Potassium, Melatonin & Nicotine: Your Questions Answered

Welcome to Integrative Medicine with Dr. Leland Stillman, the podcast where we explore the best of East and West, old and new, conventional and unconventional, in search of answers to medicine's toughest cases and most difficult problems. This podcast is for informational purposes only. Diagnostics and therapeutics discussed on this podcast may or may not be right for you, so talk to a qualified practitioner before taking action based on what you learn here. If you'd like to become a patient at at my practice, go to stillmanmd.com to schedule a complimentary discovery call. Thank you for listening and welcome to today's episode. Good morning everyone. Dr. Stillman back and excited to be answering your questions. Thank you as always to premium subscribers and practice members for supporting this content production. You get priority. So today we are just answering premium subscriber and practice member questions. Because we had plenty of them after I took a week break from Q&As last week to honor the Thanksgiving holiday. The supplement store purchases help me to produce more content. And on that note, it's been on my mind to actually ask you all something very important, which is what do you want me to do more of? We've gotten rave reviews of the Q&A, which is why I've continued to do it and I'm doing more of it. But the other things that I'm tempted to do are expand the practice, hire a nurse practitioner. If we are going to do that, we need a significant number of patients and not just maybe sort of might join the practice, like committed, because I can't afford to hire the NP, train the NP, and then not have enough patients for the NP to see. And so if you're serious about wanting to join the practice and you'd like a lower cost option to do that and a lower cost option to follow-up than just me, I would need to know that so we could create that. And I'd love to know what you would want. So if you reply to this email, if you got it as an email, or you go to the post and you post in the comments to the post what you would most like. The toughest thing would be having this person licensed in multiple states. So we would probably just start in Florida. If we don't get enough demand for that, we won't do it. When I asked you guys not long ago what you wanted me to do more of, it was protocols, articles, more content on Substack. So that's what I've been leaning into more. And what you guys ask for in demand is what will end up being delivered. That is just simple market-based economics. Without further ado, let's jump into the questions for today. Question number 1. Oh, I should add important disclaimer. The responses to these questions are intended for educational purposes only and do not constitute medical advice. Individuals should consult with their healthcare providers before making any changes to their health regimen, especially those with existing medical conditions or who are taking medications. Question 1, Tom. For individuals with compromised kidney function who have been advised to monitor potassium intake, what general guidelines exist for balancing the known benefits of potassium with safety considerations for those with kidney concerns? So you can look up the American Nephrology Society, I think, recommendations for potassium restriction based on your stage of kidney function if you have kidney dysfunction, and then observe those guidelines. I think that the nephrologists are being overly conservative. In stages 1 and possibly 2 and 3, but I only currently have patients in stage 1. I have never seen a patient in stage 1 present to the hospital with kidney failure or hyperkalemia, that's high potassium. And so what I've told my patients is shoot for 4.7 grams of potassium if you're in stage 1. I am not going to give an opinion on 2, 3, 4, and 5 here because I don't have experience directly with it, but I've told them to shoot for 4.7 grams, which is the limit the nephrologists recommend. And then if they're able to tolerate that, we could discuss them. Liberalizing their intake. Okay. And that being said, I've got plenty of them who are not restricting at all and they're not having any problems. Okay. Catherine, question 2. Could you discuss the recent study linking melatonin to heart failure? What does the research indicate and what context is important for understanding these findings? Such a great question, Catherine. And I want to actually launch here into a little talk on sleep. And I've been sharing more stories from the practice with you guys, and I will share a quick story today. A couple of quick stories. So Sleep is a function of health and also youthfulness. As sleep deteriorates, people clinically worsen. This comes up in consult all the time. How do I improve my sleep? The number one thing you can do to improve your sleep is to improve your underlying health. The number one reason people's sleep deteriorates earlier in life than it needs to is the accumulation of toxic burden over the course of one's lifespan. So, What I often see in cases with poor sleep is people have a very significant metal burden or burden of other toxins that they're not adequately mobilizing. What I don't think people realize is the amount of work it often takes to move the needle on this total toxic burden. It takes careful diet, lifestyle, exercise, usually an abundance of sauna. It requires what I would describe as the full-court press. And I want to give you guys a little bit more of a window of what I do in the practice and how we get people great results. I'll tell you about a case. Right now that I saw the other day in follow-up. Very sick, very abnormal labs, really tough case. Lots of different systems going wrong, many different markers abnormal that are correlated with significant increases in mortality, and he's already feeling 50% better with the program. What did we do? X39 patches from LifeWave, diet and lifestyle changes, including more hydration and obviously tailored supplements to an HTMA. Vitamin C. I don't think they'd started the MSM or the iodine protocols yet. So we still have meat on the bone to go through. And just those things, huge movement of the needle for this individual. Now they're not out of the woods. Healing's not linear. Patients have good weeks and bad weeks. Often they tell me they just see that they have fewer bad days and more good days, or the good days are better. But at the same time, I'm telling you, we've settled on a very clear playbook after many years of doing this in many hundreds of cases and lots and lots of refinement of systems that mentors gave me over the years. And that's what I see moving the needle. Why is it moving the needle? Because what it is doing is it is reducing that total toxic burden through the high-quality supplements that we use. And if you missed it last Q&A, you know, one of the reasons I'm so passionate about the vitamin C that we use is that I've tested it against other brands and our vitamin C— for all the details on this, listen to my Q&A, I think from last week or my last Q&A that was posted, depending on when this comes out— our, our vitamin C is twice as effective as competing brands. So if your vitamin C is half as expensive as ours, but ours is twice as good, then you spend the same amount of money for the same amount of vitamin C. So it's actually the same price. Amazing, right? My point is we reduce that total toxic burden and then things just tend to get better. So the average patient reports a 6.96, most recent data, 103 patients in the practice answered that survey between January of this year and December 3rd yesterday when I did the numbers, 6.96, if I recall correctly, out of 10 improvement in their sleep during their time with us. Which includes all the things I just mentioned, plus sometimes more. So improving underlying health is the name of the game for improving sleep. This study that Katherine's asking about that was published by— it was an American Heart Association, I believe— study is a terrible study. It's a terrible study because basically what they said is, okay, people who used melatonin are more likely to end up with heart failure. Well, no kidding, right? Because guess what? As you get older, your body is falling apart, and the more your sleep deteriorates, the more your underlying health has deteriorated which is why your sleep is deteriorating, right? And so you are going to see that people who use melatonin more are going to have worse outcomes across the board. Heart failure, stroke, I imagine you would find this. Cancer, I imagine you would find this. It doesn't mean that the melatonin is causing this. It means the people have experienced worse sleep than other people and they're trying to use the melatonin to fix their sleep. The analogy I would give you is, let's say that we found that people who had taken an ambulance ride in the last 10 years had a higher likelihood of death than people who had not taken an ambulance ride in the last 10 years. Would you use that information to refuse ambulance rides? No, you would not, because ambulances don't cause you to die. You just happen to be more likely to call one when you are dying. This melatonin heart failure study is like a classic, classic, half-boiled, terrible, awful— like, I have so little respect for anyone who would publish this. This is a waste of time to publish. It's just a waste of time. And it's one of the things that really disillusioned me with academia is these academicians are being basically paid and tenured based on how much they can publish. It's literally called in academia, publish or perish. So they just churn out high volumes of low quality studies that are easy to do. And this was easy to do. This was like they queried a database. Whoopadeedoo da day. Why does anyone think that is worth reporting on? But anyway, that's all they did as far as I know. And you can churn out tons of papers with this and make a career, but you are not improving people's lives. I am very fond of recalling that. Einstein built his entire career, his entire career, as maybe the most famous scientist ever on 3 papers. 3. Wow. And today people are like, I've got 400, 500 citations in whatever. I'm like, I don't care. Are you a good clinician? Do you know what to do with patients? Can you help them? Do you make them feel better or do you just pontificate about how many citations you have? And this is why I'm not in academia and I left academia for private practice. It's a terrible place. Don't know how people can deal with it anymore. Anyway, so I hope that's helpful, Katherine. And let me give you a little bit more context here for melatonin per se. The dean of melatonin research, Russell Reiter, like when I say the dean, I mean the guy who did more of it than anyone and understood it better. He came down on melatonin as this thing is going to prolong life, period, in humans. And he settled on something like an 8mg dose a day. I think the mechanisms behind that are just so airtight. If you look across across the board, when the final data we have, I am very confident that melatonin is going to turn out to be one of the best anti-aging longevity supplements ever. Why do I believe that? We live in a world that destroys melatonin. I mean, it annihilates it from every direction. Electromagnetic energies like wireless signals, microwave signals, radio wave signals destroy melatonin, pro-oxidants in food, rancid fats, seed oils, heavy metals, improperly complex minerals, or oxidized minerals. They deplete melatonin, strong UV light, which is getting to Earth, I'm told now, more than it should be because of changes that have been made with geoengineering. There's so many different ways that melatonin's being destroyed in the human body. It's part of why you're seeing a very organic and very viral spread of what I would describe as an obsession with red light therapy, infrared light, biohacking, all these different things that are known to boost melatonin levels. I'm gonna get you the high-dose melatonin protocol. I just have a big backlog of stuff I'm prepping for you guys. And so, by the way, your supplement store purchases help me move that along. I can't tell you how hard it is to like get it all out and make sure it's good and make sure it's all compliant so that I'm not like breaking the law by just talking about this stuff. But basically, I start with improve underlying health. That's going to improve sleep more than anything. Then add different things on top of that. One of the supplements I'll say that we have in stock right now that I've seen really move the needle for people is this product called Zen Sleep, which if you want to see it, go check it out in the supplement store. It's a great product. It has a combination of amino acids, vitamins, and I think some minerals in it that really help with sleep. And then I'll layer in magnesium on top of that. I'll layer in herbs like chamomile, passionflower, lemon balm on top of that for sleep. In women particularly who have symptoms of low progesterone, I will add progesterone and dose it until they have symptoms of progesterone excess and then back down. In men, I don't do that. After women have to max dose of progesterone, I'll introduce melatonin and then we'll follow the high-dose melatonin protocol, which again is forthcoming, and then we'll settle on a, a dose of melatonin plus progesterone long-term. In men, I will go straight to high-dose melatonin. One of the things that blew my mind was the effects I observed in the practice of, um, high-dose melatonin and iodine on particularly one case of a man who had frequent nocturnal urinations that were causing him to have very poor sleep. I was blown away by the reduction in the number of times he had to urinate each night with those two supplements, plus all the other things that we were doing for him in his diet and lifestyle regimen. By the way, not making any claims, just telling you what I observed in my practice in that one case. And I strongly suspect that low iodine status has to do with why a lot of men have prostate issues in the modern world. That also links back to melatonin though, because all the problems we see with the prostate are linked to all the same things that cause breast cancer and breast issues. And all of that's linked back to low iodine status as well as artificial light at night. And so this is where, like, you guys see, I talk about the same, like, 10 things over and over and over and over and over and over and over again. I feel like an absolutely broken record. Like, oh my gosh, if we just do enough of the things that we know that work to naturally boost melatonin, then we supplement it when we can't boost it anymore, then we add all these other nutrients that support it and synergize with it. That's how we get amazing results. I feel like that was a long rambling answer to your question, but it was a really good question, so I got really excited about it. I actually did some research for you, Catherine. Okay. Becca, could you explain the conflicting evidence around statins? Some physicians emphasize that the mechanism of action is reduced inflammation rather than cholesterol lowering. Is there truth to this perspective? Additionally, what are the general health risks associated with statin use, and what alternatives are typically considered for patients with calcifications and cardiovascular disease? Great question, Becca. My number one question that just demolishes a lot of bad narratives around drugs, let alone supplements, is what effect does the intervention have on all-cause mortality? So fun fact, as cholesterol levels drop, risk of cancer goes up. Isn't that interesting? As cholesterol levels drop below 200, all-cause mortality goes up. As cholesterol levels go up above 240, all-cause mortality goes up. I have not seen convincing evidence that the statins in any study anywhere ever have reduced all-cause mortality. Here's how you lie with numbers to get the entire world to take statins. You do a study where you make sure that there's a reduction in cardiac events, heart attacks, potentially strokes, potentially symptom burden from cardiac disease, but usually they use some kind of like heart failure, sudden cardiac death, and STEMI. Technical criteria I won't bore you with. But you make a study where there's a slight reduction in those events in the treatment group. Okay. Now you compare the reduction in events from the treatment group to the control group. And let's say that the treatment group had a 2% rate of, let's call it heart attack, and the control group had a 3%, or let's say a 4% rate of those events. Well, it looks like you reduced your risk of heart attack by 50%. That sounds really good, but the absolute risk reduction is a 2% difference, and that doesn't mean you reduce their risk of death. Because if, for example, you increase their risk of having, say, a cancer by a small percent, well, they might die of the cancer instead. So I always have looked at statins as robbing Peter to pay Paul. Okay, we're going to rob the body of cholesterol, and that may reduce cardiac events, but we are going to create all this mayhem over here. So my question to the statin industry would simply be, Why can't you demonstrate a robust and routine reduction in all-cause mortality that merits the use of your product every day for decades? And they can't do that. They can't do that. Now, here's the other big fly in this ointment, and it's a really big, ugly fly. So let's talk about it. The pharmaceutical industry has no incentive to be truthful. They have no incentive. The upside is not really there because people have already learned, or people used to trust them. So there was massive upside to lie. They've lied over and over over and over again. Here's the problem with liars: you don't know where the truth ends and the lies begin. And when you're talking about data sets where 2 or 3 people being miscategorized can result in a drug being approved or not approved and can result in a statistically significant result that gets published and gets adopted into clinical practice and not— and the stories from this world are just chilling. Like, for example, if I recall correctly, there was this woman who was a healthy, happy college girl She goes into an antidepressant study. She has no history of mental illness. She kills herself during the study. She's not even reported in the safety data they submitted to the FDA to get the drug through the approval process. When I tell you the pharmaceutical industry will lie, cheat, steal, engage in every kind of malfeasance, have no conscience, I'm really not exaggerating. And it's not even a matter of like my opinion. Just go to the historical record. Look up some of the things they've done. It's horrible. My point with that is this. I don't trust any of their studies, any of them. I don't trust any of any part of their studies because they're liars and they've established that they're liars. And at the end of the day, even the fines that they've faced, even the penalties they've faced, those companies have never had a not profitable year. So if you never make lying unprofitable. And if you never send them to jail, or let alone give them a more steep penalty, why would they ever be truthful? People want to know why the pharmaceutical industry lies? They get rewarded for it. Simple as that. And they've bought everyone in Washington, so there's— I mean, practically speaking. So no one is going to hold them accountable, period, end of story. So I just throw all of that data out. It goes in the garbage, and that's it. What alternatives are typically considered for patients with calcifications and cardiovascular disease? I would say everything we do in the practice is organized around optimizing mineral deposition in the body and healing any kind of vessel damage. I really find the data on bioidentical hormones and cardiovascular disease very compelling. I really think that the links between artificial light at night, EMF, other things, and cardiovascular disease are incredibly powerful. I really think in the end what's going to happen is we're going to find that optimizing nutrition, optimizing hormone status long-term, and optimizing the environment for lack of stress, is going to be the winner absolutely for reversing the epidemic we see of cardiovascular disease. Question 4, David, you strongly recommend sauna use, particularly for people living far from the equator. What are your thoughts on sauna blankets as an alternative? By the way, I tried to get rid of all product names in this. I want to make it about ideas and concepts. Products change, brands change. I can't vet every product. I often get questions about what about this product? What about that product? The answer is I only write about and talk about products I've tested. I already probably spend more money testing things than I should truthfully. But so I, I can't give an opinion on everything. We're going to answer this question in general. So what do you think about sauna blankets as an alternative to sauna? Do these provide comparable benefits given their lower price point and convenience? So I don't have any reason to believe they wouldn't give you the same benefits. I've opined on sauna in past Q&As, which you can go look up my answers there. And I'll reiterate here, my main two goals with sauna, and you can get a great sauna through me with an affiliate code that I earn a commission on from SaunaSpace with code StillmanMD. And I love their saunas. My main two things I want to see are number one, healthy healing frequencies of light. So it's nice if it's like a very specific frequency or wavelength, but I more than that care about the fact that you sweat a lot in your sauna because I believe that a big piece of the benefit is the detoxification that happens when you induce sweating. Do these provide comparable benefits given the lower price point and convenience? So long as you're sweating and so long as the, the quality is good. I will tell you that anytime you shop for the lower price point option, you're very likely to get a lower quality product. I can't say that across the board though. There's people selling super high-priced stuff that is just absolute trash, and it's part of why I'm so passionate about giving you guys products that are vetted, uh, because I've spent— I don't even know how much money on just bad products, and my patients have seen them spend even more than me on bad products. So anyway, okay, John, what should individuals with an elevated PSA understand about this marker? That's a prostate-specific antigen. What are typical considerations and next steps for evaluation? Okay, so Prostate-specific antigen is an antigen protein associated with the prostate that increases when the prostate has some kind of inflammation or damage. So that in most cases is either an infection or a cancer— bad things. So I say that, but any kind of irritation or inflammation of the prostate can do this. So you'll frequently have a scenario where a man, say, rides a bike and he goes for a really long bike ride and there's a lot of perineal pressure, which indirectly gets transferred to the prostate, and he'll have an elevated PSA. It can actually go up just if a man has experienced coitus or ejaculation the morning of his lab test. Fun fact. So there's lots of things that can cause this to be elevated. The truth is, people who are up to date are not just ordering a PSA anymore, they're ordering a PSA and percent free PSA. The percent free actually predicts, in conjunction with the total PSA, your risk of prostate cancer better than the PSA alone. And the trends between these two things are more important. So if you've got a rapid rise in PSA, that's very concerning. If you've got a rapid change in your percent free PSA, that's also very concerning. More than that, I'm hesitant to say because it really does require a consultation with a physician. I will tell you that I have informed consent conversations around prostate disease with men all the time, particularly surrounding testosterone replacement therapy, which we routinely use in men with low T and symptoms of low T. And one of the things I share with them is that what I do instead of offering them a prostate cancer biopsy with a urologist if their PSA is abnormal is to do a prostate MRI. Instead. And the reason why I recommend that is that if you get a prostate biopsy, there's a non-zero chance that you will end up impotent because of damage to the prostate, the nerves around the prostate that run erections. And so men can actually sometimes go in for prostate cancer biopsies and come out impotent. I think that's tragic. It's part of why I'm a big proponent of MRI for that before a biopsy. It's another reason why a lot of men in my practice have refused prostate prostate labs, prostate workups, because they've seen male family, family members go through prostate cancer treatment and decided that the cure was worse than the disease, so to speak. Very interesting. One of the books on my list to read is called something like The Invasion of the Prostate Snatchers. It's a prostate cancer industry book. Very curious to read that. I'll let you know how it is. But anyway, hopefully that helps basically answer that question. And obviously none of that's like medical advice. You've gotta work with a qualified clinician to figure out what to do with a PSA. Donna, there appears to be contradictory information about bilirubin levels. Gilbert syndrome suggests that elevated bilirubin and antioxidant anti-inflammatory can be associated with 50% lower all-cause mortality. However, other sources indicate that abnormal bilirubin elevations suggest poor toxin elimination and increased mortality risk. Can you explain this apparent contradiction? So Donna is referring to my recent repair deficit post that I made on Substack. Excellent point here, Donna. I had to go look this up because I didn't know this. So there's a benign condition, it's canonically considered benign, called Gilbert syndrome, where patients have poor uptake of unconjugated bilirubin, if I recall correctly, to liver cells. Now, I didn't know this until I researched this because of Donna's question, but it turns out that unconjugated bilirubin is an antioxidant and seems to protect these people from death, and they have as much as a 50% reduced all-cause mortality relative to the general public, which is wild. I did not know this. Here's what's important about this. It's very clear that in all comers, elevated bilirubin correlates with higher mortality. People with Gilbert syndrome seem to have a pass on this. This comes up in my practice because one of the supplements I recommend routinely has bile acids in it. And I love this supplement because bile acids bind toxins. They bind xenoestrogens, they bind, bind xenobiotics, they bind— and those mean things that are foreign to your body. So they bind foreign toxins, they bind heavy metals, they bind mold toxins, mycotoxins. And one of the reasons I am very enthusiastic about bile acids is the effects we see in reducing total toxic burden. And I've seen more than one bilirubin come down after we added these bile acids. Now, people with Gilbert's will have these fluctuations. They'll be normal one year, they'll be very abnormal the next, they'll be normal and again, and they'll be mid-range. So they bounce around a lot. I don't know how big of a deal this is for them. It's clear that they have this protective effect from it, which is great. My point is I use bile acids because I'm very convinced mechanistically that they're helping the body get rid of toxins. It's one of the things I'm non-negotiable on in terms of our protocols. They always include bile acids. And you know, on that note, that supplement is coming to the supplement store very, very soon. So hopefully that answers your question, Donna. For all comers, a low bilirubin, like I outlined in my, in my repair deficit post, which I really strongly encourage you guys to review, it's a very impactful post. I think it's really important for health optimization. Noel, what are your thoughts about post-viral treatment protocols? What does the available evidence suggest about these approaches? So I got to clarify this because I know this has to do with a specific question you're asking about a product, Noel. So Noel's asking about a product, and I'll use the product name because it's so specific, and I do think it's important. It's Aurmina, A-U-R-M-I-N-A. So it's a product being put out by Pierre Kory, MD, a friend and colleague of mine who I have the most tremendous respect for. I'm delighted to see that Pierre has arrived at the conclusion that I have arrived at some years ago now, that minerals are the bedrock of physiology. They are the most important levers for us to pull in terms of physiology. I can't tell you how important that is. I see so many people, they're chasing herbs, they're chasing, they're chasing macros, they're chasing weightlifting, they're chasing this, they're chasing that. The minerals Minerals are the spark plugs of life. You get the minerals right, boom, you're going to see some wild stuff happen based on my clinical experience, my observations in practice, purely my opinion, not making a claim, by the way. So Pierre has come up with a really cool new— I think it's a supplement would be the fair characterization, a mineral supplement that he discovered through the grapevine. And I'm fascinated to learn more about it. I would encourage all of you to go buy a copy of his book. I have bought a copy of his book. It has not been delivered yet. I'm excited to to read it, and as soon as I have an opinion, I will let you all know about it. In the meantime, I'm really convinced based on the clinical results we see in our practice that our approach to minerals and mineral biology and vitamins is very powerful, very robust, very consistent in terms of the results. I shared some of them with you earlier, and so I'm not going to run out and grab Ormina. I'm going to test it eventually. I just have so many things to test. I cannot even tell you. I have to like stop myself from running more labs on myself, or, you know, whatever. I have to stop myself from buying more products. I got a whole, whole closet full of supplements that I would like to do something with, and I'm like, oh, I'm gonna do this next, I'm gonna do that next, and then I, I get overextended. I can't do it all. So I'll get there, Noel. And if anyone has an experience with it, please let us know. Please let me know. I'd love to get your thoughts. All right, next question from Noel. What approaches would you suggest for post-viral symptoms consistent with ME/CFS— that's myalgic encephalitis and chronic fatigue syndrome— specifically for cases where previously active young adults experience significant fatigue and exercise intolerance following a mild viral illness and where HTMA testing shows patterns of sympathetic dominance along with heavy metal exposure. What role might previous mold exposure play in such cases and what types of specialized clinical guidance are most beneficial? Okay. So I've recently been reviewing my case studies in the practice and the, a huge proportion of patients who've had really great outcomes fall into this category of chronic fatigue syndrome. They meet the criteria, the diagnostic criteria. I almost think I just run a chronic fatigue syndrome recovery practice, but I don't, cuz we have a lot of other pathology that we see and that we treat and that we see good results with. No claims, no guarantees, my opinion based on my experience. That being said, what is that approach? X39 LifeWave patches for starters. Those ones are a huge favorite for me in chronic fatigue. My chronic fatigue syndrome patients, some of them are just over the moon for LifeWave patches. And by the way, you know, Meredith Oak and I did a great podcast on her chronic fatigue. We did a two-part podcast that if you haven't listened to my podcast with Meredith Oak, it's a really, really couple of episodes. Very interesting story, very inspiring story. So you can go back and listen to that if you search the podcast. So X39 is my favorite for this, and then I would add custom minerals, and usually zinc's one of the big, big things they're missing. Bs are huge. So I mean, depending on where they are in terms of oxidation state, but almost always there's some combination of thiamine, B6, NAD or B3, sometimes folate, sometimes B12. Deficiency in these cases. So I add these in every case. If you're looking for a great multivitamin, multimineral, the one we have in the supplement store rocks. When I tell you it rocks, I mean that I have seen hundreds of organic acid tests, maybe thousands at this point. I have seen hundreds, if not thousands, of HTMAs in my practice, and that supplement covers all comers better than any other supplement I've ever found. I've looked at so many multis, so many B vitamin complexes, so many of these supplements. The one I source in the supplement store is the best, in my opinion, my experience, based on thousands of cases. Anyway, X39, that really high-quality multivitamin, multimineral. If you're not doing mineral balancing with an HTMA and personalized supplements, by the way, I would use, uh, like digestive enzymes, bile acids, like I mentioned earlier today. That usually gives people a huge lift. And then I would add the vitamin C protocol on top of that for sure. And then I would add the MSM protocol and the iodine protocol. MSM protocol's coming. Haven't published it yet. Iodine protocol's live. You can go check it out if you'd like. It's one of the most recent Substack posts. So it's very, very recent. And obviously that's not my medical advice, but that's my general education and what I, what I immediately think of when I hear chronic fatigue, myalgic encephalitis in a patient in the practice. Okay. Okay. What role might previous mold exposure play in such cases and what types of specialized clinical guidance are most beneficial? So mold can play a role. One of the reasons why I really like bile acids is the properties of eliminating mold. And how could I forget Dr. Stillman's Detox Powder? That is a premium subscribers only post right now, but it's coming to the general list. If you want me to speed up the publication schedule, please, please, please upgrade to premium today or buy supplements from the supplement store. They allow us to make more content. Thank you very much. And what types of specialized clinical guidance are most beneficial? Hard to Hard to explain that one. I mean, I just find that the, the general playbook I just shared with you in those cases in my practice, I can't think of a single case in recent memory that hasn't gotten pretty much all the progress they wanted. And I would know because we track all of our outcomes. 103 patients in the last year have responded to our survey. 7 out of 10 is the average improvement overall. 7 out of 10 is the average improvement in energy since starting with us. So that's that. Philip, should most people take a probiotic? What are the general considerations for probiotic supplementation? So I don't strongly feel that everyone needs a probiotic. Part of this is just based on my experience with pill fatigue. I am a human being. I get tired of taking pills. I happen to be skeptical of anyone who says you need to take everything forever. I've got colleagues who will put together these crazy supplement protocols where it's like I'm taking 30 pills a day, and it's like, oh my gosh, I got a pill for everything. I got a pill for my hair, I got a pill for my skin, I got a pill for my nails, I got a pill for my sleep, I've got a pill for my stomach, I've got a pill for my small intestine, I got a pill for everything. Everything exhausting. I don't have time for that. I don't have— I don't even have money for that, frankly. I try to keep my supplementation very lean and efficient. And one of the things I haven't found to be a consistent game changer for people is a probiotic. Let me explain. Usually I'm taking care of patients who've seen on average 3 to 5 clinicians before they're seeing me. They've almost all tried probiotics. I very routinely ask patients what has worked for them in the past. And then I built my approach basically off of that. We did things they hadn't tried that I knew from past experience and mentorship were going to work in a huge proportion of people. Probiotics have never been something that people have come into the practice raving about. And part of this is a conversation with patients. Stop all supplements and medications as tolerated. That's my standard operating procedure when they join the practice. This is for two reasons. Number one, they may be taking things that are going to interfere with what we to do. Number 2, they cannot possibly take everything they were taking and everything we're going to give them because that would just be ridiculous. So what ends up happening is we stop a lot of supplements and a lot of medications. And I'm not telling you to stop your supplements or medications, it's education, not medical advice, just to be clear. They'll stop them and almost never does someone come back to me and say, hey, I really miss this or that. And I can't think of a single person to come back to me over the years and say, you know what, Dr. Stillman, that probiotic was really doing something amazing me. Now, I'm not saying your probiotic's not great. I'm not saying it's not important. Maybe it is. If you've had an amazing experience with a probiotic, would you actually tell me? I would be really curious to read your story. We have a testimonial form you can fill out, which is about products or services that have really worked for you. I created that just to gather data, just to expand my knowledge and my skill set and hear more stories than I could possibly gather from my practice. So if you have a story about probiotics, about anything, please share it through the testimonial form because it really will help me me help more people, which is what this is all about. So I don't use probiotics. I do use them when people are on an antibiotic, 2 hours away from the antibiotic, and I use a probiotic when people are post-antibiotic for 6 months because my assumption is we need to repopulate their microbiome. Am I wrong? Maybe I should be using more. I'm not sure, but I routinely have patients come in and say, I'm here because I want you to keep this simple, and other people like you want to put me on like 50 things, and I'm exhausted that. Not to mention the fact that I don't want to spend $1,000 a month on supplements. I just can't believe that I need that much supplementation in order to be optimal. Personally, my experience clinically, professionally, people don't need that much supplementation. If they do, they need it for a short period of time, or they have a really severe disease like cancer and they're trying to throw everything at it to win, in which case, right, make a decision with a qualified practitioner. Question 10, Sean Shauna, there's considerable discussion around nicotine supplementation and its potential benefits. What are your thoughts about regular nicotine use such as patches? What does the evidence suggest about benefits versus potential risks for overall health? Shauna, I'm not familiar with any long-term data on nicotine linking it to worse health effects. And I want to be really clear that I did not just say that smoking is not bad for you because smoking is undoubtedly bad for you, but nicotine itself doesn't seem to have that I'm aware of any downside. If you disagree, have evidence, a study, please submit it to the Q&A and I will go look into it and give you a better answer. But this has been my finding having spoken to a lot of people about it. Nicotine is incredibly helpful for a lot of different problems. And the big thing with nicotine that I'm wary of is it is an appetite suppressant. So I have to, to balance the use of nicotine with the fact that if one of our goals is weight gain, which it actually pretty frequently is, which may surprise some of you, if we're going to target weight gain as a, as an endpoint, then nicotine is not our friend, in my opinion. And in anyone who consumes too much nicotine, they will eventually wind up in a position where they are dropping body weight. So this is a dose-dependent thing. And so on that note, I'm very open to patients using nicotine. I think it's a very reasonable thing to try in many different clinical contexts. I don't use it a ton, he said, but I do actually have some nicotine lozenges on my desk, and I do occasionally use them when I need to get through an afternoon where, say, I've had like disrupted sleep from having an almost 1-year-old, uh, and I just have to be focused and on for patient care, right? I'll use nicotine as a performance enhancer then. So that's that. Question 11, Emily: For iodine supplements that contain polysorbate 80, what should people understand about this ingredient? Are there concerns about its inclusion in supplements? I am not an expert on polysorbate 80, and in full disclosure, it is of the ingredients in the iodine supplement we use or stock in our online dispensary. I've been taking this iodine for years now. I've had no problems with it. I also want to give a little bit more background on iodine and hyperthyroidism because I did get a number of questions about this recently since we posted the high-dose iodine protocol. We know that higher intakes of iodine are associated with better quality of life and longevity and lower rates of disease. I think that's very conclusively demonstrated in the literature. The other thing we see though is that when you have more iodine in the diet, you will wind up with more cases of hyperthyroidism per general populace, right? So when I was in training and we gave no one iodine, like, ever supplementally, we very rarely saw hyperthyroidism. I've seen much more hyperthyroidism since coming out and using high-dose iodine. That makes sense. Does this mean I should not use high-dose iodine? This ends up being a conversation about risk and benefit. Benefit. So one thing I said in the High Dose Iodine Protocol is that we just had so many patients who were so happy on high-dose iodine with the effects that it turns into this risk-benefit analysis. The rate of hyperthyroidism with high doses of iodine is not that great. I was doing the math the other day, and it's something like I should expect to see 1 or 2 cases per year in a practice of a couple hundred people, which— and to be clear, like, I'm not talking about full-blown Graves' disease requiring like radioactive iodine or thyroidectomy or anything extreme like that. I'm talking about a little bit too much thyroid hormone, feeling a little bit too revved up. You'll also get this if you, you know, use thyroid drugs, T3, Nature-Thyroid, Armour-Thyroid. These can all cause hyperthyroidism. It's really about adjusting the dose, right? But in my experience with hyperthyroidism, it's been very easy for us to get these patients back on track and there's no long-term term downside for them. It ends up being almost just like a mild flu, cold illness that lasts weeks to a month. And so that's been my overall general experience with this. I say that because the reality is you do have an increased risk of hyperthyroidism on high doses of iodine, but blaming the iodine for this is, is I think not fair because ultimately hyperthyroidism itself, if iodine caused it, everyone who took iodine for a long period of time would wind up with hyperthyroidism. You don't see that, right? And instead what's happening is there are underlying problems in the body, in the thyroid gland, that are resulting in the thyroid becoming— and there's lots of different things and reasons and hot nodules and cancers and, you know, toxic nodules and things like that that can do this, but also just underlying thyroid physiology. All those other factors can then create the situation or the context context or the right scenario for hyperthyroidism to emerge. And then when you load iodine into that system, that's when the hyperthyroidism will emerge, when it will happen, right? So in my experience, based on what my patients have told me, they're very happy continuing high-dose iodine and trying it. I also haven't seen it happen with what we tend to do, which is we do a loading dose of 50 milligrams for like 6 weeks. And then what we'll do is we'll taper back to 25 milligrams and we'll use that for as long as they want. Want. I don't imagine that all my patients are on iodine. Certainly based on supplement sales, that's not the case. Some of them continue it long-term because they like the effects. Others cut it short. Either way, I love the results that I see with high-dose iodine, and I still think that the benefit is worth that risk, mostly because I think the rest of that risk is modifiable if we get the, the diet, the lifestyle, the environment, and everything else right. Hopefully that's clear. Back to your question about polysorbate Brady. I don't know a ton about this supplement or this ingredient. I will go back and do a little research on it, but my impression has been that the, the dangers of this are overhyped. And if I think differently, having reviewed it, I will come back and let you know. All right. Thank you everyone for your questions. Thank you for your subscriptions and your membership at The Practice. It's been great chatting with you all today. Keep your questions coming. I really appreciate your supplement sales, your premium subscriptions, and your membership in The Practice. Take care. Have a great day. Great day.