How do we determine when intervention is necessary in our health and wellbeing treatment strategy? In our quest to conquer pathological processes, are we overlooking the fundamentals within evolutionary biology and thus potentially doing a disservice to our patient's health?
In today's podcast, part one of a three part interview series, Dr Mark Donohoe explains the concept of evolutionary medicine and the adaptive response. Mark illustrates how our adaptation response may lead to disease and dysfunction but that equally, there is value in looking beyond symptoms to discover the “why” of illness and how we may work in with it, rather than against it.
Covered in this episode
[00:58] Welcoming back Dr Mark Donohoe
[01:46] What is evolutionary medicine?
[05:51] Maladaptive responses
[08:44] Adaptation response vs disease state
[13:59] Supporting the adrenal glands
[19:10] The brain: in command of the body at war
[27:34] Looking for the “trapdoors”
[37:47] Balancing symptom management with finding the root cause
[40:54]Partnerships between various modalities
[44:30] Changing the way we think about treatment
[49:25] Thanking Mark and closing remarks
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us in the studio again today is Dr Mark Donohue who earned his medical degree from Sydney Uni in 1980, and he worked throughout the Central Coast of New South Wales honing his medical skills where his interest in integrative medicine sparked because his patients weren't fitting into those boxes of diagnoses and treatments, which were drummed into him in medical school.
Mark is considered—and this is where we joke—one of the fathers/uncles/grandfathers of integrative medicine in Australia. And he's been a vanguard for patient health throughout his whole career, and I warmly welcome you back into FX Medicine.
Mark: It's good to be reversing age here. It's very good to be reversing. I'm going down the scale. I don't want to be the great-grandfather of this area.
Mark: It does.
Andrew: It sounds a little bit esoteric. What do we mean by that term?
Mark: Medicine owns the category of diseases, right? Basically medicine is a trade union. We've defined things as diseases. It's called nosology. By definition, disease is a failure of biology leading to pathology, leading usually to death or at least permanent disability.
So we have this idea, you probably remember, we would have all been through it. This kind of “bowl of homeostasis,” that a person in homeostasis goes to the bottom of the bowl. Disease pushes them out. If they flip over the edge, you're dead. And if you don't flip over the edge, you come back to a level of reasonable health.
Well, the problem is we've beaten many of the diseases. Medicine works. My profession has done some good stuff to stop people dying. And medicine when it's worked and it's got rid of many of the fatal diseases. We know how to manage heart attacks. We know how to manage a whole lots of things. But the problem is we start to fiddle, and medicine reverses and says, "Hey, maybe we're also preventive medicine. Maybe we can take those techniques that we use, which drugs, surgery, radiotherapy, these type of things that work magically in the extreme and then move them back along the road a bit."
Evolutionary medicine is a branch of evolutionary biology. It's a medicine which says “Why does something happen?” So the critical thing that medicine has missed is not that it's failed in any scientific sense, but it says “What has happened?" And the failure of medicine, in a sense, has been to say “Why does it happen?” The “what happens,” you've got drugs or you intervene. You chop off disease, you save lives. The “why does it happen” is much more a human desire to know. People get empowered by finding out why illness occurs. Why am I suffering chronic fatigue? Why is my cholesterol rising? Why are my muscles malfunctioning, I'm building up lactic acid.
So evolutionary medicine comes back to a different state that says there's an adaptive state. It's not the same as good health, but it's certainly not the same as disease. When there is a stress on the body, the whole Hans Selye type of stress being psychological, physical, cold, hot, or anything else. When that happens, the body enters a state of adaptation, and it's really easy to misinterpret that as disease and to go full bore with the drugs that are very powerful and make the mistake of not finding out why the person is sick.
Evolutionary medicine and evolutionary biology are two branches to say, "Hey, hang on, have a think about how we developed over the millennia." Over the millions of years of evolution, there are processes in place which are adaptation which when they're going on, we should respect the body and work with it and work back to recovery.
The best-known one around the place has been what's pyrexia? What's high temperature, what does it mean, and what do we do about it? Doctors always regarded pyrexia as a thing to be controlled. So we jump in with Panadol or we'll jump in with things to drop the temperature of a person without actually recognising that...
Andrew: There's a function.
Mark: ... the temperature was important in promoting an aggressive immune response to defeat a pathogen. So that was a very good example of, "We were doing something to drop the temperature; that prolonged the illness."
Jumping in with antibiotics early. We've now learnt a lesson with antibiotics. One is that, if you jump in early, you eventually get antibiotic resistance. But the other is most people get over infections by themselves and are more resilient for having got over the infection.
So there are processes that go on in the body all the time that we think of as treatable disorders and that, if we step back from it, we can think, "No, that's the body trying to adapt to something. What is it adapting to and how can we do something about it?"
Andrew: We talk about an adaptive response, but we also get maladaptive responses. And the perfect example is shock. Shock will try to save you to a point. It will close off the periphery to ensure blood flow to the vital organs: the brain, the heart, the viscera. So it will close down the peripheries. But there comes a point where it just goes, “To hell with it,” and you get vasodilation and it just says, "I've tried."
Andrew: So is that really a piecemeal, last attempt at saying, "Hey, listen, I can't starve the peripheries forever. I'm going to have to feed them even though you're bleeding out that arm, so I have to do this vasodilatory response," or is it just, "Oh, to hell with it, you're going to die anyway so let's kill you quick"?
Mark: Yeah, I think you're right. The body does make choices all the time of, "Is this sacrifice worth making?" So there is always an adaptive response. The thing to remember is you lose something along the way. The heat stress response, the shock response are all short-term adaptations to get us through what could otherwise be a fatal outcome.
And you're right. It's pushed to the very end, and at some point, biology says, "Ah, bug it anyway. It can't go any further, so there is no point dragging this on." And if a doctor's ideal intervention point is not when the shock first starts but at the point where it starts to move out of control.
Mark: So jobs as doctors of stopping dying, that's a very, very good job to do. You can actually see the bodies that you save right on the spot. The interference of medicine going backwards into things that don't require that intervention...
Andrew: Like for instance, seizures with high temperatures.
Andrew: Very, very few ill effects unless there's an underlying disease there like epilepsy.
Mark: That's right. It only happens in children. The outcomes are universally pretty good, but we fear it. We call that epilepsy.
Andrew: And terrible to watch. Scary.
Mark: That's right, and everybody feels that we should intervene. Everybody felt for 100 years, yes nearly 100 years, that antibiotics should be used all the time because how terrible is it to have infections that you could make shorter without ever realising that was biological selection. And there was also host weakening.
What we now understand with high antibiotic use is the immune system does need to be tested to be resilient the next time, and the next time, and the next time. And when we're running early with antibiotics, we're doing a maladaptive thing for that organism. It looks good in the short-term, but in the long term, that child is likely to get more and more and more of those infections.
And you can see this in a way that medicine has been defining repeated or excessive infections in children. It's now 24 infections per year; it used to be 6. And so we're putting up with more infections by higher intervention and, in the background, losing the fight against the very bacteria that we thought we're winning the fight against.
Andrew: Exactly, yeah.
Mark: So it's not that medicine is doing the wrong thing. It's doing the right thing in the area of disease. When a person reaches a state of disease, the definition of disease is that's the failure of adaptation. What we are talking about is signs and symptoms that happen earlier. And when we try and extend medicine backwards, what we lose is the very high ratio of benefit to harm that happens in the disease state. A heart attack, you do not want to be thinking of evolutionary matters, you want to be doing something to save the person, bust the clot, to get the heart functioning again. Same with a stroke.
So this is not an argument against medicine. Medicine's job is to identify diseases, intervene as early as possible, break the nexus between that and deterioration. But the 90% of healthcare, what GPs see, what naturopaths see, what we see out in the general community is not disease; it's an adaptation.
Now, I come to this also. I've got to say this has been an awakening in the area of chronic fatigue syndrome where the genetic studies being done now keep saying the same thing. It's not one illness. It's a breakdown of an adaptive response which puts a person into a hibernating state that is really difficult to shift them from. You apply the medical model, and we give antidepressants. It works short-term. Longer-term, people deteriorate further. We use antibiotics. We use all kinds of processes.
The ones that work are those that work with re-adaptation of the organism. If you understand the person not as a diseased person but a person through intolerable stressors for them, finding the least worst outcome, and that's a really important part of this. Bodies are good at finding the least worst outcome, not always the best. And so recovery may be sacrificed, but at least things don't break down, don't go wrong.
Andrew: Right, yeah.
Mark: People with borderline hepatic function, people who are poor methylators, people who have got genetics for gluten who are eating gluten, in other words, having an inflammatory response, they don't get disease straight away and therefore they don't fall in the diagnostic categories of doctors.
Doctors say, "Oh, there's nothing wrong with you because I've done all the tests." Give those tests time, you'll get something that breaks down in the future. But at that point, the concept of evolutionary medicine is go back and think about why. What could be going on with the processes that this person is adapting to?
The way you know adaptation as opposed to disease is it's a stable state of ill health, and that's a critical issue here. Medicine deals with instability. When things go wrong, they change very quickly over time. A person's deterioration is obvious. They're collapsing the shock response, that you said, right in front of you.
But when people reach a repeated stage of chronic, stable, ill health, that's an adaptive state almost by definition and thought at that point about the why's is what doctors are not so good at. We know the drugs to treat the symptoms. We know how to give people relief from suffering and pain.
What we're not so good at is working backwards along that train to say, "Why is this person adapting? What is the diet contributing? What is the environment? Are there toxins?" So we're looking at those stressors on the body. And in fact, it's a really useful idea to go back to the Hans Selye idea of, say, let's identify the stressors.
My practice I'll tell you this every single time. I see people with chronic fatigue syndrome. I see people with sudden deterioration of their health, autoimmune disorders, and they say, "It happened five years ago." And my first question is, "What happened six and seven years ago?" And inevitably the answers are there about what was happening in those years before. Long hours of work, new family, missing sleep. There is a kind of load that comes onto a person, and for a while they do okay, and then the body says, "No, this is not sustainable," and it drops something.
So it will drop the thyroid, for example. What do we keep on seeing? We keep on seeing people who are clinically hypothyroid but the brain is not asking for more thyroid hormones. You can say this person looks hypothyroid but the TSH is 1.5 or 2, which is perfectly in the normal range. Why is that adaptation? The brain's given up asking the thyroid for more. The cholesterol will rise, the sterol hormones will drop, and the body goes back into a hibernating state. And my guess is that, if you found a bear and tried to pull him out of a hibernating state, they also would not be happy bears.
So when we're dealing with evolutionary medicine, we're dealing with root causes and going back and trying to change the substrate of that person's life: their diet, their sleep, their lifestyle, and getting the stressors off them as best we can.
Sometimes we go back and we look at the genetics. And we say, "Aha! That's what broke. You know, your DQ2, DQ8 genes. You are being inflamed. Every time you eat a glutinous meal that keeps on triggering the same kind of reactions. Those antibiotics that saved you from pneumonia five years ago, they're playing out now with a dysbiosis which is becoming an inflammatory bowel kind of problem that we've got to go and beat.
And so I think evolutionary medicine is fascinating because it's medicine coming back to ask why, and having whole different answers to the answer to the question of what is the disease state and what's the right drug for it?
Andrew: Hans Selye. You've mentioned him three times now, and the assumption by many particularly integrative practitioners is that it's the adrenal glands that shrivel and it's the adrenal glands that we need to change. We say so with the word support, and the inference is to actually change their structure and function.
Newer research shows that it tends not to be the actual adrenals, and I'm confused about this because you and I have actually spoken on changes to the adrenal gland. But most of it speaks about changes in the brain, and that the herbs and nutrients that we associate with supporting the adrenal gland are actually supporting brain structure and function. What's happening?
Mark: My view on this has changed over time. I really thought that there was a thing called adrenal exhaustion. I'm pretty convinced now that there is no such thing as adrenal exhaustion. The adrenals are regulators of particular types of function, great control of cortisol, aldosterone. They manage blood pressure. They manage our stress response, inflammation response. And when emergencies arise, the adrenal medulla unloads all the adrenaline that's required to keep your head above water.
I thought of them as failing the same way that we get heart failure, that the gland progressively gets overloaded. And I'm now pretty convinced from the research that that's not the case. That when we think we're treating adrenals, we may, in fact, be working against the very biological components that keep us safe, trying to stimulate something that has put us into a stable low-level state that is survivable.
So the adrenals are not dummies. The cortisone I measure regularly. People under high acute stress, cortisol levels in the 600, 700 range. The adrenals are pumping out stuff. Do they fail? No, they don't. In my opinion, we do see Addison's disease but it's a whole different illness. It's an autoimmune illness, it's a catastrophic crash. Sometimes it's after doctors who've given cortisone in the form of prednisone and the like for too long a period of time. And so there are disease states there, which if doctors fail to do something about it, that person is likely to die.
But the 99%, the adrenals are involved in an adaptive response. That whole sterol hormone, the cortisone, progesterone, oestrogen, testosterone, the anabolic and the catabolic. So progesterone, and the cortisone, and aldosterone on the catabolic side, and the testosterone DHEA and oestrogen on the anabolic side, the body is forever adjusting the balance between those. When under stress, the body closes down function and goes to what we call stress proteins which stabilise the cells, reduce function, and put you into a lower metabolic state. And that's a safer state to be in when the stressors on the person are intolerable.
Our difficulty is not being able to read the stressors and not being able to read what the adrenals do. There's a catch to that.
Mark: One catch that I would say is people with underactive thyroids close off that conversion of cholesterol to the pregnenolone at the very early stages. People under high stress and with the thyroid dropping low, you do see cholesterol rise, and all the sterol hormones, all of the ones based on cholesterol that regulate the body all drop to low levels. It's like having no pay coming through into your bank account. You've got to squirrel it around and give it to the most needy things at that time.
So often you do see that you do something to sort out the thyroid and the adrenal hormones come back to life again. But that said, if the thyroid is okay, the adrenals are very, very precise regulators on a second to second basis about what's going on in the body, turning things up and down, sacrificing function.
And then when all works well, you get the cortisol produced. You get all of the hormones working to save you, that when the infection is gone, or when winter is gone, or whatever the stressor was on their body, they come back to the anabolic rebuilding the testosterone, the oestrogen, the sex hormones start to return to life, and the person recovers.
Now, I have a view here, and that is the stressors that we were… I almost said "designed for" but it's not "designed for." The biology of humans that grew up in temperate climates had seasonality.
Andrew: Right. There was a winter every year. Surviving winter was a sine qua non. If you did not survive whether you didn't procreate, you didn't have a next generation. So the cortisol and stress response seems to be brilliant together through a 3 to 6-month period, but not a lower-grade stress that goes on for 25 years.
I think variety and variability of the environment, diet, and the like, is exactly what humans are bound to thrive in. And when we close that down, when we reduce diversity of temperature, when we have air-conditioned homes, when we don't have winters - no supermarket and the world has winter - then we put a different type of adaptive stress on the body, and that is those who are not designed well for that particular environment do very, very poorly.
And then they rely on a chronic stress response which progressively closes down function and people complain, "I'm tired. My brain is not working. I'm putting on weight." Those types of responses are adaptive responses, they're not diseases.
Mark: Yeah, you're right, the brain.
Andrew: We're talking about... They're under the control of stimuli from the hypothalamus.
Andrew: So when you talk about... Like, is it a case that our definition is wrong? The treatment is fine but our definition of what we think we're doing is wrong.
Like, for instance, antioxidants. I have severe questions about that term "antioxidants" as a one-way action. We have redox partners. We use redox partners for goodness' sake. Look at CoQ10. Look at ubiquinone and ubiquinol.
Andrew: So that's getting off track, but the whole thing is that we're under the control of the central stimuli command. Let's say it's the CIA or the Pentagon for a military analogy.
Mark: Right, body at war.
Andrew: Body at war. And then you've got your forward command centres, you know, your Navy, your army, and they're your thyroid, adrenal. You've got the immune system and digestion, all that sort of thing. They're your forward command centres.
They're under the influence of that central command, and they sense and respond to that, or not. So is the case that... You say we're... Are we doing the wrong things by stimulating the adaptive response? Is it a case that we're not stimulating, that we're nourishing?
Mark: If you're nourishing, then you're doing something right. You are reversing stressors.
Andrew: So things like caffeine...
Andrew: You know, things like caffeine is a stimulator, but things like soups, and rest, and sleep, and a tepid sponging and that sort of thing, are they more than nourishing types of actions?
Mark: They may be. I would step back. I think you're right. The regulator comes from the hypothalamus and the pituitary, and so the hypothalamus is a receiving centre. What's going on out there in the body? A kind of regulator of incoming signals, aggregates them and says to the pituitary, "Mm, thyroid up a bit. Hey, give the adrenals a bit of a kick. They're falling behind."
And that processing centre in the brain can be disturbed. Psychological distress, lack of sleep, there are a lot of things that can change the ability of the hypothalamus to stimulate the pituitary, to send out those messages to all those special forces out there.
Even the insulin responses, those kinds of messages that have to come out. If the brain is under stress, it will often say, "Stressful time. Put together the kind of stress responses for the body. Save up all your energy. Put on weight. Set the metabolic rate a little bit lower. Change the heart around so that the demands are a little bit less and sacrifice non-essential function like short-term memory and concentration and the things that people live their lives through."
And so people who come to me will say, "My memory is failing. I haven't got the strength. I fatigue very easily.” I look at my dog lying on the ground and think, "Hm, only humans have an imagined other that they could have." In biology, when something makes you stop and rest, you stop and rest.
Humans don't do that. Humans go to work. They keep on doing the things that they're doing. They keep on buying from the supermarket, and it takes some significant deterioration before they turn up at a practitioner to say, "Here's the bits that are going wrong."
So it would do us well to think like a brain or to at least think like a hypothalamus to be able to say, "What are the inputs here?" Well, that's where a lot of the pathology testing is worthwhile. You could do the pathology and say, "Okay, you've got gluten reactivity. You have got inflammatory processes going on." Of course, the body wants to extinguish those because, if you can't win and you certainly can't win the fight against gluten, there's no battle to be won there. Every time you eat it, you're getting another stimulus to the T cells and the regulatory cells.
Then, what's the best way? Turn the thermostat down. Just take it down to... instead of the... I'm mixing my metaphors here, but instead of running it 12 volts, how about you run it 10 or 11 or 9?
We will then say, "I'm suffering symptoms and I want to be more functional." I have spent 35 years of my life trying to get that function back in people and finding that, if I push too hard, if I use really potent drugs to try and push the metabolism back, I can make the person significantly and measurably worse. They get their function that they thought they want. Their brain is functioning, their muscles are functioning, and they go downhill and they do enter disease states.
So, yes, I recognise the hypothalamus is a great regulator of that: thyroid, all the sterol hormones around the body, all of those organs in different areas of the body, and I am fascinated by adrenals. But the nurturing response, the finding out how to unload the body is a discovery tour. It is not a drug. It's not a pill. It's very rarely going to be a magic bullet that comes along and says, "Oh, this now fixes all of the stressors that their brain has aggregated."
And the reason I say that is, I use, say, thyroid hormones. Yeah, I can give people five or six times the dose of thyroid hormones that would be needed for a person with no thyroid at all, and they still do not register a higher metabolic rate. Their pulse is still sitting there at 64 beats a minute. They have adapted to the thyroid hormone. I'm giving something, I’m thinking, “If we could just pick up your metabolic rate, this would work well.” No, the body produces reverse T3. It produces things that will blockade the thyroid hormone receptors, and that makes the person safe.
Now, it's ridiculous because I think I should be able to do that. I'm a doctor. I know better than the body, but I don't. The body is regulating that to keep a low metabolic rate, and until I discover why it's doing that, I don't have a chance by just giving, say, thyroid hormones or adrenal hormones. You know, doctors love cortisol. Prednisone in the '70s, we called it vitamin P because everybody got better on prednisone. Until everybody didn't. And that was not a very good way of understanding, yes, you can win these battles in the short-term, but the price you pay in the long-term is ridiculous.
Andrew: And there's a whole movement with integrative medicine to use cortisol.
Mark: I know.
Andrew: And it was like, as you say vitamin P, thrown around like candy, irresponsibly in my opinion, sometimes. And Dr Andrew Heyman made a very salient point about, "Hang on. If you've got an infection there, you're just covering it up. That's all you're doing."
So what benefit, what charity are you offering that patient? It makes you feel good because you’ve got no symptoms. Is that complementary or integrative medicine or just medicine? Cover up the symptoms quick.
Mark: Andrew and another guy called Tom Williams, as well. Very, very clever in this area to say, "We're staring at the body doing something trying to overwhelm it. If we try and overwhelm it, we take full responsibility for all body functions. We don't do very well with that." I think those two especially have done the work to prove that there is no such thing as adrenal exhaustion. Adrenal exhaustion doesn't exist. Adrenal adaptation does.
Mark: And I do think that when doctors get in trying to make adrenals work, we can only think one way. What's the final hormone made? Whereas the herbs clearly work another way. And as I've said to you a thousand times, one day I aspire to become a herbalist because I think that plants are the most interesting areas of evolutionary medicine.
How did we grow up in our environment with the plants, and the herbs, and the foods? And there are subtle divisions between these. How did we do it? How did people learn that you give a warming soup? How did people learn those kinds of things? They were the molecules of life that surrounded us.
Mark: The people who didn't benefit from those, who couldn't respond to those probably are not with us, and we are the evolutionary selection of those humans that are left.
So I have great respect for the traditional naturopathic herbalistic view, that if we can do something to encourage the return of function, I agree with you. Sometimes the naturopath will say, "I'm going to stimulate your adrenals," where maybe what they're doing is regulating the hypothalamus and the pituitary. It probably works on whole different levels than what we think.
Andrew: Yeah. You know, you mentioned plants. And plants don't just nourish the body as a whole, but now we're finding it's majorly, or interestingly, polyphenols which help balance our microbiota. It's polyphenols which are these "antioxidants" or redox partners, whatever you want to term them. It's plants in the form of herbs which nourish. We thought the adrenals, but now we're finding the brain, here we go, the ginsengs.
Andrew: So I find the problem is the terms we use, not the treatments we have.
Mark: The terms we use and the conceptual frameworks we have.
Andrew: Yeah, yeah.
Mark: So medicine distorted...
Andrew: We don't think... Yeah.
Mark: ...a framework by being so powerful at the end of life and in disease states. We call our system a healthcare system for no good reason at all. It's a disease care system, and it's a very good one.
Mark: But the term healthcare is not something that medicine has ever got any evidence to back it up. And in fact, you see this happening all the time. What's the evidence that diet positively affects outcomes? It's very difficult to do trials when you don't have a disease state that you could rely on.
Why do we choose people who've already had a heart attack to test statins on? Because they're really going to be likely to get a second heart attack. What do we really want to know? How to get the other 6 billion people in the world to not have heart attacks.
So we do come back to that over and over. A lot of the antioxidants, the so-called oxidants and antioxidants, are signalling molecules. Nitric oxide, signalling molecule. These are telling the body messages, stories that the brain and the hypothalamus are adapting to way below our level of consciousness. But the one thing that we can all recognise that feeds into it, is psychological and situational stress.
Often we do not know the viral load that we carry. We don't know the metabolic loads that we carry. We don't know our poor responses to glucose or sugars in the diet. But what we can say is, "My job stresses me," "My partner stresses me," "It's Valentine's Day and I haven't bought flowers," or something like that.
We can pick the points, and we lay everything on that as though stress management or stress reduction is the only thing to do. And most of the patients that I see can pick the events that triggered something, but they were already close to the edge because that same event in another healthy person would do absolutely nothing at all. It would be a bounce-back phenomenon.
So I do go looking for what are the weak spots that a person brought to their life? Everybody has trapdoors. Some are poor methylators. Some have got particular predisposition to autoimmune disorders. Some people have got lousy immunology, low IgA or something like that. Everybody brings weak points to life. There are no perfect humans. If you want CRISPRs, maybe they will be in the future, but it will still be a human-chosen perfect human.
Andrew: Yeah, brave new world.
Mark: That's right, but we all bring our weak points. And if you're really lucky, life never exposes one of them. If you're born in Northern China, you don't eat a lot of gluten so you don't know that gluten reactivity and inflammation can trigger thyroids, the diseases that are a consequent upon that just never appear. But if you're in Southern China and you do have wheat, those same genes can be very, very difficult and cause inflammation out of control.
Andrew: Wheat's a whole podcast but anyway... It's not just one podcast. Hang on, whoa, whoa, whoa, we'll get off track.
Mark: We will leave that.
Andrew: So is one of the major issues facing medicine, orthodox medicine here, that, A, we've got the pressures of modern life facing people? They need to, as a pharmaceutical company very successfully put on their cold medication, “They need to soldier on.” So people need to get back.
We also have this convenience, "Please help me with a pill,” mental attitude of our Western society. Rather than "I will do the foundation, can you help me snip off the edges so that it's all a nice, little package and I get well?” And medicine is also faced with that problem of there comes a time when you need to act. There comes a time when you need to intercede and help somebody.
Mark: Where is that point?
Andrew: Yeah, that person is asking you for succour and you need to say, "How can I change that?" So a problem facing medicine is that you need to intercede in a way that you can measure change. And is that one of the foundationary issues of medicine?
Mark: You can intercede.
Andrew: You need to prove change.
Mark: You can still go looking for the causes, right? So, people with headaches, I have no problem with people having migraine management with triptans. I have no problem with symptomatic treatment of depression when people suffer depression. You need to be clear that these are not diseases. These are symptoms and doing symptom management with a cognition that this is a step one to get you feeling better. And then we find out why the headache, why the blood sugar is rising, why the weight is going on.
If you leave it with the symptom management, you are waiting for the next thing to break in that person's adaptive response. If you give succour, as you said, if you give people relief, that also gives them a reduction of stress. The stress of pain is a real thing, and it adds to that whole load.
So I have no problem with using symptomatic treatments. Doctors, naturopaths, everybody have their favourites. It doesn't matter where you go. Herbs are used to relieve symptoms as well.
It's the failure to go backwards one step further and say, "Why is there a headache?" So there are people who've just fallen off horses, pop their neck out, and with good management of the neck, their headaches will go. There are others who are getting migraines which are triggered by particular amines in the diet. Getting amines out of the diet is going to have a big impact on that person's headaches.
So medicine's failure is not that it never thinks of it; it's that it thinks it's symptom management, and the person not turning up to your surgery is the same as a cure, and it's not. So people go to doctors over and over. And when I see them years later, "I went to the doctor. I had the headaches over and over. Why did no one pick up that I had cervical spondylitis?"
That's because the pain relievers worked, and then eventually the degenerative changes in the spine are sufficient that the pain relievers don't work, and then the doctor says, "You can't have any more of those because now you're getting bleeding from the stomach." And the cost of not paying attention to why the person was sick was always a problem.
Mark: The evolutionary medicine version of that is, "Here's pain relief. Now let's find out why."
Andrew: Yeah, so this was my next question.
Mark: And if that's the way doctors and practitioners are thinking, if they say, "We have powerful tools which used short-term have got high levels of safety," and nearly all of those drugs used long-term have got costs that we almost forget about.
We put people on acid suppressant. It works for a couple of weeks. You can get a person to be really quite relieved, and then you get the problems of aspiration, increased respiratory infection, and progressively the person who's had just a simple GORD is going to go on to develop other kinds of problems. Now we have the national...
Mark: Yeah, the national health prescribing authorities saying, "Please get people off these drugs."
Andrew: Isn't it interesting? I love this. Love-hate. I can still remember reading MIMS when...forgive me. I can't remember the generic of Zantac, ranitidine.
Andrew: When ranitidine first hit the market and it was a statement in MIMS, "should be used no longer than 6 to 8 weeks.” And yet over time this convenience, and this is where I get back to the patients are driving this, "I want a pill. I don't want to change. I just want you to change me. I want a pill."
Mark: So there is a strange aspect to this though. People know they're not better, but they're not bad enough to keep seeing a doctor or keep seeing anyone else.
Mark: So when you ask people, "Yes, the doctor put me on antidepressants which helped enough for me to not go back to the doctor," or, "They put me on pain relievers which helped," or, "They put me on ranitidine or they put me on..."
Andrew: Or a stent.
Mark: Yeah, Nexium is a very, very popular one these days. Very potent acid suppression. And of course, they work. Why are drugs trialled? They're trialled to do a job, but when you look at the long-term for something like Nexium, you have to treat 24 people to get one benefit in the medium to long-term.
Yet every doctor will say, "Well, everybody gets benefit in the short-term because it stops the acid production," but the cost of acid production stopping is poor digestion, dysbiosis. You get a whole cascade of events and you pay for that down the line.
The doctor's failure to think about “Why would acid just suddenly become part of this. Is there a dietary component to this? Is there another way of thinking about this?” That's the failure. Ranitidine or Nexium or any of the brands that you like...
Andrew: Yeah, the -prazoles. Yeah.
Mark: ...they work so well that they do not ask the second question, and we all just tend to forget that. The best practitioners that I know of ask to see a person when they're through their particular problem. So, okay, the acid suppressant is working. You no longer have the GORD. Now, what's going on? And if you ask that other question, you work your way down the dysbiosis.
I get a chance to use stewed apple or with probiotics and saccharomyces. Every doctor will have, or every practitioner who thinks about it, will have their way of going that extra step to take the load off. What does that do? Three months later, the person's never needing Nexium again in their whole life. You control the process by giving a person a way back to a level of stable normality. The brain's not a dummy.
It does take time. The longer you've been sick, the more the brain almost fossilises into this way of thinking, "That stress ain't going anywhere any time soon." And so you put people on diets who've been sick with gastrointestinal post-antibiotic stressors on the gut for 10 years, it can take a whole year to get them better. You get kids that have just had a few courses of antibiotics and are starting to run into all these problems, and you find that three months of treatment, and they are basically back on their way to normal health again.
Andrew: Okay, but then you've also got the issue of if a doctor decided to go outside of the accepted guidelines, the College Guidelines for Disease, and instead chose to support the physiological reasons for the symptoms.
Andrew: Then, would they be not be considered to be flouting the guidelines and open up themselves for legal…?
Mark: I think doctors have to make their choices about what they do. There is a value of high turnover medicine in multi-doctor medical practices, no continuity of care, get the disease, or the illness, or the symptoms under control and move the person on. There is also a place for the integrative, thoughtful approaches which ask the questions and go back in detail in the history. I think they're two different jobs in medicine.
And in many ways, integrative medicine is almost the wrong word. I think that there is a group of doctors who are saying life is more complicated than just the antibiotic treatable respiratory disease. And if we understood what that was, we may be able to do something deeper and stop you turning up to the doctor over and over. That's a common request from mine, "Why is my child getting six or seven or eight infections? They get better with the antibiotics, and then they're sick again with the same thing."
Nearly all of those are this group of Lewis non-secretors. There is a failure of one part of the mucus production system to produce the anti-adhesion molecules. You can pick them out. They're 15% of the population, and every doctor will tell you 85% or 90% get better with antibiotics. This rotten little 15% get worse.
What is it about a Lewis non-secretor? You go back over that and you say, "Well, it's an anti-adhesion." The way to manage infection is in fact with probiotics, competing organisms that can adhere better than the pathogens that are there. The others do well with antibiotics but eventually get a dysbiosis if you don't do anything about it.
So I come back to examples like that. Yes, we have to do our medicine. Every integrative doctor, we have a first priority of being a doctor, according to our training, doing the things that are evidence-based for the care of our patients. I believe we have a second obligation which is to ask the question “Why?”
And that opens up a bit of a hornet's nest for most doctors. It means time, it means paying attention to the history, finding out what happened a year or two before a person became unwell, and not wasting time, and effort, and energy on people who are going to get themselves better if you do absolutely nothing.
The College of GPs does not demand we drug-treat particular things. When you get to disease states, there is an obligation to not fail the person in your healthcare obligations. Right? We have a job to do. And no doctor, whether they decide to verge into homeopathy, integrative medicine, herbs, or anything else, loses that obligation. So we are first and foremost what we were trained to be, but then an obligation from my perspective for a doctor is to say, "And why? Why this person? Why this person?" over and over.
Now, I can make an argument. At that point, we should be handing off and talking to naturopaths, Traditional Chinese Medicine practitioners. We should be looking for other ways, but I don't have enough expertise in those areas. I can deal with diet, lifestyle, nutrition, there’s the areas that I'm trained in, environmental medicine and toxins. But we need that partnership between doctors and naturopaths, which keeps getting blocked at the level of AHPRA. Who do you refer to? An insurable person. Are they the best person?
So a little bit of our problem at the moment is I can reasonably refer a person to Traditional Chinese Medicine, chiropractor, or an osteopath out of the whole range of complementary, alternative, integrative, other approaches. That's not great for me, so I have to learn enough to be able to provide advice to a person on where else they could look. There are great naturopaths around. There are terrible naturopaths around.
Andrew: There are great doctors around. There are terrible doctors around. Accountants, mechanics.
Mark: Yeah, and the ability for our regulators and ourselves to pull ourselves together to say, "Here's what teamwork looks like." You have people talking the same language. Evolutionary medicine is one of those opportunities that the doctors don't know everything. We know how to stop the disease, but when we get people away from the edge of disease, providing health is not something that we were ever trained for.
Doctors hardly even know what health looks like. We really, really don't. We keep on trying to give statins to people who don't need it and failing to give it to people who do. There are treatments that work, and treatments that become, if you like, trendy and doctors just progress with those.
Andrew: Doctors are almost like the archetypical IT specialist. Nobody sees you unless there's a problem.
Mark: Yeah. Well, doctors have one additional problem, and that is as an IT specialist who produces a programme that's going to bugger up down the line. So a lot of the drugs we use work short-term and create business down the line.
Andrew: The perfect drug.
Mark: What I'm really arguing for is, think before there is a drug prescription. There's much more of a tendency now for doctors to say, "No, antibiotics will not help, and they may do harm." The best thing of the whole Microbiome Project is that we're paying attention to the gut for the first time. Whereas, before doctors would argue, "Oh, how much harm could it do? We use antibiotics all the time." That's a failure of thinking, to say, "If I don't see the problems, then there are no problems." The problems are of a different type. You give an antibiotic for the throat, the person comes back with irritable bowel syndrome or inflammatory bowel disease. And the worst case, you don't see them as linked, and the doctor's experience is too little to do that.
So cover the gut, cover the nutrition, cover sleep, cover the things that in lifestyle are going to contribute towards health or ill health. Allow the brain to be unstressed by being clever about what we check for. What are the drivers of inflammation? What are the drivers of irritation? What makes a person poorly nourished?
I see people who are deficient in nutrients that they should not be deficient in. People with tingling of the fingers and toes whose B12 levels are terrible, yet they're eating meat all the time, and nobody thinks to ask, "If you're eating meat, why is your B12 low?" What they do is jab a person with B12 and say, “Well, that'll fix it." But if you are a meat eater with that, you either have pernicious anaemia or you've got inflammatory problems in the gut.
Mark: Go back that way. It doesn't open a hornet's nest. It means there's simple advice you can give to get people out of having the diseases later on.
Andrew: An oncologist that I've spoken with absolutely abhors the word integrative medicine, preferring instead to use the word supportive medicine, because all of the things that are used—exercise, dietary changes to include a heap of vegetables, and some judicial supplements where evidence suggests there may be a benefit.
I just wonder if part of our really big problem with what we want to be accepted as, is the frameworks in which we choose to label.
Andrew: We need to think more about the labels that we give things.
Mark: I absolutely agree with you. How your mind thinks about something, how you separate off from other groups. “We are integrative doctors, you know, we're not just your ordinary doctor.” Every doctor from the Hippocratic version of medicine should be an integrative doctor. There is no other doctor. We have decided to go “dolour, tumour, calor, rubor," the kind of Roman way of thinking, if it's not there to cut out, puncture, or drain, or give some drug for, then it's not of interest to us.
Now we're growing back again to say, "Oh, hang on. Diet, lifestyle, microbiome, all of these things are important." It seems like a big tsunami on the other side there that we've got to relearn. But it's not learning. It's hooking up with other people, whether they're dieticians, nutritionists, whether they're naturopaths, hooking up with the literature, which is emerging on the microbial benefits on the gastrointestinal tract, learning about oxidants and antioxidants.
Yes, like everyone else, we have this vitamin C is an antioxidant. Vitamin E is an antioxidant. We had a very clear division, and it was wrong. I absolutely agree with you. However, those oxidants, pro-oxidant, the electron transfer is a signalling system that convinces the body to go in a particular direction, so it escalates up to have a biological effect. It works but it's not the reason that we thought it was.
Andrew: Yes, that's right.
Mark: And so playing with molecules of life, which are vitamins, nutrients, foods and the like, rather than molecules we've put into a laboratory just has a higher likelihood of no consequences down the line. It doesn't prove it. You can still get terrible outcomes with St John's-wort. You could terrible outcomes with any herb. Have one the other day where all the drugs work okay, but all the herbs have a very aggressive inflammatory skin rash response, and the person said, "But I'm going natural." You have to say natural is not the world.
Andrew: There comes a time when you need to intercede.
Mark: Yeah, and you break that chain, and then you work backwards to say, "Now, that's interesting that all the herbs would do that. Let's understand why."
Andrew: Yes, that's right. And I think that to me is the biggest reason. And where, I've got to say, it sits with me being a nurse, like, I don't have this... I have a distrust, but it's more of the marketing. But I don't have this avoidance of the use of pharmacological therapies. I prefer to say, "Well, why can't we optimise that use so that it has the maximum benefit and the minimal detriment i.e..."
Mark: And also probably the shortest term of use as well.
Andrew: Oh, that'd be nice...
Mark: So a lot of these drugs...
Andrew: ...but some people will be on it for long.
Mark: ...you can build a person back towards a salvageable state by a two-month course of treatment or a two-year course of treatment. The problem that a lot of us have as doctors is, once something is working, we leave a person on it until something else breaks. And that's not thinking in any evolutionary way, that's just saying, "Oh, the chewing gum in the diet there has actually stopped it. That'll be okay."
Andrew: Chewing gum is therefore for broken diets.
Mark: That's right. And so when it bursts again down the line, we think, "Wow, what happened?" or, "What went wrong there?" And we forget that the Spakfilla early on was only a temporary thing. Medicine gets you back from the edge, puts you back into a state where it's reasonable now to ask the questions about why. No one needs to ask about a car accident. If you bust your bones in a car accident, evolutionary medicine is just, “Yeah, bones break."
But if you have developed something which has progressed over a number of years to a disease state, there was an adaptive point in the middle there. And understanding that is the next new link between what we think of as naturopathic medicine and what medicine thinks of as preventative medicine.
And if we can meld those together, I see a combination of practitioner's knowledge and tradition as being a very valuable thing for understanding evolutionary medicine. Evolutionary medicine is all about the herbs, all about the nutrients, all about the food in the environment. And medicine's discovering it again as if it is a new form of medicine.
It's sitting in plain view from the very practitioners that we would love to have better qualified, better standards, the naturopaths having registration where we can refer people on, and having standards of education which are a step higher than they have tended to be in the past.
Mark: It's just an unclear podcast, isn't it? So I apologise in advance.
Andrew: But I look forward with bated breath to the day where you say the words, "I prescribed a herb at this dose."
Mark: I do hand over to people who know what they're doing. Once I know what I'm doing, I shall prescribe a herb.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.