Getting To The Root Causes Of Why We Are All Tired with Dr. Elizabeth Boham - Transcript

Dr. Elizabeth Boham (00:00): We're seeing nutritional deficiencies. I see a lot of genetic variations that influence somebody's energy level. We see digestive issues that influence energy level. We see chronic infections. Dr. Mark Hyman (00:14): Welcome to the Doctor's Farmacy. I'm Dr. Mark Hyman, and that's Farmacy with an F. F-A-R-M-A-C-Y. A place for conversations that matter. And if you've ever been tired, you have fatigue, you better listen up, because this conversation's going to make a lot of sense to you when nothing else does, because it's with our leading physician, the medical director at the Ultrawellness Center, my good friend and colleague for decades now, Dr. Elizabeth Boham. She is a star in her own right. She's an M.D., or a nutritionist, or exercise physiologist. She went to Cornell where I went also, and she's on the faculty for the Institute for Functional Medicine, and teaches all over the world, and is one of the leading stars for functional medicine. And clearly, I think if I were sick or if any of my family were sick, we'd go to Liz. So I'm just so excited to have you back on the podcast. And today, we're doing a special episode of the Doctor's Farmacy called House Call, which is basically a series to discuss how we deal with problems in functional medicine differently than conventional medicine, and what we do here at the Ultrawellness Center. And today, we're going to talk about fatigue. So it's kind of this amorphous idea of being tired, and it's a common symptom. But we don't do so well with it in medicine, right? Dr. Elizabeth Boham (01:25): Yeah, yeah. Mark, thank you so much for having me. Fatigue, they estimate that 20 to 30% of patients who come into their primary care doctor's office come in with the chief complaint of fatigue. So- Dr. Mark Hyman (01:39): I'm tired. Dr. Elizabeth Boham (01:40): I'm tired. And so it's a lot of us. It's a lot of people that we see, a lot of people that we see at the Ultrawellness Center. One of their main reasons they want to come in is, "I'm tired and I want to feel better." So I think functional medicine is really well... I think it's great for whatever we're working on, but I think it works really well with fatigue. In conventional medicine, all of our training, we were really focused a lot on acute care medicine, and not enough on chronic conditions, and definitely we're not often given, physicians aren't often given enough time to really delve into a topic like fatigue, which can be so complex. Dr. Elizabeth Boham (02:19): So one of the great things in functional medicine is we really focus on, we really focus on getting that timeline of the patient's history, which is so important because it really helps us determine what's going on with that patient, why do they have that fatigue? And I think that's really critical, and one of the great things about functional medicine is we talk about their timeline. Which just means their whole life story. What was their life like as a child, even when they were a fetus? What kind of illnesses did they have when they were younger? How did they feel when they were in their 20s? All of that really influences what's going on now, and how we work with them when they come in saying, "I have fatigue. I'm tired." Dr. Mark Hyman (02:58): You're right, and I think this is something that I sort of had the insight about decades ago with functional medicine, that when we were trained in medical school, we were trained to create an exclusive history. In other words, focus on the problem. If it doesn't seem like it's related to that problem, then you just ignore it. So if someone comes in with heartburn and they also have a rash and a headache, you go, "Well you go to the headache doctor, you go to the skin doctor. I'm going to take care of your heartburn." And we don't connect the dots. Functional medicine is an inclusive history, where we look at every possible symptom, every possible exposure, where you were born, when you were born, whether you were breastfed, whether you took antibiotics. Whatever it is, and we try to connect the dots and see what you call the timeline of how this all leads to the person being sick in this moment. Dr. Mark Hyman (03:47): And when you do that, you often get to see the answer, and the patient goes, "Oh yeah, when this happened when I was 23, then I got... oh yeah, I was in Thailand and I got sick and I've never been the same." So we begin to hear these stories, and you begin to connect the dots. But when you go to a traditional doctor with fatigue, what do they do? Dr. Elizabeth Boham (04:09): Yeah, right? They get a battery of tests, maybe they'll do a quick physical exam, do some of the basic tests. And then a lot of times, those basic tests look normal. I mean, that's what patients come to me all the time with. "Yeah, my tests were normal, and they said maybe there's, maybe have some depression." And I don't blame- Dr. Mark Hyman (04:27): So Prozac is the treatment for depression, I mean fatigue, right? Dr. Elizabeth Boham (04:31): For fatigue, right? Maybe you have a little depression. And it's not that we're... they don't blame physicians for that. They're given a very short amount of time to deal with this very complex symptom often. Dr. Mark Hyman (04:42): Yeah, you're basically anemic, you have low thyroid, or you are depressed, or maybe you have cancer that we have to look for. But there's a short list, and if those things don't pan out, there's not a lot to offer. Or maybe they give you Ritalin, or maybe they give you Provigil. There's drugs, but they often don't work. Dr. Elizabeth Boham (05:01): So I mean, I think what's great with functional medicine is we really, as I talked about, take that really detailed timeline and history, and look to connect the dots. And we're wondering, okay, what's going on of course with that person's lifestyle? Of course we're paying attention to sleep and diet and exercise and stress, but we're also thinking about all the different systems in the body, and how they're influencing somebody's energy level. So everything from, is that person dealing with a chronic infection, right? So chronic infections we've got to think about and delve through. Dr. Mark Hyman (05:38): Like Lyme disease, or a virus, or... Dr. Elizabeth Boham (05:40): Absolutely, right? Yeah. Dr. Mark Hyman (05:42): And they're not acute infections. They're these things that are lingering, smoldering things that don't make you acutely ill, but are staying there affecting your overall health. Dr. Elizabeth Boham (05:49): That can happen a lot of times, right? And sometimes acute infections turn into chronic infections, and sometimes people just have these smoldering infections in the digestive system that can really wear their body down. An overgrowth of yeast or some bacteria, and the body's just chronically having to fight that and it's exhausting. So- Dr. Mark Hyman (06:09): So your microbiome can make you tired if it's not healthy. Dr. Elizabeth Boham (06:11): Absolutely. If it's not healthy. We see that all the time, right? And then of course we're paying attention to the mitochondria, that's the powerhouse of those cells that take your food and turn it into ATP or energy. And so there can be many reasons why those organelles aren't working well. And so we're thinking about that. Dr. Mark Hyman (06:30): Toxins. Dr. Elizabeth Boham (06:30): Toxins. Dr. Mark Hyman (06:31): Sugar. Dr. Elizabeth Boham (06:31): Yes. Infections, just genetic variations. And I think that's another thing that's really important we pay attention to, is does this person have some variations in their genetics that are influencing their energy and their requirement for certain nutrients? We of course pay attention to hormones. The thyroid hormone, the adrenal hormones, the female and male hormones. We really are looking at all aspects of somebody's health, and that I think is really helpful to determine okay, what is the cause for this individual person? Dr. Mark Hyman (07:07): Yeah, because fatigue doesn't really mean a whole lot other than I'm tired, and it could be caused by so many things. For me it was mercury, heck, it was mold, and then it was my gut. I think I've become an expert in fatigue because I had chronic fatigue syndrome which is the most extreme version of it, where you can barely drag yourself out of bed and barely function. You have brain fog. That's the extreme version of it, but it's really a continuum. And we can really drive people to a solution by being these medical detectives that look at all these variables that people really don't look at. Dr. Elizabeth Boham (07:41): It's so important to ask those questions right, of how long has this been going on? Did it just start? Has it been your lifelong... have you been, your whole life been a little more tired than somebody, other people that you know? Are you always feeling a little tired or is this some acute change that happened? When did it happen? Are you tired all the time? Are you tired certain times of the day? Are you tired in certain locations right, and not in others? When you think about things like toxins and molds, right? So there's so many interesting questions that we have to ask. And so one of the things at the Ultrawellness Center that we do is we've got... one of our PAs will take a really detailed history before you even see the doctor that helps us. So 40 minutes or even more getting your whole story. Well first, you fill out a whole patient packet, which is long and extensive. Then the PA gets a long history from you, and then we get a lot of time with you as well. And all that really helps to put together your individual story, which is really what's helpful in figuring out for you. Dr. Mark Hyman (08:46): You see the whole patterns, right? You see all these patterns, you connect the dots, you see how things are linked up, and then you can decide to dive into different areas of testing, right? You say, "Well I had that tick bite five years ago and I've never been right since," or, "I love tuna fish and I live on Martha's Vineyard, and I eat swordfish every other week." You go well maybe it's mercury, or you ask other questions related to their, for example, hormones. You say, "Well how's your libido and sex life," and if you're a guy, your testosterone goes down. That could be it, or maybe your thyroid's not working, or maybe we look at your nutritional status, because vitamin D can cause fatigue if you're low on vitamin D. So we kind of really do a comprehensive map based on your story, and that directs us exactly what to test. And what are the kinds of things that you found are the common drivers of fatigue for patients? Dr. Elizabeth Boham (09:35): There's so many, and we can go through a few cases. But nutritional deficiencies, huge. You'd think that we had adequate nutritional status, but so many of us don't. Whether it's because of digestive issues and we're not absorbing well, or just inadequate intake, or we're dealing with some sort of chronic toxin exposure that's wearing down our bodies. So- Dr. Mark Hyman (09:59): Or eating processed food, or the soil's depleted, or food stored for- Dr. Elizabeth Boham (10:01): Oh my goodness, right? Dr. Mark Hyman (10:03): I mean the average apple you eat has been stored for a year, right? Dr. Elizabeth Boham (10:06): Yeah, absolutely. Dr. Mark Hyman (10:07): Go pick an apple from a tree and go eat one that's been in a warehouse for a year. Very, very different experience. Dr. Elizabeth Boham (10:11): Yeah, so I mean of course we're seeing nutritional deficiencies. I see a lot of genetic variations that influence somebody's energy level. We see digestive issues that influence energy level. We see chronic infections, and of course toxins. Dr. Mark Hyman (10:24): Heavy metals. Dr. Elizabeth Boham (10:26): Heavy metals. And what I think is really great, some patients even come in with their timeline. And sometimes, that's so helpful, because they write down over the years when certain things happened in their health history, and then you can look at that. And again, you start to see some of these patterns. Dr. Mark Hyman (10:41): Yeah. And so when I, I remember when I had chronic fatigue. I went to doctor after doctor after doctor, and they were like, "Well, there's nothing wrong. All your tests are normal. This is a little off or that's a little off, but nothing really. And take some Prozac, here's something for sleep." And it's just so frustrating as a patient to go through this litany of doctors, and not really getting an answer. And I think that fatigue, you don't often treat directly. Because yeah, you can take Provigil, which will sort of make you more awake, or you can take Ritalin or Adderall, which is a stimulant to help you have more energy. But those are sort of like beating a dead horse. You have to figure out what's really going on. Dr. Mark Hyman (11:23): And I think when I first sort of discovered what happened with me, was the mercury was the thing that was driving it, and it created a whole cascade of problems. So it affected my gut, it affected my immune system so I was chronically inflamed. I started developing all these rashes and all these sores, and all these things. My eyes would look like a raccoon if I ate certain foods, I'd get bloating, and I also developed real cognitive issues and real trouble thinking and focusing, and fatigue. And I realized, these insults that happen affect all these different systems in your body. So when you're diagnosing someone with fatigue, it's all the other symptoms and all the other pieces that give you the clues about what's really going on for this person. So it's not like one treatment for fatigue. There's dozens and dozens, depending on what you find with that story. Dr. Elizabeth Boham (12:15): Right, and that mercury for you just depleted your glutathione stores, and that then influenced all these other aspects of your health, right? Dr. Mark Hyman (12:22): Yeah. Poisoned my mitochondria. And turned out I had a gene that affects my muscle enzymes, some of my energy cycle in my mitochondria, and it leads to have an easier ability to be damaged by it, which is why I had this elevated thing called CPK, which is a muscle enzyme. And it was this abnormal test, but it wasn't really so severe that it was a disease, but it wasn't normal. They're like, "Well I don't know what's wrong." But we can figure that out using the road map of functional medicine. Dr. Elizabeth Boham (12:53): I think it's so interesting how some people just need more support than others in certain areas. And we talked about this in another podcast, about supplements, and I think that's what the key is, is when you figure out for that individual person where they need that extra support in a personalized way, it makes all the difference in the world. Dr. Mark Hyman (13:12): Yeah. I remember I was giving a lecture [inaudible 00:13:15] one year, and this guy's like, "I'm always tired. I don't know what to do." I said, "How many hours do you sleep?" He's like, "Six." I'm like, "Sleep eight. That'll be $500, please." Dr. Elizabeth Boham (13:27): Sometimes it's just that simple, right? Dr. Mark Hyman (13:29): I'm like, sleep. So yeah, quality of sleep also matters. Sleep apnea's another cause that's often very undiagnosed in patients. Dr. Elizabeth Boham (13:38): Often undiagnosed, and something we have to look for. We look for the signs of sleep apnea, from somebody snoring, not remembering their dreams, their blood pressure being elevated, they're not having a harder- Dr. Mark Hyman (13:50): Gaining weight. Dr. Elizabeth Boham (13:51): Gaining weight, right? Because it causes the weight gain. It causes you to gain weight around your belly. Signs of insulin resistance and metabolic syndrome, that high fasting insulin, the high waist to hip ratio. All those things make us think, okay, we've got to think about sleep apnea. And then when we examine them, sometimes you can see clues on exam. And it's critical that we diagnose it and treat it, because it makes a huge difference in not only how somebody feels, but their risk for all sorts of diseases, right? From diabetes to heart disease to sudden for that matter. I mean, it's serious. Dr. Mark Hyman (14:20): Sudden death, that's not a good outcome. Dr. Elizabeth Boham (14:23): No, it's not. Dr. Mark Hyman (14:25): So Liz, you had a couple of cases I want to share with everybody. And this 35 year old woman had weight gain and diabetes, and tell us about her and how she presented, and what you found, and how you worked up her case and what you did with her. Dr. Elizabeth Boham (14:39): Yeah, so this woman came to see me when she was 35. And she had obesity and type two diabetes, and depression and heartburn. She had a lot of other things too, but those were some of the main issues. And actually, the reason she came to see us was because her depression medication wasn't working. And she's like, "I really need to find another way to deal with this." So she had, when we looked at her timeline, right? She started gaining weight when she went to college in her 20s, and started to put on a bunch of weight. Enough weight also, and maybe she was eating at that point, making a lot of the wrong food choices, she also started to get some heartburn. And in her 20s, so she was put on a PPI. She was put on the acid blocker when she was in her 20s. And she was still on that same acid blocker now, 15 years later. So she was put on an acid blocker in her 20s for her reflux, and- Dr. Mark Hyman (15:37): And those medications, when they came out, they were not designed to be taken forever. They were at six weeks for an ulcer. We were told they were very powerful drugs that suppress acid production in the stomach, can cause long-term complications, and they do. But we now have them for sale over the counter, and doctors prescribe them like candy. And they have serious complications if they're used liberally like that. Dr. Elizabeth Boham (15:58): Absolutely, and- Dr. Mark Hyman (15:59): Instead of figuring out why you heartburn in the first place. Dr. Elizabeth Boham (16:01): And she couldn't get off it, because the heartburn kept coming back. So here she was 15 years later. And then she slowly, after college, the weight just kept coming on. So she just kept gaining more and more weight, her health was just deteriorating in a way. She just got more and more tired. And then in her later 20s, she started to have some depression. And she was tried on a bunch of different antidepressants, and they didn't really make any difference. And then a couple years before she came to see me, she was diagnosed with type two diabetes. Dr. Elizabeth Boham (16:35): So she wasn't yet on any medication for diabetes. She was trying to control it with diet, but her blood sugar was high enough to get the diagnosis of diabetes. And she's only 35. And she just wasn't feeling good, so she said, "I've got to try a different way." So she stopped her antidepressants because they weren't doing anything, and came to see us. And so for me, looking at her timeline and putting together, connecting the dots, when I see somebody with fatigue and depression, and on a PPI, on an acid blocker for so long, one of the things I really think about is protein, and what is that person's protein status? Dr. Mark Hyman (17:18): Hey everybody, this is Dr. Hyman. Thanks for tuning into the Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do, and introducing you to all the experts that I know and I love, and I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter, and in it I share my favorite stuff, from foods to supplements to gadgets, to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Friday's, nothing else, I promise. And all you have to do is go to to sign up. That's, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better, and live younger longer. Now back to this week's episode. Dr. Mark Hyman (18:13): Why is the acid blocker a problem for protein? Dr. Elizabeth Boham (18:17): Right, so you need acid in your stomach to break down your food. And it starts, acid also encourages a lot of our digestive enzymes to work, which is all really necessary for the body to break down its protein into amino acids that you can absorb. And then when the body absorbs those amino acids, they get used in the body for all sorts of different things, from healing your skin to making muscle. But also, they're used to make your neurotransmitters. Dr. Mark Hyman (18:45): Your happy mood chemicals. Dr. Elizabeth Boham (18:47): Absolutely, right? So they make your serotonin and your dopamine and your GABA, which help you focus and have energy and feel happy. Dr. Mark Hyman (18:54): That sounds good. Focus, energy, and feel happy. I want some of that. Dr. Elizabeth Boham (18:58): So when you take an acid blocker, you're decreasing your ability to break down your food and break down your protein, and pull all of those really important amino acids from your food. And for some people, and depending on the length of time you're on it, it can have a huge impact. Dr. Mark Hyman (19:15): It also impairs other nutrients like B12, which also is a big cause of fatigue and depression. Dr. Elizabeth Boham (19:22): Absolutely, yes. B12, it impairs the absorption of a lot of your minerals so we see people develop osteoporosis after years of being on these acid blockers, so people will have low zinc, low calcium, low magnesium. Dr. Mark Hyman (19:35): And zinc is more important than ever with COVID-19, because it helps to- Dr. Elizabeth Boham (19:37): It's so important for the immune system. Dr. Mark Hyman (19:37): ... inhibit the viral attachment and replication. Dr. Elizabeth Boham (19:38): Yeah, it's so important for your immune system, right. So I saw that she had this depression, the fatigue, the acid blocker, and I go, "Oh, I wonder what's going on with her protein." So we do this cool test where it looks at plasma amino acids, which are those building blocks of protein in your body so you can measure your amino acids in your blood. And we did, so we measured her amino acids, and she was low in lots of amino acids. And I wasn't surprised, but- Dr. Mark Hyman (20:14): And you think if she's eating enough protein, how can she be low in amino acids, but- Dr. Elizabeth Boham (20:16): Exactly. Dr. Mark Hyman (20:16): ... we don't see protein malnutrition in America. But we do see large numbers of patients with very low amino acids, for a variety of reasons. Dr. Elizabeth Boham (20:23): Right, right. And so I suspect with her that the acid blocker was a huge reason for that, that she just wasn't breaking down her food well and absorbing her amino acids well. And so one of the things we were able to do was give her some of these amino acids for the period of time. So we gave her a complex of amino acids, and then I also gave her some amino acids that were really focused on production of neurotransmitters. So things like tryptophan 5HTP, tyrosine, GABA, these things that help the body with the production of those neurotransmitters. And you have people take the amino acids between meals because it's better absorbed that way, and that was really helpful for her. That helped her energy, she noticed a tremendous difference in her energy. It actually helped her hair that wasn't... she wasn't coming in complaining about it- Dr. Mark Hyman (21:18): Oh yeah, protein is necessary for your hair, right? Dr. Elizabeth Boham (21:18): ... but of course it helped her hair. Yup. And it helped her mood, so it made a big difference in the depression, so she was started to be more active and move more. And then of course we wanted to wean her off of the acid blocker. And with the type two diabetes, we also needed to work a lot on her diet also of course. So we put her on a low glycemic diet, we took away all the refined carbohydrates and the simple sugars, and made sure she was getting good quality protein when she was eating and good healthy foods. And with that shift in diet, we've been slowly able to wean her off of the acid blocker. Dr. Mark Hyman (22:00): Which is again another one of the things we've talked about on the podcast, which is reflux or heartburn. And it's a common problem, and these medications are in the top three of all medications prescribed in the world. And they're very powerful and strong, and they do have this negative impact on causing everything from small bowel overgrowth and digestive issues, they cause irritable bowel, mineral deficiencies, osteoporosis, pneumonia and so forth. But what's interesting is that the way they're designed makes it almost impossible to get off of them, and you have to know what you're doing. So you have to sort of deal with the causes of what the reflux is, which is often diet. Sometimes it's a bacteria. But then you have to slowly taper it off, because there's something called rebound that happens. So you basically stop it, and you get a flood of acid and that causes more heartburn. So you really have to know what you're doing, and people are like, "I've tried to stop and I can't." For those listening, I want you to understand that there is a way to get off of these drugs, but you can't just stop it like that. You have to know what you're doing, and you have to figure out what the cause is. So like you said, you changed her diet, she doesn't need it anymore, right? Dr. Elizabeth Boham (23:10): Absolutely, yep. And she needed it less and less, but we still needed to wean her like you said, because there's that rebound that occurs when you've been on it for a long time. And we did have to wean her and use some other things to help with... we used a little DGL, we had to use some other things to help her digestion in addition to diet. And we were able to wean her off of it. So in the long run, her absorption of her protein's going to be better, so her mood's going to be better. So and of course now, her blood sugar's getting way much better, and she's losing weight, and she's feeling happier. It's pretty phenomenal. Dr. Mark Hyman (23:45): So fixing her gut and giving her some amino acids, that's not something that most doctors will do when someone comes in with depression or fatigue, but it's really how we approach patients at the Ultrawellness Center, and really the beautiful thing about the model of functional medicine, because it can help so many people with challenging issues that nobody can figure out. Dr. Elizabeth Boham (24:04): Absolutely, absolutely. And it's fun to do. Dr. Mark Hyman (24:07): It's so fun. It makes medicine interesting. Because I remember I used to work in the emergency room for years, and I found it really boring. And you go, "How can you say it's boring to work in the emergency room? There's all this excitement and this and that." I'm like well, once you've learned the recipe for everything, what's the recipe for asthma or back pain or a heart attack or a stroke, or somebody who needs to be intubated, or someone who comes in with a fracture or whatever, or a dislocated shoulder, it's like a cookbook recipe. So you just look at the nurse and you go, "Heart attack treatment. Stroke treatment." They know you have to write the orders, but it's like everybody knows what's going on. There's no thinking involved. It's a kidney stone, you do this. Dr. Mark Hyman (24:46): And most of the things you see in the emergency room are relatively common and relatively easy to diagnose. And occasionally there's a puzzling case, but it's kind of boring. And I've found that functional medicine is a constant puzzle that you have to figure out. Everybody's different- Dr. Elizabeth Boham (25:02): It's so fun. Dr. Mark Hyman (25:02): ... it's totally personalized. Talk about precision medicine, precise medicine, precision nutrition, personalized nutrition. That's what we do. That's what this is about. And no two people are the same. And you could have somebody else come in with depression and fatigue and diabetes, and they could have a different story with different factors and different causes. Dr. Elizabeth Boham (25:22): And I think that's why so many physicians are turning to functional medicine. Because of course they have this inquisitive mind and they want... they're problem solvers, and they want to look at how all the patterns come together. And I think that's really what has attracted a lot of people to the training, because it's getting us back to really looking at that whole person and the individualized person. Dr. Mark Hyman (25:42): That's true. I think there was some tech conference out west where they said functional medicine was sort of one of the leading trends in medicine and healthcare, so I think that's true. So you have another case Liz, of a 50 year old woman who also had been fatigued her whole life and been working hard. And tell us about her and what was going on with that, because it was a bit of a different story. Dr. Elizabeth Boham (26:01): Absolutely. So she was 50 when she came to see me, and the real reason she came in was her weight. She had started to put on weight and she was frustrated with it, so she came in because she's like, "I want to get some of the weight off." But she also noted that she had significant fatigue. It wasn't fatigue that kept her from working. So she was actually a worker. She was very successful with her job, and she had worked her whole life. And she sort of pushes through. But more fatigue than other people around her. She said even when she was a kid she had more fatigue than her friends, and she would want to sleep more and rest more and not exercise as much. So she noted she had fatigue her whole life. But over the last few years it had gotten worse, and with the weight gain she said, "Let me go in, let's deal with this," so she came in to see us. Dr. Elizabeth Boham (26:55): She's as I said, she works all day, she'd come home, she'd cook dinner, she'd have a couple glasses of wine to calm down, and just got up the next day and did it again. So I thought that was really interesting, when you hear that on somebody's timeline, right? That long history of fatigue. It makes you think about different things. And so... and also hers was not the level of... I mean she still was functioning, but just not at her optimal. So I started thinking, okay, let's look at her genetic makeup. Let's look at her genetic makeup. So we did a genetic panel that looks at some snips, some variations in somebody's genetic makeup that can influence diseases that they get as well as influence need for different nutrients or supplements. And so one of the things we found out is that she had a homozygous variation with the MTFHR gene. Dr. Mark Hyman (27:53): That's a mouthful. Dr. Elizabeth Boham (27:54): I know. Dr. Mark Hyman (27:55): What is that, break that down for us. Dr. Elizabeth Boham (27:57): So the MTFHR gene is a gene that encodes for an enzyme- Dr. Mark Hyman (28:02): And homozygous means she has two copies, one from her mom and her dad. Dr. Elizabeth Boham (28:04): Yes. She got both, which has a bigger impact in terms of her life. And so that's the methylenetetrahydrofolate reductase enzyme. Dr. Mark Hyman (28:13): Another mouthful. Dr. Elizabeth Boham (28:14): Yeah. And so that enzyme is involved in methylation of transfer of methyl groups, which is involved in multiple different processes in the body. Everything from detoxification to making your neurotransmitters, to energy production. So it's involved in so many pathways in the body. Dr. Mark Hyman (28:33): Yeah, so it's basically this process where you take the carbon and three hydrogens, which is called the methyl group, and I think of the currency of the body, where there's all these chemical reactions happening. Literally billions of reactions happening every second. And one of the main ones that's going on is this process of what we call methylation, which is a transfer of these groups. And there's genes that regulate the nutrients that are involved in pathways, and the enzymes that regulate these chemical reactions. And so you can have variations in your ability to do that that can have impact on your health, and that's what you're talking about. Dr. Elizabeth Boham (29:06): Absolutely. It's been associated with depression. People who have a homozygous variation of this gene, the MTHFR gene, have an increased risk of depression. They have an increased risk of fatigue. They have an increased risk of miscarriages, neural tube defects. And so it's significant. There's been a lot of research on this gene. It's really interesting. And it impacts lots of different systems in the body. And that enzyme needs B vitamins. So B vitamins are really crucial for that to all work well, and we know that when people have this genetic variation, they can't take folic acid that's a synthetic form of folate that's in a lot of supplements. They can't take that, activate it, and utilize it. Dr. Mark Hyman (29:52): Or even the stuff you get from food sometimes, right? Dr. Elizabeth Boham (29:55): Yeah. Some of the stuff from food too. I mean, a lot of food is naturally methylated, but a lot of our processed food has had folic acid sprayed onto it, and the body- Dr. Mark Hyman (30:06): It's fortified. Dr. Elizabeth Boham (30:06): It's fortified. The body can't really utilize it. It can't activate it and utilize it in the body. And so people- Dr. Mark Hyman (30:12): And conversely it can become toxic. Dr. Elizabeth Boham (30:15): Absolutely. Dr. Mark Hyman (30:15): And cause problems. So if you actually think you're doing something good taking folic acid and you have this problem, you're actually doing harm. Dr. Elizabeth Boham (30:21): Right, right. They're saying that it may build up in your tissue, might increase risk of cancer. There's a lot of things that we're looking at with that. So we always focus on the better quality supplements that include a better form of folate, the methylfolate. That was really important for her in this situation. We also gave her a good multivitamin, a good B complex, and we increased the folate in her diet with all the foliage, the folate rich foods, the green leafy vegetables. But all your vegetables are rich in folate, so we increased those in her diet. And we also dealt with, we cut back on her alcohol, because alcohol uses up your B vitamins. Dr. Mark Hyman (31:01): Yeah, and she was drinking two glasses of wine a night to calm down, right? Dr. Elizabeth Boham (31:05): Mm-hmm (affirmative), mm-hmm (affirmative). A lot of times people have these genetic variations, but they can express themself in different times of your life depending on what else is going on. So probably what happened with her is over years of just drinking a little too much alcohol, it became more of an issue because she was wearing down her B vitamins, and she needs those B vitamins for that methylation process to occur. So both of the things came together. She had her genetics and her environment, and they made the fatigue even worse. Dr. Elizabeth Boham (31:36): We often see that gene express itself, or people have problems, when they go to college for example. So kids that have that genetic variation, and then they go to college and start drinking more, and then they start having problems with depression. That's a kind of a pattern that we sometimes see, because you've got the change in diet, maybe not eating as much vegetables, and you're drinking more alcohol. Dr. Mark Hyman (31:57): Your mom not there making you eat your veggies, right? Dr. Elizabeth Boham (31:59): And you've got that genetic variation, and then there's so many things that come into play. But I think it's important when you look at that timeline, that helps give us those clues. Dr. Mark Hyman (32:10): Yeah, so true. And one of the other big causes we see is just what people are eating. If you're- Dr. Elizabeth Boham (32:14): Oh, all the time. Dr. Mark Hyman (32:15): ... a nutrient depleted, ultra processed diet with tons of sugar and inflammatory foods, it tends to cause you fatigue. Dr. Elizabeth Boham (32:25): We see that all the time. People eating the wrong foods at the wrong time, eating a lot of refined processed foods causing their blood sugar to spike, and then it drops. Not eating enough protein. There's so much with diet that has a huge impact. And like you mentioned, the inflammatory foods. So foods that may be causing inflammation for that person. Gluten and dairy. And so- Dr. Mark Hyman (32:48): Those are the big ones. Dr. Elizabeth Boham (32:50): Those are the big ones. And so a lot of times we'll do... one of the biggest tools we have in our toolkit right, is that comprehensive elimination diet. And it can be really helpful for patients. They work with our nutritionists and get on a really good trial elimination diet, and many times patients will say, "I started to feel so much better and my energy improved." Dr. Mark Hyman (33:11): So true. And we actually are going to be running an online group, Zoom, elimination diet. It's five weeks guiding you through that whole process. So people can try it and experience it. And I found this classically using elimination diets for decades in functional medicine. It is probably the most powerful tool we use to sort of reset people. And nine times out of 10, it works, and if it doesn't it means there's something else. Maybe they have low thyroid, maybe they have heavy metals, maybe they have Lyme disease, maybe they have something else going on. But maybe eight out of 10 to nine out of 10 people will see a dramatic change in their health in a very short time. And it's a great test, and that's why I wrote the book The 10-Day Detox Diet and created the program called 10-Day Reset, which is basically a program you can do at home with online support, where you eliminate the bad stuff, put in the good stuff, and you get to see what happens. And we always joke about something called FLC syndrome, it's when you feel like crap and that includes being tired, and that often goes away very quickly. And we sort of looked at a group of a thousand people who went through this, and there was a 62% reduction in all symptoms in all diseases in just 10 days. Dr. Elizabeth Boham (34:22): That's amazing. Dr. Mark Hyman (34:22): Not to mention weight loss, and blood pressure coming down, and blood sugar coming down. It's so funny to me as a doctor that even the smartest people don't connect what they eat with how they feel. Dr. Elizabeth Boham (34:35): All the time. We see that all the time. Dr. Mark Hyman (34:37): It's incredible to me. And I think if you get people to just try something. So look, this isn't forever. Just do it for 10 days. You see what happens. And they go, "Whoa, I didn't even know I could feel so good." And one of my patients said, "Dr. Hyman, I didn't know I was feeling so bad until I started feeling so good." And I think we were used to that elephant standing on our toe our whole life, and when he gets off we go, "Oh, wait a minute. It doesn't have to feel so bad all the time." Dr. Elizabeth Boham (35:00): Yeah. It's phenomenal. It is I think the best tool we have, and like you said, so many patients... they just get better with just the change in diet which is phenomenal, and it's a great thing to try. Dr. Mark Hyman (35:12): Yeah. So I think people come to accept things like fatigue, "Oh, that's just me, or I'm just tired or I'm stressed," or this or that. And I think what you're saying is that there is a way to navigate for each person to what the causes are, and then figure out a personalized plan to fix those causes. And in one patient, it was getting her off the acid blocker and giving her amino acids. In another patient, it was figuring out she had this genetic variation and needed special forms of B vitamins to increase her neurotransmitter function and her overall sense of wellbeing. It's what makes functional medicine so much fun, is being able to actually look at these puzzles and be able to figure out for each person what it is. Because fatigue is just a symptom, it doesn't tell you what's going on. And I think it's one of those symptoms that we do really poorly with in traditional medicine. Unless you've got a low thyroid or you've got anemia, and they give you iron or a thyroid pill, there's not- Dr. Elizabeth Boham (36:06): And it has to be really low. Dr. Mark Hyman (36:07): Really low. Dr. Elizabeth Boham (36:07): And really anemic. Dr. Mark Hyman (36:08): Really bad, right. Dr. Elizabeth Boham (36:08): Because the borderline stuff a lot of times, as you know, it's missed all the time, right? Dr. Mark Hyman (36:13): It's missed, right. Exactly. So don't fret, if you have fatigue there are answers. And now at the Ultrawellness Center here in Lenox, we are doing virtual consults all over the world. It's easy to sign up. You go to and learn more. We'd love to help you out if you have a need, and if you've been loving this podcast please share it with your friends and family on social media. Leave a comment, and we'd love to hear from you. And subscribe wherever you get your podcasts, and we'll see you next time on the Doctor's Farmacy. Dr. Elizabeth Boham (36:42): Thank you Mark.