We’ve talked a lot about the “gut-brain” axis. But did you know there’s also a “gut-skin” axis? And did you know that researchers have been aware of this connection for more than 100 years? Of course, this early work was forgotten for about 90 years, and it has only received increasing attention in the last decade. It’s an exciting area of study, and it gives us new strategies for naturally treating skin conditions like acne (vulgaris and rosacea), psoriasis, eczema, dermatitis and others.
And in this episode of Revolution Health Radio, we cover:
2:24 Does the Gut-Brain-Skin Axis hold the secret to naturally get rid of acne?
8:23 The latest study validating 100 year-old research connecting stress, leaky gut, and acne
12:20 Why these ancient gut remedies also treat skin conditions
17:59 Could leaky gut be the hidden cause of acne?
20:55 How to break the vicious constipation-acne cycle
26:00 Why rush-hour traffic can cause low stomach acid, gas, and bloating
29:40 “The first place I look when someone comes to my practice with skin conditions”
34:48 The specific Gut Healing Protocol to naturally eliminate skin problems… for good
40:00 What foods to eat – and not eat – to get rid of migraines (and clear your skin)
44:12 The telltale signs you have low stomach acid… and what to do about it
Links We Discuss
Full Text Transcript:
Steve Wright: Hello everyone, and welcome to the Revolution Health Radio Show. I’m Steve Wright from SCDlifestyle.com, and with me is Chris Kresser, health detective and creator of ChrisKresser.com. How are you doing today, man?
Chris Kresser: I’m pretty good. I’m a little tired. It’s been a long weekend, and we’re getting ready to go up to the Great White North at the end of next week. My wife is Canadian, and she’s from a town in northern British Columbia called Prince George. So, every other year we go up there; we trade off with my family for Christmas, and so it’s our Prince George year this year, and it’s probably gonna be 30 or 40 below.
Steve Wright: Woo!
Chris Kresser: That’s what it usually is when we go there, which is no joke! I’m just like why do they put a city here, you know, at 40 below? Just keep going south! I don’t get it. Yeah, so it’s actually nice to be up there because it’s pretty low key, and it feels like I’m far away from everything else in my life, so I look forward to it. I get along really well with her family. Yeah, so that’s what’s happening for me. What about you, Steve?
Steve Wright: It’s been a busy weekend for me as well. Lots of Christmas parties going on right now, and just trying to wrap up all the gift buying and make sure I’m all set for the big coming week right now. I won’t be going anywhere where it’s 40 below, so I’m feeling actually pretty good about that!
Chris Kresser: Ha-ha! Yeah, well, it’s not gonna be warm and balmy in Michigan, but not 40 below, huh?
Steve Wright: No. We don’t even have any snow, though, which is crazy for us. We might not even have a white Christmas.
Chris Kresser: Right. Weird. That’s like California, huh?
Steve Wright: Weird.
Does the Gut-Brain-Skin Axis hold the secret to naturally get rid of acne?
Chris Kresser: So, we’ve talked about the gut-brain axis on a previous show, and I’ve written about that on my blog, and today we’re gonna talk about the gut-brain-skin axis, or the gut-skin axis. I get a lot of questions about how to treat skin issues or how I look at skin issues, and I’m actually gonna write a special report about this. I know I keep saying I’m gonna write all these special reports, and I will eventually, but I think the next one will be either iron overload or the gut-skin connection, because skin issues are pretty common. I see them a lot in my practice, and I think they’re misunderstood, so we’re gonna take some time and talk about that today, and there are some pretty interesting studies I want to cover, and if we have some time, we might get to a few questions, but probably not, just looking at all the stuff we have to cover.
Steve Wright: Well, I’m pretty excited, because as somebody who has had some lifelong skin battles, I’m ready to listen, ready to hear it.
Chris Kresser: Cool, and I mean, this is n = 1, but you’ve also, of course, had gut issues, so that’s really common. I’m still waiting to find a patient with skin issues that has no gut issues and no history of gut issues. I haven’t seen that yet. I’m not saying they don’t exist, but so far everybody I’ve treated with a skin issue has a gut issue. It doesn’t necessarily work the other way around, where someone who has a gut issue absolutely has a skin issue, but it does seem to be pretty consistent with the skin. So, this connection between the skin and gut health and mental health has been known for a long time, and in recent years there are actually two new fields of study called psychodermatology and neurodermatology, entirely new fields of study dedicated to looking at this stuff.
Steve Wright: Sounds like a lot of school.
Chris Kresser: Yeah, ha-ha, no doubt about that! And we know that acne is more common with depression and anxiety and other psychological conditions, and likewise, we know that depression and other mental health disorders are more common with acne. And lately researchers have been paying a lot more attention to the gut-skin connection. There’s one study of, I think, 13,000 adolescents that found that those with acne were more likely to have constipation; halitosis, which is the fancy name for bad breath; and acid reflux. And bloating, interestingly enough, was especially correlated with acne, with about 37% of kids with acne experiencing bloating. So, in my practice, as I said, I see this all the time. Regardless of the skin condition, it could be acne vulgaris or acne rosacea or dermatitis or psoriasis or eczema — any number of different skin conditions — they’re often connected to a gut problem, as I mentioned. And I will often use a gut-healing protocol to treat skin conditions, and we’ll talk a little bit more about that towards the end of the show.
Steve Wright: Are you gonna dive into if the vulgaris and all the different versions of this — Are they all kinda the same pathology? Are we gonna talk about that?
Chris Kresser: I wasn’t planning to talk about that in detail, but it’s a good question, and generally I would say that they share some similar pathological characteristics, but the pathology, of course, is not identical because then they would look the same. If everything was identical about them, they wouldn’t be different conditions. That said, some of the mechanisms that we’re gonna talk about, like low stomach acid and small intestinal bacterial overgrowth and leaky gut and dysregulated gut microbiota or gut flora — You can find these in all of those conditions that I just mentioned, psoriasis, eczema, rosacea, acne, dermatitis, and a lot of other ones that we’re not even gonna have time to discuss. So, the answer to that is, yes, they share similar characteristics, and I think from a practical perspective, you know, from a treatment perspective, I do tend to look at them in a similar way and treat them in a similar way. The exceptions would be psoriasis and eczema, which I and a lot of other researchers consider to be autoimmune conditions, and of course, we know about the connection between leaky gut and autoimmunity, so there’s still a very strong gut connection, but there’s maybe an additional immune dysregulation happening there that may not be happening with acne and some of the other skin conditions, although maybe it is and we just don’t know at this point.
Steve Wright: So, at a lot of the base levels, it’s probably the same, but as it goes deeper, they branch off as far as the pathologies, basically?
Chris Kresser: Yeah, I think so, and maybe that’s a question of genetics and what one person’s predisposition is. It’s really interesting. You know, like, two people get a leaky gut. One person develops type 1 diabetes, the other person develops an autoimmune thyroid condition, and they both have a leaky gut, but they develop completely different manifestations of that underlying pathology, and I think it’s probably impossible to determine why, but my guess is it has something to do with genetics, it has something to do with environmental influences and personal background and any number of other factors that we don’t totally understand yet.
Steve Wright: OK.
The latest study validating 100-year-old research connecting stress, leaky gut, and acne
Chris Kresser: So, I want to talk about my new heroes, Stokes and Pillsbury. The gut-brain-skin axis idea has been around for a long time, and these two guys whom I just learned about recently, they were talking about it as far back as 1909, so over a hundred years ago. And they had connected emotional states like worry and depression and anxiety with altered gut function. They knew that changes in the microbial flora promote local and systemic inflammation that can manifest in the skin. I mean, this is crazy! If you went into a dermatologist’s office today and you started talking about this, they’d look at you like you were nuts, and they’d call it some kind of alternative quackery.
Steve Wright: Ha-ha, I’ve been there!
Chris Kresser: Ha-ha, right! But there’s a difference between being skeptical and conservative and just being uninformed. I mean, this is in the scientific literature. If you go and you search on PubMed for intestinal permeability and psoriasis, you’ll see several papers. If you search for SIBO and acne, you’ll see several papers. So, it’s interesting to me how when people encounter something that they don’t understand or that seems strange or foreign to them, they dismiss it as being irrelevant or quackery, but in the medical literature, which is supposed to guide clinical practice, it’s right there and it’s been there for over a hundred years. Yeah, side note!
Steve Wright: It’s sort of like a reoccurring theme with all these things when it comes to the different diet approaches that we’re seeing and various supplementation with vitamins, you know, your vitamin X, K2 type of thing.
Chris Kresser: Yeah, K2. Yeah, you’re right.
Steve Wright: The people that lived in the 1900s to, like, 1920, man, they were on it!
Chris Kresser: They were, and we have this idea that all things that are new are better, and if research was done in the early 20th century, it must be out of date and not worth paying attention to, but these guys were decades ahead of their time, even a century ahead of their time. So, here’s a quote from the paper. This is 1909. They said: “There is an important linkage of emotion with cutaneous outbreaks of erythema, urticaria, and dermatitis by way of the physiology and bacteriology of the gastrointestinal tract.” That was a little wordy.
Steve Wright: So, what does that mean?
Chris Kresser: Basically they were aware of the gut-brain-skin axis in 1909. That’s what they said. That quote was there’s a link between the gut and the skin, and what mediates that link is the physiology of the gut, like whether it’s permeable or not, and the bacteriology of the gut, meaning our gut flora. So, they also cited other research that showed that 40% of those with acne had hypochlorhydria, which is the medical term for low stomach acid, and low stomach acid, as a lot of you know, because I’ve discussed it on my blog and on this podcast, is what sets the stage for the migration of bacteria from the colon, where it belongs, to the small intestine, where it doesn’t belong, and that condition is called small intestinal bacterial overgrowth or SIBO, which of course, you guys talk a lot about on your blog, Steve.
Steve Wright: Yep.
Chris Kresser: So, Stokes and Pillsbury also knew that stress-induced changes in the gut microbiota lead to intestinal permeability and leaky gut, so back in 1909, they were already talking about the stress-gut connection and how stress can cause a leaky gut. And they knew that leaky gut causes both local and systemic inflammation that can then manifest in the skin.
Why these ancient gut remedies also treat skin conditions
Chris Kresser: But it gets better. The remedies they talked about to break this cycle included “direct introduction of acidophil organisms in cultures such as those of Bacillus acidophilus,” aka probiotics.
Steve Wright: Wow.
Chris Kresser: They also advocated cod liver oil, which is a rich source of omega-3’s we know now and plays an antiinflammatory role. They didn’t know that then. So, they were basically prescribing cod liver oil and probiotics for skin conditions because they were aware of the gut-skin axis. I mean, it’s incredible, really.
Steve Wright: That’s fascinating!
Chris Kresser: Ha-ha, I’m such a dork to get so excited about this, but it’s really amazing. It’s really cool to see this in the scientific literature. So, their theories, though — This was, like we said, over a hundred years ago, and it’s been largely forgotten, and it’s only in the last 10 years that they’ve really been vindicated, because we know now that low stomach acid is a significant risk factor for SIBO, small intestinal bacterial overgrowth, and I talked about that in the GERD series. In fact, my theory for — it’s not just my theory — but my perspective on what causes GERD and heartburn is not too much stomach acid as a lot of people and conventional medical establishment sometimes assumes, but not enough stomach acid, which then causes bacterial overgrowth and gas pressing up against the lower esophageal sphincter, and then that opens that sphincter and acid gets in from the stomach back into the throat.
Steve Wright: Yes, stomach acid really is the gatekeeper. It’s fascinating.
Chris Kresser: Yeah, so we know that studies show that 50% of patients on long-term PPIs, proton pump inhibitors, or antacid drugs have SIBO. That’s a crazy statistic! One in two patients who are taking PPIs over the long term have small intestinal bacterial overgrowth. And since we know that SIBO is associated with leaky gut, and we know that leaky gut is the gateway — talk about a gateway — to autoimmune conditions and all kinds of other issues like skin problems, that’s reason alone not to take antacid drugs. We know that SIBO is also correlated with functional syndromes like fibromyalgia and chronic fatigue, which suggests an inflammatory link. It suggests that SIBO causes some of kind of systemic inflammation that can manifest as these functional conditions. We know that SIBO has recently been shown to be associated with increased intestinal permeability, and we know that antimicrobial treatment helps restore the normal intestinal barrier, so when you get rid of SIBO, the intestinal barrier heals and starts to do its job of keeping things out of the bloodstream that don’t belong and keeping them in the gut. And then we’ve also seen other studies recently that show that psychological stress can decrease transit time, meaning can cause constipation, it can cause SIBO, and it can make the gut barrier permeable, and that SIBO is strongly correlated with both depression and anxiety, while eradication of SIBO improves emotional symptoms and feelings of well-being. So, I think this is a remarkable area of study, and I’ve said this before, but I think if antibiotics were the medicine of the 20th century, I think probiotics or at least just modulating the gut flora not just with probiotics but with a gut-friendly diet and other strategies that we probably haven’t even considered yet of replacing and restoring healthy gut microbiota is really gonna be the focus of medicine in the 21st century, as it was even thousands of years ago. Way back, you know, 2500 years ago, this was talked about when people in Western medical literature at that time were still talking about humors and bleeding. It was even then recognized that the gut was a major factor in health. So, things are coming around again, and it’s probably gonna take a while to penetrate into the mainstream consciousness, but I think at least in the research literature it’s already starting to happen.
Steve Wright: Yeah, there are more links and more studies coming out by the day — it’s really amazing — with the SIBO / leaky gut connection, so I think you’re right on.
Chris Kresser: Yeah, and you guys, I know you’ve interviewed a lot of people. It seems like there are a lot more doctors who are aware of it and talking about it, and I notice when people come, patients in my practice now when I say SIBO, they don’t look at me like: What the heck are you talking about? A lot of people seem to know more about it at this point.
Steve Wright: Yeah, I think it’s definitely spreading. People are contacting us on our site that are aware of it and they’re looking for different ways to treat it or improve the gut, anyway, via diet and supplements, so I think it’s really encouraging.
Could leaky gut be the hidden cause of acne?
Chris Kresser: Yeah, so the specific connection between acne and leaky gut hasn’t been studied directly, but there are a lot of mechanistic studies that suggest a link. So, for example, one study showed that acne patients are more likely to show an increased reactivity to bacterial strains that are isolated from stool. Sixty-six percent of the 57 patients in this study with acne showed a positive reactivity to stool bacteria compared to 0% of the controls. And then in another study, patients showed the presence of and higher reactivity to lipopolysaccharide endotoxins in the blood. None of the controls in the study reacted to the lipopolysaccharide endotoxin, while 65% of acne patients did have a positive reaction. I know that was a lot of jargon there, so I’m gonna explain that. Basically what those two studies suggested is that the patients with acne were having strong reactions to things that should still be in the gut but had escaped the gut into the bloodstream, so that, in turn, suggests that the gut is leaky in those patients and things like lipopolysaccharide endotoxin are getting out of the gut and into the blood, and then the patients are mounting an immune response to that, and then that’s causing inflammation, which manifests as acne.
Steve Wright: Hey, Chris, real quick for everyone, what is a lipopolysaccharide, an LPS? What is that?
Chris Kresser: It’s an endotoxin that’s produced by certain bacteria. It’s a very potent toxin, so when it gets into the bloodstream, it can cause an immune reaction. Any immune reaction is basically inflammation, so that inflammatory response, as I say, can manifest in a number of different ways, depending on people’s genetics, background, their basic physiology, who knows, but in this case, it’s manifesting as acne, but it can also manifest as an immune response mounted against the joints, like in rheumatoid arthritis, or the thyroid in autoimmune thyroid disease. The important point here is that all of this stuff is supposed to stay in the gut, and the fact that the patients with acne are reacting to it suggests that it’s leaving the gut and getting into the bloodstream.
Steve Wright: So, a normal person is still gonna have LPS toxins, it’s just not getting into the blood?
Chris Kresser: Yeah, but if your gut flora is healthy, you’re not gonna have the same amount of LPS as you would if you have an overgrowth of pathogenic gut flora.
Steve Wright: OK.
How to break the vicious constipation-acne cycle
Chris Kresser: Then you have other studies that have found a link between constipation and acne, and that’s probably mediated via changes in the gut flora too, because research has shown consistently that people with constipation have compromised gut flora, and this is definitely my clinical experience. In fact, I think in pretty much all cases of constipation, the long-term way that it needs to be treated is by restoring healthy gut flora. In the short term, other interventions are often necessary to just get the bowels moving because it’s one of those vicious cycle things, where if you’re constipated, that messes up your gut flora. And then if you have messed-up gut flora, you’re gonna be constipated. So, you have to do something to get the bowels moving just to get out of that vicious cycle, but then over the long term, you’ve got to restore normal gut flora.
Steve Wright: Do you have a go-to method to get them started right away?
Chris Kresser: I often will use magnesium glycinate in fairly high doses. That’s a chelated form of magnesium that’s easier to absorb, and it doesn’t affect the gut in the same way that magnesium citrate and oxide do. Those tend to draw more water into the bowel, and they cause either diarrhea or loose stools or what I refer to as “constirrhea.”
Steve Wright: Ha-ha.
Chris Kresser: And those of you who have ever experienced that will know exactly what I’m talking about! Whereas, magnesium glycinate is better absorbed, and it’s a smooth muscle relaxant. It promotes intestinal motility, but it’s not habit forming. It doesn’t have a stimulant laxative effect like senna or rhubarb or any of those more potent laxatives. So, that’s a good starting place, and it works for most people. And then we start addressing the gut flora, and over time that’s, as I said, the main thing because 70% to 80% of the dry weight of stool is bacteria, so if you don’t have sufficient good bacteria in your gut, you’re not gonna be able to form a normal stool, and then that will decrease the intestinal motility. So, we know, as I said, that people with constipation have compromised gut flora, and we know that chronic constipation is associated with intestinal permeability, and that’s because when someone is constipated, LPS and other endotoxins that would normally just keep moving and be cleared, they damage the gut lining and make it permeable. We also know, and I’ve mentioned this a couple times, that there is a connection between stress and altered gut flora and leaky gut, which in turn, suggests a connection between stress and skin issues. And there are a lot of experimental studies and human studies that have shown that a variety of psychological and physiological stressors can impair the normal gut flora and cause intestinal permeability. I talk about stress a lot and the importance of stress management a lot, and I think there are so many different ways to look at it, but the connection between stress and gut health, especially, is so important to understand. The gut is basically one big nerve plexus, one big nervous system tissue. In fact, some doctors refer to it as the second brain, and there’s way, way more serotonin, which is a neurotransmitter that most people associate with the brain, in the gut than there is in the brain, and there is 400 times more melatonin in the gut than there is in the pineal gland, where melatonin is produced. So, the gut is extremely sensitive to stress, and most people already know this very directly. If anyone’s ever had to give a public speech or perform and you get those butterflies in your stomach, that’s an immediate connection between the gut and the nervous system, and I think everyone has experienced that to some degree or another. But it’s maybe a little bit more difficult to get a sense of how that works over time, that over time if you continue to have activation of the sympathetic nervous system, the fight-or-flight response, even if it’s at a low level, that that will break down that intestinal barrier and cause leaky gut and cause changes in the intestinal microflora, so it would predispose you towards less good bacteria and more opportunistic or bad bacteria.
Why rush-hour traffic can cause low stomach acid, gas, and bloating
Steve Wright: Is it also true that to actually start secreting stomach acid, or at least hydrochloric acid, you need to have the parasympathetic stimulated?
Chris Kresser: That’s right. Parasympathetic is rest and digest. Everyone’s heard of fight or flight, which is the sympathetic nervous system, but parasympathetic, the catchphrase for that is rest and digest, and that’s exactly why, because when you’re in a sympathetic nervous system response, your body prioritizes everything that is required for immediate survival. So, the blood pumps to your skeletal muscles and your lungs so you can get oxygen and run away or fight, and all of the resources are devoted to only what will help you fight or flee. And all of the long-term mechanisms important for long-term survival, like reproductive function, digestion, endocrine function, hormone metabolism and synthesis, all of those things the body could care less about if your life is at stake and whether or not you live or die is gonna be determined in the next moment. And people might be listening to this and go: Well, yeah, how often is my life really at stake, though? Well, the thing is your body doesn’t really differentiate between a real threat to your life, like from an evolutionary perspective, getting chased by a predator like a lion or being in a fight, and something like driving in traffic and getting cut off. The activation of the sympathetic nervous system happens in both of those cases, and even though in one case your life may not really be in danger at all, that’s the way that the nervous system responds. So, most people in the modern world, most of us are in this chronic state of low level sympathetic nervous system activation, and you can’t really be in both at the same time. Either your sympathetic nervous system is activated or your parasympathetic is activated. So, if you’re in that chronic fight-or-flight response and you never do anything to activate the parasympathetic response, then there’s gonna be a range of symptoms like you just alluded to, Steve, low stomach acid because as part of the rest-and-digest response that’s what happens. You produce stomach acid, the peristaltic wave begins, and you produce pancreatic enzymes, and that’s, of course, one of the reasons why it’s recommended not to eat when you’re really stressed out and why a lot of people won’t even feel hungry when they’re really stressed out, because none of those mechanisms are working, and you just naturally get the sense that it’s not the right time to eat, and if you do eat when you’re really stressed out, food just sits there like a rock because your digestive system is not functioning. So, let’s see here. There’s a lot more we could talk about, and I’m gonna write more. I’ll probably write some articles about the specific skin conditions and how each mechanism contributes. I’m not sure how I’m gonna divide this series yet.
“The first place I look when someone comes to my practice with skin conditions”
Chris Kresser: But why don’t we talk a little bit about my clinical experience with this stuff and how I approach these things and maybe just a few ideas for things that people can do at home? As you’ve probably gathered by now, the first thing I look at if someone comes in and says they have a skin issue, the first thing that’s on my mind is their gut. And what’s interesting about this is that about 30% of people with leaky gut have no gut symptoms at all.
Steve Wright: Really? Did they do that in study?
Chris Kresser: Yeah. I mean, it’s extrapolation, of course, but they took people and measured for leaky gut using probably a lactulose/mannitol challenge, and then they compared those results with people who actually have gut symptoms, and they found that 30% of people with leaky gut don’t have any gut symptoms. And I have a patient who came to me with psoriasis, and they had no gut symptoms at all, perfect — well, unless they were not telling the truth — but according to them, perfect digestion, never had any gut problems in their whole life, still didn’t have any gut problems but had pretty bad psoriasis, and I suggested a pretty strict gut-healing protocol, and they were pretty resistant to that at first because they didn’t really get how that could be connected or why that would make sense for them. So, we tried it, and within three weeks there was a significant improvement, and within probably three months it was, I would say, 85% to 90% resolved. And he was obviously thrilled and pretty surprised, but he continues to follow the protocol, and it’s sometimes a little difficult because he doesn’t get the immediate feedback with the gut. Some people when they eat certain foods, they have an immediate reaction digestively, and that’s a reminder that they can’t eat those foods. For him, it’s more like if he starts eating those foods, he has a few days of free pass and then, sure enough, the skin starts to erupt again.
Steve Wright: So, is that kind of like the toxins just start to accumulate?
Chris Kresser: I don’t know. It’s probably more that if the gut barrier is relatively healed, it takes a few days, you know, if he starts eating foods that damage the gut barrier, it takes a few days for it to really get permeable and for the inflammatory process to kick in and, yeah, maybe the endotoxins to slip through. But one of the great things about the gut is that the enterocytes and the cells inside the intestine regenerate about every three days, so the gut has the potential of healing pretty quickly if you get all the conditions right. That said, there seems to be a kind of reverberation effect, and the analogy that I sometimes use when I talk about this with patients is that it’s like a bell; it’s like ringing a bell. So, if you ring a bell with a mallet, you strike it, and then you take the mallet away, you’re gonna hear the sound for quite a while afterwards even though the mallet isn’t touching the bell anymore. And if we consider that the mallet is like a parasite or a gut infection or a really stressful event or something that dysregulates the gut, even when you remove that trigger, you’re still gonna have this kind of reverberation effect for a period of time afterwards in most cases, so it’s a little paradoxical in the sense that the gut can heal very quickly because of that quick cellular turnover, but at the same time there seems to be pretty long-lasting effects from some of the triggers that can cause gut problems in the first place. So anyhow, getting back to the clinical side, when someone comes in and they have a skin problem, we’ll talk about their gut. Very often they have a digestive condition, and they may or may not be aware of the connection, so that’s where we start focus.
The specific Gut-Healing Protocol to naturally eliminate skin problems… for good
Chris Kresser: I’m kind of always tweaking my gut-healing diet. I mean, there are a number of gut-healing diets out there: the Specific Carbohydrate Diet, of course, the GAPS Diet, and there are a whole bunch of other ones that we don’t have time to cover, but what I generally start with these days is a modified version of the Paleo Diet. It’s similar to the autoimmune Paleo Diet, so it’s a Paleo Diet that removes dairy, except ghee is usually really well tolerated because it doesn’t have casein or lactose in it, and then we also remove nightshades because they have glycoalkaloids and a lot of other compounds that can be inflammatory for the gut when people are susceptible, and depending on the patient, we may also remove eggs. Then we also would take out FODMAPs, and I talk about this in the Personal Paleo Code, and we’ve talked about it on the show as well. These are foods with excess fructose or fructans, also sugar alcohols, polyols, and disaccharides and oligosaccharides, so longer-chain sugars. So, you can search for FODMAPs on Google, and you’ll get a list of these foods. So, it is fairly restrictive. Oh, and the other thing I’ll do is often limit the amount of insoluble fiber because insoluble fiber, there’s nothing wrong with it, but it can be really rough on an inflamed gut. It’s kind of like rubbing a wire brush over an open wound. This is the way that I think about it.
Steve Wright: That would be things like greens and stuff like that?
Chris Kresser: Yeah, there are two kinds of fiber. There’s soluble fiber and insoluble fiber, and the main difference between the two is that soluble fiber can be fermented by good gut bacteria, and so it promotes healthy gut flora. Insoluble fiber cannot be fermented by good gut bacteria, and just mechanically is indigestible, so it passes through the intestine without really being digested, and it has a mechanical effect of pushing stool through the intestine, but because of the texture of it, it can be just pretty rough on an inflamed gut, as I said. So, that would be broccoli, cauliflower, the winter greens, the skins of the fruits and vegetables. Things like blueberries have a fair amount of insoluble fiber. Whereas, soluble fiber is found more in things like bananas and the winter squashes, the inside, not in the peels, or sweet potatoes, not the peels, but the flesh. So, we have them focus more on soluble fiber and eat less insoluble fiber. And then we also will do probiotics, and sometimes that’s fermented foods, sometimes that’s other commercial probiotics, sometimes that’s probiotic implants rectally for people who can’t tolerate them orally. And then we might do some antimicrobial treatment to rebalance the gut flora for people who have a gut infection or have an overgrowth of pathogenic gut flora. We’ll do bone broth and glycine-rich foods because that is what provides the fuel or the raw material to help rebuild the gut barrier. And then I’ll often use supplements and botanical medicine that helps restore a healthy gut barrier, things like MSM, slippery elm, marshmallow root, glutamine, and licorice. And then, of course, hydrochloric acid, betaine HCl, to replace stomach acid for people that have low stomach acid, which is a pretty large percentage of folks who have gut issues, not everybody, but a pretty large percentage. And that’s a lot. It’s definitely a comprehensive protocol, but I find that for most people when they follow this kind of approach, they experience an improvement in both their digestive health and their skin. For some people who have really recalcitrant conditions, I might also use a custom herbal formula that has some anti-inflammatory and skin-clearing herbs in it, but in general, the basic approach is pretty effective.
What foods to eat — and not eat — to get rid of migraines (and clear your skin)
Chris Kresser: And one other interesting note: In the Personal Paleo Code, there’s an antimigraine diet in there that I talk about how to address migraines with food, and it’s a low tyramine, histamine, and arginine diet. And just kind of by accident, I noticed because I had a few patients with migraines and skin conditions, and I put them on the migraine diet, and it helped with their migraines, but then they came back to me and said: Wow, my skin is clearer than it’s been in years. And so, I started to think, Oh, that’s interesting. So, now I’ll often use that diet, the low tyramine, histamine, arginine approach for people with skin issues that don’t respond to the basic protocol. And maybe we can talk more about that at some point.
Steve Wright: Well, what are the biggest foods that you would cut out, that that diet cuts out?
Chris Kresser: Oddly enough, fermented foods are one of the biggest categories of foods that contain both histamines and tyramines, which is, of course, ironic because fermented foods have a lot of probiotic organisms, and that’s one of the keys to getting well. And then those patients, if they don’t do well with fermented foods, they we use a commercial probiotic supplement to help rebuild the gut flora. We do probiotic implants. So, like just sauerkraut and fermented vegetables, but also smelly cheeses and wine and vinegars, those are the foods that tend to be high in tyramine, and then histamine kind of also includes those fermented foods but in addition includes some random fruits and vegetables that there’s no obvious connection between them, like strawberries, for example. Again, usually if you just do a little Google research, there are some lists of these foods online.
Steve Wright: Interesting. So, when someone comes in exhibiting, because we talked a lot in the beginning about SIBO, do you ever do any SIBO testing for someone who comes in with digestive problems or skin problems?
Chris Kresser: I don’t often. If I suspect they have SIBO, I’ll usually just treat them as if they do and see how they respond, because the treatment that I do is often similar whether it’s leaky gut or SIBO or some other gut issue, but sometimes I do test. I’ll use a breath test to see if they have SIBO, and then that will help focus the treatment a little bit more. I’m kind of going back and forth on that right now because so far I haven’t noticed that it really changes the outcome of the treatment very much, and my standard for whether to run a test is whether it’s gonna change what we do in the treatment, and a second consideration would be whether it can provide some clarity or answer a burning question for a patient. For example, I don’t necessarily think gluten intolerance testing is all that helpful if somebody is convinced that gluten is inflammatory and they’re just not going to eat it, but for someone who really wants a smoking gun and just really wants the clarity of knowing that they’re gluten intolerant so that they have the commitment or the motivation to completely avoid it, then I think it’s a useful test in that circumstance. And I don’t know whether SIBO fits that guideline because it doesn’t lead to avoiding something in the diet as clear as gluten, but I’m kind of keeping an open mind about that testing, and we’ll see how that plays out.
The telltail signs you have low stomach acid… and what to do about it
Steve Wright: OK, well what about the stomach acid? How would I know if I have low stomach acid?
Chris Kresser: That’s mostly symptomatic. I mean, you can get stomach acid tested by a gastroenterologist. They could do, like, a 24-hour stomach acid test, but they’re really reluctant to run them. I’ve only ever had a few patients that have had that done. So, if you have a lot of symptoms after a meal, right after a meal, like upper GI bloating and belching and just a feeling of discomfort, bad breath, and then especially with proteins, like, if you have trouble digesting proteins, those are all signs of low stomach acid. Also I do a lot of blood testing for patients when they first come to see me, and if they’re low in a lot of vitamins and minerals, then I’ll suspect low stomach acid because one of the main purposes of stomach acid is to help digest and absorb those vitamins and minerals. So, if somebody comes in and they’re low in B12, they’re low in phosphorus and magnesium and iron and a number of other things, and they’re eating a diet with animal products, that’s gonna be one of the first things that I suspect because they shouldn’t be low in those nutrients if they’re eating a nutrient-dense diet unless there’s some problem with absorption, and that would probably be caused at least in part by low stomach acid.
Steve Wright: I’m glad you hit on the meat trend there, because I see so many women who will come and email us and say: You know, I just don’t do well with meat. I can’t switch to something like a Paleo or SCD or GAPS. And that, to me, is just a giant red flag that right away that have a stomach acid issue.
Chris Kresser: Right. That’s exactly the way I approach it too, and it’s unfortunate because a lot of people stop eating it because they think: I just don’t digest it well. Well, that may be true, but that doesn’t mean that that’s a stopping place. That’s a sign, as you’re suggesting, that there’s some work to be done. So, yeah, that’s a really good diagnostic piece of information there. And then, let’s see, the other thing you can do is the HCl challenge, which I’ve talked about. I have really explicit instructions for how to do that if you go to ChrisKresser.com/heartburn. The last couple articles are how to treat GERD from a nutritional perspective, and it lays out the whole HCl protocol. But it basically involves starting with a single HCl capsule just before a meal, and then you gradually increase the dose until you feel a mild burning sensation. And most people with adequate stomach acid will feel some burning even with one capsule, maybe two or three capsules, but I’ve had patients go up to 10 capsules and not feel a thing, and that’s definitely an indicator that stomach acid is low. And fortunately for most people after a period of time of taking betaine HCl, their own stomach acid production will kick in again. In some cases with patients who have been on PPIs, acid-suppressing drugs, for like 15 years or more, I have seen in those situations where they may need to continue to take HCl for the rest of their lives or indefinitely, but it’s way better for them to take HCl indefinitely than it is for them to continue taking a PPI in light of all of the things that we know about PPIs do to you over the long term.
Steve Wright: Can I ask from a skeptical patient or a skeptical client perspective, when I feel that mild burning, because we know that supplementing with betaine HCl is not an exact science, and when I feel that mild burning, does that mean I’m doing damage or is it just a one-time indicator and it’s not a big deal, nothing to worry about?
Chris Kresser: You mean as you’re building up the dose?
Steve Wright: Yeah, because I know that I talk with a lot of people who are trying to handle this part of their health, and they might get to four pills and they’re really, really worried about five pills because it just seems like a lot, and they’re also worried: Well, if I start this supplementation and I feel this burning, then I already know my stomach is hurt. Aren’t I just injuring it more?
Chris Kresser: Right. Yeah, if it’s just a one-time thing, I don’t think it’s a problem, and it’s a way to figure out how to get to the next phase, which is feeling better. And a single episode of feeling a little mild burning isn’t gonna cause any long-term damage. If somebody is doing that repeatedly, I wouldn’t recommend it, but that’s not really necessary as part of the protocol of figuring out what you need. Also I don’t think that it’s even necessary, I mean, everyone has to find their own dose. Like, some people, even though they build up to 10 capsules, that doesn’t mean they won’t get the same benefit at five capsules or seven capsules that they get at 10. In other words, just because you don’t feel burning until you get to 10 or 12 capsules, it doesn’t necessarily mean that you need to take 10 or 12 capsules each time. That make sense?
Steve Wright: Yeah, I think so. That’s probably definitely true, depending on the protein load of the food, of the meal.
Chris Kresser: Yeah, it really differs. And it is a kind of trial-and-error process, and it isn’t an exact science. That’s definitely true.
Steve Wright: I would encourage everyone, just as someone who uses the betaine supplementation on an everyday level even though it is a bit of a pain to figure out your correct dosage, it was night and day for me, and I know it still is night and day if I miss by a couple pills or something just because I want to test something. So, what we’re talking about shouldn’t deter you from testing this right away, because it will make the difference.
Chris Kresser: Yeah, it’s safe. I’ve done this with hundreds of patients, and I hear from people. If you look at the comment section in the heartburn articles, you’ll see people who were suffering from GERD and heartburn for 20, 25, 30 years. They were on PPIs for all that time, and they’re now completely symptom-free just from following this protocol. So, people from all over the world, all different backgrounds and histories, so it works, it’s really powerful, but it does take some time, and like you said, Steve, it’s kind of a hassle to have to always be carrying these capsules around and take them every time you eat, but for most people, it’s worth it. So, I think that’s all I’ve got for now. We’re gonna come back and talk about this a little bit more maybe in the future. And like I said, I’m gonna write a little bit more about it. Sorry we didn’t have time for questions this time. We’ll do a Q&A episode where we answer a lot of the questions that have been coming in sometime soon.
Steve Wright: OK, well, it’s been a great show, and if you’re confused about what to eat, check out the Personal Paleo Code. It’s a 3-step program designed to help you discover your own ideal diet and create a highly customized meal plan with a few clicks of a button. Visit PersonalPaleoCode.com to learn more. And if you’re trying to get pregnant or are already pregnant or nursing, don’t miss The Healthy Baby Code. It guides you through the essential steps to naturally boost fertility and promote lifelong health for you and your baby. Find out more at HealthyBabyCode.com.
Well, Chris, it’s been a great episode.
Chris Kresser: Yeah, I’ve enjoyed it. I hope everybody learned something useful, and I’m looking forward to writing and talking about this more in the future. If I don’t talk to you, Steve, have happy holidays, and I should probably mention this will be our last show until January, so everybody enjoy the holidays, whatever it is that you celebrate, and I look forward to seeing all of you in 2012.
Steve Wright: Yeah, have a happy New Year’s party, and be safe up there in that -40 degree weather.
Chris Kresser: Ha-ha, yeah. Thanks. Take care.
Steve Wright: See ya.
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