How do we take a big picture approach to our patient's personalised health journey?
Today we are joined by Alessandra Edwards who is well versed in using a vast variety of technology and testing to yield ideal results from her clients no matter where they are on their journey to wellbeing.
Covered in this episode
[00:28] Introducing Alessandra Edwards
[02:12] Beginning to talk about gut health and testing
[05:16] SIBO and why it’s becoming more common
[08:03] How diet and other factors contribute to SIBO
[12:29] Alessandra’s treatment strategy
[13:17] Genomics testing for the gut and microbiome
[17:26] Individual susceptibility
[18:42] Utilising big data in genomics
[24:07] Genetics and methylation
[31:21] The importance of diet and lifestyle in treatment
[33:19] There is no magic bullet: managing client expectations
[38:18] Developing a team approach
[40:58] Big data and future of medicine
[44:00] Commonalities between treating the sick and optimising performance
[50:33] Technology as a map, not a prescription
Mark: Hi, and welcome today to Alessandra Edwards naturopath, clinical nutritionist, and Bachelor of Health Sciences in herbal medicine. She's now taking her expertise in genomics and her training from our own practice into the area of precision medicine, for optimising health and performance. Welcome, Alessandra. It's good to talk with you. How are you going?
Alessandra: Great. We finally have a little bit of sunshine here in Melbourne today, so I'm feeling good and happy.
Mark: Sunshine in Melbourne isn't as rare as I once thought it was. Now, tell me a little bit about yourself. I've read part...going back in your history a bit. You come from naturopathy, clinical nutrition, and medical herbalism, and as far as I can read it, you've started in the area we all do of looking after sick and suffering patients, and you've taken some of the new technologies and are moving into high performance. Can you tell me a bit about your past?
Alessandra: Yes, exactly. So, as you said that's my background, so very much a clinical background in nutrition and integrated naturopathy. And I really worked for 10 years, specialising in chronic mental health and gastrointestinal health conditions.
Alessandra: And my particular interest through the years really focused on helping those patients that had done the rounds in terms of seeing both allied and traditional medical practitioners and still were not finding answers to their complex symptom picture. And so, if you like, that's really where I honed my investigative skills, which then through the years really got translated into this passion of what I call the DNA of performance.
Mark: And like most of us, you started trying to get the gut right, it sounds like the gastrointestinal tract is the starting point for almost all of us in getting people back to a level of health that they can sustain.
Alessandra: Yes, absolutely. And particularly detecting undetected infections that became my particular focus of interest, because I found that very often generalised strategies were given to the patient and general sort of gut repair protocols. And the patients would initially feel slightly better particularly when going on elimination diets, or what I call sort of the “mono-diet”, sort of the paleo, and GAPS, and those kinds of diet. So they would feel initially better but then invariably, the original symptoms would come back and often with a vengeance and then with other associated things, and so mental health disturbances and more and more food intolerances. And what I found was that actually going back to basics and having really accurate case taking, and really taking the time to do all the necessary testing very often revealed a number of co-infections at gut level and which often had been left undiagnosed.
Mark: Meaning more bacterial, parasitic, viral, or do you have a kind of take on...what were you finding mainly on your testing?
Alessandra: So, often I was finding that even a previous diagnosis of parasites, like you know, Blastocystis or Dientamoeba were usually enough for the previous petitioner to give a standard protocol.
Alessandra: But what was left was the, you know, the diagnosis of other coexisting infections, such as small intestinal bacterial overgrowth, for example, or parasites such as Helicobacter pylori further up the digestive tract, and so what happened is that the strategy basically focused on putting the eggs in one basket, and concentrated on the eradication of these parasites without really considering the upstream triggers…
Alessandra: …that perhaps caused the patient to have a parasitic infection in the first place. And then from there also looking at the specific relationship between certain genetic tendencies, for example, as well as doing sort of a broader omics approach in terms of, you know, microbiome screening and looking at the susceptibility of an individual to be able to either, you know, resolve the parasitic infection or to be able to happily and healthily coexist with this parasite.
Mark: So, just tell me, I mean, you raised SIBO there a moment ago, it's come from nowhere to being a very commonly diagnosed condition now. How do you see that? Is that because the technology's there to test successfully and to understand it, has it been something that's always there? Or is that a consequence of, say, antibiotic use in childhood? Do you have a take on, from the stories and the histories you took, what predisposes to SIBO, what predisposes to the parasitic infections and how you work through those? A bit of an order, just clinically, about how you work through from one to the other?
Alessandra: Sure, so, to answer your first question, in terms of why is it that now, it seems so many people have this diagnosis of SIBO, I think that first of all, the testing has become more widely available. Also, not just to medical practitioners but also to complementary practitioners,
Alessandra: I think also that there is an increased awareness of this condition, and so there is more frequent screening for it.
Alessandra: In terms of the predisposition, I think that first and foremost, the misuse and overuse of proton pump inhibitors over the last 20 years has much to do basically with the increase in the prevalence of SIBO.
Alessandra: I think that also we are born with defective microbiomes, and this is going to have a huge impact on increasing the risk of a child being exposed to antibiotics early on. I think this also has to do with the lack of support for breastfeeding, generally speaking, but if you like, all the practices that are going to be helping foster a healthy microbiome in the first three to four formative years, I think really have a lot to do with that.
I think that also we have high ratios of…sorry, high percentage of stress in younger and younger patients, and this is really affecting our neurology and sort of how the vagus nerve is working and so how this is going to impact the ability to digest well and have good quality hydrochloric acid, the motility in the gut, and I think that this is having a huge impact.
Mark: That vagus nerve is a tricky one, isn't it? The gut-brain and the brain-brain and the similarities of permeability between the blood brain barrier and the gut permeability, there's a whole thing going on there. How much of that do you reckon has to do with dietary changes the kind of increase in sugars in the diet trends generationally? How much do you think was always there? And we just dismissed it as, well, that's behavioural changes in kids, what can you do about it? In other words, was it always there and we were just not paying attention? Or is this something that the, at least PPIs in adulthood, but not so much in kids? Although, the babies do get it as well. How much can you put to diet? How much to the environment and how much to increased attention to this kind of problem?
Alessandra: Look, that's a great question, and I wish I had sort of an evidence-based answer based on actual figures.
Alessandra: So, what I'm going to do is basically give you my opinion. I think that you know, diet is definitely huge. However, it's definitely not the only contributing factor, because when you look at data from the 1950s, we were definitely consuming vast amounts of sugar back then.
Mark: Yes, yeah.
Alessandra: So, I don't think that we can really put it down all to sugar and I think that sort of carbohydrates has become a little bit of a scapegoat and the target of a massive witch-hunt. Whereas I think that the crux of it is a lot more complex than that. I'm not denying that overall, we are eating more poorly and our nutrient density is decreasing year-in-year-out. However, I think that the picture is much more complex, and has to do with the impoverishment of our microbial diversity through the decades, and this is due to a number of factors, some of which I mentioned earlier. So, increase in cesarian rates, the impoverishment of the microbiome diversity in pregnant mothers, and poor, inadequate practices to foster the microbiome in pregnancy.
Alessandra: You know, reduced rates of vaginal deliveries and prolonged breastfeeding, increased use of antibiotics. I think also, from a broader perspective, even school practices. So, I have a 5-year-old son, and I'm constantly shocked even though he goes to a really great school, but I'm constantly shocked by the lack of focus that is placed on the time that they're allowed to eat. So, they are literally forced to gulp down their food, so that they can run off and play.
Alessandra: And so, I think that...and also, even down to the fragmentation of the family unit, you know, we've got that to show that now in Australia we're not far behind the UK which has got really terrible rates of family-centred mealtimes at the table. So, we know that we're eating faster, we're eating more poorly, and we're distracted when we're eating, so, all these things are also going to have an impact on the gut-brain interactions as you were saying earlier, our ability to produce digestive enzymes to break down proteins and nutrients, which then are going to end up in the colon and, you know, affecting the increase of certain microbes, which are then are going to produce pro-inflammatory metabolites and this is going to have an effect upstream on the gut motility. So, I think it's a really complex issue.
Alessandra: And in terms of how I go about in terms of my treatment strategy and where I start, more often than not, I do start with the gut unless there is really significant mental health presentation, in which case I really feel strongly that that should be the priority.
Alessandra: But first and foremost basically is identifying any infections and as I mentioned earlier, working out whether there are any issues related to vagal tone and motility, and how this also relates to their genetic predisposition to underproduce certain neurotransmitters such as serotonin that are going to have an impact on their gut motility.
Mark: Right. So you do genetics, so there are two genomes are there? There's a human genome and the susceptibility genes. And then there's the whole genome of the gastrointestinal tract, which modifies so much of what we do with diet and nutrition.
Mark: Do you have a kind of favourite mechanism or methods of testing? So, on the genomic side, do you look for susceptibilities? Like, the DQ2 and 8, the Celiac type genes, methylation genes? So you do that?
Mark: And what do you do to understand where the microbiome is? What's happening in the gut? What is your favourite testing for both pathogens and normality, I suppose?
Alessandra: Yeah, so, I use a number of different tests. And so, I'm not saying that sort of this particular test I use is the best, or rather than, the other tests that are mentioned are not good enough, it's just the one that I found to be very comprehensive. So, if there is a history of gastrointestinal issues, where I suspect that function is also impaired, then I'm quite partial to utilising the Genova GI Effects, because it looks at the number of markers and not just the microbiome.
Alessandra: So, we can see basically if there is protein maldigestion, if inflammatory markers are elevated, if markers of allergies are present, if there is steatorrhea and what level of fat malabsorption is present.
Alessandra: And then looking at the microbiome, but I also use a number of other microbiome specific tests such as uBiome and also more recently a new test that has just become available in Australia although the name escapes me right now. I've only used it three times so far, I bet they will come back to me in a minute. So, that's from the gut perspective but I also...
Mark: Are these tests that look for microbial diversity or are they kind of very specific for the genome signatures of particular major species of bacteria, what's the kind of hallmark of these tests?
Alessandra: Yeah, so they will look at general phyla, and then also particular species rather than individual strains.
Alessandra: And so within that also I can identify whether, you know, specific species of microorganisms and potential contributors to an overall inflammatory picture. So, for example, high levels of E. coli for example.
Alessandra: Yeah, and so that's one aspect. The other aspect though is actually identifying these biotic pathogens, as well, such as Klebsiella, for example, Citrobacter, and so, that basically, I find that really useful as a navigating tool because it basically allows me to think in terms of how much damage control do I need to be mindful of here, or if they have dysbiotic bacteria, is there enough diversity here and enough numbers of beneficial bacteria that it basically buys me a little bit of a safety margin in terms of utilising antimicrobials, for example. Or does it mean that instead of utilising antimicrobials, we utilise instead a microbiota restoration strategy with specific prebiotics and strain-specific probiotics, which then are going to overall alter the gastric system, so that, you know, certain bacteria that are considered opportunistic, like streptococci for example, then, you know in that case, I wouldn't need to use antimicrobials…
Alessandra: …it will just be looking at the microbiota modification and dietary modification.
Mark: There are some people who seem almost bulletproof even with pathogens in their gut, almost no matter what the diet, they seem to run on through. What is it about individual susceptibility? What is it about the host whether that's genome, or...have you identified things that make some groups more susceptible that you can kind of separate out on either say, genomic testing, or metabolic testing? Is there any way of picking out the vulnerable?
Alessandra: Well, there definitely...there is and even without utilising genomic testing, a good clinician will have a very good understanding of the vulnerability, susceptibility, of the patient even just doing very, very good you know, medical screening, medical history, and clinical history. There will be certain patterns that we're looking for in terms of, you know, where they're born premature, for example? Did their mother or grandmother already have a history of digestive issues? Were they ever diagnosed with things such as IBS, for example? What's their antibiotic history as a child? Were they often ill as a child? And so, you basically start seeing a little bit of a pattern.
Alessandra: Yeah. In terms of identifying actual, you know, genes or biomarkers, that really is the area where a lot of personalised medicine and the area called future science is actually working on. So, I've attended a number of lectures by Professor Michael Snyder, who's the Chair of the Department of Genetics at Stanford University, and he basically says that the focus at the moment, and has been over the last few years, is on analysing big data, so as to come up with an accurate, reliable, and reproducible equation that could ideally be predictive from the DNA sequence…
Alessandra: …as well as any environmental exposure, as to what sort of health outcome that we can expect. So, for example, by having his full genome sequenced and utilising wearable technology that is constantly measuring his cytokine levels and other biomarkers, he was able to find out that he has a very high risk of diabetes, and when you look at him, you just could never tell because he's very fit and slim. And also pinpoints with incredible accuracy, whether he's about to come down with a virus within 10 days, without having any symptoms. So, at the moment...
Mark: Using genetic testing, so knowing his susceptibilities, or is this predictive kind of metabolomics that he's talking about?
Alessandra: Both, both. So, this is utilising big data in terms of genomics and metabolomics. So, looking at all the different biomarkers that, you know, as a doctor, for example, you would test through blood, but having this continuous monitoring. And he tells this incredible story of when he was on a flight, and because he knew exactly what his oxygen saturation levels normally were, both on-flight and on land, he knew by the difference in percentage in drop in this marker, that he was actually coming down with something.
Alessandra: And yeah, it's absolutely fascinating. And so, this is in its infancy, but this is absolutely the future of medicine and there is a lot of technological companies that are really working to develop this kind of wearable technology whereby this data is then going to be constantly fed through highly sophisticated machines and give you a very accurate picture of how well you are or whether something is happening.
Mark: They have the coolest toys at Stanford, I mean, they're just in the right area of the world to be able to use those technologies.
Alessandra: That’s right.
Mark: From the user's perspective at the other end, big data is overwhelming, especially to a doctor: we're trained in that diagnosis, working down a diagnostic narrowing it the whole way. Rather than doing what big data does: expand the information base until you see patterns emerging. And it does seem to be the way of the future that we'll be using tools, technologies, data from the genome project, we'll be using all of those, but someone has to make sense of it because it can be overwhelming as I'm sure you would have felt as a practitioner, when people walk in, dump 400 pages on your table and say, "That's my genome. Why am I sick?" It doesn't work out that way yet. Those technologies sound like they're the future. Do you use any of those? Are they applicable in clinical practice yet?
Alessandra: No, definitely not. Not yet, other than I do use heart rate variability wearables because they have been found to be very accurate and predictive, and particularly because I work in the field of cognitive performance.
Alessandra: So, I work with senior leaders in teams where cognitive performance, working memory, ability to concentrate, are prized above all else. And heart-rate variability has been shown to be a very reliable tool in terms of predicting someone's performance on the day, so I do use that. And obviously, I do not do full genome sequencing because even though the prices have come down, you know, you’re still looking at the region of $1,000. And also, as you said, I'm a clinician rather than a researcher, so having that level of information at this stage would not be, A, useful to me and, B, I wouldn't know how to interpret it. So, I focus my testing on genetic sequencing that looks at a handful of genetic variants or SNPs, which had been shown to increase susceptibility to either the speeding up or the slowing down of specific biochemical pathways, and my particular area of interest is related to neurotransmitter pathways and energy production.
Mark: All right, so this involves the movement from care of sick people to high-performance and using...these are technologies that help you do that transition?
Alessandra: Yes, absolutely. Yeah.
Mark: So, tell me what do you tend to rely on, and that we have the classic SNPs that everyone knows, the MTHFR has become almost a celebrity all by itself these days. And a lot of newbies in this field tend to go for, well, there's a SNP, and that explains everything, which it doesn't obviously.
Mark: But what do you choose out of all of the SNPs, out of all of the information that you have available, in that transfer from patient care to high performance, what's made the grade, what's crossed that boundary for you?
Alessandra: Well, interestingly, whether working in the realm of high-performance or very sick people, at the end of the day, I do believe that, you know, performance is an aspect of optimal well being. You cannot have high performance if you are, you know, tired, not sleeping well, sick, not digesting very well.
Alessandra: So, if you like, the tools are the same, it's just that the interpretation is slightly different. In terms of the perhaps specific markers I look at, I do do genetic profiling, but, in my opinion, presently, nothing beats the humble blood test. And so, I often have high performing clients who've heard of genetics and very interested in finding out more about themselves. And for me, it's very important to explain that just having a genetic variant really doesn't mean anything without understanding whether that gene is actually expressing or not, and that in a way, you know, family history, medical history, present levels of blood test results, and combining that with looking at the diet, their lifestyle, is really more, in a way almost more valuable.
Alessandra: However, understanding those genetic susceptibilities, I think is useful in the sense that particularly once we have addressed the general lifestyle aspects of an individual, if you're not achieving specific results, then it's very useful looking at those genetic markers. And particularly in terms of MTHFR, or other SNPs like MTR, MTRR, and one of my favourites is TCN2, Transporter Cobalamin 2, very much linked to someone's ability to withstand stress.
Alessandra: So, having good levels of resilience and having good cognitive function, because potentially, they have a really much increased susceptibility to vitamin B12 deficiencies.
Alessandra: I'm sorry...
Mark: And a good response to treatment, I would imagine as well that if you've identified that the B12, for example, works really well on some people and other people, it doesn't touch the sides.
Alessandra: No, exactly, and that's why it's really important, I think, to spread the message that, you know, you cannot do functional medicine by numbers. So, just knowing that someone is homozygous for MTHFR C677T does not...should not inform 90% of your strategy, of your treatment strategy.
Mark: Right. You can predict homocysteine from it, but you can't predict much else can you?
Alessandra: Possibly and yet, not even that, and so MTHFR may not, you know, does not have a direct impact on homocysteine, and also someone who has high levels of oxidative stress or a high heavy metal burden, may still present with very low levels of homocysteine.
Alessandra: So, I think the message that needs to go out there is that...to me is twofold. And having just come back from the Methylation Summit in Sydney, I think it's really important to bring home the message that yes, we now have this tool, but this is a tool among many. It is useful. However, it doesn't mean that we should be doing, again, functional medicine by numbers, particularly because messing with methylation can actually be dangerous. Yeah?
Alessandra: And when taking mega doses of either methylfolate or other methyl-donors, we don't actually know, we don't know exactly in the body, where these extra methyl-donors are going to go. And so, I like to always bring out this message of caution because when you start actually looking at DNA methylation, in the realm of genetics, you do understand that both hypo- and hypermethylation can actually initiate carcinogenesis.
Alessandra: So, I think that it's really important to do all the other things first and removing the blocks that are perhaps increasing someone's level of chronic inflammation, stress, oxidative stress, all the toxicant burdens, lack of nutrients, and living their lifestyle, their sleep-wake cycles, not according to their specific chronotype. All these things will have a huge impact, both on someone's health and someone's performance. And then, you can start tweaking and getting into that 1% by introducing nutrigenomic nutrients, but again, just doing that cautiously, because I think that this is an emerging field, and we don't know enough to keep pushing and pushing these biochemical pathways.
Alessandra: We don't have the data yet to know that it is safe in the long run.
Mark: There's the opportunity always to manage the methylation, remembering that the person that we see typically may be an adult, they've survived with those genes all of their life. So, they present adapted to whatever their genetics are, managing it however they do, and some of that's a mystery to us. A lot of the opportunities for dietary management seem to be forgotten. We get so enthused about, we found the SNP, we know how to get around that, that we do race in with highly potent, you know, s-adenosylmethionine and massive doses of B12, and over-rev the person, or bring them down in a way which is entirely unpredictable. Whereas with foods, it seems not to happen as much that if you can manage the gut and the diet, it's a safer, slower and more profound way of achieving change. I don't know if that's your findings.
Alessandra: Yeah. Absolutely. I really agree with that and look, absolutely, in some cases of severe mental illness we do need to intervene quite heavily, quite quickly. But generally speaking, I find…just a couple of weeks ago, I actually had a client presented to me with psychosis, and the psychosis was actually induced by methylfolate.
Alessandra: So, they had been, you know, in quotes, "Diagnosed with MTHFR chromosome homozygosity," and had been prescribed a formulation with high levels of methylfolate, and this person progressively got worse, and worse, and worse. And as soon as we removed that formulation, you know, within 24 hours, they started to feel better.
Alessandra: So, I absolutely agree with you. I think that diet is important and look, sometimes that is probably the most difficult conversation I have with my clients. But as you know I work with very, very busy individuals who also travel a lot, and they don't have the time to, you know, cook their food. So, that's a big consideration for them because, you know, they're not going to have the time to be at home and, you know, ferment their own sauerkraut and make their own soba noodles.
Alessandra: But even within that there is so much dietary guidance that we can give and help someone understand, for example, if they have a susceptibility to 70% reduced levels of the MTHFR enzyme, meaning they need 70% more active folate in their diet, what does this look like? If they're eating out, well, can they order a side salad with every meal that they have?
Alessandra: Can they swap their morning Macca’s on their way to work with a green smoothie, for example. And then, helping them understand that that gene and that process of methylation is also going to be impacted by their levels of stress. So, let's talk about you know, stress management, let's talk about sleep hygiene, and these things sound really boring and they're not very sexy.
Mark: I know.
Alessandra: But you know, they make such a huge difference. And you would know that because you've been working for a very long time in your...
Mark: Don't overstretch it there, not that long. I keep getting called a grandfather of various things, I don't want to head down that line. But I have visited the places you mentioned, yes.
Alessandra: Yes, but we’re looking good for it, let’s put it that way. So, waiting for a long time, but looking good for it. So, you know, that sometimes especially when patients have been sick for a long time, they kind of almost don't want to hear these things and they want a magic bullet.
Alessandra: And in my experience, there is no magic bullet. What there is often is, is a lack of accurate diagnosing and it is very complex, because often, we're talking about multiple diagnoses, and an understanding how one diagnosis then can impact all sorts of other biochemical pathways. And so, in having experienced severe chronic illness in the past myself, I don't blame these people, because I know that we want answers, you know, when you feel really unwell, or you're very tired or you can't think properly, you do want answers and you want them quickly.
Alessandra: But in my experience, there really isn't a one size fits all. And especially for very complex cases, it really takes time to unravel. You're literally looking at unravelling like a yarn of wool, and first and foremost you need to try to find the beginning of the thread.
Alessandra: So, that you can slowly start to unwind it.
Mark: We've created that expectation though, haven't we? Medicine, the miracle of medicine is that there will be a pill for everything, and we don't go back to our Hippocratic roots of the diet, the lifestyle, the sleeping, you know, let the food be your medicine.
Mark: I find it both with people wanting to improve performance and people who are really sick, that they're interested in all of these but they want something to make a move, something to make a visible move, make me feel better, give me something. And if you just move simply them back to "Well, here's how we do sleep management. Here's the dietary changes. Here's the salads you need to eat." Their eyes glaze over, and oh, you know, "That's too hard." So, is there an easy...is there something a practitioner, we as practitioners can take as an easy entry point where people can see a benefit fairly quickly, and be encouraged to go on to do more?
Alessandra: Yes, I personally think that information is key. And I talk about the difference between competence and performance. So, I was recently writing an article about sleep quality, okay? Now, in probably 7 times out of 10, my patients generally tell me that they're a good sleeper. Now, being a good sleeper for example, doesn't mean you're a competent sleeper, and by this I mean, you might feel that you're sleeping okay, but you actually don't know whether you sleep architecture is right, you don't know if you've got sleep apnea, you don't know whether you're having enough REM to non-REM cycles per night. So, we make a lot of assumptions.
Alessandra: And I think that because of the explosion of blogs and the interest of the media in general well-being, people feel that they know this stuff, but when you actually start drilling down and explain to them, so showing them a genetic report, showing them the blood tests, and bringing it all together, and relating that to their family history of depression or anxiety, I think that you have a much better case for them really understanding that perhaps even those 1% changes you're asking them to make in their lifestyle can have a huge impact, okay?
Alessandra: So, I think that as practitioners, we need to set ourselves up above the facile spreading of information about well-being that is out there…
Alessandra: …and bring the highest level of evidence that we have, and relating that to the individual in front of us and their current level of pain. Now, I think that if you have someone who's absolutely struggling with sleep or whatever gut issues, then absolutely, we do need to offer some strategies that offer symptomatic relief, first and foremost. Because if you don't start reducing someone's pain straight away, you don't have a convert and a champion of what you do. So, my approach is that, first and foremost, yes, we're going to bring out the big guns as much as possible and try and work very quickly on whether it's symptomatic relief or quick wins.
Alessandra: And then, being very open and candid about the lens and the details of the strategy and explain it. So, I constantly do a mind map, you know, for clients. And so, getting them to understand how A relates to B and C, so how their sleep might be related to their gut infection, or how their sleep might be related to everything they've done during the day because their sleep-wake cycle has been completely turned upside down compared to their chronotype. So, they're eating at the wrong time, they're eating the wrong foods at the wrong time, they're exercising at the wrong time, and then, giving them a step-wise plan as to why we need to start with this before we can then tackle the underlying cause, and then keep repeating that at every session.
Alessandra: Now, obviously, if you're a GP, I really feel, you know, I really, really feel for general practitioners in this country and abroad, and I have worked and continue to work with some astounding medical doctors and I say this because I think that there's a bit of doctor bashing that goes on in my industry. And I think that they, you know, they are so overworked, underpaid, and under incredible time and pressure constraints. I'm not talking about you know, integrative GPs that choose to kind of somewhat step outside the system, but I'm talking about general GPs.
Alessandra: And I think it's incredibly difficult. You know, when you have a, between an 8 to 15-minute consultation, how on earth are they supposed to be counselling patients on all these lifestyle things we have been talking about? It's just impossible.
Mark: Yes, it does make a case though for developing a team approach with others who can do that and who are trained in those areas, because remember, we doctors are trained in disease recognition, which can be done quickly and accurately, and where the tests are very precise and we know what we're talking about and the drugs are well proven, even though maybe we change our minds later on. That's a different world from the person who is chronically unwell, or looking to improve performance, or looking to be better in their health.
Mark: And we often try and shoehorn that into a medical consultation. And I think we may be discovering it's inappropriate, but it's always lovely if you could give advice to a patient as a doctor to say, "Well, look, here's how we're going to improve sleep, or here's the specifics of the diet." Then we run out of time, and we need partners like yourself, to be able to hand that off to, to be able to say, “and that is better handled by someone who can put in the time, effort, energy to go through the details.” And I think the team approach might just be emerging even in general practice at the moment.
Alessandra: I think so, and I think that even as, you know, the big data technology that we were talking about earlier, improves and becomes more relevant for clinical practice, I think there will always be space for a team-centric approach because just having results through big data, it doesn't matter how accurate they are, is what you were saying: people still have to be motivated to implement the strategies.
Alessandra: So, you could have the most accurate diagnosis ever, but the person still has to take either the medicine or make dietary changes, lifestyle changes. So, I hope that that is the future of medicine.
Mark: Well, I suspect there might be two branches to medicine in the future; the branch of what we have always done which is try and prevent a patient falling off the edge with a disease by being a good medical doctor, and then the second job, is having done that for that person and for their family, expanding it further so that the next, and the next, and the next time, do not happen. And I think the second job is, in fact, the more difficult of the two. Recognising disease is pretty easy when you're well trained, and treating it is very, very shall I say, it's fulfilling because the person gets better from their proximate illness right on the spot, very quickly, and doctors wipe the hands and say, "Miracle achieved."
Mark: But the real miracle is, don't do it again, and again, if you have a heart attack, don't imagine that your bypass has cured you of the reasons for your heart attack. So, there's a job to be done. When we move down that path, do you see big data from what you've learned, you know, Stanford and elsewhere, do you see big data being able to be pushed into the healthcare consultation to change practice in a way that's practically useful, say in the next 5 years, 10 years? Do you have a feeling about how quickly we're moving to something useful there?
Alessandra: Yes, I think five years for sure.
Mark: You do?
Alessandra: Yes. Yes. Absolutely. And I think that we are going to be moving more and more towards distant consultations and some consultations also being conducted by AI.
Mark: So, that there'll be inputs from the big data that actually make it more sensible for both, say, doctor or naturopath, and the patient or client before them.
Alessandra: Yes, absolutely. And I also think that much diagnosing will be done by robots in the future...
Mark: I hope they're kind to us.
Alessandra: Well, I think this is a question that affects not just the medical profession, but affects pretty much everyone at large.
Alessandra: And there are changes afoot that are going to completely revolutionise the face of the working world as we know it. Does that mean that we're all going to be out of jobs? No, I don't think so. I think that just things are going to change in the sense that the more technical side of things, in terms of more straightforward diagnosing is going to be done by artificial intelligence.
Alessandra: But I think that when it comes to dealing with patients, I think that we're still a long way off in terms of developing the kind of, you know, bedside manner and empathetic support that humans really crave. And particularly in a world where we are becoming more and more connected yet more and more isolated through the use of technology, I think that professionals that can develop that side of things will always do well.
Mark: I'm going to ask you a difficult question. So, you cover two broad areas that there is a high crossover: one is the sick person who's wanting to get back to basic levels of reasonable health, and the others are the higher performers who are looking to optimise and improve their kind of edge capabilities. Is there common advice or a piece of common practical advice you could give us as practitioners about what has paid off best to both achieve high performance and to bring people back from illness into a reasonable state of health?
Alessandra: I think first and foremost is for practitioners who are interested in moving into the area of high performance is that, I think, first of all, you need to cut your teeth on the really difficult and complex cases, because to understand the high performance, the high performers, you have to understand the worst performers.
Alessandra: And it's something that I really firmly believe in because that gives you an incredible knowledge at biochemical level of what creates cognitive performance, what improves working memory, what optimises mitochondrial health for them for optimal energy? What constitutes, you know, how do you take a microbiome that's completely impoverished and make it the best possible microbiome for that person? So, if you like, they are polar opposites, but they are opposites on the same spectrum, and so you can't have one without the other.
Mark: So, would that mean the gut is preeminent in that area, that if you get gut digestion and health, that that leads the way? Or is the gut a downstream thing that there is something we should have done before? Medically do we start to move away from antibiotics and pay attention to birthing? Is there...are there origins that you would, if you had a magic wand, could change?
Alessandra: That's a really difficult question. Because you're kind of almost asking me, you know, what do I think is the most important organ system in the body?
Mark: That's true.
Alessandra: And, you know, if I asked a psychiatrist could you have studied psychiatry without doing your medical training? The answer would be probably, no. So, I think you need to have an understanding of the fact that we are not separate body parts, and we are one continuum. So, having good knowledge of the microbiome should not preclude having good knowledge of the nervous system, because they will impact each other.
Alessandra: But then within that, absolutely, you know, specialisations are useful. And then it means that you end up attracting a certain kind of patient or client who has perhaps more need in that particular area. But I think particularly as a naturopath and nutritionist, sort of my education in this field, just like that of my peers, has always been with first and foremost, understanding the system, rather than just understanding the unique part.
Alessandra: And thinking how A plus B equals D, it's really, really important. So, I'm constantly thinking, okay, what is this person's microbiome going to be doing now? And how is this affecting their mental health? How is this then, you know, affecting their immune response? And always thinking in terms of that whole.
Mark: Right. So, it is truly personalised. There's no kind of one single foundation, you pay attention to the history, you take the data that you can get, and then each individual has their own path back to either optimum health or reasonable health from illness. So, there is no magic, is that what you were saying?
Alessandra: Awesome. That is my mantra, there is no magic. I have no magic wand, I have a brain and a lot of clinical experience. And I absolutely firmly believe that there is no one diet fits all, for example. So, I do not put all of my clients on a gluten-free, dairy-free diet. I don't put everybody on a ketogenic diet. I don't put everybody on a high grain diet, it has to be completely individualised. And while we have epidemiological data to look at, for example, the benefits of the Mediterranean diet, you know, within that, we need to also consider, you know, genetics. So, you know, some people who have specific genetic haplotypes, will not do well on even high levels of olive oil, for example, so and then what's their microbiome like, you know, do they have a microbiome that currently looks like they have an overgrowth of bacteria that love fat?
Alessandra: So, then, you know, even though they need to lose weight, putting them on a ketogenic diet may help them lose weight, but by the same token, what is that doing to that microbiome? So, everything has to be pondered and considered and I had previously got in trouble for writing blogs, dismissing some of these famous diets, and I really stand by the evidence I see in clinic. When you do microbiome testing on people who have removed all starches from their diet, they invariably have the worst microbial diversity I've ever seen, including young children and despite eating kilos of sauerkraut and fermented product. So, we have to be judicious and we have to remember that any kind of prescription we give, including dietary prescription, potentially can have a long term bearing on that person's wellness, as well as lifespan in years to come. So, I think first do no harm, and if you are making prescriptions without really knowing the full picture, then just, you know, we have to be honest and say, "This is the evidence we have for this right now, and let's see if this helps you. We're going to keep monitoring your biomarkers and your microbiome and see how we progress." But making blanket statements about, you know, grains are bad, legumes are bad, you should be on a high-fat diet, I think is actually very harmful.
Mark: It's good for getting on the bestseller list, making messages over simple seems to be something that a lot of high profile people can do, but the reality at the practitioner level for all of us is you delve into the individual's story. And it sounds to me like what you do is you use your technologies as a map, not as a kind of a prescription or a guideline, but as a map to know where the weak points are, where the strong points are, and then play them out, one by one.
Alessandra: Yeah, I love that. I'm going to reuse that, I use a map that's really, really nice. And you have really summarised very well, the essence of what I do, and sometimes, you know, what you were saying about some high-profile personalities, I often wonder even if they're doctors, I often wonder whether they're still in clinical practice. Because it's just not something I have seen in my practices of 10 years that that approach ever works.
Alessandra: And in short you might have different cohorts of people that generally you find have certain characteristics and my response to that, that just to say that everybody should be on that diet, I always think, really? Are you really a clinical practitioner?
Mark: Yes. I am sure you are right on that, that as people ascend to the heights, the dizzying heights of celebrity, they leave clinical practice behind, and that touchstone for most of us as practitioners is really, really important. You can get books that take an extreme view, and for a few people they'll work, and then you realise there's no magic in there, it's hard work and you go back to that same hard work.
Alessandra: That's it and that's exactly what it is. It's hard work. And I will share very briefly the story of a client of mine who, but he's a high performing client, very, very successful business person, and he's also very interested in meditation. So, he attended a one-month-long retreat in Spain to do a meditation retreat, and as part of the retreat, a couple of times a week they would have open discussions about, you know, what the students were finding...how the students were finding the program. And on a particular day, two or three people commented on how uncomfortable they were finding the meditation, and at this point, their meditation teacher put his hands up to stop them speaking and said, "Comfortable? Whoever said that this was going to be comfortable?" And so, my client was saying that the thought that we have, is that things should be comfortable. We live in an era of comfort, yeah? We have ready-made meals, we have, you know, even TV we can watch 10 episodes of the series at a click of a button. We don't have to wait for the next week's episode. Everything is about comfort, and behind that, he was telling me, the thought is that this shouldn't be uncomfortable. But whoever said that? Health is not easy. We take it for granted. And it's about effort. So, if you want high impact you need to put in high effort.
Mark: And on that note, Alessandra Edwards, it's been delightful to talk with you. Thank you very much for your insights and I hope to talk to you again.
Alessandra: Likewise, thank you so much for your time and your insightful questions.
Mark: Thanks, Alessandra. Bye.