The Real Causes of Autoimmunity in Women with Dr. Sara Szal

I'm someone who's in recovery from disordered eating. Having a score of 1 or higher on the adverse childhood experiences test is associated with a greater risk of autoimmune disease. I've got this genetic predisposition that sets me up for looking to food to change my state. And then you combine that with an adverse Childhood experience score of 6. I found that I had a positive antinuclear antibody and this was after going through prophylactic mastectomies for a gene mutation and I was able to convert my positive antinuclear antibody to normal.

Today I have Dr. Sarah Sall. She's a physician, researcher, educator and advisor. She graduated from Harvard Medical School and MIT and completed residency at ucsf, but is more likely to prescribe a CGM and personalized nutrition and supplement plan than the latest pharmaceutical. Dr. Gottfried is a global keynote speaker and author of four New York Times bestselling books about hormones and health. She is a clinical assistant professor in the Department of Integrative Medicine and Nutrition Sciences at Thomas and Jefferson, Thomas Jefferson University and director of precision medicine at the Marcus Institute of Integrative Health. Her focus is at the interface of mental and physical health n of 1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes. Previously, she has served as chief medical officer for health tech companies and currently is on the board of the Academy of Integrative Medicine. Welcome to the show. Dr. Sarah Azzall. What's important to me is my patient population 100% women. And that's basically I've taken care of since my career started in oncologic reconstruction. But why do women have so many specific issues with autoimmunity?

It's a critical question. I don't know that we have the answer. Rob I feel like hormones are a big part of the story. I think that there's the way I try to divide it because I like to keep my mind organized around this is sex differences. So differences in estrogen, progesterone, testosterone and then differences that are gender differences and those are more socially constructed. So the way our culture conditions women maybe conditions them into a place where boundaries are more difficult to hold because I think autoimmunity involves boundaries and then I think there's also I would put this under the sex difference. I'm getting increasingly interested in in the role of mitochondria and how mitochondria could be part of the story when it comes to autoimmunity. And women often take a hit to their mitochondria in different ways than men do. Like, especially with pregnancy, postpartum and then with the change in estrogen that occurs in women around age 40.

And I was this. You just made me think this. I have a lovely daughter, went through puberty and the changes that are accompanied through the differences that, you know, had a son and a daughter, wildly different in terms of changes because of their sex hormones and the reactions and things that were. They're quite shocking. So, like when you talk about the changes and the differences not just later in life, but you're early in life too.

Yes. Yeah. Puberty, that's when there's a huge change in terms of hormones. Now they're driving what we're interested in, how they drive biological processes. Completely different.

Yeah. And it's not Gabor, mate, but somebody else said it was him. He said, yeah, even if you're raised by the same parents, you're not raised the same way.

It's a different experience for sure.

Yeah. Because this is different between my son and daughter, you know, totally different. Especially at this stage and everything back. And I'm like, oh my God. You know, she came home and walked upstairs and came and gave me a big hug and just started crying. Never said a word to me. I was just hugging me really tight and crying. I asked her what's wrong? Wouldn't answer me. And my wife comes upstairs and I look at her and she's like, I don't know.

Yeah. How old's your daughter?

She's 17. Yeah.

Yeah. That sounds like a pretty normal experience with a teenager. I mean, I've raised two daughters and I've been taking care of women for 30 plus years. So I would say that sounds pretty squarely in the normal range.

It highlights exactly what you said, though. Like, it's very different and it starts very early. That's why, like, I always try to go back to, like when I interview my patients who've expensed it, I asked them, it's like, oh, you know, what in particular got you interested in the physical appearance or what shaped that or. And I know you talk a lot about things in childhood that are adverse experiences that affect behavior. And certainly these hormonal changes affect behavior and then media and social media and all the things now contribute to. It's a lot of stress in general.

It's a lot of stress. And you know, when I think back to my childhood, this was. I was born in 1967, so I'm Gen X and I think you're Gen X too.

Yes, I'm 69. 60.

69. Gotcha. Okay. So, you know, there was this really great understanding about what women experience called the PD myth by Naomi. I'm blanking on her name because I've got crs. Can't remember stuff.

Gotcha.

So the PD myth, and she talks about how this way of trying to keep women in thin bodies to look a certain way, to look very youthful, you know, basically to look like a busty adolescent for as long as possible, for decades. That was really the culture that I.

Grew up in, from the 50s. That started in the 50s, for sure, the 50s.

I mean, the 60s when we had Twiki and, you know, sort of this thinner phenotype. But it's a way that our culture tries to shape the female body and objectifies women that is very hard to fight against. And I think it's what Mamie Wolf there. I got her last name. What she talked about was that it was basically a political sedative. It was a way of keeping women small and tractable.

That tracks with the introduction of implants. Is 1962 in Houston. So we're not far from Houston. We're in Austin right now. And Cronin and Giroux placed the first silicon gel implants in 1962. And I went back and tracked, like, the history of the injectables and how all this began and why, just for my own edification, you know, because it's not something, you know, you went to med school and they taught, you know, in the curriculum. It was very specific. And then you got into your discipline, and then that was super specific. But the history of that discipline probably wasn't very specific. In plastic surgery, it's all about the wars and how things led to reconstructive surgery, and then not so much about things that weren't so glamorous, like the problems with implants and the moratorium and things of that nature, or why implants even came into existence, basically. And I did this series briefly about comparing autologous, which is usually in your own tissue, your own genetic material, which is always going to be better tolerated, which you talk about in terms of autoimmunity versus something that's formed, which is never going to be tolerated. So there's no hip, knee, dental, breast, any kind of device ever placed at anybody. That's perfectly tolerated, because that's not a genetic material. That's yours. And so, like Joseph Murray did the first kidney transplant. He basically showed that in an identical twin, you can just take one part and replace the other part. That's not functioning. In that instance, there's a kidney. He also went on to then do the next thing, which is transplanted cadaver kidney. Now that requires immunosuppression because as you're going to highlight for the whole audience, when the soldiers come for you, there's not much you can do. In this case, you need a immunosuppressant and it was steroids and cyclosporine and it goes on and on and on. And that's really because tolerance, or what we tolerate, is our own identity, our own genetic makeup. But when something attacks us, we attack back. Or when our own body turns on us, then we have problems with autoimmunity.

Yeah, I really appreciate this 30,000 foot view of the rise of implants and how that connects to us coming of age and going into medicine. Really appreciate this point. And you know, there are many ways to get poetic about autoimmunity and what happens. One of the ways I think about it, especially since I'm traveling too much right now, is that it's your immune system is like passport control. So it's like you've got this country, that's your body, you've got all these cells that you want to easily get through passport control. So you want to recognize your cells and pass them through the process at, at the border. And what happens with autoimmune disease or the development of autoimmunity, which can be for seven years before you get diagnosed with a disease, is that the system of passport control goes awire and you no longer can tell the difference between these cells that belong to you and these other cells. So border control is the immune system. It's the way that you're supposed to tell your normal healthy cells from these foreign invaders like bacteria or viruses. And if that border control becomes haywire, you then lose this ability to tell the difference. And that's the loss of tolerance as you're describing it.

Yeah, it's so, you know, it's hard to always appreciate all the history because we have a ton to look back on. And autoimmune diseases, obviously, as you know, we're taught, they date back over a hundred years. And I just mentioned an implant, showed up in 1962. Now there were other substances before that, paraffin, liquid silicone, all sorts of garbage that was used to enhance mainly a woman's breasts or buttocks. And. And then we get to devices because I get asked all the time, Sarah, like, did my implant cause me to have an autoimmune problem? And I always Use the same thing. Like I don't know that. But you know, autoimmune problems predate implants by a substantial number of years. So my short answer would be like, I don't think so. But you know, I always talk about genetic presay. Well, nobody can pick their parents. You got this genotype and then there's this set of exposures. And depending on where you live, where you worked, you know, the fluid you drink, the food you eat, the air you breathe, that's a lot. And I'm sure you're going to tell us that a lot of these things start in our gut, which I wholeheartedly believe that's like number one hardest thing to heal along this whole continuum is going to be the gut, which I'm sure you're going to take us there and explain hopefully in detail how our passport system starts to go haywire. Probably right there.

Oh, for sure, for sure. Yeah. There's this three legged stool that's required for the development of autoimmune disease and that's genetic predisposition. And maybe we can riff on some of those, plenty of those predispositions that we're familiar with. And then there's increased intestinal permeability, so called leaky gut. And 70% of your immune system is in your gut. So yes, the gut is foundational to this entire process. And then there's a trigger. And the trigger is where things get interesting. Because for some people that could be trauma, it could be adverse childhood experiences. Having a score of 1 or higher on the adverse childhood experiences test is associated with a greater risk of autoimmune disease. Or it could be an infection, you know, similar to there's classical autoimmune disease and then there's non classical things like long Covid. I think a lot of folks, maybe not you would put breast implant illness into a non classical category. We can debate that. So I think there's these triggers are where things get interesting. Is silicone a trigger? Are implants trigger, I think for a susceptible individual?

Oh yeah, yes, yeah, yeah, of course. Yeah. I have people who basically, you know, they're not like a nut allergy, anaphylactic allergic, but you can tell. Yeah, not for them. And then every single, the, you know, for everybody listening. So every time I take out a device, I did the same thing I would do for the many years I did cancer reconstruction. I always take all the scar tissue out and we always culture it and send it pathology. You don't ever want to miss recurrent cancer. That would Cause the patient potentially their life or you don't want underlying infection. So in 2016, I was explanting a breast cancer patient, just wanted to go flat. And I was not in a hospital. I want to say they had underlying cardiac disease. That's why I was at a hospital and on a hospital where, as Dr. Saul knows, you take a basically like a Q tip and do a swab effect or, you know, you're just rubbing it around the capsule and you send it off and typical, you know, stuff will be like normal flora or too little to, you know, recognize. This came back an E. Coli infection. So this lady had an indolent E. Coli infection for an undetermined amount of time that did not show up on.

Her.

White blood cell count or her diagnostic studies or exam. There's nothing. Zero. I said, cool. How many of these have I fucking missed in my life? Because I feel like I'm pretty astute. I've done this for a long time, right? My sister passed away from breast cancer recently after almost 20 years of dealing with it. But had somebody missed that on her, I would have been incredibly irritated and frustrated and all the things. So she put me on this Facebook group for doing in block capsulectomy surgery. Capsulectomy surgery for breast implant illness. And then I just had all these people start, you know, calling the practice when this done. And I didn't understand what was going on. But what I did understand, what I was curious about, is how many times a device is taken out or somebody had an underlying infection. Because in the cosmetic world, you would not do what I did. That would not be the standard of care because that would incur cost to the patient if that was you. And that's a very sensitive subject in aesthetics. It's all fee for service, it's all cash based. And for everybody listening, I've never taken scar tissue out of a patient or breast tissue out of a patient and not sent it for pathology because that is below the standard of care to me personally. And now I have the largest series of PCR tested explant scar specimen samples in the world. So I published last year a consecutive series of 700, I think 698, 700 that shows that 29% have bacterial contamination.

This is huge. I mean, firstly, thank you for publishing this series. I mean, we need more people like you who are looking at some of the root causes of why people are suffering. So thank you for publishing this.

And this will track with what you're going to tell me about autoimmunity. So if 29% have staph epi and cutibacterium, which readily form biofilms, biofilms like plaque on your teeth that interacts with the O acid and the breast tissue to oxidize it. It causes oxylipin 10 home. There's many oxylipins from the oxidative process. This one in particular goes downstream and causes macrophage polarization which then leads to the symptoms that you're very familiar with taking care of or anybody who takes care of patients with an autoimmune issue like rheumatoid, like something that would give you almost like a, like a pulmonary fibrosis type picture with shortness of breath, difficulty swallowing, like eosinophilic esophageal, all these things that are just really, you know, inflammatory in nature now have a, you can track back to this biomarker. It's there for everybody. You can't put your head in the sand and ignore the problem anymore. So it leads to much of what I think is more poorly understood with the other autoimmune disorders like the standard ones like rheumatoid or even type 1 diabetes or Hashimoto's or something like that. Those I, I'm interested to hear like your take on like why that really hasn't changed since we trained. It's relatively the same like process to me.

The process of understanding how autoimmune disease develops.

Yeah, that to me is still kind of the, it hasn't advanced much like what I just said in a very short period of time is all. In the last eight years I've been trying to figure out the problem. And that's not, that's a surgical problem. That's different. This is, this is a much more complex problem to me because it has so many factors and I know that's, I mean people probably say eh, I should figure it out. But that's why I bring the, I bring Dr. Saul on to explain it.

Well, I, I think there's still a lack of clarity about the root cause. So like with this three legged stool of genetic predisposition. Let me say it again. This three legged stool of genetic predisposition together with increased intestinal permeability or your tight junctions are loose combined with a trigger like that was only understood about a decade ago by Alessio Fasano at Massachusetts General Hospital. And he discovered it with celiac disease, an autoimmune disease, and then every other autoimmune disease he looked at also had this trifecta that was required So I think you're right. I mean the places where I see some advances are more with the non classical autoimmune diseases. So you look at someone with irritable bowel syndrome as an example. There's a subset of people, mostly women with irritable bowel syndrome who have auto antibodies and that seems to be part of the pattern of their disease. You look at women with endometriosis, there's a subset that have autoantibodies. So I feel like we are making some progress. But you know, one of the ways I've had the immune system described to me is it's similar to the varieties of cheese that are available in France. Like the system of your immune system, the way that you develop tolerance, the way that women deal with tolerance differently, you know, another huge sex difference is that women get pregnant and then you've got half the genome of this fetus that you're carrying is not self.

Right.

So how do you not attack it? How do you change your tolerance to be able to grow this fetus and deliver this fetus and then go back to kind of a tighter rein on your tolerance afterwards? So I take your point that the lack of progress is unsettling. Am I surprised to see that in a condition that mostly affects women. No, not at all.

Right. Because the studies have not been traditionally done on women. They've been on men. Of course, that's highlighted all the time with our lack of understanding about many things. What I was going to say, let's go back to genetic predisposition. So this is the next paper I want to publish which is very specific about. And I don't know if you're familiar with this welderly paper that Eric Topol published, but he looked at people who got the 70, 80 and 90 and maybe in the hundreds even. And it's the welderly like the, well, people.

Oh right, yeah, the superagers.

Exactly. So to your point about genetic predisposition, so people ask me all the time, can I tell who's going to get breast implant illness? And of course I can't tell you exactly who can get breast implant illness, but I can give you the genetic profile of that person very easily. And they'll have mutations in the vitamin D pathway, gpx, vdr. They'll have problems with all the different methylation genes and everybody's, you know, always, you know, cleverly talking about mthfr, but that's just one of the many genes, methylation. Totally, totally. And then probably one of the most important pathways that's not really appreciated is our use of the master antioxidant glutathione. So GSST, GSTP1 and then obviously in our antioxidant pathways, SOD2. The only thing. And this affects women specifically right now, to your endometriosis point, those women who are estrogen toxic have really difficult times with metabolism. Oh boy. That is your avatar for this problem. And then you just slap in some stress trauma, mold, parasite, Lyme, and that's your person. They're going to have, as you would imagine, the worst possible time in detoxification of anything. And all the, you know, when you say triggers. Oh, I get triggered when you say triggers because I see all this all the time and it's very obvious. So we submitted study to look at Dr. Topol's population versus ours because if you got to 70, 80, 90, 100, you don't have those problems. You can't, you can't have a problem with detoxification if you get to be that 8. Because if we talk about aging as inflammation, then those people are not experiencing inflammation in the same way that my patient population experiences inflammation because they have superior ability to detoxify what they get exposed to through their air, their fluid, their food, their environment in general.

Yeah. So I love this hypothesis. And as someone who is exquisitely sensitive to my environment with sluggish detox genes, with problems with my vitamin D receptor, with issues with my estrogen metabolism, I'm going to beg to differ. So I think there are ways to work around your genetic vulnerabilities. And I would imagine that some of those, wilderly, those superagers have figured out ways to construct and architect their lifestyle such that they are working around these problems. So I'm going to hold out faith.

All right.

And I would also add HLA DRB1.

Okay. So I always like, especially this discussion I want to talk to, because I know she has an extensive background in genetics that we've talked about in the past as it relates to performance, specifically for NBA players and, and other professional athletes.

This is how we first responded.

That's right. And there's not many plastic surgeons that know as much probably about genetics as I do. But it's not, you know, it's been a curiosity since really the genome project and, and research I did in medical school on retroviruses because I was always just fascinated by, I think genetics is like phenomenal.

It is phenomenal.

And when you see these examples over and over and over now I have obviously an incredibly biased patient population. Like nobody comes to me because nobody really wants to come to me next level. Like nobody wants to come see me to have explant surgery. That's the worst.

Yeah. They're forced.

Yeah, yeah. Everything has gotten to really bad points. So like I have the end of the smallest funnel you can find of bias.

Yeah.

Now granted the welderly population, it took him I think almost a decade to get that group together. Yeah. I could match his group in pain and suffering and inflammation in months, not years because it's very easy once they self select and get to us. But to your point, like you know, once you understand and make some, you know, we'll just say lifestyle adjustments. You take gluten and dairy and sugar and garbage out of your diet and you stop drinking, stop boozing it up and get a, maybe a separate air filter and maybe go for a walk. You know, don't smoke, don't drink. Like basic things, get some exercise. Things do turn around relatively. You know, I don't want to say quickly because that's not going to be the case for everybody. But those are all self starters that don't cost anything.

That's right. Yeah. I like to think of these as the boring basics. They're the base camp for someone who's a mountaineer. So I like to climb the mountain. I like peptides, hormone therapy, biologics. But you've got to dial in these boring basics. And I would wonder, going back to your hypothesis about the wilderly, I would wonder if I would imagine the welderly have those boring basics utterly dialed in. They do. And so they're not eating ultra processed food, they're not having these sort of daily triggers with the way that they're eating. And I think the food that you're eating is such a critical part of this conversation. And so when you've got someone with a problem with the vitamin D receptor and you've got someone who's missing glutathione S transferase and they've got issues with their methylation pathway and you give them the right food, you know, a food plan that's anti inflammatory. If they're getting all the micronutrients dialed in, I think that makes a big difference in terms of their health.

It makes a huge difference. So you live in the Bay Area. I know you have access to great food. So we're in Texas, we have access to great food. We're super fortunate. In our neighborhood where my clinic is, we have a restaurant called the well. And if you've been in Austin.

Oh, I've Heard about this.

You've eaten at the well. The well's gluten free, dairy free, no seed oil. So all of my patients.

You send them there, have.

They're all sent there. And there's a discount code, you know, for my, my practice. But most people don't know you can eat that way. To your point, like, they're coming from different parts of the country. Because my practice is not based here. My practice is from all over this country. And, you know, for everybody, we're in Austin. For those who don't know geographically, that's in Texas. And the entire country of Spain can fit in Texas. So, you know, our biggest asset is our country is phenomenal, but it's also a massive place, which is very difficult and stressful to navigate. But the food part is critical. So, like, I'll have somebody come from. I'm not picking on a specific state in the South. I'll just say somebody comes and they're floored by the fact that you can go eat that way and everything tastes so good and it's so healthy for you.

Right.

And it's, it's, you know, it's. It's sad to hear that, but it's sobering, you know, to hear that because that's, you know, part what you're describing, that's part of the biggest problem, is that what you eat, what you put in, is a big, big trigger that leads downstream to what's going to happen.

It is. I mean, I'm a bioengineer, so I like to look at inputs and outputs. And I would say your food, your nutrition, your sleep, your exercise, waiting.

Good sleep. Yeah, it's my favorite.

These are so important. And it's, you know, I had a mother who became obsessed in the 1970s with Adele Davis. And like, overnight, the Pop Tarts were cleared out of our house and she started serving me, like, this brown bread for my school lunches that was so dense you had to, like, chew it 30 times. And she would make homemade almond butter and put it on. No one would trade lunches with me. Like, I had the most weird lunches. But. But I'm so grateful because I think she set me up to have a microbiome that really supports me. And so to your point, I think a lot of folks don't know any better. They didn't have a mother who was obsessed with Adele Davis. They grew up going to McDonald's, and that was a treat. They're eating ultra processed food because it's hyper palatable. And maybe they're addicted to it. So there's all these other factors that we want to consider, but it's amazing to me what a difference it can make just to make that one change.

Absolutely. That's, you know, we talk and there's constant, like garbage now about too much protein. And so I operate on people for a living. Obviously, I'm the number one generator of cortisol you'll ever meet. And, you know, we had huberman yesterday. I was like, you know, you got to your cortisol up in the morning. Well, I start operating first thing in the morning. So everybody's cortisol goes up, but they see me and we try to get it back down as quickly as possible. The, the big things, though, like, we try to get, you know, the diet on point and we increase protein because that's basically going to flip you into an anabolic state so you can heal. And. And then I harp on sleep. Like I'm the biggest, you know, pain in the ass about sleep with patients. And they'll tell me they. They sleep well. I'm like, really? And actually, I'm, I'm like shocked by how many women get with one night to go pee.

Oh, yeah.

And I'm like, what? And I know there's cortisol involvement and stress and things like that, but they also make a lot of decisions earlier in the day that affect why that's happening. Like, they're, maybe they're trying to not be constipated so they're drinking smooth move tea before they go to bed, or they're trying to get in enough water because they were told by some influencer they need 19 gallons water a day. Some bullshit thing like that. Or they have a glass wine at night to unwind after everybody's went to bed. Yeah, I mean, I just picked those examples. There's a thousand of them that I've heard that. And I tell them, like, some simple things like, okay, like, as a male, if I had a bad prostate, I had to get up and go pee in the middle of the night. That's a physiologic problem, that, you know, problem. Like, as a woman, you don't have prostate. So let's just try to dial down, like, the reasons why this is happening and get, you know, you in a mindset, shift, if you will, to go to bed because you can't recover if you don't sleep. Obviously you're gonna, oh, I can let you, you take this over. But I do this thing where if you can't get your 7 to 9. And then, you know, we talk about some wearable stuff and I get all over people about this because if you come in swollen, you know, cranky, sleeping in the afternoon after surgery, you know, it reminds me of is like when you, we have little babies, like nobody's a baby who comes to see me, so they shouldn't be taking naps in the afternoon. Like if they get enough dietary protein in their system. But if your system's not used to that or you have spent your life eating ultra processed things and you just come into the, you know, ecosystem of hours, it's going to be a, a lot drinking through a firehouse, so to speak.

True, true. I mean, yeah, I see this in a lot of women and what I was trained to do is to ask them if they're peeing twice at night. And that's sort of the threshold for further workup. And that's one of those things I was taught that I just think is wrong. Because if you're getting up twice at night, let's intervene a lot sooner than that and let's, you know, it's kind of like I feel like going to bed is kind of like putting a baby to bed. Like you need to have a whole process. I like the hot bath for, you know, 60 to 120 minutes before you go to bed. I like, I was just looking at the data on blue light blocking glasses, how they are much more proven in men than they are in women. Yeah, but we want to look at. Okay, what are those upstream aspects that could help you get your 7 to 8.5 hours of sleep? And not just total sleep, but I like to look at what's going on with your sleep latency. How long does it take for you to go to sleep? It should be 10 to 20 minutes. You and I both know Dr. Brad Jacobs. He goes to bed and he's asleep like in five minutes. And that tells me, dude, you've got a sleep debt. Like we need to address that. I think you might have contributed to a sleep debt when I saw you recently in Arizona.

Yes, Brad's a good guy. Well, it's just I'm glad you brought it up because, you know, one of the more and I just was asked this yesterday and you know, people who have really intense jobs, lifestyles, travel schedules like you do probably have a harder time with their heart rate variability and getting that where it needs to be. So for everybody listening, you're true measure of recovery is your heart rate variability 100%. And I had a relatively famous person yesterday at the beginning, come up to me and he's like, I can't. I can't get this down. I'm sorry, I can't get. It's always down. I can't get it above a certain amount. And, and I won't say how. How it was, but Leologos wrote a book about heart rate variability. It's very good. And that is a struggle for what we're describing where they're. I would say their cortisol is high. They're not resting long enough. They're getting up and down. They're not getting deep sleep. The. The ratio to REM number, it's all up. And there's no chance that your heart reveal. Berries gonna. It's gonna be in the teens if you measure it.

Totally.

Because when people tell me they sleep okay, I'm like, really? Do you know what that means?

Yeah. Show me the data.

Exactly like, okay, well, if you don't have a whoop strap ultra human ring at eight sleep or something that I believe, you can't say that to me because you're not actually doing what you think you're doing. And your body will reflect what you're not doing to me all the time. You'll stay swollen longer. It'll be harder for you, like all the. You cannot bullshit me because I've done this for almost 30 years. And now the problem is I've caught up to all the biohacking stuff. Like I use it all. I. Whatever thing you think you've tried, I've tried five years ago already, so. But the, the, the sleep part like that. I'm glad Matt Walker and others have made such a big deal about it because I think it's in me personally as a surgeon. I put it at the top of my. What is the most important thing you do after surgery? It's totally how you sleep.

It's. It's as close to a panic as we have in medicine.

Yeah.

And yet it's one of those levers that a lot of people think that they're optimizing and they're not. So. I agree with you. Show me the data. I'm assuming it's not working until proven otherwise.

If you think since, you know, all the things we've talked about it, you know, I wanted to center this around autoimmunity and how things are contributing to that. But, you know, I don't want to sit here and blame like, cortisol. I do want to.

Oh, we can blame cortisol for a big part of it. I mean, here's what I see, Rob, I'm curious if you see this too. I would say 95% of my patients have a problem with their cortisol pattern. 95%?

Oh, yeah, yeah, yeah, yeah. For sure.

And yet I was taught when I went through my conventional medical training, which I'm so grateful for, that you either have autoimmune attack of the adrenal glands and Addison's disease, or you've got Cushing's disease. Those are the two illnesses. So low cortisol on one side, high cortisol on the other. Anything in the middle doesn't matter.

Right.

Normal.

Similarly, I think both Dr. Saul and I were trained at a time is very different than the training now, of course. And I have great respect for the folks who taught me and trained me 100%. But I'm not the person who looks back and goes, I wouldn't do that again. It was very difficult, but I was great. I wouldn't change how I was trained at all.

We love those 120 hours a week.

Yeah. It's a very different. And I'll say it here out loud, anybody trained after 2002 in surgery is not as well trained as I am.

Totally.

It's impossible.

You saw what, like 12 years worth of cases in your training?

Yes.

Yeah, same in O2.

No work hours restriction in my life. No, no. 96 to OT. It started the day I finished surgical training, which. And then the beauty of plastic surgery training was, hey, man, you're on call all the time. It's just from home, right?

Yeah. Which is like, no boundaries, none.

It was so. It was just comical anyway. But yeah, I mean, the. I was going to blame, you know, the, the cortisol, but the disturbance in sleep over time and cortisol dysregulation for the. I. I guess, is it a fourfold increase in autoimmune diagnoses, something.

Cortisol is super interesting because we think that it either is a root cause or exacerbates about 95% of chronic disease. So I would say autoimmune disease is an example of this. And what we know with cortisol is that there's usually a hypercortisol picture of producing too much cortisol as a stress response. And then over time, it becomes more of a flat pattern where you lose the diurnal rise within 30 to 60 minutes of waking up. And so that flat pattern is what's associated with autoimmune disease. So that's when you don't mount the normal rise in cortisol that huberman talks about in 30 to 60 minutes, it's just flat all day long and maybe even high at night. So it's hard to sleep.

Right. So it's dysregulated and then. Yeah, so. And I was. He spoke yesterday, and I. I was thinking about it, you know, as relative to what I see all the time and we don't do. I mean, because all of my patients have some. Really, the dysregulation is so high. I'm not gonna sit here and say I can optimize all of that prior to surgery and try to get all this solved. And then. No, that's not going to happen. When I have them and we prepare them specifically with, you know, preoperative testing, we've already discussed with looking at genetics and toxicity burden and gut health and, you know, hormone balance. Like, the amount of hormone suppression I see in very young people is disturbing. The gut dysbiosis is pretty. I mean, it's universal now. I don't even get surprised about that anymore. And the tox burdens are always like. They're the. Like Christmas gifts you don't want true. Like the crazy aunt Christmas gift. So you just don't want to open it because it's going to be bad, and you don't know how bad it is. But I can give you some states where I know it's going to be very bad. Coming from that state.

Yep.

It is really frightening places.

Texas, not so good.

No, no. The. The coast of this. This state we're in is very difficult. It's environmentally challenged, as you would imagine, with the industries you're right there. And the constant problems with natural disasters that come through. And all along that Gulf coast and all the way to the other end of the seaboard. That's a very problematic place that has not all of the. Not only the. The burden from like the. The floods and the hurricane, all that stuff, but then they are constantly spraying these, really organophosphates. I see these things and I'm like, they're. I mean, they can cause cognitive decline in someone in their 30s that's so substantial that even a dumb guy like me is a plastic surgeon can sit and have a conversation, and the patient won't track the conversation and won't process what's going on. This recently happened. I had a patient and their mother come from that area, and she hadn't been feeling well. I explained her she has. Still has swelling very, very, like, not a very big person. So it's very noticeable. And when people have adenopathy or swollen lymph nodes, they. They know that's not normal and they get freaked out. They have cancer or some other things going on. And I got a total talk test on her, and she had two organophosphates and dde, tph. These are all very bad actors. Totally and completely explain why she's having so much problems with, With. She basically has neural inflammation from a pesticide.

Yep.

And so, like, that's. They were looking for an answer. And I'm, you know, unfortunately, the person had to find the answer to that. That problem. But I'd never say it's. I don't explant people, and that's going to solve, quote, unquote, all the problems. I'm going to take a driver away from what's pissing off their immune system, and that's going to help them. But there's going to be all sorts of other things that drag, you know, attention after that.

Yeah, I appreciate, I appreciate the way that we're approaching our patients in a very similar way. So you're noticing this shift toward dysregulation and how that contributes to breast implant illness, and you're correcting it, realizing that it's not 100% explantation. It's all these lifestyle factors as well.

Oh, my God.

And I'm approaching it also looking at this drift, this physiological change that leads to dysregulation. And it's a signal that you can pick up 7, 10, 15 years before someone gets a diagnosis. So to me, that's super exciting.

Yeah. I would, like we talked about a little bit before. I can give you the genetic profile, but I can't give you the environmental profile because that gets filled out over time. And then there's the aces, you know, all these other things, including trauma, that I, I, you know, I had a patient wake up and swing at our nurse the other day and complain of pain in their back and all these things. And I'm like, this is not normal. Adolescents wake up this way, but not people in their 30s. I was like, okay. Now, ultimately, we had to get this patient a CAT scan, just make sure that everything from an anatomic standpoint was fine. There was nothing, you know, gonna harm them. And I saw the CAT scan, and from my, you know, 10 million hours of work, I just rolled back in my memory banks the pizza slices of the CAT scan. I knew there was no problem. And I went and told the mom, I'm like, she's fine. And, you know, allowed Them to give her, you know, some more pain medicine and some sedation, and she was fine. And then two weeks later, she told my nurse she was reliving an essay event. And that was the problem. And so your, your, your aces, your traumatic events, all the things that also contribute to all of this, have to be dealt with. And I always try to tell everybody, like, I am not a psychologist, I'm not a psychiatrist, and if you can't make a shifted mindset before you come see me, I'm not going to make it better. I can't.

I appreciate that. I mean, you know, your scope of practice. I do, too.

It's very hard to change mindset. That's, I mean, behavior is the hardest thing to change.

It totally is. Although I have to say, I do like psychedelic medicine. This purpose.

I thought you were gonna say gops. No, Yeah. I, I, I, you know, God, that was, that's a whole tangent we can get on. So, like, I've, I've got patients burning up their faces, their breasts and their butts and their bodies on GLP1s. Young people doing this. And that is without the lifestyle changes and modifications and exercise that you have to introduce with resistance training and increasing protein. It's just not what you should do. It's so. It's just not going to go the right way.

Yeah, I agree. We've got this vast, uncontrolled medical experiment happening right now, and we're just, we're like on the fast train to sarcopenia.

Oh, my God. I think we're gonna have, like, a bunch of skinny people break bones.

Yep.

And not because they're 90. It's gonna. Because they're like 40.

Yep.

Because they started doing this when they're. I've had people doing this in their 30s now.

I mean, there's a time and a place for it. I like it for metabolic dysfunction.

Oh, yeah, yeah, yeah.

I like it for people who are overweight and obese 100%. Maybe it's even helpful for the prevention of Alzheimer's disease, But I feel like it's overused and without the lifestyle accompaniment.

Nobody's talking about that.

Yeah. The base camp, right. I mean, this is one of those climb the mountain medications.

Yeah.

You've got to dial in the base.

Camp if you think you're not going to age faster by burning all your fat. I've got another thing for you because you're going to see this explosion of facial cosmetic surgery. And just like when, as you remember, gastric bypass surgery started and the explosion in like all this body contouring that was. Nobody warned anybody about. You're going to have that because now these things are very effective and they're only going to get better. Like the ones we have right now, they kind of suck. These new ones that are coming are more efficient. They're just going to burn fat and burn fat that it's such a good clip. Like, this is like the antithesis of what you would actually want because there's not going to be the need for the base camp. There's going to, like, somebody's going to be like, okay, I'll just give you this.

Totally. I mean, how long did you tell patients there's no magic pill to deal with?

Right. Go lose ten pounds. I can't tell you how.

Yeah, there's no magic pill. There's no shortcut.

Now there is.

Now there is.

Right. And so I have patience. Want to come or who, who come and have fat transfers. Right, Right. And then due to other issues and, and I don't know what you feel about the, the neural problems with body dysmorphia and how it relates to autoimmunity. I'm very curious about some of these things as it relates to the SNPs and things that I, I see. I, I am curious about it. I don't know if there's a direct correlation, but if I did your explant and I put fat in there to help make it as restored, rejuvenated as possible, but you still see yourself as not meeting whatever standard and you go take one of these drugs, that definitely is going to work because they work, you're going to ruin that result. Because that's what it does. Right. It works on fat. And if you're doing all the other things, like maybe they are running the program, maybe we are doing all the base camp things, but they have this fat transfer done. There is no, as you know, research done on microdosing that we can look at because it doesn't exist.

That's right.

And it's being sold like it's, you know, a hair product basically online. And I find that to be. It's very predatory, especially to women, to your point, because that's not only directed there, but it's, to me, pretty strongly directed that way.

Oh, for sure. I mean, most disordered eating, most food addiction, you know, I would say there's a continuum. It's mostly women that are affected by this. I mean, men sometimes have this as well. But I think our culture definitely targets women in this regard. And I'm fascinated by this because I'm someone who's in recovery from disordered eating and I can definitely see in my SNPs that there's a particular pattern that you can identify and a lot of.

Ask you about it.

Yeah, for sure. I mean, it's that combined with, you know, genes, intestinal permeability and then a trigger. So for me, I've got this genetic predisposition that sets me up for looking to food to change my state. And then you combine that with an adverse childhood experience score of 6. And there's a way that, you know, if you think about Stephen Porges and polyvagal theory, there's a way that the soothing that you experience with food, especially if you're someone who has a lot of stress related dysregulation as a child, you know, the way that you were breastfed versus bottle fed with formula that probably had sugar in it and you know, started to change your dopamine pathways the way that you were maybe soothed when you felt stressed by food, especially when you're first born till age three. I think it, it sets us up to have disordered eating and to have maybe also, I'm hypothesizing here, body image dysmorphia.

Yeah. I've spent a lot of time reviewing literature about it and you know, it's kind of sparse as it relates to SNPs. But when I try to look at and do the Beautiful Mind version of my data and think about what are the things that we, although they, they tell us this, like, what other things are they really saying to us? And I had one of those moments where I was just looking at a bunch of genetic data and somebody, one of our patients had, had, you know, told us they were having troubles, you know, with dysmorphia and they've had it their entire life and it's, you know, it's ongoing, it's just a challenge for them, which always makes me think, am I just looking right at this? But I'm not really seeing it. And then what do I need to do looking at it to understand it better, to help? I'm always curious about that. I just think, you know, many of the things that we struggle with are in the genetic data once we understand it well enough. I just don't think we understand it well enough yet for this because it seems to me it's like right there and I don't quite see all of the things that I need to see. I see some of them.

To your point, what do you see? So ADRB2 is an example of. It's a SNP that I have that gives you this lifelong struggle with your weight and with kind of managing your food intake. So I think there's a lot of SNPs involved in appetite, food, noise, glucose and insulin signaling and metabolic health.

I was thinking of BDNF and CRMT and some basic ones. I see all. I mean, they're just all the time. So I don't think they're. Because they're there all the time. People just kind of like. So it's not a big deal. But I was looking at him the other day and there's others to your point, like, and I don't have it. And maybe AI helps us with this when we do our project. And like, what other things are we just blatantly missing that we're just being dumb about? And it's just literally right there in front of me. And I'm not getting it because I don't do a body dysmorphia assessment preoperatively. When I see patients, such a big deal to come see me, to ever get to see me, to do this, there's just. It's a long journey and I don't. I try to lower the temperature in the room, not raise the temperature in the room and totally. So I'm. I'm always, you know, for everybody listening, I'm always playing poker. I'm not the. Everybody always asks me if I slept well the night before surgery or, you know, you know, they say obviously they're nervous before surgery. Of course, you know, you say be preoperatively. And, you know, I always tell everybody, well, if I'm nervous or the person who's going to take care of you is nervous, as a surgeon, you shouldn't be going to them. That's not a good trait. Right. So the kind of, you know, trying to figure out more about them, to help them, and it's now more on the back end. Like, I get this part done for them, but I'm trying to set them up with a real game plan to move ahead and get this in the rearview mirror and make. And take all these other steps. And then maybe they have sons and daughters kind of highlight what they may be gonna see. Right. Because you already highlighted, you know, you don't detox well and you have a couple daughters. I'm sure they exhibit traits that you're very aware of. My daughter doesn't detox well at all. And she's estrogen, toxic and I saw that on our genetics. And when it happened, I was not prepared for that, as I already told you, because I, I have only one daughter. I had no, you know, that's in A one. But if we can help, however I can help, I try to, I try to help the moms and dads. I mean, just like you're saying, taking care of a little one, a little one who's sick all the time, who quote unquote, magically has somebody told me said bullshit thing of asthma under 2 years old. That's garbage. I mean, if till you prove me they haven't been exposed to mold or some other weird stuff in their environment, especially in Texas. I don't believe you. We have so much oak cedar mold in the air. Yeah, it's very complex. Like you need a freestanding HEPA filter next to that kid's bed to see if they improve.

I agree with you. I mean, I'm not sure California is so much better. I'm just seeing so many folks with fallout after the wildfires and oh my gosh, January. But yes, I take your point.

Yeah, that is awful. So, you know, certainly programmatically we've wrapped, you know, all these concepts together as much as we can, but I find that, you know, autoimmunity still is. Dogs know just many of my clients and trying to help them better understand it. And I appreciate the foundational work. I mean we're very aligned in, in all of those, you know, concepts that you described. Are there any other, like take homes we can give them that would be helpful if they're facing or themselves or a family member has an autoimmune, you know, type situation that would be good for them.

Well, I'm remembering back, Rob, to the first conversation you and I had, which I think was three or four years ago when I was writing this book, the Autoimmune Cure. And when you look at, if we go back to the basics, which is this three legged stool of genetic predisposition, increased intestinal permeability and a trigger, you can only do something about the latter two.

Right.

So with increased intestinal permeability, so called leaky gut, there's a lot of things you can do to address it. So you can take L glutamine, you can start making smoothies with trying different supplements to see if you can improve.

Your gut health to help heal it.

And I really believe in a food first philosophy to address the gut. There's so many supplements that are out there, but I think having an anti inflammatory food plan is the Way to go. Sometimes an elimination diet which is free. So those are some of the things I think are really helpful to address autoimmunity or if you've got that early drift and you're detecting it 7, 10, 14 years before an autoimmune disease declares itself. So I think testing can be helpful. Things like antinuclear antibodies, looking for doing an autoimmune panel which I talk about in the book. And then with triggers. I think part of being an adult is to audit yourself for what triggers could be contributing to autoimmune disease or to this transition from a state of health with passport control in place to starting to lose that tolerance. So for me I think trauma is one of those triggers that we want to be mindful of. Knowing what your adverse childhood experience score is can be very helpful. Maybe we can link to the.

Yeah, let's do that. We'll do that in the show notes for sure.

Great. I've got a quiz that we do that I can send to you. And then one of the things that I found because I love NF1 experiments, it's such a critical part of precision medicine. I found that I had a positive antinuclear antibody and this was after going through prophylactic mastectomies for a gene mutation. And so I had this positive antinuclear antibody and I went through a process of addressing trauma so doing internal family systems Hakomi which is this mindfulness based somatic psychotherapy and then psychedelic assisted therapy and I was able to convert my positive antinuclear antibody to normal. So in an N of one experiment I think that's what I would really encourage our listeners to consider to try some of these techniques to address leaky gut address triggers so that you can, you know, shift that dysregulatory drift that we're talking about today and reregulate.

Well, I want to thank. I give ourselves a ton of gratitude. It's been a long time to get her in Austin here and we're in a studio that I've first time I've ever been here and it's been a great discussion. I really want to thank you and then for if someone we'll put in the show notes all the links but what is your website link where they.

Can go to learn more sarazallmd.com and I'm just in the process of reclaiming my maiden name so this is been a you know, couple years in the making.

Well we'll have all the links and thank you again.

My pleasure. Thanks so much.