If you work with patients with small intestinal bacterial overgrowth (SIBO), Crohn's disease, colitis, or food intolerances, you've probably heard about the elemental diet. But there's a lot of confusion about what the diet is, when it's appropriate, and how it can be used most effectively. In this interview, digestive health expert Lela Altman, ND, LAc, explains how the elemental diet allows the gut to rest and repair. She offers practical information for patients and practitioners about how to choose an elemental diet or how to make your own. In addition, she outlines the steps she takes to reduce the risk of relapse after coming off the diet. And she reveals the one question every practitioner needs to ask to identify a major red flag that would contraindicate the elemental diet.
Lela Altman, ND, LAc, began working in the medical field in 1998, first as a nursing assistant, then as a medical assistant. This experience inspired her to pursue an education in the natural health sciences. Altman earned her bachelor of science degree from The Evergreen State College where she focused on ethnobotany, biology, and chemistry. She then earned her doctorate in naturopathic medicine and masters of science in acupuncture at Bastyr University in 2011. She went on to complete a 3-year residency at the Bastyr Center for Natural Health. While working as a chief resident, she completed additional training in evidence-based medicine and carried out diabetes research. She recently created the Digestive Wellness clinic at the Bastyr Center for Natural Health, which she currently supervises. Additionally, she teaches full time at Bastyr University and has a private practice.
Integrative Therapeutics is focused on helping integrative medicine professionals cultivate healthy practices—from the development of science-based nutritional supplements to innovative, actionable resources and professional insights that have the power to inspire and enrich you, your patients, and your practice.
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Other resources include ElementalDiets.com.
Tina Kaczor: Hello, I'm Tina Kaczor with the Natural Medicine Journal. Before we begin, I'd like to thank the sponsor of this podcast, Integrative Therapeutics. Today we're talking about the elemental diet, which is a specialized diet sometimes used in patients with inflammatory bowel disease or small intestinal bacterial overgrowth, better known as SIBO. My guest today is naturopathic doctor Lela Altman, from Bastyr University. She's a specialist in gastrointestinal medicine and has used the elemental diet to improve her own health. Dr Altman, thank you so much for joining me.
Lela Altman: Thank you so much for having me.
Kaczor: So, let's jump right in. I'd like you to start us out with a definition. In doing a little research for this interview, I noticed that the elemental diet or, the words "elemental diet" have been around for decades. So maybe you can just start us out with just a simple definition of what is an elemental diet and what does that term exactly mean?
Altman: Sure, so a true elemental diet is a formula, it can be used in place of meals, and it proves all the nutrition that you need in its most basic, easily absorbed form. And that allows the gut to rest and repair. So, for example, instead of having proteins you would have individual amino acids, which are the building blocks of proteins. Instead of having fibers or starches it would contain simple sugars, which can be easily absorbed. And it also the essential vitamins, minerals, nutrients you need to survive. Fiber isn't typically included in an elemental formula because it can feed gut bacteria so that's something that we wanna look at and make sure it doesn't contain. There are a lot of formulas on the market that kind of market themselves as elemental diets that do have full proteins in them. And so it's not that those are bad formulas, but they're not necessarily totally an elemental formula. So it is important to know what you're looking for when you're evaluating formulas to determine whether or not they're elemental.
Kaczor: Okay, so we'll get into the diet specifics but it sounds fairly regimented in that, when I looked online I saw that there were a lot of various forms. There were homemade recipes and then there were products for sale, like you mentioned. And I guess ... the patient experience, can you tell me a little bit about the patient experience? I mean, is there a breadth of options for the patient where if they wanted to use their own kitchen they could do this diet themselves at home all the way to here's the pre-packaged thing? So what should a patient expect when they're put on this?
Altman: Yeah, absolutely. So you can make your own. Dr. Allison Siebecker has a great website, siboinfo.com, that has a recipe for a homemade version and there are also various other forms. So there are supplement companies that make them, there's, I mean, pharmaceutical-type versions of them. So there's a lot of range of what you can purchase and there's a lot variation in price based on that range. So it really depends on whether the patient wants to make their own and save a little bit of money or finds the convenience more important and maybe the taste more important and is willing to buy prepackaged option. Not all of the prepackaged options taste good but there are some that taste better than others.
Kaczor: So in, I guess ... Well it may depend on condition but is this something that people typically do for days, weeks, months, how long are we talking for patients?
Altman: It does really depend on the condition. So for SIBO it's typically done for 2 to 3 weeks. And an elemental diet, again, it's used in place of food. So you're not typically eating food with the elemental diet, you're only doing the formula. So for SIBO, that would be the formula only for 2 to 3 weeks. It can be used really anywhere from a few days for a few months depending on what you're not using it for. Or, sorry, not a few months, a month. So, if you wanna do a little bit of bowel rest you maybe would be on a elemental for 3 to 5 days. If you have maybe Crohn's disease and are using the elemental diet for treatment of an acute, really severe flare of Crohn's disease then you might be on that for up to 4 weeks. Also, sometimes I'll use the elemental formula for people who have a lot of food intolerance or allergies and are unable to maintain their weight, as a way to provide antiallergenic calories. And in that case they are eating food in additional to the elemental formula and so they may be on the formula for months while they're recovering their weight.
Kaczor: And in that, just to clarify, in that scenario they're doing it as an add-on to an otherwise tailored diet for them.
Altman: Right. Typically, if the elemental diet is being given completely alone without any other food it doesn't exceed more than 4 weeks.
Kaczor: Okay, and so what conditions exactly ... I know you mentioned food intolerances so just so are we are complete, what other conditions do you use the elemental diet for?
Altman: The big three that I use the elemental diet for is for treatment of SIBO, also for, again, as I mentioned, addition of calories in people who are underweight and have a lot of food intolerances. And then also just for a short term bowel rest, which might be needed in a Crohn's or colitis flare. There is some research on multiple other conditions though that elemental diets or sub-semi elemental diets have been used to treat. So eosinophilic esophagitis is one, cystic fibrosis, AIDS-related diseases, acute pancreatitis, sometimes rheumatological diseases. So there's a number of different conditions that we are looking at elemental diets to treat. My focus is mostly on the gastrointestinal diseases.
Kaczor: Okay, and so because it's void of fiber completely I'm guessing that the microbiota of the gut changes dramatically without those fibers. So how do people come off of this diet? In other words, how do they step off it without having a massive reaction to fiber from foods?
Altman: Yeah, so, I mean, the first part of that question really is kind of addressing the lack of fiber issue. These diets are not health long term. The elemental diet wouldn't be health long term, nor would necessarily the low-FODMAP diet or something like that. So when I take people off of the elemental diet, I usually have them start with homemade low-FODMAP broth. And if they are tolerating those well on the first day then I'll have them add some well-cooked, low-FODMAP veggies and they can even puree that into a soup to help break it down a little bit more. And if all is going well, the next day I will have them eat lightly cooked low-FODMAP veggies like steamed or lightly sauteed. And they can add some grains if they tolerate grains, though not everybody does. Meat, eggs, those things need to be well tolerated and fairly easy to digest after the elemental diet. And then on phase 3, I kind of transition back to a low-FODMAP diet, that's the diet I'm typically using. Some people are on a SCD [specific-carbohydrate diet] or SIBO-specific diet. I kind of transition them back to whatever diet they were on before that was working for them.
And then when their gut stabilizes, then we start to challenge food. So, for example, we would start challenging low-FODMAP foods to see what they can tolerate and what they can't. The idea is once the SIBO is cleared they shouldn't have to stay strictly adherent to one of those diets.
Kaczor: Okay, so that brings up a question because it seems like there's a lot of relapse in SIBO that a lot of ... there's a lot of talk in the chat groups about what does one do after they feel like they've exhausted many protocols. Do you find in your practice that there is a lot of relapse and a lot of people end up with a recurrence of it?
Altman: Yeah, definitely, so there's one study that shows the recurring aftertreatment with Rifaximin that's about 50% at 6 months. We don't have specific studies looking at different types of treatment and whether the recurrence rate changes, say, for somebody treated with Rifaximin versus somebody treated with an elemental diet. This is why, in my practice, I implement a lot of other things to help prevent recurrence like maybe long-term antimicrobial herbs, prokinetics, maybe a modified diet or a low-FODMAP diet. So, unfortunately, we don't have studies showing what if we do all of these other things too then what is the recurrence rate? But in my practice I think it's lower when we add in those things. And unfortunately, for years SIBO's just been treated with Rifaximin and follow-up testing wasn't even necessarily done and then that's it. And so the studies that we have are based on that type of treatment.
Kaczor: Okay, so, yeah, that answered one of my questions. I didn't know if this was a diet people had to go on intermittently but it sounds like if one can get to the root cause of what's going on and kind of get the gut into a healthier place and perhaps do a few things like longer-term antimicrobial herbs or prokinetics ... And just out of curiosity, prokinetics, when you say that in the naturopathic realm, what are you talking about exactly?
Altman: So, prokinetics can be in various forms. They can be pharmaceutical and they can be herbal and I use both, sort of depends on the person and what they respond to and sort of what level of prokinetics they need. So a prokinetic is essentially something that makes the gut move, it increases motility of the small intestine, which can be a really big problem, particularly in the autoimmune type of SIBO. And so naturopathically I'm generally starting with herbal options, which may include things like ginger and 5-HTP, bitter herbs, things like that.
Kaczor: Yeah and that brings up another question I have and that is with that idea of the lack of peristalsis within the small intestine that seems to be implicated in SIBO and those prokinetics working for those people, it seems to me, and correct me if I'm wrong, that stress has a lot to do with this. That people who maybe have more anxiety or anxiousness and we say they hold it in their gut kind of thing. Is that true in your experience? Do you notice stress having any effect on SIBO or on their GI symptoms?
Altman: I would definitely say so. I have a few patients whose only known risk factor for getting SIBO has been going through a very stressful event. And actually it's those people are the ones that tend to have fewer recurrences or not have recurrence at all because there's not an anatomical or motility issue that you have to deal with. Essentially once you clear the SIBO it's more stress management that helps keep it away. So yeah, that is definitely true. Also, if we think about the sympathetic versus parasympathetic nervous systems, so in the sympathetic nervous system is the fight or flight. And in the fight or flight nervous system, we shunt blood away from our digestive system to our limbs so that we can run. In a parasympathetic nervous system, that's the rest and digest, and so we're shunting blood to the digestive system to help break down food. And so if you're stressed you're kind of constantly in this sympathetic, fight or flight state and you are not shunting blood toward your digestive system to function properly. So that's a really concrete example of why stress would make this worse.
Kaczor: Yeah, yeah, that makes perfect sense. And then, I guess, kinda sticking to the mind-body idea and how the physiology is functioning, I guess, one question I had for you as a practitioner. Do you find that sometimes doing dietary restrictions like an elemental diet, especially when there is a lot of concentration, a lot of time and effort on eating the right things and making sure that the wrong things don't go down, and all of that, have you ever found that there's some trigger for relapse in those who have a prior eating disorder? Especially people, young women, and they might be in high school or college, they had bulimia or anorexia and here they are in their 50s and maybe they have to go through either an elemental diet or more likely the other diets you were talking like the FODMAP diets or the specific carbohydrate diets, very restrictive diets. And they get into kind of a neuroses about food is basically what I'm asking. Have you found that to be true at all?
Altman: Yep, unfortunately I have found that people having eating disorders by trigger them through giving them an elemental diet. So no, it wasn't in the history I was aware of and then they went on the elemental diet and then suddenly this history of an eating disorder became an issue because the elemental diet did trigger that. And that's also true for, I think, any restrictive diet. So a history of or current eating disorder for me is a relatively strong contraindication to an elemental diet or any other type of restrictive diet. I think, I agree with you, I think it's a fine line between treating SIBO and having disordered eating. So when you feel poorly every time you eat and every time you eat you get more bloated, it created a negative feedback pattern associated with food and over time that can cause bigger problems like fear of eating almost anything. You know that anything you eat is gonna make you feel poorly and I think that's something to be really careful of if you have SIBO or if you are treating a lot of SIBO.
Kaczor: Yeah, and thanks for saying it because I think that's a big heads up for everyone who is looking at using this diet. Especially practitioners, that's a very simple thing to have on an intake form so it doesn't have to be too deep of a probe with the patient. It can be very simply asked. So on that note, are there any other contraindications, any other patient populations that we should be aware of that we should be especially careful with this diet?
Altman: Well, you need to think about it, I think, really on a case by case basis. Anybody could have something that could be a contraindication. One of the biggest concerns people have is about weight loss or low BMI. I find that's a relative contraindication. A lot of people think of the elemental diet as a fast, which it's really not. You have all of the calories and nutrition you need and you can increase the amount of formula somebody's taking as needed to meet their caloric requirements. So I've actually had several patients who are really malnourished, had a lot of difficulty maintaining weight, actually gain weight on the elemental formula because it was providing nutrition for them in a way that they could actually absorb and utilize in their bodies. So, I mean, that's something to think about. Diabetes for me is some concern, especially with the insulin needs and blood sugar dysregulation. The elemental diet, as I mentioned in the beginning, the carbohydrates come in the form of sugar and so it does have some potential for blood sugar dysregulation if you're drinking it really quickly. You can really mitigate not a lot by drinking it slowly over time but that would be another concern.
Fungal overgrowth can definitely be exacerbated by an elemental diet, again, because of the sugar content. I initially, when I started using it, thought that maybe kidney disease would be a concern. But I looked it, wasn't really able to find anything that verified that there was any issue with giving an elemental diet in somebody with kidney disease. And actually there was one study I found that showed improvement in kidney function in people with chronic kidney disease on an elemental diet. You might wanna be a little bit more careful in somebody with compromised liver function because amino acid metabolism can lead to ammonia production and build up in their liver and so that might raise liver enzymes. But again, if you're only doing this for 2 weeks or so that really shouldn't make a big difference. And then, as I already mentioned, really that history of the eating disorder is a big red flag for me and then contraindication.
Kaczor: Well that's ... I know this has been incredibly helpful from a practical perspective. I think that in less than 20 minutes we've touched on a few things that are definitely what I would consider clinical pearls for our listeners. So I really appreciate you taking the time of your schedule and offering up your expertise for our listeners. So thanks for being here with me.
Altman: Oh, it's been a pleasure. Thank you.
Kaczor: And once again, this is Tina Kaczor with the Natural Medicine Journal. And I'd like to thank the sponsor of this podcast, Integrative Therapeutics.
In over half of all cases of hospitalization for a cardiovascular event, the first symptom is the event itself. So anything we can do to get any early indicator that something is going wrong in the cardiovascular system can have a huge impact. Erectile dysfunction is one such early signal. According to cardiovascular health expert Daniel Chong, ND, identifying sexual dysfunction is essential for improving cardiovascular outcomes.
Approximate listening time: 30 minutes
It may seem counterintuitive to interview a cardiologist, and not a urologist, on the topic of erectile dysfunction (ED). But we now know that ED is a result of endothelial cell dysfunction and ED can be an early warning sign of systemic atherosclerosis. Looking at ED from a cardiovascular perspective is essential.
That’s why we invited cardiovascular expert Daniel Chong, ND, to talk to us about ED’s connection to heart health. In this interview, Natural Medicine Journal’s editor-in-chief, Tina Kaczor, ND, FABNO, asks Chong about the complex interplay between vascular function and sexual function.
According to Chong, cardiovascular disease always has some degree of contribution—potentially a major one—in ED. That’s in part because blood flow is the key facet to obtaining a full erection. Cardiovascular dysfunction, including plaque in the arteries that regulate that blood flow, can therefore have an impact on ED. Even before plaque development becomes a problem, endothelial dysfunction in the inside walls of the arteries can play a role in erectile function.
In this enlightening interview, Chong explains the different issues that can contribute to ED, including anatomical, physiological, and psychological problems. It’s an important listen for any practitioner who sees men, since beyond being a problem in and of itself ED can be an early signal of other serious health concerns.
Daniel Chong, ND, has been a licensed naturopathic physician, practicing in Portland, Oregon, since 2000 and focusing on risk assessment, prevention, and drug-free treatment strategies for cardiovascular disease and diabetes, as well as general healthy aging, and acute and chronic musculoskeletal injuries. Chong has also completed certificate training in cardio-metabolic medicine from the American Academy of Anti-Aging Medicine and is an active member of the Society for Heart Attack Prevention and Eradication (SHAPE). In addition to his clinical work, Chong serves as a clinical consultant for Boston Heart Diagnostics Lab.
Tina Kaczor, ND, FABNO: Hello. I’m Tina Kaczor for the Natural Medicine Journal. Today, we’re going to be talking about erectile dysfunction and cardiovascular disease with Dr Daniel Chong. Dr Chong is a naturopathic physician with a private practice in Portland, Oregon for the past 17 years. He specializes in what he likes to call "vascular wellness optimization." He’s also the founder of the web-based consulting company, the Healthy Heart Project which offers a number of educational and direct consulting options for both the general public as well as healthcare practitioners on how best to assess and reduce risk for cardiovascular disease. Dr Chong also lectures and serves as a clinical consultant for Boston Heart Diagnostics Lab.
Thanks so much for joining me today, Dr Chong.
Daniel Chong, ND: You're welcome, Tina. Good to be here.
Kaczor: As I mentioned, our topic today is erectile dysfunction. At first, it may seem odd to our listeners that I’m talking to a cardiology expert and not a urologist or men’s health expert but we now know that erectile dysfunction is a result of dysfunction of endothelial cells and in fact, this can be an early warning sign of systemic atherosclerosis. Dr Chong, can you start us out with a brief overview of how erectile dysfunction and cardiovascular disease are related?
Chong: Sure. I can do my best there. There’s definitely going to be different circumstances that can contribute to erectile dysfunction. Some of which may not be actually anatomical, so to speak, or physiological from the cardiovascular perspective but I would say the majority is at least indirectly affected because even if we’re talking, for example, about a psychological contributor which we may touch on later, if somebody has dysfunctional arteries down there in the penis, they’re going to be more vulnerable to effects from psychological aspects than they would be otherwise. In other words, a young teenager may get stressed out in an early sexual experience but that’s not going to affect function as much as it could a 50-year-old man.
Anyways, in general, we could just say that cardiovascular disease is going to have some degree of contribution and potentially major. Obviously, blood flow is the key facet to obtaining a full erection and certain arteries are going to be more vulnerable to impacts from the development of cardiovascular disease but even so, the arteries in the penis may or may not actually have plaque in them but they can still dysfunction. Typically, we know, and we’re going to talk about this later, in cardiovascular disease, the preceding step prior to actual anatomical change or plaque development is endothelial dysfunction or dysfunction in the inside wall of the arteries and even that going on without any actual plaque having developed yet can affect erectile function and not to be noticeable by the person.
All in all, I guess you could say they’re intimately intertwined because you have to have good blood flow. It may or may not have plaque. Plaque may or may not be actually playing a role yet but it will in some cases and cause really significant dysfunction, but even minor dysfunction is going to be at least the partial result of the arteries starting to misbehave for various reasons that hopefully we’ll touch on.
Kaczor: Yeah. I actually came across some mention of erectile dysfunction in that whole idea of plaque formation. One author said that it could signify in some patients, or at least it should be followed up to see if it signifies subclinical atherosclerosis.
Kaczor: Yeah. Atherosclerosis being pretty much asymptomatic in people until there’s larger consequences. On that note-
Chong: Right. Yeah. Sorry to cut you off. Sadly, it’s been shown that in over 50% of cases of hospitalization for a cardiovascular event, the first symptom is the event and that’s over half of all of them, so anything we can do to get any early indicator of something in this, so to speak, before, for example, erectile dysfunction, is hugely important for us because we are not doing a very good job at least conventionally in identifying early on what’s going on with people.
Kaczor: Yeah. I look forward later in this discussion to talk to you about how to assess it, to find early markers besides just the symptom of erectile dysfunction but let’s start with the larger picture in conventionally recognized erectile dysfunction and cardiovascular disease risk factors. Can you talk a little bit about like when we’re, as clinicians, who walk into our office, who we should suspect it in or at least engage in the conversation because many patients won’t bring it up themselves unless they're directly asked?
Dr Chong: Yeah, absolutely, so, certainly age. The older a man gets, the more potential there's going to be for all kinds of different changes going on physiologically. Some people are well aware of testosterone production, how crucial that is and that certainly begins to change as a man ages. But certainly, very standard, interestingly enough, it’s the same standard risk factors you might consider for cardiovascular disease in general in terms of high blood pressure, diabetes, certainly, smoking.
Conventionally, you're going to see high cholesterol as a stated contributor but we can certainly talk in more detail about that because I know that some people out there in the functional medicine world, naturopathic world, et cetera, consider high cholesterol as a past tense risk factor for cardiovascular disease which it really is and it’s just more complicated than that. Obesity, lifestyle factors in terms of exercise and then certainly, psychological factors, depression and anxiety, et cetera are all going to be key things.
I also want to make a just brief mention even though this is kind of a topic in and of itself, when we talk about erectile dysfunction, obviously, we’re talking about men but it should be very clearly stated that the same potential processes are going on in women as they age. Women with difficulty with sexual activity or orgasm, et cetera, may in fact be having their own version of “erectile dysfunction” with the clitoris as essentially an analogous structure in a woman and all of these blood flow issues can occur in women as well. It’s important to really kind of make mention to that. I say men, I keep saying men, as men age, blah, blah, blah, but it really should be looked at as both sides of the coin, so to speak.
Kaczor: That’s actually an important point. Thank you for mentioning that.
Kaczor: I want to do a follow-up on that cholesterol thing that you just mentioned because I think that that’s kind of top of mind. I think it’s important to give voice to any new data on looking at cholesterol because I'm with you on it being much more complex and it’s more complex than I understand. I'm happy for you to kind of flesh it out for us.
Chong: Yeah. I mean, I guess anybody that says that cholesterol has nothing to do with cardiovascular disease is not really thinking about the fine details of the situation. You can't have a plaque form without cholesterol and lipoprotein particles being involved because they are what are the sort of primary components to the development of the plaque.
What I don’t agree with conventionally is the idea that high cholesterol, in and of itself, is just going to definitively contribute to cardiovascular disease because obviously, there are many people out there who have relatively “high cholesterol” who don’t get cardiovascular disease. There's certainly something else going on that’s playing a role as to whether or not high cholesterol is going to lead to that issue in some people versus others.
Long story short, I consider cholesterol and related markers to be secondary factors. They are absolutely involved but they are not … There's going to be other things that help sort of determine the likelihood or lack thereof of the high cholesterol sort of turning into cardiovascular disease. That’s a really fun discussion in and of itself. It could be another hour or so by itself but hopefully, that kind of answers your question, at least preliminarily.
Kaczor: Well, it brings up another question which is-
Chong: Certainly, keep going with that. Yeah.
Kaczor: Yeah. If cholesterol is considered a secondary factor, and I see what you're saying, cholesterol is not … needs to be present but can't be causative because there's not a cause and effect 100% of the time.
Kaczor: If it’s secondary, what are you looking at as primary?
Chong: Well, to me, the absolute most important thing that’s going to contribute to the potential or lack thereof of eventual cardiovascular disease development or i.e. plaque, development is the health and vitality of the walls of the artery and how well they're functioning. In other words, the healthier, more nutritionally replete the walls of the arteries are themselves and the better they're being sort of manufactured in the first place by the body, are going to be the primary factor that leads to vulnerability or not.
If you imagine like … I would like to use analogies. On a coastline, you may have, let’s say, in Hawaii versus somewhere else on the mainland. Hawaii is made up of volcanic rock which is, tends to be a little bit more brittle and it can sort of erode more easily. If you have waves crashing into the wall, into a wall of rock in Hawaii, it may erode more quickly. Then, an analogous wall somewhere else in the world that’s made up of a different, harder, more resilient material, the waves are still crashing into them with the same potential force but one’s going to erode more quickly than another.
If we then relate that to the vascular system, somebody who has poor nutrition and tons of inflammation, oxidative stress, et cetera, and especially long-term poor nutrition, they're not going to be able … especially if we’re talking about collagen production, they're not going to be able to manufacture the sort of strong, resilient vascular walls that they should which will inevitably be, if they are stronger, will inevitably be more resistant and resilient to the impact of the turbulence of the flow of blood.
There are certainly other things that are going to impact that as well especially the turbulence itself and the viscosity of the blood. That’s going to make for essentially like stronger waves crashing in which obviously, the stronger the waves is crashing into the area, the more potential there is for erosion as well. To me, long story short, the primary situation that’s going to lead to the potential development of plaque is a combination of two primary factors. That’s the vulnerability of the wall of the artery and the stress that is being placed on the wall of artery.
Chong: If you look at every single risk factor we know of, they are impacting one or both of those factors.
Kaczor: Okay. When you say stress, you mean mechanical forces, as well as chemical?
Chong: Chemical. Absolutely.
Kaczor: As in oxidative stress?
Chong: Correct. That would be one of them. I mean, even environmental toxins, different types of infectious organisms and certainly mechanical stress as well or what we call blood viscosity which is impacted by a variety of factors. Primarily, probably the main ones for blood viscosity would be hydration and like even iron levels or high sort of … basically, concentrated solid substances in the blood and then also, cloudiness of the blood, how high is fibrinogen levels and things like that are going to impact the viscosity of the blood. Then, the classic risk factor of high blood pressure is going to be too, more or less, stress on the wall of artery.
Chong: Sorry. One other thing. I mean, one of the ways that high cholesterol may be contributing to things is it’s known that the higher the cholesterol is, the stronger the impact on the vascular wall is. It actually causes … High cholesterol itself can contribute to endothelial dysfunction or stress on the function of the wall of the artery.
Kaczor: Doing mechanical forces, you're saying, to the viscosity of the blood.
Chong: Right, and more technical reasons, like it literally messes with certain aspects of how the wall, the endothelium is supposed to be functioning. It’s not just that it gets into and becomes part of the plaque. The higher your cholesterol goes, the potentially worse the endothelial function initially.
Kaczor: Okay. Let’s switch gears a little bit. If we’re talking about endothelial dysfunction as the commonality between erectile dysfunction, atherosclerosis, cardiovascular disease, it’s all about a healthy endothelium.
Kaczor: It’s interesting, in that same paper I mentioned before, I came across a term that I had not seen before. It was the endothelium as a single organ which I thought was a really interesting concept like, “Oh,” thinking, “I'm sure it’s different, in different tissues,” but just the idea of overall health of it being a singular thing was interesting to me.
Chong: Right. People look at the blood vessel as like these tubes that are just allowing for the passage of blood flow. There's so much going on at the wall of the artery physiologically. It is absolutely an entire organ.
Kaczor: Let me ask you this. As far, for us as clinicians, what are either biomarkers or assessment tools, how do we gauge endothelial function in a patient?
Chong: Well, technically, when we’re specifically talking about endothelial function, there's only a few ways to directly assess that. Clinically, they're going to involve some way, shape, or form of actually testing, in-office, the function of the arteries themselves. There's a general … There's a few … There's basically two main machines that I'm aware of. One is called an EndoPAT and one is called the EndoTherm that are designed to directly assess endothelial function.
The way they basically work is they … You have your fingers in some type of device that’s monitoring either blood flow or temperature at the fingertips. Then, you basically occlude the artery and the arm like you would with the blood pressure cuff. You have to do that for about 5 minutes which is not enjoyable for the patient because, as you can imagine, it isn’t feel very good to have your blood occluded for 5 minutes. Then, prior to doing that though, you're doing a general assessment on blood flow and temperature of the fingers. Then, you occlude the blood flow and then you let it out all at once.
When the blood comes, as you might imagine, rushing back into the extremities in the fingers, you should get some degree of expansion of the arteries. Normal function would lead to the arteries, as the blood really rushes in there, would lead to the arteries expanding to a certain extent. People that have endothelial dysfunction, their blood vessels will not expand appropriately. The machines are designed to sort of read that, sort of the tip, where your tips of your fingers are sitting, the machines is detecting, is there a significant enough change in temperature and or blood flow.
There's also something called arterial pulse velocity which basically, there's a smaller device called an iHeart like an iPod but it’s iHeart. I'm not connected to any of these companies or anything like that but that is a newer device that’s being developed that checks sort of indirectly the same thing. It looks kind of like a pulse oximeter but it’s actually detecting arterial pulse wave velocity and literally how quickly a pulse rate is moving down the arterial tree.
If you might imagine, the sort of left compliant and arterial, an artery is, the quicker the pulse rate is going to move down it. That’s generated by heart, a heartbeat. Those are the only ways that I'm aware that are … Those are the only things that I'm aware that are being used in-office to directly assess endothelial function. There is a lab test that can be measured with people called ADMA. It stands for asymmetric dimethylarginine. That is considered a surrogate or indirect assessment of endothelial function. The higher the ADMA is, the higher the potential for endothelial dysfunction because it’s a direct sort of inhibitor of nitric oxide production.
Kaczor: All right. Well, that leads us into our next little piece, doesn’t it? Nitric oxide production being integral to the whole relaxation of the smooth muscle and the endothelium to allow for blood flow whether we’re talking about the fingertips or the penis. Can you talk a little bit about nitric oxide? Maybe briefly mention how an assessment can be made, the ADMA being one of the means of assessing that as far as the blood test and anything else that might be accessible to a general physician or clinician that might be seeing these patients.
Chong: Well, I mean, endothelial function is, to me, the ideal way to get an assessment of that because I'm a big proponent of the idea that we want to check end of point factors as often as we can. Classic example of this is looking at the different impacts of certain dietary changes on cholesterol markers and making conclusions about whether or not that is good for the vascular system or not, certain changes like HDL going up, for example, after the implementation of a certain diet did not guarantee by any stretch of the imagination that you're having a positive effect on the vascular system so I like to use endpoint markers or end, sort of, functional markers as much as possible so far and away still, the best way to me to assess nitric oxide levels is via those endothelial function tests that we mentioned already.
Other ways to sort of try to get an assessment of it, the only other way that I’m really aware of is if you've seen … You've been to enough conferences, I know. You’ve probably seen this company that has this little saliva test that you can use to check basically nitrate levels in the saliva. That’s going to be … Nitrate is a crucial factor, nitric oxide production as well, so some people are using these little saliva tests to check what a person’s typical nitrate intake is and then recommending dietary or supplement interventions based on that. Those are really the only ways that I’m aware of to sort of really truly get an assessment on that other than, obviously, history and talking to a person, seeing how well things are working, so to speak.
Kaczor: Can I ask you a question? I don’t mean to put you on the spot and I do not know the company that’s offering nitrate levels in saliva but is this something that’s been validated or is it with any rigor or is this one of those early adoption things that happen?
Chong: Right. You're asking me if something has been validated with scientific tests or research? Can you restate?
Kaczor: Or at least … Yeah.
Chong: You do that with everything which is great. That’s why I like you so much but I don't know for sure. This is … In all honesty, I haven’t really looked too deeply into that method of assessment with people, so I wouldn’t be able to say with any certainty at all. I know that they’re quite widely used and it’s not a very complicated, technically complicated test so I think it’s pretty straightforward. I do recall seeing literature being made available by these companies but I have not looked that in-depth at that at this point.
Kaczor: Well, I appreciate your honesty. When you're on the cutting edge, early adoption of new technologies is part of our … We get to do that. We get to be right there doing, instituting things but it’s important, I think, for us all to go at a pace that has some, at least reproducibility, if not rigor.
Chong: Absolutely. The other thing that I would say to add to that is like using different angles of assessment is also crucial, not just relying on one piece of information whether it be cholesterol. That’s why the classic conventional mistake is like, “Okay, we’re going to check and see if you have a high risk for cardiovascular disease. Let’s check your lipid panel. There’s so much more beyond that that can be done to assess and evaluate people and get a much clearer picture. That’s a classic idea, just sort of not settling on one thing, not just using the newest thing, whatever it is. Use as many tools as you can within reason to get the clearest picture.
Kaczor: Yeah. I want to continue on the molecular biology of this and specifically, we have just a few minutes left, really talk about-
Chong: Time flies when you're talking about erectile dysfunction.
Kaczor: What’s that?
Chong: I said time flies when you're talking about erectile dysfunction.
Kaczor: Well, oxidative stress, being something that you mentioned and it’s just something that we’re … That inflammation is kind of always at the forefront of anyone who’s doing integrative medicine or optimal wellness or however you want to term it. I guess my thought is this. In a concise way, can you tell me if you use any actual blood markers that are widely available and what are some of your favorite ways of, kind of across the board, addressing oxidative stress issues, which even beyond erectile dysfunction, it becomes part and parcel with that but it’s also just part of life and part of being alive, is creating oxidation?
Chong: Right. In the realm of assessment, especially if we were going to so far as to separate out inflammation in oxidative stress because obviously, they aren’t exactly the same thing, when we’re talking inflammation, the primary markers that I’m measuring with people certainly are high sensitivity CRP as our sort of general global marker of inflammation or lack thereof. When we’re talking about the vascular system, I’m also typically going to be checking something called Lp-PLA2 or what’s also known as the PLAC test. That is more specifically an inflammation marker for the vascular system so it’s going to actually reveal immunoactivity and inflammation going on in the wall of the artery whereas a high CRP is not going to be able to definitively determine that or not. MPO or myeloperoxidase is a later stage, nonspecific but frequently correlated marker for late stage vascular inflammation for a vulnerable vascular system.
In the realm of oxidative stress, the 2 primary markers that I might look at is actually … number 1 is actually oxidized LDL so it’s pretty hard to have moderately elevated LDL levels and a high amount of oxidative stress and not see a relatively increased level of oxidized LDL in the bloodstream. That is sort of a good, what you'd call extracellular oxidative stress marker, but we can also get intracellular oxidative stress for different reasons.
For that, you can also check something called 8-oxoguanine which is an actual, actually a urinary test. Not too many labs run that. I’m not sure if we’re supposed to name names here but that is an … If you just Google 8-oxoguanine test or something like that, you can probably find the labs that run that but that’s going to give you more of an assessment of intracellular oxidative stress. Then, beyond that, you can, in all honesty, get a pretty good idea whether or not somebody is going to be a candidate for high oxidative stress just by talking to them and looking at them and that type of thing as well.
Kaczor: Yeah. A lot of those other markers for cardiovascular disease like obesity, even the aging process, certainly smoking, all-
Chong: Right. Absolutely.
Kaczor: Obviously, we would take into account for oxidation. Can you let me know or let the listeners know your top three? Someone looks at you and they’re like, “Listen. I do everything right. I exercise. I eat well. My BMI is normal. I don’t drink. I don’t smoke. What are the three supplements you …” You only get to see them once. They’re going to leave your office.
Chong: These people are eating well, you said, in my opinion?
Kaczor: Okay. That brings up the point. What would that look like in your opinion?
Chong: No, no. I’m sorry. I’m just-
Kaczor: We only have 2 minutes left but what would be an ideal guy in your opinion and then-
Chong: No, no, no, no, no. I’m sorry. I was just clarifying the question. If these people are already eating well like they’re eating lots of fruits and vegetables, et cetera and I’m just talking about supplements, the 3 main ones I’m going to recommend are going to be vitamin C, magnesium, and then probably some type of concentrated plant-based antioxidant. As a naturopath, herbal medicine trained, I have an affinity to hawthorn but also, I frequently recommend hibiscus tea to people.
Kaczor: Nice. Hibiscus being, you're also from Hawaii so that’s-
Chong: Good point. You could certainly go beyond that and complement it with things like arginine, citrulline, and then there are a number of nitric oxide precursor type of products that are high in dietary nitrates.
Kaczor: Well, Dan, I really appreciate this. I feel like we could have a whole part 2 where we go into the therapeutics and more details into all of this but I think the listeners have gotten good overview today and I really do appreciate the time you've taken and your expertise, and best of luck with your Healthy Heart Project.
Chong: Thank you, Tina. It was good to talk to you and happy to help as I can.
Kaczor: All right. Take care.
Chong: All right.
One in four men over the age of 65 has urinary incontinence, according to the Centers for Disease Control and Prevention. In this interview, men's health expert Ronald Morton, MD, FACS, describes how urinary incontinence is diagnosed and treated. He also provides detailed information about the key medical devices that are available to treat this condition.
Approximate listening time: 14 minutes
Although urinary incontinence is not as common in men as it is in women, it is more prevalent than many people think. According to the Centers for Disease Control and Prevention, one in four men over the age of 65 suffers from it.
The underlying causes are often similar in both genders: aging and weakening of the pelvic floor muscles. However, pelvic trauma or prostate disease or surgery can also contribute to the problem in men.
Urinary incontinence creates significant quality-of-life issues, so finding effective treatments is very important.
In this interview with urologist Ronald A. Morton, Jr., MD, FACS, Natural Medicine Journal’s publisher Karolyn A. Gazella discusses the prevailing treatment options for male urinary incontinence. For some men, pelvic floor exercises alone can provide relief. For others, diet and weight modification are necessary. Others may opt for more advanced interventions, including surgery.
Surgical options range minimally invasive to extensive. On the simpler end of the spectrum is the basic urinary sling. In this quick procedure, a sling is inserted to replicate the support lost in previous interventions or trauma. On the other end of the spectrum is an artificial urinary sphincter, which regulates urine flow through a pump.
Of course, surgical interventions are not without risks and side effects. Morton addresses those and discusses how to determine whether a patient is a good candidate for surgery.
Listen to this interview to learn more about the current treatment options for male urinary incontinence, as well as Morton’s predictions for the future of incontinence treatment.
Scroll down for the full transcript.
Ronald A. Morton, JR, MD, FACS, is the vice president of clinical sciences for the Urology and Pelvic Health division of Boston Scientific, a position that he has held since August 2015. Before joining Boston Scientific, via acquisition, Morton worked for Endo International plc as chief surgical officer, American Medical Systems. Previously, he worked for GTx, a biotech company in Memphis, TN, as chief medical officer. Prior to joining GTx, Morton was chief of urology at Robert Wood Johnson Medical School and director of urologic oncology for the Cancer Institute of New Jersey. He also held an endowed chair position as director of the General Clinical Research Center. Morton holds a BA in natural sciences from The Johns Hopkins University and received his medical doctorate from The Johns Hopkins University School of Medicine. He has board certification as a diplomat, American Board of Urology.
Karolyn: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today our topic is male urinary incontinence and my expert guest is Dr. Ronald Morton. Dr. Morton, thank you for joining me.
Dr. Morton: Hi, Karolyn, and thank you for having me today.
Karolyn: Well great. Well, let's just start with the basics. How is urinary incontinence diagnosed in men?
Dr. Morton: Karolyn, urinary incontinence is not as common in men as it is in women, although it does happen more commonly than people think. The main causes are as it is with women, aging and weakening of the pelvic floor muscles. But more importantly, and the reason for many of the interventions that we have for urinary incontinence in men is it can be due to trauma to the male pelvis and/or surgery for diseases of the prostate. When I say disease of the prostate I mean both benign conditions like BPH, which many men suffer from and are aware of, and then also prostate cancer, which is a very common cause for surgery on the male pelvis.
Karolyn: And then what's considered the gold standard of treatment for this particular men's health condition?
Dr. Morton: There are many ways to treat male incontinence, as there are many ways to treat female incontinence. The usual approach that will be taken by a urologist is to go from the least invasive to more invasive solutions until the patient is happy. I think that one thing that always has to be kept in mind is that this is really a quality of life issue for most men, especially since urinary incontinence in males is generally a disease of men who are older. The median age of diagnosis of prostate cancer is about 63 years of age or so. Since operations on the prostate are the common cause for this, they're generally older men and it's a quality of life issue.
What one male will find satisfactory control of the urinary incontinence might be totally unsatisfactory to another. So the general approach would be to start with exercises, commonly called Kegel exercises. The same exercises that we suggest that women do who have a mild degree of urinary incontinence and see if that won't help. If Kegel exercises won't help and it's not something that can be helped with diet and weight modification, then we go into more invasive treatments for male urinary incontinence.
The first level of invasion is a procedure that only takes a few minutes, really, less than a half an hour called a male urinary sling. It's much like the slings that are used in women. It supports the male urethra and holds it up, providing support that has been lost due to the previous surgical intervention or pelvic trauma in hopes that that will correct the incontinence.
Fore more severe degrees of incontinence we often times need to move towards what is really considered, as you say in your question, the gold standard for severe incontinence, which is the artificial urinary sphincter [AUS]. In that procedure, a cuff is placed around the urethra and this cuff is connected to a pressure-regulating balloon, which controls pressure in the cuff, keeping the urethra closed and preventing leakage of urine and also a pump, which is placed in the scrotum. When it's time to urinate, the male can just activate the device. The fluid leaves the cuff and goes into the pressure-regulating balloon, opening the urethra. The male can then urinate and then after a period of lock-out time, the cuff will refill, returning him to a state of continence.
Karolyn: So let's talk about these two, the sling and the sphincter. What determines whether or not a patient is severe enough for the sphincter versus the sling? What's the difference between those two patients, the one that gets the sling and the one that gets the sphincter?
Dr. Morton: Good question because again, it has a lot to do with personal preference. But there are some general guidelines that one can go by. When we measure incontinence and it can be a difficult thing to put a number on, but most men who have incontinence will use urinary pads in their shorts in order to trap urine leaking. A good gauge of to what degree a male leaks is how many times they have to change that pad. Now, some men will as soon as there's a small amount of urine because of the discomfort it will cause will change that pad right away. Some men tend to allow the pad to get very, very soaked before they'll change it. Everyone behaves a little bit differently.
A way to get a handle on exactly how much leakage a man has it to do what we call the pad weight test. So we'll give them all the pads that they might need for a day and a bag that can prevent evaporation and they just collect the pads that they use for the day, put it in this bag, and everything is pre weighed, and then we weigh it to see what the volume of urine leakage is.
A rule of thumb, if they're leaking around five pads or 300cc of urine a day, that's severe and is more likely to be treated with the artificial urinary sphincter. Degrees of urinary leakage that are less than that can be and generally might be recommended that they be treated with the sling procedure.
Karolyn: Now are there are any contraindications associated with each of these options, the sling or the sphincter? So in other words, are there men who would not be a good candidate for either of these options?
Dr. Morton: Well, they have to be able to undergo a surgical procedure, and while the sling procedure is relatively short, it does require at least a regional anesthetic. The artificial urinary sphincter procedure is a little bit longer and requires a general anesthetic so they have to be fit for the surgery. The sling is generally not recommended for men if they have been treated for prostate cancer with radiation. The outcomes there haven't been as good as they have been with the artificial urinary sphincter so in that setting we generally would recommend a sphincter as opposed to a sling, even if they were otherwise a good candidate for a sling.
Karolyn: What about side effects? Are there any side effects associated with either of these devices?
Dr. Morton: I'll take that question separately for each of the two devices. The side effects associated with the sling are that if you don't choose the patient in the best way, two things can happen. One, the patient can not have their incontinence adequately treated. A second issue is if you put a sling in a patient whose major problem is not one of the urethra but is a bladder issue, and that can be sorted out ahead of time with uro dynamics, but if you did you may render that patient obstructed or in urinary retention. The problem doesn't have to do with external sphincter deficiency for that patient.
For the artificial urinary sphincter what we're doing is we're placing this cuff around the urethra. It does over time potentially compromise some of the blood supply to the urethra in that area and you can get what's known as atrophy of the urethra in the area of the cuff. When you get atrophy in the area of the cuff there can be a return to urinary incontinence. Of course for both of these procedures, since you're putting a foreign body in, there's a risk of infection, although infectious problems with these devices have been relatively low.
Karolyn: Okay, that makes a lot of sense. Now, I'm just curious because you have a certain expertise in this area as chief surgical officer of American Medical Systems. What general advice do you give to physicians who are treating men with urinary incontinence?
Dr. Morton: One, most of the advice that I have is for physicians who have men with incontinence but aren't necessarily the experts in treating them. There's a couple of things. One of the things that our research has shown us is that many men who are subjected to surgery for prostate cancer, for example, and who then suffer from incontinence don't recognize, or aren't made aware that there are treatments for it and they suffer in silence we like to say. So, if we can get anything out to the many physicians listening to this podcast it would be don't let this happen to any of your patients. Make sure they understand that if they do get incontinence after, for example, radical prostatectomy, there are options and there are potential solutions for this.
The second message is I spend a lot of time working with the engineers and we're constantly looking at ways to come up with a better mouse trap if you will. What can we do to avoid the complications we spoke of earlier? What can we do to help physicians identify the proper patients so we don't use a sling in a patient who should've had an AUS, or an AUS in a patient who should've had a sling? And what can we do to make the functioning of the AUS a little bit easier so that in this elderly population of men they are always candidates for the device?
Karolyn: Yeah, that makes a lot of sense and I'm glad that you brought that up about suffering in silence and information. Obviously, a well-informed patient is the best patient to have. So letting that patient know his options is absolutely critical.
So one final question for you Dr. Morton. What is on the horizon when it comes to devices for this particular issue with men? Do you see existing devices just being improved? Do you see new devices? Are we kind of where we should be? Look into your crystal ball and tell me what the future holds for this.
Dr. Morton: I don't know if I'm the best person to predict the future, but I think that our efforts are to make sure that A, these are the right solutions. We are constantly looking at, are there other options? Are there other ways to manage urinary incontinence? Could we come up with a less invasive way to place the sling or a less invasive device would replicate the great performance of a sling?
On the urinary sphincter side of things it's a mechanical device, so can we simplify that mechanism so that it's easier for the patient to implement? Remember there's a patient interface with the AUS. Most devices that we implant, like when a cardiologist implants a pacemaker, there's no patient interface. The patient doesn't have to decide whether or not their pacemakers work. It's in and it just works. For our device, at least for the artificial urinary sphincter, there's that patient interface. So if we can improve that patient interface with the device and make it as reliable as possible, that's what we're looking to do in order to improve the overall performance of the device and have men have a greater satisfaction with their quality of life.
Karolyn: Yeah, that makes a lot of sense. Well, this has been very informative. Once again, thank you, Dr. Morton, for joining me today.
Dr. Morton: Karolyn, thank you for having me.
Karolyn: Have a great day.