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Category: Paleo Diet

  • RHR: The Ocular Microbiome, with Dr. Harvey Fishman

    Post From https://chriskresser.com/the-ocular-microbiome-with-dr-harvey-fishman/

    revolution health radio

    In this episode we discuss:

    • What is the ocular microbiome?
    • How the microbiome affects eye diseases
    • T cell activation in the eye
    • HLA-B27 and genes that play an important role in immune function
    • A nutrient-dense and anti-inflammatory diet for eye health
    • Antibiotics prior to surgery

    Show notes:

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    Chris Kresser: Dr. Fishman, welcome to Revolution Health Radio. I’m so happy you could join us. I’ve really been looking forward to this.

    Dr Harvey Fishman: Thank you so much for having me, Chris. This is wonderful.

    What is the ocular microbiome?

    Chris Kresser: So, my audience has been well aware of the gut microbiome for many years. We’ve also talked about the skin microbiome. We talked about the vaginal microbiome, the lung microbiome, more recently the nasal microbiology, and so it’s not surprising to learn that there is also an ocular microbiome. I’m really looking forward to talking to you more about this and how it contributes to eye disease. Because in the conventional world, the options for preventing eye disease in the first place and then addressing them, I think, have come a long way but maybe still leaves something to be desired. I’d first love to start out with just hearing a little bit more about your background, how you became interested in the ocular microbiome in your work as an ophthalmologist, and what led you down this path.

    Dr. Fishman: That’s great. So, I have a pretty interesting background, where I started off in the world as a physical chemist, studied neuroscience. I was in an analytical chemistry microfluidic laser lab at Stanford and really got interested in how to measure molecules almost at the single molecule level. We were looking at vesicular and synaptic release, neurotransmitters, and what the chemical basis of learning and memory was.

     You’ve heard of the gut microbiome—and maybe even the skin, nasal, and vaginal microbiome. But did you know that the eyes also have a microbiome and that it plays a key role in ocular health? 

    That was sort of my background, and then I sort of did some interesting work in neurobiology, looking at retinal cells and how they grow and their regeneration, so I’ve had a lot of sort of technical background and analytical chemistry background. And then the last couple of years, I started getting very interested in the microbiome of the intestine and the gut, which led me into this whole world of what is actually happening in the eyes. Is there an ocular microbiome and is there a biome that controls disease in the eye that similar to that in the gut?

    What’s interesting is that I didn’t necessarily sort of think about it in those ways. I actually got into my research that I’m working on right now is we’re actually looking at how to measure cancer on the eye. We’re using some of the analytical techniques that I developed or had been working on for my whole sort of academic career, which is how do you measure very small amounts of materials in microenvironments, and so I naturally led to this concept of how do you measure cancers on the eye. We started using similar techniques and sort of the illumina high throughput sequencing technology using 16S rDNA and rRNA to look at different things on the cancer. Chris has led me right into how they are looking at the microbiome and that’s sort of what got my interest sparked. The other thing that’s sort of interesting is I’ve been working with a company called Microbiome to do some studies where I’m actually looking at intestinal microbiomes and how that compares to disease in the eye. That’s sort of a whirlwind tour of how I got interested.

    Chris Kresser: Right. It’s a fascinating background, and as is often the case, it seems like in some way you could have never designed this career path or predicted it would happen, but when you look at it in retrospect, it seems like each step kind of perfectly informed the next step.

    Dr. Fishman: That’s right. It’s actually really interesting; I never in my wildest dreams would have thought that I’d be doing genomics, and in fact one of my previous advisers always laughs because I’m doing genomics and I was a physical chemist and a microanalytical guy.

    Chris Kresser: Right, right.

    Dr. Fishman: Whippersnapper.

    Chris Kresser: Right. So let’s talk a little bit about the ocular microbiome and what we know about it so far and what we don’t know about it. Do we have any sense of the number of species, microorganisms, what the functions of the ocular microbiome are? I imagine it’s significantly less developed as a field of study than the gut microbiome, but what do we know so far?

    Dr. Fishman: It’s really the beginning of this field. What’s interesting about the microbiome of the eye is that we’ve been interested in, as ophthalmologists, not me personally, but at the ophthalmology community, we’ve been very interested in the bacteria that lived on the eye. The reason is that most of our intraocular surgeries like cataract surgery, vitreoretinal surgery, corneal surgery, when you make incisions into the eye, most of the serious infections that occur, occur because the exogeneous either bacteria that live on the lashes, the eyelid margin, or in the cornea. And so we’ve been very interested in this for years, and they’ve done a lot of interesting work, but the concept of the ocular microbiome, whether there’s like some low-level core bacteria and microbiological species that lives on, in, and around the eye, that’s really kind of a new concept.

    One of the papers that has come out just recently was actually by Mark Wilcox. I don’t know if you’re familiar with it; it was a major paper in 2017, and they looked at basically the temporal stability and composition of the ocular surface microbiome. It was probably one of the best papers, if not the sentinel paper in the field. What they found is … well, there’s a couple of things they found, that first of all the ocular biome is very different, if at all, than the microbiome of the intestine. One of the things that they found is that in addition to other work that’s been done, is that it’s actually a pretty low number of species. I mean, there’s a diverse number of species, but it’s a low number. It’s just a regular number. And then there was some work that was done by Russell Van Gelder who’s also shown similar work, but basically they started to talk about a bacteria microbiome that’s just very small in number.

    Chris Kresser:  It’s interesting; there is some parallel too with the gut. For most of the 20th century, we were very well aware of the existence of pathogenic bacteria, parasites and other organisms that could cause dysfunction in the gut, and most of the focus there was on identifying those pathogens and then treating the disease, eradicating them if possible with antibiotics or treating the diseases that were caused by them, whereas now at least, the awareness has shifted, and to some extent toward how do we support and nourish the protective microbiome and look at it more in the context of an ecosystem where we understand that if the health of the ecosystem is the primary focus, then that may actually be the most effective way of protecting against pathogenic activity.

    Do you think that something similar is going to happen with the ocular microbiome or that it’s just too— because it’s not as significant in terms of the volume of the number of organisms and we may not have as much ability to influence it with things like diet and lifestyle, we’re not going to go down a similar path there?

    How the microbiome affects eye diseases

    Dr. Fishman: It’s a great question, and that’s really what a lot of … myself and many other people are working on—whether you can influence it. I have some anecdotal discussions on that, papers as well, that actually would suggest that you may be able to do the exact same thing for the ocular health as you do for the gut health. Let me give you a couple examples. There are some really significant diseases of the eye, like, for example, dry eye disease, which is actually an area that I’m super interested in and really focusing a lot of my academic and clinical research. Dry eye disease is … they think there’s a very big component of how the ocular microbiome interacts with the cornea and the lid and so forth, but there are also a bunch of other diseases like episcleritis, chronic follicular conjunctivitis, pterygium, or surfer’s eye, scleritis, even things that are as interesting as macular degeneration and glaucoma, a lot of people are starting to have … some of these diseases are actually idiopathic, not macular degeneration necessarily, but like episcleritis and dry eye disease. There are these so-called idiopathic diseases. What we think is that it’s really controlled by dysbiosis of microbiome.

    Chris Kresser: Wow, that’s interesting. For listeners, idiopathic means “we don’t really know.” It’s a fancy way of saying, “We don’t know where this comes from or how it starts.” It’s fascinating and by now not surprising, given what we talked about at the beginning of the show, we know now about the microbiome is not just in the gut. There’s microbiology and virtually in any surface that interacts with the exterior world, whether it’s the gut, the inside of the gut, technically is outside the body. We’ve talked about that on the show, which is always kind of fascinating, especially if you haven’t thought about that, and then the lungs, which of course interface with the exterior environment, and the skin, the vagina, there’s a penis microbiome, and clearly these organisms are playing some important role and clearly there’s something about the modern lifestyle that is antithetical to the health of microbiomes. I imagine with the ocular microbiome, is it influenced by the same factors? Does systemic antibiotic use contribute to a degradation of the quality of the ocular microbiome? Are any kind of eye products that people use like drops, can they interfere? What do we know about that?

    Dr. Fishman: Right. Those are great. Certainly areas that people are looking at. In the eye, there are so many aspects of the eye in terms of the ocular microbiome of the eye that makes it complex because the thing about the microbiome of the eye is that it’s not only that we think a core microbiome exist in a very low level, there’s a lot of other bacteria and other species of organisms that sort of “contaminate” those measurements and also the surface.

    One of the interesting things, there’s a lot of sort of noise, in the sense that there’s the noise from contaminants at any one time on the eye can overwhelm the signal of the actual microbiome. But what does seem to occur is that it’s very possible that when people have sort of acute issues is because they do get some sort of dysregulation of their normal biome by this sort of contaminant. The sort of things that can really change the ocular surface biome is exactly the source that you’re mentioning. If you use makeup, if you use products—Latisse, for instance, the Latisse, which people use to make their eyelashes grow longer contain a lot of— basically cause of the eyelashes that have more inflammation, more debris on them and that those are basically culture plates for bacteria on the eyelashes. That really does change it.

    A lot of what you’re mentioning really is sort of the dry eye disease realm, which is that all these different products that people use, including unnecessary eye drops or things like viral bacterial conjunctivitis, which you wouldn’t use an antibiotic but that changes the microbiome. The other thing that is very fascinating is parasites. It turns out Demodex, I’m sure you—maybe we had many shows on Demodex, but Demodex is a big, big deal, and there is an interesting sort of life cycle of Demodex in the lashes and how that relates not only to the skin microbiome, but actually of people who have dysbiosis of their intestine. It’s just incredibly fascinating and it plays into the whole ocular rosacea story as well.

    Chris Kresser: Not too long ago we had a periodontist, Al Danenberg, who’s been through my clinician training program and is a really knowledgeable guy. He has looked at the connection between the gut microbiome and the oral microbiome and has found from his perspective and from what the research is showing that when there’s a disruption in the oral microbiome, it’s usually or often driven by dysfunction of the gut microbiome rather than the other way around, although certainly we know that infections in the mouth can influence the gut and other parts of the body, but because stomach acid protects against, hopefully if it’s sufficient, a lot of what we would swallow and the saliva from the mouth that the relationship is probably more strongly influenced in the other direction. Has there been much work done on the influence of the gut microbiome on the ocular microbiome?

    Dr. Fishman: That’s a huge area that people … there’s a lot of really interesting work, but just to kind of go back to what you said, there was a really interesting paper that came out that talked about the oral microbiome linked to neurodegeneration and glaucoma.

    Chris Kresser:  Ah …

    Dr. Fishman: We actually know that there are people with worse oral disease and dental disease. Actually, you have higher rates of primary glaucoma than other people, and that was a very well done study that was recently published. Essentially one of the things that we’ve known forever, and as a medical student, we learned very early in the game, the connection between ulcerative colitis, Crohn’s disease, and uveitis. You may have touched upon before, but that is one of the most clear-cut associations that we have enough knowledge. In fact, ophthalmologists often sometimes will look … brilliant clinicians … when the person comes in and we see uveitis and then we do a little bit of the history and it turns out that they have Crohn’s and then we send them to the GI specialist and the GI guy thinks we’re brilliant. We’ve discovered Crohn’s disease by looking in their eye and yet there are a few associations.

    What’s interesting is that there are multisystem disorders, autoimmune diseases that are associated with uveitis that are absolutely related to the gut and in other areas. That’s an area that NIH is doing a very—there is a big push to look at the association. In particular, some of the work they’re doing with T cell activation, both protective T cells and non-protective T cells, and how it influences uveitis, and they’ve been looking at some really interesting experimental autoimmune uveitis models, the EUA, so to speak, and they looked at how the regulatory T cells in the gut and other tissues really affect the uveitis and so forth.

    Chris Kresser: I think there are probably a fair number of listeners who are not that familiar with disease. Uveitis being an inflammation of the middle layer of the eye, right?

    Dr. Fishman: That’s right.

    Chris Kresser: With the connection between the gut and depression for example, the speculation is that in terms of the mechanism is that inflammatory cytokines are produced in the gut and they enter the bloodstream, perhaps because the barrier is permeable and they travel through the blood and they cross the blood–brain barrier and they suppress the activity of the frontal cortex, and that’s one way gut pathology can lead to anxiety and depression.

    In the case of the connection between the gut and eye disease, let’s take ulcerative colitis and Crohn’s, which are both autoimmune GI pathologies. Is the speculation that the systemic inflammation caused by the autoimmune disease is what’s causing the inflammation in the eye, or is it that something related to a disruption of the microbiome leading to maybe the production of certain chemicals or inflammatory cytokines or something that’s more specific to the microbial ecology of the gut is the contributing factor, or do we just not really know?

    T cell activation in the eye

    Dr. Fishman: One of the thoughts, and there was a paper that … and these are all interesting, really recent papers like 2015 to 2016, but there’s that commensal microbiota and bacteria in the gut that activate T cells. These T cells then circulate and then actually pass into and through the retina, in other parts of the eye, to then activate directly. It’s definitely via the immune system, but there are very specific immune cells that actually can penetrate into the eye. There’s always been that thought that the eye is immunologically pristine, and that really is obviously not the case, but there are very selective T cells that can in fact get into the eye or pass into the eye, and so that’s what we think that is going on, is that there’s a dysregulation in the microbiome of the gut.

    As you pointed out, you get T cell activation, and then it actually activates the local immune system in the eye. Actually, a really interesting situation that we see with respect to that, we actually can see diseases like sympathetic ophthalmia, which is a disease where if you injure one eye, activation of the T cells from one eye actually can go to the other eye, and you can actually lose the other eye, so you could actually have a question where are you …

    Chris Kresser: Oh, wow.

    Dr. Fishman: Yes, it’s awful. That’s why people have to get their eyes enucleated or taken out when they have a trauma. They have to do that within about 10 to 15 days or sooner because they can get this autoimmune activation that can actually blind them in the other eye. It’s just fascinating how that works, but that is sort of the same idea in the gut that you get with activation, and it causes inflammation. One of the things that we know, Chris, and this is my own personal experience in my practice, and I’ve seen this over and over and over again, is that my uveitis patients, they always come in with an active disease, almost always some kind of a gut-related situation that sets off their uveitis or inflammation. They’ll come in and I’ll say, “What did you do last week?” “I was in Las Vegas and then we ate a lot of carbohydrates,” and these are patients who are very strict about being on a gluten-free diet, and they just say they cheated, so to speak, they had a bad weekend, fun weekend, but now they’re paying the price and then they come back and they get uveitis. I can’t tell you the number of times I’ve seen that. It’s just clear cut. That’s actually withm in particular, HLA-B27 uveitis. I don’t know if you have covered that, but that’s a big area.

    HLA-B27 and genes that play an important role in immune function

    Chris Kresser: I love to hear a little bit. I’m familiar with HLA-B27 and AS, ankylosing spondylitis, and the connection there. In fact, in our clinic, we will often test patients for HLA-B27 if they have joint pain, and if they test positive for Klebsiella bacteria on the stool test, I forget the name of a physician in London who discovered that connection, but then we’ll often put them on a low-starch diet and will treat the Klebsiella, and their joint pain will go away, or at least that will significantly improve. Tell me more about HLA-B27 and the eye.

    Dr. Fishman: That’s our biggest immune screening. We screen for that in every single uveitis patient and screen for HLA-B27. In fact, 50 percent of every non-necrotising anterior uveitis, which is just a fancy word for basically idiopathic, meaning we don’t know what the cause is, it’s almost always related to an HLA-B27-positive uveitis, and so we see that all the time. Those patients are particularly sensitive to changes in their diet, and a lot of those patients, I will really push for strong control, at least in my practice. We always start off with a gluten-type restriction because that seems to be one of the big areas that sets off uveitis. HLA-B27 is such a prominent factor in most of our inflammation. You can also get sclerites with HLA-B27, you can get uveitis, you can get episcleritis, any of the autoimmune diseases around the eye seemed to be linked to that marker.

    Chris Kresser: Just for the listeners, if your eyes are glazing over here, we’re geeking out a little bit, but I want to back up. HLA-B27 is a gene, and it’s one that plays a really important role in immune function. Its prevalence varies around the world in different ethnic groups and populations. I think it’s about 8 percent in Caucasians, maybe this 2 to 9 percent in Chinese, 4 percent North Africans. As I was mentioning before, the association that I was most familiar with, I’m really fascinated to learn about the connection with uveitis is with ankylosing spondylitis. Back in the ’80s, there was a physician in London, whose name I’m unfortunately forgetting at the moment, and he was treating patients with AS, and by accident some of them he put on a low-carb diet for weight loss, and their AS improved dramatically. He did some more research and he found that there is a greater abundance of Klebsiella in stool samples of patients with AS, and then he found that Klebsiella bacteria that have preference for starch, and the patients that he put on a low-carb diet were of course eating a lot less starch. The low starch intake starved the Klebsiella and reduced the Klebsiella, which then reduced the autoimmune attack against the HLA-B27-expressed enzymes that were in the joints, and that’s reduced the symptoms of AS, or ankylosing spondylitis, but there was later research that showed that sometimes can be connected to Crohn’s disease. You just told me that Crohn’s is connected to uveitis. Things like this, there’s a very interesting connection going on here, and that it may possibly a low-carb, low-starch diet, if it works for AS and HLA-B27, might be effective for uveitis.

    Dr. Fishman: Absolutely. I basically, in a very non-scientific way, have my patients try these diets and often they don’t want to go on to these heavy-duty immunosuppressants like methotrexate or Imuran. They want a natural … not natural, but they want a way to control the inflammation not to do these other sources. They will grab it, and a lot of the way I practice is I’ve learned so much from the multitude of patients who tell me, maybe the patients who have seen you as well, I learn from them what works, and I can then pass it on to other people. But in terms of the gut association with HLA-B27, it’s fascinating when you were mentioning Klebsiella, it turns out that Klebsiella as well as other bacteria … and in particular, there’s a big connection with blepharitis and dry eye disease. In fact they did a study where they looked at patients—Bacillus was the other one—they looked at a setting where they looked at patients who had dry eye disease, and it turned out that Bacillus and Klebsiella were the huge association with blepharitis and dry eye disease. Just as an aside, another very interesting thing, because I’m very interested in dry eye disease and a lot of people with ocular rosacea, there is that story that the microbiome of your gut are being eaten, so bacteria that actually get eaten by the parasites, which hurt the Demodex on your eyelashes and your hair follicles, they eat the bacteria, then the parasites puke up the bacteria, and then the products and the exogenous components from the bacteria then irritates the eyelashes and the meibomian glands, which are glands in your eyelid, cause severe dry eyes. That’s this interesting lifecycle between bacteria, Demodex.  The other thing that I’ve looked at, and I know that you guys have talked about SIBO, and there seems to be this association with SIBO, bacteria, blepharitis, Demodex and ocular rosacea and dry eye disease.

    Nutrient-dense and anti-inflammatory diet for eye health

    Chris Kresser: Fascinating. I mean, there’s so many directions, but it all really comes back to, I mean, I think one of the things I like to emphasize, these discussions are fascinating and they’re important, and these lines of research are really crucial to figuring out what’s going on, and at the same time it comes back to the same basic steps that we need to take. Eat a nutrient-dense, anti-inflammatory diet, make sure you’re taking care of your gut microbiome, avoid unnecessary antibiotics.Make sure to eat plenty of fermented foods and fermentable fibers. It can be easy to get overwhelmed by the complexity of all of these connections, but the good news is that usually it’s just the same simple steps that we need to take in order to protect our health.

    Dr. Fishman: Absolutely. One of the things that we found, and you’ll just be amazed, ophthalmologists, we have been running the largest nutritional study in the history of mankind, and it was for macular degeneration. That statement is not a trivial one. I don’t know if you’ve talked about this, and essentially the use of lutein as the advancement in your diet. There are a lot of interesting connections between the intestine and macular degeneration, and there’s a big suggestion that the intestinal dysbiosis as seen in AMD patients … and when you’re doing these supplementations, you’re really supplementing the intestinal microbiome to reduce inflammation in the retina, which is actually the cause of macular degeneration, so it’s just incredibly fascinating. Every time I leave my patient, I feel that there are two things I want you guys to leave this office with because I don’t have the bandwidth, obviously, that your practice has in terms of … I have this focus on different things, but I tell them spinach pills, which is just spinach and omega-3 fatty acids. Omega-3 fatty acid is a very interesting controller of eyelid health and dry eye disease despite the fact that there was a recent paper that came out that disputed that, and I would really argue that that was not a very well-done … it was a study that was well done, but they had a lot of problems with it. My two big go-to things at least in my practice are spinach and fish.

    Chris Kresser: That certainly fits into the context of the nutrient-dense, anti-inflammatory diet. It’s really fascinating to me how the change, I think, that’s happening in medicine, not just in functional integrative medicine but even in conventional medicine, that we started out allopathic medicine grew out of this Cartesian dualistic framework, where the body is basically just a bunch of disconnected parts that are kind of loosely connected, but not really influencing each other, and now we’re really starting to understand that under traditional systems of medicine, they certainly didn’t get everything right, but the one thing that they did get right was this idea of holism, that every part of the body is connected to and influences the body as a whole.

    Now we’re seeing this, I think, really play out. Look, it’s Crohn’s disease and ulcerative colitis increase your risk of eye inflammation. We now have the inflammatory cytokine model of depression that shows that inflammation in the gut can cause inflammation in the brain and symptoms that mimic depression. We’ve got connections between dysfunction in the HPA axis and stress and all kinds of skin conditions like eczema and psoriasis. I mean, the list goes on and on, and now we’re adding to this the connection between the oral microbiome and the gut microbiome and inflammation in the eye, which even just, I think, 20 or 30 years ago would have been completely dismissed as a woo-woo kind of out-there stuff. It’s just encouraging to me that we’re really starting to move, no matter what kind of perspective on medicine, we’re talking about into a more holistic view of the body.

    Dr. Fishman: There was an interesting paper where one researcher looked at treating, it wasn’t a corneal ulcer, but they were treating sort of a conjunctivitis using a probiotic eye drop.

    Chris Kresser: I was going to ask you about that.

    Dr. Fishman: There’s a disease called vernal keratoconjunctivitis, and that’s a pretty tough one to treat. Vernal means spring, and basically it’s allergic conjunctivitis. A lot of kids get it, and the way we typically treat that is with steroids and so forth, which you obviously don’t want to do for children. There was a paper back in 2008 where they looked at using a probiotic eye drop, and they found it was equivalent to some of the other drops that they were using, which to me makes complete sense. I had a very interesting case recently of a patient who had actually an open globe. She actually had some sort of a tube that was put in for glaucoma, and it eroded through the conjunctiva. Bottom line, you see an open globe and she had opened up for essentially six months and nothing happened. She didn’t get an infection, nothing. For whatever reason, she had a very well-controlled ocular biome.

    One of the interesting questions that we’re now looking at is how do the intestinal, oral, or skin biomes relate to the ocular microbiome? I think it’s a pretty clear situation, and we know and I’ve had private conversations with some pretty famous microbiologists, anything that comes out of your intestine is going to be in your eyes, so basically just think of it that way. I mean, it doesn’t sound great, and I joke with my patients, “You’re basically getting poop in your eyes, and it happens all the time, every single day.” That’s what happens, not to be completely crap, but that is the connection.

    Chris Kresser: Yes, yes. That’s interesting. The probiotic eye drop reminds me of, I talked about this before, the nasal microbiome and the connection between the nasal microbiome and sinusitis. Dr. Susan Lynch at UCSF has done some really interesting work in this area. She did a fascinating study that was both animal and human, and they had an animal model of sinusitis, and they found that the main difference between animals with sinusitis and the controls was not—and this was true in humans too—was not the presence of certain pathogens. It wasn’t that the people with sinusitis had much higher levels of fungus or certain species of pathogenic bacteria. The biggest difference between the two groups was microbial diversity.

    Dr. Fishman: Right.

    Chris Kresser: The people who were the controls, the people who didn’t have sinusitis, had a much richer diversity of healthy protective bacteria, whereas the people who had sinusitis had a lower diversity, even when the presence of pathogenic species was basically the same. There was no difference between the two groups. The difference was that the healthy people had much higher levels of protective bacteria, and then she went a step further, and in the animals, they treated them with antibiotics until they were basically depleted of the microbiome in both the healthy controls and the animals with sinusitis. And in one group of animals, they didn’t do anything. They just let the bacteria grow back as they would, and then the other group, they inoculated them with a protective species, Lactobacillus sakei, which they had observed in higher numbers in the healthy controls. And those animals that were inoculated with that nasal probiotic didn’t develop sinusitis or anything the other animals that were not inoculated with that. That really actually speaks to probiotics in both maintaining and then restoring a healthy microbiome as being a more effective strategy than using antibiotics or antimicrobials to try to get rid of pathogens.

    Dr. Fishman: Right. When you mention those two things, there were two interesting things that come to mind. The first one, just to let you know that there was a paper that came out in Nature in 2016 which said exactly the same thing. They were looking at Sjӧgren’s disease—for your listeners, it’s one of the most severe forms of dry eye disease and other dry parts of your body. They found the exact same finding, that people with the severity of Sjӧgren’s disease was inversely correlated with microbial diversity in your gut.

    Chris Kresser: Wow.

    Dr. Fishman: And with just as clear as day. It was just super clear that this was the case. We know, and I know from my own clinical experiences, that people who have, do have, a much higher control level, people who do a better job in terms of their diet, people who are more precise about the food that they eat and so forth, do much better with dry eyes. Dry eye disease, for the longest time, we’ve been treating dry eye disease with omega-3s or any type of fatty acid, but any sort of derived can lead to that. What I always mention is that, is it actually the omega-3 acting directly in your eye, or is it basically an activation, a biological cascade, that then causes the improved function in the eye? I clearly believe that it is a cascade effect because there is no way that just a simple little fish oil capsule could have that much of an improvement in people with dry eye disease.

    Chris Kresser: Right, right.


    Chris Kresser: Go ahead, please.

    Antibiotics prior to surgery

    Dr. Fishman: Yes. I just have one other really interesting comment, which was one of the things that is interesting is that you talked about treating infections with basically displacing the bad bacteria with “good bacteria” and so forth, and that whole concept, which makes a lot of sense. One of the things that we’ve seen is that in eye disease, especially in ocular surgery, we routinely treat our patients basically from medicolegal reasons with antibiotics prior to surgery.

    Chris Kresser: Right.

    Dr. Fishman: It turns out that the studies are coming out that there’s no data whatsoever to support those claims.

    Chris Kresser: Yes.

    Dr. Fishman: Those are billions of dollars a year in an antibiotics that were sold by pharmaceutical companies to basically do nothing and maybe, who knows, but maybe actually not even improve outcomes, but maybe make outcomes worse by selecting for bacteria that if it does get into eye, it actually would be a much worse situation.

    Chris Kresser: Right.

    Dr. Fishman: That’s really interesting data that we have.

    Chris Kresser: That happens, of course, not just in the world of the eye, ocular issues, but of course in the dental surgery, where patients will often come and say, “Oh, I’m about to get this dental surgery. My dentist is just prescribing antibiotics prophylactically.” Of course I’ve had the thought, “Well, okay, does this become a self-fulfilling prophecy?” Because we know that disruption of the oral microbiome with antibiotics can actually predispose you to an oral infection, and so by prophylactically prescribing an antibiotic is not really prophylaxis, or is that actually more likely to develop an infection? And as you said, not only have you reduced your body’s ability to fight the infection, if it does happen, by reducing the number of beneficial protective bacteria, you’ve also potentially contributed to creating a more resistant strain of pathogenic bacteria by killing the ones that were least … the types of pathogenic bacteria that were least robust and just leaving the ones that were more robust.

    Dr. Fishman: Well, there is some evidence that suggests that may actually be the case. I mean, with eye surgery, we use povidone iodine before surgery. That is the gold standard and at least cuts down sort of universally all … it doesn’t select, do you know what I mean? You’re not selecting for bacteria. You’re basically wiping it out. Antibiotics, on the other hand, are probably selecting for it. That’s a good example where that period self-selecting bad bacteria really might be coming true. It’s very interesting where we’re going, especially with the eye, because there are still many “idiopathic” diseases and infections that really relate to the biome, not only of the eye, but also the gut being the cause of it.

    Chris Kresser: Who knows? Maybe someday you’ll go to the dentist and you’ll get a dental probiotic instead of antibiotic for an infection. Maybe you’ll go to your ENT for an ear infection, and instead of putting antibiotic ear drops, they’ll put in probiotic ear drops. You’ll go the ophthalmologist and instead of getting antimicrobial treatment, you’ll get probiotic eye drops. Seems that’s not far-fetched at this point.

    Dr. Fishman: Not at all. In fact, you might argue we’re already doing that through indirectly by using our gut as a way to … [crosstalk]

    Chris Kresser: Right. To modulate.

    Dr. Fishman: Correct.

    Chris Kresser: Well, this has been really fascinating, Dr. Fishman. I’ve enjoyed talking with you, and I think the listeners are really going to get a lot out of this, and it’s hopeful. I feel hopeful to know that there are folks like you who are exploring these new frontiers and really kind of pushing the boundaries and questioning some of the most basic assumptions that we’ve made and finding a new path forward that could lead to better, safer treatments. Where can folks learn more about your work or if people are in the Bay Area? It sounds like you definitely are still seeing some patients. Tell us where people can learn more.

    Dr. Fishman: Sure. Well, they can always find me on my website, which is www.fishmanvision.com, and they can get involved in my practice in multiple ways. I definitely see patients. Half the time I’m seeing patients, half the time I’m doing research.


    Chris Kresser: It looks like they can do some video consultation as well. Is that right?

    Dr. Fishman: Yes. For people in California, I can do video consultations if they can’t make it to the office. Especially for dry eye disease, it’s very helpful.

    Chris Kresser: Right, right. Great. Well, keep us posted on your research. We’d love to hear it, stay in touch, and have you back on the show at some point and just keep track of your work. These are really exciting developments.

    Dr. Fishman: I really appreciate the opportunity, and I wanted to thank you because we’ve shared some patients, and their lives have actually changed because of the work that you’re doing with them, so thank you.

    Chris Kresser: Fantastic. It’s my pleasure. Take care.

    Dr. Fishman: Okay, thank you.

    The post RHR: The Ocular Microbiome, with Dr. Harvey Fishman appeared first on Chris Kresser.

  • When Chronic Illness Makes You Feel Like a Burden – a Guest Post by Kerry Jeffery

    Post From https://www.thepaleomom.com/chronic-illness-kerry-jeffery/

    Kerry Jeffery (B.A.) is a qualified Clinical Hypnotherapist, Counselor, and Life Coach, living well with Hashimoto’s Thyroiditis, Celiac Disease and Antiphospholipid Syndrome in Melbourne, Australia. She is the author of “Moving through the Grief of Chronic Illness: A 9 phase model from anxiety to resilience” to help people understand the many complex emotions that come with becoming chronically ill. Kerry works with people all over the world, helping them heal the emotional and psychological side of chronic illness. She specializes in safely removing past and present trauma, guilt, anxiety and all of the effects chronic illness can have on your relationships. Kerry is also an expert at overcoming the effects of toxic relationships and dealing with toxic family or parents.

    Kerry works primarily on Skype and offers a free 20-minute Discovery Session on her website:  www.emotionalautoimmunity.com

    One of things that chronic illness is really good at is creating lots of grief and guilt. It can feel like you have lost the person who you once were.  The capable, active, energetic and independent person who used to be able to get things done, stay out late, burn the candle at both ends and bounce back after a good nights sleep and eat whatever they wanted. Becoming chronically ill is a life-changing event that affects every single area of your life, and the worst impact it can have is on your relationship with your partner.

    The guilt can start in simple ways. You start feeling guilty because you can no longer do the things that you used to do for yourself or your partner or your children, so you find yourself apologizing all the time.

    I’m sorry that you have to help me.

    I’m sorry that I can’t get things done.

    I’m sorry that I am letting you down.

    I’m sorry that I am always sick.

    Then gradually, over time, the way that you think about your partner can begin to change. Somewhere along the way, as your chronic illness takes more of a toll on you and your life, your partner changes from being your friend, lover, and co-parent, to becoming your caretaker, provider or manager of your health and medical appointments. Even worse, they can become someone who doesn’t seem to understand or make allowances for the many ways having chronic illness has changed your life and expect you to carry on as normal. However, there is no more normal and everything feels different now. The lens through which you view yourself and your relationship grows increasingly dark and negative as the guilt really begins to set in. You feel like you can no longer do your share around the house because you feel so sick and exhausted all the time, so you can feel like everyone is judging you as being lazy or disorganized.

    So you feel guilty. If you are a parent, you can feel like you are ruining your children’s lives because all they see is a parent who is constantly sick. You feel guilty about what this is doing to them and how it will affect their future. If you need to make dietary changes, like switching to AIP to help reduce your flares and create some healing, you can feel that you are depriving your partner and family of all of the foods that they love and enjoy, so you feel guilty for taking that away from them. You can’t stay out late anymore or socialize because you are exhausted or in pain or so brain fogged that you can’t even think, so you have to keep saying no to all of the social invitations and events. You feel guilty because you feel like your friends will think that you no longer care or want to see them and that your partner is missing out because of you.

    Pain, disability and lack of energy means that your sex life can begin to suffer. Chronic illness can change so much about you that you can look in the mirror and no longer even recognize yourself. You start to wonder how your partner could ever think you are attractive, let alone sexy and your self-confidence goes out the window. Even if you do have the time and energy for intimacy, the anxiety and self-consciousness gets in the way, so the guilt gets even bigger. There can come a point where the guilt becomes so bad that you start feeling sorry for your partner, because you no longer feel like the person that they fell in love with.

    You can even find yourself starting to believe that your partner would be better off without you. In fact, you may even feel that you need to offer them an “out” from the relationship, because somewhere along the way, you feel like you have become someone who is just dragging them down, spoiling their enjoyment of life and holding them back from the happiness that they deserve.

    You feel like you have become a burden to them.

    The more guilt you feel, the more you begin to withdraw from your partner, from your children and from your life. Guilt changes everything and it can poison everything that you care about. But here is the thing about guilt: Guilt is the great deceiver. It whispers in your ear, trying to make you believe that all of your worst fears and doubts are coming true and if you let it, guilt can ruin your relationships. Guilt can lead you to a dark and dismal place where you are not able to make the right choices for yourself or for your relationship because you feel like a burden.

    Feeling like a burden stops you from really hearing what your partner is actually saying to you. Feeling like a burden sinks you further down into depression, apathy and hopelessness. Most of all, feeling like a burden stops you from actively creating solutions and adapting to the changes that chronic illness has brought into your life. However, there is one big truth about feeling like a burden that you really need to hear and accept and understand.

    You can only feel like a burden if you allow yourself to believe it.

    The truth is that you are still the same amazing and wonderful person that your partner first fell in love with. You are still as lovable, worthy, deserving and enough as you have ever been

    The only difference is, that now you are a person going through a life-changing crisis that everyone in your life will need to adapt to and live with as well.

    If you are in a relationship, chronic illness is something that you both need to deal with, just like any other crisis or challenge in your relationship so far. Don’t believe me? Let’s flip the situation and turn it around. If this was happening to your partner instead of you, what would you do? Would you see your partner as a burden or would you want to face the challenges as a couple and find ways to adapt and change and face it together? Would you want to blame your partner and abandon them or would you want to find ways to support them and make your lives together as happy and fulfilling as you can? The truth is that chronic illness is one of those devastating and challenging events that can happen to anyone at any time through no fault of their own.

    Chronic illness is not something you deserve or created or brought upon yourself because of something you may have done in the past. We still don’t know exactly what causes chronic illness, but what we do know is, that as individuals, we have enormous power and influence to change our lives and create the best possible health and happiness we can.

    So how do you stop feeling like a burden?

    Begin by understanding that continuous guilt is a useless and crippling emotion. Guilt is meant to be a powerful reminder of when we have stepped outside our own moral compass and done something that we feel was wrong, that we need to own and apologize for. It helps us learn to take responsibility, be honest and live up to our own standard of what being a good person means.

    Getting chronic illness is nothing to feel guilty about.  It is something that can happen to anyone at any time and it is not your fault. So start really listening to what your partner is telling you without letting guilt whisper in your ear. If your partner is telling you that you will both work it out and find a way to manage this, believe them. Go back to what you would do and how you would feel if the situation was reversed and your loved one was chronically ill and let that ground you in what is true. Understand that what you are going through is for now, not forever.

    Feeling like a burden can fool you into believing that things are going to be this way for the rest of your life and none of us can see the future. We can only do the best that we can with the present moment that we have right now and the only sure and certain thing in life is change. As you begin to work through all of the complex emotions of becoming chronically ill, you will begin to adapt and feel more in control. Remind yourself of all of the difficult things that you have already overcome.

    When you stop believing in the things that guilt is telling you, that resilience and strength and determination will begin to come back. Talk to your partner openly and honestly about how you are feeling. Tell them that you feel that you have become a burden. Tell them that you feel like you are dragging them down and how worried you are about your future together. Having an open, honest and vulnerable conversation with your partner can create a wonderful opportunity for more connection, trust, love and commitment between you both and make your relationship even stronger.

    Right about now, I know exactly what you are going to say: but what if they tell me that I am a burden? What if my fears are true?

    As hard and as heartbreaking as this can be to hear, at least you will know exactly where you stand and what you can expect from them. If this does happen, chances are that there have been issues in your relationship that were already there, long before the chronic illness arrived. The chronic illness has just made them so clear that they can no longer be ignored or denied. Continuing to feel like a burden and not talking about it, will only continue to keep you stuck in guilt, anxiety and stress, all of which is enough to trigger your autoimmune conditions and make you feel even worse.

    What I have seen in so many cases with the couples that I work with, is that marriages and relationships where one person has chronic illness can grow even stronger, closer and more loving than before. It can create new opportunities for you to both see what is really important in your relationship and that can only happen once you choose to let go of the guilt and stop believing that you are a burden. Feeling like a burden will deprive you of all of the joy, comfort, love, reassurance and connection that is available to you right now.

    Guilt is a normal phase of the grieving process and it can be overcome if you are willing to be honest, vulnerable and have the tough conversations. You are only a burden if you believe yourself to be. Don’t let the guilt tell you otherwise.

    Would you like to work with Kerry? She offers a free 20-minute Discovery Session on her website:  www.emotionalautoimmunity.com

    The post When Chronic Illness Makes You Feel Like a Burden – a Guest Post by Kerry Jeffery appeared first on The Paleo Mom.

  • 6 Benefits of Red Light Therapy (and how it improved my skin!)

    Post From http://www.rubiesandradishes.com/2018/06/28/6-benefits-red-light-therapy-improved-skin/

    How Red Light Therapy Improved My Skin

    Be sure to use code ‘ARSY’ for $25 off of your Joovv light!  I’ve been spending most mornings, in front of a red light looking like an alien. My 6-year-old finds this hilarious. For months, I’ve been religiously including red light therapy in my morning routine and I’ve experienced better sleep, a happier mood and improved […]

    The post 6 Benefits of Red Light Therapy (and how it improved my skin!) appeared first on Rubies & Radishes.


  • Turkey Meatballs with Roasted Spaghetti Squash

  • What Is the Gut Microbiome? And Why Should We Care About It?

    Post From https://www.thepaleomom.com/what-is-the-gut-microbiome-and-why-should-we-care-about-it/

    The gut is a biological niche, home to a diverse array of microbes that influence nearly all aspects of human biology through their interactions with our bodies.

    The term gut microbiota refers to the massive collection of microorganisms that inhabit our gastrointestinal tract. And “massive” is far from hyperbole: an estimated 30-100 trillion bacteria (along with fungi, viruses, and archaea) comprise the microbiota, collectively weighing around 4.5 pounds and containing over 150 times more genes than our own human genome! These microbes include a mixture of commensal (neutrally existing), symbiotic (mutually beneficial), and pathogenic (harmful to us) organisms, and can consist of any of 35,000 species known to inhabit the human gut.  Every person’s gut contains approximately 400 to 1,500 different species of the possible 35,000 different microorganisms that are well adapted to survive in the gastrointestinal tract, although about 99 percent of those microorganisms come from thirty to forty species of bacteria. Our guts are inhabited by other microorganisms besides bacteria, including archaea (similar to bacteria), viruses, and single-cell eukaryotes (like yeast).

    The term gut microbiome is often used a catch-all term to describe the gut microbiota plus its metabolome (the collection of biologically active molecules within and produced by our gut microbes), but microbiome technically refers to the amazing collection of genes that our gut microbiota have. The contribute 3.3 million genes whereas humans only have  about 23,000 genes.  This is important because our gut microbiota regulate many aspect of human health via their genetic contribution.  While gut microbiome, microbiota and metabolome are often used interchangeably, it’s important to note that these three terms all describe different aspects of the microbial community in our guts.  For the sake of clarity, I will use the term microbiota when referring to the collection of microbes in our guts and the term microbiome when referring to the ecosystem as a whole.

    Amazingly, the gut microbiome wasn’t even widely recognized to exist until the late 1990s!


    The Diverse Roles of Our Gut Microbiota

    Our gut microbiota help us digest food, produce chemicals that improve the health of the cells that form the gut barrier, and directly regulate the immune system, and they can even influence brain health by producing neuroactive chemicals that are absorbed into the bloodstream and travel to the brain. A healthy diversity of the right kinds of microorganisms in the gut is one of the most fundamental aspects of good health.

    The gut microbiome performs diverse functions essential to our health. Perhaps best understood is their role in digestion. Our gut microbiota have enzymes that break down certain types of sugars, starches, and fiber from foods so that we can digest them and absorb their nutrients. Bacteria also ferment fiber in our digestive tracts, producing short-chain fatty acids—such as acetic acid, propionic acid, and butyric acid—which are extremely beneficial energy sources for the body and are essential for regulating metabolism. These short-chain fatty acids also aid in the absorption of minerals such as calcium, magnesium, copper, zinc, and iron. Our gut bacteria aid in the absorption of minerals in other ways too. They degrade minerals complexing with phytate (an “antinutrient” present to varying degrees in all plant-based foods that binds minerals and makes them less absorbable; see for example Is Oxalate Sensitivity Real? and Nuts and the Paleo Diet: Moderation is Key), making those minerals available for absorption. Our gut bacteria also synthesize vitamins, B and K vitamins in particular, which our bodies then absorb (and which provide us with important micronutrients that we may not get enough of otherwise). Gut bacteria may also play a key role in facilitating absorption of dietary fatty acids, thereby also increasing absorption of important fat-soluble vitamins like A, E, D, and K (although the results of this cutting-edge research have yet to be confirmed in humans).  Gut bacteria can also ferment proteins, producing branched-chain amino acids, well known to be important for muscle recovery and athletic performance.

    Our gut bacteria also directly control the integrity of the gut barrier by regulating important tight junction proteins (claudin-2, occludin, cingulin, ZO-1, ZO-2) between the gut epithelial cells (see What Is A Leaky Gut? (And How Can It Cause So Many Health Issues?)). These effects aren’t limited to the gut either: recent studies have shown that our gut bacteria can regulate the permeability of epithelial barriers elsewhere in the body , including the blood-brain barrier.  Yes, our gut bacteria control how leaky the blood-brain barrier is, again through regulating important tight junction proteins ( in this case, claudins, tricellulin, and occludin).  There’s also an indirect effect on gut barrier integrity via modulation of serotonin (which regulates gastric motility) and Toll-like receptors (TLRs) which are important for antigen presentation by dendritic cells and macrophages to the adaptive immune system.

    The microorganisms in our guts help to maintain the delicate balance required by our immune systems, keeping the various populations of immune cells in check and modulating their activity. Achieving a healthy balance in the immune system is therefore reliant on having a healthy population of gut microbiota, growing in the correct numbers in the correct locations and with appropriate diversity.  In fact, let’s dig into the details on this role…


    Our Gut Microbiome  and the Immune System

    Let’s first review the key players of the adaptive immune system, so we can understand just how vital a healthy, diverse gut microbiota is for immune function. (For more details, see The Paleo Approach)

    The adaptive immune system is the part of the immune system that attacks on invading organisms (pathogens) with specificity, meaning its attacks are targeted for exactly that specific virus, bacteria, fugus or parasite that is infecting us.  It also remembers invaders (this is called immunological memory) so that it responds more intensely and quickly for subsequent infections. The adaptive immune system is why vaccines protect us against infection and why we get chicken pox only once.  The adaptive immune system also tailors responses to eliminate specific pathogens or pathogen-infected cells in the most effective and efficient way possible. (Contrast this to the innate immune system which is like our immune system’s first-responders; they’re fast to mobilize but can’t attack with much specificity.  The innate immune system is responsible for detecting a foreign invader in the first place and then recruiting the adaptive immune system to help fight them off.)

    There are two main cell types that drive adaptive immune responses: B cells (which produce antibodies) and T cells (many of which act like the middle management of the immune system).

    There are a variety of different subtypes of T cells, each with it’s own function in the adaptive immune system.  Among these are the helper T cells, whose job it is to control the actions of most other cell types in the immune system (hence the middle management metaphor). Some drive the immune system and inflammation, and some suppress and regulate the immune system, effectively turning off inflammation when the pathogen is vanquished. The important helper T cells for driving the immune system and inflammation are Th1, Th2, Th9, Th17, and Th22 cells). Th1 cells recruit and regulate nonspecific immune cells, such as macrophages, and secrete cytokines that stimulate T cells to mature into cytotoxic T cells. Th2 cells activate B cells (which then divide rapidly and secrete antibodies). Th9 cells are similar to Th2 cells (they are activated by different cytokines) and are important for host defense against parasitic infections (specifically helminth worms), but are also implicated in the development of chronic allergic inflammation, airway remodeling such as in asthma, and autoimmune disease. Th17 cells are similar to Th1 cells (they secrete different cytokines), are highly inflammatory, and are activated in response to certain bacteria and parasites. Excessive numbers of activated Th17 cells are present and probably responsible for tissue damage in some autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and inflammatory bowel disorders. There is also some evidence that Th17 cells may have a regulatory function similar to Th3 cells or Tr1 cells (see below), but the research on this isn’t conclusive. Th22 cells are also similar to Th1 cells (they secrete different cytokines than Th1 and Th17 cells) and have been implicated in inflammatory skin disorders such as psoriasis, atopic eczema, and allergic contact dermatitis.

    There are also helper T cells that are immune modulators: their job it is to help suppress the immune system. Th3 cells (also known as adaptive regulatory T cells or induced regulatory T cells) protect the lining of the gut (the gut mucosa, or mucosal barrier of the gut) from nonpathogenic antigens (foreign substances other than viruses, bacteria, fungi, and parasites). Th3 cells also suppress Th1 and Th2 cells, making Th3 cells important immune modulators. Tr1 cells (also called type 1 regulatory T cells), which are similar to Th3 cells (they secrete different cytokines than Th3 cells), control the activation of memory T cells  and suppress Th1- and Th2-mediated immune responses to pathogens, tumors, and to “self.”

    Regulatory T cells are another type of T cell (not a helper T cell) that are crucial for regulating the adaptive immune system. These cells suppress the activity of immune and inflammatory cells to shut down T-cell-mediated immunity toward the end of an immune reaction. Their immune modulating activity extends to the innate immune system as regulatory T cells can also suppress activation of dendritic cells. Regulatory T cells maintain “immune tolerance,” or the process by which the immune system tolerates and chooses not to attack an antigen (which is important during pregnancy, for example). Beyond this, regulatory T cells have the critical job of suppressing the activity of any T cells that recognize self and therefore might attack healthy cells in the body. A lack (or perhaps reduced ability) of regulatory T cells is thought to be crucial the development of autoimmune disease. Cytokines produced by Th3 cells may be important in the activation of regulatory T cells.

    Summary: there are many types of immune cells that work together like instruments in an orchestra to fight off an invading pathogen.  When the immune system isn’t balanced (as in cancer, autoimmune disease, allergic diseases, and all situations in which systemic (bodywide) inflammation is present which really just means all chronic diseases), it’s as though the instruments aren’t in tune and are all playing different pieces. That cacophony results in an immune system that both fails at its primary role and also damages us in a variety of different ways.  The gut microbiome acts as a conductor, helping to tune each instrument and making sure that the entire orchestra is playing the right piece.

    A healthy gut microbiome is critical for the development and maturation of the immune system, modulating nearly every aspect of the adaptive immune system and even some of the innate immune system. For example, a complete lack of gut microbiota is known to result in severe deficiencies of most helper T cell subsets, but an increase of Th2 cells. Some bacterial components are known to balance Th1, Th2, and Th3 cell populations through regulation of dendritic cell activation (increasing or decreasing dendritic cell activation depending on the circumstance). Some bacterial components stimulate the production of Th17 cells, some modulate the activation of natural killer cells (innate immune system cells), some influence the interaction between antigen receptors on the immune cell surfaces and the antigens themselves. Probiotic bacteria not only keep the immune system in check during times of health, but also help control the immune defense against invading pathogens, for example, by stimulating the production of antibodies against the foreign microorganism.

    Different bacterial components modulate different aspects of the immune system, including modulating/regulating all of the following:

    • gene expression of cytokines (chemical messengers of inflammation, including IL-10, IL-22, IL-1β, IFN-γ, TGF-β1)
    • production and activity of regulatory T cells
    • number and activity of IgA-secreting plasma cells in the gut lining
    • the balance between  Th1, Th2, and Th3 cell populations via regulation of dendritic cell activation
    • production of Th17 cells
    • activation of natural killer cells
    • the interaction between antigen receptors on the immune cell surfaces and the antigens themselves (via Toll-like receptors, TLRs)
    • the production of antibodies against foreign microorganisms

    For those of you who nerd out on the details of immune function like I do, you’re reading that list and thinking “woah, our gut microbiome is basically the managers of our entire immune system!”.  For those of you who read that list and start going cross-eyed, the take-home message is that our gut microbiome controls virtually every aspect of how our immune system functions.  Given that inflammation is part of the pathogenesis of all chronic illness, it’s no wonder we now have conclusive links between all chronic illness and irregularities in our gut bacteria.


    Gut Dysbiosis and Chronic Disease

    Gut dysbiosis is a general term that refers to any abnormality in our gut microbiota. This includes too many or too few microorganisms growing in the various sections of the gastrointestinal tract, the wrong kinds of microorganisms or the wrong balance between the different populations of microorganisms, and microorganisms in the wrong place. Any of these situations can have profound impacts on our digestion, gut barrier health, and the modulation of our immune systems.

    One common form of gut dysbiosis is overgrowth of bacteria or yeast in the small intestine. This is referred to as small intestinal bacterial overgrowth, or SIBO, (this term does apply to yeast overgrowth) and it is now believed to be the cause of irritable bowel syndrome (or at least some forms of IBS, which is probably a collection of disorders that have yet to be sorted out).

    Importantly, gut dysbiosis is strongly linked to chronic disease.  In fact, a link has been found in every chronic disease in which a connection to gut bacteria has been investigated.


    What Does a Healthy Gut Microbiome Look Like?

    Diversity is considered the number one hallmark of a healthy gut microbiome.

    When the microbiota of people living in Western cultures were analyzed in comparison with those of people living in rural settings who had hunter-gatherer lifestyles and with those of wild primates like chimpanzees, Western-culture gut microbiota were found to be significantly lacking in both richness and biodiversity. This is directly attributable to diets high in industrially processed foods (which are also low in fiber), which don’t supply enough nutrition for our microbiota to thrive. Interestingly, there is even less diversity of gut bacteria in obese people than in lean people: more food does not equal more nutrition, and the worse our diet, the more our gut microbiota suffer.

    In the adult human gut, two phyla (the taxonomic category right below “kingdom”) dominate: Bacteroidetes and Firmicutes. These are present in every human gut, and much smaller proportions of the phyla Actinobacteria, Proteobacteria, Verrucomicrobia, and Fusobacteria can also be present. While there are literally thousands of species of bacteria belonging to each of these phyla (including ones that are probiotic, commensal and pathogenic), it’s useful to look at some of the broad strokes when it comes to this birds-eye look at the gut microbiom.

    Bacteroidetes Phylum: Bacteroidetes is one of the two most abundant phyla in the human gut microbiome (the other being Firmicutes). This phyla is relatively less susceptible to perturbations than Firmicutes and Proteobacteria, and all of its members are Gram-negative and nonsporeforming. Bacteroidetes appear strongly implicated in weight maintenance and obesity, with a higher predominance (relative to Firmicutes) being associated with significant weight loss, and a lower predominance found in obese individuals. (The obesity link is potentially due to more efficient energy extraction from carbohydrates when the Firmicutes/Bacteroidetes ratio is high, leading to an increased energy balance.) Due to its dominance in the gut microbiome, as well as its extensive positive interactions with other taxa, Bacteroidetes fits the criteria for “foundational taxon.”

    Firmicutes Phylum: Along with Bacteroidetes, Firmicutes are one of the two most abundant phyla in humans, and compared to Bacteroidetes is relatively susceptible to perturbations. This phyla is represented mostly by lactic acid bacteria (such as Lactobacillus and Enterococcus, as well as Clostridium). Relatively lower levels are found in diabetics compared to nondiabetics, and lower levels are also found in patients with Crohn’s disease or IBD. A higher proportion of Firmicutes is associated with obesity, possibly due to the bacteria in this phylum increasing the efficiency of energy extraction from carbohydrates. The story here is complex though, because the gut microbiota of hunter-gatherers are dominated by Firmicutes and these bacteria dominate when diets are rich in vegetables.

    Actinobacteria Phylum: Although this phylum comprises a very small proportion of the gut microbiome, it fits the criteria for “keystone taxon” due to its positive association with microbial diversity and high level of ecological connectedness. All Actinobacteria members are gram-positive, nonmotile, nonsporulating, and non-gas-producing anaerobes, and the phyla as a whole is relatively stable and resistant to perturbations.

    Proteobacteria Phylum: The Proteobacteria phylum is gram negative and relatively less stable than Bacteroidetes and Actinobacteria. Most of the known pathogenic bacteria in humans belong to this phylum, and some evidence suggests that Proteobacteria members may play a key role in IBD. Proteobacteria members reside within the mucus layer in the colon and can use mucus as an energy source.

    Verrucomicrobia Phylum: This phylum contains only a handful of described species, but some of those species are extremely important—namely Akkermansia muciniphilia, a major player in immune signaling and chronic disease.


    How to Support a Healthy Gut Microbiome

    Diet is the single biggest influence on microbiota composition. In fact, diet is directly responsible for more than 60% of the variation in bacterial species in the gut.

    We know that inadequate fiber intake, high intake of omega-6 polyunsaturated fats (relative to omega-3s), high intake of saturated fat and low levels of vitamin D all cause a shift in the gut microbiota from probiotic to commensal, opportunitistic and pathogenic strains. In particular, inadequate fiber tends to shift the population of gut bacteria from majority Gram-positive strains (mainly those in the Firmucutes phylum) to more Gram-negative strains (mainly those in the Bacteroidetes phylum).  High omega-6 fat intake depletes growth of both Firmicutes and Bacteroidetes phyla.  And, high saturated fat intake skews microbiota unfavorably towards more Bilophila, Turicibacter, and Bacteroides. Vitamin D deficiency leads to shift toward pathogenic bacteria (Helicobacter, Veillonella and Erysipelotrichaceae), whereas supplementation restores levels of probiotic bacteria (Lactococcus, Akkermansia).

    Some individual food compounds can also promote the growth of the wrong kinds of bacteria. Grains, dairy, legumes, nightshades, and alcohol are all known to contain compounds that can hinder the growth of beneficial strains of bacteria while supporting the growth of undesirable strains, like E. coli.  These include agglutinins, prolamins, digestive enzyme inhibitors and alochols (including sugar alcohols).  See Are all lectins bad? (and what are lectins, anyway?)Why Grains Are Bad-Part 1, Lectins and the GutWheat and Innate ImmunityIs It Paleo? Splenda, Erythritol, Stevia and other low-calorie sweeteners and The WHYs behind the Autoimmune Protocol: Alcohol.  Some emulsifiers also preferentially feed undesirable strains of bacteria (see Is It Paleo? Guar Gum, Xanthan Gum and Lecithin, Oh My!).

    It’s not just a question of which kinds of bacteria our diet nourishes but also a question of bacterial metabolism (yep, the metabolome). Just as a high-sugar diet causes oxidative stress in our bodies (see Why Is Sugar Bad?), a high-sugar diet causes oxidative stress in our gut bacteria. Those bacteria adapt by altering their metabolism, which greatly affects our health.

    The good news here is that the population of microbes in the gut (types, total and relative quantities, and location) adapts quite rapidly to changes in diet, in a matter of a few days to a few weeks.

    • Dramatically increasing intake of fresh vegetables and fruit restores levels and diversity of probiotic species in as little as 3 to 4 days.
    • Fish oil supplementation can restore levels of probiotic bacteria in about two weeks.

    In fact, these are the two most important dietary factors for supporting healthy and diverse gut microbiota: eat plenty of whole vegetables and fruits, eat plenty of seafood, don’t go crazy on saturated fat. (Also see Saturated Fat: Healthful, Harmful, or Somewhere In Between?)

    Lifestyle also plays a role here.  Inadequate sleep, high chronic stress, living a sedentary lifestyle, and overtraining all negatively impact the microbial diversity and proportion of probiotic species in the gut.  Living an active lifestyle, getting adequate sleep, and managing stress all support a healthy and diverse gut microbial community.

    Exposure to probiotic organisms to inoculate the gut is also important. This is discussed in The Benefits of Probiotics and The Health Benefits of Fermented Foods.


    Gut Health Quick-Start Guide

    Having a healthy gut means more than just fixing a leaky one (see What Is A Leaky Gut? (And How Can It Cause So Many Health Issues?)). It also means restoring gut microbiota to the appropriate diversity, numbers, and locations—different types of bacteria grow in different amounts in different parts of the gut. In general, this means consuming a moderate amount saturated fat, a balanced ratio of omega-3 to omega-6 polyunsaturated fats, and a diversity of fiber types from a wide range of fruits and vegetables. Choosing foods as well as engaging in lifestyle choices that support gut health is a major guiding principle behind the Paleo template.

    This is a guide out of my book, Paleo Principles. It represents not just the best choices for gut microbiome health but also gut barrier health, detoxification, hormone regulation and digestion (all aspects of gut health).  You can also learn more in my Leaky Gut Mini-Course.



    Bjarnason, I., Intestinal permeability, Gut. 1994;35(1 Suppl):S18-S22

    Blaser MJ. “The microbiome revolution.” J Clin Invest. 2014 Oct;124(10):4162-5.

    Purohit, V., et al., Alcohol, Intestinal Bacterial Growth, Intestinal Permeability to Endotoxin, and Medical Consequences, Alcohol. 2008;42(5):349-361

    Swank GM, Deitch EA. Role of the gut in multiple organ failure: bacterial translocation and permeability changes. World J Surg 1996;20:411-417.

    Cresci GA, Bawden E. Gut Microbiome: What We Do and Don’t Know. Nutr Clin Pract. 2015 Dec;30(6):734-46. doi: 10.1177/0884533615609899

    Wu GD. The Gut Microbiome, Its Metabolome, and Their Relationship to Health and Disease. Nestle Nutr Inst Workshop Ser. 2016;84:103-10. doi: 10.1159/000436993.

    Wu GD. Diet, the gut microbiome and the metabolome in IBD. Nestle Nutr Inst Workshop Ser. 2014;79:73-82. doi: 10.1159/000360686

    John GK et al. Dietary Alteration of the Gut Microbiome and Its Impact on Weight and Fat Mass: A Systematic Review and Meta-Analysis. Genes (Basel). 2018 Mar 16;9(3). pii: E167. doi: 10.3390/genes9030167.

    Tengeler AC et al. Relationship between diet, the gut microbiota, and brain function. Nutr Rev. 2018 Apr 28. doi: 10.1093/nutrit/nuy016.


    The post What Is the Gut Microbiome? And Why Should We Care About It? appeared first on The Paleo Mom.

  • Cooking keto: Chicken fajita bowl

  • How to Make a DIY Standing Desk in 10 Seconds!

    Post From http://feedproxy.google.com/~r/PaleoPlan/~3/pYTkAeKoeCA/


    We wake up, get ready for work, sit in traffic, get to work, sit at a desk, take a short lunch break, sit at a desk some more, then it’s back into the car to sit in traffic again. Is it any wonder that much of our culture is sluggish, unmotivated, and just plain tired?

    These days, most of us actually spend more time sitting than we do standing and being active. Even after a long day of sitting at work, we often come home and sit in front of the TV in an attempt to unwind from the day.

    While some of us may think we have an active life if we spend an hour in the gym each day, this simply does not counterbalance the sedentary behaviors of a seated daily workflow.

    Standing Desk Basics


    So how do we balance our daily job with finding a more active lifestyle? Enter standing desks.

    A standing desk is exactly what it sounds like: a desk that is designed to be used by a person while standing upright. New research shows that prolonged sitting is extremely detrimental to overall health.

    Dr. Levine, a co-director of the Obesity Initiative for the Mayo Clinic, says there are at least 24 different chronic diseases and conditions associated with excess sitting. (1) Workplaces, schools, and even modern conveniences favor sitting (drive-through banks, drive-through restaurants), but more and more studies are illustrating the physiological implications of being excessively sedentary. (2)

    While it’s hard to completely get away from a modern life – especially if your daily job keeps you confined to an office – there are certainly workarounds that can still leave us productive, while getting healthier at the same time.

    7 Reasons You Should Get a Standing Desk

    Our bodies are designed for regular movement, but Americans spend an average of nine to 10 hours each day sitting. While standing desks have several health benefits that extend well beyond the scope of this article, here are the seven most crucial reasons why you need to start standing while you work.

    1. Heart Health


    Research shows that prolonged sitting is a risk factor for coronary heart disease. (3) The adverse effects of total sitting time impacts cardiovascular health and is associated with several disease risk factors. According to a science advisory from the American Heart Association, even people who exercise regularly could be at increased risk for heart disease and stroke if they spend lots of time sitting. Prolonged sedentary time is bad for your heart and blood vessels regardless of how much physical activity you get. (4)

    2. Weight Management

    As a culture, we are moving less and sitting more. Coupled with mindless snacking and stress-induced poor food choices, it’s no wonder that the obesity epidemic really shows no signs of slowing.

    Recent research showed that people who increased habitual walking and standing burn more fat versus those who stay seated significantly more and actually gain the most body fat. Breaking up sitting time can improve glucose levels and balance, which plays an important role in weight management. (5)

    3. Brain Health


    Sedentary behaviors have been linked with adverse long-term effects like poor cognitive development and function. Decreased blood flow to the brain – which can happen after prolonged bouts of sitting – can decrease the expression of neurotrophins such as brain-derived neurotrophic factor (BDNF), which is important for the survival, development, and health of our neurons.

    BDNF is important for learning and memory and is responsible for the growth of brain cells. Sitting for long periods of time, day in and day out, can literally harm your brain’s cells! Physical inactivity can also cause the body to release less norepinephrine, which decreases mental alertness and brain function. (6)

    4. Muscle and Bone Health

    Prolonged sitting adversely impacts bone growth and has been associated with lower bone mineral density and osteoporosis. Research has found that being seated alters the activation patterns of multiple weight-bearing muscles and therefore, excessive disuse is associated with adverse back curvature, back pain, and even upper extremity problems like carpal tunnel syndrome. (7)

    5. Low Energy


    Sitting a lot has been linked to low energy levels. This is because sensory inputs from muscles, joints, tendons, nerves, metabolic systems, and brain regions can alter energy pathways. Sitting for too long can decrease blood flow throughout the body, particularly decreased cerebral blood flow, which can make you feel fatigued, sleepy, and lethargic, even after you’ve visited the coffee pot several times. (8)

    6. Poor Digestion

    While we place a lot of emphasis on the importance of fiber and digestive health, research is finding that body posture can affect abdominal bloating, distension, and flatulence. When we are sitting all day, not only do we forget about keeping our core tight and our spine erect, but we also end up being slouched over, which puts a good amount of strain on intestinal transit. (9)

    7. Strained Neck


    Work-related neck disorders are quite common these days in office workers, especially in those who use a computer daily. In a recent study, 512 office workers were studied for 12 months regarding neck pain. The research concluded that the prevalence of neck pain in office workers was three times greater in persons older than 30, with women having a two-fold risk compared to men. Holding the neck in a forward bent position for a prolonged time while sitting was associated with neck pain, and that’s pretty much the only way that we sit while we are working at a desk. (10)

    How to Choose a Standing Desk


    Upgrade your office life (and health) with these different standing desk options.

    1. The ApexDesk Vortex

    While this is a bit of an initial financial investment, the return on your health will be tenfold. This is the best overall standing desk thanks to its durability and lift capabilities. It is also scratch resistant and has plenty of room for a monitor, keyboard, and mouse. It comes in four different colors and has a six-button memory controller and pre-set height ranges.

    2. Stand Steady Conversion Desk

    This is the best budget-friendly option and allows you to convert a regular desk to a standing one, which is perfect for office situations where you can’t just haul in an entirely new work surface. The Stand Steady desk is simple and effective. It is lightweight and can support up to 75 pounds of computer and work equipment. and it can be set up without any tools in five minutes or less.

    3. FlexiSpot

    This is the perfect option if you are tight on space and looking for something a little more compact. This sit-stand workstation makes switching back and forth between seated or standing rather easy. You don’t need any special tools to put it together, and it comes fully assembled when it is shipped to you! There is a separate keyboard tray and if you find yourself needing a little extra height for your monitor, you can purchase the tall user kit, all with a five year guaranteed warranty.

    4. DIY Standing Desk

    If purchasing a standing desk is not a viable option for you, you can find effective ways to improvise while making improvements to your work environment.

    If you have a laptop, simply stand up and find a surface that allows your wrists to be straight while typing.

    If you want to remain at your existing desk, you can also place a pile of books on top of each other until you reach the desired working height, or rely on other options, like boxes, plastic crates, or anything else that offers height and a semi-durable surface. It might not be the prettiest, but it’ll get the job done, cut down on your sitting hours, and work toward improving your health – all without spending a dime.

    Bottom Line

    Sitting is detrimental to health on many levels, but especially when you sit for nearly an entire day in an office. Finding ways to increase your standing and walking time will help boost your mood and your physical well-being without taking time out of your already jam-packed work day.


    The post How to Make a DIY Standing Desk in 10 Seconds! appeared first on PaleoPlan.

  • TPV Podcast, Episode 307: Are Mushrooms Really Magic?

    Post From https://www.thepaleomom.com/paleo-podcast-magic-mushrooms/

    In this episode, Stacy and Sarah tackle the latest trend of using mushrooms as a supplement

    Click here to listen in iTunes

    or download and listen by clicking the PodBean Player below

    If you enjoy the show, please review it in iTunes!

    The Paleo View (TPV), Episode 307: Are Mushrooms Really Magic?

    • Intro (0:00)
    • News and Views (0:40)
      • Stacy asked Sarah to prioritize this week’s topic.
      • Sarah had to do a lot of research (and learned a lot of things!) researching this week’s topic.
      • Stacy’s question to Sarah was, “should we really be putting mushrooms in coffee?”
    • Listener Questions (5:55)
      • Jan writes, “Hey ladies!! Love your show. Thanks for everything that you do to help so many people be the best versions that they can be!!! I was wanting your thoughts on the medicinal mushroom drinks. I keep hearing about them and seeing ads for the four stigmatic drinks. I have several autoimmune so would love to know for that as well as for those that don’t have auto immunes.”
      • Annik writes, “Bonjour Sarah et Stacy, I love your books and your podcast – the science you bring to health topics is so refreshing and helpful in navigating the tremendous amount of health claims we are bombarded with daily, and weeding out the fads and those that are not scientifically proven. This brings me to my question. The new health push seems to be for including powdered mushrooms into our diet. Claims include increased energy and reduced fatigue, mental clarity, immune boosting properties, hormone balancing, etc. Is there any science that shows the benefits of including cordyceps, chaga, lion’s mane, reishi, etc., into our diet? And if so, how long does it take for someone to feel the benefits of including these supplements into our diet? I’m particularly interested in the claims around reduced fatigue, increased energy, and immune boosting properties. I do not have an autoimmune condition diagnosis yet but I have been dealing with fatigue, congestion and lots of colds in the last year which continues to be unexplained by my medical doctor. While I know quick fixes don’t work, if adding powdered mushrooms to my morning tea would help with energy then why not?! Lastly, I want to say a big thank you to Dr. Ballantyne for the Autoimmune Protocol Lecture Series. I took the 6-week course and learned so much! I was already eating a paleo diet but saw tremendous benefits in fine-tuning my diet to see how it could help with my health challenges described above. I am most grateful for the continued access to the course material; I messed up the reintroduction part and will now restart the course! Thank you both for all that you do and for your active social media info sharing. You set the standard high for evidence-based health information and make it accessible to all of us! It is highly appreciated!”
        • Thanks, Annik for telling us how much you love the Autoimmune Lecture Series!
        • Edible mushrooms are really nutrient-dense and have unique carbohydrate and fiber types.
        • Medicinal mushroom use goes back thousands of years.
          • They date back to the ancient Egyptians and ancient Chinese cultures.
        • In the last 50 years, there have been a lot of scientific studies on mushrooms.
          • Specifically, health-promoting properties can include:
            • Antioxidants
            • Cholesterol-lowering properties
            • Anti-hypertensive
            • Anti-inflammatory and immunomodulatory
            • Liver protection
            • Anti-diabetic
            • Anti-obesity
            • Anti-tumor (note, only animal studies and cell culture studies to date)
            • Anti-viral
            • Anti-microbial properties
          • Some drugs have been created from mushroom extracts, specifically used in cancer patients to boost immune function during treatments.
        • Phytochemicals found in mushrooms are a contributor to the health benefits of mushrooms.
          • Mushrooms are high in gallic acid.
            • An antioxidant and heavy metal chelator.
          • Mushrooms are high in Triterpenes.
            • These properties include anti-inflammatory, anti-virus, anti-diabetes, anti-cancer, anti-oxidant and speed wound healing.
        • Glucans are a unique carbohydrate found in mushrooms.
          • Fungal glucans can be water-soluble or insoluble.
          • Chitin fiber is a fermentable fiber found in mushrooms.
            • This type of fiber is great for gut health and microbiome diversity.
          • Some glucans are very small molecules, so they can actually bind to immune cells directly and modulate the immune system.
        • Mushroom extracts versus whole mushrooms.
          • Most medicinal extracts use a double extraction process.
            • Some of the compounds are water soluble and some are not.
            • Some medicinal preparations can have one, some, or many of these compounds included.
        • Well-known properties of commonly used mushrooms.
          • Reishi
            • Probably the most studied medicinal mushroom.
            • Main uses: lung infection (expectorant), liver protective, reduces blood pressure, improves exercise performance, adaptogen (relaxer), reduce allergies, reduce ulcers, anti-inflammatory, anti-cancer, reduce infections, reduces anxiety and depression, anti-diabetes.
          • Maitake
            • Main uses: reduces high blood pressure, tumor inhibition, liver protectant, fights infection, anti-diabetic.
          • Shiitake
            • Main uses: immune regulator, tumor inhibition, antiviral, antibacterial, liver protectant, anti-obesity, anti-diabetic, reduces cholesterol, antimicrobial, anti-cancer.
          • Chaga
            • Main uses: immune regulator, Anti-Cancer, Anti-Viral & Anti-Inflammatory! Antioxidant, reduces cholesterol and high blood pressure, improves performance, Also adaptogenic (relaxer).
          • Lion’s Main
            • Main uses: enhances brain function, anti-cancer, lowers cholesterol, reduces gastric ulcers, anti-inflammatory, anti-diabetic, immune regulating.
          • Cordyceps
            • Main uses: energizing adaptogen, improves exercise performance, anti-inflammatory, immune stimulating or regulating (fighting infection), anti-cancer, liver protective, anti-diabetes acts as a natural aphrodisiac.
          • Turkey Tail
            • Main uses: anti-cancer (one of the best studied for helping fight cancer, adjuvant for chemo patients), helps fight infection (HIV).
          • Almond Mushroom
            • Main uses: anti-cancer, anti-inflammatory, anti-microbial, anti-virus, reduces allergies, immune regulatory.
            • Not edible whole, usually only available as a supplement.
        • Mushrooms and Cancer
          • One of the benefits is that mushrooms can suppress the regulatory immune system and stimulate the attacking part of the immune system.
            • Reishi, Cordyceps, Maitake, and Turkey Tail.
              • Studies have shown they are able to boost the immune system’s ability to find and kill cancerous cells.
              • There are no clinical trials showing medicinal mushrooms can kill cancer.
        • Mushrooms and Autoimmunity
          • Emerging preliminary evidence suggest that mushroom extracts are immune modulators rather than immune stimulators, meaning they can help balance the immune system.
            • This could be because of their influence on the gut microbiome.
            • This could be because of the high level of phytochemicals.
          • Medicinal mushrooms may be beneficial in instances of under-active immune systems, overactive immune function, and dysfunctional immune systems.
        • Reishi and Cancer
          • Able to activate natural killer cells, increasing their activity and the body’s ability to fight tumors.
          • Reduces the chances of metastasis, which is when cancer spreads to another part of the body.
          • Adjunct therapy (not primary, first-line therapy) for colorectal cancer, lung cancer, prostate cancer, and breast cancer, and is shown to increase the survival rate.
        • Reishi and Autoimmune Disease
          • Studies in RA patients showed no increase in inflammatory cells or cytokines, and a decrease in IL-18, which activates Th1.
            • Impact on the immune system was not the same as it is in cancer.
              • This suggests immune modulating rather than stimulating.
            • Study participants reported lower joint pain.
          • A Lupus mouse study showed a decrease in autoantibodies and increased survival.
        • In summary:
          • Eating more whole mushrooms, in general, can be beneficial for health.
          • There are people who would probably benefit from medicinal mushrooms.
            • Talking to your healthcare provider first is always a good idea.
          • Adding more mushrooms to our diets is a great choice!
          • If you take mushrooms, let us know if they have helped you.
    • If you’ve enjoyed the show, please recommend it to someone who might enjoy it.
    • We love when you share and when you leave reviews for us! Thanks for listening!

    The post TPV Podcast, Episode 307: Are Mushrooms Really Magic? appeared first on The Paleo Mom.

  • Pumpkin Pancake Recipe – Paleo and Gluten Free!

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