Written by Christopher Kelly
Jan. 6, 2017
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Christopher: Hello and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I'm joined again by Dr. Tim Gerstmar of Aspire Natural Health. Hi, Tim. Thanks again.
Tim: Absolutely glad to be on.
Christopher: Yes. So, for people that didn't hear the first episode, I should link to that in the show notes because I think we did a really interesting and informative episode about non-metal environmental pollutants and their effects on our health and performance and possibly fertility. I really enjoyed that. I will link to that in the show notes.
Today, we're going to talk about testing. I really wanted to -- Before we get into this, the details of the testing, I'm a computer scientist and I'm a data guy and I love mechanisms and all that kind of stuff. I thought it'd be really important to start out by talking about why we would bother testing in the first place and to talk about why I thought it might be useful to illustrate an example.
A couple of weeks ago, I had Bob McRae on the podcast and he talked about his journey from when he talked to me initially. I mean, it was really not so clear whether he was going to be able to continue his sport of Ironman triathlon to where he recorded the podcast with me where he's had the most successful season of his career, now the top rank in his age group in the US. So, an amazing transformation.
I think it's really important to keep that in mind. So, our program, it costs $8,000 in year one. Most of the cost of that program is the mass spec to do the testing. So, the money you're paying is not really for the mass spec and the testing. I don't link to concentrate on that. I like to concentrate on the transformation that you achieved by doing the test and having this additional information and knowing what actions to take based on the data. That's really where your money is going. Maybe, do you work with different types of people? Do you have something else in mind when you think about the testing?
Tim: Well, I mean, here's the thing that brought this to me. We're both functional medicine providers and, in general, that means we run a lot more tests, different tests, but generally quite a few tests. And so, neither you nor I are kind of seeing your average person who's just like motoring along, doing pretty well, no special needs or problems or anything. That's not our population. You're geared towards athletics and I'm geared towards sick people.
So, 90% plus of the people who see me have some real problems going on. And often they've already been to multiple other doctors before they decide to stop in and see me and a lot of times like really basic routine tests have already been done and either they're told: Hey, everything looks fine. You don't really have a problem or we don't know what your problem is or maybe we have some insight into what your problem is but the treatments and things that had been recommended for you aren't working very well or causing other problems or something like that.
We come from a standpoint that neither you nor I are treating "average normal people" and so the needs of our populations are going to be different. Having said that, functional medicine docs, one of the criticisms against us is we run a lot of tests and it costs a lot of money because some of these tests can be covered by insurance, health insurance, some of them can be a little bit covered by health insurance and a bunch of them have little to no insurance coverage, and so looking at out of pocket costs to the patient.
I try to be very skeptical of the work that I do as well and think about can I work better, cheaper for people, easier, faster? How can I improve the care that I'm giving people? I try to look at the cases where I fail and look and see is there something I can change and do better to get better results for my patients? And so this idea of testing has been one kind of I'd been reflecting critically on myself and pondering how much testing should we do, how often should we do it, is this really necessary?
And so when we connected, it was something I was just thinking about. I wanted to -- I think there's a lot of valuable points we can cover but I also just kind of wanted to have this conversation and think things through a little bit.
Christopher: But still the principle is the same. So, maybe somebody comes to you and they don't so much have a performance goal but there's still that transformation of life. And when you throw down money for testing, that's what you're really paying for. And sometimes the economy is a false one. I'll give you an example. We were at Dale Bredesen's training at the Buck Institute in Marin a few weeks ago. And, of course, people say to him all this testing, it costs so much money. And his response to that is, "Have you looked at the cost of a nursing home?"
We're keeping people out of nursing homes here. So, overall, you may end up saving money. For me, personally, it completely transformed my life. It allowed me to start a new business. I got married. I had a baby. That's a lot more than $8,000 worth of stuff to me.
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Tim: Sure. I mean, I'm 100% behind you. And we've got a couple of issue going on, is that people don't sort of factor in lifetime costs. Like you said, if you're 20 years old and you've got some kind of smoldering underlying issues and they're not really going to severely affect you until you're 60 or 70 years old, and then it's going to be heinously expensive to deal with all of that, it's sort of human beings are really bad at kind of doing that long term calculus and saying: Okay, look, if I spend whatever it is, $8,000, right now and made some subtle tweaks and changes over the next 50 years I could go in a completely different direction and never have Alzheimer's or dementia or whatever, like other sub-cancer, other severe health consequences.
It's just we as human beings are really bad at doing that. And then our system is very much incentivized to not do much preventative medicine. Because the average -- Again, getting back to health insurance, which is both great and horrible all at the same time, the average person these days is insurance hopping like regularly. I mean, I know my wife works for a major company and they do provide health insurance but every year that health insurance policy, the carrier, all that changes because companies are shopping and looking for lower rates and everything.
And so what happens then is your insurance policy is incentivized to give you the least amount of care possible and not do preventative care because, again, if I give you preventative care, so they pay for preventative care now but you're not seeing the benefit until ten or 12 or 20, 30 years down the road, as that insurance company, they paid now to not get any benefit later because you're not going to be insured with them ten or 2o or 30 years down the road.
That's where the advantage we're seeing at some of the socialized systems whether it's Medicare, whether it's veterans, whether it's what Canada or the UK or many of these other countries are doing is if they have a lifetime vested interest in keeping payments as low as they can then paying more upfront for a lower total cost, I don't know if we're going off in the weeds here, Chris, but paying more upfront for a lower total cost economically makes sense for them.
But I agree with you. It is a little unnatural for individuals to easily make that jump and say, "Okay, Chris, I invest $8,000 right now to change the trajectory of my life." It clicks for some people and it's hard for other people to make that leap.
Christopher: Right. And I can give you an example, another example of someone different that really gets this. I'm sure this comes from his occupation. This particular gentleman is a plumber. When do you call a plumber? When you're up to your knees in water and you don't really know what's going on. It's a similar sort of thing as in health. People are very problem drive and then they typically only take some action once their house is on fire or they're up to their knees in water. But plumbers, they get this because they see that problem every day. If you only come and talk to me two years ago, I could have done something about this. But nobody every calls me and then says, "Oh, can you just have a look at my plumbing? Just make sure that it's okay."
This particular plumber, that's exactly what he's been doing with me for a couple of years now. We have some very detailed blood chemistry history for him and it was clear that over time he was becoming Iron overloaded. And so all he did was he went to the Red Cross and he donated blood and it's not purely altruistic. It's kind of a symbiotic thing to do. We basically cured his pre-diabetes. His hemoglobin A1C was 6.0 and it dropped down to 5.5 with one donation of blood.
His hemoglobin, which he really cares about because he's very high end mountain bike racer, was the best we'd ever seen in that time series. I can't really explain that. It doesn't make too much sense but still that's what we saw. I really thought that was to do with his profession. He gets it. He gets that the preventative side of things is really important.
Tim: Well, prevention is, again, prevention is hard for people because it's sort of like, hey, we're trying to do something so something doesn't happen. And this is where tests can be really valuable because you can see some of the changes. But if we're saying too, Chris -- I encourage all my male patients to go and donate blood. Like you said, not only is it an altruistic, like a good thing to do, you could save someone's life by having that blood there but Iron overload is not an insignificant condition. I know you guys do this.
I'm always frustrated when I see ferritin levels which are an easy, cheap common screen that could be just quickly checked in men and it's never checked. And then you check ferritin and you're like, wow. Like you may not be in hemochromatosis with frank Iron overload and liver damage and everything else but your Iron levels are just too high. And if you would just donate some blood once in a while, this would never be an issue for you.
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Christopher: Right. Absolutely. There are 11 people hopefully still walking around in this planet that saved my life once upon a time when I had a motorcycle accident and I tore an artery out of my neck. I had 11 units of blood donated to me whist I was having surgery. Yeah, there's 11 people that saved my life. I'll be dead right now if it wasn't for people that donate blood. I wish I could do it. But, of course, being British, they think I've got mad cow disease so I can't go do it. But I'm going to have to find a way sooner or later because I too, since I adapted -- Well, fixed my gut was probably the main thing that I did. But I adopted a Paleo type diet. It seems to be too rich in some nutrients and I am starting to become a little bit iron overloaded myself. At some point I'm going to have to take a trip back to the UK and give back some of my blood from whence it came.
Tim: Right. I was going to say your other option, what I'll do sometimes for people is, a doctor can order what's called therapeutic phlebotomy. So, phlebotomy is just the drawing of blood. So, I can put -- and I've done this for patients before. You put in an order with the blood bank or whatever and you say, "Hey, listen, for a medical reason, this person needs to have some blood drawn." And they may even just throw away the blood, basically, if they deem that it's not acceptable but they're just getting it out of you. That's another option you might want to. And for anybody out there, for whatever reason, if they can't donate blood but really need to, get your doctor to write order for therapeutic phlebotomy. A lot of places will do that for you.
Christopher: Okay. Well, let's talk about some of the testing that we do. I take a very much an engineering approach where everybody that walks in my door, I don't really care about your symptoms too much. I just still want to do a proper investigation. I think a good analogy would be you're driving your car down the freeway, the engine check light comes on, you're starting to lose power and eventually you pull over to the hard shoulder and you take your foot off the gas in the engine stores and you're like, "Oh, shit."
And so you call the tow truck and they take your car to the garage and they plug it into a machine and they do this big diagnostic session and they tell you what's wrong. And then you're at a position, you can start fixing things and so I do exactly the same with all the athletes that come in our door and like, "I don't really care about your symptoms too much. I'm going to listen to them. I'm going to write them down. I'm going to make sure that I do understand your situation. But at the same time I'm still going to run this fixed menu of testing that tells me what's going on inside your body right now."
Because that data is what enables me to do what I do. And if I don't have that data I'm no better than any coach that you could find anywhere in the world really. I don't have anything special. I don't have a magical ability to know what's going on inside the people's bodies without these tests. But at the same time I wonder, I doubt myself, I think, am I an idiot? Could I be doing this so much better if I had a classical training like yours?
You'd just have that education and you have that experience and sometimes you have the ability to actually lay your eyeballs or even your hands on a person. And so would you be able to know what's going on for this person without having all of these expensive tests?
Tim: There's a couple of sides here. So, when someone comes -- I'd give you my process kind of in the short version. So, someone comes to me and, again, 90% of the time they're complaining of an issue. We'll make something up and say they're coming in complaining of stomach pain, their stomach hurts. You're trying to get more clarity on that. Obviously, the common questions a doctor would ask you is like, "Well, when did it start? What else was going on? What makes it better? Does anything make it better? If so, what? Does anything make it worse? If so, what? What else is going on with you? How bad does it get?"
You're just trying to kind of pin down that symptom and, for me, I mean, I'm somewhat similar to you in the sense of you imagine a tree and the symptoms are like the branches or the leaves on that tree and you go, "Okay." It's important to look at that and understand it but you're trying to trace it back down to sort of the root and say like where is this symptom coming from?
Because what I tell my patients is if your symptom is significant and if your symptom is relatively mild we may just leave it alone and we may not actually directly be treating that symptom. If the symptom is bad, like it's really interfering with quality of life or really giving you trouble, we may have to directly go in and treat that symptom to get control of it, to, again, improve quality of life.
I'll give you an example. I had a patient just this week with eczema, lots of itching and eczema. Now, we know the conventional treatment for eczema is going to be put steroids on the skin, suppress the immune system that calms everything down. It alleviates at least, when everything works right, alleviates the itching, the person feels a lot better. But again, are you dealing with the root cause? Not in any way, shape or form. And for most people, when they stop the steroid cream, everything just comes back again because, again, the underlying cause hasn't been treated.
So, in general, I don't like steroid creams and the general dermatologists recommendation of just put steroids on it is like, okay, guys, you're sort of you're looking at the leaves and you're treating the leaves and you're ignoring the real problem.
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But this person, their eczema and itching was so bad that they weren't sleeping at night, that their mood was completely wracked, that they were just -- it was severely impacting the quality of their life.
Christopher: So, it's not just the symptom then. It's a reinforcing cycle that's driving into other things.
Tim: Right. So, the symptom becomes a cause because if you can't sleep then you're causing all the negative consequences of not sleeping which then further -- Like it becomes a vicious cycle that we just have to break the cycle. The last thing you would expect a naturopathic doctor to do is recommend steroid creams but I was like, "Hey, we need to use a steroid cream, interrupt the cycle, so that you're sleeping again while we're getting to the underlying causes."
I got a little off there but when someone presents with a symptom I'm always trying to understand the symptom and then backtrack and then try and understand where that comes from. Now, training and years of experience have given me a lot of likely hunches about what's going on. So, if someone is saying their stomach hurts and these are the kinds of symptoms and this is what tends to make it better and this is what tends to make it worse and this is some of the other things that going on, I can get, I have a general idea before I do any testing that this is probably your issue, Chris, based on the symptoms that you've told me.
And then the question becomes, and we always have a little discussion, I have always have a little discussion and I always say: Listen, I prefer to test and have objective measurements rather than just guess about what's going on for you. And here is the pros and cons. If we just guess, it's probably X, Y and Z but I can't say for sure without some hard data to back up my theories about what's going on for you. And if we guess, we save money on the front end because we say, "Okay, look, we probably have some "adrenal fatigue" or some adrenal dysregulation. Your symptom suggests your thyroid might be a little off. You probably have bacterial overgrowth going on in your gut. There's probably some malabsorption." Whatever it is, based on their symptoms.
And we can go ahead and create a treatment plan based on that, saves money up front. But then essentially the testing comes into play in that we need to watch the change in your symptomatology and your overall sense of wellbeing. And again, for some people, that can be really straightforward. If you have severe stomach pains every day, you're going to know fairly quickly if you're seeing a change there.
Some of the other, what the testing also does is it allows us to access things that people can't feel. So like diabetes is a great example. People can't feel high blood sugar until severe damage has been done. If we did no testing whatsoever, we'd have to wait until people are in really bad shape before we found it and went, "Oh my god, you're diabetic. Now, we need to do something." Whereas, like you said in your example, by doing some testing, we can find diabetes well before it ever becomes diabetes or even if it is diabetes well before it causes severe damage for a person, treat it and sort of put them on a different path from the one they were going down.
Christopher: Your thinking here, it sounds so simple. It just seems like common sense to most human beings. But I have to tell you that it really isn't common sense. Most doctors, I think, are not thinking like this. I'll give you another example. We just got back from an artificial intelligence in medicine conference down in Southern California and I was in this conference listening to all these doctors and computer scientists talk about artificial intelligence in medicine and there were some guys there from Google and they were presenting the detection algorithm for diabetic retinopathy.
There's a really nice paper. I'll link to that in the show notes. Basically, what they were able to do is train a model based on 500,000 labeled images of diabetic retinopathy and then the algorithm was then able to predict much better than any human whether or not the image shows retinopathy or not. And this sounds awesome and they're really excited about it, absolutely amazing.
And I just sat there fuming in the audience going, "You idiots. If you've just done an oral glucose tolerance test on these people 20 years ago, you could have saved their eyesight. You're barking up the wrong tree." I know that what you're saying makes total sense and it seems really simple but I can, I know that's not the way that most people are thinking about these problems.
Tim: Right. Partly, it comes back again to where payment comes from because, listen, not to sound all mercenary but if you're conventionally trained, conventional system, straight vanilla MD, they're not being paid to do preventative medicine both in themselves, the services that they're providing for you.
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The tests that they would run for you for preventative medicine are not going to be covered by insurance. It's really not going to happen. You know what I mean? One example I found, because we try to use people's, for lab testing and things, we try to use as much of people's health insurance as we can get away with because, obviously, we want to reduce their out of pocket costs as much as we can. But, for example, at least around here, vitamin D, 25 OH vitamin D, is basically no longer being covered by health insurance.
Christopher: Oh, wow, really? Even in Seattle where you know everyone is going to potentially have a problem?
Tim: Yeah. The insurance companies basically came back and said, "Listen, almost everybody who gets tested is deficient in vitamin D so you just assume that everyone is deficient in vitamin D and give them some vitamin D. There's no need to test. Just do it." Obviously, on some level, yeah, sure we can just give someone very modest dose of vitamin D, probably enough that the vast majority of people are going to achieve a non-deficient level of vitamin D. But again, sort of being able to pinpoint and really customize, we can't do it without a test to guide us.
That's the same thing. Like simple ones. Even ferritin. We talked about that before. The iron one. I've had tests come back where the lab, Lab Corp, we use commonly, big giant lab testing company that tons and tons of doctors of all stripes and shades use, and it was interesting because I got a note in December here when we're recording this podcast and the company is telling me, "Hey, you're running more ferritin than sort of the average doctor in your area." And you're like, "Come on. This is, at best, a $20 or less test. You're flagging me for running a really cheap and inexpensive and very, very useful test for people."
Or like hemoglobin A1C, the one that you talked about earlier, which is a measurement of long term blood sugar control. Normally, unless you're a diabetic, they don't want you, the system in general, doesn't want or doesn't see the need to run an A1C on someone unless they're diabetic or you're strongly suspecting diabetes. I don't know. My high horse here. We have to be aware. I mean, we need a couple of things.
We need the system itself to change because certainly it costs us entering into it and I'm with you. We have to look at many, as individuals, we have to look at many of these things as investments. So, I'm investing in some preventative blood work and I'm doing it at least semi-regularly to watch trends in my health and everything. And if I cannot go down the average root of becoming diabetic or having a heart attack or getting dementia or getting cancer or at least reducing my risk of all those bad things happening, then it's a wise investment. But certainly, if the conventional system would pay for some of these things or value them it would sure be a lot easier to get it done for people.
Christopher: Say, I walk into your office then and I don't care about insurance. Right now, I genuinely do not care about insurance, not for my own family personally. I'm in no way financially affiliated with this company and I make this recommendation very tentatively but we have this thing called Liberty Health Share and it's technically not insurance but it does qualify you for exemption from the Affordable Care Act so I don't pay a tax penalty.
Basically, the way it works is you walk into a doctor's office and you say, "I'm paying cash." And then you get a completely different price. I've done it recently when I went to see a foot doctor. They said, "$100." I'm like, "Okay." And you know that's not what they would have charged had I given them a PPO insurance card. I really don't care about insurance at all at this point. By the way, it's only $400 a month for this Liberty Health Share for my whole family.
Tim: I think it's great. That's a new trend that we're seeing emerge called direct primary care essentially. I know of it. I don't know the -- What did you say it's called? Liberty?
Christopher: It's Liberty Health Share. There's another one in Oregon too that I can link to. They all work very similarly where you pay this fixed monthly fee and then they have this thing called a share box and then you have to pay $1500 of your first expenses, so a deductible. They don't call it a deductible but effectively it's a deductible. And it's $1500 which is nothing compared to even the best PPO plans that I've seen recently.
And then the rest is covered. And the only catch with all this is it's a quasi-religious sort of thing where they don't cover -- In fact, it's not quasi-religious at all. It's religious. They don't cover things like abortions and if you're an alcoholic then they want you to go and see a counselor and all of this so it comes with strings attached in certain situations. But compared to anything that's available through California for me, it's in a different league completely.
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Tim: Right. I think, for a lot of people who are listening to this podcast, the idea -- So, what we're seeing a lot of -- I don't even want to say that word because that could be demeaning. When I say intelligent, I'm not putting down anybody else but, I mean, people who sort of researched, thought about this, evaluated their life priorities and decided what works for them. They're finding that either the HSAs, the health savings accounts, which give people more control over where they're spending their healthcare dollars or this new emerging thing and it's really kind of started to take off in the last probably two years or so known as direct primary care.
I know this isn't our topic but just super briefly, what happens when you have health insurance is you go and have a doctor's appointment, the doctor then turns around and submits bills for that. So, you pay a co pay and then the doctor is going to submit the bill to your insurance company based on that visit and all these different codes and everything else. And then that insurance company is going to process that, kind of think about it, and then submit that, pay the doctor at a certain rate.
There's this big middleman that sits in between you wanting to receive care and your doctor trying to give you care. It's been proven over and over that it sucks up time, it sucks up tons of money and it results in a lot of inferior care and a lot of shaping of care like we talked about, what they decide they will cover, they won't cover, all these different things. Direct primary care is sort of this new system where they're saying, well, what would happen if we sort of cut the middleman out or really slim that middleman down to a very, very small chunk?
And essentially, doctors were contracting on cash rates and with the way it works out, it's a new trend. I certainly encourage anybody who's listening to at least consider the idea of direct primary care if it's not for you to make sure switch over your insurance policy to health savings account or something similar. It gives you some control and you can -- We're saying what if you walk in and you're saying I'm paying cash, don't care about insurance, let's evaluate, let's do whatever I need and let's make it happen.
Health savings accounts can help a bit there because at least until that deductibles met you have control over where you're spending your cash. I'm sorry to cut you off there.
Christopher: No, no, no, that's good. That's good information. Back to my -- So, I just walked into your office, I don't care about insurance, and let's say -- I'll present with my actual symptoms that I had. I look incredibly lean, maybe even sarcopenic but I've got this huge baseball where my -- not baseball. I mean, basketball. I get my American sports mixed up. They're all the same to me. There's a huge basketball where my belly is. There's, obviously, a lot of bloating, visible bloating and distention, a lot of GI symptoms, very inconsistent. For me, it was mostly diarrhea but I know that some people alternate between the two.
And with it comes a lot of fatigue. I had a lot of insomnia. My circadian rhythm was obviously broken but I didn't know anything about that at that time. And so I walk into your office and I say, "I'm paying cash, Tim." What test would you do first?
Tim: So, partly, there would be an opening discussion about how much testing do you want to do? I'd be up front with you that, look, again, depending on whether insurance can pick up any of the tests and how many we want to do, we can spend potentially up to a few thousand dollars just depending on what we want to do. And so some people are going to come to me and they're going to say, "Well, let's try and -- I have about this much money. Let's do this and let's prioritize." And other people are like sky's the limit, let's do everything. Being that I see a lot of digestive problems, I'm going to run a stool test straight up on you and take a look at what we're seeing.
Christopher: So, which one?
Tim: Sure. We're good to name names here?
Christopher: Oh, yeah, of course.
Tim: Okay, cool. For most people right now, we're doing the Genova's GI Effects. So, it's a combination. I know there's a lot of stool tests out there. I know some docs are running, they'll run two or even three stool tests on someone and we need to talk about this that there is no perfect test. No test covers everything, does it super exceptionally well. So, in a perfect world, you could run a couple of tests. A lot of people are doing the BioHealth which I've seen has worked really well for picking up parasites but that seems to be about the best extent of that test.
Christopher: Right. The stool culturomics on it is pretty primitive although they have just recently improved it. It's gotten a little bit better but it's nowhere near as advanced as the GI Effects that you're talking about.
Tim: Right. Some of the older culturing like Doctor's Data has been around forever and does a really nice comprehensive stool analysis. It's culture based so you miss out on the DNA but it's pretty rock solid reliable. But for most people, if you were presenting kind of a basketball tummy and diarrhea, I'd be looking at a few things.
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I want to know, first off, I want to know if you have celiac disease so we'd run a blood panel and just look and see if -- Again, we take a look at your diet. So, depending on that--
Christopher: So, tell me about the celiac panel. Actually, I think that was the case but I never got the gold standard diagnosis. Nobody ever did a biopsy. I'm done with gluten. Like you can keep the biopsy. So, what blood test are you doing?
Tim: Yeah. They're called celiac panel. There's basic ones and there's complete ones. And so if I have my druthers about it, I'll run the complete. I'd have to double check. I think there's six different antibodies that are looked for in the complete. There's your transglutaminases. There's deaminated gluten. There's, shoot. I want to say there's a -- I could take a look and see there's a couple more and I'll tell you sometimes -- Like one guy I caught on a very uncommon celiac marker.
He was clean of the other five but the sixth one that is not run on normal kind of slimmed down celiac tests, you're not going to find it so we kind of caught him luckily there by being more comprehensive in running the test. But certainly there are antibodies that you can run for celiac disease and so we'd want to know that. And then there's genetics that you can run for celiac as well.
Genetics are a little tricky because, basically, 95% of people with celiac disease have a certain kind of range of genetics and if you have those genetics it puts you at varying risk percentages for developing celiac disease from kind of very high risks to relatively low risk. And then if you don't have those genetics you're considered to be at extremely low risk of developing celiac.
But the thing is, even if you have the high risk genetics, it doesn't necessarily mean that you do have celiac. I know your audience here is pretty smart, Chris. They know the idea that genetics sort of provide the predisposition most of the time but they don't, they're not generally speaking, like one to one if you have this you're absolutely going to get that.
Christopher: Right. And, of course, it could be that maybe you're not a true celiac in the medical diagnosis sense but you do have some degree of gluten sensitivity and maybe that gluten sensitivity is being orchestrated by the microbiome that's going on for you right now.
Tim: Absolutely. It gets complicated for sure. I am a big believer, whatever you want to call it, the non-celiac gluten sensitivity kind of piece where people just find they eliminate gluten and whether it's a fodmap issue, whether it's celiac issue or wheat allergy issue, innate immunity through different pathways issue, there are definitely people out there they avoid gluten and symptoms clear up and they feel so much better.
For me, I really do counsel that it is worthwhile to be tested for celiac disease and differentiate it from just sort of the non-celiac gluten sensitivity. Because here's the deal, with celiac disease, it is an active autoimmune disease and even trace amounts of gluten are enough to activate or keep it activated. So, that can be as ridiculous as someone cut a loaf of bread on a cutting board, sort of wiped off the cutting board so there's no visible specs of bread or anything, slaps your food down on that cutting board and that transfer can be enough to keep the celiac disease going.
If someone uses a toaster and puts gluten, something with gluten into the toaster and then you're putting your gluten free whatever into the toaster, there can be enough transfer to keep that going. So, true celiac households where gluten is still being consumed, they often have separate toaster, separate cutting boards, separate pots and pans, separate and labeled these are the ones for gluten, these are the ones not for gluten.
Because even those trace amounts of gluten can be enough to keep celiac disease going. And one of the things we're concerned about is there's a specific type of cancer known as intestinal lymphoma that there's 700% greater incidents in people with active celiac disease. Kind of that inflammation just keeps rolling along. And so as opposed to non-celiac gluten sensitivity or whatever you want to call it where people feel terrible when they eat gluten but then they don't eat gluten and the terribleness goes away for them.
So, for me, it's the difference between being -- Listen, you're a smart dude, Chris. You know when you eat gluten you feel bad. Most of the time you should not eat gluten. If once in a while you decide to make that decision, have at it, suffer the consequences and get on with your life. Whereas if you truly have celiac disease, of course, you're still an adult, you can make whatever decisions you want but the consequences are much more dire.
[0:35:08]
That's why I'm a big fan -- Like if we have any concern that someone might have celiac disease, it's getting them tested. This is an important piece that a lot of people miss. The general consensus is that if you've been truly gluten free for six months or longer, those antibody tests will be negative. They will not show anything because your immune system has been, well, there's no gluten of levels of antibodies fall.
And the general consensus, there's debate, but the general consensus is if you then want to go and get a celiac test done to see if you truly have celiac, that you should eat the equivalent of two slices of bread, gluten bread every day for two weeks before doing that test. You need to have -- So, most people --
Christopher: This exact thing happened to me. I was like, "Yeah, goodbye." There was a puff of smoke where I was sitting in the doctor's office when they said--
Tim: Often, if we're suspicious, we'd run the celiac test up front because before we say, okay -- Because on the flipside, we can say, okay, we do a diet evaluation, Chris. We see you're eating many of the common food allergens, the ones that are most problematic, how about doing a 30-day elimination and sort of seeing how you feel? Did that make you feel a lot better? A little better? Not any better or even potentially worse?
And that in of itself is a test. So, we look at tests and we think of blood tests and we think of poop test and we think of whatever but therapeutic trials of different things whether it's an elimination diet, whether it's antibiotic, a steroid, an herb, whatever, are also, if you will, tests. And so if you take that thing or do that thing and you feel a lot better, well, we have a positive test result that said something about that intervention makes you feel better.
If you feel worse, okay, something about that intervention has pushed you in a direction, your body in a direction that exacerbated or made worse your symptoms. And if you don't notice any change, then again, it's a symptom that that therapy, whatever it was, was ineffective for you. So, let me just say, I have a lot of people that come in who've already done quite a bit of testing by the time they come to see me. And they're obviously, very disappointed and usually they've spent some money out of pocket and it's like, "Oh, man, I did this and I did that."
And I always tell them that it's important to look at those uninformative test results as still useful data. So, if we look and we say, "Okay, Chris, well, you have a basketball shaped abdomen but we looked, your MD ran these tests and we see that your liver looks good, your kidneys look good, your white blood cells appear to be normal, you don't seem to be anemic, your cholesterol seems reasonable, a whole other discussion."
On one level, there's nothing there. On another level, there's useful data there. We can say, okay, your kidneys are not severely inflamed or damaged, your liver is not inflamed or damaged, your red blood cell production is normal, your white blood cells are not skewed in a really messed up way. So, still useful data to be gleaned out of that. And often we can use that again in these big matrices of sort of deciding what to do to point us in a variety of different directions, right?
So, if you came in with a basketball size abdomen and your liver enzymes, your liver inflammation was elevated, that would push us in one direction versus maybe another direction. Or if you're quite anemic then we'd be looking in a different direction.
Christopher: Right. And I was, actually. I had both elevated liver enzymes and I was anemic too. So, the opposite of what I just said. Like I seem to be becoming a little bit iron overloaded now but back then I ended up in the hospital having iron put in through IV. Yeah, I was anemic.
Tim: Right. So, I mean, that leads you down different directions. But in general, so we're doing like a -- If that basic lab work has not been done, things like a CBC, metabolic panel, I often will look at things like CRP, which is an inflammatory marker, ferritin for iron, something called GGT, which is both a measure of, another measure of liver essentially, but also can be a sign of detox stress on the system.
Depending on what someone is complaining of, we may even do just do a quick test and look at testosterone levels, thyroid we're commonly looking at just because I see, in my practice, I see so many thyroid issues going on. Anything to do with digestion. We're doing stool panels. So, my most common one is the GI Effects just because I find it works and it's sensitive and it gives us a lot of good data to go on.
[0:40:05]
If I'm suspecting SIBO, if that distention, that basketball tummy -- I kind of make the distinction between is it gaseous, are you bloated with gas or are you passing a lot, are you burping a lot, are you farting a lot, are you really kind of -- when you feel someone's abdomen, is it more gassy in nature or are we looking at more like edema, more fluid?
So, someone can be really swollen fluid, more fluid wise and that's more there are variety of reasons but I always think of that as a more kind of inflammatory -- When you feel someone's belly, you can feel the difference between that. And so, again, especially if it's more gassy, then I'm thinking more could SIBO be an issue here? So, we should run a SIBO test. I'm often just using the Genova's Bacterial Overgrowth, which I find works just fine for me.
I'm a big fan and I run quite a bit of the organic acids and I've gone back and forth between, again, Genova's organic acids and Great Plains Labs organic acids and they both seem to work just fine.
Christopher: And tell me about what the sort of things you find on the organic acids test.
Tim: Well, I mean, I commonly see quite a few issues. So, with fatigue and stuff, we're often seeing -- The organic acid is going to cover a variety of things. I like the test in general because it's a simple test you just have to pee essentially. It's not big super complicated test to get it done. It's reasonably inexpensive. I mean, depending on whether insurance will pick up anything, it's kind of the $200 to $300 range, which is--
Christopher: I have to warn people about this, actually. Because I've seen at least one example where someone's done an organic acids test and it'd be covered by insurance and then the insurance ninja comes six months later and whacks you over the head with the $3000 bill because the doctor produced an ICD10 code, I guess it is now, for each of the organic acids and they were billed out at like $50 each or something and the insurance company said, "Oh, I'll pay $10 of this," or something ridiculous. And then you end up with a bill that far exceeded the original cost of the test.
Tim: Right. Yeah, honest to god, it's a mess. Again, we try to work with insurance a lot and it's always this internal question because we're a cash pay practice. In other words, you come to see us for the visits and you pay for the visits and then we can give you those codes and everything to reimburse back. And we try to use as much insurance as we can for testing to try and save patient's money by -- whatever this means. But the amount of time that we have to spend kind of helping people through the process and dealing with the labs and the insurance and everything else--
Christopher: It's just not a good use of your time.
Tim: Yeah. You just wonder sometimes. And you're doing it to try and help people but, oh my god, some days, my assistant wants to pull her hair out. She can't deal with it some days. But make sure that's all squared and often we're advising people, look, I know it's a little bit of a hassle but call your insurance company, verify your policy, really get the information from them, write it down, write down the name of the agent that you talked to, have that data. It's a shame to have to deal with all of this stuff but better than finding out, like you said, six months down the road, all of a sudden this bill pops up and you're like, what the--
Christopher: You don't even know what it is half the time. I've always have that with insurance. I don't even know whether this guy was present at the surgery. Who knows?
Tim: But the organic acid is really nice because in one test it covers a broad swath of things that other common tests don't cover. So, to look at kind of your metabolism and are you metabolizing your carbs and fats, what's called your Krebs cycle where you're making ATP, is that working well or does that suggesting mitochondrial dysfunctions that are going on for you? It can tell us about a variety of nutrient deficiencies.
So like the Genova will pick up on a lot of B deficiencies. The Great Plains Lab will pick up on some amino acid issues, which can point to malabsorption if those are really low or cofactor depletion if they're really high. Again, this is the context of a reasonable diet. If someone is on a really unusual diet or something then, obviously, that can cause some issues for people as well.
It's looking at, it gives us a clue into neurotransmitters and brain function as well. Often that's really helpful. Oxidative stress. Are people inflamed and generating a lot of free radicals and kind of overwhelming the antioxidant capacity of the body?
[0:45:04]
Detox stress, so again it's not perfect but it can give us a clue is someone's body really struggling to detoxify effectively? Like are we seeing that glutathione status is really depleted or the red lining all their detox systems and it doesn't necessarily tell us why but it at least gives us a clue that that's going on and that that should be investigated further.
And then it has an indirect panel of bacterial and yeast markers. So, it's not perfect. It's not a replacement for a stool test but if we see lots of markers of dysbiosis then it's a clue like, wow, there's a lot going on. For me, in the functional world, this organic acid test is a really nice almost screening tool. Because in one shot, we can see, are we looking at mitochondrial dysfunction, neurotransmitter dysfunction, nutrient deficiencies, detox stress, oxidative damage and gut dysbiosis.
And it's like, holy cow, for a couple of hundred bucks. I don't know of a test besides good blood work and things that can give us that broad of a range. And so, if you came in with those symptoms, we'd be looking at, again, is there celiac disease or if you were saying are you having any bleeding with your bowel movements and stuff then we have to consider inflammatory bowel disease or other things?
Could there be SIBO present? Do we need to test for that? There are other issues that make us look at hormones or do anything else. And then organic acids. Another test that's kind of gone up and down for me over the years is kind of cortisol testing and just how much should we test it?
Christopher: Right. So, tell me about this. I know this is a controversial subject. I feel like the DUTCH test has given us a lot more data that I very much appreciate and I would hate to give it up but I have a feeling that I'm going to be able to predict the results of that test using other data that we collect. And I'm going to do that using a machine learning algorithm. And maybe I'll get into more of that later. But tell me about your experience testing cortisol.
Tim: Well, again, it's sort of like -- A lot of times once you've seen enough people you sort of get a sense of where people are. I mean, so again, with cortisol, we're sort of looking at is their pattern intact? And so if it is, generally speaking, you should be more energetic, you should be able to wake up and be energetic during the day. You should be able to wind down and go to bed at night, roughly speaking. And so if you see that that pattern is grossly disrupted, people saying like, "I can't get up in the morning and I can't go to bed at night," well then we know that their pattern is disrupted.
Christopher: Right. You've basically described me to a T so far, by the way. Everything that Tim has talked about so far I'm like checking boxes here, yeah, yeah, yeah. He's obviously seen me before.
Tim: Right, right. Well, and that's part of it. Again, you come back to a lot of education and it's a lot of just clinical experience and seeing people. And so part of the question is can we find ways essentially to replicate that whole education plus clinical experience piece so that we don't just have to rely on doctors and other health care professionals who'd been in the field that long. Can we use smart algorithms? Can we do some of these things? I think the answer is if it's done correctly, yes, we can.
Christopher: I can speak to that, actually. I've made some progress. So, maybe for our regular listeners who remember the professor Pedro Domingues from the University of Washington, and I should make a correction, actually. I said the University of Washington, and that's correct. What I actually said in the podcast was Washington University, which I realize now is a completely different place. Maybe I should just make that correction now and apologize to Pedro, sorry.
But anyway, he talked about lots of different algorithms but one of the algorithms he talked about was called XGBoost. I've done some experimentations with our data and I have successfully been able to predict the results of some of the tests that we do using nothing but all of the other data points. So, some of the markers on the blood chemistry are extremely predictable and maybe I'll post a couple of scatter plots that people can look at in the show notes for this episode, which will be linked. I'll send people that on my email list as well.
But basically, I can take, say, LDL cholesterol and not -- So, train the model on all of the values that I've seen, all of the other data that I've collected and then hold back a certain set of the data. So, the model has never seen that data and then use XGBoost to predict the value of LDL cholesterol. And you'll see in the scatter plot that I posted in the show notes that when the dot is on the diagonal line the prediction was perfect and you'll see the scatter plot is like all of the dots are on these diagonal lines.
[0:50:03]
So, what this will mean, I think, in the future is that I won't have to do so much testing. The cost of our program will come down because I'll just collect the data points that I know are very predictive of the other things that I find interesting. I think the cost is going to come down. That's what's going to mean for the people is like the program is going to become less expensive. But, I think, it's going to take me a while sort of really get this kind of figured out and up and running.
Tim: Well, I mean, there's a few sides to this. I know Robb Wolf, to kind of paraphrase him, kind of said something, look, when things first come out they're at a premium because you're looking at intellectual cost and low production volume and all of these things. So, when an item or a test or whatever first comes out, it's going to be very expensive. And so the early adopters and everything that are paying that premium fee, if you will, kind of subsidize and create the market place for those things.
And then as that service or item becomes better adopted, the technology smoothed out, becomes faster, more replicable, everything, the cost begins to fall on those items and so the good news is that some of these premium tests and everything like the GI Effects with the DNA analysis of the microbiome was heinously expensive and the cost is falling very rapidly on the cost to do that.
And so we're seeing just by its very nature as these tests kind of mature and get out there into the community and are used, the cost for the test themselves should be falling and then I agree with you, Chris, in the sense of can we use some combination of inexpensive testing plus maybe some quantification in terms of both data like things like heart rate variability and temperature and various other self collected data and like formulate stuff.
I'm sure you've seen these. A number of the various supplement companies and other companies have compiled symptom questionnaires and so it's like if you're seeing, when it comes to whatever it is, the stomach, you're seeing high self reported ratings, the very least it can steer you in directions and in combination with other data may be able to make pretty accurate predictions. Then the tests really come into play in that kind of scenario, at least for me, the tests really come into play then if things aren't going the direction that we expect that they are.
Christopher: Right, right. And, of course, the nice thing about my model with the prediction is it's predicting the results of an expensive test. But there's no reason why you can't do that test. So, maybe I would have a self serve model where you start with a relatively inexpensive blood chemistry and then you put that data through my model and it says probabilistically you have a yeast overgrowth at the very least you should do the organic acids test and have a look at arabinose. And so there's this greater confidence as you move through the testing and, I think, almost certainly that's going to reduce the cost overall.
Tim: I agree, yeah. I mean, I think the promise, and I truly hope it happens, with machine learning and big data when we're gathering hundreds of thousands, millions and possibly like billions of data points and we can make sense of them and we can filter out the noise and everything. Because one of the dangers that I've heard of testing especially doing a lot of testing is that we're going to generate some random readings that can be noise but that can push people down expensive time consuming and possibly potentially, depending on your therapy, dangerous routes when they don't really need to go there.
So, one of my pieces to people is, and all the practitioners, anybody who's listening, is if you get test results that don't make sense within the context of this person then you need to view those test results with skepticism. Depending on how expensive the tests were, repeat the test again. For example, if I'm running a test and someone has been fine and then suddenly their liver enzymes spiked and you're like, "Wait, what is that?"
You question them and it doesn't make sense and nothing is going on there. Like send them back and get another lab test. And if they come back elevated again then something is going on and if they come back normal then the test was either it was a total transient weird thing or the test was wrong.
Christopher: Yeah. And I should say something about it. This is common term that people are throwing around, big data. And I can tell you we do not have big data.
[0:55:00]
We're at this AI med conference and the hospitals are talking about doing 16 million blood tests per month. And we have data from between 800 and 900 athletes total. And the model that I've developed that has a really good predictive accuracy I did so with data from 250 people. This idea of big data, I think it almost needs to go away because you really do not need big data in order to do something useful with these machine learning techniques.
And the other thing I should say is that I'm pretty sure that my model is really good at predicting biomarkers for athletes because that is the only data that it has ever seen. And it's really interesting to see what you just said there is like where the model has the worst predictive accuracy are the outliers. Like you see somebody with a C-reactive protein that just like doesn't make almost physiological sense. The model did a really bad job of predicting that.
That might be another use for it, is abnormality detection. The model predicted this. We're seeing something, an order of magnitude different, maybe you need to go back to the lab and have this blood test done again.
Tim: That would make sense. And certainly, I mean, both of us, I think, if you think of the bell curve and the general population and where sort of our respective clientele sits on the bell curve, both of us are going to be not dealing with people under the bell essentially. We're going to be dealing with more of the outliers. I, again, deal with more of the really sick people and you deal with very athletic people and neither of them are average.
And so, I think, one of the average other things, and this is a whole discussion maybe for another time, Chris, is just the difference between functional lab ranges and kind of standard or what I call them pathologic lab ranges. And just super brief, because I need to wrap up this conversation in just a couple of minutes, Chris, but people don't know that labs basically calculate their reference ranges based on kind of the sum total of what comes into them not typically based on sort of a healthy norm.
Anyway, we can save that for another time because I think it's a fascinating discussion that a lot of people don't realize and we see it a lot in hormone levels, things like thyroid, things like testosterone, that people may say well, my doctor checked me and I'm fine and you look at it and you go, "Well, technically, you make it but you're not fine."
Christopher: Yeah, absolutely. I think that most of the listeners will be familiar with that concept. We have talked about reference ranges on the podcast before. I think it's another thing that the functional labs do a much better job of. So, for example, Mark Newman is the analytical chemist that came up with the reference ranges which are on the DUTCH hormone test and I know from interviewing him that he has seen a lot of data and he's done, I think, a really good job or those reference ranges. Yeah, absolutely, if you just go down to Lab Corp and get your testosterone checked, what does that reference range mean? Well, it depends on what type of person gets their testosterone checked. It's questionable.
Tim: I have definitely seen that reference range go down in my practice career. It's definitely gone. It's decreased. And so people who would have been abnormal a number of years ago now technically fall in the normal range.
Christopher: It's like the sizes of jeans. Like a size whatever used to be. Now, I'm a small. In the US, I'm a small now for some reason. I never used to be.
Tim: Yeah, totally. It's funny but kind of scary at the same time called vanity sizing where they've increased -- The actual size of the pants or whatever have gone up but the label size has not. And so, yeah, yeah.
Christopher: Something is going on here. It sounds fishy.
Tim: Yeah. So, testing, it is an interesting thing. So, for me, there's the balance between does the person want to go with saving money on the front end knowing that it may cause them more money on the long end, on the longer end. So, in other words, you come in, depending on what your symptoms are, I probably have a decent idea of what the actual problem is. And I could then create a treatment plan that would probably help you out.
And so we certainly can test if you will in that way of saying, okay, well, does your bloating get better? Do you feel better? Do your energy levels improve? Do this variety of symptoms change for you? if they do, then we know we're generally speaking on the right track and if they don't then we either need to vary treatment or we need to get some testing done. And so some people will choose to wait through a couple of iterations and so one of the things that just calls for is just patience on the part of the person.
And so if someone wants change quickly or as quickly as it's possible to make it then this approach is not going to work well for them. And then it would be if we don't get the kind of results we want then we would move on to testing and identification.
[1:00:11]
Most people who come to see me, they've been down that road a little bit already by the time come in and they're ready to try and find some more definitive answers and have some objective benchmarks to help gauge the effectiveness of their therapy. And so then the question just is what makes sense?
So like you, we kind of have some standardized testing that we use a lot. And then it's, well, we go forward with that, generalized testing or modify it in some way or add additional pieces or does your symptom picture strongly suggests? I think we might have mentioned this last time. There was a person who had thyroid cancer and they grew up literally down the street from a mine. It's like, okay, heavy metals and things should absolutely be looked for in your particular case. Does the history strongly suggest certain avenues that need to be explored? More strongly than for someone else.
Christopher: Well, this has been fantastic, Tim. I really appreciate you. Aspire Natural Health. I should make another apology, that is that last time we spoke I didn't realize that you had a podcast. I've got some catching up to do. And I will, of course, link to Tim's podcast in the show notes.
Tim: Yeah, absolutely. And I am excited I get to meet with your co-conspirator, Dr. Wood, Tommy. We're going to put together a podcast of our meeting as well. We'll see what we get up to.
Christopher: He's the organ grinder. I'm the monkey. So, yeah, definitely look out for that episode on Tim's podcast that I think you're going to be recording soon. I will, of course, link to your podcast in the show notes.
Tim: Thank you, thank you. Yeah, basically, the hub is aspirenaturalhealth.com. If you go there you can find our Facebook page, you can find links to the podcast, you can link to our videos that we put together. That would be the central place to go to.
Christopher: Awesome. Thank you so much, Tim. I really appreciate your time.
Tim: Awesome. I appreciate the time, Chris. I appreciate kind of thinking through these issues. I think we all, all of us, need to be skeptical about what we do. We need to think things through. We need to pause from time to time and evaluate what we're doing. We need to look at our failures because no one is going to be successful all the time. Some of those failures have key insights that we can use to drive our progress forward.
If your healthcare practitioner, if your doctor isn't continually educating themselves, isn't sort of skeptical of what they do and really thinking about things, my two cents is find another healthcare provider basically.
Christopher: Yes, great advice.
Tim: All right. Thanks, Chris.
Christopher: Cheers, Tim.
[1:02:49] End of Audio
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