Exclusive Dr. Hyman+ Ask A Doctor: Breast Cancer, Peripheral Neuropathy, And More

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Hi everyone. Thanks so much for tuning in to.

The newest episode of Ask a Doctor Anything. My name is Hershel Peretz. I'm the Dr. Hyman Plus Community Manager. And as you guys know, Dr. Hyman is traveling the world. So of course we're back here with his friend and colleague, Dr. Elizabeth Boham. As many of you know, Dr. Dr. Broham is the medical director of the Ultra Wellness Center in Massachusetts and has done several deep dives for our community. And she was just here for the September episode of Ask a Doctor Anything and we enjoyed her being with us so much. So she's back with us again.

So welcome, Dr. Broham. Thank you, Rochelle. It's great to be with you and everyone.

So thanks for having me again. Of course, we love having you here. So we're ready to get started. So let's go ahead and ask you our first question. So we know this past July you spoke at the Endocrine Disrupting Chemicals and Women's Health Symposium. What was a hot topic at this symposium and what do you think needs additional attention? Was there anything that you feel like was mentioned there that maybe people don't know about?

Yeah, you know, I was, I felt so honored to be asked to be a part of this symposium. So the US Department of Health and Human Services Department of Women's Health put together this symposium, which was a great idea to discuss endocrine disrupting chemicals and how they're impacting women's health. And so I was so excited that we were putting a, you know, a spotlight on this. And it was a bunch of researchers that came together and then a few clinicians like myself to talk about how endocrine disrupting chemicals are really impacting women's health. And so my focus was on breast cancer since, you know, I talk so much about breast cancer. So that was that was the area they asked me to speak about. and, you know, we talked about how endocrine disrupting chemicals can influence a woman's risk of breast cancer. So endocrine disrupting chemicals include things like parabens, phthalates, BPA, you know, we've heard so much about in the hard plastic water bottles or plastic, you know, parabens in your moisturizers, phthalates in your fragrances and other plastics. And these, these The chemicals are pervasive in our environment, unfortunately. And we are learning how much they impact our overall health and women's health. My talk, I divided it into four parts. And I talked about exposure, timing of exposure, genetics, and lifestyle. So for exposure, you know, we all want to decrease our exposure, right? So we're paying attention to that. We're trying to have less exposure whenever possible. can sometimes feel overwhelming because we're always learning about new chemicals and it's in everything, but we always want to try to have as less exposure as we can, right? Switching to glass, not heating in plastic, not drinking from plastic, not storing food in plastic, looking at your moisturizers and your makeups and that sort of thing, making sure they're paraben free. So we want to lower exposure. But one thing that I think is showing in the research and a lot of people don't realize is that timing of exposure is critical. And so if we have exposure, where they're showing that when people have exposure early in life or at critical stages in life, so maybe even in our prenatal years when we're in our mom's belly or during puberty, that exposure in some of these critical times in our life can have a huge impact 50 years later. So sometimes women get frustrated and they're like, I haven't been drinking from any plastic and I'm trying so hard, but unfortunately sometimes the exposure was when we were a fetus or very young or before anybody knew that these products were so bad for us. And there's not a linear relationship like there is with a lot of other chemicals. Because they influence the endocrine system, they can influence the endocrine system at the receptor or how the hormones work or how the hormones break down. There's so many ways that they impact the hormones in our body that there doesn't seem to be this direct linear relationship like that occurs with a lot of other chemicals, right? Which means that even small exposures at critical times in our life can cause some changes. Like, for example, can cause some changes in our breast tissue and then make our breast tissue more likely to develop cancer when we're 50 or with some other chemical exposure. So it's unfortunately so much more complex than we'd like it to be, right? It's not as easy sometimes to completely say, okay, now I'm safe, right? But we want to do the best we can. So the next two areas that I spoke about were genetics and lifestyle. So genetics, you know, we really focus on this all the time in functional medicine. We know that there are these high penetrance genes and low penetrance genes. High penetrance genes are things like BRCA. When somebody has a gene like that, it increases the risk significantly. But there are low penetrance genes that we all have variations in. And that's something we're always testing for at the Ultra Wellness Center. We're always looking for these genes that lots of us have variations in. and when they come together in a certain way, they can influence our risk. The other thing to really realize about these genes, both high and low, is that our lifestyle has a tremendous impact on how they express themselves. So it's not just like, oh, you've got this gene, you're stuck. When we do certain things that can influence how those genes express themselves. And in an area that I spoke also about in lifestyle, was the importance of phytonutrients. Really dynamic, dynamic study showing that came out a couple of years ago showing that phytonutrients, so those components in your plant foods that we talk about all the time, right? You know, everything from the glucosinolates or the lycopene, right? These phytonutrients can actually block the harmful action that these endocrine disrupting chemicals can have. And they've shown how that happens on a cellular level. So the one thing that we're always talking about is, you know, choosing organic and getting as many phytonutrients in your day, right? That's when you say, okay, we're gonna eat from the rainbow, we're gonna get eight to 12 servings of colorful plant foods, fruits, vegetables, spices, teas, coffees in your day. And from a wide variety of colors, because that's gonna really help prevent some of these toxins from having negative impact in the body.

Yeah, that's actually so helpful and I'm so happy that you shared all of that information with us. I know that this is something that that's definitely on my mind. I think as many of you guys have heard in the past, you've helped my mom with her breast cancer situation. So I'm always looking for more information on this topic and just what kinds of things are important to keep an eye out for both myself and my daughter and my family and all that. So thank you so much for all all that. I also know that you recently had a, is it cancer free anniversary? I believe it was like 24 years. So congratulations to you on that. Yeah.

Yeah, 24 years. It's exciting. Thank you very much.

Amazing. Amazing. So thank you so much. All right. So our next question is, why are we less tolerant of equilibrium changes? So let's say, like roller coaster rides. And is there anything we can do? as we're getting older to improve this, we had a community member who said that, you know, she's kind of working on handstands and various movements, but she recently got on the carousel with her kids and, you know, was feeling super dizzy. I can relate to this. I feel like the older, you know, I'm getting, I normally would be fine on roller coasters. And I was on the carousel recently with the kids and was like, oh, this is a little too much for me. So what's going on with us?

I know, right? So I'm the same way. I am very motion sensitive, so I definitely relate. But good for that community member doing those handstands and putting the body in different positions. So one of the things we know about our equilibrium or how we sort of navigate the world around us is our senses, our vision and our inner ear are really important for us to, you know, our bodies to figure out, you know, when we're upright and when we're sideways and when we, you know, when things are getting disturbed or are alignment is out of order. So we have these senses, our inner ear and our eyes, and they make sense of the world. And what research has shown is that as we, you know, as we, when we're children, the pathways between the senses and our brain aren't as strongly established. And so sometimes kids have an easier time on amusement park rides because they haven't that whole pathway, their brain learning has, isn't as ingrained as it is as we get older. So as as we get older, the eyes and the inner ears really know, okay, this is what's supposed to be happening. And oh no, it's not happening. And so when there's quick movements, there's this mismatch between what our bodies think should be happening and what is actually happening. And so of course that can cause things like nausea and dizziness and even vomiting. And so it's those unexpected movements that can happen with amusement park rides. interesting, I also, you know, was looking a little, you know, doing a little research on this. There's some research that says that as we get older, that our senses become less attuned. And so it's possible that, you know, in later years, when we're, when we're going like 70s, 80s, 90s, we may actually become more tolerant again to some of this motion. And there's been some studies that show that older adults will do better on cruise ships because they're not as sensitive as they maybe in their middle life years. So we have an easier time when we're young and maybe even as we get older. There are a few things we can all do. We know that when we're dehydrated, we're more sensitive to motion. So staying well hydrated, avoiding alcohol at the amusement parks, getting enough sleep, avoiding too much caffeine, all of those things can help our you know, how sensitive we are to the motion. And there may be something to the fact that this community member is doing all these handstands and inversions and stuff like that, that that may do it, you know, trying more amusement park rides over time, our body may get more comfortable with them over time and we might get we might have less symptoms over time. So it is good to keep keep, you know, putting our body in different positions within reason.

Yeah, definitely. So, so interesting. I think that the same sort of idea applies to sort of like, you know, car sickness and sort of motion sickness on boats and whatnot. I know that's something that my husband has, you know, was never dealing with any sort of motion sickness on a boat and then suddenly kind of got to his, you know, 40s and all of a sudden he's just, you know, very, very sick on boats. So, yeah, I guess it's sort of the same idea, right? Right.

It's like this, it gets worse and then it might start to get better again for some.

Okay. Well, let's hope so.

Yeah.

All right. So our next question is about food combining. Have you ever heard of the idea of food combining? This community member asked a question that it was first described by the late Dr. William Howard Hey and Dr. Herbert Shelton. What do you think about food combining?

You know, when I was starting out in the field of nutrition, this was actually quite popular. I can remember back when, you know, 30 plus years ago, it was definitely something that people talked about and even tried at times. The idea of food combining is that we should, to help our digestive system work properly, keep our carbohydrates away from our protein, right? So they would recommend, they were recommending maybe have fruit for breakfast and then at lunch have your protein. And really, you know, the science just does not support these claims. You know, our digestive system and all of our digestive enzymes and stomach acid really has the to handle all of the macronutrients together, the fats, carbohydrates, and protein. And in fact, combining foods like that is way better for our blood sugar and that response, you know, that blood sugar response and the insulin response. So I don't recommend, you know, following those principles. And that if you're really struggling from a digestive perspective, it means we need to look deeper. We need to look for things like is there dysbiosis? do you have some deficiencies in enzymes and are there some things we can do to support that? But I don't necessarily recommend separating macronutrients in your meals.

Okay, super helpful. So the next question is about peripheral neuropathy. What is it and what can you do about it?

So peripheral neuropathy is a condition where your nerves, your peripheral nerves, are impacted. And you can have things like pain, changes in sensation, changes in movement. So we've got our central nervous system that includes the brain and the spinal column, and then we have our peripheral nervous system, right? That's like the nerves that go to your feet, for example. And then if you step on a stone, you're like, Ow, that hurts, right? So when somebody gets peripheral neuropathy, it just means those nerves aren't working as well. And that can be the pain neurons or the motor neurons. And as I said, you can get more pain, loss of sensation, sometimes even people will have a lot of achiness at night or they have an ulcer in their foot that just can't heal. And unfortunately, peripheral neuropathy is common. It's very common in diabetics. About 60 to 70% of people with diabetes that require insulin will have damage to their nerves and they will have some neuropathy. so the first thing we can do is we can work on prevention, right? Right? We can work to prevent insulin resistance and diabetes. We can focus on making sure we're eating the whole foods diet, we're balancing our blood sugar, we're exercising, we're keeping our carbohydrates low, we're avoiding simple sugars, that sort of thing. We also really focus a lot on blood flow. Blood flow is really critical because for the nerves to work properly, you have to have good blood flow to the extremities. So when somebody comes in to see me with peripheral neuropathy, in addition to looking for insulin resistance and diabetes, I'm also paying attention to, is there any signs of endothelial dysfunction? That's dysfunction of the inside of the arteries, that cell layer in the arteries that can get damaged or not work as well if there is oxidative stress, a lot of high blood pressure, inflammation, Ages, remember the ages, those are the advanced glycosylated end products that occur when blood sugar is too high and it binds to proteins and it causes these ages which then can increase oxidative stress and inflammation in the body. We also screen a lot for heavy metals because they can of course cause a lot of oxidative stress and increased risk of peripheral neuropathy. And we always are looking at B vitamins. B12 levels, methylmalonic acid, which is a functional marker for B12, homocysteine, which tells us more about B vitamin levels, are really important things that we are looking for, okay, and testing for. And so the first thing we're focused on improving insulin resistance. And in fact, one thing that's important to know is that sometimes people think, oh, I don't have diabetes yet. I shouldn't have peripheral neuropathy. But there's definitely been studies showing that when people have insulin resistance and we improve insulin resistance, we improve insulin sensitivity, we make the insulin work better through lifestyle and everything Dr. Mark is always talking about, right? When we improve insulin resistance, we can see peripheral neuropathy improve. So you don't have to actually have the diabetes before you get the peripheral neuropathy. You might just be on that continuum of metabolic syndrome and insulin resistance. There's also been, from a B vitamin perspective, there's some studies that show that if we give high doses of B vitamins, we can reverse some peripheral neuropathy. Now, it's a high dose. It's like 3 milligrams of methylfolate, 2 milligrams of methyl B12, and like 35 milligrams of a type of B6 twice a day. So it's a lot, and it takes a couple of years, like a year or two to have significant improvement, but for some people, it can make a big difference. As I said, we also are really focused on heavy metals and toxins because they can damage the nerves and cause oxidative stress. So we may give some N-A-C-E or glutathione or even alpha lipoic acid, even capsaicin cream, you know, topical capsaicin cream can be helpful for the pain. So there's a lot that we can do for peripheral neuropathy.

Okay, super, super helpful. I didn't even realize that it could be something that could come up if maybe you're in sort of the pre-diabetic stage.

Yes.

So good to know about that. Yeah.

And it reverses when people get, when people's insulin improves and blood sugar improves. So, so often people will come to see me and they're like, oh, no, it's, I've got it now and it's just going to get worse and worse and worse. But we see Improvement often. It takes work and it depends on the person, but we can see some Improvement. Absolutely.

All right. Okay, good and helpful for anyone that's headed towards that. It's definitely something to consider, definitely even more reason to stay on top of what your insulin levels are and how in your diet and all that kind of stuff and lifestyle.

So, yeah.

All right, so the next question is, what are the best supplements to help induce autophagy? And when should you take them? Is there a 12 to 13 hour period of digestive rest sufficient or do we need a longer period?

Right. So autophagy, and remember autophagy is that process of renewal and recycling. So the lysosomes in the in the cells will come and engulf and get rid of old proteins, old cellular parts, and it's in a process that allows the body to renew and regenerate. And so, you know, we're thinking a lot, okay, what can we do to help improve that process of autophagy and help the body turn over. And you mentioned supplements and, you know, should we be taking supplements? Absolutely. Many supplements can help improve autophagy from resveratrol and EGCG and quercetin and curcumin and berberine have all been shown to have a positive impact on autophagy. We can get a lot of these phytonutrients from foods. so, you know, always remember that, like, eating from the rainbow and getting all your colorful foods, like your resveratrol and your purple foods and the EGCG and your green tea and the. The quercetin in your onions and apples. So again, a lot of, like, plant foods are really helpful, but supplements we sometimes use and can be helpful as well. So absolutely. The question about fasting. So what we know about autophagy is that if we are constantly eating, so let's say we're snacking throughout the day, eating late at night, you know, we're not really giving our body time to fast, we can shut down this process of mTOR, which is really necessary for autophagy to occur. So we definitely want to fast for at least 12 to 13 hours at night. I think a lot of research for this, as well as a lot of other reasons, has supported the benefit of fasting for at least 12 to 13 hours at night and not eating after dinner. I mean, that's like what we can all really do and focus on. And then the question is, do we need to fast more? Right? Should we be doing 16-hour, 24-hour fasts? Would we get more benefit, would there be better longevity? And I think that's where, you know, as a clinician, I really focus with patients to individualize this and create balance for them. And so, you know, you want to think about, okay, listen to your body, because we want to activate these pathways of renewal, but we don't want to put too much, like there's this balance between stress and too much stress, right? So we don't want to overtax the body for some people long fasts. they may be they may start to get tired or they might impact their adrenal gland or they may not be able to get enough protein and phytonutrients in their diet. And that's the thing I worry about the most. So one of the things I'll recommend a lot is that people mix it up. So definitely that baseline to 12 to 13 hours at night. And then, you know, you know, mixing it up where you might say, well, maybe two times a week, I'm going to do a 16 hour fast or even for some people, might need it a 24-hour fast, right? But that I don't do it every single day. I'm mixing it up or maybe once a month or once every other month, I do sort of that fasting mimicking diet that Valter Longo has put together where it's sort of a type of a fast, low calorie intake for a period of time, but it's not like you're doing the same thing every day. So I think mixing it up here is really helpful and of course listen to your body. and pay attention to your protein because if you're not getting sufficient protein and you're doing that day after day after day, you're going to lose lean muscle mass and your body's going to break down. And so that we don't want that either, right?

Definitely. So, so important to make sure that you're looking at your individual situation and not trying to do what you see others out there maybe doing and just thinking, that's what I should be doing as well. So, yeah, absolutely.

And more is not always better. It's crazy about balance, isn't it? We really have to find balance in so many ways. I have people who come to see me who don't exercise at all, and then people who come to see me who exercise a little too much. And for all of us, it's all about finding balance with all of these lifestyle factors, right? Exercise, nutrition, fasting, stress management, sleep. It's all balance is key.

Absolutely. That's something definitely that all the people in our team are constantly talking about is how do we sort of figure out what the right mix of everything is? And I think it's also important to look at what you're going through at that moment in time, you know, whether it's you have young kids and you're not sleeping, it's like maybe this is not the time to be taking on all the extra stuff and then wait it out a little bit. So, yeah, absolutely. Look at your individual situation.

100%.

Yeah. All right. So can you talk about the differences between visceral and subcutaneous fat? What should the percentage range be in these fats? And what is the best way to get it in normal range? Is there a way to test for this?

Yeah. So visceral fat is that fat that's in the abdomen, deep in the belly. So it's actually when they look at CT scans, that it's actually the fat that's around the organs deep inside the abdomen, inside your belly. So that's visceral fat. And that fat has been found to be the most concerning fat when we're talking about risk of disease, right? So those chronic diseases of aging, stroke, heart disease, cancer, dementia, that visceral fat we know is more concerning than the subcutaneous fat. And the subcutaneous fat is that fat that sits underneath the skin. So like that whole, oh, can you pinch an inch? That subcutaneous fat that's right underneath your skin that is assessed often with caliper testing actually is not as concerning as that deep visceral fat. So you ask a great question, how can we assess it? Right? How do we know? So we can do the best ways to test somebody's visceral adiposity or or visceral fat is with DEXA scanning. So the same machine that does a bone density can do body composition. So DEXA scans are really good. And then BIA testing, bioelectrical impedance. In fact, at the Ultra Wellness Center, we just got an in-body scale, which is a BIA, it uses the BIA technology. So we're excited that we're going to start to use that because I think it gives people another assessment of of how they're doing and where they need to focus to improve their health. You can also do a waist-hip ratio. That's a very rough estimate of your visceral adiposity. It's not perfect, but it's pretty good. So when you do waist-hip ratio, you check below the last rib, like that, the lowest rib you can find, and the top of your hip bone, and in between those two places on your body, that's where you put the tape measure. and that's your waist circumference. Okay? And then the hip circumference is pretty much it's over the greater trochanter, which is over your hip, but it's pretty much the biggest area you can get in the hip usually for people. So for men, you want your waist to be less than, and this is a very generic recommendation. There are some populations where we want these numbers to be stricter or lower, but in general for men we want to be less less than 40 inches around their waist or less than 0.9 for their waist to hip ratio. And then if they're doing a BIA or a DEXA scan, their body fat, the percentage of body fat, we want to be between 10 to 20% is a very common recommendation. Okay. We know that greater than 25% body fat is associated with increased risk of heart disease. so 10 to 20 is about what people around there that people have feel is good. And then of that body fat, you want less than 10% to be in the visceral area. And some testing like, like the BIA testing will tell you how much your body fat is in the visceral area or in the belly. For women, you want to have your waist less than 35 inches. less than 0.8 for the waist-to-hip ratio, and typically a body fat between 18 and 28%. Some people will say we can go as low as 17%, and some people say maybe up to 30% is okay, but the typical range is that 18 to 28%. And for women, the research is showing greater than 25% body fat is associated with increased risk of heart disease. And again, of that body fat, of that whatever yours is, less than 10% of it you want in the visceral area. So those are some ways to get a sense of, okay, how am I doing and where do I need to focus?

Okay, super, super helpful. And I'm so excited that you guys have that new, is it called BEIA?

We got an in-body scale, which uses the BEIA technology, which is bioelectrical impedance. Got it.

Got it. Okay. Super excited to see all kinds of information that you can get from that. That's very exciting. So I wonder, like, I wonder what kinds of new cool things that you'll find out from there that'll be helpful in your patient, you know, analysis for what's, like, good for somebody. So be sure to let us know how that goes.

I mean, I think that, you know, I think that so often if we just focus on the scale, right, then we're like, oh, I just need to lose five pounds. But unfortunately, sometimes when we just lose five pounds, if we lose it too fast or we're not getting enough protein or we're not really exercising enough when we're on that regimen, then a lot of that five pounds, I'm just making up five pounds, is lean muscle mass. And so then what happens after that is then our metabolism slows down. And so then our resting metabolic rate is lower and then we can't eat as many calories and it's easy for us to put the weight back on. so it's critical to make sure we're getting enough protein and we're doing enough strength training and exercise when we're saying, okay, I want to work to change my body composition.

And that's what it's about, right? Is the whole body composition, not necessarily just the weight, it's about your muscle and all the other things too. So definitely important to keep in mind.

Yeah, and you know, it's also about like what is our, what is optimal health for each individual person. So, you know, you don't necessarily have to get to that. I threw out a lot of percentages, right? And it doesn't necessarily mean you have to get to that ideal percentage for you to be as healthy as you can be. So each person is different. It's important to look at all sorts of factors such as what's that person's blood pressure and what's their marker of inflammation and what's their insulin level. And we wanna look at all of that to figure out how much they need to move the needle, right? so that's important.

Yeah, definitely. Thank you. Okay, so kind of along the topics of strength training muscle, we know that both you and Dr. Heyman have talked a lot about the importance of strength training and building muscle. One of our community members wants to know if rucking is a healthy consideration for a 55 year old. So what can you tell us about rucking?

Yeah, you know, I haven't done any rucking yet, except for, I guess, back in college in Rucking is when you wear a rucksack that has weight in it. And a rucksack is a type of a backpack, you know, is a backpack that just helps with your body's alignment. So your shoulders will be back and it can help put people in the right spinal alignment. And typical rucksacks have about 20 pounds in them. And the idea is that when you're walking with weight in a backpack, not like a like a, not like you're holding the weight, but it's in a backpack. That's great for a lot of reasons because it can increase the work of walking and, but it's putting the weight in a place that helps with your alignment and can maybe help with with your back and back pain. And so it can help with also help improving bone density and strength and muscle strength and power and improving all of the things without having to like run. And not everybody's feeling comfortable with running all the time or even anymore. And so it can be a helpful way for people to get more intense exercise without the running piece and still get some of those benefits.

So yeah, definitely. This is actually something that my husband picked up recently. And so previously he was using sort of a vest that had weights in it. And what he was noticing was that, you know, whether it was him or his friends when they were using it tended to bring their shoulders in because, you know, there's weight on both sides. And so it was sort of curving in, which is already a problem for many of us because we're at the computer hunched over anyway. So the rucksack was very helpful because it was sort of making you, you know, bring your shoulders back, which is the natural way that we're supposed to be, but just have kind of hunched over over the years. So he definitely loves it and says, you he can see why it would be helpful for better like posture and strength. Um, and definitely enjoyable, pretty easy to put on and, you know, just feels like a little backpack and then you can, improve your posture along the way.

Right, right, right. You get this, the exercise, the more intense exercise and posture improvement. I love it. It's great.

Yes. Thank you. All right. So what is the maximum amount of protein a person can absorb in any one meal sitting? Are there any upper limits of protein intake for one meal? yeah.

So we are typically recommending about 25 to 40 grams of protein in a meal. That's a typical recommendation. Of course, that depends on your activity level, your body weight, your size, the amount of lean muscle mass you have. There's been some conversation about, okay, maybe there's only so much protein we can absorb.

Right.

So some people have said, well, what if we can only absorb 20 or 25 grams with a meal? what the research is showing is that's really when it's just amino acids or just protein. And so we're never really just eating protein, right? So most of the time when we're eating protein, there's fat with it too. Let's say you have a piece of salmon. You know, there's protein and fat, and then you're having it with some vegetables, there's fiber. The fat and the fiber will slow down the digestion and absorption, and so we can absorb a lot more protein over time. when there's food combining going on. So yeah, 25 to 40 grams is a great goal for most people, for most meals.

That's super helpful. I actually think that, you know, I don't know that people always think about the fact that you're often eating the protein with something else and then I didn't realize that that would actually help to kind of slow down the process. So that's true. Most people don't usually just have just the protein. It's usually, you know, something else in there with it. Super helpful.

I guess if you were just having a protein powder in water with nothing else and you're drinking it fast, of course there's going to be a certain amount that the body can absorb at one time. But when you're having a meal, I mean, many of us know that if we have a big meal, you're still digesting an hour later, you're still digesting that food. So that's going to, of course, impact how much you can absorb.

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