Phoenix Integrative and Naturopathic Medicine Blog

What Causes High Homocysteine Levels?

Dr. Robin Terranella — Sat, 24 Oct 2026 13:00:00 GMT

Do you have ongoing elevations in your homocysteine levels? Maybe you're wondering what the heck could be causing this high homocysteine level. In this article we're going to look at all the causes of high homocysteine — the B vitamins and the medical conditions that can lead to high homocysteine levels.

What Homocysteine Is Actually Measuring

First off, homocysteine is a molecule in your blood that we use to measure the relative abundance or deficiency of things like B12, folate and B6. It can also be more of a reflection of your protein intake and your body's overall inflammation state.

So typically, if you're high in your homocysteine level, you're either consuming a bunch of protein or you're deficient in one of those three vitamins. And when you have a high homocysteine for a period of time, there are definitely consequences to that — problems that happen in the body.

Homocysteine above 9 is elevated; 15 and above is hyperhomocysteinemia.

B12 And Folate Deficiency

Both B12 and folate are needed to break down homocysteine and turn that homocysteine into methionine. If you don't have enough of one or both of those, then you end up with elevated homocysteine levels.

Genetics, Even Without A Deficiency

Sometimes there are genetic problems, even independent of deficiency, where your body is not making the conversion. There are problems with folate metabolism and B12 utilization that can lead to deficiencies independent of what the blood test shows.

So your blood test may show you look all good, you're in the normal ranges, but you still have a problem with high homocysteine. That's where you need to understand that sometimes genetic issues like MTHFR and other genetic alterations come into play.

Medications

Methotrexate and some other medications can also lead to high homocysteine. Methotrexate actually interferes with folate metabolism, so it makes sense that methotrexate could potentially raise your homocysteine levels.

Kidney Disease

Kidney disease and problems with the kidneys can also lead to elevated homocysteine levels, and this is thought to be related to losing B12 and folate through the urinary tract.

Lifestyle: Smoking, Alcohol, And High Protein Diets

Lifestyle factors like smoking, excessive alcohol consumption and high protein diets can also lead to elevations in homocysteine. Most of those are going to be tied in with folate and B12 deficiency.

The high protein diet in and of itself is going to contain methionine, so it can raise your homocysteine levels — because methionine is then turned back into homocysteine, and then it has to be turned back into methionine. So if you're consuming a lot of methionine-rich foods, which are animal protein, you may end up with higher homocysteine levels. (I went into that in more detail in diet's actual role in high homocysteine.)

Smoking has also been reported to cause elevated levels of homocysteine. And of course alcohol consumption depletes B vitamins like B12 and folate, and so that can also lead to high homocysteine levels.

Age And Sex

Homocysteine levels tend to increase with age, and it's also more common in men than women. The exact link there between age and male versus female is not fully understood.

B6 Deficiency — And Why Fasting Matters When You Test

I should also note that a deficiency in B6 can also lead to high homocysteine levels. And when you're measuring your homocysteine levels, you want to be in a fasting state to look at B12 and folate deficiency.

If it's elevated when you're in a fasting state, that means you're probably deficient in one or both of those. If it's elevating when you're in a fed state, that could be more of an indication of B6 deficiency.

What Counts As Elevated

When we say elevation here, I usually use the marker of anything above 9 would be considered elevated. But depending on how high it is will depend on the level of intervention, and also what kind of symptoms you have.

As it gets into the double digits like 12 and 15 — 15 is actually considered hyperhomocysteinemia, and that's when you see more serious problems from high homocysteine. I covered those in the health problems from high homocysteine.

If your homocysteine keeps coming back high and you want help finding which of these is driving it, schedule an appointment and we can work through the testing together.

High Homocysteine? Diet's Actual Role

Dr. Robin Terranella — Wed, 21 Oct 2026 13:00:06 GMT

Are you noticing that you have an elevated homocysteine, and you're making diet changes and finding that it's actually going up and not down? In this video we're going to look at the role of diet in causing high homocysteine. We're going to look at what foods have the highest homocysteine, what some of the research says about this, and why it's important to make sure you have enough B12 and folate when you're trying to answer this question.

A Viewer's Homocysteine Went From 13.7 To 26.9

I recently had a question from a viewer about his homocysteine levels. Originally it was 13.7 micromoles per liter, and after following a carnivore diet with lots of red meat it went up to 26.9 micromoles per liter. So what could be the reason?

While this question is pretty straightforward, I did want to double check that I wasn't missing anything, and I wanted to look into the methionine sources of different proteins and different foods in general.

Methionine keeps coming in; B12 and folate are the outlet. Narrow the outlet and the level rises.

Methionine In Animal Protein Versus Plants

As I've said in other videos, animal protein is very rich in methionine. Per 100 grams you're going to get somewhere around .9 grams of methionine from whole eggs. Fish sources like tuna might have 7 grams of methionine per 100 grams. Things like turkey, chicken, beef are going to have a little bit less, and so you get the general idea here. And plant sources are going to have very, very little amount of methionine, whether you're eating dark leafy greens or beans or lentils. They're all going to be, relative to these animal sources, much lower in methionine.

So you can see that if someone is mostly eating meat and fish, their methionine levels are going to go up.

Methionine, SAMe And Homocysteine

Now if you don't know, methionine turns into SAMe, and SAMe then turns into adenosylhomocysteine, and then from that you get homocysteine. If you have sufficient levels of B12 and folate and you're consuming this protein, there should not be any issue turning that homocysteine into methionine again, and being able to use that on a regular basis. If you are deficient in either one of these, that homocysteine just sits there, and the more methionine that you consume, the higher that homocysteine goes.

It's sort of like a river that gets dammed and has a small release valve or release outlet. When it starts to rain, the river levels rise, and so does the dam levels. In this case what you need is to widen the release valve, and this would be the equivalent of increasing your B12 or folate levels.

Now of course B12 is pretty plentiful in animal products, so one would think that if they're increasing the consumption of those, their B12 would be going up as well. But I would suspect that this person for some reason is not absorbing those. In addition, they may just be really low in folate, or they could be having difficulty converting their folate into methyl folate, and this often happens with MTHFR genetic alterations.

What The Research Says

But is this always the case? Is there another way to look at that? Is there ever a case where it rains and the dam doesn't fill up? It really depends on how much it's raining, but let's see what some of the research has to say about this question.

There have been some studies looking at dietary patterns and homocysteine levels, and they're mostly observational survey type studies, where you give someone a questionnaire and they fill out what they've been eating. So not super reliable, but somewhat helpful in terms of giving us direction on what's going on with homocysteine.

One was done in Pakistan and they looked at 872 healthy adults, and they found basically what would be expected. A diet higher in fruit and uncooked vegetables had lower homocysteine than those with higher chicken, red meat, milk, etc., who were more prone or more likely to have hyperhomocysteinemia.

Another study out of China found that those eating a cereal-based diet had higher homocysteine, and it was confirmed that they had lower B vitamin intake compared to the intake patterns of other people in the research study. So for example, those that were eating more fruit and milk had the lowest homocysteine level, but they also had the highest B vitamin level.

Make Sure You Have Enough B Vitamins

So I think overall, when it comes to homocysteine and diet's role in elevated homocysteine, is making sure that your body has sufficient B12 levels and folate levels. In some cases B6 may also be important, and some people are obviously more susceptible to vitamin B6 deficiency than others.

Homocysteine is very responsive to these B vitamins, and I don't think I've seen a case that has not responded, meaning going down, when you have elevated homocysteine levels. And I would expect it to go down even in the presence of high meat, fish intake. Even if you're eating those exclusively, as long as you're getting enough B vitamins, that homocysteine level should stay normal.

If you've had issues with elevated homocysteine in the context of diet changes, maybe you should be checking your B vitamin status to get a better understanding of what's going on with those.

If your homocysteine won't come down and you want help sorting out the B12, folate, and methylation picture, schedule an appointment and we can dig into it together.

Topics: Homocysteine, Methionine, B12, Folate, Methylation, MTHFR, Carnivore Diet

How To Diagnose Hashimoto's Disease?

Dr. Robin Terranella — Sat, 17 Oct 2026 12:59:59 GMT

Do you feel swelling in your neck or thyroid area? Maybe you're having symptoms of fatigue, or maybe you've gotten some thyroid lab results back and you're wondering how to diagnose Hashimoto's disease. In this article we're going to look at that question — what specific lab tests you need to diagnose Hashimoto's, and some of the different ways it can present itself, to give you a better understanding of how we actually make the diagnosis.

What Hashimoto's Actually Is

Hashimoto's disease, also known as Hashimoto's thyroiditis or chronic lymphocytic thyroiditis, is by nature an autoimmune disorder: lymphocytes — types of white blood cells — are inflaming and attacking the thyroid gland. In the U.S. and other developed nations, this is the most common cause of hypothyroidism, or underactive thyroid.

The thyroid is a small butterfly-shaped gland that sits right in the neck and produces thyroid hormones like T3 and T4. So when we want to diagnose Hashimoto's, we need to look at both thyroid function and autoimmune activity.

Thyroid function plus autoimmune antibodies plus symptoms — read together.

Signs And Symptoms First

It's important to do a thorough intake and understand what symptoms the person is having — one of the most common is fatigue. On physical exam, a lot of the workup happens through blood testing, but sometimes you can also feel nodules along the thyroid gland, which may be an indicator that something is going on with the thyroid.

The Thyroid Function Tests: TSH, Free T3, Free T4

The tests we use to look at thyroid functionality are TSH — thyroid stimulating hormone — and T3 and T4, the thyroid hormone output from the gland. Most of what the thyroid produces is T4, so that's one of the more important ones to measure, but both T3 and T4 can be low, so it's good to measure both. You also want the free, bioavailable versions of these tests, because that gives you a better indicator of the active amount of thyroid hormone.

High TSH with low T3 or T4 can indicate hypothyroidism, and that's really common with Hashimoto's. But the presence of high TSH or low T3 and T4 isn't enough to diagnose Hashimoto's — you can have hypothyroidism without Hashimoto's. How high the TSH is and how low the T3 and T4 are will determine how treatment moves forward.

The Autoimmune Tests: Anti-TPO And Thyroglobulin Antibodies

For the autoimmune part of the diagnosis, you're looking at anti-thyroid peroxidase — the anti-TPO antibody — which is the most commonly used to diagnose Hashimoto's, and sometimes thyroglobulin antibodies as well. Anti-TPO is the most telling because it interferes with the production of the thyroid hormone itself, while anti-thyroglobulin has more to do with transport. Both are indicators of autoimmune disease.

The antibodies need to be above a certain threshold to make the diagnosis. Some of us have small amounts in our body without enough to trigger a positive result — but when they're high above that threshold, that's Hashimoto's thyroiditis.

You Can Have The Antibodies With Normal Thyroid Numbers

It's also possible to have Hashimoto's antibodies in your blood and not have hypothyroidism — TSH, T3 and T4 all look really good. But if the autoimmune component is present, your immune system is still interfering with thyroid hormone production. Because that interference is inconsistent, your hormone levels can fluctuate: check your blood one day and the levels may be different a day later.

So if your symptoms seem to fluctuate a lot, it may be important to get multiple serial tests before you make a decision about starting thyroid hormone.

Imaging

An ultrasound can also be used to image the thyroid — bouncing sound waves off the gland gives a better view of whether nodules are present, which can be an indicator of inflammation in the thyroid.

Putting It Together

The diagnosis of Hashimoto's disease is typically made through a combination of lab testing — thyroid function plus the autoimmune antibodies — together with your symptoms. If the pieces don't line up neatly, serial testing over time is often what clarifies the picture.

Related reading: How To Cure Hashimoto's Disease and our thyroid treatment program.

If your thyroid labs and symptoms are not adding up, schedule an appointment and we can run the full panel properly.

TRT And High Estrogen: What's Normal And What Is Too High

Dr. Robin Terranella — Sat, 10 Oct 2026 12:59:59 GMT

Let's face it — starting on TRT is like dropping a high-performance engine into your car. Your power's back up. But what happens when your cooling system can't keep up with all that extra power? The engine starts to overheat and things start breaking.

On TRT, your estrogen is kind of like the temperature gauge. For many guys on testosterone, it's often public enemy number one. You're told to block it, crush it, destroy it at all costs. What if I told you this war on estrogen is a big mistake, and it may be the very thing that's causing you to be more tired, have issues with libido, and have more joint aches?

Today we're popping the hood on estrogen so you can stop fearing it and start fine-tuning your system like a master mechanic. By the end of this article you should understand what the science says about high and low estrogen, how to test for it in the right way, and how to find that performance sweet spot for yourself.

You Absolutely Need Estrogen To Feel Good

Here's the biggest thing you really need to internalize about your TRT and estrogen: you absolutely need estrogen to feel good. The goal is not to have zero estrogen. That will make you feel just as miserable as having super high estrogen, if not worse. And we know this from landmark human studies that really analyze and look at this distinction.

The real goal is finding the optimal balance. Feeling puffy and moody could definitely be from high E2. But having achy joints, maybe super low libido, brain fog — those are also classic signs of super low estrogen, and often come from using estrogen blockers injudiciously and crushing that estrogen. Optimal living and optimal health is going to be found in the middle, not at the extremes.

Both ends cause problems. The target is the level where you have neither high nor low E2 symptoms.

Why Testosterone Turns Into Estrogen In The First Place

Why does testosterone even turn into estrogen? This is a natural process. Your body uses an enzyme called the aromatase enzyme to convert a portion of that testosterone into estradiol, or E2. The more testosterone in the system, the more estradiol you're going to get — it's basically the raw material for the estrogen to be produced.

So E2 is naturally going to rise with going on testosterone replacement therapy. It's a normal process. The question really is how much is too much, and what do we do in those scenarios.

Symptoms Of High Estradiol

When your testosterone dose is too high, or you're just a high converter of testosterone into estrogen, those levels are definitely going to climb, leading to the classic symptoms of high estradiol:

Water retention and puffiness — a bloated or puffy face
Blood pressure issues
Gynecomastia — puffy or sore nipples, and potentially growth of breast tissue over long periods
Increased emotional volatility — moodiness, irritability, even crying for no reason or more frequently
Libido and erectile issues — too much estrogen can impair sexual function, because it has a blocking effect on testosterone too

Symptoms Of Estradiol That's Too Low

This is what happens when men panic and overuse aromatase inhibitors, or perhaps they just got fed some poor advice. They crush their E2 into single digits, and the consequences are sometimes more severe in some than others. I've had people that have low E2 where we've overshot the mark and they don't even really notice it, so it is individually based. But some of the symptoms people do report:

Painful, achy joints. Estradiol is crucial for joint health — it acts kind of like a lubrication. In fact, a lot of times when men go on testosterone they notice less joint pain, and that's likely from the estradiol levels going up alongside the testosterone.
Low libido and erectile problems. Without adequate E2, most men will experience very low sex drive.
Brain fog, anxiety, depression. Very low estrogen can contribute to this — but so can low testosterone, so you have to be careful evaluating all these markers together.

What The New England Journal Study Showed

You may be thinking, how do we actually know this is true? A landmark study published in the New England Journal of Medicine clarified some of these things perfectly. They gave men testosterone, but in some groups they used an estrogen blocker — an aromatase inhibitor — to block the conversion of testosterone into estrogen.

The results were pretty clear. While testosterone itself was primarily responsible for increasing muscle mass and strength, the estradiol was essential for regulating body fat. When E2 was blocked, body fat actually increased. And critically, both testosterone and estradiol were required for normal libido and erectile function — when either was deficient, sexual function went down.

This study pretty much validates that trying to eliminate estrogen is a massive mistake for your health. But that doesn't mean we want sky-high estrogen either.

So What Is The Optimal Level?

This is the million-dollar question. Labs often list the normal range as somewhere around 20 to 40 picograms per mL, but a symptom-plus-lab-based approach is far superior to just looking at a number on the page.

Even more critical: just like your testosterone levels have a peak and a trough after the injection, so does your estradiol. Why? Because E2 is created from testosterone. The higher the testosterone, the more aromatization, and therefore the more E2 you're going to have. As your testosterone falls into the trough before your next injection, so will the E2. Same with the peak.

This means a single estradiol marker is really just a snapshot in time. You have to extrapolate from that one number what else is going on. A high E2 reading at the peak might not be a problem at all if your trough E2 is in a good range and you don't have any high estrogen symptoms. The context is always critical here.

What I like to use is this: your optimal E2 level is the level at which you have no high E2 symptoms and no low E2 symptoms. For one person that might be 25 pg/mL, another might be 45 pg/mL. In my clinic, symptoms are just as important a guide as your lab metrics.

Many clinicians find that monitoring the ratio between total testosterone and estradiol is more useful than looking at E2 in isolation. I don't use this approach — but either way, always use the ultrasensitive estradiol assay for your blood test. This is a more accurate way to check your E2.

The Numbers I Get Concerned About

You may wonder what's absolutely too low and what's absolutely too high. I would say anything below 20 is definitely too low if you're on testosterone and trying to block it. If it just naturally sits at 20, that doesn't mean you need to take extra estrogen.

What's absolutely too high? Above 50 pg/mL is where I start to get more concerned about lowering that E2, even in the context of not having a lot of symptoms. You have to know what the risks and benefits are — if you're fine with the risk, you can let it ride.

The Bottom Line

I think we just need to stop fearing the estradiol. Both high and low levels can cause problems, and the goal is to find the symptom-free, somewhat Goldilocks zone for you. Remember that your E2 level fluctuates, so make sure you're testing and interpreting your results in the context of your last injection.

And since managing high or low estrogen is often a direct result of getting your testosterone dose right in the first place, that's the next thing worth reading. If you haven't sorted out why your testosterone was low to begin with, start with primary versus secondary low testosterone.

Want to see where your estradiol sits relative to everything else? Run your labs through the TRT Lab Analyzer, or schedule an appointment.

High AST With Normal ALT: What It Means

Dr. Robin Terranella — Wed, 07 Oct 2026 16:59:59 GMT

If your blood work came back showing a high AST while your ALT looks normal, it's natural to assume something is wrong with your liver. Often, it isn't. AST and ALT are both commonly called liver enzymes, but they aren't quite the same, and the gap between them tells a story. In this post we'll look at what's actually going on when AST is high but ALT is normal, the most likely cause, and when the pattern points to something that does need attention.

AST And ALT, The Basics

AST stands for aspartate aminotransferase, and ALT stands for alanine aminotransferase. Both are enzymes commonly measured on blood tests to evaluate liver function. When a cell is damaged or injured, by a toxin, by too much alcohol, or by other causes, it bursts open and releases these enzymes into the bloodstream. That's why liver damage shows up as elevated liver enzyme values on a blood test.

Why AST Is Different

Here's the key detail that explains the whole pattern. AST is not found only in the liver. It's also present in other tissues, including the kidney, the heart, and skeletal muscle. ALT is much more specific to the liver.

So when AST is high but ALT is normal, depending on how low or normal that ALT actually is, the elevation may be coming from one of those other tissues rather than the liver itself. And importantly, it isn't always a problem at all.

The Most Common Cause Is Muscle

The first and most likely explanation for a high AST with a normal ALT is muscle damage, usually from exercise. Every time you exercise, you damage your muscles to some degree. The more intense the workout, the more of that damage occurs. Those muscle cells burst open and spill AST into the bloodstream, and then it shows up on your labs.

A useful rule of thumb from the video: if your AST is genuinely high and your ALT is pretty much normal, under about 25, then muscle is most likely the source. This is why timing matters so much, and why a hard workout in the days before a blood draw is worth mentioning to your doctor. I've covered this specific connection in more depth in can exercise affect liver enzymes.

The Other Possibilities

Muscle isn't the only source. Because AST also lives in the kidney and heart, problems with those organs can raise it too. The helpful part is that those problems usually don't show up alone. A kidney issue would more than likely come with other kidney-related signs, such as a high creatinine. A heart issue would tend to come with other elevated cardiac markers. No single test gives you 100 percent certainty, but the surrounding labs usually point you in the right direction.

And of course AST can come from the liver itself. Alcohol use is one of the more common reasons for liver-related AST elevation. But when alcohol is the cause, the AST elevation is usually accompanied by a corresponding rise in ALT, and often GGT as well. So an isolated high AST with a normal ALT and normal GGT argues against the liver being the source. If your liver enzymes as a group are elevated, that's a different conversation, and worth reading how to lower liver enzymes naturally and the post on GGT and the glutathione connection.

What To Do About It

If you have a high AST with a normal ALT, the calm interpretation is that it may simply be from exercising. But don't just assume that. It's only a safe assumption if the timeline matches a recent hard workout and you have no other reason to suspect your liver, kidneys, or heart. Whatever the suspected cause, the smart move is the same: get a second, follow-up test once you're well away from the exercise or whatever else might be the culprit. That tells you whether the elevation is a one-off or something ongoing.

Bottom Line

A high AST with a normal ALT usually points away from the liver, not toward it, because AST also comes from muscle, kidney, and heart. Far and away the most common cause is muscle damage from exercise. Look at the rest of your labs for clues, consider your recent activity, and repeat the test under calmer conditions to confirm what's really going on.

When liver enzymes are genuinely elevated, glutathione is one of the supplements I most often use to support liver detoxification. Here's the one I use with patients (affiliate link). Or work with me directly to build a plan around your specific labs.

Topics: AST, ALT, Liver Enzymes, Liver Function, Muscle Damage, Blood Test

Tips To Reverse Low Kidney Function

Dr. Robin Terranella — Wed, 07 Oct 2026 13:00:00 GMT

Did you know that over 37 million Americans suffer from kidney disease, and many of them don't even know it? Today we're going to go into some simple actionable steps you can take to improve or reverse your low kidney function. We're going to use some of my clinical experience and understanding of what causes low kidney function to deliver some lifestyle tips, some ideas around what optimal kidney function is, understanding why you have low kidney function if you do have low kidney function, and some lifestyle, diet, exercise and a few supplements you can take that research suggests may improve your low or declining kidney function.

How Kidney Function Is Measured

Today we're going to be diving into some simple actionable steps that you can do to improve or reverse your low kidney function. But you do have to be mindful of how severe your kidney function is, and make sure you're running these things through your doctor, make sure they know what you're taking and doing. The worse your kidney function is, the more things you put into your body, sometimes things can get worse.

With that in mind, before we jump into the things you can do to reverse low kidney function, I want to touch briefly on what normal kidney function is and how it's measured. The measurement of kidney function is usually done by two primary tests. One is called the creatinine test, which gives you an estimated GFR, and the other one, which is lesser known, less commonly run, is called cystatin C.

Creatinine is the waste product from muscle metabolism, and high levels indicate a poor or low kidney function, because the kidneys aren't filtering it out, it's building up in your body. So the optimal range for creatinine is actually the lower the better, but the optimal is going to be around 0.6 to 1.2 mg per deciliter. Now there are some other things to note about this too. It's going to change with size, it's going to change whether you're male or female, and some other things that I've gone into in other videos, so I won't review that here.

But because there is so much variability in the creatinine, and sometimes it can change from one day to the next based on something as simple as how well hydrated you are or whether or not you exercise, there are alternative tests, one of which is called cystatin C, and this can give you a more accurate assessment with less variability for your kidney function. Still, the optimal GFR that you're going to want to go for is still going to be around that 80 to 90 mark or above.

eGFR of 90 or above is optimal — the trend over years matters more than any single test.

Look At The Consistency Of Your Tests

So keep that in mind, more so on the consistency of your test. One test may jump out as an outlier and say, oh, there's a problem. Another test may show, oh, everything's fine. And as long as you're getting, for the most part, normal kidney function levels, it's not really something to be worried about. But if you're getting over the years declining, declining, declining, and it's not bouncing back up, that's when you know you might have a problem, and you might want to implement some of these strategies or look at what could be impacting your kidneys to create this lower kidney function.

Remember, your kidneys are filtering waste, so the more efficient that is, the less waste products are going to be circulating around in your body. So an estimated GFR of 90 or higher is going to be normal or optimal kidney function. As it starts to slip below that 80 to 90 mark, there may be an indication of mild or decreased kidney function. That's when you want to be more alert and diligent about what's going on in your body. Now again, one test wouldn't necessarily say, oh, looks like you have some declining kidney function.

And as we get older the kidney function is going to decline more and more, because basically what's happening is you're exposed to more inflammatory things that are going to potentially damage the cells that are responsible for the filtration process. You can think of the mechanism of kidney filtration kind of like a vacuum, and as that vacuum process is no longer able to occur, the filtration process goes down. Instead of things getting sucked into the filtration process, they just keep going around in the blood and less stuff gets filtered. And so that's why it's important to be mindful of some of these lifestyle things that we're going to discuss.

Specific Contributors To The Damage

So let's look at some specific contributors to that damage or decreased filtration process, so you can better understand how to decrease the burden on your body and possibly reverse your low kidney function.

There are multiple things that can contribute to decreased kidney function, but there are three, possibly four, that are kind of high up on the list. And the first thing that I think about when my patients have decreased kidney function is, is their blood pressure good and normal, and is their blood sugar good and normal? And sometimes this can be more difficult to assess when we're just doing a simple blood test every six months, three months, because you're not capturing the day-to-day rises and falls in both the blood pressure and the blood sugar. And so the diagnosis of what's causing these problems is also essential to understanding this. Medications and inflammation are another key variable to consider, and we'll look at some things you can do for that as well.

Blood Sugar

So when we're thinking about how to reverse low kidney function, the key thing is to first understand what is causing your decreased kidney function, and first and foremost is getting multiple tests that show that decline in kidney function. So if you already have that, blood sugar is probably one of the most common reasons for this, followed by blood pressure.

When you have improved glycemic control you have less damage to those kidney cells, and we know that blood sugar is a major contributor to decreased kidney function because diabetes is one of the most common causes of chronic kidney disease. Now you don't have to have actual overt diabetes in order to start having problems with your kidneys. So having a more even blood sugar is going to keep the insult to those kidney cells lower. And remember, the more damage or inflammation that's occurring to those kidney cells, the more likely you are to have problems with those kidney cells and decreased kidney function.

So diet and exercise are the main things that you can do to improve your glycemic control. You can also wear a continuous glucose monitor to see if you're having higher than normal peaks, to see if that may be an additional contributor to your decreased kidney function. Now improving your blood sugar control sometimes can take months or even years to get to more of that optimal state, and with that you're also going to see a slow improvement in your kidney function as well. So don't expect to see a change overnight, unless you just had some kind of fluke decline in your last kidney function test.

And just to put another finer point on what's happening with the kidneys, the hemoglobin A1c is a measurement of the amount of glycation that's happening to the protein on the hemoglobin molecule. So the more of that that's occurring, the more high blood sugar you have, and that's basically damage that's occurring to that hemoglobin molecule. So the same thing could be happening inside the cells of the kidney, that's damaging those kidney cells. So the higher your A1c, the more likely you have a problem like this occurring in your kidney cells, kidney tissue as well. But you don't necessarily need to have a high A1c to have this problem.

Blood Pressure

Okay, moving on to blood pressure. We know that high blood pressure can damage kidneys as well. You can think of this more like a pressurized effect on those kidney cells. When you're pressure washing something, or the pressure that happens with each step that you take, you start to build up a callus, or using your hands a lot you start to get calluses, that same kind of pressure, high pressure environment in those kidney cells, which are very delicate, can lead to some kind of callousing effect there and reduce their ability to filter that blood.

When you have super high elevated blood pressure you don't want to necessarily drop it too quickly, but you do want to get your blood pressure reading down to around 120 over 80, or perhaps even lower than that. With intensive interventions at lowering your blood pressure when it's elevated, you can also see a marked improvement in your function over the short and long term, short meaning months, long term meaning years. This can be achieved by taking medications, and I've also gone into a lot more detail in some other videos on how to optimize your blood pressure.

When you're having ongoing blood pressure issues, again, it can go back to some of the dietary things that we just mentioned, low carb, low glycemic index foods, which are going to lead to more even blood sugar. And also exercising more regularly is going to allow those arteries to be more responsive and dynamic to the need for higher pressure at different times. It's going to allow your blood to be able to get diffused to where it's needed without necessarily pressuring those arteries too much.

And remember, it's not always just about doing the right things and putting it on autopilot. You also have to test to make sure these interventions are actually working. Testing is always essential to make sure you're on the right track.

NAC

So now I want to talk a little bit about some supplements you can use to reverse low kidney function. N-acetylcysteine is something that's used in a lot of different areas in our body, and that's because NAC, or N-acetylcysteine, is used to make a very important thing in our bodies called glutathione.

Research has shown that patients that receive contrast to do some kind of imaging study, and have subsequently had decreased kidney function, taking NAC actually helped raise or improve their creatinine clearance. Other research has shown that NAC can improve the outcome in transplant patients that are undergoing kidney transplant, their ultimate kidney function that results from that transplant. Other studies looking at stage three chronic kidney disease didn't show an improvement in creatinine clearance after taking NAC.

So NAC may have some upside potential, and I think it has very little downside. It may not always work. I think it depends what the ultimate mechanism of action on why you have decreased kidney function. If you're having ongoing high blood pressure, NAC may not be the right thing for you. If you have decreased kidney function due to inflammatory reasons, or if you have decreased glutathione levels for other reasons, NAC may be the right thing. So it's important to, again, diagnose and figure out why you have this problem first, and then some of these things may be more effective.

Vitamin E

Vitamin E is another supplement that's shown some promise in decreased kidney function. Supplementing with vitamin E normalized creatinine clearance in patients with diabetes, suggesting that that antioxidant effect may be helpful to improve kidney function in diabetic patients, and this was in one study.

Putting It Together

Now I mentioned some lifestyle things above, but regular exercise, and making sure your tissues are getting perfused or able to dilate and move throughout your body, and especially that the kidneys are getting what they need, is going to be crucial to optimizing your kidney function.

So decreasing inflammation by optimizing your diet, decreasing your blood pressure through exercise, diet or medications, is going to reduce the impact, the negative impact, on those kidney cells. And maybe some NAC or glutathione support and vitamin E all may be helpful for helping you reverse your low kidney function. It's important to remember though, the diagnosis is the most essential part. Without the diagnosis you're kind of just shooting in the dark.

If your kidney numbers have been slowly declining and you want help figuring out why, schedule an appointment and we can build a plan around your specific situation.

Topics: Kidney Function, Creatinine, eGFR, Cystatin C, Blood Sugar, Blood Pressure, NAC

Here is How To Decrease Th2 Dominance

Dr. Robin Terranella — Sat, 03 Oct 2026 12:59:59 GMT

This article we will look at how to decrease Th2 dominance. If you are struggling with things like Atopic dermatitis, asthma, and other Atopic like syndromes, this article is going to help you understand what you can do. This article specifically following up on a question that asked about what supplements or herbs that can balance out elevated Th2 levels. We will also talk about what Th2 and T-helper cells are in the context of the immune system.

If this interests you keep reading, we are going to discuss the details.

Can You Decrease TH2 Dominance Using Supplements?

This question came from a video that was talking about increased Th2 immune activity in eczema. With eczema there is generally a shift towards more of this Th2 activity. So in the case of eczema, we want to look at how to decrease Th2 dominance or decrease Th2 activity in shift more towards a more balanced immune system.

Specifically what we want to look at what herbs and supplements can be used to do this. So we'll be looking at some herbal themes and ideas that you can use to decrease the Th2 activity. Before we jump into that I wanted to mention that you should not take this advise like a prescription. Instead look at this information as a way to and like help you understand what general things you can use to help balance your body's immune system.

What Do T. Helper Cells Do?

The first thing to know is that the immune system has different lines of cells in it. There are B cells, lymphocytes, macrophages, T. helper cells, and many others. These are all types of white blood cells that help the body prepare and respond to problems when they see them. The T. helper cells are like this too. With eczema the T. helper cells are not these cells until they start responding to the trigger. Before the trigger is noticed these cells are undifferentiated. The cells respond to what they see causing them to turn into T helper cells. This response is appropriately but the number of white blood cells turning into Th2 will increase based on the amount of trigger the immune cells see.

When you have a lot of triggers you have a lot of Th2 cells. This is Th2 dominance. The immune cells can turn into Th1 or other types of T helper cells as well. Th2 dominance is a result of what the immune system is responding to. Depending on what the immune system sees determines which type of T. helper cells are produced. Many of the triggers to shift the immune system in this way come from the digestive tracts. Taken as a whole we want to look at things that will reduce toxins, allergens, and things of this nature. These are the things that tend to stimulate the immune system towards that T cells.

In a previous video on eczema we talked about how the relative balance in the microbiome is important. Because most of these toxins and allergens are coming in and generated from the digestive tract, this is a good place to start. The bacteria in your digestive tract respond to the food that you eat. They will produce more by-products (toxins for our bodies) when they are fed things that make them grow.

Eczema's Link to Gut Health

Supplements To Decrease Th2 Activity

Because the toxins are stimulating the immune system, we want to look at things that can remove those toxins. So in order to reduce the Th2 dominance one thing you can look at is decreasing the toxins with supplements. Things like for fiber (specifically psyllium fiber) and other types of binders can bind these toxins in the digestive tract. Another good option is activated charcoal. These will not bind all the toxins but can bind and reduce some of them. Using these will help decrease the Th2 dominance but only if the problem is coming from increased toxins. Of course, there are other reasons why this Th2 dominance can be expressed. Using binders is a relatively simple and effective way to approach it.

Probiotics are another angle to look at. probiotics can help with balancing out your microbiome. There are many different probiotic strains and some should be avoided if you have Th2 dominance. Probiotics that interfere with histamine breakdown or promote histamine production should be avoided. The strains that do this are many of the Lactobacillus strains. The probiotics strains you should take and are helpful include the bifodo strains and lactobacillus rhamnosis (even though it is lactobacillus it still helps) .

Another thing you want to look at or think about to decrease Th2 dominance is stabilizing the mast cells. Mast cells are the cells that contain histamine. With Th2 dominance there is an increased abundance of the mast cells. More mast cells is one of the results of this increase Th2 activity. There are certain herbs and and nutrients that you can use to stabilize these mast cells. Some of those herbs and nutrients include things like Quercetin, nettle leaf, and Vitamin C. Quercitin is a type of plant bioflavonoid and there are other bio-flavonoids that can be used to metabolize mast cells.

So those are two or three general ideas you can use to reduce the Th2 dominance. Again I don't want you to take this as prescriptive advice because there's a lot of different reasons why people have skin reactions like eczema. You should always take new things in consultation with your doctor.

If you have questions about any of the content discussed, please ask in the comment section below. For a customized plan for your, asthma, eczema, and general Th2 dominance, click on the link below to get started.

https://pubmed.ncbi.nlm.nih.gov/9206708/

Th2 is the allergic arm of the immune system — the gut is usually the first lever.

Want help rebalancing this properly, starting with the gut? Our digestive health program is where we usually begin — or schedule an appointment.

What Is Erythrocyte Sedimentation Rate (ESR)?

Dr. Robin Terranella — Wed, 30 Sep 2026 16:59:59 GMT

If you've looked at a blood test and seen something called your erythrocyte sedimentation rate, or ESR, sitting high, you may be wondering what the test even measures. It's one of the older lab tests still in regular use, and it tells you something useful about inflammation in your body. In this post we'll walk through what ESR actually measures, why inflammation changes the result, and what a high number does and doesn't tell you.

What ESR Actually Measures

Erythrocyte sedimentation rate, also called sed rate or simply ESR, measures the rate at which red blood cells settle in a vertical tube of blood over a set period of time. That settling process is greatly influenced by inflammation, and in particular by the immune system and how it's responding to whatever is going on in the body.

So although the test sounds purely mechanical, what it's really capturing is a signal of immune activity. When the immune system is working, it changes the behavior of your red blood cells in a way that this simple test can detect.

Why Inflammation Changes The Result

Here's the chain of events. The immune system is responsible for inflammation and for responding to infections, injuries, and other problems. When it's active, it sends signals that prompt the liver to produce a group of molecules known as acute phase proteins, which include globulins and fibrinogen.

Fibrinogen is a fairly large protein, and normally it's present in the blood at very low levels. During inflammation, its concentration rises significantly, as do the other acute phase proteins. Besides fibrinogen, this group includes proteins like serum amyloid A, fibronectin, haptoglobin, alpha-1 antitrypsin, alpha-2 macroglobulin, ceruloplasmin, and ferritin. That last one is worth noting, because ferritin doubling as an inflammation marker is exactly why high ferritin can be confusing to interpret, something I cover in detail in the danger of high ferritin.

The Stack Of Coins

Of all those proteins, fibrinogen is the main driver of what ESR detects. As its concentration rises, it alters the surface properties and the electrical charge of your red blood cells. That change makes the surface of the cells much more sticky.

Sticky red blood cells adhere to one another and stack together. Under a microscope, this stacking looks remarkably like a stack of coins. And those stacks behave differently from individual cells, which is the whole basis of the test.

How The Test Is Performed

The test itself is straightforward. A blood sample is taken from your arm and placed into a vertical tube, then observed over the course of an hour. Red blood cells that are stacked or clumped together are heavier than freely moving individual cells, so they settle more quickly. As they settle, they leave a visible column, which is measured in millimeters per hour. The faster the cells settle, the taller that column, and the higher your ESR.

A Non-Specific Marker

This is the most important thing to understand about ESR: it's a non-specific marker of inflammation. It doesn't directly identify a cause. It won't tell you whether you have a bacterial infection, a fungal infection, or some other process going on. What it reflects is the presence of those acute phase proteins and the corresponding stickiness of your red blood cells.

So an elevated ESR isn't a diagnosis. What it tells you is that your immune system is more active than it should be, and that it's likely producing more fibrinogen and other acute phase proteins. From there, you'll typically need additional testing to narrow down what's actually driving it.

Bottom Line

ESR is a simple, time-tested window into inflammation. It works by detecting how readily your red blood cells stack and settle, a behavior driven mostly by fibrinogen rising during an immune response. A high result is a meaningful signal that something is provoking your immune system, but it's a starting point, not an answer. The next step is figuring out the cause.

If your ESR is elevated and you want help tracking down what's driving the inflammation, work with me directly to build a plan around your specific labs.

Topics: ESR, Erythrocyte Sedimentation Rate, Inflammation, Blood Test, Fibrinogen, Acute Phase Proteins

Have You Tried Methylfolate For Depression?

Dr. Robin Terranella — Sat, 26 Sep 2026 13:00:00 GMT

Has your mood been down, depressed? Maybe you're lacking energy and motivation. In this article we're going to look at methylfolate for depression, and specifically we're going to look at some of the research behind this — what it means for people with MTHFR, and for those without an MTHFR gene alteration.

Folate For Depression Is Not A New Idea — Methylfolate Is

Using folate and folic acid for the treatment of depression is not really a new concept, but the use of methylfolate is fairly new, or relatively new.

What's interesting to note is that some of the research on methylfolate for depression is in people that don't actually have MTHFR gene alterations.

Remission rates from the 12-week primary care trial: 48% on methylfolate, 32% on placebo.

A Quick Background On MTHFR

For those of you not familiar with this concept: MTHFR is an enzyme that all of us have, but when it's altered it leads to alterations in how we metabolize folate, and it renders the person's enzyme less capable of making methylfolate.

Giving these people with the gene alteration more methylfolate does seem to help in a lot of ways, including fatigue, depression, and anxiety, among other things. People with an MTHFR alteration clearly do have a reduction in their ability to produce methylfolate.

Why It May Help People Without MTHFR Too

Based on some of the research that I recently came across, it seems that even those without an MTHFR gene alteration but with depression may benefit from methylfolate. Well, why could this be?

There are other genetic alterations that some people may have, such as folate transport gene alterations. And then also, maybe they're just not consuming enough folate in general, including folic acid, in their foods. So there's an overall reduced delivery to the areas that are needed to help with neurotransmitter production. Perhaps these are some of the reasons.

What The Research Actually Found

Treatment-resistant depression is a common cohort of patients that different things are tried on. For one, they've already kind of maxed out all the things they could try. But for two, if it works on this population, there's a good chance it probably will work on other people with depression as well.

So in 2010 a study looked at this population, and they found that adding methylfolate to a standard therapy for depression such as an SSRI was effective at reducing depressive symptoms.

In another study, patients were recruited from 124 different primary care practices throughout the U.S. The patients were randomly assigned to receive either methylfolate or placebo for 12 weeks. The primary outcome the research study was looking at was a change in the Hamilton Depression Rating Scale — this is a common depression scale that's used to measure the severity of depression symptoms.

The study found that the change in the Hamilton score was significantly greater in the methylfolate group compared to the placebo group, meaning that the improvements were greater. It also found that the methylfolate group was more likely to achieve remission of their depression symptoms than the placebo group. Remission in this case was defined as a seven or less on the Hamilton Depression Rating Scale. About 48 percent of the methylfolate group achieved remission versus 32 percent in the placebo group.

Overall they concluded that methylfolate is effective at improving depression symptoms in a real-world setting, and that it was also well tolerated by the patients that took it.

A Caveat On Who Funded Some Of This

There are some other studies that were funded by the maker of Deplin, and these had even more positive associations, as you can assume. Deplin is a prescription/over-the-counter product that has high doses of methylfolate in it, and so those studies of course may have a bit of a conflict of interest.

But still, it is interesting that there are findings suggesting methylfolate is effective at improving depression even in people that don't have MTHFR.

How I Actually Use It

I don't typically give methylfolate to people without MTHFR or some sort of folate deficiency. And even those with an MTHFR gene alteration, I usually start slowly and carefully, because of the potential for side effects. In the right person at the right time it can be really, really helpful to uplift mood and stabilize some of the negative thought patterns.

If you're thinking about using this approach for your depression or mood issues, it's important to work with a healthcare provider that knows and understands this particular supplement/medication. Too much can actually have the opposite effect on your energy, mood, and well-being — which is exactly why methylfolate makes some people feel worse.

If depression has been resistant to everything else you've tried, it's also worth reading about the MTHFR connection to treatment-resistant depression.

If you want help working out whether methylfolate belongs in your plan — and at what dose — schedule an appointment and we can go through your genetics, labs, and symptoms together.

Does Coffee Raise Cholesterol?

Dr. Robin Terranella — Wed, 23 Sep 2026 17:00:00 GMT

If you've been watching your cholesterol, you may have wondered whether your daily cup of coffee is part of the problem. It's a fair question, and the answer is more interesting than a simple yes or no. Coffee can raise LDL cholesterol, but whether it does, and by how much, comes down to how the coffee is made and how much you drink. In this post we'll look at what the research shows, the two compounds that actually drive the effect, and how to think about your own cup.

The Short Answer

LDL cholesterol is worth keeping in check because it's a major contributor to atherosclerosis and heart disease. When it comes to coffee, the reassuring news is that in small to moderate amounts it doesn't seem to contribute a great deal to elevated LDL. Some studies have even shown a small beneficial effect, while others show no effect at all.

The reason the research looks mixed is that the answer really depends on two things: the individual, and the type of coffee. By type, I don't just mean the beans. I mean how the coffee is prepared.

It's Not Just The Coffee, It's How It's Made

Two preparation factors matter most. The first is what you add. Stirring in high-fat dairy or coconut is not going to help keep your LDL in check, and it can raise it before we even get to the coffee itself.

The second, and the more surprising one, is whether the coffee is filtered or unfiltered. If you're boiling your coffee or using a French press, that lack of filtration allows higher amounts of certain compounds to end up in your cup, and those compounds can raise LDL cholesterol.

Cafestol And Kahweol, The Two Compounds

Unfiltered coffee contains two particular compounds that can raise LDL: cafestol and kahweol. Both have been shown to increase LDL cholesterol in some people. When coffee is passed through a paper filter or a metal mesh filter, much of the cafestol and kahweol is removed, so the final cup carries far less of them.

How much these two compounds affect your cholesterol varies from person to person, and it also interacts with the rest of your diet and lifestyle, including your overall saturated fat intake. Cafestol appears to be the stronger of the two. Kahweol's effect is less well understood and may matter less.

How Much Is Actually In Your Cup

Here's where it gets practical. Some studies have shown that high doses of cafestol, somewhere around 14 to 20 milligrams, can raise LDL cholesterol by as much as 10 to 15 percent. So an LDL of 110 might climb toward 120 or beyond.

So how much is in a cup? Filtered coffee is probably nothing to worry about. Unfiltered coffee, like French press or espresso, is where these compounds show up, and the amount also depends on the bean, the roast, and the brew time. On average, a cup of unfiltered coffee carries roughly 2 to 5 milligrams of cafestol and 2 to 4 milligrams of kahweol. At the high end, that's around 9 milligrams from a single cup. Since 14 to 20 milligrams is the range that starts to move LDL, you'd generally need to drink somewhere around two to four cups of unfiltered coffee before the effect becomes meaningful.

What This Means For You

If you drink one cup of filtered coffee a day, there's really not much to worry about here. If you're drinking two or three cups of unfiltered coffee, that's when the impact starts to add up. And if you happen to use beans or a brew method that runs high in these compounds, even a single strong cup could put you near the threshold.

The honest answer is that you may have to experiment. Going without coffee for a stretch and rechecking your numbers is the only way to know for sure how much your coffee is contributing. And remember that genetics and other lifestyle factors play a large role in your overall LDL, so it's worth looking at the whole picture rather than blaming the coffee alone. If your cholesterol is the bigger concern, I've covered the broader strategy in how to lower cholesterol without statins and how to control high cholesterol naturally.

Bottom Line

Coffee can raise LDL cholesterol, but it's mostly a story about brewing. Filtered coffee removes most of the cafestol and kahweol that drive the effect, while unfiltered coffee like French press and espresso carries more. One filtered cup a day is a non-issue for most people. If you drink several cups of unfiltered coffee and your LDL is creeping up, switching to filtered, or simply cutting back, is an easy lever to pull.

If you want help sorting out what's actually driving your cholesterol numbers, work with me directly to build a plan around your specific labs.

Topics: Cholesterol, LDL Cholesterol, Coffee, Cafestol, Heart Health, Diet