Dr. Victoria Maizes
Hi Andy.

Dr. Andrew Weil
Hi Victoria.

Dr. Victoria Maizes
We have a very interesting guest today is actually one of our fellowship graduates Dr. Akil Palanisamy and his focus is on an autoimmune disease.

Dr. Andrew Weil
Well that's very timely because autoimmune diseases are increasing in our population probably for many reasons. And I think integrative medicine is a very powerful approach to managing it.

Dr. Victoria Maizes
Well, let's hear what he has to say.

Dr. Victoria Maizes
Dr. Akil Palanisamy is an integrative medicine physician, and the department chair for integrative medicine at the Sutter Health Institute for Health and Healing. He is the author of The Tiger Protocol and Integrative Five Step Program to Treat and Heal Your Autoimmunity, and also the Paleovedic Diet, a complete program to burn fat, increase energy and reverse disease.

Welcome, Akil.

Dr. Akil Palanisamy
Thank you so much, Victoria and Andy, Great to be with you.

Dr. Victoria Maizes
Akil, to start with, you designed a protocol to address autoimmunity. Can you briefly describe the T.I.G.E.R protocol?

Dr. Akil Palanisamy
Yes. And the reason I designed this was that I noticed that many of my patients with autoimmune disease were hungry for this kind of information. And in terms of integrative medicine and and also they were often on medications that were powerful immune suppressants with certain side effects and long term risks. And not a lot of attention was given to their diet, lifestyle, stress or other factors.

And so I put together what I found from the research to be five drivers of autoimmunity and other chronic inflammatory diseases into the TIGER acronym. And so that stands for Toxins, infections, gut health eating. So optimal diet and rest, which encompasses sleep and managing stress. So these were the five key factors that I put together in the TIGER protocol.

Dr. Andrew Weil
Do you find that autoimmunity is becoming more common? My impression is that it is.

Dr. Akil Palanisamy
Yes, absolutely. It is one of the fastest growing categories of disease. And I'm increasingly seeing young children as well, where it's growing quite rapidly in pediatrics, as young as like five or six years old in my practice. And yes, it definitely seems to be skyrocketing. So, for example, celiac disease appears to have increased by 500% in the past 50 years. So clearly too rapid for a genetic explanation.

Dr.Andrew Weil
So what do you think are the drivers of this?

Dr. Akil Palanisamy
So I think it's a perfect storm of these five factors, all of which are really becoming more prominent in our environment. So the rise of environmental toxins, rise of infections and drug resistant bacteria and microbes, real significant deteriorate of the gut microbiome in both adults and children. We could talk more about the reasons for that changes in the food supply, changes in our in our diet, and then dramatic increase in stress as well with our modern lifestyle.
So I think it's really a perfect storm of these five factors.

Dr. Andrew Weil
Do you think that COVID is one of the infections that you would call responsible?

Dr. Akil Palanisamy
I do, yeah, because there's early research showing that there may be a slight increase in the risk of autoimmune disease from COVID. There have been case reports of individuals diagnosed with new onset autoimmune diseases right after COVID infection and also with long COVID. Some research thinks it may be an autoimmune component.

Dr. Victoria Maizes
I've been seeing those explanations for a long and certainly one of them is this potential of the activation of autoimmunity. I want to get back to the T, which is toxins. I know that this is something that I focused a lot on in my professional work. Andy has spoken a lot about this, but why is it that toxins trigger an autoimmune reaction?

Dr. Akil Palanisamy
Yes. by toxins, I'm not referring to obvious toxins like cigarette smoke, although smoking is well known to raise the risk of autoimmunity. These are low level chronic exposures over many years and decades, which are really not well-studied. But in the book I review 20 different toxins that have each been individually tied to increased risk of autoimmune disease, things like heavy metals, you know, other industrial compounds, pollutants, PFC PBDEs.

And there's a long list, but a couple of the mechanisms that seem to be involved. One is oxidative stress. So toxins generate higher levels of oxidative stress in the body. And research also shows that patients with autoimmune disease tend to have lower levels of antioxidants in their blood. So I think that's that's one factor. And then second is a component of sthe bystander effect.

Because, for example, with Mercury, it has been shown that it can combine with human cells to create these chimeric cells, which the immune system then recognizes as foreign. And so it attacks those cells. And the bystander effect is where there's a collateral damage to the surrounding tissues as a result of this toxin trigger.

Dr. Victoria Maizes
Wow. I have never thought of myself as a part human part metaphor.

Dr. Akil Palanisamy
Right, Right. Yeah, that's that's right.

Dr. Victoria Maizes
But so what can people do to reduce some of these toxic exposures that are really so ubiquitous in our environment?

Dr. Akil Palanisamy
Yes, I think there's two things I recommend. One is reducing exposure to toxins in multiple ways. And then second is boosting the body's innate detox pathways, because it does have built in multiple mechanisms of detoxification that if we can just support, you know, that can actually have pretty rapid effects. So, for example, one study found that switching to a mostly organic diet led to 80% reduction in urine pesticide levels within seven days.

And another study found that reducing exposure to flame retardants, so clearing dust in the home, which often contains this and then hand-washing because often that's hand-washing before meals. That's another source of it. So that reduced the PDB or flame retardant levels in the body by about 45% in just three days. So I think that reducing exposures can have rapid effects.

And then I also recommend boosting detox pathways.

Dr. Victoria Maizes
I know, but I would say I know that Andy you've had a chance to experience some of the ayurvedic pancha karma, which is the detoxification protocols, which are really, I think, most intensively designed in Aveda compared to maybe any other traditional system in conventional medicine as well. Maybe you could speak a little to your experience and what you think about those for modern use.

Dr. Andrew Weil
Well, I mean, [AUDIO 2 TRADITIONAL METHODS TO DETOXIFY] some of the components of that are steam baths to increase sweating, drinking lots of fluids, to increase urinary excretion. Really eating a very clean diet for a period of time. ayurvedic detoxification also includes massage techniques, which is not very cost effective in this country because often they'll have six people working on you at the same time.

But I think those are the major components. Ayurveda is very focused on accumulation of waste in the body and ways of getting rid gateways of getting rid of it. And I also have found one of the areas that I rate is particularly effective in is treating autoimmunity.

Dr. Akil Palanisamy
Yes, I would agree. And I have found in pre and post testing of some of my patients who have gone through pancha karma, which is the intensive irony that detoxification that there is typically dramatic reduction in toxins across the board, multiple, multiple different types. And I think it's because of the strength of ayurveda that for detox. So I agree.

I think it has a lot to offer in the area of autoimmune disease.

Dr. Andrew Weil
In my experience with autoimmunity, I have always been struck by the prominence of the mind body component and have found mind body methods very effective in managing autoimmunity. Assume that's included under your at the end of TIGER. Is that so?

Dr. Akil Palanisamy
Yes, absolutely. Stress is established to be a trigger for the initial diagnosis of multiple autoimmune diseases and also a driver of flare ups and exacerbations once one does have an autoimmune disease. So it is a really huge factor.

Dr. Victoria Maizes
Andy you have written in some of your books about really interesting beginnings of what we consider autoimmune conditions like rheumatoid arthritis that responded to reduction in stress, But how do you think about the underlying mechanism of what's happening that makes you susceptible? Do we become chimeras in this particular part?

Dr. Andrew Weil
Well, immune phenomena are so response to changes in mental state. You know, the demonstration that hypnotic suggestion can make words fall off. That's an immune mediated phenomenon or prevent blisters from forming and people in trance who were touched with a piece of hot metal. I mean, we've known those things for years and it shows that the immune system is very responsive to interventions at the mental level.

Dr. Victoria Maizes
Yeah. So, Andy, do you have a favorite way that you suggest to people who may have been diagnosed with an autoimmune disease to activate their natural immunity to use this mind body connection?

Dr. Andrew Weil
Well, my favorite technique, which I can't always do, is to introduce a patient to someone who has their condition, who is now well, that can override a lot of medical hexing that they may have been exposed to. And many people don't believe that they can get better. And to see someone that you know has their condition who is now better can be a very powerful way to change that mindset.

Dr. Victoria Maizes
Now, how about you, Akil? What do you do with people around that mind body connection?

Dr. Akil Palanisamy
I give people choices because the studies do show there's multiple ways to effectively reduce stress, to impact autoimmunity favorably. I'm a big fan of meditation. I think there's excellent research on the neuroplasticity effects of meditation, how it boosts both gray matter and white matter, reduces age related atrophy of the brain and promotes beneficial gamma brainwaves and multiple things.

So if a person is open to meditation, I encourage that. But if not, I tell them there's other alternatives like being out in nature or doing psychotherapy, you know, counseling, biofeedback, guided imagery. Journaling, prayer can be a very powerful practice. So I try to find what a person enjoys because that's the key thing. They have to stick with it consistently.

Dr. Andrew Weil
What do you feel is the place of the biologic in treatment of autoimmune disorders? These are such powerful new agents they're very expensive. They certainly have downside to them. I worry that they're often introduced very early before other methods are tried.

Dr. Akil Palanisamy
Yeah, I do share your concerns and I think, you know, these are very powerful immune suppressants and so they carry long term risk of serious infections in some cases increased risk of certain cancers. And yeah, and I agree. I think it's better if there are kind of a second or third line rather than the very first treatment, although increasingly I'm seeing in my patients that they're recommended biologics as a first line therapy, which is yeah, which is unfortunate because there's so much else that can be done in integrative medicine and even in with regular conventional medicine, anti-inflammatories and other things.

So I agree. I think I am concerned about that.

Dr. Victoria Maizes
You mentioned gut health as one of the letters of the acronym, and we are learning so much about the microbiome. How do you think this gut either brain axis or gut immune access? How do you think of it playing a role in autoimmune disease? And again, what can we do to have the healthiest gut possible?

Dr. Akil Palanisamy
Yes, I think that with autoimmune disease there's three main gut microbiome findings that have been associated. First is reduced diversity of the microbiome. So we know that's a good metric for overall robustness. How diverse the microbiome is. Second is dysbiosis, where there's a decline in beneficial bacteria and overgrowth of potential pathogens, which trigger immune activation and inflammation. And then third is increased intestinal permeability, which is also seen as one of the earliest steps in that progression to autoimmune disease.

Dr. Andrew Weil
What do you recommend?

Dr. Akil Palanisamy
Yeah. So I think, you know, there's multiple things that affect the microbiome. I think diet is one of the biggest. So having plenty of plant based fibers boosting the diversity of plants in the diet, including plenty of prebiotic foods that those are foods that feed the keystone species in the microbiome, incorporating fermented foods. There was a study from Stanford showing that six weeks of fermented foods actually boosted the diversity of the microbiome and reduced 19 markers of inflammation in the blood.

So diet, I think, is by far the biggest factor. And then in addition to that, avoiding unnecessary antibiotic use, if it's, you know, essential, that's that's fine. But antibiotics are associated with the loss of diversity and dysbiosis. And then stress also has been shown to have a negative impact on the gut bacteria through this gut brain axis. So I think managing stress does help the gut directly.

Dr. Victoria Maizes
And you are a big fan of spices and some of those spices that come again from the ayurvedic  tradition. Can you talk a little bit about spices and their role in gut health?

Dr. Akil Palanisamy
Yeah, that's another strength of ayurveda there and something valuable it can offer in our modern times, because spices are considered a branch of medicine in all ayurveda. Because not only are they anti-inflammatory and excellent antioxidants, but they actually are antimicrobial because that's how we preserved food for millennia before we had refrigeration was with spices and salt.

And then they also really help with metabolism and blood sugar regulation. So some of my favorite spices in autoimmune conditions are ajwain. So ajwain is a lesser known spice, but it's a very powerful anti-microbial, also has anti-inflammatory properties and it does boost the digestion as well. So ajwain seeds, if you go to an Indian restaurant and you see a little bowl near the cash register with the seeds, usually ajwain seeds are one of those because it helps you after that heavy meal to digest food.

And then you know, everyone knows about turmeric, so maybe no need to mention that. But it's amazing for so many reasons. I think black cumin is very powerful and it's not as well known. It's different from regular cumin, but black cumin, also known as Black seed or Nigella sativa, has really powerful anti-inflammatory effects. In fact, there was a randomized placebo controlled trial in patients with Hashimoto's thyroid disease showing that a month of taking black seed oil actually lowered their antibody levels, improved their thyroid hormone levels. So I think black cumin is another one. I would emphasize.

Dr. Victoria Maizes
Do you have younger patients incorporate these in their food or do you have them take them as supplements?

Dr. Akil Palanisamy
Yes, For most people, I think getting them through foods is effective because so with black cumin, for example, I recommend people put it in a like a peppercorn grinder and just grind it like you would black pepper over dishes. I think with turmeric, it's really best to get it in as many different forms as you can. You know, I think like cumulative lifetime intake of turmeric is probably, you know, an important health factor.

And and then, you know, with a lot of these spices, they're designed for cooking culinary use. So those quantities have measurable effects. So in one study, one eighth of a teaspoon of clove powder actually reduced markers of inflammation in the blood of healthy adults. So that's just a pinch, you know, one eighth of a teaspoon. So for most people, I think just incorporating that in the diet is what I recommend.


Dr. Andrew Weil
How open do you find rheumatologists are to this approach these days? Is that changing?

Dr. Akil Palanisamy
I think it is changing slowly, yeah. So in our medical group, you know, Sutter Health, which is one of the largest medical groups on the West Coast, the rheumatologists actually came to us in integrative medicine and asked if we could do a presentation about some of the things that are helpful and to their, you know, their group. And and they've started to refer more and more patients to us.

So even though they themselves don't use integrative medicine, they're increasingly open to it.

Dr. Andrew Weil
Victoria, we've had a fair number of rheumatologists come through the fellowship is that yeah.

Dr. Victorira Maizes
We've had about 40 and we I'll just say this, if any of our listeners are rheumatologists, we actually have a full scholarship that was awarded by two wonderful donors for rheumatologists to do our Integrative Medicine Fellowship One of the things I think integrative medicine is really good at is interrupting a process early on.

So sometimes we have someone who comes in and they tell a story and you say, Well, they don't have rheumatoid arthritis, but it sounds like they may be moving in that direction or ulcerative colitis or, you know, something else where they don't meet all the criteria, but you sure are worried about them and I think this is a place where integrative medicine can be especially effective at stopping something, reversing something.

Has that been your experience?

Dr. Akil Palanisamy
Yes, absolutely. I think that, you know, in your made that there is a six stage steps pathogenesis for diseases and symptoms only appear in step five out of six. So those first four steps, you know, things are occurring often nonspecific symptoms or are asymptomatic and catching it earlier is beneficial. And with autoimmune disease especially, we know it develops slowly over in some cases ten, 20 or even 30 years.

So for example, with rheumatoid arthritis, a study found that you could detect the rheumatoid factor autoantibody in the blood, in some cases 12 to 14 years before the person was diagnosed with rheumatoid arthritis. So there are a lot of opportunities for early intervention and I think the earlier you can catch them, the more likely it is you'll be able to reverse it.

Dr. Victoria Maizes
so the E is eating well and I know you wrote a whole book about eating well, but one of the things I have heard you speak about a bit is the carnivore diet, which is the latest fad, of course, carnivore, you should only eat meat. And what I heard you say, which I thought was intriguing, was that in some sense it's an extreme form of an elimination diet.

We're not meant to stay on elimination diets, but sometimes there can be benefit. So do you ever recommend the carnivore diet? And if so, what have you found?

Dr. Akil Palanisamy
Yeah, I typically don't because I find that a more moderate approach still works for more people because that is an elimination diet. But there's much less radical elimination diets that still include, you know, healthy plant foods. And I think the challenge with the carnivore diet is you're really not providing any food to the microbiome, you know, because that the bacteria do not feed on animal proteins.

So over time, if you're staying on it for a long time, like months and months, you're slowly starving the microbiome. And we know that has detrimental effects in the long run. So short term, I do believe there's more balanced elimination diets and that's what I recommend it.

Dr. Victoria Maizes
So never a reason to go all the way to Carnivore.

Dr. Akil Palanisamy
Yeah, it's not something I recommend. You know, I do have patients on their own who have tried it and reported remarkable results, which is great. But then I, I try to get them to reintroduce some fibers from plants because that's that's essential.

Dr. Andrew Weil
How about vegan diets or vegetarian diets?

Dr. Akil Palanisamy
Yeah. So with vegan and vegetarian diets, there is research for rheumatoid arthritis showing that in some cases that can be helpful. So in all my patients with RA, I do recommend at least a trial of a vegetarian or vegan diet because for some that can really be a game changer. We have less research for other autoimmune diseases, but I think that if a person ultimately is following a plant forward diet where they're incorporating, you know, plenty of plants as the foundation of the diet, and even if they want to incorporate a little animal protein or stay vegetarian, I think the foundation of the diet is should be based on plants, and that's the key for immune health, I believe.

Dr. Andrew Weil
What about fasting? There have been some dramatic reports of remissions, total remissions of rheumatoid arthritis, for example, that long term fasting, although typically the disease comes back when people start eating again unless they find a way to transition.

Dr. Akil Palanisamy
Yes, exactly. So yeah, fasting and especially intermittent fasting does have evidence of benefit in rheumatoid arthritis and also psoriasis. Patients and some early research in multiple sclerosis as well. That was done with the fasting mimicking diet, which is like a low calorie diet designed to mimic the benefits of fasting. So yeah, I definitely encourage it. You know, reduces inflammation, improves metabolic health, boosts your brain derived neurotrophic factor.

I think there's multiple benefits to fasting.

Dr. Victoria Maizes
I want to again point to your expertise in ayurvedic medicine and ask about the role of doses in your diet. You know, if someone is a pitta, kafa, vatta, what are you exploring different diets for people who have these different constitutions?

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Dr. Akil Palanisamy
Yes, absolutely. Yeah. So I think one of the strengths of irony is it's understanding that everything needs to be customized because no two individuals are the same. And that holds true with the doses which are the three main forces in the body, you know, bottle, appetite and cover. And each person has a unique proportion of those three, which is their body type.

And then there are different dietary recommendations for that. So I definitely include that as one of my lenses in dietary counseling. And also it's very important to eat according to the seasons because that makes a difference. You know, during the summer versus winter, the types of foods that are recommended. So eating locally, eating in tune with the seasons and eating for your body type are all critical.

Dr. Victoria Maizes
What else did you learn during the research for this new book and from your care of patients that you think is important for people to understand when it comes to overview of disease?
Dr. Akil Palanisamy
I think the role of stress is really under-recognized and, and also the effects of early childhood trauma, you know, those stressful experiences, the ACS in adverse childhood experiences, those have been linked to much higher risk of autoimmune disease in adulthood. So a person with two adverse childhood experiences has a 200% higher chance of developing autoimmune disease in adulthood, you know, 30 years later.

And I think it's because of the chronic stress and sympathetic activation of those traumatic events that then persists for decades and contributes to inflammation. So I think in some cases I found with autoimmune patients addressing trauma through practices like EMDR or a good psychotherapies that's trauma focused can really be transformative for their autoimmune condition.

Dr. Victoria Maize
Well, Akil, I just want to thank you for your groundbreaking work in autoimmune disease. And I think it's it's really empowering for people to discover that there are actually maybe a set of things that they can do to either reverse their autoimmune disease or to greatly improve their health so that maybe they just need a very small amount of medication. And I'm not sure that so many people have put this together the way you have. So thank you for your book. And for your work.

Dr. Akil Palanisamy
you're very welcome. And yeah, and I think that it was my goal because, you know, the medications are lifesaving and there's a role for them. So we're not rejecting those. But if we can reduce the dosages by boosting some of the integrative medicine strategies or even reduce the number of medications, maybe bring a person down from three medications down to two, you know, I think that's a value in the long term because of the potential side effects of these drugs.

Dr. Victoria Maizes
thank you so much for being our guest on Body of Wonder. And so glad that you're out there doing this this work with patients.

Dr. Akil Palanisamy
Yeah. Thank you so much. Victoria and Andy. I really enjoyed our conversation today.