As noted in the first email on autoimmune clinical pearls, gut integrity or imbalances appear to be a part of the trifecta that triggers autoimmunity.
Currently, the go-to dietary recommendation in the functional and integrative medicine space for anyone with an autoimmune condition is an Elimination Diet, Wahl's protocol, or the AIP (autoimmune paleo/protocol). And when I first started working in this space, this was what I recommended as well.
Until I started seeing that a lot of patients had long-lasting psychological repercussions from this therapeutic intervention....
Overview of today’s email:
- Patient example
- Diet and autoimmunity
- Clinical tip on addressing the role of diet in autoimmunity
1. A patient example
It is not uncommon for me to work with a patient who has seen other functional medicine practitioners.
And many come to me on a strict diet and are hypervigilant, pointing out that they can't eat certain foods because they have lectins, oxalates, phytates, or any other molecule that *will* cause a health issue if eaten.
This was the case with Sara, a 40 year old female.
She started on the AIP diet in 2021 after testing revealed a mild increase in thyroid peroxidase antibodies (anything under 100 is a mild elevation). Thyroid function testing (TFTs) was normal. Her primary concern was fatigue.
She initially felt better, but her fatigue didn't change.
Hashimoto's became her identity, and every symptom she experienced was attributed to Hashimoto's.
Over the years, we ran various labs, including bloodwork, SIBO testing, mold testing, urinary hormone testing, and stool testing. The primary findings? Low levels of many nutrients (zinc, copper, iron, vitamin A, omegas, amino acids, iodine), very low gut diversity with high sIgA, and cortisol imbalances.
Almost every therapeutic intervention we tried caused palpitations and anxiety, which she attributed to believing that something in the new treatments was making her antibodies go up.
Prior to her diagnosis, she had immense stress in 2020 when she witnessed a family member's illness and suffering, had a lot of childhood trauma, and was the caretaker to her young child (who was recently diagnosed with autism). She doesn't sleep well, has bloating with most meals despite having digestive support on board, and can't exercise due to her exhaustion.
There's only so much I can say on this case in an email, but here are some learning points:
- Her primary concern - fatigue - is NOT from a thyroid imbalance.
- When initially treating Hashimoto's, focus on how someone is symptomatically responding to interventions (and adjust accordingly).
- Getting TPO antibodies to a normal range is not the goal - focus on decreasing disease progression (e.g. changes in TFTs, decreasing thyroid replacement dosing, symptoms, etc.).
- Prescribing AIP to someone who has anxiety and lots of stress is not a good step.
2: Diet and autoimmunity
I won't deny that an elimination diet has helped many, but as practitioners, we have to make sure we are not causing more problems with our recommendations.
There are many things to consider:
- A healthy gut is one that is diverse; long-term elimination diets dramatically decrease diversity (ever seen the stool test of someone on long-term dietary restrictions?)
- The primary trigger in autoimmunity is stress, and these diets are not easy (and tend to drive a lot of stress, especially with reintroducing foods - we have no way of knowing if the food itself or the expectation of what the food may do to the body drives a negative response)
- Nutritional research is still young, and just because one compound is identified in a lab as being problematic does not mean the food is "bad" (there are thousands or millions of other compounds that can counteract the impact of one compound)
- Orthorexia is a very common condition I see (and is hard to improve) in majority of the patient's who I have worked with who went through AIP or have read so much that they see many foods as "bad"
- The more intense the protocol or dietary change, the less sustainable it is.
3: Clinical Tip on Addressing the Role of Diet in Autoimmunity
In anyone suffering with an autoimmune condition, assess various factors before asking someone to eliminate a food or group of foods from their diet. The factors include but aren't limited to:
- Current dietary habits and meal preferences (especially if they cook for children).
- If they are a "type A", have anxiety, have a history of eating disorder, or one that could become hypervigilent with information that you share
- Gastrointestinal health
- Stressors in a patient's life
If eliminating a food seems to be a good idea, lay out expectations (e.g. decrease in symptoms within 2-3 weeks, or a change in antibodies within 6 weeks), ask if they feel confident that eliminating gluten and wheat is something they can do without adding stress, and start with a strict gluten free trial for 6 weeks.
This topic is a tough and maybe even a controversial subject, and we all have our own experiences, but hope this information was helpful!
Meg
P.S. Join me for the last brainstorming session on the Functional Medicine Collective Mentorship! Click here to register for February 1st (Saturday) at 10am MST
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