Ancestral Health Symposium ‘18 Recap [transcript]

Written by Christopher Kelly

Aug. 29, 2018

[0:00:00]

Christopher:    So, Tommy, just tell us everything you just told us in the kitchen here at Bozeman, Montana. We're here for the Ancestral Health Symposium 2018. There was a very interesting conversation going on in the kitchen about coffee. Can you repeat everything you said?

Tommy:    I can try. Megan asked about the type of decaf coffee that you want to get if you're drinking decaf coffee. It's called Swiss Water Decaf. The main reason you want to do that is because the cheaper decaf versions like what you might get at the commercial coffee bars, they use a variety of solvents to dissolve out caffeine, things like hexane. You don't really want that in your coffee. Most of it evaporates but there's still going to be some in there.

    The difference with Swiss Water Decaf is an interesting process. They basically take the beans and then they dissolve out pretty much everything with water. They remove the caffeine with, I think, it's carbon-based filter. They dunk the beans back in, what's left, and let it soak back into the beans. You'll definitely lose some other stuff and there'll be slightly different flavor profile.

Christopher:    What will you lose?

Tommy:    You'd just lose some of the polyphenols and other things that are in the coffee because it's not just caffeine that's going to be absorbed by the filter. Instead of whatever it was that came out of the coffee originally, they might use some polyphenols and stuff that came from another batch of coffee. There's a mixture of things that end up getting soaked back into it depending on who's doing it, depending on the coffee.

    But if you're thinking about some of the health benefits of coffee, which there certainly seems to be some, again, you have to look at epidemiological studies, but there's certainly no detriment and there seems to be a signal that suggests benefits. The largest study that I've seen on it just came out, a UK Biobank study, and people drinking up to six cups of coffee a day seem to see a reduce in all cause mortality or associated with the reduction of all cause mortality. That was regardless of the kind of coffee that they were drinking. That's decaf or instant coffee or regular coffee.

    You might say, well, the people drinking instant decaf coffee is probably full of all the crap that they use to decaffeinate it, all the stuff I mentioned earlier, and they still saw benefits, so that's a good point. But if you're trying to reduce your overall exposure to whatever it is out there then the Swiss Water probably is the best way to do it.

Christopher:    Why? Why would I want decaf in the first place? I've always thought of decaf coffee like alcoholic free beer. What's the point?

Tommy:    I remember my dad saying something about decaf tea. It's like sex with a condom. It's good but it's just not the same. That's a good point. But I really like coffee but I also know that if I drink a lot of caffeine it affects my sleep later in the day. I enjoy the flavor. I enjoy the process of making it. And so then decaf coffee gives you most of that.

Christopher:    This is where you really need to get into individual variability. It's up to you. You can't look to an expert to get the advice. You have to do your own experiment.

Tommy:    And there's definitely variability in response based on genetics. There's a number of different enzymes that metabolize caffeine. CYP1A2 is the one that people look at the most and there are snips in that that change how fast you metabolize caffeine. Traditionally, we thought that you can see in the literature that caffeine is ergogenic. It improves performance in a number of different -- both in terms of strength ad in terms of endurance.

    When they've redone those studies recently, there seems to be a greater effect in people who have the fast metabolizing gene of caffeine, at least when you're giving caffeine like an hour or so before. That's probably because some of the downstream metabolites of caffeine are involved in the process of improving performance. It isn't just caffeine itself. It's the metabolites and you're getting these metabolites faster.

    They're still figuring that out. It's just a couple of studies that just came out about the one that's looking at resistance training while looking at endurance performance and both seem to show a greater benefit in the people who have two copies of the fast metabolizing gene.

Christopher:    Interesting. I'll get the snps and I'll post those in the show notes along with the references for that so that people -- I know you can do that in 23andMe. You don't need to order a fancy report. You can just look that up.

Tommy:    Yeah. Actually, 23andMe tells you about your caffeine metabolism.

Christopher:    Right. Okay. We'll talk about the Ancestral Health Symposium then. Let's get into it. So, the first person I saw was Dave Feldman talk about cholesterol. I'm going to ask Megan. Megan, what do you think of Dave Feldman and his ideas on cholesterol?

Megan:    I think Dave is very smart. I know he's been on our podcast before. I know we have link to that.

Christopher:    I'll link to that.

Megan:    Yeah, for sure. I would encourage our clients who are concerned about high cholesterol to definitely check his work out especially on what's it called, the lean mass hyper-responders.

Christopher:    Which is basically going to be -- I don't know. I don't really know anything but I'm guessing it's going to be a lot of people listening to this podcast will be interested in Dave's lean mass hyper-responders.

Zach:    He has three criteria. You have to have an HDL over a certain amount, triglycerides under a certain amount and then LDL over a certain amount.

Tommy:    And this is after transitioning to a low carb or ketogenic diet. Specifically, lean people, very active, who run a low carb or keto diet who saw an increase in LDL but everything else improves. HDL went up, triglycerides went down.

Christopher:    Yeah. I really enjoyed Dave and his determination and focus. I heard him do the first version of that talk at Low Carb Breckenridge, which is a couple of years ago now, isn't it?

[0:05:02]

    And that wasn't even new then. I probably heard him on a podcast before that, actually. The central message has stayed the same but he's just gotten better and better at doing that talk and collected more and more data. Somehow, he's resisted the temptation to diversify into other things. I don't know. If I was him I would want to talk about something else by now and he hasn't done that. I think his message is just getting stronger because of that. But maybe you disagree. Do you think it's important?

    One of the questions I have is like why does he keep talking about this? If you listen to my interview with Malcolm Kendrick and you agree with everything that Malcolm said then you would agree that blood levels of cholesterol have no effect on cardiovascular disease. I thought that was why we were interested in cholesterol in the first place. If it's true that cholesterol levels have no effect on cardiovascular disease then why the hell are we still talking about cholesterol?

Tommy:    In that specific scenario, when you're on a very low carbohydrate diet and most of your calorie is coming from fat, what his data seems to show and his hypothesis which is borne out, and he's shown me the data, I've done the analysis myself and they definitely agree with what he's shown, it's an energy distribution network essentially. The particles that we're measuring secreted from the liver, so they come initially as VLDLs and then they become IDLs and then they become LDLs. That's what we're measuring.

    When you're measuring LDL cholesterol, it's the cholesterol in the LDL particles but actually most of what that particle was carrying around was triglycerides as fat. There's a mix up in terms of what you're really thinking about there. When you're in that scenario then the amount of calories that are driving it really, the total number of calories that you're eating, if you are running on fat, say most of your metabolism is fat-based, if you're eating a lot of calories as fat, then they will circulate as chylomicrons from the gut and the tissues can just take them up like that.

    However, if you're calorie restricted, fasting or just not eating very many calories from fat, then the body needs to make up for that. VLDL is secreted from the liver instead and they go and circulate around the body. The main way you measure that is the LDLs. They have the longest circulation half life of that whole pathway.

    The LDL goes up as your calorie or your fat intake goes down because the body is compensating, is creating packages of fat to be sent around the body to be used as energy. But if you ate a load of fat your LDL would go down because you don't need to do that. You don't compensate for it. There's like a base line effect. You always have some LDL. And it's interesting because from the data I've seen that he sent me both his and other people's, the high your LDL is to start with on a ketogenic diet the more it will drop down as you add a lot of fat to the diet.

    It's not perfect but it definitely seems to be that that's the pattern. It makes a lot of sense. But as soon as Dave starts adding carbohydrates back to the diet, the picture is completely different. That's something that he's working on now. I won't talk about it. He's definitely in that specific scenario where most of the metabolism is fat-based.

Christopher:    And can you expand a bit more? Dave mentioned that he'd been working on a paper with you. Can you talk a bit more about that?

Tommy:    He's mentioned it in public now but, basically, his original pattern, the inversion pattern he calls it, which is just that, so somebody who's on a ketogenic diet, their LDL went up, both him and some other people and then he's now, I think, he's had hundreds of people sent him their data. Basically, if they add a load of fat to the diet, they'll see a decrease in their LDL cholesterol.

    We're writing a paper with his data and a couple of other people who sent him data that's really high quality so we know exactly what they ate, when they ate it and they have multiple blood tests, like he does. Not as many. But rather than -- A lot of what people have sent him are just a bit too messy to publish just because it's people doing it on themselves at home, which is fine, just to show yourself the pattern that it's replicating in you. That's enough to do it. But to publish it, you need a bit more stringent data collection.

    So, where we have that data collection and we have really good information on what people had been eating and how LDL has changed then they'll go into the paper too and we'll just discuss that initial pattern.

Christopher:    Have you any idea where it will be published? Will it be peer-reviewed?

Tommy:    Yes, it will be peer-reviewed. I think I'm going to submit it to online open access journals that are freely available and also free to publish in a couple of those. And the benefit of those is that as soon as it's published, people can read it. Dave is very interested in people seeing all his data, seeing all the working. He doesn't want the whole kind of peer-review behind hidden doors.

    There are some papers where the peer review is also open access. Like the peer reviewer, you can see the review that they wrote so you can see the whole process. So, we'll probably publish it in a journal like that because then everything is out in the open and Dave is very keen for that to be the case.

Christopher:    That's great. It's a great team, don't you think? Zach, do you think that's -- You love that idea of you're a practitioner, you're collecting data and you're seeing what works. You don't necessarily have the time or skills to write something up and get it published. And, therefore, maybe nobody else learns about what you know so having Tommy come in and do something like that, would you be excited about publishing some of the things that only you know but you've not seen in a journal?

Zach:    Oh, yeah, definitely. I don't know. That's one of the reasons why I really like Dave because he is doing this, experimenting on himself and then just seeing all the data he is collecting. I think it allows people to experiment on themselves a little bit more, give themselves confidence to try different things. I'm just excited to see that get out.

[0:10:16]

Tommy:    Yeah. I know he's had a lot of -- even doctors and scientists say, "You need to publish a paper so I can reference it in my paper."

Christopher:    I can't reference your blog.

Tommy:    Yeah, exactly. You can't reference the blogs. That's just part of how science works. That's why I'm really passionate about helping people publish this data they have so that other people can see it and it's considered real science rather than just something a guy wrote in a blog, which is interesting, but it doesn't have quite the same credibility.

Zach:    Yeah. And when I have clients ask me it's not very credible to be like, "Oh, go read this blog post. This will explain everything." But now having a paper or something published, it seems a little more real to them and that gives it more credibility.

Christopher:    Did anyone see Ivor's talk? Ivor has also been on the podcast that I can link to in the show notes. I think we all went to see Dave.

Tommy:    We all went to see Dave, yeah.

Christopher:    Sorry, Ivor. I think the reason I really believe in Ivor's message, if you don't want to die of cardiovascular disease then listen to Ivor. I think that's really -- and the book is great as well. I've interviewed Jeff Gerber as well on the podcast.

Tommy:    And I interviewed Ivor.

Christopher:    That's what you need to understand, if you don't want to die of cardiovascular disease.

Zach:    Well, I've always been a big fan of his message but this was the first time I met him and he was just -- he's a great guy.

Christopher:    He is a great guy.

Zach:    He is super friendly, funny. So, it's really neat to me.

Christopher:    I think all Irish. Is that a sweeping generalization? Is that casual racism? I always think that all Irish people as being like that.

Tommy:    He is also very no nonsense. Like somebody will say something that he thinks is bullshit, he'd be like, "No, that's bullshit."

Christopher:    Yeah. He doesn't -- there's no ruinous empathy from Ivor.

Tommy:    Apparently, he's been blocked by Peter Attia on Twitter because he keeps on coming up saying, "Okay, can you please tell me how LDL causes heart disease? I have all these papers here which disprove it. There are all these other examples where it's not the case. Can you please explain the process?" And he just got blocked.

Christopher:    Do you know why he blocked him? It's because he can't explain that process. There isn't one. Let's talk about Tim Gerstmar. Tim Gerstmar is also someone that's been on the podcast a couple of times and I very much enjoy Tim's work. in fact, I very much remember his 2014 presentation in Berkeley on methylation. I thought it was interesting that Tim's presentation this year was much, much more basic.

    He wasn't talking about fancy blood test that needed to be sent to Germany for some sort of analysis and then you found the least metabolites of fat -- It was so niche and so complicated and he went back to the basics of diet and lifestyle. I don't think I really learned anything from that talk but I just thought it was really interesting that he'd gone back to those basics.

    I stood up after the talk and asked him a question, "Hey, Tim, I don't want to ask you about this talk. I want to ask you about your 2014 talk. And the reason I want to ask you about that 2014 talk is because I feel like the longer information is around the longer it's going to be around. It's anti-fragile." I got this idea from Taleb and the Lindy effect, if anyone is familiar with that.

    "And so if you're still doing 23andMe tests and looking at people's folate cycle or that fancy blood test that needs to go to Germany then that, I think, is even more valuable than it was even in 2014. That tells me that it stood the test of time." And I don't think that Tim is still doing that fancy blood test. And it's interesting to know that he's getting back to the basic diet and lifestyle stuff which I'd say is also the core of our program. Did any of you guys pick up anything? Anyone?

Zach:    I like his honesty about -- I mean, he gave some statistics on his success rate with autoimmunity because a lot of people get up and talk, they tend to be like this is going to cure everything and this just access this one or two things and you're going to be cured. But he gave some statistics on how many of his patients succeed with maybe just diet and things like that. I thought that was helpful information just to give people some realistic expectation.

Christopher:    What do you say to people, Megan, with someone, a client comes to you and he's got Hashimoto's thyroiditis and I've heard about this autoimmune Paleo thing? Will that cure my Hashimoto's? How do you manage expectation in somebody that -- I'm assuming they have said something like that to you because they've said something like that to me.

Megan:    I think typically what I do is I say, okay, we're going to start with the foundation just like Tim talked about. And if we don't have those foundations in place, including something like that AIP diet, then looking at thyroid antibodies and saying, "Oh, well, mine are 300 still," if you're still missing one of those baseline foundation pieces then we need to go back to basics.

    But then as far as expectations are concerned, I think that's going to be very individual and also what was the trigger for this person? Was it an environmental thing? Was it a leaky gut thing? Was it something else? Whatever caused the autoimmunity in the first place is probably going to be a large part in their recovery.

Christopher:    And do you think it's reasonable to expect that you will cure it? Will I ever do a blood test where I see no elevation of any of the thyroid antibodies?

Megan:    I'm doubtful. I have heard of that happening before.

[0:15:01]

Christopher:    But how do you feel about thyroid antibodies above 500? Would you be happy to send home a client with a low gluten diet and a Nietzsche quote as long as their autoantibodies are 500 or below, Tommy?

Tommy:    It's really complicated. This is something that I've been discussing with people offline and there'll be a podcast in the future. What I can say is that there's definitely been some discussion and a lot of it comes from Michael Ruscio who people know about how focusing on specific lab tests especially when it comes to thyroids, so antibodies above a certain level people get scared about or TSH above a certain level people will get scared about and how people get fixated on the lab result and it can be very scary to them if they think there is something bad going on and they haven't been able to fix it yet.

    Pushing back against that, I think that is really important. You are not your lab test. There's a whole other stuff that's really important to take into account particularly just quality of life and how you adjust and improve your environment and your interaction with others. That's much more important than a given lab test.

Christopher:    Right. The blood test is a means to an end, not an end in itself. You have to be really careful because if you do enough blood tests you will find problems and then you can't let those define your wellness. Your subjective experience at the end of the day is what matters.

Tommy:    Absolutely. But the one thing that I would say in terms of there's definitely a risk. The other side, there's a risk of normalizing sickness. We get to a point where the normal ranges for most things -- we talk about this many times -- the normal ranges are based on the population that's pretty sick to begin with. With saying, "Oh, yeah, don't worry about this," at some point you're basically diluting the health within the population because you're not focusing on things that you could focus on.

    There's definitely two parts to it. The way that we approach things, we probably have stricter ranges for most of the stuff that we look at. But it's not that we get hyper focused on the number itself. It's what is this number telling me about the physiology of the person in front of me. It should be part of the bigger picture. What processes are going on that I can think about that I can maybe try and work on?

    That's very different from saying you need your antibodies to be under this or your TSH to be under this. But if they're not under that, what can that be telling you? One of the benefits of the way that we work with clients is it's a very high contact process. We can spend a lot of time talking about these processes. We don't have to have a half hour consult where we scare somebody about their TSH or their antibody levels. We can actually talk about the underlying things and why we shouldn't be focusing on that but also what it could be telling us.

    I think there's definitely risks of scaring people with specific ranges that they should be in, if they're not in then they're not healthy. But on the other side, there's also a risk of normalizing sickness and as the population gets more and more sick we're really at risk of that. That's the kind of thing Ken Ford talked on the podcast, about the changing grip strength particularly in males in the last 30 years.

    They said, the summary of the paper was we need to re-change the normal range for grip strength. They're like, "No, no, no, no. We need to go back and make people get back their grip strength." It's not that. You shouldn't be normalizing the pathology of the fact that people don't pick stuff up with their hands anymore. There's multiple ways to combat it and I think that's one thing that we need to be mindful of.

Tommy:    It's so curious, isn't it, when you see a conclusion that you totally disagree with. You've got to the point, you've seen the data and you've got your own conclusion. I mean, when I see data like that, I think, well, perhaps we should be sending more children to forest school. That's why Ivy goes to forest school and they're swinging from trees all day long. Guess what? I bet her grip strength is nothing like kids that have done something where they're indoors, sat at a seat all day long.

    But then that would be my conclusion. But, obviously, the authors of the paper thought of something very, very different. It's a curious thing indeed. Well, let's move on to age-related macular degeneration. Tommy, did you see that talk?

Tommy:    No. I was in a different talk.

Christopher:    All right. Let's talk about the talk that you did see then. You saw the gut-skin access scientific evidence and integrated approach to testing and treatment.

Tommy:    You were there, Megan, too, weren't you? What do you think?

Megan:    I thought that was a great one. This lady is an MD PhD.

Tommy:    Lucy Maling.

Megan:    Yes. She talked about specifically how the gut-skin access can go fat to skin and also there's some evidence for skin to gut. Lucy also had a poster on athletes and the gut which was another interesting topic.

Christopher:    That's why I was confused. I thought she was going to talk about athletes but she didn't.

Tommy:    She had a talk and a poster. I think she's been -- Part of her PhD has been researching mainly the effects of exercise on the gut microbiota, I think it's what they wrote down.

Christopher:    Did she talk about any specific skin condition or was it more of a general hypothesis?

Megan:    No. She talked about specific autoimmune skin conditions, eczema, psoriasis, acne as well. So, definitely a broad range of conditions. They were the typical diet and lifestyle things that we talk about and some specific Lactobacillus reuteri strains that could potentially be helpful.

Christopher:    Okay. We see that all the time. You feel like, and I feel like I see that just out and about in the street that maybe someone's skin is a good proxy for what's going on in the gut, don't you think?

[0:20:02]

Tommy:    Well, they're connected. Essentially, it's a continue -- No, no, but it's a continuous layer of cells essentially from the outside to the inside of the gut.

Christopher:    That's amazing. I never thought about it like that. I mean, that was my experience. I used to have a ton of acne. And Julie did as well, actually. Yeah, you fix your gut and all that just goes away. Years of antibacterial face soap and antibiotics and like, oh god, it's like you've gone completely wrong way about trying to solve this problem.

Megan:    Yeah. And the other thing that she talked about as well was the stress connection. We know that there's the gut-stress connection and there's also definitely a skin-stress connection through that gut mediated.

Christopher:    You got some exams coming up and you suddenly break out. Super interesting. Which talk did you see, Zach?

Zach:    I saw the Lucy one. You guys have been talking about the gut-skin access. I actually came in a little late on that one so I missed the first part of it. I don't know if I have much to add to what you guys said. I was going to bring up the stress connection like Megan brought up because that's so important. I think people overlook that a lot. Yeah, I don't think anything to add beyond that. I thought she did a good job. Didn't you say, Tommy, that you are approaching her about getting on the podcast, at least to talk about the training and the gut?

Tommy:    Yeah. I spoke to her a little bit because, obviously, some of the stuff that she was talking about are the stuff that we're very interested in. I'll get her on the podcast.

Christopher:    Okay. So, age-related macular degeneration. I felt this is probably a theme of the ancestral health symposium and maybe of marketing in general. That sounds derogatory already but let me continue. You can't just turn up and say, "Oh, this ancestral health thing is going to fix every problem known to man." You have to show up and talk about something specific. In this case, it was age-related macular degeneration.

    And then the rest of the talk feels the same. Oh, we introduced white flour and sugar and then suddenly age-related macular degeneration was a thing. This presentation was a lot of correlation, showing people in Sub-Saharan Africa that had a naught point something rate of age-related macular degeneration. In fact, he presented some evidence showing that hundred years ago it had never been seen. It was like five cases in the literature.

    He was adamant that the apparatus to see it had been around for a long time. And then suddenly there was this explosion and he showed lots and lots of correlations to the point where I got bored of the correlations. Can you just tell me about the mechanism? And then especially when he talked about how Africans might have been taken out of Africa and taken to Barbados where they then started consuming lots of white flour and sugar.

    I'm scratching my head saying, "I don't think those people went there through choice, right? Weren't they dragged there on a slave ship?" I mean, I'm not historian and I don't really know anything about it but I think there might have been a little more going on than just white flour and sugar. And so that one-dimensional view of the world, I don't really enjoy.

    I'm sure he's right. He has the right answer. But at some point, you have to explain the mechanism. I actually left the presentation before I heard all the questions but that was -- Lynda Frassetto, who's also been on our podcast, actually. She's a kidney doctor, a nephrologist. That was her first question. It was like: Well, this is very interesting but can you explain the mechanism to me? Because at the moment I don't understand it. Yes, super interesting. People didn't get age-related macular degeneration. And then we had white flour and sugar and then suddenly we did.

Tommy:    That's the only thing that's changed.

Christopher:    That's not the only thing that's changed. But, yeah, it was still interesting. It gives this hope for the future that maybe all this stuff that we're doing, we won't get -- I mean, they're talking about 20% now of western population get age-related macular degeneration. So, quite terrifying. It gives me hope for the future too. Okay. So, where should we move on to from there? What about sun avoidance is as dangerous as smoking, an evidence-based review of sun exposure's impact on health? Megan, I know that you were in that talk. Can you tell us about what you learned?

Megan:    Dr. Ruscio talked about specifically cancer and sun exposure, which was interesting. I think in the future we'll definitely have more literature that comes out that shows not just physiological cancer related and disease related benefits of sun exposure or lack thereof but also specific mechanisms like nitric oxide production that's coming from being out in the sun versus not.

Christopher:    So, Michael has also been on our podcast recently. Did he talk about nitric oxide production?

Megan:    Not to my knowledge.

Christopher:    At this point, I feel like vitamin D is perhaps the least interesting thing about sunlight. We need to do a whole other podcast on the alternative benefits of sunlight although we've talked about many of them already on the podcast. It has to be said.

Tommy:    Yeah, two years ago.

Christopher:    Okay. Let's move on. I listened to Todd Becker's talk on hormesis and Todd Becker has also been on the podcast. You can tell that I launched the podcast in 2014 by going to the Ancestral Health Symposium and asking all those speakers if they would be in my podcast and graciously most of them agreed. I very much enjoy Todd Becker's thoughts on hormesis.

[0:25:02]

    This is the idea that a little bit of what doesn't kill you makes you stronger. And that many modern diseases are, in fact, a deficiency of these small stresses. And so he talked about hot and cold. He talked about light and dark. He talked about strength, of course, and rest. He talked about plant compounds that can act as hormetic stresses.

    I know in the past he's talked about even ionizing radiation as a hormetic stressor. Really interesting stuff. He's got fantastic blog getting stronger. Clay, can I rotate you? We actually got more people than microphones. I want to rotate Clay in here because I know that Clay is a big hot and cold guy. You've actually been to the XPT Life thing, haven't you?

Clay:    So, at XPT, I was introduced for the first time to underwater training which is very cool because your brain keeps telling you to go to the surface and you have to work through that, which is cool. But before that, we had done the hot and cold contrast therapy which I had never done. We had talked a lot about sauna. I have a sauna. I think a few people here have sauna and access to sauna.

    But when I added the cold to it, it was totally different because, again, if you're not used to it, your brain is telling you get out. Just sticking with that really, aside from the science behind of why it's good for you and the cold, especially away from exercise because you don't want to blunt the effects of the inflammation, but I have found and have just recently acquired a freezer and filled it full of water. Oddly, I find it addictive.

    It's one of those things, like the sauna, once I put one in, found myself using it at least five times a week. And now it's like, "Uh, when can I--" I can come home from work and strip down and jump in the freezer for three minutes. It's great. The epinephrine and norepinephrine that you give -- I mean, to me, it's my happy pill. It's really nice. Tommy can probably speak definitely to the deep science of it.

Tommy:    I was just going to say can you tell us how you set it up? Because now everybody is going to be wanting to go and buy a freezer on eBay that they can turn into a cold pool.

Clay:    I kept thinking of how I could do this because in the winter you can walk outside and anything that has water in it, it's going to be cold enough. Setting it up really, I mean, you can buy these things cheap for -- I didn't spend that much money but I did get a new one. I just found one. It's very simple. The first thing I had to do was silicone all the joints, filled it with half full of water and then dumped all the ice that I could find around the house. They're just to speed the process.

    I live in the south. The compressor in the middle of summer, that's a tough one. That sped up the process. But essentially, it's not that much in the fact that you chill it for 24 hours and then after that it's on a timer and you just run it for an hour to two hours. I do that in the morning so that you can -- It's nice and chilly if you want to use it that morning.

Tommy:    What protections did you make against the fact that you're sitting in a water-filled electrified box?

Clay:    Exactly. That one I'm still working on, except for I unplug it. The easy answer is I unplug it. That is a definite. When you're sitting in this thing, you're looking around going, "This just feels wrong." But you're having to coach yourself through keeping it, staying in. I've certainly enjoyed it. And I do notice the recovery, the sleep benefits, all that kind of stuff. You feel amazing. So, any stressors that you can do that are like that. It's really not that cost prohibitive.

Christopher:    Can you talk about the XPT Life? Who is it? Where was it? Did you enjoy it?

Clay:    It's in Malibu. Laird Hamilton, who is the big wave surfer and his wife, Gabby Reece, who was a, I guess, world class volleyball. She was a Nike athlete years ago. It's like they have invented or reinvented themselves doing these kinds of things. It stemmed from Laird Hamilton being a big wave surfer and having to survive multiple hold downs which is where he got trapped under the waves.

Christopher:    I've done that on a kite, actually. It can happen in kiteboarding that you get barreled and then, "Which way is up? I don't even know anymore."

Clay:    And then the next wave comes and you got to--

Christopher:    It's terrifying actually.

Clay:    That's what I hear. And just the limited amount of time I've spent in the ocean and you get wiped and then that comes along again. So, again, a big part of their training is resisting that.

[0:30:00]

    Because in the pool, you just shoot to the surface. What I really liked with them is the fact that you're doing training that you would normally do but you're in the water. One is called an ammo box where you have a 20-30 pound weight, you have it to your chest and you're swimming across and then you switch hands and you swim back across and you want a breath naturally.

    You realize as even just that one day, that one session goes on a lot of it is in your head and you're fighting that urge. I mean, underwater, it's just that other layer of you think that it's like I've got to get to the surface. And the more you can calm that down.

Christopher:    And do you think those skills are transferrable? Do you find them that it might be useful elsewhere in your life when you're not walking across the bottom of a swimming pool?

Clay:    Yeah, absolutely. It seems odd but it's a cool way to stress yourself. It's just a form of meditation. It's practice. There is no finish line. It's the practice. Everybody can use a little focus in their life.

Christopher:    That's very cool. You're listening to Clay Higgins. Clay has been on the podcast before. He is one of our awesome health coaches. It has been a while. We need to get back on the podcast more, Clay. The female voice is Megan, Megan Roberts, who has also been on the podcast. She is also our researcher and health coach and hopefully by now you know me and Tommy's voice. That was Zach that you heard earlier.

    I'm going to be rotating. We got more people than headsets so I'm going to rotate people in and out. Who wants to add? Who wants to interview Tommy about his presentation on the athlete's gut? Have I got any takers here? We've got another doctor, another real doctor. So, I've got to tell you. We got Josh Turknett here who is another fantastic doctor that spent some time in our Slack. I was first introduced to Josh's work in 2014 at the Ancestral Health Symposium, of course, where he presented the migraine as the hypothalamic distress signal.

    I can remember sitting in the audience with Julie and we were looking at each other going, "Oh my god." Julie had the same experience that she stopped getting migraines when she fixed her diet. They're not as bad as I think some people get them but they were bad enough to where they caused her a lot of distress. We just couldn't believe it. And the thing that we couldn't believe the most was this was a legitimate medical doctor that was talking about diet and how maybe the drugs weren't the best solutions for migraines.

    We told Julie's mom about it. I was living in Oakland and we were just in Berkeley at that time and then Julie's mom started pasting this talk on -- it was your website, mymigrainemiracle.com. Just trips off the tongue. I love that. Mymigrainemiracle.com. She was posting on Facebook and telling all of her friends that got migraines, of which there were many. You don't really get any better than that when you're an entrepreneur, having people evangelize your work quite as much as that.

Tommy:    I feel like we need to get him to talk about that now.

Christopher:    Yeah, I know. I was going down that route.

Tommy:    Back to AHS '14, and tell us about your talk.

Josh:    The talk there was, like you say, was about my view of migraines as the hypothalamic distress signal. That came from -- I talked in that talk, the first piece of that was myself going down this road into ancestral health and adopting an ancestral diet and unexpectedly impacting my own migraines that essentially went away, and starting to use that with patients, finding out that there were actually a lot of people in either low carb or ancestral health communities who had that same experience like Julie.

    Leading to the question of why is that? There's evidence based on that and based on studies of indigenous populations that would indicate that migraines are another disease of civilization. The question becomes what is it about? Modern living and lifestyle and diets, that would cause them to be released based on the mechanisms we understand of migraines.

    There is a good bit of evidence to suggest that if you want to find out where they originate in the brain, that the hypothalamus comes up as a really good candidate. I won't go into the details of why that is. But then if you figure the role of the hypothalamus is essentially coordination of homeostasis throughout the body, all these processes that have to be regulated so that all the chemical reactions that occur can unfold properly.

    And so you think body temperature and sleep-wake cycles and energy regulation and all that sort of thing, where in the brain might in modern world be exerting some of the worst impact or what part of the brain would feel that the most. Certainly, in certain domains in particular, with energy distribution and eating and diet being a big one, that led to this idea that if we think hypothalamus is where they originate and then we know that all of these scenarios that we would consider to be significant homeostatic stressors also happen to be the biggest triggers for migrainers, you can sort of put together a pretty good model as that being both where it originates and why a modern lifestyle would be -- why we would only see it in that context.

[0:35:13]

Tommy:    Were you able to integrate the thoughts behind hormesis and these stresses that produce beneficial adaptations versus the homeostatic stresses that are causing migraines in people?

Josh:    I haven't thought too much about that. That's an interesting idea and whether or not that could even be used therapeutically.

Tommy:    That's increased distress tolerance.

Josh:    That's a good question. I'd have to think more about that. But if I reflect a little bit on my own experience, I wonder if my own hormetic stressors have built up some of my own, my resilience as well. I think we could probably, at least anecdotally--

Tommy:    Find some paper.

Josh:    Find some evidence that that's happening. But that's an interesting idea.

Christopher:    The thing that makes Josh so extraordinary is not only is he a neurologist that helps people with migraines, he's also a migrainer himself. He has this tremendous ability to empathize because you know exactly what it's like. Josh, would you mind talking about last night? You felt like you had a migraine coming on and then you did something special. I don't want to like jinx it at this point.

Josh:    Having done this so many times, it's pretty predictable. I know where I am in the cycle. One of the things that's a challenge still, speaking of homeostatic stressor, is travel. And one of the non-negotiable issues is sleep. Any alterations there are challenging to deal with and then you throw in a meal that's a little later than you're used to with perhaps a few more carbs than typically consuming and you get the perfect storm.

    Middle of the night last night or the night before last, a new one was coming on. I'll back up a little bit so I can get to the strategy that I now rely on if I am feeling one evolving. It was about two years ago now, I realized that -- One of the big problems, big hurdles that migrainers face is getting to the point that I've gotten to, getting on ancestral diet and having success with it, is removing the impact of drugs, of the medications, which can help things in the short term for migraine relief but can prolong the issue in the long term. They raise vulnerability.

    I realized that to help people with that, we had to have a reliable strategy beyond drugs that people could turn to at least even if it's just every other time they get one, alternative, to lessen the impact that the drugs are having on their migraine vulnerability. I actually did my own self-experimentation with inducing migraines and trying a bunch of different strategies.

Christopher:    How did you induce it?

Josh:    I can easily, if I had drink something and go to bed feeling the effects of alcohol, I'll automatically have a migraine the next morning. That's how I did it. Tried a bunch of different strategies, some more effective than others, because there's a lot if you look around, of people trying drug-free stuff to end their migraines. I've had some things that I've done over the years, but the far and away most effective thing was just the fast, just to not eat. I'll usually combine that with exercise, if I can. I've called it starve and sink strategy. Starve the migraine and then create an energy sink to divert energy away from it further.

Christopher:    And how reliable is that?

Josh:    It's super reliable, especially if I haven't -- If you remove the whole impact of medications from the picture, that's a process that takes a while. Myself and now, there's a lot of other folks who do it in our community that we work with who use that same approach. So, for me, it's pretty well a 24-hour cycle and there's an evolution of changes that I can experience during that cycle.

Christopher:    How did you do that? You must have tremendous willpower. Last night after we got back, we had this incredible barbecue. Clay knows his meat and he sauced the local butcher that gave us a rib cage of a cow. Obviously, in Montana, there's lots of grass, incredible beautiful views. I'm posting pictures on the show notes so you can see what we can see. In fact, we've got some pictures of the brontosaurus steaks that we had.

    How did you do that? It was all these people and there's this social group and it's kind of a party going down and all this delicious food and you literally get to sit and hold the baby. I've got a five-month old baby and Josh sat there and held the baby.

Josh:    It's a real bummer. This is one of the more challenging times. It's because I know. So, if I'd that steak, I'd be out of commission today and tomorrow.

Christopher:    It's just a really pointy stick that's going to--

Josh:    Exactly. It's like having been conditioned. So, that's pretty powerful thing. And plus, you don't feel too much like eating in any way. In the old days, I would have actually -- This is part of the problem. A lot of migrainers think I have to eat. If I don't eat, it's going to make it worse.

Christopher:    Is that what they're told? Why do they think that?

Josh:    Probably because, at least my own view of it, there is a phenomenon known as hunger headaches. People, if they get hungry, probably more to do with swings in blood glucose and energy levels.

Christopher:    Right. You're on a rollercoaster.

Josh:    You're on a rollercoaster. In my experience, actually, what I've realized in retrospect is that what I would do oftentimes when I was on that ride, feel the headache coming on, I'd reach for something really sweet, instant source of energy. And then I would get a migraine. I would think I just waited too late. It was already there. When it was the actual thing that I did that caused it to escalate.

[0:40:19]

Christopher:    Just think about all these people that spend a lifetime suffering unnecessarily that will never learn this through trial and error.

Josh:    Right. That's part of the thing now as we crowd source a lot of these trial and error things.

Christopher:    Right. And then tell everyone about the resources that you have now to help people with migraines because you've got some really phenomenal and inexpensive resources.

Josh:    Yeah. We all started with the book. That was The Migraine Miracle, which is still out and available. And then we have our website, mymigrainemiracle.com. There we have articles, we have a Facebook community that's free, we have a podcast called the Miracle Moment, comes out about once a week, and then we have other more extensive resource for folks that want more help.

    We have a membership community that contains -- you get a weekly meal plan. We have a private group with a private once a week coaching session that we do. So, trying to give something for anybody regardless of where they're at and how much help and assistance they need. There's a pretty big spectrum in terms of the migraine community, how much any one person suffering, how long they have been suffering, how much the medications are playing a role, how big a road they have to go.

    Some folks can just read the book and they're off and running and they're doing great. Whereas we find others who need a little more assistance in individualizing and customizing to their situation and hearing from some of these strategies that I've used to tackle some of the harder bits.

Christopher:    Clearly, you've been finding the ketogenic diet as an effective strategy for dealing with migraines because you have a website--

Josh:    We periodically do a challenge called the Keto Blast. We definitely found, and others as well, and there's research to validate too that ketosis is another tool for migrainers. It's not a universal cure all. They relate more to where someone is in their recovery process, as to how helpful it's going to be. But we certainly have had a lot of folks now who have done it, loved it and stayed, who are afraid to go out of ketosis because of that. But, yes, that's part of -- one of the things we offer is to help guide people through trying to changing their diets.

Christopher:    It's amazing. It's a phenomenal work. Talk about skin in the game and doctor-preneur.

Josh:    Yeah. I mean, it's like I've been to worst depths of this and I've thought like nobody should have to deal with this and if this is like a preventable thing, it's just like you have to put whatever you can out there to help.

Christopher:    I'll rotate Zach back in. Sorry, Josh. You can ask Tommy about some questions about his talk. I'll just say a few words before I duck out there. I think, honestly, genuinely, and of course, I'm biased, but I honestly believe that that was by far the best talk I've seen so far in terms of the usefulness of the content, the scientific evidence that you presented to explain what might be going on, and then the prescription. What the hell do I do about this?

    The reason I knew it was so good is that as I'm going along and as I often do as I interact with you, Tommy, I've got a question and then two slides later you would answer my question. It was like you really, you can still walk a mile in my shoes because you are me. You're obviously thinking. There's no way you could have accidentally answered three of my questions as you were going along.

    You must have thought, "Oh, what questions do people have? Let's just get that in the talk rather than leaving them dangling like that." Anyway, I'll let Josh ask you about the talk and I'll rotate Zach back in.

Zach:    Yeah, let's just get on that topic of preparing a talk. Is that part of your process? Do you think about, okay, where are people going to object?

Tommy:    Yeah, that's actually -- I'll often construct something that I like as a timeline or a story to the talk. Actually, when I was doing this one I was reusing or the basis was the talk that I gave at Physicians for Ancestral Health in January. As I was inserting stuff that I thought would be useful, I was like, "This just doesn't make any sense anymore." I completely restructured it and reordered it to try and create a cohesive story.

    One thing that I frequently do -- and actually somebody recently said that they think that I'm somebody who people rarely disagree with. I honestly have no idea about that but at least one reason I try and counteract that is--

Zach:    In public, at least.

Tommy:    in public. People would disagree with me in private all the time which is great. I think it's one of the best things you could be exposed to, is people telling you that you're wrong. But, you all think -- Okay, so where is somebody going to disagree with this? I know the audience fairly well. I'm going to have a lot of ancestral minded people. There's got to be a lot of keto people and at some point I'm going to talk about eating more carbs, how do I balance all this stuff in there as well as the exercise patterns and all that kind of stuff?

    That's definitely part of my thought process of building a talk, is where would the audience disagree with this? Does that give me an opportunity to explain something else? So, add some more information in and then help them build a framework or understand where I'm coming from at least so I can build a picture such that what I'm saying doesn't discount whatever it is that you believe or that you do but in the scenario that I'm talking about I think this is the framework we're thinking about. That's definitely part of my process.

[0:45:10]

Zach:    Yeah. So, why don't you tell us what was your talk about?

Tommy:    It was called the athlete's gut. I think it was pitfalls of training for modern sports. I started out by talking about hunter-gatherer movement patterns and it was very brief. It was a couple of slides. The best example that we have is the Hadza who had been extensively monitored by the west. I imagine us turning up with heart monitors in hand and these guys are like, "What on earth are you doing?" Sort of being quite confused about what it is that we want to know, anyway.

    If you look at their -- There's a couple of recent papers coming out in the last couple of years looking at this. The Hadza tribe, they do about two to three hours of what they call moderate to vigorous physically activity which is basically the equivalent of brisk walking, two to three hours of walking a day and zero to 30 minutes of vigorous intensity exercise, sort of moving really hard. That could be a bit of sprinting or chopping or digging or whatever.

    Then if you look at the amount of calories that they -- their total energy expenditure in the day, despite the fact that they're more physically active, it's very similar to what a total energy expenditure in the western person is about, depending on body size, about 2,000 to 3,000 calories a day. Part of that is that the more active we become, physically active in exercise or whatever, we adapt and then are less active the rest of the time. We reduce our non-exercise activity thermogenesis which is basically it's all about the fidgeting. We're right now, we're standing up, we're sweating around.

    If we have done a really hard exercise we probably would have sat down and we wouldn't be moving. It's an automatic adaptation to the energy we've expended elsewhere. But if you look at the modern -- Particularly endurance athletes. I took a training program from a competitive Ironman athlete who might expect to complete an Ironman in under 12 hours, something like that.

    They're training 20 hours a week, two to three hours per day of vigorous activity. If you scale activity based on how much energy you're expending, they're doing five to six times as much vigorous activity as a traditional hunter-gatherer. At that point, you're essentially breaking the amount of energy that we're used to both putting into our mouths and then expending in physical activity, at least on a regular basis.

    So, there's a number of potential detrimental facts there. Both the vigorous activity, the effect that it can have on the gut, plus just the total amount of food and energy you're putting into the system, that's hard work on the gut, that's hard work on various metabolic processes. And then there's also the risk of you're just not eating enough calories and then expending too much and then you have a whole host of hormonal problems that come downstream of that.

    That was basically the rest of the talk, was in modern athletic sports, I think, a lot of what we're trying to do is perform but at the expense of long term health. So, we're getting short term performance at the expense of long term health. A lot of that can be centered around the food that we eat and what we're asking our guts to do over long periods of time. That was then the rest of how I approached things.

Zach:    Got you. A lot of your talk was about the changes in gut permeability that happened with exercise and I was particularly interested in that issue and any ways that we can mitigate what happens there. Can you talk a little bit about the research on gut permeability and exercise and then any thoughts that you have about how we can mitigate the impact of that?

Tommy:    Yeah. So, pretty much every study that's looked at this, the longer and harder you exercise the less blood flow goes to the gut and then the greater the permeability in the gut both during and afterwards. You can measure the breakdown products of essentially the endothelium that lines the gut. You can measure the things that are inside those cells. They end up in the bloodstream because you're basically losing those cells because they're losing their blood supply.

    You can also measure things coming across the gut which shouldn't be there and you can at the same time measure a reducibility to absorb nutrients from the gut, so both amino acids and carbohydrates. An important thing to think about is that depending on the study and the intensity of exercise but on average about 70% of people who do endurance exercise get some kind of gastrointestinal symptoms.

    That could be nausea, vomiting, diarrhea, all that kind of stuff. There's various reasons for that but one of them is just the fact that you're putting, you end up putting food in that doesn't get absorbed, doesn't get digested properly. Either the gut bacteria ferment it and then you get gas and bloating and things, or you have an osmotic effect so it draws water to the gut and then you end up with diarrhea.

    Whenever I think about that, I think of Paula Radcliffe who is still the women's world record holder in the marathon, one famous race where she was just running and all this stuff is coming out of her essentially. She just can't control it. It's just very common even in the elites. There's a famous quote by Bill Rodgers that says that more marathons are won and lost in the potty toilets than they are at the dinner table, is his quote. A lot of that fueling strategy during exercise makes a big difference especially if you're doing longer.

[0:49:59]

    If you're doing shorter events, under 12 hours, you probably don't need to eat anything. You're maintaining hydration, just drinking to thirst is important. If you're going longer, a small amount of -- So, 45 grams per hour of carbohydrate or protein, basically maintains a little bit of blood flow to the gut and actually maintains some of that gut integrity. Some but not lots, and there's definitely -- People just like throwing back hundreds of grams of carbohydrates in gels and drinks and stuff and I think that that's definitely having a detrimental effect on a lot of them.

    Being less reliant on inter-race nutrition. So, fasted workouts, sleep low strategy where you deplete glycogen then have a high intensity exercise session then you have a low carb dinner, the next morning you do a fasted workout and you're sort of training the fat adaptation side of your metabolism but then you can refuel with carbs. So periods of carb cycling can certainly be beneficial just so you're eating less during your races.

    And then also not necessarily eating straight afterwards. A lot of people think that as soon as you finish workout you need to get some recovery stuff and you'd have a protein shake or whatever. And somebody asked me about this after the talk. My running coach says I need to have my protein shake immediately after my run.

    When you look at the data particularly in 99% of people and especially of the average athlete, the most important thing for recovery in terms of protein intake is getting enough in the 24 hours after your workout. That first half an hour when actually your gut probably isn't really ready to be absorbing stuff, that's a great time to not eat and then just delay a little bit and then certainly not going to impact your recovery.

    Timing, recovery meal is important. And then also just thinking about training for performance versus longevity, and I think a lot of people that we end up working with, they came to a point where they want to perform for long periods of time but they also want to live long and be healthy, as healthy as possible. And then if you're looking at that then it's something like up to 45 minutes of vigorous activity a day.

    But vigorous is not like going out and crushing yourself on a run. It's everything from brisk walking to weightlifting to cycling or running even at fairly sedate paces. That still counts as vigorous in the literature so that's what we're looking at. That's going to be a balance of some aerobic work, some strength work, some sprint work. That's definitely going to give you the best all around capability as a human and definitely going to be protective long term in terms of health and then performance.

    Especially if we're thinking about [0:52:16] [Indiscernible] athletes, the guys who are coming up against are not doing all that stuff and at some point they're just going to fall apart and they're not even going to make it to the start line let alone the finish line, if you're thinking about true longevity and performance. Having that balanced program is really important.

    I have people think about if you build a program that looks like that 45 minutes to an hour a day plus all the walking on top and making sure we're not spending too much time sitting down, that's very important too. All the sleep and recovery and stuff, that's important too. I didn't mention that at the talk just because I didn't have time, but something like that, like an hour a day maybe, and balanced across the different energy systems.

    And then if you try and perform for a different sport, what do you need to add to get performance in that sport? Maybe you need to add a few hours of longer aerobic work. That's fine. Plenty of people do that. If you're doing all the other stuff well, you're removing dietary triggers that might be upsetting the gut and so people who have gotten symptoms during exercise, that's more likely to happen if they have symptoms at rest. So, investigating anything that's going on in the gut. Elimination diet is something that we use a lot, and now showing up in the sports med, some literature, as being beneficial for athletes who have gastrointestinal symptoms.

    So, if you're doing all of that then you can certainly probably tolerate a greater volume and you can add that in if that's what you need for your sport. Then also taking away what you don't need for your performance, that's what you're thinking about. And then there's definitely you get to a point where you have people who are doing two or three hours a day and you just like wonder why. Why is it you feel the need to do all those exercises?

    And then we get into a whole other can of worms about exercise addiction and some people feel like unless they're doing a certain amount they're just not really good athlete or they're not doing it properly and you have to dig down into that stuff too. But that was where we wrapped up, just trying to build a program that's going to be sustainable for long periods of time that's going to be strong, also going to make you aerobically fit but isn't going to take a huge amount of time and you got a lot of time to do other things and isn't going to be detrimental to your physiology because you can have too much of a good thing and you can certainly see risks of cardiovascular particularly disorders that seem to appear in people who have very high volume high intensity athletes.

Zach:    On the issues of people who are exercising primarily for health and longevity versus a performance goal, would you say that experiencing gut symptoms after exercise is an indication that you may be bearing too far on the U shape curve of benefit from the exercise, assuming that you're not having gut symptoms at rest?

Tommy:    That's a good question. I think we should be able to tolerate definitely that amount, an hour of vigorous intensity. Anybody should be able to do that. And, obviously, vigorous intensity is very subjective, so depending on wherever you start out that will change over time. And if people are experiencing gut symptoms afterwards, it could certainly be that they're doing too much.

    I think what -- Again, it goes back to the fact that -- And running is the best example. It's also the most sport where you get gut symptoms most regularly or most commonly, is the fact that people are like, "Well, I run to stay fit and when I run I go out for an hour and when I go out for an hour I literally just crush myself as hard. I'll just run as hard as I can for an hour."

[0:55:07]

    I don't know. The strategy that we use is polarized training. A lot of time, most of the time just the MAF pace, really slow aerobic stuff, and then you can throw in some sprints and things like that on top particularly in people who have quite a long training history or training background. That seems to work really well.

    Just remembering that exercise doesn't mean that you need to come home in this awful sweaty heap and then shit your guts out and you feel terrible for the next 24 hours. There's very few beneficial things happening there. It's interesting when you look at that type of training you're like you're spending all your time around lactate threshold maybe 70-80% of VO2 max, something like that, like around that 70% to 90%, somewhere like that, and just going really hard for long periods of time.

    It actually seems to get some of the smallest training benefit in terms of actual performance. When they've studied like that polarized approaches, at least it's good if not better. But you're also spending less time in that range, which is really hard on the gut and on certain other aspects of physiology. You're not getting the training benefit and you know it's causing problems elsewhere. If you can polarize it and let yourself realize that going out and just running really, really hard is not the best way to train, then there's a number of benefits that come from that.

Zach:    You spoke a little bit about some of the athletes you worked with. One of the main things that many of them need is just to eat more calories. I guess, the first question would be, what is the usual resistance to that and then you did talk about how you would frame that, the reason for doing so and it gets back to your discussion about the total energy expenditure during the day and how that's allocated and that presenting in that way dispels some of the resistance that they might have. Talk about that for a second. I think that's really interesting and probably not something a lot of people have heard about.

Tommy:    I tied some of this back to what I would call the ancestral athletes. It's fairly common in the people that we work with. They have some modern sport they want to perform in. Again, training 15-20 hours a week perhaps. At the same time they know they need to eat real food which is less calorie dense which immediately becomes a problem.

    But then at the same time they've heard that carbs cause diabetes and protein causes cancer and then there's always calorie resistance particularly in the endurance training community because gaining weight, obviously, slows you down pretty significantly. They're scared of gaining weight. What happens is you're not eating enough and then that gap in energy requirement, particularly if you're training for long periods of time, what you lose is normal hormonal function. The body is just liquidating its assets and it's saying, "You know what, there's no point in having testosterone or normal estrogen and progesterone production because we're definitely not going to be reproducing right now. There's definitely no--"

Zach:    And those processes take energy.

Tommy:    And those processes take energy, absolutely. What we think about is, and what we've certainly seen with people, is the fact that we think that there's this immediate level of number of calories and then if you go above that you're going to gain weight and if you go below that you're going to lose weight. But that is just really not true.

    And what we see is there's a buffer. You can reduce the number of calories and then as you keep reducing them there's going to be this period of time where you start to just switch off processes of recovery, repair, certain hormonal signaling processes, and then those calories come down more than you hit some level and then you start to lose weight.

    What we think about is making sure that we're eating at the top of that buffer. So, the idea is to eat as much as you can before you start gaining weight because if you're eating at the top of that buffer then you are fueling whatever exercise you're doing and all those other stuff, you're also giving or providing energy that will then help all those other processes happen.

    We still have guys who are doing really long races, training really hard, but then their hormonal responses and profiles and function can still come back as long as you're providing energy for those and then the adequate rest and recovery. It's not that you have to quit all modern sports and the training required to do them but you just have to make sure that you're providing the fuel to do it and then letting your body recover and structuring the training differently if you need to.

    It's that kind of buffering. Basically, eating as much as you can and adding back carbs is really beneficial there. It doesn't need to be a lot either. One to two grams per pound of body weight seems to be like just a magical area where things start to come back online. Zach and I had been talking about whether it's the carbs or whether it's the calories. I honestly don't have a great answer there.

    When people add carbohydrates back they get hungrier and so it allows them to eat more. It's less of a struggle. That's definitely part of normal insulin signaling and then change in blood glucose and it's going to just help facilitate that process. And we haven't seen that be detrimental at all particularly in high volume athletes. There's definitely some part where some spikes in insulin are going to be important for thyroid and sex hormone signaling because it's the short term energy availability hormone, so letting you know that short term energy availability versus leptin is probably one of the longer term energy availability hormones.

[1:00:00]

    So, having small spikes in insulin, letting your body know that there are, in the absence of spiking glucagon at the same time, perhaps helps tell the body that, yes, there are these carbohydrates or this energy available to do these processes. That's purely theory on my part. That certainly makes sense. Whether it's the calories or it's the carbs, it's probably a bit of both. But we also have plenty of people who do this well whilst still restricting carbohydrates but often it's just harder work to get in enough calories. However, if somebody wants to do it, we're happy to help them do that but it just takes many different ways to skin a cat as usual.

Zach:    A really interesting concept. Not all excess calories are going to go in the adipose tissue.

Tommy:    Yeah, exactly.

Zach:    Just to reiterate what you said, and you did touch on this a little bit, like you said, you and I have been having back and forth and a lot of claims I hear is like, well, protein will spike insulin so that's why we need for the -- Like you said, maybe it depends on that insulin to glucagon ratio and we know that protein will also stimulate glucagon. That's why the carbs might be helpful on top of the protein. I just get that question a lot so I just wanted to point it out.

Christopher:    I have a question about your talk, Tommy. You did talk about the role of dysbiosis and gut pathogens in the etiology of this mess. My question is: Which do you think comes first? Let's take the example, someone we have worked with, I'm thinking of specific example in mind here, we aren't mentioning names, but a professional road cyclist who notice a decrease in their performance, increase in their body weight, felt like death, came home, stopped everything, still the problems persisted.

    You do some gut testing, you find the giardia infection and a C-diff overgrowth. What happened first? What do you think? I mean, so we see this over and over again. What's going on here? Are these people picking up the giardia infection and that's destroying their health and performance? Or are they training and racing in such a way that's destroying their health and then they pick up a giardia infection?

Tommy:    I'm fairly certain it's the latter. You're creating a gut that support -- Because we're exposed to these things all the time. There was one study, an Italian study where something like 30% of all lettuce had parasites on it, something crazy. You're exposed to these things all the time. There is some really nice work, and this is the other something I talked about.

    Sebastian Winter is -- I need to get him on the podcast. He's a professor in Texas. He's looked at this. Basically, if you instigate some kind of inflammation in the gut, you automatically change what bacteria will thrive in that environment. There's a couple of different ways that we can be introducing inflammation in the athletes. The exercise itself, if somebody moved, then the stresses of moving country and jobs and all that kind of stuff, that's certainly going to be involved.

    

    There's going to be dietary triggers, things that we're eating that are just causing some low level inflammation in the gut and that's going to be very different from person to person in terms of what that might be. And so if you're creating inflammation in the gut lining, you change what bacteria or what parasites might, yeast, all of those, all of the microbes, what's going to thrive in that environment.

    We certainly worked with other people where they know that when they're in season training hard racing they just like -- yeast starts to pop up. They just need to start looking. They just like start to take antimicrobial herbs, something just to look after during the races, and then when volume comes down and things relax in the off season then all the problems go away. They don't have to worry about it. I'm certain that there were a lot of things that athletes were doing particularly training style but then also the lifestyle that comes with it which is often a lot of travel, a lot of stress, and then also maybe diets that aren't ideal for them.

    

    And then that's setting up susceptibility for things to then cause problems. It's based on both our experiences and then the mechanistic researches coming out, I'm pretty sure that you're creating a gut that fosters these things or creates a supportive environment for these things rather than you pick it up and then the problem stop.

Christopher:    And then how do I unwind the whole situation? So, do you think that person needs to stop training completely? I told more than one client that when I went through this process, how the belly that was the size of a basketball when the rest of me lean, I was super gassy, and I continued to race and train whilst pounding fistfuls of herbal supplements. In fact, I've talked about this on the podcast before, but I was even taking supplements during the BC Bike race. I was trying to cross the Canadian border with a Ziploc bag stuffed full of probably $500 worth of herbs.

    It worked. My belly deflated. I was super happy. The road has been non-linear, shall we say, since. It's not like I just continued to get better in a linear fashion. But for the most part, I'm doing really well now especially with respect to then. But I'm not sure that's always true and I'm certainly not sure that I did the right thing. Should I have just said, "Okay, this season's a dead loss. Let's just fix what's going on, take a break for the rest of the year, and then get back into training and racing next year." What do you think?

Tommy:    It depends. There's always a difference between what works and what might work best. So, what you did definitely worked for you but could you have achieved the results faster with a more linear process potentially? We don't know.

 

[1:05:09]

    One thing that's worth mentioning is the fact that exercise is actually beneficial for the gut up to a certain point. It helps maintain gut integrity, gut function. I think if you completely remove that you might get some issues. But you could probably get enough stimulus from some very light aerobic work, going and lifting weights, stuff like that could be enough.

    You don't have to stop exercising completely. I think in many cases that may actually be detrimental. One reason I'm thinking that is one paper that I talked about was the one by Lauren Petersen which looked at the gut microbiota of different categories of cyclists.

Christopher:    And Lauren has also been on the podcast.

Tommy:    Loren's been on the podcast twice. So, Methanobrevibacter smithii which some people may have heard of if they're thinking about methane dominant SIBO, constipation, it certainly seems to be associated with that methane producing bacteria [1:05:56] [Indiscernible] in the gut seems to slow down gut transit time and they were particularly prevalent in professional cyclist, the top level cyclist. It seems to be important probably in slowing down gut transit time if you're at risk of things like diarrhea and stuff.

    I mean, if you're in the Tour de France and you get off and go to the porta-toilet, the peloton is going to be gone by the time -- That's going to be tough to catch up with them. Sometimes people don't have to do that. But there's certainly some benefits there. And it also seems to help with carbohydrate metabolism, having this particular bacteria in the gut.

    However, it then immediately makes me think of all these athletes who can't pass stool unless they exercise. And if they stop exercising they get constipated immediately. And so there's this adaptation of the microbiota which is beneficial to use as an athlete but then if you stop exercising and you become constipated that's certainly going to continue to cause problems, and if you're trying to treat the gut.

    I think there's definitely going to be a balance there. So, continuing to exercise can certainly be beneficial for both of those reasons if not others. However, you might want to dial back like the racing and the volume because that might then be causing detriment above any benefit.

Christopher:    You just reminded me. I can do a little plug for Simon's book here. The Brave Athlete has an entire chapter on what to do when you're injured. It's the same situation, right? What are you going to do when you're injured? It's an opportunity, is what it is. You can work on something else. Okay, you're not going to be doing 20 hours a week of endurance activity anymore. Can you work on your running form? Can you improve your swimming stroke?

    For me, as a mountain biker, is there something else? Could I maybe go to -- my neighbor has a pump track. [1:07:26] [Indiscernible] has a pump track in his garden. Could I maybe go and work -- Do you see what I'm just getting at? You work on something else. And then when you come back and you start adding back in the volume then you're a better athlete than you were had you not have had the injury essentially. Yeah, fantastic chapter in The Brave Athlete: Calm the F*ck Down and Rise to the Occasion. I'll link to that in the show notes.     

Zach:    Yeah, any leg injuries, just a lot of bicep curls.

Christopher:    Well, Doug, since I've got you sat here -- Doug Hilbert from Virta Health. We've previously interviewed Jim McCarter on the podcast. We had Christy here as well. Christy, unfortunately, had to leave. She's also from Virta Health. I think Jim owes me referral fees for two employees now, doesn't he? Christy found Jim through the podcast as well. Tell us about Virta Health. What is Virta Health trying to do and how are they trying to do it?

Doug:    Okay. So, Virta Health, fairly new company. I guess, we could still be considered a startup.

Christopher:    I would call you a startup certainly.

Doug:    And the mission is to reverse type II diabetes in 100 million people by 2025. Obviously, very audacious goal. It's really what attracted me to the company. I'm going to do something. I want to do something big. Sometimes that becomes personal pathology but in this case I think it's well directed energy on that side. I'd been here two and a half years in multiple roles. We started an online patient community. Obviously, where patients can interact, share their experience, strength and hope. I think that's been very impactful on that side, just people connecting with each other, suffering from the same thing. I think we connect the most through shared suffering with other humans. Everything is going perfect. Yeah, everything is great.

    We could shake hands, do those things, but we go through hard times together and have other people to support. Those really developed, I think, and foster those bonds that last. And then we have something called intake call. It's really the first call where someone explains what Virta is to a potential patient, very impactful.

    Us in this industry, we understand ketosis and, at least in my mind I'm like, "You don't know what ketosis is?" But when we look at the average American, it's a very new concept. The might come in with some misconceptions. It's becoming more popular and click bait on social media. Sometimes we're explaining it and sometimes we're dispelling some myths that are circulating around the internet.

Christopher:    Which is probably good for you to talk about the type of people that you're working with because this has been my criticism when I've heard other experts talk about the ketogenic diet. They keep switching between talking about elite athletes winning the western states 100 mile running race and then suddenly you're talking about an overweight obese insulin resistant person and then you're back talking about the elite athletes again. And then the elite athletes get really confused because they think they need to do something that--

[1:10:04]

    

Doug:    What applies to me?

Christopher:    Yeah. It's very confusing when you're listening to podcast trying to understand what things apply to you or not. Talk about the type of people that come to Virta Health for help?

Doug:    Yeah. It's just what we could say is maybe the typical American, if we look at the statistics, they're quite staggering, the amount of people that are overweight and insulin resistant and have high A1C and are on medications what you call -- really it's kind of an epidemic. That's really a population that we serve versus who you serve.

Christopher:    Yeah. We're in a tiny, tiny bubble and I'm sure that most listeners who engage in some athletic activity appreciate that they are the tiny minority. I mean, you only have to walk down the street. Just go to an airport. I mean, Josh comes from Atlanta. Atlanta Airport, holy. I did that recently. Lord, it's terrifying.

Doug:    Yeah, I have that experience. I'm in Saint Louis. I wouldn't say we're on the rank of healthiest cities in the nation. It's shocking on one level but it's also somewhat heartbreaking. Flew here right I'm walking through the airport and in my head is I could help that person, I could help that person, I could help that person.

Christopher:    Isn't that sad? You just want to give them, just trying to give out business cards in the airport.

Doug:    That was my goal in getting into health coaching, was I want to help people and then I look and I say, in my career, maybe I'll help 100 or 1000 people if I did this on my own. And then Virta comes along and I said even if I sweep the floors of this place and we do help 100 million people I've contributed to that larger goal really of impacting greater social change.

    I think in changing healthcare at a national level, one way of a lot of budget issues, government's broke, state is broke, Medicaid is broke, VA is broke. Everybody is broke. The pressure of these diseases. That could really change the financial conditions in the United States and then in other countries as we expand.

    But then creating a generation of healthier people physically also mentally, emotionally, what kind of trickle down effect could that have on a lot of other epidemics, could this -- If people are healthy they have better social connections, right? Could that have an impact on the opioid crisis? There's a lot of things that tackling it from this and I think could have a lot of really unexpected benefits that we don't even know could happen.

    And one of the questions was, "When are you guys going to start working on other diseases, right?" There's common thing, I think, I wouldn't call it criticism but I think everybody wants us to rush out and cure everything. We are evidence-based and we are a medical practice. We want to see the evidence. There's a lot of great anecdotes and there's a lot of small trials and there's a lot of mouse data.

    That's all great in getting us to the point. We definitely consider those things in the future as the mindset about things like Alzheimer's and potentially certain types of cancer being metabolic diseases. So, we're kind of helping push research forward on our end and really relying on what other researchers can do too. So, we want to see that it's safe and we want to see that it actually works before we rush out. But it's good to see people at AHS. They're in the know. "When are you guys going to do this and when are you guys going to do that?" And I'm like, "Well, this is a huge enough problem right here in type II diabetes."

Christopher:    I haven't even thought of that, actually.

Doug:    Yeah . I mean, it's massive. Obviously, Alzheimer's and cancer are massive as well. It's like, hey, let's get great at one thing and build the model in the system so when we add the next thing on we've already got structure.

Christopher:    Or let me propose that if you tackle this huge underlying thing right now, that by the time you get to solve these other problems they won't exist.

Doug:    Exactly. This is, you talk about Dave and Ivor and you guys have this approach and the computer guys have this approach of root causes, system analysis. So, insulin resistance is the underlying root cause of many of these things.

Christopher:    Or at least a part of it. It's part of the process.

Doug:    We could dig under and that's what I like about your work is that sleep, movement, stress reduction. I worked with you, guys.

Christopher:    Right. Yes, I forget. Doug is another NBT person, a former client from way back in the day. You've been in the podcast talking about your journey. That was fantastic. Let's pretend for a moment I weigh 300 pounds and I'm still the same height, 5'8" and I come to Virta Health and I'm on several medications to treat my type II diabetes, maybe blood sugar lowering medicine, perhaps some hypertensive. What can I expect from Virta Health?

Doug:    So, the process of enrolment, you're going to have that intake call. Usually people apply on the website and then we want him to talk to a human. It's a program that needs to be explained, maybe sometime down the road won't necessarily need to be explained and people have a basic understanding of what we do. But they walk you through and really want to make sure that the patient knows what they're getting themselves into.

    We don't want them to get in and start on day one and be like, "Hey, I can't eat carbs. That's just not going to be a winning relationship for either party. But then they start to also do an H&P which is history and physical. They'll do a video call, the physician.

[1:15:01]

    The physician gets the medical background and medical records and all those. And we do typically have people do a series of blood labs when they start. We really want a base line, see where they're at coming in. That also helps for tracking progress. We want to update labs and we want to measure A1C and we want to track all those things and see how they go through.

    Then they'll be connected with a coach. They'll do a welcome call and that could be a video call or a phone call. The technology is a big piece but I think the human connection still matters. The patient needs to trust and in some level connect with their care provider. And so we do utilize phone calls and video calls. They'll go through and get a history and it's more of lifestyle, what food you like, what food you not like.

    

    We want to help set up the plan from the beginning. We don't want to give someone, "Hey, here's a food plan," and they hate all hundred foods. We're not really creating the conditions for success from the beginning. Really the more information we can get, develop that initial level of trust and connection, that's going to grow throughout the program.

    When you and I worked together, the big selling point was, "That guy's honest. I trust him. I like him. He tells me what he knows he knows. He tells me what he doesn't know."

Christopher:    Hopefully, know the limits to my knowledge.

Doug:    Yeah, there's not going to be a bunch of BS coming through and we're not going to be speculating about care and just taking unnecessary risks on that side. The human connection is super important. And then from there, they're shipped the start kit. We're going to track things by marker tracking. We want data. It's not solely qualitative so we're going to have them test blood glucose, blood ketones, weigh themselves on a routine basis, usually daily at the beginning and as I go through the program, depending on psychological factors too. Weight loss, sometimes we will reduce weighing. There can be a little negative or -- neurosis is a hard word.

    I went through my weight loss process. Stand on the scale, I gained two pounds today, I'm losing my mind all day. That could be hydration. It could they didn't have a bowel movement. There's all these other reasons besides, "Hey, I screwed up yesterday."

Christopher:    So, a two-week rolling average is more appropriate.

Doug:    Yeah, absolutely. That's really something that we always refocus on, even with glucose and ketones. It's like the daily data is important but it's really the long term training consistency of what we're doing over time. If you're perfect for one day and then terrible the next day and then perfect one day and terrible the next day we develop no consistency. But if you're 90% or 80% or whatever the number is for that person to develop that consistency and then we look at larger trend lines, then we'll see.

    A lot of the time with coaching that's focusing on patients. To me, it's a skill that needs to be developed. I didn't have a lot of patience when I was younger. That's like [1:17:32] [Indiscernible]. And culture in general, our quick fix, pop pill, instant results, feel great right now. That's how we're marketed too. That's really where our culture focus is on. Really work on taking a long term approach to a slow and steady wins the race. You're going to have good days, you're going to have bad days, you're still a human, and that's okay.

    If we have a bad day we want to learn from it, take a step back, refocus on our goals. All right. So, we didn't execute perfectly on the plan today. Okay, what are some strategies we can come up for tomorrow or for when the situation comes around? There are going to be holidays. Christmas is going to come every year. We screwed the first Christmas up, all right, what happened? What were we feeling? What were we thinking? Did we have external stress? Did we have internal stress? Did we want to feel like we were part of the group and that's why we ate half that pie with everybody else?

    That's invaluable things that we learned about ourselves. I think one of the benefits that people might not know when they come in is personal growth. Through my journey through this and working with you guys, it's like I am actually a better person now. It's not fun to see those things. I came from addiction recovery and I eat food like I used to drink. This is uncomfortable learning. But it was invaluable and having that courage to face those things and then having some other to support you through that process, not judging, accepting, creating space when necessary and just creating an environment for conversation so the patient can explore, really how they're living as a whole.

Christopher:    It's a pretty intensive program, then. It's certainly not for the faint of heart. I have to be very ready to change and committed to putting some hard work. It's not like you're going to send me some exogenous ketones in the mail and that's going to cure my diabetes.

Doug:    Yeah. That was one of the other questions. How do you work with unmotivated people? Well, the process of becoming a patient takes some level of effort, phone call, video call with the physician. You got to fill some forms out, blood labs. It's not like, hey, you're going to call us today and then you're going to be in the clinic tomorrow. That would be great for our business if we had that model but there are processes that you need to go through.

    So, some had showed some level of interest. A lot of times they come in motivated and it's pain and suffering and fear. I've just been diagnosed or being diagnosed this long and I'm facing a greater complication, possibly an amputation, eyesight, all this kind of things. That fear set in and that's created a great motivation. Pain is the greatest motivation for change.

[1:20:04]

Christopher:    That's what you said about the migraine, Josh.

Doug:    Yeah, absolutely. But I think we also find it's temporary, especially as people do make progress. And they do make progress in our program and then all of a sudden some of that fear goes away, the pain goes away, some of the suffering goes away. Life becomes a little easier. And then there's something that's taken up a lot of time and effort and mental energy in their life. Now, there's a whole, and it's a positive whole, but there's a void there and we need to fill that with something else.

    In the longer term parts of the process where we take hobbies, social connection. Connecting with friends, spending time with family, maybe somebody wants to run a 5k, maybe pick up a new exercise, they want to go back to the gym. They want to do all these things, volunteer, have a vocation. We've got people go back to work. They were unable to work. So then again we could tie that into the economic health of the nation, is that we're helping somebody get off the disability insurance.

    They want to work. There's this kind of thinking out there that they're just lazy people who don't want to do anything. Obviously, in a country this big, there's going to be a few free riders that do that thing. But by and large, our people want to re-engage with life and really experience it to the fullest on that side.

Christopher:    My favorite thing is when people start cracking jokes. When you're on the fifth or sixth call, someone that's -- Chronic fatigue is like no joke. You're not making jokes when you're tired. And then you got to that fifth or sixth call--

Doug:    Yeah, you see the change.

Christopher:    Yeah. They'd be like cracking a joke and like--

Doug:    It's a great sign in a hospital patient too.

Christopher:    You go back to something that you previously enjoyed and then had stopped enjoying or you take up something new and I'll tell you something like, "You never guess what I've done. I've hired a personal trainer. I can't believe it." That's one of my favorite things to hear.

Doug:    There's a patient in Florida I'd been working with, a lady, and she's very sweet and we'd been doing video calls weekly which is not typically what happens but I want to be able to offer what the person needs. If they've opened the door -- She wanted to work on self-sabotage and that's a very deep topic really to explore.

    We're going to go somewhere -- she came to me, she wants to work on it. I'm going to create the conditions where she can actually work on that and work on that with me. We're doing video calls and I get a message, we get a lot of text messaging that comes to the app, and she's like, "You'll never believe what I did today." I'm kind of, "Okay. All right, what?" She's like, "It was raining outside our office and I ran from the door to my car and that's the first time I've ran in 25 years."

Christopher:    That's amazing.

Doug:    And she was a high school track athlete. She lost, I don't know how far away her car was, but it was just that act of having the confidence of feeling better and doing that.

Christopher:    That's amazing.

Doug:    She's like, "I think I want to start running again." I'm like, all right, this might seem small from the outside but this is a huge breakthrough for her. And those are things that really keep me inspired to continue doing this job. It's great to see the stats. The numbers are obviously important. A1C reduction, glucose curve gets better, they make a little bit of ketones, the weight comes down. All those number goals we're tracking, we're measuring.

    We want to see progress. That's how we use numbers to do those things. But when I get those messages and hear those things on phone calls and see those on video calls -- we have a weekly company conference call and we started with what's called the patient voice. Not everybody at our company is a practitioner. We have a very large group of tech and we have sales and we have HR and we have legal. They don't see the direct impact of their work.

    What we do is basically do a patient voice where we tell the story like that to really reconnect them to what's happening on the ground level. Most of the people that come to Virta come here with some type of mission or purpose and they want to do something meaningful. Especially our tech guys. These are very highly skilled people that could be at Google and Facebook and--

Christopher:    I'm not because I want meaningful work. I'm here doing this because I find meaning in that.

Doug:    Yeah.

Christopher:    It's fantastic. I think that's a really great place to wrap up. Where can people find out more about Virta Health? How can I do one of those new patient intake things you talked about?

Doug:    Okay. So, the website is www.virtahealth.com. If you want to apply, I believe it's /apply. I haven't looked at the website today so I don't memorize it but I'm sure there's--

Christopher:    I'll find that. If someone talks about a thing or a link or something, we always find those, track those down and put them in the show notes. You can find those. If you poke around in your podcast, you'll find the show notes. You can also find them over at nourishbalancethrive.com/podcast. Virtahealth.com.

Doug:    Correct.

Christopher:    It's the main place to find the blog and all the fantastic content that Virta are producing and that new patient intake appointment.

Doug:    It is.

Christopher:    Awesome. Well, Zach Moore, Josh Turknett and that was Douglas Hilbert you were listening to, thank you very much for your time. You also heard Megan Roberts, Clay Higgins and, of course, Tommy Wood. Thank you. Cheers.

[1:24:50]    End of Audio

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