Q & A

Q & A

This page as an open thread for reader questions, especially questions about personal health concerns.

I am putting this page up as a way to share knowledge — my knowledge with questioners, but also so that others with similar concerns can read the conversation, and readers with relevant knowledge can chip in with their own thoughts.

Please keep in mind that I can’t research questions in any depth, so my answers should be considered tentative, incomplete, and subject to later correction. Also, I am not a doctor, and nothing I say should be construed as a substitute for medical diagnosis and treatment. I am only sharing opinions about disease origins and general therapeutic strategies which may or may not be applicable in any given case.

To get the page started, I’ll put up a few questions from recent emails. Here is an index by disease, with clickable links:

And here are my answers.

Chronic Lymphocytic Leukemia (CLL)


Been following your work on the PHD before the publication of the book and commented on my CLL and the usefulness of Vitamin D once on your blog and you responded to keep an eye on my Vitamin K intake, which I do now.. Am fortunate in a way to have my form of CLL as it indolent which gives me the opportunity to experiment without the pressure of undergoing conventional treatment. The PHD, I think, is helpful in this regard.

Wonder if you could point anything out to me that may be useful. Anything at all. And I will be happy to share with you my results.

Surely you know of the helpfulness of green tea with CLL. You may not be familiar with research that points out that those with low levels of Vitamin D need treatment for CLL far sooner than those with elevated levels.

Feel strongly that your version of a ketogenic diet would be helpful but also feel I need some direction in this area. Do you have any suggestions?

Warmest Regards,


Hi A,

I remember your comment, thanks for writing back. I’m glad you’re enjoying our diet and wish you the best.

Thanks for the tips about green tea and vitamin D. Neither one surprises me.

Most likely CLL is caused by a viral infection. So enhancing viral immunity is probably a good idea. Good strategies may include: (1) low-protein dieting, which inhibits viral reproduction and can promote autophagy; (2) maintaining high vitamin D levels; and (3) intermittent fasting, which promotes autophagy.

Some food compounds have been reported to have antiviral effects. An example is green tea catechins, eg http://pmid.us/16137775, http://pmid.us/18313149, and http://pmid.us/18363746, and this could be why green tea is helpful against cancers, http://pmid.us/21595018, which are usually viral in origin.

I might search Pubmed for herbs and spices with antiviral effects, and use them abundantly in cooking, along with antiviral foods. Turmeric / curcumin is a good choice, this needs to be taken with black pepper to enter the body. See http://pmid.us/21299124, http://pmid.us/20434445, http://pmid.us/20026048.

Coconut oil / lauric acid also has some antiviral properties, so inducing ketosis with coconut oil could benefit you even aside from the ketosis. You could also try monolaurin supplements which may enter the body better and which some people have reported to help viral infections.

You might also try HDL-raising tactics as discussed in this series: HDL and Immunity, April 12; HDL: Higher is Good, But is Highest Best?, April 14; How to Raise HDL, April 20.

Another possible tactic is high-dose riboflavin with UV exposure on the eyes. This requires going outdoors at midday and not wearing glasses or contact lenses. Riboflavin+UV is toxic to blood-borne viruses, and the retina is a location where UV can reach circulating blood cells. Sun exposure will also help you optimize vitamin D.

That’s a few ideas, at some point I’ll do some research to come up with more and do a blog post. Do keep me posted on your results!

Best, Paul

Bloating, acid reflux, anxiety, depression, hypoglycemia, hypothyroidism, fatigue

Just came upon your website and had a question for you. I have had some health concerns for the last four years, bloating, acid reflux, anxiety, depression, hypoglycemia symptoms, female complaints (I am in my forties), thyroid antibodies at 333, weight gain around my middle and too tired to work out like I once did. I used to be fikiiled with energy and great health no depression or anxiety. My doctor thinks these symtoms are all from peri-menopause and wants to treat me with Zoloft.

Needless to say I have tried to avoid the Zoloft. I have tired every avenue out there to cure myself. Most recently the Primal type diet. When I eat no grains or dairy I get horrible hypoglycemia symptoms and don’t feel great like everyone else on a low carb diet. I feel weak and more anxious. Do you think your diet would be easier for me with the addition of rice and potatoes?


Hi G,

Yes, I do think our diet will be better for you. You should eat enough starches to avoid hypoglycemia.

The key thing for you is treating the infections which are consuming so much glucose and making you glucose-deficient if you don’t eat enough carbs. Whatever pathogen(s) this is, it seems to have infected your gut and caused the various gut problems; circulating pathogen-derived toxins and immune cytokines are probably responsible for the anxiety and depression. Hashimoto’s hypothyroidism may be either due to circulating toxins or a thyroid infection.

I would suspect some kind of protozoal or parasitic infection due to the hypoglycemia, but what I really recommend is getting your doctor to have a stool sample analyzed for pathogens. Metametrix has a good test. Once you know what pathogen to treat, and get on a better diet like ours, you should improve quickly.


I am writing on behalf of my mother … We live in Dhaka Bangladesh …

Before her illness, my mom was 105 lbs, 5 feet tall and always 10ft tall in spirit…. When she was diagnosed with Lupus at the age of 30, we were all overwhelmed and out of our depths. My beautiful, athletic mother was in a wheelchair and given 6 months to live….

The doctors has advised her to eat literally nothing, minimum protein (1 small piece of chicken/fish, limited to 20g protein per day), only 2-3 types of vegetable and 2-3 fruits and of course lots of carbs to apparently compensate for her failing KIDNEY and LUPUS. She is on tons of medication, no food except the wrong foods (carbs) and in chronic pain. She currently weighs 139 lbs.

Please advise. — S

Hi S,

I believe lupus is a catch-all diagnosis for a variety of conditions which are probably caused by undiagnosed infections. In the US the infections are usually bacterial. I’ve known several people with diagnosed lupus who were cured by antibiotic treatments – in one case the problem was Lyme disease (Borrelia). I have no idea what the likely pathogens would be in Bangladesh. If she does better on low carb and coconut oil, that indicates bacteria; if she does better on high-carb, that indicates protozoa.

A healthy diet is very important. It is very bad advice to “eat literally nothing,” it is essential to be well nourished. Protein is necessary for healing and immune function, and 20 g/day is too little. Fasting is good, but it should be intermittent – not starvation! She needs healthy fats, more protein, and lots of micronutrients. Eggs, shellfish, seafood, bone broth soups, vegetable soups, and fermented vegetables may all be helpful. Coconut milk is probably good for her. You should basically follow the program in our book.

I would try to put her on a good diet, give her a little time for kidneys and other tissues to heal, and then try antimicrobial medicines. Usually, if they’re not working, then you don’t notice an effect. Any strong effect, good or bad, means they are working. Bad effects mean that pathogens are dying and releasing a lot of toxins as they disintegrate. If this occurs, detox aids (salt, water, and one of cholestyramine/charcoal/bentonite clay; also glutathione supports and vitamin C) will help.

Please stay in touch and let me know how things go.

Best, Paul


Jersie wrote:

I’ve suffered from depression for decades. A few months ago, I decided to try the Dr. Kruse protocol for jumpstarting leptin sensitivity and 2 interesting things happened.

When I went very low carb – below 50 gm -. I had half-day periods where the depression suddenly lifted (something that has rarely happened otherwise). However, I also suffered from darker than normal periods.

I stopped the Dr. Kruse protocol after 6 weeks, and went back to regular paleo (approx. 200 – 300 gm. Carb/day). I’m now generally more depressed than usual, without the good periods.

These changes seem to indicate that I can have an influence on my depression with diet, but not sure what diet to try. Thoughts?

Hi Jersie,

I think your experience on very low carb is diagnostically telling.

I would interpret it this way:

  1. Your depression is caused by an interferon-gamma mediated immune response in the brain, probably caused by a viral or bacterial infection. This leads to tryptophan being directed away from serotonin and toward the kynurenine pathway. So you have a serotonin deficiency and kynurenine excess.
  2. A ketogenic diet is both therapeutic (promotes immunity against bacterial and viral infections) and mood-improving (clears kynurenine).
  3. However, you are at risk for hypoglycemia in the brain (especially if the infection is bacterial) and hypoglycemia causes irritability/anxiety and can aggravate depression.

So the very low-carb diet had mixed effects (ketosis, hypoglycemia).

What I would do is follow our ketogenic diet advice. Eat at least 50 g/day carbs from starches to get sufficient glucose, plus sufficient protein to reach 600 calories/day protein+carb, but add in large amounts of MCT oil or coconut oil. Also, do intermittent fasting – eat all the carbs within an 8-hour window; eat at least half the MCT oil in the 16-hour fasting window.

Once on a good diet, I might experiment with antibiotics to see if they relieve symptoms.

Please let me know how things go.

Leave a comment ?


  1. Thoughts on xantham gum and guar gum? They are in a lot of products that are otherwise PHD complaint.

  2. Hi Paul,
    I am 41 and recently got a few tests done for the first time including lipid profile. My LDL has come at 160 (total at 230). I bought and read your book first time in 2013 and since then we switched to cooking with saturated fat at home (we do eat out but not very often). Also, we are vegetarians so our diet is high carb (we do eat eggs and dairy). What can I do to reduce LDL?

    • Hi Pawan,

      The common causes of high LDL are (1) metabolic endotoxemia, i.e. too much entry of fragments of cell walls from dead gut bacteria into the body, possibly caused by poor gut barrier integrity and/or small intestinal bacterial overgrowth and/or inflammation in the gut from pathogenic microbes; (2) hypothyroidism or iodine or selenium deficiency — note both deficiencies are common on vegetarian diets, though eggs will help with selenium, and hypothyroidism can be treated by replacement thyroid hormone; (3) excess iron which can be relieved by donating blood.

      PHD eating, intermittent fasting, circadian rhythm entrainment, egg yolks, vinegar, and extracellular matrix (shellfish, bones/joints/tendon soups) will help with (1). Can you add shellfish or bone/joint/tendon stocks to your diet?

      Best, Paul

  3. Hi Paul,

    How long can fermented vegetables stay in the fridge without going bad? Should I go by the smell?


    • I’ve read indefinitely, but best within 1 year if fully submerged in brine. I ferment, and my suggestion for most is within 6 months unless you’re fine with them getting softer.

  4. Hi Paul,
    Any additional thoughts on OCD and anxiety? I have heard brain health comes 85% from gut health. I started a strong probiotic, but am wondering about additional diet changes or supplements.

    Also, where can I find thoughts on ingredients such as xantham gum, guar gum, lactic acid, etc.?

    • I would avoid xantham gum. It seems like it has bacterial fragments on it, which are extremely immunogenic. Not something I would eat!

      Guar gum may be OK as an exception, in small quantities, probably not like something you would add to your food on purpose. It comes from a legume, so it’s suspicious. I don’t know about the extraction methods but they may or may not be an issue too.

      Lactic acid is healthy. It’s a product of bacterial fermentation. It’s produced in our gut too.

  5. Sooo appreciate this site–thank you! If you have time, would you please share your take on longer fasting (24hr up to 2 weeks). Have looked at Fung’s approach and since I am morbidly obese and have prediabetes, I’m wondering about the efficacy of combining PHD with longer fasting.


    • Hi Connie,

      Longer fasting may have some benefits, but I think the crucial thing is to set up a good daily rhythm that properly entrains circadian rhythms every day. Consistency is important. Try to finish eating as early as possible in the day, and don’t eat at all at night (only calorie-free beverages like water or herbal tea). Have a 12 hour night in which you get no blue or white light exposure, install two sets of lights in your home with orange bulbs for night use. Then, rigorously cut out omega-6 fats from your diet.

      An overnight 16 hour fast is perfect and something you should be able to do every day. Then, if you want to throw in occasional longer fasts, go for it.

      Best, Paul

  6. Any suggestions on substitutions for soy sauce? It compliments many Asian dishes so nicely, but I know we are supposed to avoid soy.

    • Hi Sara,
      Soy sauce is made from fermented soybeans, so not so bad.
      But wheat is also an ingredient.
      Tamari is a wheat/gluten free soy sauce. But confirm this on label before buying, as some inferior products may still include some wheat/gluten.

      Or, a soy free alternative you can try is Coconut Aminos… give it a google.

    • Soy or tamari sauce is fine. We’re not worried about soy proteins in the quantity you get in soy sauce.

      Best, Paul

  7. Paul,

    My sister in law is expecting a baby any day, and has been feeling dehydrated (also possibly associated with recently moving from Texas to the Southwest elevation about 4000 ft). The symptoms, dry sinus, mouth, and lungs haven’t been helped by drinking copious amounts of water. But, her OB prescribed 1 liter of saline in an IV, at her request, and it helped noticeably but only for two days.

    My question, do you have any idea why saline IV would help when drinking plain water (and some “Pedialyte”) didn’t? Can you think of any mineral waters or electrolyte drinks that might help her? She eats a typical American diet unfortunately (in spite of having received a copy of PHD as a gift two years ago), and is somewhat overweight but healthy otherwise. We are working encourage her to follow your recommendations in the book.


    • Hi David,

      In order to be hydrated, you need electrolytes (sodium and potassium primarily, also chlorine, iodine, and others may matter). If you don’t have the electrolytes in your body, any water you drink will be peed away, because the body has to maintain a fixed ratio of water to sodium and potassium. She should eat lots of fruits and vegetables (tomatoes, bananas) and some salt along with water. Try salted tomatoes.

      If she is low-carb, eating more carbs will also help.

      For weight loss, minimize omega-6 fats and entrain circadian rhythms are the two most important steps.

      Best, Paul

  8. Hello,
    I am reading your book for the very first time and I was wondering about your recommended dosage of safe starches. Are the weight units you mention (for example 2.7 pounds of sweet potatoes) supposed to be when the starches are cooked or raw. I’d really appreciate your help. Thanks so much. Kali from Germany

    • Hi Kali,

      That is “moist weight” or weight after gentle cooking. Harsh cooking dries out the starch and reduces the weight. Generally, boiling or steaming constitute gentle cooking. Weight after gentle cooking is usually the same as raw weight, except in the case of dehydrated foods like rice which gain water during cooking.

      Best, Paul

  9. Clare Boldurmaz

    Hi Paul,
    I hope I’m not being greedy here asking 3 questions! They’re just things that nutritionists have told me in the past so I thought I’d ask 🙂

    1) I was told it’s good to eat protein away from starchy carbs, and that not it’s good for the gut – I imagine that you would not agree with that as I don’t think I’ve seen references to it in the PHD diet?
    2) also from a nutritionist: vitamin C is important to have with iron source (i.e meat) for iron absorption. Is that the case, you may have mentioned in your book ?
    3) is it worth making your own fruit / veg juices for extra vitamin consumption? Have a juicer, trying to decide whether to keep it!

    Many thanks, as ever, so grateful for the time you give up to do this!


    • Hi Clare,

      I don’t agree that protein and carb should be separated. Vitamin C helps iron absorption so if you are prone to iron deficiency anemia it’s good to combine them, but if your iron is normal then you don’t need to worry about it. There’s no advantage to juicing over simply eating vegetables. However if juicing enables you to eat vegetables, it could be beneficial. I personally find juicing to be more work.

      Best, Paul

  10. Hi Paul,

    My mother in law recently had brain surgery to clear a subdural hematoma. The neurosurgeons said that this often occurs in the elderly because of a loss of brain volume that puts stress on the veins in the dura which allows them to tear and bleed more easily. Are there any nutritional/supplemental steps that will slow or possibly reverse age related brain volume loss? Thank you!


  11. Hi Paul,
    I’ve followed PHD for 4 years running and love it but have 2 main concerns based on my recent blood work that came back yesterday:

    1) Fasted Hemo A1C has never been tested before and is 5.8 (!)

    (note: Glucose is 84 (was 87))

    2) LDL is 122 (was 91 before starting PHD 4 yrs ago). (For reference my HDL is 82 (was 88) and total Chol is 214 (was 187).

    Last night I reread your chapters on lipids, and if I’m reading correctly, my LDL and HDL are good in your opinion? Or do they need to be tweaked? and how? I follow your apple, but I trim all my meats and use full fat milk and yogurt, but not much added fat. I have religiously eaten 3 eggs per day for 4 years. I’m inconsistent with bone broth and organ meats, but I eat ~ 1 lb wild salmon/wk. I eat TONS of veggies and fermented veg and foods daily. 4-8 oz animal meat in addition to the eggs, a cup of Greek yogurt and maybe 1+ oz of full fat cheese.

    The A1C is of greater concern though — this was quite a shock. I do eat ~1 lb sugary (berries, melon, tomatoes mainly, and an occasional banana, apple or fig but modest and rarely). I rarely eat even paleo type treats (just a few times per year) and the only time I eat honey is in them. I don’t add any sweeteners to my food. My main starches are white potatoes steamed in microwave (always reheated if batch cooked), winter squash like Kabocha, pumpkin, and Hubbard, less frequently a cassava tortilla and almost never white rice. I always add acid and/or sauerkraut juice and some Greek yogurt to my starch. If I’m guilty of something, it’s not eating enough pure fat. But I often sprinkle nuts or Feta cheese over my food, or eat a slice of avocado.

    What am I doing wrong? What should I change? I’m 60 and lean (5’4″ and 116 lb this morning). My main exercise is walking, with hills, 40-60 min per day.

    (BTW, only other minor changes in my bloodwork — Vit D has dropped a bit over 4 yrs — now 31 vs 41 before, so I’ll increase my Vit D to 4K IU and my RBC is a bit low at 3.7 (down from 4.1).)

    Thanks in advance!

    • Hi Susan,

      5.8 is normal for Hemoglobin A1c. With your normal blood glucose, I wouldn’t be concerned at all. Some people have long-lived blood cells and get slightly more glycation than average for that reason. If you want to look at data, see the bottom panel of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5642750/figure/F3/. 5.8% is very close to the mortality minimum.

      Your LDL is great, I consider 130 mg/dl to be optimal. 91 mg/dl is immune suppressed. HDL of 82 is also great. See our series on the topic, http://perfecthealthdiet.com/category/biomarkers/hdlldlcholesterol/

      You might try supplementing vitamin B12 and eating green leafy vegetables to help with the RBC count (also have your iron status checked, if you are iron deficient supplement iron and vitamin C). But it seems like you are in great health and worrying needlessly!

      Best, Paul

      • Paul,
        THANK YOU for taking the time to respond and for putting my fears to rest! That is great news!

        My LabCorp report said that 5.8 A1C was pre-diabetes level which is what got me worried. I guess this is a great example of how the lab normals are really off.

        On LDL, I’m glad that I understood your book correctly. When my LDL was 91, I’d been on a severe elimination diet for several months, eating no meat or fat, and had dropped down to 105 lbs, so my immunity was probably low indeed. I use to get colds many times per year, and the biggest change I’ve noticed on PHD over the past few years is that I don’t get colds anymore! And if I feel like I might be coming down with something or have been exposed, I’m able to brush it off overnight!

        I eat massive quantities of farm fresh greens of all types daily. But I might not be a good converter. My 23andme showed 2 types of methylation SNPs (one from each parent) so at one point I took a ton of the Seeking Health supps to address that, but it got too cumbersome.

        I don’t know if you would consider this iron deficient or not (LabCorp blood test range says normal):

        Iron 76
        Iron Saturation 26
        Ferritin, serum 96
        Vitamin B12 637
        Folate, serum 17.3

        I’ll try to be more consistent about liver and broth — I’ve fallen off that wagon of late. I take vitamin C, but may need more.

        Thanks again Paul!!!

        • Hi Susan,

          Iron is normal, everything seems normal so I don’t know why your RBC count would be low. Maybe you need more aerobic exercise.

          I’m glad you don’t get colds any more! More evidence that everything is fine.

          Best, Paul

  12. Hi, Paul (and Susan above),

    Susan, I’m in almost exactly the same boat as you. I have been following PHD for years and have made great gains in a number of different areas. I had one minor setback of eczema during this time, but you (Paul) really helped me focus on a few areas and I eventually got better. So great!

    Like you, Susan, I recently had blood work. My doc wrote me today and said I need to correct my diet and/or go on a statin. Say what? I’m a healthy 48-year old woman who exercises regularly, eats PHD, doesn’t drink or smoke, and leads a pretty chill life. I do take thyroid medication daily, but that’s it. That said, my sleep is horrid (has been for decades) and I’m sure that contributes to any issues I have.

    I won’t bore you with all my lab work except for the two things Susan expressed concern with. My A1c is 5.6 (the highest it has ever been), but now I see I shouldn’t be concerned. My lipids, however, are:

    Total: 261
    Trig: 62
    HDL: 81
    LDL: 168

    I’m at a loss as to what to tell my doctor and/or how to correct my numbers. I feel I’m doing really well and don’t see a need for a statin. Paul, if you have any of your amazing suggestions, I’m all ears. Thanks for all you do! Laura

    • Hi Laura,

      Your triglycerides and HDL are perfect, so it’s just a matter of the high LDL. Common causes are iron excess and hypothyroidism. So I would start by getting an iron status test and if iron is high, donating blood; and considering whether you may be undertreating your hypothyroidism. Perhaps you would benefit from iodine supplementation, selenium occasionally, some T3 in your medication along with levothyroxine, or a higher dose. Be sure to eat at least 3 egg yolks per day, if not you should supplement inositol and phospholipids. If you have detailed lab values you could share them.

      Best, Paul

      • Thank you, Paul! You are truly amazing to answer our questions. I specifically went to get my thyroid labs and my doctor added on several other tests, too (Comp Metabolic, CBC, lipids, vitamin D, etc). Sadly, the lab forgot to add on my Free T3!

        I will look into getting an iron status test (though I’m usually low). Currently, I take a grain of generic NP Thyroid (a T3/T4 combo med) daily. (TSH 0.920 uIU/mL; Free T-4 0.78 ng/dL; Free T-3 ?)

        I was surprised to see my Vitamin D this low (32 ng/mL) so I will be increasing my supplementation.

        I eat two to three eggs daily and already take your supplements (including the iodine and eating nori daily). Perhaps the iron status test will be revealing.

        Thank you again for all your time and commitment to your readers. My husband jokes with me all the time by saying, “Well, what would your Dr. Jaminet say?”

        Many thanks, Laura

        • Hi Laura, the lab will still have your blood if you need them to run the T3 or FT3 test.
          The labs hang onto the samples in case they need to re run tests, or do add-ons.

          • Hi, Darrin. Unfortunately, my lab only keeps the blood for five days; they already disposed my samples. My doctor just wrote and said I could retest if I want or just wait another three to six months and test again. In the meantime, she wants me to eat a mostly vegetarian diet, no red meat or high fat dairy, and quinoa/brown rice. Argh!

          • Hi Darrin,
            FYI, I had the same experience as Laura. My lab screwed up my test and I had to go back for another blood draw. My doc checked with the lab first, and they’d already tossed my blood sample.

        • Hi Laura,
          After Paul responded to my post, I listened to an interesting podcast by Robb Wolf and Dave Feldman about lipids, and they echoed many of the same points that Paul has made here.
          Since then I’ve also heard back from the NP who works with my functional doc (Chris Kresser) and they say ditto to Paul’s comments about both lipids and blood sugar. The other marker she mentioned was my insulin which was very low (indicating excellent insulin sensitivity).
          All of this is making me realize (even more than before) that there are many people out there who are making bad changes in their diets and taking unnecessary meds because most doctors are relying on standard “normal ranges” on lab readings and not really understanding all of the complexities of nutrition science and their impact on markers.
          I’m so incredibly grateful to have people like Paul (and this community) and Chris’ team in my life and guiding me on the right course.
          Good luck with identifying the specific cause and fix of the LDL level, and keep us posted — I’ll be very interested in hearing about it.

          • Thank you so much for your response, Susan. I feel like you and I have such similar situations at the moment. I, too, am so grateful for Paul and the other commenter’s responses. I have learned a great deal on this site; however, this is the first time a physician has actually said she was “very concerned” about one of my labs. Makes me take pause and doubt everything I have learned over the years. I appreciate your feedback and will continue to educate myself and keep on keepin’ on. 😉 I will post my progress if it seems remotely interesting to anyone else. Take care, Laura

  13. Hi Paul, just to check – the supplements that Amazon recommends on your supplements page – are they recommended by you, or just brands that Amazon has picked out? I know getting the right brand is key 🙂

    Many thanks !

  14. Hi Paul,

    Any ideas on Keratosis Pilaris? Is it just genetic or something else is causing it? Any ways to get rid of it?


  15. Dear Paul,

    I hope you and the family are well and Angiex is going from strength to strength. I’ve been a faithful adherent of the perfect health diet for the past 7 years or so. This year I was diagnosed with a very rare cancer called Pseudomyxoma Peritonei. It’s a borderline malign cancer that originated in my appendix. It progresses very slowly and it’s quite possible I developed the condition c.10 years ago. Mercifully I was diagnosed quickly (it’s so rare it’s often misdiagnosed). I was operated on about a month ago in Basingstoke, UK which is I think one of the best places in the world to treat this particular condition and where they pioneered the application of what’s called the Sugarbaker technique to this kind of cancer (named after Dr Paul Sugarbaker). They have tremendous experience and carry out c.300 of these operations every year. It’s a huge operation – c.10 hrs- which involved the removal of my spleen, appendix, omentum, gallbladder and peritoneum. I’m now recovering but the good news is that my outlook is good in the sense they believe they removed everything, the histology revealed the tumour all to be low grade and I had no post op complications. It is not uncommon for the procedure to result in a complete cure of the condition. In fact the team told me that I had one of the fastest post op recoveries they had ever seen which they put down to my fitness (I’m a 50 yr old now) but I also explained the PHD and on the evidence of my recovery some of the medical staff were persuaded to buy your book! They were also very surprised I was able to cope with the chemo so well. They apply a heated chemo treatment in the operation itself but also subsequent to the op in the ICU unit you get 4 days of 24hr chemo being piped into your abdomen via abdominal drains. Normally people can only take a couple of days of this but I was able to do the full four – not from any greater personal courage on my part but just because whilst unpleasant I did not suffer from any of the really bad symptoms. One of the consultants was particularly surprised my bloods were so stable through the 4 day chemo treatment. I had a lot of people praying for me through this whole process.

    My question is what general advice you could give me now for a tweaked PHD diet given what I’ve been through and the loss of some of these organs. Once I’m fully recovered do you think it might be beneficial to engage in slightly more prolonged fasts for example? I’m not engaging in any fasts at the moment as I need to recover and it takes 3-6 months to do so. Once I am recovered though are there any slight modifications you would recommend or particular foods I could emphasize more? I know without a spleen and omentum my immunity is going to be a bit impaired. Is there any way I can tackle this vulnerability through diet?

    Best wishes,


    • Dear James,

      So sorry that you lost so many organs. I always hate to hear that. I hope the cancer is gone forever, blessings to you.

      We’ve heard from many PHD readers who have undergone chemo that they tolerate it very well, so I’m not surprised you did well too. Based on Bruce Ames’s triage theory, it makes sense that detoxification pathways are the first to be lost during malnutrition, and therefore that a nourishing diet will help the body deal with toxins.

      I don’t have a lot of advice for you, I think you’ll have to experiment. I don’t think prolonged fasts (beyond our usual recommendation of 16 hours nightly) will have any special value, but circadian rhythm entrainment will be very important. With the loss of the gallbladder, bile flow will be altered and you could find oils harder to tolerate and/or a tendency to diarrhea. But I think you’ll find that only some tweaks are required. Be sure to optimize vitamins A and D for mucosal immunity and eat lots of extracellular matrix for wound healing. Soups/stews made with bones/joints and shellfish will help. This is especially important in the first few months.

      Best, Paul

  16. Hi Paul,

    I have hypothyroidism and I take levothyroxine daily. I want to try combining levothyroxine with some low dose T3 (I will discuss this with my doctor). I know you also recommend combining these two (I read comments from you here where you recommended it to other people).

    My question is, is it better to combine levothyroxine with synthetic T3 (like Cytomel), or with natural desiccated thyroid (like Armour)? Which one would you prefer?

    Thank you

    • Hi Gio,

      Either should work. Synthetic T3 may make it easier for you to control the dose. Some people feel they get better results with Armour. Either way it takes some experimentation to find the dose, but more experimentation and more care with the Armour.

      Best, Paul

  17. Hi Paul,

    I need your help!

    Firstly, thank you! Your PHD diet cured 13 weeks of mysterious chronic diarrhea – after which time the doctor said he had never seen such pink intestines of a woman my age!

    Secondly, by following your PHD diet as outlined, I was able to lose some nagging middle age weight – which worked just as you said it would! I am now a very trim 53 post menopausal woman – thanks to your science and generosity :). Unfortunately, I find it difficult to take excessive fats, MCT or Coconut Oil without diarrhea (eg even Avocado with my sardines and rice and kimchi goes straight through me) and I do not have access to Liver/ organ meats – so may not be getting sufficient there.

    HELP Required : I have had chronic insomnia for the last 9 months to the point at which a doctor & psychologist prescribed Ambien CR 6.25. I’ve had to take the medication for the last 5 months because otherwise I would have been a zombie – or worse. It is awful and I now suffer from DRY THROAT and DRY EYES – not sure if it’s the insomnia or the drugs?

    The insomnia started very mildly 10 years ago – at peri-menopause age 43 – and was considered apparently fairly typical. It only became chronic this year – 10 years along (meaning no sleep at all – just a maddening uncontrollable graphic film which played behind my eyes all night long). I suppose I recall it starting around the time of my 13 week chronic diarrhea 10 months ago in late January. I assumed all of the above disrupted my circadian rhythm and I have followed all the entrainment steps you have outlined. BUT SADLY… Still NO SLEEP.

    The only thing I have not done… is consumed the supplements you recommend since I can’t buy them in Asia. I have used a Vitamin B complex by Thorne #6, a Blackmores 1000mg of Vitamin C and Vitamin D. However, I know these will not be sufficient for overall health. I am now happy to buy them from Amazon and have them sent though!

    Other info: Blood work shows I have no estrogen which is normal for post menopause. I did use a Vagifem pessary to help build the lining in my uterus over a 31 day period then twice weekly for 8 weeks – also at the beginning of the year. I don’t know if this could have caused any insomnia either?

    Paul, I am at a loss. I feel like there is no hope in sight. Can you please ADVISE if anything obvious nutrition wise comes to mind?

    And PLEASE would you be so kind as to recommend the correct supplements I should be taking for a slim 53 year old woman with a fragile stomach (I once broke out in hives with an inferior B complex so can only take high quality supplements and not too many, only a few per day).

    THANKS IN ADVANCE – I really appreciate your help!
    With kindest regards,
    Rachel 🙂

    • Hi Rachel,

      There are a few clues in there to work with. Steatorrhea suggests a lack of bile: good nutrients for that are glycine, taurine or N-acetylcysteine, vitamin C, and egg yolks. Eat 3-5 egg yolks per day, maybe 2 with the white and the rest without. Buy glycine as a bulk powder and have 1/2 to 1 teaspoon (3-5 g) per day, preferably in the early evening with dessert. A mug of warm milk mixed with honey, glycine, and turmeric would make an excellent dessert. Taurine and N-acetylcysteine, 500 mg each per day, you can also buy as powders which are cheaper and which you would probably tolerate better than the capsules. Vitamin C get as tablets to avoid acid damage to your teeth. B-50 complex once a week is good. Along with the egg yolks get 2 tbsp apple cider vinegar per day, distributed in small amounts frequently through the day mixed with food and water. Also, supplement molybdenum occasionally, maybe once a week, and optimize copper and zinc per PHD. You need molybdenum, copper, and the choline from egg yolks to dispose of inflammatory amines which may keep you awake.

      Your microbiome (or an infection) may have prevented bile from being recycled leading to the diarrhea and inducing the deficiency. To help overcome this, and to reduce inflammation which is a cause of poor sleep, be sure to maintain good vitamin A and D status, per PHD recommendations. I recommend supplementing a little preformed A, eating lots of carrots, and supplementing D if you can’t get sun on bare skin.

      Dry eyes suggests a deficiency of carbs – are you eating enough? That can also cause insomnia. In general, a deficiency of carbs, protein, or some micronutrients can promote insomnia. Try to add more potatoes, rice, and fruit to your diet. As you get older appetite lessens and you need less fat and more carb and protein, proportionately.

      Also, add extracellular matrix to your diet, in the form of shellfish or soups/stews made with bones/joints/tendons.

      Circadian rhythm entrainment is critical for sleep. Have a 12 hour personal day year-round. Try this: In the first hour of day, get exercise, sunshine, and then eat a protein-dominant breakfast. Use 5000 K bright white lights indoors. Get more exercise in the afternoon. Make the mid-day meal your biggest, and stop eating an hour before the end of day. At the onset of night, wear blue-blocking glasses, shift to orange/amber lighting from white, use “night light” or f.lux on your computer and similar settings on your phone or tablets. Make sure you have no stress at night — move any stressful personal interactions to the next day in daytime hours.

      Finally, nutritionally, tend to electrolytes to prevent dehydration. Potassium from potatoes, bananas, tomatoes; adequate salt; a little iodine; enough calcium and magnesium. Be sure to supplement magnesium, it is crucial!

      That’s what I would start with.

      Best, Paul

      • Dear Paul
        I really appreciate your kind and thoughtful reply.
        I will start on all of your recommendations immediately and revert back in 6 weeks to let you know how I’m getting on.
        I am currently taking Magnesium each night and eating rice, sweet potatoes, bananas, blueberries, mandarins, spinach and broccoli and some nuts at each meal together with a protein and kimchi or seaweed. However, perhaps I’m just not eating enough of the carbs as you suggest, and will increase these to see what happens. I’ll also purchase the supplements and follow your other sleep entrainment recommendations too.
        Paul, I am just so so grateful for your reply, thank you again for taking the time out of your incredibly busy world – much appreciated.
        Best wishes to you and your family and good luck with all the work – your research is really so exciting! Happy holidays,
        With kindest regards
        Rachel 🙂

        • Rachel,
          You noted that you are taking magnesium each night, and are generally sensitive to supplements.
          It might be worth a try to move your magnesium (and perhaps your other evening supplements) to the first half of the day (such as at lunch, or at breakfast), and see if that improves your sleep during the night.
          Also, you might try splitting the daily dose of magnesium and taking half of it at breakfast and half of it with lunch, or half at breakfast and half with an early dinner.
          Those ideas are based on my experience of helping my mother to figure out a good supplement regimen for herself a couple of years ago. With her magnesium intake, instead of the magnesium making her feel relaxed and sleepy (which it apparently does to most people who take it as a supplement), when she took it in the evening, it made her feel energetic and it disturbed her sleep all night long (plus, she would have nightmares). It was definitely the magnesium causing that, because on days when she took everything else she normally took but left out the magnesium, that didn’t happen. We tried several different brands and two different forms (she tried capsules and tablets – she did not want to try the magnesium powder, topical oil, or epsom salt soaks), and every kind of magnesium that was readily available (including some forms that are supposed to be extra-relaxing — one of them might be magnesium glycinate?) Another issue she often experienced with magnesium was that it would give her loose stools, so we had to factor that in, too.
          In the end, we found that she tolerated the “magnesium citrate” form the best, that it had to be a specific product from Now Foods (no other brand worked as well for her) in the 133 mg capsule (just plain magnesium citrate), and that she couldn’t take more than one capsule at the same time because it would give her diarrhea. Her best schedule for taking magnesium worked out to be taking 1 capsule (half of her daily dose) with a noontime meal, and 1 capsule with a 6 pm meal. (Taking it any later in the evening would noticeably affect her sleep and cause nightmares.)
          After some trial-and-error, we ended up moving most of her other supplements and all-but-one of her prescription medicines (we got her doctor’s okay to do that) to the noon meal, and her nighttime sleep and her bowel function improved.
          About a year ago, she happened to try a 1-mg dose of liquid melatonin (Sundown Naturals) that a family member was using, and she said that it improved her sleep a huge amount – helped her fall asleep sooner, and stay asleep until about 5 am, when she’d wake up briefly, but was able to go back to sleep until 8 am. We checked with her doctor to see if that would be okay for her to take (according to bottle instructions, which say to take 1 week off after 7 weeks on), and her doctor said it would be fine. Out of curiosity, we tried her on a lower dose (apparently 300 mcg is a good starting dose, close to physiologic levels, to see how one responds), but 300 mcg and 600 mcg doses did not work as well as 1 mg for her. She is very pleased with how restful and regular her sleep is now.

    • Rachel — another thought on sleep aids.
      You say you are postmenopausal…
      A little bit of progesterone tends to be relaxing and to promote sleep (as well as do other positive things health-wise).
      It’s not right for every woman, but it helps many.
      Therefore, to help your sleep, maybe you’d like to try out a tiny, tiny bit (for example, as low as 1/4 to 1/2 a teaspoon a day) of progesterone cream (topical), according to the dosage and application schedule that is appropriate for your health/age situation and recommended by the manufacturer of the cream (it will usually be explained on the box insert and on the manufacturer’s website).
      You can also take a look at reputable and pertinent websites that deal with women’s hormonal health, and survey their recommendations about progesterone cream. There is some good info in a handful of books by a Dr. John E. Lee (I think I got his name right). He passed away and the books were last updated some years ago, but most of the information is still helpful.
      One reputable, major brand of progesterone cream is called Emerita. You can find it at numerous online retailers. Have a read through some of the customer comments on major retail sites like the one starting with ‘Am’. 🙂

      • Monroe, interesting to hear that magnesium supplements cause your mother to be wired at night. They do the exact same thing to me. I wonder why this is???

  18. Paul,
    About six months ago, my sister was diagnosed with something called Dupuytren’s contracture. Prior to this, she had injured her right thumb – tore a ligament – and underwent a very painful prp treatment for that. At this point she has pain and inflammation in both hands. She has been told that there isn’t much that can be done for her. She is very discouraged. Do you have any ideas or suggestions that might help her? Any help you might be able to give would be greatly appreciated. Thank you.

  19. Hi Paul,

    What do you think of Subclinical Hypothyroidism? Why would the TSH be high when the Free T4 and Free T3 levels are normal (not even on the low end of normal range)? And why is Levothyroxine prescribed in this case (to those with high TSH and normal T4 levels)? My condition was like this and my TSH normalized after starting Levothyroxine. I do not understand this.

    Thank you

    • An high TSH means that the pituitary gland is shouting at the thyroid so that the thyroid works harder to produce hormones suchbas the T4.

      So, the thyroid may be able to reach the normal levels of T4, but at the expense of a lot of stress and screaming.

      Prescribing some T4 at those situations is a way that the putuiraty glands relaxes the shouts, so the thyroid can relax more because the synthetic T4 is doing part of its job.

      It is very relevant especially if one suffers from Hashimoto’s, because relaxing the amount of stress on the thyroid may help to calm the fire on it.

      I’m not a doctor so can’t provide details, but this is how I understand it.

      T4 isn’t a bad drug because it just mimicks a natural hormone. Of course it can have problems e.g. regarding its conversion, or adjusting the dose so that it’s optimal and not too much, but in general it’s among the safest medications out there so you don’t need to worry about being on it

      • But if your hypo isn’t Hashimoto’s (i.e. autoimmune kind), you do want to solve the root cause instead of just using exogenous T4.

        Look for causes such as deficiencies (iodine is the most common but there are a bunch more that can cause hypo), persistent inflammation, etc. Improve diet, lifestyle, Circadian rythm, etc. And keep track with your doctor because if your thyroid improves, the exogenous T4 may be too much and you may start having hyperthyroid symptomns

  20. Hi Paul, slightly random question. I’ve been told that grapeseed oil is very good for the skin (applied topically)…but as soon as I heard the words ‘seed oil’ I thought I’d better check in with you to see if it’s OK to use this way 🙂

  21. Paul,
    Do you have any advice for ways to decrease one’s liver enzymes? I follow the PHD diet, eating a moderate amount of fat and drinking no alcohol at all. Yet my liver enzymes (AST and ALT) are elevated – 47 and 60 respectively. I would appreciate any advice you can give. Thank you.

    • Hi Mary,

      First I’d note that those levels are at the high end of the normal reference ranges, or only slightly above the top end, so they are not levels which call for great concern. To understand them, they would have to be looked at in the context of other lab values, your health history, and other indications of liver health. Also, one would want to see that the enzyme level was persistent, as many transient causes can lift these enzyme levels for a few weeks.

      The simplest explanation for persistently slightly elevated liver enzymes on a good diet is some sort of infection (e.g. viral hepatitis) or toxin exposure (such as household mold). Good strategies for improving it would be to remove environmental toxins if possible, to improve detoxification and immune supports (e.g. supplement glycine and N-acetylcysteine or taurine, vitamin C, optimize vitamins A and D) and to be consistent with circadian rhythm entrainment and intermittent fasting.

      Best, Paul

  22. Hi Paul,

    Can daily Glycine supplementation replace your Bone broth 3 times a week recommendation? If not, what are the other nutrients in bone broth that are important to ingest besides glycine?

    Thank you

    • One page back there is a discussion on this topic. This is a comment by Eric that may help, but there are more relevant info in that page:

      “Bone is essentially a web of extracellular matrix, mineralized mostly with calcium phosphate.

      Since calcium phosphate has almost zero solubility in water — see https://en.wikipedia.org/wiki/Solubility_table — while collagen and other extracellular matrix components readily hydrolyze to become water-soluble, the process of making broth basically extracts almost all the extracellular matrix from the bone, while leaving almost all the calcium phosphate behind.

      (As an aside, the process of making broth also extracts a meaningful amount of certain trace minerals that accumulate in bone, such as fluoride — a couple milligrams of fluoride is biologically meaningful, while a couple milligrams of calcium is not.)

      This means bone and bone broth have completely different nutrient compositions: If you eat bone directly, you will overdose on calcium and phosphorus long before you get a meaningful amount of extracellular matrix components. If you drink broth, you will overdose on extracellular matrix components long before you get a meaningful amount of calcium and phosphorus.”

  23. I have been reading this site for the past few days (when I can find the time) because I’m trying to absorb the general info and get an idea of Paul’s current positions on PHD-related topics, some of which have (naturally) changed from the last edition of his book.
    I have skimmed about 3 years’ worth/20 pages of comments on another of the more active pages of this site, and it’s just overwhelming now, because I’m nowhere near done with that comments section, and there is valuable information in the comments sections of MANY other pages here too. I’ve realized that I’m not going to be able to try to get a handle on their latest information/opinions/research in this “piecemeal” way, I fear, because there are just too many disparate places on this site where important tidbits and updates are mentioned.
    …And for some reason, I don’t see a search box at all for this site? Maybe it’s due to my ad/tracker blocker on my browser? It’s odd, because usually I can at least *see* a site’s search box, even if the searching itself is not functional due to my ad/tracker blocker.
    Anyway, I am not sure why I didn’t realize it before now, but I have just twigged onto the fact that *this* Q&A page is one of the more active ones for comments and questions… I have not spent much time on this one, so far… but I am dismayed to see that there are nearly 10,000 comments on this page alone — Aaugh! :-O
    Well, I wanted to make a post on a page that is probably visited by the majority of visitors to this site, and this seems to be the best place.
    …I’ve just seen a trackback (or whatever the term is) in the righthand column about a podcast that Paul recently did which was published online 2 days ago, and the trackback link to that podcast is oddly buried on the PHD Retreats webpage here (which has comparatively few visitors because the retreats have been on hiatus for quite a while).
    Fortunately, the website that the podcast is published on provides a transcript of the interview — which, the site claims, requires 51 minutes to read, so it sounds like it was a pretty in-depth interview!
    Because this interview with Paul appears to be very recent, I expect that it might give me a good outline of Paul and Shou-Ching’s *current* thinking on the PHD topics. (I realize their overall approach is generally the same as it’s been for a number of years, but they’ve also changed some of the nitty-gritty recommendations, which one might only know about if one had read through scores of old comments on this site.)
    I haven’t read the transcript yet — will do so tomorrow — but here is the link: https://optimalperformance.com/paul-jaminet-the-perfect-health-diet-opp-018/

    • I’ve read the transcript now — even though the website it’s published on says that it was posted “2 days ago”, and the “trackback” thing on the sidebar here says that the trackback doohickey was a recently-left comment on this site, I am wondering if the podcast is actually an interview that happened some *years* ago, because in it, Paul talks about the PH retreat as if it’s an ongoing enterprise and people can sign up for it by emailing him. There is no actual date mentioned on the webpage/transcript, as far as I can see.
      The transcript was interesting, but it wasn’t as in-depth about the specifics of the diet (as it stands today) as I was hoping for – though I realize I was expecting a lot from a brief conversation. 🙂
      Frighteningly, in the last paragraph Paul talks about all these things that can individually “take 6 years off your life”, and by my sleepy, instantaneous computation, it seems I’m working on about a 36 year deficit already, so it’s really good I’ve been doing stuff that adds x-many years to one’s life like never smoking, not answering the door to strangers, sometimes choosing the 85% chocolate instead of the 70% bar, and suchlike. 😉

  24. Hello Paul,

    Is there type 2 collagen in bone/joint broth? Is chicken bone broth richer in type 2 collagen than beef bone broth? If yes, why?

    Thank you

  25. Dear Paul,

    What is your take on whether the ‘parboiling’ process just forces part of the ‘antinutrients’ in the whole rice grain that you are trying to avoid by eating white rice, back into the parboiled endosperm?

    I find that parboiled rice could be an interesting choice… But this unresolved enigma is a thing.

    Thank you very much for your attention.
    Best regards

    • I asked this time ago but couldn’t find aty answer yet. It’s very specific so at best we can make an argument.

      First, I think parboiled rice should have more resistant starch because the starch has already been cooked and cooled down. It is something good! And it prevents it fnom loosig its shape and overcooking!

      Also it has more vitamins and some minerals more, because they leech from the outer to the inside. This is good too, but not too relevant, since there are better sources of nutrients in the diet.

      Now regarding the anti nutrients…
      I think they are much bigger than vitamins and minerals. I don’t know for sure, but for instance you can search for vitamin A structure on wikipedia. Compare that to the structure of phytic acid. Or just compare that to the structure of lecthins, which are proteins… The difference in size and complexity is huge. I don’t think they can leak into the endosperm, just like vitamins and minerals do. They are not even soluble in water (although phytic acid is).

      However, some heavy metals like arsenic may be able to leach inside. I don’t know. These all are just guesses!

      So parboiled rice may be healthier than regular rice, but the difference isn’t very high, and it may have some little risks as well.

  26. Clare Boldurmaz

    Hi Paul,
    You talk about the optimum quantity of fats, i.e 2-4 spoonfuls of healthful fats a day. Can I ask, would this include fermented or fatty dairy grass fed products such as sour cream, ice cream, cheese, yoghurt? Or can you have those in addition?
    Many thanks,

    • Hi Clare,

      I would include sour cream as a flavoring, but I’d think of cheese or yogurt as closer to complete foods. Ice cream a dessert.

      The guidelines are approximate and the actual optimum will vary with age, young people can have more fat and elderly less. For the most part you can eat to taste as long as you are in the ballpark of optimum.

      Best, Paul

  27. Philippa Antell

    Dear Paul,

    Thank you so much for all your hard work. My husband is already reaping the benefits of adding back some safe starches after 1 year of low carb. I had a couple of questions:

    In the book section on fasting it begins by using an example of a mouse fasting for 24 hours being beneficial, and notes that a mouse fast of 24hrs is equivalent of several days of fasting in humans. But you then go on to give further evidence from mouse studies to support your proposal that fasts longer than 24 hours are not beneficial for humans. This seems to be contradictory. Is there evidence in humans that fasts longer than 24hours are detrimental? If a mouse 24hrs is equivalent to a human 5 days (for example), then presumably all we can draw from those mouse studies is that there is no advantage to a human fasting for longer than 5 days?

    Also, is bone marrow a good source of choline?

    Many thanks,

    • Hi Philippa, great question. I would say that occasional long fasts are better than no fasts at all, but not as good as more frequent shorter fasts. The reason is that the benefits of fasting are increased if they are obtained frequently in small doses, while the risks from fasting (such as suppressed autophagy upon refeeding) rise dramatically with the length of the fast. So extended overnight fasting without calorie restriction on a daily basis is better than rare multi-day fasts.

      Best, Paul

      • Dear Paul,
        Thank you very much for such a prompt reply. I suppose the question really is, do we have any evidence in humans to show what is the length of a fast which maximises the benefits of autophagy without inducing the risks of autophagy suppression during refeeding. Do you think there could be a sweet spot around 24, 36, or even 48 hours of fasting?

        The reason I am so interested in this aspect is that my husband has been diagnosed with a benign tumor on his heart valve called a papillary fibroelastoma. The doctors have been talking about open heart surgery to remove it but the prospect of that terrifies him beyond belief. We have been hoping we may be able to find some way to persuade it to regress spontaneously. From my reading it seems that it can be triggered by chronic cytomegalovirus infection.
        I know from your book that you think most cancerous tumors arise out of viral infections – presumably benign tumors are likely to be similar?

        So that is really why I am interested in maximising anything that can fight viral infections – autophagy seems to be a key factor. My husband has been doing 18:6 intermittent fasting for the last year but I was wondering if we could get greater benefits from a 24 or 36 hour fast once per week, for example.
        Any thoughts on this or other suggestions would be most welcome.
        Thank you again so much for your help

        • Hi Philippa,

          I think there is limited evidence, but what I would try is having one large meal in late morning or at noon every day, then a 22 hour fast around it. Get exercise before the meal.

          Best, Paul

          • Thanks Paul, we will try that. I guess that keeping one meal in the day helps keep the circadian rhythm ticking, right?

            Just a couple more things:
            Is it worth trying to work up to the higher doses of iodine, or would that only be effective against extracellular pathogens, not intracellular pathogens?

            Do you think lysine supplementation is worth a shot as an anti-viral strategy? If so any suggestions for dose/frequency/timing?

            Thanks so much for your advice,

    • In answer to your question re bone marrow and choline: Chronometer says no.
      I looked up a few of the closest listings and found no choline.

      (I liked your question and Paul’s answer. I’ve had similar thoughts)

      • Thanks Randy,
        On the choline question I did a little more digging and found this:
        It says: Phosphaditylcholine is the major phospholipid present in most marrows.
        What that translates to in terms of milligrams of choline I don’t know. But….a clue from chronometer (frustratingly there is no entry for bone marrow itself in chronometer): However Osso Buco is a cut of beef/veal shin that contains a section of the bone plus marrow. Chronometer gives us 700mg choline per 500g of osso buco, which is pretty impressive.

  28. Hi Paul,

    You used to recommend eating coconut oil during the daily 16 hour fast, but it seems like you no longer recommend this, what made you change your mind about this?


    • It was always optional, as a way to generate ketones which could be beneficial in some circumstances. However ingesting calories ends the fast and a shorter fast may have less benefits. It is a balance. I may be less optimistic that ketosis is beneficial than I was at times in the past.

  29. Hi Paul and Shou-Ching,

    Thank you for all your work. I reread the book last year and I consider it the absolute best book for overall health. Hey, what does the ideal exercise routine for health look like to you these days? Also, if you care to share, what are you personally doing in that regard? I look forward to hearing about you curing cancer.


  30. Hi Paul,

    Chris Kresser once said this in an interview:

    “Choline sufficiency is dependent on intake of folate, B12, B6 and betaine. This means that additional intake of these micronutrients can spare choline, i.e. perform its functions and reduce your dietary requirement of it.”

    Do you agree with this statement?

    Thank you

    • Hi John, one could just as readily put it the other way around, that choline performs the functions and mitigates a deficiency of the others. Best, Paul

      • Does this mean that I can just take folate/B12/B6/betaine instead of taking choline (through eggs), and I will receive all the benefits of choline (since they perform the same functions)?

        If this is the case, I would rather supplement those B vitamins/betaine and not eat egg yolks daily (I don’t really like eggs). So would those B vitamins/betaine fully compensate for lack of choline in diet, or would they only partially compensate?

        Thank you

  31. What is your opinion of other rice, such as brown, wild, etc? Also what about Hemp oil?

    • Brown rice has some toxins on it after cooking. White rice is better according to PHD arguments.

      Wild rice is more nutritive, but will also have more toxins.

      Hemp oil is rich in poliunsaturated fats. The proportion between omega 3 and 6 is good, but the problem is the amount. Also it may be prone to oxidation, those fatty acids are very delicate. I can only think of in being useful if you are vegan and need to obtain omega 3 from somewhere. Even that way, conversion from vegetable omega 3 to the useful omega 3 depends on genetic, and usually is lower than 10%, so if one is vegan one may go for omega 3 from micro algae which is the useful kind

  32. Paul,

    I was very surprised to see that you recommend baby formula brands that contain vegetable oils (Enfamil, Similac and Gerber). I understand that you chose these brands because they are the most similar to breast milk, but why are you not concerned about the vegetable oil content?


    • Hi Jivo, vegetable oils are not dangerous if the composition does not deviate from that of breast milk. Unfortunately there is no good substitute for authentic human breast milk, but the commercial formulas are better than the recipes I’ve seen from the natural health community. I’m open to hearing of new alternatives. Best, Paul

      • Thank you for your answer. I understand, but there is also the issue of rancidity of these oils, but I guess you are not that concerned since the vegetable oil content is not high.

        Have you thought about coming up with your own homemade baby formula recipe? I’m sure many people following your advice would appreciate that.


        • Hi Jivo,

          See http://perfecthealthdiet.com/recipe/phd-baby-food/. It’s not possible to create a homemade formula that adequately replicates breast milk (for example, breast milk has a higher ratio of zinc to other nutrients than is found in any food). So you need breast milk or a synthetic replica for infants. But at a somewhat older age, when they are transitioning to food, you can make food mixtures like the above recipe that are good transitions and will be enjoyed by the baby.

          Best, Paul

  33. Hi Paul, I could not find much on blood pressure. What would you recommend a woman in mid 30s to lower blood pressure. It is constantly high even with medications. Is it only excersise and losing weight that helps? How much more can I take Magnesium? Any other suggestions.
    I went to a Nephrologist and they said everything is good and only prescribed medications. So It is not a kidney function issue.

    • Hi Anna, the two most important things for blood pressure are electrolytes (especially potassium, which you can get from eating adequate vegetables — tomatoes are a good source, along with magnesium, iodine, optimization of salt intake, and optimization of calcium), and circadian rhythm entrainment, including exercise.

      Best, Paul

  34. Hi Paul,
    Just wondering about potatoes. I’ve read before that mashed potatoes are higher GI – is that right? I presume because it’s more easily digested / absorbed? I remember that from a low GI diet I did quite a while ago. That diet also recommended not over-cooking things like rice because it increased its GI. Would love to hear your thoughts on that!


    • That’s true, especially if it’s store bought as an ‘instant puree’. Think about this: what is cooked first, big whole potatoes, or small potatoe dices? The same thing happens in your digestive system. The smaller the particles, the more specific surface area they have and therefore they are digested sooner. Industrial mills can create much smaller particles than your jaw is capable of.

      There are ways in which potatoes can have a fairly low glycemic index. Cook them and cool them in the fridge (you can reheat them before eating them), that will form more resistant starch. Or accompany them with some vinegar, fat, and fiber. Cook them gently, instead of methods like deep frying. Paul talks about this in the book and in some articles.

      In any case, PHD doesn’t advocate a lot of carbs a day. That means that the glycemic load will be low even if the glycemic index of a food may be high. And in athletes who need to eat more carbohydrates, the insulin peak may be favorable for bringing nutrients to the muscles. So unless you have problems like diabetes or insulin resistance, it’s not something to worry about.

  35. Hi Paul,

    Trying to keep my omega 6 intake below 4% of calories – it’s tough!

    Obviously if I increase my exercise so I’m expending and ingesting 500-1000 extra calories per day that gives me an extra couple of grams of ‘allowed’ omega 6 per day……..but is this ‘cheating’?

    Is there an absolute quantity of omega 6’s beyond which there is likely to be toxicity? Or is the limit literally 4% of calories so that if I use/consume 4000 per day vs 2000 per day, I can actually safely eat double the amount of omega 6?

    Thanks for all that you do

  36. Hi Paul,
    It’s me (Clare) again – don’t worry about the mashed potato question above (!) because I have something more urgent from a friend of mine. She has renal failure and type two diabetes . She knows if she loses weight then she’d be eligible to have a transplant from a living donor (someone from her family has offered I believe) rather than go on dialysis. She had a transplant 20 years ago and it’s now starting to fail sadly.

    She has to avoid potassium and also is limited with other things – they’ve told her low sugar, low protein (she thinks 6oz meat or cheese a day). My question to you is, would this diet be safe for her to do? AS it was the first thing I recommended to her…but I said I would check with you. Perhaps a modified version (obviously the potassium is something to watch). She’s described what she should be doing as a ‘non-fluid restricted dialysis diet’.

    Any help would be very gratefully received. I understand that your answer might be to modify a bit and then take it to her renal doc, but whatever, would like to hear your thoughts. She’s pretty desperate.
    Many thanks,

  37. Hi Paul,
    I have found an interesting study and don’t know if you have heard about this. Sorry if this doesn’t fit the Q & A format, I didn’t know where else to put this.

    Anyway, here is a study about the connection of glyphosate, celiac and gluten intolerance: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945755/

    Glyphosate seems to kill gut bacteria and traces are present in wheat.
    What do you think?

    • I’ve heard anecdotal evidence from people reporting that they can handle wheat during their vacation on Europe, but not in the USA. They say it’s because glyphosate is not used so aggresively in Europe. I have no idea if this is true, but sounds plausible and would be interesting to research it

  38. What would you recommend for someone who would like to learn how to understand scientific articles but doesn’t have a scientific background?
    I’d like to be able to understand research articles on the link between Vitamin A and lipid metabolism. Vitamin/mineral textbooks are not really helpful for understanding the research I am interested in.

  39. Hi Paul,

    Do you have any recommendations for an overactive bladder?

    Thank you,

  40. I am in desperate need of help. I’m a 74 yr old woman; have had digestive problems many years. Because of that (and possibly my bronchiectisis) I am down to 90 lbs and look like a skeleton. I tested positive for all grains so I’m sure I need a diet like yours. But here is the problem: I’m sure I need the upper limit of carbs but since I believe rice may also be a problem, it seems I would need to eat potatoes and fruit all day to get enough carbs. Eating potatoes all day will get old and lots of fruit is not good. Good fats should be the answer but those of us with IBS don’t digest fats well. I seem to starve without grains but believe they are a big problem. Would greatly appreciate help.

    • Hey Sharon
      That sounds terrible 🙁
      Why don’t you start the diet and see how it goes? I have been working through similar issues, and the diet works quite well for me, with various tweaks. I think you’ll find that potatoes aren’t terribly boring – there are many varieties. And there are also starchy plants such as rutabagas, parsnips, turnips, etc.
      You won’t know how many carbs you need until you try – I’ve discovered that I do quite well on fewer carbs and no grains whatsoever. I was eating rice but temporarily taking a break from it.
      Best of luck.

  41. Hi Paul,

    My husband wants to go on TRT since his levels came out too low. He is 40 years of age. He does not mind going on it for the rest of his life since I know if shuts the T production permanently after few years. He feels amazing on it and lost weight. What is your view on it overall? If you do get monitored by the doctor and control your estrogen for example. My main question do you have any real concerns or is this a longevity help?

    Did you ever publish anything on this topic, sorry I could not find.

  42. Is it possible that vegetables aren’t healthy for me? I have a history of Hashimoto’s disease. Spent about 18 months on a whole foods /plant based/low fat diet and gained a lot of weight and fatigue. Four months ago I started the Autoimmune Protocol Diet (AIP) and initially list about eight pounds but I became constipated so started adding in more non-starchy vegetables. Like clockwork I’m gaining weight and bloat again and fatigue is returning. Sweet potatoes trigger major bloating and pain. I’m taking Betaine plus HCL for digestion. Was also taking enzymes but they didn’t seem to help much so I discontinued them. Any ideas for me?

    • They may be problematic under certain circunstances, no doubt. I suffer from Crohn’s disease, which lead to a SIBO so I wasn’t able to tolerate most vegetables. I had a dysbiosis in my migrobiota that prevented me from properly handle most vegetables. FODMAPS, inulin, etc, were problematic. So when you talk about gas, it does suggest you have problems with those little guys fermenting your vegetables and producing trouble.

      Maybe you should try to work on shapping the microbiota and then you will tolerate those. It’s easy to say but can be difficult to persue, because there are a ton problems that can be affecting it. Hypo is one of those. Try to perfect your lifestyle and solve issues such as the hypothyroid, then other problems will start improving. At that point you start trying troubleshooting. Most health problems are interlinked. In the meanwhile you can try to find the offenders. If it were a FODMAP issue, I know that some good Nutritionist Dietician would prescribe a low FODMAP diet and over time would reintroduce it. They don’t really know why this procedere works, but it works in 95% of cases. This is just an example so you know that things can be done, so don’t lose hope and will!

      Also, sometimes it’s good to eat very little amounts of those vegetables on a daily basis so you can build a microbiota capable of digesting them, little by little.

  43. Hi Paul,

    How come during the day it is unhealthy to remain inactive for more than 20 minutes (we should either stand or move for at least 5 minutes every 20 minutes – as you said), but at night it is okay to sleep 8 hours without any movement?


    • Hi John,

      It is beneficial to health to exercise during the day, but harmful to health to exercise at night. Similarly it is beneficial to be exposed to blue and white light during the day, but harmful to be exposed to it at night. Circadian rhythm entrainment is an important contributor to health.

      Best, Paul

  44. Hi Paul,
    I am reading the German Edition. The translation is very well done and I will hand it out to some who are not so fluent in English.

    Funny thing is that all German nutrion data sites have about half or less copper content for beef or veal liver. Is there a logical reason why German/European liver could contain significant less copper? I tend to agree with the German values because I had a low copper test result (whole blood). After eating three months 150g veal liver per week I repeated the test and while it came back 10% improved it is still out of range.

    Do you think vitamin a toxicity might become a problem when I up it to 200g/week?

    All the best

  45. Hi Paul,

    Why no response about TRT? Is it that conterversial or is that something no enough informaton about yet?

  46. Hey Paul, what’s your take on Dr. William Li’s new take on soy and soy-based products (that it’s actually beneficial) according to his analysis of the latest research?


    He also discusses it at length in his new book.

    • Hi Victor, there’s evidence that soy is beneficial against cancer / cancer cells. However, since cancer cells are human cells, that can be taken as evidence that soy is not good for healthy people.

      Best, Paul

  47. Hi Paul, I have been following the perfect health diet for some time now in order to treat my gut issues and HPA axis dysregulation. I get the impression that starches aggravate my digestive issues. I am considering replacing my starches with fruit and honey like in the SCD approach. This seems like an overabundance of fructose however. I suppose I could use dextrose, but I am concerned that that is too unhealthy as well and that it may cause blood sugar issues. Do you have any suggestions? Thank you

    • Hi Markus,

      Starches can interact with the gut microbiome to generate toxins, this is a cause of ankylosing spondylitis (search our blog for that) and some other autoimmune diseases. If you have the problematic gut microbiome, then sugar will be safer than starch, a la SCD or GAPS. Dextrose is a substitute carb source.

      Best, Paul

  48. Rosalyn Clement

    Hello. Is there any way a vegetarian can follow the Perfect Health Diet? Do you have any suggestions for those of us who don’t eat meat? Thank you very much.

    • Hi Rosalyn,

      The principles in the book are valid for vegetarians as for others. It can be challenging to optimize nutrition on a vegetarian diet. It is important to eat eggs (especially the yolks), and dairy is helpful. It is important to minimize empty calories (esp. processed foods made with starches, sugars, oils) and eat natural whole foods. It’s challenging to be a healthy vegetarian and we haven’t put together vegetarian meal plans, but you can come close with work.

      Best, Paul

  49. Hello,

    I strongly support the idea of safe starches and avoiding things like oats and brown rice. But why is white sourdough bread not considered a safe starch? I always thought the sourdough process deactivates the anti nutrients in it

    • Definitely it’s much better, but I think the problem is that not all the problematic compounds are fully metabolized by the fermentation. There will still be anti nutrients on it, not the fancy kind that leads to hormesis, but the hard kind. Not even extensive cooking with high pressure is capable to render WGA or gluten inoffensive, so we can imagine how hard those guys are

  50. Hello. According to the book it isn’t safe to combine alcohol and a omega-3 rich meal. I wonder how much later it is okay to have a glass again or is it better to stay off for the whole day. Thanks.

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