Latest / Gladden Longevity Podcast / Functional Medicine: Beyond Traditional Thyroid Treatment - Episode 320

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Functional Medicine: Beyond Traditional Thyroid Treatment - Episode 320 · Gladden Longevity Podcast

• 0:00
  then coming on, looking at the hormones, I think it's a big deal.
• 0:02
  We've had, you know, a low fat, cholesterol kind of dogma for a while.
• 0:06
  And you being a cardiologist, you probably have been preached that for a bit.
• 0:09
  But cholesterol is the raw material building block for all your hormones, right?
• 0:13
  Outside of your peptide hormones, which are gonna be your insulin growth hormone, most of your hormones are gonna be steroid based and that's a cholesterol backbone.
• 0:20
  And so you need that healthy cholesterol building block from from healthy fats and proteins that are aren't oxidized ideally, right?
• 0:26
  Grass-fed, good quality,
• 0:28
  to be key but that's gonna be the building block for that raw material.
• 0:31
  The guts are a major role and I can't tell you how many patients I see that have different infections whether it's SIBO right SIFO right.
• 0:39
  small intestinal bacterial overgrowth, small intestinal fungal overgrowth or candida overgrowth or H.
• 0:44
  pylori or other infections.
• 0:46
  These kind of infections play a big role because 80 % of your immune system is in the gut.
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  And so anytime we have autoimmunity, is like the fastest most diagnosed disease really you see is autoimmune issues.
• 0:58
  Any kind of weird new disease you see today, like the new autoimmune condition.
• 1:02
  Your body's destroying itself in another unique way.
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  It's like, well, the gut plays a big role because 80 % of all your immune cells are in the gout and the gap.
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  So that.
• 1:13
  So when we deal with inflammation, not only do we have to really focus at the gut.
• 1:47
  Welcome everybody to this edition of the Gladden Longevity podcast.
• 1:50
  I'm your host, Dr.
• 1:51
  Jeffrey Gladden.
• 1:52
  And today we're going to be talking to Justin Marchegiani However, the podcast, as you know, is devoted to answering five big questions.
• 2:02
  How good can you be?
• 2:03
  How do you make 100 to do 30?
• 2:05
  How do you live well beyond 120?
• 2:08
  How do we live young for a lifetime?
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  And how do we develop a 300 year old mind?
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  And the conversation with Justin today, he's a chiropractor who went into functional medicine with a passion for hormone optimization and thyroid optimization becomes an
• 2:21
  interesting conversation.
• 2:22
  You'll see his approach and then you'll see the, some of the additions that we, that we have in addition to some of his thought process that kind of rounds out the podcast.
• 2:31
  But I think you'll enjoy this.
• 2:33
  should be interesting for you to, to hear.
• 2:37
  somewhat of the different and complementary approaches that we have and you can decide for yourself what you think is best.
• 2:45
  Welcome everybody to this edition of the Gladden Longevity Podcast.
• 2:48
  I'm your host, Dr.
• 2:49
  Jeffrey Gladden, and I'm here today with Dr.
• 2:52
  Justin Marchegiani I don't think I pronounced your last name correct.
• 2:56
  Why don't you say that for us, Dr.
• 2:59
  J?
• 2:59
  got it, Dr.
• 3:00
  Justin, Marchegiani Marchegiani, you got it.
• 3:03
  Yeah, you're right there.
• 3:04
  Good.
• 3:05
  Yeah.
• 3:06
  In the neighborhood at least.
• 3:07
  So, Justin, um, you know, you, you kind of have, started out in the chiropractic world and transitioned into a functional medicine kind of thought process and approach.
• 3:20
  And I think that's led you into, a real fascination with hormone and thyroid and things like that.
• 3:27
  Do you want to talk us a little bit through your.
• 3:29
  your journey of how you got to where you are.
• 3:31
  Great question.
• 3:32
  So I have an autoimmune thyroid disease myself Hashimoto's and so I wrote the book I spent the last 10 years writing a book called the thyroid reboot all on kind of the root causes
• 3:42
  and in regards to Hashimoto's and thyroid dysfunction and most people think about thyroid they just see their conventional endo here you got high TSH here's some synthroid let's
• 3:51
  bring that down and then you're normal but you could have a whole bunch of other symptoms and when you understand root cause physiology you know that you didn't fix all the other
• 3:58
  physiological imbalances in the
• 4:00
  background.
• 4:01
  You didn't fix the gut inflammation.
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  You didn't fix nutrient deficiencies.
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  You didn't fix any of the stress physiological hormone imbalances.
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  That wasn't touched.
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  But conventional medicine feels really good that they did their job.
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  Which I get.
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  You don't want overly high TSAs.
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  That causes problems.
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  And so I was on this journey of trying to help my own health issues.
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  And before that I worked in a surgery center where I would help position patients that had
• 4:22
  limb amputations because of chronic high blood sugar.
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  And then the more you go down the functional medicine kind of pathways, you see how insulin resistance, high blood sugar, oxidative stress is part of kind of the root cause
• 4:34
  of most conditions.
• 4:36
  Especially your background being a cardiologist in insulin problems.
• 4:39
  Number the one—number one, you know, root cause of cardiovascular issues in that area.
• 4:43
  Especially a lot of the blockages and such.
• 4:45
  Yeah, we see that all the time in our practice because we're doing a two hour glucose tolerance tests with insulin curves on everybody.
• 4:54
  And it's really dramatic when you do that to see somebody that has what looks like a normal hemoglobin A1C and even a normal fasting insulin.
• 5:03
  When they get challenged, my gosh, they, you know, they either their insulin shoots way up or they're, or, they cover the glucose or the glucose and insulin shoot way up.
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  And they're diabetic for an hour or two.
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  And it's really dramatic in terms of the health, you know, destroying impacts of that, right?
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  You get increased con senescent cells and destroying the glycocalyx and the arteries.
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  And so it's a big deal.
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  It's one of these things that I call it.
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  It's looking behind the curtain, behind the curtain.
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  And to your point in traditional medicine, it's just not people look at the first curtain.
• 5:41
  never opened that and then I never opened the curtain behind that curtain to see what's really going on.
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  So yeah, that's kind how we see that.
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  Dr.
• 5:48
  Ph.D.
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  And what do we need to remove from a diet and lifestyle standpoint?
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  What nutrients and supports can we do to accelerate it versus hey, what drugs can we do to down regulate block re uptake ports?
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  Put a break on physiology to control symptoms versus hey, how can we up regulate and support the healing of physiology?
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  So one's a allopathic model, right?
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  The other one's a vitalistic, let's get your body to heal kind of model.
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  I think you made a good point about the first thing that we see that typically needs to be done is to think about what needs to be removed.
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  What do you take out, right?
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  When you're taking this functional approach, people are always wanting to know, what are you going to do for me?
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  What are you going to put in?
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  What are you going to do?
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  Because medicine, that's usually what they do.
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  They write a prescription and put something into the system.
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  But many times it's about what you take out.
• 6:40
  You know how you either improve detox capabilities, upregulate detox genetics, know, lots of things like this that we look at in great detail and how you get certain things out of
• 6:51
  the body before you actually start putting stuff in.
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  And it can be done simultaneously when you see there's obvious deficiencies.
• 6:57
  But it's really important for the audience to understand that what you take out is as important as what you're putting in.
• 7:05
  Correct.
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  You how I look at it and many functional medicine doctors do.
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  I look at the underlying stressors physical chemical and emotional stressors that broke the person down.
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  The problem is what broke them down in the beginning then creates imbalances in their body systems.
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  could be hormones it could be gut detox immune it can create nutrient deficiencies it can create inflammation systemically in the vasculature and then that creates symptoms
• 7:30
  downstream.
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  And so it's really easy to be hyper focused on all the symptoms the fatigue.
• 7:34
  the high cholesterol, the depression, the brain fog, but then forget to go upstream to see what symptoms or what systems are not working well, right?
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  We want a system-based approach versus symptom-based.
• 7:46
  And then also go back to the underlying stressors that- that proceeded, that started the whole domino rally.
• 7:52
  And so if you look at it like that, you have a much better physiological, I should say philosophical kind of framework where you're gonna catch
• 8:01
  all the root causes that started this whole domino cascade along the way here.
• 8:06
  Yeah, I think it's another good point you're making around the stressors.
• 8:10
  And to your point, they can be physical or chemical or whatever, but many of them can be psychological uh and even psych spiritual.
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  And so in our world, the life energy circle, we have five circles over here.
• 8:24
  The life energy circles are really the one that binds all the other four together because it's, the most important.
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  And people are carrying around a lot of toxic thoughts or
• 8:33
  you know, lots of psychological trauma that they're living in reaction to.
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  It has a massive impact on their biology.
• 8:42
  right, and understanding the genetics that actually makes somebody more susceptible to the trauma in the first place, and knowing how to actually make them more resilient by
• 8:55
  augmenting genetic function, SNP function.
• 8:57
  We find that to be super helpful at help
• 9:00
  Moving people in other words setting them up physiologically to then benefit from the psychological inputs and the spiritual know revelations and things like that.
• 9:09
  It's like it's like um creating the Substrates so you can actually handle the healthy things are that you want to do So, I mean that's true with addiction as well, right?
• 9:18
  There are People that are genetically much more prone to alcoholism per se once you understand what genes they have you can go in and actually manipulate those
• 9:27
  to where they're less prone to be addicted.
• 9:28
  Now you can actually start to work on the rehab.
• 9:30
  Dr.
• 9:30
  And so when you look at and you manage your physical, chemical, emotional stressors, that's activating like we talked about the epigenetics that's gonna activate the genes,
• 9:39
  right?
• 9:39
  Because just because you have a certain gene for something, doesn't necessarily have to express because the epigenetics play the role on which genes flip on or off.
• 9:47
  And and like we talked about, you mentioned the emotional stress side of it.
• 9:52
  It's very hard if you're in chronic pain to be emotionally present.
• 9:56
  When you're in pain, you're just so focused on the pain, it's gonna be hard for you to
• 10:00
  process the different stressors, right?
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  Or if you don't sleep, you don't sleep last night and now you're in chronic pain, good luck trying to deal with your taxes the next day or good luck trying to have a, you know,
• 10:10
  difficult conversation with your wife or kids.
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  You're just not gonna be able to handle it as if you had a good night's sleep and your body feels good.
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  And so the physiological, the physiological structural side of the fence plus the chemical
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  that all feeds into the emotional and of course if the emotional is good, right, and you're feeling good and you're loving your relationships and loving your job, that's gonna
• 10:28
  allow better healthier chemistry and that's gonna allow better healthier body but they all kind of feed in and the more you you work on that three-legged stool the better balance
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  you have.
• 10:37
  Yeah, that's right.
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  For us, it's uh yeah, we that's approach we take is you can't leave any part out.
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  And it's one of the problems with medicine in general is that it becomes too siloed.
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  You know, I was a cardiologist.
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  People get trained or specialized in certain things.
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  And it's it's really does an injustice to the entire system, if you will, to just focus on one aspect of one organ system.
• 11:00
  So, yeah, I think I think.
• 11:02
  We're synchronized on that.
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  Talk to me a little bit about your approach to thyroid disorders, because you talked a little bit about Hashimoto's.
• 11:09
  Dr.
• 11:10
  so I got a book, The Thyroid Reboot, and in that book, most we talk about, you know, the root underlying factors that drive thyroid issue.
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  And it's not just a, you have this high TSH, here's some level of thyroxine, look, it's good now.
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  We look at the underlying issues and most thyroid issues, there's an autoimmune component.
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  That means your immune system is attacking your thyroid gland.
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  And then over time, that can create scar tissue that can decrease the functional capacity of your thyroid gland.
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  Uhm— that also can uhm— impact the hormones from working in binding to receptor sites.
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  Now conventional medicine, as you know, when it has— comes to autoimmune issues, what does conventional medicine typically do?
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  It's pretty straightforward.
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  They're going to steroids.
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  They're going to some kind of a biologic.
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  Whether it's like Remicade or Humira or some kind of a you know suppressant right those are the big three.
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  Now when it comes to thyroid autoimmunity those side effects of those medications are kind of like maybe not appropriate for autoimmune thyroid issue like they would be for Crohn's
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  or some kind of RA condition.
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  So they do nothing.
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  So they don't even look under that rock because they have nothing to do to it.
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  There's not a ICD 10 or CPC code they can do to get billing for it.
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  They just leave it alone.
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  But in the functional medicine world there's a lot we do.
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  Right?
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  We can look at supporting healthy selenium levels.
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  We can work out supporting healthy vitamin D and glutathione.
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  Because these all produce inflammation.
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  They help balance your T regulatory system.
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  We can look at dealing with dysglycemia.
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  That blood sugar roller coaster.
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  You said patients can be, you know, diabetic for an hour or two after each meal.
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  I see it all the time.
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  I have patients run what I call functional glucose tolerance.
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  I haven't given them a blood sugar meter.
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  I have them take their blood sugar, right, fasting and then one hours, two hours later, they should be no higher than 120 in the first hour back below 100 within our two.
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  can't tell you how many patients are still diabetic in two hours.
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  They're still above 126.
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  It's like that is not good.
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  And what that's doing, like you talked about, right, the the the glycohalics and the cross linking of your proteins in your vasculature, what that's doing to the interleukins that's
• 13:09
  driving more autoimmunity, what that's doing to your adrenals because your adrenals, you got this blood sugar.
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  So your blood sugar goes up.
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  your pancreas beta cells make a bunch of insulin, right?
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  The more resistant you are, the more insulin you make.
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  That is a whole bunch of bad things to your hormones.
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  If you're guy, it's more rummage, rummatization.
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  If you're a female, it's causing more testosterone.
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  Not good either way.
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  That's causing the your blood sugar to drop.
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  When your blood sugar drops, especially suddenly, that's called reactive hypoglycemia.
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  That can create more cortisol.
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  That can create more adrenaline issues and make you feel anxious and jittery.
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  And I call it the blood sugar roller coaster.
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  Blood sugar up.
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  too much process too much inflammation, beta cells come out, knock the blood sugar down, adrenaline, cortisol bring it back up and then you're in this blood sugar kind of spiral.
• 13:54
  Yeah, no, I think that's that's right.
• 13:56
  I would say that it's nice that you're doing the functional glucose tolerance test with the, you know, with the CGM continuous glucose monitor or whatever device you're using.
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  I will just let you know, though, that there are people that will never spike their sugar above 120 that have significant insulin issues.
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  So when we do the insulin curve, as well as looking at the glucose, we see that people will have a high resting insulin level.
• 14:21
  should be around two or three, maybe 12 or 13.
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  We'll see that their blood sugar may go from 90 to 118, but instead of going from two or three up to 10 to control that, or 10 or 15 to control that, they may shoot up to 60.
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  And so that super high spike in insulin, while it's controlling the blood sugar,
• 14:44
  is also driving risk of cancer.
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  It's driving aging, it's driving inessant cell formation, it's stiffening arteries, it's doing all kinds of things behind the scenes.
• 14:53
  And that's why I say the curtain behind the curtain behind the curtain is really interesting.
• 14:58
  And then when you look at the genetics behind that, you can say that some people just are built not to actually get the signaling when they consume glucose through the in-creten
• 15:07
  system to actually tell their, their pancreas to start making or releasing insulin.
• 15:13
  And so for those people, they're going to spike and then they're going to crash it on the back end.
• 15:18
  So there's many, many, many, many, uh, curtains to look behind to actually piece it together.
• 15:23
  The point being, once you do it, you can actually start from the jeans and work forward.
• 15:27
  Now, you know, Oh, well, this person will respond better if we do this and this and this, and you can kind of build it from the ground up if you will.
• 15:34
  And that's how we think about, um, you know, helping people with this.
• 15:38
  So.
• 15:38
  think fasting insulin is really important to look at.
• 15:41
  I think you can really tell a lot in that first hour after a meal because your blood sugar has got to go up that then pituitary sees that and then you get this huge beta cell
• 15:50
  production.
• 15:50
  So that first hour usually you're gonna get a pretty good window.
• 15:53
  I like finger pricks because I find that the interstitial fluid assessment which is like your CGM like your freestyle Libre 3 or Dexcom that's using interstitial fluid and it
• 16:03
  tends to just give you a little bit more of a delay.
• 16:04
  It doesn't give you that fast immediate response so it's a little bit delayed which it's fine if you're type
• 16:08
  one or you wanna do it over a long period of time just to see I think it's good but I you get a faster look at it um when you just do the blood by itself.
• 16:16
  Do you see the blood sugar go up though in that first hour or so and then you see the big insulin?
• 16:21
  necessarily.
• 16:22
  Not necessarily.
• 16:23
  Well, we see all kinds of combinations.
• 16:26
  So, for example, we'll see somebody where their blood sugar doesn't go up at all, and yet their insulin will go up dramatically.
• 16:33
  So they control the blood sugar extremely well.
• 16:36
  That's not the issue.
• 16:37
  it on a fasting insulin though.
• 16:38
  You probably see it there on an insulin.
• 16:41
  No, the fasting insulin is not enough.
• 16:44
  You're well, you do a two hour glucose tolerance test with an insulin curve.
• 16:49
  So you measure glucose and insulin and fasting.
• 16:53
  75 grams of glucose measured again, both at an hour and both again, two hours.
• 16:58
  Now you actually can see what's what's actually happening in both in both with the insulin and the glucose.
• 17:03
  And we find that that gives us tremendous insight.
• 17:06
  You know, you take somebody with cancer because
• 17:09
  You know insulin is a driver of malignancy and so you can see who's susceptible to more insulin release You also get an idea of just how much insulin resistance they have So it's
• 17:23
  really been phenomenal.
• 17:24
  We just saw a gentleman this morning and You know typical story, know fasting blood sugar was normal fasting insulin was elevated at about 14
• 17:32
  His blood sugar went up to 185 and his fasting or his one hour insulin went up to I think over 70 and then at two hours his fasting insulin was even higher.
• 17:46
  It was like 80 or 90 and his blood sugar was coming back down.
• 17:49
  So you see all kinds of permutations there to let you know kind of the extent of the insulin resistance and we find that super helpful.
• 17:57
  think it's good.
• 17:58
  There's a lot of ways to do it.
• 17:59
  So when I do it, I just do patients meals.
• 18:01
  And so that way we can test their meals and see how it does throughout the weeks.
• 18:04
  I've had a patient last week where they were coming in in that first hour at 180.
• 18:09
  And within an hour or two, they were at 140, still incredibly elevated, just a little tweak of the diet.
• 18:13
  And we had them, you know, below that 120 in the first hour and back below 100.
• 18:16
  I like that because I'll have patients test three different random meals.
• 18:19
  The functional the glucose tolerance you're talking about is nice.
• 18:23
  You have a lab and you can do that.
• 18:24
  My only concern is, you know, some people even if they're
• 18:27
  healthy, that's 75 grams of sugar.
• 18:29
  They may still not be able to handle it even if they're even if they're on point just because that's such a stress to their body that may be too much for most people.
• 18:36
  But I think either way it's blood sugar is such an important thing to look at and the more tools or windows you can use is vital.
• 18:43
  Yeah, no, I think that's right.
• 18:44
  I think you want to understand it as best you can.
• 18:47
  And then we are big users of CGMs just because people don't like to prick their fingers that much and you can continuously see what's happening.
• 18:56
  And we find them very useful.
• 18:58
  One of the things that I wish they would create though, and I've talked to several manufacturers about this, is actually an insulin sensor.
• 19:04
  Yeah.
• 19:07
  get insulin on there, we're gonna be amazing.
• 19:09
  Even if like, you know, I got the keto mojo, it's got a strip for ketones.
• 19:13
  It's got a strip for insulin.
• 19:14
  Just give me a strip for insulin, man.
• 19:16
  And I'm like, I am tickled pink.
• 19:19
  Yeah.
• 19:20
  really, it's kind of a deficit, I think, in the field that we don't have the ability to have a sensor for insulin that we have to, you know, go through a laboratory test to get
• 19:27
  it.
• 19:28
  yeah.
• 19:29
  Like if I were to do a startup right now, I'd be like, let's find a way to do insulin with that.
• 19:33
  That'd be amazing.
• 19:34
  It's gotta be being researched now.
• 19:36
  But I agree.
• 19:37
  And again, insulin's a big deal, especially for guys listening, right?
• 19:40
  That's gonna upregulate aromatase.
• 19:42
  That's gonna cause more of your teeth, testosterone to go to estrogen.
• 19:45
  And for women listening, right?
• 19:46
  That upregulates the 1720-Liase enzyme, which causes more of your female hormones to go to androgens, which is the root cause of infertility in most women, right?
• 19:55
  You have this elevation of prolactin.
• 19:57
  high amounts of androgens that causes ovarian cyst, right?
• 20:00
  That's why the major medication for treating PCOS, right, is what?
• 20:04
  It's Glucophage, Metformin.
• 20:06
  It's an insulin sensitizing compound.
• 20:08
  So insulin impacts both sexes equally, but in different ways.
• 20:12
  Yeah, yeah, no, I think that's a really good point that you make.
• 20:16
  And I would just point out to men that what we find is that genetically, again, people have different predispositions, whether they're male or female, to aromatize testosterone
• 20:26
  and estrogen.
• 20:27
  So there are some women that are low aromatizers, generally speaking, and some men that are very high aromatizers.
• 20:34
  And it's important to understand
• 20:36
  you know, where you fall and then to measure the actual levels.
• 20:40
  Um, because what we find as well is that the concept of replacing testosterone or boosting testosterone and trying to block estrogen production is really, it's really foolhardy in
• 20:52
  our case.
• 20:53
  Um, because men need estrogen just as much as women need estrogen, especially if you have APOE4 genes and you have predisposition for Alzheimer's, estrogen is a godsend to your
• 21:04
  brain.
• 21:05
  And so.
• 21:06
  actually bone density is more related to estrogen than it is to testosterone.
• 21:10
  So you really, need estrogen.
• 21:13
  It's just that we need it in a different balance.
• 21:14
  And so the idea of crushing estrogen production is really, I think, kind of a fool's errand, but that's kind of how we're.
• 21:22
  you see lots of doctors, you know, prescribing HRT for men, I think way too willy nilly.
• 21:27
  Number one, they when they prescribe it, they prescribe way outside of the physiological norms.
• 21:33
  Your typical guy makes about six to eight milligrams per day.
• 21:36
  And the average doctor starting at 150 milligrams per week.
• 21:40
  And they don't they don't even dose it physiologically appropriate.
• 21:43
  um I say the more you can dose it daily if you have to.
• 21:47
  First off guy in your 20 30s 40s even 50s if you're doing the right thing you should be able to get the aromatization in check at your diet and check and you shouldn't have to
• 21:56
  need testosterone.
• 21:58
  Let's say for instance you're doing all the right things all the principles all the herbs all the nutrients and you need it fine but it should come later into the game and it
• 22:05
  should be used within that physiological norm start low.
• 22:09
  the lowest possible, right?
• 22:10
  Maybe 4 or 6 milligrams per day.
• 22:12
  Try to do it every day or every other day at the lowest level.
• 22:15
  And ideally, if you're having a compound or Remedex and use estrogen blockers, you're not doing it right.
• 22:20
  You're lazy.
• 22:20
  You need to do it at the right physiological levels.
• 22:23
  As you know, the major reason why most bodybuilders have heart issues, it's not necessarily because of too much testosterone.
• 22:30
  It's because they're taking estrogen blockers that destroy their heart.
• 22:33
  Right?
• 22:33
  You let— you mentioned earlier, estrogen is very cardio-protective on the heart.
• 22:37
  And if you—
• 22:38
  lower estrogen too much with drugs like Arimidex or uhm— which— what you see— I see a lot of doctors prescribing testosterone with Arimidex or estrogen blockers in the compounds
• 22:48
  and that can cause a lot of cardiovascular problems.
• 22:51
  And again, we're not talking dim or, you know, glutathione or sulfur that naturally helps clear it out.
• 22:55
  We're talking about, you know, blocking drugs, if you will.
• 22:57
  Comments on that.
• 22:58
  What do think?
• 22:59
  So what, just for the audience to understand what we're talking about here, it's important to realize that testosterone is turned into estrogen, uh, both for men and women.
• 23:07
  And then the body ends up detoxing the estrogen through three different pathways.
• 23:11
  Um, they're called hydroxylation pathways.
• 23:15
  So there's a, a 16, a four and a two hydroxy pathway.
• 23:18
  And the two hydroxies really the safe pathway.
• 23:21
  And then you need to be able to methylate that hydroxy compound for the second stage of detox.
• 23:27
  And some people are poor methylators.
• 23:29
  So we go in and genetically look at that and then see how well they're able to methylate.
• 23:33
  And there are many things we can do to boost methylation capacity.
• 23:37
  So that being said, we want to decrease the 4-hydroxy, which is the most toxic for both men and women.
• 23:42
  It increases breast cancer risk, prostate cancer risk, et cetera.
• 23:47
  And then the 16-hydrosky is not
• 23:49
  good but not quite as bad as the four.
• 23:51
  So the dim comment is that we can push those metabolites of estrogen through estrone and then down through the two hydroxy pathway preferentially.
• 24:01
  So that's important.
• 24:02
  And these drugs, the aromadexies referring to blocks the enzyme that takes testosterone and turns it into estrogen in the first place.
• 24:10
  when you're thinking about
• 24:12
  hormone optimization.
• 24:14
  It's so important not to simply measure blood levels.
• 24:17
  It's so important actually to measure the urine metabolites in our world to actually understand how is somebody metabolizing these things because it's different and just
• 24:26
  genetically driven for in part, but it's also driven by what people are eating or what they're taking or how much stress they're under and things like that.
• 24:33
  So you can't just look at the genetics and get it right either.
• 24:36
  It can give you an idea of where you might have a leverage point, but you've got to measure those.
• 24:42
  those urine metabolites to know what you're dealing with to keep somebody safe.
• 24:46
  That's the way we think about it.
• 24:47
  Dr.
• 24:48
  I'll use some of the precision analytics testing a lot to look at testosterone, you know, the estrogen, the 2, 4, the 16, the 2 methoxy, 2 hydroxy pathways, that's important.
• 24:57
  And as I was talking about earlier, a lot of doctors use estrogen blocking medication because they give way too high of hormonal dose for someone.
• 25:05
  And it's just they're lazy.
• 25:06
  They don't want to adjust the dose.
• 25:07
  They want to give it weekly.
• 25:09
  They want maximal compliance.
• 25:10
  They don't want to have to worry about fine tuning.
• 25:12
  And in functional medicine world, hormones
• 25:16
  They're measured in picograms and nanograms.
• 25:18
  That's right to the, you know, to the ninth degree or to the 12 degrees.
• 25:21
  These are very potent things.
• 25:23
  And so I try not to use hormones unless someone absolutely needs them or we're using precursor hormone support.
• 25:30
  And so, for instance, guys are given testosterone way too early.
• 25:34
  Uhm— and also testosterone can thicken the blood as you know.
• 25:37
  Can increase your platelets, make your cells more sticky.
• 25:40
  And then of course, we have to be using physiological norms.
• 25:43
  And so, if I give testosterone and recommend it, we're giving it to guys that are older, that have already maxed out everything regarding sleep, movement, exercise, nutrient
• 25:53
  deficiency, zinc, selenium, you know, some of the herbs that have a really good impact on LH and FSH.
• 25:59
  And then if we have to, then
• 26:00
  we can recommend that but I'd say 95 % of guys that come to me that have some of these issues, whether it's muscle libido mood, we're able to avoid having to go that bio
• 26:09
  identical t routes and if we have to there's micro dosing strategies that work far better and keep you within the physiological range in that top 25 % or so.
• 26:20
  Yeah, I think that's a good point.
• 26:21
  You know, the other thing for people to realize as they listen to this is that everyone's aware that women go through menopause, which essentially means that the life cycle of the
• 26:31
  ovary for releasing eggs on a monthly basis has diminished.
• 26:37
  And the light egg cells inside the testicles that make testosterone also have a shortened life expectancy compared to your own life expectancy.
• 26:46
  Correct.
• 26:47
  If you, if you live long enough, odds are that the light excels will eventually poop out.
• 26:53
  and so you may end up needing testosterone, but there are many, many things that can be done for a woman in her thirties who's experiencing, you know, not even pre menopause, but
• 27:05
  sort of pre pre menopausal kind of changes and symptoms to kind of optimize the biology.
• 27:11
  And the same is true for men that are experiencing,
• 27:15
  you know, low T symptoms in their thirties.
• 27:17
  And one of the things we find is that there are a lot of environmental bioregulators that get in the way, a lot of plastics and things like this.
• 27:24
  So we're testing for all of that in our people as well to see what are they, what are they exposed to?
• 27:29
  What, you know, what do we need to detox?
• 27:31
  Not only get the detox system to work, but what do we need to sort of get out of their environment or out of, you know, the soap they're using or the plastic bottles are
• 27:39
  drinking from or whatever they're doing.
• 27:41
  Right.
• 27:41
  So it's a
• 27:42
  It's a complex arena here and there's so many endocrine disruptors or hormone disruptors in these chemicals that we're exposed to every day that a lot of the problems for a 35
• 27:53
  year old can be both stress related as well as environmentally related.
• 27:57
  It's kind of how we think about it.
• 27:58
  Dr.
• 27:59
  I agree and I'm seeing lots of guys come in to me in their 20s and 30s and they're being recommended testosterone, which I think is a it's a miscarriage.
• 28:11
  Number one, to these guys potentially could be infertile because as you increase testosterone, you're gonna take the FSH which talks to the sartorium cells that make sperm
• 28:19
  and then your cells elated is the LH ones that make testosterone and do you silence that's why guys notoriously, you know, get atrophy of their testicles.
• 28:27
  because of testosterone.
• 28:28
  so that happens too long, you may not be able to reestablish that feedback loop and you're gonna have low sperm and you may be infertile.
• 28:34
  And so most people aren't thinking about that.
• 28:36
  So from a functional medicine standpoint, how you treat a 60 year old is gonna be different than how you treat 20, 20 or 30 year old.
• 28:43
  And so I just want
• 28:44
  the guys to know that and with my females too of course you know this different guys kind of have this andropause that's kind of more slower and steady as you mentioned doc
• 28:52
  regarding the sartoli cells or the cells of lady kind of pooping out a little bit a little bit more slow and gradual where women's to be a little bit more punctuated in that late
• 29:00
  late 40s early 50s with their follicular reserve kind of going dry if you will and so there may be a greater need for a female hormone intervention on the hormone side.
• 29:09
  So we like to treat, you know, the sexes and you know, a little bit differently in that because how their physiology works, we gotta meet them where their physiology is.
• 29:17
  100%.
• 29:17
  Yeah, 100%.
• 29:20
  It's just that a lot of men are aware of the fact that women go through menopause, but they're not aware that they also run a timeline and that they will go through enderpaws at
• 29:30
  some point.
• 29:30
  um So that being said, we have people, clients in our seventies who still have
• 29:36
  you know, quite healthy testosterone and free testosterone levels, right?
• 29:39
  That's another thing that's not looked at is sex, women, binding, globulin and free testosterone.
• 29:44
  Cause it's not the, it's not the testosterone number that really matters.
• 29:47
  It's what's the free testosterone, right?
• 29:49
  That's really what's doing the work.
• 29:51
  So again, it's a sophisticated, it's not just walk into a tea clinic.
• 29:56
  your tea is low.
• 29:57
  We'll give you tea and give you an aromatase inhibitor.
• 29:59
  I think that is such a disservice to not only the person, but really to humanity on some level.
• 30:05
  because of the sperm counts and the other things you're mentioning.
• 30:08
  And it's not uncommon for me to be able to help the men that come and see me and double their testosterone.
• 30:13
  Double it.
• 30:14
  Mm-hmm.
• 30:15
  Sure.
• 30:15
  we have to look at all of the Xenoestrogens in our environment have to be removed.
• 30:20
  whether it's the phthalates in your soaps or in your dish washing detergents or the little tree car freshener or the glade plug-in those are all a soup of estrogen.
• 30:30
  right.
• 30:30
  And estrogens and also the organochlorine, pesticides, the glyphosate when you have estrogens or Xenoestrogen compounds that comes into your system and that shuts down LH
• 30:40
  that shuts down luteinizing hormone.
• 30:42
  So the feedback loop in the pituitary the
• 30:44
  cells, the cells of ladeic to make testosterone drop.
• 30:47
  So the first thing you have to do is get rid of the chemicals in the environment that's screwing up that feedback loop.
• 30:52
  That's number one.
• 30:53
  Even if you're gonna use testosterone or herbs or whatever, or nutrients, have to reestablish healthy feedback loop and the first thing is get the environmental toxins
• 31:02
  down.
• 31:03
  That's right.
• 31:03
  Again, well, it's back to what we said at the beginning.
• 31:06
  One of the earliest comments you made was beginning by looking at what it is that needs to be taken out, right?
• 31:13
  This is, it's really key.
• 31:14
  You can't, other words, you can put in all day long, but if you're not taking out the stuff that needs to come out, you're kind of, you know, trying to breach a wall that's
• 31:22
  unbreachable.
• 31:23
  So yeah.
• 31:24
  me they're like, well, what should I do for detoxification?
• 31:26
  Well, the first thing is let's just work on removing stuff like from our environment.
• 31:30
  There's that because it's so much easier to detoxify once you've pulled out all the crud.
• 31:35
  Now your system can work so much better once the you know, the junkie foods out.
• 31:41
  That's right.
• 31:42
  And to your point about that is that if you're if you're still being exposed to all those toxins, even though you're on a good detox protocol, right.
• 31:50
  It's coming in as fast as you're getting it out.
• 31:53
  So ah we see that with mercury all the time.
• 31:57
  You can actually look at the rate of mercury clearance.
• 32:00
  through a Quicksilver test and you can see whether or not people are actually getting rid of it faster than they're accumulating it or vice versa.
• 32:07
  So we've been able to detox people of mercury without having to go to chelation, but a lot of it involves getting the mercury out of their system, whether it's the fish they're
• 32:16
  eating or the coal plant that's up the road or whatever it else where it's coming from, getting the air purifiers in.
• 32:22
  And then when they get in the sauna and you give them the charcoal and you give them the
• 32:26
  metal free and the other things that help them pull it out through the gut as well as the skin.
• 32:30
  We see mercury levels go back down to normal very quickly.
• 32:33
  So it's pretty cool.
• 32:34
  Yeah.
• 32:35
  absolutely.
• 32:35
  then coming on, looking at the hormones, I think it's a big deal.
• 32:38
  We've had, you know, a low fat, cholesterol kind of dogma for a while.
• 32:42
  And you being a cardiologist, you probably have been preached that for a bit.
• 32:45
  But cholesterol is the raw material building block for all your hormones, right?
• 32:49
  Outside of your peptide hormones, which are gonna be your insulin growth hormone, most of your hormones are gonna be steroid based and that's a cholesterol backbone.
• 32:56
  And so you need that healthy cholesterol building block from from healthy fats and proteins that are aren't oxidized ideally, right?
• 33:02
  Grass-fed, good quality,
• 33:03
  to be key but that's gonna be the building block for that raw material.
• 33:07
  Yep.
• 33:08
  No, that's right.
• 33:09
  I think, you know, we went through a phase where we demonized cholesterol.
• 33:13
  We all know this.
• 33:14
  And then we went to the low fat, low everything.
• 33:19
  And we robbed ourselves of a lot of things also, you know, the C15 molecule, which shows up in whole fat dairy and things like that.
• 33:28
  People were losing a great deal of that.
• 33:32
  And it turns out that C15 tends to be associated with longevity.
• 33:37
  So there's beyond that cholesterol, as you point out, is needed for lots of steroid based hormone synthesis.
• 33:44
  And so you don't want your cholesterol to be too low.
• 33:47
  In fact, if you look at population data, people that have cholesterol's total cholesterol's below about 220 actually have a higher mortality relative to people that
• 33:57
  have a cholesterol of around 220 or 240.
• 34:01
  So and obviously, if it's too high and it can be that increases mortality as well.
• 34:06
  But
• 34:07
  This is where for us in the cardiology world, it really boils down to focusing on the glycocalyx and the nitric oxide system to be able to keep an artery healthy and then
• 34:17
  decreasing insulin resistance, high blood sugar spikes, glycocalyx, things like that.
• 34:22
  So all that becomes super helpful as well.
• 34:25
  Yeah.
• 34:26
  Dr.
• 34:26
  I think that's really important and when we look at things like statins for instance, A statin is an HMG CoA reductase inhibitor, right?
• 34:33
  When you look at most medications, they just inhibit.
• 34:35
  It's a PPI, proton pump inhibitor, an ACE inhibitor, angiotensin receptor site blocker, right?
• 34:41
  You know, all these medications, right?
• 34:42
  They just inhibit, inhibit, inhibit.
• 34:43
  But when you look at that, what are the— what's the major thing that stimulates that HMG CoA reductase enzyme?
• 34:49
  The major compound, the major hormone that stimulates its insulin.
• 34:53
  right?
• 34:53
  Because we know most cholesterol is made by the body and your body can overproduce it if you're in a insulin resistant state and if you're overly inflamed cholesterol can go up
• 35:02
  and so I'd be curious to know your kind of ranges.
• 35:06
  don't typically worry too much about cholesterol until it starts going into the 300s but if I start to if I'm really trying to rule out risk factors we're gonna look at things
• 35:15
  like oxidized LDL small dense LDL and make sure that cholesterol is not oxidizing we're gonna look at
• 35:22
  clotting factors, because we know most cardiovascular incidents, right?
• 35:26
  Most MI's is not necessarily a blockage, it's a clot being thrown.
• 35:29
  60 % of clots being thrown.
• 35:30
  So we'll look at D-dimer, fibrinogen, we'll look at homocysteine, we'll look at fasting insulin, we'll look at LPPLA2, which is an inflammation marker in the blood vessels, and
• 35:39
  I'll do that to kind of weigh kind of you know the balance of where these lipids are at and also just making sure that trig to HDL ratio ideally is close to one as possible for
• 35:48
  healthy uhm— go ahead.
• 35:50
  so we do that.
• 35:52
  We take probably a little bit different approach in that we're looking at markers of inflammation, including LPPLA2, but myeloperoxidase as well.
• 36:01
  We're also looking at oxidized LDL, F2H2, prostane, ADMA, SDMA, and also microalbumin creatinine.
• 36:09
  This is a really sensitive marker for vascular inflammation.
• 36:14
  So you put those together, it turns out that inflammation is what drives events.
• 36:18
  And then we look at genetics around clotting because some certain people are more predisposed to clotting and when they are, we'll put them on things like natokinase or
• 36:26
  pycnogenal actually helps in the blood, right?
• 36:28
  And so, and then LP little a is very important.
• 36:32
  So we look at that because that's a big driver of cardiac events.
• 36:35
  And the problem with LP little a is that when it's elevated and is genetically determined, it decreases your ability to
• 36:42
  to dissolve a clot that might form in your blood.
• 36:44
  So let's say you're having a heart attack and normally your body would try to dissolve that clot.
• 36:48
  If you've got LP little A around it, blocks your ability to dissolve that.
• 36:51
  So you end up having a bigger heart attack.
• 36:53
  And it also potentiates plaque formation in the first place.
• 36:56
  So we're looking at LP little A, then we're looking at...
• 36:59
  to help bring down the Lp little a?
• 37:02
  there isn't any that actually work.
• 37:03
  So we go to the PCSK9 inhibitors that seems to bring it down.
• 37:07
  And then we're also looking at, you know, there's lots of talk about NISIN, but quite honestly, it's never really proven to be that effective.
• 37:15
  So then the other thing we look at is the APOA family, which is all the good guys and the APOB family, which is all the bad guys.
• 37:22
  We look at small dense LDL, as you mentioned, but the thing that's more important
• 37:27
  than almost anything except LP little a and what we've talked about is what's the ability for reverse cholesterol transport?
• 37:34
  Because if you can actually get cholesterol out of a plaque or out of a cell membrane back to the liver, you're actually much more protected than if you don't have the ability to do
• 37:43
  reverse cholesterol transport.
• 37:45
  And that becomes a function of plasmalogen levels.
• 37:47
  It becomes a function of phosphatidylcholine levels.
• 37:50
  And so we're measuring all these and we help people.
• 37:53
  augment their ability to do reverse cholesterol transport because if you have a healthy glycocalyx and you have good reverse cholesterol transport, you can have a cholesterol 240
• 38:03
  and you're okay.
• 38:05
  But if you don't have good reverse cholesterol transport and a high HDL is not indicative of reverse cholesterol transport because a lot of that HDL is dysfunctional.
• 38:13
  So you've got to actually have a metric to look at reverse cholesterol transport.
• 38:17
  So in a Cleveland Heart Lab study that we do,
• 38:20
  profile, it does give us at least an algorithm to look at reverse cholesterol transport.
• 38:25
  So we look at all of that.
• 38:26
  And then we actually have a glyco check scope where we can actually under the tongue, we can look at the microcirculation and actually measure the thickness of the glycocalyx and
• 38:34
  where it's failing or where it's not.
• 38:38
  we have many, many lenses to look at the cardiovascular system through as well as.
• 38:42
  at to look at HDL?
• 38:43
  I mean, HDL is the bus that brings the cholesterol back from the artery back to the liver to recycle and LDL the reverse.
• 38:49
  What's the what's the marker?
• 38:51
  Well, the HDL is part of the APAWA family.
• 38:55
  And as I mentioned, HDL can be dysfunctional.
• 38:59
  So just because you have an HDL of 70 or 90 doesn't mean it's actually doing the job.
• 39:04
  on oxidation?
• 39:05
  What's the marker to look at dysfunctionalists?
• 39:08
  there's an algorithm that looks at subtypes of HDL to basically calculate what the actual capacity is for reverse cholesterol transport.
• 39:17
  It's available on the Cleveland Heart Lab profile.
• 39:20
  Yep.
• 39:21
  Okay.
• 39:21
  I mean, the good old fashioned way to bump up HDL and make it more functional is what?
• 39:25
  It's gonna be really just trying to choose healthy fats and proteins that aren't oxidized, correct?
• 39:32
  yeah.
• 39:32
  And yes, yes.
• 39:33
  Any particular type.
• 39:33
  Are you more interval, zone two, a combination of the two?
• 39:37
  Yeah, this is interesting too.
• 39:39
  So we measure cardiopulmonary exercise tests on every, every client.
• 39:43
  So we actually measure VO2 max and anaerobic threshold.
• 39:46
  And you're probably aware that VO2 max for longevity is one of the strongest indicators for longevity, right?
• 39:52
  Even stronger than muscle mass by a factor of two and a half.
• 39:55
  So how do you train for VO2 max?
• 39:57
  Well, there's a lot of misinformation out there around zone two.
• 40:01
  We find zone two is
• 40:02
  I've been doing it for over 20 years now, measuring cardiopulmonary exercise tests and training people for VO two max optimization.
• 40:08
  And what we found is that zone two is good in a couple of situations.
• 40:12
  Um, zone two, you can, if you're listening to this zone two is essentially a form of exercise where you can carry on a conversation.
• 40:19
  Right?
• 40:19
  So you're walking, you know, you're, lightly doing something that's not that yeah, that's zone two.
• 40:26
  And if you are overtraining zone two is great.
• 40:30
  If you are just coming off the couch.
• 40:31
  Zone two is great.
• 40:33
  But if you're actually reasonably athletic to build VO2, what we found is you need zone three and you need zone three three days a week for about 45 minutes.
• 40:43
  And then you need interval training where you're at zone five, which is all in, so to speak, for about interval training.
• 40:50
  It would be like one minute intervals or 90 second intervals or maybe even 30 second intervals.
• 40:55
  maybe six to eight of those within a 20 minute period where you're kind of going all in, then you have a 90 to 120 second recovery.
• 41:03
  So you do that twice a week and you do the zone three, three days a week.
• 41:08
  And we see, we routinely always see VO two go up, but people will tell us that, I'm doing orange theory now and I'm plenty of cardio.
• 41:17
  My trainer says we're getting plenty of cardio.
• 41:19
  I do some cardio before I lift my weights and then
• 41:21
  I'm doing circuit training.
• 41:23
  My heart rate's always elevated.
• 41:24
  I said, great, let's measure your VO2.
• 41:26
  It always goes down.
• 41:28
  Always.
• 41:28
  I've never seen it go up.
• 41:30
  And it's not that I didn't want it to go up.
• 41:32
  It just went down.
• 41:33
  it's like, well, okay, well then we need to come up with a strategy that actually works.
• 41:36
  And cardio will raise not only HDL, but it also raises Clotho.
• 41:42
  And Clotho is God's gift to your kidneys, your heart, your brain from a stand and longevity.
• 41:47
  So lifting weights lowers Clotho and
• 41:50
  and cardio raises clothes though.
• 41:51
  So really there's so many benefits to cardio when it comes to cardiovascular health and longevity.
• 41:56
  uh
• 41:57
  Makes sense?
• 41:58
  Absolutely.
• 42:00
  Yeah.
• 42:01
  So what are the things, what are the things would you like to chat about?
• 42:06
  Dr.
• 42:06
  So I would say when we look at thyroid, we want to get to the underlying issue of that because we don't just want to rely TSA rely on TSA is our underlying metric of thyroid
• 42:15
  health.
• 42:15
  I think it's important that we dial TSA in if we're overly high because that's your sign that your pituitary is freaking out and we want a little bit more thyroid hormone most of
• 42:24
  the time but we have to support the underlying factor.
• 42:26
  The guts are a major role and I can't tell you how many patients I see that have different infections whether it's SIBO right SIFO right.
• 42:34
  small intestinal bacterial overgrowth, small intestinal fungal overgrowth or candida overgrowth or H.
• 42:39
  pylori or other infections.
• 42:41
  These kind of infections play a big role because 80 % of your immune system is in the gut.
• 42:45
  And so anytime we have autoimmunity, is like the fastest most diagnosed disease really you see is autoimmune issues.
• 42:53
  Any kind of weird new disease you see today, like the new autoimmune condition.
• 42:57
  Your body's destroying itself in another unique way.
• 42:59
  It's like, well, the gut plays a big role because 80 % of all your immune cells are in the gout and the gap.
• 43:05
  So that.
• 43:09
  So when we deal with inflammation, not only do we have to really focus at the gut.
• 43:14
  100%.
• 43:15
  100%.
• 43:16
  I think that is the key place to start.
• 43:19
  Yeah.
• 43:19
  so cleaning up the gut becomes really, really important.
• 43:22
  First, you got to kill off the bad guys, then you got to rebuild the mucosa, then you've got to basically keep people from destroying it.
• 43:28
  And so there's a lot that goes into that.
• 43:31
  Getting digestive enzymes right, getting the food sensitivities right.
• 43:34
  And then we use peptides to help with that as well.
• 43:37
  Oral BPC-156.
• 43:38
  uh
• 43:39
  and KPV, those are very helpful at rebuilding the gut.
• 43:42
  But I agree with you that a lot of autoimmunity occurs there and that can, you know, show up as Hashimoto's and other forms of autoimmunity with dysregulation of Treg cells, et
• 43:52
  cetera, et cetera.
• 43:54
  One of the things that we do for thyroid is we do resting metabolic rates on everyone.
• 43:57
  And we've been stunned that blood work is useful, but really not accurate.
• 44:04
  For example, we see many people with normal TSHs or even what most people consider a good TSH and they're still hypothyroid or they're hyperthyroid and they don't know it.
• 44:15
  And so we find that a resting metabolic rate is really for us the gold standard when it comes to dialing in thyroid.
• 44:22
  We've had many people come to us that are on thyroid.
• 44:24
  and they just don't feel right.
• 44:25
  And the first thing we do is we do the blood work, of course, very comprehensive blood work, but we also do the rest of the metabolic rate and all of a sudden it's sitting right
• 44:32
  there in front of us.
• 44:33
  that being tested?
• 44:35
  with a metabolic cart.
• 44:36
  So it's the same way that we would do it like a VO2 max just sitting in a chair.
• 44:42
  The other thing that's missed commonly is we're doing genetics on a DIO2 gene, which is basically the ability to convert inactive to active thyroid T4 to T3 in the brain
• 44:52
  specifically.
• 44:53
  So you can even have a normal resting metabolic rate.
• 44:55
  You can have normal systemic thyroid levels.
• 45:00
  T3, T4, free T3, free T4, TSH, uh reverse T3, all of those can be normal.
• 45:06
  And yet somebody can still not have adequate thyroid activity in the brain.
• 45:11
  And we've had cases where we've added a small amount of T3 only, Cytomel, and people, brains come back online.
• 45:19
  So it's really, really, it's a nuanced art, I think, to...
• 45:24
  to really dial in thyroid for an individual.
• 45:26
  And for us, it really requires the DIO2 gene measurement as well as the resting metabolic rate.
• 45:31
  Yeah, now that makes sense.
• 45:33
  Yeah, good stuff.
• 45:36
  So it sounds like it sounds like you've got a robust practice down there in Austin helping people.
• 45:42
  How do people get a hold of you if they'd like to make contact?
• 45:45
  Dr.
• 45:46
  my website is justinhelt.com.
• 45:49
  I'm Dr.
• 45:49
  Justin, so J-U-S-T-I-N-H-E-A-L-T-H.com.
• 45:53
  There's a work with Dr.
• 45:54
  J.
• 45:54
  Button.
• 45:54
  I see patients all over the world.
• 45:56
  So patients wanna reach out and schedule.
• 45:57
  Also, I got a book called The Thyroid Reboot.
• 46:00
  It number one on Amazon for preventative medicine.
• 46:02
  Talk all about this and we kinda connect the dots and that's a great kind of opportunity to reach out, get more information.
• 46:07
  It's also podcast and YouTube channel.
• 46:09
  I got almost 100,000 subscribers on YouTube and doing this for 15 plus years.
• 46:14
  So I've been at it for a while.
• 46:15
  So just trying to provide lots of great information to the general public to help them kind of take control their health more.
• 46:21
  Yeah, no, that sounds great.
• 46:22
  Sounds great.
• 46:24
  Well, good.
• 46:24
  Well, thanks for.
• 46:25
  and nice chatting with you, Dr.
• 46:26
  Jeff.
• 46:26
  It was nice.
• 46:28
  Yeah, appreciate that.
• 46:29
  Okay, thanks.
• 46:30
  nice to meet you.