Episode 6: Insights on Functional Medicine & Supplements
Hosts
Ruby Booras Anne JudgeGuest
Sarah de la TorreAbout This Episode
Insights on Functional Medicine & supplements with Sarah de la Torre
Show Notes
Your average drugstore or grocery store holds a dizzying array of supplements. Gummies versus pills, this brand versus that, one-a-day versus as-needed, and don’t get us started on the dosage discrepancies.
The FDA doesn’t regulate nutritional supplements the way it does medications, even though some ingredients in supplements can have profound affects on the body.
When it comes to your fertility or your health in general, how do you know which one(s) to choose?
In this episode, Ruby and Anne talk with Dr. Sarah de la Torre, a board-certified OB-GYN who has worked in private practice for over 16 years.
A medical and wellness consultant for over 7 years, Dr. de la Torre is an ACLM Board Certified Lifestyle Medicine Physician and has specialized training in Functional Medicine.
She joined SRM in 2019 and has been a leader in launching and developing our Wellness program, which has been a huge success and benefit to our patients here at SRM as well as those referred from clinicians outside our practice.
Links:
Dietary Supplement Label Database
FDA Current Good Manufacturing Practice (CGMP) Regulations
Consumer Reports: How to Choose Supplements Wisely
International Fish Oil Standards / International Krill Oil Standards
Transcript
00:05
RUBY
Welcome to The Whole Pineapple. I’m Ruby Booras.
00:07
ANNE
And I’m Anne Judge. The Whole Pineapple is a podcast about wellness focused around fertility. We’ll talk with experts on a wide range of topics including nutrition, stress relief, sleep, mental health, etc.
00:19
RUBY
And we’ll dig into the issues that can cause fertility challenges, like PCOS, or early menopause or cancer treatment.
00:26
ANNE
So if you’re curious about your fertility, whether you’re ready to start a family,
00:30
RUBY
Or you’re preserving your options for the future, let’s dig in. Hello, hello, I’m Ruby Booras.
00:40
ANNE
I’m Anne Judge.
00:41
RUBY
We’re here for another episode of The Whole Pineapple and today we are going to talk about functional medicine. So the functional medicine approach to fertility and wellness, and we’ll dive into some common supplements you may have heard of as they relate to fertility and reproductive health. And today I am happy to introduce our guest, Dr. Sarah de la Torre, who is a board certified OB GYN and has worked in private practice for over 16 years. She has been a medical and wellness consultant for over seven years. She is an ACLM board-certified lifestyle medicine physician and has specialized training in functional medicine. Dr. de la Torre joined SRM in 2019, and has been a leader in launching and developing our wellness program here, which has been a huge success and has had so many benefits not only for our own patients here at SRM, but also from those referred from other clinics outside of our practice. So Dr. de la Torre, welcome to The Whole Pineapple.
01:36
SARAH
Great. Well, it’s so great to be here. You guys, I love talking with you. And I think this podcast is so helpful and informative. So great job.
01:43
RUBY
Thanks so much. So first, you know, let’s just talk about what is functional medicine?
01:48
SARAH
Functional medicine. So there’s a kind of a fancy way to explain functional medicine, and that’s by saying systems biology approach. And I think when people hear that they say, what, like, what does that mean? And so I think it’s helpful to talk about functional medicine as functional. So you think about how your body functions, your liver doesn’t function completely independently from your kidney, and it doesn’t function completely independently from your gut, for example. So a systems approach is looking at the different systems in your body, and then trying to put them together and not putting each of them in a silo. So allopathic medicine, western medicine is great. I’m a western medicine trained physician. It’s wonderful for many things, but what it tends to do is say, okay, go see the gastroenterologist for your GI problem, or go see the psychiatrist for your mental health issues. Where a functional medicine provider thinks those are all related together. So we like to identify and address the root cause of an illness. Instead of saying, okay, well, this is your problem, and we’re just going to focus on this problem and not look at everything else. Or we’re just going to give you medication to suppress your symptoms, right? That’s very common in medicine. So we think that each symptom are differential diagnosis, meaning what’s the potential diagnosis. There can be many things contributing to that illness. One more thing I’d say about it as an example, I’ll tell my patients or tell people to explain functional medicine, if you have heartburn, you know, in my western medicine hat, I’ll say well here, take some Pepcid, take some Tums, reduce the acid in your food, right? Don’t have caffeine, watch your spicy food. But as a functional medicine provider, I put on the hat that says, well, why do you have heartburn? Like what’s going on there? Do you have an imbalance in the bacteria in your gut? Do you have too much HCl acid in your gut? Do you have too little, do you have too much, you know, what’s going on? So that’s kind of a synopsis of what a functional medicine provider does.
03:46
RUBY
Looking at, basically, like you said, the root cause and tying it all together. So instead of looking at the one issue or one organ system, you’re looking at the person as a whole, and how it all interconnects.
03:57
SARAH
Right. Exactly, yeah.
03:58
ANNE
Which is so important, because I feel like so many patients, that’s what’s most frustrating is that they’re trying to figure out what’s going on with their body. And they do get siloed to these different specialists. But everything’s happening in their body, and everything does relate to everything else. And that can be really hard as a patient when you feel like you’re the only one who’s keeping track of everything based on the different people that you talked to.
04:19
SARAH
Right, then it’s really challenging as a patient to do that, you know, most patients have a baseline knowledge of health or their own health, but to try to interpret what this doctor is saying or that doctor is saying, and not being able to integrate at all. So I listened to your podcast that you posted last week about different types of medicine, and it was really helpful and I think it’s a great way to define things. Integrative medicine is kind of more how my approach is, essentially where you’re sort of integrating all parts together. I think that in the person’s body, but then also for integrating different treatment options, right? So integrative medicine, the typical diagnosis is sort of, you’re taking this type and this complimentary. And western, you know, kind of putting it in an integrated fashion. But I like to think of that in the body too, is that you integrate all the parts together and try to figure out how to obtain your best health.
05:08
RUBY
Wow, that’s a really good way of looking at it. So it’s not only the practitioners that are treating you, but also what’s happening within your body.
05:15
SARAH
Right, which is why, in Seattle, I always loved a lot of the naturopathic doctors that I work with, because I think after apathy, they’re trained as a baseline to do this approach, a systems approach, as opposed to our training. And I think it is more similar to that as well, that they kind of look at the body as a whole instead of in different silos of our systems.
05:38
ANNE
I feel like a lot of that’s probably tied culturally, I mean, western, especially American culture tends to be such a focus on the individual. And everything that we do is our own choice, versus if you come from more of an eastern philosophy, where collective and the group is considered way more important for function in society. I mean, I think they’re more likely to have that holistic approach. But I’m excited that there’s more of an interest here in the US of realizing that maybe our way is not the best.
06:03
SARAH
Right, right. Exactly.
06:04
RUBY
Yeah. And maybe, you know, we shouldn’t just be taking a pill for every little thing. Maybe they’re all connected, and we should be looking at what is the root cause of these issues, they may all have the same starting point.
06:17
SARAH
I actually feel really encouraged. You know, we’re in Seattle. So it’s a little bit different than maybe other communities in the US. But I get the sense that more and more allopathic physicians and providers are open to, well gosh, maybe there’s a gut connection, or maybe there’s this. Microbiome has gotten so much press in the last several years. And there’s so much data that sort of solidifies that the microbiome is real, and it does affect our health in many different ways. So I feel like things are kind of getting better from that standpoint, and kind of moving forward and progressing.
06:51
ANNE
And I think a lot of that is driven by patients, you know, we have so many people that want more of this approach, and they’re not willing to just settle for care that’s not treating all of them.
06:59
SARAH
Right. There’s other patients who are like, just give me a pill. <all laugh>. There’s plenty of those patients too, like everybody, you know, everybody has their thing, that’s for sure.
07:07
RUBY
Yeah, yeah. And even in the last few conferences I’ve gone to, I’ve noticed that too, where they’re pulling together more of this holistic approach to things. So I went to a lifestyle medicine conference and the American Society of Reproductive Medicine (ASRM) conference this year. And both of them had really great talks on the microbiome, and a holistic approach to GYN health care and gynecological health care and fertility health care, which was really cool. So it definitely is becoming more mainstream.
07:34
SARAH
I’m really happy about that. Yeah, I love it.
07:36
ANNE
So what kind of encouraged you to pivot into more of this functional medicine approach? Because I know, I’ve talked about this when I talked about my background, when I was working in OB that was one of things that drove me crazy, is there was such a resistance to change. People kind of wanted to keep doing things the way they’ve been doing things forever. And I feel like even when you had evidence for a change, there was such a slow progression. So what kind of caused you to become more knowledgeable and trained for this as your actual day-to-day practice?
08:01
ANNE
Yeah, thanks Anne, for asking that. I think everyone’s journey in their practice is interesting and mine stems from the fact that I grew up with a mother who never let me have Coca Cola. <all laugh>. I mean, we were so, you know, and she was very much non-hippie culturally. But in terms of her health, just a supernatural woman, and so I always had that tendency of, you know, medicines weren’t big in our family. We really went through how we were feeding ourselves and things like that. And so that was sort of a baseline of my personality. And then I got into medical school and loved it and residency, but then probably, let’s see, I’ve been practicing for over 20 years. So probably around maybe 10 years into practicing, I felt frustrated. I felt like especially with perimenopause and menopause, I felt like, gosh, these poor women, like all we have is like hormones or no hormones. Good luck, hormones might cause breast cancer, <Ruby laughs>, you know, it’s just so not fair. It’s such limited options.
08:55
RUBY
Good luck with your vaginal dryness. <all laugh>
08:59
SARAH
Yeah, good luck your vaginal dryness, and with those hot flashes and terrible sleep. And I just thought, really, that’s all we have? And then I noticed just more and more that patients, well, patients but also all of us, are just getting unhealthier by the moment. And so I felt unsatisfied with my treatment options for patients. I felt like, gosh, there’s got to be more, maybe I need to look into other ways. And just like you said, everything was somewhat, well this is the way you do things. And that doesn’t go along with my personality. <Anne laughs>. And I thought, you know, there has to be more. So my first thing that I went into, is I became a wellness coach, I started learning about wellness and I got certified as a wellness coach, and started thinking about mind-body connections, and then decided looking around that functional medicine kind of suited me best. I really liked the approach and there’s plenty of things I don’t like about it. So I kind of take my own, you know, approach to how I integrate functional medicine with allopathic. But that’s what it was, was just sort of me being sort of wellness-oriented my whole life and then noticing that patients need more of that counseling, and then feeling frustrated about the treatment options that I could give.
10:04
ANNE
Totally, when I was growing up, Krispix was our fancy cereal. <Ruby laughs>. It’s like a real treat. And then when I went to college, and I saw the wall of all the candy, sugary cereals, I was like, what is this madness? <Ruby laughs>. Oh my God, Corn Pops are amazing, <all laugh>. So I know, whatever you grew up with, I think does shape what you’re interested in for the rest of your life.
10:23
SARAH
I know. Well, I’m proud to say my kids eat salad. Like they eat a ton of junk food, but they do eat salad. So I feel like that’s a win, right? Because at least they eat salad.
10:31
RUBY
Yes. I always wonder what the future is gonna hold when my kids are older too, because I feel like I have little experiments, because I was not plant-based for my first pregnancy. And I was plant-based for my second. And my first, I mean, he has sensory integration concerns. So that plays a big role in what he chooses to eat. But he is far more picky than my younger, who his favorite food is cashews, broccoli, tofu and brown rice. <all laugh>
11:02
ANNE
So you started, you were certified in functional medicine first, and then you went back and did lifestyle medicine? Which one for you was your initial?
11:10
SARAH
I did functional medicine probably five years ago and got certified then. And it’s a hard certification. There’s lots of money and there’s a lot of things to learn. The test is really hard, similar to ACLM. <Ruby laughs>. Yeah, ACLM was really not fun. And so yeah, I did that. And I went back to lifestyle medicine because I thought, well, what can this add?
11:32
ANNE
Yeah, I guess that was my question. Why did you do lifestyle medicine, but you’ve already done functional medicine?
11:36
SARAH
Part of it was education, like what is this going to offer me? What is lifestyle medicine going to offer me? The other one was functional medicines, and this career driven, professional driven. Functional medicine is not a board certification, I can’t be boarded in functional medicine. And being boarded, to me is really important, because it means that you’ve gone through the hard work, the education, the test taking, which I did with functional medicine, but it’s just a certification, because it’s not recognized by the American Board of Medicine. And so I really wanted a board certification that showed that I’ve done extensive training in lifestyle based medicine. So that’s why I did it.
12:15
ANNE
Yeah. I mean, there’s something to be said, if you’re talking about patients trying to look for providers, I mean, anybody can watch some videos and say, yeah, I’ve done this. But to actually prove it in some way and have to share that knowledge, I think is important in terms of knowing that it’s not just something that people in theory believe in, but they feel like they’re ready to put that knowledge into practice and be ready to help you.
12:35
SARAH
Right, exactly. Yeah, I agree.
12:37
RUBY
We talked previously with Nicole Barker about that first new patient visit when you come to the fertility clinic. And you know, what the approach to that first visit looks like for a reproductive endocrinologist or a fertility provider. So coming from the functional medicine perspective, what are the things that you are looking for when you’re talking to patients?
12:57
SARAH
Yeah, I want to listen to Nicole’s because I’d love to hear what other providers do, because then it always kind of adds to your practice a little bit. So I’m sure at the visit, Nicole and I are looking at very similar things in terms of what a women’s cycle is like, what are the risk factors for sperm quality, things like that, you know, how’s their general health, what’s going on? Because we all know that general health will influence our fertility. But I think I really take the approach of, I’m looking for signs of general or specific inflammation. So if a patient comes in, and gosh I’m bloated all the time, I have pain, like that’s always a mess. I think I have, you know, irritable bowel syndrome or I’ve been told I have irritable bowel syndrome, or the guy’s like, gosh, I have terrible heartburn. That’s a big red flag for me that may or may not be affecting their fertility, but there’s definitely inflammation going on. And there’s likely gut health issues there. So for that, I think of like, okay well, then when this woman gets pregnant, you know, how is she going to feel, what is the gut microbiome she’s passing on to her fetus, and then her baby when the baby comes to the vaginal canal. So I kind of think long term in general health. If someone’s depressed or anxious, I think about what’s contributing to that, because there’s so many factors, you know, our lifestyle for sure. But genetics, trauma in our life, unresolved trauma, which in functional medicine and many types of medicine, we believe that unresolved trauma really affects our physical health, right? So I’m kind of taking the truly holistic approach, but then trying to filter it through the eyes of fertility and what could be potentially affecting our fertility. So that’s kind of how I think of any patient when they come in my office, whether it used to be for OB GYN, and now specifically for fertility. That’s kind of the lens I’m looking through.
14:42
RUBY
And you mentioned inflammation, and inflammation, it can show up in many different ways, as you had mentioned. So in GI symptoms, in our mental health even, I’ve noticed one of the things that cues me into levels of inflammation on the cardiac side of things, is erectile dysfunction or sexual dysfunction. For sure, because that can indicate that you’re not getting enough blood flow. So inflammation is hugely important, both directly and indirectly for fertility, is that right?
15:09
SARAH
Correct, I would agree 100%. And also just inflammation can lead to hormone imbalance, right? So when you think about oxidative stress, and we think about that a lot with heart health, right, so oxidative damage, cholesterol in the plaques rupturing, and all that kind of stuff. So oxidative stress occurs in our body everyday, from the food we eat, from sunshine, you know, all this stuff, our body’s constantly working to keep us healthy. So the more oxidative stress we have, and the less that we’re doing to reduce that oxidative stress, the more likely it’s going to have an effect on our body. So if you take a man and he’s a tobacco user or excessive alcohol user, like that’s just oxidative stress. There’s something specific about the nicotine in terms of, I’m sure very small biochemical reactions, but in general, you’re just putting more stress on your body and damage. And so things are not going to function as well. I mean, we know that when women are pregnant, and whether they’re pregnant with a male or female fetus, and back in the days when we had a lot of BPA, you know, bad plastics, that was reducing those fetuses’ potential fertility. So it’s just the idea that inflammation, oxidative stress, our body’s constantly working to reduce it and keep ourselves healthy. And so what we do to our bodies makes a big difference about how that inflammation works. So when a patient comes in, I’m looking at all those potential causes for oxidative stress, that they may have, pre-diabetes, being overweight, insulin resistance, all that stuff, you know, is inflammation in our body.
16:40
RUBY
So it’s kind of like a teeter totter a little bit. So when you have all these outside influences coming in, what we’re putting in our bodies, what we’re putting on our bodies, what we’re exposed to in the environment, are causing all of these inflammatory oxidative stresses. And then our body has healing properties. So it’s kind of like this balance, if you have more of the inflammatory properties and less of the healing or vice versa, that will impact how your health is projected.
17:06
SARAH
Right? What’s the net effect? Like where’s your balance on oxidative stress and allowing your own body’s natural healing properties, which I think is a good way to think of it, is our bodies are naturally made to fix things like when we, you know, everyday our little DNA gets kind of off-kilter, right? And then they go back in and repair it. And so the more you have in your body to support those repair processes, and to me, that’s through excellent sleep, which gosh, I’m not saying I’m a good sleeper, I wish I was but that’s so important. And then really good nutrition. Exercise is an antioxidant. So I’m looking at the potential causes of inflammation in a patient that comes in to see me, and then what are they doing to help themselves reduce that oxidative stress? So it’s kind of looking at all that.
17:50
ANNE
That is so important to think about, because I think otherwise, you just get so scared, <Sarah laughs>, especially in the setting of pregnancy. <Ruby laughs>. I remember thinking, do I just need to lock myself in my house and only drink from my glass bottle, because the world is full of things that are trying to poison me. And so focusing on what you can control and what you can do to kind of boost your body’s natural abilities, I think is equally, if not more important, to making people realize the things that are harmful for them, because there is a lot that we can do. And I know that’s why we’re also here to kind of talk about supplements and what else we can do to support our body’s natural advantages.
18:21
SARAH
Yeah, and that’s a really good point. Because the other thing about, you know, talking to patients, more and more everybody’s anxious nowadays. Like, why wouldn’t we be, we have a pandemic, our political systems are messed up, you get too much information all the time. So I absolutely think it’s always important to focus on not just what’s wrong, but what is working. And then how can you optimize that? And then reduce as much as you can, but we’re not going to reduce all the oxidative stress. I mean, there’s plenty of people who never drink alcohol. But if people want to drink alcohol, of course, you should have some alcohol. Should you have a lot of alcohol? No. Should you have a lot of sugar? No. But should you have no sugar ever? I mean if that works for you, fine, but that doesn’t work for me. <all laugh>. And so I think it’s just striking the balance, and then really optimizing what is good and healthy for your body, and making sure you’re maximizing that and minimizing the rest of the bad stuff. But you know, again, not causing yourself to be super anxious and paranoid, because then that’s, you know, that’s not healthy either. So, balance is kind of the key.
19:22
ANNE
Yeah, when I got married, we had everybody send us one of their favorite quotes, so we can make a little book of advice and one of my aunts sent me one that just said, “All things in moderation, including moderation”. <all laugh>. Sometimes you’re not gonna have the best day but that’s okay.
19:37
SARAH
Yeah.
19:38
RUBY
Well, let’s talk about supplements. So when somebody comes in for their first visit, they’re having infertility problems, are there supplements that are go-tos for you for most patients?
19:50
SARAH
Well, supplements are interesting. And I think you know, Ruby, you and I’ve talked a little bit about this is like, really, do we need to take supplements? Like is this just, you know, substituting an aspirin for, you know, whatever. But supplements, it’s a $30 billion industry, it’s crazy. And I think unfortunately, my take on it is that a lot of people are making a lot of money on supplements, and the public is not generally that educated about supplements. And so you could be just wasting your money. I mean, you can buy some supplements, and they’re doing very little for you or you’re not absorbing them, or they’re not in the right amount, or they don’t actually have what they claim to have in them. So it’s a confusing industry, I would say, and we can get into sort of that in another podcast, just like, how do you choose supplements? But I do, I am a supplement believer to a certain extent, I would absolutely say that what I would recommend for patients is that their kitchen is their base source of their nutrients. All the things that are in supplements, you should get in food first, like that should be your goal. The way you do that, as we all know, lots of vegetables, especially green vegetables, dark green leaves, a little bit of fruit, you know, plant-based proteins. I mean, that’s the way to eat, to not have to worry about taking a supplement.
21:04
ANNE
That’s what one of our nutritionists always says, like, you can’t supplement your way out of a bad diet.
21:08
SARAH
Right, just like you can’t exercise your way out of a bad diet, you cannot supplement your way out of a bad diet. But the problem is that most people don’t eat a good diet. Most people don’t have good nutrition. I mean, look at the United States, like most of us don’t eat well, most of us are overweight or obese. So our health in general is not optimal. And we’re probably not eating the foods that we should as frequently as we should. So from that standpoint, I think supplements can help for sure. I also think that the quality of our food, even if let’s say, you know, Ruby I know you eat really healthy, but let’s say you don’t have access to organic food. Or let’s say the food that you eat, even though you eat whole foods, they’ve been sitting in a storage unit for the last 12 days. Do they really have the same amount of vitamin D that they had when they were first picked out of the ground? And what was the soil that it was grown in, does it have pesticides in it? You know, there’s all these things and so yes, food is the most important. Absolutely everybody should be eating healthy, most people don’t. And then it depends on your quality of food, what access you have in terms of can you afford organic, you know, all these things, right? So one supplement I always recommend, and obviously, I work in women’s health. So I love women to be on a prenatal or multivitamin, you know, because most of us are probably not getting enough vitamin D, magnesium, again, mainly because of our food sources and our use of sunscreen. Zinc is oftentimes on the low, vitamin D12. You know, there’s just things that in general, studies have shown that most people are low on. So I think a really good solid multivitamin, you know, not going excessive, not taking four a day. But just taking a really good solid multivitamin is a baseline that I think men and women should be on. That’s where I’d start.
22:49
RUBY
Absolutely, just to cover some of those essential vitamins and nutrients that just covers from day to day. Even I have found that even if you do eat pretty clean and eat a whole food plant-predominant diet, it is actually challenging to make sure that you are balancing really well. And you have to eat a variety and change up what you’re eating constantly in order to get the right amount of minerals and vitamins and antioxidants that you need.
23:18
ANNE
Yeah, you can eat a really unhealthy vegetarian diet if you want to, like boxed products.
23:23
RUBY
Yeah, the whole food is very key. Yeah, now they slap the plant-based label on almost everything. But you want the things that are as close to nature as possible. But it is very, very challenging. And it’s kind of impossible to know if you are hitting all the markers and checking all the boxes for all those micronutrients. So sometimes having that essential multivitamin covers those essential vitamins and nutrients that you may not be getting on a daily basis.
23:51
SARAH
Right, and when I think about how I talked to my patients about this, and sometimes I think all providers can do this, maybe doctors in particular, or maybe just me. But we tend to have this like, oh well, you just need to do this, like you just need to eat this. But when you really think about, and I again, with women’s health, I think about a woman who’s working, let’s say she already has one child and she’s working full time. How hard is it as a working mom, and even just as a working person, but as a working mom to be able to be like, okay, did I eat all my vegetables today? You know, it’s just you have to really be proactive like you did, and to feed your family healthily. So it’s not like it’s this, it’s a simple idea, but it’s not necessarily that it’s that easy to execute. So I think supporting our patients in this and not being like, oh my gosh, what’s wrong with you? Why aren’t you eating a plant-based, you know, blah, blah, blah. Diet is, you know, having brought some realism to what modern day living is like and how we can make it sustainable. So that’s why I love having our nutritionist at Seattle Reproductive Medicine, or a patient seeing a nutritionist or wellness coach if they can, because again, it’s a simple concept, but it can be somewhat complex to execute. And so having a support team to do that, whether it’s a nutritionist or a wellness coach or whatever, it can be really helpful.
25:09
ANNE
Especially because that way they can make it personalized to you. Because I hate mushrooms, so I’m not going to follow a meal plan. <all laugh>. And remedy things if you’re trying to be plant-based, or use the mushrooms for that savory umami flavor. And you want someone that’ll talk with you about what foods do you really like? What foods do you hate? What things have you just never tried before, and you’re open to expanding and being able to have that? Plus, especially if you’re in a relationship, sometimes both people are not on the same page about how they want to eat. And so how can you kind of find a place in the middle? If one of you is a little more motivated to make change than the other person might be.
25:45
SARAH
Right. And also, what’s your lifestyle like? Are you up and out of the house by 5am and then in bed by 8pm? You know, like that’s what I love, again, about working with a specific nutritionist or coaches, it is what you’re saying personalized, not only your food preferences, but what is your life like? And how do you incorporate this type of healthy eating, depending on your schedule and what’s sustainable for you.
26:08
ANNE
And it’s funny to me how many people sometimes balk at the cost of seeing a nutritionist, but are willing to spend hundreds of dollars on supplements. It’s kind of like, you know, if I had to pick I’d much rather you talk with a nutritionist and figure out how to try and get what you need from your food as opposed to taking something that may not even be that helpful.
26:24
SARAH
That’s a really good point. And again, that kind of goes to our cultural basis of let me just take a pill. Because it’s too hard to think about that as a thing, which I completely understand and can empathize with, when you know, patients are in the unfortunate position of having to spend a lot of money on fertility treatments. And you think, okay well, if you can adjust certain lifestyle things, not extremely, not to the point that it’s, you know, not sustainable for you. But you may get yourself to a point, this is in particular with polycystic ovarian syndrome, but if you’re able to adjust your diet, reduce your insulin resistance, that’s quite inexpensive to do. It takes some time and training, but you might save yourself quite a bit of effort and energy and finances with treatment. So anyway, yeah, I think we’re all on the same page. But to get back to the original question, a multivitamin baseline, and then it kind of goes to the patient’s particular issues. So some common ones in fertility, you know, that I think all the providers are really comfortable with and I certainly am, is COQ10. So COQ10 is something we have naturally in our body. And it’s important in lots of functions, lots of biochemical functions in our body, and especially important in mitochondria. Mitochondria are kind of the energy packing things in ourselves. Things, that’s a specific word, <Sarah laughs>.
27:40
ANNE
My kids are doing cell biology now, and they came home and they’re like mitochondria, and I’m like, powerhouse of the cell! Exactly. <all laugh>
27:48
SARAH
That’s true. Like these mitochondria are amazing, like they do so much. And sperm are essentially, not completely, but essentially mitochondria DNA, right? So mitochondria is needed for cell function, for optimal cell function. It’s a great antioxidant. And there’s data for women who are 40 and over undergoing IVF, that it improves egg quality, and mitochondria are key for the egg, right? The egg is mostly about mitochondria. So COQ10, absolutely, I think when women are over 35 there’s no harm in it. And there may be some benefit, but the data shows at age 40 and over that you really can benefit from it for egg quality.
28:25
ANNE
I can always tell it’s January because when I walk into Costco in January, they have the giant bottles of COQ10, right by the entrance. Because everybody’s all like, it’s the new year, I’m going to be healthy, where are my supplements?
28:36
RUBY
Protein Powder. Yeah, it’s the supplements and the protein powder that get the centerstage.
28:41
SARAH
They’ve got our number, that’s for sure about marketing. So a couple things about COQ10, I just want to mention which can be confusing. So Ubiquinol and ubiquinone, are other words people use or names for COQ10. So Ubiquinol is a little bit more expensive. One is the oxidized form, and one is the reduced form. So not to get too technical, but it just depends on how many electrons they have, right? So Ubiquinol has been patented, so it’s more expensive, but either one is fine. So ubiquinone is fine, Ubiquinol is fine, they’re both bioavailable, so you want to look for a type of COQ10 that’s bioavailable, and I would just choose ubiquinone. If it just says COQ10 then it’s kind of confusing how much it has and how bioavailable, so dosing gets kind of difficult with that in terms of like, I always say 600 milligrams of COQ10. Whereas if you’re actually taking true ubiquinone, which is its already bioavailable form, probably 200-400 mg/day is enough but see your provider about that, you know, patients need to talk to their provider about it. But COQ10 I think is awesome for egg quality, awesome for sperm quality. The other ones that are common are DHEA. So DHEA is a hormone that’s produced in our adrenal glands. It’s a precursor to our male hormones. It has more androgen male hormone-like characteristics. But it’s really important. We have tons of it when we’re 20, we have lots of it. And that’s why we usually feel pretty good when we’re 20. But it decreases with age. The more cortisol you have, meaning the more stressed out you are and releasing these stress hormones, then your DHEA cortisol levels start to alter. And then when your cortisol gets much higher than your DHEA, then there’s some data that suggests that, you know, libido goes down, your sex drive goes down, you don’t feel as good. So DHA, when I treat perimenopause and menopause patients, I think every woman honestly in their 40s should be on a little DHEA, just a little bit like 5-10 milligrams. The data for fertility though is in, again, women 40 and over undergoing IVF, DHEA and COQ10 together have been shown to improve egg quality. The doses just for that are pretty hefty for fertility and egg quality, at like 25 milligrams two times a day. So there are some potential side effects, like acne, you know, oily skin, things like that, unwanted hair can happen. And so, you know, I talked to women about starting at just 25 mg, and then seeing what side effects they have and going up from there. So that’s another supplement that’s very common in fertility.
31:13
ANNE
Can you talk about DHA versus DHEA? Because I think people get confused a lot.
31:17
SARAH
Oh yeah, sure. Yeah, that is confusing. So DHEA is a hormone from the adrenal glands. DHA is an essential fatty acid that comes from fish and it’s in the fish oil, or it can come from algae and other food sources. But when people talk about fish oil, DHA and EPA are two different types of essential fatty acids. Essential fatty acids are really important. They’ve been related to a lot of things like decreasing depression, heart health, fertility, essential fatty acids stabilize the cell membrane, and a stabilized cell membrane is a healthy cell membrane.
31:51
RUBY
Little important I would say, yeah. <all laugh>
31:55
ANNE
Yeah, it’s kind of scary with cell membranes. In general, you don’t want anything in your body, right? You want everything to just have a good tight seal. <all laugh>
32:02
SARAH
So yeah, absolutely DHA is important. As a previous OB GYN, I liked having my patients on DHA before they got pregnant. DHA and EPA, it’s known to be great for the fetal brain and other, you know, in our brains as well. So that’s the difference between DHA and DHEA. There are some studies of DHA in fertility but like many studies of supplements, there’s not a lot of robust evidence. And so there’s some providers that kind of say, well forget it, there’s not enough evidence, and I think a more generous approach is, you know, maybe there’s some benefit here. Let’s look at you as a whole person, are you eating fish twice a week? Maybe you don’t need DHA, you know, that kind of thing. But I would not completely say, no you don’t need that because there’s not enough data, just because people aren’t doing studies. So it’s hard to say what’s helpful, but if you think about how certain substances act in our body, then you know, to me that’s reasonable evidence that they may be beneficial as long as they are without harm. Folate and folic acid is another big question when I think about when you said EPA and DHA. So folate and folic acid, people get confused on this as well as methylated folate and methylated vitamin B12. Okay, so folate is the natural substance that comes in food, and it’s vitamin B9, it’s a vitamin B. So folate is really important for our bodies like red blood cell development. The fetus’ spinal cord is formed in the first 28 days and so you need folate to have that be effective and healthy. So folate, it’s really important. So, you know, everybody knows this, but food started to be supplemented in the United States with folic acid, which is a synthetic form of folate. Technically, they’re both fine, if you’re eating folate in food good for you, that’s really helpful. The downside, I’m going to add one more confusing thing here. The downside of folate is that it’s not always absorbed as well. And then if you have something called MTHFR, methyl tetrahydrofolate reductase, which is an enzyme in our body that switches fully to, I can’t remember if it reduces it, anyway, so biochemistry there. But if you have one of those genes, that MTHFR gene, if you’re missing one or one is not as effective as the other there is certain genetic,
34:26
ANNE
Which is pretty common, very common. So it’s not that it is something, you know, unusually wrong with you.
34:33
SARAH
It’s a common thing. Most people have one gene that works and one that works and one that doesn’t. And so that means that you might have a hard time, so called methylating your folate for it to be effective. So you can give someone methylated folate so their body is not as efficient at processing it. So you just give them methyl folate, so methylated folate and folic acid again, folic acid is synthetic, our food, our grains are processed with it, they added it to it. And then folate is naturally in foods and then methylated folate can be found in a vitamin. Most people who have normally functioning MTHFR genes can take methylated folate, no problem. So if you go, gosh, I don’t know if I have MTHFR or not, it’s not going to harm you to take a methylated folate. And one of my functional medicine buddies would say, well, can it sometimes make people more anxious? Well, it just depends. I think you’d have to take it, and if you found that then you should probably have your snips tested, your genes tested to see if you carry that and then if you didn’t, you could go back to regular folate. So it makes sense, or is that too complicated biochemistry?
35:39
RUBY
No, it definitely makes sense. And I think one thing that I would throw out too is, I’m going to get the statistics wrong, but it’s something like 30% of the population or something is positive for one of those MTHFR gene mutations. And so it’s not something that we routinely test for, I would say like most of the time, patients will come to me and be like, should I be tested for this? In general, not usually.
36:01
ANNE
Yeah. Do you feel like you would recommend that everybody usually use methylfolate, though, because I feel like we don’t routinely say that. And then people get really concerned that what if they are someone that should be on that. What do you tell people when they don’t know and they’re just trying to pick the prenatal that’s best for them?
36:17
SARAH
Yeah, that’s a great question. So it’s interesting that NIH, National Institutes of Health and the CDC, pretty much recommend you don’t need methylated folate. So if you go by our US guidelines, you would say no, you don’t need a methylated folate. And I think in general, if you have a healthy diet and you eat beans and dark green leafy greens, you are probably getting enough folate and it wouldn’t matter if you took methylated folate. If you have a history of early heart disease in your family, things like that could indicate that maybe you do have MTHFR snip. So in general, I would say no, you don’t need to have a methylated folate. The other confusing thing, which I think providers are even confused about is dietary folate equivalents now that they’ve come out with, I think it’s really confusing, DFEs. But essentially, sticking with the micrograms. I think most vitamins now, most supplements are sticking with micrograms instead of DFEs. And if they put dietary folate equivalent on the bottle, they should actually put the micrograms too, and women who are attempting to be pregnant, in my opinion, need to be on at least 800. And then if they have a history of a baby with spina bifida, that’s much higher than that. But 800-2000 micrograms is a really reasonable place for a prenatal vitamin to be.
37:31
RUBY
I would say most prenatals these days have 800 micrograms in them. It’s pretty unusual. Every once in a while I’ll stroll down the supplement aisle, just kind of look at things. And they usually advertise like we have this much folate because it is one of the more common things that people are recommended to take.
37:50
ANNE
And you’d mentioned anxiety, I have had patients tell me like they have questions about methylfolate and depression. And what do you know about that related to mental health?
37:59
SARAH
Well, I mean, folate is really important for cognition and some importance in mood. So I think if someone is experiencing mood issues, and they’re not taking a methylated folate, it’s not that expensive to have these tests done to get your MTHFR. I mean, you could do it online kind of a thing, or you could see your provider and be tested for it. And I need to circle back with my functional medicine partner that we worked with each other for a long time, about the experience of anxiety and methylated folate. But it’s sort of like your, if you methylate well, and then you have an additional methylation in your body, extra methylation is not necessarily beneficial. So I think that’s what it comes down to.
38:37
RUBY
And then we had mentioned just briefly vitamin D. So I know it’s a big thing here where we live.
38:45
ANNE
And that’s one of the things that we say is that a multivitamin is made for everybody. And so people who live in Arizona probably don’t need as much vitamin D as we do here in Seattle. So I know that’s one that we usually do say people should take on top of even a good prenatal.
38:58
RUBY
Yeah, I swear it’s 9 out of 10 people that I test vitamin D on are low.
39:04
SARAH
Absolutely, in the northwest, my goodness everybody’s not only low, they’re pretty low. So I think in the northwest, everybody should just be on a vitamin D supplement, you know, at least 2000 if you’re low. When people are really low, I’ll have them take 10,000 for a couple weeks and then go down to 5,000 and recheck it. Vitamin D is really important. There’s data that women who have PCOS and are low in vitamin D have more fertility issues. Testing for vitamin D, again yes, if you live in Arizona or California or Texas, you know places where you’re gonna have lots of sun year round, you probably don’t need to be tested. Probably a regular vitamin, but anywhere where there’s significant cloud cover and access to sun is low, such as where we live. Then yeah, I think supplementing is a good idea.
39:47
RUBY
Yeah, I had somebody that came back as non-detectable once. And I was just like, wow. Like, can you just go, you need a vacation somewhere sunny. <all laugh>
40:01
ANNE
Are they a vampire? Because those are in the northwest too. <all laugh>
40:05
RUBY
Yes, I am curious. I wish I would have known, like I could follow myself over time. You know, what were my vitamin D levels when I lived in Montana, because even when it’s below 0 like -30, the sun is generally out in Montana. And even though you are covered, usually your face is, you’re getting some sunshine. But then here, it’s like, yes it’s more mild. But man, do I never see the sun for weeks sometimes.
40:29
SARAH
I know. That’s crap. That affects my mood, too. I can’t do that.
40:34
RUBY
I know, yeah. Which is why I have my little sun lamp that I turn on every morning. <Ruby laughs>. And I wanted to kind of circle back to those that are on a plant-based diet too. Because multivitamin will probably cover a lot of your things, but something to be particularly mindful of for those that are on a primarily a whole food plant-based diet, not getting any animal products, you want to make sure that you’re getting adequate B12. Yeah, can you speak to B12?
41:00
SARAH
Yeah, B12 is really, I mean, it’s one of the most important B vitamins and we tend to be low on it. And absolutely vegetarians, vegans, they don’t have sources for it. So you do need to supplement, whether anybody non vegetarian, non vegan needs to excessively supplement with B12. Probably not over a multivitamin.
41:19
ANNE
My gym is advertising because it’s the new year, coming in for your B12 injections.
41:27
SARAH
Yeah, it’s true. I mean, I’ve done those things before, too. And I’m not, you know, you don’t know if it’s placebo based or not. So honestly, I can’t speak directly to if anybody should have a B12 injection or not without having their B levels checked.
41:39
RUBY
And with a plant-based diet, so where B12 comes from, it comes from the microorganisms in the soil. And most people get their B 12 from animals who eat plants that are covered in dirt and things and get all these microorganisms, and then they eat those animals and kind of indirectly get the B12. But when you are plant-based and you’re not eating animal products, and these days, we tend to have, well hopefully, cleaned and washed produce. So we are not eating just outright dirt these days. So we’re not getting B12 from the soil. So that is why as a plant-based diet, you want to make sure you’re getting B12l because you aren’t getting that, you’re excessively cleaning your produce, you won’t get that same level or an adequate amount.
42:27
SARAH
Yeah. So another common one I would say is melatonin. We get asked about melatonin and there is pretty good data on melatonin and quality. So some IVF centers will use melatonin specifically before IVF. My problem with melatonin is not melatonin itself, as much as that people tend to overdose on melatonin, meaning not truly overdose but they take too much. Only, you know, depending on your size, your age, your body type, no more than 5 milligrams, and typically for most women 1-3 milligrams is adequate. So with melatonin, I would say you know, it can help support sleep and your circadian rhythm and there’s some data for quality. But I’ve had patients be on it for like 10 milligrams and that’s not going to help your circadian rhythm, it’s going to probably mess it up a little bit.
43:13
RUBY
And with that, you know, you should also be looking at, as you mentioned with functional medicine, what’s the root cause of the sleep issue too? Do we need to do a sleep consult or talk about your sleep, and a health coach can do that too to eliminate things that might be interfering. We’re in such a go go go, constant attention kind of culture that I think that’s the source of a lot of people’s sleep issues, and sometimes it takes getting back to that the basics of supporting your sleep, and then maybe you want me to supplement.
43:43
SARAH
Right, and then, you know, naturopaths oftentimes can test that melatonin levels and physicians too. So you can delve into it more but I think in general if people think, gosh my sleep is kind of crappy, I want to try melatonin or I’ve heard it’s good for me, just 1-3 milligrams.
43:58
ANNE
Is there anything else that you recommend for sperm relative to what you’re talking about when you’re talking about eggs?
44:03
SARAH
You know, if I don’t have a semen analysis on a patient, if it’s just, oh what can a man in general do for good sperm quality? Then I would say, you know, exercise, healthy diet, all those things that promote antioxidants in our bodies naturally. But let’s say a man has a motility issue with the sperm, you know the count is good, the motility is poor, you know taking out any sort of potential negative lifestyle factors like tobacco or marijuana use. COQ10, there’s good data on L carnitine, and alanine I believe too. I have to double check that you guys, but L carnitine and acetyl L carnitine, ALC, have good data for sperm motility. So I usually recommend that if a man comes in, a semen analysis is abnormal when it comes to motility, I put them on a multivitamin, COQ10 and L carnitine or acetyl L carnitine.
44:57
RUBY
And for those that are, the multivitamins that are designated for sperm health do they typically have those things in them?
45:05
SARAH
Usually they will. So there’s a couple of brand names that we typically prescribe at SRM or recommend because it’s just easier, it kind of has everything that a guy needs. So you know zinc and selenium which sperm love, Vitamin C is really good for sperm. And then carnitine and COQ10 are helpful too, but yeah, again a lot of stuff online you know, again it’s not that I would say no to them, there’s just I don’t think there’s robust data behind them. So I don’t feel as comfortable recommending those.
45:36
ANNE
And that’s going to be our short snack mini episode, how do you figure out a brand? How do you tell the quality? How do you like twos, if you decide you want to supplement, what is the best supplement for you? So definitely people that want to hear more, tune into that for our snort snack this week.
45:49
RUBY
Just to recap all this too is, you know, this really should be a discussion with your provider too for what’s best for you, particularly if you have a provider that has a functional medicine or background to talk about these more biochemical, like what is individualized for each patient. And one that we didn’t mention actually is ovasital. I know that it has become more well known out there. And we talk about it a lot here at SRM for our PCOS, polycystic ovary syndrome patients. Sarah, what is ovasital, what does it do and why is it helpful for these patients?
46:23
SARAH
Yeah, so ovasital is actually a brand name by Theralogics, which is a great brand, we recommend it often, but what it has in it is d-chiro inositol and myo inositol. So inositols exist in our body to help us regulate the glucose going into ourselves, it kind of takes glucose and insulin and balances it out. So we’re able to use and access our glucose better, and have our insulin be more effective and efficient. And so with PCOS, polycystic ovarian syndrome, they’re inherently insulin resistant, even if they’re thin, even if they have a good diet. They have a high predisposition to being insulin resistant. So ovasital helps balance the glucose and insulin, those two molecules in our body, to help women ovulate. There’s actually good studies that show that when you use these d-chiro and myo inositol, that women are more likely to ovulate even without weight loss. So I put a lot of people on that, even women who don’t have PCOS, but are overweight or they have a tendency to have a more carb heavy diet, just to help regulate their blood glucose. So d-chiro inositol, myo inositol are really important and helpful. And I think a lot of people even separate from, you know, fertility or PCOS should be on them. A couple other ones that I want to mention really quickly are NAC, N acetyl cysteine, is a really great antioxidant. It’s actually okay in preconception. Most providers would have you stop it before an IVF cycle and before pregnancy, but that could be supportive for egg quality. There’s some data and also some data for promoting ovulation in PCOS patients. If people drink a lot of alcohol, I put them on NAC because it’s liver support. And actually, it’s what we give people in the hospital if they’ve overdosed on Tylenol. See if there’s any other ones, you know, a lot of women are on evening primrose oil or vytex to help, they’ve just been told it helps balance their hormones. Evening Primrose is another essential fatty acid, it’s an omega 6. And generally you want more omega 3s than omega 6s. So you have to look out for that. But it can be helpful for supporting the luteal phase. So that would be something to talk to your physician about, or your provider.
48:35
ANNE
Do you take it the whole time? Or do you start it just after you think you’ve ovulated?
48:39
SARAH
You can take it the whole time. So some providers will say, okay, just take it in the luteal phase and others say just take it the whole time. I know there’s no data that supports one way or the other. Chasteberry, I actually do really love it because it’s helpful with PMS. I think it does help support some hormonal balance when women have really bad PMS they usually put them on vytex.
48:58
ANNE
That was one of my final board questions for the Nursing exam, was asking about supplements for, I think it was actually for pre-menopausal. But I remember thinking, oh, I totally passed if they’re giving me the supplement question as the last question, that means that they’re onto the test questions that are trialing because supplements were not a big thing, you know, 15 years ago.
49:14
SARAH
Are there any other supplements you guys wanted me to go over?
49:21
ANNE
Yeah, I think that’s our list.
49:23
RUBY
Okay, well, we covered so much this is one that our listeners might need to come back to.
49:28
ANNE
Yeah, slow down and listen to the sections a few more times while you take notes and then talk to your provider. <both laugh>
49:33
RUBY
Yeah, talk to your provider and if you really like biochemistry or you’re just really loving this because we talked about some really cool stuff. I know I was nerding out a little bit.
49:42
ANNE
Yes, check our transcripts, we do have transcripts. So if you’re like wait, what did she say, which letters are what, you can go to our website and actually read back what we’ve been talking about.
49:51
RUBY
Yeah, and this was super important because it does get confusing, and so it is nice to have somebody on that really knows their stuff in this area and can explain what these supplements are, why they’re important or how you should use them. So Sarah, thank you so much for coming on. We had so much fun talking with you. It’s been great.
50:08
SARAH
Thanks, guys. That was fun. And I would just again, put a plug in for patients talking to their providers about this. And if you’re not getting the answers that you want or need from your providers, don’t use Dr. Google, <all laugh>, try to find someone who knows their stuff and can help guide you in your health journey that way.
50:27
ANNE
Perfect. Thank you so much for sharing your knowledge with us. Thanks Sarah.
50:31
SARAH
You’re welcome. Thanks for having me. All right, take care.
50:37
ANNE
Thanks for joining us for this week’s episode of The Whole Pineapple podcast. We hope it was helpful.
50:41
RUBY
If you know someone who could benefit from hearing the podcast. We hope you’ll share it with them.
50:45
ANNE
And don’t forget to subscribe, rate and review The Whole Pineapple on your favorite podcast app. Every rating and review makes us easier to find.
50:53
RUBY
This podcast is sponsored by Seattle Reproductive Medicine and is produced by Audiotocracy Podcast Production. We’ll see you next time. Have a delicious week.
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