Thanks to Dr. Susan Blum, functional medicine has even more to offer for patients with rheumatoid arthritis (RA) and osteoarthritis (OA). She shares new insights about RA’s underlying causes, details what goes missed in treatment plans, and gives practical tips for mining data from stool tests, utilizing functional blood markers, and combining herbs and probiotics to reverse processes that other practitioners may think are permanent. In this podcast, you’ll hear Susan cover:
- The underlying causes of rheumatoid arthritis – what goes missed, and why a focus on gut health and inflammation is not enough
- Oxidative stress at the joint synovium—why it’s so important to address this
- What to know about osteoarthritis as a metabolic disease, and why losing fat, not just weight, makes the difference
- A major driver behind the leaky gut and autoimmune disease link (including a lab test tip for measuring bacterial cell wall displacement and translocation!)
- Timing and advanced utilization of stool tests for rheumatoid arthritis
- How (and how long) to treat oxidative stress and dysbiosis, and ways to avoid remission
- Using broad spectrum botanicals and probiotocs for dysbiosis, and how to specifically tackle candida
- How food and stress change the microbiome in major ways and why we really need to help clients find balance
- The oral microbiome’s impact on RA, and restorative steps
- Advice from a seasoned practitioner: the top priority for transitioning to a successful functional medicine practice
A true pioneer in Functional Medicine, Susan Blum, MD, is a nationally recognized speaker, author and teacher. As Founder and Director of Blum Center for Health and through her patient care, writing, research and mentoring, she is a passionate advocate for those with chronic illness.
Dr. Blum, is Assistant Clinical Professor in Preventive Medicine at the Icahn School of Medicine, Mount Sinai and Senior Faculty with the Center for Mind-Body Medicine. She is Certified in Functional Medicine, author of The Immune System Recovery Program, and medical advisor for the Dr. Oz show and the Institute for Integrative Nutrition.
Podcast sponsored by Designs For Health
Designs for Health is a professional brand, offered exclusively to health care professionals and their patients through referral. By providing comprehensive support through our extensive line of nutritional products, our research and education division, and our practice development services, we are able to maximize the potential for successful clinical health outcomes.
Dr. Kara Fitzgerald Hi everybody. Welcome to New Frontiers in Functional Medicine. I’m your host, Dr. Kara Fitzgerald. Today, I am going to be speaking with a woman who I love and adore. A teacher, a brilliant functional medicine clinician, Dr. Susan Blum.
Let me give you a little bit about her background. I know you’re probably aware of her. She’s got some great books out, and is working on another one, and she’s just been in our space for a while, but she is a functional medicine pioneer. She’s nationally recognized as a speaker, author, and teacher. As founder and director of Blum Center for Health, and through her patient care writing, research, and mentoring, she is a passionate advocate for those with chronic illness. She’s also a great supporter of functional medicine training, and new doctors and clinicians transitioning in. We’re going to ping her on some of those questions, and get some advice from her for new docs coming in to functional medicine as well.
Dr. Blum is Assistant Clinical Professor in Preventative Medicine at the Icahn School of Medicine Mount Sinai, and Senior Faculty with the Center for Mind Body Medicine. She is certified in functional medicine, author of the Immune System Recovery Program, and Medical Advisor for the Dr. Oz Show and the Institute for Integrative Nutrition. Susan, welcome to New Frontiers.
Dr. S. Blum: Thank you for having me, Kara. I have a mutual lovefest with you. I look at you as one of my favorite colleagues, mentors. When I have a problem, you’re my go-to. Thank you for having me. Happy to be here.
Dr. Kara Fitzgerald Again, I’m psyched to have you. Yeah, it’s great that you’re nice and close, in that you’re in New York, and I’m on Exit 1 in Connecticut, as we were just talking about.
Today, one of your areas of focus has been on gut systemic connection, inflammatory arthritis. You’ve been looking at all sorts of autoimmune conditions. You’ve been looking at osteoarthritis. You’ve really a done a nice drill-down into, not only the literature around this, but then, how you translate into clinical practice. You’re looking at antecedents, triggers and mediators of inflammation. You’re thinking about it at the molecular level like oxidative stress, et cetera. Then, you’re thinking about microbial imbalances, be it the oral microbiome, the urinary tract, et cetera. You’ve just done a really nice look at all of these various moving targets, and how we can address them in our practice.
I want to jump in with you right now thinking about rheumatoid arthritis, specifically, and synovial hyperplasia from oxidative stress. Let’s go to the molecular level, and talk to me about this whole oxidative stress mechanism driving RA.
Dr. S. Blum: Okay, I’d love to. Actually, I’m just wrapping up my next book, which is Arthritis. I learned so much writing a book. That’s one of the really fun things about digging in. The book will be out at the end of this year in the fall. I really started reading all these articles about oxidative stress in the joint, in the joint capsule, and the role that it plays in triggering and perpetuating the inflammatory process.
I was really fascinated because, somehow, when I’m working with my arthritis patients, I really was more focused on just inflammation, anti-inflammatories, working with fish oils, fix the gut, and I really was not focused very much on oxidative stress, and evaluating it, and the status of their oxidative stress in their body, in general. As well as, you can’t really evaluate it in the joint capsule. There’s research that does, but we can at least evaluate it systematically.
I added this whole dimension to my practice. This is one of these things that I’ve learned, and that I really want to share with people because I know as I came up through, and over the years practicing functional medicine, it’s not something that was obvious, or that I was doing, but I am doing now, and it’s really fascinating.
It turns out that in rheumatoid arthritis, there is a very, very high level of reactive… they measure reactive oxygen reactive species at the synovial surface, and that they really discovered that this is one of the foundational causes of the damage to the joint, to the synovial membrane. It triggers hyperplasia and damage in the joint capsule. The research has been able to look at that and say, “Okay. Well, when there’s reactive…, all this inflammatory activity and oxidative stress at the surface, can we correlate that to measuring it, or is it the systematic antioxidative stress as well?” and it turns out that there is.
The research has really connected lipid peroxidation, protein oxidation, DNA damage. They’ve measured low glutathione levels, low vitamin C. Really looking at levels of antioxidants in the body that you could measure – measures of oxidative stress, especially like lipid peroxides and F2-isoprostanes, things like that that you actually can measure.
It just was really interesting, and that with rheumatoid arthritis, in particular, studies have shown that the higher the levels of oxidative stress and the lower the levels of antioxidants, it was correlated with more symptomatic RA, and the longer duration of their symptoms. It’s a really important thing for us to look at, and actually to treat, to measure it and to work on treating oxidative stress.
Dr. Kara Fitzgerald Absolutely. This is very interesting because I agree with you, the inflammation is driving the oxidative stress. I think drilling down to this molecular level is incredibly important. Of course, we’ve got a rich toolkit for addressing oxidative stress that we’ll talk about in a second.
Dr. S. Blum: Of course, we do have to look below that. In functional medicine, we always say, “Why is there ox- …” Like, “Where did that come from, and where did that come from? How did that get here? “There’s always drilling down to try to figuring out, “Okay, that’s fine. There’s oxidative stress but how did that start? Where did that come from?”
Dr. Kara Fitzgerald I know but wait a second. You’re-
Dr. S. Blum: Yeah, sorry. I’m getting ahead of myself.
Dr. Kara Fitzgerald Wait a second. We’re going to go there for sure. We want to gather in our arms all of those antecedent factors, what prompts the oxidative stress. Yeah, we have to answer that. You can’t just quench somebody with antioxidants, and expect good outcome. We have to get to those original antecedent factors. We’re going to circle back there. One of the fundamental molecular mediators perpetuating the damage in arthritis is this increased oxidative stress happening locally at the level of a synovium. Then, it’s also happening systematically. As you say, there’s evidence where we can see a decrease in various antioxidants and a corresponding increase in oxidative markers.
Dr. S. Blum: Which is a compelling way that we can follow and track what people are doing, right?
Dr. Kara Fitzgerald Yes. This is where we’re going to go. What are your go-to laboratories for monitoring? Are you looking at F2-isoprostanes, lipid peroxides?
Dr. S. Blum: Actually, yeah. I’m in the middle of trying to find where to get F2-isoprostanes covered by insurance. I haven’t been using that yet, but that’s one of my next go-to that I’m going to try to bring into the practice. I do a lot of NutrEval tests with Genova. I do their whole oxidative stress panel. It’s glutathione, lipid peroxides, the-
Dr. Kara Fitzgerald 8-OH.
Dr. S. Blum: Right, and 8-OHdG. I do those three basically. In terms of validating, we’re looking at the studies. Lipid peroxide is a pretty good, valid … It’s in the studies, whole studies as being shown to be a good, valid marker to follow. I definitely follow that, and I look at oxidative stress, and I follow them. In addition to working, like we’re talking about, with making sure they have enough antioxidants on board, working on looking for those antecedents for why they have oxidative stress. We’re working on that, which most of the time, it’s in the gut. It’s just where our discussion is going to end up taking us.
Dr. Kara Fitzgerald That’s right, a foreshadowing of events to come.
Dr. S. Blum: Or oral microbiome.
Dr. Kara Fitzgerald Yes, I know.
Dr. S. Blum: This is one thing to talk about too, which is another huge thing that I really learned writing the book.
Dr. Kara Fitzgerald All right, give me a second. We’re going to talk about it.
Dr. S. Blum: Wait. Before we move there about antioxidants, the book is very inclusive. I really did a deep dive into osteoarthritis as well. You can think of, really, there’s more than two categories of arthritis. The inflammatory arthritis, which is the autoimmune ones like rheumatoid, and spondyloarthritises like rheumatoid and psoriatic arthritis. But there’s also arthritis from rheumatic disease, which is lupus, and Sjogren’s, and things like that. Those are the autoimmune inflammatory arthritis. Then, there’s also a whole category of undifferentiated early RA. Those people with no markers, but it’s inflammatory, and we don’t know what it is yet. We have those people. That’s all the inflammatory arthritis.
Then, osteoarthritis as another whole group. Then, there’s the whole group of infectious disease like lyme and… Also, there’s uric acid and gout, which gout is, I guess, theoretically an inflammatory arthritis. As we’re looking at categories, I think, today, there is oxidative stress in osteoarthritis as well, and we’ll look at that, too. I just wanted to point that out.
Dr. Kara Fitzgerald Perfect. Thank you. That’s incredibly … Your book is going to be a treasure trove just given what you’ve thrown out there in one really long sentence.
Dr. S. Blum: Yes, sorry for that.
Dr. Kara Fitzgerald No, it really is going to be very useful. It’s incredibly important. The way that you’re going to address all of these, even if they have shared molecular underpinnings in the form of oxidative stress, you’re still going to be coming at them. You’re going to be addressing gout differently than osteoarthritis, or the rheumatic arthritises, or infectious. Listen, just give me just a high-level view on osteoarthritis, just some of the mechanisms there.
Dr. S. Blum: Osteoarthritis, what I learned and what I’ve come to really understand is that osteoarthritis is a metabolic disease. It is driven, the number one cause, as we know, is obesity, but it turns out that it’s not because you weigh too much, and your knees hurt because of the body weight that’s on the knees, just from torque destroying the plate. It turns out that it’s because of metabolic syndrome, inflammatory fat. It’s the inflammatory fat, and it’s leptin.
People with inflammatory fat, which is the visceral adipose tissue, that’s what’s driving the inflammation from metabolic syndrome. It’s what’s driving the inflammation in the joints. People that lose weight, they do better, but it’s more because their body fat goes down, and the inflammation goes down. It’s really a metabolic disease that’s tied with the diabesity, the metabolic obesity. It’s really a metabolic disease of the bone.
When you help people lose weight, it’s really looking at body composition. It’s really looking at the abdominal, the abdominal obesity. That’s the problem with osteoarthritis. When we work on helping people, it’s … Coming back to the gut, there’s always a gut connection somewhere it always seems, because we know that obesity is associated with the different pattern of gut flora as well. There’s still a component of healing the gut that needs to happen with people with too much visceral adipose, the VAT people and the metabolic syndrome people, but a lot of the drive, even if there’s injury and predisposing people, at the end of the day, the number one is abdominal obesity.
Dr. Kara Fitzgerald That’s such a great pearl and a really terrific finding in your efforts.
Dr. S. Blum: Yeah, and it also shows you that you don’t give up. I used to think, “Okay, you have, you know, osteoarthritis,” but it goes to show you, and what I’ve learned working with people with osteoarthritis, is that you clean up their diet, you put them on an anti-inflammatory diet, and you reduce their inflammatory markers in that way. You bring down the A1C, and you bring down their glucose insulin stabilizers a little bit, and they lose a little weight, and their joints feel better. I think that’s why. I think it’s a whole glucose metabolic syndrome sensitivity piece. The anti-inflammatory work that you do comes in that way.
Dr. Kara Fitzgerald There’s a lot of overlap in the approaches. I can see there’s some distinguishing features, but there’s a Venn diagram with all of these.
Dr. S. Blum: Yeah, totally.
Dr. Kara Fitzgerald Alright, give me an overview on how you’re thinking about … Actually, you know what, I want to go over to the gut microbiome here, or just the microbiome in general. Just analyzing environmental triggers really in any arthritis, understanding that there’s that oxidative stress underpinning, what are you looking for?
Dr. S. Blum: The first thing that I look for is dysbiosis in the gut. It’s been extensively studied in RA, really. It’s so fascinating that it’s really well studied, and studied looking at different patterns of the gut flora. A lot of these studies, what they’re showing, which I thought was so interesting, and look, I’ve been doing stool tests forever. We probably do thousands a year or something ridiculous at Blum’s Center for Health because there’s five of us practicing medicine there, so we’re all doing stool tests.
What studies have shown is that the increased intestinal permeability, which we all know about leaky gut and the association with autoimmune disease, but what actually happens? It appears that bacterial cell wall components from the gut end up in the bloodstream. Studies have shown that there’s cell wall components both in the bloodstream. There’s cell wall components that have been found in the joints. Studies have shown that if you use a model system like in mice, and you give them bacteria cell wall protein, the bacteria cell wall components, and if you give to them intravenously, you give them in the blood, they end up in the joints, and destroy the joints themselves, and they end up mimicking rheumatoid arthritis. We know that bacterial cell walls components are important.
In RA patients, really good research showing that RA patients have an immune response against the bacterial cell wall components, and it’s of many bacteria. What I learned, which is so great, right? We know Proteus. There’s been studies about Proteus floating around for a long time. Proteus is an enterobacteria, as its phyla. That enterobacteriaceae, however you pronounce. You pronounce things differently than me… Proteus is one of those. RA patients, specifically, the studies have shown that response against many different enterobacteria like Klebsiella, Citrobacter, Proteus, those are all enterobacteria.
We culture those all the time. I see Klebsiella and Citrobacter all the time, in the cultures of people in the stools test that I’m doing. I always wonder, what role that’s having. Klebsiella, in particular, the studies have shown that Klebsiella is with ankylosing spondylitis and uveitis. There are good studies of stool, that fecal, that Klebsiella is associated with that. Lots of really good studies on bacteria.
We also could get excited and try to figure out. A lot of the studies have been doing that, trying to figure out, is there specific bacteria that we could say, “This is the RA bacteria?” I think you and I were joking about this before we got on about the whole Proteus mirabilis because the urinary tract, there’s always been research pointing about urinary tract Proteus. There are definitely studies that appear that with Proteus in the gut, also needs to be involved, and it appears to have the ability to actually initiate autoimmune events in people with RA.
Studies have shown that if you lower Proteus antibodies, and there’s a great study that was done in 2015. Let’s see, it’s … I don’t know how to say the name, Cockenow… C-O-C-K is the lead researcher, but the study was done looking, at using herbs to treat the gut and they correlated lowering Proteus antibodies with a reduction in symptoms.
Now, I am also a believer. I actually try to resist the reductionist model where we’re just going after one bug because you and I both know, there’s so much we don’t know. We’ve had great conversations about what stool test, and the metabolome versus the microbiome, and what you want to measure, and which bugs are actually active versus the PCR DNA. There’s so much we don’t know, but I think that we can all agree, and this is really… I have to say my favorite thing these days is bring the sanity back. Bring the sanity back.
Dr. Kara Fitzgerald You’ve been doing that too. You’ve been doing a good job now.
Dr. S. Blum: I’m really trying to. I got this thing about bring the sanity back. Bring the sanity back about food. Bring it back about how we’re treating the gut. I think that the nice thing about what you and I do using herbs instead of one drug one bug is, herbs are broad spectrum. They prune. They prune the gut. They reduce overgrowth of populations of bacteria. When you use herbs, I am sure in this study, they can’t say they only reduced Proteus. They reduced other bacteria as well.
Dr. Kara Fitzgerald Absolutely. Yeah, they’re broad spectrum. First of all, folks, I will absolutely have the citation posted on Susan’s page, along with how you can reach out to her, and all of that jazz.
Dr. S. Blum: Yes, I’ll send you the link to that.
Dr. Kara Fitzgerald Okay. Do you know what the botanicals were they used in this 2015 study?
Dr. S. Blum: It was interesting. I didn’t really, but the study, the name of it is called The Potential of Selected Australian Medicinal Plants with Anti-Proteus Activity for the Treatment and Prevention of Rheumatoid Arthritis. It was a Pharmacognosy Magazine story. It was Australian medicinal plants. I didn’t really, but I have to go back and read what I wrote about it. What I was impressed with was the herbs they used, they demonstrated lowered the Proteus antibodies, and they also … I can look at that, and we can post something afterwards, and I can-
Dr. Kara Fitzgerald Yeah, if we can deal with, if we can hear about all the botanicals, that would be interesting.
Dr. S. Blum: Some of them aren’t familiar to me. I think that’s why it’s not off the top of my head, but I think even so, I think it’s a reinforcement that herbs work, all different kinds of herbs, and they demonstrated the effectiveness of the herbs because they had a before-and-after change in the antibodies for the Proteus. I think it just points to the fact that we need to treat the gut and that there are various kinds of bacteria that are associated.
If we talk about Proteus, and that’s fine. The other ones that really have been associated too is Prevotella, Prevotella copri. There have been many studies on Prevotella. When we do our stool testing, and so that brings us to how do we measure these things or can we? Some of the studies just link groupings, like the general phyla. For example, another study I’m happy to put up for people is the intestinal microbiome and spondyloarthritis. Tejpal is the name of the author. This one, they just looked at Bacteroidetes species and associated with arthritis, not really drilling down to the subspecies. Prevotella is within the phylum of … I know we pronounce this differently… Bacteroidetes.
Dr. Kara Fitzgerald That works.
Dr. S. Blum: I’m afraid to say it because I know you say it differently.
Dr. Kara Fitzgerald I know. I’m sorry.
Dr. S. Blum: It’s okay, but there’s a great review article, and it looked at Bacteroidetes, it looked at Klebsiella, it looked at Prevotella copri, and all different Prevotella species. As a whole, I really look at when I look at the PCR stool test, I look at … At first, I didn’t really understand what to make of the GI effects from Genova, which is limited really, and you can deduce from it. We all know we wish we had more information about the metabolome like instead of just these could be all dead bacteria right, what are they doing, but I’ve come to really appreciate this Firmicutes/Bacteroidetes Ratio in this context because it really looks like the inflammatory arthritis or the inflammatory pattern and the bacteria that are most associated with inflammatory arthritis are in that whole first phylum, the Bacteroidetes.
Dr. Kara Fitzgerald Okay, good. We’re talking about Genova’s GI effects test. This is the second page. This is all the predominant microflora. You’re doing an interpretation. You’re, first of all, looking at the Bacteroidetes phyla being elevated. You’re looking at that. Then, you’re looking at specific genuses within the Bacteroidetes, like you’re flagged on Prevotella and-
Dr. S. Blum: I’m definitely flagged on Prevotella. Then, they don’t really do a good job of breaking up the Bacteroidetes at all. They just have Bacteroidetes Prevotella as a group. Then, they have one Bacteroidetes they break out, which I haven’t really found if that particular one, other than that is associated with higher amounts of animal fat in the diet, makes that one meaningful.
I think that the simplest way to look at it and actually I really tended … Now, because of what I learned, I do look at that whole, the piece … There’s a few things I flag out for myself but from an inflammatory arthritis perspective, part of the question is, when do you know that you’re done? When do you know that you’ve done enough gut treatment, and that you can stop treating with herbs, or if they have SIBO, treating even for SIBO, treating with rifaximin, or however you choose to treat a dysbiosis? You treat, you treat, you treat. Usually for rheumatoid arthritis, I do two months of gut treatment right off the bat with herbs. We can talk about my favorite herbs and all that.
Dr. Kara Fitzgerald Yes, absolutely. Yup.
Dr. S. Blum: I did two months right off the bat, and you need some way to follow this. Actually, not that I’m pitching Genova or anything, but I did do a webinar for them a month ago. It should be on their website. I did a sequential stool testing in inflammatory arthritis talk for them.
Dr. Kara Fitzgerald Wow.
Dr. S. Blum: I showed how I use stool testing to manage people over time, and I showed sequential stool testing. One of the things that I have come around to use this one page for is if it looks like you have a straight high, across the wall, or that ratio, the Firmicutes/Bacteroidetes Ratio is a two or four, and you have just have a lot, and you can see it’s still really high Prevotella, really high Bacteroidetes, I might feel like I’m not done, and I might feel like they need another round of herbs, or maybe we pause for a little bit, and then we retreat.
In my mind, I feel like we might not be done because it’s just an imbalance towards an inflammatory pattern. This sort of enterotype, so to speak, if you want to talk about what enterotypes at all, I don’t know.
Dr. Kara Fitzgerald Folks, if you’re not familiar with the GI effects, I think most of you are, but you can certainly download a sample test report and look at this page that Dr. Blum was referring to. You can see the Bacteroidetes phylum right at the top, and she’s seeing this big right shift. All those markers, the numbers of those markers are very high. Then, conversely, the Firmicutes just below it, that group of microbes tend to be low. At the very bottom of that page, there’s the Firmicutes/Bacteroidetes Ratio. That’s down too. You’re looking at it, two to four.
Dr. S. Blum: These are really low numbers.
Dr. Kara Fitzgerald Yes, very low.
Dr. S. Blum: Most of the time, very low numbers.
Dr. Kara Fitzgerald Okay, perfect.
Dr. S. Blum: I do want to correct one thing you said is that sometimes Firmicutes isn’t low. Sometimes those are high-
Dr. Kara Fitzgerald Yes, that’s right.
Dr. S. Blum: … because imagine, if these things were low. This is not. It’s just that the Bacteroidetes are higher or that they are really high.
Dr. Kara Fitzgerald Yeah, got it.
Dr. S. Blum: You can view this and it looks like it’s just everything is high.
Dr. Kara Fitzgerald Yeah, that makes total sense.
Dr. S. Blum: Yeah. Then, I think that just does signify they, definitely need a pruning of some sort.
Dr. Kara Fitzgerald Yeah, yeah. There are some people who are just very bias to that pro-inflammatory pattern. You treat for a while, and then you do your follow-up testing, and they’re still elevated, and you go back in. Do you do your follow-up stool tests after two months?
Dr. S. Blum: Yeah, I wait. I do two months of treatment, pause for a month, and then I send out another stool test. They’ll send out the stool test at three months and then I’ll see them. I’ll review it with them at four months, just in terms of testing, yeah.
Dr. Kara Fitzgerald That’s very useful.
Dr. S. Blum: I always like to wait, and not test immediately when you finish the herbs because I want to see what kind of homeostasis the gut comes back into.
Dr. Kara Fitzgerald You concurrently, obviously. You’re not isolating treatment or limiting it to just altering the microbiome using herbs or antibiotics. Obviously, you’ve got diet going. You’ve got appropriate test limits at that time. You’ve got the full approach.
Dr. S. Blum: Yeah, the full approach. Two things I just want to remember to point out. One is even though we’re telling everybody about that the stool test can show them, theoretically, you don’t need a stool test to treat someone’s gut with rheumatoid arthritis. You know from the studies, they have dysbiosis. These are the trends. These are what the studies show us. The gut, as a whole, statistically significant alternation in the microbiome in these directions.
I find stool testing useful so you can track, and so to know when you’re done. I think we don’t always talk about long-term treatment, which is really what I wanted to focus on in my new book, which is also a lot of patient stories. There are 11 stories of different cases. Because people, it’s another thing that I have bug about, which is let’s bring the sanity back to long term. We’re just not fixers. We can’t just quick-fix people. This is a long-term thing, which brings me then to diet, which you just brought up.
Food is critical. The number one most important factor that determines your gut microbiome is what you’re eating, the number one biggest influence. As a whole, when you look at the kind of bacteria, animal food promotes more Bacteroidetes. And fiber, eating a lot more fiber, and vegetables, and plants, that increases the Firmicutes, which includes lactobacillus, Faecalibacterium prausnitzii, which is thought to be a good bacteria, and a lot of good butyrate and short chain fatty acid-producing bacteria. What you eat really, really matters.
Dr. Kara Fitzgerald Yes. That’s great. It is. When I was in the lab back when it was Metametrix, and we were the lab that launched this test, we were the first lab to bring DNA microbial analysis to the clinical laboratory setting, it was pretty exciting.
Dr. S. Blum: Cool. Yeah.
Dr. Kara Fitzgerald I know, I know. We were it, but we were burning the midnight oil analyzing what all these organisms meant. What diseases-
Dr. S. Blum: You know better than me. You should be giving this. You should be talking.
Dr. Kara Fitzgerald No, no, no. I just really appreciate the amount of energy and time you’ve put into this. The research evolves. It’s been a while that I was sitting in the trenches doing that. The big aha moment for me, just like what you’re saying, was I thought when I was doing this, I was like, “We’re going to find really precision treatment interventions. We’re going to know which pharmaceuticals and botanicals to use, et cetera. We’re going to just really be able to get in there, and manipulate it in this really controlled way.” That’s what I was hoping for which is terrible, I think, as a naturopath that I want to be so controlling about it instead of big picture.
But really after very exhaustive literature searches, we all concluded that, without question, it was diet that was the major player. It’s just this interesting paradox. The more precise we’re able to evaluate looking at the microbiome, looking at the epigenome, the genome, the metabolome, et cetera, et cetera, the more precise we get into diagnostics. We really go way upstream. It, again, reflects, “Wow, diet is the big leverage point here.” I just want to underscore that.
Dr. S. Blum: Absolutely. I’ll use myself as an example for a second, because I think that I will just have to qualify that by saying that diet alone won’t necessarily change this habit if you already have it or something else triggered it. A couple of years ago, one of my joints got, I got this episcleritis. It was after a period of a lot, a lot of stress. One of my kids had a head injury, and it was a terrible time. I got this inflammation in my eye, and one of my joints was a little inflamed and bugging me. I thought, “Oh my God. I have arthritis.” Actually, a part of that is what inspired me to dig in to arthritis and that’s my second book.
I did my stool test and I’m a vegetarian. I don’t eat animal. I eat fish once or twice a week. I don’t eat dairy. I don’t eat red meat. Now, I eat chicken maybe once a week, but for five to 10 years, I wasn’t even eating chicken. I was completely overwhelmed with Bacteroidetes, compared to Firmicutes. Diet alone doesn’t necessarily do that. There was a different reason. You think I should just be great. There’s something else pushing the microbiome, which, of course, stress is huge in terms of this as well.
That stress, I would say, is number two. I think stress is the number one reason why my arthritis people relapse. The inflammatory people relapse because stress and acute trauma, or traumatic things, someone dies. All of a sudden, the microbiome is completely out of balance again, and the dysbiosis is back, and then, the inflammation is back. Helping yourself and helping your people have some practice every day where they find balance, whatever that means, really, you need to put a little protective bubble around yourself to protect that, keeping that stress from coming in, and altering your microbiome again. I think stress drives the bacteria in a different way.
Dr. Kara Fitzgerald I’ve certainly seen that in my own practice. Yeah, that’s just a beautiful point to hit home. The microbiome can become refractory to some of the very upstream interventions like diet and lifestyle, and we do need to get in there.
Dr. S. Blum: What? Doing diet, but it’s not changing things. I know we’re going to run out of time, but there’s so much we want to talk about, and I just want to do mention one thing that I found really interesting is this whole discussion, now, about something called enterotypes. An enterotype is like your body type. It’s like, this is the pattern of the flora that your whole family has, that you’re born with, and it’s sort of like your body type. Despite your best efforts, your body wants to revert back to that enterotype. It does make you wonder, can we ever really overcome the pull towards your enterotype? The three main enterotypes that there are, that are at least defined in the literature as of this moment that I read about is the Bacteroides, Prevotella and Ruminococcus.
Ruminococcus is a Firmicutes. That’s more of a Firmicutes, but the Bacteroides and Prevotella, which also does speak to the fact that within the Bacteroidetes, those two Bacteroides and Prevotella, we shouldn’t lump them together because they are two distinct-
Dr. Kara Fitzgerald Enterotypes.
Dr. S. Blum: … enterotypes that fall into those categories. I just figured I must have one of those enterotypes that my body wants to keep pulling me back to. When I get out of balance, I go back to an original enterotype. Perhaps, I don’t know. I don’t know that we know.
Dr. Kara Fitzgerald Yeah, that’s right. This continues to be very, very much emerging. There are many variables that impact it. When you look at the whole obesity microbiome association, of course, it’s there, it’s strong, it’s growing, and the research is mixed. We’re still figuring it out. In your review of the literature, is there any enterotype that appears to be more closely associated with problems, with chronic disease. Is the Bacteroidetes that enterotype?
Dr. S. Blum: Not necessarily. We really didn’t discuss it in that way because really Bacteroides and Prevotella are good. They’re considered essential.
Dr. Kara Fitzgerald They’re essential. Yeah, they’re part of the predominant.
Dr. S. Blum: Yeah, they’re part of the predominant. It’s just a question of, so I think it’s okay to have an enterotype where that’s your dominant bacteria, but I think there must just be a threshold where it crosses over, and it ends up you have just too many. It becomes just really an imbalance, a true imbalance. I don’t know. It’s like the wild west. We’re trying to sort this out. I don’t really know quite what it means. When I read about enterotypes or the way I just bring it in to my own framework is I think, “Okay, well, that explains why it’s just so hard to help shift people’s microbiomes.”
Dr. Kara Fitzgerald It’s a lifetime commitment.
Dr. S. Blum: It’s a lifetime commitment.
Dr. Kara Fitzgerald It’s not just, as you pointed out, making sure you’re eating a super clean, pristine diet. It’s all the other variables.
Dr. S. Blum: It’s all the other variables. It says enterotype, when you read about it, enterotype is driven by long-term diet and lifestyle. It is a lifelong thing. That’s why you can’t just do a 21-day detox or 30-day gut reboot, and go back to your old ways because your flora, you’ll pull back to the old enterotype.
Dr. Kara Fitzgerald Listen, I just want to circle back to… First of all, I want to get your opinion on probiotics in a second. Let me just throw that out there, but leaky gut. Of course, leaky gut is fundamental. We’re thinking about it all the time in arthritis, not just inflammatory but all forms of arthritis. Are you diagnosing…
Dr. Kara Fitzgerald Are you diagnosing it? If so-
Dr. S. Blum: Am I using testing for it, you mean?
Dr. Kara Fitzgerald Yes. Sorry, not diagnosing.
Dr. S. Blum: No, I don’t do any testing for leaky gut.
Dr. Kara Fitzgerald Okay, all right. You just assume it’s there if the person presents with … Yeah, okay.
Dr. S. Blum: I just assume it’s there. Look, it might be helpful.
Dr. Kara Fitzgerald I’m with you. I’m not testing for it either because we know that it’s a piece of the puzzle. It’s just been so strongly established, I don’t know that it’s another test that we need to do, but it is … Yeah, okay. Then-
Dr. S. Blum: I do think that a surrogate test that I’ll do sometimes, that gives me an indication of how leaky the gut is, is the IgG food sensitivity.
Dr. Kara Fitzgerald Yes. Okay. I’m with you. I’m doing the same thing.
Dr. S. Blum: You too?
Dr. Kara Fitzgerald Yeah.
Dr. S. Blum: I do that as my surrogate. If you do that test, and it’s lit up like Christmas, that gut is very leaky.
Dr. Kara Fitzgerald I think there’s a place for zonulin, and I do look at zonulin sometimes, but I really just assume. As far as the testing dollars go, I think we get a stool test.
Dr. S. Blum: Right, exactly. That’s what I think.
Dr. Kara Fitzgerald Now, in terms of the cell wall displacement and the translocation of it.
Dr. S. Blum: I don’t know how to measure that. Do you know how to measure that?
Dr. Kara Fitzgerald Dunwoody does offer an LPS.
Dr. S. Blum: That would be a great test, yeah.
Dr. Kara Fitzgerald Yeah. Dunwoody does a handful of them. They do F2-isoprostanes, which is that oxidative stress-.
Dr. S. Blum: I keep having them on my list to call and set that up.
Dr. Kara Fitzgerald They do a handful of these things. Let’s move on.
Dr. S. Blum: Perfectly good test, thumbs up on that. No, really, thank you. It was just a reminder.
Dr. Kara Fitzgerald Absolutely.
Dr. S. Blum: I’m always tracing these things. Then, they don’t always get done.
Dr. Kara Fitzgerald I know. I’m with you.
Dr. S. Blum: Probiotics.
Dr. Kara Fitzgerald Yeah, probiotics.
Dr. S. Blum: Probiotics and herbs. My favorite herbs that I use, the one that I currently use, and I tend to rotate a little bit, but I really like GI Microb-X from Designs for Health.
Dr. Kara Fitzgerald Which is a botanical combination. It’s actually very broad spectrum.
Dr. S. Blum: It’s a botanical combination. Right. It’s black walnut, it’s artemesia, it’s uva ursi, it’s berberine. It’s like a broad spectrum. I use that and I combine that with oregano a lot, some sort of aromatic oil.
Dr. Kara Fitzgerald What brand are you using for your oregano?
Dr. S. Blum: I usually use Biotics, the ADP. Some people, those are those round big tablets that sometime people choke down. Some sometimes, in my pockets, I have these custom pockets that I make, I just use the Design for Health little oregano gel caps, gel little things, which are really easy to swallow. I think aromatics are really a great, especially if there’s any kind of candida or yeast. I try to throw in some of that. The other aromatic oil combo I like is Biocidin. Do you use that sometimes?
Dr. Kara Fitzgerald I sure do, yeah. Actually,everything you’re outlining, I’m using.
Dr. S. Blum: The Biocidin is really nice. I think it might not be enough by itself but coupled with, I call it the green herbs, and then the oily, the oils. I think when somebody has a lot of dysbiosis, it’s nice to combine those two. The other product that I just discovered that I really like is from Apex Energetics, which is the GI Synergy Packets. They have little packets, and there’s three pills in each one. It’s just that it’s just got of great candida stuff in there like…
Dr. Kara Fitzgerald Lauricidin.
Dr. S. Blum: Thank you. It will come to me. It’s got some good candida stuff in there, and as well as just all different herbs. It’s just, I think, it’s nice to change things up. I use that sometimes. Sometimes, I use CandiBactin from Metagenics when I just need berberine because sometimes people, they have black walnut or a walnut allergy, you can’t use any of the other stuff because everything has black walnut in it. Go ahead. Sorry.
Dr. Kara Fitzgerald We don’t have that much more time. I want to-
Dr. S. Blum: Probiotics are really important. There’s a lot and lot of studies on probiotics. Probiotics-
Dr. Kara Fitzgerald Give me your shortlist on what you’re doing with probiotics because we have to have time to talk about the oral microbiome. Then, I want to ask you about did any…
Dr. S. Blum: Yes, no problem. Shortlist on probiotics is that there’s some really important probiotics that have been shown to … They’ve done a lot of studies on just treating RA patients with probiotics and they get better. Lactobacillus casei is one of them. That’s very well-studied and has the best, lower CRP, improved symptoms. A lot of lactobacilli like rhamnosus and reuteri, improvement in symptoms. I do believe that people need probiotics because they actually help symptoms in the research.
I tend to use Klaire’s products, Ther-Biotic Complete. It covers everything. It has all those. You want to make sure it has casei, and make sure it has those several different lactobacillus species, and bifidus. I tend to go broad spectrum rather just using one. I think that’s simple on the probiotics. I tend to give them while I’m treating. I give it to them at bedtime while they’re taking the herbs during the day.
Dr. Kara Fitzgerald Now, let’s talk about the oral microbiome. This is a major piece of focus. I know that you’re addressing it and referring to appropriate-
Dr. S. Blum: Let me help you very quickly with this.
Dr. Kara Fitzgerald Yeah. Yeah, yeah bang it out.
Dr. S. Blum: Yeah, I’m going to bang it out. Fascinating, fascinating that when you check your patients, your rheumatoid arthritis patients, and you check the CCP antibody, the Cyclic Citrullinated Peptide antibody, what’s happening is that antibody, in particular, is associated with bacteria from the mouth that are translocating into the body, and causing these bacteria, Porphyromonas gingivalis, especially, but there are other ones as well. I think of Prevotella copri, or intermedia, is the one in the mouth.
There’s other citrullinating bacteria in the mouth. What they do is they secrete enzymes that causes citrullination of your proteins that then causes an immune response against the citrullinated protein. That immune response are the CCP antibodies. When you see somebody, take home is, you do your rheumatoid arthritis testing, you always check CCP antibodies. CCP antibodies are the most consistently associated with disease activity and remission.
If somebody still has high CCP antibodies, they could symptomatically, even if they’re on meds, and they come see you, and they’re seeing a rheumatologist and, “I’m fine. I’m in remission,” but their CCP antibodies are still up, they’re not in remission. It’s the number one way to predict relapse. CCP antibodies, in your mind, you have to think, treat the mouth. What’s going on the mouth? Are there bacteria coming from the mouth?
What I do is I send them to a periodontist for an evaluation. Some of them, half the time, they’re going to be like, “Yeah, I’m seeing a periodontist. I have pockets.” They’ll tell you they already have stuff going on. You send them to the periodontist. There’s a test that I’ve been doing called MyPerioPath. You can actually do a swab, and look at the microbiome of the mouth. It’s been very helpful. I’ve been using that in treating people and following them.
My own personal treatment, what I tell people to do, in addition to flossing and everything everyone else tells you is see the periodontist and do whatever they tell you, short of antibiotics. We want to avoid antibiotics. I have people do both a mouth rinse every day. There’s some good herbal stuff out there. On Amazon, you could find, like Herb Pharm makes Oral Health herbal moutwash. It’s just like you swish it for 60 seconds, and spit it out, but I also send people to get a Waterpik.
Dr. Kara Fitzgerald Yes, absolutely.
Dr. S. Blum: I send them to get a Waterpik, and you can get an oral cleaning, a concentrate. You can do just get a hydrogen peroxide. Put it in like a, but you can also do… I found something called Nature’s Answer, PerioCleanse Oral Cleansing Concentrate. You put two pumps in the water reservoir, and you can do that twice a day, or even if they just do it once a day, and do the mouthwash rinse once a day, but you have to get people on an oral care program.
Dr. Kara Fitzgerald Are you having them chew on an oral probiotic? I know there’s some of those out.
Dr. S. Blum: That’s a great idea. I actually have not. I had one person. I’ve only tried that with one of my patients so far. She actually had bleeding gums. She had a lot of bleeding in her mouth. That’s the reason she came to see me because she has this bleeding issue. It didn’t help her, but that’s just an “n” of 1. I have not consistently used… Do you want to share some information on that because I’d be happy to try that?
Dr. Kara Fitzgerald I think Designs for Health has an oral-
Dr. S. Blum: They do, yeah.
Dr. Kara Fitzgerald … probiotic. I have not been using it either as consistently, but I do think you could just have them throw some of Ther-Biotic Complete powder into the reservoir of the Waterpik.
Dr. S. Blum: That’s a good idea.
Dr. Kara Fitzgerald Yeah, you could do it easily.
Dr. S. Blum: It’s nice to alternate with the herbs, because you can’t do that at the same moment you throw the herbs in because they’re antibacterial.
Dr. Kara Fitzgerald That’s right or you could have them just do a nice, really …
Dr. S. Blum: [Crosstalk 00:48:23].
Dr. Kara Fitzgerald Yeah, exactly. Exactly. This is fabulous. It’s been such, such great information. Thank you so much. Then, just give me a couple of words. Now, I turn to you a lot for my business questions because you’ve done such an amazing job at your clinic and beyond. There’s a lot of clinicians transitioning into our field as you know. We’ve got a nice bunch of people listening to this podcast. What do you say to these folks making the journey into practicing this medicine?
Dr. S. Blum: The first thing is to have patience, and patience as in be patient. One of the things just popping in my head as you’re asking me this, I think the best advice I could ever give anybody is, my motto has been that a successful practice is one that has successful patients. If your patients are successful you’re going to have no problem growing your practice because they’re going to keep coming, they’re going to send everybody they know. Word of mouth will spread, and your practice will grow.
For me, what’s been critical was to figure out what needs to happen both administratively and clinically at my center. What do I need to provide people in order for them to be successful? That always comes out to a lot of support with like, “How do I do the kits?” and that stuff. A lot of just patient-coordinating support, as well as a lot of, in a way, coaching support, like “How do I implement this food plan. How do I stay on track?” Really having really good nutrition support because we do nutritional medicine. That’s what we all do. Really building a team that helps assure the success of your patients.
For anybody out there, I think you just have to really formulate for yourself how you’re going to help your people be the most successful. For me, I have a kitchen, and I have free pantry makeover class. I brought on a team. I always thought about it like I want to grow sideways. I want to bring a team together that will assure that the person, from the moment they call to the moment they walk out our door, and work on their program that they have all the support that they need to be successful because if you’re just by yourself, and somebody comes in, and you give them this whole long to-do-list, they’re not necessarily going to be successful. We really practice lifestyle medicine, and we really practice behavior change, and we really need a team that supports the journey. We’ve come a long run.
Dr. Kara Fitzgerald Yeah. You’ve done a really beautiful job building at that out. I know you’re an inspiration to a lot of us because you’ve manifested your vision in such a lovely way.
Dr. S. Blum: Thank you. At the end of the day, do what you need, do what you can to ensure the success of your patients, and that’s all that you need.
Dr. Kara Fitzgerald Yeah, yeah. Folks, thank you again for joining us for this fabulous episode of New Frontiers. You’ll find the abstracts, you’ll find Dr. Blum’s links and information about her newest book, and anything else you want on the website when we release this. Thanks so much, Susan.
Dr. S. Blum: Thank you, Kara.
Dr. Kara Fitzgerald All right. Take care.
Dr. S. Blum: Have a great day. Thank you.