Gaby’s Textbook on Nutritional Medicine

A review by Jacob Schor ND, FABNO

Nutritional Medicine (Second Edition) by Alan Gaby, MD

2017; 1456 pp; Available at https://doctorgaby.com/the-book/.

This is a review of the second edition of Alan Gaby’s book Nutritional Medicine. It was tempting to write Alan Gaby’s “Life Work,” as this book embodies pretty much everything he’s ever given much thought to, well, except his music.

We should begin with a conflict of interest statement. I hold Dr Gaby in the highest respect. I admire and emulate his writing style. I believe that as a profession we are in his debt. I am honored that the Townsend Letter is even allowing me the opportunity to review this book. Thus, it may be difficult to be a critical reviewer. Yet, being critical comes easy for some people and this may not be the first time that I say unflattering things about a friend.

Let me also begin by admitting that I have not read the book in its entirety. No one, aside from the author probably ever will. There are 1420 pages printed in small font. Think of War and Peace without a hint of plot. Instead the book is divided into 26 sections. The first several chapters cover nutritional medicine from Gaby’s perspective, then review a long list of therapeutic agents including individual sections on vitamins, mineral, amino acids, and chemical agents such as acetyl-carnitine to S-Adenosylmethionine (SAMe) that don’t fit into those first three categories. These are followed by twenty-one chapters divided by disease name or –ology’s: cardiovascular disease, pulmonary disease, gastroenterology, liver diseases, neurology, rheumatology, musculoskeletal, dermatology, renal disease, urology, gynecology, obstetrics, pediatrics, ophthalmology, oral diseases, otolaryngology, psychiatry, endocrine diseases, hematology, infectious disease, genetic diseases, and miscellaneous conditions. Chapters follow on various particular modalities and drug nutrient interactions.

Each chapter is subdivided into essays on specific diseases. For example, the chapter on endocrine disorders has articles on diabetes mellitus, diabetic neuropathy, Grave’s disease, Hashimoto’s thyroiditis, and hypoadrenalism. In total, over 400 separate medical conditions are covered.

I never finished reading War and Peace for book group so never expect to get all the way Gaby’s book either. What I’ve done instead is to read some sections at random and some sections as patients come in with specific conditions and a few sections that I thought I knew a lot about already, and a few sections I knew little to nothing about. In every case, our good Dr. Gaby has had something useful to teach me. There’s no surprise in that. For long time readers of the Townsend Letter, we all feel like we know Gaby well and are not startled by his insights and occasional moments of brilliance. The book is without a doubt useful to own. All this is not to say that the book is easy to use, even if it is well organized and indexed.

Logistically the book is a nightmare. I balanced my copy on a kitchen scale. It weighs in at 3.555 kilograms. That’s seven pounds, 13.4 ounces. This isn’t a book that you carry between office and home. (Sure, Alan, I know that’s a reason to get two copies). It’s not a book to read in bed at night or even to read with it open on your lap. You need to rest it on something solid, like a desk or table. My copy has its own seat at the dining room table. You don’t lift it casually from the bookshelf. When you pick it up an inner voice says, “bend your knees.” You need to create a dedicated spot in your office for it to sit, where you can read it as needed without moving it. To kind of paraphrase that line about Mohammed and the mountain, in this case the mountain stays put and you go to it. This is doable and well worth the effort. I’ve got a spot picked out on top of a two-drawer filing cabinet in my office where eventually my copy will sit. My idea is to read it as needed for specific patients. Just the other day Alan informed me through the text that l-glutamine was contraindicated in Crohn’s disease. I hadn’t known. Having the book is like having an extended private tutorial with Alan Gaby in nutritional medicine. To me this feels like a great privilege.

Reading Gaby is something of a déjà vu experience. It all feels just so familiar, probably because I have tended to read pretty much everything Alan Gaby writes more than once. In the old days, I kept hanging folders in a filing cabinet dedicated to Gaby articles. He’s been a monthly contributor to the Townsend Letter nearly forever. His style is distinct in its clarity, objectivity, and concise information.

To quote Bill Manahan from the book’s forward, “When I think of precise science, evidence-based research, impeccable references, and a knack for speaking the truth, I think of Alan Gaby, M.D.” A sentiment that we all feel. Dr Gaby has overset the standard in our profession for utilizing evidence-based science to inform our clinical protocols. (Perhaps more than anyone else I can think of, but that will be too inflammatory a statement to print) This Gaby edition contains over 16,000 references, by the way, in case you are counting.

Way back in 1983, Dr. Gaby partnered with Jonathan Wright, MD, and together they started giving what became regular and well thought of seminars called “Nutritional Therapy in Medical Practice.” Their presentations stood out at the time because they used citations from the scientific literature to justify their protocols. Some of our younger colleagues won’t recall but, at that time, there were no shortage of seminars on alternative medicine that justified protocols based on muscle testing, pendulum swings, or simply channeled discourse. The Gaby Wright seminar was rather unique.

To quote Dr. Wright, for their first seminar, “… our book of citations to the scientific literature was slightly less than 80 pages, and included nearly every research article we could find. Our 2011 seminar book of citations was 360 pages, and lack of space forced us to exclude many more citations than were included.”

It’s been six years since the first edition of Nutritional Medicine was published. There have been some changes in the science over that time. New studies of clinical relevance are incorporated into the text as they are published. For example, the use of niacinamide to prevent development of skin cancer, the eradication of Helicobacter pylori to prevent stomach ulcers, and the use of Co-Q10 to reduce mortality in congestive heart failure patients. The second edition contains 1,700 new references. In comparing the second with the first edition, about 10% is new material and 90% was retained from the first edition.

Dr. Gaby is old school, literally; he attended medical school in the late 1970s, a time when there was no worldwide web and if you wanted to read the literature, you simply did so in the medical school library.

As Jonathan Wright explained in that first seminar, “In the early 1980s, well prior to online research libraries, he spent 30 hours a week for more than two years going through the entire table of contents of 50 major medical journals back to 1920, and about 200 other journals back to their beginnings. He photocopied, categorized, and we jointly filed every important research article concerning diet, vitamins, minerals, amino acids, essential fatty acids, and other important natural substances ever published in these journals.” This second edition is nothing more but a continuation of this work.

Somewhere, Gaby’s distinguished education should be alluded to; the undergraduate degree at Yale in political science, the Masters in biochemistry from Emory, and medical school at University of Maryland.

I first met Dr Gaby when he spoke in Tempe, Arizona, at a conference of the American Association of Naturopathic Physicians, perhaps in 1992. Gaby lectured on among other things, using Armour Thyroid. Actually, I should say he sang the praises of Armour as he pulled out a guitar partway through the lecture. As a result (of his pragmatic presentation, not his singing), we began using thyroid in our practice and did so for the next several decades and only stopped after receiving letters from the State questioning our legal ability to do so and hinting at various legal implications if we continued to be in violation of certain statutes.

That Arizona conference was notable because of another speaker’s lecture. The late Wade Boyle, ND, gave his famous lecture on liver herbs, the lecture in which he differentiated between the naturopathic use of herbal medicine and what at the time we disdainfully referred to as green allopathy, the way MDs tend to prescribe herbs. In naturopathic medicine, according to Dr. Boyle, we use herbs to tonify the targeted system and to invoke the natural healing force of the body. In contrast, medical doctors at the time were jumping to use herbs but in the same way they use drugs, to control physiologic function. Back in those days, we naturopathic doctors thought these distinctions were paramount. I recall thinking that Alan Gaby, as entertaining a speaker as he was, still fit into that green allopath category, though he was using vitamins as drugs rather than herbs. After all he was a MD, so we cut him some slack.

A quarter century later, that thought is still there. Alan Gaby is a medical doctor who has for his entire career practiced alternative medicine; he has not done what he was taught in medical school. He has substituted other things; vitamins, amino acids, and a few other supplements for drugs. He may be my favorite medical doctor, or one of my favorite medical doctors; yet the bottom line is that he can’t escape his training; he is forever going to be a medical doctor and can’t stop thinking like one. Thus, some might critique this book as a green allopathy cookbook.

Our philosophical approach to disease was once a big thing in naturopathic medicine. Do people still care? With the AANP lobbying in Washington to support compounding pharmacies and our practices focused on intravenous therapies, are we still the ‘drugless physicians’ we once took such pride in being?

When it comes to figuring out how to help a sick patient, these debates carry little weight. Information is useful. I read the Merck Manual like a bible in preparation to seeing a patient with a condition I am unfamiliar with. I now pair Merck with Gaby so I can see both medical approaches to treating the disease.

While Gaby’s book contains a wide range of information, mention should be made of what is missing. This is perhaps best explained by explaining exactly what Gaby means by his term ‘nutritional medicine’. He writes, “In 1973, shortly after graduating from college, I became interested in the possibility that dietary modifications, nutritional supplements and other “natural” remedies could be used as the basis for an approach to medical care that would be safer, less expensive and sometimes more effective than the usual drugs-and-surgery approach.” He credits Linus Pauling, Roger Williams, Abram Hoffer, and Adele Davis for starting him on this path.

Their approach at the time was revolutionary. The original focus of nutritional science had been to identify diseases caused by deficiency in necessary nutrients and correcting the illness through physiologic doses of the lacked nutrient. This new school of nutrition that Gaby followed used supra-physiologic doses of nutrient, not necessarily to correct deficiency but to steer body function. For a period, this was called “Orthomolecular Medicine.” As a result, Gaby’s book is not at all about correcting deficiency disease. There is no index listing for beriberi, pellagra, rickets, or scurvy.

Herbal medicine or even the concentrated botanical extracts that many of us consider to be almost drugs are only occasionally mentioned. Ginkgo and ginger are covered but milk thistle isn’t. Curcumin is mentioned only three times: for treating familial adenomatous polyps, proctitis, and ulcerative colitis and that’s it.

Homeopathy, well, if you know Dr. Gaby you would laugh to think that I even checked the index; of course, there is no listing for homeopathy. Suffice to say Gaby practices with a narrow pharmacy. Be that as it may, he does a good job with what he has.

In preparation for a patient visit the other morning, I attempted to read up on prostate cancer. It is not in the index. Nor for that matter was breast cancer, or any specific cancer. Cancer receives only minor attention in the book, less than two dozen pages hidden away in the chapter “Miscellaneous Conditions.” Cancer follows the section on burns. Though brief, the cancer section does review the data related to nutritional supplements in an excellent manner, reviewing the research in a concise even-handed manner. Still, the cancer information feels scant and the list of supplements covered feels out of date. No mention of melatonin, berberine, or caloric restriction; in fact, there is no listing of caloric restriction or fasting in the entire index.

Something else missing that our younger colleagues might find surprising is an in-depth discussion of MTHFR polymorphisms. The only mention I’ve come across is under the forms of folate available as supplements. Granted that some doctors may think the clinical fascination with all things MTHFR is a passing fad, but whether it is or not, one would think it deserves more attention, at least as much as frostbite, which does have a section.

In contrast to the scant coverage of MTHFR, Gaby devotes what seems to be an inordinate amount of space and attention to candidiasis, the “fungal (yeast) infection caused by Candida albicans or other Candida species.” A full section under the “Fundamentals of Nutritional Medicine” is devoted to Candidiasis Related Complex, and it is mentioned as a contributing or causative factor in the discussion sections of nearly two dozen different diseases and conditions, including anemia, chronic fatigue, Hashimoto’s, multiple sclerosis, premenstrual syndrome, schizophrenia, and systemic lupus. At one point in time, the alternative medical consensus was that Candida caused almost all illness.

Thus, in a way we should view Nutritional Medicine in part as an historical record of the practice of alternative medicine over the past four decades as it is a record of the subjects that have attracted Dr. Gaby’s clinical and intellectual interest. We should see Dr. Gaby’s treatise as his own attempt to chronicle what he has learned during his decades of practice, the sum accumulation of knowledge and experience. This book isn’t a textbook produced by a team of editors who have created a comprehensive encyclopedia on all related subjects. This is Gaby pure and simple, a medical doctor who came of age in the 1970s and who has always been a stickler for evidence-based medicine, even before it came into fashion among alternative practitioners. It is Gaby reviewing and summarizing the science on the conditions we have commonly seen, diagnosed, and treated in practice.

Hypoglycemia also receives focused attention, both its own section and frequent mention in the text under conditions such as arthritis, restless leg syndrome, and various types of headache. Is it that diseases become less common over time or do diagnoses fall out of fashion? I can’t recall the last time I felt a patient needed treatment for hypoglycemia.

In the end, Gaby has created an opportunity to learn what he has learned in his career, to hear him at his best and clearest explain the basic knowledge one needs to practice nutritional medicine. In a way, it is like having Gaby as a private tutor, like precepting with him in practice, like being able to say, “Dr. Gaby, could you explain this to me?” What could be more valuable to any practitioner?