Transcript for:
MS Focus Conference: Supplements for MS

hello and welcome to this conference hosted by ms focus the multiple sclerosis foundation i'm your host deborah forman the educational programs coordinator for ms focus and i'm joined by marco vespignani who will be talking to us about supplements for ms and what you need to know about them after a presentation from the doctor we'll open it up to your questions and comments and now i'm delighted to introduce our speaker dr marco vespignani is a neuropathic doctor licensed in washington in california he is currently the medical director at seattle integrative medicine a private group clinic in seattle he focuses his clinical care on patients experiencing autoimmune neurodegenerative and complex pain syndromes in addition he is an adjunct faculty member at baster university where he received his medical training he has written articles and contributed to an integrative neurology textbook and published in 2020. dr marco is also an experienced public speaker having lectured throughout three states he has called home washington california and hawaii so now i'm delighted to introduce marco i'm i'm so thankful that you're here with us today we're very pleased to have you present this wonderful topic and i'm going to turn it over to you that's great thank you so much debra i've always liked working with the ms foundation it's really been fun for me um over the years and chances do things like this so you know as as you and i talked you know there's kind of the option of of slides and and live kind of interactive and so what i've tried to do is really put together a fairly simple slideshow just in the sense of keeping me on topic but hopefully this will be uh information that that the viewers haven't seen before or at least kind of explain in a different way so i'm going to go ahead and start that here so hopefully everyone get a good view of that and still still see me there in the corner um so i tried to think about like what what you need to know with ms and supplements what what's kind of the the overall sense of of the playing field as a whole so that's my my goal today um as mentioned uh my name is marco vespagnani i'm a naturopathic doctor so that's a training in um you know it's a post graduate so i went to school uh in biology at university of hawaii and so received my bachelor's and then four years of med school and then a residency um and so that was it last year and then since 2010 um i've run a practice called seattle integrative medicine which has a number of other doctors who focus in various disciplines parkinson's women health and otherwise and so that's uh i'm interested in neurology i spent years working in that field and so that's kind of where i'm i'm drawn to so uh my dad uh you may be able to tell from my name marco vaspinani my dad's an immigrant from from uh italy and so for him languages were always interesting and and the contract english so english as it's written in a contract is always his favorite like if he could understand that that was to him kind of proof that he'd made it right and so i grew up with the word legalese he loved the legalese and so this is my tribute to him there these are the legalese of kind of what we'll be talking about today so first i am a licensed naturopathic doctor i do have a license to practice medicine but it is only in washington california naturopathic medicine is licensed state by state so depending on where you're listening from you know there may not be a naturopathic doctor who could you know treat you or diagnose you based on kind of uh the laws of the state there and you know i am a doctor but i'm not your doctor so anything that we kind of talk about today is is not necessarily specific to you it's it's generalizations about supplements in ms my experience and otherwise so if you're looking to act on any of this information it's important that you at least consult with someone who is your care provider and can guide you in the right direction and if for some reason they wanted to reach out directly to me i'm happy to to communicate in that way with another provider i'm also not a neurologist i just play one on the internet it's kind of that take off from not a doctor but i play one on tv so my experience is in neurology but i am not a board certified neurologist and i have great respect for board-certified neurologists and i've worked closely with them throughout my career i'm certainly here in seattle names you might know dr bowen dr keita um you know dr thrower these are all people that that i'm on a you know more or less first name basis with so that's the that's the specifics of of my licensure and my practice the legalese of the supplement industry it's important to recognize that a supplement is is a kind of different animal in that it's a non-fda approved something called grass which stands for generally recognized as safe now that means that either through some kinds of animal or human studies this this substance has been defined as safe or there's thousands or hundreds of years of experience with this you know individual thing that shows that it's not harmful at least in kind of normal usage and so a grass substance gras is an important part of the the supplement world right so these are these are things that are recognized as safe it's also something that has not been proven to treat or manage a particular disease so supplements are not treatments per se um and that's an important thing and that's that's kind of around this label labels in in from a medicine standpoint or important thing you may hear you know that drug is used off label for this or the label claims or label use and so the label of a particular product is a very important legal designation um and so it's important in medicine it's important in law so if something is you know fda approved to treat ms that means that it has a label that essentially says this is used for ms and so that would be something like copaxone or something like you know uh bermud um uh the new techfit era i'm trying to think of the the the vomerity right so that's the the more recent approval of a compound that's very similar to tech fidera and so essentially if this product says it treats something it better be provable and so when it comes to supplements because they're not regulated by the fda they fall into a different designation legally so in 1994 there was some legislation put through uh congress that's called the deshay act which is the dietary supplement and health and education act and so the attempt here was to create some consumer protection so that if there's something that's on a shelf that has a label on it there better be proof that what's in that container is the same thing as what's written on that label and so it it fell short of the mark of saying that supplements can treat a particular condition but it landed squarely on the idea that you shouldn't be buying something and not know what it is right and i think that's a pretty fair uh expectation from for a consumer and so that means that the label is very important you know that if it says there's 500 milligrams of ascorbic acid which is vitamin c then it better be in there because that label is saying that's there and there's a law that says that if it's not the same thing as what's written on the outside then then you have you know a claim as a consumer that this thing might might create harm so basically you can't you know sell something and not have that thing actually be in there and it's also important to know that label claims things written on a label for a supplement can't you know say particular things you know label claims have to at least for supplements fall in the range of support enhance provide this is an essential part of x it needs to be some kind of a roundabout description as its role in in medicine or science or whatever uh it cannot say you know this supplement treats you know ms neuropathy right that is a claim that is a claim for a particular condition neuropathy ms and so that would mean the fda has to be able to say yeah we did you know 15 peer-reviewed studies and we found that this dose of this treated this and so then that actually becomes something like a medical food um you know an interesting there's things that do both right there's something called pernicious anemia which is a problem of b12 deficiency and so b12 treats pernicious anemia and so you can get a prescription for cyanocobalamin as a as a you know injection and inject that for the treatment of that condition you don't necessarily see b12 on the shelf that says you know treats pernicious anemia right so you know some of these claims there are things you know even l-carnitine which is a a kind of amino acid that that can help with uh [Music] drugs that affect epilepsy and so there may be people who have an l-carnitine deficiency and so here's this levocarnitine which is both a supplement and an actual fda approved food for a particular condition or substance so some things will cross the mark but in general a supplement cannot have a claim of treatment and you know it has to have what it says it has in it now there are some roundabouts right the the you may open them you know a box or something and see on the on the you know tiny print there that it has this much calcium this much magnesium and then you know 346 milligrams of the proprietary blend of you know this marshmallow root and this thing and so it's a big paragraph of stuff and it just says 346 milligrams so that means that that manufacturer has to state how much of their recipe is in there this kind of 346 milligrams of stuff but they're protected under their own you know proprietary laws that say we don't have to disclose this recipe of how much of each thing is in here and so that might be a little bit confusing for some because you're looking at this and you're like well there's like all these individual herbs or individual supplements and all i know is the total i don't know what each thing is in there so how do i compare these two products and that's unfortunately something that you really can't you know get down into the manufacturer will not disclose that recipe because they're protected there another thing that's really important on the labels is looking at you know who's testing this right how do they know that what's on the label is what's in the in the capsule and so typically you're going to see something like gmp and that just basically means that this product meant good manufacturing practices that that somebody came along and put a stamp on in there and said yeah we didn't find very many rat hairs in this in this supplement or you know everyone that we looked at was wearing gloves you know there are other organizations the nsf which is your national science foundation you know there's the usp which is the u.s pharmacopoeia you'll see those sometimes in things like a progesterone cream because progesterone is a hormone or maybe even like melatonin or something so sometimes something has a pharmaceutical origin but the dosage of it is small enough that it falls into the supplement category or it comes from a natural substance and so basically the the long and the short of it is that you're trying to find some kind of proof that that company has paid someone or someone has inspected them or something right um and so you may see something that says you know this was manufactured in an fda approved laboratory well that's kind of a funny little game right because the lab is approved by the fda not the product but they brought the product to the lab at the lab analyze it and then send a sample in and you know verify and so they say well we were we were you know tested by the fda and and it's approved or whatever it might be and that's that's kind of a a game of moving things around you will not find a supplement that has been approved by the fda because once that happens that becomes a medical food or a drug and so that's a different thing entirely a good example of this if you're interested in kind of the nuts and bolts and details there's a drug food supplement called deplen depolin is a methylfolate it's a form of folate that's just a very you know great form of it it has this methylation in there i'll talk about methylation in a bit and so 7.2 milligrams of methyl folate is a dosage that has been used as an adjunctive for you know antidepressants uh so if someone's on an ssri something like maybe you know prozac or lexapro or something else and it doesn't seem to be working as well that individual provider may decide well we don't really want to add another drug to this but if we add some methylfolate your ssri might work better and so let's use deplen a drug that's actually just a high dose of a vitamin that you can get as a supplement in like one or three milligrams but at 7.2 milligrams it has been approved as a drug so again there's these kind of you know funny little designations where the same product might cross a line and then become a drug because it's been proven in some study to be used for this stuff so that's that's the the legalese essentially right so now we get into more of the like well how does this even affect my condition or or what is this you know what's the point of this right and so it's very common for me to have someone sit with me and say you know my neurologist my primary care is it doesn't really matter you know what i eat or if i take any supplements they just really want me to make sure i take my my dmd that that it's most important to them that i'm on a medication and that i stay true to it and and that for the most part what i eat or you know supplements as long as i'm eating i'm fine and so why is that what you know how come you're coming from a different direction there and i think the first answer is well you know that's that's a valid point right the these studies were done on lots of people who did lots of different things in eight different ways and may or may not have taken supplements and in the hole it seemed like these medications helped slow progression so they're coming from a place of the evidence they have right i also think you know when you're a hammer things look like nails and so if that's where they're coming from they're not necessarily thinking about how the nervous system works as you know the cellular level what kind of things might help a nerve to heal what kind of things might bring down inflammation in the body on a lower level than something like a dose of solumetrol you know what what can you do to kind of enhance the the gentle function of the body over time versus these big hits of of medications or something that might might disrupt and so that's really where my focus is is what are the the small changes that people can do every day that over a lifetime have a huge impact on how the body functions as opposed to these big hits of something you know in every six month uh dose of orchivus that you know inhibits some part of the b cells and creates this change versus something that has a you know like omega-3s that slowly change the way cytokines are released in the body over time right and that in general the the therapies of dmt and dmds are are part of immunomodulation but the goal of these treatments is to shift the immune system that you're trying to make it less aggressive or to change the way in which it it identifies targets and so that's an immunomodulatory approach to ms you're you're you're treating the condition by changing the immune system in some way and from my perspective that is just one part of a you know ms treatment protocol a very important part but just one and so again with everything that i do i am absolutely there's nothing that i recommend or suggest or anything that goes counter to anything that a neurologist would suggest now they may think that some of my stuff is you know maybe overdone or there isn't enough research but there isn't anything about my approach that goes counter to what the the neurological community would like to do in in treatment of ms and so i kind of think of myself as an additive to all of this what's a supplement to the supplements right so again immunomodulation and i'll talk a little bit more about you know how i see that and what are the specifics of the supplements that affect that and kind of how that fits in the larger tree of ms treatment so you know do i need them like what's even the point right and so it depends right everyone's doing their own thing and so it's possible that someone is living a life that is you know functional enough they're eating well enough they're sleeping well enough that everything is working really well that supplements would have a minor impact on what already good things are going on and it's really important to recognize that there isn't any supplement that can take the place of these really good lifestyle things you know a good diet right often people are trying to supplement things to make up for what might be in their diet things they may not like to eat or otherwise um quality sleep i'll talk more about this in a bit but sleep is one of the most important things when you're dealing with a neurodegenerative condition the sleep is when the brain heals and so if someone is not sleeping well and often you know issues with pain issues with you know problems around incontinence or bladder issues or other things you know their spasticity there's all kinds of things that can impact a good night's sleep and and so that's an important thing to focus on as as an individual who who's dealing with ms how do i improve my sleep i think that that is is should be a primary goal whether it be through you know making sure there's not sleep apnea or you know issues with you know waking up a lot through the night not getting you know good enough depth of sleep and unfortunately a lot of sleep medications tend to have diminishing returns there tends to be issues with the way the medications affect how people function and sleep and so supplements become a really interesting place around sleep and i'll talk about that um activity you know there is no exercise pill i really wish there was but uh it turns out you just have to try to move um and then stress management you know how how an individual deals with the stress of their environment whatever that might be um and so within that there might be people who need support in different ways to achieve these levels of you know improving their diet improving their sleep you know helping build muscle you know whatever that might be to kind of improve that process overall so as i mentioned uh ms in my mind has you know four very clear pillars of management that that when i'm thinking about how to uh help my patients with ms i'm always thinking about these four things and and how do i how do i enhance each part of that so first you know antioxidant the the oxidation is the process by which we break down the process by which we age right oxidation is is the internal rusting of the body now we use oxygen for you know our air to breathe to to burn fuel in our body so there's no way to avoid oxidation you know oxygen is something that we have to take in and deal with but the kind of breakdown of that oxygen the the release of those oxidizing chemicals is something that we have methods by which we can control perhaps some of you've heard of glutathione glutathione is one of the major antioxidants in the body something that's made in the liver it's made in the brain and you know glutathione is is the kind of mother of all antioxidants but there's also antioxidant vitamins there's uh vitamin c or vitamin e there's some other you know things like alpha lipoic acid and so i i have this stuff you know in other slides so i'll go deeper into that but the antioxidant pathway is important anti-inflammatory inflammation is the process by which autoimmune conditions develop you you have the immune system discover something you know often the immune system discovers something that you don't want to be there you know a virus a bacteria a cancer and so you want to draw the immune system in and create inflammation create oxidation and damage that so that you can get rid of it in the case of of autoimmune that's a self protein that's something that we have kind of within us that we should have and now the immune system is there kind of wreaking havoc and so if you can reduce inflammation you can reduce some of the collateral damage you can reduce some of the kind of extended periods of inflammation that can develop from an attack um so making sure that there's good anti-inflammatory process in there now it's important to know that you know when someone's in a flare solumedral which is a you know a high dose of of steroids iv is an extremely powerful anti-inflammatory it can cross the blood-brain barrier and take care of that inflammation so anti-inflammatories are used in in the management but they're not used in the long-term management that it's used for spikes and and you know some of you may have been told you know we don't necessarily want to use solubility all the time there's a lot of problems that come from that you know diminishing returns with that as well and so again my strategy is what anti-inflammatory approaches can be done on a regular basis maybe not nearly as strong definitely not nearly as strong as something like sultry medrol but can kind of create a slow amount of anti-inflammatory activity over time um and there's dietary changes that can do both of these you know antioxidant and anti-inflammatory things amino modulation that's got the star on it because that's what i was talking about with the the dmd dmt's that is where this falls and so as you can see you know if that's being taken care of by a conventional provider then i can focus on the other three now i can suggest some things on that particular category but it doesn't it doesn't affect the rest of my treatment and then the important thing that only recently have i been hearing in the in the conventional community you know when i started treating ms you know almost 20 years ago no one talked about repair or remyelination or neuro regeneration it was just kind of thought that you know you have a certain number of brain cells and that's kind of what you get and when they're damaged that's kind of how it is and there you are and now we know there's a lot of uh forces within the brain within the nervous system that help to try to repair and heal and so that's that's again where i try to put a lot of energy in because i feel like that's a place to focus certainly for people who've been dealing with this condition for a while because you need that hope you know it's it's not just about slowing progression it's about reversing if you can or improving and i think what some people have seen with relapsing remitting is you get this burst of symptoms you have this problem and then your body heals and and so you don't have that same problem that you had say three or four months ago when when the relapse first occurred and so whatever that is we want to really focus in on that how did that heal how did that change what was going on there um a lot of the lesions that you see in the brain are results of healing it just didn't heal as well that time so lifestyle diet supplements and medication all are part of this right this this is all part of this four pillar strategy so focus a little deeper on the supplements since that's what the topic today is so antioxidants as i mentioned there's vitamins vitamin a or beta-carotene which can kind of be transformed into vitamin a vitamin c vitamin e selenium you know i'm not a huge fan of of supplementing vitamin e for some reason i just in my experience i've never really seen it be all that helpful it's not like you necessarily measure that um and there's studies looking at using vitamin e in conjunction with other you know treatments you know various things like you know people with with history of lung cancer or prostate cancer and vitamin e doesn't seem to be that protective all by itself um and and my sense from that is that the vitamin e is a unique molecule it's something called amphoteric so it's it's water-soluble and fat soluble and it kind of sits in the middle and so it can pass things through itself you know take something that was in fat like the brain you know an oxidizing agent that's in the brain that's all fatty grab that electron and move it into water where vitamin c can take it so it's a little bit of a middle man and it could be you know this is my own theory i have nothing to base this off but from my own thinking but it could be that having all that vitamin e as you supplement might create too many middlemen maybe it's passing too many uh oxidants back and forth and you never really are able to kind of catch them and so it creates more damage oxidation and fat tissue is certainly more complicated it can bounce through all those carbon chains a little more aggressively so it could be that vitamin e is not something that you need to have a ton of but if you don't have any you can't pass those things through so for that reason e doesn't really fall very high on my list of things that people need to worry about um selenium is a really interesting you know micro mineral you don't need very much of but if you don't have any you can't make glutathione and glutathione is important as i mentioned here this gsh so nac n-acetyl cysteine the amino acid above there and selenium that metal get together with a couple other amino acids and they make glutathione so selenium and nac those two that you see above form the the kind of rate limiting important steps of glutathione so having enough of this brazil nuts are a great source and maybe even supplementing something like nac which is something that can help with liver function help with lung function it's certainly been on some of my covert protocols when people are getting that i make sure that nac is something that they're taking so it can help their lungs that these two coming together can make more glutathione which is your major antioxidant from a dietary standpoint the brassica family which is your broccoli cauliflower kale brussels sprouts cabbage they have chemical constituents in them that actually have antioxidant activity themselves or they stimulate the body to make more antioxidants like glutathione an example of that's something called sulforaphane which is found in broccoli so one could take sulforaphane which is a a compound that has been taken away from you know broccoli it's been it's been isolated and then in the body it stimulates the response of making more antioxidants inside so it kind of has this amplification effect or you can just eat a lot of broccoli right you know looking at i'll talk about this in a bit but looking at some of the diets around ms something like the wall protocol the brassica family is its own unique part of that dietary protocol not only are you supposed to be eating leafy greens and brightly colored vegetables but very specifically this family of brassica and so that's part of that is that antioxidant quality alpha lipoic acid you guys might be hearing more about this because they're doing more and more studies a swedish uh hospital here in in seattle is doing a study on alphavoice acid for you know the effect on progressive ms um i've seen a couple of patients that i have down in california who've been sending their notes up from some of the the doctors down in california some of the neurologists down there i'm seeing alpha bone acid show up on more treatment plans now this is something i've used for years because it's an antioxidant that's specific to the nervous system um you know it's actually part of a electron chain issue in in the mitochondria as well as a form of something called coenzyme a but alpha lipoic acid is is one of these really special i think antioxidants for someone with a neurological condition um what's unique here what's important to know as a consumer is that if alpha lipoic acid is made in a lab if it's made synthetically that anytime you make something synthetically it's not made in nature it's made you know by a chemical reaction by putting two you know chemicals together and watching them you know form in a bucket it does something called the racemic mix where it's 50 one shape which is usually called left-handed and then 50 another shape right-handed right and so there's these different forms these these these uh isoforms in the case of lipoic acid you only want the r form the right-handed form you don't want the s form or the sinister as the left-handed person i've always felt a little you know being called sinister but that's s form um is is considered to be not as effective if effective at all um so when purchasing something like lipoic acid you want to see you know is this is this compound r and s in which case 50 of what i'm buying is not useful and maybe not good for me or is it only r in which case it's what you want right so these are these little tricky things that that no one tells you which again is you know why i don't know what you need to know so lipoic acid is an important antioxidant i feel moving into the anti-inflammatory um you the the one that gets a lot of attention and i think it's deserved is turmeric uh it has these humanoids the the so the herb turmeric has a compound in it called curcuminoids and these are thought to be the the most active compounds within there and so often you'll see on a label you know some turmeric blend or something and then you look on the back and it's like standardized to 95 of curcuminoids and you're like okay then but that's actually telling you something really important that's saying we took the turmeric we extracted the most you know important compound from that and that's what you're taking which is a little bit different than taking just the herb you can take just the herb it's a food it's very safe and it's important to know with turmeric we're so inclined to believe that one capsule one tablet of something is what you take right that that you know you would take a 200 milligram of ibuprofen and that's what it comes in is a 200 milligram capsule and so you take one and so when it comes to turmeric a lot of people have that same idea like well it's 500 milligrams in a capsule and so i would take one but the reality is turmeric is much you know it's not absorbed very well and its activity is not incredibly strong and so i'll always say turmeric is not mobic you know mobic mobik is a very powerful antioxidant you don't need very much of it where with turmeric you need quite a bit so 500 milligram capsule you might need to take three before that actually does something that you're looking for you know in the case of turmeric the herb you know 500 milligrams of the herb is essentially a tenth of a teaspoon and so that's not going to do very much you probably need a teaspoon which is five grams and so if you're if you're putting that into say a smoothie making something called golden milk where you put some turmeric and maybe some coconut milk and maybe a little bit of honey um that that needs to have you know two tablespoons you know maybe even three tablespoons of turmeric before it's going to have a good anti-inflammatory effect so it's important to think about strength of what you're taking as well if something is standardized these humanoids it is going to be a bit stronger um omega-3 so flax fish algae these are all sources of omega-3 that's important because of the way omega-3s impact the way the body deals with with damage that when a cell breaks when there's some kind of cell damage there's a cascade of events that occur after that and so if your body has more omega-3s then that inflammatory response may not be as aggressive as it would be otherwise and so you know there's other ways to get around this too you know eating fish definitely cold water fish the reason omega-3s are in fish certainly the cold water ones is that if they have these unsaturated fats in their body they can go deeper into the ocean then go to colder places and not freeze up right if a fish was filled with coconut oil which i'm not sure if you've seen much coconut oil in your house but it gets hard when it gets cold um you know these fish would freeze up in the ocean and drop at the bottom and die right so you you have to have something that can handle these changes in temperature and so you find that in these cold water fish i like sardines as a choice for omega-3s versus the larger fish but even grass-fed you know animals things that maybe are more wild will have more omega-3s than something that's been raised with grain or maybe corn or something that's more omega-6 um boswellia that's also an herb that has some antioxidant or sorry anti-inflammatory qualities to it often i see that used for pain um headaches joint pains it affects a different enzyme than say the advil or aspirin or something um but it's it's also anti-inflammatory and so that's something that that i've seen people use and there's even theories about digestive enzymes that if you take digestive enzymes you break down your food a bit more but also helps to maybe break down some of the proteins that would cause inflammation and so i've had some patients with you know [Music] lifelong autoimmune conditions that they're managing with digestive enzymes and other things amino modulation so again this is important uh part of the kind of autoimmune story how to treat that it was a realization to me that the immune system lives in your gut i mean i think for the longest time i'd always think about drawing blood from someone and think i'm going to check their cells what i was really doing is really just counting cars on the freeway you know i'm watching them go by you know we got we got a red one a white one we got a semi you know uh where they're going and where they're where they're leaving to and going to work and where they're coming home to matters and so most of the most of the immune system lives in the gut it lives in these places called the galt or the malt and so makes sense right if you if you put something into your body if you swallow it you know that's kind of the dirtiest place you're gonna expose right there was something on the floor i could pick it up and eat it hopefully you know wouldn't do it on camera but if i put that same thing in my veins i would die right so there's a difference between putting something in your body versus directly in and so the the immune system sits right at that dirtiest place in your body to watch things come in and gets ready and so if it's being told that a lot of dirty stuff is coming down the track it's going to be really focused on the outside world it's a dirty world out there if there isn't that much dirt to deal with it might turn itself inward and start to look for stuff to fight on the inside and so there's some interesting you know longitudinal studies looking at children from other countries who've been exposed to tropical diseases or parasites or other things that don't develop autoimmune diseases at the same rate as you know some of our cleaner societies and so is that you know is is that just a coincidence or is there something about the way the immune system is triggered by this kind of dirty world that we're putting in our mouths and if we're not doing that then the immune system is not triggered as much to look out and it looks more in and so that's why i think something like probiotics are really important because that's putting safe dirt you know probiotics are essentially friendly dirt but even friendly bacteria that you're putting in your immune system has no idea they're friendly it didn't ask it just knows you know 5 10 billion things just showed up today and we need to be ready to deal with it those organisms are not harmful you know in some cases they're very beneficial they might make vitamins or other things for us break down foods but the immune system is triggered by those presence of cell walls and kind of creates a barrier there and sets a presence looking on the outside and so if it's being you know regularly triggered to look out it's going to be ready when things show up um and there are things that people eat that might trigger the immune system further there may be a particular you know intolerance or a particular allergy you know maybe something like celiac where there's actually changes in the gut lining that make the immune system even more upset in the sense that everything's kind of sliding right through so you know in some cases with my patients i may do a set of you know allergy tests and say you know is there some particular food that we need to cut out because while it didn't cause your ms it might trigger your immune system to be upset and then start to turn itself inward to look for more of these things and maybe in the process create some inflammatory response that can then cascade we know for sure with with you know ms that a urinary tract infection an upper respiratory infection you know these kind of things can can kind of be the precursor to a relapse and so if we can shift the immune system to be a little bit more aware and protected and and less you know upset being poked all the time then over time there may be less relapses and therefore you know less progression of condition and then looking at you know as i mentioned the diet the diets are often focused around all these things the immunomodulation the anti-inflammatory the antioxidant so a wall protocol the swing diet mcdual even the dash diet i've seen some research on that just cutting out some you know sodium and processed foods there's some concern that maybe sodium too much sodium in the body might actually trigger some of the the firing in the nervous system maybe lead it to kind of short out a little too soon so even just too much salt might be a problem from a supplement standpoint the two that make the most you know importance in my mind is vitamin d which i'm sure all of you are aware of vitamin d is interesting because vitamin d is not a vitamin as much as it's a hormone it's it's something that influences the way cells develop i like to think of it as graduate school for cells it helps to teach them you know to become the best they can be right so in the presence of a lot of vitamin d cells differentiate very well and in the case of t cells these t helper cells and other parts of the immune system it can actually shift the balance of what kind of cells they become and therefore what kind of teachers they become to other cells and so vitamin d can influence the immune system over long periods of time because it has an impact on the cells that then influence other cells you know your immune system there are parts of your immune system that are considered to be immortal but often those cells live about six months they're kind of around they do their thing they look for what they look for and then as they start to divide and and make you know daughters essentially they pass on this information and say you know uh this is what i used to fight there's this thing called myelin i don't really like it you shouldn't like it either right and so if that cell grows up in the presence of more vitamin d maybe it doesn't fight myelin as hard and then when it gives birth to its daughters it's like well you know mylan it's there but we don't need to hate it as much as my mom did you know and so there's this idea of kind of changing the immune system over time um so when it comes to to vitamin d dosing every everyone's kind of different right i mean i i have neurologists that i work with that are like 800 ius there's plenty you needn't take any more um and there's this coin bird protocol i have a doctor in brazil who's like yeah 20 200 000 i use for a little bit is probably okay right and that to me is beyond what i'm willing to do um so i kind of range i'm in the northwest so suggesting vitamin d is pretty easy because you know i can kind of assume that most people aren't getting it all year um and so all range you know two thousand to six thousand your body can absorb up to ten so ten thousand ius for a period of time is not a concern it would be smart to get a blood value and see what that you know three five six months of 10 000 is doing because there is a point where calcium can raise and that can cause especially for someone who has already spasticity if your calcium gets too high that makes muscles contract and so you don't really want to make a spasticity worse because your calcium is too high from the vitamin d that you're taking to try to help your immune system but you know there's theories around uh vitamin d receptors and how that influences you know the immune system over time then you know we just have to wait and see how how effective those kinds of protocols are probiotics also very important um is colony forming units uh is what you're looking for on a label so if you see a probiotic that's designated in milligrams you know there's 200 milligrams of probiotic in there that's a confusing designation you don't really i don't really know what to do with that that just means how much it weighed it doesn't really tell me what the bacteria is going to do once it gets into your body is it something that's going to form a certain number of colonies is it going to last so you're always looking for colony forming units and generally you're looking for billions you know 5 billion 10 billion 50 billion 100 billion the research looking at you know certainly animal models and kind of extrapolating that into human would suggest that 10 billion cfus of three or more types of you know bacteria in which case i just tell patients if you see three latin names or more kind of in cursive there and it says 10 billion then you're you're in the right ballpark but this is something that is is in the right world there are very particular uh strains that have been studied in the animal forms of ms something called eae so there's a lactobacillus rhamnosus lactobacillus plantarum these things have been been studied and been shown to reduce the amount of lesions and the amount of activity that happens in these animals some of the first probiotic studies the the theory was that the probiotics would be immunostimulatory and therefore damaging to the animal and so that by giving a probiotic to a rat you're basically going to see that disease progress and what they saw instead was that these rats were doing better and so then they had to figure out well like what what happened there you know and there's even you know some some animals here in seattle they're the bender research institute that have a th17 gene knockout that makes it so that they will guarantee develop the condition if you just let them be if you if you just let them grow up they will develop the animal version of ms but if you expose them to probiotics when they're first you know born kind of like the idea of people with tropical diseases they don't develop the disease at all and so to me that's fascinating i mean i think that's that's that's research to me that's worth really leaning into but when i talk to the researchers about they're like yeah that's kind of what we expected but i don't i don't know why why that's not you know moved into some other avenue somehow um i'm seeing hands and questions i i think i'm i'm going to try to get through this and then i i promise to answer questions at the end and then the last pillar here is this repair remyelination regeneration um so it's that's a primary thing in my mind because so often my patients are concerned with progression but they're often concerned with well how do i make what i have going on better how can i improve how i feel how can i not have this neuropathy anymore or you know improve my balance or whatever it might be and the brain is an amazing thing the brain the plasticity of the brain is amazing and and again these things are reforming all the time new connections and new neurons there they exist and so sleep is one of those places that really needs to be focused on and so when it comes to repair sleep is the thing i think of and and so supplements may or may not be the strategy for that right it might be helpful um sleep hygiene is an important thing learning learning about how you best sleep where you best sleep what your sleep structure is you know how you can be the most comfortable you know sleep's an interesting thing it is it is the kind of most vulnerable one could be right you are you are putting yourself in a place where you are you know removing yourself from consciousness and so if there's a history of trauma if there's a history of anxiety if there's a history of fear that's not you know something that just necessarily goes away and so sleep might be the place where that crops up right is this a safe time for me to be unconscious and just as you know if you were running from a lion or something and you ran until you were so exhausted you had to sleep you would sleep but you would probably wake up as soon as you were rested enough to keep running right so chances are that you know you would be running through the jungle and take a you know 10 hour nap somewhere pretty low right it's gonna be a short burst of sleep and then you're up and ready to go and a lot of people live their whole lives this way they are waiting for this uh kind of just enough recovery to keep running and so if that's part of a history for you if that's if that's something that that is true for you then figuring out what the basis of that fear that trauma that anxiety is is going to help your sleep in some cases it's just the condition itself right the there's difficulty with movement there's there's all the anxiety and fear of having the condition there's pain um you may not get the activity that you need in a day and so then you're restless through the night and so that that can be a very difficult thing to manage in a condition that has such a broad impact right ms can do just about anything and and so it's hard to make a general statement about how best to help someone with sleep that might be having their sleep impacted because of the condition itself um but melatonin is something that i think is is really useful and i can actually see this little uh question just popped up so one of the things that they say with melatonin and it's been said for years is that melatonin is immunostimulatory and so may not be good in autoimmune diseases you know i i came into medicine with that statement but i've seen i've been to various cmsc and other things where they've talked about melatonin for sleep exercise is immunostimulatory there's no doctors that tell you not to exercise because it stimulates your immune system sleep is immunostimulatory you know so their melatonin is something that everybody makes so you know it could have an impact on the immune system but i don't know how we would ever really know that and i think the benefits of melatonin in my opinion outweigh that melatonin is an antioxidant by itself so just its chemical structure is going to scavenge antioxidants and the brain will pull it up if it sees it in the blood it'll grab it and put it right in the brain excuse me it stimulates um glutathione production in the brain so melatonin will stimulate glutathione which again is an antioxidant and melatonin enhances slow wave sleep which is one of the points at which you heal so there's this trifecta of melatonin that has you know a dramatic impact on the brain now i have patients who don't tolerate it and so what i tell those patients are you know start low you know sometimes with melatonin less is more so a half a milligram a milligram you know you start a few minutes before you would normally want to go to bed so 20 30 minutes before your your your optimal bedtime turn off all the lights you know don't stimulate yourself just kind of get down into a dark place um and then what it should do is enhance sleep onset for some people the dreams are too much they don't like the dreams they have on melatonin some people wake up in the middle of night they feel groggy so if melatonin is something that you can't supplement fine you still need to enhance its production naturally in your body and so that's done through you know avoiding a lot of lights and other things so uh melatonin is super important magnesium also helpful can can reduce some of the the tension in the body magnesium is something that relaxes muscles to contract a muscle you have to use calcium that's what binds those things together magnesium is what unhooks that contraction so magnesium allows for relaxation l-theanine a very safe amino acid that helps with slow-wave sleep the same thing with l-glycine and then more recently you know cbd thc cbg some of these uh you know cannabinoids and and their impact on on the nervous system and so you know the issue there is you know in a state like washington it's not a big deal i have patients who come in all the time and say you know i'm using these gummies for sleep um or i have this tincture or you know whatever it might be i generally do not uh support isn't the right word um if i have a patient who is inhaling uh marijuana either through you know combusting it or vaping i'm generally trying to get them to use a different route um you know the smoking is not great for the lungs and vaping we we don't know really what some of these oils and other things that are in there some of the carriers and you know it's very rare but there are cases where the lithium battery has exploded and blown people's jaws off so um you know or they blow up in the car because they get hot or something so these little pens you know they look fine but there could be danger in that stick um versus marijuana by mouth i mean it is so safe right there's a question about allergy and i'll talk about that in a minute but you know it the likelihood that it's going to create some kind of overdose or some kind of problem um extremely low now consuming too much for your system and having a really rough you know six hours of you know hiding in the closet could happen right and so that's something that you need to be mindful of uh for for consuming that but you know there's there's the ld50 which is what's used to assess whether or not something is dangerous you know like the ld50 of tylenol is quite quite low you can't take very much of it um the ld50 of of you know thc and marijuana is quite high uh it's it's not something that's easy to to get sick you know you can feel sick different thing um another important or important parts of nerve repair methylation um methylation is is a hugely important chemical reaction in the body it's used in the liver it's used in the brain and so to get methylation you have to bring methyl donors you need you need methyl donors to bring methyl groups and so b12 b6 folate sami those are your general methyl donors and so i like methylated forms of these vitamins you know i mentioned deplen which is a methylated form of folate it's a methyl folate methyl b12 or something called p5p which is a methylated b6 you know you can get these vitamins as as non-methylated and your body has to add a methyl group to it right so if you bring it in methylated already you kind of bring you bring a methyl group to the party already um and then looking at things like you know neurogenesis you know this stimulating what is already occurring in the brain to some extent these new neurons coming on um you know some of the research there and so you have you know lion's mane this is this is something that is getting a lot of tension um that that you know may support remyelination so that's that's something that is is important um skull cap which is an herb there's a compound called bicyclin and so they're doing some research with spinal cord injuries and rats and seeing whether or not the application of this compound actually improves the way those nerves repair lithium orotate now lithium when you say lithium to a provider or kind of the general public the first thing they think of is lithium carbonate kind of a one flew over the cuckoo's nest uh you know this this thing for bipolar or mania lithium can be used in very small amounts where it's more of like a vitamin or it helps neurotransmission so what they have done is looked at people who were on lithium carbonate for for medical treatment you know grams of lithium to control you know mood disorders or might be and they actually see that some of that those individuals don't have as much atrophy in their brain and so the idea is that lithium might improve that and so then there's studies looking at low doses of lithium you know milligrams versus grams so five milligrams 10 milligrams 20. um and that lithium enhances not only some of the firing in the brain but also can support some neurogenesis and then you know one of my personal favorites is cdp choline or cytocholine this is a precursor to acetylcholine which is what the brain uses for processing speed it's kind of what fires all these signals around and some studies you know in europe mostly looking at this for mild cognitive impairment or mci some studies in this country a traumatic brain injury this is a product i use quite frequently with patients certainly those that have had a recent concussion maybe someone who had a recent stroke someone who's had a recent relapse and so there's some damage that we're concerned about you know that showed up on the mri you know if i have a patient who has an active lesion i'm often recommending some alpha lipoic acid some you know cdp choline i want to try to make sure that whatever is some magnesium whatever can get in there and really help that tissue to heal as best as possible because you kind of get that one shot in the beginning and if that tissue can get laid down really well in the beginning you might get better function versus trying you know after the fact to try to get some other part of the brain to make up for whatever damage was there oh yeah fxn does stand for function so in summary uh supplements you know there's thousands of them and for the most part they're pretty loosely regulated you know you you are in the wild west in some ways as a consumer without much you know knowledge what to buy like how do you know um so for me you know the way i try and and function i've never felt good you know running a business and saying like you need to buy these these are my supplements that you need to buy this is some kind of salesy thing about that but i've never really liked but i do like the idea that everything that i do carry and everything you recommend has been tested by some third party you know i have a sheet of paper that can say this is exactly what's in this label it is the r form of alpha lipoic acid it is the ubqh form of coq10 you know whatever it might be this is this is the lion's mane that comes from the guy who you know is a mushroom uh pro and he would never choose anything that wasn't you know the best product um and so that's that's something that uh i i try to stick to patients will bring things in and i try to look at the label and say oh well it's got you know here's got a little nsf thing here's the gmp thing oh look it it says you know methylfolate anyone who's gonna you know any company that's gonna go through the trouble of of paying for the patent for the methylfolate to put in their product is probably doing the same thing with other products so that's probably a good sign um but it's difficult it's hard for me to say there's a particular brand that's good but in general supplements are going to have a support function they're going to be an also end you know and rather than instead um you should be consulting with somebody you know someone who has some expertise or if you want to you know spend the hours you know in the rabbit hole the internet trying to develop your own expertise you can do that i mean you can go to a company go to their website see if you can download the pdf of their product to see if it's been tested you know you can call them you know you could you could do the leg work and try to figure out if they've got all the all the you know t's crossed and eyes dotted and all that um and so i think the main thing to take away certainly in something like ms if it sounds too good to be true you know if someone's like this product i took it for a month and my ms went away you know that's not really how things go i mean it could be it hasn't in my experience now i've given someone a b12 shot and had them feel amazing right that enhanced their you know nerve function and maybe they needed it and and so that b12 you know may have had the effect of reversing a relapse to some extent um they didn't cure their ms right so it's just important to know kind of what the purpose of what you're doing each thing for and just not overdo it and and really focus on that it's lifestyle it's sleep it's diet it's stress management it's all those things that you know i always tell patients we don't know necessarily what would make you better but i know how to make you worse if i wanted to make your ms worse i got i got a really good protocol for it you start smoking you gain as much weight as you can you live a super stressful life where you don't get enough sleep and you feel like you're constantly under the gun and nothing that really goes your way and you get sick as much as you can you get some uti some earring track infections if you can get sick three four five times a year you're pretty much set to have your ms progress really well right so you have to think about the inverse of that well how do i make sure i'm not smoking anything make sure my diet is really focused on you know whole foods that are lots of colors and have lots of antioxidants and aren't aggravating my immune system and my god how can i sleep how can i move what can i do these things that kind of improve my overall well-being um so that's just more of this right these antioxidants diet supplements immunomodulation um repair and all those things there um some more resources for you so this is just kind of the fda's you know cut cut and paste there of uh supplements kind of how they view them this again kind of legally stuff this is this uh textbook that was referenced where i wrote chapter nine which is the uh multiple sclerosis what i call that i should know this right integrative approaches to multiple sclerosis that's chapter nine um of this book here integrative neurology i don't get any money for this this was my payment right here was this one copy um but you know some street cred uh and then dr alan bolling who you guys may recognize that name he's a colorado neurologist he ran the rocky mountain ms center for a bit he's kind of thought to be the expert neurologist on anything alternative supplement wise i know him we've talked many times we have different views on things um you know he he's written a whole lot on cannabis he's he's done an incredible amount of research on that because colorado is one of the first states to to move forward with that so he's he's a great resource for that um so i'm going to start to kind of tear through this uh list of questions deborah is there anything that you want to say before i number one that was amazing information okay great great information do you um i don't know if you have access to everything can we at least start with the initial question that came in about yeah for sure there's quite a few on the chat too um i think i've got 12 or 13 questions on that right we have q a so if we do the ones that came in initially sure yeah elizabeth who says she's she said if you're allergic to mmj cannabis hemp is there anything equivalent natural like cannabis not medicinal that can help spasticity and neurologic pain yeah i mean to be completely honest there isn't anything quite like cannabis it is a very unique plant it's very rare to have something that has so much impact on the human physiology and so little risk um you know most things that can affect the brain and the body in that way would have some kind of you know you're gonna die if you get too much of this or you know something not to say it's without risk and not to say that people haven't been harmed from it but you know comparing it to say alcohol or opioids or or benzodiazepines or really anything else from from the effect it has on the on the human body it's pretty incredible that it's as safe as it is um [Music] so the allergy i think i would have a few more questions as to what specifically that is is it an allergy to the plant in which case maybe the oils the extracts or something may not have the same effect because allergies are generally to proteins so if there were a way to get an extract that maybe wasn't from the plant you know didn't have as much plant material in it um you know maybe topical versus inhaled like i i don't know an allergy is an allergy and so if you've got an allergy there isn't really a way around it and i don't think that there's really much that has quite the same impact as a singular thing now something like cava which is a root i've had some you know good benefit for that reducing spasticity for helping with sleep there's some great teas yogi makes a tea called kava stress relief that's got some lavender and some kava in it um and so that that has an impact um but i i don't i kind of think of of cannabis as its own animal in that way um and so you would be trying to kind of cut and paste some other things that had individual function to try to combine that that singular thing um passion flower i've heard you know extracts of that might be helpful for spasticity um so i think my my first my first question would be what kind of allergy my my second point would be there isn't really much like it if if it if you can't take it there probably isn't one thing that that replaces it thank you um we did have a couple questions and i know you mentioned it a little earlier in your slide about the um the lion's mane yeah somebody wanted to know is the pill form better than the actual plant um so my concern with the actual plant is just the uh identification of it you know mushroom identification is a very difficult thing i took you know a 400 level class in college to learn to identify you know fungus i took an additional class when i was in med school i've done spore prints you know i've looked at all the drawings i've looked at fruiting bodies like i'm interested in in mushrooms and fungus i think they're fascinating one of the most amazing kind of organisms that we have um and i don't feel confident identifying them in nature so you know if you knew for sure that's what it was but i i kind of feel like i'd rather have a label a company that is like yeah we we made sure this wasn't toxic and and we're gonna put it out there so there's a company called fungi perfecti a gentleman named paul stamens he's in my opinion he's like the mycology guy and so any product put out by them i trust because i know that he has done the work and so we carry that lion's mane in our in our facility i believe one capsule has 550 500 milligrams something like that and usually it's recommended to take a gram a day at least you know if not twice a day so i'm sorry but it doesn't matter what because it was part of the question it doesn't matter how much the person weighs they would take the same amount of grams yeah i mean it it must matter on some level but i don't think we really know enough about the constituents to say at what point it becomes therapeutic and again i think we're we're stuck on that mindset of like a capsule right and capsules are just that size that's what you can swallow so the idea that one capsule is enough is is not necessarily the way things kind of play out so you know two two is a gram and that to me you know certainly from a from an ability to take it an ability to afford it you know it's gonna do what it's gonna do i i don't really know whether three grams is what you need to get remyelination or not um i'd love to have that information but it's just not something that i have access to thank you um joanne asked what are your thoughts on alpha lipoic acid for neuropathy and what dose would she take if there is such a yeah so i i love ala i think it's one of the things that i'm i'm constantly recommending for my patients with neurological issues um the the dosages that were were pushed out for the study was 600 milligrams twice a day this was the ms study so 1200 milligrams or yeah 1200 total um i've had some people you know one that can be cost prohibitive for some you know it's not it's not the most inexpensive supplement um so i kind of feel like any is something so if 100 milligrams in there then 100 milligrams is what you're doing and that's more than you're doing yesterday right 1200 is what's been done in research and so we'll come to find out if that had a measurable difference whether there was a different study group or not you know looking at those um so 600 is kind of the meet the middle for me it's i know that most people can you know take that and tolerate that and it's doing something so when it comes to ala i'd say any is something um 600 is is you know thread in the needle and 1200 is on the high end there and yeah it's used for diabetic neuropathy it's used for idiopathic neuropathy it's used um i think of a couple other conditions but it's it's it's typically something that helps with the protection of nerves thank you um i think you mentioned this also but jason asked what do you think about using fermented foods in order to promote probiotics in the diet yeah so it's a great natural source in general that's going to be one type of organism so it's it's usually a single strain of something and so there's there's benefit there that you're bringing in these prebiotics the stuff that the bug likes to eat and then it has the bug itself on there so it's those probiotics there um i would never discourage someone from from eating fermented foods and and getting it in that way it is a single strain and i guess is my guess would be it's a lower content than what you can get packed in a in a supplement that has all these colony forming units um but i've never done like a head-to-head you know analysis you know i guess we could we could do some microbiology tests and do a swab and see you know how many colonies would form um but typically you know something like a kimchi or something is going to be one one type of organism when it comes to kombucha which which is a yeast often that organism can't survive in the gut so you're you're introducing it in but it has trouble kind of setting up colonies and continuing so it's a great probiotic in the sense that it's it's going in there you know it's having some impact on the on the microbiome there is a response from the immune system and kind of all those things but it isn't necessarily sustained in the way that like a lactobacillus that's going to set up a colony and stay there um the bugs in the gut you can kind of think of them like almost like living on these icebergs that are constantly shifting and melting and so the inside of the gut is always pushing to the middle it's kind of it's just like our skin in a way it's always sloughing and it's always going to the center of that tube and then going out and so 25 of stool is just these cells that are kind of sloughing and going in and so those bacteria are getting you know pushed and then they're trying to find another you know and they're getting pushed and try to get back in there and push and then if you dump some antibiotics in there they die right and they all just slough out and it's only the ones that were able to survive and kind of hold on and sometimes those are not the ones you want you know anyone who's had c difficile clostridium difficile from antibiotics can tell you you know when you get too many antibiotics and you're left with the bad ones it's bad news so you're constantly needing to repopulate them i guess that's my point so long story short you want to eat fermented foods more power to you um that may or may not i can't really say for certain whether that's the equivalent to taking a 10 billion colony-forming unit bacteria um esta asked where can you mention some reputable sellers of supplements yeah i mean i there's there's different so nature's way which is a very common you'll find it in in lots and lots of stores you know they're they're in rite aid and other places nature's way was purchased by a german company called schwabe this was about 15 years ago schwabe also owns integrative therapeutics and enzymatic therapy which are are two companies that go direct to consumer or in my case with iti you know they're a professional brand but all three of those products are made out of the same facilities so nature's way enzymatic therapy and iti are all different price points and there's different kind of combinations of products that are in there but in general because of their you know master company everything is done on the same on the level right um a company like uh thorn which is again a direct to doctor company uh is very they're very focused on hypoallergenic you know there's they they reduce the kind of additives that are in there um and and they're very specific with the kind of of uh starting you know these substrates the the raw material and so that's a good company vital or pure encapsulations um zymogen these are the kind of companies that that that we use it's a little bit harder when you're just standing at the health food store and you got 15 different ones and you don't know right um now is is a company that is is pretty easy to to find and has some fairly good products so you know it kind of depends on what you're looking for and then it still matters when you look at the label you know in the case of like alpha lipoic acid is there an r and s there in which case don't buy that that's that's not something you want if you look at the you know vitamin e like i mentioned if it says dnl on there well now you're seeing like oh that's those are two letters i think i remember dr mark was saying it's one thing about two letters means it was synthetic and you only want one form not the other you know okay so if i answered that or managed to talk around it you've you've talked so much that if i if i ask a question that you've already talked about just tell me that because i'm trying to remember everything you've discussed somebody did thomas asked broccoli sprouts are they as effective as broccoli uh so the question is are broccoli sprouts are effective as broccoli yeah is there a difference you know i i don't know um that's a good answer what would i think of that uh i would think that adult broccoli if that's what you would call it versus the sprouts um would have a different chemical constituency than the sprouse that might be focused more on growth versus protection um i don't know i mean the question becomes why do these com why do these plants even make this stuff you know there's been some some pretty good research looking at wild herbs versus herbs that were grown in you know farms and that the ones that have to struggle to survive the ones that are growing on rocks with not enough water and you know maybe too much sun they have so much more kind of therapeutic potential because they've made all these compounds and result of the stress of their lives versus the the plants that got everything they wanted right and so it would be hard to say i don't know the difference between you know kind of when the sprout would make sulforaphane versus when something else but i would say eating either one is great better than better than gummy bears i would say so deborah's asking if you take probiotics um and you're taking antibiotics every day for an issue does that kill the probiotic it does but you're almost better off you know throwing them on the grenade you know i'd rather i'd rather it kill some of the probiotics to protect what you have in there or at least allow for some of them to survive that onslaught taking them at the same time like having them both in your stomach at the same time is probably not that smart but a few hours apart you know take the antibiotic and then you know three or four or five hours later stomach's empty the the antibiotics already broken down it's in your bloodstream it's in the it's in the bowels then taking the probiotic yeah very likely it will kill a majority of what you've just swallowed but if you're taking you know 10 billion and you lose 60 percent you still got 4 billion that's a pretty good number she also asked if yogurt helps with the probiotics well yogurt contains them so yeah but it again it's the same with the fermented foods usually it's one one single organism um so yeah it's honestly there's there's a con there's a organism called saccharomyces ballardia it's actually more of a yeast than a bacteria it's very similar to like brewer's yeast and that has been shown to prevent some of the antibiotic problems so you know the risk of c difficile or other things so if if that's a concern that a patient of mine has or has a history of that i'm usually having them do some sac b which is what the cool kids call it um so putting in some sac b with with that and maybe having an additional there's there's a company called orthomolecular products and there's a product they have called ortho orthobiotic and so that has three of the strains that were used in the ms animal studies and has saccharomyces b in it and so when i have a neurologist that i'm working with that's very like by the book and doesn't want me giving their patient anything that's abnormal then i'm usually choosing that ortho biotic probiotic because i can say well here's these studies that show that this strain was used in these animal studies and here's the saccharomyces b in the event that we need to put the patient on an antibiotic for uti or something that'll prevent this c diff and so i'm able to use that single product as kind of a two piece to say hey i'm just here to try to protect our patient you know um versus another product that may not have those things in there thank you yaz and barbara asked about vitamin d um one of them wants to know what level of vitamin d the other one wants to know what type of vitamin d do you recommend like vitamin d3 is there any yeah well d3 is what you find uh commercially um d2 is prescription so vitamin d2 is usually prescribed at 50 000 ius once a week and that's a prescription that you would get from the pharmacy again it's fda approved for vitamin d deficiency it's got a label that whole thing um d3 is a more active form it's usually used in lower doses so 2000 you know 400 800 something like that they have different chemical names oh ergo calciferol cholesterol um levels it kind of depends on the lab because labs have different measurements but the most standard lab in the us i think is nanograms per deciliter micro liter or something along those lines um and so 50 to 75 is the range that's thought to be optimal on this test and anything under 30 is considered deficient anything over 100 is considered risky so below 30 your vitamin d deficiency above 100 you're running the risk of hypercalcemia between 50 and 75 is kind of this perfect range for supporting all the function in the body um and you know there's certainly other physicians that would argue all around that would say you know it's fine if it's lower or you know i've had my patient be up at 200 and nothing happened um so that's 50 to 75 is what i'm shooting for on a lab um somebody asked if if the slides are going to be available and i'll discuss that later when we leave but they are going to be available because they're going to be on our youtube channel you'll be able to see them in other realms also um but yeah so they will be available and i can't really pronounce this and i'm embarrassed but i somebody asked about acetyl l-carnitine is it yeah yeah um well so as i mentioned l-carnitine is is a compound that's used in the body it's part of something called a energy transport in the mitochondria carnitine shuttle so carnitine is something that can be used when you have concerns about nerve function it's also something that can help with muscle development and i've had patients who are on dialysis and l-carnitine can help reduce the risk of anemia from dialysis it can it can slow that um as i mentioned there's some anti-convulsants dilantin i think is is the one um valproic acid that creates a risk of low carnitine and so you would take it in that case so carnitine l carnitine is very safe acetyl-l-carnitine is just a different form of it it has an acetyl group it's supposed to be more absorbable in the stomach um so it tends to be a little more pricey you know acetyl-l-carnitine tends to cost a little bit more than l-carnitine um so that's it i'm not exactly sure what the question might be but yes i have had patients with you know ms use that for nerve support or muscle support or energy support or you know whatever it might be marco i know it's late we went way past you have a couple more minutes to do it yeah okay so barbara's asked what you recommend for fatigue being the worst of her symptoms yeah symptom management gets tricky um you know the fatigue i understand the question i think the answer is is super complex right the the first thing would be sleep right that and and so is that so i i don't i don't know how to answer that in a simple way with a simple supplement um i've had patients there's an herb called rhodiola rose root it's an adrenal support very safe rhodiola rho d i o l a rhodia rhodiola um it's been studied for you know altitude sickness for performance enhancement other things it's kind of loosely the studies or loosely support that um but for my patients who would normally take like pro vigil but they don't like the way it makes them feel i've had them take rhodiola and they're like yeah it's kind of like a weak pro vigil like yeah i could i could see how that helps with focus and keeps me awake and you know it's it's kind of like you know in the way of having a cup of coffee to stay awake but it doesn't have the same jittery effects um does that really solve the fatigue not necessarily but there's some some symptom management there um but i would say that ms fatigue is such a huge problem that i would need more more time and focus to get a good answer on that okay um allison said currently she's taking baclofen marinol cbd oil and she has botox injections for spasticity and spasm it still has extensor spasticity especially when she's still in the night do you have any recommend recommended supplements to reduce that problem yeah i mean that spasticity is is really really difficult once it sets in um magnesium is is something that i is super safe right and and done in in low enough doses orally won't cause diarrhea if you take too much you get diarrhea but you can magnesium oil i've had some patients where they get magnesium topical and and put that on um you know it's often with spasticity and ms it's difficult to kind of get in and out of like a bath so like a epsom salt bath isn't really practical um but something like that where you can get kind of magnesium on the surface to soak into the muscles can help it to relax um marinol is not really the same thing as cannabis it's it's a it's a synthetic it's used more for kind of the nausea piece so maybe there's some benefit to something like cbd or thc or something else that that's more natural in the cannabis world versus marinol which is a derivative um anything about pro bionic acid for ms propionic acid ionic forgive me yeah i don't know a ton about that when i think of that i think of digestion i i i know that that's maybe like a a breakdown product in the gut i have to i have to be honest i don't know a ton about that and i could look into it but it's not something that makes sense um does meditation do you feel how many feelings about meditation and how it can help cell repair yeah i mean meditation is is amazing in that way right that you're able to kind of one relax right the ability to to get the system to to relax um the idea of putting together these visuals of like a healing light and all these things can help to to stimulate the cells to grow and repair um i don't think there's any you know negative on meditation and so even if it's just helping with sleep it's doing something for the nervous system um let's see we have there was a recent study called n acetoglucosa melatonin by triggering do you see that one yeah so you know how nac is called nak this one's called nag nag um so it was first used in supporting the gut because it helps with with repairing the gut lining so you see a lot of that with leaky gut and other things so yeah i have seen this and i have seen it used in some products i haven't used this exclusively um so i i i can't speak to it from a therapeutic standpoint to say yeah i've had patients who have taken this and have seen improvement it makes sense um it's it's part of a repair repair process um nag was first used as i'm aware as more of the gut healing world and maybe as part of that kind of got picked up as as part of helping to heal the nervous system as well um so uh i think my my only concerns with it would be that it's one of these you know sulfur containing compounds just like nac and so for some people that can really bother their gut um so just making sure that it's not something that's making someone feel worse when they take it um but it's it's definitely possible that it's doing this okay marco we have so many questions to go and i know that um you must have yeah or you're already home so what i would ask is if if the listeners or the viewers were willing to send us their question and i were to forward them to you would you be able to answer them as best you could yeah are you okay and then have maybe to have that on an answer sheet or something yeah exactly so i'm gonna suggest that the email that everyone received with the access in you can simply return that use that email address and send your question in and i'll make sure to get it over to marco and wonderful okay that's great so this was amazing information um i think that's all the time we have for now i really really appreciate you going well beyond the the normal time frame so if you missed any part of this conference it will be replayed on msfocusradio.org and available on demand on our ms focus sound code page or our youtube page remember to follow ms focus on facebook twitter and instagram for times and access information our next teleconference is going to be tuesday september 14th at 3 30 eastern time and that's going to be featuring dr ben thrower who will be discussing vision and ms i can see your thanks to all of our attendees for your participation and especially to marco vespignani who was kind enough to take time out of his busy schedule to share his information with us goodbye everyone and we certainly hope to see you next time thank you thank you so much for having me i really enjoyed it it was a pleasure thank you take care