When I was studying my under-graduate I imagined my clinic was going to be full of them: well patients wanting to maintain or even improve upon their wellness. Turns out…not so much…all the really really sick people have taken their spots and the former has been listed as an endangered species. But I do catch glimpses of them, as I am sure we all do, in their natural habitat, with over-flowing baskets at the organic grocery store or farmer’s market, routinely up the front of the pilates class and also sometimes in our clinics. So now that naturopathy, by consumer demand, not practitioner intent, has transitioned so much into the ‘unwellness space’, do we know anymore what to do with the well ones??
I heard some great talks at the NHAA conference recently. One, in particular, was by my stellar colleague, Liza Oates, who observed that contemporary naturopaths tend to respond to these clients in 1 of 2 ways:
a) Unaccustomed to a patient who eats, exercises, sleeps and balances their work & non-work worlds better than themselves…PANIC…Â
b) Dig deep back through the dusty archives of their personal & family medical history until they FIND A PROBLEM THEY CAN TREAT!!! such as, ‘Once I was constipated for a couple of days’ or, ‘Once I took a course of antibiotics’.
I know…we’re hilarious…we have to laugh at ourselves đ Liza offered up some great ideas about how to approach our consults with these patients. Many of her tips, however, could be applied to the rest of our patients as well to gather some really valuable insights. And it’s always great to hear from someone who has been seeing patients over decades…there’s so much to be gained from those who’ve gone before us (or alongside us…in my case!) and can speak to these firsthand lessons. Here are just a few of her pearls
The ‘not stressed’ patient
We encounter a lot of people who can misreport their stress levels, not because they are trying to lead us astray but that’s that slippery slope of self-reporting & the possibility that someone has normalised their ‘load’. Liza says she likes to step away from that potential trigger word, ‘stress’ and instead ask, ” What are your tell-tale signs when the demands exceed your capacity?”
This is not so that we can fulfil option b) mentioned at the beginning…digging desperately to find some unwellness to treat – but rather as an aid for both practitioner and patient alike to understand better that individual’s response to their psychosocial environment.
Ask them to design their own health retreat
If they reply, “I would start every day with a little meditation and yoga, a chai and then a healthy hot meal”, then these can be translated into little goals we can set to bring some of their ‘best self ‘ into their every day. It also helps to better understand their values, individualised self-soothing and self-care & great prescriptions to begin with, given they’re telling you they are already at contemplation in terms of their readiness for behavioural change. They’re not going to require too much convincing – they’re already converts they just need permission and support to implement.
And if you’re sitting there reading this and thinking, ‘Hey! These are exactly the patients I want my clinic full of”…then to hear more of Liza & Greg Connolly’s commentary and insights about how the wellness space has been hijacked by others and how naturopathy needs to move centre-stage in this increasingly popular trend, take a listen to this interview they recorded at the conference.
This UU30 recording from our back catalogue on the behavioural change model and how it impacts patients’ response to our advice is a key element in developing a professional approach that actually works. Unless practitioners are aware of the way that patients approach changing their dietary behaviour or exercise regimes, they the mystery of non-compliance will never be solved!
b. Every herbalist’s jaw at my table at the NHAA conference gala dinner, when I got almost all my Latin binomials right during the trivia quiz?…and after some champagne, that’s a particular achievementÂ
c. My jaw, when I saw firsthand how much those herbalists could drink of ye-not-so-olde herbal extracts!!
d. The latest Update and Under 30 – Milk Madness Part 2
e. All of the above
If you answered, ‘e’…. you must have been one of those herbalists at my table, otherwise you have way too much insider information! But yes you are correct on all accounts. So this latest UU30 is an extension of our discussion last month about the potential contribution from to mental health from dairy intake in a subset of patients. This whole topic, the research for which dates all the way back to the 70s, was too big to fit into one – given the current evidence base that now depicts at least 2 different mechanisms that might be at play, and the different types of mental health problems, each has been linked with. Last month was all about retracing the ‘dietary exorphin’ path, this month it’s about the propensity for some individuals to make antibodies to casein and the significant growing data that suggest this happens to a larger extent in patients with certain psychiatric diagnoses. More importantly, we talk about the ‘why’.
What compelled me to make time to look through all the literature on this was that there is some. No seriously. When I initially learned of the GFCF dietary approach to ASD patients I was told that in spite of a lack of supportive research, the empirical clinical evidence was irrefutable, which I later saw with my own eyes. In the couple of decades since, I only really heard about negative findings, short trials of the elimination diet specifically in ASD kids, that failed to produce significant change. Funny how the bad stories rise to the top, right? But when I spent the time doing a thorough literature review, I found these negative findings were far from the whole story. In fact, I was really surprised by the high level of evidence employed by researchers of late, who have repeatedly found associations between either exorphin or antibody levels and patients with particular diagnoses, in addition to really progressing our understanding of why these measurable differences (urinary exorphins, plasma IgG and to a lesser extent IgA casein antibodies) are meaningful. Do we know everything? What do you think? The answer, of course, is always no. But we know enough to consider this aspect in our comprehensive workup of mental health patients and all their biological drivers and we know dramatically more than anyone in mainstream medicine, or the dairy industry for that matter, is ever going to let on!
If you want to hear a synthesis of the casein antibody link with mental health then download the latest UU30 – Milk Madness – part 2.  If you can’t go that far, then “do yourself a favour” and read a couple of seriously important articles on this topic – and why not start at the deep end with this study by Severance in 2015.
Could dairy intake in susceptible individuals be a risk promoter for mental health problems? In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms. Specifically, the IgG and, to a much lesser extent, IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically. The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling.
Q: If a patient says they can only tolerate 7 foods…how many did they start with?
A: Typically about 20
No, this answer doesn’t come from some complex mathematical formula…it comes from appreciating the low dietary diversity of those eating a Western diet. When we boil down these diets to the number of foods from different biological origins (families) it can be a frighteningly small number.
You see, like most practitioners, I feel utter dread when I encounter the patient who prefaces their diet story with a statement similar to the one above. It speaks to the severity of their symptoms, their attribution of these with food, that by the way is essential for their sustenance and nutritional salvation, and implies an exhaustive pursuit they’ve undertaken probably over years to find ‘safe foods’. And yes, as discussed in my recent talk A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? – food reactions, as in more than one mechanism of food reaction, often do move in packs and that comes typically back to a poorly functioning gut…BUT…that latter assumption…’they’ve explored and exhausted all foods’ is the one we need to keep in check.
Have they tried daikon? Prickly pear or jambu? Okra? Snake beans? Quail or duck eggs? Kangaroo? Crickets? Etc Etc. Etc.
Are you catching my drift? Because someone has DIY diagnosed a wheat, dairy, soy and, and, and, reaction (correctly or incorrectly) and perceive themselves to react also to most of the limited fruit and veg they can identify in Woolies…doesn’t mean they’ve remotely exhausted the global food supply! Where am I going with this? When patients tell us they’re down to 7 foods they can tolerate – some sensible follow up actions on our behalf may include:
Check the strength and validity of their level & strength of evidence for their DIY diagnosis
Think about the linking ‘process’ (more than likely gut) that is the real potential issue (aka don’t eliminate the messenger and do nothing more!)
Encourage and advise them to shop anywhere other than where they normally do – somewhere that sells fresh produce they don’t recognise at all…like Asian, Indian or Middle Eastern supermarkets and grocers
My tour of A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? (and the weeks of lit review leading up to this) provided me with enormous food for thought…and this is just one! If you want to hear more about how to find method in the madness of food reactions…you should probably listen in to the whole shebang…goodness knows with the increasing number of patients who present with self-determined food reactions and an increasingly narrow menu of safe foods…practitioners and patients alike need all the help we can get!
Confronted with the possibility of adverse food reactions in an increasing number of our patients can be an overwhelming prospect, in terms of accurately identifying and understanding the faulty mechanism underpinning these aberrant responses to healthy foods. Elimination of culprits in most situations is only a short term reliever, not an appropriate long term solution, so to optimise results we need to know the real mechanism of action. The majority of these, of course stem from the gut, but being able to elucidate exactly which of the many things that can go wrong there, is going wrong and therefore what foods are problematic until we address this, is the key. This 2hr mp4 is all about the bigger picture and helping you find method in the madness that can be the AFR landscape. Along the way we detail the science of where IgG reactions fit into this and it’s a fascinating story that just might be the missing puzzle in your leaky gut patients.
Click here to purchase A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it?
We’re not deaf…we heard that stampede of Iron-Inundated Practitioners!
Our recordings and clinical resources for improving your skill-set in all things iron including, your accuracy of diagnosing deficiencies, pseudo-deficiencies & excesses, plus radically rethinking the best treatment approaches for each scenario…have been some of our most popular. Because nailing iron (pardon the pun) is harder than we were all lead to believe and at least 1 ‘iron maiden’ or ‘iron man’ walks into our practice every day, right? So we’ve brought together 5 extremely popular UU30’s on Iron into one bundle for the price of 4! So if you’re more than ready to graduate from ‘iron school’, now’s your best chance!
1. So You Think You Know How to Read Iron Studies? (â¤30 min audio + Cheat Sheet)
Overt Iron Deficiency Anaemia or Haemochromatosis aside…do you understand the critical insights markers like transferrin and its saturation reveal about your patients iron status? Most practitioners don’t and as a result give iron when they shouldn’t and fail to sometimes when they should. This audio complete with an amazing cheat sheet for interpreting your patients Iron Study results will sharpen your skills around iron assessment, enabling you to recognise the real story of your patients’ relationship with iron.
2. Pseudo Iron Deficiency (â¤30 minute audio)
The most common mistake made in the interpretation of Iron Studies is this one: confusing inflammation driven iron âhidingâ with a genuine iron deficiency. Worse still, following through and giving such a patient oral iron â when in fact it is at its most âtoxicâ to them.
This audio together with some key patient pathology examples will prevent you ever falling for this one! Learn how to recognise a âPseudo Iron Deficiencyâ in a heartbeat!
3. Iron Overload… But not as you know it (â¤30 minute audio)
Weâre increasingly seeing high ferritin levels in our patients and getting more comfortable referring those patients for gene testing of the haemochromatosis mutations; but, do you know how to distinguish between high ferritin levels that are likely to be genetic and those that are not? This can save you and your patient time and money and there are some strong road signs you need to know. In addition to this, what could cause ferritin results in the hundreds if itâs not genetic nor inflammation? This Update in Under 30 summary will help you streamline your investigations and add a whole new dimension to understanding iron overloadâŚbut not as you know it!
4. So You Think You Know How To Treat Iron Deficiency? (â¤30 min audio)
And then you don’t. The reality is we all struggle at times with correcting low ferritin or iron deficiency anaemia – so what have we got wrong? In spite of being the most common nutritional deficiency worldwide, the traditional treatment approaches to supplementation have been rudimentary, falling under the hit hard and heavy model e.g. 70mg TIDS, and are relatively unconvincing in terms of success. New research into iron homeostasis has revealed why these prescriptions are all wrong and what even us low-dosers need to do to get it more right, more often!
5. So You Think You Know the Best Iron Supplement, Right?! (â¤30 min audio + Iron Supplement Guide)
Iron supplementation, regardless of brand, presents us with some major challenges: low efficacy, poor tolerability & high toxicity – in terms of oxidative stress, inflammation (local and systemic) and detrimental effects on patients’ microbiome.  What should we look for to minimise these issues & enhance our patients’ chance of success. Which nutritional adjuvants are likely to turn a non-responder into a success story and how do we tailor the approach for each patient? It’s not what you’ve been taught nor is it what you think! This comes with a bonus clinical tool, a fabulous easy reference guide – to help you individualise your approach to iron deficiency and increase your likelihood of success.
You’ll never look at iron studies or your iron-challenged patients the same way.
Listen to these audios straight away in your online account.
While we’re on the topic…I tend to think, that as good as we are at asking a lot about a patient’s health, we can always do better. One of the classic pitfalls for practitioners is having to rely so much on patient self-reporting: Is your period heavy,moderate or light?; How would you rate your appetite?; Do you suffer from excess flatulence? When our patients answer these questions, who are they able to compare their own experiences with? Or do they only compare them with themselves at another time in their life, e.g. my periods are heavier/lighter than they were before? Either way, this may lead to unintentionally misleading information from our patients, producing erroneous conclusions for us as clinicians. Do you suffer from excess flatulence?  Well do they?? How exactly would most of us know?! Unless we can define what ‘normal’ looks like…?
14
(But as many as 22 times a day – that’s almost one on the hour)
That’s the average number of ‘pop offs’, ‘air biscuits’, ‘bench-warmers’, ‘fluffs’, or whatever you want to call them, healthy humans do per day as cited in this great evidence based & entertaining article. Funnily enough I had exactly the same lecturing experience as the author: performing a snap poll on my students, asking for averages…and can I just say almost everyone was clearly under-reporting!! But the point is clear. How can our patients accurately rate the magnitude, severity or normality V abnormality of their bowels, menses, appetite, pain threshold etc – unless we provide some goalposts? And are we, in fact being lead to believe there is a problem when perhaps there isn’t? That certainly has been the conclusion of several studies into the matter of self-reported excessive flatulence. Hippocrates himself put in a good word for bottom trumpeting, saying “passing gas is necessary to well-being” and as a recent article in the Harvard Health Letter reads,  âA little bit of extra flatulence, could be an indication that youâre eating the way you should!â Here here!
But my favourite quote from this article has to be about the high tech solutions on offer – for those who do accurately fall into the excessive category:
“Such as carbon fiber odor-eating underwear (cost: $65), which were put to the test in an American Journal of Gastroenterology study that included such gems as âUtilising gas-tight Mylar pantaloons, the ability of a charcoal lined cushion to adsorb sulphur-containing gases instilled at the anus of eight subjects was assessed.â Assessed, that is, by a panel of fart-sniffing judges. And the name of the charcoal lined cushion? The âToot Trapper.â
How different that scene in Bridge Jones’ Diary would have been had these been her undergarment of choice instead of the control briefs!
Of course, if there is associated pain or an odour (which the article discusses as well) that makes the family dog leave the room…well, that’s another matter…;)
Is Glutamine your go-to prescription for patients with gut problems? Do you look for good levels of it when youâre choosing your gut repair formulas? Most of us do this because weâve heard that a deficiency negatively impacts the gut tight junctions , villi structure and immunity etc. but how long has it been since youâve reviewed the latest human studies on the digestive effects of Glutamine supplementation? The time is now. This previous UU30 installment cuts to the chase on the big research findings that warrant our urgent attention and necessitate big adjustments in how we use glutamine for guts.
I have a good friend…who happens to be a naturopath…who happens to also be a patient of mine. Have you got a few of these as well? A month ago, looking over her recent bloods which included fasting lipids that had been steadily climbing for the last couple of years, post-menopause, she said, ‘do you think I should take something for that?’ Ahhhhhh no. My reasoning went like this:
“You love saturated fat right? You eat butter and cheese and and and…and the type of elevated lipid pattern you have LOOKS like it is at least partially the result of this, your triglycerides are low, your HDLs are good it’s just this LDL component that is too high. You could add in another supplement…and take it…forever…or you could do a little n=1 experiment and just lower your butter, cheese & coconut oil intake for a month and repeat the test.”
The horror on her face! You see I didn’t know exactly how much she loved butter but it all became clear with the first text a few hours after I had thrown down the gauntlet…which included a sobbing emoji and the comment that her afternoon snack will never be the same…turns out it was a shortbread biscuit with butter on it!!! But as a practitioner who does pride herself on walking the talk…off she went determined to give it a good go for a month.  But boy did it hurt!(more…)
No, I haven’t gone crazy for the ‘caped crusader’… but I thought that would get your attention…. oh look it did! đ
Iâm off to Melbourne for the ACNEM Conference May 5-6th and Batmania was one of the interim names of this very cool and happenin’ town before it became known as Melbourne in 1837! Things have certainly changed in nutrition and the environment since then and as practitioners we now need to address sometimes very complex dynamics between genes, gut, nutrition and environmental health. Which, luckily enough this conference is all about!
This yearâs theme for ACNEM is Health for Life – Mastering the Integrated Approach.Â
I am fortunate to be included in the exceptional speaker line-up (thanks for lovely sentiments many of you have expressed so far about that đ ) I am presenting on ageing..which many of you know that I am suddenly now very interested in…getting old and all.
Standing at the podium, I looked down at my notes & slowly read out the title of my presentation to the hundreds of people attending, ‘Paediatric Digestive Issues & Neurocognitive Abnormalities’ and briefly froze thinking, Holy Heck (!) this is someone else’s presentation! Seriously. No, this is not one of my work stress dreams. This happened. I thought…oh my how am I going to deliver this, it sounds very complex and lofty and scary!!
Then I saw my scribbled hand notes on the page, the unofficial name I had affectionately given this presentation as I researched, compiled my case studies and brought it into being, months prior and I instantly relaxed…oh…Kids’ Guts Are Mental…now that I have some serious experience with and something to say about!(more…)
Another young female presents in my clinic with a newly diagnosed thyroid cancer and has been recommended urgent thyroidectomy. Â Her story is increasingly common. If you’re not seeing it in your clinic, you will, because thyroid cancer, and almost exclusively papillary thyroid carcinoma (the form my patient and most young patients have), is dramatically increasing. Â Since the 1970s the early 2000s there was a 67% increase in the incidence in women and a 48% increase in men, documented in 5 continents (Peterson et al 2012). Our Australian data is equally shocking with the number of new cases of thyroid cancer diagnosed increased from 361 (104 males and 257 females) in 1982 to 3,154 in 2017. The question begging to be answered is why…?!
Increased screening and more effective detection of smaller tumours was the going theory for years.  New research rejects this absolutely and concludes instead this is a ‘true increase in occurrence’.  Increased radiation exposure?  Mutation studies say no.  Many researchers are pointing to is a ‘new environmental chemical and/or dietary factor’ and EDCs (Endocrine Disrupting Chemicals) that target the thyroid such as perchlorates, phthalates, parabens and phenols are the likely suspects. And, more than likely, with iodine deficiency in an individual, conveying even greater susceptibility to these EDCs.
But wait there’s more.These ‘new goitrogens’ aren’t only implicated in thyroid cancer, a large number of human studies confirm the higher your urinary metabolites of these, the lower your thyroid function. More worryingly is that they might be doing this ‘without a trace’. With myriad impacts at the receptor level, altered hormone excretion rates, impaired peripheral conversion etc. the data to date suggest these patients TFT results might only look ‘slightly low’ or even ‘normal’ but the reality is they are suffering hypothyroidism. Sound familiar?
There is a HUGE body of scientific evidence we can pull from to understand the role of EDCs in thyroid problems in our patients, how to maximise prevention and minimise impact – even when your patient, like mine, is perhaps already in the full grip of the consequences. I’ve read all the papers and summarised them in this 30min recording…
Hypothyroid without a trace – the role of EDCs.
Have you got patients with hypothyroid symptoms but normal results?  Or results that suggest the HPT axis just seems to be broken? Could it be the result of a combination of Endocrine Disrupting Chemicals (EDCs)? How do you assess  for these ‘new goitrogens’, which act more potently and more insidiously, inducing hypothyroidism ‘without a trace’. How do you maximise prevention for all of your clients and the most at risk sub-populations or minimise impact for those already in the full grip of their consequences.
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This Update in Under 30 audio comes with 3 key related scientific articles and a bonus larger powerpoint presentation
In an ASLM Tweet I shared this weekend, I mentioned our own ‘Gut Guru’, Jason Hawrelak reported dietary saturated fat (including coconut oil) increases GIT endotoxin uptake and boy did that stir the pot! The social media switchboard lit up! It’s ok I know there isn’t a switchboard anymore…but I am old school đ  This got just about everybody talking on Twitter & Facebook…and thinking out there in the real world…which is good, right?  And if you read to the end you will find prizes galore for those of you that want to add to this discussion đ(more…)
This week I must have spent more than my daily time allocation (5mins) on Facebook and as a result I stumbled across an article I actually read from beginning to finish!  The title called to me, “Bad Parent, Hey Bad Parent”…it works every time right?  Anyway, once I started reading it I thought, no this is useful, we all need that manual that everybody talks about but nobody seems to own and I know this relates to not only the way I am bringing up my teens but I can pass on its pearls to my patients who are parents of teens as well.
My kids have been teens mathematically speaking for 3.5 years now, but I’m pretty certain, the metamorphosis happened just last Tuesday for one and a couple of months prior for the other.(more…)
Howdy practitioners – I’ve had an inspiring month of clients. Not because I cured anyone, answered some major riddle previously unsolved by modern medicine or any of these enormous tasks we or our patients often set ourselves but rather because I got back to basics.  Many of you will know that I spend most of my practice time working at the pointy end of complex chronic multi-system disease and while it is deeply satisfying when you have a breakthrough with someone’s health, it is challenging.  Often I am the last bastion, my clients have been referred to me and therefore typically have already addressed their diet and other health behaviours to a certain extent.  So unlike perhaps many naturopaths, I don’t spend most of my time in practice talking about food and doing the grassroots education that is at the core of naturopathic medicine (in my humble opinion) đ
This month was different.  I had a bunch of clients who, while they did have pointy end (that’s a technical term!) multi-system disease, e.g. one client alone had retinal detachment, coronary stents, a genetic bone disease, NAFLD and a liver abscess, they clearly hadn’t been educated about food in the way that we do so well and which can make such a huge impact on a person’s life and health.
When was the last time you drank or ate something that contained an artificial sweetener (AS)? I remember it well and my most striking recollection was the way it âhit the spotâ just like I would have expected sugar to, making me immediately suspicious of the effects it would have on my body. It seemed implausible that it could mimic the taste/the sensation/the mood effects of a major sugar hit but not evoke any of the physiological responses of sugarâŚwhether that be in my brain, my pancreas, my whatever! Weâve been sold the concept that AS offer the western world an exit point from our collective march towards metabolic syndrome for decades but sweet relief (pardon the pun ;)), new scientific studies are piecing together the real impact of AS consumption.
“‘We found that artificial sweeteners may drive…an exaggerated elevation in blood glucose levels, the very same condition that we often aim to prevent by consuming them,’ Eran Elinav, MD, PhD, from the Department of Immunology at the Weizmann Institute of Science, Rehovot, Israel, said at a press briefing.” Medscape(more…)
In the Byron shire we have a fabulous local comedian called Mandy Nolan who makes a lot of fun of the health and food fads that regularly sweep this area and one of her favourite catch-cries is âIâm gluten intolerant-intolerant, if I meet another person who tells me theyâre gluten intolerant Iâm going to scream!â Although I take genuine gluten reactions very seriously I do get where sheâs coming from and it stems primarily from pervasive misunderstandings & misuse of terms in the community. The problems with this are multiple: firstly those people who are walking around with an exaggerated sense of their problem will unnecessarily limit their diet (and perhaps the diets of their loved ones) at significant financial, nutritional & even psychological cost and then we have people who have the most extreme gluten reactions not receiving the serious attention that they absolutely need in all sorts of settings like restaurants, childcare centres and schoolsâŚbecause seemingly everyone has some sort of âgluten issueâ & therefore it has become dangerously ânormalisedâ.
So letâs just recap the possibilities and try to clear the confusion. When people walk through our door and tell us they âcanât eat breadâ or âpasta makes them bloatâ or âI donât think wheat agrees with meâ, thatâs where our work just begins in terms of needing to clarify what the nature of their reaction is. Putting them immediately on a gluten free diet is a mistake because it doesnât tell us which one of the below issues is at play and therefore fails to give us clear guidance about what is an appropriate course of treatment & dietary intervention.
Coeliac disease â while there are a multitude of testing options for CD the first place to start is the genotype. If you donât have the gene it is extremely unlikely that you have CD. If you have the gene then thereâs about a 1/3 chance you might & specific tailored antibody testing or jejunal investigations are necessary.
A genuine wheat allergy (not CD) is rare but is more common in infants & toddlers. It can be diagnosed by blood antibody tests (IgE RAST) or skin prick testing (SPT) for wheat
Non-coeliac disease gluten sensitivity â may not involve the immune system at all, however, raised anti-gliadin antibodies are frequently seen in these patients
FODMAPS â is not an allergy but a type of intolerance due to impaired digestion of the fructans found in wheat. We must rule this out as a possible explanation for someoneâs reaction  and I would start with a good checklist of other FODMAP foods to check tolerance e.g. soy, dairy, increased fruit intake and check for other conditions that can lead to this via disruption or destruction of the small intestinal brush border
Carbohydrate digestion issues other than (or in addition to) FODMAPs i.e. underfunctioning of the pancreas
Red herring!  And donât forget this old pearl⌠it could of course be a total red herring. Perhaps the reaction is due to another component in bread (yeasts, preservatives etc.), or the other foods they always eat with the pasta (tomato etc.) or their general poor diet quality and speed of eating, lack of relaxation around meals etc. etc.
My one exception would be in children diagnosed on the spectrum for autism. Â I think going gluten free where possible is appropriate from the get-go in ASD. Â For everyone else, a correct diagnosis is the essential first step to effective & proportionate treatment so keep your wits about you my fabulous fellow diet detectives!
