Monday, October 28, 2013

Your Emotionally Hot-Headed Aunt Amygdala

We all have one.  She comes to family gatherings bearing inedibly sweet desserts.  She sends you non-sensical birthday gifts three months late.  Her name comes up 100% of the time when family drama arises.  She's your crazy Aunt Amy.  Everybody in the family knows that Aunt Amy doesn't take kindly to criticism.  She has finely-tuned survival instincts.  Cross her or spook her, and everyone within earshot braces themselves for the backlash.  

Aunt Amy represents special structures in the brain called the amygdalae.  As opposed to the frontal lobe, which directs rational, decision-making, your amygdalae drive survival instincts.  To demonstrate the difference between these two operating systems, recall this clip from one of the greatest movies of all time: 

Dr. Grant (guy in the hat) reacts calmly when it becomes clear that a large dinosaur is approaching.  He has studied dinosaurs his whole life, and he knows (somehow) that the T-rex senses motion.  He cooly handles the situation, using this knowledge to avoid a certain demise by the giant's teeth.  Dr. Grant's frontal lobe is calling the shots.

On the other hand, the bald lawyer guy reacts impulsively.  In sheer terror, his brain yells "Get me out of here! Scream!  Panic!  Run!"   Baldy's amygdalae are performing exactly as they should.  They respond in whichever way seems most suitable for survival. 

The Evolution of Survival
Through the beauty of human evolution, we have become master survivalists.  Nowadays, however, we rely so much on creature comforts that the idea of "surviving" without our iPhone for a day is out of the question.  Despite this, our brains have remained wired for survival above all else.  

Amygdalae activation when test subjects
were shown faces rated as low in
trustworthiness or attractiveness.
(Mende-Siedlecki et al, 2013)
Imagine you are sitting in a business meeting.  Your company has been struggling financially, and you
sense that the boss may be required to make some cuts soon.  He begins asking questions about a recent project that wasn't executed properly.  You've had the feeling for a while that Greg, one of your colleagues, routinely drops the ball on his end.  As the discussion continues, suddenly a voice from the far end of the room chimes in and throws your name into the mix.  "He should have done such and such differently, blah blah blah."  You immediately react.  Your blood feels like it's about to boil.  Your face turns red, and you nearly burst as you wait for your turn to spit out a rebuttal.  "Greg, are you f*$%ing kidding me?!  You finished the spreadsheet two weeks late!  You held us all back!  You piece of sh*t!"  Whoa.  Easy there, killer. 

In this moment you allowed your amygdalae to take over.  Often times these scenarios are followed by an apology that sounds something like: "Sorry about that...I lost my cool."  You didn't want the boss to leave the meeting with the impression that you were responsible for the company failure, so your amygdalae kicked in.  Survival!  With some practice and self-reflection you likely won't let this happen again, lest your work colleagues begin to clump you in the same category as Aunt Amy: emotionally explosive and overly dramatic. 
 Special forces in the U.S. military routinely run drills in realistic combat scenarios in order to train their amygdalae to chill out when patience and calm are required to complete a mission.  If you are infiltrating a facility to rescue some hostages, you don't want to open fire on every living soul that moves.  You need to be able to react appropriately only when the time arises to shoot the bad guy.  If you haven't trained your amygdalae through hours of training to allow your frontal lobe to take the reigns in these scenarios, you could startle easily and open fire on civilians or your teammates.  No bueno.  These guys run through tactial scenarios for months so that they know what to expect, and they are prepared to respond rationally as opposed to impulsively when faced with the decision: to shoot or not to shoot.

Survival Instincts and Your Bad Habits
I've harped a lot on the amygdalae's role in responding to negative stimuli (Clinical evidence?  You betcha. See Aggleton, J.P., & Young, A.W. (2000)) but positive stimuli also can trigger an amygdaloid reaction.  

In addition to reacting to a ravenous beast that emerges from the jungle (negative), your brain also evolved to feed when food becomes available (positive).  Dieters often report specific food cravings as a major difficulty to sticking to their plan.  

"I could NEVER give up bread."  
"I've been doing great...except when I have access to chocolate."  

Evolutionary survival theory suggests that we instinctively stuff our faces when the opportunity arises.  Early hunter gatherers would often go days without a substantial meal.  To keep their energy up, they would eat anything that they came across in the environment.  The amygdalae trigger that feeling of "eat it...NOW!"  If you have experimented with long fasts - intentionally or unintentionally - you've experienced this reaction.  As soon as you sit down to eat a meal after not having eaten anything substantial for a week, you will ravenously stuff your face.  Your body knows it hasn't eaten for a while, and the amygdalae respond to help you survive by taking control of your actions once fuel is available.  This keeps you from starving in the event that you may have to go another long period without food.  Most of which is consumed in excess will be stored as fat, which will hold you over until the next large meal. 

Drugs, alcohol, and sex are also driven by the amygdalae.  The fact that drugs and alcohol stimulate the reward center in the brain may have a link to evolutionary survival, but this remains controversial.  Sex, on the other hand, clearly offers a survival advantage, as it increases the breadth of your gene pool.  Guys, the next time your wife accuses you of checking out the leggy blonde across the street, just tell her that it's merely a sign that your amygdalae are healthy.  

"Golly, Jennifer.  Your laugh really gets the 
glutamate bouncing all up in my amygdalae!"
Breaking the habits
What I'm getting at here is that there are two main operating systems that direct behavior: impulsive vs rational.  You need both, but the amygdalae trump all when allowed to operate unchecked.  When it kicks into gear, your rational mind goes out the window.  The goods news?  You can train yourself to overcome the amygdalae's emotional response to impulse.   

As I've already mentioned, positive or negative stimuli may stimulate the amygdalae to react for maximal survival potential.  In addition, the amygdalae are also involved in memory formation.  This shouldn't be a shocker.  You respond to various stimuli based on previous experiences.   Small children will approach dogs in the household fearlessly, regardless of the dog's body language or growl.  If the child is attacked during the first attempt, the incident may result in a lifelong fear of dogs.  The sight of a dog in the future may result in the child running in terror.  Bad experiences like this condition the child's amygdalae to respond with RUN! at the sight of a dog.  

On the flip side, if you cave in to the cravings for chocolate every time chocolate presents itself, this positive stimulus is conditioning your amygdalae to respond with EAT! every time you see chocolate.  What sets those with self control apart from those who claim that it's impossible to give up certain foods is that the former - whether or not it was a conscious effort - have conditioned their brains not to jump at the opportunity to consume the prohibited food.  With practice, it's possible to train yourself to do the same.

Psychologists have been using fear conditioning for years to help patients overcome irrational fears.  The process starts by having a patient recognize their fear and intellectualize it.  Take the fear of dogs as an example.  Why are you afraid?  What is your response?  Is this the response that you wish to have?  How would you prefer to respond in the future?  This question and answer format slowly transitions to exposing the patient to pictures of dogs, then perhaps inviting the patient to view a dog from a distance.  Eventually, the clinician will invite the patient to approach a dog and to pet it.  

Another example of conditioning used in impulse control is exposure & response prevention (ERP) for the treatment of obsessive compulsive disorder (OCD).  OCD commonly manifests as impulsive hand washing.  If the amygdalae in these patients are allowed to run rampant, they'll insist on washing their hands dozens or even hundreds of times per day despite realizing that it's excessive.  Sound familiar mister candy bowl scavenger?  ERP works by forcing a patient to identify these impulses in order to understand them.  The full therapy requires the patient to wait progressively longer periods of time before they are allowed to give in to the temptation until, eventually, they have trained themselves to wait it out indefinitely.  A 2011 study found that 88% of patients with OCD benefited from ERP therapy. 

The same can be done for a food that you have been struggling to quit.  Sweets are ubiquitous on clients' lists of dietary foes.  If I gave you a Hershey kiss, you would probably unwrap it and pop it into your mouth without even thinking about it.  You've allowed your amygdalae to drive this behavior for years.  If there was a bowl of Hershey kisses in your office, you would frequent the bowl, eating one after another without realizing it because you've conditioned your amygdalae to respond to chocolate like this.  This is why it's difficult to stick to your diet.  It's not the fact that you had a piece of candy.  The problem is that you eat an entire bag of candy without realizing it.  You need to take control.

When you're looking at a restaurant menu, the cravings you get for dessert are prayed upon by the chef.  Our society has been conditioned over our whole lives to jump on the opportunity to eat delicious chocolate mousse.  Even the sight of something you've enjoyed only once before activates the amygdalae.  Instead of allowing your amygdala to take control, think about your dietary goals.  Think about the mousse.  Do you really need to order that?  It's going to taste good for a few minutes, but is this important to you?

Your Turn
I want you to try something.  Go find a piece of your favorite candy.  Hold the candy, touch it, examine it.  Look very carefully at every curve.  Feel the texture.  Smell it.  Press it to your lips.  Unwrap it.  Re-wrap it.  Spend 10 minutes with the piece of candy.   Then put it in your mouth, but don't chew.  Just let it sit in your mouth for another 3 minutes.  Eventually, chew it up and swallow it.  Enjoy!  Then go back to what you were doing.  Take the time to recognize how your body reacts to the food vices in your life.  Dieting is not about prohibiting yourself from eating your favorite foods.  It's about transforming your behavior from negative to positive in order to achieve your goals.  

Want to give it a shot?  Choose a food that you know is bad for you but that you can't seem to quit.  When a craving arises, follow this check-list:

1)  Acknowledge the craving.

2)  Consider the impulse that this particular food incites ("I want that in my face.")
3)  Ask yourself, "Is this in line with my health goals?"

Conditioning exercises are an essential practice in controlling dietary reflexes.  Additionally, they will help you control your response to the jerk at a business meeting, the dude that cut you off on the highway, temptations for a smoke break, or the hottie at the bar looking for bros to buy her free drinks on Friday nights.  

This is exactly what we train our health coaching clients to do, as it's the key to breaking unhealthy habits.  Many of our clients ask us for a checklist describing what they should do to be healthy.  They adopt the checklist as gospel, then they feel like failures if they slip up.  You shouldn't feel like a failure!  You must realize that you have practiced these bad habits for years, and it's going to take some time to break those habits.  You'll probably fail more than once even with diligent practice, but, if you're serious about breaking these habits, then patience is requiredThere are no silver bullets to fix your health concerns.  Your amygdalae are important for your survival; eating the entire plate of brownies is not.  

It's going to be hard, but Sweat and Butter is here to help.  Let's break some bad habits!
Offline resources: 
  • Aggleton, J.P., & Young, A.W. (2000). The enigma of the amygdala: On its contribution to human emotion. In R.D. Lane & L. Nadel (Eds.), Cognitive Neuroscience of Emotion (pp. 106-128). New York: Oxford University Press.
  • Patterson, Kerry. Influencer: The Power to Change Anything. New York, McGraw-Hill. 2008. Audiobook.

Nathan Riley is a 2014 MD candidate at Temple University School of Medicine.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at  You can also connect with him on Google+.

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Sunday, October 20, 2013

Guest Post: Human Kindness in the ER

This post was originally published on Facebook.  The author gave us permission to re-post it for the benefit of our readership.

I very rarely post on facebook, but tonight (or I suppose, this morning), I'm making an exception.  Please read this with an open mind, and, more importantly, with an open heart...

I watched a man die tonight, slowly and painfully.  I watched his wife stand by his side for the

three hours it took him to pass, despite her bilateral knee replacements a few weeks ago.  I watched three of his doctors disregard his wife's tears as he winced his way to death.

A culture of indifference has crept into our society. I regularly see people pass over the needs of others, not because of personal inconvenience (which would be justifiable on some level), but for no reason at all.  I'm only 25-years old, and I've already begun to lose faith in humanity; something simply does not seem “right” about that.  Perhaps I'm too young to understand the true nature of the world, or perhaps I'm too naïve to appreciate it.  Hell, maybe I just don't focus on the “good” in life enough.  What I am confident in, though, is the massive amount of suffering I've noticed in the society around me since my passage into adulthood.

I'm just as guilty as anyone else in this matter.  Just the other day, I watched someone trip across the street and spill the contents of a box he was carrying.  It would have taken me an extra 5 minutes to cross the street and help him pick up his things.  What did I do? I avoided eye contact and walked quickly around the corner.  I had no reason for not crossing the street; I simply felt uncomfortable approaching someone I didn't know to help them.  I'm ashamed to admit this next part, but, a few seconds after turning the corner, I got back to my car and wept over the fact that I preferred to walk by instead of stopping.  For no reason at all, I avoided another person in need, despite feeling immensely guilty almost immediately after.
This will never happen again.

What I'm proposing is very simple: an unprovoked act of kindness when an opportunity presents itself.  Reinstate my faith in humanity.  Challenge my notion that the world is not as self-centric as I believe.  Change someone's life, even if it's as small as picking up a dropped pen.  These types of things aren't going to change the world, and if you think that's my aim, you've missed the point entirely.  To simply do a handful of things, each day for the sake of another, improves the most basic quality of life for a single person.  It shows another person that someone else cares, even if it's the most minimal level of care you can imagine.  You haven't changed their whole life, just five minutes of it.  Imagine if I had been that guy on the street... another person jogging over to help me pick up a few things that had rolled out of my reach.  I wouldn't be grateful that he helped me, I'd simply be grateful that someone cared. The human experience does not have to be a lonely one.

The day after I skipped over the man-in-need on the street, I encountered a young girl in the emergency department who had been in a car accident.  She wasn't my patient, but rather someone who was waiting in the department to be admitted to the hospital.  Her boyfriend had also been in the same accident, and brought to the emergency room as well, though she had been unable to see him since arriving.  She was quite distraught over this fact, despite being told countless times that he was OK.  I tracked him down, and with my phone, took a picture of him smiling with his thumbs up for his girlfriend.  His face was covered in bruises, his left eye was swollen shut, and a neck brace throttled his throat.  It took five minutes for me to snap the photo, walk over to her room, and show her the picture of her mangled partner. Her response was immediate tears and an enormous hug.  She embraced someone she didn't know, in a state of complete vulnerability, and she felt innumerably better from simply seeing a digital snap of his weathered face.  For just a moment, the massive level of chaos, pain, and anxiety of her world was alleviated, through simply seeing her boyfriends lips curled into a smile.

Thank you for reading through this entire rambling discourse.  I fully appreciate that this pseudo-hippy request may carry a sentiment of candid ignorance, but whether I'm naive, or whether my plea rings true to you, there's no harm in taking a few minutes to demonstrate care for someone else.

Acts of kindness don't change the world, they only change a single person's experience, moments at a time.

Vedant Desai is a medical student at Temple University.  He is currently applying for residency in Emergency Medicine.

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Thursday, October 17, 2013

Time to Misbehave

My friends, it’s time to throw in the towel on being such goody two-shoes.  Let’s start misbehaving. When we set health goals, we tend to follow a routine, always trying to accomplish more.  We wake up early, eat a healthy breakfast, get to work on time, quickly respond to emails, work hard to meet the day’s deadlines, come home, work out, healthy dinner, rinse and repeat.

In our constant efforts to do and be our best, things get left out, and those things are often things we want to do, eat and be.  I’m not advocating that you ditch your best efforts, lounge on the couch and get fired from your job.  What I am saying is that you need to lighten up a bit.  In western culture, we praise the go-getter attitude and even try to cultivate that behavior in our children: “You’re such a good girl!"  From an early age, we are instilled with the attitude that the more you get done, the more successful you will be.  Keep your ears open, and you will hear it from co-workers, among friends and in the media.

I met a very old Italian man one day a few years ago, and his words have been with me ever since. “You know what the problem is with Americans? You act like you have to earn leisure time,” he said as he sipped his red wine mid-afternoon. This pressure to earn time for ourselves forces us to prioritize our lives such that leisure is a rare treat. Americans’ definition of self-improvement rarely includes leisure, yet we often feel our best during leisure activities.  So how, then, do we balance doing our best with feeling our best?  This question is so important to answer that I spend two weeks on it with each of my health coaching clients.  The answer is simple: You misbehave.  Start to rebel against the small things that bring you down.  Delete an email at work that you’d rather not deal with (If it’s important enough, they’ll email you again).  Call in sick once in a while on those perfect weather days.  Screen phone calls that you don’t feel like answering.  Eat a freakin’ cookie once in a while!  It’s not going to crush your weight loss goals.

Breaking out of our constant cycle to satisfy the many roles we play can free up time and mental energy, which will allow us to listen to ourselves and consider what it is that we truly want from life. For some of us, so many years have passed since we considered the why behind what we do on a daily basis.  We become so dedicated to our roles as employees or homeowners that often we’ve forgotten about our dreams completely.  I was struggling through a very difficult time a few years ago, and my eldest sister gave me some good advice: “Stop asking yourself,  'Where do I want to be in 5 years?'  What do you want right at this second?  If you usually turn right and you feel like turning left, do it.  You’ll train yourself to listen to your instinct, which will lead you in the right direction.” This advice has guided me ever since.  Once you master misbehaving in small ways, take it as far as you’d like.  If you’re in a job that you hate and that makes you miserable, jump ship, follow your heart, and chase down that muffled dream.

Apply this misbehavior to whatever area in your life that needs attention.  At Sweat and Butter, we focus on five primary areas: sleep, relationships, food, stress and movement.  We believe that you must create balance in each area to optimize your health and happiness.  If you’re sacrificing too much from one area to focus on another, you’re out of balance.  Sleeping less to work more for money that you don’t have time to enjoy doesn’t make sense.  Get things back in balance.  Sleep in, work out, listen to your body, follow your heart and cultivate your mind.  It feels good to be bad.

Maybe this simple strategy of breaking the rules will get you to where you wanted to go in the first place.  If you have any questions about any of this, email me.  I promise I won’t delete it.

Vanessa Alberts is a co-founder and health coach at Sweat and Butter. She received her training at the Institute for Integrative Nutrition and holds a master's degree in Health Policy and Management from Carnegie Mellon University. She coaches clients to optimize their health and happiness through nutrition and personal evaluation. She can be reached at 

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Tuesday, October 8, 2013

Your Lactobacillus is Showing: A New Way to Look At Poop

After decades of eating grains, legumes, laboratory-produced additives, and a lot of miscellaneous junk, our gut health is gradually pooping out (see what I did there? I'm so punny).  It took a while, but probiotics are finally on the lips of vitamin shoppers and health foodies around the world.  These capsules of live bacteria have worked wonders for millions with a wide array of resistant health issues.
The human gastrointestinal (GI) tract

As it turns out, the integrity of the lining of your gastrointestinal (GI) tract is extremely important for your overall health.  Who knew?!  Despite this topic lying largely on the fringe in the conventional medical community, gut lining inflammation has been of interest to researchers since the 1980s.  This lining has built-in mechanisms  to help it withstand years of abuse from what we eat, but, over time, these mechanisms begin to falter, and the results can be devastating.  The main players in keeping your gut healthy are the trillions of bacterial and fungal flora living there.  They aid in the digestion of nutrients for easy absorption as well as attenuating the effects of harsh compounds on the gut lining.  If we want to remain healthy, we need to keep the flora healthy, and this is where Sweat and Butter enters the picture.

In this post, I hope to accomplish three things:

1) Describe the role of bacteria in keeping us healthy.
2) Examine the impact of poor diet on these bacteria.
3) Describe the conditions that may result from poor gut health.
4) Provide recommendations on how to replenish your gut flora.

Bacteria in your body
Your body is comprised of between fifty and one-hundred trillion human cells - that's 100,000,000,000!!!  Can you even believe it?!  The number of bacteria that we provide a home to outnumbers human cells 10-1.  These little guys line your mouth, nose, airways, esophagus, the intestines, skin, hair follicles, eye balls, ear drums, and then some.  While most people generally think of bacteria as harmful, they actually serve some very important roles in our body, particularly in the gut. 

Bacteria often have the ability to digest raw materials better than the cells lining our intestine.  In fact, many food molecules that we eat require some level of processing by bacteria living in the gut in order to be absorbed into our blood.  Fascinating!  

The bacteria that live in your intestines are accumulated at a young age.  A newborn's GI tract is largely unpopulated by bacteria, though breastfeeding rapidly introduces a variety of bacterial species.  Breast milk also supplies the infant's populated gut environment with simple sugars to help foster growth and multiplication of these flora.  As an infant begins to eat more foods and is exposed to different environments, the gut floral species shift towards a perfect balance of between 500 to 1000 different species.  This variety of species in specific proportions to one another serves an important role in digestion while simultaneously protecting your gut by maintaining the mucosal barrier, which is your first line of defense against invaders that enter our body through food.

Not all of the bacteria in your gut are beneficial.  The species of bacteria that aid in digestion are probiotics, meaning they promote health.  They are also important for keeping pathogenic, harmful gut bacteria in check.  The probiotics feed off the food that you swallow.  If you eat or drink the wrong stuff, the balance of probiotic to pathogenic bacteria becomes deranged, and your health suffers.

We can explain virtually everything in human physiology through an evolutionary biologic filter.  Humans and bacteria co-evolved such that both parties mutually benefited.  Sort of like: "Hey bacteria, if you help me digest polysaccharides, I'll give you safe harbor.  Deal?"  Bacteria wouldn't say much in response because they're bacteria, so they can't talk, silly. This intimate romance between our gut and the bacteria's need for a safe home is reflected in the fact that certain species of gut bacteria digest sugars in the mucus produced by the cells lining our intestines.  The volume of mucus is regulated by these bacteria, and, in exchange, the bacteria go to bed happy and fed.

Clinical research on the role of intestinal flora in maintaining healthy physiology and biochemistry is still premature, but studies thus far suggest that probiotic bacteria play a variety of roles in maintaining the health of your digestive system.  In addition, these microorganisms are also thought to influence energy metabolism (to the left, to the right, up top, down low, too slow) and nutrient absorption (shake, shake, shake, señora), particularly iron, B12, Vitamin D, and folic acid.  If the balance of good to bad bacteria gets jumbled, it is reasonable to assume that the imbalance may carry negative health consequences.  More on this later. 

Bacteria have needs, too, ya know... 
Because the inside of your intestines is devoid of oxygen, the bacteria living in your gut are unable to break down fatty acids, a process known as oxidation (oxi = related to oxygen). Bacteria thus preferentially eat carbohydrates, and they're particularly hungry for fiber and fructose. 

Here's how it works.  When you eat a meal, a lot of stuff is absorbed in the small intestine, including simple sugars.  The remaining fecal matter passes to the large intestine (aka the colon) where fiber - abundant in fruits and vegetables - is fermented by the trillions of bacteria that call the colon home.  What remains from this breakdown process are short chain triglycerides (aka fatty acids) such as butyrate, which can be absorbed and used by tissues around the body as fuel.  The process of digesting fiber provides your body with energy at a slower rate than eating sugars, which, as I mentioned, are absorbed readily in the small intestine - no bacteria required. 

As it turns out, the process of metabolizing fiber alters the varying proportions of bacterial species in the colon, and this can be a problem.  Medical researchers don't fully understand the specifics yet, but one theory is that overfeeding your gut bacteria increases the rate at which they multiply.  An excess of fuel for the bacteria - fructose and fiber - may shift the balance in such a way that pathogenic bacteria are permitted to multiply beyond the control of the probiotic bacteria.  When pathogenic bacteria die, they release endotoxins, so more bacteria means more endotoxins.  These endotoxins have been implicated in metabolic syndrome, liver disease, heart disease, and other inflammatory conditions.  No bueno.  More on this here.

When things go awry
Anything that we do to the environment inside of the gut - that is, the stuff that we put into our intestines in the form of food - can harm us indirectly by disturbing the peace amongst the thousand or so species of bacteria residing in our intestines.  If you have ever been treated for a few weeks or months with oral antibiotics, you may recall developing diarrhea.  Certain pathogenic strains of the intestinal flora - namely Clostridium difficile (C. diff) - are permitted to flourish under the influence of high dose antibiotics.  This pathogenic overgrowth causes a host of gastrointestinal problems including a horrible, stinky diarrhea. 
This is your gut lining under a powerful microscope.

Fortunately - or unfortunately, depending on how you look at it - the complications of C. diff arise shortly after the antibiotic treatment, and your doctor can respond accordingly.  It's easy to see the relationship between gut flora and your health in this case.  On the other hand, when diet leads to pathogenic bacterial overgrowth or if it knocks out your probiotic bacteria, it may take years for you to become very very sick.  On the other hand, you may have no clue that you aren't performing optimally if your gut flora have been deranged for decades.  It's difficult to diagnose imbalances in gut flora because there are few specific symptoms.  If, in fact, the probiotic gut flora are important in the processing nutrient absorption in addition to keeping the pathogenic (bad) bacteria in check to maintain the intestinal lining, the health of your intestinal environment is as critical to your general health as the food you put into it.  

A study conducted way back in 1983 concluded that rodents who had their gut flora wiped out required 30% more calories than rodents with normal, healthy gut flora to maintain body weight.  Furthermore, gut flora are thought to be involved in the regulation of body fat.  As I mentioned previously, clinical research on the role of gut bacteria is still premature.  Many researchers have observed that the gut flora of obese individuals differs from that of lean individuals, but the evidence is insufficient to conclude any causal relationship.  In other words, the intestinal floral make up of an individual may reflect their body composition or it may be the cause of their body composition.  This is a sexy topic in medical research right now, so more evidence is on the horizon.  For now, suffice it to say that even if you aren't experiencing diarrhea or heart burn, your gut may still be struggling with inflammation or an imbalance in gut floral species.

The underlying mechanism by which an imbalance in gut flora causes health problems is related to inflammation of the gut lining.  Remember: probiotic bacteria protect our gut!  If this lining is disturbed, small holes will allow endotoxins produced by the pathogenic bacteria as well as undigestible proteins contained in our food easy access to our bloodstream.  This scenario is commonly termed "leaky gut syndrome", and it can carry grave consequences.  

Some other health conditions that may improve once you get your gut flora under control are autoimmunity (including eczema), inflammatory bowel diseasenon-alcoholic fatty liver disease, inflammation, diabetes, Alzheimer's dementia, and bacterial vaginosis.  

Control the bacterial burn
It's reasonable to assume that fixing disturbances in gut flora may lead to improvement of these conditions, and this is an increasingly hot topic in medical research.  The foul-smelling condition I mentioned before, C. diff infection, is normally treated with IV fluids and additional antibiotics targeted specifically towards this pathogenic strain of bacteria.  In  addition, fecal transplants are increasingly being tested as a viable solution to severe C. diff.  The procedure sounds archaic, but clinical studies have shown overwhelmingly positive results. Basically, a clinician will get a large sample of stool from a patient with healthy gut flora and perform an enema to deliver this sample into the intestines of a patient with severe C. diff.

Replacing the sick patient's flora with the gut flora from a healthy patient seems to work, but it's a pretty radical procedure, and it could make a person pretty sick if they don't tolerate the transplant.  We simply can't say whether or not fecal transplants are a plausible treatment option in any condition other than C. diff infection.  I'm sure you are just aching to receive an enema of a stranger's stool, but, before you call your doctor for a session, let's first try to fix your gut floral derangement through lifestyle modification.

The state of gut flora is most heavily influenced by our diet, so eating foods that support the amount and quality of these flora is critical to your health.  Even people that aren't having diarrhea, indigestion, heart burn, etc. will likely benefit from the recommendations below:

1) Replace your probiotic gut flora
Image from paper by Qin et al;
accessed via

Oral supplements:
Probiotic supplements can be picked up in any health food store; however, it's still unclear which probiotic strains are the most beneficial in your quest for the perfect supplement.  Quite frankly, I'm not sure if any specific probiotics supplement is going to be perfect for everybody.  Clinical studies have examined the effects of supplementing with various combinations of different bacterial species.  Some studies have tried multiple strains of lactobacillus.  Others have looked at combinations of lactobacillus, bifidobacteria, and streptococcus.  The point is that these supplements, which come in oral form, have been poorly studied, though I don't foresee them having any negative effect on your health if you try them out.  Look for high quality brands that require refrigeration.  You need live cultures of bacteria!  So if it has a long shelf life at room temperature, it's probably not the best choice.  One brand our clients have found great success with is Garden of Life.

Fermented foods: An even better source of probiotics is fermented foods.  While probiotic supplementation will likely show some benefit, there are far too many strains of healthy bacteria found in the gut to fully supplement through oral capsules. Regardless of whether you decide to take oral probiotics supplements, you'll likely find even greater benefit from eating probiotics-rich foods.  Sauerkraut, kimchi, and kombucha are great sources.  They tend to have an acidic, vinegary taste, which turns a lot of people off, but give them a shot and you'll eventually acquire the taste!  Your gut will thank-you.

**Note: We don't recommend dairy for daily consumption, but if you find a raw yogurt source near you that adds live cultures, this might serve as a good last resort.  Major store brands of yogurt are sadly loaded with sugar and likely don't contain that much variety in the bacterial strains that they add to their products. 

2) Avoid fiber supplementation and excess fructose consumption
Instead of mixing up one of those nasty shakes of expensive fiber powder, get your fiber from fruit, vegetables, and tubers.  While several large studies in the past have found a positive benefit from fiber supplementation, a basic understanding of the digestive process suggests that this increases the potential for bacterial overgrowth.  Remember, bacteria eat fiber, so feeding them too much may cause them to reproduce too rapidly.  In fact, a condition known as SIBO (small intestine bacterial overgrowth) is treated adjunctively by limiting the amount of carbohydrates and fiber in the diet. You should also avoid eating too much fruit, which is loaded with fructose.  In addition to fructose's tendency to drive fatty liver disease and diabetes, it is also a preferential food for gut bacteria.  We want our intestinal friends to be full, not overstuffed!

3) Avoid gluten, legumes, dairy, alcohol and vegetable oils
Wheat, legumes, and dairy contain proteins that our gut has a hard time digesting.  Because we can't digest them, they cause inflammation to the gut lining.  Vegetable oils are rich in omega 6 fatty acids, which are inflammatory in and of themselves.  Excess alcohol consumption also has a direct inflammatory effect on the intestinal lining.  Remember, inflammation is public enemy number one.  This gut inflammation ultimately causes the gut lining to become leaky (read more above), and it allows stuff - including the endotoxins produced by gut bacteria - to enter your blood.  The gut flora protect your intestinal lining, which is why we are trying to balance this environment in the first place.  Does it make sense to fuel the inflammatory fire even more?  (That's a rhetorical question.)

4) Manage stress in your life
Stress leads to inflammation everywhere, including your gut.  If you are chronically stressed out, your gut health is likely less than optimal.  Research hasn't concluded that the link is solely due to a derangement of the floral species or increased propensity for gut lining inflammation.  A combination of both is likely to blame.  Even without sufficient clinical evidence, though, it's clear that there is some link between anxiety and digestion.  Think about those days when you aren't sleeping well, you are working on hitting deadlines, etc.  You tend to eat inflammatory foods (processed junk, gluten-rich foods, etc.) and your digestive processes don't function optimally.  Keeping stress in check (including getting sufficient sleep) is important for maintaining gut health.

Hopefully this guide has served to elucidate some of the confusion around probiotics.  As always, let us know if you've benefited from supplementing with probiotics or increasing your fermented food intake. Though, I have a feeling that we already know the answer to that...

Nathan Riley is a 2014 MD candidate at Temple University School of Medicine.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD. He can be reached at

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Thursday, October 3, 2013

Guest Post: Work Hard, Play Hard, Get Sicker? - A Reclamation of Health

Considering the general content on blogs geared towards individuals that want to lose weight and discover new ways to improve their health, you might be surprised by this post.  Maybe you are expecting a story about an obese, sedentary medical student who finally ran that 10K.  Or maybe you anticipated a story about my arduous triumph over a long-time sugar addiction from unhealthy eating habits developed during long nights of studying.  I'm sorry to inform you that this isn't one of those stories.  Well, not exactly, anyway.  

As I write this, it's 2:37 am on a Tuesday.  I fell asleep around 11:30 pm last night and slept for approximately three hours before I woke up fifteen minutes ago.  No alarm.  No urge to go to the bathroom.  No need to grab a glass of water.  My body simply decided that three hours of sleep would suffice for the time being, and I've been wide awake ever since.  I wish I could say that this scenario was unusual, but, unfortunately, it has become the norm for me lately.

So who am I, and why am I telling you all of this?  Prior to medical school, I had a brief career in finance but decided to go back to school because I have a fervent desire to change the way people think about their health.  I have always been one of those annoying people who gets way too excited about nutrition and fitness,  yammering on and on to those willing to listen about how illness can be prevented or even reversed through proper nutrition and exercise.  But with this passion for fitness and nutrition came the gradual cultivation of someone who became a little too anal about her health.  You probably know someone like me.  Eats lean meats, usually with a sweet potato or a green vegetable of some variety.  Drinks water or tea exclusively, probably from a reusable water bottle, because, you know, caring about the environment is what healthy people do.  Never misses a workout.  Wouldn't be caught dead with a soda or a sugary treat. 

From the outside, these people (yes, myself included) seem to have it all together, but the secret is that people like this often struggle with unforeseen health problems and chronic fatigue.  So here I am, almost  halfway through my medical education, and I'm writing about reclaiming my health.  You're probably still confused, thinking, "What is this post doing on the Sweat and Butter Journal?"  Allow me to paint a picture of my life from an outsider's perspective:  

28-year-old female, 2nd year medical student at a U.S. allopathic medical school.  Crossfit 4-6 days per week.  Eats a strict Paleo diet 85% of the time. Clothing size: anywhere from a zero to a size two.  Studies hard and fairly efficiently during the school week to allow herself the freedom of taking at least 1 day off per weekend.  Making above average grades in school.  

Life appears to be in order for the most part, right?  Now for the insider's perspective: 

28-year-old female, 2nd year medical student at a U.S. allopathic medical school.  Crossfit 4-6 days per week but often goes into workouts feeling exhausted and hungry.  Eats a strict Paleo diet 85% of the time but struggles with feelings of fear and guilt around eating.  Preoccupation with which foods will contribute to weight gain and which foods "should" or "shouldn't" be consumed.  Clothing size: zero to two but definitely on the smaller side since starting 2nd year of medical school.  Studies hard and efficiently, but largely because she takes prescribed Dexmethylphenidate (an ADHD stimulant similar to Adderall) as a study aid.  Not physically dependent on the stimulant but has definitely developed a psychological dependence.  During the week, sleeps ~6 hours per night at best, and most of the time those hours are not consecutive.  Usually needs to take Melatonin before bed in order to fall asleep.  Has noticed an increase in skin breakouts.  Irregular menstrual periods for almost one year.  Low energy.  Mood fluctuations. 

I could go on, but hopefully I have made my point.  To put it simply, my hormones are completely out of whack.  Despite physical fitness and a clean diet, I feel like I am slipping further and further from true health.  Many of us operate under this illusion of what is healthy.  We are some combination of over-stimulated, over-worked, under-rested, and malnourished.  Our bodies, in careful hormonal and chemical balance when working their best, are becoming fatigued and out of sync as a result.

I recently made the decision to wean myself off of my stimulant medications, and it has been one of the hardest things I have had to do in a long time.  While my hormones gradually readjust, I'm struggling to stay focused and study without a crutch.  Most importantly (pay attention here), I'm having to relearn that I am enough and that my body can only do so much. I’ll repeat that so that you can apply it to yourself: YOU ARE ENOUGH, AND YOUR BODY CAN ONLY DO SO MUCH.  Please, read that statement a few times, and let it really sink in.  Print t-shirts with that slogan on the front if it helps.

My point in telling you my story is this: much of our lives are dictated by excess.  Doing more.  Having more.  Wanting more.  Purchasing.  Consuming.  Achieving.  Endless social media accounts to portray a variety of images to the world.  We’re a culture that values being busy and productive.  Our worth is measured by how we look, the clothes we wear, the number of friends/followers on social media websites, our productivity level, how much we can lift in the gym, our class ranking, our alma mater, etc, but the awesomely liberating thing is that none of that really matters.

I left my prior career to pursue medicine, because I have a deep desire to really affect change in people’s lives through proper health management, and, without realizing it, I slowly became a hypocrite of the gospel I was preaching.  More isn't always better.  I am beyond excited that I’m slowly reclaiming my health while staying true to my values.  Will my productivity suffer?  Maybe.  Will I be a healthier person and a better role model to my patients, friends and family because I’ve decided to take my health back?  I'd like to think so.

So please, from one imperfect human being to another: Slow down. Love yourself. Love others. And always remind yourself that you are enough.

Whether you're a medical student, physician, nutritionist, Crossfit gym owner, parent, nurse, dietitician, wizard...remember that you are a role model of health to somebody somewhere. Please periodically re-evaluate why you worked so hard to get wherever you are in life and why you continue to work so hard now that you’re there.  Would you consider yourself to be a good role model of health?   Life is hard, and nobody is perfect, but it is up to each one of us to challenge our own excuses and take an honest look at how our actions positively or negatively contribute to the current state of our health.  

Also, go to bed.  There's always tomorrow...  

Ashley Thomas is a 2nd year medical student with a passion for people, preventative medicine, mental wellness, and living life outside the box. She is always looking to meet new people and learn from their personal struggles and triumphs with regards to health and wellness. Please do not hesitate to contact her at

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