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Controversies in Nutrition with Dr Alan Gaby

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Controversies in Nutrition with Dr Alan Gaby

With so many opinions from well-meaning but perhaps over-zealous clinicians, it's important to keep a level head and to be skeptical enough to check that things are how they seem. This is where Dr Alan Gaby's expertise lies in debunking myths, exposing unsafe dosages and educating us on the misinterpretation of research. From his commonsense approach to Iodine dosing to the medical uses of high-dose B6, Dr Gaby is someone you want on your side as an advocate when faced with those who refute ANY efficacy of supplements.

Listen in as we divulge just some of the true hero supplements and debunk a few more myths along the way. 

Covered in this episode

[01:12] Welcoming Dr Alan Gaby
[01:08] The current climate of nutritional medicine and natural therapies in the USA
[03:54] Discussing Alan’s background and what drew him to natural medicine
[07:07] Writing Nutritional Medicine
[08:15] The controversy over high dosages of Iodine
[15:13] Accepting the use of Vitamin C to treat sepsis
[20:03] The Myers’ cocktail
[21:33] Vitamin E: helpful or harmful?
[25:45] Vitamin D
[31:22] The safety of methylated forms of vitamins
[39:33] Nutrients and dietary adjustment for migraines and chronic pain
[44:21] Red flags and fraudulent research
[45:51] Closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Dr Alan Gaby, M.D. He's internationally recognised as an expert in nutritional therapy, his career encompassing both clinical and academic work over several decades. He's past-president of the American Holistic Medical Association and gave expert testimony to the White House Commission on the cost-effectiveness of nutritional supplementation. He's the author of numerous books and scientific papers in the field of nutritional medicine including his 30-year project, his own textbook titled simply Nutritional Medicine now in its second edition.

Dr Gaby's CV is extensive and we'll hear about some of his career in a moment. Let's just say I'm a huge fan, and I'm so excited to be talking with you, Alan. Welcome to FX Medicine.

Alan: Thank you for having me. I'm doing fine.

Andrew: I followed your work for a number of years, and I've always been impressed by the way that you defend the reasonable use of safe, natural approaches, and particularly one which we'll talk about later which was a real issue in safety. 

But let's first go through and just discuss what's the state of affairs of nutritional medicine in the US at the moment and how's natural medicine viewed by the “authorities," the government, the FDA, etc. and what's the stance of the public in demanding natural medicines?

Alan: Sure. Well, I got interested in this field in 1973 so it's been 46 years. Back then, when I went to medical school, people thought I was completely crazy. 

Andrew: Yeah.

Alan: Now there's a growing minority of people and healthcare professionals who have signed on to the use of natural therapies, but it is still in the great minority and officially the so-called authorities that have control over what's going to get in medical journals are still very sceptical and sometimes even hostile.

I will say though, that nutritional medicine and other forms of natural medicine are becoming more and more popular among the public. The demand for it is probably greater than the supply. We have a few thousand naturopathic doctors in the United States, probably a few thousand medical doctors that call themselves integrative medicine, and certainly some chiropractors and dieticians also get involved in this field. But we have a long way to go. 

On the plus side, I would say that in the 45 years that I've been doing this, there is much more evidence supporting the effectiveness and there is a much greatest interest than there used to be.

Andrew: Yeah, we're going to talk a little bit that sort of acceptance by orthodoxy, if you like, of one poster child of vitamins. But first, you earned your BA from Yale, your masters in Biochem from Emory, and your MD from Maryland. Very early on, you wrote The Doctor's Guide to B6. Was it your biochem training which sparked this interest in nutrition? What changed?

Alan: Actually, it was my interest in nutrition that enticed me to go to graduate school in biochemistry so I could learn about it. 

Andrew: Right.

Alan: Before I went to medical school, I came from a medical family and my dad was strongly encouraging me to go into medicine but I didn't feel right about it. I didn't like the idea of giving people lots of drugs and cutting them up. 

But then I read some books back in the early '70s. Linus Pauling wrote a book on vitamin C. Roger Williams wrote a landmark book called "Nutrition Against Disease" and this really spoke to me. So I decided that my goal in life would be to learn all I could about nutritional therapy, what works, what doesn't work, and teach it to anybody who would listen to me. And that's what I've been doing since 1973.

Andrew: It would have been some very interesting conversations across the table with your dad. Were you accepted?

Alan: Actually he's 96 and he's a big believer in nutritional medicine. He was very skeptical at first but he taught me to be open-minded. When I put some papers on his desk, he read them and he said, "Wow, this is really interesting," and he started incorporating it into his surgery practice. For example, he started putting 3 grams of vitamin C into the IV bottles of people after operations, and he discovered that they didn't get urinary tract infections anymore after that. Typically you put a catheter in after surgery and people get urinary tract infections but they stopped having that after that and he did some other things with it, too.

Andrew: Wouldn't it be great if more orthodox practitioners were open to at least looking at some of the evidence on natural compounds?

Alan: Well, it depends on the person. I had a good friend that I grew up with, and we went to medical school together, and we remained good friends. I remember one day I said to him, "You know, you can shrink an enlarged prostate and improve symptoms with saw palmetto berry," and his reply was, "Did you see the baseball game last night?" 

Andrew: Really, okay.

Alan: He was not capable of even engaging in the fact that I had made the statement. And then there are others who read something and they realise that what they've been taught is so incomplete and often misrepresented, and it represents a complete shift for them. So it really depends entirely on the person.

But what I can say is there is so much more evidence now. When I first started teaching this in 1983, there wasn't enough evidence to say with confidence that a lot of this works. We thought it did. But now we have thousands of double-blind studies and all I can say now is, anybody who isn't looking at this, it's for some psychological reason other than I can understand.

Andrew: Alan, I've been following your work for a number of years, and you've written...it's not extensively, it's prolifically, and in not just one type of journal like Alternative Medicine Review, there's so much work, but also other journals as well. This is culminated in your textbook Nutritional Medicine. How long did it take to collate all of this knowledge and get it written properly?

Alan: Well I worked about half time seeing patients and half time collecting, and reviewing, and categorising all the studies that I was able to find. There's numbers over 50,000 papers now in the past 47 years. So it took me 30 years to write the first edition of the textbook. It took me 6 weeks to proofread it. That's how big it is. 

And then the second edition is pretty much just an update of the original edition, and that was another 6 years. That came out in 2017. But it is a comprehensive overview. It discusses over 400 health conditions, and it also discusses each individual nutrient, how to use it safely, and effectively, what it interacts with, what the proper dosages are, etc.

Andrew: One of the earliest times I read your work was actually in the "Townsend Letter for Doctors.” That was then there was this exchange - let’s call it politely an exchange - where you rebutted the advocates of extraordinarily - I would say irresponsibly - high doses of Iodine. I've mentioned it so many times in podcasts whenever we're talking about Iodine. What was the end result of this exchange with regards to, not just personal sort of stuff, but more like practice with Iodine dosing in the U.S.?

Alan: Sure. Let me first preface it by saying that the first 20 or 25 years of my looking into this, I spent calling conventional medicine out for ignoring or misrepresenting the research demonstrating the effectiveness of nutritional therapies. And then it gradually became clear to me that some people, in my opinion, were hyping up the therapies more than they deserved, making exaggerated claims, and sometimes doing things that I did not consider appropriate.

So while I still promote the value of nutritional therapy and call out the conventional medical community, I have spent more of my time criticising some of the people on “our side" because I don't necessarily agree with what they're saying. 

This Iodine idea, I learned about Iodine as an essential nutrient. It's important for thyroid function and it probably has some other effects in the body as well. But the human body has evolved in such a way that it gets by with very tiny doses of iodine and large doses can actually have a number of different adverse effects, including messing up the thyroid. It can cause hyperthyroidism, or hypothyroidism, or thyroiditis.

In the early 2000s, two doctors, Guy Abraham and David Brownstein, began promoting the idea that we should be taking about 85 times the recommended dietary allowance for Iodine. The RDA is around 200 micrograms per day and they were recommending 7,500 as a minimum, and sometimes even higher than that. 

They based this on two points. Number one is they claimed that in Japan, people on average consume 13,000 micrograms or 13 milligrams a day of Iodine and that they're very healthy people. The other point that they raised was that if you do a so-called Iodine load test that they had developed, that people can be demonstrated according to that test almost 100% of the time to need more Iodine. 

So I challenged, A: the concept that people in Japan were consuming that much Iodine and, B: the validity of the Iodine load test. I can get into more detail if you're interested but, after that, Abraham and Brownstein wrote back and accused me of what they called “iodophobic bioterrorism," and I attempted to keep it on a scientific level but it got to be quite difficult.

Andrew: And yet, to me, it was one of the first balancing arguments of somebody that was in the nutritional medicine theatre but went "Hang on, guys. We've got to be a little bit cautious here about what we're doing." There's paranoid, there's responsible, there's heroic, and then there's just silly and dangerous. It was really trending towards that. Indeed, there were those people, supporters in Australia talking about these really high doses and of course they caused a furor, not just with the endocrinologists, but caused some real upsets in patients.

Alan: We have to take it in the context of the fact that high-dose Iodine is actually a quite powerful and effective medicine in certain situations. 

Andrew: Yes. Yes.

Alan: It is antiviral, it's antibacterial, and it's antifungal. It also has some effect on steroid hormone metabolism. But, in that respect, we have to view it as a drug, a powerful drug that has potential side effects as some other powerful drugs do as well. So the idea that everybody should be consuming huge amounts based on the nutritional value of Iodine was what I was challenging. 

There's no question that some people do much better when they take very large doses of Iodine. My theory is that they have probably small intestinal bacterial overgrowth and that the Iodine is wiping out those unwanted bugs and that's why some people feel better.

But the concept of people in Japan consuming Iodine in large amounts was based on a misunderstanding of a study published back in the 1960s where they multiplied the amount of seaweed consumed by the amount of Iodine per gram of seaweed. They came up with 13.8 milligrams a day. The problem is that they were confusing wet weight with dry weight, so they overestimated by about tenfold the amount of Iodine people in Japan are consuming. It would have been very easy to get that answer by looking at a bunch of other studies where they collect urinary Iodine and they did this multiple times in Japan. They found out that the actual iodine consumption was anywhere from 88% less to about 93% less than they were claiming. That was point number one.

Point number two was the Iodine load test where they gave people 50 milligrams of Iodine, that's 50,000 micrograms, a couple hundred times the RDA. And then they collected the urine for 24 hours. If people did not excrete 90% or more of that Iodine load, then they inferred that it had been taken up by the tissues and therefore they were deficient. 

Well, that raises a couple questions. The idea that you have to excrete almost all of it presupposes that you can absorb almost all of it. They've never demonstrated that people can absorb close to 100% of a massive dose of Iodine. The only evidence we have is in cows, cattle. When you give them a large dose of Iodine, they only absorb about 50%. So the idea that people have to excrete it is based on improper thinking. Even if it were true that the tissues were hanging on to it, it's not clear that saturating the tissues with Iodine is actually good for people. It might be harmful.

So on a number of different levels, I challenged this and it was never resolved really. They had their points and I had my points. There are some people that use large doses of Iodine and I just caution them “Be careful. Watch for side effects, and make sure you're not harming people.”

Andrew: We were talking earlier about the gradual acceptance of certain nutrients by mainstream medicine. Indeed, good old vitamin C has now garnered support in a hard-to-treat condition, sepsis.

Alan: Yes. This was done by the head of an intensive care unit in a hospital in Virginia. He couldn't be a more conventional doctor. He has written chapters in critical care textbooks. He's widely thought of in the conventional medical community as an expert in critical care. He became interested in the idea that high doses of intravenous vitamin C could be useful in cases of septic shock.

There had been some anecdotal reports of this in one small double-blind trial, and he had three patients who, according to his statement, were certain to die. Septic shock has a death rate of 40% to 50%. The shock component, you cannot bring the blood pressure up and they often die from hypotension. He decided to give 6 grams of vitamin C in 4 divided doses per day, so 1,500 milligrams IV every 6 hours. He also gave them hydrocortisone. 

Hydrocortisone is thought to enhance the effect of vitamin C, and hydrocortisone is actually used as a component of the treatment of septic shock, but all the research suggests that it doesn't really do much good. The problem is they don't have much else to do so they give hydrocortisone with it. He also gave vitamin B1 or thiamine because a lot of people are deficient in thiamine when they have septic shock and there's some evidence that that might help as well.

He treated 48 patients over a one-year period that had septic shock, and he compared the results to the mortality rate in the previous year in the same hospital with the same types of patients. The death rate was approximately 40% in the first year and then when he instituted this vitamin C protocol, it had dropped to 8% which was about 80% reduction in the death rate. 

This made the news and there are now, as I'm told, 12 randomised controlled trials in process to see if what this doctor said is actually real. I have been in contact with him and he informed me just a couple weeks ago that one of these double-blind trials has been completed and that they have gotten exactly the same results that he did. 

So that appears to confirm the idea that a massive dose of vitamin C when combined with some other therapies which, by themselves, are not particularly useful can dramatically reduce the death rate from a serious illness. Once that becomes accepted medicine...and it will because you can't ignore dramatic results like that in an otherwise fatal condition. Once that becomes accepted, I think the envelope is going to open up or, let's say, the onion layers will get peeled back or whatever other metaphor I can think of, and people will realise, if it works this well for that serious a condition, maybe we should start looking at the other research that shows that it works for so many other conditions.

Andrew: Yeah, now I think it's a salient point to make that this is IV dosing and we're talking suprapharmacological doses here. What I think is interesting is there was this real reticence to use anything above 100 milligrams, 250 milligrams. I mean, 250 milligrams was thought to be a pharmacological dose. It was shunned in studies. 

I remember Linus Pauling going through a really tough time with regards to trying to get reasonable research done and yet now we see this jump. It's very interesting to see where there just isn't a suitable treatment for a condition. Caregivers will look for anything that will offer succour to their patients and this is one that sort of seems to scream efficacy, so that's great.

Alan: They will. However, we need to look at the history. Frederick Klenner who was probably the pioneer of the use of massive doses of vitamin C for a lot of different conditions, stated in writing well over 50 years ago that you could bring someone out of shock almost immediately by putting 12 grams of vitamin C in a syringe and pushing it in. 

That was over 50 years ago, and a lot of doctors have been using massive doses of vitamin C for many different conditions. I've used it with patients. It's just amazing some of the things you can do, but you're right that once you have a condition where it's hopeless and then you save them, then they can't really ignore that.

Andrew: Right. You were mentioning the Myers' cocktail, is that right?

Alan: Yeah. Well, that's something that I kind of developed myself and named it after Dr Myers from whom I learned the concept of giving IV nutrients. He used to give magnesium and calcium and B vitamins and vitamin C along with some other things, and he actually lived in the same studio that I did. When he died in 1984, a lot of his patients came to my office knowing that I was willing to do, shall we say, avant-garde things. They said, "Well, this is what I've been doing," and I looked at it and said, "Well, you know, we could probably change this dose and that dose based on my own understanding of the literature," and started giving these IV infusions over a period of about 10 minutes. I just was more and more impressed with all the things that you could do with it.

Chronic fatigue, fibromyalgia, about half the people with those chronic conditions do much better. I had one patient going through acute opioid withdrawal and literally, within 2 minutes, his withdrawal symptoms were gone. It lasted about 36 hours and I had to repeat it, but with a total of three of these infusions we were able to get him off of morphine. He was chronically addicted to it. We were able to get him off without withdrawal symptoms, and that's something that I'd love to see. There's a huge opioid crisis in the United States. And then many other conditions that I've seen benefit from this.

Andrew: Oh, hear, hear. Vitamin E has had a rough trot in research as well. The synthetic instead of the natural form used by those who popularised it like Dr Lady Cilento and the cardiologist who were basically lambasted, two small doses, etc. What does the evidence say about vitamin E?

Alan: We don't fully understand the vitamin E story yet. Way back in the 1950s, there were two brothers, Dr Wilfrid Shute and Dr Evan Shute, who were making numerous claims about the cardiovascular benefits and the benefits for other conditions. It was widely used among avant-garde doctors. And then in the 1990s finally, the cardiology community here got interested because there were many observational studies that showed use of vitamin E is associated with less heart attacks and other cardiovascular problems.

However, 10 years after that, there were randomised controlled trials that showed no benefit and, in fact, with congestive heart failure, there was a 17% increase in the risk of heart failure in patients who had type 2 diabetes and were randomised either to vitamin E or placebo. That was a statistically significant adverse effect. So vitamin E totally fell out of favour.

There were also some studies showing an increase in mortality but that was probably due to the use of the wrong kind. Let me just explain some of these issues. 

We know that vitamin E occurs in food in four different forms: alpha, beta, gamma, and delta-tocopherol. The type of vitamin E that's been used in all of the clinical trials has been just alpha-tocopherol. We also know that if you take a large dose of alpha-tocopherol by itself and by a large dose, I mean anything from 200 units a day or more, that's approximately 200 milligrams a day or more, you deplete gamma-tocopherol. It occurs rapidly and it occurs substantially.

We now also know that gamma-tocopherol has numerous effects of potential benefit both for cancer prevention and cardiovascular disease prevention. Number one, it inhibits platelet aggregation. Number two, it is a precursor to a molecule that appears to be a natriuretic hormone. By natriuretic, I mean it promotes the excretion of sodium and water. So if you have a natriuretic hormone and you interfere with it, you then impair the body's ability to deal with regulating salt and water balance. 

Andrew: Yeah.

Alan: Therefore, depleting gamma-tocopherol may invalidate any potential benefit that you get from alpha-tocopherol. So where it stands right now is we really don't know. 

I've been encouraging people and actually the Journal of the American Medical Association published two of my letters which urged the research community to go back and repeat the studies with mixed tocopherols, mixed means that contain alpha, beta, gamma, and delta as opposed to pure gamma-tocopherol. 

We saw an increase in prostate cancer risk with high-dose alpha-tocopherol and we saw an increase in congestive heart failure with that. All of the other evidence suggests that, if we were to use mixed tocopherol, not only would there not be that negative effect but there might be a positive effect for both of those conditions. Unfortunately, the research has not yet been done.

Andrew: What about the four isomers of the tocotrienols? How does that sit?

Alan: Well, strictly speaking, tocotrienols are considered part of the vitamin E complex, and they are intriguing in terms of their potential but there has been very little research on them. So, certainly, it would be nice to do further research on that but, for every study on tocotrienols, there's probably been 30 or 40 on vitamin E, so I'd have to say at this point we don't really know much about them.

Andrew: The same might apply to vitamin D. There's issues certainly with deficiency both in Australia, America, and around the world. But there are also issues with overtesting. There's issues with poorly dosed trials in the opinion of some researchers and there's the issue of the different forms of vitamin D. So what's the story with vitamin D?

Alan: Well, there's 342 chapters in my book, and that was the one I wrote last. I wrote that last because it is so complicated and so controversial but I believe I got a hold on this. I'd have to say that I am at odds with many in the holistic medical community. 

From what I can tell from the research, and there are hundreds of studies, a moderate dose of vitamin D is sufficient both to prevent deficiency signs, and in most cases get the maximum benefit that you're going to get from vitamin D. A very large dose has not been shown to provide any additional benefits and, in some cases, the effects are worse. 

For example, in multiple sclerosis, they compared 13,000 units a day with 1,000 units a day, and there was greater disability with the high-dose than there was with the low-dose. With osteoporosis, they compared 6,500 units a day with 800 units a day, and although the results were not statistically significant, the gain in bone mineral density was better with the moderate dose than it was with the high dose. A few other studies compared high and low dose of vitamin D for bones, and they found no difference between the two.

The reason people have been pushing high doses is based on observational studies. It is very clear that people with reasonably high levels of 25-hydroxy vitamin D, which is the measurement we do in the lab, those with high levels have less diseases than people with low or moderate levels. Therefore, people inferred, incorrectly, I might add, that taking enough vitamin D to push the level up to that so-called optimal value is going to do people some good.

What they overlooked is the fact that vitamin D is a so-called “acute phase reactant,” which means the level drops in response to inflammation, both acute inflammation and chronic inflammation. 

Andrew: Yeah.

Alan: Therefore, it is no longer a reliable indicator of vitamin D status in people with chronic inflammatory diseases. The fact that higher levels in the bloodstream indicate better health outcomes may simply mean that people with inflammation are sicker than people without inflammation, and it may have absolutely nothing to do with vitamin D.

So, in order to determine whether vitamin D is really useful, you've got to do randomised controlled trials and there have been hundreds that have been done. The results have been pathetically underwhelming, if I might say. Very little demonstrated benefit using high dose or even moderate dose of vitamin D for most conditions. 

What I have been telling patients is, if you don't go out in the sun or if you cover yourself up too much, take 800 to 1,200 units a day and don't ever talk to me again about vitamin D and don't ask me to measure your level because they don't even know what they're measuring. That's a whole other story. When you think you're measuring 25-hydroxy vitamin D, you're actually measuring some other things in the body as well.

Basically, I agree with you. This testing is a big waste of money. It leads to actions that may not be medically appropriate and potentially harmful if you subscribe to the idea that you have to push the level to a certain point.

Andrew: The greatest thing about vitamin D from sunlight is that it's for free, and if we could all just get a small amount of responsible sun exposure at midday, we'd get not just the sunlight but of course the negative ions from the fresh air as well.

Alan: I agree with that. The idea of sunshine, humans evolved without any vitamin D in their diet unless they lived near the ocean and got a little bit of fish, or maybe they stole a pterodactyl egg and that had a little bit of vitamin D in it. 

Vitamin D is not really a nutrient according to human history. It is a hormone precursor produced by ultraviolet light exposure from the sun. That's important to distinguish because ultraviolet light exposure on the skin does not just produce vitamin D. It also produces corticotropin-releasing hormone which is a hypothalamic hormone. It is produced in the skin from sunlight exposure. 

The sun also goes through the retina. The ultraviolet light stimulates the pineal gland which then stimulates the hypothalamic pituitary axis. Finally, it's not only vitamin D that's produced by the skin but also vitamin D degradation products which modulate the effect of vitamin D.

So vitamin D as a pill is only one small component of what I might call the vitamin D complex, which is the complex biochemical effects of sunlight exposure. We should try to mimic sunlight exposure and remember the song by John Denver who said, "Sunshine on my shoulder makes me happy."

Andrew: If you start singing, Alan...

Alan: He did not say “vitamin D pill was on my shoulder.”

Andrew: Methylation issues are another hot topic currently. In Australia, we've only recently in the past say 3 or 4 years or so been able to access the methyl forms of folate and B12, the active forms. Can you take us through the safety issues of folic acid, folate supplements, and treating methylation issues?

Alan: This is also a very complex and controversial area where not all the answers are in. Also, you're picking all these topics where I find myself criticising the whole medical community, but I think this needs to be brought up because I think people are doing some stuff that maybe isn't the best idea. So, as you know, folic acid is a precursor molecule. It is not biologically active. It has to be converted to 5-methyltetrahydrofolate or 5-MTHF which you also call methylfolate. That is the active form.

The problem is there's been virtually no research on the clinical uses of methylfolate. There are a few studies that show that it is useful as an adjunct to antidepressant drugs in the treatment of depression. After that, there's not much. 

The idea that you have to use a biologically active form sounds appealing on an intuitive level but we don't know very much about how the active form is transported into the cells from the bloodstream, and we also have virtually no research on comparative efficacy. So the little that has been done in that area does not support the use of 5-MTHF or methylfolate. That is the homocysteine-lowering effect.

They compared folic acid with 5-MTHF in a large population. They gave them 200 micrograms a day and the reduction in the homocysteine level was about the same, maybe slightly better with folic acid than with 5-MTHF. But then when you looked at the subgroup of people who were homozygous for the SNP that we're most commonly looking at, that's the 677C>T polymorphism, that is the one that is supposed to point to the need to use methylfolate rather than folic acid. 

And you would predict according to that theory that the homocysteine-lowering effect will be greater in that subgroup with methylfolate than with folic acid. In fact, it was exactly the opposite. Homocysteine went down by about 30% with folic acid and only went down about 8% with 5-MTHF. So the theory does not hold there.

In addition, when they looked at the treatment of depression, there has not been any head to head trials with folic acid or 5-MTHF but what they have shown is that 15 milligrams of 5-MTHF is effective as an adjunct to antidepressants. Whereas 7.5 milligrams a day is not. In contrast, as little as 0.5 milligrams up to about 5 milligrams of folic acid is effective as an adjunct to the same drugs in the treatment of depression. So folic acid appears to be more potent than 5-MTHF in the adjunctive treatment of depression.

Another issue…and I don't know what the legal situation is in Australia but there are a lot of malpractice suits in America. The US Public Health Service says that you should give 0.4 milligrams of folic acid, it doesn't say anything about methylfolate or 5-MTHF, that you should give that amount to women of child-bearing age to prevent neural tube defects. 

Now I would speculate based on what we know that 5-MTHF is probably just as effective as folic acid for preventing neural tube defects, but if you have a mother who gives birth to a baby with a neural tube defect and then some lawyer finds out that you didn't give them folic acid, you're going to have a little bit of explaining to do. So that's more of a legal question than a medical question.

The final point that you brought up was for cancer. Now that's still unclear about the relationship between folic acid and cancer. There have been a few studies indicating that, in the short-term, with older people, that is people in their 70s and 80s, folic acid as compared with placebo significantly increased the risk of getting certain types of cancer. Other research suggests however that what is going on it's not that's caused cancer but it merely accelerated the clinical expression of cancer that was already there. No is that good or is that bad? I don't know. You could say it's bad because it accelerated the appearance. You could say it's good because they had early diagnosis. Bottom line is we don't know.

But in the longer-term studies with folic acid, there's no evidence that over an 8-year or 10-year period or something like that that folic acid increases the risk of cancer, and it may actually be the opposite. So it may increase the short-term clinical expression of cancers that are already there and it may prevent cancers over the long run. We don't know that yet but we also have no evidence that, if folic acid does increase the risk of cancer in some way, we don't have any evidence that 5-MTHF is any safer. 

Andrew: Yeah.

Alan: So that is not a reason to recommend that.

Andrew: The new way of assessing methylation is by SNP testing. But people like Ben Lynch and Carolyn Ledowski have cautioned against the hammer-nail approach without looking upstream, and this is, of course, looking at the complex biochemistry which you've studied. So how important are these accessory nutrients in methylation?

Alan: I have tried my best to try to understand what people are talking about with this methylation thing, and you're absolutely right. There are many different nutrients in the body that are involved in methylation and they're also involved in many other conditions. For example, choline prevents the development of fatty liver in numerous experimental animal models. It also prevents the development of fatty liver in people who are receiving long-term total parenteral nutrition. It's funny that they call it total parenteral nutrition. It's really subtotal because there’s no choline in there. And then they put the choline and then they found out it really helps. There's also some evidence that choline helps prevent foetal alcohol syndrome in mothers who drink during pregnancy. 

So we take this one biochemical pathway that we call methylation that is so complex that I respectfully suggest that the people who are making claims about it could not know what they claim to know. Maybe it's because I don't understand it, but I've done my best to read all the evidence. My tentative conclusion is that some of the claims that are being made are exaggerated claims. 

What we do know is that people who have these specific SNPs, the 677C>T SNP of the MTHFR gene, they have a higher than normal folic acid requirement. That's all we know. So I give them more folic acid or I just tell them to take a decent multivitamin in the first place and not necessarily even test them.

I think we tend to over test. In my practice, I have rarely done any test other than the standard test that any doctor would do because I think, with a good history and a good physical exam and basic understanding of what has been studied, what works, what doesn't work, that you can come up with a treatment program that is usually effective without trying to spend everybody's money on all these tests.

Andrew: What are some of the nutrients we should be employing for things like migraine and chronic pain? You mentioned a few before but, given the opioid epidemic, it's in the US and Australia, codeine is now restricted to doctor's prescription only in Australia. So you're now getting the fallout of saying paracetamol is just as... You're getting the marketing coming through indeed saying paracetamol for migraine. What do you find effective for migraines and chronic pain?

Alan: Well, first off, I'd have to say that nutritional treatments for pain per se are not very effective. I mean it's not like there's nothing like morphine or acetaminophen, you call paracetamol, or aspirin or nonsteroidal anti-inflammatories. There is no nutritional treatment that can blunt pain like that, but what we can do is we can treat conditions that have pain as a component. In the case of migraine, if you can prevent the migraine from occurring or if you can somehow intervene to stop the process of the migraine, then the pain goes away.

So the first thing I look at with migraine is I get people to cut out all the sugar and the caffeine. Sometimes that's harder to do than to say but, if people do that sometimes they're better. And then the next level I look at is hidden food allergies. We put people on an elimination diet with individual testing followed by that, and probably 50% or more of migraines will be preventable simply by identifying and avoiding the foods that trigger it. I'm not talking so much about tyramine and these other vasoactive amines. I'm talking about hidden allergic reactions. The most common food that triggers migraines is wheat, surprisingly. Second most common is oranges.

Anyway, so after we've done that, there are some specific nutrients that have been shown both in clinical research and in my own experience to reduce migraine recurrences. Magnesium is one. We'll often use 400 milligrams a day. I've seen many people say that it completely prevents their migraines. Others say that it reduces it from 20% to 50%. And then in some that it doesn't work. 

Riboflavin or vitamin B2 was first mentioned in the 1940s in a letter in the British Medical Journal saying 15 milligrams a day of riboflavin prevents migraines and nobody followed up on that. And then, 10 years later, somebody said the same thing and then it wasn't until the 1990s that somebody did a randomised controlled trial and found out that about 59% of people with migraines have a greater than 50% reduction in the number of migraines when they take riboflavin. They used 400 milligrams a day in the study and compared to only about 15% of people in the placebo group. So magnesium, riboflavin, and also there's one study indicating that coenzyme Q10 can prevent migraines as well. 

For the acute treatment of migraine, the published research suggests that IV magnesium can knock out an acute migraine reasonably effectively. In my own clinical experience, I've used the Myers' cocktail which contains magnesium but it also has calcium, B vitamins and vitamin C. In my experience with probably about 15 migraine patients, some of them coming in multiple times for different attacks, about 90% of the time, you can have either marked relief or complete elimination of the migraine within about 2 minutes.

Andrew: And there you talk about a pig-headed condition which is resistant largely to pharmacologic treatment. There are neurologists indeed doing work with natural medicines because they've been frustrated with, let's say, complete control.

Alan: Do you have time for an amusing anecdote?

Andrew: Yeah, sure.

Alan: I got an email seven years ago from someone named Arnold Williams and he said, "I'm a biochemist and I've been trying for a year to get my neurologist friends to prescribe riboflavin. I am aware of the research but none of them seemed to be interested. Do you have any recommendations on how I can convince these doctors that they should try this? By the way, you may have heard of my father whose name was Roger Williams. He discovered pantothenic acid and he named folic acid," and my jaw dropped because Roger Williams was my mentor. I never met him but the book that he wrote Nutrition Against Disease is what got me into this field, and here was the 80-year-old son of my mentor asking me for advice.

Andrew: Wow.

Alan: It was cosmic.

Andrew: Alan, there is so much that we could go through. Look, I think to really to do it justice, you need your book. I mean that, to me, is a given. There are so many other areas where nutritional medicine can help but we've got to be responsible about how we approach that, and there are certain caveats. Do you have any red flags or things that we just need to leave behind, things that just simply don't work?

Alan: Well, I think poly-cholestanol was a con by the Cubans. It does not lower serum cholesterol. I'd have to think of the other ones. Another thing I've been concerned about is, in my opinion, there is more and more research fraud in the past 5 or 10 years. People are publishing research that they actually never even conducted. There are a couple of countries, in particular, probably Iran is the most common. It's gotten to the point where, when I read the title of something, I can tell from the title that it was done in Iran and that they had dramatically positive results. It's just gotten to that.

Andrew: Yeah. Look, if you read "Retraction Watch,” it's a cavalcade of issues with research, and it's both sides of the camp. It's not just in nutritional medicine, there’s celebrated oncologists being found out for fraud and things like that. 

Alan: Absolutely.

Andrew: Dr. Alan Gaby, thank you so much. We have so much that we didn't cover. I would love to invite you back for another topic.

Alan: I'd be happy to do it. This was fun.

Andrew: That'd be great. But thank you so much for taking us through this really important stuff and really salient advice that you've garnered over years of clinical experience, so thanks very much for joining us on FX Medicine.

Alan: Okay. Thank you. Take care.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.


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