Episode Summary:
Natural Medicine is partnering with Western Medicine in 21st-century health care. In this episode, learn about this trend, and how natural products—supplements and herbs—compare to pharmaceuticals, how to know what products are the safest to use, and the current state of knowledge on what supplements do and don’t work for various body systems and issues.
Episode Guest:
Brice Thompson N.D., M.S., Post Doctoral Research Fellow in interdisciplinary Integrative research, University of Washington
During This Episode We Discuss:
- What the supplement industry and supplements claim they can do. Buyer beware.
- Are all natural products equal?
- ‘Organic’ manufacturing requirements.
- USP and NSF labeling gives better reassurance.
- What natural products do and can’t do.
- The role of Naturopathic Physicians (N.D.).
- Common naturopathic products, indications, safety, side effects.
- How naturopathic practitioners can work with your allopathic physician.
- What works for common health issues, sleep, reflux (DGL Licorice for Reflux), cardiac health, bowel regularity, arthritis, sexual health.
- Claims of “Miracle Cure”…. A grain of salt and wisdom.
Quotes (Tweetables):
“The supplement industry doesn’t have any premarket regulation tied to it. When a new drug comes out it has to go through the FDA process. It has to be vetted, it has to be tested for safety and efficacy, it has to do what the manufacturer claims it will do. The opposite is true for any supplement that is marketed.”
Brice Thompson, N.D., M.S.
Recommended Resources:
Episode Transcript:
Dr Richard Pelman (00:07):
Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!
Dr Richard Pelman (01:24):
On this episode of “The Original Guide to Men’s Health,” we will be exploring supplements, nutraceuticals, herbs, and natural products. We’re fortunate to have Dr. Brice Thompson ND MS. Dr. Thompson received his Naturopathic Doctorate and Masters of Science from the national University of Natural Medicine in Portland, Oregon. He is now a post-doctorate research fellow in an interdisciplinary research program between integrative practitioners and researchers, the University of Washington and the National University of Natural Medicine. Dr. Thompson, welcome.
Dr. Brice Thompson ND
Thank you for having me.
Dr Pelman
I think folks are very interested in natural products. Obviously, billions are produced in income from companies that produce supplements. There are some rules about supplements versus FDA approved. And if you want to go into a little background when people hear an ad on TV for a supplement or a natural product versus an FDA approved, what’s the difference there?
Dr. Brice Thompson (02:29):
Yes, that’s a huge difference. And it’s a really important one to understand the supplement industry doesn’t have any pre-market regulation tied with it. For instance, when we get a new drug out, it has to go through the FDA process. It has to be vetted. It has to be tested for safety and efficacy. Is it going to actually do what they claim it’s going to do? And the opposites true for any sort of supplement that’s marketed as a supplement, it’s actually considered a dietary food source, um, to supplement the diet and I’m using air quotes, because that’s the direct quote from the act, which was passed in 1994. So with dietary supplements, since they don’t have to have any pre-market regulation, anything can come out into the market, whether or not it is scientifically valid or not. As long as it was in the food chain before that act was passed in 1994, if it’s not, then they have to go through the FDA process and prove that it’s actually safe.
Speaker 3 (03:32):
Not that it’s effective, just that it’s safe. If they plan on introducing it into the food chain after 1994. So, and then once a product is out on the market, it’s kind of it’s there. The only thing that, that a dietary supplement can’t do is claim any sort of health benefit or disease process, the structure and function claim is the only allowable claim that a dietary supplement can say that it improves, that it’s going to improve structure and function that this supplement is going to improve your heart health. What not, it’s not necessarily going to improve somebody with congestive heart failure. They can’t claim a specific disease process or anything, cause that would be against what a dietary supplement is. That it’s a drug at that.
Dr Richard Pelman (04:24):
So if It just said it will make you have more energy.
Dr. Brice Thompson (04:28):
Yes. Okay. Then that would be fine. The one thing to note is that whatever they claim on the label they are then held liable for, then this is where the FDA and the Federal Trade Commission kind of overlap. So oftentimes supplement makers get in trouble for claiming something on the label that isn’t a pharmaceutical claim, but it actually still doesn’t do what it’s claiming that they do. And that’s actually a Federal Trade Commission violation. That’s false advertising you know.
Dr Richard Pelman (04:58):
So again, going back to a hypothetical, it will give you more energy, will anybody investigate? If there are no clinical trials that are required for outcomes, how would somebody be able to say you’re making false claims and how does that come up?
Dr. Brice Thompson (05:14):
And that’s the really hard part. Most people I find with dietary supplements, they hear about it from word of mouth. They say, “oh, my friend started taking ginseng and they started to improve his energy all of a sudden,” is a common one for instance. And if people really want to critically assess and really want to assess whether or not a dietary supplement would be good for them outside of, because, you know, everybody’s specific advice of go and see your medical practitioner and ask them if this is right for you. Outside of that, you should look on government funded websites as that would be my first stop. So the Office of Dietary Supplements* within the NIH has a good list of what the mechanisms of action are. What research has been done on all of these drugs. And also, if there’s a recent adulterated product that’s been found on the market, they will flag it in their database. They have several databases available that are open to the public and it’s funded by taxpayer dollars. So everyone has access.
Dr Richard Pelman (06:13):
So from our conversation, I assume that a supplement is a natural product. You’re saying it’s unadulterated. So there are one in this supplement and an herb would be one in the same? Or oral medication.
Dr Brice Thomson (06:27):
It’ll fall in that same category. I use the terms interchangeably. When I say a natural product, most people tend to kind of lean on that. It’s an herb of some sort, or some sort of plant ingredient. You get real crazy. You can do like desiccated animal parts at some points. There’s some for like the thyroid, but that’s a medication, but there’s a company out there that I do know that does desiccate adrenal glands. And it does exist. Natural products kind of covers that entire realm. In my book, I’m talking about a dietary supplement. That’s an even broader term that covers most of your non herbs. So your multivitamins and minerals.
Dr Richard Pelman (07:06):
So let’s say we have a company and we take a natural product that we’re going to produce for more energy. We have to produce that in a consumable way. Does the consumer have to be concerned about some of the processing and contaminants that they might be taking in is company A, equal to company B, equal to company C? Who is producing this and how do they find out if there’s some contaminant that could be harmful to them, if it’s imported from somewhere, how do they know what they’re taking? What they’re putting in their body?
Dr Brice Thomson (07:35):
You’ve hit on another big topic, and since there’s no pre-market regulation that happens there’s not a lot of enforcement on manufacturing practices going on. The FDA does require all manufacturers to be testing their product, whether or not that is actually happening. It’s kind of up in the air. There’s so many manufacturers out there. They can’t test everybody all the time, make sure that their product is completely unadulterated. And most of these companies are getting the large shipments from overseas or someplace else. And maybe that one batch was contaminated for some reason, and it wasn’t necessarily the company’s fault, but they’re supposed to catch it. So how does the consumer know the best way that you can protect yourself as a consumer is you look for specific markers on the bottle. If a manufacturer is worth their salt, in my opinion, they have agreed to get two marks or one of the two marks that I associate with good quality that they’ve tested, that the product is what it actually says.
Dr Brice Thomson (08:30):
It is a USP, in the United States, Pharmacopeia Mark. They have to abide by certain manufacturing standards. And then they also have to prove that the product is what it is. And then there’s also an NSF mark kind of like the USDA organic label. You have to follow certain things and to call something organic. The same with these two marks, the USP and the NSF mark, that would be on the label. You have to follow certain manufacturing standards and processes to confirm that they are what they say they are in order to have those marks on your label.
Dr Richard Pelman (09:05):
So USP, NSF, and they are clearly found. And so if you are in a large marketplace their shelf of supplements, you look at the label and you choose the one that has those you’ll be better off?
Dr Brice Thomson
Yes, of course.
Dr Richard Pelman
As you bring the supplement and somebody has a general supplement. I mean, for vitamins, I guess. But then there are more specific supplements right? For conditions, which is why you went to school. So a little background into that. I mean, what do we know that works? And if you wanted to list some conditions specifically that you have recall, go ahead.
Dr Brice Thomson (09:47):
Herbs I think are fascinating. They have a whole host of constituents in them, and they have a long history of use, which is kind of why we use them is because they have been effective, whether or not they’re as effective as an antibiotic or as another pharmaceutical. We throw those all up in the air because a lot of those effectiveness studies have not been done back-to-back, a lot have, and they’ve proven that the pharmaceutical is 9 times out of 10 more effective for treating a certain condition. A lot of consumers that I saw when I was going through school and doing my clinical rounds were concerned about side effects and whether or not it was appropriate to take it. And so the biggest one that I can give an example for was I would get the patient that would come in and say, my doctor just told me that I have type two diabetes and that I need to start taking Metformin.
Dr Brice Thomson (10:35):
“I don’t want to start taking Metformin.” and they were really balking against this whole having to take a pharmaceutical to bring their diabetes under control and they want to know what natural product they can take to bring it back under control. To me, that’s a conversation starter of, well why don’t you want to take the pharmaceutical? Because if you’re using a supplement in the same sense that you would use a pharmaceutical in my mind, then we’re not doing the same thing. You’re treating the supplement as a pharmaceutical and the pharmaceutical has more evidence behind it. Let’s talk about that. If they truly do not want to take the pharmaceutical for whatever value system or they want to try bringing their diet under control beforehand and stuff like that, then, you know, I will work with them to help them bring their diet and everything under control.
Dr Brice Thomson (11:26):
But then if we’re looking at an actual product, we could say something like berberine in place of the Metformin and berberine has a lot of evidence. And in terms of the same mechanism of action as Metformin being an amp K inducer, it’ll lower your blood sugar a little bit. We won’t see as great an effect as we would with Metformin. Typically, if a patient is, you know, there are that pre-diabetes are like just over the cusp of the diabetes, then I’m like, okay. Then if we want to bring diet, lifestyle, everything under control, and then we can try the berberine for a while and see if it all works out for you then. Great. Awesome. and then we don’t have to go to the Metformin route, but then it’s constant monitoring by both the patient and me to make sure that the numbers don’t continue to increase because then their health is at risk. And so we would then say, start talking about more, more rigorous types of treatments such as Metformin.
https://deckerst.medium.com/lets-talk-about-berberine-ampk-and-metformin-1f23b5eea288
Dr Richard Pelman (12:26):
And you bring up something that I think that listeners may not really realize when they go to a naturopath. The naturopath is going to say, “oh don’t take that pharmaceutical. Don’t take that medication.” You’re trained in recognizing disease processes and advising patients who may want to supplement something and say, well, what else can I do to be healthier? But at least in my experience, when I see a referral from a naturopath, it’s not because naturally I said, don’t go down that route. They’re helping the patient with some other therapies, but they’re fully behind what has been prescribed. Cancer treatment in this case, a lot of patients that I see, it’s like, we’ll keep you healthy during your cancer. We’ll try to give you something that will give you some more energy, give you some help, help rebuild your gut bacteria. We will help you with side effects of whatever cancer chemotherapy you’re undergoing, but the message isn’t “don’t do the chemo.”
Dr Brice Thomson
Yeah, of course.
Dr Richard Pelman
So let’s go back to then exploring that relationship of somebody who comes in, who says, I don’t have a primary care doctor, and sees a naturopath as their primary. You’re going to be looking at them stem to stern. Correct?
Dr Brice Thomson (13:41):
Yeah! So if a patient were to come in to me and they said that they wanted to establish primary care with me, and this obviously varies by state, where naturopathic doctors can practice in, in which realm they can practice in. So here in Washington, we can actually be their primary care physician. And as you know, but that comes with a whole host of things that we have to do to make sure, to ensure, that this person is staying healthy. And, you know, we’re constantly monitoring their blood pressure throughout their life. And we’re constantly monitoring their various risk factors that they could develop over their lifetime to prevent disease, because the prevention is worth an ounce of cure. And that’s really our training, it is always like the prevention, the prevention, the prevention. And then when something does happen, we’re gonna jump in, in an integrative setting.
Dr Brice Thomson (14:26):
We’re always trained to be very, very integrative, and that we’re going to bring in as many people as we need to make sure that this person is healthy. And we have our toolbox, which involves, which can sometimes involve pharmaceuticals, but a lot of emphasis on the nutrition and the diet and the, yeah, let’s do some microbiome stuff. Try to make your gut a little bit healthier too, because we know that can influence your health greatly, but going to leave the primary aim of treatments for your cancer to your oncologist. And we’re just going to work side by side. And I’m going to follow the evidence in how this should follow. And our visits are also our visits, whether or not we can go into a whole theoretical debate and philosophical debate, whether or not this is actually feasible for naturopathic physicians to do.
Dr Brice Thomson (15:15):
But typically our visits are longer. They’re at least an hour. We talk about top to bottom. You know, not just the disease process, because the person isn’t just the disease process, but also how are things at home? How are your stress levels? How’s work? Could you have any other random symptoms that have popped up and we’re checking in on everything that we can possibly touch in, because we’d really like to view the person as like the whole being, as most doctors I would argue of any sort would want to do. Most MDs. That’s why they went to school. I would imagine, is to help people. And they would hope to spend more time with their patients 9 times out of 10, but because of the system in way that it’s geared, oftentimes they don’t get that long of a patient relationship. And so we kind of fill in the gaps there as much as we can, and then try to work in an integrative setting as much as we can.
Dr Richard Pelman (16:05):
So are there supplements that you recommend routinely just for general health for people?
Dr Brice Thomson (16:11):
Oh, that is a tough question. You know, there’s that argument of, you know, if you take a multivitamin every day, all you’re doing is making your urine very expensive, right? Because you’re urinating out most of those things. The counter to that argument is that the majority of Americans are following the standard American diet, which we know is deficient in a lot of our vitamins and minerals. And, you know, there’s all this data coming out. That’s showing that the soils are being depleted and the plants don’t longer contain the nutrients that they use to. And then some people, even in an organic setting where they’re supposed to be more micronutrient densely grown. And so it’s an interesting battle that I find myself in. And I was like, “should you take something on a daily basis and spend that money?” It’s very person by person in my opinion, it’s very very person by person. I do stand by that. If you are a relatively healthy adult, then you should be able to get all of your nutritional needs met through your diet.
Dr Richard Pelman (17:14):
So the act that Congress allowed supplements to be advertised also funded the Dietary Guidelines for Americans, which is a great diet book. We have it in a prior episode on diet and one of the authors who’s at the Hutch* and people don’t realize it’s free and it’s done every five years and has great information on diet. So I always like to remind listeners about that because you know, we’re talking about natural products and diet is so important as you said, and in getting basic building blocks. So when patients come in, are some of the common things that they would be looking at, but let’s say sleep health, are there good supplements for sleep health?
*Fred Hutchinson Cancer Research Center
https://www.dietaryguidelines.gov
Dr Brice Thomson (17:56):
Yeah. So the one that I think is the most common, I would think for sleep health would be melatonin, right? And there’s a current debate about what dose of melatonin is appropriate. There was this myth in our community for a while, where we shied away from melatonin for a little bit, because there was a worry that taking a melatonin would suppress your endogenous production of melatonin because your body produces it. Naturally, that’s turned out to not be the case. People have taken high doses of melatonin for a very long period of time and not had any change in their own endogenous production. What I find with melatonin is that it’s really trial by error. You know, there’s this range in which you start prescribing in. And some people respond at a really low dose, like 0.5 milligrams to one milligram, and some people take around three milligrams.
Dr Brice Thomson (18:44):
And that seems to be okay with them. The side effect is just like any sort of treatment that you’re going to have for sleep is going to be, yeah, you might make you drowsy the next day. Right? We can’t deny any treatment has risk, even if it is an actual product, always remember that. And so melatonin may make you drowsy the next day. If you have to bump it up to a certain dosage in order for it to be effective for you. I think it’s all trial by error and by the individual. And you should probably work with a practitioner in assessing whether or not it is working for you. But the baseline, the basics, we always have to go back to the basics because of supplements, not going to answer all your problems, go back to the basics of: is your sleeping environment conducive.
Dr Brice Thomson (19:27):
Let’s make it as, as happy and healthy as it possibly can be. Is your room dark? Is there less disturbances throughout the night? Is it relatively colder to the rest of the house? Do you have your cell phone in bed with you? We all know that we’re not supposed to be scrolling through the New York Times right before we go to sleep for so many reasons, but light being one of them, the other is reading the news causes your heart rate to go up. I guarantee it.
Dr Pelman
But are you doing the basic things first?
Dr Brice Thomson
Yes, we can add a supplement or even a pharmaceutical on top of those things. If we really have to, let’s build the bottom, let’s build the foundation first and then let’s add things as we need.
Dr Richard Pelman (20:03):
Let’s talk about seasonal allergies, you know go get a beekeeper, honey, Pollen. What happens when somebody comes in and say, I have horrible seasonal allergies?
Dr Brice Thomson (20:14):
Yeah. The beekeeper pollen treatment for seasonal allergies. I have never used that one personally on a patient before. The theory behind it is that what you’re doing is you’re taking all of the antigens, that your body’s going to be reacting against to give you the allergies, right. And you’re putting in a concentrated syrup, and then you’re taking it orally. When you’re doing that. When you take something orally, we’re trying to shift that immune response into much more of a tolerance level, for someone who has seasonal allergies, they tend to be more in that IgE histamine type of reaction. And if we can actually get the body to switch to an IgA mediated reaction, which is what’s happening when you’re taking something orally, your body’s like, Hey, food’s good for me. I don’t really necessarily want to have an allergic reaction to it.
Dr Brice Thomson (21:08):
If we can get it to switch over to an IgA, that’s not reactive, that’s just protective, but it’s not reactive and you won’t get the allergies. So that’s kind of the theory is that we’re trying to class switch some of those, that immune response over to a much more of a tolerance level, same theory that with allergy shots. So that’s why we moved to an allergy shot. Like if you have a really anaphylactic shock against peanuts, someone will go in, and they’ll get allergy shots for an extended period of time. And they’re giving you a very small, small, small micro doses of peanut antigen to kind of trick your body into saying, “oh, this is something that’s just kind of around. And it’s not something I needed to waste energy” having a reaction against” kind of the same theory. I would not suggest that you do this with anything else, but seasonal allergies that tends to be the road that some people will go down.
Dr Pelman
What do you use for seasonal allergies?
Dr Brice Thomson (21:53):
I use a product called quercetin*, it’s an enzyme that’s found in the pineapple family. And it has a mechanism that they go back and forth on. At first, it was something like “it breaks down histamine”, but now it’s coming out like “Hey, actually it might be blocking the histamine receptor a little bit.” So that’s kind of the one that I tend to go for. The kicker with that guy is that it doesn’t work too much once You’ve started your seasonal allergy season. It doesn’t really help you too much. It kind of has to build up in your system over time. And by the time it’s gotten to an appropriate level and the cells have all turned over and everything, then you’re already out of your allergy season anyways. And so I tend to use it in “prep”. If I know that someone’s going to use it and is going to have a really bad allergy season, I would start early, like a month or two ahead of time. And then when they’re in it, they take just the same dose. And then they stop once their season is over.
*Quercetin is one of the important bioflavonoids present in more than twenty plants material and which is known for its anti-inflammatory, antihypertensive, vasodilator effects, antiobesity, antihypercholesterolemic and antiatherosclerotic activities.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214562/
*Bromelain is a complex mixture of protease also extracted from the fruit or stem of the pineapple plant. Although the complete molecular mechanism of action of bromelain has not been completely identified, bromelain gained universal acceptability as a phytotherapeutic agent due to its history of safe use and lack of side effects. Bromelain is widely administered for its well-recognized properties, such as its anti-inflammatory, antithrombotic and fibrinolytic affects, anticancer activity and immunomodulatory effects, in addition to being a wound healing and circulatory improvement agent.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998156/
Dr Richard Pelman (22:54):
And that’s called, again, quercetin, and it’s found in pineapple
Dr Brice Thomson (22:57):
Yeah. It can be found in some of your natural food sections. You can also find it online relatively easy. You want to spell it for people? Yeah. So of course, the is spelled Q U E R C E T I N.
Dr Richard Pelman (23:12):
And if they went to a natural or natural product store, would they find it packaged or something?
Dr Brice Thomson (23:19):
Yeah, they should find it packaged. Another one that people will use in the same sense is nettle. In the old traditional herbal medicine that was the one where they’d steep the nettle leaves, and then they’d drink a nettle tea for a while.
Dr Pelman
So nettles is…,
Dr Brice Thomson
Nettles are back in the old, old school. Traditional herbalists use nettles steeped in tea and has been used as a fortifying agent and also as an anti-allergy agent. I find that to be effective if you’re a heavy tea drinker. In order, for most things, if you have to drink it in tea form, you have to drink a lot of tea. Then you have to take it several times throughout the day. So if you’re a heavy tea drinker, like your hot drinks, then Hey, maybe that will work for you. But I find that most people don’t want to drag around a bag of nettles with them all day and be steeping tea, you know, four times.
Dr Richard Pelman (24:12):
In a patient who comes in with, you know, I have reflux and suggest a digestive that a naturopath might look at.
Dr Brice Thomson (24:20):
Yeah. Well, we would definitely tell them the same thing that an MD would when it came to their digestion. GERD, refluxes are due to in a large part, diet. And given that we’ve ruled out everything else that could be more serious, like H pylori infection or an ulcer. But if you just have the basic reflux after you eat a lot of tomatoes and pizza, you know that the acronym that we would use in a school is “cut out the crap,” which is cut out coffee, cut out your refined grains and your processed foods. Those tend to be your big offenders when it comes to the GERD picture. If somebody is still doing all the things with the diet, or they can’t do anything. Cause there’s a lot of people they have minimal control over their diet due to whatever constraint.
Dr Brice Thomson (25:11):
Then they could add a supplement in there to potentially help with things. And so we’ll do things like digestive bitters before eating to kind of get the digestive process kind of up and roaring before we put food in there. I Find that that actually tends to help. I’m a little confused as to how that tends to help. My personal theory is that it just preps the body and it’s like, “Hey, we’re going to have some food here soon.” And it’s instead of a real abrupt response, when somebody eats food, they’re ready for it. Bitters is one that a naturopathic doctor might use. Another one that has a really good amount of effectiveness for me that I’ve found is the licorice. Um, they’ll use a deglycyrrhizinated form of licorice, which means they’ve removed the toxic compound out of it.
*https://www.healthline.com/health/digestive-health/dgl-for-acid-reflux#benefits
Dr Brice Thomson (25:55):
Um, that can be kind of toxic at high doses. And you want to look for that called DGL or deglycyrrhizinated licorice, and they put it in a capsule and then you take it and it kind of coats your stomach adds a little bit of a coating to it and kind of calms the stomach down. Another one that we would use is marshmallow root, same effect. That one is more fun to give to patients because we tend to do it in a powder form and say, you know, mix it in your drink. And then, if you sit there and watch it, it’ll turn into like almost gelatinous type of stuff for the patient, and then they have to throw it down. And the concept is that it’s coating on its way down. I find that to also be really effective at protecting the gut lining.
Dr Richard Pelman (26:42):
And of course everybody’s interested in improving their mental function and memory, anything that’s legitimate at this point.
Dr Brice Thomson (26:50):
I mean, the biggest bang for your buck is diet and exercise, man. And that’s just what they’ve always said, if we could put exercise in a pill we’d cure so many things that all of us are effected with. And so, exercise, you know, not only does it increase your cardiovascular outcomes, but you could get that surge in BDNF, * which is like basically miracle grow for your brain. That’s produced in your gut, and it actually does cross the blood-brain barrier. If you eat a diet heavy in a fiber, like with vegetables and stuff, then you’re going to produce a lot more butyrate from your colon and butyrate is also very good for your brain cells to have, and that does also cross the blood brain barrier. So you know, the diet and exercise thing, it can’t be minimized at all in terms of taking a supplement to hell. Outside of people that are, you know, oh my mood’s a little bit off or type thing.
*Brain Derived Neurotrophic Factor (BDNF) is a key molecule involved in plastic changes related to learning and memory. Some interventions like exercise or antidepressant administration enhance the expression of BDNF in normal and pathological conditions. It has been proposed that although BDNF may not be a valid biomarker for neurodegenerative/neuropsychiatric diseases because of its dysregulation common to many pathological conditions, it could be thought of as a marker that specifically relates to the occurrence and/or progression of the mnemonic symptoms (memory related) that are common to many pathological conditions.
https://www.frontiersin.org/articles/10.3389/fncel.2019.00363/full
Dr Brice Thomson (27:51):
And they were describing more of a mood problem. But if they’re like just wanting to improve their memory and be their top selves, no, there’s, there’s not much evidence out there for increasing memory and stuff. There’s a little bit, if you look at the meta-analysis for omega-threes, there’s just that effect sizes just across the line, as far as it having an effect, but it’s very small. And if you have a diet that is, you know, relatively high in omega 3, so if you eat fish more than once a week and you have a lot of flax, a lot of chia seeds, things that are really high in omega threes, then you’re probably gonna not see much of a benefit with those.
Dr Richard Pelman (28:36):
And jumping back to bowel regularity, I tell patients about all bran buds used to be 51% fiber. I think now they changed the label. It’s 47% of your daily fiber and flax seed meal, either the meal, or just get the seeds and flax seeds themselves and grind them depending on if you want to buy a grinder and just grind them pretty good for regularity.
Dr Brice Thomson (29:00):
Oh, of course, they’re great for regularity. And for all of those, like drink plenty of water when you do take them because they can work in the opposite direction if you’re not. And, you know fiber is fantastic. Can’t minimize fibers in the importance for bowel movements at all. it’s fantastic. Another one, off the top of my head, I would just, focus on that regularity piece. If you’re having problems with having a more than if you’re having too many bowel movements in a day, if you feel like you have too many bowel movements, then let’s try looking at some of the foods that may be irritating, your bowel that may be causing a little bit of an issue if we’re looking at the constipation and things. And first let’s look at hydration, let’s make sure we’re drinking plenty of fluids throughout the, and then let’s also start looking at things like the fiber. Let’s start looking at maybe a little bit of magnesium in there, because it also has an effect, assuming that there’s no other reason not to use magnesium, you know, it could have a little bit of a bowel movement effect in different forms of magnesium can have more or less of an effect. But yeah, just fiber, fiber, fiber, and fiber.
Dr Richard Pelman (30:13):
So then the patient comes in and says, I’m pretty arthritic and hard moving around. What’s your go-to supplement for helping people with joints?
Dr Brice Thomson (30:23):
Yeah. By the time that patient has found their way into coming in and seeing me, they’ve ‘ve probably tried glucosamine, which would be the one that most people would reach for. The glucosamine data is a little mixed, there’s some studies that have shown effectiveness, but it is really tiny. And then there’s some in bigger studies that has shown effectiveness and it’s also really tiny. And so it tends not to lean the effect side a little bit farther on that positive end, but there’s a lot of studies that have shown that it’s not effective for the joint complaint area. And I honestly think it depends on the known disease process, what’s happening. Are we looking at our rheumatoid arthritis, which is obviously much more advanced or are we talking about just plain osteoarthritis that happens when we start getting a little bit older or is it because this person’s joint has had severe damage throughout its life and it’s just breaking down faster than the rest??
*Rheumatoid arthritis is an autoimmune condition wherein your body’s immune system attacks your joints connective tissue leading to inflammation and joint degradation. Certain supplements like glucosamine which are purported to act as building blocks to strengthen this tissue are handicapped by this disease process. As what is built is soon destroyed by the body. Osteoarthritis, as implied is a more general degradation of cartilage and connective tissue within the joints over time due to wear and tear in conjunction with the body’s reduction in capacity for repair that comes with age.
https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html
https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
Dr Brice Thomson (31:19):
And so I think when a patient comes in to me, they’ve usually already reached for the glucosamine and they’ve found that it’s not effective and they’re looking for something else. And so they, if we’re going to add another one in there, then I would go for most of your anti-inflammatories would probably be the ones that I would go for, just for minimizing that inflammatory reaction as much as possible. And the one off the top of my head, I think is Boswellia. Boswellia has an anti-inflammatory, kind of your same one that inhibits COX pathway as well, a little bit more benign than a typical NSAID* would be due to its poor bioavailability, but it tends to act more like Aleve is what I tell people, because it tends to work better for musculoskeletal complaints as opposed to like your Tylenol does for it.
https://www.healthline.com/health/boswellia
https://www.webmd.com/vitamins/ai/ingredientmono-63/indian-frankincense
*NSAIDs — or nonsteroidal anti-inflammatory drugs — are among the most common pain relief medicines in the world. When you get injured — say with a sprain — the damaged tissue releases chemicals called prostaglandins, which are like hormones. These prostaglandins cause the tissue to swell. They also amplify the electrical signal coming from the nerves. Basically, they increase the pain you feel. NSAIDs work by reducing the production of prostaglandins. They block the effects of special enzymes — specifically Cox-1 and Cox-2 enzymes. These enzymes play a key role in making prostaglandins. By blocking the Cox enzymes, NSAIDs stop your body from making as many prostaglandins as possible. This means less swelling and less pain. Commons NSAIDS include Ibuprofen, Naproxen Sodium, and Aspirin.
Dr Brice Thomson (32:10):
So, yeah, that’s kind of my go-to for that, but arthritis you hit the hard one. That one’s just… hard. Like, you’ve done damage and now we’re just trying to minimize it as much as possible. Again, hydration, if that joint doesn’t have enough fluids in it then it’s obviously gonna cause more pain. And so I would almost always emphasize hydrating and making sure that you’re hydrated throughout the day. It’s a vascular tissue it’s going to take just making sure that your urine is on the brighter end. Once a day is not necessarily enough because it’s an avascular tissue. It needs a constant positive hydration status in order to really, in my opinion, in order to really like soak up as much hydration as possible.
Dr Pelman (32:55):
In cardiovascular health. I know that citrulline ends up going down the nitric oxide pathway and that is available as a supplement. Do you have thoughts about what people might take, who have some underlying disease, say they’re being treated for their coronary disease or peripheral vascular disease, or they want to maintain better erections later in life and they have some elevated cholesterol and lipids issues and say, what else can I do to get better blood flow through?
Dr Brice Thomson (33:23):
Yeah. So for your like ED kind of route, there’s a couple that we can go down. And the funny thing is, there’s pharmaceuticals for all of these because the mechanisms are not new. But if somebody wants something that’s a little bit poor in the bioavailability status, they want to try something that it’s probably going to have a little bit more of a withdrawn effect. And maybe it won’t have like a side effect that they’re associating with it. You can go horny goat weed, which is the common name. And I find that funny that that’s an aphrodisiac type of agent, but it has a compound in it called Icariin. It will bind to your alpha one and two receptors entering a receptors in your brain and will kind of inhibit your those receptors inhibit erections. *
UPDATE*
*https://www.healthline.com/health/erectile-dysfunction/horny-goat-weed#_noHeaderPrefixedContent
*The science is still out on how Icariin, the main bioactive of interest in Horny Goat Weed, works, the primary action is believed to be PDE5 inhibition like erectile dysfunction meds such as Sildenafil, but it has shown activity in other pathways as well.
Dr Brice Thomson (34:14):
So then you’re more likely to be able to have an erection if you’re taking something like that, then there’s yohimbe*, that’s an African bark that someone might take. And that one, it’s active constituents are also on the nitric oxide kind of level.* It’s supposed to have more of that dilating effect on your smooth muscular tissue. And so you’re going to be able to hold and maintain an erection. As far as other things, like from a naturopathic perspective, we would be like, do you have diabetes? Do you have peripheral vascular disease for specifically an ED issue? Because we all know those small little veins are very delicate.
*Yohimbe is believed to predominantly exert its effects by antagonizing alpha 2 adrenergic receptors, however it effects many other pathways as well. It may indirectly promote the generation of nitric oxide by receptors called alpha 1 adrenergic receptors, but it does regardless cause vasodilation in erectile arteries.
Dr Pelman (34:54):
The arteries are smaller than coronaries.
Dr Brice Thomson (34:57):
Arteries, sorry.
Dr Pelman (34:58):
No, no, Correct. Most of it though is Vein occlusive issues because the little spaces that fill with blood are aligned just like you’re inside of an artery, and if they don’t stretch out, they don’t include the outflow. So it all has to do with intake, in and out, and sort of the ability to keep your cardiovascular system healthy, leads to better quality erections.
Speaker 3 (35:19):
So some people for heart health, a lot of people, will take CoQ10*. That one….as far as improving cardiovascular outcomes. Not really. Someone will supplement it when they’re taking a statin, because statins inhibit your endogenous production of Coq10, which is an important to us as an antioxidant and also a part of the electron transport chain. And so that’s why you can sometimes with the statin therapies, get those myalgias. And that’s the theorized mechanism is that you’re just not making enough CoQ10. And that’s why you end up with those myalgias sometimes. And so then CoQ10, you can supplement orally. It’s pretty bioavailable. I Haven’t seen any data of using it to treat somebody who has myalgias with a statin therapy. I’ve seen people worried about it, and then they take the CoQ10 to prevent potential any interaction with the statin therapy, but it’s a very good antioxidant as well. So it’s going to protect your mitochondria and it lives in those lipid membranes of your cells. And so it’s one of those few that lives in those membrane areas. And so that’s a really good, good place for an antioxidant to prevent damage.
*Only a few studies have looked at whether CoQ10 might help prevent heart disease, and their results are inconclusive. Research on the effects of CoQ10 in heart failure is also inconclusive. However, there is evidence that CoQ10 may reduce the risk of some complications of heart surgery.
* Although results of individual studies have varied, the overall scientific evidence does not support the idea that CoQ10 can reduce muscle pain caused by the cholesterol-lowering drugs known as statins.
Coenzyme Q10 | NCCIH (nih.gov)
Dr Pelman (36:33):
Yeah. And then with my specialty in men’s health, we look at BPH and now we’re moving on to the urinary system. Somebody comes to you with trouble voiding, and you think they have some prostate enlargement symptoms, benign prostatic enlargement. And so “I don’t really want to take any of those actual medications, but I picked up this supplement,” or “I heard this supplement on TV.” What do you tell them?
Dr Brice Thomson (37:02):
It might help. The funny thing is that most of your supplements out there to treat BPH are herbs that are doing the same thing that a medication would, the five alpha reductase inhibitors*, right? And so any of your herbs that are going to be doing that are going to be doing the same thing as you as a medication. If you just started having BPH and you’re really medication wary, I would say, maybe give it a shot. Let’s see if it works. Problem is, is that those guys are not really bioavailable. So the concentration of the active and constituents in those herbs don’t really get too high. But then maybe it’ll work. I have seen it work for some people. If you have a really established BPH and you want to come off of a five alpha reductase inhibitor, I’ve never seen that to be successful. I’ve never seen somebody able to reduce either reduce their dose or come off of it, um, with any of the herbs. But then again, my clinical experience, I’m relatively new in the field. So my clinical experience has minimal. I’m sure there are some doctors out there that have been able to.
Discovery of Natural Steroid 5 Alpha-Reductase Inhibitors – PubMed (nih.gov)
*The enzyme 5 alpha-reductase catalyses the reduction of testosterone into the more potent androgen dihydrotestosterone (DHT). The abnormal production of DHT is associated with pathologies of the main target organs of this hormone: the prostate and the skin. Benign prostatic hyperplasia (BPH), prostate cancer, acne, androgenetic alopecia in men, and hirsutism in women appear related to excess DHT production.
Dr Pelman (38:08):
You know, patients come in with the prostate supplement, they all have Saw Palmetto. * In our studies that we’ve looked at, the Saw Palmetto, it did not outperform a placebo. But I always tell patients, look, as long as you’re not taking it to prevent prostate cancer, because there’s no data that says it does that, and you’re not taking it to really prevent prostate growth. Cause we can’t absolutely say that, but just symptom-wise if you feel great and you want to spend the money, I don’t see any problem with it. One of the herbs that does seem to have some actual potency against placebo was Pygeum Africanum,* and it’s usually in the supplement industry distribution, not in high enough dosages to really be effective They actually would have to just go get Pygeum by itself.
*Twenty years ago, the urologic community was encouraged by trial results that suggested phytotherapy could effectively treat symptomatic benign prostatic hyperplasia. Since that time, several well-constructed studies have consistently demonstrated that these agents are no more efficacious than placebo, despite being largely safe for ingestion.
Phytotherapy for Benign Prostatic Hyperplasia – PubMed (nih.gov)
*The older literature on P. Africanum for the treatment of benign prostatic hyperplasia is limited by the short duration of studies and the variability in study design, the use of phytotherapeutic preparations, and the types of reported outcomes. However, the evidence suggested that P. africanum modestly, but significantly, improved urologic symptoms and flow measures. Further research was conducted using standardized preparations of P. africanum to determine its long-term effectiveness and ability to prevent complications associated with benign prostatic hyperplasia and was not found to be concretely superior to placebo.
*Pygeum africanum for benign prostatic hyperplasia – PubMed (nih.gov)
Dr Brice Thomson (38:56):
Yeah. That’s, that’s one thing to really make sure when taking any supplement is a supplement bottle will come with the suggested dosage, but it would behoove you to look up online to see what an actual dosage would be like. Because oftentimes it’s not high enough. And there’s two reasons behind that. One is that the supplement industry is trying to cover their backs. And so they’ll lower the dose so there’s less likelihood that there’s potentially going to be a problem or a symptom that occurs due to taking their supplement. And then to the puddle lasts, uh, lake can put less in there, uh, right. Uh, and then, then you can, then they don’t spend as much money making this supplement as they would, but there are some good supplement companies out there that have correct dosages.
Dr Pelman (39:41):
What do you see as problematic supplements? You know, what could be harmful
Dr Brice Thomson (39:49):
As far as broad categories of supplements go, anything that talks about men’s health is a perfect example. Honestly, because this is a huge, huge problem in the men’s health world, like anything that’s gonna increase your libido and make you the most amazing, constantly turned-on person on the face of the planet. No, it’s probably fake if it’s a new supplement that’s been out there for a while. I always try to vet that one out and be really, really cautious towards going into a new brand or a new supplement that hasn’t been on the market before, because a lot of these supplement from lots of the supplement companies, they’ll get shut down and then they open up under a new name just to move the product off of their shelves so that they can make their money back whether or not it’s actually what it is.
*Editor’s Opinion: There is no magic pill that will reliably raise a man’s testosterone. Not truly, small changes may in fact be possible, but a man’s testosterone levels fluctuate over the course of a twenty-four-hour period anyway, and rather substantially. And fluctuates day to day at that as well. Essentially nothing has really been shown to reliably raise testosterone in men that can’t be attributed to these natural fluctuations. The best things you can do are eat healthy, get enough sleep, exercise, avoid drugs by and large, and take care of your mental health. It is possible that taking a vitamin or mineral you’re severely deficient in like zinc or magnesium could increase your testosterone levels, but that’s fixing a deficiency. If you’re doing everything else right, that’s pretty much the long and the short of it. For now.
Dr Brice Thomson (40:33):
So anything new, watch out for anything that’s going to “help you gain muscle and gain mass.” Yeah, no, probably not. And also, just look at everything with the critical eye. I’m a big fan of asking myself when I go into a supplement store and being like, “man, if I’m hoping that this is going to be the miracle cure for me, don’t I also think that if the miracle cure it exists, that it would all be out and available for people as the miracle cure?” A lot of these herbs and supplements that are on the market. They’ve been on the market for a really, really long time. And if they actually did cure or make things amazing for an individual or for a group of people suffering from something it would be well-known and well-established and it’s. And in a lot of the cases, it’s not what these supplements and advertisements claim that they’re doing. Weight loss is another one. You know, if there was a magic here for weight loss out there, the fad diets, or we’d go from left to right on whether or not which one is going to be the best. You have your “macro counting” and then you’ve got your “ketogenic.” And then you’ve got back over here to your “Atkins diet.” And you know, some of them have some efficacy behind them, but just be really, really cautious in how you approach these things and also be very, very critically aware.
*Macro counting/IIFYM
IIFYM stands for (if it fits your macros) which basically means that you can eat ANYTHING you want as long as it fits into your daily calorie requirements and daily macronutrient split of protein, carbohydrates and fats. IIFYM explained in a nutshell means if you eat oats and brown rice as opposed to bread and donuts for your choice of carbohydrates, it will have no difference at all on improving body composition. As long as your calorie intake is equal and macronutrient targets are met, eating a donut or a pizza will not automatically make you ‘fat’, The gist of “what is IIFYM” is that gaining body fat is not about the types of foods you consume, rather the excess calories you are consuming.
A more common, and likely much healthier, philosophy of IIFYM is it does not mean you can eat however much of whatever you want. It means you can maintain your sanity by eating like a regular human being from time to time. Just using common sense and keep it all in moderation, someone should always base their diet mostly around good healthy nutritious foods (which the IIFYM principle still applies to). This will help people get in their micronutrients such as fiber, omega’s vitamins and minerals as these are still important and should not be ignored!
*Atkins Diet
The basics: A four-phase plan, the diet starts out severely restricting carb consumption and gradually increases the amount allowed.
Positives: Stresses nutrient-rich foods. Has shown effectiveness for weight loss. The original plan from Dr. Atkins’ New Diet Revolution by Dr. Robert Atkins has been updated to offer variations that meet individual needs and preferences.
Drawbacks: Requires tracking carbs. Fairly restrictive, especially in the first phases.
*Keto Diet
The basics: High fat, moderate protein, very low carb
Positives: The keto diet eliminates processed, empty-calorie staples like white breads, white rice and sugary drinks. Many followers experience fast weight loss, without having to give up favorite foods like bacon and butter.
Drawbacks and concerns: It eliminates many nutritious fruits and vegetables with a high carb count. Eating too much fat or too much protein can have an adverse effect on overall health.
The list of foods you can eat on keto is limited and following the diet requires meticulously tracking every bite to keep to a 5% carb/10% protein/75% fat ratio for weight loss or maintenance. Though keto advocates often credit this way of eating with increasing their energy, many find that the lack of carbs leads to fatigue, especially in the first weeks of transitioning to the diet.
The Latest Diets and Diet Plan Reviews (webmd.com)
Dr Pelman (41:51):
So if someone who comes to you and a man who says, “I think I have low testosterone,” when they come to us, there’s very standard protocols for evaluation because it’s multifactorial, right? So many, you can have 10 guys come in with the same symptoms and there may be 10 different reasons for it. And it isn’t all low testosterone. Yeah. But if somebody is really just interested in supplements, what does DHEA do? How does that work? Does it work?
Dr Brice Thomson (42:20):
In terms of testosterone? Supplementation? I would say it’s mixed in my experience with it. So DHEA, it’s that precursor to building those hormones, your testosterone being the one of interest that most guys end up taking DHEA for. The problem with the DHEA supplementation is that hormone metabolism is so balanced, right? And if you take a bunch of DHEA, you’re gonna raise a bunch of these other hormones as well, because DHEA is also a precursor for them, and your body likes to have things balanced. And so it’s going to shift your metabolism of these hormones around to keep that balance. And yes, your testosterone levels may go up, but so will some of your other hormones that you’re maybe not as interested in raising? I find that if it works for people, it works, and it works very clearly.
Dr Brice Thomson (43:15):
It’s not this “ambiguous zone” that we find ourselves in. But if we’re talking with somebody who you may have clinical symptoms and they have low tests and they’ve been tested and everything else has been ruled out as to why they have clinical symptoms, anything can be low testosterone nowadays. It seems like. And so when you go through the same testing procedure to make sure that it’s not due to any XYZ disease and you reach the final conclusion of, yes, it is low testosterone and we can supplement your testosterone levels if you are at that point of supplementation, DHEA is not okay.
Dt Pelman (43:50):
Then if we looked at a population who looks at these ads, they may have trouble evaluating, maybe they doesn’t have the expertise to go to the online resources, which we’ll talk about in a moment, but that’s certainly why there’s naturopaths and the expertise of naturopathic programs is in helping people and guide them through if they really want to go through the natural product pathway or in addition to what they’re taking. There’s good guidance. How does somebody find a naturopath besides the yellow pages?
Dr Brice Thomson (44:25):
That’s a good question. And there’s a, there’s a little bit of confusion. So there’s what we call lay naturopath. And then there’s the naturopathic doctors. And you want to make sure that the naturopathic doctor that you’re going to go and see is one that went to one of the four-year doctorate programs, not an online or even like a two-year certificate program, which those do exist. Those individuals do practice in states where my degree is not licensable. And they also practice in states where it is licensable, but they can’t use specific verbiage and names and stuff. So if you’re trying to find an actual certified naturopathic doctor that went to a four year medical program to assess the literature and look at things that are effective and work in an integrative setting, you can reach out to the state association for naturopathic doctors. They are usually very active and keep tabs on most of the naturopathic physicians that are in their state. So if you just type in State Association of Naturopathic Doctors into Google, you’ll find usually whatever state you’re in, a state association, and then also there’s the American Association of Naturopathic Physicians. They have a find an ND tab. If you just click our button, if you just click the button, then everyone that’s enrolled in the AANP will be available to you to look up and oftentimes their specialties and what their expertise are.
American Association of Naturopathic Physicians
Dr Pelman (45:47):
Then if we want to revisit online resources, somebody who’s more interested in finding out if the supplements they’re currently taking are useful. Where do you send people to?
Dr Brice Thomson (45:57):
Resources? If you know, most people are familiar with WebMD for better or worse. But that’s a good one for getting a very broad picture of what your supplement could or could not be. And what is the actual effectiveness when it’s held to like certain standard for like the pharmaceutical industry is held to which I believe supplements should be held to, but if you’re looking for more like of your mechanism and what are the individual studies and stuff I would always point somebody towards The Office of Dietary Supplements Website, for medical practitioners there’s the Natural Medicines database that exists. That one is really good. It has a drug herb interaction checker. It’s very conservative in its assessing of the literature and assessing whether or not a drug and an herb will potentially interact with one another, which I really appreciate. And that would probably be my first go-to. For the consumer, go to The Office of Dietary Supplements. If they want to look up what their individual supplements are all about, there’ll be just so many resources that they could read forever.
Office of Dietary Supplements (ODS) (nih.gov)
Welcome to the Natural Medicines Research Collaboration (therapeuticresearch.com)
Dr Pelman (47:06):
Yeah. And then I’m going to wrap up by asking you, what advice would you give to patients who are going to have surgery as far as supplements, they need to make certain that are doctors aware of and perhaps stop prior to surgery that could increase a propensity for bleeding. There’s a lot of people who are aware of aspirin, certainly if they’re on blood thinners, but they forgot to put down supplements.
Dr Brice Thomson (47:27):
Yeah. The big one is their omega three’s. They take a really high dose of omega three’s every day, or not even a high dose, a medium/small dose, and it can increase your bleeding. My biggest advice is always to be transparent with your physician. The worst and the last thing that you want is for a surprise to happen, especially when you’re in surgery. And your physician wants to know these things. I would give them my full list of supplements. Every single one of them that’s on there. Your surgeon will know which ones and which ones won’t interact, and if they don’t, then they will find out because they are very, very invested in making this surgery very successful. So all of them would be my answer, make sure that they’re all there, but omega three’s is a big one. And anything that could potentially affect your bleeding time, but that’s going to be on an individual basis at first. Pre-surgery I might just say let’s cut them all out, because a lot of it we don’t know. There’s so much we don’t know about dietary supplements.
Dr Pelman (48:28):
So that’s very reasonable advice, they’re not necessarily harmless because there could be side effects that we don’t know just for that period. Usually a week before, stop, let them get out of your system and then you can resume after you’ve healed.
Dr Brice Thomson (48:42):
And that’s been our advice whenever we’ve had a patient going in for surgery, is we’re going to pull everything back because there’s no evidence whether or not it’ll interact, positive or negative. But we don’t know, it hasn’t been tested. So we don’t want to find out with you.
Dr Pelman (48:57):
Well, this has been truly enlightening. I mean, we’ve gone through organ systems and we can’t go through every supplement, but I think there’s enough there for people to have a sense of when they’re listening to the TV or radio and they hear something advertised, maybe how to find more information, who to go to, how to assess this. And then, you know, we did talk about some common issues. So, Dr. Thompson, thank you.
Dr Brice Thomson:
Thank you.
Dr Pelman :
This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society. Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.
