OBGYN.net Conference CoverageFrom IPPS - Simsbury, Connecticut - April/May, 1999
Dr. Metzger: "I'm Dr. Debra Metzger - I'm Medical Director of the Helena Women's Health in Palo Alto, California, and I'm also course director for this International Pelvic Pain Society meeting. It's my pleasure to be interviewing Dr. Pat Mulready."
Dr. Mulready: "Hi, certainly nice to see you."
Dr. Metzger: "She's a holistic physician and she's a family practitioner who actually helps people regain their health."
Dr. Mulready: "That's a very high compliment, thank you. And one time out of ten it's often true, thank God."
Dr. Metzger: "You just gave a very wonderful talk on the inter-relationships between diet and pain and a lot of the other ills that plague us. Can you give us a summary of what you said because I think it has such a far reaching impact on everything that we do."
Dr. Mulready: "The focus of the talk today was on insulin, and many people are walking around with very high insulin levels and don't know it. Sometimes they have no symptoms, yet other times they're diagnosed with multiple diseases such as: high blood pressure, diabetes, polycystic ovary disease, or maybe a pain condition such as fibromyalgia, arthritis, or something like that. Often times the underlining theme of all of those conditions is high insulin. What I was speaking about today was when a patient comes to you with such a condition or comes to you saying, "I have a history of hypoglycemia" or "I have a history of chronic fatigue," or something like that - to start to think insulin because the way that we typically eat in this country with very high carbohydrates and high saturated fat, it promotes disregulation of insulin. That's really the general gist of what I said."
Dr. Metzger: "Now this has an impact on other things, for example, the immune system and the nervous system. What sorts of things can happen as a result of high insulin levels with poor diet or whatever?"
Dr. Mulready: "A couple of things can happen; one is that when insulin is disregulated it can disregulate the body's ability to handle cholesterol so that we get high cholesterol - that's one way we get high cholesterol. Another thing that happens with insulin is it can cause the inflammatory papillae to become activated, and when the inflammatory papillae become activated - then you have chronic pain that often is not easily diagnosable."
Dr. Metzger: "Can you give some examples?"
Dr. Mulready: "Sometimes the pain is activated by allergies and it's kind of complicated; I hope you follow me with this. You may be taking something in, in terms of food, that you're allergic to or you may be breathing something in that you're allergic to, whether it be pollen or out-gas from chemicals from carpets. What happens is there's certain cells in the body, as you know, called "mast cells" that release a product called "histamine" and histamine activates inflammation. It can do it very locally, such as in a bee sting; or it can be transported up to the brain, and the brain will shift it around and it will go out to another part of the body. So even though you may not have taken in the noxious thing either by breathing or by mouth, you may wind up having the brain shift it over into the musculoskeletan, which is called "fibromyalgia," and that's a very painful inflammatory condition."
Dr. Metzger: "What other sorts of things can be manifested through this histamine release or this systemic release of histamine?"
Dr. Mulready: "Lots of times what happens is people will come to their physician with multiple systems involved that don't seem to make sense. For instance, they'll complain of memory loss and brain fogging up - in particular, when they're in closed buildings. They'll complain of digestive things - bloating, gas, musculoskeletal pain, lots of times asthma. And it looks like the patient has multiple problems or - unfortunate for some patients, particularly women - they get told that they can't possibly have all this stuff, it's all in their head, and therefore, they need to see a psychiatrist to attend to the underlying psychiatric conditions which makes them want to manifest all this illness. I think before any person, particularly women, told they have a psychiatric condition - it's important that the biology of the body be looked at first, and high insulin with it's ability to disregulate so many things is often the underlying theme. One of the things that insulin will do is cause the little energy producers in the cells to not function properly. Scientific studies have shown that the people who have fibromyalgia and chronic pain syndrome get chronic fatigue syndrome; actually these little power houses don't work right and high insulin will contribute to that. So anyone with those conditions needs to really seriously have an insulin test."
Dr. Metzger: "So would going on an appropriate diet cure these people?"
Dr. Mulready: "If it doesn't cure it, it will certainly push them in the right direction for help. The diet is not one that's a real happy diet for Americans unfortunately, because what it requires is to have all the processed foods taken out, all the convenience foods - which as a very fast paced society we like. What that does is it takes out high sugar, high fat, and chemicals - real high offenders. It requires patients to eat healthy modest amounts of protein which is in meat, fish, eggs, things of that sort, preferably grown without anti-biotic hormones. It requires patients to eat modest amounts of carbohydrates, because it's the carbohydrates more than anything that causes the insulin to pour out. So that means eating legumes - which is beans, peas, and all that sort of thing; modest amounts of bread - which may be one to two slices a day with modest amounts of things like rice and other grains of that nature. The starchy vegetables - you have to eat modest amounts of - half of a sweet potato, third of a cup of a white potato, and you can't eat that with the grain because the insulin won't do its job. Lots of vegetables are good, and fats are important but they have to be the right fat. There's a certain kind of fat that comes from eating fish; avoid eating fish everyday if you can, if not, supplement your diet with a tablespoon of flaxseed oil. No saturated fat, no junk fat, no more junk food like potato chips and that sort of thing. Chicken, fish, turkey, and lamb are the best meats to eat; modest amounts of low fat beef or pork would be ok."
Dr. Metzger: "Now you tied all of this in somehow to an overgrowth of candida. Can you go into that a little bit more?"
Dr. Mulready: "Sometimes what happens is a patient will have an allergic reaction to something, for instance, a company will move into a new building where the windows are sealed, there's no fresh air coming in, they've put new carpeting down - which is out-gassing formaldehyde and other dyes. The photocopy machine is there out-gassing products that are used to print things. The cleaning company comes in and uses petroleum based cleaning products, and all of this is recycled because there's very little fresh air coming in - so people are breathing this over and over. There's some people who are very sensitive, and they start to develop breathing problems. They go to their doctor, and the doctor will often think they have a cold or bronchitis or something and treat them with antibiotics. It doesn't get better because it's not a bacterial infection, they go back and get treated again, perhaps a third time with stronger and stronger antibiotics. Unfortunately most physicians and patients don't know that when you take an antibiotic you also kill off healthy bacteria that keep your body healthy, and you don't replace it with acidophilus capsules or tablets which you can get from the health food store. So yeast, which is not killed by antibiotics, is part of our normal body will suddenly start to overgrow, and that creates it's own problems with toxic product release, and people start to have lots of bloating, gas, and inability to digest foods."
Dr. Metzger: "Does that have a relationship with development of food allergies?"
Dr. Mulready: "There's some thinking that as the yeast overgrows - and yeast is a fungus and has little fingers and attaches to the gut wall; the little fingers infiltrate like lichen does on a stone fence - it will begin to crumble the wall so the GI tract is leaky. If partially digested food in any way leaks out, that can create allergies because the body will see it as foreign and will begin to fight. That's one of the theories about how food allergies develop."
Dr. Metzger: "So basically, we have a vicious cycle going on here. Where does it begin, and where do you interrupt the cycle?"
Dr. Mulready: "That's a difficult question. What I look at is what is causing the most concern for the patient, and where do I think the basic intervention to treat somebody superficially may take away the problem at a very superficial level, but it will recur if the basic problem is not resolved. A really thorough history will often give you - where did it start, and is this where we intervene. Diet is always part of it with a patient. We had discussions about that because it's actually life style changes - the diet is vital. You can give anybody all the medications you want, if the diet doesn't change, it keeps feeding the problem. Whether it be a diet that controls the yeast overgrowth, the insulin, or whatever. The diet is basic - anything else is fancy stuff."
Dr. Metzger: "But what happens if a patient goes on this diet, whether it's a low carbohydrate diet to decrease insulin resistance or, for example, a diet that is related to their food allergies? What if they cheat? What if a person on a low-carbohydrate diet cheats and has three Twinkie's or something?"
Dr. Mulready: "Well, it depends how often they cheat and how much they cheat. I have expectations of my patients, around holiday times and birthdays I know they're going to cheat, and that's a given in my mind, and I'll even tell them how to cheat. I will tell them how to cheat at holiday time - this is how you can cheat so that you won't feel too guilty and then you'll blow the whole diet until you see me again - so let's plan what it is you're going to do, enjoy it, and then go back on the diet. They also need to know they're not going to feel as well because the diet is there for a reason, the diet is part of the health building, and if they cheat they're not going to feel as well. The hard part is, if they cheat once and you don't have bad things, then you cheat twice, and before you know it you've cheated multiple times, and then you're sick again."
Dr. Metzger: "Now, someone who has the symptoms of high insulin levels, if they go on a low carbohydrate diet, and they have symptoms of hypoglycemia, chronic fatigue, or fibromyalgia - how quickly can they expect to feel a difference, to feel better?"
Dr. Mulready: "It depends how sick they are. If the high insulin's creating hypoglycemia, learning to eat right and learning to eat frequently - very quickly will start to show. For someone who has candida - overgrowth of yeast - that usually takes longer because it usually involves medicine and exercise and so on; so that is often a longer term thing and that can take a good month before someone will start to feel better."
Dr. Metzger: "What about allergies with candida? Where do they play a role in all of this?
Dr. Mulready: "It's kind of like being allergic almost to yourself with candida; it's a disease that's actually part of you. Some physicians will actually treat it in a neutralizing way as they would pollen, and that helps lots of people. Other people, if they simply stay away from things that feed the overgrowth of it, it will calm it down. People who have chronic illnesses like this need to realize that the diet is a life style change, it's not a temporary fix, but assume if they feel better they're going to go back and eat the old way. It's a life style change and the restrictions become modified, but they never go away."
Dr. Metzger: "Now is it helpful for a patient to feel better on a diet, cheat, and see how bad they can feel if they cheat, and have that serve as positive re-enforcement of the life style change?"
Dr. Mulready: "It usually will happen. Usually it will start out really good, then they'll start to get fed up with the restrictions and they'll say, "Oh, she doesn't know anything anyway." They'll go off the diet, become violently ill, and as one patient said, "I was teachable again. I realized you really did know what you were talking about." And then we talk, and at that point we say, "Do we need to modify it a little bit to make it fit your lifestyle a little bit better?" It's not cookie cutter - the diet is similar but you try to adapt it so it can be a real thing for a person and not be overburdened because that's when people will follow it."
Dr. Metzger: "So what recommendations would you make in someone who is feeling ok, but just in terms of protecting general health, dealing with the usual aches and pains of living, and things like that? What would make the most difference?"
Dr. Mulready: "Diet would and what I would suggest is modifying things. If you're going to eat meat, and if you can afford to - eat meat that is grown outdoors that is not injected with hormones and antibiotics because that affects us as well; eat the lower fat cuts of that. Eat lots of fresh vegetables because those are carbohydrates but they're like free carbohydrates - they're vitamins and minerals that are good for you, and they fill you up a bit. Use caution when using grain, that's very hard on vegetarian patients where a large portion of their diet is grain, that person has to seriously look at - if you have a health problem. If they don't and they feel well - vegetarianism is good for them. If they're not feeling well, if they're gaining weight - you need to check to see if their insulin is not responding well to the grain. Eat the allotted amount of grain, you don't want to take grains out of your diet unless you have to because they provide good fiber and good nutrients. Starchy vegetables are good in moderation. Fat - it's not healthy to eat no fat…"
Dr. Metzger: "Can you repeat that because I think that is so important because as Americans we have really overdone it. We've taken low-fat to mean no fat."
Dr. Mulready: "Right, fats are an essential part of our body; so much of us is made up of fat, every cell in the body needs fat to be healthy, but it has to be the right fat. If it's the fat from eating potato chips, that's a fat that will make you sick because it doesn't allow the cell membranes surrounding every cell to remain healthy, it causes it to start leaking and to not function properly. So that's not the right kind of fat. The right kind of fats are fats from fish, the fats of olive oil; and olive oil is actually the only fat that should be heated because it doesn't turn into the bad fat. Deep fried food is not healthy because it's fried in oil that has converted into bad fat - it's human vegetable oil. Flaxseed oil is good because it has good essential fatty acids that the body needs, a tablespoon a day kept refrigerated is a healthy kind of fat. What we're not talking about is the kind of meat you see that is riddled with fat - not a good fat. Chicken skin - not a good fat."
Dr. Metzger: "What about eggs, cheese, milk, and things like that, that contain saturated fat?"
Dr. Mulready: "It's kind of a battle ground because within every egg are fat multipliers called lecithin multiple eggs are ok if your cholesterol is not off the scale. Healthy food is protein. Milk products are highly allergic foods, for some people they have lots of allergies to milk fail to block this intolerance which are two separate issues. Milk also has sugar in it so people who are very sensitive to sugar probably should avoid the milk, use soy, or use rice in order to supplement the calcium that you're not going to be taking; calcium magnesium supplements is real important, otherwise for women particularly, Prolong."
Dr. Metzger: "I can certainly second everything that you've said about diet and everything because in my practice which is a very different practice - chronic pelvic pain, I found that diet is key, and the low carbohydrate diet, no caffeine, no sugar, and as soon as you say - "no caffeine, no sugar" - "What can I eat?" The patients look at you in horror like what are you trying to do to me, however, they come back within a week or two and they say, "Wow - what a difference." I've had women who had pelvic pain that we treated from a lot of different ways, and we just couldn't get over the hump in terms of relieving it. Those women got significant relief when they were switched to a low carbohydrate diet, so there's a lot here that we're not taking advantage of in treating chronic pelvic pain."
Dr. Mulready: "I think the important thing is to not suddenly take carbohydrates out of your diet, but go to a nutritionist, or physician, or go to a healthcare practitioner who can guide you in what things to do because so many of our patients try to do it at home alone and make things worse by misunderstanding how the body works."
Dr. Metzger: "Or taking things to an extreme."
Dr. Mulready: "Exactly. Once you know how to do it, then your empowered to go home and do it, and then it's your responsibility. But we've learned carefully how to supplement, how to fix your diet to make it healthy for you.
Dr. Metzger: "So how would someone find someone to help them with their diet?"
Dr. Mulready: "That's always a very hard question. If one is looking towards a nutritionist it has to be someone who is open to alternative ways and has been working with what the American Dietetic Association says because they have the food pyramid which does not fit this kind of description. This is a therapeutic diet, this is not a diet that the average public may or may not choose so it's a healthy diet if you choose to follow it as a general healthy person."
Dr. Metzger: "Are there things that patients can read that would help them in understanding this one regulation or polycystic ovarian disease or any of these things that are so inter-related to what you're talking about."
Dr. Mulready: "A really old book and I'm not even sure it's in print, Low Blood Sugar and You by Carlton Fredericks he was an nutritionist back in the 70's that got hooted at a lot. In reality, every other insulin regulating diet I've seen is very similar to his diet with the exception of information on fats has been updated - you can't eat the bacon that he talks about. But his diet essentially is a hypoglycemic diet to regulate sugar which is really in effect a regulating influence. Barry Sears diet is an insulin regulating diet."
Dr. Metzger: "And what book is that?
Dr. Mulready: "His book is The Zone Diet. Some people have complaints about it - modify what he says to fit your life style."
Dr. Metzger: "What about Sugar Busters?"
Dr. Mulready: "Sugar Busters has some good information in it also. So there's books out there, the hard part is to know if that book applies to you, and the hard part is if you take it to a physician who doesn't have any interest in this kind of medicine, you might be "poo-poo'd" out of the office. So the American Academy of Environmental Physicians is a group that has doctors oriented this way. It sounds like a lot of the doctors in the Pelvic Pain Society are oriented this way and you ask around. You start asking around to who is open to this kind of medicine and then you're more likely to be taken seriously when you walk in and say, "I think I have hypoglycemia, I think I have pelvic pain." Because it's very hard on patients to walk in, and come in as an educated lay-person and be told that you really don't know anything, get hold of a psychiatrist or just go home and have a life - very hard, particularly on women."
Dr. Metzger: "You've given us some really important information here that will be of use to not only those who are interested in chronic pelvic pain, but those that are interested in general health."
Dr. Mulready: "Good."
Dr. Metzger: "Pleasure talking to you."