Listen to Ep 06 where Dr. Nathan talks of his 40 years of being a Chronic Illness Detective, how to approach the complexity of ME/CFS, DHEA, mold, anti-virals, and more...
Full Text Transcript:
Dr. Craig: You’re listening to Spoonie Radio. I’m your host Dr. Courtney Craig. Today my guest is Dr. Neil Nathan. He’s a board-certified family physician and a founding Diplomate of the American Board of integrative and holistic medicine.
He is in practice with Gordon Medical Associates in Santa Rosa California and specializes in what he calls complex medical problem-solving, which includes such conditions as Lyme disease, fibromyalgia, chronic fatigue syndrome, mold toxicity, autism, and other difficult to diagnose pain conditions.
He’s written several books, the latest of which is called Healing is Possible: New Hope for Chronic Fatigue, Fibromyalgia, Persistent Pain and Other Illness. He’s also the host of a weekly radio program on Voice America called The Cutting Edge Health and Wellness Today. He welcomes listeners to check out his website at www.NeilNathanMD.com where he gives phone consultations and other information.
Welcome to the show Dr. Nathan!
Dr. Nathan: Thank you, thank you.
Dr. Craig: Now one thing that struck me just reading your bio that I want to start with is you are an expert in complex medical problem-solving and you have over 40 years experience in this complex medical detective work. So could you talk a little bit about what that means to you and how that’s different than maybe the traditional medical approach?
Dr. Nathan: Of course. The conventional medical care has changed dramatically in the last 20- 25 years. The advent of managed health care and reducing office visits to seven minute segments, reducing new patient visits to short segments, has not allowed conventional physicians to devote the kind of time and energy they need when patients are sick. So if a patient is ill with anything complicated, usually the primary care physician will refer it quickly to one of their colleagues. Unfortunately the way medicine is evolving, those colleagues are working into narrower and narrower boxes so that if you see say, an endocrinologist or a neurologist or any specialist, they have a well-defined skillset or toolset that they will use.
And this has fragmented healthcare so that most patients, if they have anything complicated, will get bounced from one practitioner to another without getting their needs met. And my work has been devoted to expanding the box if you will, it’s been devoted to how can we look at the bigger picture? How can we take this complicated series of symptoms and not reduce it to, “Oh, this is psychogenic. I know you feel so sick and so ill and you have so many systems that are being affected that there’s nothing I can think of that would help you. So here, take this antidepressant,” or, “Take this anti-anxiety agent and go way.” And patients do not feel listened to, they do not feel heard, because they are not.
So we have this odd process where despite all of the advances of medical science, patients are getting worse and worse health care if anything complicated occurs.
Dr. Craig: Yes and it doesn’t really get much more complex than chronic fatigue syndrome. And there is many overlapping conditions with that like chronic Lyme and fibromyalgia which we will talk a little bit about later. But a lot of the root kind of players in this are things like mitochondrial issues, gut issues, immune dysfunction, hormonal imbalance. So when you are doing this complex medical problem-solving detective work, how do you know how to approach such a complicated illness with so many different systems involved?
Dr. Nathan: That is a great question. I’ve tried over these years to create a method by which other healthcare providers can do what I do which is to take a look at this. So okay, let’s say we are with somebody who has chronic fatigue. First of all my visit with them is a minimum now of two hours. It takes me that long to really listen to what they have to say, to understand how it evolved, how it started, what they’ve done, what they haven’t done, what worked, what didn’t work. And what I am looking for is patterns.
Over the years there are certain patterns that fit certain in this is more than others; I would be happy to go into more detail with that. For example depending on the symptoms that you have, it might point more to Lyme disease or it might point more to mold toxicity or it might point more to a hormonal imbalance.
My overriding question that I have during my first visit is, “Is there anything that can explain all of these symptoms as a unified theory?” If there isn’t the next question is, “Are there groups of things that could explain these so that I can begin looking for the cause?” Because the whole issue here is getting at the root cause of what is going on. If you work only with pieces of it, it will help a little bit but it won’t fix it.
Is that answering your question?
Dr. Craig: Yeah, that’s a great way to look at it. And that’s my approach too with my patients and it’s the whole basis of integrative and functional medicine, is to look at the cause. I think a lot of people and especially dealing with chronic fatigue syndrome only look at a small piece of the puzzle. They are only looking at the chronic viruses. They are only looking at maybe the gut issues but you need to take a whole systems approach and instead of treating this diagnosis of chronic fatigue syndrome, no, we are treating the patient, and each patient has a different presentation and you’ve just have to put the pieces together and find out how to approach it.
Dr. Nathan: That’s key. Each patient is different. There isn’t an algorithm that you can put people into where I always do this, this, this first and this, this, this second. The algorithm is individual based on a person’s genetics, biochemistry, family history, exposures. And once you really delve into those you can create a process for that person individually.
Dr. Craig: Right. So let’s talk more about all these little pieces of the puzzle. And in your book is so excellent because it is so comprehensive. It goes into all of these little pieces. It goes into things like methylation, exposures to mold and other toxic agents. But first I want to talk about the role of hormone issues and chronic fatigue syndrome and that’s the first thing you talk about in the beginning of your book. You say that if you have one single lab test that you could offer to a patient it would be testing for DHEA.
So why is DHEA so important? What is its role in chronic fatigue patients?
Dr. Nathan: Well DHEA is the adrenal hormone that is made in greatest quantity. It is an excellent barometer of what the adrenal gland is doing. So when someone gets sick, pretty much the first thing that happens is that it is a stressor to the body. And the adrenal gland is the stress gland of the body, that’s what it’s dealing with.
So when someone has been sick for any period of time it is almost universal that the adrenal gland is not keeping up with the need. So initially like in the first few months of any illness, injury or medical condition, the adrenal gland fires up and actually makes more hormone. But after a period of time and of course it varies from one person to another, it begins to burn out and make less. So in my experience the single most common deficiency that I find in all of my chronically ill patients is DHEA.
Dr. Craig: And how do you measure for that?
Dr. Nathan: Well there are several tests. It’s available through virtually any laboratory. You can test it by saliva, you can test it by a variety of urine testing but from my experience, the blood test is the best. There is two kinds of DHEA that you can measure. One is called, forgive the technical term – unconjugated and the other is called the sulfated form. So DHEA-S is the storage form and the DHEA unconjugated is the form that really kind of circulates in the body. I measure DHEA unconjugated.
Quest does a very good test, LabCorp does an adequate test. So if you ask your healthcare provider, it is something that can be readily measured.
Dr. Craig: Now is there a difference with this hormone, like in other hormones, between men and women? Should we look at a reference range differently depending on gender?
Dr. Nathan: Yeah, absolutely. And the reference range, when it comes back from Quest or LabCorp will reflect that.
Now what makes DHEA a little hard to read even for healthcare providers is that unlike many lab tests, this one is an age-based normal. And what I mean by that is if you have a hematocrit, a red blood count, the range is just the range and you can look at the number, look at the range and you can know where you stand.
If you look at DHEA, you have to age adjust it which the lab slip does not do. For example for women the DHEA range would run 130 to 1000, which is a huge range of normal. And the reason it is so huge is that it’s age-based. So 130 would be normal for a 90-year-old woman, and 1000 would be normal for a 20-year-old woman.
So if you are a 30-year-old woman with the onset of chronic fatigue and you have a number that would be 180 and you look at the lab slip and you go, “Oh, okay, that’s normal, I’m in the normal range,” then you would be wrong. You would have a fifth of the DHEA you want to have and you really would need to be replacing it in order to begin the process of healing.
Dr. Craig: That’s a really important clinical pearl, thanks for that.
So that’s the hormonal piece. The immune piece is also huge with chronic fatigue syndrome. A lot of patients are given antiviral medications with mixed results. Do you rely on those, or what do you rely on more natural antiviral measures?
Dr. Nathan: I actually do both and you are asking of course a very complicated question. The viral piece is a piece for many chronic fatigue patients but it isn’t a standard piece. By no means do all chronic fatigue patients have a viral cause. Sometimes it was triggered by a viral cause.
When you go back into the history you can often find people saying, especially if they started when they were young. If they said, “I was really well until I was 13 or 14 and then I had a case of mono or had a flu-like symptom and then I have not really been well since,” commonly, that’s an Epstein-Barr viral trigger. But by no means does that apply to other people.
There are other viruses that are commonly involved like HHV-6, cytomegalovirus, some of the Echoviruses. Second, it doesn’t apply to everybody. So it’s helpful to look at the virus but always within the context of, “Does this apply to this being that is in front of me right now with these symptoms?”
So you can get viral titers, very easily obtained lab tests. The problem with viral titers is that it is suggestive but not diagnostic. Example: you could have very high titers to Epstein-Barr but you might not know, “Does this apply? It’s this current? Is this a holdover from an Epstein-Barr infection that is not resolved? Or is this an ongoing current Epstein-Barr infection?”
And with Epstein-Barr, there is another viral titer that you can get called an early antigen. And the early antigen does reflect a recurring Epstein-Barr infection. Still, you are looking at these numbers and any infectious disease person will tell you, “You don’t know what you’re looking at. Is this ongoing, current or old?” And the answer is, “Hard to say.”
Now there is a new test that does help us begin to sort this out and it is called a nagalase. Nagalase is a test only done by the Health Diagnostics Lab in New Jersey. And it reflects what a virus is doing to disable your immune system.
What I mean by that is viruses have a variety of ways of hiding from or disabling your immune system to keep you from destroying them. So nagalase is one of them and what nagalase does is it’s an enzyme that cleaves a receptor off a monocyte. And before I get too technical; in order to fight a viral infection, the way the body does it, is it takes vitamin D and binds it by vitamin D receptors to a monocyte which is a type of white blood cell and it transforms the monocyte into a macrophage which is the main cell line that destroys viruses.
If nagalase is being produced by the virus, it cleaves the receptors so vitamin D has nothing to bind to and it can’t do that, literally disabling the immune system. And although I am oversimplifying this process, by measuring nagalase, we can get a much more active understanding of what viruses are doing in that body and really have a better idea, is this an active viral process?
Dr. Craig: I am pretty sure that that is not a standard routine test. Can you do that through LabCorp or Quest or any of the common labs?
Dr. Nathan: Yeah, not a chance. It’s only been done by a very few labs in this country.
Dr. Craig: That’s interesting.
In addition to looking at viruses and using traditional antivirals and other things like that recently saw some of the slides that you presented at the ILADS Conference earlier this year. And you talked about many different ways to approach antiviral treatment. And one thing you mentioned that I was really excited to see because this is something that I utilize a lot with my patients, is a supplement called Transfer Factor.
So could you tell us a little bit about what transfer factors are?
Dr. Nathan: Absolutely. They have really been around for a long time meaning for about 20 years now. But as with many of the things that we’re talking about, they somehow have not gravitated into conventional medical practice.
Transfer factors are small molecules that stimulate the immune system to be how do I say it? - Actively involved in rebooting the immune system to fight that infection specifically. Let me try to be clearer about that.
We can make transfer factors specifically for any infectious agent we want. We can make it for Epstein-Barr. We can make it for cytomegalovirus. We can make it specific for HHV-6. We can make it for Lyme disease; we can make it for some of the other herpes viruses. And by doing so these molecules, once we begin to ingest that, they are taken very simply. They are a capsule you take once a day or twice a day.
Once you take that, what it does is it kind of, the way that I look at it again simplistically, is it kind of rubs your nose and – “yes, deal with this.” Let me back up a minute to talk about that. Another way that viruses hide from the immune system, we’ve known this for a long time particularly this family of viruses called the herpes family of which Epstein-Barr and HHV-6 and cytomegalovirus, they are all members, all hide by going into and burrowing into nerve tissue. We know that happens with shingles, or herpes zoster, but it happens with the others as well so again, simplistic way of looking at it.
Your immune system is out there looking for viruses trying to attack them and trying to rid the body and do this job that it was designed to do. Okay you get a scout to cell that goes, “Oh, you’ve got the herpes virus out here.” So it goes back to get reinforcements and recruitments. In the meantime the virus knows it’s been detected, burrows into the nerve cell so by the time all the recruits show up they can’t find anybody. So they look around, “I know it was here somewhere, I don’t see it.” And so, “Okay everybody, out of the pool. We are going back.” And that happens repeatedly so that the body never mounts an appropriate all out attack on the virus.
What transfer factors do is it specifically “rubs” the immune systems nose in this virus and goes, “See this? Go after it,” And by doing so over time it will mount an immune response that is much more productive and allow the body to deal with it. Am I’m answering your question?
Dr. Craig: Yes, that’s a very clear explanation actually. And one thing that I find really interesting about transfer factors, it’s that they are specific. So where a lot of antivirals like Immunovir, Acyclovir and some of these other valcytes, are not specific per se. But the transfer factor is specific. So how is a transfer factor procured and how is it made specific for certain viruses?
Dr. Nathan: Well I will give you the way it was made originally. Back in the 90s there was a company called Immunity Today which Dr. Joe Brewer was associated with and he did quite a bit of the research on this in the beginning. Joe is an infection disease specialist from Kansas City who has been a leading researcher in chronic fatigue for a very long time. He is the one was done some recent work on mold toxicity that’s really very exciting as a component.
Since I am mentioning this let me comment, he published a paper about a year and a half ago in which he took 112 patients with chronic fatigue and measured their level of mold toxin and found 93% of them were positive which is A, relatively astonishing and B, very important because I think mold toxicity has been one of those elephants in the room; things that we have not recognized until now, how much it might contribute to chronic fatigue as an entity.
But leaving that, what Dr. Brewer did was he injected the virus, call it Epstein-Barr, cytomegalovirus, HHV-6, injected specific viruses into the udders of pregnant cows. And they made antibodies. Now that might sound cruel but cows don’t get Epstein-Barr or cytomegalovirus or HHV-6 so they are relatively immune to it as an infection.
But in making the antibodies to it, he then took the colostrum which is the first breast milk made by those cows after those calfs got born and they purified out of it, this specific fraction that was related to those viruses so that he is literally making these transfer factors specific.
That method is not what’s being used right now. It’s now being made primarily using eggs as the main source of making the transfer factors but that should give your listeners a better idea of how the process works.
Dr. Craig: Yeah, and there’s actually a lot of research on these if you go on to PubMed. I was surprised at how the history, there is a lot of research especially in other countries using transfer factors which are also known as proline rich peptides or PRP’s as possible supplements for vaccination in a way.
Dr. Nathan: Yes, I would comment that one of the companies that’s really been a leader in this area is Researched Nutritionals that has probably the best most comprehensive line of transfer factors on the market. So if your listeners want to go to a website. If you go to www.researchednutritionals.com you can really learn a lot more about some of these materials.
Dr. Craig: Right. I use that company frequently as well and they just released a paper I think last month, a small clinical trial using transfer factor in a group of chronic fatigue patients. And they noticed a marked improvement in natural killer cell function which I found also very interesting.
Dr. Craig: Now we briefly touched on mold. I want to explore that more because you have talked extensively about mold and written a lot about mold. I’m also noticing a large percentage of patients with chronic fatigue syndrome have these mold issues. But how do you assess mold?
Dr. Nathan: Well there is a variety of ways of looking at it. First of all we can talk about assessing it in a home; meaning you can get what are called mold plates which is simply a petri dish that grows mold and you can open it in various rooms of your home and leave it open for an hour or two, put the top on the plate and see if anything grows. If after 3 to 5 days you are looking at this plate and you are seeing virtually no growth then okay, that’s probably okay.
On the other hand, if you’re looking at the plate that is a gross then you probably want to get that analyzed. That’s the cheapest, simplest way to do it.
Another way which is the one most liked by Dr. Ritchie Shoemaker is using the ERMI test which uses either a vacuum or a Swiffer to vacuum the dust of a room, send it to the ERMI company and they will analyze that very, very meticulously for different mold fragments and species and actually give you a quantitative readout. And Dr. Shoemaker has developed a scoring system called the Hertsmi-2 scoring system which allows you to know – is my home toxic or non-toxic? And that’s answering your question. That’s a way of looking at your home.
Looking at your body, Dr. Shoemaker has developed a variety of laboratory tests which are suggestive of mold toxicity including a visual contrast test where you can go online to his website which is www.survivingmold.com and take a quick look at – is it possible that mold toxin is affecting your visual areas? And the test that I have come to like most is the one by Real-Time Laboratories which is from Houston Texas where you take a urine specimen and they will measure the three main mold toxins; ochratoxin, trichothecene and aflatoxin and actually quantitate that.
So if your urine is loaded with mold toxin as far as I’m concerned, you have mold toxicity and you really ought to start dealing with it.
Dr. Craig: Now mold is a kind of controversial topic especially in more traditional medicine because mold is ubiquitous and I feel like water damaged buildings are ubiquitous. So maybe you have mold in your home but how do you decide if that’s causing your symptoms?
I have read that there is a gene; there is a genetic predisposition for some people to be more sensitive to mold than others.
Dr. Nathan: There are. Dr. Shoemaker’s done a lot of work with the genetic… There is a test that LabCorp does called an HLA-DR which can tell whether or not you are genetically predisposed to mold or Lyme or chemical sensitivities or all of the above.
Now this only tells you if you are predisposed. It does not really tell you whether or not you can ultimately get rid of it or handle it. So while helpful, it doesn’t really tell you whether you are fighting with mold at this moment in time. On the other hand if you have mold toxins in your body and you have symptoms that reflect that, then that would be a high likelihood that mold is part of your issue here.
Dr. Craig: And then from your clinical experience, what percentage of chronic fatigue patients would you estimate have these mold or biotoxin issues?
Dr. Nathan: Well again Dr. Brewer’s recent research showed 93% of his patients had it. I would add though that Dr. Brewer and I see a similar patient population which is not a purely mold based, it is not pure chronic fatigue, it’s not pure fibromyalgia. I see a lot of complicated stuff because as my practice has evolved I am kind of a referral source for other physicians where if they are not sure what’s going on they will send me their most complicated patients. So please understand that my observations are now based on a rarified group of patients.
If there was a basic group of patients, my comment would be if you had a chronic fatigue or fibromyalgia you ought to get tested for mold. Missing it might be doing you a great disservice - going along as if it’s not occurring. Because the key point that Dr. Brewer taught us in his last paper is that you might not have any mold in your current environment. It might be clean as a whistle. You might have been exposed to mold three years ago, five years ago, 10 even 20 and if your immune system was weakened, the mold could have gotten a toe hold in your body. It could have started colonizing so that what we believe is that the mold is now growing in your sinus and gut areas producing the toxin ongoing. So missing that would be not be doing you a favor.
You might easily say, “Oh, there is no mold in my environment, dry as a bone. Don’t see it, don’t smell it, great!” But 15 years ago when you were in university and you are living in a moldy dorm, in a water damaged building, maybe you got exposed back then. And again, missing that would not be doing it any favors.
Dr. Craig: I had no idea the effects could be that latent. So what if you do find out with some of this testing that you have a mold issue. How do you approach it? What sort of treatment do you use?
Dr. Nathan: Well first of all I would encourage people to work with a healthcare provider who knew what they were doing. And since this is relatively new work, Dr. Brewer wrote his paper merely a year and a half ago, there are not 20,000 healthcare providers in the country who actually know what they are doing. So unfortunately you might have to do some research.
You could go to The Real-Time Laboratory where they do have on their website listed “some physicians” and Dr. Shoemaker and his website, www.survivingmold.com, has a list of physicians who practice it his way. But the bottom line is if we think mold is an issue you need to number one, check your home, work, even car sometimes to be sure that you are not being currently exposed. Number two, knowing which mold toxins you have allows us to be more selective about what binders we can use to actually bind the specific toxins and pull it out of your body.
Meaning, we know that ochratoxin is best bound by cholestyramine or welchol. And we know that aflatoxin and trichothecene is best bound by chlorella, activated charcoal, and bentonite clay. So knowing that is a start. Then you need to find someone who knows how to use the materials that Dr. Brewer has developed which are nasal sprays that specifically can kill mold and oral treatments keeping in mind that one of our findings is that it’s not enough to just use things that can kill mold in those areas. You also have to deal with the biofilm that the mold makes in order to get at it because the biofilm is a major protective layer that prevents the immune system and our treatments from working appropriately.
Dr. Craig: Yeah, that’s an important point, also with just things like dysbiosis in the gut and even chronic viral infections. We have biofilms and a similar protective mechanisms that these stealth infections create to hinder our immune system so it’s always a key thing you have to address as well.
Dr. Nathan: Correct. And again there are both medications you can use for this and they work best if you combine them with other natural materials. Examples would be Dr. Brewer uses amphotericin b, ketoconazole and nystatin nasally and orally. But we love adding Colloidal silver, particularly Argentum 23 as a nasal spray and an oral treatment.
There are some homeopathics that are made by Bio Resource, SyFungin is a great one for both nasal and oral use. It is also for topical use. So as you mentioned, grapefruit seed extract and there are dozens of other natural materials that can enhance this process. And we find we need to do that. Mold is very happy once it’s colonized. It loves damp, moist, warm areas filled with nutrients – hello body!
Dr. Craig: Exactly. Yes, especially the nasal mucosa as well as the gut, absolutely.
Now recently you’ve started a weekly radio show with Dr. Teitelbaum which is really exciting. Can you tell us more about your radio show and what you’re talking about there?
Dr. Nathan: Sure. Thank you for bringing that up.
Jacob and I have been friends for a very, very long time and some of your listeners may know he is one of the pioneers in chronic fatigue and fibromyalgia. I might be as well but I’m not going to go there quite yet.
And what our vision was is we wanted to put together a radio show that would archive shows in which we would interview people that we consider to be top in their field on every subject that we can think of. Jacob and I are now officially old enough that by age alone we are friends with a whole lot of people who are pretty much top of their field.
So our goal was to create a go to site where patients can literally learn about any subject in this field that they want. So that includes an overview of chronic fatigue and fibromyalgia that Jacob and I provide but also specific subjects including thyroid, adrenal. I have interviews with Dr. Shoemaker and Dr. Brewer on mold. We have interviews with Lyme specialists on Lyme. Upcoming shows will include Jean Shipman who is an expert on testosterone. Carolyn Torkelson, an expert on bioidentical hormones. Dan Dunphy, an expert on cancer and so on, literally down the line.
So the hope was that whatever problem you have we could provide an integrative alternative show for you to listen to, to at least get you started to understand it better and understand what resources are available to work with.
Dr. Craig: That sounds like a lot of great information. So where can our listeners go? Is there a website to check that out and listen to those?
Dr. Nathan: Well you can go to www.VoiceAmerica.com and the show is called The Cutting Edge of Wellness Today. And an easy way to access it is through my website which is just www.NeilNathanMD.com. And there is a quick link to the radio show and if people are interested I also have a link to lectures that I have given at various hospitals on mold, Lyme, autism, chronic pain and a variety of other subjects. So I would certainly encourage people to use that as a resource.
I would also encourage people to go to Dr. Teitelbaum’s website which is www.endfatigue.com and Jacob has a wide array of resources for people to learn from and learn about again, almost every aspect of what we’re talking about.
Dr. Craig: Excellent. There is so much information available for free online. We are almost out of time but I want to end with a short passage from your book that really hit me. In the afterword of your book you write,
"Sometimes we get caught up in the details of our medical world and we get wrapped up in all of the technology and the chemistry and the multisyllabic words and the difficult to pronounce names. And sometimes life reminds us that we are essentially only human and that it is our caring for others that is our finest gift.”
I think that’s a beautiful way to end your book and to end this show. We have already mentioned your website www.NeilNathanMD.com so please check that out and visit www.voiceAmerica.com to view The Cutting Edge and Wellness Today.
Any last words Dr. Nathan?
Dr. Nathan: Sure. You can also go to the website where I work which is Gordon Medical Associates, www.GordonMedical.com for more information about me and my colleagues, all of whom do this very difficult but very rewarding work. And thank you Dr. Craig for allowing me to be on your show today.
Dr. Craig: Thanks. We learned a lot today and I am really looking forward to putting this up on iTunes and links to all of those great resources and tests we talked about today so patients can delve more into their chronic illnesses and become their own complex medical problem-solving detectives.
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