Exclusive Dr. Hyman+ Ask a Doctor: Gut Health and Alzheimer’s, Genetic Risk of Disease, And More

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Hi everyone. Thank you so much for tuning into today's episode. My name is Melanie Harrelson and I am one of the producers of the Doctors Pharmacy podcast. I'm joined by Darcy Gross, one of the producers of the Longevity Roadmap docuseries. And we are so excited to have Dr. Elizabeth Boham back to answer your questions this month. As many of you know, Dr. Boham is the Medical Director of the Ultra Wellness Center in Lenox, Massachusetts, and has done several deep dives through the community as well as our AMA episodes. So Dr. Boham, we are so excited.

To have you back for this month's episode. Welcome. Thank you, Melanie.

It's great to be with you and Darcy again and all of the listeners.

So thanks for having me.

So we've collected our Community's top questions and we are here to ask you anything. So let's get started with the first question. So we had a couple questions about lipoprotein A from our Community members. So the first one comes from a member who had a blood test that showed he had high lipoprotein A cholesterol. His doctor says that it's hereditary and put him on a statin to lower it. So his questions are, should he get an annual LPA cholesterol test to monitor it? His doctor said that it's a once in a lifetime test to see if you do have it, is that true? And then he also read that niacin supplements can lower Lp cholesterol, is that also true? And anything that he can do to lower it? And then I'll ask you the second one after that.

So right, so lipoprotein little A. So that's, we say lipoprotein little A, so it's the word lipoprotein and then this little A afterwards in parentheses. But that's a lipoprotein that floats around in the bloodstream and it has been found to be a risk factor for vascular disease. So high levels of lipoprotein little A has been found to increase risk of heart disease and stroke. And it's an independent risk factor, meaning that it's independent from other cholesterol levels and other risk factors for heart disease. So there's a lot of different biomarkers we look at when we're trying to determine what somebody's risk is for vascular disease. and one of them is the lipoprotein little A. So it is largely genetic. The reason that you have a high level or a low level is largely dependent on your genes, and it's really hard to move with lifestyle or even supplements or medications. And there's some that do, and we'll talk about that, but it is a very fixed number. It doesn't move around a lot. That's very different from other markers like your cholesterol levels or your LDLP or particle numbers of cholesterol. or your insulin levels or your blood sugar, all of those markers are more easy. We have an easier time modulating them or improving them when we add in lifestyle change. And this marker is a lot more stable. So what his doctor, what this person's doctor is saying is true. Often you only test it once and if it's high, it influences how you treat or what other tests you do with a person. So it doesn't mean that everybody with a high LP little a or a lipoprotein little a is at high risk for heart disease, but we use it in addition to all the other tests that we do to determine what somebody's risk is. And typically if it's, we want it less than 125 nanomoles per liter. If you're using milligrams per deciliter, you want it less than 50. But most labs are using nanomoles per liter now. We know it's a very pro thrombotic, and it causes more, inflammation and clotting and coagulation in the arteries, and that's why it can increase risk. And so we use it to kind of determine if people are at higher risk for heart disease and if we wanna do additional testing or treatments. We do know that some things can lower it. Niacin can lower it a little bit, 10, 20%. For a lot of people, that's not enough, but you know, one to three grams of niacin. We know the PCSK9 medication that is now being used to lower cholesterol actually does lower lipoprotein little A by 20 to 30% or so. Statins do not lower lipoprotein little A. In fact, like Lipitor and Crestor, in fact, they might even increase it, but it's not felt to be a It's still felt, statins are still felt to be protective in those people that they're necessary to be used for. So typically we just test it once, unless we're doing something, we're adding something in to help lower the level, like the niacin, CoQ10 might help a little bit, red yeast rice, ground flaxseed, but in general it doesn't move around very much.

Okay, so those two particular supplements and then you were saying the statin doesn't really lower it, but there was another medication you had mentioned that the PK?

The PCSK9 medications, they're a group of medications that are less commonly used now, but they're newer and they're being used to lower cholesterol. So for some high-risk patients, they're being used and they do actually lower the lipoprotein little a.

Okay, got it. So the next question, she had asked about non-genetic Lp, but maybe this isn't totally accurate since you're saying it is genetic. But she was wondering, does Lp become elevated in menopause and stay elevated even with hormone replacement therapy and are there natural ways to lower it? Is there, yeah, what are your thoughts on that?

There are some things outside of genetics that can influence the level to some extent. So we do know that for some people it increases for some women when they go into menopause. And if your thyroid is under treated or if you have hypothyroidism, that may cause your level to be elevated. And if we add in some hormone therapy, whether it's estrogen therapy, thyroid therapy, testosterone therapy, sometimes that will lower the level 20 or 30% or so for some people. So there are a group of people where we do see an increase with those hormonal shifts. Okay.

But the same thing as before, you would lower it with the two particular supplements and potentially that medication, right?

Yeah, same situation. We do use niacin, CoQ10, red yeast rice, those supplements to help lower it. But for some people, it doesn't make a big difference. So I think a lot of times patients will be like, oh, I'm so frustrated. I can't get it to come down. And we know that for those patients, it's largely genetic. There's not a lot they can do for the lipoprotein little A in terms of getting it to come down sometimes. if it's large, it can be largely genetic.

Okay, awesome. Thanks so much. All right, Darcy, over to you.

All right, kind of switching gears on this next question. So this question comes from a community member who wants to know about GI issues and Alzheimer's disease prevention. So they have a couple of follow-up questions, but I think let's just start off with, is there a connection between the health of your gut and Alzheimer's disease?

Yeah, absolutely, there's a connection between the health of your gut and Alzheimer's disease. When we're looking from a functional medicine approach, when we're working with patients to either decrease their dementia that they have going on or prevent it from happening, we are looking everywhere in the body for sources of inflammation because we know that inflammation can trigger and contribute to dementia and/or Alzheimer's disease. So we do pay attention to the gut. There is a connection because the gut, if it's out of balance, that can be a source of inflammation in the body, absolutely.

Yeah, so that makes sense. So kind of a follow-up question to that is regarding gut health. So specifically, methane-dominant SIBO. So the question is, is methane-dominant SIBO a chronic or recurring condition, And then if so, what's recommended long-term diet for this condition?

So, methane-dominant SIBO or intestinal methane overgrowth or overgrowth of methane production because of bacterial overgrowth in the small intestines. So that's what SIBO is, is small intestinal bacterial overgrowth. and you can have either a methane dominant picture or hydrogen dominant picture. Typically when people have a methane dominant picture where they are producing a lot of methane because of certain bacteria in the small intestine, they may have more constipation and definitely bloating after a meal. I think with all bacterial overgrowths in the small intestine, there are times when they can become a chronic condition for somebody, but other times where it happens, we treat it and it goes goes away. So I think there are sometimes it's recurrent and chronic, but not all the time.

Okay. And is there a connection between SIBO and Alzheimer's?

You know, that's a great question. Like, is there a connection between this either bacterial overgrowth, methane predominant bacterial overgrowth and Alzheimer's? I haven't seen research to show exactly that, but anything that increases inflammation in the body could contribute for some people to to an increased risk for dementia. I mean, everybody's different, right? So, but when there is increased inflammation in the body, depending on your other risk factors and your genetics, that could increase risk of something like dementia in one person. But somebody else that might increase risk of rheumatoid arthritis or somebody else, depression. So, it's many things coming together that influences risk.

Yeah, interesting. Okay. So on a similar note, for somebody who has a double APOE4, and maybe we can start with an explanation of exactly what that genetic result is, what would be the best diet for somebody who is positive for a double APOE4 carrier?

Right. So there are many genes that we're looking at, that can influence risk of multiple different diseases. So the APOE4 gene is considered a low penetrance gene. So that just means that it can influence your risk, but it doesn't mean that if you have it, then you're going to get the disease. So a high penetrance gene is a gene, something like the BRCA gene for breast cancer. When people have that variation, they have a high risk a much higher risk for getting that disease. The APOE gene, when people have an APOE4, they have an increased risk for dementia, but it's not as high of a penetrance. It doesn't influence the risk as much as some other genes could. But it is something we look at because we can influence the expression of this gene through lifestyle. So it is often a gene that's on a lot of genetic panel testing. that we do. So the ApoE4 is definitely a gene where, or the ApoE gene is a gene that we're often looking at. And when people have an ApoE gene variation, you know, they are, there, you can be an ApoE2-2, an ApoE2-3, an ApoE3-3, an ApoE3-4, or an ApoE4-4. Oh my goodness, those are all the things that people, you know, those are the different categories that people can be in. And the ApoE3-3 is the most common variant. That means half of the population has the ApoE3-3 like if they were tested over half of the population. And the APOE 4/4 is much more rare, but it has been shown to be associated with an increased risk of dementia. And doesn't mean that person's gonna get it, but they have a higher risk than somebody who's an APOE 3/3, for example. So for those patients, we work really, we make sure they don't have signs of inflammation in their body, right? We work to make sure that everything they're doing in terms of their lifestyle is right on track so they don't increase their risk of getting dementia. In terms of diet, the diet that's been the best studied for people with the APOE4/4 in terms of lowering risk of dementia is the MIND diet, which is a variant of the Mediterranean diet. And so that good old Mediterranean diet, which is really a whole foods diet rich in omega-3 fats, so fish oil, flax, walnuts, right, that are rich in omega-3 fats, and a nice balance between vegetable and animal sources of protein with a lot of phytonutrients in it. I mean, that's the major diet that we go to for people with the APOE 4/4 variation. The other thing we do is we work to get their omega-3 levels really on the higher end. So we do the omega-quant, which is a test that tells us the percentage of omega-3s in the red blood cell membrane. And the goal for the Omega-3 index is around 8%. That means you want 8% of their red blood cell membrane to be made up of those omega-3 fats found in fish oil, ground flaxseed, right? And with people with the APOE4/4, we might push it more toward 8 to 12%, right? So we definitely want it on the higher end.

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Practice at the Ultra Wellness Center, my work at Cleveland Clinic and Function Health, where I'm the chief medical officer. This podcast represents my opinions and my guest opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only. It's not a substitute for professional care by a doctor or other qualified medical professional. This podcast has provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner now. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their Find a Practitioner database. It's important that you have someone in your corner who is trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.