Diverticulitis: A Functional Medicine Approach

Mark Hyman, MD

Full Transcript

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Speaker 1: Coming up on this episode of The Doctor's Farmacy. Dr. George Papanicolaou: And we do this before people develop diverticulitis. We help them arrange their diet and their lifestyle because stress plays a big role in diverticulitis. Dr. Mark Hyman: Welcome to Doctor's Farmacy. I'm Dr. Mark Hyman. That's Farmacy with an F, a place for conversations that matter. And today, well, maybe it's going to matter to you, but it affects about most people at some point in their life, which is diverticulosis and its companion problem diverticulitis. Now, my mother had it. My grandfather had it. It's pretty common. It's not the most exciting, sexy topic, but we're going to make it fun and sexy. Dr. Mark Hyman: And so, none other than my colleague and friend Dr. George Papanicolaou from the UltraWellness Center. George is a great physician. He's a graduate of Philadelphia College of Osteopathic Medicine. He's board certified in family medicine. He's an IFM certified doctor, and he's done a lot of work on the Native American reservations, and just really developed his own system. And he's just a wonderful human being. Welcome, George. Dr. George Papanicolaou: Mark, pleasure. Thank you for having me today. Dr. Mark Hyman: So, on this special episode of House Call, The Doctor's Farmacy, we're going to dive into a topic that is not on everybody's radar, but it should be because we are living in a world where we torture our guts, and the gut is so important to our overall health. And for many reasons, obviously the microbiome we've been talking about a lot, but one of the things that I remember from medical school, you probably remember this, was a guy named Dennis Burkitt who was a physician from England who went to Africa and he studied the difference between the populations that were hunter-gatherers, and the same genetic crew that had moved to the city and were living in urban African cities. And he found that the average stool weight for the hunter-gatherers was two pounds a day because they eat so much fiber, and the average stool weight for the city dweller was four ounces. So four ounces versus 32 ounces. Okay? Dr. George Papanicolaou: Yep. Dr. Mark Hyman: And he found that it correlated with all these chronic Western ailments, things like cancer and heart disease and diabetes. But he also noted that the hunter-gatherers had no diverticulitis or diverticulosis, which was fascinating. Dr. Mark Hyman: So, this is an entirely Western disease, and is really a reflection of the lack of our quality diet, the lack of fiber. I mean, we had about 8% of our diet now is fiber. It used to be 100... Sorry, eight grams of fiber a day if we're lucky, maybe 15 if we are on the high end of the American population. And in hunter-gatherer times, it used to be 100 or 150 grams a day. Which seems like a lot, but it's actually what our guts and bugs like. And that's led to this problem of diverticula. So George, take us through what are diverticula, how do they form, and why are they a problem, and who gets them? Dr. George Papanicolaou: Well, yeah. Before I get to that, I always just want to say that the Dennis Burkitt story is a great one. And he was a phenomenal doctor, and nothing's changed because they did recent research to compare Ugandan population to the United Kingdom. They looked at 1,200 people, Ugandan, versus 1,200 in the UK, and they looked at gastric transit time and stool weight. Dr. George Papanicolaou: And the gastric transit time for a Ugandan is 34 hours. For somebody in the UK, a Western population, it was 80 hours. Okay? 80 hours- Dr. Mark Hyman: Oh my God. Dr. George Papanicolaou: ... for food to pass through your gut. And the stool weight was, again, that phenomenal number that you just talked about, 110 grams of stool weight for the average UK population, and for the Ugandan, it was 400 grams. Four times heavier. Dr. Mark Hyman: Wow. Dr. George Papanicolaou: So, nothing's changed since- Dr. Mark Hyman: That's crazy. Dr. George Papanicolaou: ... Dr. Burkitt made his first observations. It's still the same- Dr. Mark Hyman: That's crazy. Dr. George Papanicolaou: ... and our diets have just gotten worse. Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: So, to just start this conversation, just a couple of definitions. How does this all start? So, the diverticula are little pouchings in your colon. So, your colon is this long tube, and it's wrapped with mucosa on the inside. And then on the outside layers, it's multiple layers of muscle, and then another final layer. So, you've heard of hernias? Hernias are again, outpouching of your internal organs through the fat and the muscle layers, and so it's sticking out in your abdomen. Most people are aware of those. Dr. George Papanicolaou: Well, the same thing happens inside the colon. You have the inner lining starts of push through and form a sac, and that sac is a diverticula. Now, you're actually born with diverticula, and so you are going to have maybe one or two diverticula when you're born, but as you get older, you begin to have more. Dr. George Papanicolaou: And so research has said that at least 35% of people that are under age 50 have multiple diverticula and have diverticulosis. And then above the age of 60, you're looking at closer to 70-80% of people- Dr. Mark Hyman: Wow. Dr. George Papanicolaou: ... have diverticulosis. And then 5% of people, adults, will go on to have diverticulitis. What's diverticulitis? That's when those diverticula become infected. And so, you get bacteria that gets in there, and you have now an infection, and that can spread to multiple diverticula. And it usually happens on the left side of your abdomen, where your colon, your large intestine, is descending. And then it goes to the sigmoid colon, and then the rectum, and that's where the stool comes out. It's that lower third of the descending colon, and sigmoid that are typically affected. Dr. George Papanicolaou: And if you've ever had it, and unfortunately, I've had it, it is extraordinarily painful. They call it the appendicitis on the left side. So, left sided appendicitis. It's that painful, and you can get nauseous, and you can get fevers, and you can get chills, and you lose your appetite, you get constipated. And it's just really, really, uncomfortable. Dr. Mark Hyman: Oh, it sounds like fun. Dr. George Papanicolaou: Yeah. It's not. Dr. Mark Hyman: Sounds like fun. Dr. George Papanicolaou: And so, yeah. I'm not a very fun patient, so I don't think anybody in my house was having fun while I had it. I certainly wasn't. So, it's an issue. Now, I'm not the only person that gets I. about 200,000 people per year get it, and many of them end up in the hospital. Although now, we do a lot more treatment outpatient. Dr. George Papanicolaou: So, what are some of the risk factors? So, if you're over 40 and your male and you're heavy, overweight, or obese, if you eat a low-fiber diet, we've already talked about that. If you eat a diet that's high in inflammatory fats, you're going to have a problem. If you don't exercise, and if you take non-steroidal antiinflammatory drugs like aspirin, ibuprofen, which is Motrin or Advil, or you use steroids or opioids, or you smoke, those are some of the major risk factors for going on to developing diverticulitis. Dr. Mark Hyman: Amazing. And so, George, we really figured out that this is a common problem that's preventable, mostly from lack of fiber and a healthy gut. The traditional treatments are basically surgery and antibiotics, and then it just keeps coming back. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: So, from a conventional perspective, what can we do to prevent it? And what do we do to treat it differently? So, take us through what that would look like. Dr. George Papanicolaou: Well, I think you mean from a functional medicine perspective, what do we do to prevent it. Dr. Mark Hyman: Yeah, from a functional medicine perspective. Right. Dr. George Papanicolaou: Because conventional medicine doesn't prevent it, and that's the big difference. Conventional medicine does what it does best. It treats disease, and it does that really well if it's acute disease. And so, you have these diverticula floating around. You're going to have tons of them by the time somebody turns 60, and you know that at least 5% of those people are going to end up with diverticulitis. But we'll just let it happen, and we'll treat with antibiotics. And if there's a complication, like an abscess, or an obstruction, or a fistula forms, you have a tract that goes from your intestine to your bladder or intestine to your uterus, because we let that infection fester and get out of hand, then you're going to need surgery. And so, that's how conventional medicine deals with it. Dr. George Papanicolaou: Functional medicine, we don't think of it as just a fiber issue. There are more things going on. We start to think about the gut microbiome, and balancing the gut microbiome, and how that can lead to leaky gut and inflammation. And that whole process can be avoided. We think about gastric motility. Yes, fiber can improve gastric motility, but there are other things that play a role in gastric motility, and some people, once they hit that point where they have irritable bowel syndrome with constipation, their gastric motility is oftentimes beyond improvement with fiber. And we have to be addressing that. And so, we look at motility, we look at the gut microbiome balance. We look at the gut permeability. We look at the possibility for inflammation. So, we look for stealth infections, and we do this before people develop diverticulitis. We help them arrange their diet and their lifestyle because stress plays a big role in diverticulitis. Dr. Mark Hyman: Huge. Yeah. Dr. George Papanicolaou: At the time I had it, I was under an enormous amount of stress. And of course, my diet wasn't as good as it should have been at the same time, but stress plays a big role, because we know that cortisol produced by the adrenal glands can impact the makeup of the gut microbiome. You can have less-favorable bacteria that can cause inflammation that can push out the good bacteria that can protect us. Dr. George Papanicolaou: And so, when that happens, cortisol can also trigger leaky gut. And when that begins to happen, when that process happens, now you're starting that cascade towards inflammation that will lead to the infection that results in diverticulitis. So, that's how we approach it. We look at it much deeply, much more deeper, and we're attempting to prevent and to maximize and optimize gut function. That prevents disease and maximizes, optimizes, gut function. Dr. Mark Hyman: That's really amazing. And so, what are the kinds of things you would do diagnostic-wise to look at things differently? And can you maybe share some case story of a patient that- Dr. George Papanicolaou: Yeah. So, once the diverticulitis happens, I've seen it enough that in an outpatient setting, just the clinical presentation is usually enough because most people have had, by the time they have their diverticulitis, I'd say three-quarters of my patients have at least had a colonoscopy and they know they have diverticula. So, I get the call, "Hey, my gut's killing me." "What side?" "Left." "How old are you?" I know their age. I'm usually looking at their chart, and I can pretty much know that. "Yeah. And did you have a colonoscopy?" "Yeah, I had one two years ago." "Did you have diverticula?" "Yeah, I remember he told me that." Dr. George Papanicolaou: It's a left-sided pain. It's really painful. They're really struggling. I mean, it can be as simple as just using your powers of observation, your experience, and the art of medicine that you've developed that your years as a doctor to make that diagnosis. It can be done as simple as that. If I need further confirmation, I can get a blood count to look for elevated white blood cells. Dr. George Papanicolaou: If I think there might be the possibility it's something else, maybe a bladder infection, I might get a UA, urinalysis. Ultimately, if I need to confirm what's going on, you get a CAT scan. That's the definitive way to diagnose it. And then on the CAT scan, you'll see swelling and inflammation of that lower third of the colon and maybe sigmoid. And that's how the diagnosis of diverticulitis is finally made. Dr. George Papanicolaou: And then the treatment is typically going to be antibiotics. There are a host of different pharmaceutical agents that would be used, and they can be done orally, and you can stay at home. Or, if you're really that sick, you'll get IV antibiotics in the hospital. And then hopefully you don't have any of the complications, like development of an abscess, or an obstruction, or possibly even a bursting of your abscess, so now you have all this pus and bacteria flooding your abdominal cavity. Dr. Mark Hyman: Wow. That's fun. Dr. George Papanicolaou: That's that's bad. And if any of those complications happen, you might be getting surgery done, and surgery can be either laparoscopic, where they enter in with tubes and they're able to take out a piece of your colon, or it might be open surgery to clear out the abscess, or clear out your abdomen if the abscess has burst. So, that's the sort of the horizon, the playing field, of treating diverticulitis. Dr. George Papanicolaou: And that's the acute diverticulitis. Now, if you have a mild case... I had my really bad episode, but after that, I had another episode where I just knew it was coming on. I could just feel it starting to happen. Dr. Mark Hyman: Yeah. Yeah. Dr. George Papanicolaou: And so if you're getting there, you don't have to wait. There are things that you can start to do. So I did, and I ended up getting better within like five days, move on to becoming an all-out problem. And what I did is, I use bone broth. Bone broth has an enormous amount of nutrients, has antibacterial capabilities. So, I stopped eating a solid diet, and I made a big batch of bone broth. Dr. George Papanicolaou: You get water, you get an antibiotic-, hormone-free chicken, it dump it in, you chop up some root vegetables, you put in some great herbs, thyme or rosemary, you put in garlic and onion, you put in carrots and celery, and you just let that boil and simmer for 24 hours, adding water. And then you have a lot of bone broth. Dr. George Papanicolaou: And so, then I would just drink it like it was coffee or tea throughout the day, and I also did drink clove tea. Dr. Mark Hyman: Clove tea. Dr. George Papanicolaou: Clove is really... Clove tea, really high in polyphenols. It's one of the botanicals, peppermint tea, peppermint and clove have some of the highest levels of polyphenols. Why are polyphenols important? They are really good at restoring your gut microbiome. Phenols are really important to the health of your bacteria. And so, I was doing clove tea, my bone broth, and then I was juicing. I was just using some fresh juice, taking the pulp out. And I did that for about 48 hours. About 72 hours, I really felt like the pain was starting to diminish. Dr. Mark Hyman: And the clove tea, you just put cloves in water and boil them up? Dr. George Papanicolaou: Yep, that's exactly what I did. I have a little tea basket, and I just crush up the cloves, put it in a tea basket, put it in hot water, and there you go. It's really good. Dr. Mark Hyman: Amazing. Amazing. Dr. George Papanicolaou: Yeah. And then you can slowly begin to add in some vegetables, raw vegetables, some quinoa, and refined grains, fermented black rice, fermented grains like barley, spelt. So, I added those things in slowly. And then by day four, I was feeling really good. I started adding in more fiber. Dr. George Papanicolaou: Now, two things I want to mention. In the conventional world, you hear, "Hey, if you have diverticula, don't eat seeds." Right? Well, a lot of research has been done. Dr. Mark Hyman: Yeah, right. Dr. George Papanicolaou: And recently, nuts and seeds are not the cause of diverticuli. In fact, because- Dr. Mark Hyman: What is with that advice? Because we were all told, if you have diverticula, "Oh, I can't eat fruit. I can't eat raspberries. I can't eat seeds." It's that really true? Dr. George Papanicolaou: You know why? No, it's not true. Dr. Mark Hyman: No. Dr. George Papanicolaou: The research shows, and you can pretty much now if you read anything on diverticulitis, you'll be told you can eat seeds. I think it was more of a mechanical issue, that these things get stuck, that even the smallest seeds from berries can accumulate inside the diverticuli, then block bacteria in there, and then you get the diverticulitis. Dr. George Papanicolaou: That's been debunked. You can eat seeds. In fact, because of the high levels in nuts and seeds of alpha linoleic acid, that becomes omega 3s, they actually have an anti-inflammatory effect, and it's shown to have a benefit for helping you avoid diverticulitis, and also as you're getting better from it, it can help the healing process. Dr. George Papanicolaou: So, nuts and seeds. And the other one is fiber. So, fiber. It has has been said, "Don't eat fiber because, during your acute diverticulitis, because it's going to build bulk and it could potentially stretch the colon. You might get a rupture. And so, again- Dr. Mark Hyman: Or the seeds will get caught in the diverticuli and cause problems. Dr. George Papanicolaou: Right. Yeah. You've good seeds in diverticuli, and then during your episode, you should avoid all fiber. Well, when I started feeling a little bit better, I did want to have fiber, because I wanted to start moving stool through. I was constipated, and I knew that to get better, I needed to get those toxins out of my bowel. So, then I started adding in fiber. Dr. George Papanicolaou: And I added in both the soluble kind of fiber, like the oat bran, and nuts and seeds and beans and lentils, because that absorbs lots of water. It gets gel-like in its quality, it actually slows things down, but it allows all the nutrients from those fiber foods to be absorbed by the gut. Because those nutrients are very healing. So, you get a super-high saturation of good compounds and nutrients from those types of soluble fibers. Dr. George Papanicolaou: And then, insoluble fiber I add in because that's going to absorb water and move bulk through. And that'll allow me to detox and clean out. So, about that third or fourth day, when you're feeling better, it's only a mild episode, you can start adding in insoluble fiber, and then also soluble fiber, because they do two different things. Dr. George Papanicolaou: And the insoluble fiber is going to be more of like your grains, your cruciferous vegetables, you can even find it in avocados, in some fruits. You'll find certain levels of the insoluble fiber that will bulk up your stool, make it nice and soft, and pass through. And that's what you should be eating all the time, because you want those nice full bowel movements. That's why fiber is so important. Dr. George Papanicolaou: So, that's a way that you can treat a mild, early diverticulitis, if you want to really try and keep it from getting worse to the point that you're going to end up in the doctor's office and the emergency room, and they're going to start doing all types of bad things to you. Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: And there are some targeted supplements that you can use that can help the gut heal. Glutamine, what are some the other things I use? Marshmallow root, those are some of the targeted supplements that you can use that are healthy for the gut. I'm just having a little bit of a mind blank on some of the other ones. There's slippery Elm, marshmallow root, glutamine... Dr. George Papanicolaou: So, you can apply those, too, as well, when you're starting out with your mild early diverticulitis. Dr. Mark Hyman: That's great. So, basically we're getting people on a gut health program, right? Dr. George Papanicolaou: Yep. Dr. Mark Hyman: And we're looking at things that help. So, talk us through that patient you had, the 52-year old with arthritis. Dr. George Papanicolaou: That's a really interesting patient. Dr. Mark Hyman: What you found, and how you treated her and helped her. Dr. George Papanicolaou: Yeah. So, this is a 50-year-old female who had arthritis in her right hip that was planning on a hip replacement. She had long-standing constipation. She had recurrent diverticulitis. I think it was over like a three-, maybe four-year period. She had at least one episode a year. It may have been less than four years, maybe three. But so, that occurred prior to seeing me. And she was coming to me primarily because of those recurrent diverticulitis episodes, and the fact that she'd been constipated for most of her life. Dr. George Papanicolaou: So, interesting case. The things that were running through my mind were like, "Why would this woman have so many episodes of diverticulitis?" And so I asked her, of course about her hip, and the pain had really gotten a lot worse. She, as I said, was planning to have hip replacement, but she was eating Advil all day long. Dr. Mark Hyman: Oh, wow. Dr. George Papanicolaou: And so, Advil is one of those triggers inflammation in the colonic tissue, and she had diverticula. And so, now with the constant use of the NSAID that had increased over the last three, four or five years, she was triggering diverticulitis. And on top of that, she had been constipated most of her life. Dr. Mark Hyman: Wow. Dr. George Papanicolaou: So, the tests that I ran, I ran a stool test. So, the stool test is, again, always looking at the gut microbiome, giving us the balance between good and bad bacteria, it's giving us information about how well you're digesting, you have everything you need to digest well, it's letting us know if you have any stealth infections that you've picked up along the way, parasites, viruses protozoas that may be impacting your health. Dr. George Papanicolaou: And that test also has an inflammatory marker called calprotectin. Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: So, calprotectin can tell us if you have this chronic ongoing inflammation, which is not uncommon. In the diets we have today, it's not uncommon to have this stealth inflammation that you just don't know about. Dr. George Papanicolaou: So, I checked her calprotectin. Because she had irritable bowel constipation, 50-60% of those patients have small intestinal bacterial overgrowth, and that overgrowth can lead to constipation, can lead to slower gut motility. Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: And then that becomes that set up as you get older, one of the pieces to the puzzle that might give you diverticulitis. So, I tested her for that, and I did some gluten and food sensitivity testing. Dr. George Papanicolaou: So, what we found on her was that her calprotectin was indeed elevated, so she had marked inflammation. She did have SIBO, and it was methane-producing bacteria. Methane-producing bacteria have a significant impact on gut motility, particularly on something called migrating motor complex. So, I want to mention that because I think it's really fascinating, and it's part of what we try and do with our diet, but when you eat, you know you get that rumbling in your stomach, your intestines start to move, that's peristalsis. That's taking your food, it's being broken down, moving it through your system, having it broken down, getting it digested. And then finally, it's going to leave your body. That's the peristalsis engaged when you eat. Dr. George Papanicolaou: But when you stop eating, about 90-120 minutes later, there's a signal that happens that triggers something called the migrating motor complex. There's no food in your stomach or traveling through your intestines, but your brain tells your intestines to start moving. And so, you might notice that you get this growling in your stomach, or you notice that your intestines are moving and you haven't eaten. That's the migrating motor complex, and it's the street sweeping effect. It's doing that secondary cleanup in your gut of any food that hasn't left. It's really important, particularly in a small intestine, because if food particles stay there, they become a [inaudible 00:25:58] for bacterial overgrowth. Dr. George Papanicolaou: And so, and that bacterial overgrowth leads to SIBO. SIBO leads to either diarrhea or constipation. It leads the inflammation, it neatly leads to nutritional deficiencies, malabsorption. It can trigger your... It can actually have an upstream effect where it will cause less gastric acid in your stomach. It might impact the ability of your pancreas to appropriately discharge pancreatic enzymes to break down fats and carbs. Dr. George Papanicolaou: So, it's an important thing to understand. And why do I say that? Because if you have problems with constipation, and even diarrhea, you're probably having a migrating motor complex issue. You have to let them turn on and do their job, and that takes about four hours. So, snacking between meals, when you have irritable bowel, is not a good idea. You want to give yourself at least three to four hours in between meals so you can get this migrating motor complex to do that secondary peristaltic sweep up. So, that's why I wanted to mention that. Dr. Mark Hyman: Wow. Amazing. Dr. George Papanicolaou: So if our listeners might have that issue, that's a key fact, has gut motility, when you're dealing with either IBS, constipation, or diarrhea is a big deal. And a lot of people don't know about that migrating motor complex, the need for it to be triggered and do its work. Dr. George Papanicolaou: So, what did I do with this young woman? I basically found out that she had SIBO. I treated her SIBO. I used botanical antibacterials. I gave her some gut motility activators. I used 5-HTP. I use ginger and artichoke to get her motility to work. I told her to stop snacking between meals, and we were able to clear up her SIBO for her inflammation. I just had to clean up her diet. Dr. George Papanicolaou: Really, a lot of inflammation was coming from her diet, and her NSAIDs. So, there are two things I did. One is I started to give her really high doses of fish oil, and then I used something called SPM. Those are special pro resolvins that are- Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: I call them super concentrated fish oil. It's derived from fish oil. Have a very potent anti-inflammatory, inflammatory modulating effect. So, SPMs, high dose of fish oil. I put her on 4 to 6 grams a day. I put her on some curcumin, that was really high-end curcumin that's readily absorbed, and I had her using that instead of an NSAIDs for her pain. I also added in some CBD oil, and between those things, she was able to stop using her Advil, reduce her inflammation, as we treated her SIBO. And those are the major things that turned her around. Dr. Mark Hyman: That's great. Dr. George Papanicolaou: And so she has- Dr. Mark Hyman: That's great, so- Dr. George Papanicolaou: Yeah, and she's gone on, it's been almost two and a half years, and she hasn't had her diverticulitis return. Dr. Mark Hyman: So, basically if you don't have it and you want to prevent it, it's really focusing on all the things you mentioned, your diet, stress, motility, and dealing with those things before they become a problem. And then if you have it, if you have diverticulosis, which we'll find an off and on in a colonoscopy, you want to make sure you're really up in the fiber and the food program that you mentioned, things like the increased fiber-rich foods of nuts and seeds, and lots of fruits and veggies. And don't worry about all the seed thing. It's fine. And then if you get it, there's things you can do to actually deal with it acutely, like bone broth and eating fruits, and veggies and fruits, and grains and fibers and proteins, and so forth. Dr. Mark Hyman: So, it's a very different perspective about how we address the problem of diverticulosis, which is really common, like you said. It affects most people as they're older. Dr. George Papanicolaou: So, yeah. Dr. Mark Hyman: So, this has been great, George, this is hopefully helpful to those people who are suffering from this. If you listened to it and you have struggled with diverticulosis or diverticulitis, you should follow these guidelines. If you want to come see us, we're happy to see you at the UltraWellness Center. We see people from all over. I've got a waiting list now, but we're hoping to try to get you in, and we've got a great team of five doctors and five nutritionists, and if you've struggled with diverticulosis and you know what's worked for you, share it with us. We'd love to hear your experiences in the comments. We'd love to hear from you, and subscribe wherever you get your podcasts, and we'll see you next week on The Doctor's Farmacy. Speaker 1: Hi, everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their Find a Practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.