Bringing blood sugar into the spotlight. Revealing the intimate details of your health using critical biomarkers with Dr. Molly Maloof

Bringing blood sugar into the spotlight. Revealing the intimate details of your health using critical biomarkers with Dr. Molly Maloof

For far too long, healthcare has been a system designed to treat and bill for disease. However, a growing population of patients and doctors have started to build a more accurate picture than ever of each individual’s health with the use of biotech innovations, fine-tuned testing, and a quantified-self toolkit.  

Molly Maloof, MD, is an innovator in health sciences, a practitioner of personalized medicine, and a major advocate for health optimization through regular tracking of key biometrics. She emphasizes a commitment to foundational health involving resilience to stress, continuous glucose monitoring, and proper consumption of micro and macro nutrients. 

In this discussion, we unpack the importance of monitoring the body's dynamic capacity to regulate in real time. Highlighting some surprising facts about diabetes, blood sugar, and aging, we offer new priorities to consider for your health goals.  Find out which crucial bio-markers to look at, to inform effective choice. We discuss the objectives of personalized medicine, shifting healthcare to a multi-modal approach aimed at prevention over treatment. Empowering patients to proactively measure and manage their health on a consistent basis, with meaningful data and lifestyle modifications, is at the core of sustainable well-being.



In This Episode We Discussed:

  • Personalized medicine and health technology

  • insulin resistance, prediabetes, type I and II diabetes

  • Continuous glucose monitoring: The ultimate lifestyle biomarker

  • The field of diagnostics and health assessment 

  • Hunger training

  • The risk of diabetes at a healthy body weight 

  • Insulin resistance and metabolic syndrome 

  • Top soil depletion and declining nutrient density

  • Ubiquitous subclinical deficiency 

  • Heart disease is hand-in-hand with diabetes 

  • Issues of doing research science within capitalism 

  • Managing stress and a fundamental sense of safety

  • Heart rate variability, stress hormones, and adaptability 

  • Eustress and distress

  • Nutrigenomics 

  • Warrior or worrier gene


Show notes:

0:00      Intro
3:28      Physician Heal Thyself, evidence based lifestyle course.
3:54      A system optimized for prevention? Nobody pays for that.
4:50      The combination of the foundations of health and personalized medicine.
8:25      Annual blood labs are just not enough.
8:50      A comprehensive menu of important testing.
10:30    Defining health as homeodynamic capacity, rather than homeostatic state.
13:30    The consequences of ignoring blood sugar, and the hunger bio-signal.
17:34    Multiple markers are key to understanding blood sugar health.
20:16    Many surprising factors which can affect blood sugar.
22:21    Pre-diabetic patients have already lost 30% of beta-cell function.
25:46    Too many calories and not enough micronutrients.
28:10    A diet of whole foods that resembles an evolutionary environment.
32:47    Links between diseases and specific soil nutrient depletion.
41:28    The connection between aging skin and tantalizing fried carbohydrates.
43:11    The relationship of blood sugar markers, longevity, and disease.
45:26    Cancer metabolic dynamics, and insulin potentiated chemotherapy.
53:40    Correlating cortisol levels, sleep derangement, and weight gain.
1:00:28 Chronic loneliness, a huge stressor and a detriment to the immune system.
1:02:50 Lacking basic socio-economic provisions is a pandemic stressor.
1:05:19 The overlap between nutrition and stress.
1:07:21 The right nutrition for your unique metabolic and neurological profile.
1:08:31 Precision nutrition; labs and recommendations to get started.
1:18:00 The cost structure and economics of personalized functional medicine.



Mentioned in This Episode:

The North Karelia Project, Finland 

Innovation Diffusion Theory 

P5 Protocols Podcast 

Advanced Glycation End Products 

Heart Rate Variability

Blue Zones

Maslow’s Hierarchy of Needs

COMT gene

MTHFR.net

Nutrition and the Autonomic Nervous System, Nicholas J. Gonzalez M.D.

Nutrigenomics

Precision Nutrition

Parsley Health, Dr. Robin Boursin 

Dr. Stephanie Daniel | Functional Medicine 

Evo Med

DrMolly.Co

VO2 max

Books and Products Mentioned in This Episode:

Empty Harvest by Dr. Bernard Jensen

Lief Therapeutics Smart Patch

Oura Ring (Save $75 with code NEUROHACKER)

First Beat

DexaFit

Abbott Glucose Monitor

The Intelligent Gardener: Growing Nutrient Dense Food by Steve Solomon

The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It by Kelly McGonigal

Dr. Molly Maloof's Bio:

Dr. Molly Maloof's goal is to maximize human potential by dramatically extending human healthspan (the period of a person's life during which they are healthy and free from serious or chronic illness) through medical technology, scientific wellness, and educational media. When she saw the digital revolution transforming medicine she knew she had to be a part of it. Since 2012 she has worked as an independent advisor and strategy consultant to over 20 companies in San Francisco and Silicon Valley in industries including biotechnology, digital health, and wearable technology. Her fascination with innovation has transferred into her private medical practice, which is focused on providing health optimization and personalized medicine to her patients. She is particularly interested in the intersection between systems biology, data-driven wellness and personal health technologies for optimizing health. Dr. Molly believes dietary risks are responsible for the majority of lifestyle-related illness in America. She is passionate about personalized nutrition and aims for food system transformation by helping to improve corporate choices.

Full Episode Transcript:

Daniel:Welcome, everyone, to the Collective Insights Podcast. My name is Daniel. I'm with research and development here at the Collective. We are excited and delighted to have Dr. Molly Maloof, M.D., with us today. Molly is a really brilliant doctor and innovator in health sciences and [00:01:00] a good friend and lovely human being. She, after graduating medical school and getting into medicine, has worked in San Francisco, Silicon Valley, with a number of tech companies, innovating the biotech space as an advisor and consultant to a number of them in areas of nutrigenomics and continuous glucose monitoring and other forms of quantified self and bio data and personalized medicine. [00:01:30] So, we're going to get to talk with her about a number of cutting-edge things in the personalized medicine, biohacking, as well as future biotech space. Molly, thank you for being here with us today.

Molly Maloof:Thanks, Daniel, for inviting me.

Daniel:Before we dive right into some of the areas that you're actively working on that are, I think, going to be fascinating to our listeners here, I'd just [00:02:00] like a short little bit on what got you into medicine and what got you into, specifically, integrative and personalized medicine and the tech side of it. What's your story into this space?

Molly Maloof:It goes pretty far back into my childhood and to about fifth grade, when I decided that my calling was to become a doctor. Since then, I guess I was reading books [00:02:30] by Michael Crichton and Chekhov and randomly reading Russian novels and just was really inspired by the physicians and stories about doctors and wanted to help the world. So, I spent most of my life committed to this path and had a lot of people tell me not to do it, including the president of the Peoria Medical Association, who told me to become a corporate lawyer instead, but I persisted and found my way into medicine and [00:03:00] found my way into a system that was really a system that I understood was designed to treat and bill for disease. 

It occurred to me in medical school that human health is actually really important, and it's a science that we should be studying, but it wasn't really taught well in my medical school. So, I designed a course for doctors, for medical students, called Physician Heal Thyself, Evidence-Based Lifestyle, and it was really just all about [00:03:30] the different facets of medicine that weren't being taught. We weren't being taught nutrition well. We were being taught calories in, calories out, just really antiquated theories on nutrition. We were not being taught about exercise. We were not being taught about sleep. We were not being taught about behavioral medicine. In fact, a lot of doctors would tell me, "No one pays for that, so we're not going to teach it." That's really what hit me in med school, that maybe [00:04:00] the full-on doctor job in a hospital wouldn't be my destiny.

I got into my residency and found myself really profoundly unhappy and decided to change the course of my career by pursuing a career in personalized medicine and health technology. From there, I have flourished in San Francisco. If you want to learn more about me, I guess you could read about my LinkedIn, but I've done a lot of really crazy things in the last five years, a lot of jobs. So, it's been a [00:04:30] crazy, amazing adventure.

Daniel:I heard you say the foundations of health, which is sleep and better understanding of nutrition and behavioral medicine, and then I also heard you say personalized medicine, which is beyond, "Everyone should get enough sleep." How do we make sure that we're really customizing to the person? Can you kind of talk a little bit about the relationship between foundations and personalized medicine?

Molly Maloof:Sure. I guess the framework that I would place to center [00:05:00] is everyone kind of knows the guidelines of health. The government promotes certain guidelines that people do. People are supposed to eat five servings of fruits and vegetables a day. People are supposed to move 30 minutes a day, but knowing what we're supposed to do and how to get there is profoundly unique and personalized in an individual, because everyone has a different path to health, and what works for one person isn't going to work for everyone. I think that's where the movement [00:05:30] of guideline space, public health recommendations has become more personalized medicine, because we're just realizing that just telling people what to do isn't working. We have to show them the unique path that they need to take to get to where they want to be. 

I, myself, have been on this journey for many, many years, of trying to figure out, how do I achieve my goals and maintain really good health in the process? I think that we're moving into an era where we're starting to have [00:06:00] a data-driven approach to doing this. Rather than just traditional recommendations that our grandmother would have told us, we're learning that there are even more detailed, nuanced ways to go about optimizing our health. That, I guess, gets into the discussion of things like wearable technology and continuous monitoring and [inaudible 00:06:20] testing genetics. 

Daniel:Okay. When you talk about a data-driven approach ... and obviously the personalized medicine we can pay attention [00:06:30] to just our subjective experience, but we can also track bio data. We've got both the kinds of data that you can go get from blood tests or other medical tests, and there's obviously deeper functional medicine testing than what will often happen in a general GP's office. Then there's also the kind of at-home Quantified Self that can give us more continuous insights and insights under stress conditions. Maybe talk to us a little bit about the field of diagnostics [00:07:00] and health assessment.

Molly Maloof:Sure. Gosh, I could really go on for days on this topic because one of my first jobs before I became a doctor was working in a hospital lab. I was actually wondering around the hallways, drawing blood, learning about how to process the specimens, and then also running specimens to and from different departments in the laboratory. So, I got a really different perspective on [00:07:30] medicine before most people. Most doctors just don't know how labs work. They know how to order them, and they know what they need, but they don't really understand the nuanced details of how they're gathered and how they're processed and how they're performed. 

I, I guess, got a really good head start on all this, and because of that, I've been just really fascinated by the field itself, because we used to be getting labs like once [00:08:00] every few years from our doctors, and now we've got this chronic disease epidemic, so people are getting their labs like once a year. But what I learned a few years ago, working for a company called GeneSolve that ... It no longer exists, but was a really cool company that created a personalized nutrition, custom combat and nutraceutical and hormones for people, basically like bespoke medicine. It was really, really cool. I learned that people's biology is changing pretty rapidly throughout the year, and getting their blood labs [00:08:30] drawn once a year, I would argue, isn't enough because you're changing so much. We were doing labs every quarter, and then we were optimizing people's medicines every quarter so that their bodies would function like high-performance race cars. A lot of people that we worked with were executives, and that was just blood labs and a few genetic snips. That was like four years ago, maybe. 

Then I've been doing functional testing throughout all of those things, like [00:09:00] micronutrient testing, like the NutrEval from Genova Diagnostics, or the stool assessments from Doctor's Data or GI Effects from Genova. Then there's a bunch of other tests that you can do, things like steroid hormone, biochemical pathways and immunology testing and antibody testing, and there's so much you can do to really get a picture of what's really happening in a person's body. But, again, these tests are all done in ... They're all one-spot checked [00:09:30] that day that you've gotten them. That's where I got an interest in continuous monitoring, because it occurred to me that since our bodies are constantly changing and shifting, there's probably some things that we might want to look at in real time. To me, those things have become ... One second. Those things have become things like heart rate variability testing, which I consider to be a diagnostic test, [00:10:00] and then continuous glucose monitoring, which, to me, is like the ultimate lifestyle biomarker because you can see what's happening in your bloodstream in real time. It's awesome. 

Daniel:I know that continuous glucose monitoring is an area that you have worked with a lot and worked with some of the companies that are innovating technologies for how to assess blood sugar in real time. I'm interested in diving in there. Something that we've talked about [00:10:30] on this show and other podcasts quite a lot is defining health not as a homeostatic state, where the markers are relative to a reference frame in one moment, but defining it as homeostatic or homeodynamic capacity, the capacity for the body to regulate and stay within range, and the ability to do it under a wider degree of stressors, basically the adaptive capacity of the systems. 

The concept of just running a blood sugar panel where we look at glucose [00:11:00] and insulin and A1c, obviously we just get a snapshot, and without factoring the stressor, if we do a glucose stress test, we get to see some response to putting sugar in the body and seeing how it does, but we're not going to get to see how it does over a very long time and how it does with low blood sugar, et cetera. Then continuous glucose monitoring gives us, really, the sense of how the body is regulating one of the core homeodynamic [00:11:30] axes. Talk to us a little bit-

Molly Maloof:Right.

Daniel:Most people think about this as something for type 1 diabetics.

Molly Maloof:Sure. 

Daniel:What is this as a health metric and a bio-optimizing metric?

Molly Maloof:[inaudible 00:11:43] Well, I guess, let me take you back to a few years ago, when I did a talk for the Quantified Self meetup. I was doing some consulting for a company that was asking me to dig into all the different biomarkers you could measure in interstitial fluid, and that's the fluid that's not in your bloodstream. [00:12:00] That's the fluid that's in your tissue, like outside of your bloodstream, the sort of crystalline matrix, right? That tissue has lots of biomarkers, but, to me, I was looking at, "Okay. What are the biggest problems in society, in terms of health?" To me, it was very obvious that diabetes was going to become an even worse problem, and it has. In the last four years, it's gotten worse and worse.

I said, "Look. You guys need to look at glucose." So, I started wearing the Dexcom, and I found, "Wow. Here I am, [00:12:30] trying to promote optimal health. Here I am, working with patients, and I'm letting my blood sugar drop way too low. I'm getting hangry. My relationships are being affected. I'm not maintaining regular blood sugar in a healthy way." That was a big eye-opening experience for me, and so I really started caring about it at that moment, when I realized that, "Wow. Even I can benefit from this."

Daniel:And I'm guessing-

Molly Maloof:One of the things that I was listening ... Yeah?

Daniel:I'm guessing that when you were noticing [00:13:00] that, you already were on a relatively good diet. 

Molly Maloof:Yeah. I mean, I was eating a fairly healthy diet, I guess. I was eating healthier than most people would be eating. I wasn't eating-

Daniel:Right.

Molly Maloof:... fast food or junk food. For me, it was really about meal timing and maintaining consistent blood sugars and not letting myself get low. I was surprised at how I wasn't doing a good job with that. One of the things that we're learning [00:13:30] now about hypoglycemia is that for people who have autoimmune disease, it's actually really important to maintain regular meal times, because when you drop too low, it actually activates [inaudible 00:13:41] and causes inflammation to arise, and that's not healthy for anybody. So, too low blood sugar is one way you can optimize your health. 

You can also use glucose monitoring for hunger training. A lot of people are totally out of touch with their hunger biosignal, and we need to know when we need fuel, and we need to know when we don't need fuel. People are [00:14:00] just eating all the time, and that's not great because we're never really getting into [inaudible 00:14:06] We're never really taking the garbage out of ourselves, and everyone is kind of like overnourished. Hunger training is cool because you can use the blood sugar numbers to say, "Okay. I'm going to only eat when I get below 85." [inaudible 00:14:21] and there's actually papers on this, biofeedback papers on obese and overweight people who have not felt [00:14:30] the feeling of hunger in a long time, and they're finding it's just one really simple tool you can use to identify when you need to eat. Regular meal timing is key. Eating when you are actually hungry is key. These are all basic little things we should all know, but we don't do. Probably the reason why we don't do it is because there's food in our face all the time in modern society.

The other markers that I look at are I'm looking at the fasting glucose. Fasting glucose, right now the government [00:15:00] says, "As long as you're below 100, you're good to go," but there's actually evidence that shows that above 90, you start increasing your risk of diabetes significantly. I actually want to see people below 89. That's my personal preference. I don't see everybody there, and so that's a room for improvement. 

The other thing that people don't realize is that postprandial blood sugars, most people aren't even looking at them. Doctors are diagnosing prediabetes and diabetes with hemoglobin A1c, which is your average glucose over the last few months, and they're diagnosing [00:15:30] it with your fasting glucose, but they're not looking at your body's response to food, and that's also [inaudible 00:15:35] way to diagnose prediabetes or diabetes. If you're not looking at that, that's problematic, and these glucose tolerance tests are really good tests, but they're really painful to do because you have to be at a hospital or a clinic for like two hours. Having a glucose test you can do at home to actually see in real time how your body's responding to food is absolutely phenomenal. 

That's where a lot of my research is going into right now. I'm [00:16:00] literally reading hundreds of papers on postprandial blood sugar, because I actually think that the standards we have for people are, again, too high and that we should all be trying to aim for blood sugars probably below 120, because most healthy people are below 120 after meals, and that's ... By the way, I wasn't a year ago, and that was pretty profoundly interesting, too, is realizing, "Shoot. I have even more to work on." The last year, I've [00:16:30] dramatically dropped my blood sugar from like 5.6 to about 4.7. We can get into the theories behind what's the best way to go about this, but there's really a lot that you can do for your health using this one biomarker. I mean, I didn't even talk about stress. Stress changes the variability of your blood sugar, as well as inducing insulin resistance. There's quite a lot to be discussed here.

Daniel:Okay. So, you actually brought up about eight things that I [00:17:00] want to ask you more about. First one is if we're doing continuous glucose monitoring, and we're seeing that blood sugar is or isn't dropping below certain metrics and going above certain metrics, how well does that correspond, just the blood glucose, to checking fasting insulin, hemoglobin A1c, GlycoMark, other measures that we would normally use to be able to test long-term [00:17:30] blood sugar health in a snapshot?

Molly Maloof:Right. Yeah. My big personal belief is that if you really care about your blood sugar and really care about the homeostatic capacity, then you're going to want to do a lot more labs than just one marker. You're not going to just want to do continuous glucose monitoring. You're going to want to see your fructosamine. You're going to want to see your glycated albumin. You're going to want to see your HOMA-IR. Also, I just read a book on the oral glucose tolerance test. Really, we should all be getting [00:18:00] a two-hour glucose tolerance test with insulin. We should be measuring our blood glucose over the course of two hours, at one hour and two hours, with insulin as well, and going into that test completely fasting, because a lot of people are going to show insulin resistance before they even show a blood sugar dysregulation. 

The only way to really tell if you have insulin resistance ... You can check fasting insulin, but that's only going to tell you about your hepatic insulin sensitivity. It's not going to tell you about your muscle influences, that sensitivity, [00:18:30] and that's what a lot of people don't understand, is that insulin sensitivity is tissue dependent, right? You can have abnormal fasting glucose and normal muscle insulin sensitivity and normal postprandial glucose. I'm probably getting way too into the biomarkers here, but what I'm trying to say is that to be able to really look at what's happening inside your body, you're going to need more than one marker. I mean, hemoglobin A1c isn't a perfect test because if you have anemia or you have too much ferritin or too much iron in your [00:19:00] body, you're going to have abnormal numbers, and most people don't realize that. It's key to see this all in context, and then also really looking at a person's lifestyle, and not just focusing on food, but also looking at what their sleep is like and what their exercise is like and what their stress levels are like.

Daniel:So, I want to go to the topic that you were mentioning earlier, the difference between the current normal ranges and the actual physiologic ranges that we're identifying correspond to optimized health. 

Molly Maloof:[00:19:30] Yeah. 

Daniel:You're mentioning blood sugar of 100 not that great. For people who are not overweight and who don't think that they are candidates for type two diabetes, should they care about this topic at all?

Molly Maloof:Oh my god, yes, because everybody is at risk these days. I mean, the number of people who are developing diabetes and prediabetes is astonishing. If I can have [00:20:00] issues in my blood sugar, anyone can, because I was eating an incredibly healthy diet, with no fake sugar, no white sugar. The only sugar in my diet a year ago was by fruit, maple syrup, and honey, and I still had blood sugar issues. It's far more complicated than eating a normal diet. I think there's a lot to ... I mean, people need to think about pollution, which can affect blood sugar, vitamin D levels, hormone levels, oxidative stress, [00:20:30] issues with methylation. All these things affect your blood sugar. 

I think that because it's such a big epidemic and because it's becoming worse by the year, and because I see healthy-looking people, who have healthy diets, who are skinny, have insulin resistance, I think it's important for everyone to look at it. 

Daniel:So, would you explain ... because not all the listeners are going to know what this is. What is insulin resistance and metabolic syndrome and-

Molly Maloof:Sure.

Daniel:... very early prediabetes?

Molly Maloof:Right. [00:21:00] Metabolic syndrome is a cluster of conditions that we bind together, and if you have enough of them, you get diagnosed with metabolic syndrome. It's things like hypertension, high triglycerides, high waist circumference. If you have like three out of five of the ... I believe it's low HDL, high triglycerides. If you have three out of five of these, you get the diagnosis of metabolic syndrome. The reason why that matters [00:21:30] is because metabolic syndrome puts you at great risk for diabetes and heart disease, because these are metabolic diseases. 

Now, prediabetes is not actually like a clinical diagnosis in a frank sense as much as it's a specific range of blood sugar that doctors care about because you're highly likely to end up with diabetes. The conversion rates are ... I've been trying to hone in on these because [00:22:00] I'm writing a paper for the FDA right now all about why people should care about this stuff. The point is that a large percentage of people are going to convert within 10 years. Something like 10% a year will end up developing diabetes. The reason why we care about prediabetes is really because we want to start aggressively targeting people who are going to get diabetes.

Now, here's the reason why all this really matters. When you're prediabetic, you've already lost 30% of your beta cell function, and your beta [00:22:30] cells produce insulin, and insulin allows you to take glucose into your cells. By the time you're diabetic, you've already lost 50% of your beta cell function, which means your body's not ... You're basically like a half of a type 1 diabetic. No one thinks about it this way, but that's really what's happening in your body. Insulin resistance develops when we have consistently too high of insulin levels, because our body's pumping out extra insulin because it's trying to put the glucose away into our cells and use it as fuel, but it can't [00:23:00] because our cells are becoming resistant to the insulin. 

There's a few ways that you can develop insulin resistance, and this is something that I can go on, because there's really two schools of thought around how to treat this disease nutritionally, and I have some pretty astonishing things that I've found that I'd love to tell you about. 

Daniel:Yeah. I would love to hear the two schools of thought and the astonishing things you've found, and you started to mention micronutrient deficiency. You mentioned vitamin D, [00:23:30] but also we could talk about chromium and vanadium-

Molly Maloof:Sure.

Daniel:... and zinc, because the traditional school of thought that most people are familiar with is eat lower glycemic index food, get your macros right, and exercise, and you're fine. So, I'm curious for you to say why that's not the whole picture. 

Molly Maloof:Right. Well, because the microbiome, because if you eat a diet that just allows you to get the macronutrients you need but doesn't have large quantities [00:24:00] of fiber or phytonutrients that are filled with ... When you eat plant material, you're getting all these minerals and vitamins and [inaudible 00:24:08] and all these things that your body needs, and when you're eating healthy forms of protein and healthy forms of fat, you're getting all these signals in your body that are sensing ... Your cells are sensing, "Okay. I can function optimally," and if you're deficient in anything, it just throws off these metabolic cycles. 

A lot of people are eating nutritionally-deficient ... what I call dead food, which is packaged processed American crap that's [00:24:30] highly refined and very nutrient poor, and they're not nourished. They've got calories, and they've got carbohydrates, but they don't have ones that are bound to fiber or bound to what they call heavy water, the water that's found in these cells of plants that is so good for our bodies, and they don't come with all these wonderful pigments from plants that are helpful for combating oxidative stress. [00:25:00] Diabetes is a disease of inflammation and oxidative stress. If you eat a diet that doesn't have these anti-inflammatory and antioxidant substances, you're going to have problems. This is my big argument against things like [inaudible 00:25:16] against just drinking our food through man-made, manufactured shakes. I just don't think that that's living food. 

Daniel:Okay, so you said something that's really key. Earlier, [00:25:30] you said we're overfed or we have excessive nutrition, and then here you're talking about deficient nutrition, and they're happening at the same time, right?

Molly Maloof:Right.

Daniel:Which is too many calories and macros and not enough micronutrients.

Molly Maloof:Right. 

Daniel:I think, if I was going to give people any diet advice, this would be pretty close to the top, is increase your micronutrients and decrease your macros. Obviously, we need to get the right ratio of macros and the right types of fatty acids and amino [00:26:00] acids, but in general, when we look at caloric restriction, we see that people with less calories live longer, but it's not [crosstalk 00:26:07]

Molly Maloof:Well, let's talk about decreasing macros for a second, because-

Daniel:Okay. 

Molly Maloof:... I'm going to blow your mind. I have been talking to all these groups of people who are trying to combat diabetes with different nutritional prescriptions. On one end, we've got this guy in San Diego, Cyrus, of MangoMan Nutrition, and on the other end, we've got Virta Health. Virta [00:26:30] Health is the ketogenic diet company in San Francisco. Both groups are seeing ... and, by the way, you can actually see ... I got the results of Cyrus' cohort from him directly, and then I got Virta Health's results off of their website, and both groups are seeing the same amount of drop of hemoglobin A1c and the same amount of drop in weight, and they're completely different macronutrient recommendations. One end of [00:27:00] the spectrum is less than 10% of calories from fat, and the other one is less than 90% of calories from carbs. Both of them have fairly consistent protein amounts. Although, I'd say that the MangoMan guy, he's probably a little bit less protein because he's fully plant based, but we're seeing that people moving into a whole food diet, they're getting similar results.

Now, what I'm really curious about with both these companies [00:27:30] is I want to talk to the people who failed, because I want to figure out what happens if we put them on the other end? What happens if we bring them to the other side? Are they going to have a better response? To me, that's going to be the future of personalized nutrition, is we give you a diet ... and maybe it's not that extreme. Maybe we don't need to go to this massive extreme to get people to a better health, but what happens when we have this ability to actually prescribe you the perfect amount of micronutrients and the right amount of whole [00:28:00] foods so that a person's body just reverts back to normal because it's what the body needs to be eating?

Daniel:So, this is the interesting thing when we talk about making sure that we're not in excessive macros, meaning that we're not consuming just way too many calories a day and, of course, then calories from shitty sources and enough micros, is that if you look at an evolutionary environment that didn't have a bunch of refined starch and sugars, all the stuff that you would have been able to gather pre-agriculture was going to have a lot of vitamins, minerals, phytochemicals, [00:28:30] and not a whole lot of macro concentration.

Molly Maloof:Right. 

Daniel:From an evolutionary sense, if you're just eating things that look like they came out of a living ecosystem, you're going to be much closer, and it also makes sense that the macro ratio would change throughout the course of the year, and even just change with whether hunting went well, or you're mostly depending on gathering.

Molly Maloof:Absolutely. 

Daniel:And so there's something-

Molly Maloof:I think a lot of people aren't thinking about that at all, right? And also just where you're located in the world.

Daniel:[00:29:00] Yeah. 

Molly Maloof:Right? People who live by the equator eat more carbs. They also tend to be outside, moving around more. 

Daniel:Yeah.

Molly Maloof:People who live more towards arctic regions, they don't have the ability to go hunt and fish that often, so they're eating slower-burning, high-fat diets. This is where my mini theory that I ... It's probably not a theory. It's more of like a metaphor for nutrition, where certain people are going to thrive on kindling and certain people are going to thrive on candles. It's like candles are slow-burning fuel, and kindling [00:29:30] is very quick, and you typically see these people who are eating ... I mean, I know people who eat carbs all day long and they're just fine. Their blood sugar's just fine, because their metabolism is basically working just fine being stoked lightly with kindling. On the other end, you see people who are burning very slowly. They're eating high fat, and they're like, "I'm never hungry. I don't have to eat very much." 

You know what? What I really hate about the nutrition field [00:30:00] is just how antagonistic everyone is against everyone, and everyone's just trying to pretend like everyone's right. The vegans hate the keto people, and the keto people think the vegans are nuts, and I'm just like, "Everyone needs to stop, take a step back, and just think about biology."

Daniel:Now, there's a couple interesting things. One thing is someone can get good results for a short term and then bad results longer term because they either are adapting to whatever this thing is, and/or they're getting some nutrient deficiencies or excesses that start to pool after a while.

Molly Maloof:[00:30:30] Right. 

Daniel:So, it's pretty common that people ... You have two studies, and both people are going to get better for a while, but then we have to really track longer-term effects. 

Molly Maloof:Yes, and this is where tracking matters. 

Daniel:Yeah. 

Molly Maloof:This is why I believe in micronutrient testing, because there's so many people who don't realize just how much ... Oh, sorry. Sorry, my phone just rang. There's so many people who don't realize how [00:31:00] screwed up our soil has become because of constant farming and over-farming and topsoil depletion. We don't have the nutrient density that we used to have from vegetables. There's a really great book called The Intelligent Gardner. It's literally just a book about how you should test your garden that you're growing ... and let's say you're growing vegetables in your back garden. The entire premise of the book is that you should really [00:31:30] just measure the minerals in the soil and replete whatever's missing if you want to grow nutrient-dense food. 

My argument is that the same thing could be applied to a human being. We should be measuring our minerals and our vitamins and our nutrients in our body to see what we're missing, what we need to add. To me, this is just first principles, but yet the government won't pay for this because optimizing health just isn't something people want to do, because it's like ... I don't know why. I mean, it's because you're not getting paid for it, [00:32:00] I guess, but disease is what we pay for. We don't pay for making people healthier, and that needs to shift, and that's what I want to see change in the country. 

Daniel:I appreciate that you brought up soil conditions. I got into studying health and wellness as a kid because some of my family members were diagnosed with interval illnesses, and so we got on that journey. One of the first books that I read was Empty Harvest by Dr. Bernard Jensen where he was ... and then Weston Price's stuff all about soil nutrients and that-

Molly Maloof:[00:32:30] Right.

Daniel:... conventional agriculture's depletion of soil nutrients started statistically tracking to the types of disease in an area, and that where the selenium was gone from the soil, heart disease went up. Where the chromium and vanadium were gone, diabetes went up, and it was-

Molly Maloof:Oh my god, so true. 

Daniel:This is one of those things where even if someone is eating fruits and vegetables but they're eating them from poor sources deficient in trace minerals, deficient in microbiome is going to be a part of that whole picture. 

Molly Maloof:Yeah, and I think [00:33:00] the thing you brought up around selenium is really fascinating. The North Karelia Project in Finland that was done in the '90s, one of the main aspects of the program was remineralization of the soil [inaudible 00:33:14] and long with changing people's dietary preferences through innovation diffusion theory and subsidizing berry production in the country and trying to get people off of high-fat dairy and reducing their red meat consumption. The selenium remineralization [00:33:30] probably played a pretty big role, but it was a multimodal approach. It's not like you can just fix someone's selenium level and everything's going to get better in their body, right?

Daniel:So, you use micronutrient testing as one of the bases. Obviously, you just foundationally say, "Are people eating enough plants?"

Molly Maloof:Yes. 

Daniel:And, "Is their microbiome good, and are they digesting and absorbing their nutrients?"

Molly Maloof:Right. 

Daniel:But then you do [00:34:00] micronutrient testing. Again, when you're looking at people who don't have diagnosed diseases, how often are you seeing micronutrient ranges that are not in physiologic optimum?

Molly Maloof:I see most people are ... I guess the way I would describe it is most people have some subclinical deficiency. Almost everybody is low on magnesium. Almost everyone is low on vitamin D. Those are often [inaudible 00:34:27] deficiencies.

Daniel:Yeah. 

Molly Maloof:Most people [00:34:30] need probiotics, believe it or not, and then the B vitamins tend to reflect fairly well with a person's methylation patterns. Then there's things like vitamin A and fat-soluble vitamins. For example, I have some vitamin A genetic issues, so I need a bit more vitamin A than the average person does. Those things you can look at genetics, as well as you can look at your micronutrients, but [00:35:00] I'd say most people have pretty consistent subclinical deficiencies of vitamins and minerals. 

Now, the funny thing is that I once took care of this guy who was a bodybuilder, and he ate a pretty typical bodybuilder diet, and he was one of the only people that I've ever seen ... He ate a lot of meat, by the way. He's one of the only people I've ever seen who had like zero nutritional deficiencies, like zero, but his gut was super inflamed. It [00:35:30] was really fascinating because he had all his gut inflammation, but yet I'm pretty sure ... People don't realize that meat actually has quite a lot of nutrition in it. He actually had pretty great micronutrient levels, but he didn't have enough fiber in his gut. We got him eating a lot more vegetables, too, because that's really the key. If you're going to be a meat eater, you have to eat vegetables with it because it really just makes a huge difference in the health of your microbiome. 

Daniel:As a bodybuilder, if he was eating four or five thousand calories [00:36:00] a day ...

Molly Maloof:That too. 

Daniel:[crosstalk 00:36:02] a total quantity of intake. 

Molly Maloof:Yeah. That was probably an issue as well. I don't think he was eating that much per day, though. 

Daniel:Yeah. Okay. The reason the continuous glucose monitoring then becomes so interesting is because someone can be on a paleo diet or a keto diet or a Zone diet or a vegan diet and think that it's appropriate for them, and it's not, but how would they know? Whether you're actually doing well on the diet you're on or not, this is going to be one of the better ways to tell.

Molly Maloof:[00:36:30] Exactly. I mean, I just got off of a ketogenic diet, and I did it as a challenge with one of my friends, Brit Morin, from the company Brit + Co, and I was like, "Okay. This will be fun," because last time I did it was a year ago, and I felt like garbage, but I lost a ton of weight right before my sister's wedding, so I looked great in the dress, but it came right back on afterwards. I was like, "Okay. Let's see if I do this right, if I take the right supplements and I really optimize my nutrition [00:37:00] and I track everything even more deeply, let's see if I can get through this." 

I ended up staying on it for about a month, because that's generally where I think you start seeing some actual [inaudible 00:37:09] I have to admit, the first two weeks were not that bad, first few days were not that great, but I, by the end of the month, was like, "This is just heading towards orthorexic territory," where I'm literally freaking out about everything I'm eating like, "Does it have too many carbs?" It's not a sustainable lifestyle for [00:37:30] most people, and I know that I'm going to ... I actually bought the cardio track, and I have it sitting here, and I'm going to check my blood lipids tomorrow morning and find out how high they've gotten because I have an ApoE 4 gene, and I know that you're not supposed to eat super high fat with that gene, specifically high saturated fat. 

No matter what I did and no matter how many monounsaturated fats I tried to consume, I still found myself leaning back on saturated fats during that diet, and it's just too hard to do if you can't eat a lot of saturated fat. It's [00:38:00] just too hard. 

Daniel:Obviously, we've heard a lot of people do brilliantly on the keto diet, and a lot of people have a miserable time, and it might be that they're getting it right or not getting it right, but it also might be appropriateness for their body. As you mentioned, something like ApoE 4 is going to make a pretty big difference as to how high you want your blood lipids to get of certain types. 

Molly Maloof:Totally. 

Daniel:So, [00:38:30] I'm curious. When you started getting your blood sugar closer in range with continuous glucose monitoring, what changed that you could subjectively notice?

Molly Maloof:Oh, wow. Yeah. The big thing was tiredness after meals. When I would have a blood sugar spike and drop, I would just get profoundly tired, and it was the kind of tired where I was just really upset that I couldn't focus. [00:39:00] I really couldn't get great work done because all I wanted to do was sit down and chill out. When you get your blood sugar so stable that you're not having these peaks and drops anymore, you find yourself with far more mental capacity to do things you want to do, and that means you're not losing hours of your day that you used to lose because you're tired after meals. The big one was just the not being tired after meals. 

The other things that I've noticed ... I guess ADD and ADHD [00:39:30] symptoms dramatically improved, and then what else improved? I mean, mental function and ADHD are the big ones for me, and so energy consistency is big. The other things [inaudible 00:39:48] I have a pretty consistent weight. For me, it wasn't really a weight loss thing for me, but some people who do get their blood sugar normalized do find their weight [00:40:00] improve. Another thing that really improved is my skin. Now, people don't realize this, but, man, acne and blood sugar are so intertwined, because your blood sugar and your hormones are so intertwined. 

When I got my blood sugar back to normal ... I used to get these hormonal breakouts, and they're basically gone. They really only come back when my blood sugar goes crazy or my stress is super, super out of control. Even then, what's funny is that I had some pretty significant [00:40:30] stress over the last few months, but as long as my blood sugar was under control, my skin was actually pretty great, and people always comment about my skin. I'd say that just the general quality of my skin ... and basically it looks a lot younger. I used to have some wrinkles around my eyes, and I actually think that ... and I really think it's the blood sugar normalization that's made a huge difference in that. 

Daniel:Beyond the effect on hormones, which would be significant, talk about advanced glycation end-products. 

Molly Maloof:[00:41:00] Sure, yeah.

Daniel:It seems like you have an automatic life extension effect of getting that dialed in. 

Molly Maloof:You know, people don't quite think ... Okay. What really drives me nuts about advanced glycation end-products is there are literally companies in the Bay Area that are developing drugs to fight AGEs. This, to me, is just the dumbest thing in the world, because why do you need to take drugs when all you have to do is stop eating so many refined carbohydrates? The other thing people don't talk about is [00:41:30] the most amazing, delicious Maillard reaction in food, the crispy outside of any fried carbohydrate that you consume, that's actually pretty carcinogenic and a great source of AGEs. It's a great source of acrylamide and AGEs. I did eat fried potatoes for the first time in like God knows, maybe six months, yesterday, in Chicago, because the chef literally heated up fresh oil for me because he knew I was celiac, so I wasn't going to be like, "No," but [00:42:00] I rarely eat fried food for this reason, because it's such an aging ... The most aging food you can eat is fried carbohydrates, period, and maybe fried meat, because fried meat also has the same problems.

But yeah, I just really try to avoid fried food in general because I don't want those AGEs to get into my body to age my skin. That's part of the reason why I ... A lot of people don't realize baked goods, all those browned, beautiful croissants, it's [00:42:30] really not good for your body at the end of the day. It tastes so delicious. It's so tantalizing, but it's bad. The realization is I do really do miss eating these things. There's not a day that goes by where I'm like, "Man, I would love to eat a chocolate croissant," but I'd also really like to live and feel amazing as I age. I haven't been granted the genetics to live off of processed, standard American food. I just haven't. That's [00:43:00] just not me. So, I have to be vigilant. For me, it means avoiding these things that I know give me subjective and objective measures of inflammation that I can feel and I can see on labs.

Daniel:Other than diabetes, how does instability in blood sugar and the blood sugar related markers relate to longevity and other disease processes? You're talking about [crosstalk 00:43:26] and [crosstalk 00:43:28]

Molly Maloof:Oh god, yes. Okay. [00:43:30] Most people like you and I, we get this, but a lot of people aren't aware that heart disease is hand-in-hand with diabetes, and the vast majority of heart disease could be prevented through reducing sugar intake and reducing prediabetes and diabetes, because you're actually ... There's evidence that shows that postprandial blood sugar is a greater risk factor for heart disease. High postprandial blood sugar spikes [00:44:00] and drops is a bigger risk factor for heart disease than high fasting blood sugar, because the oxidative stress effect that this has on your blood vessels. 

The fact that blood sugar sitting around, not getting used by your tissues is damaging the internal lining of your blood vessels. It damages the linings of all your blood vessels, not just your heart, not just the macrovasculature, but the microvasculature. The vasculature in your eyes, in your kidneys, in your fingers and your toes, [00:44:30] all of these get damaged. The problem with that is that you end up ... By the time you have diabetes, you already have damage in all these areas, so you're already basically set up to eventually lose your limbs, lose your kidney function, lose your vision. A large quantity of people's macular degeneration could be prevented through blood sugar control. 

And I haven't even talked about cancer, where cancer basically lives on glucose. If you don't make sure your glucose is under control, you're setting yourself [00:45:00] up for cancer as well. These are all going to kill you eventually. Basically, infection will kill you eventually too. If you end up getting infection, what does infection live off of? It lives off of glucose. Bacteria eat glucose, right? So, if you have bacteria in your bloodstream, and you've got a lot of blood sugar in your bloodstream, you've got a perfect storm.

Daniel:I think that this isn't the topic that everybody knows, but since cancer cells are reproducing [00:45:30] at a faster rate than normal healthy cells, they can't actually convert energy from fats and proteins, so they need to take energy from sugar, which both can mean increase in cravings for sugar and that unstable blood sugar leads to faster carcinogenesis of many kinds.

Molly Maloof:Right. 

Daniel:The work on insulin potentiated chemo I found very interesting, where do almost no carbohydrate diet for some period of time, cancer cells are starving, the other cells are converting [00:46:00] to process energy from protein and fat more effectively, and then they do a low dose of the chemotherapeutic agent with a lot of sugar so that basically the cancer cells are uptaking the sugar and uptaking the laced chemotherapeutic agent, and so you get much less toxic effect on the overall body while having more anticarcinogenic effect.

Molly Maloof:That is brilliant. 

Daniel:Just seeing that insulin-potentiated chemo makes chemo so much more effective gives you a little bit of sense of how big a deal blood sugar would be [00:46:30] in carcinogenesis. 

Molly Maloof:Yes, and, Daniel, when I was in the hospital working in a pediatric cancer ward, one of the largest pediatric cancer wards in Northern California ...

Daniel:Feeding them sugar.

Molly Maloof:... all I saw was these kids eating Oreos and cake and candy, and I would complain to my professors and my attendings. I said, "Look. This is violating first principles."

Daniel:Yeah.

Molly Maloof:They would look at me like I was crazy, and I'm just like ... Honestly, I [00:47:00] couldn't handle it. I had patients dying, and I just felt really, really unhappy watching the system just be so antiquated, be so ignorant of what is so basic to biology, you know? It's heartbreaking, is what it is. 

Daniel:So, for listeners that have heard me talk about this before, it's going to sound like I'm harping on it, but if you're listening to this podcast, I just want to kind of reiterate that research has to get paid [00:47:30] for by somebody. Within capitalism, science has this issue of, "Who's paying for the research, and if that's money out, does the money come back?" Is there return on investment, and if there's return on investment, you're going to get more research dollars. If a doctor's going to recommend something, it has to be FDA approved for that disease, which means you've got to go through clinical trials for FDA approval, which, if we're looking at a drug, is going to cost half a billion to a billion dollars, which means that if you don't have a patent on it, there's no way you could ever recoup [00:48:00] that money, so you're only going to look at synthetic molecules that you can get a patent on. 

Anything that the body naturally produces as part of its healing can't be patented. We're just not going to do that much research on it, any nutrient, any plant from an evolutionary environment, any microbes from the evolutionary environment. The intersection of the financial motives and the financial structure with the IP structure with the regulatory structure means that the things that you would expect the answers [00:48:30] to live just will never get the funding for research, and the only thing that will is going to be synthetic chemicals that weren't part of the evolutionary health environment at all. This isn't really the fault of the pharma companies or regulation. It's the fault of the whole complex is just build wrong, and it's built in a way that makes managing symptoms much more profitable than preventing or curing illness, and-

Molly Maloof:You know what, though? I mean, not to interrupt you, but I have to say that these do seem to be ... Doctors are starting to wake up a little bit. There [00:49:00] are pockets of doctors that are studying this stuff, and there are people that are bundling these metabolic therapies with chemotherapies, and I've talked to DCs, and they're actually starting to become interested in investing in these multimodal approaches to optimizing health, and really because the precision medicine movement is actually taking foot. I see this as possible. 

Daniel:But really-

Molly Maloof:Because of bundled payments and this new way of paying for disease, there is money to be made in these new types of therapies, [00:49:30] but we're in this early, early, early stage of that happening. 

Daniel:And with people paying out of pocket, who are interested in-

Molly Maloof:Right. 

Daniel:... health because of conversations like these.

Molly Maloof:Right. 

Daniel:You have people who will go do micronutrient testing that insurance won't cover, and so there starts to become an actual market basis for it. 

Molly Maloof:Right. If you're interested in actually getting into this a little bit more, my friend has a podcast called P5 Protocols, and he's talking to doctors [00:50:00] who are on the forefront of these new types of cancer therapies, these metabolic therapies for cancer, and really the way that they're trying to combine them into actual companies. That's a great podcast if you really feel like digging into cancer metabolism. He's been covering a few people who are doing that. 

Daniel:Say the name of the podcast again. 

Molly Maloof:P5 Protocols. 

Daniel:All right. 

Molly Maloof:David Eigen.

Daniel:Awesome. 

Molly Maloof:Yeah. 

Daniel:Going back to continuous glucose monitoring and then how it starts to relate to [00:50:30] the other thing I wanted to ask you about, which is heart rate variability, as a tie-in between them, what's the relationship between blood sugar and stress?

Molly Maloof:Yeah. I have just been, like I said, reading a bunch of papers on this really under-recognized problem and phenomenon, but ... Okay. So, one of the definitions of stress is the consequence of a failure of an organism to respond appropriately to emotional or physical [00:51:00] threats, whether actual or imagined. We've all heard it before, the story of how we're not living in primitive times. We don't have saber-tooth tigers. Our problems are mostly psychological. Our problems are mostly relational. We don't have enough people doing what is actually fundamental to managing stress to keep them at a state of a sense of safety, internally. Most [00:51:30] people are operating as though there's danger everywhere, all the time, every day. 

One of the worst sources of stress for people in America is unemployment or low socioeconomic status, and it's not surprising that a lot of people with diabetes are in this demographic, because when you have to worry about where your next meal is coming from, that's as close as you can get to the primitive experience of not having food to eat. [00:52:00] That's one problem. When you have this constant sense of fear, it adds up over time. You can get acute stress, which is like this epinephrine-norepinephrine experience of, "Get me out of this dangerous situation," but then, over time, this becomes chronic if you consistently have no way of resolving these stressful experiences. 

One of the best ways to resolve stress is exercise, because the fundamental reason why we have these stress responses is to get us to move, [00:52:30] and nobody's moving. Our culture is not moving enough. We are not literally moving the stress out of our bodies. Exercise is like the fundamental antidote for stress, and people aren't doing that. So, we're developing all these symptoms, these cognitive symptoms, these emotional symptoms, moodiness, poor judgment, physical symptoms, diarrhea, constipation, nausea, because we're not really digesting the food we're eating because we're so stressed out, and then all these behavioral systems add up. People end up isolating themselves, which further compounds the problem. 

Next thing you know, [00:53:00] your cortisol curve went from high cortisol to low. Now you're flatlined, and now your variability is gone. That variability is actually the key to homeostatic balance. It's the ability for our bodies to adapt to whatever we face. This is where heart rate variability and cortisol are great measures of stress in real time and over the course of a few months, because they tell us if our bodies have the variability that we want to see, that it's telling us that we are [00:53:30] fit to respond. If we have flatlined cortisol curves, if we have low heart rate variability, we're not adapting to stress. In fact, we're breaking down. Our bodies are breaking down. 

The problem is that chronic cortisol access increases insulin resistance just by nature of the fact that there's too much cortisol around, and so people are getting insulin resistance from just being too stressed out. Another big source of cortisol excess is sleep [00:54:00] derangement. It's not surprising that people who are low socioeconomic status who have to do things like shift work have really big problems in this area, and we see shift workers have terrible metabolic disturbances. Even people working in hospitals have terrible metabolic disturbances. You see a lot of obesity and overweight in hospital employees because these people have to work during times when they should be sleeping, and their cortisol levels are all haywire. I hope that does a decent job of explaining why there's [00:54:30] a relationship here.

Daniel:Yeah, and when people are not sleeping well and they're tired, then they crave sugar as a way of trying to get some energy spike.

Molly Maloof:Absolutely. 

Daniel:We've seen sleep issues correlated with weight so clearly and with diabetes and insulin resistance. So, you're talking about heart rate variability and talking about cortisol, and so I'd like to talk about the relationship between them, but for people who aren't familiar, what is heart rate variability? How do we assess it? What does it tell us?

Molly Maloof:Sure. So, heart rate variability, the way [00:55:00] I describe it, is the beat-to-beat variation in terms of the length of time in between heartbeats. When your heartbeat is low, your body's constantly adjusting that time frame to whatever you're doing. If you breathe really nice and deeply, you can actually lengthen the amount of time between beats. If you are breathing really fast and you're stressed out, your heart rates going to go up, and that variability's going to go down because your heart rate's just beating so fast.

[00:55:30] One of the funny things that I've experienced in my own health is, over the course of the last two years and getting off of stimulant medicine that I started when I was in medical school, my heart rate has gone from 70s to 50s. There is evidence that shows that people who have lower heart rates have much better longevity. It's part of this whole big picture around [inaudible 00:55:55] and your heart health in general, but [00:56:00] fundamentally, a healthy heart is a heart that's able to respond when necessary and that isn't constantly in a state of terror.

Daniel:The way that I think about heart rate variability is that ... and this is an indirect measure, but it's a highly correlated indirect measure ... is that it gives us the ratio of sympathetic to parasympathetic activity writ large. It's a-

Molly Maloof:Right. 

Daniel:... measure of stress or sympathetic overtone comprehensively.

Molly Maloof:Right, absolutely. 

Daniel:And so-

Molly Maloof:I mean, you can see [00:56:30] this. You can see this when you measure it. This company, Firstbeat, I used to use their test. I took a three-day assessment, and you can see if a person is in sympathetic or parasympathetic tone, and you can actually ... Because they're tracking what they do during those three days, you see a timestamp of when things are happening. It's not a perfect test because you have to go over it in retrospect, but I have found that everybody's source of stress is unique. This is where we get back into personalized medicine. [00:57:00] There are people who go to work and they're in flow state, and then they go home, and it's a disaster zone. There's people whose home life is literally their wonderful place where they ... their sanctuary, and life is good, and then they get to work, and they've got a bad relationship with their boss, or they've got problems with their coworkers. It's just bad, and they're not getting any recovery. 

This is really important, too, is thinking about the fact that we actually don't want to live [00:57:30] without stress. We need stress to thrive. We just need enough stress. We don't need ... and we need to have the right opinion of stress, too. Having the opinion that your life is stressful and that you are stressed out is actually probably more damaging than people realize, because you're actually adding a level of psychological stress on top of the objective experience that you're having in reality. So, you're basically doubling your stress. That's where this great book by Kelly ... I think, no, that's the low power ... There's [00:58:00] a book called The Upside of Stress, I believe, and it's really just all about this, that we want to get to a certain state of stress that keeps us moving and going, but not so much that we're burning out and breaking down.

Daniel:Well, I think Hans Selye, who really defined a lot of this early work, defined it well with eustress and distress.

Molly Maloof:Yep, exactly. 

Daniel:And that basically every adaptive system, you have to stress its adaptive capacity for it to continue to grow adaptive capacity. That means you [00:58:30] have to bring your cardiovascular system to its max if you want to get better cardiovascular health. You have to bring a muscle to its max. You have to stretch to the limit of stretching if you want to get more flexible.

Molly Maloof:Right. 

Daniel:The same with hot and cold, the same with so many things, but then you need a certain amount of that, and then you need repair time.

Molly Maloof:Exactly, and the amount that you can tolerate is unique to you. The catechol-O-methyltransferase gene becomes very important here, because, to me, it's a pretty good marker of [00:59:00] how much stress a person can tolerate before they break down. What I typically see is the warriors ... I see them all the time in entrepreneurship and investing, and the warriors are, a lot of times, the people who are the worker bees of the company who just keep their head down and do the work, and they like to have a stable, consistent environment. But it's so funny that you see ... Not that it's that simplified, but it is one of the many tools you can use to start really identifying where [00:59:30] can a person really meet their limit, and my interest is also like, "How do you optimize to that point?" I'm in the middle. I'm like warrior/warrior. I can handle a pretty good amount of stress, and I really do need a good amount of stress to function at my best, but once I hit that breaking point, I just fall apart. I have to really train myself to give myself recovery. 

I was telling you earlier, I spent three days without my computer in Illinois with my family. [01:00:00] I'm very, very, very lucky. I have a great relationship with my family. My sisters are amazing. We all just thrive and get along together when we're together. Oh my god, I went from having about a 9 out of 10 feeling of overwhelm on Friday to like two to three today. Literally, it was just three days of quality time with my loves ones. I think that it's very, very underutilized, this quality time with our community and our family [01:00:30] and friends. Chronic loneliness is a huge source of stress in the American culture, and it's really bad for our immune systems. 

Daniel:Yeah. I think this is one of the most interesting things that the study of Blue Zones tells us.

Molly Maloof:Yep, absolutely. 

Daniel:That the societies that live over 100 the most, there are a number of correlations with diet and lifestyle, but one of the highest correlations [01:01:00] is high quality social connections. 

Molly Maloof:Absolutely. Yeah. It's part of Maslow's hierarchy. We always get back to that hierarchy, but the problem is that a lot of people's baseline physiology is not being met. If you're searching for food and you're searching for safety and you don't have ... I'm sorry. Someone is knocking above me. If you're searching for food and safety, love and community are kind of above that. [01:01:30] That's where the possibility of living in more tribal communities is probably best for humanity, too. Having more tight-knit communities where everyone helps support each other is really, really key.

Daniel:I have a friend who had an interesting thing to say about Maslow's hierarchy, which is we think about safety and security at the bottom of the stack, and then belonging next, but his comment was that that was a perspective that we created [01:02:00] in the developed wold where you could have safety and security as an individual because of police force and military force and the ability to go buy most of the things you needed, but for the entire evolutionary history of humans until recently, if you didn't belong to a tribe, you were definitely dead, and so that there was no such thing as safety and security outside of belonging. He was arguing that you actually flip, putting belonging at the bottom of the stack, and I think it's an interesting perspective.

Molly Maloof:Yeah. I think you're right. [01:02:30] I mean, I think that Maslow's hierarchy is really just a nice framework and map to think about what human needs and wants are, human needs are in particular. As a person who works in ... I have a comfortable living in San Francisco. It's a very experience city to live in. I realized more and more, though, that just by looking at people on the street, looking at people who are homeless, [01:03:00] those of us who have comfortable lives, we have absolutely no idea what it's like to be really struggling and what it means to be living day to day, paycheck to paycheck. It's got to be an unbelievable stressor for a lot of people, and I really do think that ... Maybe we're getting a little bit too into politics now, but I do think that if we had better access to healthcare and a basic income, we'd see the health of the country dramatically improve, just by [01:03:30] giving people the ability to feed themselves and the ability to house themselves, you know?

Daniel:Yeah, clearly. Okay. So, I wanted to go back ... I know we have to wrap up soon, but just a couple quick things. You mentioned the COMT gene and mutations there and the worrier and warrior mutation types, and I don't know that that's something everyone's familiar with. Specifically, why would someone's stress capacity [01:04:00] correspond to mutations on this gene?

Molly Maloof:I mean, this is kind of like a long, long discussion if we're going to get into nutrigenomics, but basically it's a dopamine metabolism gene, catechol-O-methyltransferase. If people really want to get into this, I recommend reading up on [inaudible 01:04:20] or whatnot, but the fundamental point is that some people thrive with more or less dopamine around. For some [01:04:30] people, they need more stimulus. They need a little bit more stress. They need to be going after something in order for them to feel like they're literally at their best, which is why I think you see a lot of warriors who are entrepreneurs, because they function best when they have more dopamine around, and they get more dopamine around when they're under stress. They need a bit more stress than the average person to be at their best. 

On the other hand, some people who, [01:05:00] when you put them under stress and they have more dopamine around, they feel overwhelmed by that. They feel like it's too much, and they can't function because it's causing them to feel overstimulated. That's the simplest way I describe it, but one of the things we haven't really talked a little bit about that I think people should probably know if we're going to get into this overlap between nutrition and stress is this Dr. Gonzalez, who wrote Nutrition and [01:05:30] the Autonomic Nervous System. It's basically like a compendium of a bunch of other doctors who came before him and dentists who ... There's a few really big leaders in this space, like Weston Price and Dr. Kelly, who basically were dentists who realized that different people needed different diets to survive and to thrive. 

What he found was ... and Dr. Gonzalez kind of picked up where they left off ... was that people were more likely to develop cancerous tumors when they weren't being fed the right food [01:06:00] for their metabolism. When they corrected their metabolism by feeding them the right fuel and giving them the right nutrients, they were finding that they had a much better response to their therapies. I'm of the school of thought that we should use both modern medicine and nutritional medicine together to fight cancer, and I think that there's an exciting possibility that we'll be able to figure out, using continuous heart rate variability and continuous glucose monitoring, what is the [01:06:30] right amount of macronutrients for a person's best metabolic profile. 

Basically, what Dr. Kelly discovered was that certain people would really respond to the vegan/vegetarian diet profile where they were eating large quantities of raw and plant-based diets. He, himself, fought his own malignant cancer this way. Doctors basically told him he was going to die, and he was like, "Well, I have a bunch of orphaned children that I take care of, so I'm going to have to not die," and [01:07:00] he started treating himself with nutrition and found that his tumors were shrinking when he fed his body what it needed. But then there would be people who came along to him who would give them the same diet, and they wouldn't respond. So, he gave them the opposite. He gave them more animal fats and cooked vegetables and root vegetables, and he found that they were responding to that. He was like, "Whoa. Okay." 

He developed a series of questionnaires that would basically help you profile the right nutrition for your metabolism, but I've done these questionnaires. [01:07:30] They take like three or four hours of your day to do. Where I think we're heading is actually both questionnaires combined with laboratory testing combined with glucose monitoring and wearable monitoring to figure out what is the right diet for your nervous system and for your metabolism. I think it's super complex, and I think we have a lot of research that should go into this, but it seems like we're kind of heading in a really cool direction with all this. I mean, everybody who ... I talk [01:08:00] to a lot of people who've beaten cancer with both medicine and nutrition. You often find people who've gone the ketogenic route, and they've mastered their glioblastoma, or you find people who've gone the ... What is it? The Gerson Protocol route, which is the vegan route, the super high plant based route. What I think is fascinating is people are responding to both, and maybe we'll be able to use software in the next few years [01:08:30] that can do this better.

Daniel:So, practical side. If there are people who are listening to this who are interested in starting to find out what the right nutrition is for them for optimizing health, preventing disease, what are some basic ways they can get started?

Molly Maloof:Sure. The first thing that I would recommend is, obviously, your basic labs. [01:09:00] Let me see what I sent my sister earlier. My sister ... I probably shouldn't be mentioning family online, but she's like, "My hair's thinner than I'd like. How can I make the hair grow faster?" I'm like, "Okay ..." What I want to know if, for example, somebody's hair is too thin ... To me, if someone's hair is too thin, it's like looking at a plant whose leaves are shriveling. There's something missing from that person's body that they need to get. In women, [01:09:30] typically you don't see enough protein. I would do a NutrEval test, or an easier test to that would be an albumin. You can kind of get an assessment of a person's protein needs through some of their basic labs.

I'd also want to look at their lipid panel. You don't want too of low lipids, and you don't want too high of lipids. You want just right. I would look at their lipid panels. I would see what they're eating. I would see where they're getting their fats. I would see what [01:10:00] their genetics look like. Looking at their ApoE 4 gene, that's really key for [inaudible 01:10:03] and I'm more likely [inaudible 01:10:07] protein analysis to look at the type of LDL just because you can have normal LDL, but you can have a lot of the bad, and you can have ... One of the things that I'm also digging into is I have really high HDL, and it's possible that that's not even that healthy. You really don't want too high or too low of anything. You want just right. 

So, I would look at the lipid panel. I would always look at vitamin D. [01:10:30] I mean, everyone should be doing this more than once a year. Please do your vitamin D levels a few times a year because it's really the simplest biohack. I mean, Dave Asprey has been saying this for years, but everyone knows this is true. This is really, really a simple way to biohack your metabolism, your hormones, your immunity, your bone health, making sure you replete your vitamin D with vitamin K. I would also look at your RBC magnesium to see if you need to improve that. I would look at your typical chemistry panel. [01:11:00] I would look at your CBC and manual differential to get an idea of your immune system function. 

These are just really simple, things like ferritin. A lot of women are anemic and don't know it because the doctors aren't always checking. I like to look at ferritin levels and then omega-3s. Almost everybody's deficient in omega-3s, so upping the fish or supplementing with a really good quality fish oil is really, really important. DHEA is another good one that I like to look at, and [01:11:30] then I like to see a microbiome test. You can look at a Genova GI Effects and you can see if a person has any malabsorption. You can see if they need more enzymes. A lot of people need more digestive enzymes because they're not eating foods that have naturally-occurring enzymes in them, and their bodies are not making up for the difference. 

A lot of people, their digestion is just super taxed by the amount of work that they have to do on a regular basis to really process the food that they're [01:12:00] eating, and you can see if a person needs more diversity. For example, I have low lactobacillus almost always on every single microbiome test I've ever done. So, what am I doing? I'm literally lacto-fermenting everything now. I'm getting lacto-fermented foods into my body to replete that missing lactobacillus. You can do the same thing with bifidobacter. You could look at the FUT2 gene to understand bifidobacter metabolism, and you could also see if you've got overgrowth [01:12:30] or you have ... So, some people have too many bacteria growing in their gut, and some people have too little. 

Those are some simple ways of optimizing your nutrition. At the end of the day, most people need more plant-based antioxidants, and you can see that on a NutrEval. You can see if a person is getting enough plant-based antioxidants, and you can see if they are getting enough protein. You can see if there's any amino acid problems. 

Daniel:Okay. So, you [01:13:00] just mentioned a number of baseline labs that you like to look at-

Molly Maloof:Yeah. 

Daniel:... that may or may not be familiar to the people who are listening, and they-

Molly Maloof:Yeah. 

Daniel:... [crosstalk 01:13:07] on their own. One thing that you're saying is still find a functional medicine doctor who specializes in-

Molly Maloof:Sure. 

Daniel:... specialized precision medicine and get foundational labs done and work with someone who can actually really help you.

Molly Maloof:And you know what? What's really cool is that there's even a movement in the, I'd say, affordable world of this company called Precision Nutrition. I've always really admired this company [01:13:30] because they seem to have a really solid approach to nutrition. They're starting to partner with a lot of these personalized nutrition companies and developing far reduced cost access to some of these labs. Even if you can't afford to work with a full-blown functional medicine doctor, there's so many different tiers of what you can do and where you can spend your money, and so finding a good Precision Nutrition coach ... Most people would benefit from just really working with the coach to increase their vegetable intake. [01:14:00] The Wahls Protocol, to me, whether you eat meat or not, everybody should be aiming to eat more fruits and vegetables every day. 

Daniel:So, I've heard you-

Molly Maloof:And that's just ... yeah.

Daniel:... say a number of things that, independent of testing, sound like they're generally recommended, which was omega-3, vitamin D-

Molly Maloof:Omega-3, vitamin D, magnesium.

Daniel:... vitamin K, magnesium, probiotics, exercise.

Molly Maloof:Enzymes, exercise. 

Daniel:Sleep. 

Molly Maloof:Exercise is really, really key. I mean, sleep is like a ... [01:14:30] I know you've spoken with Dan Pardi a bunch about sleep, but listen to those two podcasts, because if your sleep is not good, then everything's going to be harder. Exercise is going to be harder, nutrition, will power, everything. You have to get your sleep right if you want to get your behaviors better, and that's something that I learned in medical school. I started working with a sleep doctor. I was doing sleep research. I really prioritize sleep when I started learning about it and educating myself on it. [01:15:00] I sleep pretty impeccably well. I dream every night, and I remember my dreams. I feel like I have a really healthy relationship with sleep. To me, that has not always been the case. If I didn't sleep the way that I did, I would burn out a lot more often. 

Daniel:Yeah. Yeah. Similarly, it's hard to say that anything is more important than exercise or more important than nutrition or more important than stress management, but if I had to, I would say sleep is more important. 

Molly Maloof:[01:15:30] Yeah. It's just so fundamental to the rhythm of life, right?

Daniel:Yeah. Yeah. So, I'm curious. If there are people who are in the Bay Area and not that far away and they're wanting to run their labs and get a personalized program together, are you still seeing anybody?

Molly Maloof:I do still see patients. I have a very small panel, and it's very personalized, very bespoke. It's not inexpensive, but it's because I'm [01:16:00] like ... It's like detailing cars. You can go to an out-of-the-box doctor's office and get a really good assessment from a lot of good doctors, but I'm just taking it a step above, and I'm also just doing a lot of things myself for people. 

I think it's not for everybody, but if you want ... I'm not trying to downplay my practice, because there is a certain sense of guilt that I [01:16:30] have that I do charge so much, but part of the reason why I'm working with Sano Intelligence in developing this continuous glucose monitor for the masses, which we haven't really talked about, but I'm not trying to shamelessly plug this company because they're not even out yet. They're not even going to be available for like a year, but there's a wearable patch that we're working on that's a continuous glucose monitor that's going to be a 24-hour wear and direct to consumer. No prescription neck. I'm really, really working hard to develop technology that can be scalable because I want people to have access to [01:17:00] the simple tools that I think are the most useful in my practice. 

I also am a big, big fan of Parsley Health, my friend Robin Berzin is an amazing doctor. He would train under Stephanie Daniels. She's also a great functional medicine doctor. There are really great ... There's a huge range of possibility of what you can afford that's out there. If you listen to the basics of things that I've told you today, you'll be, well, [01:17:30] 50% of the way there. The problem is that most people aren't even doing the basics, and if you're not doing the simple, simple things that you need to optimize your health, then it's like you're taking a dirty car to get detailed without cleaning it, you know? It's like clean off the windshield first. It's not going to make a difference if you don't clean off the windshield and keep yourself ... and fill up the gas tank, you know?

Daniel:So, I want to restate something that you said here, which is [01:18:00] with regard to the cost of doing very personalized functional medicine, precision medicine, [crosstalk 01:18:06] medicine. For those listening, most of the doctors that we've had on this podcast, Dr. Stickler, Dr. Sandison, and now with Molly, they're all people who have pretty small medicine practices, and that's why they actually have cutting-edge insights because they're able to run a lot of labs with people, do cutting-edge therapies, research the cases [01:18:30] individually, then run the labs again, watch what changes. For most things, this is not necessary, but either for severe illness where we're trying to overcome-

Molly Maloof:Right. 

Daniel:... a complex illness or for really elite optimization, it makes a huge difference. 

Molly Maloof:Right. 

Daniel:We have to get to economics that allow this to be the future of medicine for everyone, but one thing I just kind of want people to know is the doctors who are working in this space are not working [01:19:00] in the most profitable space they could be working in. 

Molly Maloof:That's true. 

Daniel:The raw cost on the labs is stupid expensive, as is the amount of time that it takes to actually research a case. If you're putting together, trying to make sense of hundreds or maybe thousands of biomarkers, the doctor's spending a lot of time and then a lot of training time that's non-paid to be able to do it.

Molly Maloof:Yep. 

Daniel:And they could just be doing aesthetic medicine and making so much more money. This just happens to be the only [01:19:30] way the cost structure works, but what they're doing on the cutting-edge is showing that what we thought was incurable is not actually incurable, what we thought that peak of health was isn't the peak of health, and then we get to see how do we bring that to economies of scale, which is part of the work we're all working on together.

Molly Maloof:Right. Yeah. I mean, I think that there are some people that are trying to do this at scale. One of my friends, James Maskell, he's been trying to introduce me to his company for a while called ... [01:20:00] I think it's called EvoMed or New-

Daniel:Yeah. 

Molly Maloof:Yeah. They're really trying to make functional medicine more scalable for everyone. I think it's going to get there. If you're lucky, you can get some of the stuff paid for by your insurance if you've already met your deductible. I have a friend in Chicago or New York who found a functional doctor that takes your insurance. The key is really just working hard to understand your benefits. I use [01:20:30] a health savings account for even my own health, because I don't need the doctor that much, but when I do, I like what I spend my money on to be tax free. I did Rolfing last year, and it was tax free. I did a 10 series of Rolfing which is a type of massage. For me, massage is one of the best ways to spend your healthcare dollars because it's such an important way to reduce stress. 

I think there's a lot of ways that you can go about finding affordable [01:21:00] access to this stuff. There's also direct labs online. There's ways that you can even just order labs directly. They're going to be more expensive because the company online that's ordering labs for you is taking the cut. In my practice, I don't actually upsell labs. I just charge on top of everything. I charge a flat fee, and then I charge a retainer, and then some people just want to do it by hourly, but what they don't realize is that the hourly is actually more expensive than the retainer. It's whatever people's preference is, which is so funny, but [01:21:30] I split my time in between my practice and working with tech companies. 

That's part of the reason why I also charge a lot, because every person is like a mini company in themselves in that I have so much work to do for each individual, but it is really gratifying, and I've seen some pretty remarkable things in some people's health. I've seen some people's life change, and that's pretty awesome, but it isn't for everyone. You have to really be willing to do the work, and not everybody's willing to do the work. Some of the clients that I've worked with, [01:22:00] I've had to find another doctor because they just didn't want to put the work in. They wanted it done for them, and health optimization is not this thing that I do for you. It's a thing that I do with you. 

Daniel:So, if someone does want to find out more and reach out, what's the best contact for you?

Molly Maloof:My website is one way to find me, D-R-M-O-L-L-Y-dot-C-O. You can also text me on Twitter, @MollyMaloofMD. [01:22:30] You can find me on Instagram, which I'm fairly active on Instagram Stories, @D-R-M-O-L-L-Y-dot-C-O, @DrMolly.co, same thing as my website. You can even find me on LinkedIn, which is where, if you're like a professional and you want to see my background, you can find me there, and then you can always email me through one of those ways. Yeah. 

Daniel:Great, and then-

Molly Maloof:We should probably do a sequel to this because we didn't even get into the weird [inaudible 01:22:58] for technological [01:23:00] San Francisco and Silicon Valley nonsense.

Daniel:No, I was about to say just continuous glucose monitoring and then a little bit on lifestyle and heart rate variability and stress took the time that we had, and it really deserves that, and there's more that we could do just on these topics, but one on genetics, personalized medicine, and then future biotech longevity extension. I would love to have you back on the show and have a sequel. For just a couple more resources for people [01:23:30] right now, if someone's wanting to do heart rate variability monitoring, is there a device that you recommend?

Molly Maloof:Oh my god, yes. This company literally just came out with their product available to consumers. It's called Lief Therapeutics, L-I-E-F Therapeutics. I am obsessed with this company because they've created a patch that you can attach to your chest, and it's kind of like a wearable stress test. You don't [01:24:00] have to use it forever, but what it does is it measures your heart rate variability. It also sense your breathing, and when it notices that your heart rate variability is declining, it will send you haptic feedback and teach you how to breathe deeply using the haptic feedback. 

It's great for self-regulation, for anxiety, for lowering blood pressure, and I'm a super big fan of this company because ... and I'm actually not affiliated with them, even though I probably would love to be, because [01:24:30] they are so ... Once I found out about this, I was like, "Great. Now we have a tool that I don't have to prescribe, that's in real time, that I don't have to spend three days waiting for them to give me the attachment back to get the data." It says pre-order on their website, but I do think that they should be ... Yeah, you can pre-order it right now. This should be available very soon. 

There's actually going to be a ... I was just interviewed for The Today Show on heart rate variability monitoring. That will [01:25:00] be airing April 9th at like 8:00 AM or a 9:00 Am in the morning. No, 8:00 AM in the morning, a big segment on technology for stress, but this is my favorite tool. I don't have this tool yet, but a lot of people love [inaudible 01:25:14] I hear that from everybody. I don't have it yet, but I really should probably try it. Then Firstbeat is a tool that you might be able to find. That's pretty rad. 

Then another thing that I wanted to plug is [01:25:30] a lot of people keep on asking me about more consumer-oriented tools for tracking metrics on health, and there's two companies that are getting a lot of attention. One of them is DexaFit, and the other one is Go Forward. Both of these companies are providing you with one thing we didn't talk about today, which is monitoring bigger metrics on your health, like VO2 max, resting metabolic rates, these [01:26:00] things that are actually pretty important markers for optimizing health. DexaFit's pretty cool. I'm going to go try them tomorrow, so I'll let you guys know on our next podcast what I think of their experience, but I'm a big fan of anything that can provide the ability to find these metrics over time, so that's pretty cool. 

Daniel:Awesome. Then with regard to the continuous glucose monitoring, Sano, I know you work with them, and you said they're about a year away from coming out with a next-gen tech. Is there any tech that people can currently get that is [01:26:30] meaningful?

Molly Maloof:For glucose monitoring?

Daniel:Yeah. 

Molly Maloof:Yeah. Abbott is my favorite company for glucose monitoring. Their spot check monitor that you can buy, the ... What is it called? Not the Libre, but the Abbott ... What is it called? Well, basically the Abbott Freestyle Libre is the continuous monitor, but then Abbott also makes a [01:27:00] spot check monitor for blood testing, so it's a finger prick. Both of these are really good tools. I like the spot check monitor for more accuracy because it has about a 5% inaccuracy measured by this thing called MARD, and the Abbott Libre Pro, which you wear on your body, which is a continuous monitor, has about a 10% to 15% inaccuracy. It's not perfect, but it's better for trends. 

[01:27:30] But for spot checks and for like if you see something abnormal on your blood sugar, on your wearable, if you really want to verify that it's abnormal, you'll do the finger prick. If you are a diabetic, you should not be using the CGM necessarily to dose your insulin. You should be using the finger prick, but for trends, I like the continuous monitoring for spot testing. I like the finger pricks tools. You can also go to your doctor and do labs such as an AM [01:28:00] fasting glucose and AM fasting insulin, HOMA-IR, which is a marker of insulin resistance, which you can actually get from your ... It's just a calculation of your fasting insulin and fasting glucose. You can do your hemoglobin A1c. You can do your fructosamine. Those are pretty good starting points for glucose metabolism. 

Daniel:Molly, it was a delight to have you on the show. I think this was a good introduction to people understanding why blood sugar [01:28:30] is a meaningful topic beyond just thinking about type two diabetes and why continuous monitoring is interesting and a bunch of other things, and I would love to have you back and go deeper into more topics. 

Molly Maloof:Awesome. This was super fun. Thank you so much. 

Daniel:All right. More soon [inaudible 01:28:47]

Molly Maloof:Bye. 

Daniel:Bye. 



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