 The dictionary defines “germophobe” as “a person who fears physical contact with germs and is therefore obsessed with cleanliness”.
Given what we know now about the fact that there are 10 bacterial cells to each human cell in our bodies, this seems like strange behavior indeed. How can you even focus on the germs outside when there are so many germs inside? Yet, germophobes are very common. A recent entertaining blog contrasted “germophile” and “germophobe”, insisting that one was not better than the other. But should we choose consciously? Is one better than the other? What would “better” mean in this case? Of course from my point of view as a functional medicine physician, “better” means free of illness, and full of vitality and a sense of well-being. If that is the goal, I think “germophile” wins. WE SPREAD GERMS INSTINCTIVELY The thing that I find most relevant to thinking about this question, is how many of our automatic and most treasured behaviors involve maximizing the transfer and spreading of germs. From the first moment of life, which, if we are lucky, involves a short trip down the birth canal, it’s all about getting as many germs as we possibly can. Breast milk is full not only of germs, but of germ “landing docks”, that allow germs to take residence in the baby’s intestine. Breast milk is also full of certain substances the baby cannot digest. They are solely for feeding the bugs that begin to inhabit the baby—letting them go hungry would be a disaster! Of course that is just the start. For some reason, I was overwhelmingly driven to kiss my babies over and over again. I touched them a lot and I have to say, I didn’t bathe them daily because they just didn’t seem dirty to me. Many of our other behaviors (kissing in general, shaking hands, touching, hugging) also seem aimed at sampling the environment and each other, and becoming maximally colonized with germs. Babies are notorious at mouthing everything within their reach. Is this really because the mouth is another “sense organ” to them, or is it because they are busily and systematically putting together an extensive germ collection? Read just a bit of the latest science on the gut-brain connection and you will learn that gut bacteria impact brain development and our responses to stress later in life. Even certain parasites are favorable to the brain. I am becoming a bigger and bigger fan of germs. To be honest, I am in awe of what they do for us. WE RELY ON BACTERIA DNA in the human cell comprises about 20,000 genes. Each gene is the blueprint for a protein that will then carry out a function within the cell or in another part of the body. However, the human organism requires about 500,000 to a million different proteins to function. Where do they come from? Some have hypothesized that the 20,000 human genes mix and match and combine bits of each other to become half a million different proteins. Others have argued that this is not the case: we get the vast majority of our cellular-level tools from bacteria. Each bacteria only has a few thousand genes. So the goal, clearly, is to collect as many different bacterial strains as possible as quickly as you can. Babies are especially well-suited for this. They have a “weak” immune system, so as not to kill off germs right away: the germs get the benefit of the doubt. As we get older, we still have a compulsion (or brilliant adaptation) to keep sampling: we touch things, then touch our face or somehow put fingers in the mouth. There could be a way that this helps us cope with what our environment requires of us: detoxification, absorption or manufacture of vitamins, immune system training and performance, connection with other human beings. We know bacteria influence or perform these functions. There could be more: we could be adapting to different threats: savanna vs. forest, tide pools vs. mountaintops. I’m deeply intrigued. And in turn, we impact our environment bacteriologically in exquisitely specific ways: each finger has its specific bacterial signature. What purpose does that serve? GUT BIOME DIVERSITY Now that we are measuring the gut biome (collection of all bacterial DNA within a human being), we know that within the body, about 99 genes are of bacterial origin for each 1 human gene. This is due to the large variety of bacteria we possess. The diversity of bacterial species within the gut is reported as a measure of robust gut health. When we observe indigenous cultures, we find that they do outrageously “germy” things, like let a carcass fester in the sun before consuming certain animals. All traditional cultures have a typical fermented food. Some will only consume certain foods if they have been fermented. We also notice that their rates of allergies, asthma, autoimmune disease, obesity, diabetes and most cancers are or were lower than ours. We think this is all related to gut biome diversity. Our laboratory animals may also be too sterile and may not represent how life really means to proceed. Rat cages are routinely sterilized, and their food, if you think about it, is typically entirely processed. Perhaps they represent what it would be like for us if we lived like that. GUT AND PSYCHOLOGY The most exciting findings recently are in psychobacteriology (I made that up, I don’t think they have a name yet). Most of our nervous system is in the gut. Most of our immune system is there too. It is where the action is, clearly. Bacteria make substances that are recognized by our nervous system. Researchers have found that bacteria in the gut communicate with our brains using the vagus nerve, that links the intestinal area with the brain. They help us be calm, resourceful and connect better with others. They may control appetite and food choices. In turn, all of the above influences our immune system function. I’m starting to think that germs make us better people—healthier, more connected with each other, more adaptable, and more relaxed. I think the vast majority of bacteria are helpful, and we should re-examine each one of our assumptions about killing them. There is a minimum of sanitation that prevents important infectious illnesses but by and large, we have gone overboard. So I am a germophile.
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VIDEO VERSION here:   What is your opinion about gluten? How have you come to your conclusions? As a functional medicine physician, I find most articles I read in the popular press incomplete. I would like to share what I have learned in my journey from conventional doctor to functional medicine physician.
The basic statistic is this: 1% of Americans have celiac disease, a well-established autoimmune disease. An additional 5-6% of Americans may have non-celiac gluten sensitivity (NCGS), which has very recently been recognized as a real illness by gastroenterologists. Both celiac disease and NCGS can have symptoms that have nothing to do with the gut. So, why are 10-30% of Americans (depending on the survey) trying to reduce the gluten in their diets? Are most of them fools? A new disease First let me point out that until 2011, most gastroenterologists refused to believe that gluten could cause stomach cramps in patients without celiac disease. That is barely 4 years ago. Now many admit that they were missing a lot of people with NCGS. Could they be missing something else? What will they admit to in another 4 years? Would you prefer to get healthier now, or would you like to wait? I understand the strong drive to prevent our patients from falling prey to expensive scams. I understand our hesitation to recommend a diet that has not been “proven” safe. I also understand that we worry that patients will neglect some other treatable condition and instead do diet experiments we believe are doomed to fail. So I think physicians who don’t believe so many people should be gluten-free have good intentions. I also know that American agriculture has a strong vested interest in maintaining (increasing, really) our collective consumption of wheat products. And American processed food manufacturing and food retailing has a similar strong vested interest. In the setting of powerful conflicts of interest, mainstream media does not serve us well. Here is my point of view As a doctor, I see sick people. I don’t see well people because they don’t seek me out. Out of the sick people I see, many have a problem with gluten. As a quick review, gluten is a protein found in wheat, barley, rye and in contaminated oats. It contains another protein called gliadin, which seems to be the one to cause problems. Types of problems with gluten Here’s some of the problems my patients are having, in order of increasing difficulty to diagnose: o Some people have wheat allergies. When they eat wheat, they get a stuffy nose, or they break out in hives. This is diagnosed with a simple blood test for Wheat IgE. o Many people have a problem with processing carbohydrates (40% or more, actually). This may show up in the blood as a high Hemoglobin A1C (over 5.6%). People with this problem can easily demonstrate to themselves, by using an inexpensive glucometer (freely available on Amazon) that a meal consisting of cereal, or sandwich, or pasta, results in elevated blood sugar (as opposed to a salad, or a meal consisting of only lean protein plus broccoli). o Some people have celiac disease. They have the genetics that put them at risk (positive DQ2 or DQ8 genes) and in addition, they have a positive transglutaminase (tTg) IgA antibody, endomysial antibody or deamidated gliadin antibody. Note that testing only for the tTg is not enough to rule out celiac disease. In addition to blood testing, gastroenterologists recommend an intestinal biopsy to officially call it celiac disease, but some argue that positive antibodies are sufficient to recommend a gluten-free diet. o Some patients have a problem tolerating lectins, which are also in beans and some other foods. A possible test for lectin sensitivity is the wheat germ agglutinin antibody test. o Some people have a problem with FODMAPs. These are components (fermentable carbohydrates) abundant in certain foods (including wheat) that cause bloating in susceptible individuals. There is a hydrogen breath test that may or may not help with detecting this. o Some people react to breakdown products of gluten and dairy called gluteomophins and casomorphins. I am not sure these can be measured outside of research labs. o Some people have non-celiac gluten sensitivity (NCGS). At this time, this is a condition without clear diagnostic criteria. If you say that you feel better off wheat, that makes you a candidate. There are tests for anti-gliadin antibodies, but they are not universally accepted by conventional medicine. There are also biopsy findings but most people with gluten sensitivity do not undergo intestinal biopsies. The test I use is from Cyrex Laboratories. It finds more people with anti-gliadin antibodies than any other test. You will see the figure of 3-5% of people having NCGS. This is when you test all the patients in a gastroenterology practice. If you take people with joint pains, or people with balance problems, or people with autoimmune disease, or people in my practice, you will find a different percentage--sometimes lower, sometimes much higher. Why do I take patients off gluten? Taking people off gluten is one of my most common initial dietary changes. Here’s why I do it, and why this makes all the articles you read by science journalists who have consulted with conventional medical sources incomplete. I take anyone off gluten who has significant inflammation. How do I know they have inflammation? I learned that from reading research studies about the medical conditions I treat. Most people who haven’t felt well for months or years (my specialty is chronic illness) have inflammation. In any given person with a health complaint, I actually have to prove it’s not a factor. It is my job to improve this aspect of the immune system in all my patients. It’s the only way I can hope to reverse illness without the use of drugs. Why is gluten a problem for inflammation? First, gluten causes increased intestinal permeability in everyone temporarily. For some, this is repaired before the next dose of gluten. For others, it’s not. Leaky gut will cause leakage of large poorly digested proteins from the gut into the bloodstream, and basic immunology tells us that these tend to elicit an immune response (i.e. inflammation). In addition to this, some people are exquisitely sensitive to some undigested proteins from specific foods. Leaky gut also allows gut bacteria to leak into the bloodstream, and these bacteria have a substance on them called lipopolysaccharide (LPS), which is also a strong immune system stimulant (i.e. inflammatory). It has been hypothesized that a healthy gut microbiome may minimize the issues with intestinal permeability. However, as we well know, our microbiomes have been weakened by our environment and our customs (such as hygiene and antibiotics). Second, wheat products tend to take the place of healthier products in our diet. They present a number of drawbacks, including the fact that they have a high glycemic index, and the fact that they don’t have as many vitamins and phytonutrients as do fruits, vegetables, seeds and nuts. If you replace your cereal/bread/pasta with a “gluten-free” version, you will not see much of a difference in your nutrient intake. However, this is not what I recommend. Gluten-free products are processed foods, and thus of little use to any person who is trying to overcome a serious medical problem. If you replace your breakfast cereal with a smoothie full of fresh produce, your lunchtime sandwich with a big colorful salad, and your evening noodles or pizza with healthy protein and a vegetable stir-fry—then you will indeed reap the rewards of a healthier diet. Third, changing your diet changes your beneficial bacteria. As they are in charge of your immune system, of making vitamins for you, of breaking down toxins or causing inflammation, changing them is often beneficial in changing your symptoms. Traditional vs. updated The controversy about gluten relates to the different ways in which patients with chronic illness are viewed in the conventional vs. the alternative medicine model. In the conventional model, we seek a single cause—an infectious agent, an injury, a genetic predisposition. In the alternative model (or more precisely in this case, the functional medicine model), the “terrain” or underlying weakness of the individual is the most important factor: the microbiome modulates genetics to create inflammation that results in disease. Gluten acts almost like a litmus test that reveals significant inflammation and gut microbiome weakness. These preconditions exist before gluten is added but worsen with the addition of gluten. Thus, many people find that they feel better when they transition from a standard diet to a high nutrient, gluten-free diet. The controversy about gluten might simply be related to our shifting understanding of the underlying drivers of health and disease.  In functional medicine, we talk a lot about the term “root-cause resolution”. What does it mean though? How do you know that you are tackling the root cause of your illness? When I go online to see what people are saying about functional medicine, I see that they seem confused by the term “root cause”. They say that all medicine is oriented to finding the cause of your concerns and resolving it. For example if you go in to see a doctor and you complain of urinary discomfort, they will look for an infection, or some other cause, and treat you accordingly. Are they right? Is all medicine “root cause” medicine? Well it depends if your illness is acute (has lasted only a short time) or chronic. If your illness is chronic, such as a rising blood pressure that has now exceeded the threshold for “abnormal”, your doctor will check a blood test, recommend you eat less salt, and put you on a medication. That is because conventional medicine considers that hypertension is most often “idiopathic”.  IDIOPATHIC Idiopathic is a Greek word meaning “sickens itself”, from (idio-, self, and –pathic, illness). Hypertension sickens itself. That is absurd, of course. So in medical school I refused to use that word, and substituted another Greek word, “cryptogenic”, which means that the origin (-genic) is hidden (crypto-). To practice root cause medicine you begin by believing that there’s a good chance you can find the hidden origins of diseases that conventional medicine believes are “cryptogenic.” The reason root-cause medicine is so valuable is that if you can find the root cause, you stand a better chance to reverse the illness (not just manage it). So if a patient comes in with joint pains, and he or she gets ibuprofen, or curcumin, if that is all that gets done, this is not “root cause” medicine. The patient didn’t have a curcumin deficiency. The patient will be more comfortable on curcumin, but if you are practicing functional medicine, you will not stop there. LOOK FOR A CAUSE You will target inflammation and there are many ways to do that. You will take a full history, to see how this pain came about, and that will give you a clue as to whether you should try first to change the diet, teach stress reduction, recommend rest or exercise, or target something more obscure like coenzyme Q10, leaky gut, thyroid problems, insulin issues, heavy metals, and so on. Once you find, say, leaky gut, you still have not found the root cause. Why does he have leaky gut? This could be a variety of things from diet to stress, to poor probiotics. And if it’s stress, what is the root cause of that? You have to consider your patient’s early life history, and investigate perhaps trauma work or therapy. So, how do you know when to stop looking for underlying causes? How do you know you are dealing with a root cause? I’ve made up an acronym to remind me of the main root causes that may not have deeper underlying causes: G-FLAT  G stands for Genetics, and Germs.
FLAT are events, or external inputs: Food, Life events, Actions and Toxins “Genetics” may include for example MTHFR: by giving people with a slow variant of the MTHFR gene a surplus of folate (sometimes through food, sometimes with supplements) we compensate for a genetic problem. We only have a few genes we know how to bypass, but we can help the body modify the expression of hundreds of genes by targeting inflammation genes with lifestyle or nutraceuticals (even better, according to recent research, with both). “Germs” refers to causes like Lyme disease and chronic viruses that can be participants in patients’ chronic conditions. External inputs are the most common issues. They include the following: - “food” includes inflammatory food, like too many grains, meat, or salt - “life events” includes trauma, either psychological or physical - “actions” includes lack of sleep, repetitive motion, lack of exercise - “toxins” include processed foods, and environmental toxins Of course, illness arises from the interaction of these factors, but first we have to strip the situation down to these essential elements, and then devise a plan of action. It may take many steps to uncover the root cause, and you really want a motivated patient and a patient and persistent provider. So make sure you go all the way to G-FLAT! This past month has seen an onslaught of highly damning research results on the most fundamental tools of conventional medicine. It has left me wondering what is left for doctors to do that will help more than harm?
ANTACIDS ARE NOT SAFE Medscape, a highly read conventional medical newsfeed, reports that the most popular article of the month among readers was the one reporting that proton pump inhibitors (PPIs) were linked to a rise in heart attacks. PPIs are medications like omeprazole (Prilosec), pantoprazole (Protonix), dexlansoprazole (Dexilant), esomeprazole (Nexium) and lansoprazole (Prevacid). They are prescribed for a variety of complaints, especially acid reflux and indigestion. Millions of people are on these medications, sometimes for decades. It can be very hard to stop these medications, because stopping them may cause rebound heartburn (though I have my tricks). How do PPIs cause heart attacks? Scientists are not sure, but it could be because we need the acid in the stomach for a number of reasons, and one of them is to use a substance made by mouth bacteria and turn it into a very important substance called nitric oxide, that protects blood vessels. Far fetched, but, it’s only a start. IBUPROFEN IS NOT SAFE Today the FDA put out a warning that NSAIDs, well-loved drug category reducing pain and inflammation, also likely increase heart attacks and strokes. This category includes ibuprofen (Advil, Nuprin, Motrin), naproxen (Aleve, Naprosyn), and many others. Almost everyone has at least tried something from this category, or taken it for a week or more to manage an injury, and millions take it most days to manage chronic pain. So what are doctors supposed to do with patients’ pain? Interestingly, the regular use of NSAIDs can cause heartburn, and I have often seen patients started on PPIs because of their NSAID, sometimes preventatively. I am not looking forward to the study about what the combination does to your heart attack risk. In case you thought you would turn to acetaminophen (Tylenol), remember that it worsens asthma and impairs detoxification by reducing your levels of glutathione. It has also been connected to asthma development in babies and to ADHD in the children born to women who used it during pregnancy. All of these are associations, but they are not reassuring. STATINS ARE NOT SAFE What about statins? Everyone should be on one, right? Well they cause diabetes. They were thought to cause a little diabetes, but it turns out they cause more diabetes than originally thought. So how is it that they can still be beneficial? After all, another study this month tells us that a significant number of patients have a sudden decline in cognitive function after starting statins. Researchers are not sure if this is a real effect of the drug or some sort of research distortion, but it sure could be real. DIABETES IS WORSE THAN WE THOUGHT, EVEN WELL-TREATED Yesterday saw the publication of a study showing that diabetics have an accelerated decline in cognitive function, even when treated. So maybe those people who had heart attacks and were placed on statins are living longer but living with cognitive decline? AND LET’S NOT FORGET This month the Cochrane Collaboration, a highly respected European group that reviews research on therapy and prevention, declared that there was no good evidence that water fluoridation prevents dental caries. This is the same group that pointed out that influenza vaccination is probably not worthwhile for the vast majority of people. And more recent research suggest that whooping cough vaccination (not lack of vaccination) is a cause of disease resurgence. Does this leave anything for the average doctor to do that will actually work, and won’t make the patient worse? How about preventative tests that aim to detect cancer? CANCER IS NOT AS WE THOUGHT This week, we also had the report on an enormous study comparing breast cancer incidence and mortality across US counties with high and low mammography rates. If mammography saves lives then the counties with high mammography rates would have had fewer breast cancer deaths, and fewer larger tumors. But that is not the case. Mammograms do find many more small cancers, but these may not be cancers that would have become noticeable over time. We know this because counties with a high rate of mammography did not have a lower rate of large tumors. Therefore mammograms do not prevent small tumors from turning into large tumors. Nor did counties with high mammography rates have lower breast cancer mortality. So mammograms do not save lives. But these counties did have higher breast cancer incidence rates. So really all mammography does is cause more women to have to undergo cancer treatment. Overall, lives are not saved. I am NOT talking about false positive scares. This is full-fledged chemotherapy, lumpectomy or mastectomy and/or radiotherapy; and then more medications like tamoxifen; and long-term side effects like heart failure and cognitive decline from chemo and immune system anomalies from radiotherapy. THE PRICE TO PAY FOR PEACE OF MIND It appears that what really happened is that some women gained reassurance at the expense of other women going through a diagnosis of breast cancer (either invasive breast cancer or DCIS), and undergoing dangerous chemotherapy and disfiguring and painful removal of a body part. Women that were going to die, died anyways (the mortality didn’t change). UNLESS-- what we are seeing is a lot more real breast cancer than before—but no one is admitting to that. The following concept is now gaining favor: that cancer does not always proceed from small to large in predictable fashion. I know it makes no sense but it is true: cancer sometimes starts small and explodes very fast. Sometimes it starts small and regresses back to nothing. Sometimes it progresses the way we used to think, from small to large to widespread. HERE’S WHAT I THINK The concept of better living through chemistry is backfiring. Chronic disease prevention through surgery will also not work. There’s that devil once again, in the details. The idea that you could continue with your previous lifestyle, the one that brought on the heartburn, joint pain or headache, high cholesterol (which may not even be harmful cholesterol) or high glucose, or maybe even cancer—the idea that a pill could make it just fine to continue with that lifestyle—that has turned out to be WRONG. Doctors can’t save you from a symptom without giving you a disease, which may be worse. What we need to do is to find and fix the underlying cause. For some people, it’s not a choice they made. The underlying cause is toxins, or immune dysfunction, or multigenerational trauma. Help may be available for them too. There are worthwhile trade-offs to be found, there is trauma therapy, and immune support. But for others who have space to improve their lifestyle, to eat healthier, sleep more, exercise more, stress less, focus more on meaning, purpose, community, love, and service, it will actually NOT be very hard to sidestep antacids, anti-inflammatories, statins, and whatever is on those rows and rows of shelves at the drugstore—and diabetes, strokes and heart attacks, and in many cases even cancer. The work we do to resolve heartburn or reflux, joint pains, headache, cholesterol and glucose issues is the same work that studies suggest leads to a long and healthy life. INDEED, ALL CAUSE MORTALITY IS SHARPLY REDUCED WITH FRUITS, VEGETABLES, EXERCISE and MEDITATION. A study from 2012 shows an 8-fold reduction in all-cause mortality in the participants who ate more than 5 portions of fruit and vegetables daily and who were in the fittest subset. A separate study showed a 40% reduction in all-cause mortality with meditation. I would love to see the study that combines diet, exercise and meditation. And the study that further measures the effect of having a strong sense of mission, and a good close-knit group of family or friends. The skills and practice of functional medicine have helped me squarely focus on the promotion of wellness. My goal is to continue to learn efficient and effective ways to guide my patients to optimal health through natural means. REFERENCES FOR THE SKEPTIC—bring to your physician and have a conversation! Proton Pump Inhibitors and Cardiovascular health http://www.scientificamerican.com/article/certain-heartburn-drugs-linked-to-increased-risk-of-heart-attack/ NSAIDS and cardiovascular health http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm#collapseSix Statins risk for diabetes—March 2015 http://www.sciencedaily.com/releases/2015/05/150507145328.htm Statins affect memory http://www.ncbi.nlm.nih.gov/pubmed/26054031 Water fluoridation not proven to prevent cavities http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010856.pub2/abstract Influenza shots probably not worthwhile in most people http://www.cochrane.org/CD001269/ARI_vaccines-to-prevent-influenza-in-healthy-adults Whooping cough vaccination spreads disease http://www.sciencedaily.com/releases/2015/06/150624071018.htm Mammography and cancer rates in US counties http://archinte.jamanetwork.com/article.aspx?articleid=2363025 Fruit and vegetable intake, physical activity, and mortality in older community-dwelling women. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639003/ |
Blog AuthorDr. Myrto Ashe MD, MPH is a functional medicine family physician. Archives
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