it so clearly. We went to Chamonix in France for a holiday, and my son stopped moving. His arms went back. He had a convulsion, and really I panicked because I thought he might be choking. My wife had called out to me and I knew that he had a lot of mucus and phlegm throughout the day. I tried to turn him over and slap him on the back and clear his airway and nothing was happening. The truth is, in that moment, I wasn't a highly qualified medical doctor, I was a worried father.

Chris: Absolutely. It must have been terrifying.

Dr. Chatterjee: Even now I think back to it, and it was horrible. It really was horrible, and my wife said, “Come on, we've got to go now. We got to get to hospital.” And we rushed into the car. I nearly killed us all. It’s just snowed there and we went on a steep road down to the main roads and the car skidded, but ultimately we got to a hospital, and many of your listeners might be familiar that a six-month-old having a convulsion is not that uncommon if there is a fever there. It’s what we here call a febrile convulsion, but he didn't have a fever. His temperature was absolutely normal, and you could see the admitting doctors and nurses were incredibly worried because, “Why has this boy stopped moving? Why is he having a convulsion without a fever?” We were in a small hospital. He had to be blue-lighted in an ambulance down to the main hospital, down the valley through the mountains.

A few hours later, some of the preliminary blood started coming back. Now in this time frame, he already had two lumbar punctures. We are a health-conscious family. My wife had breastfed for six months as this sort of public health guidance. We’re pretty switched on, we thought, with respect to our health, and then the blood results come back, and the doctor said he's had a seizure because his calcium levels were too low in his body. He had a hypocalcemic convulsion. To put it in perspective, the normal range for serum calcium in that hospital is the same as in the UK, which is 2.2 to 2.6. His calcium level was 0.97, frankly, barely compatible with actually life, in many ways. Everyone was scratching their head—why has he got such a low calcium level? What's been going on there? And then again, you had to wait a bit later on, because in this time frame, initially we thought he might have meningitis. The doctors were very worried, and we were panicked, in a foreign hospital trying to figure out what the hell was going on, and it turns out that his vitamin D level was almost nonexistent.

To cut a long story short, ultimately a fully preventable vitamin D deficiency caused him to have a low calcium level in his blood, which caused him to have a convulsion. That was incredibly challenging to get my head around. I mean, of course, I was delighted that we found out what the problem was and that modern medicine saved his life. He had an intravenous calcium infusion, right? Great. Superb. You bring the calcium level back up into the normal range. That was fantastic, but nobody that taught me or told me what are the consequences of the fact that your son may have been deficient, or certainly suboptimal levels, of vitamin D potentially for the last six months, arguably in the utero as well.

What are the consequences of that? How can you go about potentially repairing some of those? My son had pretty bad eczema at that time and obviously we know now, I wish many doctors knew about then, that it's pretty clear that vitamin D is a critical nutrient immune system. Eczema is in some way dysfunction of the immune system. Could the two be linked? Of course they could be. For me, Chris, really what happened in that moment was, yes, I'd been frustrated, but in that moment, it was like, I, by conventional measures, am highly qualified, double-board certified medical doctor, yet my son nearly died from a preventable vitamin deficiency, and suddenly it was like a switch changing me. In that moment, I'm going to find out why this happened, how this happens, and I'm going to get my son back to full optimal health. I'm going to try as if nothing of this has ever happened. That was the challenge that I set to myself.

In the age of the internet, Chris, you can spend three, four hours a day researching, and that's exactly what I did. Week after week, month after month, year after year, the more I learned, the more I put into practice with him, the more I put into practice with my family and myself. I can see that the immense benefits for my son, I felt the benefits for myself, started applying the same principles with my patients, I was like, this is the sort of medicine I wish I'd learned in medical school. Understanding root causes of ill health. I'm figuring out how you can help people, not only improve their symptoms, but certainly, in many cases, reverse that illness, and it’s just transformed my career, Chris. It has transformed the way I look at health. It has, in many ways, shaped what I've done in the media for the past four or five years. I reflect back and think, had this not happened to my son, would I be doing what I'm doing? I don't know. I can't answer that. Potentially I would have found—maybe the frustration would have gotten the better of me in another way, but this really forced my hand. I'm pleased to say that my son is a thriving, healthy, eczema-free seven-year-old boy who I think is incredibly well and arguably healthier than many kids around him who maybe have not had this problem. It’s a slightly long-winded story, Chris, but that in a nutshell is why I do what I do.

Chris: It's so great. It got very real and very personal for you in a way that it did for me, a slightly different way, but that's what, really, I think at the end of the day, almost everybody who's doing this work that we talk about, Mark Hyman and many of us thought leaders and influencers, have a similar story because when it affects you personally or a family member personally, there's just no other motivation that's quite as urgent.

Dr. Chatterjee: Yes, absolutely, but Chris, we need to … we started talking months before … at the moment I find that the people who are trying to adopt this approach to chronic disease, the thought leaders, but all the thousands of practitioners around the world who are also trying to do this, pretty much all of them behind that have got a personal story. I get that because I'm one of those, but we need to move beyond that. We need to move like what you're doing with the Kresser Institute. We need this education to be that—all healthcare professionals, basically, not just those who have had a personal experience.

WNL: We’re not looking

Chris: Absolutely, yes. Your story with your son is really, I think, revealing because it points to this principle of “we're not looking,” or that's my version of WNL. In medicine we think of WNL as “within normal limits,” if you do a lab test and it’s within the normal limits. But I have another way of looking at WNL, which is “we’re not looking.” Your story with your son, like the vitamin D thing, was easy to detect and easy to correct, but it wasn't part of the standard thought process of what you should be looking for early on in his life. I had a patient last week in her late 70s who came in, and she had some of the typical complaints you might expect of someone of that age. She had kind of a mild tremor. She was having some cognitive decline and brain fog, difficulty concentrating, and her GP had just written it off as, “You're getting older. And you're in your late 70s. What do you expect? This is standard.” And yet when we tested, did a full comprehensive blood panel on her, we found out that she had very severe B12 and folate deficiency and very high homocysteine, and she had again a very easily correctable, at least if it had been detected in time, nutrient deficiency that was misdiagnosed as dementia and early mild Parkinson's. There's really no excuse for missing and not correcting that, and yet we're not looking.

Dr. Chatterjee: Absolutely, Chris, and I'm sure you've got countless more stories like that from seeing patients, as I have. One thing to add there with my son’s story as I'm sure many people listening might be thinking, “It’s so obvious, why wasn't he just giving his son vitamin D from birth?” I think it's a reasonable question because the guidelines in this country actually do state that you should be doing that. The problem is, nobody knows those guidelines.

Chris: Yes.

Dr. Chatterjee: And they're not being followed. As the same with all my patients, I didn’t know that. But I tell you this, I have replayed this over in my head so many times, three weeks before we got on that plane at the start of December, so son's maybe 5 to 5 1/2 months old. I had been coming across a bit more research on vitamin D, and we had a protocol in our surgery in a different sort of part of the UK where I would start to prescribe a lot of vitamin D to certain patients. I started to think, “I think my son should be on this.” Now it's drilled into us in the UK by the GMC, the General Medical Council, that we should not be making those kind of decisions on our own family. It is very much frowned upon here to do anything treatment-wise for your own family. I did what I thought I should do back then, and so I crossed off the protocol and I phoned my wife up and I said to her, “Hey, babe, can you just go make an appointment to the GP? Just go and ask him what he thinks about this. I think that our son should probably be on vitamin D.” And so she prints it off, she goes to see a doctor, and the doctor knows that I'm also a fellow healthcare professional, and he laughed at her and he said, “Look, this is just complete rubbish. You could have just printed this off yourself and typed it up on Word and given it to me. Look, you're breastfeeding; you're doing a great thing. There's nothing more you need to give your son.” And she was a bit upset with the way it went down because I didn't think he was compassionate, and when she reported this back to me, I thought, “Okay, fine. All right, let me do a bit more research. Let me look into this. I’ll figure it out,” not realizing the urgency of the situation. I often think back, could I, should I just put my foot down then, and it’s not a nice emotion as a dad when you get these things. Having said that, Chris, he could well have been deficient for months prior to that.

Chris: Absolutely.

Dr. Chatterjee: And arguably, have I supplemented then, supplementing just before this happens with a very low dose, let’s say, 400 IU of vitamin D or something like that or 800, arguably, it may not change anything, or it could have gone undetected for a lot longer. At least this way, and again, I wish this had never happened, certainly for my son’s sake, but by having it happen with that sort of magnitude, I was forced to confront some very difficult questions and uncomfortable realities, and I felt compelled to fix them. I do kind of believe that things happen for a reason. Maybe as humans we have to believe that in order to get through, but I had a lot of guilt for a number of years. That actually drove me to learn more and help as many people as possible, but I know you're a father as well, Chris. I'm learning now to let go of that guilt.

Chris: Yes. I mean, we can always second guess ourselves, and there's so many situations like that that I can think of myself with my daughter, things I wish I would have done differently. But I think this is more what you were saying before—it's about getting this knowledge and these guidelines and this understanding out on a wider scale because it is true. There's a saying that a doctor who treats himself has a fool for a patient, and you could possibly extend that to family members, because sometimes we're too close to really be able to tell. But what if there had been guidelines that not only should babies be tested, but pregnant women should be tested for their vitamin D levels because guess where kids are supposed to get it? From breast milk, and if a woman is deficient in pregnancy, then her breast milk is not going to be a sufficient source of it, and I always test my pregnant women patients for that now, but that's not something that's really widespread now, at least in our in this country. I don’t know how it is in the UK.

Dr. Chatterjee: One of the biggest frustrations for me about the way medicine currently operates—I should say conventional or allopathic medicine, whatever you want to call it—it's very much a black-or-white situation. You've either got an abnormal result or it's normal.

Chris: Right.

Dr. Chatterjee: There has been no or very little recognition as optimal, and there is this huge gray area in between overtly abnormal and disease and deficiency versus what is an optimal level for this human being to be functioning as well as they can. A little bit like Dale Bredesen, a professor, who is sort of showing how in some cases you can reverse cognitive decline, certainly in early cases of Alzheimer’s disease. He's managed to demonstrate that, but I love his approach, which is you've got to treat that person like a Formula One car. You’ve got to optimize every single parameter that you can. I love that because that really isn't how we do things here, certainly the UK, and I know it's the same in the US. Even if you talk about blood sugar, you talk about a common condition, type 2 diabetes, we’ve got slightly different ranges from you guys, so an HbA1c, the average blood sugar marker, is 6.5 and above, and in this country is, I think the same as you, is a diagnosis of type 2 diabetes. Our prediabetic range starts at 6, so 6 to 6.4 is what we call prediabetic, whereas with you guys, it's 5.7.

Chris: It’s a little lower, yes.

Dr. Chatterjee: A little lower, and you know these are just arbitrary figures that we could argue about all the day. One of the practices I would tap recently, patients who come in and get their blood sugar checked, if it comes back at 5.9, I know doctors who are still reporting that as normal. What's happening is that patient phones at reception to say, “Hey, you know what, my bloods are okay.” The receptionist will report back saying, “Yes, doc said absolutely normal, nothing to worry about.” That patient then who has come, maybe they come in for a medical or for a checkup just to see where does their health look like at the moment, in that opportunity we are reporting an HbA1c of 5.9 as normal, which is madness. I just don’t know how we got so far off track in medicine where we can call that a normal blood sugar.

Chris: Right. Just because it hasn't reached the arbitrary … as if something magical happens when it goes one-tenth of a point higher, then all of a sudden you have diabetes, whereas it was perfectly normal before that.

Dr. Chatterjee: Yes. And even if all we did in conventional medicine, even if we did not adopt a full kind of Functional Medicine approach, is if we simply recognize that as an optimal range, and then there’s a deficiency range, and we should be striving to get our patients in those optimal ranges—just to say, with blood sugar, for example, we could start maybe once the HbA1c is 5.2 or 5.3, start to get people back in and say, “Hey, look, you're not prediabetic yet. You don’t have type 2 diabetes yet, but actually your blood sugar is not as good as it could be. Can I show you some things that we can do to help optimize that?” So many members of the public would welcome that, and they’ll go, “I didn’t realize it. Yes. Tell me what I can do.” Rather than waiting until it has crossed that 6.5 to 6.6 type 2 diabetes threshold, when yes, sure you can still turn it around sometimes, but it’s going to be suboptimal to be getting involved then.

Raising public awareness of functional and progressive medicine through  mainstream media

Chris: Absolutely. Speaking of this, we're talking about raising awareness of Functional Medicine and preventative medicine and what you call progressive medicine. I think arguably you've had a bigger impact in terms of raising the public awareness of these concepts than just about anybody else because you've been doing a mainstream TV show about Functional Medicine in the UK for the last several years. I mean, we don't have anything like that still here in the US, and I've really..

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In this episode, we discuss:

  • The Berkeley Fire Department wellness program overview and team introductions
  • Module 1 – Diet and using a continuous glucose monitor
  • Module 2 – Stress management and the role it plays in mental and physical performance
  • Module 3 – Sleep and happiness
  • Module 4 – Sustainability and achieving long term goals
  • Nutrino and the technology pieces to the puzzle
  • The Oura ring: the most advanced wearable on the market
  • Amory Langmo and his inspiration to develop the program
  • Continuing education, empowering each other, and creating lasting change 

Show notes:

  • 14Four framework plan developed by Chris Kresser
  • Buddhify – meditation technique app
  • Nutrino – nutrition-related data services, analytics, and technologies
  • HeartMath – biofeedback and heart rate variability sensors
  • Oura – smart, wearable ring: Use code “VISUALIZE” for $75 off of the generation-two ring, launching next month
  • Zenbelly Catering – donated cookbooks and prizes

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RHR: Scaling Functional Medicine - The Berkeley Fire Department Wellness Program - YouTube

Chris Kresser: Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. I’m really excited about today. We are going to talk about how to apply some of these concepts of Functional Medicine and ancestral diet and lifestyle that we talk about so much in a different setting. When I go to conferences and when I speak publicly, I’m often asked, “You know, Functional Medicine’s great, but it’s really expensive if we’re doing it in a one-on-one setting. It’s cost-prohibitive for most people, and we need to get this approach out on a wider scale. We need to start doing it in companies, we need to do it in our communities, and we need to roll this out in a different way than we’ve done so far.”

And that’s exactly what we’re going to be talking about today. So I’m actually going to turn this over to Dr. Sunjya Schweig, my co-director at CCFM, whom you’ve met. He’s been on the podcast several times, and he really headed up this program that we’re going to be talking about today. So I’m going to let him hijack my show and talk about this program and what happened. And we also have several other guests that were a part of this program that Dr. Schweig will introduce. So without further ado, I’ll turn it over to you, Sunjya.

The Berkeley Fire Department wellness program overview and team introductions

Sunjya Schweig: Great, thanks, Chris. Good morning, everybody, and good afternoon, good evening, wherever you are. So today we’re super, super excited to be talking about a pilot project that our clinic took part in and launched with developing a wellness program for the Berkeley Fire Department in the city of Berkeley. And as Chris mentioned, we do have several guests on the line today. I was going to run down who we have with us and we’ll jump in with each of them later.

But we have with us Amory Langmo, apparatus operator from the Berkeley Fire Department. We have David Sprague, the Assistant Training and EMS/EMT chief at Berkeley Fire Department. We have Danielle Cook, our California Center for Functional Medicine registered dietitian and health coach, as well as Tracey O'Shea, our CCFM nurse practitioner. And we have Yaron Hadad, the founder and chief science officer from Nutrino––a very exciting health and nutrition company. And we also have Chuck Hazzard, vice president of sales from Oura, one of the hottest self-tracking devices on the market.

There’s no question that Functional Medicine is the future of medicine—but how do we scale it to a wider audience? In this episode of Revolution Health Radio, we’ll explore one possible answer to that question.

So backing up, and we’ll jump in with each of those people shortly, but backing up, what we were talking about today is again, this wellness project that we took part in and developed for the city of Berkeley, for their fire department. And we were approached last summer by Amory, Amory Langmo, to develop this program for their incoming class of 10 new recruits. So basically, this is a group of 10 young men, all men. Sometimes I do have women who join the department, but this class happened to be all men, and their age range was early to mid-20s to early 30s. Average age was about 26. And we basically walked them through and developed this wellness program for the 20-week academy, training academy, that they were partaking in.

And I want to really give a shout-out to Amory and to the Berkeley Fire Department because again they came to us and it was just so impressive to have their insight and proactive thinking in even considering bringing nutrition information, Functional Medicine, ancestral health information, stress reduction information, how to optimize sleep, all these pieces, and bringing that to their recruits and to their department. And when we were asked, it was a no-brainer. We were so excited and immediately jumped on the opportunity.

And as we started having initial conversations with the department, with Amory, with Chief Sprague, it kind of came down to the basic ideas of what we are targeting. And really, we wanted to teach this class of new recruits skills and techniques for better performance to help them to be able to increase their mental and physical well-being. And also teach them long-term skills that could hopefully reduce injuries, workers’ comp issues, number of sick days that they might have to take, and again, provide them with these long-term tools for sustainability and health. So these new recruits, give them this at the beginning at their entry to the department, and then hopefully provide them with an education that would carry them throughout their careers. And as we’ll see, also the feedback we got from the recruits, it really did seem like that was achieved in a large measure. So really, really exciting.

But the hope also then, was that they would take this information, it would educate them at the start gate, and then they would bring it into the larger department, kind of like a trickle-up theory where, over time, these values and information would take a larger hold and really start to shift the larger culture of the department and bring health to the entire fire department in the city of Berkeley. And then also finally, we were really hoping this was an opportunity to pilot a program that could be a model for a wider rollout across the Berkeley Fire Department, maybe even other departments in the city, and beyond. So a really, really exciting opportunity for all of us involved.

So I want to invite Assistant Training and EMT Chief David Sprague to jump in here and do a little bit of an introduction into what inspired him and the Berkeley Fire Department to approach us with this project in the beginning.

David Sprague: Yeah, thanks for having us. I’m super excited to be here, and this was a really cool experience for us that we’re hoping to continue, and like you said, Doc, take pieces of this and roll it out to our whole department. So essentially the idea was we put our new hires through a 20-week really physically and mentally intensive experience there Monday to Friday, 8 to 5. There's a PT component every morning, and we've done a variety of different kind of exercise regimens, but it's always very intense that starts out the day. And then the rest of the day is a combination of didactic classroom time and a lot of physical manipulative work where they're actually learning the skills of what it's like to be a firefighter and how to pull hose and how to fight fire, and how to use power tools and hand tools.

Needless to say, it's really physically taxing on people. So we've always had a significant number of injuries in our academy, and most of them are strains, sprains. But even those can take somebody out of the game for a couple of days and put them at a significant deficit as related to the rest of the class. And we don't, it's really difficult for us to stop, hit pause and bring them back up to speed. So those are the common injuries and although they don't oftentimes put people off work, they have a huge impact on our instructional schedule. On top of that, once you get out of the academy, which is a really controlled environment, you get into the field and we work odd shifts, 24- or 48-hour shifts. You can be up all night, so you can be, calls coming in all day, so missing meals. Or you're scrambling to get a meal.

And this, over a career, this can lead to poor diet, especially if you don't know how to make a quick meal or grab a quick bite. Interrupted sleep just has a cumulative effect on our health, and it's a stressful job on top of that. So you kind of add all those things up and we realize we had a need to kind of address all of this stuff in the very beginning of somebody's career with some basic education about nutrition, diet, sleep, stress, and look at how we're physically conditioning in the academy to better reduce injuries, maintain flexibility, and create healthy lifestyles that people can learn in the academy and then carry out throughout the rest of their career.

Sunjya Schweig: Yeah, absolutely. Yeah, and again, we were super honored to be able to come in and assist with some of those educational pieces. So, Chief Sprague, again that’s, we’re real excited to be part of this project with you guys, and I really applaud you and your department for this level of forward thinking. And the fact that you were, I think we’re all in the right stage at the right time to bring this to the department. But the fact that you were able to present this information to your fire chief, David Brennigan, and also your deputy fire chief, Abe Roman, and that they were excited and willing to sign off on this, I thought that was really impressive.

David Sprague: Yeah, I agree with you. I think the time is right. This is, I think, something that we’re going to start seeing fire service-wide, and once we push this proposal up the chain with what the work that you and Amory did, it was pretty much a rubber stamp at the top is, yeah, let’s see if we can do something better. We’re all for more education, and we realize, especially, kind of, nutrition, stress management, sleep management is a gap in our knowledge base. It’s a huge issue in the fire service. So let’s talk about it. Let’s experiment and see if we can do better.

Sunjya Schweig: And do you know of any other fire departments that have developed a similar program that bring this type of information to their recruits or their firefighters?

David Sprague: I don't. Amory might have a better handle on that. But I know that especially sleep management and sleep deprivation is a hot topic in the fire service, and improving our wellness specifically around cancer prevention is a big area that people are looking at.

Sunjya Schweig: Yeah, yeah, absolutely. We talked about that a fair amount in terms of considerations for the phase two of this project. So very good, very good point. So again as we develop this program, it was very much within our wheelhouse here at CCFM because we were able to really kind of develop that nutrition piece. And we'll talk about some of the in-depth dietary work and interventions that we did. We also provide robust education around sleep, we’re able to provide tracking and data on that for the recruits, as well as the stress management piece.

So I want to kind of go through some of the nuts and bolts of exactly what this looks like. So the program development happened over the summer, the academy started in October and ran through about mid-March, about a 20-week-long program. Ten new recruits. Again, all male, average age was about 26, almost 27 years of age. So fairly young and healthy. And we broke the program down into four different modules. And I’m going to invite Danielle and Tracey to tell us a little bit about how the modules were organized and implemented, if you guys want to jump in....

Module 1 – Diet and using a continuous glucose monitor

Danielle Cook: I’ll go ahead and jump in. This is Danielle. Thanks for having this. This is great to be talking about it, and it was really a wonderful opportunity to be able to participate in this. The recruits were really fun to work with. So I'm going to just talk about the first module that we did, and that was the nutrition module. And we really wanted to address nutrition as a piece. One, it was one of our requests, but secondly, a lot of the meals are eaten at the station in groups. And so if we could educate new recruits about healthier eating, then that could have, like Dr. Schweig said, it could have a really widespread effect.

So what we did was we used the 14Four framework developed by Chris Kresser, and we used that as our framework for the whole diet program. And what we did was we did an in-person module and presentation on nutrition, and we talked about a whole-foods diet and just general nuts and bolts of healthy eating. And then what we did is we talked to them and taught them about the 14Four reset diet. And what it is, is it's just a whole-foods, nutrient-rich Paleo diet template. And then what we did is we had our recruits follow this diet for a two-week period. And we wanted to see if the diet would make a difference in their blood sugars. So we had them wear what's called a continuous glucose monitor. It's just a little device that they wear on their arms and that measures their blood sugars throughout the day, just continuously.

Sunjya Schweig: Yeah, about every five minutes, right?

Danielle Cook: Yeah, yeah. So we had them wear this monitor, and we had them wear that before they started the diet to get some baseline measurements just to see what their average blood sugars were before starting a diet. And then we had them do that one week into the diet reset. And we had some, we're going to talk about some statistics at the end and just some improvements and pretty impressive improvements we saw in their blood sugar readings just from one week following this reset diet. And then the other thing we had them do was we wanted them to track what they were eating, for several reasons.

One, to see if there was any correlation in what they're eating to what their blood sugar readings were. And the second reason is we wanted to see what they were eating and also bring some awareness to what they were eating. And so what we used was a device or an application, Nutrino, and Yaron is going to be talking about Nutrino a little bit more in depth, and also looking at some of the data that we got from these Nutrino reports. And Tracey, do you want to go ahead and talk about the stress module?

Module 2 – Stress management and the role it plays in mental and physical performance

Tracey O'Shea: Yeah, sure. This is Tracey, and I do want to just reiterate what Danielle and everyone else has said about what an amazing experience this project has been. And it was just really enlightening to be part of. And so we're really excited to see what the future holds. So I’m going to talk about our second module, which talked about stress management, and particularly, we really wanted to give the recruits education and discuss the impact that poorly managed stress has on both mental and physical performance.

And specifically, we really wanted to discuss the role that chronic stress plays, especially in the unique environments of the emergency service occupations and how to kind of work with them on balancing stress response both in the work environment, but also once they go home and they have an opportunity to decompress, and how to do that, and how to be successful and create a sustainable stress management practice.

Sunjya Schweig: Yeah, yeah.

Tracey O'Shea: Yeah. So we gave them tools for balancing stress response and specifically really recommended technology applications where they could use at home on their phone and also something that they could create as a daily practice. And specifically, we were able to provide through generous donations the HeartMath biofeedback and heart rate variability sensors, so that the recruits could have real-time information about how well they are able to kind of bring themselves down from a high-intensity situation, which we've seen in research to be especially important for these emergency service occupations. And we can talk a little bit more about that, but that specifically was what we were trying to do, is find the sustainability and a way to provide these recruits with long-term management tools. We also were able to introduce breathing and meditation techniques that recruits can do on their own, like 4-7-8 breathing and being that they may not necessarily need their phone or need some technological device to get through.

Module 3 – Sleep and happiness

So we provided them with some techniques, and then we also encourage participation in some of these challenges where we asked recruits to incorporate a stress management technique that they liked, that they enjoyed, that they found easy to implement into their life for 30 days at a time. So we could look to see how well their heart rate variability changed before they were really learning these techniques and tools, and then as they were starting to implement them daily. So that was the stress module in itself. And then the third module we moved into was the sleep and happiness module. And as Chief Sprague kind of alluded to, it's difficult when the recruits and firefighters are having odd hours and they never know how many calls they may get in their shift, and sometimes there's a lot of downtime and other times it's just go, go, go, and it's high intensity, and so being able to discuss shift work and how we can provide options for the recruits and firefighters to kind of decompress and get back into a normal sleep pattern once they get home.

So that's really what we focused on in the sleep module. It's how to optimize sleep for emotional well-being. Also daily performance and safety, because as we all know, there's a lot of information out there about poor safety and accidents and things that happen when people are tired and when they have lack of sleep or just not high-quality sleep. So we were really looking for kind of that safety in daily performance as well as overall longevity and vitality and health. So we provided information and different solutions on how to kind of shift from those long hours, high-intensity work with not knowing how much sleep you'll get to kind of getting back into the normal routine in between the days working.

We also encouraged a technology-free zone in the bedroom for 30 days. We really were talking about the impact that technology and certain lights have on your quality of sleep and ability to fall asleep. So we really focused on technology and the impact that that has on sleep. And then we kind of transitioned into the happiness module and how overall attitude and your outlook on life can influence health. And we really discussed neuroplasticity and how experience-dependent neuroplasticity and the things that you do and the actions that you take can really create these positive neural traits and create for more happiness and more enjoyment and kind of overall this practice of gratitude and finding joy in daily activities and how that impacts your health in kind of a more general sense.

Sunjya Schweig: Yeah.

Tracey O'Shea: So those were the stress and sleep modules. I think Danielle was going to kind of jump in for module 4, which was our sustainability and wrap-up module.

Module 4 – Sustainability and achieving long-term goals

Danielle Cook: Yeah. So the last module was a great opportunity for us to sit in front of the recruits and not only review what we had done throughout the program, but also get feedback and hopefully work on improved programs in the future to make them even more effective. And so what we did is we went through each of the modules and just reviewed each of the modules, and we wanted to also develop long-term goals within each of the modules. So a long-term goal for nutrition, stress reduction, optimizing sleep, and practicing a gratitude practice. And so we had them fill out some funnels to do some goal setting.

And the other thing we did is we went through a survey just to assess how they liked the program and how much of the program they enjoyed, what parts of the program they would like to see some improvement or maybe some expansion. And like Tracey mentioned earlier, with sleep and stress, to a high extent is, their work is kind of shift-like and it's really hard to get a regular routine for sleeping. And so that's one of the areas that we definitely want to delve further into in the future and do some more research on that and really get some sort of sustainable plan together and work with the fire department to get a sustainable plan together to really optimize all of their individuals’ or their employees’ sleep. Because that's a huge challenge, and that's one of the things that we found that we wanted to really talk about more. The other thing we did is we reviewed a lot of the data.

So we reviewed the Oura data, which measured heart rate variability and sleep quality, sleep duration. We also reviewed the HeartMath, some of the HeartMath. We didn’t need statistics for that, but just people's experience with HeartMath. And again review how it can be useful, especially and in emergency career-type situations where they’re coming from very high stress and having to then practice some sort of modality to relieve that stress. And HeartMath has been shown in numerous study situations to really be beneficial and effective for that.

And then we also reviewed the Nutrino data and again, Yaron is the expert at this. So he’s going to review some of that data for us today. We reviewed a lot of the high points and..

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Let’s face it, you can have all the information in the world about diet and exercise, but that information won’t do anything for you unless you put it into action. “You should do this” and “You should do that,” but how many of those “shoulds” are you actually doing?

It can be tough to go it alone. There’s so much information out there about the Paleo diet and lifestyle, some of which can even be contradictory. You want to adopt the “ancestral” lifestyle, but where do you begin? There is no one-size-fits-all answer. You need three things in addition to information: tools, practice, and support.


There’s no better place to find the best tools for getting on board with a Paleo lifestyle than the annual Paleo f(x) event, held in Austin, Texas, April 27–29. It is a gathering not only of your tribe, but also of companies developing the best, cutting-edge products and tools to support you in reaching your health goals. You’ll find tools in every category:

  • Diet: cooking equipment, cookbooks, and lots of yummy Paleo-friendly snacks
  • Lifestyle: products for everything from sleep to stress management to detoxing
  • Fitness: equipment, coaches, movement programs, and even Paleo footwear
  • And so much more

You might have heard me say this before, but you cannot become good at basketball by just learning about basketball. The same can be said about a Paleo lifestyle. You must practice and actually DO things. At Paleo f(x), you’ll find things to actually TRY and DO.

For example, there’s a dedicated Strength & Conditioning area where you can find a variety of demonstrations and workshops by world-class coaches and athletes. These are taught in small-group settings. Are you looking to perfect your squatting technique? Have you always wanted to incorporate kettlebells into your workout? Whether you’re a beginner or an expert, there’s something for you. 


It’s one thing to choose a Paleo lifestyle for yourself. It’s another to be surrounded by thousands of other people who love it too. Paleo f(x) is exactly that. It’s the largest gathering of Paleo / ancestral health / keto / Functional Medicine / strength & conditioning experts in the world.

It’s where we get to connect with thousands of like-minded people pursuing a Paleo-inspired diet and lifestyle—and not in a buzzy, superficial way, but in a way that embraces Paleo as a 360-degree template for adapting your habits to reverse countless chronic conditions.

Paleo f(x) is the who’s who gathering of the ancestral health movement. Gather with your tribe as you grow and learn together. You’ll find the latest, most cutting-edge science as well as a strategy on how to create the best version of your life.

Imagine spending three days with like-minded people who are just as eager as you to change their lives for the better. Meet the leading names in the Paleo world, and meet each other. One of the best ways to stay on track is to have a support group. You can create a network of people that will help you reach and maintain your goals.

And that doesn’t include the experts you can hear from and even meet. Who can you find at Paleo f(x)?

You’ll get to hear from speakers such as:

  • Joseph Mercola
  • Mark Sisson
  • David Perlmutter
  • Robb Wolf
  • Yours truly
  • And so many great others

(You’ll also be more likely to catch me at our booth this year since most years I take some time to go play at Austin’s amazing surf park, which is closed this year.)

The event takes place April 27–29. Get your tickets now before prices go up on April 24.

If you can’t make it to Austin, you can virtually attend all the keynote sessions for $99, or get livestream access and recordings of all the keynote sessions for $199.

The Kresser Institute team and I will be at Booth #44—make sure you come say hi. And throughout the conference, I’ll being talking about such topics as:

  • How to end chronic disease (my keynote address on 4/28, 4:25 p.m.)
  • The biomarkers of health, wellness, and vibrancy (panel talk, 4/28, 10 a.m.)
  • Care and feeding of a healthy gut microbiome (panel talk, 4/28, 5:35 p.m.)
  • Expert health coaching techniques to change your health—and your life (TBD)

I’ll also be sharing information about the ADAPT Health Coach Training Program, our first-in-the-nation health coach training to take an ancestral approach to diet and lifestyle. The program is specifically designed to equip, support, and train health coaches to do paradigm-shifting work that reinvents healthcare.

Making real, lasting lifestyle and behavior changes isn’t a switch you flip. It takes ongoing effort and support. Paleo f(x) can help kickstart those behavior changes.

Get your tickets before prices increase or even worse, sell out, and join me and thousands of others April 27–29.

Learn more about Paleo f(x) and get your tickets here, or learn more about the virtual sessions and get access here.

The post Paleo f(x): A Kickstart for Lasting Change appeared first on Chris Kresser.

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Obesity is a major public health epidemic. Forty percent of adults are already obese, and if current trends continue, more than half of adults will be obese by 2030 (1). Obesity is associated with an increased risk of heart disease, diabetes, and cancer and presents a massive $147 billion burden on the healthcare system each year (2).

Researchers have long debated whether low-fat or low-carbohydrate diets are best for weight loss. Regardless of the macronutrient content, however, most long-term studies have reported little success in achieving and maintaining significant weight loss. In 2016, I wrote an article called “Carbohydrates: Why Quality Trumps Quantity,” in which I argued that the answer to obesity and metabolic disease lies not in how much carbohydrate we eat, but rather what types of carbohydrate we eat.

A new study found that people who cut back on added sugar, refined grains, and processed food lost weight over 12 months—regardless of whether they were low-carb or low-fat

A landmark study recently published in the Journal of the American Medical Association supports this argument and suggests that the same principles apply to fats. The researchers found that on average, people who cut back on added sugar, refined grains, and processed food lost weight over 12 months—regardless of whether the diet was low-carb or low-fat (3). In this article, I’ll break down the methods and findings of the study.

Treading where few researchers have gone before

Nutrition science research is already fraught with problems, and weight loss studies bring their own unique difficulties. In order to produce a robust weight loss trial, an aspiring research group must:

  • Have enough funding to support a large scale randomized trial
  • Recruit and retain a very large group of subjects
  • Collect data over a long-term period
  • Ensure subjects are complying with the dietary intervention

Ideally, they would also use weight loss strategies that can be applied and sustained by free-living people. Unfortunately, few, if any, studies published in the literature have succeeded in meeting all four of these criteria—until now, that is. In February, the results of a long-term, large-scale, randomized clinical trial led by Dr. Christopher Gardner, Director of Nutrition Studies at the Stanford Prevention Research Center, were published in JAMA.

The study design: whole foods low-fat vs. low-carb

The scientists recruited 609 adults to participate in the 12-month study. The subjects were both male and female, were between 18 and 50 years old, and had an average body mass index of 33 (class I obesity). Those with uncontrolled metabolic disease were excluded from the study. The researchers randomly split them into two diet groups: “healthy low-carb” and “healthy low-fat.”

During the first eight weeks, participants in the low-fat and low-carb groups were instructed to reduce intake of total fat or digestible carbohydrates, respectively, to 20 grams per day. They then slowly added fats or carbohydrates back into their diets until they reached the lowest level of intake that they believed they could sustain indefinitely. Additionally, both diet groups “were instructed to 1) maximize vegetable intake; 2) minimize intake of added sugars, refined flours, and trans fats; and 3) focus on whole foods that were minimally processed, nutrient dense, and prepared at home whenever possible” (3).

For example, foods like fruit juice, pastries, white rice, white bread, and soft drinks are low in fat, but were not recommended to the low-fat group. Instead, the dietitians encouraged participants to eat whole foods like lean meat, brown rice, lentils, low-fat dairy products, legumes, and fruit. Meanwhile, the low-carb group was instructed to focus on foods rich in healthy fats, like olive oil, avocados, salmon, cheese, nut butters, and pasture-raised animal products.

The best part? The participants were told not to worry about counting calories or limiting portion sizes, but to simply eat enough to avoid feeling hungry.

Both groups attended 22 instructional classes led by registered dietitians over the course of the 12 months to help support them in these changes. Overall, 79 percent of the participants completed the trial. At the end of the year, average macronutrient breakdown by energy was as follows:

Low-fat group: 48% carbohydrate, 29% fat, 21% protein
Low-carb group: 30% carbohydrate, 45% fat, 23% protein

This was determined by random 24-hour dietary recalls, but was also confirmed with more objective measures of compliance to the diet, like respiratory exchange ratio.

Weight loss without calorie counting or restriction

The results? Both diet groups eating a whole-foods, nutrient-dense diet spontaneously reduced caloric intake and lost significant weight in the year-long study. However, there were no significant differences between the low-carb and low-fat groups in regard to weight loss, body fat, or waist circumference. On average, the low-carb group lost 13.2 pounds (6 kg), while the low-fat group lost 11.7 pounds (5.3 kg).

This might not seem like a dramatic amount of weight loss, but according to the National Heart Forum, even a modest (5 percent) reduction in body mass index could spare the lives of millions of Americans and save billions of dollars in healthcare costs (4).

Indeed, both groups also experienced improvements in other health markers. After 12 months, participants had reduced fasting glucose, insulin, and triglycerides and improved systolic and diastolic blood pressure. In fact, 36 participants in each group that had metabolic syndrome at baseline had improved their health so much that they no longer fit the diagnostic criteria for metabolic syndrome.

Just to reiterate, there were no differences between low-carb and low-fat. When the subjects focused on real, whole foods and cut refined grains, sugars, and processed foods out of their diet, they lost significant weight, without having to count calories or restrict energy intake. However, this was based on averages, and does not mean that an individual might not respond better to a low-carb or low-fat diet.

Open questions and future directions

This study represents an incredible effort by the researchers and fills an important gap in the scientific literature. Still, any study worth its marbles will inevitably create some open questions:

Why did some people lose weight and others didn’t? While participants on average lost weight in both groups, there was a huge variability in individual responses: some lost up to 50 pounds, while a few gained weight. The researchers hypothesized that individual responses would depend on genetics or insulin response to carbohydrates, but the data didn’t support this idea. Thus, the elusive factor that determines success in weight loss is still unknown. (I heard through the grapevine that they also collected fecal samples in this study, so analysis of the gut microbiome may offer some clues.)

Was the low-carb group truly low-carb? Despite starting off at a carbohydrate intake of about 20 grams per day in the first two months, the low-carb group was already consuming 97 grams per day by three months, 113 grams per day by six months, and 132 grams per day by 12 months (including 22 grams of added sugar). In other words, while they started the trial on a very-low-carb diet, by month 12, they were consuming more of a moderate-carb diet. It’s conceivable that sustained ketosis could have sparked greater weight loss in the low-carb group. However, the subjects were instructed to eat the lowest amount of carbs they could sustain over time, and most found that ketosis was simply unsustainable.

Will both groups keep it off? It will be interesting to see the five-, 10-, and 15-year follow-ups of this study, to see how many people in each group were able to successfully keep off the weight they lost. If they stick to a whole-foods way of eating, my guess is that they might!

“Western” diets vs. ancestral diets

Not too surprisingly, the findings from this study align with what we see in populations eating a more ancestral diet. Among traditional cultures, fat and carbohydrate consumption vary widely, yet obesity is essentially nonexistent. The Inuit, Masai, Turkhana, and Kavirondo consume up to 58 percent of their daily energy from animal fat, yet are lean and have excellent metabolic health (5). Likewise, the Kitavan Islanders of Melanesia consume 60 to 70 percent of their daily energy as carbohydrates from fruit and tubers (6), yet boast healthy levels of insulin and blood glucose (7, 8) and have a virtual absence of obesity (9).

These tribes don’t just have superior genetics. Inuit that have left their traditional lifestyle for a Western diet and lifestyle also left their protection against cardiovascular disease behind (10). Similarly, Kitavan Islanders who leave for the mainland and begin to eat a Western diet quickly become overweight (11).

What we can learn from this study

Altogether, this new research adds to anthropological data to clearly show that the quality of food is far more important than the macronutrient composition. Here are the overall takeaways from this article:

  1. Eat real food for weight loss. Focus on fresh, whole foods that are minimally processed, and eat mindfully, stopping when you’re full.
  2. Self-experiment. The study described here found that on average, there were no differences in weight loss between the low-fat and low-carb groups. However, it doesn’t mean that a single individual won’t fare better on one diet versus another.
  3. Consider life stage and underlying conditions. This study was performed on obese adults without major underlying conditions. If you are pregnant, lactating, or have poor thyroid function, you probably still need a moderate to high carb intake. If you have diabetes, a lower-carb diet may help manage the condition.
  4. Get support. This study also provides evidence that access to regular support from dietitians or health coaches can help people make lasting behavior change and improvements in their health.

Now I’d like to hear from you. Have you tried low-carb or low-fat for weight loss? Which ancestral tribe does your diet look most like? Let us know in the comments!

The post Why Quality Trumps Quantity When it Comes to Diet appeared first on Chris Kresser.

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In this episode, we discuss:

  • Michael Ruscio’s new book: Healthy Gut, Healthy You
  • The importance of gut health
  • Improving the gut without relying on medical testing
  • The role of the gut as the second brain and technology addiction
  • Linking gut health to a good night’s sleep
  • The biggest mistakes people make when addressing gut health
  • Listening to your gut and consolidating all probiotics into a few categories

Show notes:

[smart_track_player url="http://traffic.libsyn.com/thehealthyskeptic/RHR_-_Practical_Steps_for_Healing_the_Gutwith_Michael_Ruscio.mp3" title="RHR: Practical Steps for Healing the Gut—with Michael Ruscio" artist="Chris Kresser" ]

RHR: Practical Steps for Healing the Gut - with Michael Ruscio - YouTube

Hey, everybody, it's Chris Kresser. Welcome to another episode of Revolution Health Radio. This week, I'm very happy to welcome Dr. Michael Ruscio as my guest. He is a Functional Medicine practitioner, clinical researcher, and international lecturer. He's a leader in the movement to make integrative medicine and natural health solutions more accepted and accessible, and his practice is located up here in Northern California, right by me. Dr. Ruscio is a friend and a colleague. I've known him for several years and I've always appreciated his very balanced and sensible approach, which is a little unusual, I find sometimes, in this field. He has a really smart way of looking at the research and separating the wheat from the chaff, and, as I just mentioned, he's very passionate about making Functional Medicine and integrative medicine accessible and avoiding unnecessary and expensive lab testing, and just focusing on the basics. And I think it's very easy to overlook the importance of the basics despite how much we talk about them, especially when you dive into the Functional Medicine rabbit hole. So, I'm really looking forward to talking with Dr. Ruscio today. Let's dive in. 

Chris: Mike, it's always a pleasure to talk to you. Thanks for coming and joining us on the show.

Michael Ruscio: Absolutely. My pleasure. Thanks for having me.

Chris: So, we're gonna talk about the gut, one of my favorite topics, and I know yours.

Michael Ruscio: Yup. [chuckle]

Chris: We're both big fans of the quote from Hippocrates, "All disease begins in the gut." He knew that 2,500 years ago. We forgot, but it seems like we're starting to relearn that, even in mainstream conventional medicine, huh?

Michael Ruscio: Yeah. Absolutely. I'd agree. There's definitely a gut renaissance occurring, thankfully.

Michael Ruscio’s new book: Healthy Gut, Healthy You

Chris: So you have a new book about this topic, of course, Healthy Gut, Healthy You. And tell us a little bit about why you wrote this book. There's obviously a lot of info out there on the gut and gut health. What inspired you and motivated you to put this out there?

Michael Ruscio: Sure. Well, there's a number of things, but I think the few that are the most salient were, I wanted to write a book that would help people with the things that I saw all my patients grappling with. And this is kinda the A to Z companion, everything from your relationship with food, where I'm sure you see some people that are really making themselves sick out of becoming overly neurotic about their diet, and they're very confused about their diet. And some of that kinda pseudo-orthorexia, if you will, stems from the fact that there's so many conflicting opinions out there on diets that people flounder. All the way through, "Okay, I think I have SIBO, do I use probiotics? Do I not use probiotics? Do I use antimicrobial herbs? What if I used herbs, felt good for a while, then I relapsed, what do I do? Should I use a prokinetic? Should I not use a prokinetic? When can I reintroduce food?"

Michael Ruscio: So you have this litany of questions that people are really encumbered with, and I wanted to write a guide that would really hold someone's hand through a self-help protocol, a step-by-step to really help them improve their health. And part of that was because I was frustrated with some of the books that I saw out there that I think are all written with a good intent, but from my estimation, you got one book that was all about gluten free and another book all about probiotics, or another book all about how important it is to feed your gut bacteria. Which can all have a very positive impact on people, but they don't work for everyone because they're not giving you kind of the whole picture. So I really wanted to write a book that would walk someone through the process of healing our gut health that is all encompassing, that's intellectually honest, that's evidence-based, but not evidence-limited, and could really help someone walk away from the read feeling empowered and educated, and not feeling confused and kinda fear-mongered into avoidance. Those are a few of the things that come to mind. [chuckle]

All disease begins in the gut.” Hippocrates knew that 2,500 years ago, but we forgot. Dr. Michael Ruscio wants to get you back on track by helping you transform your health from the inside out with his new book: Healthy Gut, Healthy You

Chris: That's all super important and it's something that you and I have always connected on. And a reason I loved your approach is your evidence-based emphasis, but not being, as you said, evidence-limited. I love that term. And also your focus on practical application, which really makes a difference when it comes ... When the rubber meets the road, and you're working on the stuff either in your own life or with a practitioner. But let's step back a little bit. Most of the people who listen to my podcast are well aware of the connection between gut health and overall health and why gut health is so important. But let's assume maybe that we're talking, there's some newer listeners and they're not as familiar, why is the gut so important? Why should everybody be thinking about their gut health, and what have we learned about that over the past 20 years?

The importance of gut health

Michael Ruscio: It's a great question. And that's exactly part one of the book, which is entitled "The Importance of Your Gut," to kind of establish this premise. And I think one of the most important overarching concepts to connect is that you can have non-digestive symptoms that are driven by a digestive problem. And I actually learned that when I had my health challenges, now about 15 years ago, when my predominant symptoms were brain fog, very, very bad insomnia, fatigue, feeling cold, and also having mood dips. And I went from feeling really well to experiencing all these problems, and all the dietary and lifestyles boxes were ticked, meaning I was getting enough sleep, I loved what I was doing, I was exercising, I was eating a healthy diet.

Michael Ruscio: And so I learned a lot from that process in terms of I didn't have gas, bloating, diarrhea, some of the typical gastrointestinal symptoms, but I did have a diagnosed amoebic infection in my intestines that was driving all of these symptoms, and I was chasing down, I thought it was metal toxicity, I thought it was hypothyroid, I thought it was low testosterone, I thought it was adrenal fatigue. And I chased down all those different symptoms and conditions and corresponding treatments. And I saw flickers of improvement, but nothing really long-standing. And so kinda fast forward, we're now really coming to understand from a modern scientific evidence perspective, that yes, there is a gut–brain connection, there's a gut–skin connection, there's a gut–immune and autoimmune connection. There's a gut–metabolism connection.

Chris: And here's my newest one, the gut–eye connection. We're working on an article on the connection between the microbiome and ocular health. [chuckle]

Michael Ruscio: That makes ... Yeah.

Chris: It's getting kind of ridiculous. There's a gut–everything connection at this point.

Michael Ruscio: Right. Exactly. And so that's why my general posit has always been, once you've somewhat adequately, or taken the best step you can with your diet and lifestyle and tried to get those in halfway decent order, if you're still not feeling well, the next evaluation should be into your gut health. It's not to say it's a panacea, it's not to say it's a cure-all, but before you go looking into other things, I would recommend starting with the gut, optimizing your gut health, and then reevaluating, because as you're alluding to, there's a wide array of symptoms that may rectify after you've improved one's gut health.

Chris: I wanna pause here and kinda reiterate this because I think it's such an important point and it's very often missed. Maybe we can both share a couple of examples from our practice. So, imagine parents that are struggling with maybe a four- or five-year-old child who has a lot of behavioral issues. They've been diagnosed on the autism spectrum or with Asperger's or perhaps they have ADHD, it's a lot of the problems which unfortunately have become so common these days in our society. I mean, we all ... All of us who have kids or are around kids we know, maybe ourselves, we have kids who are dealing with these kinds of problems. I get so many of these kids in my practice, and very often the parents are not necessarily thinking about the gut. These kids may have gut symptoms, or they may not. But just in conversations with friends and family members who don't follow this stuff and who are more kinda part of the general population, if they start ... If the kid starts experiencing these symptoms, what's very often gonna happen is they'll get taken to a primary care provider, they might get referred to a psychiatrist or a specialist in these areas, and they'll be a prescribed medication, and nobody is thinking about or talking about the gut as a contributor.

Chris: And yet, if you look in the scientific literature, there is tons of evidence linking changes in gut health, everything from intestinal permeability, to dysbiosis, to microbial shifts and overgrowth, to SIBO, to these mental and behavioral and mood disorders, and yet that information really has not percolated down into standard primary care or in the general public.

Michael Ruscio: Yeah. I agree with you 100 percent. And it's something that I tried to be very diligent in referencing. Every point that I make that's not common sense in the book, I reference. And that's why there's just under a thousand references. And, you know, if I'm being fully candid here, sometimes people get into a muscle-flexing contest with references to see who can put the most references in the book. But the real key is, how relevant are those references? And so I pride myself in that fact that in the book, the vast majority of the references are clinical trials, or even better than clinical trials, systematic reviews, or even better yet still, meta-analyses. So this means all the data is either a study in humans to see what happens, or a study that's summarized all the available studies in humans to summarize what the available evidence in interventional trials in humans shows. It's much different than saying, "This happened to a group of rats," or, "We noticed this happened in the cell culture, or we noticed this observation." That type of evidence can oftentimes mislead. And that's where I think a lot of confusion comes from. And that's actually something else I talk about in the book, which is why levels of evidence are important, because you can be really misled.

Michael Ruscio: But back to your point about examples. And absolutely, with children, one of the things that I've seen is just simple interventions foundationally, like improving one's diet, getting them off of inflammatory foods and using something like a probiotic, can be vastly beneficial. Sometimes in children you'll see things like histamine intolerance, which unfortunately happens with some parents who go through the regulars of going on like a GAPS diet, which has a lot of fermented foods in it. But sometimes children especially are sensitive to these fermented foods. And we've seen some miraculous changes by reducing dietary histamine in combination with treating dysbiosis. And to your point about literature, there was one study recently, I believe the findings, I'm paraphrasing here, were essentially that there was a higher incidence of fungal overgrowths in children with autism.

Michael Ruscio: And so, we certainly see, yes, there is evidence here. There was another study that showed that patients with urticaria, or hives, had a high incidence of infections, mainly a protozoa known as Blastocystis hominis, and more importantly, after treating these infections or imbalances, there was an improvement in their urticaria, or their hives. In the book, I detail a patient case study where he came in with rheumatoid arthritis and was on pretty powerful anti-inflammatory drugs, and we found SIBO, even though he had no digestive symptoms, treated the SIBO, and he was able to come off of his ... I believe he was on Humira, a very strong medication. So, yes. You're absolutely right. I think we're in full agreement on this. The literature is littered with examples of this. And then clinicians are littered with their case studies that support this. So it's definitely an idea that I think the time has come.

Chris: Let's give some other examples, just because I think that helps people to bring this to life. It's easy to say, "Oh, the gut's connected to everything." But when it really affects people personally, I think that's when they really ... when they start to get it in a different way. Skin conditions are another very common example. We often, we'll see patients with psoriasis or eczema, and they might not have any gut symptoms. So they go to the dermatologist, the dermatologist gives them a steroid cream or something like that to put on their skin, it might help a little bit, but it doesn't go away or get better. We know that in people with celiac disease, especially silent celiac with no gut symptoms, about 50 percent of them have extra-intestinal skin manifestations like eczema, dermatitis. That's something that again, most people in general public and dermatologists, even, are not even thinking about. Now, what are some other examples from your practice of people who have had gut issues, that didn't ... maybe they didn't even have gut symptoms, but it was the gut that was driving that?

Michael Ruscio: Right. And again, that's such a key connection to make, which is you can have a gut problem that's not manifesting as gut symptoms but that is causing whatever external symptom, whether it be brain fog or skin issues or what have you. Two just come to mind. And a lot of these ... We've published patient conversations on our website where I sit down with someone and we talk through their cases. It's not like cramming a camera in someone's face, and saying, "Tell me how good you feel," [chuckle] testimonial. It's more so, "Let's talk through what you came in with and what we did, how you felt going through this." Because I do try to pull the curtain back into my clinic and let people see what some of these results look like in practical terms. There was one patient that came in, and I wasn't even really sure if I could help her because the presentation was so unique. She had this chronic condition of swelling and chapping of her lips. And that was the only symptom that she had, everything else looked fairly unremarkable. And I told her, "Well, we certainly know that the gut–skin connection does exist. I can't say I've just seen this before, but we could certainly do a work-up, see if we find anything out of whack, and perform some interventions to improve your gut health."

Michael Ruscio: And it turned out that she had some dysbiosis in her gut. I wanna say she also had a protozoa. I'm not sure what the exact pathogen or dysbiosis was. But she had an imbalance in the gut that's not very hard to treat. And a lot of this, again, is covered in the protocol in my book, so I don't want people to think they have to go through this elaborate testing to figure out exactly what they have. Foundationally, you can go through a number of steps to rectify imbalances, absent of lab testing. But since she was in my clinic, we had the ability to fairly easily run some lab testing, we found, again, I believe it was a protozoa. And I was shocked that a month later, her lip swelling completely went away. So something I wouldn't even have thought was connected was absolutely connected. And another patient, and we also published a case study on our website for this gal. She was doing really everything right. And actually, there's a friend of mine in town here who does similar work, and he said, "I'm gonna refer you this patient because she's too smart for me." [laughter] He said, "She knows more than I do, because she's very, very well educated." And she came in, she was doing everything right. She was in your Paleo, low-carb diet, exercising, getting adequate sleep, doing some supplementation, yet she was about 50 pounds overweight.

Michael Ruscio: And in her case, we found a fungal overgrowth that was resistant to treatment because it was likely protected by a biofilm, so we had to treat again with agents that break down this protective fence that certain bacteria and fungus can build around themselves to make them somewhat impenetrable to treatment. And the only thing we did was treat that problem in her gut. She lost, over the course of about six months, a little over that 50 pounds that she was wanting to lose. And she also was sleeping better. And so, this stuff is legitimate, and it's not a, "Here is the next weight loss panacea," because I think unfortunately, the gut–weight loss connection has been way overexploited for marketing purposes. But you can see some people definitely lose a notable amount of weight if they're overweight. And at the other end of the spectrum, some patients come in and they're losing weight and they don't know why. And that's because their gut is malabsorbing nutrients. And so ... Those are a few examples that come to mind.

Improving the gut without relying on medical testing

Chris: Yeah. And there's so many, we could go on and just talk all about that. But I wanna come back to something that you just hinted at because I think it's an important topic. There's no doubt that Functional Medicine testing for the gut can be extremely helpful, and even necessary, in some cases, but there's also no doubt that a lot can be done to improve and heal the gut. Without that, in some cases, we're relying too much on that testing. I know that this is something you are pretty passionate about. So let's talk a little bit about that.

Michael Ruscio: Yeah. [chuckle] Something I'm very passionate about. And it's for multifold reasons. One, I think that it doesn't help healthcare practitioners. I think too much testing and an overreliance on testing actually makes it harder for a practitioner to get results. And the short story behind that is, there are a fair number of tests that haven't been clinically validated, meaning the results have no real utility. And so when you're trying to treat a lab that doesn't have any clinical utility, you're adding a variable into the clinical process that's meaningless. And so you're adding another non-meaningful variable into an already variable-rich process, thus making it much harder to produce results. And microbiota assays, I think, are one of the best examples of this, where a patient may have, let's say they have bloating, abdominal pain, and loose stools.

Michael Ruscio: And they do a stool test and it shows that you're deficient in some of these good bacteria. And so the doctor ... And I see a case study like this at least once or twice a month. The doctor gives them fiber and prebiotics supplementation, and the person ends up getting more bloated, having looser stools. And what's happening underneath the surface there, is the lab company is trying to replicate something that's being done at a research center using a microbiota assay, where they essentially map all the bacteria in the gut. But what the lab is using and what the research center are using are two different methods of technology, although similar, and they're using them outside of the context that was used in that research paper. And so if you look at the clinical literature, and this is where the levels of evidence I was mentioning before come in and are very important, you see that oftentimes where people with digestive maladies, they need to undergo some type of bacterial and/or fungal reduction strategy, at least in the short term. And so rather than treating their “labs,” we may wanna look at the condition that the person has and the symptoms they present with, and treat those instead.

Michael Ruscio: So instead of giving them the fiber and the prebiotics, we may put them on a low-FODMAP diet that actually starves bacteria, and potentially, if that doesn't get all the result, you may perform a round of herbal medicines that can clean out bacterial and fungal overgrowths. And I had to say that, the better I get, the more experience I obtain in the clinic, the less testing that I do. And this is what I've also tried to incorporate into the book, which is, there is a whole lot you can do without needing lab tests. Especially if you perform an intervention and then reevaluate at the end of that intervention how you're feeling, and then you can kinda go one way or the other. And so what I've written is kind of a “choose your own adventure” guide, if you will, where there's not necessarily one path, but there's ... There's one main path, but there's divergent paths in there, depending on how someone responds.

Michael Ruscio: And at the risk of being long winded here, [chuckle] I think the most ... One of the fundamentals that's important here is the more symptomatic someone is, the more cautious they'll probably wanna be with strong bacterial feeding interventions right out of the gate. And the healthier someone is, the more likely they can undergo a bacterial feeding intervention like prebiotics and fiber right out of the gate and respond favorably. So I built this into the algorithm of the steps, so that a healthy person can do maybe three steps. An unhealthy person will do more steps because they're gonna have to first go through that bacterial reduction phase before going to the bacterial feeding phase.

The role of the gut as the second brain and technology addiction

Chris: Yeah, that's really important to understand. We hear the recommendations to eat four tablespoons of resistant..

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I’m constantly inundated with concerns over the latest media headlines. Last month, a study titled “Low carbohydrate diets may increase risk of neural tube defects” was published in the journal Birth Defects Research (1). Media sources picked up the story:

Women with low carbohydrate intake are 30 percent more likely to have babies with neural tube defects, when compared with women who do not restrict their carbohydrate intake (2).

While this is true, it’s an oversimplification of the authors’ findings. In this article, I’ll break down the study design and give my interpretation of the dataset. I’ll also discuss other studies that may give us clues as to how many carbohydrates women need during pregnancy and how macronutrient intake during pregnancy may program our children’s metabolism for life.

Not only is nutrition during pregnancy important for supporting growth and development, it also programs the metabolism of our children for the world they will be born into. 

Breaking down the study results

In the study mentioned above, the researchers analyzed data from the National Birth Defects Prevention Study for infants conceived between 1998 and 2011. This included:

  • 1,740 mothers of infants, stillbirths, and terminations with cases of anencephaly, where part of the brain or skull is missing, or spina bifida, where the spinal cord does not completely close
  • 9,545 mothers of control infants born without birth defects

So what did they find? Women who consumed less than 95 grams of carbohydrate per day prior to conception were 30 percent more likely to have an infant with a neural tube defect (1). Yikes!

Not so fast, though. Here are my four qualms with this study:

  • This 30 percent change is a change in relative risk. The absolute risk of giving birth to an infant with a neural tube defect is about one in 1,700 births, so any change to the absolute risk is still quite small.
  • Carbohydrate intake prior to conception was estimated from food frequency questionnaires. Self-reported food intake is notoriously inaccurate and a huge problem in nutrition research. On average, the researchers interviewed women up to nine months after their due date and asked them to recall their diet in the year before pregnancy! Quick, can you remember how many carbs you ate a year and a half ago? I think you see my point.
  • It was the folate intake that mattered most. As the authors report: “Our measures of carbohydrates and folic acid are not independent in that they both come from the same reported food.” Estimated dietary intake of folate among women restricting carb intake was less than half that of other women. Insufficient folate is well known to cause neural tube defects, so it’s much more plausible that this was the true cause for the difference.
  • The effect also depended on pregnancy intention. The embryologic period of neural tube development often occurs before a woman realizes that she is pregnant. The author's comment:

The association between restricted carbohydrate intake and NTDs was observed only among women with unintended pregnancies. We speculate this could be because women who intended to get pregnant made positive changes to their diet or began consistently taking the recommended dose of folic acid supplement.

This further suggests that folate deficiency is the culprit, not the low carbohydrate intake.

A more descriptive title of this study might be: “Low self-reported folate intake before conception is associated with an increased risk of neural tube defects. Women who have unplanned pregnancies while restricting carbohydrates may be most at risk for folate deficiency.”

But that’s not as catchy, is it?

What we know from traditional cultures

Clearly, the study discussed in the previous section itself is not reason to avoid low-carbohydrate diets during pregnancy, provided that you mind your folate intake by consuming foods like liver and dark leafy greens. But are there other reasons to avoid a low-carbohydrate diet during pregnancy? Will it reduce the health of the child, whether at birth or later in life? These are the questions that I will try to answer in the remainder of this article. First, we’ll look at the role of carbohydrate in maternal health and practices of traditional cultures around pregnancy.

According to Weston A. Price, who journeyed around the globe to document the diets and lives of traditional cultures, special dietary practices were common around the time of conception, pregnancy, and lactation. In Africa and South America, tribes went to extensive lengths to properly prepare grains during this time:

Among many of the tribes in Africa there were not only special nutritional programs for the women before pregnancy, but also during the gestation period, and again during the nursing period. As an illustration of the remarkable wisdom of these primitive tribes, I found them using for the nursing period two cereals with unusual properties. One was a red millet which was not only high in carotin [carotene] but had a calcium content of five to ten times that of most other cereals. They used also for nursing mothers in several tribes in Africa, a cereal called by them linga-linga. This proved to be the same cereal under the name of quinua that the Indians of Peru use liberally, particularly the nursing mothers. The botanical name is quinoa. This cereal has the remarkable property of being not only rich in minerals, but a powerful stimulant to the flow of milk (3).

Carbohydrate is particularly important for supporting thyroid function, since insulin stimulates the conversion of inactive T4 to active T3. Cultures that subsisted largely on protein and fat for much of the year and had little access to plant foods had to make other arrangements to support fertility:

Among the Indians in the moose country near the Arctic Circle a larger percentage of the children were born in June than in any other month. This was accomplished, I was told, by both parents eating liberally of the thyroid glands of the male moose as they came down from the high mountain areas for the mating season, at which time the large protuberances carrying the thyroids under the throat were greatly enlarged (3).

In other words, these cultures could conceive healthy children without eating carbohydrate, but their fertility was not optimal unless they self-medicated with the thyroid glands of other animals.

The fetal origins of disease

Nutrition during pregnancy is important for more than just supporting the growth and development of the fetus, though. It also programs the metabolism of our children for the world they will be born into.

This is more formally called the “fetal origins of disease” hypothesis, which has been well supported by the scientific literature. The most oft-cited example is children who were born to women during the Dutch Hunger Winter during World War II. Severe undernutrition of these women early in pregnancy produced children who were metabolically programmed for a world where food was scarce and where conserving energy and storing fat was advantageous. When the famine ended and food became plentiful again, these children were predisposed to obesity and metabolic syndrome in adulthood (4).

Bringing it back to carbohydrate intake, it’s clear that we have two distinct questions:

  • Does a low-carb diet during pregnancy prevent a woman from giving birth to a healthy baby?
  • Does a low-carb diet pregnancy predispose offspring to disease later in life?

I think the answer to question #1 is clear. Most women can give birth to a healthy baby while on a low-carbohydrate diet, provided that they are obtaining adequate folate and other micronutrients (and that their thyroid health doesn’t suffer). Anecdotally, several women in the blogosphere report eating a low-carbohydrate or even ketogenic diet throughout pregnancy and lactation without issues.

However, the answer to question #2 is still a bit uncertain. There are only a few studies that have looked at carbohydrate restriction and how this affects the health of offspring later in life, but in general, they don’t favor low-carb diets.

  • One study in humans found that the offspring of mothers who had consumed higher levels of protein and fat (likely resulting in lower carbohydrate intake) had significantly reduced insulin production in response to a glucose challenge 40 years later. For mothers consuming adequate protein, there was also an average 9.3 mm Hg increase in adult blood pressure for each 100 gram decrease in maternal carbohydrate intake (5).
  • A similar study found that a high-protein, low-carbohydrate diet during pregnancy was associated with increased cortisol levels in the offspring 30 years later (6). (Unfortunately, these studies did not report micronutrient intakes.)
  • Animal studies have suggested that a ketogenic diet during pregnancy may reduce the size of brain regions like the hippocampus in offspring, while increasing the size of others, such as the hypothalamus (7).

In other words, eating a very-low-carbohydrate diet during pregnancy may produce a baby free of birth defects, but it may also program the fetus for a world that contains few carbohydrates. If the child sticks to a low-carb diet, she may be perfectly healthy. However, I think our goal as parents should be to maximize the metabolic flexibility of our children—particularly in a world full of readily available carbohydrates—such that they can remain healthy without unnecessary restriction.


To sum up, low-carbohydrate diets are not acutely harmful to the growth of the fetus, provided that micronutrient needs are met and the mother is not attempting to lose weight. However, wisdom from traditional cultures points to an increased need for carbohydrates during pregnancy, and carbohydrate restriction may have long-term implications on metabolic health and the ability to consume a wide variety of foods. Therefore, I think it’s safest to consume a moderate to high carbohydrate intake (about 75 to 150 grams) when pregnant or breastfeeding, unless a low-carb diet is being used therapeutically to treat a particular condition, such as gestational diabetes.

Of course, this does not mean bingeing on cakes, bread, and sweets. Simple sugars and refined carbohydrates have been associated with poor birth outcomes and increase the risk of gestational diabetes (8). Focus on high-quality carbohydrates like sweet potatoes, potatoes, plantains, fruit, and other starchy carbohydrates. These are packed with nutrients and fiber and accompanied by high-quality fats and proteins, will help to support the health of the mom and proper growth and development of the baby.

Now I’d like to hear from you. What do you think of the research? Did you know about the fetal origins of disease theory? Share your thoughts in the comments!

The post Do Low-Carb Diets During Pregnancy Increase the Risk of Birth Defects? appeared first on Chris Kresser.

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In this episode we cover:
  • I’m eating all the right foods. Why should I be concerned?
  • Medical conditions impair nutrient absorption
  • You're not a probability, you're a person.
  • The varying bioavailability of nutrients in our foods
  • The difference between precursor and active forms of nutrients
  • Optimal supplementation for your health
  • Nutrient Cheat Sheet
Show notes: [smart_track_player url="http://traffic.libsyn.com/thehealthyskeptic/RHR_-_How_to_Maximize_Your_Nutrient_Intakewith_Chris_Masterjohn.mp3" title="RHR: How to Maximize Your Nutrient Intake—with Chris Masterjohn" artist="Chris Kresser" ]
RHR: How to Maximize Your Nutrient Intake—with Chris Masterjohn - YouTube
Chris Kresser: Chris, it’s such a pleasure to have you back on the show. Chris Masterjohn: Thanks for having me, Chris. It's great to be here. Chris Kresser: One of my earliest guests, I think this is number three or four appearances, right? Chris Masterjohn: This would be number four. Chris Kresser: Number four, awesome. So we're going to talk about something a little bit different today, but obviously well within your wheelhouse, and I'm really excited to discuss it. Last week I was asked to give a talk at the UCSF Osher Center for Integrative Medicine, and they wanted me to talk about supplements. But I told them that in order to talk about supplements, I needed to spend the first 90 percent of the talk discussing important concepts like nutrient density, why it's important to get nutrients from food whenever possible, and what the nutrients are that we should be thinking the most about. It occurred to me that even though I have talked about nutrition for years, we've never really had that specific discussion in depth on my podcast, and when I thought of somebody that I wanted to have that discussion with, you were the most obvious choice because this is something you spent years and countless hours of study on, both personally and professionally over the past decade. I'd love to do a really deep dive here on nutrition, meeting nutrient needs from food, the concept of nutrient density, and then more specifically how the average person can figure this all out because it can be really confusing, and they're not going to get the answers they need if they go into their doctor in most cases. Chris Masterjohn: Absolutely, sounds great. I’m eating all the right foods. Why should I be concerned? Chris Kresser: Let's start with somebody who might be listening to this and thinking, I eat a nutrient-dense, Paleo-type of diet or Weston Price-style diet. Why should I be concerned? I'm eating all the right foods. I'm meeting my needs for nutrients, so do I even really need to pay attention to this? Chris Masterjohn: Yes. Well, I think that's kind of the point of eating that way, is that you want to do whatever can bring you closest to not having to care about it in as simple a way that you can integrate into your life as possible. We eat that way in large part because that way of eating is the way that focuses on the right mix of nutrient-dense foods that should make sure all our nutrients are there. The thing is, you have to consider two things. One is just from a theoretical standpoint, is that actually guaranteeing you that you're meeting all your nutritional needs, and then also, what is your experience like? Because if you're coming to this eating this way and having zero problems in your life, no problems with your skin, you're incredibly youthful, you're incredibly energetic, everything's going right, well, that's one thing. But if you're coming from this and you are always a little bit more tired than you think you should be or your skin is a little bit flakier than it should be or you're getting wrinkles a little bit earlier than you thought you would, or God forbid something even greater, like you had a heart attack and you're only 47, then of course you should care because there are things that you have not fixed yet no matter what that theoretical framework is. If we go back to the first part of that, the theoretical framework, first of all, we are trying to do what is ancestral, but we are doing that from (a) imperfect knowledge of what is ancestral, and (b) imperfect resources. To take something, a really simple concept, like our ancestors ate nose to tail, well, what does that mean exactly? Well, in the modern incarnation, it means I try to eat liver once a week and I try to make some soups out of bones, and so I'm using the whole animal, right? Well actually you just used a couple pieces of that animal that we did and our ancestors either because they knew it was important or economic necessity or both, utilized most of the animal that they could, and so they got a totally different balance of nutrients by incorporating the different organ meats. But fact be told, we don't really know exactly how often they ate liver. We don't know everything about did they eat the liver of this animal versus that animal and what mix. There's a lot of things where we're relying on what people have passed down to us from studying certain groups for a couple of months and trying to understand what they understood, but there's just a lot that we don't know. Then you get actually into the kitchen and the question is, are you really eating nose to tail? Did you actually eat the heart also? Did you eat the kidneys? There are a lot of different nutrient profiles in those organs and none of us are really eating nose to tail. We're just trying to incorporate what is easy and simple out of the nose-to-tail concept.
You're not a probability, you're a person. Discover your own, unique dietary needs and eat the right foods to eat to achieve nutrient fulfillment
If you look at an animal carcass, about half of it is probably collagen. Are you really getting that half of your protein from collagen because you're making gravy and soups out of bones? Probably not. You can eat bones, you're getting way more of the collagen and proteins, way more of the minerals when you're ... like the Inuit, for example, they would take fish bones and freeze dry and pulverize them. They didn't soak them and get whatever leached into the water, they ate the bones, right? Chris Kresser: Right, right. Chris Masterjohn: There are many traditions that we’re only imperfectly carrying out, and that's one part of that framework. Chris Kresser: There are other issues, like for produce, where we're now eating domesticated, genetically modified, not in the sense of scientifically or with modern technology genetically modified, although there is that too, but just engineered by humans over many generations to be sweeter and have a different flavor profile and they're far less nutrient-dense than their wild ancestors, right? Chris Masterjohn: Absolutely. And not only that, but on top of that, just transportation of food causes a huge nutrient loss and loss of flavor profile. I mean, this is a major problem for the food industry that they're trying to solve that whatever breeding they've done to make the foods have a sweeter flavor or enrich this or that, the fact is that they can't harvest fruits, including some culinary vegetables like tomatoes, they can't harvest these foods when they're fully ripe because they will be bad by the time people buy them. They're actually harvested at a time that is not ideal for the flavor profile or the nutrient density. You can eat all those same foods, but because of the soil or because of the transportation or because when it's harvested, you're losing out on a lot of those nutrients, and we only have a partial grasp on to what extent is that for all the different foods. The other leg of that is, who are you? If we’re trying to eat ancestrally, we're drawing from all these different ancestral groups, but some of our ancestors or some hunter–gatherers that weren't our direct ancestors personally all these different groups were in specific environments that caused them to evolve genetically in ways that changed the nutrients that they need. If you look at the Inuit, for example, they have genetic adaptations and cultural adaptations to the arctic environment. They have different needs for vitamin D and calcium than most people with ancestry from Europe do, for example. You can then say, well you could try to think about it like, “Well, I'm just going to eat like my European ancestors did.” But first of all, do you really have like a monolithic ancestry to one part of Europe? Probably not. I know I certainly am mixed. Most of us are pretty mixed. But then even still it's always the case that within each of those groups there's a lot of variation between individuals so that group adapted to that environment to best support those people on the whole, but it's still the case that different individuals in any population are going to have varying nutritional needs, and so who are you as a person, and what are your nutritional needs? That we can only be going to test with the genetic testing that's available to us. For the large part, it's only going to be our cumulative experience that is going to allow us to fine-tune our diet to our own needs. Medical conditions impair nutrient absorption Chris Kresser: It’s so important for people to understand, and there are so many other factors too that we haven't even really touched on yet. One of them that I mentioned in my talk was just the increase in the incidence of health conditions that impair nutrient absorption and assimilation. SIBO would be a great example of that. I constantly see patients in my clinic who are following a Paleo or other kind of nutrient-dense diet and yet they're still deficient in nutrients. They have SIBO, we treat their SIBO without giving them any change in their diet or giving them any supplements and those nutrient levels return to normal. That's just one example, but there are so many other examples of conditions that impairing nutrient absorption. Then we have things like changes to the microbiome. We know that our gut bacteria play a large role in nutrient absorption and assimilation as well. It's really kind of mind-boggling when you start to consider all the factors in the modern lifestyle that affect us. Chris Masterjohn: Definitely. Even outside the gut. Chronic inflammation, just as one example, increases the degradation of and the need for vitamin B6. Chris Kresser: Right. Chris Masterjohn: And so it doesn't matter if that inflammation is coming from the gut or from something else. It’s going impact your nutritional needs even after you're absorbing the B6 that’s relevant. Chris Kresser: And obesity and inflammation decrease the conversion of sunlight to vitamin D and decrease the absorption of vitamin D. And then we have environmental toxins like heavy metals that interfere with nutrient absorption and assimilation. Chris Masterjohn: And nutritional impacts on being able to deal with those heavy metals too, like arsenic, for example, is primarily detoxified through methylation, so arsenic sapping your methyl groups. But if you don't have enough methyl groups, that arsenic is accumulating and poisoning other metabolic pathways too, so it's a two-way street, or more than a two-way street more often than not. Chris Kresser: Right. So, I can hear some listeners throwing up their hands and saying, “F*** it. I'm not going to pay attention to this anymore. I thought I was doing all the right things.” Don’t do that. It is true that we have a lot of challenges, but we're going to talk about an incredible document that Chris has put together, a Nutrient Cheat Sheet that I've been using in my practice and all the clinicians have been. It’s really super helpful for helping you get your head around this in a number of ways. We'll come back to that later, so there is a path forward. Don't despair. But it is important to realize that just eating a good diet isn't necessarily enough to insulate you from all of the considerable challenges that we face in this modern world that we live in. With that context, Chris, maybe let's move into some of the primary nutrients of concern. We hear a lot all the time about, of course, the basic vitamins and minerals, but then a whole bunch of other phytonutrients, antioxidants, and when I did the talk at UCSF, there was so much confusion about what ... there are people who are taking all kinds of different supplements from things you've never even heard of that they read about on the internet to, of course, the more basic vitamins and minerals. If someone is wanting to take the next step and focus their efforts, where do they start? Do we start with the basics, or do they think about these more exotic kinds of substances which are very popular right now? Chris Masterjohn: Well, I think that however you start, you want to be comprehensive in some way. If you wanted to be truly comprehensive, then you would do a comprehensive lab screening. You would do a comprehensive dietary and lifestyle analysis. You would do a comprehensive signs-and-symptoms checklist, but what kind of resources you have at your disposal really has to dictate what actually makes sense for you. At this point in our juncture—and I'm sure you have more experience than I do with this—but it's my impression that the average person is not going to be able to run all of the best tests without paying out of pocket for most of it. Chris Kresser: That's correct. Chris Masterjohn: And if they are paying out of pocket for most of it, the average person for whom it is important to understand this stuff cannot afford to do comprehensive lab testing paying out of pocket initially. Chris Kresser: Also correct. Chris Masterjohn: And so, I do know some people for whom that is the best initial approach, but that's not the average person. For most people, the resources that they have, I think all of us feel strapped for time, but that's a matter of priorities. All of us could say, “I'm going to put ... I'm going to re-prioritize what I'm doing this week, and I'm going to put the effort into cataloging the food that I see where it matches up in a nutritional database. I think that can be one of the most helpful places for people to just start with this, and if you're doing something like that, maybe you have other tools that you use. What I would be doing is, I'd use Chronometer, which is a smartphone app where you can plug in all the foods that you're eating and it will tell you how you're matching up to the recommended daily values. That doesn't tell you everything because your needs might be higher or lower than the recommended daily values, and also the food that you're eating may be higher or lower in nutrients and whatever's in the nutritional database. But it gives you a starting place to assess probability because if you don't have ... I mean, you may discover from that, “Wow, my dietary selection is leading me to get 10 percent of the RDA for vitamin B1, and everything else looks good.” Suddenly, that's a major clue that can point you in the right direction. But then the other thing that you can do is catalog your signs and symptoms, and anyone can go plug their food into a nutritional database. The signs and symptoms are a little bit harder. That's where I think one of the places where the cheat sheet that I produced comes into value because I've cataloged together in alphabetical order all the things that you can look through and then trace it back to those nutrients and their probabilities, but if you can do that, then you can say, “Well, my signs and symptoms match up to vitamin B1. So does my diet.” Suddenly, you've put maybe a few hours of time into this, and you've gotten on a lead that has led you to this one particular nutrient, which no one else was talking about. A lot of people are talking about vitamin D, and that may well be your top problem, but you don't want to be at the mercy of what everyone else is talking about. You don't even want to be at the mercy of whatever the highest probability nutrient deficiency is because you're not a probability, you're a person. I think it's useful to say, well, in my consulting I see zinc deficiency coming up as much more common than these other things. It makes sense to have that discussion, but at the end of the day, for you as an individual, it's much more valuable to look at your own diet, lifestyle, and signs and symptoms to see what's most probable for you. You’re not a probability, you’re a person Chris Kresser: I agree a hundred percent, and having said that, I think it is useful to talk a little bit about nutrient intake and even the concept of RDA because that's somewhat problematic. In my UCSF talk, I had a slide, and this was data from the NHANES Survey that was reproduced from a table on the Environmental Working Group website which they got from the NHANES Survey. It has the percentage of dietary intake below the RDA broken down by nutrient by population, two- to eight-year-old kids, 14- to 18-year-old teenagers, and then adults 19 and older. People in the audience were pretty shocked to see some of these numbers, but 95 percent of adults don't get enough vitamin D, 90 percent don't get enough vitamin E, 61 percent get enough magnesium, 51 percent don't get enough vitamin A, 49 percent don't get enough calcium, 43 percent don't get enough vitamin C, and so on. Those are the major ones as you pointed out— Chris Masterjohn: Ninety-eight percent don’t get enough potassium. Chris Kresser: Right. This is a partial list, and there are others, as you pointed out, that aren’t on this list, but suffice it to say that a majority of Americans, and sometimes almost everybody, are not getting enough key nutrients and minerals and not enough as defined by the RDA. Let's talk a little bit about the RDA and what some of the problems with the RDA are because if they're not even getting enough RDA and the RDA is not sufficient, what does that mean? Chris Masterjohn: I don't think the RDA in and of itself is problematic conceptually, and I think that there is a misperception in a lot of the alternative health community that the RDAs are established just to prevent diseases of nutrient deficiencies that no one gets anymore, and that's not true at all. The RDA is … now, what they try to do is a comprehensive review of all of the science and figure out what is the best measure for optimal health. Now, that's always going to be imperfect because number one, there's a lot of disagreement on how to approach that. Ten experts can look at a study and come to the same study and come to different conclusions. There are philosophical differences on should you err on the side of getting a little bit more than you need versus a little bit less than you need if you're trying to be optimal, and then there's just the fact that the science evolves. Almost all of the RDAs that are currently published are years old. Even the vitamin D and calcium ones, which are fairly recent, are eight years old now, so there's evolving research that has not been incorporated into a lot of the RDA. Some of them that we currently have are from the 1990s, and we could certainly say a lot about what studies have come out since then about maybe needing more than that value. RDA is not based on the principle that everyone needs to get the RDA; it’s based on the principle that we assume there is variation in nutritional needs, and the RDA is meant to capture 97.5 percent of those people. Even by its own admission conceptually, meeting the RDA for 2.5 percent of people will mean that they're not getting enough, even according to the RDA. But there are also people who just don't need the RDA because they're lower. But what you find is that in most of the RDAs, when they set them, they say there's enough evidence to say what the variation and needs are, so we're just going to assume it's 20 percent or something like that. There's not really any evidence-based way to capture what that variation is. At the end of the day, also this philosophical idea of, “Do you want to set your goal to get just enough?” If you look at the research of Weston Price in his epic work Nutrition and Physical Degeneration, one of the points that he made was our ancestral diets were generally full of four times as much nutrients— Chris Kresser: Yes. Way above the RDA. [Crosstalk] Chris Masterjohn: —minimum. Because what you don't want is to meet your bare minimum needs and then get pregnant. Chris Kresser: Right. Chris Masterjohn: —or then get injured, or then get sick. Chris Kresser: Right. No buffer. Chris Masterjohn: Then all of a sudden your reserves have no extra, and now your needs are twice as much and now your diet has half of what you need. I think that's where the big divergence is between the ancestral approach and the RDA, is that the RDA is trying to capture those minimal needs and our ancestors were trying to eat as nutrient-dense an abundance as they could to cover all of those contingencies. The varying bioavailability of nutrients in our foods Chris Kresser: Yes. That's a great point. I want to expand on it a little bit and mention another one too. If the RDA is what's required to avoid acute deficiency syndromes, they also don't tell us what amount of that nutrient is required to avoid chronic problems, for one thing, much less what amount is required for optimal health, which is perhaps a different question altogether, and that's what you were hinting at just now, I think. The other issue that we haven't touched on yet is bioavailability of a particular nutrient. If you look at just a sheet of paper, a list of foods that contain certain nutrients ... let's talk about calcium just as an example of this. If you look at a list of calcium in foods, you'll see that foods like collard greens and spinach are pretty high on the list. About a cup of collard greens has 268 mg of calcium, spinach has 245, and those are listed above, foods like bone-in and sockeye salmon with 188 mg of calcium. Somebody might justifiably look at that list and say, “Oh, I'm eating plenty of dark leafy greens so I must be meeting my calcium needs.” What's the problem with that assumption? Chris Masterjohn: Yes. Well, the problem is those vegetables. Most plants accumulate oxalate as a way of preventing calcium concentrations from getting too high. It's sort of like if your if your calcium level in your blood goes too high, you have hypercalcemia, and in humans we want most of our calcium in our bones and teeth, so that we can let it out into the blood when we need more and we can store it when we need less...
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Green smoothies: Not necessarily a “health food” In the health community, the green smoothie has become the poster child for healthy eating. If you are a green smoothie fan, your typical recipe probably looks something like this:
  • 1 apple, peeled, cored, and chopped
  • 8 ounces unsweetened almond milk
  • 2 cups stemmed and chopped spinach or kale
  • 1 cup broccoli
This green smoothie is full of veggies—spinach, kale, and broccoli—so it must be healthy, right? Well, not necessarily. While cruciferous vegetables and leafy greens certainly have health benefits, consuming large amounts of them in green smoothies may not be healthy in the long run, for several significant reasons.
  1. Cruciferous vegetables, such as kale, broccoli, cauliflower, and cabbage, have been found to contain high levels of a toxic heavy metal, thallium.
  2. Cruciferous vegetables contain goitrogens, which are naturally occurring plant chemicals that inhibit the uptake of iodine by the thyroid gland and reduce the production of thyroid hormone, thus lowering thyroid function.
  3. Many leafy greens, such as spinach and collard greens, are high in oxalates. Oxalates are plant-based compounds that may promote kidney stone formation and inflammation when consumed in large amounts.
As you can see, it may be time to reconsider whether regularly drinking green smoothies is a wise choice for our health.
Cruciferous veggies and leafy greens undoubtedly have many health benefits, but consuming large amounts of them in green smoothies may not be healthy in the long run
Are there heavy metals in your kale? The soil in which vegetables grow has a significant impact on their micronutrient content. However, just as beneficial minerals are transferred from soil into plants, so too are toxic metals. Unfortunately, research shows that the toxic heavy metal thallium, which occurs in soil as a byproduct of smelting and coal-burning, preferentially accumulates in cruciferous vegetables such as kale, broccoli, cauliflower, cabbage, brussels sprouts, and bok choy. (1) This means that people who eat a lot of cruciferous vegetables, as green smoothie aficionados are wont to do, may be exposing themselves to high levels of thallium. In fact, an astute molecular biologist and alternative health practitioner named Ernie Hubbard found this to be just the case among his health-conscious clients, who were experiencing many bizarre symptoms that did not fit any standard disease pattern. After much investigation, he was eventually able to trace their symptoms back to thallium toxicity resulting from their cruciferous vegetable-heavy green smoothie habits. (2) Unfortunately, when it comes to thallium, even low-level exposures can cause symptoms such as nausea, diarrhea, stomach pain, hair loss, and peripheral neuropathy. (3) While some medical authorities have argued that toxic metals are present throughout our environment and that we shouldn’t worry about trace levels in otherwise-healthy vegetables, the problem remains that heavy metal exposures are additive and synergistic. Many heavy metals have similar adverse effects on the body, so continuous consumption of thallium in vegetables, plus daily exposure to other heavy metal sources, exponentially increases the body’s toxic burden. Based on this evidence, if you are regularly drinking green smoothies and experiencing any unusual health problems, it may be time to investigate your thallium level and reconsider your green smoothie habit. If you aren’t ready to get rid of your green smoothie just yet, at least consider using only organic cruciferous vegetables in your drink. Soils that are rich in carbon-based matter, such as soil on organic farms, have been found to impede the transfer of thallium into plants; this effect is less likely to occur in the carbon-depleted soils used on conventional farms. This means that organic produce may contain lower levels of heavy metals, such as thallium, compared to conventionally raised produce, potentially resulting in a healthier green smoothie. (4, 5, 6) Green smoothies and the thyroid gland Concerningly, green smoothies may also have adverse effects on the thyroid gland. The thyroid gland requires the mineral iodine to produce thyroid hormones. Cruciferous vegetables—common ingredients in green smoothies—contain compounds called glucosinolates, which inhibit iodine uptake by the thyroid. This may result in a reduced ability of the thyroid gland to produce hormones, leading to reduced thyroid function. (7) Furthermore, the risk of high cruciferous vegetable intake impairing thyroid function is greater in people with iodine deficiency. Iodine deficiency is not uncommon in folks on a Paleo or otherwise “healthy” diet, since the main dietary sources of iodine available are sea vegetables, iodized salt, dairy, and fortified foods, which are often excluded on a Paleo or unprocessed diet. While large quantities of raw cruciferous vegetables pose a problem to the thyroid gland, cooked cruciferous vegetables appear to be much safer. Cooking cruciferous vegetables stimulates the production of an enzyme called myrosinase that helps to deactivate goitrogenic glucosinolates. (8) Opting to eat cruciferous vegetables in their whole-food form is another way to reap the health benefits of these vegetables without getting a heavy hit of goitrogens; it is much harder to overeat vegetables when they are in their whole form versus juiced or blended in a green smoothie. Oxalates in green smoothies Another significant problem with green smoothies is that they are often high in oxalate, a type of naturally occurring plant compound that promotes kidney stone formation and inflammation in certain people when eaten in excess. (9) Oxalate occurs in high amounts in spinach, chard, dandelion greens, beets, collard greens, berries, broccoli, cabbage, and carrots. In some people, oxalates accumulate in body tissues and provoke inflammation. In fact, oxalate accumulation has been associated with chronic pain, nephrolithiasis (aka kidney stones), neurological symptoms, vulvar pain, and fibromyalgia pain. Currently, a high oxalate intake is defined as the consumption of 250 mg oxalate per day. For reference, one cup of raw spinach contains around 656 mg oxalate. (10) As you can see, it would be quite easy to overdo it on oxalates if you are regularly drinking green smoothies, which often contain a cup or more of spinach! Research has confirmed that green juices made using common vegetables contain high levels of soluble oxalates and that the consumption of these drinks may precipitate oxalate kidney stone formation. (11, 12) Some green smoothie proponents advocate “rotating” greens to include low-oxalate options such as mustard greens, watercress, and lettuce; this may help prevent green smoothie-induced oxalate overload. Certain genetic variants, such as the SLC26A1 variant, and pre-existing gut issues, such as Crohn’s disease and dysbiosis, may increase an individual’s susceptibility to the harmful effects of dietary oxalates. For these individuals, reducing dietary oxalate intake may significantly relieve symptoms. (13, 14) Replenishing the gut with beneficial bacteria from probiotics and fermented foods may also assist in the degradation of oxalate, since several probiotic species, including Lactobacillus rhamnosus, Bifidobacterium animalis subsp. lactis BI07, and Oxalobacter formigenes, have been found to degrade dietary oxalate. (15, 16, 17) Final thoughts on green smoothies Unfortunately, green smoothies are not quite as healthy as we have been led to believe, due to their thallium, goitrogen, and oxalate content. Rather than relying on green smoothies as a primary source of vegetables, I recommend eating veggies in their whole-food form and cooking cruciferous vegetables to lower their goitrogen content. If you are not ready to forgo green smoothies entirely, choose organic vegetables, which may be lower in heavy metals; rotate your greens so that you are regularly including low-oxalate options such as mustard greens and watercress; and consider supplementing with oxalate-degrading probiotics such as Lactobacilli and Bifidobacteria. Now I want to hear from you. Are you a fan of green smoothies? Have you noticed any adverse health effects as the result of your green smoothie habit? Let me know in the comments below. 
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