Fatigue & Triad: Mast Cell Activation, Dysautonomia & Hypermobility Syndrome

Episode 81:

Fatigue & Triad: Mast Cell Activation, Dysautonomia & Hypermobility Syndrome with

Jamie Kunkle and Evan H. Hirsch, MD

Evan H. Hirsch, MD 00:07

Hey everybody, welcome back to the energy MD podcast where we help people with

chronic fatigue MECFS and long COVID get their lives back so that they can enjoy. What

would they have been given here in this life. So, thanks so much for joining me here.

Today we're gonna be talking about the triad and I know you're super curious about what

the triad is, because I am as well, we're gonna be doing that with Dr. Jamie Kunkel. And

so let's learn a little bit about him. So he's been practicing as a dual licensed

naturopathic doctor and East Asian medical practitioner acupuncturist for 10 years. He

specializes in tick borne illness Lyme disease, long haul syndrome, autoimmunity and

chronic pain. He received a Bachelors of Science in neuroscience from the University of

Pittsburgh and a master's in acupuncture and traditional Chinese medicine and a

doctorate in naturopathic medicine from Bastyr University in Seattle. He currently works

with the Gordon Medical Association associates in San Rafael, California. He has two

daughters that keep them very busy. He enjoys being in nature working on his house

and spending time with his wife, whom also is a naturopathic doctor. And he is also an

electronic musician when he finds the time. Dr. Kunkel, thanks so much for joining me

today. lotor Happy to be here. So I'm gonna have to ask you about the the electronic

music at some point, but we're going to start it off. We're going to start off jumping into

the triads. So we're gonna be talking about fatigue and the triad and the triad. Well, why

don't you tell us what is the triad?

Dr. Jamie Kunkle 01:42

Yeah, what is the triad? That's a really good question. I mean, this is a very complex

connected set of symptoms that a lot of my patients are now presenting with. And you

know, something maybe I just wasn't as aware of before and more aware of now I think

COVID, sort of maybe amplified some of this, it's really hard to say, but what I would say

is the triad plain and simply is a combination of mast cell activation, dysautonomia, and

Hypermobility syndrome. So when those three come together, it's, they're very

interconnected, they kind of feed each other. And not always, the best way is it makes

how you approach those patients, this case is a little more complicated. So the

awareness of identifying the presence of the triad and an individual can really help

streamline the process and what you need to do. And in the context of fatigue, all three

of those things together are almost certainly feeding into the presentation, the symptom

of fatigue that may be the most debilitating to that individual, whether they're diagnosed

with chronic fatigue syndrome, me or post COVID, or any number of other conditions. So

you really got to dig for this because a patient may come with a Lyme diagnosis, or they

may come with like stuff that was pretty hard to find to begin with. Yet, the

understanding of the tribe isn't exactly there. So I have to kind of parcel that out and

figure out how I can support these people because it was probably the it's it's an

interplay of the genetics of the individual, you know, and what their susceptibilities are

to this type of trial, this type of syndrome, the child, and then the epigenetic influences

that come at them. And there are multiple, many, and one of them maybe infection like

COVID, in this kind of thing. One of it could be in a toxin illnesses like mold, or other

environmental pieces, and you remember those things drive the process. So it's a

coalescence then in that case, between genetic and epigenetic or environmental

influences on this person. So it really helps me to understand that because if I go back

in their history and look at their family history, or you know, I can find some soft signs of

this stuff, developing their early age, it just didn't become so dysfunctional, it didn't

become so debilitating until, you know, later. So, you know, it can happen at a really

young age, certainly, but it's, you know, it's a process so it really helps me to better

understand so I'm gonna talk more about that in just a little bit, but that's pretty much

what the triad is Masel activation dysautonomia, there's a lot of different types of

dysautonomia, and Hypermobility syndrome.

Evan H. Hirsch, MD 04:22

Thank you. So can you define each of those terms?

04:27

Sure. I mean, I think mast cell activation gets thrown around a lot. I mean, maybe it

should really be mast cell disorder, because I think there might be a little bit of a

differentiation there. First of all, mast cell activation is a little hard to diagnose. We don't

really have really great tests for that right now. There are tests and I can certainly

discuss them If interested, but they're not perfect. far from perfect. NASA activation is

generally a clinical diagnosis. But there's a lot of different aspects of the immune

system that can activate or signal the mast cells. So just calling it Masel activation

shouldn't cross the board. It's kind of a simplification in some ways, but maybe it's more

appropriate to call it a mast cell disorder. So this is a type this is a part of your immune

immune system, what's called your innate immune system, kind of like your first line of

defense, to the outside world to infection to whatever's, you know, triggering the immune

system response. It produces histamine among many, many other inflammatory signals

or cytokines. But we most often think of the mast cells as being histamine producing,

get stung by a bee, that big, giant, terrible red response, you get initially, a lot of mast cell

mediation there as one could imagine. So they lie on our skin, they lie on our gut, they lie

on our brain, they let our sinuses they're all over the place ready and waiting to jump

when needed. So they're appropriate, they have an appropriate response to but

sometimes they can get a little overwhelming. As you can imagine, I mean, think about

even just classically in flexes or something, you know, like having trouble breathing from

an allergic reaction or when the beasting goes bad, for example, and those are really

severe and really extreme ends of it. Chronic Masel activation is kind of like a low level

activation. It doesn't exactly go back to its calm, quiescent state, it stays activated.

Some believe it's a gene switch, you know. So there's a lot to talk about there. But that's

Masel activation in a nutshell. dysautonomia comes in many forms, it's basically an

imbalance in your autonomic nervous system, your nervous system is constantly

adapting to the world around them that maybe positional changes or stressors or

infection or anything, and it lives in these two different states. sympathetic nervous

system, which is your fight or flight or freeze response, primarily driven by adrenaline.

And then the parasympathetic nervous system, which is your rest and digest response

from are primarily driven by acetylcholine, which, you know, don't need to know that. So,

where does this autonomia what's the most common presentation, they're probably

plots or Postural Orthostatic Tachycardia Syndrome, that's a mouthful. Basically, if

you're standing up from seating your heart rate goes up, you feel like you're going to

pass out very common. People in post COVID for example, might notice more

dysautonomia symptoms it may be driving their fatigue and maybe driving the

symptoms I just mentioned, they may feel really dizzy or lightheaded quite often, but it

comes in many forms can happen in the gut to for example, what we think of as SIBO or

gastroparesis, I can talk about but motility or movement issues in the gut that can

manifest in different ways is is a dysautonomia to Hypermobility syndrome. Well, you

might be asking the question, Well, I'm really flexible, but I'm not sick. It's not always a

problem to be really mobile. It's really not. But it's when you are inflamed, or all these

other things start to happen, or the mast cells or whatever they're all interconnected,

start to make the hypermobility less, less and less and less functional. You can't be born

with a really severe form of it and have a lot of dislocations get injured very easily. It's

like every time you get a trauma, you feel worse and worse and worse. And then it's

much easier to get another trauma later, like a dislocation or another twisted ankle or

something like that. But hypermobility isn't inherently a problem. You see many

gymnasts out there, who are doing pretty well for themselves and, you know, don't have

plots or something and, you know, don't have allergies, and they're really healthy. It's

usually whenever those environmental influences come again, into the equation further

and flame, the collagen and the soft tissue further soften that system and make it less

stable. So that's pretty much hypermobility, and why it's important in this context. So

that's, that's the one that gets missed the most I know, patients in their 50s 60s, who

have never been diagnosed their entire life or recognized as being hyper mobile. So that

one's the one that we miss a lot.

Evan H. Hirsch, MD 08:56

So what's the connection between these? Sure, how do they relate?

09:02

Sure. Well, it's really quite interesting. There's, there's there are many connections

between them I guess I should say to start off with, but let's just say let's give a

scenario. And I can give you an example of how they're connected. So, mast cells, as I

mentioned, can be activated by the environment by toxins by infectious triggers, for

example. So there is an inflammatory response, the mast cells become activated. As

those mast cells are activated, they start affecting the nerves in the nervous system,

they can affect the autonomic nervous system they can affect the vagus nerve or the

infection or the toxin can directly affect the effect the autonomic nervous system. And

that inflammation, as I just mentioned, can also directly affect the soft tissue or the

collagen and worsen the hypermobility and the instability and you add a trauma or

something other big on top of that, and it's just a time bomb waiting to happen in terms

of blowing up the syndrome and turning it into Something's not so functional. So that's

kind of the simple answer to it is it's all inflammation really, it's inflammatory response

connects, every one of these points, the mast cell is clearly a inflammatory response.

And the other parts of the system like the autonomic, and you know, the connective

tissue are affected by that information.

Evan H. Hirsch, MD 10:20

Yeah, you know, for me, I'm always looking at okay, like, you know, what's the cause of

something, right? What's the underlying cause? And what I found is that heavy metals,

chemicals, molds, infections, and trauma are kind of the cause of everything. And they

ended up triggering inflammation, and depending on the location of some of these

determines whether or not they have different symptoms, is that kind of what you're

saying here?

10:47

Yeah, in a sense, I'd say you have to think about the causes of this to treat it. But what's

also very important to understand about the triad is that this is one example where

palliative supportive care is of the utmost importance to that we don't want to

necessarily just tunnel vision on treating the cause all the time, if the person is terribly

unstable, you can get to that. But I think of it sort of is more of a phasic system where

this is this is a complex presentation where you have to sometimes actually bandaid it

first, in order for the person to heal. So that is just and there are many other syndromes

that I think can take that order. But this one, I think, is one way to differentiate it. So yes,

you need to figure out the causes. A lot of times with these things, there are a lot of

causes, I'd have to say it's the coalescence of things. But certainly, if it happened and

started after COVID, or after a big trauma, you do want to hone in on that. But if they

started trying to address those things, and they feel significantly worse, the Paleo ation

needs to happen. First, you know, the things that bring the symptoms down need to

happen first.

Evan H. Hirsch, MD 11:56

Absolutely, yeah. And so I call that in my program, I call that step two, which is kind of

like replacing deficiencies and hormones and nutrients and stuff like that, before we

kind of start removing a lot of these toxins. What how do you do that? How do you see

that in terms of some of that, that palliation? Or what I call a natural Band Aid?

12:18

Yeah, no, absolutely. I think that the foundations are always incredibly important. And I

certainly don't jump them I think that's, that's one of the first conversations that I have in

terms of, you know, their nutrients, their diet, their, their support systems, their social

health, their emotional health, their spiritual health, all these kinds of things are of the

utmost importance, especially for the autonomic system naturally, in terms of the the

ladder stuff, like the emotions in the spirit and stuff like this, because those will help to

keep the people more in parasympathetic tone. And then most of these folks, which

we'll get to some some of the reasons why people are fatigued here, but most of these

folks do not have quality, nutrient nutrition for a variety of reasons. Either there's

malabsorption, or overutilization, or it's very common when you have all this together to

be very low on very vital nutrients, especially fat soluble vitamins, for example, maybe

vitamin D, for example, but iron is also up there. So you have to really fine tooth comb

the nutrient systems and really understand where they're where they're at a loss,

because even just simply repeating those things can be very important. And their diet is

absolutely affecting the mast cell system, most of the time, they're reacting to the foods

that they're eating. And it's it's worsening their inflammation and their fatigue and

everything in the worst kind of way. So you really have to overhaul sometimes their diet,

not always permanently, but temporarily, at the very least until this stuff calms down.

And so in with that in mind, you're also optimizing their nutrient intake, you're making

sure that you're supporting their collagen systems in regards to their hypermobility,

because they need collagen, and just straight processed collagen might not always be

good for their mast cells, so they need it in food form. And it's it's hard. I mean, I'm not

against anybody that's philosophically or ethically Against Meat, because there's a lot of

bad stuff that's going on in the meat industry, understandably, but if you can find

ethically sourced meat and be okay with using it therapeutically, it's a great source of

collagen. And if it's fresh as can be, you know, fresh, fresh, fresh, you know, only frozen

once, it's not going to activate the mast cells as much. So you see how you can easily

connect all these things together when you're formulating a plan. And so yes, the

foundations, as mentioned are are absolutely integral here.

Evan H. Hirsch, MD 14:33

Interesting. And so, you're you're a TBD guy, you're understand tick borne diseases. And

so I struggle with collagen because I know that Bartonella likes to feed on collagen. And

so the question is, if you think somebody's got Bartonella do you give them collagen? It's

a good question,

14:53

honestly, and it comes up quite a bit. I am not. I guess I should say I'm not terribly

doggone addict on this for a variety of reasons because these people are so nutrient

deplete that sometimes Sometimes they're very nutrient depleted. So my patients are,

let's just say that the ones that come to me, not all of them are. So for me, I need them

to have core basic nutrition, I really do. And it's like the absence of that collagen is

causing more harm to them than possibly feeding the bog a little bit. And so there are

times in places where I might deprive that system a little bit more if the patient is more

robust. But most of the time when patient people are presenting to me with the triad

here, they are not stable enough for me to deprive deprived, vital, vital nutrients and vital

aspects for them. So that's kind of the way I personally see it. And I haven't really

honestly had been able to connect clinically that that's causing a big harm to them. I

think sometimes Massell reactions are misconstrued as first reactions to or Herxheimer

reactions or basically increased infection activity or die off or whatever people tend to

call it all Hertz's but that's not really always what it is.

Evan H. Hirsch, MD 16:05

And what do you recommend for the for as an M cast diet? Are you low histamine, a

paleo What do you like? Yeah, low histamine,

16:13

I think is a general rule, because there's foods that contain a lot of histamines. And

there's foods that tend to increase the production of histamines. And so starting there is

really a good place to begin. And it's interesting, because a lot of those foods are

otherwise very healthy for us, you know, some of them are really, so you have to kind of

reframe what's, what's good and what's not the time, I'd have to say, and but it still

comes down to the reality of it. It's just like any other dietary interventions, whether

you're doing elimination challenge, and you food sensitivities, or whatever, you have to

kind of challenge this stuff and see what the person is actually reacting to, because the

thing about mast cell activation is they can literally be reacting to anything, they can be

reacting to the meta substance that is treating their mast cell activation. Go figure. So

you start with the low histamine and you kind of work your way through there. Some

people have definitely been going into the paleo and some people have even been going

as far as the carnivore and still being somewhat successful here, especially if they have

really bad SIBO or small intestine bacterial overgrowth or, you know, some other gut

issues that where they they're not as easily easily able to eat vegetables, or, like

FODMAPs are, you know, fruits and stuff like this, you know, things that cause

fermentation in their system.

Evan H. Hirsch, MD 17:30

And does the does identifying this triad help you clinically? Or how does it help you

politically? Oh, yeah, severity, or

17:38

Yeah, it does often tell me a little bit more about severity, you know, how much I need to

maybe do for this person. Maybe prognosis to some degree to you know, how long it

may take to kind of unwind their situation. And it really does depend on where they

come in the process, you know, if they've been to 20 other doctors before me, and

they've all sort of missed the mark on understanding some of these things. You know,

okay, it might be a little bit harder, because it might have been five or 10 years, and there

might have been progressions of some of these illnesses. For example, there's a

progression of hypermobility called CCI, cranial cervical instability. And basically, if that

starts to happen, it can be incredibly disruptive. So what was once a infection illness

now becomes a structural issue that needs to be dealt with appropriately. So it really

just depends on where they come in the process. So yes, it does help me I think it just

puts things into a little bit better perspective about where I need to put my energy, and

how I maybe need to adjust their lifestyle intervention, their lifestyle in different ways,

like, if they're exercising really intensely, even when they're fatigued. And that might be a

problem in and of itself. But if they're hyper mobile, and might need to back off or

change the way in which they exercise or change the way in which they eat if they have

Masel activation and it's it's really just helpful to understand their day to day better

what's important to them. It to him the more they're educated and empowered with this,

the more it's supportive of, of getting them better quicker. So yes, it is it's important for

prognosis, and just how aggressive I need to be with the treatment and how much I

needed to do or not do with somebody.

Evan H. Hirsch, MD 19:26

And I've seen resolution of M casts and dysautonomia by removing toxins replacing

deficiencies, stuff like that, but I haven't seen a change in hypermobility is that because

that is and I haven't worked with a lot of people who have it but is that because that's

more genetic than some of these other ones or tell me a little bit more I guess about

hypermobility and Ehlers Danlos. Maybe the

19:53

day there's danlos. So there's danlos is just one form of Hypermobility syndrome. It's

been maybe not knocked out a little bit more, but it's not actually the most common

form of hypermobility. So if you do genetic testing on somebody and expect to get an

EDS diagnosis, you're more often than not going to come up dry there. Because the

genes that that basically are related to Hypermobility syndrome itself HST versus E, you

know, HST or whatever, EDF and all these acronyms, basically just hypermobility itself, it

hasn't really been fully mapped out in the genome. So it's so the the presumption though

here, just like mast cell is that there is often some sort of genetic predisposition people

believe that you can also acquire Masel activation. I think it is reasonable to say that in

certain circumstances you can probably acquire hypermobility to through different

means chronic inflammation softens college and as mentioned, repetitive traumas,

physical traumas, especially to the head and neck can cause instability. So you can have

regional instability that we call sort of a hyper mobile, whatever cervical spine or

something like that. It's not a full on full body Hypermobility syndrome because the

Hypermobility syndrome that we think of generally, is diagnosed typically, by the EDS

standards, the Beighton score, you know how many joints move too much bend too

much in the body. And if you score a certain amount, depending on your age, because

the older people get with hypermobility, the stiffer they get. And it's actually harder to

diagnose them based on just the Beighton score alone. It just it becomes a little bit

more complicated. So that's the reason why these things can get missed too. But I'd say

that hypermobility doesn't exactly go away once it's developed. But physical therapy and

physical therapists can really tell you this, I think they've probably done some of the best

work with hypermobility, if anybody in medicine, there's, I've met some amazing physical

therapists, there are ways to rehabilitate people and to get their systems stronger. And I

think with regenerative medicine, there may actually be a way to, to on soften that

collagen further, but really, to get the call to get the inflammation down is going to be

the primary objective all the time with these people. But really, the muscles the tendons

are always the modifiable factor in hypermobility, you can always get to the people to a

point where they can rehabilitate, they can do PT. And, you know, you can restore a

certain level of function and those people. So yeah.

Evan H. Hirsch, MD 22:32

Thank you. So how does the triad plan with chronic fatigue?

22:38

In many, many ways, actually, I could start with just really simply put with hypermobility,

for example, the muscles and the tendons and everything have to work really hard to

compensate for laxity in the ligaments and that actually uses up a lot more energies to

walk around. You'll see a lot of people with hypermobility that just they can't stand on

their feet for a long period of time. And it's like their body, their mitochondria have to

work twice as hard to do some some simpler things. And so that can easily be

misconstrued as like a classic chronic fatigue thing, but it may just be that they have to

work a lot harder. As far as that goes. The mast cell activation, the inflammation

response can certainly directly affect the brain, the nervous system. There are a lot of

mitochondrial disorders that are associated with these folks, there are a lot of sleep

disturbances. sleep studies are very important with people with a lot of apnea with

hypermobility, a lot of apnea with anything in the triad. Theoretically, the dysautonomia

causes disturbed sleep two people wake up more frequently, whether they recognize it

or not. If they're in chronic pain, they don't sleep well. I mean, a lot of sleep sleep is a

very hard difficult thing to address in this in the triad, but it's it's absolutely integral to if I

didn't mention that already. hormone dysregulation is very common. That can certainly

contribute to fatigue. Women unfortunately tend to have it a little bit worse with the triad

because estrogen progesterone, which I can elaborate on further, but estrogen

dominance can activate mast cells. Progesterone contributes to ligament laxity, and

then pregnancy has relaxed and all kinds of fun stuff. So people with the triad tend to

produce more insulin, they tend to get more hypoglycemic easier, they can develop a

whole array of endocrine disorders. If it's really severe, there can be changes in

intracranial pressure, high pressure, low pressure, those things can really make people

terribly fatigued. I mean, if you had a CSF leak, cerebral spinal fluid leak, you would want

to be upright at all, pretty much autoimmunity is very common in this population, as you

can imagine, that drives fatigue, nutritional disturbances that I already mentioned, drive

fatigue, and of course, you know, they they tend to get anemic very easily, which is really

you know, Simple thing to look out for people is to look at their iron and ferritin. And, you

know, try to get them to a place where they feel comfortable, whether their hemoglobin

is in range technically or not, because these people were very sensitive to shifts in their

arm, once again, women tend to get the short end of the straw for for that as well. So

those are just some general general explanations. And there's probably a lot more too,

that we maybe didn't mention, or that we, that we don't know about even. But that's,

that's pretty much the big ones that I know of.

Evan H. Hirsch, MD 25:36

And what would you say is, is the biggest needle mover when it comes to the triad? Is it

changing the lifestyle habits? Is it boosting the deficiencies? Is it removing some of

these toxins? What have you what have you seen?

25:51

Well, I think it does take a holistic approach, I'd have to say, you need to do all of it. If it's

really severe. I mean, that goes without saying, you need to do all of it. What's most

effective? I think, I mean, I think the awareness of it is the first step to really like

diagnose it, and to empower people with the knowledge of what it means to them, I

think is really big deal, because for a long time, most of these people get gaslighted into

oblivion by conventional medicine. They're just told that no, you're not in that much pain,

are you? No, no, and possibly be as sick as you say you are, you know, you're just

depressed or you're just anxious to like, well, I am depressed and anxious. But I also

have this really complex medical condition that nobody's diagnosing. So I think the

recognition of it in the diagnosis of it and the empowerment that comes with that is

actually one of the most powerful things you can do first off, which is why I'm talking

about it today. And then after that, you have to dive in. And the toxins are of the utmost

importance. A lot of people do believe that one of the main reasons why this is

becoming more recognized and more of an issue and less functional for people, even

with their genetics, the genetics haven't necessarily changed entirely. It's the epigenetic

influences, the toxins, a lot of the toxins were exposed to on a regular basis are less

than 100 years old, and you know, they're newer, or humans have not had an opportunity

to adapt to toxins in the environment. I mean, you can even ask the question, why we're

having more problems with mold than we did, if we've been around mold for 1000s of

years to. So you know, so I would blame toxins probably, above all, for one of the

reasons that this is becoming more of an issue. And so if you can identify that and

figure that out, that's probably the second biggest game changer and needle mover,

because if you go guns blazing into the infections, and you don't know about this other

stuff, you can make these patients incredibly ill, incredibly sick. And that's been

definitely something that I've seen too. So I'm careful. I'm very careful. Yes, I I work with

with Lyme and tick borne infection. But, you know, I've learned we've all learned over the

years, we have to really take a more holistic approach to this, we can't just go straight

after them, because that's creating more toxicity for that, and that's creating more

dysregulation in their immune system. And it's, you know, doesn't always go the way that

you hope it is.

Evan H. Hirsch, MD 28:17

So would you say when I talk about toxins, I'm talking about like heavy metals,

chemicals, molds, infections, I kind of group all them in there. Which toxins? Would you

say or which one of those would you say? is kind of the biggest needle mover?

28:32

Yeah, I mean, I guess I would say, oddly enough, despite my recent statement, I still think

mold seems to be one of the bigger ones. You know, mycotoxins just they really, you

know, mess up the autonomic system, a certain number of people get worse and mast

cell issues with that. And the effect of those toxins on the chronic inflammatory cycle

really does seem to worsen the instability. So I think we also maybe have, I don't know, I

guess maybe we have better testing sometimes. I don't think the testing is perfect for

mycotoxins, but I think it's, it's as hard as it is to identify mold. We actually seem to have

the resources to do that. In some cases. I think there are probably a lot of other toxins

we haven't fully understood, like some of the work of Dr. Andrew maxvill, talking about

toxic algae blooms and stuff. You know, he's researched that in the East Bay, for

example, like, you know, cyanobacteria and stuff. You know, there's got to be other

toxins in the environment course there is. But I think once you identify the mold, I think it

also is important to note that the detox regimen you put people on with mold probably

helps with other toxins, too. And I certainly don't want to downplay heavy metals,

whether the patient is young or old, heavy metals can be found in this population, and

they're there. They're very hot, they're very high typically. So I usually will get them out of

mold or remove them from any clear environmental influences first. In the metals, I will

get to oftentimes I will have already sort of done some work on them by probably

detoxing them, you know, with whatever I think is more important, like the mold first, and

then the metals kind of come later. But metals will definitely affect the collagen effect.

The joints, of course, affect the god effect ever everything, you know, even NASA, I've

seen with metals too, you can, you can see the whole shebang with heavy metals too.

Evan H. Hirsch, MD 30:25

And you find that you have to address the molds in the heavy metals before the

infections,

30:30

that's, that's the way I'm operating these days, the only time I jumped ship is if the

person is more acute, like if they had an acute tick bite, if they have like an acute,

massive autoimmune type presentation of an infection, I will sometimes have to rescue

that situation with either antibiotics or other, you know, natural anti microbials for a

short period of time, it's because they're so sick and not functional, it's like, I'm trying to

bring them off the edge. So those are the times when I really, you know, jumped ship a

little bit. But generally speaking, I think I appreciate my colleague, I work with Dr.

Poppea, she really is very strict about detox first and give it time. And that's, that's

actually a really important principle. And a really good reminder, and I definitely did not

have as much patience is that in my earlier career, and I'm learning to come around and

be a little more patient, even if it even if I know the infections are underlying in there. But

there's a time and a place, I am not rigid on that acute acute tick bites, acute

manifestations that are really destructive, they sometimes have to be treated.

Evan H. Hirsch, MD 31:41

Yeah, you know, we're having conversations right now. In our, in our business, and in our

practice, and with other and with our clients around expectations, you know, and all of

our programs are 12 months, because that's kind of generally the minimum amount that

it takes to go through this process. Because Slow and steady wins the race. What have

you seen in terms of what do you think are realistic expectations for people who have

the triad who have a number of these toxins, and you're trying to get rid of them out of

the body

32:11

add at least a year to that, I'd say two years minimum is realistic. But there's that doesn't

mean there's not a lot of progress we can make in a shorter amount of time, I think, you

know, with the advent of these fancy new medicines like peptides and other things,

regenerative supports and stuff, sometimes we can improve them a little bit quicker. But

I'd say realistically, really, if you're presenting with, you know, some of the worst

manifestations of the try out, it's going to be probably more than a year, realistically

speaking. So the better you can frame that in the beginning, I think that doesn't once

again, it does not mean you're not going to improve that you're not going to feel better

through the process. And it's so encouraging when you start taking that step in the right

direction when you start seeing that momentum. But you definitely have to have some

patience in this game. Chronic Illness is not, you know, the acute stuff that we usually

think it would be if I get a flu, I might be better. And a couple of weeks or maybe a month

worst case scenario. This is this is kind of a year or years sometimes. Yeah.

Evan H. Hirsch, MD 33:10

Yeah. And oftentimes, that's kind of daunting for folks. And they're like, oh, you know, but

I've been sick for a decade, you know, and the reality is, is that, you know, when they

invest that, that time, that energy, that money, you know, it goes the time goes by quite

quickly, and then you have your back, you know, really does actually

33:29

work, it's hard. But I remember

Evan H. Hirsch, MD 33:31

when I went through residency, and it was kind of like, Gosh, I really don't want to go

through residency, I could probably come out, I already knew I wanted to be practicing

more holistically. And it's like, well, you know, I'm gonna put this time in, and it's gonna

allow me to do things that I couldn't do before, you know, and it's same sort of idea,

there is a return on your investment, it's kind of like getting a master's degree, like you go

in a couple of years, you do the work, and then you come out and you can do things that

you couldn't do before.

33:56

Yeah, no, absolutely. Sometimes, there are things that were a little more functional for

them, that's still affecting their daily life that also improves. So sometimes you do come

out, you know, a little better all around, because once again, earlier on before the illness

got too bad, there were these soft signs that there was a tendency toward dysfunction

or dysregulation, so you started addressing those deeper things in people too. And it's

yeah, it's, it's pretty amazing. So it is a bit of an investment time. Certainly financial.

Unfortunately, our conventional system isn't as supportive of this process in terms of

chronic illness and holistic care. I really wish it was believed me, I think, you know, that's,

that's something I hope to see in my lifetime. And is that change it's gonna take, it's a

whole other conversation for another time.

Evan H. Hirsch, MD 34:41

Yeah, I'm really an important one. You know, that's something that I struggle with is, you

know, the cost of a lot of the therapies, you know, a lot of the supplements that we're

using and so, what do you feel like, I know now we've got peptides. I don't know if you're

doing IV therapy. I know you're doing like hyperbaric and stuff like that, too. What do you

what do you feel like is is the biggest bang for the buck? Generally?

35:09

Yeah. I mean, that's a good question. I guess I want to say that, with my previous

statement of this does take some time and patience and sort of directed energy toward

it in terms of lifestyle shifts, and you know, basic stuff, there's a lot you can do with a

little with this, too, there's not a guarantee that you need all the high end stuff. But the

high end stuff, I think, is very important for one either enhancing the treatment and

hopefully expediting it and really supporting it on a, on a higher level in terms of maybe

moving things forward. But in the other side of it is the people that often come to our

clinic, or very, very, very sick and not functional. So the higher dimension stuff is for a

certain group of people and people of Israel, the privilege to have the resources to kind

of, you know, really step it up quicker, and the people that really nothing else is moving

the needle, we have to try to use these bigger interventions with them. But the majority

of people if they present with more on the functional end of the triad here, there's a lot of

stuff they can do orally, you know, at home, not as always as expensive in terms of

supplementation. And even for example, with this autonomia let's just say getting

somebody some compression socks can be quite helpful, you know, getting the blood

flow up to the core up to the head up to the brain, kind of artificially creating a pumping

motion for them can be a big deal. Whenever you're on your feet walking around, you

won't feel like you need to be horizontal quite as much. Really simple. You can find those

on Amazon salt intake, increasing salt intake and hydration. We used to always be told

that salt was bad for us and it's gonna cause problems. That's not entirely true. I do

have patients that are salt sensitive to the majority that have the Tria need a lot of it

more than you think you would need. So that's really basic stuff for dysautonomia. If

you're kind of hard pressed to with the Masel activation. There are a lot of over the

counter antihistamines, I don't love them, because they have a lot of additives and

excipients they don't always do well. But there are ways you can Yes, it is a drug model.

But unfortunately, drugs are sometimes cheaper. So I mean, people were they are some

times with that process. But I can do antihistamines, I can do you know really basic

prescription sometimes to kind of navigate the mast cell activation and kind of Palia

those symptoms even. And then the hypermobility is a little more challenging in some

ways, but some of the stuff that affects the mass still are going to it's going to reduce

the inflammation in the soft collagen too. And even just getting more dietary curcumin

or turmeric might be really helpful for some of those people and just removing the

inflammation from their from their diet, getting getting those foods out that are

triggering them really terribly. So some of the foundational stuff here that is really

actually quite important and can be really profound is actually pretty inexpensive, too.

It's just It depends on where the person is in process and how severe and how not

functional they may be. And as mentioned, our clinic really ends up seeing most of the

ones that have kind of seen other doctors and been through that process and they need

higher interventions of medicine to be clear.

Evan H. Hirsch, MD 38:20

And what are your favorite peptides these days to treat the triad and some of these

underlying causes? Oh, for sure. Well,

38:27

for hypermobility, we use BPC 157 Because that can help with collagen, reduce

inflammation. It does a lot of stuff to gut barrier, blood brain barrier, liver support, you

know immune modulation, viral support all kinds of cool stuff. It's really quite, quite

quite far, far reaching. And then we use copper peptides hkcu copper peptide is a really

good one. It's a blue peptide, it's kind of fun. That one's good for soft collagen to and

trying to help increase stability can reduce inflammation sometimes it helps energy to

BPC also can help energy and fatigue, which is really nice. And then we'll use thymosin

beta four frag from you know the Oral sprays that are available out there. That's a good

one because it doesn't activate the mast cells, for example. So it's a good one for

general immune modulation and healing. Also for more pain or connective tissue

support, I think is how I use that. And then I'll branch into the mast cell ones like KPV.

Also good for large intestine support. has some good overlaps with with some of the

mold rehabilitation stuff, too. I believe that the Msh we'll get into that too much. And

then the M lexan. Hawks have been using more it's an oral that helps modulate

histamine leukotrienes that one's been studied with a topic DERM has a really good

safety profile. It's an oral peptide, like that one quite a bit. And yeah, and I do more than

that too. I've just depends but that's my core. I'd have to say And I don't necessarily do

those all ones, although sometimes I might layer them in slowly one at a time, and I'll

rotate them or I'll load them in the beginning until people are more stable, and then I'll

Paulson kind of thereafter. So it really just depends. But most of these people do better

with the injections, typically, but if I'm really trying to treat the gut directly, I think the

orals are just fine.

Evan H. Hirsch, MD 40:20

Very nice. And so the M Lexa. Nox, you said that was for atopic dermatitis? Is that like

an auto immune modulator?

40:28

Yeah, just I mean, technically, it probably is hitting most of the mast cell signals, as I

mentioned. But yeah, it's been studied a little bit with auto immunity as well. It had some

other Yeah. It's it doesn't have a ton of papers on it. But I haven't had really like the

safety on it has been really good. I'd have to say you can get it from I think one

pharmacy tailor made, I believe is only one you can get it from that I know of.

Evan H. Hirsch, MD 40:54

Excellent. And do you like it better than KPV? Or how do you use them differently,

40:57

really depends, I'd have to say that what happens in a lot of these cases is I really have

to challenge these things. And like micro doses to these people half the time. So I might

have them get a capsule and take a small bit of it out or even do one unit of an injection

or something like crazy. Once I can establish tolerance, that's always my first step with

any of these peptides, then I can kind of move them through. So some people do better

with one versus the other. Lately, I've been preferencing in luxon, ox over KPV.

Sometimes I've had more reactions with KPV. But it's not guaranteed, there may be

some bio modulation with KPV that's happening to in the gut, I don't know, you know,

has a little bit of a mount antimicrobial effect is what I've read. So there could be a little

bit of disruption there that a lot of these people were really sensitive to just a little bit of

movement in the microbiome too.

Evan H. Hirsch, MD 41:43

So with M casts, you know, a lot of people are really sensitive, who cares for by

definition. And so consequently, they may have a hard time tolerating supplements. We

like to go topically with tinctures. And, you know, obviously removing foods and stuff like

that. But, you know, oftentimes the more sensitive they are, the more toxins are, the

more toxins they have, the more sensitive they are. And so it's really you don't really

make a dent until you start removing the toxins. What What have you seen as like the

biggest needle mover for some of these folks with em cast to get them to tolerate

treatment?

42:22

Yeah, it's a good question. I mean, unfortunately, some of it is still trial and error. There's

not some sort of like, perfect algorithm that works for it. But for example, some of my

patients with M casts I realized just a reactive to almost everything from the natural

world, for some reason, like all the herbs, because it's closer to the foods is one

suggestion. And I can actually give them drugs, and they do really well with it. So you

know, not, not, nothing is off the table with these people, when you start something my

patients literally can't take anything by mouth, but yet I can give them stuff in IVs, all day

long. And so I can kind of like give them very slow titration of IV medicine, for example,

until they're more stable. So the route is really important, if a lot of the MCAT is in the

gut, you have to be really careful how much stuff you throw in the gut. And then what

type of substance that you're using, as I mentioned, you know, don't don't necessarily

throw out all your, all your drugs, if the person is reacting to your natural stuff, and vice

versa. You know, don't don't neglect the natural world, if all the drugs are making you feel

absolutely terrible. So, you know, those are some ways in which I've, I've navigated it, but

it's a slow and steady process. And it is trial and error. It's being very transparent with

people that even with the best of intentions, this drug may have a body of research or

this substance may have 1020 papers that say it's going to help you. But it's still you,

you know that you're it's a personal, personal situation, it's a personal response. And so

we have to really be communicating regularly, and really try to move this forward. So

step one can be the most challenging when people are really far on the dysfunctional

end of that spectrum.

Evan H. Hirsch, MD 44:05

Well, Dr. Jamie, this has been excellent. Any last things you want to share with folks that

we haven't talked about?

44:14

Um, I mean, no, I think I would just say that generally, there may have been a little bit of

an uptick in these syndromes since COVID. So even though we're further away from

COVID One, and 2020 or 2019 are just recognize that it is still out there and it can still

influence these conditions. And that doesn't mean like live in a cave under a rock or

anything that you have to be like really fearful of it but just recognize that some people

who get these these responses heightened immensely when they're exposed to COVID.

Some people still don't do well with that particular virus and probably the spike protein, a

lot of different theories on what's happening there. So just be mindful of what's around

us. You know, flu and other infections and stuff like that, too, you know, but, but yeah, I

just wanted to put a little plug in for awareness around COVID. Because right now it's

kind of all around us in high in high mount. So if you get that and your symptoms are

worsening immensely, you know, hopefully you seek somebody that's in COVID two,

which is kind of becoming its own its own sort of thing. It fell, it's been modeled off of a

lot of what we've understood in the past about post viral syndromes. It really has its own

little perks. So I just wanted to put a little awareness plug in there.

Evan H. Hirsch, MD 45:31

Thank you. And do you have a favorite COVID prevention strategy?

45:35

Well, the all the foundations has mentioned sleep and healthy diet, you know, stressors,

stress management, all that kind of stuff. But yeah, generally, the nutrition nutrient

factors are really integral making sure that people have enough vitamin D have enough

C, vitamin C, zinc, you know, just kind of some very basic stuff, honestly, that they have

enough resources to be able to manage it effectively, and that they're not, you know,

basically over stressing or overstraining themselves through working too much, or

putting themselves in places that are going to be harmful or problematic. And then also

keeping their blood sugar's insulin, you know, all the cardiovascular and heart disease

type kind of stuff in checked as well. So really just healthy lifestyle and core nutrients

are a good way to offset to some degree. And then early treatment. Yeah, early

treatment is my opinion on on what to do with it, you know, treat it, treat it early. If that

means packs live in for you, that's fine, if it means nutrients and other things. Do do

what is right for you and your care team.

Evan H. Hirsch, MD 46:42

Excellent. And where can people go to learn more about you to connect if they want to

work with you?

46:48

Oh, sure. Well, you can visit us, I believe Gordon medical.com. Or you can just search

Gordon Gordon Medical Associates on the web. And you can search my name, you

might find me on some YouTube videos to doing more of these things. So you could you

could probably find me but definitely go to Gordon medical, you can talk to Rachel is our

new patient coordinator. She'll, she'll talk you through all the details. So give

Evan H. Hirsch, MD 47:11

us a call. Excellent. Yeah, we'll drop the link below. Thank you. If you've listened to this or

you've watched it and you like it, please give us a thumbs up or five stars. We really

appreciate it. Dr. Kunkel, thanks so much for joining me today. This was excellent.

47:26

Thank you. Have a good day.

Evan H. Hirsch, MD 47:30

I hope you learned something on today's podcast. If you did, please share it with your

friends and family and leave us a five star review on iTunes. It's really helpful for getting

this information out to more people desperately needed. Sharing all the experts I know

in love, and the powerful tips I have is one of my absolute favorite things to do. Thanks

for being part of my community. Just a reminder, this podcast is for educational

purposes only, and is not a substitute for professional care by a doctor or other qualified

medical professional. It is provided with the understanding that it does not constitute

medical or other professional advice or services. Thanks for listening, and have an

amazing day.