The Dr. Hyman Show - Why You Are Tired All The Time

Episode Date: January 21, 2022

This episode is brought to you by Rupa Health, Athletic Greens, and Eight Sleep. Feeling tired during the day may not just be due to a poor night’s sleep. Most of us can relate to feeling run-down and tired, even when we’re getting enough sleep. There are many reasons why your body might not be functioning well during the day. In this compilation episode, I talk to Dr. Steven Gundry and Dr. Elizabeth Boham about the many factors that can impact energy production such as diet, circadian rhythm, movement, gut health, and more. We also get into dietary recommendations, fixing nutritional deficiencies and hormonal imbalances, and much more.  Dr. Steven Gundry is one of the world’s top cardiothoracic surgeons and a pioneer in nutrition, as well as medical director at The International Heart and Lung Institute Center for Restorative Medicine. He has spent the last two decades studying the microbiome and now helps patients use diet and nutrition as a key form of treatment. He is author of many New York Times bestselling books including The Plant Paradox, and The Plant Paradox Cookbook, and The Longevity Paradox: How to Die Young at a Ripe Old Age, and just released The Energy Paradox: What to Do When Your Get-Up-and-Go Has Got Up and Gone. He also is the founder of GundryMD, a line of wellness products and supplements, and host of The Dr. Gundry Podcast. Dr. Elizabeth Boham is Board Certified in Family Medicine from Albany Medical School, and she is an Institute for Functional Medicine Certified Practitioner and the Medical Director of The UltraWellness Center. Dr. Boham lectures on a variety of topics, including Women’s Health and Breast Cancer Prevention, insulin resistance, heart health, weight control and allergies. She is on the faculty for the Institute for Functional Medicine. This episode is brought to you by Rupa Health, Athletic Greens, and Eight Sleep. Rupa Health is a place for Functional Medicine practitioners to access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, Great Plains, and more. You can check out a free live demo with a Q&A or create an account at RupaHealth.com.  AG1 contains 75 high-quality vitamins, minerals, whole-food sourced superfoods, probiotics, and adaptogens to support your entire body. Right now when you purchase AG1 from Athletic Greens, you will receive 10 FREE travel packs with your first purchase by visiting athleticgreens.com/hyman. Eight Sleep’s Pod Pro mattress is so smart that it adjusts your temperature and also gives you individualized recommendations on how to sleep better the next night. To get yours, go to eightsleep.com/mark to check out the Pod Pro mattress or mattress cover and save $150 at checkout.

Coming up on this episode of The Doctor's Pharmacy. Time-controlled eating, and that is limiting the amount of time during the day that you consume food, is probably one of the number one fixes in our current energy crisis. Hey everyone, it's Dr. Mark. I know a lot of you out there are practitioners like me helping patients heal using real food and functional medicine as your framework for getting to the root cause. What's critical to understanding what each individual person and body needs is testing, which is why I'm excited to tell you about Rupa Health. Looking at hormones, organic acids, nutrient levels,

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And it's 90% faster, letting you simplify the entire process of getting the functional medicine lab tests you need and giving you more time to focus on patients. This is really a much needed option in functional medicine space and I'm so excited about it. It means better service for you and your patients. You can check it out and look at a free live demo with a Q&A or create an account at rupahealth.com. That's R-U-P-A health.com. I'm all about streamlining my daily health routine to be as powerful and yet simple as possible. And that's why I love AG1 from Athletic Greens. Because when it comes to my health, I want it all. I want my gut to function great, my brain to feel sharp, my immune system to be strong, my body to feel

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All you have to do is visit athleticgreens.com forward slash hyman. Again, that's athleticgreens.com forward slash hyman to take ownership over your health and pick up the ultimate daily nutritional insurance. Now let's get back to this week's episode of The Doctor's Pharmacy. Hi, this is Lauren Feehan, one of the producers of The Doctor's Pharmacy podcast. Feeling tired during the day may be a result of more than just a poor night's sleep. There are many reasons why your body might not be functioning well during the day, ranging from suboptimal mitochondrial function, stress, hormonal imbalance, and more. Functional

medicine doctors look at a range of factors to resolve conditions like insomnia and fatigue. In this compilation episode, Dr. Hyman talks to Dr. Stephen Gundry and Dr. Elizabeth Boehm about how they work with patients to get to the root cause of symptoms. They discuss many factors that impact energy production, such as diet, circadian rhythm, movement, gut health, and much more. Let's jump in. We are overfed and underpowered. And what the heck does that mean? We, in general, Americans eat nearly 16 hours a day, almost continuously from sunup until well after sundown. And we have what's called mitochondrial rush hour, which living in LA is easy to understand.

But simplistically, our mitochondria can handle sugars, fats, and proteins. And we use a slightly different system for making energy from sugar, from fat, and from protein. And in the good old days when we ate whole food, like you advocate and I advocate, these different components, Sugars would arrive first in the mitochondria. They'd be followed by proteins sometimes later. And a long time later, they'd be followed by fats. And mitochondria have, if you will, basically a freeway, an energy-producing freeway. Now, when these things arrive in a staggered fashion, the freeway moves great. But what happens is with our modern diet, with processed foods, with ultra-processed foods, we have combined simple sugars, simple proteins, and easily absorbed fats that hit our mitochondria simultaneously. And the mitochondria actually can't handle all these. So

we actually have stagnation in the energy producing highways. And we have systems on freeways, okay, we're going to have traffic lights that's going to control the onslaught of all this, but we get mitochondrial gridlock. And I use the example. So, okay, let's have breakfast at seven o'clock in the morning. All of a sudden you're slamming with all three of these components and your mitochondria literally go into gridlock for two or three hours. You begin to get sleepy at 10 o'clock and you say, oh, I need a little pick me up-up. I'll have a donut and a cup of coffee. And once again, traffic gets slammed. By that time, it's lunch. We slam it again. And so this process of gridlock really never stops until we go to sleep. And even after we go to sleep, there's still two to three hours of backup, if you will,

on the mitochondrial freeways. So our mitochondria really never have a chance. And in researching this book and trying this out on my patients, one of the things that was dramatic was that if I could lessen the period of time that you're asking mitochondria to handle food, the better off you're going to be because they have a chance to recover and heal themselves, if you will. And that gets into part two of the book. How do you put this into practice? So your book is quite extensive and really goes into detail about a lot of these unusual compounds that come from a disturbed gut microbiome that have broad spectrum challenges in the body.

And this is what we've been doing in functional medicine for decades. It's really the foundation of my practice. It's really the key to getting people healthy. And I sort of agree with you that a lot of the beginning and the end of health starts in the gut. And it's really always the first place we start with food and gut repair and functional medicine. But you talk about, you know, the plan of how do you do this? What are the do's and don'ts of the energy paradox when it comes to eating? Well, first of all, the more, and you and I, I think, would agree complete with this, the more you stay away from processed foods, from ultra-processed foods, that's really the fundamental starting

point. The more you actually use whole foods and literally foods in their whole state, the better off you're going to be. Number two, I can't resist telling people to get lectin-containing foods out of their diet. Lectins are part of the plant defense system against being eaten or having their seeds being eaten. And these are proteins that Dr. Fasano and others have shown disrupt the gut wall. And they in themselves are antigens that in my original line of work, heart disease, attract inflammation to the wall of blood vessels. And so they're a nasty bunch of compounds and they're in so many of our favorite foods, such as whole grains. The nice thing about beans is beans are loaded with lectins, but pressure cooking and soaking beans and fermenting beans actually eliminates the lectin problem.

So there's pressure cooking grains do the same thing. Great question. It will pressure cooking will not break the gluten in wheat, barley, or rye. Gluten resists pressure cooking. There is a gluten like protein in oats that also resists pressure cooking. And I can't tell you the number of people who have gone on a gluten-free diet with autoimmune diseases, with celiac, who are not cured. They still have celiac because the foods that they're eating, like oats, like corn, are loaded with lectins. And just recently, I had a gentleman who we, I don't like to use the word cured of rheumatoid arthritis,

but his markers vanished by following our program. And then he was a snowbird, and he came back this winter, and his rheumatoid, one of his RA markers was elevated for the first time in like four years. And I said, you've been cheating. He said, no, no, no. Are you kidding? I wouldn't do that. And I said, well, something's getting into your diet.

I said, what do you have for breakfast? He says, oh, glad you asked. I've been on a pressure cooked oatmeal kick. Every morning I have a bowl of pressure cookouts. And I said, wait a minute. You can't do that. It's on. I have a bowl of pressure cookouts. And I said, wait a minute, you can't do that. It's on your list.

You can't pressure cook oats. And you would pull out the list. He said, Oh, Oh no, that's, that's the change. And so we took it out a month later.

His RA was back to normal. Yeah, absolutely. I see that so often. Yeah, I see that so often. So, so getting out lectins, eating whole foods, any other sort of key dietary do's and don'ts?

Yeah. So one of the, I think the shocking benefit of time-controlled eating, and that is limiting the amount of time during the day that you consume food, is probably one of the number one fixes in our current energy crisis. And it seems almost contradictory, paradoxical, if you will. The more you kind of snack throughout the day, the actual harder it is for your mitochondria to make energy. You have to eat to get energy, but what you're saying is if you stop eating, you actually are better at, at the end of the day, making more energy. Yeah, that's exactly right. I'll give you an example. We're actually supposed to have

significant downtime for repair work, for repair work for our brains, repair work for our mitochondria. And that would normally have happened because we were sunlight creatures, and we were controlled by sun. And we'd get up when the sun came out and we'd basically go to bed when the sun went down. And even the advent of fire 150,000 years ago, we were still exposed to orange light, red light, and we certainly weren't exposed to blue light. So we still had a limited period of eating.

And the evidence is if we have a 12-hour window of no eating, which is really easy if you think about it, that's 7 a.m. to 7 p.m., that's a 12-hour eating window, and you'd have from 7 p.m. to 7 a.m. of not eating, we begin to shift into mitochondrial repair. And what's really exciting is the more you go beyond 12 hours, the better the repair work goes. Let me give you an example. There's not a lot of repair work done on L.A. freeways during the day because the traffic is so bad.

I drive into L.A. very early in the morning or to Palm Springs very early in the morning from Santa Barbara. And that's when the repair work's going on because there is much traffic on the road. Well, our mitochondria do the same thing. If they're doing work, they have no time to repair. And it's the repair of mitochondria, undoing the damage of our eating that actually allows mitochondria to get back to full power. So the more we can limit the time period that people eat, the better. Now, the first thing we don't want to have people do is, okay, what Dr. Gundry says tomorrow morning, my first break fast is going to be at noon, I'm going to hold off, break fast until noon. And I can tell you that 80% of your listeners and my listeners will fall

flat on their faces. Because 80% of Americans are insulin resistant. And with insulin resistance, that's in the book too, you can't use free fatty acids, fat as a fuel. You can't, you can't get to them. And so you got to build up slowly in tolerance. And we have a six week program of holding people by the hand and changing when they eat breakfast one hour at a time so that we're going to stepwise because people fall flat on their faces with attempting intermittent fasting because they don't have the availability to mitochondrial flexibility of changing fat metabolism. So you talk about a lot of other things that are really important parts of energy, including exercise, packing, sun exposure, avoiding blue light, which ruins our circadian rhythms, and even getting a dog. And can you talk a little bit about those things before we have to wrap up the podcast? Yeah. You know, I mentioned that blue light from our devices, from our lights, we are constantly being exposed to blue light.

And blue light is really detrimental to almost all of our functioning, including our mitochondria. And it really, we are awash in what I call junk light. And I think one of the most important things people can do is two things. Be exposed to red light at sunrise or sunset. If you're going to take walks, that's the time to do it. If you can't get exposed to red light, get yourself a red light box. There's a number of red light and near infrared light makers. I particularly use a Juve device, but there's plenty of other ones. And expose yourself to red light. Interesting.

One of the things I learned, which I found hard to believe but we actually produce atp from melanin exposure from natural sunlight and so we do photosynthesis exactly like a plant and it may be why fundamentally we want to be outdoors we want to be at the beach we want to be outdoors. We want to be at the beach. We want to be exposed to sunlight. And it may be that we're far more attuned to what sunlight is actually doing for us at a basic level than we thought. Plus, there's really cool evidence that sunlight actually activates mitochondria. And it changes the way water moves in mitochondria. But that's a whole other subject. So why get a dog?

Two reasons. I'm a big fan in the book of exercise snacking. And there's really good evidence that walking upstairs for a minute, up and downstairs for a minute, may have the same effect on your mitochondrial function through the production of myokines from our muscle cells as 20, 30 minutes of walking on a treadmill. And the effect of five minutes is even more. So why get a dog? Dogs are going to have to go out at least twice a treadmill. And the effect of five minutes is even more. So why get a dog? Dogs are going to have to go out at least twice a day. And dogs will take you for a walk. The other thing about dogs is the evidence is overwhelming that people who have dogs

have a much healthier and diverse microbiome than people who don't have dogs. Because the dogs... You get licked in the face. Yeah, let your dog lick your face, and they bring in all these amazing dirt microbes into your house that you will mix with. Amazing. So a take-home from the Energy book you've written, it's really extraordinary sort of breakdown of a lot of the reasons why we're all struggling with fatigue.

What you do when you get up and go has got up and gone. You know, what are the most important things people can do on day one to really look at what the causes are of their energy deficit and how to reboot it. If you were to sort of summarize the take-homes from the book, what would they be? I think the take-home of the book is the more you get processed foods, simple, ultra-processed foods, and quite frankly, early on, the more you get modern fruit out of your diet, the better. And that always gets people riled up and my Twitter lights up. Modern fruit has nothing to do with healthy fruit. Believe it or not, a cup of grapes has more sugar than a full-sized Hershey's chocolate bar. And I could tell you which I'd rather have, but neither.

These things have been bred for sugar content. And we have to also remember that it's actually the fructose that's the troublemaker in stopping energy production. Fructose goes directly to your liver and regular table sugars have fructose, folks, goes directly to your liver and actually stops ATP production. And it was one of the most enlightening findings of my research through the last few years. And the more I research how fructose works, the more scared I am of how much fructose is in a typical American diet. So that's number one. Number two, the less you snack, the better. The farther you stop eating before you go to bed, the better. And if you can get a three-hour window between the last thing that went in your mouth and going to sleep,

it'll make a huge difference in your energy levels and your sleep. Hey everybody, it's Dr. Mark. Now you probably figured out by now that I'm super passionate about getting regular deep restful sleep. It's a foundational piece for optimizing metabolism, brain function, and pretty much our health as a whole. And one

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the next level, check out eightsleep.com forward slash mark, and you can save $150 at checkout. That's eightsleep, E-I-G-H-T-S-L-E-E-P.com slash mark, and you can get $150 off. And now let's get back to this week's episode of The Doctor's Pharmacy. What are the kinds of things that, you know, you found are the common drivers of fatigue for patients? Oh, you know, there's so many, and we can go through a few cases, but, you know, nutritional deficiencies, huge. You know, you'd think that we were adequately, you know, we had adequate nutritional status, but so many of us don't, whether it's because of digestive issues and we're not absorbing well, or just inadequate intake, or we're dealing with some sort of chronic toxin exposure

that's wearing down our body. So- Or eating processed food, or the soil is depleted, or- Oh my goodness, right? I mean, the average apple you eat has been stored for a year. Yeah. Right? Yeah, absolutely.

Go pick an apple from a tree and go eat one that's been in a warehouse for a year. Very, very different experience. Yeah. So, I mean, of course, we're seeing nutritional deficiencies. I see a lot of genetic variations that influence somebody's energy level. We see digestive issues that influence energy level. We see chronic infections and, of course, toxins. Heavy metals. Heavy metals. You know, what I think is really great,

some patients even come in with their timeline, you know, and sometimes that's so helpful because they write down, you know, over the years when certain things happened in their health history. And then you can look at that and, again, you start to see some of these patterns. Yeah. And, and so when, when I, you know, remember when I had chronic fatigue, I, you know, went to doctor after doctor after doctor and they're like, well, there's nothing wrong or you're testing normal, or this is a little off or that's a little off, but nothing really. And, you know, take some Prozac, you know, here's something for sleep. Right. You know, and it's just, it's so frustrating as a patient to go through this litany of doctors and not really getting an answer. And, you know, and I think that the fatigue you don't often treat directly because, you

know, you, yeah, you can take Provigil, which will sort of make you more awake, or you can take Ritalin or Adderall, which is like a, you know, stimulant to help you have more energy. But, but those are sort of like beating a dead horse. You have to figure out what's really going on. And I think, you know, when I first sort of discovered what happened with me was the mercury was the thing that was driving it. And it created a whole cascade of problems. So it affected my gut. It affected my immune system. So I was chronically inflamed.

I started developing all these rashes and all these sores and all these things around my eyes would look like a raccoon if I ate certain foods, I'd get bloating. And I also developed, you know, real cognitive issues and real trouble thinking and focusing and fatigue. And I realized that, you know, these insults that happen, you know, affect all the different systems in your body. So when you're diagnosed with something with fatigue, it's all the other symptoms and all the other pieces that give you the clues about what's really going on for this person. So it's not like one treatment for fatigue.

There's dozens and dozens, depending on what you find with that story. Right. And that mercury for you just depleted your glutathione stores and that then influenced all these other aspects of your health. Yeah. Poisoned my mitochondria. And it turned out I had a gene that affects my muscle enzymes, my energy cycle and my mitochondria. And it leads to have an easier ability to be damaged by it, which is why I had this elevated thing called CPK, which is a muscle enzyme. And it was this abnormal test, but it wasn't really so severe that it was a disease, but it wasn't normal.

And they're like, well, I don't know what's wrong. You know, like, but we can figure that out using the roadmap of functional medicine. I think it's so interesting how some people just need more support than others in certain areas. And, you know, we talked about this on another podcast about supplements. And I think that's what the key is, is when you figure out for that individual person where they need that extra support in a personalized way, it makes all the difference in the world. Yeah. I remember I was giving a lecture at Canyon Ranch one year and I'm like,

this guy's like, you know, I'm always tired. I don't know what to do. I said, how many hours do you sleep? He's like, six. I'm like, sleep eight. That'll be $500, please. Sometimes it's just that simple, right? I'm like, sleep. So, yeah, quality of sleep also matters. You know, sleep apnea is another cause.

It's often very undiagnosed in patients. Often undiagnosed and something we have to look for. You know, we look for the signs of sleep apnea from somebody snoring, not remembering their dreams, their blood pressure being elevated, they're not having a heart rate, gaining weight, right? Because it causes the weight gain. It causes you to gain weight around your belly. Signs of insulin resistance and metabolic syndrome, that high fasting insulin, the high waist to hip ratio. All those things make us think, okay, we got to think about sleep apnea. And then when we examine them, sometimes you can see clues

on exam. And it's critical that we diagnose it and treat it because it makes a huge difference in not only how somebody feels, but their risk for all sorts of diseases, right? From diabetes to heart disease to, you know, sudden death for that matter. I mean, it's-. Sudden death, that's not a good outcome. No, that's not good. So Liz, you had a couple of cases I wanted to share with everybody. And this 35-year-old woman with weight gain and diabetes. And tell us about her and how she presented and what you found and how you worked up a case and what you did with her.

So this woman came to see me when she was 35. And she had obesity and type 2 diabetes and depression and heartburn. She had a lot of other things too, but those were some of the main issues. And actually the reason she came to see us was because her depression medication wasn't working. And she's like, I really need to find another way to deal with this. So she had, when we looked at her timeline, right, she started gaining weight when she went to college in her 20s and started to put on a bunch of weight. Enough weight also, and maybe she was at that point eating, making a lot of the wrong food choices. She also started to get some heartburn. And in her 20s, so she was put on a PPI. She was put on the acid blocker when she was in her 20s. And she was still on that same acid

blocker now, 15 years later. So she was put on the acid blocker in her 20s for her reflux. And those medications, when they came out, they were not designed to be taken forever. They were six weeks for an ulcer. We were told they are very powerful drugs that suppress acid production in the stomach, that cause long-term complications. And they do. Yep. But we now have them for sale over the counter. And doctors prescribe them like candy.

And they have serious complications if they're used liberally like that. Absolutely. Instead of figuring out why you have heartburn in the first place. And she couldn't get off it because the heartburn kept coming back. So here she was 15 years later. And then she slowly, after college, the weight just kept coming on. So she just kept gaining more and more weight. Her health was just deteriorating in a way. She just got more and more tired. And then in her later 20s, she started to have some depression. And she was, you know, she was tried on a bunch of different antidepressants.

And they didn't really make any difference. And then a couple years before she came to see me, she was diagnosed with type 2 diabetes. So she wasn't yet on her any medication for diabetes. She was trying to control it with diet. But her blood sugar was high enough to get the diagnosis of diabetes. And she's only 35. And she just wasn't feeling good. So she said, you know what, I've got to try a different way. So she stopped her antidepressants because they weren't doing anything and came to see us. And so for me, looking at her timeline and putting together, you know, connecting the dots, when I see somebody with fatigue and depression and on a PPI, on an acid blocker for so long, you know, one of the things I really think about is protein and what is

that person's protein status. Why is the acid blocker a problem for protein? Right. So you need acid in your stomach to break down your food. And it starts, acid also encourages a lot of our digestive enzymes to work, which is all really necessary for the body to break down its protein into amino acids that you can absorb. And then when the body absorbs those amino acids, they get used in the body for all sorts of different things from healing your skin to making muscle, but also they're used to

make your neurotransmitters. Your happy new mood chemicals. Absolutely, right? So they make your serotonin and your dopamine and your GABA, which help you focus and have energy and feel happy. That sounds good. Yeah. Focus, energy, and feel happy.

I want some of that. So when you take an acid blocker, you're decreasing your ability to break down your food and break down your protein and pull all those really important amino acids from your food. And for some people, and depending on the length of time you're on it, it can have a huge impact. It also impairs other nutrients like B12, which also is a big cause of fatigue and depression. Yes, B12. It impairs the absorption of a lot of your minerals. So we see people develop osteoporosis after years of being on these acid blockers. So people will have low zinc, low calcium, low magnesium.

And zinc is more important than ever with COVID-19 because it helps to inhibit the viral attachment replication. Yeah. So important for your immune system. Right. So I saw that she had this depression, the fatigue, the acid blocker, and I go, oh, I wonder what's going on with her protein. So we do this cool test where it looks at plasma amino acids, which are those building blocks of protein in your body. So you can measure your amino acids in your blood. And we did. So we measured her amino acids and she was low in lots of amino acids. I wasn't surprised. And you think I was seeing a protein, how can she be low in amino acids? We don't see protein malnutrition in America. But we do see large numbers of patients with very low amino acids for a variety of reasons.

Right, right. And so I suspect with her that the acid blocker was a huge reason for that, that she just wasn't breaking down her food well and absorbing her amino acids well. And so one of the things we were able to do was give her some of these amino acids for the period of time. So we gave her a complex of amino acids. And then I also gave her some amino acids that were really focused on production of neurotransmitters. So things like tryptophan, 5-HTP, tyrosine, GABA, these things that help the body with production of those neurotransmitters. And, you know, you have people take the amino acids between meals because it

helps with, it's better absorbed that way. And that was really helpful for her, you know, that helped her energy. She noticed a tremendous difference in her energy. It actually helped her hair. That wasn't, you know, she wasn't coming in complaining about it, but of course it helped her hair. And it helped, it helped her mood. So it made a big difference in the depression. So she was started to be more active and move more. And, and then of course we wanted to wean her off of the acid blocker. So, and with the type two diabetes, we also needed to work a lot on her diet also, of course. So wean her off of the acid blocker. So, and with the type two diabetes, we also needed to work a lot on her diet also, of course. So we put her on a low glycemic diet.

We took away all the refined carbohydrates and the simple sugars and, you know, made sure she was getting good quality protein when she was eating and good healthy foods. And with that shift in diet, we've been slowly able to wean her off of the acid blocker. Which is, again, another one of the things we've talked about on the podcast, which is reflux or heartburn. And it's such a problem. These medications are in the top three of all

medications prescribed in the world. And they are very powerful and strong. And they do have this negative impact on causing everything from small bowel overgrowth and digestive issues. They cause irritable bowel, mineral deficiencies, osteoporosis, pneumonia, and so forth. But what's interesting is that the way they're designed makes it almost impossible to get off of them. And you have to know what you're doing. So you have to sort of deal with the causes of what the reflux is, which is often diet. Sometimes it's a bacteria, but then you have to slowly taper it off because there's something called rebound that happens. So you basically stop it and you get a flood of acid and that causes more heartburn. So you really have to know what you're doing.

And people are like, oh, I've tried to stop it. I can't. For those listening, I want you to understand that there is a way to get off of these drugs, but you can't just stop it like that. You have to know what you're doing. And you have to figure out what the cause is. So like you said, you change your diet. She doesn't need it anymore. Yep. Right?

And well, you know, she needed it less and less, but we still needed to wean her, like you said, because there's that rebound that occurs when you've been on it for a long time. So we did have to wean her and use some other things to help with, you know, we used a little DGL. We, you know, we had to use some other things to help her digestion in addition to diet. And we were able to, you know, wean her off of it. So in the long run, her absorption of her protein is going to be better. So her mood is going to be better. So, you know, and of course now her, her blood sugar is getting way much better and she's losing weight and she's feeling happier. You know, it's, it's, it's pretty phenomenal. So, so fixing her gut and giving her some amino acids, that's not something that most doctors will do when someone comes in with

depression or fatigue, but it's really how we, how we approach patients at the ultravolume center. And really the beautiful thing about the model of functional medicine because it can help so many people with challenging issues that nobody can figure out. Absolutely. Absolutely. And it's fun to do. It's so fun. Yeah. It makes the medicine interesting because I remember I used to work in the emergency room for years and I found it really boring. And how can you say it's boring to work in the emergency room? There's all this excitement and this and that i'm like well once you've learned how to the recipe for everything what's the recipe for asthma or back pain or heart attack or stroke or someone who's got you know needs to be intubated or someone who comes in with a fracture whatever dislocated shoulder it's it's

like a cookbook recipe so right then you just look at the nurse and you go heart attack treatment stroke treatment it's like they know it's it's you have to write the orders but it's like a cookbook recipe. So you just look at the nurse and you go, heart attack treatment, stroke treatment. It's like they know you have to write the orders, but it's like everybody knows what's going on. There's no thinking involved. Right. You make the, you know, it's a kidney stone, you do this. And most of the things you see in the emergency room are relatively common and relatively

easy to diagnose. And occasionally there's a puzzling case, but it's kind of boring. And I found that functional medicine is a constant puzzle that you have to figure out. Everybody's different. It's totally personalized. Talk about precision medicine, personalized medicine, precision nutrition, personalized nutrition. That's what we do. That's what this is about. And no two people are the same. And you could have somebody else coming in with depression and fatigue and diabetes, and they could have a different story with different factors and different causes. And I think that's why so many physicians are turning to functional medicine. Because, you know, of course, they have this inquisitive mind, and they want their problem solvers, and they want to look at how all the patterns come together. And I think that's really what has attracted a lot of people to the training, because it's

getting us back to really, you know, looking at that whole person and the individualized person. It's true. I think there was some tech conference out west where they said, you know, functional medicine was sort of one of the leading trends in medicine and healthcare. So I think that's true. Yeah. So you have another case, Liz, of a 50-year-old woman who also had been fatigued her whole life and, you know, been working hard. And tell us about her and what was going on with that, because it was a little bit of a different story.

Absolutely. So she was 50 when she came to see me. And the real reason she came in was her weight. She had started to put on weight, and she was frustrated with it. So she came in because she's like, I want to get some of the weight off. But she also noted that she had significant fatigue. It wasn't fatigue that kept her from working. So she was actually a worker. She was very successful with her job. And then she had worked her whole life. And she sort of pushes through, you know, but more fatigue than, you know, other people

around her. She'd note, you know, even when she said even when she was a kid, she had more fatigue than her friends. And she would want to sleep more and, you know, rest more and not exercise as much. So she noted she had fatigue her whole life. But, you know, over the last few years, it had gotten worse. And, you know, with the weight gain, she said, let me go in. Let's let's let's deal with this.

So she came in to see us. You know, she she's as I said, she works all day. She'd come home. She'd cook dinner. She'd have a couple glasses of wine to calm down and, you know, just got up the next day and did it again. So I thought that was really interesting when you hear that on somebody's timeline, right, that long history of fatigue. Yeah. It makes you think about different things, right?

And so and also hers was like not the level of fatigue. It makes you think about different things, right? And so, and also hers was like, not the level of fatigue. I mean, she still was functioning, but just not at her optimal. So, you know, I started thinking, okay, let's look at her genetic makeup. Let's look at her genetic makeup. So we did a genetic panel that looks at, you know, some SNPs, some variations in somebody's genetic makeup that can influence diseases that they get, as well as influence need for different nutrients or supplements. And so one of the things we found out is that she had a homozygous variation with the MTHFR gene. That's a mouthful. I know.

What is that? Break that down for us. So the MTHFR gene is a gene that encodes a mouthful. I know. What is that? Break that down for us. So the MTHFR gene is a gene that encodes for an enzyme. And homozygous means she has two copies, one from her mom and her dad. She got both. It has a bigger impact in terms of her life. And so that's the methyl tetrahydrofolate reductase enzyme. Another mouthful. Yeah. And that enzyme is involved in methylation or transfer of methyl groups, which is involved in multiple different processes in the body. Everything from detoxification to making your neurotransmitters to energy production.

So it's involved in so many pathways in the body. Yes. It's basically like this process where you take the carbon and three hydrogens, which is called the methyl group. And I think of like the currency of the body where there's all these chemical reactions happening, literally billions of reactions happening every second. And one of the main ones that is going on is this process of called methylation, which is a transfer of these groups. And there's genes that regulate the nutrients that are involved in pathways, the enzymes

that regulate these chemical reactions. Yeah. And so you can have variations in your ability to do that that can have impact on your health. And that's what you're talking about. Absolutely. You know, it's been associated with depression. People who have a homozygous variation of this gene, the MTHFR gene, have an increased risk of depression.

They have an increased risk of fatigue. They have an increased risk of miscarriages, neural tube defects. And so it's significant. There's been a lot of research on this gene. It's very interesting. And it impacts lots of different systems in the body. And that enzyme needs B vitamins. So B vitamins are really crucial for that to all work well. And we know that when people have this genetic variation, they can't take folic acid, that's a synthetic form of folate that's in a lot of supplements. They can't take that, activate it and utilize it. Or even the stuff you get from food sometimes, right? Yeah. Some of the stuff from food too. I mean, a lot of food is naturally methylated, but like a lot of our processed food has had folic acid

sprayed onto it. It's fortified. It's fortified. The body can't really utilize it. It can't activate it and utilize it in the body. And so people, you know- And commercially, it can become toxic. Absolutely. It causes problems. So if you actually think you're doing something good, taking folic acid and you have this problem, you're actually doing harm. Right, right. They're saying that it may build up in your tissue, might increase risk of cancer. There's a lot of things that we're looking at with that.

So we always focus on the better quality supplements that include a better form of folate, the methylfolate. That was really important for her in this situation. We also gave her a good multivitamin, a good B-complex, and we increased the folate in her diet with all the foliage, the folate-rich foods, the green leafy vegetables, but all your vegetables are rich in folate. So we increased those in her diet. And we also dealt with with we cut back on her alcohol, because alcohol uses up your B vitamins. Yeah. So I was drinking two glasses of wine at night to calm down, right? Mm hmm. Mm hmm. You know, a lot of times, you know, people have these genetic

variations, but they can express themselves in different times of your life, depending on what else is going on. So, you know, you know, probably what happened with her is over years of just drinking a little too much alcohol, it became more of an issue because she was wearing down her B vitamins and she needs those B vitamins for that methylation process to occur. So, you know, both of the things came together. She had her genetics and her environment and they made the fatigue even worse. We often see that gene express itself or people have problems when they go to college, for example. So kids that have that genetic variation, and then they go to college and start drinking

more, and then they start having problems with depression. You know, that's a kind of a pattern that we sometimes see because, you know, you've got the change in diet, you know, maybe, you know, not eating as much vegetables, and you're drinking more alcohol. They're making you know, maybe, you know, not eating as much vegetables and you're drinking more alcohol and you've got that genetic variation. And then, you know, you know, there's so many things that come into play, but I think it's important when you look at that timeline that helps us give a, give us those, those clues. Yeah, so true. And one of the other big causes we see is just what people are eating. Like if you're eating a nutrient depleted, ultra processed diet with tons of sugar and inflammatory foods, it tends to cause you fatigue.

We see that all the time. You know, people eating the wrong foods at the wrong time, eating a lot of refined processed foods, causing their blood sugar to spike. And then they, then it drops, not eating enough protein. I mean, there's so much with diet that has a huge impact. And like you mentioned, the inflammatory foods, so foods that may be causing inflammation for that person, gluten and dairy. And so- Those are the big ones. Those are the big ones. And so a lot of times we'll do, one of the biggest tools we have in our toolkit, right, is that comprehensive elimination diet. And it can be really helpful for patients. They work with our nutritionists and get on a really good, you know, try an elimination diet.

And many times patients will say, I started to feel so much better, right, and my energy improved. Over time, if we've got chronic stress for some reason, because of our perception of the world around us, or we're not taking time to take care of ourselves, or we're eating a diet that's really stressful on the body, or we're not getting enough sleep, or we have a chronic infection. I mean, we do see this with illnesses too, like a chronic infection. Those chronic stressful events over time really can disrupt how all aspects of our hormone system works together. That whole HPA axis works and it can get dysregulated. And so that's the whole talk of that HPA axis dysregulation. So it's your hypothalamus,

which is in your brain and your pituitary. So it's all the command and control centers in your brain that then send messages to your adrenal glands that are on top of your kidneys and they produce adrenaline, right? Cortisol, norepinephrine and epinephrine, but also DHEA, which is a hormone that gets turned into testosterone and estrogen and hormones that impact our blood pressure and electrolyte balance. So it's involved in a lot of things. And it's important to recognize that the pituitary also impacts lots of other hormones in our body, our female hormones, our male hormones, and so our thyroid hormones. It's all

really connected, which is interesting as well. So when people are under a lot of chronic stress over time, the cortisol levels are, um, are remaining higher than they should be for long periods of time. And so this is a whole feedback loop, right? This, this, this system in our body is a whole feedback loop. So that high cortisol sort of shifts the way that the, there's a feedback mechanism that occurs. And in a way, the body sort of slows everything down. And so over time, with high levels of cortisol, that are getting released all the time, people start to crash, they have like that what they call burnout, or, you know, their body sort of just slows down, we see their thyroid slow down, we see, we can see other hormones shift, but we definitely can over time, if we look,

we can see a decrease in cortisol levels. So we can do some special tests that look at that. It's so important what you're saying because the stress response is a good thing in the short run, but not in the long term. And we never really had these chronic stresses that we do now. We'd be in threat of danger. We'd mount the response. And it was good. Right now, you're releasing high amounts of cortisol. And it's like a drug we give for people with autoimmune disease called prednisone. Or when you, for example, have a disease called Cushing's disease, where your adrenal glands or pituitary tumor will produce a lot of cortisol that is not regulated by any feedback mechanisms.

And when that happens, you get all these problems, right? You get high blood pressure, you get diabetes, your brain shrinks, the memory center in your brain shrinks, you can get dementia, you have muscle loss. You're more likely to get sick more easily. You get sick, your immune system stops working as well. So you're really likely to get sick more easily you get sick your immune system stops working as well so you're you're really accelerating all these age-related diseases and you're also suffering from flc syndrome which is basically when you feel like crap so so let's let's drill down into some of the symptoms that people who might have this dysfunction get. Absolutely. So, you know, a lot of times people will, you know, people with HPA axis dysfunction, they'll say, well, you know, I have a good night's sleep, but I still feel tired in the morning.

I can't get going. Or other people, depending on where they are in this whole process, they may feel like they're anxious all the time. They can't calm down. They're tired, but wired. And they're just, you know, really feeling anxious. You get. They can't calm down. They're tired but wired and they're just, you know, really feeling anxious. You get into bed and you lay there, you're tired, but you can't fall asleep. Yeah. I've been there.

You know, they can have a hard time dealing with the stress of everyday life. They can feel more depressed or irritable. Things that they used to be able to do really easily are hard to do. So things that they, you know, their job maybe, or handling going to the grocery store even, you know, things that used to be really easy to do every day become tasks for them. They feel overwhelmed and exhausted. And they might get, as I said, sick more easily. You can have more cravings for foods. You're looking for things to pick you up, right? So sugary foods, salty foods. Can you have cravings for them?

You might feel more fatigued when you stand up. You get more tired. You might have low blood pressure over time and low blood sugar over time with an underactive HPA axis. So... Yeah, and it's often the syndrome I see of tall, thin women, which is really common where they get sort of adrenal burnout. They get low blood pressure, so dizzy when they stand up.

They crave salt. They have anxiety. They have palpitations. They tend to get hypoglycemic. So their blood sugar actually is not coming up when it should. And so you can kind of pretty much tell that this is going on with people. But what's interesting is, it might be worth breaking down, is that adrenal burnout, let's just call it that, comes in stages, right?

Absolutely. So the first stage is, tell us about the first stage and how it progresses to full burnout. Because the symptoms and the treatment are a little different for each one. They are a little different. So at first, when you've got that overactive adrenal gland, it's the beginning, let's say, of just handling all this chronic stress. People feel that wired and tired. They're like anxious. They feel like they just can't calm down. They feel upregulated inside. And then over time, what can happen is with having that chronic levels of high cortisol, what can happen over time, as we talked about with that feedback loop,

they get a decreased level of cortisol that occurs. So initially, you'll see high levels when you do the testing. And we'll talk about the testing in a minute. And then you see this flat line. And when it's flat line, what it feels like is burnt out. You just feel exhausted. You can't get going in the morning. You're getting sick more frequently.

That's when you see a lot of low blood pressure low blood sugar you know salt cravings but just you know literally you feel that burned out you know you're exhausted feeling so one is like chronically high and there's like chronically low and there's kind of an in between where you get low in the morning and high at night so you're exhausted in the morning but you can't fall asleep at night because you're more yeah it's like circadian rhythm is all screwed so that's what we do differently than than what you than what conventional doctors often do. So let me tell you. By the way, this isn't even a diagnosis in conventional medicine.

No, really, like you were saying, if somebody has really low cortisol or really high cortisol on blood testing, they'll call it, it might be Cushing's or Addison's or a very serious adrenal issue. And we were taught about that in medical school. But we weren't really taught about these situations where if you did a blood level first thing in the morning, it probably would look okay. And you wouldn't really see a lot of abnormalities in the blood testing. But if you look a little deeper and you do saliva testing and you check saliva four times in a day, and you can check saliva for cortisol when you first wake

up in the morning, they call that the cortisol awakening response. What we should see with that saliva testing is that when you first wake up in the morning, your cortisol increases. It's almost like a stress test for your adrenal glands. The cortisol awakening response is like a stress test for your adrenal glands. Getting up in the morning is a little bit of a stress for the body, right? It needs to get going and wake up. And so what we typically see is the cortisol increase first thing in the morning. And that's a good thing. We want to see that. That means that the system's working well.

And what we see is the cortisol levels in the beginning of the day are higher. And as the day goes on, they come down. So when you check somebody's saliva tests during the day, we should see it go up when they first wake up in the morning and then start to come down as the day goes on. And that's a very normal pattern. And what we were talking about is over time, if people have a lot of stress and anxiety going on, you might see high levels of cortisol. And then over time, you might see that it starts to flip where they're low in the morning, but too high at night. And then if things really go on for a while,

you might see a low level of cortisol throughout the whole day. And it really gives us a lot of information about how best to treat somebody and how best to take care of them and what they need to really focus on. This is something you wouldn't get at a traditional doctor's office. They're not going to look at your salivate cortisol levels. They'll say, oh, you have Cushing's and there's tests for that or Addison's and there's tests for that. But short of these two extremes, and that's what's so different about functional medicine. It's really about this continuum of dysfunction. It's not just on or off.

It's not like you have diabetes or you don't. Right, like you have high blood pressure or you don't. It's a gradual worsening over time. And those diseases are very particular because they're either a tumor, which is Cushing's, or they're an autoimmune disease, which is usually caused by gluten, the Addison's disease, which is what President Kennedy had, actually. And it certainly, I'm sure, affected him. So when you have these patients come in, you do this history, you find these symptoms,

you sort of hear their story. How do you start to approach correcting this? Because I found, you know, some things are really easy in functional medicine. Someone has, you know, bacterial overgrowth, or they have gut issues, irritable valve, one, two, three, it's fixed. This takes a little bit of time because of the amount of stress we've put on our adrenals. We have to constantly try to build them back up over time. And it takes a little bit of time to recover. Yeah.

I mean, I think what's fascinating is, and what we realize is the body has this tremendous ability to heal, right? And we, this is an area where our body can heal. We see it heal all the time. It just sometimes takes a little TLC and some care. And that's where, that's where the lifestyle factors really, really make a huge impact. You know, we work with people to, to really balance their, their diet and focus on nutrition. And we can delve into each of these more, you know, we work with people to really balance their diet and focus on nutrition. And we can delve into each of these more, you know, getting good sleep, resting. Resting's important, right? We need to give our body time to rest.

And, you know, we're living in a world where it's hard sometimes to turn it off and people aren't. And so they're really having issues because of it. So we have to help them rest and recuperate and get in their regular meditation and breath work and take time for themselves and turn off the lights at night and turn off the computer and the cell phone. And diet makes a huge difference. There's so much we can do.

Wait, wait. Before you get into diet, let's go back to what you just said. Because the light thing, the computers, the screen screen it's not just that they're distracting there's a biology around your adrenals that has to do with something called your circadian rhythm and it requires certain types of stimuli at certain times of the day and and different kinds of stimuli at the other times of the day so in the morning the way to get going with your circadian rhythm and your adrenal glands to properly function is to have sunlight for 20 minutes in the morning which how many of us actually do that yeah and get outside and the same thing at night if you are stimulating your eyes with bright light that isn't, have all the blue filtered out, which

is you can see blue, black glasses, or just getting off screens, you will actually stimulate more awakefulness and you will suppress cortisol. Because like, I mean, suppress melatonin. Yes. Right? Because in the morning you wake up and you see the sunlight, well, your melatonin levels go down, so you don't feel sleepy all day. But if you're having light at night, it actually keeps the melatonin down, so you can't fall asleep. Yeah. I mean, so circadian rhythm is critical. And we're going

to touch on it with one of the cases I have because, you know, we'll get into it in a minute, but she was working more in the evening shift. And I think it really is hard for a lot of people with depending on the shifts that they have to work. But you mentioned that, you know, getting up in the morning, getting outside, getting that sunshine helps for so many reasons. It helps our mood, it helps us fall asleep more at night, and it helps us, you know, our body likes to have regularity and rhythm. And I think that's one thing we really work on with people when they're really struggling with this is getting them in some pattern and rhythm. And I think that's one thing we really work on with people when they're really struggling with this is getting them in some pattern and rhythm of, you know, getting a

good sleep cycle, getting a good eating cycle, you know, not grabbing and going, you know, not skipping meals. I mean, there's a lot to be said for fasting. You know, you've done a lot of podcasts on this, and there can be really a lot of great things with fasting. But sometimes when people are really, when their HPA axis is really underactive and it's not working very well and they've got the signs of burnout or adrenal dysfunction, right? We, fasting sometimes for too long can be more stress on their body. Or some extreme diets can be more stress on their body. Or some extreme diets can be more stress on their body. And they might not be at a point where they can do it,

they can feel good with it, right? They can't get all the benefit from it. So they can still fast for 12 hours, but we might not be fasting them for 16 hours or 18 hours during that time. Well, it's really important what you bring up about food because there are certain foods that actually cause stress in the body independent of your thoughts. And there are certain foods that reduce stress in the body independent of what you're thinking, right?

So it's actually food can be a stressor or a relaxer depending on what you're eating. Can you talk about the foods that tend to cause more cortisol, adrenaline, and stress in the body? And then some of the foods that we would be thinking about that might help reduce that. That's such a great point. You know, if we eat a donut with coffee and sugar, I'm going to an extreme here for breakfast, right?

It's not that extreme. It's probably the breakfast of most Americans. Dunkin' Donuts or coffee. That is really stressful on the body, right? Why? Because it causes this spike in our blood sugar because it gets digested and absorbed really quickly. Our blood sugar goes up quickly and the body goes, oh no, right? It gets stressful for the body. The body produces a bunch of insulin to help lower it. And then what happens is the

blood sugar drops afterwards. And so those ups and downs in blood sugar like that are really stressful for the body. And when the blood- If your blood sugar is dropping, it's a life-threatening emergency. You've got to go get food. Right, right. So those, you know, if you're eating a lot of foods that cause your blood sugar to go up and then drop with, you know, those easily to digest and absorb. You know, you have a can of soda. I mean, we're, you know, those things really are stressful for the body. They create this stress. They create the cortisol response. It's one of

the reasons we get a lot of weight gain around the belly when we eat those kinds of foods, because they are stressful for the body. And so instead, we want to be really balancing our blood sugar. And before you get into how to be really balancing our blood sugar. And before you get into how to fix it, I just want to point out this study that was just so mind-blowing when I read it years ago by a friend of ours, Dr. David Ludwig from Harvard. And he took kids that were overweight and fed them three different breakfasts, right? Oatmeal, steel cutouts, and omelet. Same calories, okay? Same calories, but different carbohydrate, protein, different fat.

What he found was that the kids who had the regular oatmeal, like the quickly absorbed oatmeal, we think oatmeal is healthy, right? It's not like you're having a donut. Their insulin went up, obviously their blood sugar went up, but their cortisol went up, their adrenaline went up. So the body perceived it as a stress. Yes. Whereas the kids who ate the omelet didn't happen.

Yes. And then the kids who ate the oatmeal were hungrier, wanted more food. So we know that starch and sugar create a biological stress response in the body. And that's bad. In addition to the fact that the sugar causes a problem, your brain chemistry and your

neurotransmitters are talking to your fat cells. And they're telling them when they're under stress to store more fat. So literally stress makes you gain weight independent of what you're eating. So it's really, it's fascinating when you look at weight and other issues. It's so connected. It's so connected. It's so connected. It's fascinating. So really balancing blood sugar is so powerful.

People, sometimes we say these things again and again, like balance your blood sugar, have a good source of protein, healthy fat and fiber at each meal. And sometimes we say it so much that I wonder people just, oh yeah, it's the same thing. They're just saying eat healthy. But it's really critical to have a good source of protein, healthy fat and great source of fiber at every meal because it's it's it is not allowing for that stress response to happen in the body. It's it's nourishing the body. And that's exactly what the body needs. So. Yeah. And so I think, you know, using food and having the right quality fats, low glycemic diet, lots of fiber, phytochemicals,

these are all messenger molecules that help reduce the stress in the body. Yes. So, you know, so we always start with food first, and this is a great place to start in this area, you know, really working to balance the blood sugar, preventing those spikes in blood sugar, preventing that stress. We often work to pull people off a caffeine for a period of time. You know, if they're in that state where they're really anxious, they don't need the caffeine. If they're in that state where they're burnt out and exhausted, they might feel like they need the caffeine, but that's actually, you know, a little bit of a stress for their body. And so when the adrenal glands or the whole HPA axis isn't able to handle that stress at this point in time, you don't want to add to it.

So we often will pull people away from caffeine or really lower their levels or keep it to a little bit of green tea and, and just not excessive amounts. How about alcohol? Is that going to relax you? Or is it going to cause a problem? You know, I mean, so, you know, it's really with alcohol, it's all about moderation, right? It's really all about moderation. We know that too much alcohol is going to wake us up in the middle of the night. We know that when it wears off, it's, you know, alcohol is a depressant. When it wears off, we get that rebound stimulating effect. We really need to be working on sleep during this period of time, all the time, but we need to get good restful sleep. So we just have to watch the amount. I mean, that's really, really important. And so for some

of our patients, we take them off of most of the alcohol for a period of time. And it also wears down your B vitamins and B vitamins are really important for- So when you drink, you deplete your B vitamins. That's what you're saying. Yeah. And B vitamins are critical for the- So when you drink, you deplete your B vitamins. That's what you're saying. Yeah, and B vitamins are critical for the functioning of our adrenal glands. So things that you might've been, you know, people will say to me, well, I've always had two cups of coffee in the morning

and it's been fine. You know, why can't I have two cups of coffee now in the morning? And, you know, when you get to that exhausted, burnt out stage, that's just too much for your body at this period of time. You know, we just have to be a little more gentle. Yeah, I think that's absolutely right.

And I also think what you said before, I want to come back to, because it's such an important point, we jumped right over it. You said something that I think is worth underscoring, which is that infections or any physical illness can cause a stress response. Yes. So let's say you have Lyme disease or you have a virus or whatever. Independent of all your thoughts or feelings or perceptions, it can cause a stress. And there are certain foods that drive inflammation that cause a physiologic stress response.

So anything in the body that causes inflammation, either your thoughts, which can cause inflammation, or gluten or dairy or food sensitivities or sugar, all these can cause a stress response. So sometimes getting rid of not just the junk food, obviously, and the sugar, but actually potential food sensitivities or gluten, dairy can be enormously effective. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introduce to you all the experts that I

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