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?
Let’s talk turkey about our pharmaceutical Pet Hates, mine are Proton Pump Inhibitors (PPIs). They irk me more than any other drug class. It’s not entirely rational. Let’s face it, they have some stiff competition but for some reason, in my mind, they almost always win: helping so little & at such a high cost to patients. What fuels my fire of course is their over-prescription, followed closely by the complete disregard for the prescribing guidelines which state:
“When clinically indicated, PPIs should be used for the shortest duration necessary and chronic use is not recommended except for treatment of pathological hypersecretory conditions including Zollinger-Ellison syndrome and maintenance healing of erosive oesophagitis.”
Sorry…did I hear you correctly?Chronic use is not recommended – yet this is one of the drugs most commonly on ‘set and forget mode’ in general practice. To boot, their chronic use has been associated with a number of serious concerns, which I’ve touched on before, from osteoporosis to increased rates of GIT infections. not to mention just the little ol’ detail of malabsorption of multiple nutrients! But this week, yet another health concern has popped up and into my inbox…and well..I found myself shouting at the medical newsfeed on my screen…[again] 🙁
“In their analysis, more than 42,500 adverse events reported to the US Food and Drug Administration by patients on PPI monotherapy were compared with more than 8300 reports from patients on histamine-2 receptor antagonists (H2RAs)….Patients on PPIs alone were 28 times more likely to report chronic kidney disease than those taking H2RAs, while the frequency of acute kidney injury reports was around four times higher…Reports of end-stage renal disease were 35-fold higher among PPI users, while reports of renal nephrolithiasis were three times higher”
To be clear, while these increased rates are TERRIBLE and unacceptable in the context of the ‘set and forget’ prescribing that seems it be rife in most countries, they still only effect a small % of patients e.g. approx 5% of patients had adverse renal effects on PPIs Vs 1% on the older generation H2 blockers for reflux but it’s yet another reason (like we needed more?!) to think twice before our patients are initiated on these meds, which are presented to patients as being benign. Typically with drug development, the older drugs in a class are superseded by newer ones that are ‘cleaner’, and therefore more effective with less adverse effects but this is one situation where if one of my patients really did need a med, I would say out with the new and in with the old!
One scenario where PPIs in combo with multiple antibiotics get routinely rolled out is of course H.pylori infections. But does this make sense??
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking. A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot. You can find out here with our previous UU30: H.pylori- Eradicate or Rehabilitate?
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, “A little bit of extra flatulence, could be an indication that you’re eating the way you should!” 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 “Utilising 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.” Assessed, that is, by a panel of fart-sniffing judges. And the name of the charcoal lined cushion? The “Toot Trapper.”
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 you’re choosing your gut repair formulas? Most of us do this because we’ve heard that a deficiency negatively impacts the gut tight junctions , villi structure and immunity etc. but how long has it been since you’ve 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.
Oral sex. There I said it. Last month when I talked about Helicobacter pylori and where people might ‘catch’ this – if they didn’t inherit the little critter from their mum or family as an infant – we thankfully were able to rule out kissing as a source of transmission between couples P.H.E.W…but I sort of got shy (Who, you, Rachel?!!) and danced a little bit around the question of whether other forms of sexual contact represent a possible route of exposure (pardon the pun). Until a lovely colleague after listening to Blowing the lid on H.pylori-who gets it & why – said, ‘Now seriously Rach, are you trying to say, oral sex may be an issue?’ Well…ahem…maybe. You see, remember what I said about candida being a vector for H.pylori and therefore H.pylori being present in the vaginas of women who have this bacteria residing in their stomachs. Ok…enough of that now I am blushing..but if you want to read more on this grab this article in BMJ from 2000 by Eslick who discusses (and seems a little too interested in, can I just say), the risks of H.pylori transmission via a myriad of sexual activities.
A month has passed since that last UU30 edition and it’s time for another instalment. This month, I’ve taken the giant leap forward many of you requested, into the fascinating realm of how best to manage H.pylori positive patients, in whom this bacteria really does constitute a pathogen.
Do we just try with multiple relentless antimicrobials to blast holes in this critter, a lot like the conventional approach…which, thanks to its significant capacity for developing resistance, is like aiming at a constantly moving target,…or…?
I’ve got a very different suggestion and approach. Increasingly we realise that the GIT microbiome is a vulnerable & dynamic balancing act and as a result, when treating patients with confirmed parasites, or worms or potentially (but not always) pathogenic bacteria such as H.pylori, most of us are doing much less ‘weeding’, less ‘eradicating’ and definitely less ‘shooting at things only to hit others’, these days. Instead we think about how we can best change the environment. So, what is it about someone’s stomach that opens the door to H. pylori and lets it in, and then perpetually ‘feeds’ it to ensure it stays longer and wreaks some real havoc, we identify & treat what about this over-friendly stomach is amenable to rehabilitation? As it turns out…that’s a lot.
And surely if add to our antimicrobials a larger focus on rejuvenating the gastric environment of H.pylori patients, to control the growth and activity of this bacteria, and in some cases even kick it out of the big brother house altogether…the chances of relapse and reinfection (a big one in this condition) will be dramatically less..not to mention the broader benefits on the greater GIT function, now the stomach has been remediated.
Or you could just keep trying to hit the moving bulls-eye?
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking. A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome includes a bigger focus on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot.
Hear all about it by listening by my latest Update in Under 30: H.pylori – Eradicate or Rehabilitate? For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.
A few months back I seriously ‘blew over’. Not on an RBT but on a UBT (Urea Breath Test). In spite of it being not the kind of test you want to score top marks for, my result was in the high 2000s, when all I needed was around 800 to confirm, and anything over 50 to be suspicious, that Helicobacter pylori had taken up residence in my stomach lining. I tell you, I knew it when I blew it! 😉 After ingesting the radioactive urea and waiting to blow up my sampling balloon, I felt like I could still fill a room full of balloons with all the gas being produced in my stomach and those balloons, I imagined, would all rise to the ceiling as if full of helium! Yep…I burped all the way home, which was representative of what I’d been experiencing daily for a month beforehand and what lead me to get the test done.
But initially, it wasn’t so clear.
The very first symptom I experienced was a sudden onset of severe tightness around my throat that lasted for minutes but started to happen multiple times in a day. Yep..no one panic. Together with a strange sensation of ‘extreme emptiness’ in my stomach on waking or delayed meals, and then mild nausea both with an empty and full stomach…only some days or weeks later the fabulously-unprecedented-&-socially-adorable-burping started, proper.
So a month or so later, I’ve solved my own mystery. Happy? Not in the least…where the heck have I picked up H.pylori from? Yes…that’s what I said because it had to come from somewhere people…right? I think there is much we have misunderstood about this bacteria with an incredibly long and interesting human history. Animals don’t and can’t carry this bacteria. The evidence suggests that it can’t survive for very long in the environment either (approx 4 days) but that is long enough to get into our food and water and maybe even onto shared chopsticks…just saying (listen in to hear the lowdown on all these and more!) Essentially hoomans are the traffickers, people! In fact one of the things that surprises people the most is the very high prevalence in young children and the clusters of positive tests & identical strains within families…but once you learn a little more about this bacteria…it won’t surprise you at all.(more…)
As an avid reader of medical news I face a barrage of headlines both domestic & international everyday. I feel this is important for many reasons – not just so that I know what’s being said about their medicine but what they’re saying about ours as well! Anyone see the jaw-dropping headline last week: Could Probiotics be bad for your gut? Yep.
Now how many of you didn’t make it past the headline? It’s hard isn’t it.
There’s almost a reflexive shutdown for many of us to dismiss such a proposition as simply ‘ridiculous’, surely on par with our response to an article from a climate skeptic…as we shake our heads with ‘you gotta be joking right?’… but unless we read on, we’ll never know. (more…)
I was lucky enough to hear Jason Hawrelak’s excellent presentation at the Australian Naturopathic Summit last weekend, titled: A Case of Blastocystis Infection – Or Is It?Timely, highly valuable, immediately usable, provocative education (just how I like it 😉 ) on how perhaps often Blasto is playing the scapegoat for another condition/cause of patients’ GIT symptoms. During this case study, Jason detailed the shonky diagnostic work-up of his current patient by a naturopath 12 years prior…that naturopath was him.
There was so much to love about his telling of this case study and the discourse around it but here are my Top 3 Takes:
None of us know everything or practice perfectly but rather we do what we do, until we know to do differently…even Jason 😉
As there are 9 strains of B.hominis found in humans and many of these are in fact benign commensals, even perhaps important ‘apex predators’ for the microbiome, attributing someone’s health problems (digestive or otherwise) to the presence of this parasite should in fact be a diagnosis of exclusion…always asking yourself first, what else could it be?? e.g. coeliac, SIBO, food reactions etc etc
The cost of being a ‘premature evaluator’, to your patients and to yourself, can be very high…
If you’ve not seen Kitty Flanagan’s skit on current coffee culture...it’s essential viewing. In true Kitty-fashion, she wants to simplify coffee ordering down to 2 basic lines – White or Black – says all our pretentious coffee orders; macchiato, skinny, decaf, half strength, latte etc can essentially be reduced down to a much faster 2 queue system. But she’s forgotten the line for taking your coffee rectally. Sorry – did I make you just spill your coffee? Knowing How across health trends Kitty is, she’ll add this 3rd queue soon, if the number of patients asking me about this or telling me they’re already doing it. Now, while enemas had a place in naturopathic history, my training never covered them and, consequently, I’ve never included them in my practice. But the more hype I heard around coffee enemas specifically, the more I thought we better find out as much as we can, so at least we can better inform ourselves and our patients. And of course the monkey on your back, called FOMO, jumps up and down, incessantly asking, “Are you (and your patients) missing out on an amazing therapy?”
The first patient who told me they were using coffee enemas daily was a celeb. A very anxious one. Who also told me she couldn’t possibly drink chai let alone coffee because of the caffeine. This had me a bit stumped…I knew she wasn’t inserting decaff up there and I thought…well given the colon is SUCH an absorptive surface surely this is why she reported feeling, ‘so energised, more clear headed’ etc. with every enema?
When I look back over how I’ve raised my kids there are a few serious ‘what tha…’ moments – like the time I thought shopping with a child in rollerskates was doable…I mean she loved those rollerskates and she was amazingly agile and good…just not quite good enough to hold onto that 1L Biodynamic Yoghurt sufficiently…who knew?! Dietary wise, I can look back and be critical in hindsight about different details, the contents of our fridge and pantry have morphed over the years with my changing knowledge (money & time!) but there are a few things I can confidently say – ‘Nailed it’, accompanied by a fist pump! We’re all meat eaters, not carnivores by any stretch of the imagination but we do partake, however the kids and I were just reflecting the other day on the absolute constancy of legumes in our life. (I know you want CCTV footage of our dinner time chats now don’t you 😉 ) There would rarely be a day in our house without them…several times!
Now I sound like I’m showing off but trust me it’s not that impressive or exotic – it goes a little something like this: soup,(split red lentils or cannellini), bolognaise & lasagne (1:4 brown lentils with the meat), nachos for school lunches (kidney beans 4:1 with mince), falafel & hummus (chick peas) & tofu (my kids love this stuff for snacks often & for mains at least once a week).
Ok now everyone relax, I don’t make our own almond milk, grow our own vegetables or ferment stuff…see…it’s swings & roundabouts 😉(more…)
These little blighters are getting a lot of airplay this month and rightly so…..! Oh Em Geeeeeeeee….so much misinformation out there!! It’s time to set the record straight
Worm infestations never conjure up a pretty picture in our minds although a video of humans trying to bum slide across the floor like some dogs we know would get a fair few laughs (…will share that vid later)
Despite much talk of the potential therapeutic activity of helminths for things like autoimmune diseases and allergies due to their immuosuppressive effects, there’s nothing nice, friendly or ‘good for us’ about a chronic Enterobius vermicularis (threadworm) infestation in a child or adult (YES! You heard me). Oh and don’t forget the possible link with your D.fragilis patients…you just might need to treat these guys instead.
It was great to get down and dirty on worms with Andrew at FX Medicine. This podcast has us uncovering and debunking myths on these creepy critters that have more to answer for than you probably realise…
The outcry from the public is enormous, in terms of their need for help and the gaps that are there at the moment in terms of getting it. There is an online resource called thewormwhisperer.com.au, which is primarily there for the public to meet this need and practitioners can learn a lot by going on there as well.
Ever feel like you’re chasing your own tail trying to treat & find the source of GIT parasites in some patients?! Well guess what, you just might be!
We’re seeing more & more patients test positive for Dientamoeba fragilis and increasingly patients struggling to eradicate it and prevent relapse. And then there’s Blastocystis hominis affected patients… and then those lucky enough to have both.
Well, while we might have been grouping D.frag together with B.hominis, being the two most common GIT parasites in humans, looking for what they share in common, they are worlds apart (we think!) in terms of how they are transmitted to humans.(more…)
You know I’m not one to raise my voice and make scene.
Ok, I always raise my voice and make a scene, but only when I think something really warrants our attention and the issue of under-recognised, under-estimated and mismanaged chronic worms, demands our attention. I’ve been talking about this ever since the first patient stepped into my clinic, a young girl with severe mood issues who just happened to also have treatment-resistant chronic threadworm, and since then, as the volume of patients I see affected by this has grown, so too has the volume of my message. And there’s actually so much to say.
Chronic worm problems don’t always come with an itchy bottom calling card. In fact, many individuals don’t have any of the telltale signs you might be used to screening for. Recent research suggests adult men, in particular, are commonly asymptomatic when infected with them (Boga et al 2016)
So what alerts us as practitioners to the possibility of chronic worms – so many things…but here’s just some thought bubbles to get you started.
Are you treating patients with recurrent or treatment-resistant Dientamoeba fragilis?
Are you seeing women who have thrush-like symptoms, in spite of negative swabs and no benefit from antifungals?
Are you faced with families coming undone because of one child’s behaviour whether that’s aggression, defiance, emotional lability or just serious sleep problems?(more…)
Is this the way of the future for health practitioners interested in patients’ digestion…?
“The team developed an ingestible electronic capsule to monitor gas levels in the human gut. When it’s paired with a pocket-sized receiver and a mobile phone app, the pill reports tail-wind conditions in real time as it passes from the stomach to the colon…The authors are optimistic that the capsule’s gas readings can help clear the air over the inner workings of our intricate innards and the multitudes of microbes they contain. Such fume data could clarify the conditions of each section of the gut, what microbes are up to, and which foods may cause problems in the system. “(more…)
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…)
Last week I threw down a challenge. Following on from the ruffling of many feathers regarding Jason Hawrelak’s report that dietary saturated fat increases uptake of endotoxins from the gut, I provided his reference list in support of this claim, effectively saying, “if you don’t like his findings, then make your own informed conclusions but make sure you read all the evidence first”. I offered a prize to everyone who made an attempt and a year’s free subscription to Update in Under 30, to the person who produced arguably the best summary.
I’ve said it before and I will say it again, and again, and again: Our professional community abounds with extraordinary individuals.
People’s response to this challenge proved that once again.(more…)
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 😉 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 🙂(more…)
Watch the gap! You know I love a good diagnostic test probably (way!) more than the next person but I am slow to come around when there’s suddenly a ‘new-kid-on-the-block’ that every functional testing company wants to offer you. This is how I felt about serum zonulin testing as marker of intestinal permeability too. In spite of Fasano’s important work, identifying this molecule and its role in the reversible opening of tight junctions in the small intestine – I didn’t embrace the test.Why not? Didn’t I love Fasano’s ability to add this piece to the jigsaw that had been missing til now? Well I did. Does that make it an accurate and reliable marker of intestinal permeability in every client with any kind of digestive issue…? Well heck no! That’s not how science works friends and I suspect we may have really jumped the gun a little on this one.(more…)
Recently, I posted about my very positive experience of the AIMA NZ conference, prior to that I was gabbing on about the upcoming ACNEM Brain Health conference in Melbourne in May and now I am going for the conference hat trick! I want to revisit a really impacting lecture for me at last year’s Australasian Society of Lifestyle Medicine (ASLM) conference, delivered by the Emeritus Professor Mark L. Wahlqvist AO, BMedSc, MBBS, MD (Adelaide), MD (Uppsala),on the relationship between ecology and human health.
Why did I find his talk so impacting? Why should every integrative practitioner take the time to watch this?(more…)
I’ve been digging around in the scientific literature all about appendicitis and I’ve ended up here. Long gone are the days when medicine foolishly considered the appendix without purpose – a dispensable ‘extra’ of the GIT and now, thanks to genetic PCR bacterial identification, gone also is its more recent portrayal as something sinister – a potential harbourer of ‘bad bugs’. The current consensus about this apparently complex little sac is that it constitutes a ‘safe house’ for the microbiota within the GIT, making one of its key roles the healthy recolonisation of the gut following diarrhoeal episodes and even oral antibiotics. Amazingly, antibiotics that can quickly sterilise the rest of the digestive tract, fail to clean out the appendix, due in part to its specialised and exaggerated biofilm as well as its more diverse and environmentally tough species. Wouldn’t you know it, the strange little sac has a critical role in keeping us well?!
Given this radical rethink of the healthy appendix I wondered whether medicine’s understanding of appendicitis and in particular what causes it, had also undergone a revolution. This condition, which was first described over 100 years ago has confounded scientists and clinicians ever since – I love this quote from a 1972 paper in the Medical Journal of Australia (Williams):
“It is interesting and humiliating that a small organ which in man performs no useful function can so frequently give rise to problems which, if not treated, may have fatal complications, and of which we still do not fully know the cause.”(more…)
