Season 8, Episode 1: Tackling Liver Health and Mitochondrial Health with Dr. Robert Rountree

Evelyne Lambrecht: Great to see you too. Today we’ll be talking about Bob’s journey in integrative and functional medicine, as well as two main topics which could easily be multiple episodes on their own liver health and mitochondrial health.

So, Bob, you have always been one of my favorite people in our field in this industry, and I just feel so lucky that I got to work alongside you when I first started working in the practitioner supplement space. I just learned so much from you from working together, but also from attending so many lectures. I’ve always loved listening to you at the Institute for Functional Medicine conferences. And I love that you’re always a favorite there. No offense to anybody else, but I feel like whenever somebody listens to you, you know, for the first time or the 20th time, we’re all just part of your fan club. So, I’m so grateful to call you friend. And honestly, since we started this podcast, I had hoped that one day I’d get to interview you.

Dr. Robert Rountree: Well, that day is here.

Evelyne Lambrecht: That day is here. So now I’m a little nervous. So, to kick us off, what is lighting you up this week?

Dr. Robert Rountree: Oh, what’s lighting me up? Well, I’m preparing some presentations for a conference this summer, and so I’ve really been diving into the very same topics we are going to talk about today. I’ve been diving into fatty liver, looking to see what the latest research is.

And I’ve been doing a deeper dive into mitochondrial health. I have to say, it’s kind of interesting that I don’t know when the podcast is coming out, but, you know, Dr. Casey Means just got nominated for surgeon general, and she has written this book on mitochondrial health. Right. Suddenly there’s all this pushback from experts saying, well, the only mitochondrial diseases are genetic. And so, what is she talking about? Mitochondrial disease and chronic disease. You know, it’s all quackery.

And I’m like, I don’t see how anybody can say that because there’s so much research on mitochondrial dysfunction that’s out there already. So, she’s kind of stirring up the whole debate scenario about functional medicine, the whole idea that, that minor dysfunctions can lead to more major dysfunctions and that can lead to disease on a continuum. So, this is how I relate to what’s going on in the news, right? Say, oh, okay, here we go again.

Evelyne Lambrecht: Yeah. Well, it’s interesting. I feel like functional medicine has come a long way. So, we’ll definitely dive a little more into that. So just a little background, Dr. Bob Rountree received his medical degree from the University of North Carolina School of Medicine at Chapel Hill in 1980. He completed a three-year residency in family and community medicine at the Milton S. Hershey Medical Center in Hershey, Pennsylvania, after which he was certified by the American Board of Family Practice. He completed extensive postgraduate studies in nutritional and herbal pharmacology and has been practicing his unique combination of traditional family medicine, nutrition, herbology and mind-body therapy in Boulder, Colorado since 1983. He’s also the co-author of three books on integrative medicine. So, Bob, I’d love to hear your background story. What drew you to medicine in the first place?

Dr. Robert Rountree: Oh, well, that is an interesting story. It started when I was, I think, 19, somebody gave me a book on herbal medicine called Herbs: The Magic Healers, and at the time, I had no idea about any of that. What’s an herb? I didn’t even know. Like, I grew up in the Deep South, basically eating a diet that should be abbreviated as CRAP, right? That is just the worst diet you can imagine. You know, fried food, sauces, gravy. Just the worst junk. My whole life I had no idea there was anything else. And then I read this book about herbal medicine and about diets in general, and it just woke me up, and I thought, I want to do that. I want to get involved in that in some way.

So, I started hanging out at health food stores, which at the time was a very crude, precursor to what we have now. That’s back in the days where you’d go in there and there were big bins full of almonds and rice and herbs and, you just took a bag and scooped it out and got what you wanted. And that was the end of the story. So, it was very much a primitive version of what, you know, it’s become a pretty big industry now.

So, I started meeting herbalist and talking about making teas and infusions and that kind of thing, and, decided, well, I want to do something along these lines, and I also want to study biology. So, I thought, well, if I go to medical school, then I’ll at least get a degree and it’ll give me some kind of credibility. What surprised me was how much I love the science. When I went to medical school, how much I loved the biochemistry, the physiology, the biology. I just loved it. I love what was going on the intracellular level etc. And I thought, okay, medicine has this huge potential. If it was focused on what actually goes wrong inside the cell or with physiology as opposed to how traditional therapeutics is taught, which is that you look for a pattern, you diagnose a syndrome, a person has this condition, they got hypertension, and you give them this drug, and that’s the end of the story. And why ask questions about how that hypertension developed?

So yeah, I learned the therapeutics. I did what I was told, I was a good boy. Okay. And, and I just wanted to get the information out. But then as soon as I got out of training, the first month after my training, I went and spent a week with Jeff Bland, Leo Galland, Sid Baker, Neil Orenstein up at the Omega Institute in New York and, spent a week learning what became functional medicine. It wasn’t called functional medicine at the time? But it was all about understanding the pathways of how things go awry and what you can do about it, so that really got me early on and that it’s been a long journey. It’s been 40 years.

Evelyne Lambrecht: Yeah, I love that because most people who go into traditional medicine, conventional medicine, they don’t start that way, like right away practicing functional medicine. So that’s amazing. So I’m curious, what have been some of your biggest learnings as a family practice doctor and also, as, you know, a functional medicine educator for many years? Like, what do you know to be true?

Dr. Robert Rountree: What do I know to be true? I mean, I could spend a couple of days about that. I mean, the first thing I would say is what we know to be true is that there’s nothing that we know to be true. Right? I was reading, an article from a doc the other day that was talking about the advantages of wisdom versus basic training and what he was saying is that, when you’re in medical school, in residency, postgraduate training, everything seems so crystal clear. In fact, he said the kind of knowledge you get from that training is crystalline, right? It’s a crystal. It’s solid. It’s clear. You know exactly what to do. And then when you get into practice, you do the things that you were taught. And a lot of times they don’t work. And you scratch your head and go why didn’t that work. What’s wrong. And that’s when you begin to realize, well every patient that walks in that door is an individual is a biochemical individual.

The whole notion of biochemical individuality, when you really apply that in clinical practice, it makes life harder. Everything’s easy. When you first go into practice, you think you know everything and it’s all crystalline. It’s all very clear. But then over time, you realize every single person has got a slightly different scenario. And that means the larger your repertoire is, the more possibilities you have, the more you can pivot, you can shift, you can try different things. So it’s it makes life more challenging. But it also makes it infinitely more interesting.

And, and I say that because, you know, I never stop looking things up, even when I think that I know exactly what a person has or how to manage it, etc., I still go back and double check to see if there’s anything new, if anything has changed, etc. so it’s just constantly shifting, expanding body of knowledge that we have.

Evelyne Lambrecht: I love that and is amazing in our field how there is just always more to learn every single day, always more research. It’s exciting to stay on top of it all. So let’s shift to liver health. You gave a great talk on this topic a few months ago at the Susan Samueli Supplement Conference. And, so I learned, you probably actually mentioned in your talk that I forgot if you did, but so nonalcoholic fatty liver disease is not called that anymore since 2023. So I want to talk about those definitions. So nonalcoholic fatty liver disease is now called metabolic dysfunction associated steatotic liver disease or MASLD

Dr. Robert Rountree: Mass old. Just rolls off the tongue, doesn’t it?

Evelyne Lambrecht: Mass old. And then fatty liver disease is now called diatonic liver disease. Yeah okay. And then NASH which was nonalcoholic steatohepatitis hepatitis is now called metabolic dysfunction associated hepatitis. So what I find so interesting

Dr. Robert Rountree: NASH to BASH.

Evelyne Lambrecht: Yes. So this is really interesting. That word metabolic function because this is from the Liver society, right? So I think we’re saying okay, there may be recognizing that there’s like more to the picture. So I’m curious what made you so passionate about liver health and why should practitioners be more informed about it?

Dr. Robert Rountree: Well, I guess for me, it started with hearing a presentation by Dr. Lynn Patrick. I think I can’t even remember how many years ago, ten, 15 years ago. And this happened right about the same time I started having a few really well-informed patients asking me how I treated NAFLD. Right? And I thought, oh, what is NAFLD? I haven’t heard about it, so it can’t be that important, but I’ll check into it when I have time. And then Dr. Patrick gave a presentation on the convergence of chronic hepatitis C and fatty liver.

And that was significant because we didn’t have drugs for hepatitis C at the time. So I had a lot of patients with chronic hep C, with elevated liver enzymes and no drug options, really. So they were looking for anything and everything that they could try. Well, Dr. Patrick says, hey, did you know that that hepatitis C increases your risk of fatty liver?

And, you know, I respond with, well, what exactly is that? What does that mean? Because we just didn’t have the prevalence data that we do now. So I started doing research on it. And lo and behold, it turned into this huge epidemic. You know, now we’re talking about at least a third of the world’s population has some degree. Yes, a third of the world’s population has some degree of fatty liver.

Evelyne Lambrecht: How is that even possible? How is that possible?

Dr. Robert Rountree: In Latin America, it’s more like 40 to 45%.

Evelyne Lambrecht: That’s crazy.

Dr. Robert Rountree: Wow. So this is just crazy how much this has exploded. So let me give you a little background. I mean, this condition was first described at the Mayo Clinic by a pathologist who had a group of patients who were obese, diabetic or prediabetic, and they had elevated liver enzymes, and they biopsied them and said, well there’s inflammation in your liver.

And then they assumed that this was related to alcohol people. But people would say, but I don’t drink. Well, you’re lying to me, right? Because we only see this in alcoholics. So that was the genesis of it. Hey, here are these people that have a liver disease, it looks exactly like alcohol related liver disease, but they don’t drink. So there’s something else going on.

And the initial description was only in the people that had more severe hepatitis. They had full on inflammation. But then they began to realize there are people that have this fat accumulation in their liver that hadn’t caused inflammation. So there C-reactive protein was not up, other inflammatory markers were not up, but they had the precursor to that inflammation. So that was the genesis of the “nonalcoholic fatty liver”.

But as this epidemic, and it really is an epidemic now is this continued to increase a lot of people started saying, hey, it’s pejorative just to tell a patient you have nonalcoholic disease, right? And the problem was that that diagnosis was a rule out diagnosis. Well, your liver enzymes are up. Something’s going on. But we don’t find hepatitis C, we don’t find excessive alcohol intake. We don’t see hemochromatosis. So we’ve ruled everything out. So you must have nonalcoholic fatty liver.

But then it became really obvious that this condition mostly occurred in people that had prediabetes or metabolic syndrome or type two diabetes. So instead of saying these things travel together, type two diabetes and liver disease, why not just name it for what it is? It’s a metabolic associated fat accumulation in the liver. So that’s where the name change came from.

Evelyne Lambrecht: Okay. And it’s a silent epidemic, right? Like when do people usually discover it. Is it just when they see elevated liver enzymes and then are you as their primary care physician, are you referring them to get an ultrasound? Or are so many people running around with it and they have no idea.

Dr. Robert Rountree: Most people don’t know that it does not cause any symptoms. They wouldn’t have any way of knowing. So yeah, it’s mostly discovered as a result of standard screening tests. Oh, you go see your doctor for routine physical. You get a liver panel and one of the enzymes is, well, let’s make sure this isn’t a viral hepatitis or you haven’t overdosed on acetaminophen or something else or maybe you’ve been drinking a little too much. Well, no, I don’t have this. No, I don’t I don’t take acetaminophen. Okay, well, let’s get an ultrasound and see what’s going on.

Now, the technical definition of fatty liver is that the liver has to have more than 5% fat, right? You can’t really see that really well on an ultrasound. All you can tell is that there’s a lot of fat in the liver. So the reports I get of the ultrasounds don’t come back saying this person has 6% or 7%, right? So even though the definition is hinges on that percentage, that’s not really what primary care doctors are seeing in their practice and said they see people maybe having elevated liver enzymes, but not always.

And here’s the deal. If a person’s got type two diabetes, there’s a pretty good assumption that they’ve got some degree of fatty liver.

Evelyne Lambrecht: Right. So let’s talk about some solutions potentially. And I want to bring up well before we get to the nutrients, something you mentioned to me the other day is a lot of people are using GLP-1s, right. Because of metabolic syndrome if it’s associated with that. So talk to me about that.

Dr. Robert Rountree: Well I’m not going to say these are bad drugs. And I’m not going to say that I don’t prescribe them. I mostly prescribe to the people that come in and beg for them. Right? It’s not my first choice. It’s pretty clear that they work. I just saw that Weight Watchers had declared bankruptcy, and I thought, well, isn’t that interesting? They used to be the number one solution for weight loss, right? The group support, etc. But what happened was these GLP-1s suddenly came out of nowhere. And companies that were prescribing those, that’s where everybody went. Oprah Winfrey. Right? Oprah Winfrey says, hey, why do I need Weight Watchers anymore? I’ll just shoot myself up with this drug once a week. Yeah, the drugs make you lose weight. There’s really no question about it.

But there’s a couple of problems. One, they’re very expensive and insurance often doesn’t pay. So some people have to pay $1,000 out of pocket, or more. That’s one. The other is the weight loss is so rapid that people lose muscle mass. And that doesn’t come back when you stop that. Once that muscle mass is gone, it’s not going to come back on its own. It’s going to take a lot of work. And sarcopenia is turning out, the lack of muscle mass, it’s turning out to be a big deal, especially with aging.

And there are a lot of experts now, Gabrielle Lyon, Stacy Sims, they’re all talking about how we need to figure out what to do about sarcopenia. So I think the GLP-1s have really brought that into focus. That’s a big deal. You lose muscle mass. What are you going to do about it? So it’s the rapid weight loss from the drugs that induces that.

You still see potential loss of muscle mass from other weight loss programs. It’s just not as profound because I think people have more of an opportunity with slower weight loss programs to, to weightlifting, induce muscle synthesis, etc. So they’re expensive. They can cause significant loss of muscle mass. And number three, the discontinuance rate is pretty high.

Evelyne Lambrecht: Tell us more about that.

Dr. Robert Rountree: I just sent you that article I don’t know if you happen to have the reference right here, but this is a published article that looked at how many people discontinue after a year, more than well over half of the people who are not diabetic.

So if a diabetic is on these drugs, they’ve got an incentive to keep their blood sugar low, right? But if they’re prediabetic or metabolic syndrome, in that category, less of an incentive. And so they get to a point where they say, I’m just tired of the nausea all the time, the lack of appetite, the lack of enjoyment for food, etc. And this drug is expensive. Why would I do that? So one year discontinue rate is well over 50% and two years is even much higher.

Evelyne Lambrecht: That’s really interesting. So do you think that GLP-1s on their own, or are there studies showing that it actually does help with fatty liver?

Dr. Robert Rountree: Yes, absolutely. But the studies that have been published, there’s one on TRS appetite and there’s one on semaglutide. They were both in people with more advanced liver disease, the inflammatory stage. And they showed that they decreased inflammation. So here’s the deal. We’ve known forever that if you lose 10 to 15% of your body weight, well not you specifically but a person who’s got fatty liver, weight loss alone has been shown in study after study to be the single most effective thing for getting that fat out of the liver. So we know that it works. So it’s no surprise that GLP-1s would help.

The issue that I see here is that people are saying, well, I’ll just take the drug and I don’t have to do anything else. I’ll let the drug do the work. And as I said, it’s not a good long term solution. It’s expensive. And there was another study just published showing that the amount of emergency room visits for side effects related to GLP-1 inhibitors has gone through the roof. Right? So these are not benign drugs and people can have pretty significant side effects from.

So consequently I want to know is there anything you can do that’s less expensive, less toxic, that’s more sustainable over the long run? Those to me are better solutions.

Evelyne Lambrecht: Yeah. So let’s get into some of those. What are your favorite nutrients for fatty liver that you’ve successfully used in your practice?

Dr. Robert Rountree: Well I think curcumin is hard to beat, right? There are multiple published studies giving various forms of curcumin to people with fatty liver, that have shown on ultrasound that the percentage of fat goes down, their liver enzymes get better, they lose weight, their blood sugar control gets better. So how would that work? Well, the curcumin is mainly an anti-inflammatory. So that suggests that it’s working by multiple mechanisms. So I love that, I put everybody on it. I take it myself.

The vitamin E studies have been around for decades. You and I have talked about that in the past, and you brought up the issue with me. Well, what about tocotrienols? When people think about Vitamin D and they think D, alpha, tocopherol and the Society for Studying Liver Disease, they’ve endorsed D alpha L. Well, so you would think, okay, well, that probably isn’t any other research out there.

Evelyne Lambrecht: But there is!

Dr. Robert Rountree: Right. Because it turns out there’s multiple published studies on tocotrienol. So when we hear vitamin K, I think more mainstream doctors, they only think D-alpha for tocopherol. They don’t realize that there are all these different isomers. There’s what, four different types of tocopherol and four different types of tocotrienols. Maybe using all of them together is an even better option.

Now, how do they work? We don’t even we’re I don’t think we really know exactly what the mechanism is. I mean, they’re antioxidants. Clearly they’re anti-inflammatory, but they’re multiple mechanisms. Sorry. You were going to add something.

Evelyne Lambrecht: Oh, I was just going to say I mean, those studies did show on tocotrienol only Delta and Gamma that they did reduce liver enzymes and did reduce fatty liver.

Dr. Robert Rountree: So I think that’s a great option. Essential fatty acids, omega three, EPA and DHA, several published studies on those. I think they’re really good option. And why not? I mean, there’s studies showing that EPA, DHEA and a dose of around 2,000mg of total, help with insulin resistance, anything that helps with insulin resistance is going to help with fatty liver. And only rarely are you only treating one right. Right.

So I don’t tell a patient, well, I’m treating your fatty liver and we’re not even going to talk about your A1-C being up or anything like that. No, it’s all part of the whole system.

Evelyne Lambrecht: Yeah. So you said two grams of EPA and DHA. I mean, I know that we’re kind of generalizing, but what about dosing for vitamin E and for curcumin generally?

Dr. Robert Rountree: Well, the DL tocopherol doses, around 800 units a day total. The delta tocotrienol studies that you sent me. And then I went back and dug into the literature more. They were getting the best results at around 600mg a day of the, I think that one study was just an isolated delta tocotrienol and I was using, a 300 twice a day.

So that’s kind of the ballpark. And again, people have made the argument that you should never give D-alpha tocopherol by itself because there may be some counterproductive aspect to that. And that’s been true for my practice for a long time. I don’t use isolated vitamin A. I kind of make a little editorial here. I’ve seen some mainstream studies saying that, well, we’ve got to be careful with vitamin D because it may have side effects, and we haven’t really studied it enough with those studies on vitamin E for fatty liver go back decades. And I think, okay, I don’t I don’t understand the standard here. We don’t know if vitamin E is safe and it hasn’t been studied enough.

So let’s endorse GLP-1s. There’s something weird going on. There’s a logical flaw in all of that. So yeah, I think vitamin D is safe. I have it, I’ve been prescribing it really as long as I’ve been in medicine. I remember the shoot brothers with the remember the Shute Brothers, the vitamin E Institute in London, Ontario were advocating vitamin E for a whole range of things. You know, that was decades ago. So it’s not like this is a brand-new thing that somebody just discovered.

Evelyne Lambrecht: I’m curious too. When you are putting someone on a program, how long does it take to see changes on an ultrasound or when do you generally retest?

Dr. Robert Rountree: Well, I don’t think there’s a hard and fast rule generally within a few months. You don’t do it a month later. You’re not going to see changes that fast. And if a person is losing weight you might want to do the ultrasound sooner rather than later. So I would say for an average person maybe I repeat the ultrasound in 6 to 12 months. So I’m not in a big rush to do that. But I do track liver enzymes and one thing I try a lot is gamma glutamine transcriptase. Right? GGT. GGT is this very underappreciated liver enzyme that it’s been around as long as I’ve been in medicine for over four decades. But it kind of fell off the map for a while because it’s so nonspecific, at least from the perspective of maybe a hepatologist. It’s nonspecific. But what does that mean exactly? That it’s nonspecific. It’s involved in glutathione recycling.

So for people like you and me, that’s very specific. Yeah. So glutathione we know what that is. If you’re recycling glutathione, that means your body’s dealing with some kind of toxic insult, whether it’s alcohol or glyphosate or a heavy metal or acetaminophen. Often, you know, there are many, many things that are neutralized by glutathione. So GGT is a very sensitive indicator of some kind of damage to the liver.

But I’ve actually had discussions with gastroenterologists that told me I don’t measure it because it’s so vague and nonspecific that I don’t know what to tell people when it’s elevated. So I don’t even bother to measure it. I think that’s nuts, right? It’s a cheap, easy thing to do, but it used to be on a standard liver panel, and they took it off because they said, oh, I don’t know what it adds, but I add it back in routinely. And that’s something that I’d like to know again in a month or two months. So the ultrasound, six, 12 months later, the early changes would be in a drop in the GGT.

Evelyne Lambrecht: Interesting. So you just made me think of something. I was under the impression for a while that high fructose corn syrup is one of the big issues that can lead to fatty liver. But because you mentioned glyphosate, do you think that one of the reasons that we’ve seen such an increase in prevalence of this is because of our environmental toxins, specifically glyphosate?

Dr. Robert Rountree: It’s funny you would mention that because an article just got published yesterday, and the journal is something like Environmental Toxicology. It’s a very respected journal that reviewed all the literature on fatty liver, MASLD and herbicides, especially glyphosate related herbicides, and said, well, we have mechanistic base connections here. We know that studies done in vitro of individual cells so show that glyphosate can cause liver injury.

We’ve got animal studies showing that glyphosate can cause liver injury and the changes that lead to methyl. And we’ve got population studies of measuring glyphosate in people’s urine that show that people with higher levels of glyphosate, the active ingredient in Roundup, that people with those higher levels have a greater incidence of fatty liver.

Evelyne Lambrecht: Fascinating.

Dr. Robert Rountree: Now, you know, the mainstream folks are going to, especially the people that make those chemicals are going to say those are only association studies. Well, that’s what we had in the beginning with cigarette smoking. And that’s the same come back. They said, well, there’s only an association with cigarette smoking. You can’t prove that cigarette smoking causes lung cancer or lung disease or anything like that. And they used that argument for a really long time might come back is, well, I don’t want to be exposed to glyphosate. I want to have a choice of whether I’m exposed to it or not.

Evelyne Lambrecht: Right.

Dr. Robert Rountree: I know I don’t want to be a rent-free storage facility for this chemical that I didn’t know. But we are rent-free storage facilities. And this article that I mentioned said, well, okay, here we have this condition, MASLD that affects a third or more of the population and the prevalence has doubled. They’ve got worse. It’s gone up by 50%. Not like double, but it’s gone up by 50% in the last couple of decades. And at the same time, the use of glyphosate and glyphosate related herbicides has gone up in parallel.

Evelyne Lambrecht: Yeah. Super, super interesting.

Dr. Robert Rountree: So, you know, they weren’t saying we can’t prove this, but what do you think? Do you think we should be, is there cause for concern? Right. That’s all we’re saying. You can’t prove it and we’ll never really be able to prove it. But there’s enough concern that I think people should say, well, I need a monitor the water that I’m drinking, the food that I’m eating, etc., and try to minimize exposure.

Evelyne Lambrecht: Right. I love how you put that. We’re rent-free storage facilities for microplastics and all the things, we don’t we don’t have a choice. And it is interesting when you, when you think about it that way, because the liver is our detoxification and recycling mechanism. And so it makes sense that it might become a little less efficient, though, I hear, because I follow a lot of like conventional medicine doctors because I want to know what they say.

And they’re kind of like against, cleanses and detoxes because they say the liver just like, knows to do that on its own, which is true. But, at some point it can’t like, handle all the insults that we just continue to throw at it, right?

Dr. Robert Rountree: Yeah. That’s actually the subject of one of my lectures is, oh, to talk about the notion that if you just drink enough water, then that all your liver needs for support. My good friend Deanna Minich. I know you know her.

Evelyne Lambrecht: Yeah. We interviewed her recently.

Dr. Robert Rountree: Yeah. Lovely, super smart lady. Has done a great job reviewing the literature on things you can do to support the liver’s ability to process toxins. In the functional medicine world, the term we’re using is mitigate. You can mitigate toxins, which mitigation doesn’t just involve, enzymatic transformation of things. It also involves things like neutralizing free radicals or neutralizing heavy metals, sequestering heavy metals. So there are a lot of different ways you can neutralize these external toxins. The better word to use is toxicins.

And so again, when I hear a doc say, oh, cleanses are nonsense. I just think, well, have you been to a library recently? Or maybe you haven’t been to a library, but have you been on PubMed? Maybe you should look at some of the articles that Doctor Minich sites.

Evelyne Lambrecht: Yeah, absolutely. And I want to go back to the nutrients. But you made me think of another question is, have you ever used a metabolic detoxification protocol or one of those cleanses in isolation just for your fatty liver?

Dr. Robert Rountree: Yeah. I think it depends on how many changes a person needs to make. I have some patients, because I live in Boulder, Colorado, right? Where everybody’s heard of everything, and it’s not unusual for one of my patients to also see a naturopath and a chiropractor and an acupuncture. So I have people that are already super aware of their diet and those people and I find their enzymes are up, they go, what the heck, like I’m doing. I’m already doing all the right things. And maybe they want to take it to the next level. And that’s the kind of person that I would use, say a rice pea protein bowel rest or something like that. And then what about the person that comes in that’s clueless? They’ve never heard of any of this stuff. And I see folks like that too. They were told by their doc, your liver enzymes are up, your gut is up, and maybe you need to be on medication for that, but no real attempt to take a comprehensive look at their diet, their lifestyle, their sleep, their exercise, all of those kind of things.

And so doing a bowel rest program protein sparing, modified fast is the term we used to use for that. Sure. That can be a really helpful thing.

Evelyne Lambrecht: Yeah. And I find that when people do them, even I did one of ours, back in February. And it just kind of helped me reset, get back on the right track, you know? So, I want to go back to the nutrients. Are there any that you use or from the literature that you find work really well for this?

Dr. Robert Rountree: Berberine. Berberine.

Evelyne Lambrecht: I love berberine.

Dr. Robert Rountree: I just love it. I’ve taken it myself for 20 years, I think. And I’ve consulted with a number of nutraceutical companies over the years where I’ve told them, hey, you need to up your dose, because the, the higher doses, 1,500 to 2,000mg a day is much more likely to be effective.

So that’s an interesting story because berberine is a traditional Chinese medicine, right. But it’s mostly been used for gut health, and, and for things like traveler’s diarrhea, which it’s pretty good for that because it’s an anti-microbial and can actually kill parasites and yeast and certain kinds of unhealthy bacteria. So we’ve known that forever. And it was probably one of the first herbal extracts I started using things like golden seal, Oregon grape root, cauthesgenensis, a lot of these herbs have berberine as the active ingredient in them. And I think it was more of an incidental discovery in China of people who were taking berberine for gut health, where their doctors in China would say, hey, look at this. Your blood sugar has gone down, the hemoglobin A1-C has gone down, your blood pressure has gone down. And for some people, they’re losing weight as well.

And of course, the initial push back when it’s sort of being recommended that people take higher doses of berberine for longer periods of time is, well, this is an antibiotic. It’s going to mess up your gut microbiome. Do you know what? It doesn’t seem to do that. And I can say that from personal experience, I’ve had my gut microbiome tested in four different labs at least, and I haven’t seen significant dysbiosis from it, and I haven’t seen it in my patients as well. So I just haven’t seen it be a long term problem for gut health.

And the studies keep coming out about how beneficial it is for insulin resistance, for liver support. It does a lot of the same things that metformin does, but it doesn’t have that potential for persistent nausea, which is a big deal for metformin users.

Evelyne Lambrecht: Yeah I do hear that about berberine sometimes, like the concern about taking it for too long. But you’ve been taking it for 20 years.

Dr. Robert Rountree: So that’s 20 years. And I’ve had other patients taking it for similar periods of time.

Evelyne Lambrecht: And we have a more bioavailable form, but I’m curious about the doses that you mentioned because are you talking about the dry herb or a standardized extract in that dose?

Dr. Robert Rountree: Well, I always use a standardized extract because otherwise I don’t know exactly how much a person’s getting. So I based on the studies that use standardized extracts, we’re just using berberine hydrochloride. And those studies gave 1500 to 2000 mg a day. Now there are newer forms of berberine that supposedly are more bioavailable. The phytosome, for example. But that’s not the only one that’s out there that’s supposedly a better absorption. We don’t know. I’m still giving roughly the same number of capsules a day. And I still can’t give you a clear answer yet, because I haven’t seen enough head that had published studies, but I’m generally getting similar results. So the product that I take is a combination of the hydrochloride and the phytosome itself. I’m kind of hedging my bets on that. But I’ve had a few people that have gone back and forth, and I’m getting pretty similar results with the same number of capsules, even though technically the dose is lower.

Now, the other question that’s come up in the last year or two is there’s a form called dihydroberberine. As far as I know, only one company is making that. They claim it’s five times better absorbed than berberine, and it should work better. Well, I’ve tried it in a couple of patients, and I don’t have the experience yet that it’s dramatically different. Right, because you’re using a much lower dose. So you’re using 200, 300mg a day as opposed to 1500 or 2000. So I don’t know yet. But this is all it’s very interesting to me that it’s evolving that way.

Evelyne Lambrecht: Anything else you want to add on liver health before we shift topics?

Dr. Robert Rountree: Well, the important thing to understand is that what’s going on in the gut microbiome is a major contributor. Right. And there are several thoughts about that. One is that dysbiosis is a major cause of leaky gut.

And even though there’s still some mainstream docs and hold out that there is no such thing as a leaky gut, that’s simply not true. There are many published studies in mainstream journals on intestinal hyper permeability and how that contributes to massively and to MASH. So it’s pretty clear that dysbiosis is a major player here. The question is, well, what’s the best way to address dysbiosis, prebiotics and probiotics and is there any one specific probiotic that I recommend? No, I have to be clear about that is I think probiotics are generally helpful. And I think different probiotics help different people at different times.

So I’ve been going back and forth on this issue, which one they use for decades now. And I think it’s more trial and error. I think the most important thing is that you have a probiotic that, it’s got a specific number of colony forming units. So if you look on a label of a product and it says, yeah, it’s got some it’s got some in there. Well, any good company is going to tell you exactly the number CFUs and the specific strains. And those are important things to keep in mind. But there isn’t any one probiotic. Should one probiotic be used exclusively or should you use a combination? There’s studies suggesting both.

Evelyne Lambrecht: I think it’s a good way to rotate some right.

Dr. Robert Rountree: Yeah. It’s good. Theoretically it’s good. And then you know the prebiotic fibers. Your inulin, your plant fibers. All those things are very helpful.

Evelyne Lambrecht: And I thought it was also interesting, was it the American Liver Society that I was looking at when they recommend,

Dr. Robert Rountree: Some liver societies like the American Association for the Study of Liver Disease or something.

Evelyne Lambrecht: Okay. So the ones who recommend vitamin E, they also recommend coffee. Dr. Robert Roundtree: Yeah. There was a study done in England, I think, where they said there’s a huge biobank in England where they, they keep data on people, they keep blood studies, etc. and they do questionnaires where they ask them what do they consume?

And there was a study that came out a year or two ago that I cited in that lecture that I gave for UC Irvine that basically showed that coffee had a negative association with fatty liver. Negative association means the more coffee you drink, the less fatty liver you have. So I thought yay for coffee and espresso seem to be particularly helpful. Why is that? Because there are a lot of beneficial chemicals in good coffee. Chlorogenic acid is one of them. Cafeic acid. And, you know, this is a subject for another discussion, but those chemicals seem to upregulate Nrf2, which is the body’s resistance mechanism against injury. So coffee’s good.

Evelyne Lambrecht: Cool. I will keep drinking my cappuccinos. Just before we shift to mitochondrial health. You’ve worked at many different supplement companies over the years, and you actually have some history at Designs for Health, too. And we love sharing the legacy and the family story on the podcast, I’ve interviewed Jonathan Lizotte, our founder; David Brady a few times; our Chief Medical Officer, Stella Lizotte Talkie, and you were close to Robert Crayhon, right, who also cofounded Designs for Health with Jonathan Lizotte. And I’d love to just hear a little bit more about those founding days, those early days.

Dr. Robert Rountree: Okay. Make no bones about it. I loved Robert, I thought he was an amazing human being. A mentor, one of the most brilliant people I’ve ever met. Totally inspiring. He had the ability to dive through the medical journals and to separate out the signal from the noise, and I really appreciated that about him. He was incredibly funny. Funny as hell. I mean, we all went on a kayaking trip, a, kayaking expedition in British Columbia for a week, and the guy had us cracking up day and night. There’s this constant stream of brilliant, insightful jokes. So he was a great guy to be around.

And, he had this keen mind and was great at going through the latest discoveries in nutrition and telling us all what that meant. So it really inspired me to be more of a scholar. I would say I was, I appreciate the scholarship at the time, and what I mean by scholarship is like a willingness to really dive into the studies and, and extract out meaningful bits of information from them.

Something I always talk to my colleagues about is where do you get your information? Is it always secondary? Is it that you heard somebody say this or did you go read the paper yourself? Robert read the papers, Robert read the papers. And one of the things he did that was really brilliant was he brought out all this research about things like acetylcarnitine for brain health, phospatidylcholine for brain health, glycerolphosphatecholine for brain health, when really nobody was talking about it. And he put together some great products that originally were only available through his company. And then he merged with Designs for Health and I kind of follow that merger. So I started looking for Robert at his conferences. Got a chance to meet some really brilliant people because Robert was also a great connector. And then eventually that company, Crayhon Research, merged in with Designs for Health. And so that was actually quite a thrill to see that get a bigger and bigger audience.

Evelyne Lambrecht: I love hearing that. Thank you so much for sharing. I’ve only heard the most amazing things about him. We’ve shared it on some company calls internally. And so, it’s just really special. And how cool that you got to know him. And the scholarship piece is interesting because throughout our conversation, I’ve been thinking, oh, my gosh, Bob, you’ve read every paper like you truly are on top of, all the research, all the time. So thank you.

Dr. Robert Rountree: I just realized, I mean, Robert is one of the people that helped me realize if you rely on secondary sources all the time, you can get it wrong. Yeah. Now that we have artificial intelligence, assistants that are out there, I’ve really learned that because I’ve gone to some of these AI assistants and asked a question, and I’ve gotten incorrect answers.

Evelyne Lambrecht: Same.

Dr. Robert Rountree: Right. And I go, oh my God, it’s quick. And the problem is, these answers you get sounds so logical and great and evidence based and then but something intuitively and me would say, I don’t know, that doesn’t seem right. And I would challenge the answer. And I’ve actually had the AI assistants say, you’re exactly right. Thank you for challenging me, which is very interesting. So Robert helped teach me that. He helped teach me that, that I had the ability to go read a neurology journal and make sense out of it, that it’s really not that hard once you get the lingo, once you understand what you’re looking for, and it’s much more rewarding to be able to do that.

So when I use an AI assistant, I still use them. You know, I asked for the references. Well, where did you get that from? And then I go back and look at the references myself. So I use the AI system as kind of an initial navigation step, but I never use it as an endpoint.

Evelyne Lambrecht: Yeah, I’m actually really glad you brought that up because I think it’s so important. When I was preparing for that presentation at the Mexican Association of Lifestyle Medicine conference, I did a talk on adaptogens. We’re going to be there together next year for sure. But I asked for to give me 2 to 3 references for each of the herbs that I was speaking to. And then I obviously fact-checked them. Some of them were completely made up, nowhere to be found. Some of them were about different herbs. So it was crazy because if I just took it at face value, I would have been like, oh, okay, great. Thank you. Like, this is great information, but, we can’t do that. We have to fact-check with PubMed.

Dr. Robert Rountree: We have to fact-check. And some myths get perpetuated, like the myth that Eleutherococcus, Siberian ginseng causes hypertension. I see it in all these medical textbooks. And, you know, I’d love for the reference. Well, where did you get that from? And I keep tracking it back. And then, oh, the original reference was published in Russian and never actually got translated. And so somebody read an abstract of a Russian study and said it causes hypertension. And then it just gets perpetuated. And it’s in the pharmacology textbooks. So how often does something like that happen that you shouldn’t do that or certain herbs that you hear can cause bleeding, don’t take this. You’ll bleed to death if you take garlic. Okay. Give me a break.

Evelyne Lambrecht: Yeah. That’s funny. Okay, so we don’t have a ton of time left. But I do want to talk about some mitochondria health nutrients. What are your top nutrients when it comes to like mitochondrial biogenesis, mitochondrial efficiency but also mitophagy.

Dr. Robert Rountree: So to answer that I have to say a little bit about just the concept that mitochondria go through a process called quality control. QC we say in the supplement industry that you don’t just get a bunch of mitochondria in your cells and you’re done. Right. We’re constantly recycling the mitochondria that we have. And the main stimulus for doing that is exercise. And how would that work exactly? Well, when you exercise, you deplete the body of ATP. ATP has got three phosphates on it. So you get rid of one of them, you go from ATP to ADP, adenosine diphosphate, and you get rid of that one and you have adenosine monophosphate. And ANP is actually a big signal to cells that something needs to happen. Right. Some something needs to change because now the cell’s depleted of energy. So how do we make more?

Interestingly enough, berberine seems to it activates that same signal called the AMP kinase, AMPK, turning out to be a huge signal that that’s quite beneficial to mitochondria, that stimulates biogenesis. So it’s working through the same mechanism as exercise. So we did an exercise mimic. I always use berberine as part of that protocol. Some people would say well why not use metformin. Well it’s a prescription drug. It can cause chronic nausea. Some people just don’t do well on it. And berberine does a lot of the same things. So I’m going to use that a lot.

There’s some pretty good data on resveratrol for that. Probably resveratrol needs to be combined with an NAD precursor. And I know NAD precursors. That’s a kind of charged term, isn’t it? Because NAD precursors, whether we’re talking about NNM or in our nicotinamide, riboside or just niacinamide as an NAD precursor? All of those probably factor into this, and it’s a little bit of a kind of a complicated beast to try to sort all that out. But I, I think there’s something going on there. I think raising NAD with something, along with resveratrol, is a really good way to go.

Evelyne Lambrecht: Yeah. Since you brought up the NAD precursors, I remember when NR first came out, I think it was like 2013, so it’s been out for a long time. What do you find clinically that your patients notice? Like who are the kinds of patients that you are mostly using it in. And I know now everybody’s on like the Biohacker train, and taking it for those reasons. But I’m curious how you use it in your clinical practice.

Dr. Robert Rountree: I use it more for metabolic things as a part of an overall program. And, I’m using it more for neurologic things. There’s actually some pretty good data on precursors for Parkinson’s disease.

Evelyne Lambrecht: Interesting.

Dr. Robert Rountree: What is Parkinson’s disease? Well, it’s a mitochondrial disorder. It’s a problem with mitochondrial quality control, with an inability to get rid of the rusty old mitochondria that aren’t working right, and to stimulate the body to make more mitochondria. And there was one pretty good study, showing that when you raise NDA, it can be helpful for Parkinson’s. So I tend to use it more for neurologic things. I tend to use it more for overall dysmetabolism, metabolic syndrome, fatty liver. Now, I won’t tell you that by itself on seeing anything magic happen. Berberine, if you use it by itself, you can see all kinds of metabolic changes going on. And the precursors, I think, have to be part of this whole program, typically combined with resveratrol or another one of my all-time favorite supplements is quercetin. Which person is actually been shown by itself to stimulate mitochondrial biogenesis.

Evelyne Lambrecht: I don’t know if I’ve heard that.

Dr. Robert Rountree: Well there’s this study showing it improves athletic performance a very underappreciated nutrient. If you just drink you know French onion soup and you’re going to get some of course it in that but not a lot.

Evelyne Lambrecht: That’s great. Thank you for sharing. What just to wrap this up, what’s a list of some of your other favorite mitochondrial support nutrients?

Dr. Robert Rountree: I list alpha-lipoic acid. I think that’s a really good one. CoQ10. It’s been with us for a long time. We know that CoQ10 levels drop with aging, as do mitochondria. So the number of mitochondria drop with aging the same time CoQ10 does. So I think CoQ10 is a really helpful thing.

Simple B vitamins can be helpful, even just a basic B-complex can be quite helpful. Magnesium. Magnesium is part of ATP, right? You need magnesium for ATP to work. And a lot of different kinds of magnesium can help. So I recommend the type of magnesium that’s best tolerated by and individual. There’s emerging research on urolithin A for mitochondrial quality control. I think it’s an interesting molecule. I don’t use it a lot, but I do prescribe it sometimes. I know it’s being heavily promoted for mitochondria. So I just thought it should be mentioned is something that’s out there. You know spermidine is being recommended. I don’t have any experience with it. It seems a bit pricey to me and the data seems a bit preliminary, but that’s one worth taking a look at. David Sinclair is really big on it, and he’s kind of a mitochondrial guy.

What about ketones? Okay. Well, that’s another thing we could talk about for a long time. Mitochondria love ketones, especially the neuronal mitochondria do really well in ketones. Which explains why kids that have intractable seizure disorders do well on a ketogenic diet. So we’ve done that for decades. We’ve known that people with brain tumors with glioblastoma and multiforme, which is incredibly hard to treat, seem to do better on ketogenic style diets. So we know that the diets can be helpful, but we’re just learning more about now. It’s rather exogenous ketones, using a powder, the beta hydroxybutyrate, was it 1-3 butane dials, the MCT oils. Robert Crayhon was one of those people talking about MCT oils.

And it turns out MCT is help the body help the liver produce more ketones, which would give you benefits for brain health, metabolic health, etc. So, I think that’s kind of an exciting area for opening up is looking at ketones for brain health or athletic performance for metabolic health. I kind of love looking into that.

Evelyne Lambrecht: Thank you for sharing. And I do know that exogenous ketones are a lot harder now to source. We used to sell them, but we can’t anymore. And even that one company, do they even still have them?

Dr. Robert Rountree: Well, there are a lot of companies selling the drinks to athletes or selling shots, so they’re out there. One of the biggest problems with them is taste. They taste like nail polish remover. And so you got to do something. You have to play with the chemistry a little bit to make it palatable. The first generation of the ketone drinks that came out were just God-awful. I don’t know how anybody could do it. And they were really, really expensive. So only professional athletes were doing it. But I think there are some emerging products on the market now that are a little bit more tolerable.

Evelyne Lambrecht: Interesting. Well, thank you so much for sharing those. And I love hearing, when it comes to mitochondrial health that we’re using a lot of like the basics that we already know, not necessarily like the shiniest new things. So that’s great. Anything else you want to add before I ask your closing questions on mitochondrial health that practitioners that you really like want to share?

Dr. Robert Rountree: Well, I just think when you pull back and you look at the big concept here, you have to say, why is it that a person who’s really obese and, and prediabetic or diabetic can eat 3 or 4,000 calories a day and not have energy. What explains that? So when I hear mainstream doc saying the only mitochondrial disorders are genetic, then I think, okay, well then why do we have this epidemic of fatty liver? Why do we have this epidemic of chronic fatigue? Why do we have this epidemic of prediabetes? And when they do biopsies of people with prediabetes, their mitochondria are fewer in number and have less content. There’s less in them.

So to say that mitochondrial disorders are only the genetic ones are simply not evidence based. And so that’s the big takeaway that I want people to hear is that there’s a large body of data saying mitochondrial health is really critical for metabolic health, for liver health, for neuronal health. It’s really kind of a core issue. And so if you keep your mitochondria happy and healthy, with the right amount of exercise, for starters, with not eating junk food, avoiding toxic exposures like glyphosate, all those things can make a difference in the quality of your mitochondria.

Evelyne Lambrecht: Thank you. And I know I said that was the last thing, but I did want to bring up one more thing. Since we’re talking so much about metabolic health, you have recently started using, a, blood glucose monitor yourself.

Dr. Robert Rountree: I’m wearing one now.

Evelyne Lambrecht: Nice. I need to put mine back on. But I did want to share with practitioners listening because I think this is so important to know that your patients, your clients can now purchase the CGM directly from Dexcom and from Abbott. So it’s either the Stelo or the Lingo is the one from, Abbott. I think it’s like the Freestyle equivalent. Lingo is from Abbott.

Dr. Robert Rountree: And they’re both about 100 bucks a month. Something like that.

Evelyne Lambrecht: It was $89.

Dr. Robert Rountree: Yes, if you get on a subscription, it’s cheaper.

Evelyne Lambrecht: Oh, I think I bought the first for like $89.

Dr. Robert Rountree: You got the deal.

Evelyne Lambrecht: I got the deal. But you can even do just one or a two week period for a lesser price and I think this is so helpful for people to know and it’s just so much more accessible. And then it hasn’t rolled out on my Aura yet, but I’m going to switch from Lingo to Stelo because Stelo is going to incorporate with the Aura ring.

Dr. Robert Rountree: It’s showing on my Aura now.

Evelyne Lambrecht: Oh it is? Oh, nice.

Dr. Robert Rountree: It’s amazing. It used to be the in order to integrate all this information, you had to go through Levels or Nutrisense, one of these companies and to their credit they kind of introduced the idea that you don’t have to be a diabetic to benefit from using a CGM.

And when Levels and Nutrisense first got going, I started seeing a lot of athletes at my gym wearing CGMs. And I’m going, you’re big, strong, healthy guy, why are you wearing this? And he’s like, Because I’m interested in performance. And how does blood sugar spike influence my ability to perform athletically? So to their credit, they kind of introduced that concept, but now it’s really readily available.

So I’m not discouraging people from using Nutrisense or Levels. I think those apps really have their place. But for people who say, well, I don’t want to get involved in something that elaborate, then yeah, you can just go to Stelo.com

Evelyne Lambrecht: What’s the biggest thing you’ve personally learned from using yours?

Dr. Robert Rountree: That you can look up high and low glycemic index foods online, and a lot of the stuff you read is wrong, right? It’s just wrong. Oh, this is a low GI food. And then I eat it and I get a glucose spike and I go, what? That’s not supposed to happen, right? You know, I’ve been following the notion of carb restriction back since the days I was hanging out with Robert Crayhon and Mike and Mary Dan Eades, who wrote the book Protein Power. Johnny Bowden wrote the low carb living book. I’ve been following that stuff for a long time, but I thought if I ate healthy carbs whole grains, whole wheat bread that’s got nuts in it and coarse grains. And I always thought, yeah, this is great stuff. And then I get a CGM and I ate a slab of whole grain bread. That’s all nutty. And I see my glucose go up, and I’m like, you’ve got to be kidding, right? For people who are carb, who are insulin resistant, which evidently I am much more than I realize. And they’re carb sensitive as a result of that, then any carb can potentially be a problem.

Evelyne Lambrecht: So it’s good to have that data and to just discover it for yourself.

Dr. Robert Rountree: And to see the influence of things like sleep and exercise, all that, which it’s great in the Aura ring now because I can say, oh, look, I didn’t sleep as well last night. My fasting sugar is a little higher. Or I went out and jumped in the pool and I swam a mile and a half and look, now my sugar’s good. So it’s really nice to see that correlation.

Evelyne Lambrecht: Really cool. Okay. So we’re going to finish here with our rapid fire questions. So what are your three favorite supplements right now for yourself?

Dr. Robert Rountree: Oh my god my favorite three?

Evelyne Lambrecht: Berberine?

Dr. Robert Rountree: I would definitely say berberine is pretty far up there. Maybe fish oil. You know I have to say that. I have to say that fish oil, maybe CoQ10.

Evelyne Lambrecht: Okay, great.

Dr. Robert Rountree: If I could say four I would say some kind of probiotic.

Evelyne Lambrecht: Okay.

Dr. Robert Rountree: This is off the top of my head, but I taking a lot of things, right?

Evelyne Lambrecht: Oh. I’m sure. Yeah. What are your favorite health practices to keep you balanced?

Dr. Robert Rountree: Meditate every day. Without fail, it keeps me sane. It doesn’t turn me into an enlighten monk or anything like that, but it helps me deal with what’s going on in the world. Number two is I swim a couple of times a week, and it’s a pretty vigorous swim, and getting in the water and moving, I just can’t tell you how much I love that. Getting out into nature as much as I can. Into wild nature of a cabin up in the mountains, and I love going out up on the trails and just smelling the air and looking for animals and that sort of thing.

Evelyne Lambrecht: I love that. Same. And last question, what is something you’ve changed your mind about through all of your years in this field?

Dr. Robert Rountree: Well, the thing I was just talking about is this whole notion that, well, as long as you’re eating good carbs, then you’re fine. And maybe for some people, that’s true. But I’ve always thought I was eating good carbs until I started looking at CGM readings. So that’s really been pretty eye-opening for me years ago. Okay. That just isn’t going to work right now. Maybe someday I can go back and have a nice big slab of whole wheat bread. But for the time being, it’s just not in the cards.

Evelyne Lambrecht: Thank you so much for sharing that. And thank you so much, Bob. This has just been such a fun conversation. I am so grateful to know you and you’ve just always shared so generously with everybody. I’m just so grateful.

Dr. Robert Rountree: I’m looking forward to see you got to get the word out.

Evelyne Lambrecht: Yes, absolutely. And thank you for tuning in to Conversations for Health. Check out the show notes for resources from today’s episode. Please share this podcast with your colleagues. Follow, rate or leave a review wherever you listen or watch. And thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence based, cutting edge research and practical tips.