#205 – The links between gastrointestinal health, metabolic health, and fertility | Dr. Robin Rose & Ben Grynol

Gastrointestinal health, metabolic health, and fertility are all linked. The gut microbiome impacts other microbiomes in the body, which can then impact the ability to conceive. Our gut microbiomes are becoming less diverse through modern farming practices and the consumption of processed foods. Dr. Robin Rose and Ben Grynol discuss how gut microbiome testing can determine underlying factors of gastrointestinal distress and the lifestyle changes that can help address symptoms and even aid fertility.

Helpful links

Terrain Health: Terrainhealth.org
Microgenesis Corporation: https://www.microgenesis.net
Dr. Robin Rose on Instagram: https://instagram.com/dr.robinrose

8:05 — Gastrointestinal issues are associated with metabolic health issues

According to the National Institute of Diabetes and Digestive and Kidney Diseases, 60 to 70 million people are affected by some kind of digestive disease, including gastroesophageal reflux disease (GERD), inflammatory bowel diseases, irritable bowel syndrome, small intestinal bacterial overgrowth (SIBO), and more. Due to gut microbiome issues, many of these conditions have links to metabolic health.

The standard American diet doesn’t help the situation. And the way we eat, the way the food is processed and moving away from a whole-foods, plant-centric diet to one of processed foods, very heavily meat based. Obviously, people aren’t eating meat that’s grass fed, pasture raised—things of that nature. You know, regenerative farming, we can get into that too. That combined with lack of sleep, that combined with lack of movement, and stress and cortisol through the roof, driving glucose, insulin resistance, so on and so forth. That all plays a role in the health of the gut microbiome and our overall health.

8:56 — Many people lack gut microbiome diversity

Modernized farming practices, industrialization, deforestation, and more have contributed to the depletion of soil microbiomes. This soil depletion then contributes to less diverse gut microbiomes in humans.

There are hundreds of trillions of organisms—mostly bacteria, but fungi, viruses, parasites, these other organisms called Euryarchaeota or methanogen-producing organisms. There’s so many different thing—candida, I think I said fungus, all these things, but the vast majority are these bacteria. You have all these organisms, but there’s something called microbial diversity. And the idea is you want to have as much diversity as possible because that then equates to a healthier gut microbiome and overall health. But there’s only really about 250 different identifiable species that we know about or that have been researched. And so really having as close to those 250 different species in your gut is something to strive for. Many people fall very short of it—especially in the United States because of our lifestyle and how we eat.

15:24 — Infertility in some people has links to the gut microbiome

Dr. Rose has partnered with Microgenesis Corporation, a company that’s working to help women with their fertility after the founder researched the connection between infertility and gut dysbiosis.

So basically, whatever’s happening in the gut microbiome is then translated or is mirrored in the other biomes in your body. So when we’re talking about fertility in woman, we’re talking about the vaginal biome in particular. So for example, the microRNAs can be secreted in the gut in response to changes in that gut microbiome. And then they travel to the reproductive tissue, and then they affect the function and integrity there of that organ. Does that make sense? So, through this technology, that’s how it’s tested basically. That’s how we figure out what’s going on. But she has been able to figure out that, over all these years, that the infertility—the problem that the woman is having—is basically stemming from the health and balance of the gut microbiome. And so infertility is just a symptom of something else.

30:56 — PCOS and gut dysbiosis share a connection that’s still being researched

Although correlation does not equal causation, Dr. Rose notes a link between polycystic ovarian syndrome and gastrointestinal issues, such as constipation, bloating, discomfort, and more. She examines patients’ microbiomes through metagenomic testing.

There are two different types of PCOS—two different phenotypes. One of the phenotypes is PCOS that stems from gut dysbiosis and leaky gut. And the other one—that’s more of an insulin resistant PCOS. So that’s fascinating too because they get treated a little bit differently. So I do put a lot of my PCOS patients—even if they’re not ready to conceive or they’re not even in their twenties—I’ll put them through this because it regresses and reverses the PCOS. It really solves the problem in a lot of cases—because again, it’s this metabolic disturbance that’s being driven from the health of the gut microbiome.

32: 26 — Restoring gut and metabolic health may help alleviate PCOS symptoms

Although PCOS does not have a cure, improving gut and metabolic health may serve as a treatment by addressing underlying factors.

If you just go after the gut and restore health and balance to that gut microbiome and get them on the right things to really restore health to the intestinal barrier mucosa and to really get these tight junctions—not letting anything leak out and cause this sort of chronic low-grade inflammation that then stimulates problems with insulin, glucose dysregulation, and things like that—it’s really so powerful. And I think that’s a big piece that’s missed in these women, and it’s so easily fixed.

34:44 — Metagenomic testing assesses gut health

Dr. Rose tests the gut microbiome to determine its makeup and what might be contributing to health issues.

I do next-generation sequencing on the gut microbiome in almost all my patients, or the vast majority of my patients. It’s metagenomic testing. So at that cellular level, molecular level, what’s going on in the gut microbiome? Who’s taking up real estate in the gut? What good guys are there? What bad guys are there? Are they in balance or not? Do they have leaky gut based on what we’re seeing? And then, from a structural standpoint and then also from a functional standpoint, what’s going on in that gut? Are they making their short-chain fatty acids? Are they producing too much ammonia, methane, hydrogen sulfide… So I can tell you from diet, from what people choose, it does significantly or markedly affect the balance of the gut microbiome and who’s living there and what species are taking up space there—and what’s not—based on how they’ve chosen to eat.

39:47 — Gut health often requires balanced macronutrient intake

Dr. Rose discusses her “Goldilocks rule” of macronutrient intake, meaning that just the right amount of each macronutrient is beneficial. For some people, the ketogenic diet isn’t optimal because of their AE genotype.

They’ll say to me—9 out of 10 times—”Oh my God, I did a ketogenic diet and I felt terrible.” And the reason why they felt terrible was they couldn’t handle that high fat content and their body was telling them something. So intuitively they knew that something was off. And what’s so interesting about this too is that’s why I love precision medicine in so many different ways. Because here you have a ginormous percentage of the population being like, “I’m going to do keto.” And they’re likely doing more damage than good, right? So that’s why I totally believe in balance and moderation and all that stuff. But ketogenic is powerful for a lot of different things—a lot of different cancers. But I believe for short term to treat that issue or problem. Not long term—any of these fad diets.

49:14 — Regenerative farming practices could help us get more quality nutrients

Modernized farming and ranching practices in the United States are detrimental to nutrient composition of vegetables and meats. Regenerative farming practices, which preserve soil and animal health, have the potential to boost human gut microbiome health.

Then I started doing a much deeper dive into farming techniques and how they process foods in Europe, or even New Zealand or Australia. It’s  just so different than how we do it here. And that’s why I really support regenerative farms. And these farms that from the minute the calves or the baby goats and sheep are born, they’re just pasture raised. They’re out there grazing. They’re just eating from the earth and the grass. Because when we eat them, we’re eating what they have in them—that’s being passed on to us. So we want to make sure that they’re full of nutrients and amazing compounds and vitamins that we need. We’re not getting that because everything is so processed and everything’s factory farmed, and the soil is nutritionally depleted and so on and so forth. I really am such a big supporter and believer in regenerative farms, and if we could get back to that, that would be super helpful. And I think people’s guts would feel a lot better, and we’d have a lot less GI problems and symptoms.

54:57 — Eliminating dairy and gluten may ease gastrointestinal symptoms

Dr. Rose recommends abstaining from gluten and dairy—at least temporarily—as a first line of defense against gastrointestinal concerns.

Both of them are extremely inflammatory, extremely damaging to the gut microbiome. When many people just take those two things out, I can’t even tell you how much better they feel. So that in and of itself is a big deal. I always say, “It doesn’t have to be forever. You have to heal. The diet that heals isn’t the diet that seals.” I always tell patients that they can go back to an 80/20 rule—unless they really have an underlying condition that predisposes them to really not be on these two particular things. But I always say to try that first because it does make a huge difference for a lot of people because that is driving a lot of their symptoms. The other thing is hydration. People are so under hydrated. And drinking a lot more water is super-duper important.

56:29 — Sleep quality and quantity also inform gut health

Dr. Rose recommends a focus on sleep to also aid the gut microbiome.

Our circadian rhythms are timed with our gut microbiome. Circadian rhythms really have this bidirectional pathway and really influence each other in a lot of ways. And most of us don’t sleep. There’s an insomnia epidemic as well, and people don’t get into deep sleep either. And when that happens, it really does a lot of damage to the gut microbiome. Our vagal tone goes down, and the vagus nerve is so super important in that whole gut-brain connection and in controlling motility and so on and so forth. And also, when you don’t sleep, guess what you want to eat: Crap.

Dr. Robin Rose (00:06):

I do next generation sequencing on the gut microbiome in almost all my patients or the vast majority of my patient. I’m able to see metagenomic testing. At that cellular level, molecular level, what’s going on in the gut microbiome? Who’s taking up real estate in the gut? What good guys are there? What bad guys are there? Are they in balance or not? Do they have leaky gut based on what we’re seeing from a structural standpoint? And then also from a functional standpoint, what’s going on in that gut?

(00:36):

I can tell you from diet, from what people choose, it does significantly or markedly affect the balance of the gut microbiome and who’s living there and what species are taking up space there and what’s not based on how they’ve chosen to eat.

Ben Grynol (01:01):

I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And along the way, we have conversations with thought leaders about research backed information so you can take your health into your own hands. This is A Whole New Level. When it comes to the cross-section of gastrointestinal issues as they relate to metabolic health, well, there’s no one greater to talk to than Dr. Robin Rose. Dr. Rose is founder and CEO of Terrain Health, where she works with her patients to identify the root cause of many different GI conditions.

(01:49):

She and I sat down and we talked about this cross-section of GI as it relates to metabolic health. We talked about things like diet. Does that come into play when thinking through different instances of GI conditions that can occur from people consuming certain diets? It’s not to say that one diet might lead to a higher rate than another, but it’s something to be aware of when we think about the food, the inputs, the lifestyle choices we make, and how does that pertain to downstream outcomes.

(02:21):

We talked about the fertility epidemic as it relates to GI issues, and mostly we talked about how people can think about mitigating some of these conditions as they work through different lifestyle factors and adapt the changes in their behavior needed to live healthier, happier lives. No need to wait, here’s our conversation with Dr. Rose. A couple of things that would be interesting to cover is the cross-section of metabolic health as it relates to gastrointestinal issues, PCOS, fertility, and then even some things related to…

(03:01):

I mean, it’s parallel to metabolic health, but more along the lines of diet as it relates to gastrointestinal issues and some of the things that might be misconceptions where people can nod their heads and agree, avoid sugar, avoid highly processed foods. But I think there’s a misconception of sometimes people go really hard in one direction towards a certain type of diet if they make lifestyle changes and they think they’re eating healthy by still eating whole foods. But if you’re eliminating, let’s say, not to label a specific diet, but carnivore or keto or some of these diets where the idea is to eliminate some of the micronutrients you’ll get from plants…

Dr. Robin Rose (03:37):

Like the macronutrient that you’re sort of?

Ben Grynol (03:40):

Doubling down?

Dr. Robin Rose (03:40):

Yeah.

Ben Grynol (03:41):

It’d be interesting to touch on all of those things as they relate to GI issues. Why don’t we kick it off with the scale, the number of people that are affected by digestive diseases? According to the National Institute of Diabetes and Digestive and Kidney Diseases, 60 to 70 million people are affected by some type of digestive disease. Don’t quote me on that. That was a quote from you, I believe, in an article. We will run with it is a large scale, but it’s a large number of people affected by these diseases. What are some of the common types of GI issues that people would face or people might have heard of?

Dr. Robin Rose (04:23):

Obviously some of the most common… Let’s start above and then we’ll move our way down. Starting up above, gastroesophageal reflux disease, people that present with heartburn, epigastric pain, throat burning, feeling like something stuck in their throat, that sort of thing. Then there’s dyspepsia or functional dyspepsia, which is like a global term for upper GI discomfort. People that have bloating, feeling full fast, nausea, things of that nature. Peptic ulcer disease, SIBO, small intestinal bacteria overgrowth, irritable bowel syndrome, which could be of the constipation predominant type, the diarrhea predominant type, or the mix type where you’re alternating between both of those.

(05:13):

Now, remember, irritable bowel syndrome, you have to really constitutes both the modification of the bowel habit or bowel movement plus abdominal pain and/or bloating. Now, people get that confused with or it sort of is a spectrum, but chronic constipation or chronic diarrhea. Because the people who have chronic constipation or chronic diarrhea, they really lack the abdominal pain component. That’s what makes that person fit into the category of irritable bowel syndrome when you have the abdominal pain piece of it.

(05:48):

And then there’s inflammatory bowel disease, Crohn’s disease, ulcerative colitis, microscopic colitis. There are so many different gastrointestinal illnesses and problems clearly. We could name probably a hundred more.

Ben Grynol (06:00):

When thinking through diet, it’s apparent that as things become faster and more convenient and we start to strip away a lot of the nutrients, we strip away the fiber, we strip away what we need in our diet to promote a healthy microbiome, what is it that has caused so many people to start to realize? You hear of people saying, “Oh, I’ve got IBS,” or they have maybe some other GI issue that they are living with and trying to mitigate in the best respect. Is it food? Is it other lifestyle factors that contribute to some of these diseases being more prevalent maybe in we’ll call it the social fabric of conversation?

Dr. Robin Rose (06:41):

First of all, when you talk about the four pillars of health, sleep, movement, nutrition, stress management or mindfulness, all of those things contribute to dysbiosis and imbalance of the gut microbiome, leaky gut, so on and so forth, and then leading to any of these different disease manifestations that we just talked about. Clearly the standard American diet doesn’t help the situation.

(07:13):

The way we eat, the way the food is processed and moving away from a whole food plant centric diet to one of processed foods, very heavily meat-based, and obviously people aren’t eating meat that’s grass-fed, grass-finished, pasture raised, and things of that nature, regenerative farming, we can get into that too, and that combined with lack of sleep, that combined with lack of movement and stress and cortisol through the roof, driving glucose, insulin resistance, so on and so forth, that all plays a role in the health of the gut microbiome and our overall health.

Ben Grynol (07:55):

How many microorganisms are typically in a person’s gut?

Dr. Robin Rose (07:59):

There’s trillions, hundreds of trillions of organisms, mostly bacteria, but fungi, viruses, parasites, these other organisms called Euryarchaeota or methanogen producing organism. There are so many different things, candida. I think I said fungus, all these things. But the vast majority are these bacteria. You have all these organisms, but there’s something called microbial diversity. The idea is, is you want to have as much diversity as possible because that then equates to a healthier gut microbiome and overall health.

(08:40):

But there’s only really about 250 different identifiable species that we know about or that have been researched. Really having as close to those 250 different species in your gut is something to strive for. Many people fall very short of it, especially in the United States because of our lifestyle and how we eat, but that’s really what you want to try to get as close to as possible.

Ben Grynol (09:13):

It sounds analogous to the idea of regenerative farming. What makes for a great ecosystem? It’s the idea of diversity. Without diversity, we know what happens with… To digress for a sec, you get into monoculture and everything gets stripped away and you go, “Well, where are all the microorganisms? Where all the things that make the whole ecosystem rich?” If people are stripping away some of these microorganisms from their microbiome, then over time it’s easy to see how it leads to some of these issues.

Dr. Robin Rose (09:45):

Absolutely. I don’t know why this just popped in my head, but another thing just to piggyback off of what you said, over the last century through urbanization, deforestation, industrialization, we’ve lost contact with nature. There’s hundreds of thousands or tens of thousands of organisms from unmined soil or earth that we used to be in contact with on a daily basis that we used to breathe in, that we used to swallow, that we would absorb through our skin when we were walking barefoot in the forest, and so on and so forth. Those organisms are so super important for our health. I actually do use this one product, it’s very interesting, called Razo Health that comes from unmined soil.

(10:34):

It’s unbelievable the array of different things that it helps treat and helps people with because of these missing groupings of organism from the unmined soil that we don’t have contact with and that is likely contributing to disease. These organisms have been shown, we’ll touch on metabolism and metabolic health, but they do play a big role in insulin glucose metabolism and regulation.

Ben Grynol (11:07):

It’s super interesting because in a society of efficiency, we end up stripping away some of the things that give us long-term benefit in so many aspects of life. It’s this trade-off of convenience and efficiency and maybe living in a world that we want to be faster and faster, when really what we have to do is slow down to think about what we’re doing and why. One of the things that you touch on frequently is this idea of fertility as it relates to gastrointestinal issues. We know there’s a fertility epidemic that’s apparent. It is happening across men and women.

(11:45):

I think especially with let’s say men in particular, that was always the, well, it’s an issue with female fertility and it doesn’t have to do with the men. As we start to look at things like sperm count, sperm quality, all of these things decreasing over time, and you’re going, no, no, this is a both issue. Now let’s address it. We’d love to get into some of the ideas of what causes this fertility epidemic that we’re in, and then get into some of the ties to GI issues.

Dr. Robin Rose (12:19):

We have partnered with, and I’ll give you the whole background because it’s so super interesting, with this biotechnology company called Microgenesis. The woman that started it, she has dedicated literally two decades of her life to cracking the code on infertility. What she has found is that it stems from dysbiosis or an imbalance of the gut microbiome and a problem with the gut microbiome. The way she was able to figure this out is through what’s called microRNAs technology. MicroRNAs are these small non-coding RNA molecules, and they play a really important role in regulating gene expression.

(13:07):

And then what happens is, is they can regulate cellular metabolism by targeting certain metabolic enzymes and multiple signaling pathways, and then the microRNAs themselves can regulate the cell metabolism by modulating the expression of different proteins involved in gut integrity, like the tight junctions in your gut, and also immune cells, and then the secretion of different inflammatory related mediators. The microRNAs, you’re like, “Oh, how does that relate to infertility?” Basically the microRNAs can affect gene expression locally in the GI tract. They’re expressed by particularly macrophages, which is a type of immune cell.

(13:56):

Locally they can exert their effect. They are like exosomes, and they’re secreted and transported by these extracellular carriers to different targets in the human body and different organs. Basically whatever’s happening in the gut microbiome is then translated or is mirrored in the other biomes in your body. When we’re talking about fertility in woman, we’re talking about the vaginal biome in particular. For example, the microRNAs can be secreted in the gut in response to changes in that gut microbiome, and then they travel to the reproductive tissue, and then they affect the function and integrity there of that organ.

(14:43):

Through this technology, that’s how it’s tested basically. That’s how we figure out what’s going on. She has been able to figure out over all these years that the infertility the problem that the woman is having is basically stemming from the health and balance of the gut microbiome. Infertility is just a symptom of something else. When you test these women, because we do a vaginal biome swab, plus we layer it with specific biomarkers… Because you can imagine, there’s specific algorithms that are involved to figure out what this woman is expressing.

(15:27):

To back up, she figured out or so far has identified 64 different phenotypes, phenotypes meaning expressions, different expressions of the gut microbiome or variation in the gut microbiome, that are occurring or found in these women that have infertility. Let’s say you’re phenotype 34, I don’t know. It’s a symptom of something else smoldering. A lot of these women have a smoldering autoimmune process, a smoldering Hashimoto’s, PCOS that maybe has never been diagnosed, endometriosis, recurrent vaginitis. The list goes on and on with a million other different things that these women can have.

(16:12):

Whether they’ve expressed it or not can remain to be seen. Some of the women might be like, “I do have a history. I was recently diagnosed with Hashimoto’s, or I have X, Y, and Z,” and that’s because they are one of these phenotypes. Or if the woman hasn’t maybe expressed it yet, we’re catching them so that they don’t express it. The idea is to restore health and balance to the gut microbiome through a specific program so that then these women can get pregnant successfully.

Ben Grynol (16:45):

Interesting. It’s fascinating because it sounds like everything is a step upstream to get to that root cause of exactly what the underlying issue is, as opposed to giving it the blanket statement of, well, somebody has challenges with fertility. There are so many causes. There are so many reasons that that can happen.

Dr. Robin Rose (17:04):

Right. A lot of these women, obviously they’ve been worked up. Their partner has been worked up, the sperm, whether it’s fine or not, or maybe they have low sperm count, or they’ve definitely been ruled out to have a structural or an anatomical issue. They go into this, oh, it’s infertility of unknown ideology or undetermined. They don’t know why. But the reason why is because of what we’re talking about. All of those women that have been worked up and don’t have any of these, they fall into this category where this technology, both the medical testing and the interventional treatment, which is all natural by the way, will really help them.

(17:48):

There’s two clinical trials. They’ve studied over 300 women both in the United States and in the EU and South America, and she shows a 75% success rate in conception. Just to give you a little bit of context around this, if you look at the CDC data around this, a healthy young woman, so really under 35 years old, that undergoes in vitro fertilization has a 29.5% chance of getting pregnant. She takes that to 75% with the understanding what the phenotype is and then treating them. The treatment is only 10 weeks. She studied both women that had refractory. On average, they went through 4.2 cycles of IVF and never got pregnant.

(18:46):

Some of them over 10 years, couldn’t get pregnant. Again, she showed in the study a 75% success rate in conception. When she repeated the study, because the original study with the refractory IVF patients, that was in Spain and South America, the repeat study was done in American woman, they, on average, I think time span for them trying to get pregnant was three years on average. They were taking three years to get pregnant. I think some of them had dabbled with hormone therapy in the context of infertility. She reproduced the results and showed 75% success rate in conception, in conceiving.

Ben Grynol (19:32):

That is such a wild outcome to think about, because one, it is very much addressing the downstream goal, the downstream goal being, “I’d like to get pregnant. I’d like to have a family,” but the upstream root cause of everything is still not addressed. And over time, we know with some of these chronic conditions, they compound. They just get worse and worse and worse. I mean, it’s really unfortunate that those can be left in the dark or they can be left behind because you do achieve the one goal, but in the end, you’re still not at optimal health.

Dr. Robin Rose (20:05):

Correct. That’s why I was so taken by what she has done and how she has done it. As a woman myself, I mean, I, thankfully, never had issues with fertility, but I had so many friends and I watched them struggle and go through it, besides the financial burden and not even that, but the mental, physical, and emotional trauma from it and what they go through to get the baby. It’s only just banding the situation. You’re not getting to the root cause. Why I love this so much is that we are helping these women become healthier people. We are saving them from either going on to express that conditioner underlying disease, or we’re helping them regress or reverse what they have going on currently.

(20:57):

Not only are they going to have a baby and have a healthier baby, but they’re going to be healthier. When a woman is trying to get pregnant, they don’t care about anything. They could care less about their health. They just want to get pregnant. I totally get that on every level. But why this is so powerful is that we are changing the trajectory of their health. She’s even starting to show, and this is going to come out soon and it’s being studied right now, but the babies of the women that go through these programs versus women that go through traditional IVF, they have much healthier microbiomes and they’re much healthier.

(21:39):

You’re winning on all fronts. It’s a very powerful tool in our toolkit when it comes to chronic disease and infertility in general.

Ben Grynol (21:50):

Do you have any insight around IVF with women who might not be metabolically healthy or might have some underlying GI conditions, they get pregnant, versus women that are going upstream, taking care of the root cause? Do you have any insight as to the success rate? Assume somebody gets pregnant through IVF, but maybe they have an unhealthy pregnancy, or, unfortunately, if they have a miscarriage. I mean, disheartening in every respect to go down some of these paths.

(22:23):

But do you have any insight into the long-term outcome of IVF being unhealthy and the health of the baby versus going upstream, taking care of root cause, and then having a higher success rate in getting pregnant and having a healthy pregnancy?

Dr. Robin Rose (22:37):

This is so interesting, that’s what we’re trying to unravel right now. We are looking at that data. That’s what we are going to show in the months or the next few years to come. But anecdotally, and I guess some of it’s maybe been studied, but these women that go through multiple rounds of IVF and the exposure to hormones and repeated exposure and so on and so forth, what does that do? What does that do to their health long-term? Are they at higher risk for certain cancers? Are they destroying their gut microbiome and really causing a dysregulated gut immune access from all of that exposure that they’ve had, that gut metabolic access?

(23:22):

What do the babies look like? That we’re in the middle of studying right now, looking at the babies and showing what the gut microbiome looks like and how it’s a much healthier gut microbiome likely in the babies that are being born by going after root cause and the woman really addressing her underlying health and really restoring health and balance to the gut microbiome, lowering these inflammatory biomarkers, versus the women that go through the traditional conventional way of doing things. I want to qualify one thing. The women in that need IVF or an embryo transfer, so on and so forth, we put them through the program, because a lot of these women don’t need to do that.

(24:03):

But the point is, is instead of them having this 29.5% or lower chance of getting pregnant, it markedly or significantly increases their chance of conceiving. On top of that, you lowered their exposure, because maybe you’ve brought them from maybe having to go three or four times through it to only one time or two times. Again, you’ve addressed, like you said, the root cause or the underlying issue of that woman’s health, of what’s driving some of the problems contributing to the infertility.

Ben Grynol (24:38):

Are there any instances or any data that you can point to as far as the differences in outcomes for gestational diabetes as it relates to somebody who goes through IVF?

Dr. Robin Rose (24:50):

No. You know what? I’m going to look that up. That’s so fascinating. But I will say we do use insulin as a biomarker, and we watch it fall and come down. Insulin is one of the biomarkers we use, and we repeat the labs at day 30, 60, and so forth. And that biomarker tremendously and markedly falls in the women that go through this program. Especially in the context of the women that have diagnosed or undiagnosed PCOS, that’s a huge driver of why they can’t get pregnant.

(25:27):

When they go through this intervention of certain nutraceuticals, the specific probiotic strains that they have to be reinoculated with and the specific nutrition plan that they’re going to do, that significantly plays a role in that whole gut metabolic access and that insulin really comes down nicely. That I can speak to from a clinical perspective because we see it all the time.

Ben Grynol (25:55):

It’s wild because there’s this misconception I think that exists in society that when women are pregnant, the thought, oh, well, I’m going to eat what I want and I can eat anything. If somebody is experiencing morning sickness, I think the tale we tell ourselves is go grab some crackers or eat a bagel, eat something high carb, high sugar. What does it do? It puts you on this glucose rollercoaster that over time you’re developing more insulin resistance. Especially if you’re already starting off in a place where you maybe had mild insulin resistance, the long-term outcome of that is not great.

(26:32):

Getting to a place where you go into wanting to be in a state of family planning, or if you are getting pregnant, having good baseline metabolic health overall, good baseline of insulin, good baseline of glucose variability and control, it’s going to put you in a better long-term position to have a healthy pregnancy and overall health for yourself.

Dr. Robin Rose (26:58):

That was so well said. I will add this too, my partner, she’s a woman’s health expert. She’s been doing OBGYN for over 20 years, and she really does a lot with this program that we’re talking about. She says every day, oh my God, that this just the most amazing thing. She would never think of not putting a woman who’s having difficulty not through this program. Because in her experience, especially with the women that have to go through IUI, IVF, so on and so forth, they are considered high risk. They have to be followed so closely. They’re sitting on pins and needles hoping for this woman not to have a miscarriage and not to have a complication.

(27:43):

She says that this just adds this layer of protection and this feeling of, wow, I feel good, and I’m not so worried that this woman’s going to maybe miscarry or going to have some mishap during the pregnancy because she knows that we’ve really addressed these underlying issues. She sees these biomarkers that have trended down so beautifully, and it makes a huge difference in likely the mom’s health and then the baby’s health and how she carries. It’s just so funny that you brought that up because she says it all the time how it just makes such a difference. We’re starting to see what a difference it makes too. It’s really exciting.

Ben Grynol (28:22):

When thinking about things like PCOS, so we know women who have PCOS and are interested in getting pregnant and they start experiencing some of the challenges with getting pregnant, what are some of the closest gastrointestinal conditions that are associated, knowing that correlation does not equal causation, but that you see in your practice? What are some of the most common issues that women with PCOS might have from a GI perspective?

Dr. Robin Rose (28:55):

They could have mostly chronic constipation, more than diarrhea, but they could have both, tons of bloating, discomfort, things of that nature. It’s interesting in this platform that I’m talking about too, there are two different types of PCOS, two different phenotypes. One of the phenotypes is a PCOS that stems from gut dysbiosis and leaky gut, and the other one that’s more of an insulin resistant PCOS. That’s fascinating too, because they get treated a little bit differently.

(29:26):

I do put a lot of my PCOS patients, even if they’re not ready to conceive or they’re not even in their twenties, I’ll put them through this because it regresses and reverses the PCOS. It really solves the problem in a lot of cases, because again, it’s this metabolic disturbance that’s being driven from the health of the gut microbiome.

Ben Grynol (29:48):

A good distinction to make too. Because I think when we, specifically we as a company, talk a lot about PCOS, whether it’s through the blog or through the podcast, we’re talking about it as it relates to metabolic health, insulin resistance. Having that distinction between there are two different paths that women can experience PCOS, maybe there’s overlap. When starting to dig into your research and the work that you’re doing, it was very eye-opening for myself saying, “I wasn’t aware that that was the case.” But learning about that is interesting because then you can understand different directions or different approaches that can be or need to be taken in order to mitigate some of these conditions.

Dr. Robin Rose (30:29):

Correct. Again, sadly, these women with PCOS, God, if you just go after the gut and restore health and balance to that gut microbiome and get them on the right things to really restore health to the intestinal barrier mucosa and to really get these tight junctions nice and tight again, and not letting anything leak out and cause this chronic low grade inflammation that then stimulates problems with insulin-glucose dysregulation and things like that, it’s really so powerful. I think that’s a big piece that’s missed in these women. It’s so easily thick. It really is, but unfortunately, not everybody’s on the same page.

Ben Grynol (31:16):

We all can do certain things when it comes to lifestyle, men and women, that being sleep. You touched on many of the pillars at the beginning of the conversation, but sleep, diet, exercise. When thinking about diet specifically, what are some of the misconceptions that you’ve come across? We try very hard not to be prescriptive saying, go eat this or go eat that, from a diet perspective. What we are prescriptive with is avoid highly processed food, avoid sugar, giving people the foundation of knowledge so that they can make their own decisions as to what they consume.

(31:55):

But with the, what do we call them, the diet wars maybe where you have the ketogenic group arguing against the carnivore group, arguing against the plant-based group, are there any specific diets that you’ve seen that leads to more GI conditions than others? The reason I ask is the ketogenic diet focuses so highly on fat and protein, carnivore, meat only, stripping away some of the micronutrients we get from things like plants. What are some of the diets that you’ve seen that have higher instances of different GI issues?

Dr. Robin Rose (32:30):

First, before I answer that, I want to say I don’t discriminate. I don’t discriminate against any macronutrient. I think you should have everything on board. That’s first of all. But second of all, let’s dive into what you’re asking me. I do next generation sequencing on the gut microbiome in almost all my patients or the vast majority of my patient. I’m able to see, it’s metagenomic testing, at that cellular level, molecular level, what’s going on in the gut microbiome? Who’s taking up real estate in the gut? What good guys are there? What bad guys are there? Are they in balance or not? Do they have leaky gut based on what we’re seeing from a structural standpoint?

(33:15):

And then also from a functional standpoint, what’s going on in that gut? Are they making their short-chain fatty acids? Are they producing too much ammonia, methane, hydrogen sulfide, so on and so forth? I can tell you from diet, from what people choose, it does significantly or markedly affect the balance of the gut microbiome and who’s living there and what species are taking up space there and what’s not based on how they’ve chosen to eat. Let’s talk about some examples. Let’s talk about carnivore, for example. I’ve had patients argue with me, and that’s fine because it’s a team, we’re a partnership, that they feel the best on a carnivore diet.

(34:03):

And I’m fine with that. The problem is, is what’s going on at a cellular or biochemical level with these people. The vast majority of them, when I look, because we do extensive testing, when we see our patients, we do probably 150 analytes or more. When you go to your primary care doctor for your yearly physical, they’re checking 42 analytes, and then they’re like, “Oh, you’re within normal,” which is nonsense. We are looking at trends, and we are looking at all of these different biomarkers, especially I do a deep, deep dive into cardiovascular biomarkers into the cardio IQ. Cleveland Clinic, Mayo, they have this amazing panel that shows everything.

(34:50):

We’re looking at not just the number, not like the LDL number or the HDL number and your triglycerides, but we’re looking at what’s called LDL particle size and number. We’re looking at your apolipoprotein like ApoB and LipoA, and then we’re looking at hsCRP, Lp-PLA2, oxidized LDL, myeloperoxidase, all these different. I will tell you that the people that are strictly carnivore, they have a ton of cardiovascular inflammation, many of them. I’m not saying they have insulin-glucose dysregulate, but they do have cardiovascular inflammation.

(35:24):

Again, remember your HDL and your LDL are immunomodulators, meaning that when your immune system is negatively impacted, your HDL and your LDL will also be impacted. It’s not just like, oh, it’s my genes. It’s my genes. No, no, no. It’s not just your genes. It’s likely coming from your gut. The bacteria in your gut, Their main source of energy comes from what’s called saccharolytic fermentation. Saccharolytic fermentation, the root of that word is sugar. But I’m not talking about refined simple sugars. I’m talking about complex carbohydrates, high fiber foods, resistant starches. That’s what the gut microbiome prefer or those bacteria prefer so that then they can use that, they utilize that.

(36:19):

That’s the energy source that they use to produce all these amazing postbiotics or metabolites in our body, such as short-chain fatty acids. You need that. Now, from an evolutionary standpoint, the bacteria developed a secondary source of energy utilization, which was proteolytic fermentation or coming from protein. Because if you think about it, way, way back when we were hunter-gatherers, mostly you were picking off whatever you… It was all the different colors of the rainbow and the plants and this and that. You were just picking off as you went, and you were eating that. You were foraging.

(37:04):

Unless there was drought and so on and so forth, that’s probably when gaming started. And then you had to develop a way to break down animal protein, which is this proteolytic fermentation. The problem with that is that when you have too much of that, then you’re making these byproducts of protein metabolism that can be very, very toxic to the gut lining and the gut microbiome in general. That’s the issue. Not that we don’t need some of these products of protein degradation or byproducts of protein, we do, but it’s like I always say to my patient, it’s the Goldilocks Rule. You want just the right amount of everything.

(37:46):

What happens in a lot of these patients is that’s off the charts. That’s not good because that’s causing a lot of issues with leaky guy, having this chronic low-grade inflammation stemming from the gut, dinging the immune system, ding, ding, and then that in turn is causing all these issues with cardiovascular inflammation, metabolic issues, so on and so forth. I see it. I see it. I’ll let you talk and then I’ll talk about ketogenic, because you might have a question or two, but then I’ll go into the keto thing.

Ben Grynol (38:24):

I’d love to hear about keto, but it’s the idea that I think the human tendency is the brain on overdrive. Assume that somebody wants to make we’ll call it the January 1st best intentions, some arbitrary point in time that we make a decision. Life is made up of behaviors and decisions and how much willpower we have to stick to them, but we say, “I’m ready to make that meaningful change, whatever the end state of the goal is.” That meaningful change might be removing all processed food, avoiding sugar altogether. I’m going to go and eat keto, or I’m going to go and eat carnivore or Paleo, name some diet.

(39:04):

The overdrive function comes in where we almost game it ourselves. We will consume way too much of the one thing that is no longer good. The best intentions no longer come through because we have pushed ourselves so far over the edge that we’re actually maybe not doing worse. No one’s going to argue that eating whole foods is worse than eating sugar and highly processed carbohydrates. But in general, the idea of too much of anything, like it is the old adage, too much of anything is never good. It’s about finding that balance, but very curious to hear more about what you’ve seen with keto as it relates to GI issues.

Dr. Robin Rose (39:45):

When I do all of those advanced biomarkers that I was talking about, we check with called APOE genotype, the APOE genotype. That genotype, they say it’s not only for cardiovascular risk, but for Alzheimer’s, dementia risk. When you inherit your alleles or your genes, mom and dad will give you a two, three, or four. It’s a two, three, or four. You get one from mom, one from dad. You can be any combination. You can be a 2/3, a 3/3, a 4/4, 3/4, 2/4, any of those combinations. The most common genotype is a 3/3. You get a three from mom, a three from dad. About 25% of the population is a 3/4, and then a lower percentage are 4/4.

(40:33):

The issue is with the four allele. Let’s say you’re a 3/4. You have basically a three times higher risk of Alzheimer’s, dementia, or cardiovascular disease. If you’re a 4/4, you have a 12 times higher risk. But here’s the thing, you can tone the gene down. Based on epigenetics, what we eat and how we interact and adapt to the world around us, how we are epigenetically programmed, or what we’re doing from an epigenetic standpoint can turn the gene on or tone it up, amplify it, or tone it down. We have the power to basically switch the gene. I don’t like to say off, but really tone it down. This is where I’m coming into keto, which is so fascinating.

(41:26):

Well, first of all, patients that are 4/4 should never do a ketogenic diet. I would say almost never, and I’ll explain to you why. 3/4 should be pretty cautious. If I have someone with a 3/3, a 2/3, I feel fine if they want to go ketogenic. But the problem is, is those people have issues with the fat and fat metabolism. It’s for that reason that the gene gets weak. The accumulation of this and what’s happening in the body is what basically turns it on and drives that risk up. Those patients can’t have… We restrict them to about 30 grams of specifically bad fats. People in society don’t really understand the difference between…

(42:11):

They think a lot of good fats are good, they’re really not, like all the seed oils and so on and so forth. They don’t get that. People are consuming mega amounts of those, especially when they’re on keto. I try to use some of the precision healthcare that we do to tailor their nutritional needs to that profile. It’s so amazing, again, from a clinical perspective, when I speak to my patients that never knew they were a 4/4 or 3/4, they’ll say to me nine out of 10 times, “Oh my God, I did a ketogenic diet and I felt terrible.” The reason why they felt terrible was because they couldn’t handle that high fat content and their body was telling them something.

(42:52):

It’s like intuitively, they knew that something was off. What’s so interesting about this too is that’s why I love precision medicine in so many different ways because here you have a ginormous percentage of the population being like, “I’m going to do keto,” and they’re likely doing more damage than good. That’s why I totally believe in balance and moderation and all that stuff. But ketogenic is powerful for a lot of different things, a lot of different cancer, but I believe for short-term to treat that issue or problem, not long term, any of these fad diets.

Ben Grynol (43:34):

Assume somebody was a 4/4, would that lead to downstream long-term more instances of things like gallstones?

Dr. Robin Rose (43:43):

Oh, I’m not really sure. It’s a good question that I’m not sure about. That’s a good question. Maybe, but gallstones is different. It’s different. It’s not just the fat in general. There’s a lot of other factors and the enterohepatic circulation and how the bile acids are recycled. There’s a lot of different things that play a role there too, so I’m not really sure.

Ben Grynol (44:05):

Here’s one final one is, have you seen anything with GI issues as it relates to geography or ethnicity? Geography is very hard, let’s give the caveat, because geography and different cultures have such different diets. That can be a factor in itself. But have you seen anything from either geography or ethnicity where you see higher instances of GI issues across the board, or specific ones where one country people have depth in one versus another?

Dr. Robin Rose (44:40):

First of all, I would say my Hispanic population, when I was practicing conventional GI, a lot of them have irritable bowel syndrome. I really feel like that stems from dysbiosis and their lifestyle and their diet and what they’re feeding themselves for sure. That was very pervasive. A lot of Hispanic patients will tell you they have GI issues. Very, very common. But what’s even more interesting is my European patients. This is fascinating. Here, I have all of these Polish patients, all of these patients from France, whatever, when I was in my conventional GI practice.

(45:27):

They would have significant issues with chronic diarrhea or chronic constipation or irritable bowel syndrome, any of these functional bowel disorders. It all started when they moved here. The vast majority, it started when they moved here. But you want to hear the kicker? When they go home and they go back to Poland or they go back to France or they go back to wherever they’re going, their symptoms are fine. They can eat whatever they want. They don’t have to limit what they want. They feel great. They feel great. I believe that one of the major drivers is glyphosate and the Roundup. I don’t know if Europe as a whole or the EU as a whole or just specific nations, but it’s outlawed.

(46:20):

It’s not allowed. They’re not allowed to put Roundup in the wheat, so therefore the patients can tolerate it because you’re removing the inciting factor that’s likely the stimulus for a lot of their symptoms. I always found that fascinating, just fascinating. And then I started doing a much deeper dive into farming techniques and how they process foods in Europe or even New Zealand, Australia, so on and so forth. It’s just so different than how we do it here in a lot of ways. That’s why, I mean, really supporting regenerative farms and these farms that have from the minute the calves or the sheep are born, they’re just pasture raised. They’re out. They’re grazing.

(47:11):

They’re just eating from the earth and the grass. Because when we eat them, we’re eating what they have in them that’s being passed on to us. We want to make sure that they’re full of nutrients and amazing compounds and vitamins that we need that we’re not getting, because everything is so processed and everything’s factory farmed, and the soil is nutritionally depleted, and so on and so forth. I really am such a big supporter and believer in regenerative farms. If we could get back to that, that would be super helpful. I think people’s guts would feel a lot better, and we’d have a lot less GI problems and symptoms.

Ben Grynol (47:49):

I mean, it’s a fascinating deep dive to go down the path. I wonder if in continents like the EU, a lot of it has to do also with maybe the food procurement, where people are very used to… Their habit is to walk to whatever small market. Let’s make an assumption. Somebody’s in a city where things are sold. That is the eggplant vendor. I mean, that’s probably a little bit hyperbolic, but in general, there are all of these one-off. That person only sells X, Y, or Z. The quality of that food will differ.

(48:26):

That food is not made to be shelf-stable. Even in some of the supermarkets here, there’s the bakery in the store, but that bread, it’s still made fresh every day. It’s made to have some shelf stability because that’s what you have to do. You have to do that. In Europe, it is basically throw the three ingredients together for bread. You’re going to throw your flour, some eggs, some water, a little bit of salt.

Dr. Robin Rose (48:51):

So pure. It’s so pure.

Ben Grynol (48:55):

I wonder how much of it also has to do with that, where…

Dr. Robin Rose (48:57):

I think a lot has to do with that. I think lot has to do with that as well. It’s funny, because a lot of my patients from Europe too, I have such a large Polish population because of where I was geographically in Connecticut, there’s a big population there. They would tell me how they had farms in their backyard. They literally had small farms. I mean, small gardens where they grew so much of their own food. You just touched on it. In America, I mean, how many days or weeks do you think these different fruits and vegetables are sitting on these trucks coming across the country to us or down South, up North, and so on and so forth?

(49:39):

It loses so much of the nutrient content. We do a little bit of urban farming at my house. I have a tower garden. Even my kids say to me over the summer when I make a salad from all of the fresh greens and herbs that I grow on the garden, “This tastes amazing. It tastes so different.” I’m like, that’s because it’s chock-full of all these amazing nutrients that are likely not… There’s just so much of that content that’s being lost from what we’re talking about and urbanization in general.

Ben Grynol (50:18):

I mean, that is such a common thing is growing the food in different parts of Europe. It’s just part of what you do. Here, I think it is a practice that is becoming more common we’ll say in North America in general. But because of seasonality, because of interest, because of population density, all of these things, you lose the apple tree in the yard where you’re picking all the apples. They don’t get sprayed with the wax and all the pesticides, all the things that make them shelf-stable, which make apples last for, I can’t remember the exact number of years.

(50:52):

But there are the common fruit such as apples or even vegetables like potatoes where they’re around for years sitting in different silos or warehouses at a cool temperature. People say, “What? That apple or that potato is a year and a half or two years old?” It just is because the harvest is made… The only way that we can get this consistent food production and delivery as far as the supply chain goes, the stuff doesn’t magically appear on the shelves. There has to be a system. If we are growing our own food, it is a lot more difficult, but it does taste better. It is more pure. It is better for us.

(51:32):

Are there any takeaways as far as underlying advice if somebody wants to get in front of a GI issue that they have that they can mitigate with certain things? What are some of the recommended takeaways that you have for people aside from the natural things like get more sleep, get more exercise?

Dr. Robin Rose (51:50):

Everyone thinks this, it’s just a fad, but I do have many of my patients stop gluten and dairy. Both of them are extremely inflammatory, extremely damaging to the gut microbiome. When many people just take those two things out, I can’t even tell you how much better they feel. That in and of itself is a big deal. I always say it doesn’t have to be forever. You have to heal. The diet that heals is the diet that seals. Eventually I always tell patients that they go back to an 80/20 rule unless they really have an underlying condition that really predisposes them to really not beyond these particular things.

(52:36):

But I always say to try that first because it does make a huge difference for a lot of people because that is driving a lot of their symptoms. The other thing is, is hydration. People are so under hydrated and drinking a lot more water is super-duper important. I always tell people to have a big tall glass of lemon water, because the lemon water really helps the distal colon become more basic. When that happens, the bad bacteria don’t like that environment. They prefer a much more acidic environment. That’s helpful too. I will say, in our clinic, we are so big into getting people to sleep and getting people into deep sleep, because our circadian rhythms are timed with our gut microbiome’s circadian rhythm.

(53:32):

They really have this bidirectional pathway and really influence each other in a lot of ways. Most of us don’t sleep. There is an insomnia epidemic as well, and people don’t get into deep sleep either. When that happens, it really does a lot of damage to the gut microbiome. Our vagal tone goes down and the vagus nerve is so super important in that whole gut-brain connection and in controlling motility and so on and so forth. And also when you don’t sleep, guess what? You want to eat crap. You want to eat all the sugar and all the chocolate and all the bad stuff all the time because you’re so tired and you’re so run down. It’s like a feed forward cycle.

(54:21):

And then I will bring up that my patients that don’t sleep, we do use continuous glucose monitors on a vast majority of our patients, and I can’t tell you how many women that think they’re so healthy and whatever, their glucoses are through the roof during the night. That’s because cortisol and cortisol is married to glucose. They’re so stressed and they’re not sleeping. It’s so fascinating what we learn from these medical devices and the impact on our… I call it the gut metabolic… It’s like a triangle. It’s like gut metabolic hormone, this triangle, especially in a lot of our middle-aged females. It’s fascinating what you can learn from this little bit of information and the changes you can make based on that.

Ben Grynol (55:15):

I mean, it’s exactly what you touched on earlier in the podcast, which was the idea of the importance of monitoring multiple analytes. You take anything in isolation, you could have your HDL and LDL look great, but you’ve got highly elevated insulin levels. Somebody is insulin resistant. There are all of these factors. Looking at anything in isolation, we always talk about glucose is super important and so is insulin and so are all these markers, but in isolation, they are a single marker.

(55:48):

And especially if we’re looking at point in time, which is non-continuous monitoring, those can cause challenges where we make decisions and we extrapolate that in perpetuity into the future and we say, there’s my point in time, I’m either healthy or I’m unhealthy. Having the holistic view, looking at root cause, that’s so important to see how it all is interconnected.

Dr. Robin Rose (56:09):

I couldn’t agree with you more. It’s exciting and it’s a such great way to take care of patients and heal patients. When we practice conventional medicine, it really is medicine. We’re seeing 30 patients. There’s a revolving door of people coming in and out. We can’t spend the time that we need. We can’t be investigative. We can’t be that stealth detective and really figuring out what’s going on. It just becomes a pill for every ill and you’re just band-aiding the problem.

(56:41):

For me, that was just not why I became a doctor. I think that’s the reason why a lot of doctors get burned out and leave medicine or are depressed and why the suicide rate is so high, unfortunately, because it’s not rewarding to practice medicine that way. It’s not. This is such a much more rewarding way and it’s such a great way to help people.

Ben Grynol (57:04):

Well, thank you for all the work you are doing in spreading awareness about it. Where is the best place for people to find you?

Dr. Robin Rose (57:14):

They can go to our website, which is Terrain Health, all one word, dot org, or I am on Instagram @drrobin, and then it’s @drrobin too on Facebook. @Goterrainhealth as well is the practice’s handle on Instagram and Facebook as well.