Sara Szal Gottfried, MD, joins Integrative Practitioner Content Specialist, Avery St. Onge, to discuss how she uses in-depth testing and wearable technology to tailor personalized treatment plans to help optimize her patient’s health and meet their individual goals.

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About the Expert

Sara Szal Gottfried, MD, is a physician, researcher, educator, and seeker. She graduated from Harvard Medical School and Massachusetts Institute of Technology, and completed residency at University of California, San Francisco, but is more likely to prescribe a continuous glucose monitor and personalized nutrition plan than the latest pharmaceutical. Szal is a global keynote speaker and the author of four New York Times bestselling books about trauma, hormones, and health. She is Clinical Assistant Professor in Dept. of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University, and Director of Precision Medicine at the Marcus Institute of Integrative Health. Her focus is at the interface of mental and physical health, N-of-1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes and promote deepening transformative experiences.


Avery St. Onge: Welcome Dr. Szal. Thank you so much for joining me on the podcast today.

Sara Szal: My pleasure; nice to be with you, Avery.

Avery St. Onge: So, to begin, can you give me an overview of what you will be discussing at the symposium?

Sara Szal: We're going to be talking about personalized medicine and in the panel. The focus is on personalized nutrition.

Avery St. Onge: Okay, and then I know the audience is familiar with this concept, but can you define personalized medicine or personalized nutrition?

Sara Szal: Sure, so personalized medicine is what I practice, and I would say personalized nutrition is a subset of it. The way that I define it is that it's a type of medical care that is customized to the individual. So that's that. And gene-environment interface and how do we optimize it for whatever goal the client or patient has. So, for instance, I take care of executives at Thomas Jefferson University, and I also take care of professional athletes. And so their goals are a little bit different. Executives often are focused on career longevity, energy fitness, and cognitive performance, and then pro athletes, of course, are very focused on physical performance.

Avery St. Onge: How did you personally become interested in Personalized medicine? How did that journey begin for you?

Sara Szal: Yeah, I got interested, Avery, because I felt like the type of medicine that I was taught at Harvard Medical School and then in residency at the University Of California San Francisco was really medicine for the population. Which becomes medicine for the average. So if you think of, for instance, ah, you know Ah, ah, cholesterol level, if you think about lipids, we know what the bell shape curve looks like. We know what, Um, the average American has. But the problem is average in the United States. It's not that good, right? Because 88% of Americans are metabolically unhealthy, the average is not the same as optimal. If you're more interested in optimal performance, you're more interested in having the wind at your back. With the energy you have to seek your mission to do whatever you're on the planet to do, I think it's important to personalize. So, I've always been interested in that I'm a bioengineer before I went to medical school. And then when I struggled in my thirties with hormone imbalances, and, you know, finding that I had Insulin resistance, I realized that a lot of the things that are designed for a population-based model, you know, medicine for the average, didn't work for me. And so that started me on this path of doing N-of-1 experiments and really being able to tailor the way that I design my life, The way that I eat, sleep, think, and love Connect. All those things are personalized to who I am, and then I started to offer that to my patients, and it's really effective.

Avery St. Onge: And can you tell me just a bit about what personalized medicine actually looks like in practice? Then you got into this a little, but what does your patient population look like?

Sara Szal: Yeah, my patients primarily now are executives through the Executive Great Life program that we have at Thomas Jefferson, which is where I serve as the director of precision medicine. Um, so I take care of executives. They come in 2 different paths: either through the precision medicine program or they come in through the precision brain program. So ah, they spend a day with us and at the end they leave with a. Ah, protocol. That's really designed specifically for them, considering their genetics, goals, and biomarkers, so that mostly, in this case, is blood testing, so that's the executive. Great life program. Then, I also take care of professional athletes, which is a different beast because we're focused on genetics again because genetics determine about 40% of your capacity. Your physical performance, your recovery, your risk of injury, but another 60%, of course, is your environment, and so how do we? How do we know about genetics? So we know what we have to work around, but then how do we also design the environment so that it's working? Genetics to improve whatever the goal is, most of the pro athletes I work with are NBA players, and they want to gain muscle, lose fat, and, you know, run up and down the court. Um, the entire game. So yeah, that's what we're working with, and then I also take care of everyday folks. I've got a lot of men and women who come to me because they've got hormone of balance or they've got an autoimmune disease or ah prediabetes or some kind of metabolic dysfunction because that's the area of my research I do multi-omic phenotype being 4 Transition from health to prediabetes. So that's kind of the 3 classes of patients I've got: the executives, the pro athletes, and then kind of the everyday folks.

Avery St. Onge: And how do things like genetics and that kind of precision testing guide the treatment? For instance, is there a specific diet you would suggest to someone who has a specific set of genes?

Sara Szal: Yeah, you know, when I first started learning about genetics twenty or thirty years ago, I really felt like the human genome project would revolutionize medical care. You know, allow us to personalize and allow us to. Come up with recommendations based on your genetics, and what we've learned is that you can't quite do that. You have to look at the way genes are expressed, much of which is modifiable with epigenetic change, and then you also have to look at biomarkers. For instance, you might have a gene like apoa two that changes the way that you respond to saturated fat, and you don't know how you respond to saturated fat. You may have increased insulin resistance, or you may not. Depending on how that genus is expressed, we really have to do the two together. We have to have the genetics together with the biomarker testing, so blood work and urine testing are what I like to do for hormones. I like to look at nutritional testing, I like to look at um. Advanced lipid profiles and inflammation profiles I like to look at stool testing the microbiome and how the gut is functioning, and so you need the two together to really have a full phenotype for the individual, you know, kind of who they are in the World. So, It's the phenotype. That's more important than the genotype in terms of diet. The experience I've seen in the past is where you get a genetic test, and you know you are told that you've got mtfr or some other snp. Then, you customize a diet based on that, not with biomarkers. I haven't seen that be successful, so you have to have the two side by side to really customize a food plan, and um, so I would say the way that I typically start. So, look at genetics to give us a ballpark, and I think we have to do pathway-based genomics. You know, looking at things like cellular pathways detoxication, inflammation, oxidative stress methylation, and then we want to look at systems with genomics like yours. Ah, brain Health, your metabolic Health, glucose, and insulin. Um, you know the way that you deal with neurotransmitters now; those talk to hormones in terms of your mood and behavior and so on. When you do genetics that way, you can then look at biomarkers, see what genes are being expressed, which variations of single Nu Nucleot Ibolymorphineisms are being expressed, and then come up with personalized recommendations such as for nutrition.

Sara Szal: So, give you an example, if I've got a patient who's got an autoimmune disease, so Alaio Fasano, I've heard him talk at ihs about how you need a three three-legged stool to develop, um, autoimmune disease, you need a genetic predisposition, together with increased intestinal permeability and then some kind of trigger. So that trigger could be Covid. It could be, um, trauma usually, there's some sort of trigger. Maybe it's gluten. Um, if you've got celiac and so. In that situation with autoimmune disease. We then want to look at the genetics; we want to look at the biomarkers. If you've got someone with celiac, you're going to cut out gluten if you've got someone who's got some other type of autoimmune disease like rheumatoid arthritis. Often, we start with an elimination diet to be able to identify. Okay, here are the triggers for this particular person, and we've got decades of data to support that kind of approach for someone who's got metabolic dysfunction. Maybe they've got prediabetes. I often use the Institute for Functional Medicine cardiometabolic food plan, and then I'll tailor it to the individual. So those are some examples of how we do personalized nutrition based on genetics plus biomarker testing.

Avery St. Onge: That makes a lot of sense then. Do you use wearable technology in your practice, and how does that contribute to the treatment plan?

Sara Szal: Yeah, wearables are incredibly important. We know that about half of Americans right now are using wearables, so things like a ring or, you know, an Apple watch or a whoop, and then we also know that implantable. Wearables are becoming more important, so I wear a continuous glucose monitor, and frankly, I found that wearables, including the continuous glucose monitor, allow us to personalize diet better than any other strategy that I've seen because they set up this immediate feedback loop. What's happening with the food that you eat? So, it's really helpful with personalized nutrition. A lot of folks are surprised you know I have prediabetes that's in remission now, and I think the continuous glucose monitor has really helped me to get it into remission, but all of the. You know, recommendations that I followed in terms of exercise and reducing carbohydrates. You know the following. Ah, the advice of the American ah the a d ada that didn't work for me because it wasn’t personalized. But when I got a continuous glucose monitor, I found that all of these foods, things like fruit, apples, legumes, sweet potatoes, and any kind of potato, were spiking my glucose up to levels that are in the diabetic range and so having that. Kind of, um, insight into your particular physiology with a wearable such as a CGM really makes a difference with personalization.

Avery St. Onge: I actually have type one diabetes. So, I wear a CGM too. But I know I've noticed more people are using them and people who don't have diabetes at all. Do you think that? We're kind of going in that direction, and do you think they're helpful for people who don't have diabetes?

Sara Szal: Well, we're still proving the case that it's helpful in people who don't have diabetes, so it was used first, as you described, in type one diabetes, and it's particularly helpful in terms of delivery of insulin. And then increasingly over the past ten years, we're using continuous glucose monitoring in people with type two diabetes and then as you start to look a little upstream earlier in the process. We know that people with prediabetes are diabetic, and it's just that when you do. A snapshot of a blood test, fasting glucose, and a look at hemoglobin A1C once or twice a year may not be sufficient to give you an accurate diagnosis. So, the benefit is that you get much more dense data sets, and there was one study that was published. By haul at all from Michael Michael Snyder's lab at Stanford where they found that if you do testing at the big beginning kind of the gold standard testing of a fasting glucose um hemoglobin a one c and you take people who are so-called healthy and then you. Suppose you put a continuous glucose monitor on them; about 15% end up being prediabetic, and about 2% end up being diabetic. So, I do think it's helpful to do it sooner, and that's why my research is focused on some of the dynamics that you see with a continuous glucose monitor. That can predate the diagnosis of either prediabetes or diabetes.

Avery St. Onge: Well, those are really all the questions that I had for you. Do you have anything else that you'd like to add?

Sara Szal: Well, hopefully, on the panel. We'll also talk about the role of hormones because I think hormones are so important, you know, with personalized nutrition. The thing I think of first is insulin resistance. How do you get insulin and get back on your side again? How do you become insulin-sensitive? And what works for one person might be different than what is personal, as some people need a ketogenic diet, like a therapeutic ketogenic diet, for four weeks. Some people do great with intermittent fasting, and that would be sufficient for them to address their insulin resistance. Some people have to dial in their glucose a little bit better, like with a continuous glucose monitor, so we want to consider some of these upstream forces. We also want to consider the gut. The role of the gut. The microbiome is how that often shifts eating and how much stress you have. Other factors. We want to look at the entire ecosystem when we think about personalized nutrition.

Avery St. Onge: Yeah, I wish all doctors were like you because the personalized approach is so important, and it really is just a one-size-fits-all fit, and you can just feel makes patients feel like they're crazy.

Sara Szal: Well, it can, it can fail patients. I mean, that's what we found. Now, if you just look at auto disease, we've got 24000000 Americans with autoimmune disease, and they really struggle to get an inaccurate diagnosis, and they tend to suffer with their symptoms for somewhere around 4.5 to 7 years before someone finally accurately diagnoses them and it can take looking at genetics and looking at some of this advanced biomarker testing that we talk about at ihs to be able to make that. Diagnosis. The other thing that happens is they see, on average, 4 to 6 physicians before they get that correct diagnosis. So you're right? There's a way that conventional medicine, as much as we love it, for acute problems like you break a bone or you need antibiotics for pneumonia. It just doesn't help with chronic disease the way that we need it to. That's why personalized medicine is so critical.

Avery St. Onge: Yes, definitely. Well, thank you again. Doctors, thank you for speaking with me this afternoon, and I look forward to your presentation.

Sara Szal: Thanks, Avery. Great to be with you.

Editor's note: Transcripts are autogenerated.