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Testing for SIBO, Graves Disease, and all about Anemia


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Another Q&A episode, folks! Remember to tune in next week for our interview with Dr. Alessio Fasano, a pioneer in the fields of gluten intolerance, leaky gut and autoimmunity.

In this episode, we cover:

12:39 How to tell if digestive problems are caused by leaky gut, SIBO, or food intolerance
26:25 What to do about Epstein-Barr Virus
32:43 Does a furry tongue mean anything?
35:43 How baby is telling you it’s time for different foods
37:50 The specific Graves Disease Protocol to keep it in check… for good
48:52 Everything you need to know about Anemia (and more)

Links We Discuss:

Full Text Transcript:

Steve Wright:  Hi, and welcome to another episode of 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.  Chris, how are you doing today, man?

Chris Kresser:  Oh, I’m pretty good, Steve.  How are you?

Steve Wright:  I’m good, man.  I’m pumped up.  We’ve got a lot of questions to cover today.

Chris Kresser:  Yeah.  A Q&A episode.  We’re doing it again.

Steve Wright:  Going rapid fire this time.

Chris Kresser:  So, before we get into that, I want to make a couple announcements.  One is just a reminder that the next show we’re gonna be interviewing Dr. Alessio Fasano, which I’m really excited about.  He’s a pioneer in the field of gluten intolerance and celiac disease research and also in establishing the connection between intestinal permeability, or leaky gut, and autoimmune disease.  He’s a real research hero of mine, and we’re honored that he’s gonna be joining us on the show, so make sure to tune into that one.  Don’t miss it.  It’s gonna be a great episode.

And then, as I’m sure all you know, the Ancestral Health Symposium is coming up, and I’ve been busy preparing my talk for that.  The topic is on iron overload.  That’s something I’ve talked about on the show quite a bit, and specifically I’m gonna be discussing how even mild iron overload, you know, nonhereditary hemochromatosis iron overload, can contribute to a number of different diseases and even increase the risk of death, and of course, how to test for it and what to do about it.  So if you’re at AHS, I look forward to seeing you at my talk and meeting you.  And I think, if last year was any indication, the talks will be available online after the event.  So if you’re not able to make it there in person, I think you’ll still be able to watch the talk.  I’m not sure about that, but that’s at least what happened last year in most cases.

And then the last thing I want to do is talk a little bit about something that I’m also really excited about, which is a new program that I’ve been working on over the past few months.  Actually really I’ve been working on it over the past several years because it’s a topic that I’ve, of course, been interested in for a long time, as you’ll know if you’ve been following my blog, and it’s really how my blog started.  The very first articles I ever wrote for my blog back when it was The Healthy Skeptic were about the relationship between cholesterol and heart disease.  And this program is gonna be called The High Cholesterol Action Plan, and the reason I’m doing it is that there’s still a lot of confusion out there about the relationship between cholesterol and heart disease, and that’s understandable because it’s an extremely complex topic.  In fact, the more I learn about it, the more intricacies I discover and subtle distinctions that become apparent and the more that I realize that the two extremes that we typically see out there, like, the one extreme, as Chris Masterjohn said, the cholesterol warriors, the people who say that high cholesterol is the cause of heart disease and that, you know, eating saturated fat and cholesterol in the diet raise cholesterol levels and so we should eat a low-fat diet and take statin drugs and do everything possible to lower our cholesterol to reduce our risk of heart disease.  We have that.  That’s one extreme, the cholesterol warriors.  And then on the other side of the extreme you’ve got the cholesterol skeptics who say cholesterol has nothing to do with heart disease, we shouldn’t worry about our cholesterol levels at all, and if you get your cholesterol tested and it’s 350, you know, go out and celebrate with a low-carb, high-fat meal!  So those are two extremes, and it turns out that I think the truth is somewhere in the middle.

And over even the last year, I’ve learned a tremendous amount about this issue, and because I’ve just been so busy with my practice and the show and my writing and everything else I’m doing, I haven’t unfortunately had the chance to update a lot of the articles on my site, and I haven’t had the chance to write new articles sharing all of my new research and what that means to you or anybody that you know that has been diagnosed with “high cholesterol” and usually then prescribed a statin.  And I have so many patients and so many readers and listeners and people in my life who write me and say:  Hey, I got diagnosed with high cholesterol, and my doctor wants me to take a statin.  I’m really confused about this.  Should I get my particle size tested?  Should I get CRP tested?  What other tests should I get to really figure out what my risk is?  Or maybe my dad or my mom was diagnosed with high cholesterol, and they’re already on a statin, and I’m concerned about them.  And you know, it’s a big issue, and it affects a lot of people, and there’s probably not a single one of us listening to this show right now that doesn’t know somebody that’s on a statin or that’s been prescribed a statin.  So I wanted to just put all of the information in one place, like, to just talk about the most current research, all of the cutting-edge staff about how to really truly determine your heart disease risk, which tests are best, which tests are bunk and a waste of time and money.  And then once you establish what your risk is, how you decide what to do about it.  What’s the best dietary approach?  You know, is a low-carb, paleo type of diet best for everybody, or is there a situation where that’s not a good choice?  And statins, should they always be avoided, or are there some people that may actually be good candidates for statins?  And for those who statins aren’t a good choice for, what are the natural alternatives to statins?

So it’s a huge topic, and I started out thinking that I’d be able to do it in a pretty succinct way, and it still will be very practical and focused, but it’s gonna cover, you know, it’s gonna be like a soup-to-nuts thing, from beginning to end, and it’ll have a really practical framework, like a decision tree for going through the process step by step of determining what your risk is and then how to respond appropriately.  It’s probably about six weeks away, and I’ve been working a little bit too much on it.  I get into these modes where I just completely dork out and get really lost in what I’m doing, and yeah, that’s how I’ve been spending my time lately, but I’m excited about it and I can’t wait to get it out there because I think it’s gonna help a lot of people.

Steve Wright:  Sounds like an awesome project.  I am excited to get my hands on it.  So you’re talking the end of August-ish right now tentatively?

Chris Kresser:  That’s what I’m hoping for.  This thing, you know, sleep is getting in the way.

Steve Wright:  I hate sleep.  God.

Chris Kresser:  The need to sleep at least a little bit and take care of my body and stuff, but yeah, I’m shooting for the end of August, and it’s gonna be a combination of video screencasts, me going through presentation slides, audio versions of that, PDF transcripts, and then an action guide, as I described, takes you through step by step, and you know, specific recommendations for supplements and diet and exercise and other ways of treating and preventing heart disease naturally.  So yeah, we’ll talk about it again when the time comes and go into a little bit more detail on it, but it’s on my mind and I’m excited about it, so I just wanted to share a little bit.

Steve Wright:  Well, it sounds great.  And if anybody caught my Real Food Summit talk, you know I love step-by-step, so I’m excited right now, to say the least.

So you had an awesome Real Food Summit talk, Chris, I think probably one of the most popular, seeing how you got the encore day and everything.

Chris Kresser:  Thanks, Steve.  Yeah, I mean, it was a good experience.  I, as many of you know, did the Paleo Summit with Sean a while back, and this was similar.  It was an online conference with a number of experts and authorities in the real food genre, so not paleo, per se, but nutrient-dense approaches to diet, which would include, like, the diet that the Weston A. Price Foundation advocates.  And it was a great conference.  I think it was even better attended than the Paleo Summit.  And my talk was on the importance of eating fish and seafood in the context of a real food diet and why it’s important to do that, how much and which types and fish are best to eat.  You know, I talk a little bit about some of the concerns surrounding fish consumption like mercury and PCBs and dioxins and why for much people and much types of fish that’s not really a concern.  So yeah, if you missed it, you can buy the whole set of talks.  I think there are about 27 presentations.  Is that right, Steve?

Steve Wright:  Yeah, I think there were 27 that were live, and then there were six or seven bonus.

Chris Kresser:  Oh, right.  Yeah, so there are like 33 presentations, all like an hour or an hour and a half, and then there are audio recordings, PDF transcripts.  I think you get a free subscription to Organic Gardening.  There are some other bonuses thrown in there.  You can go to my website and look at the homepage.  I think one or two pages back there’s an article there that I wrote about the Summit, and you can check it out and then click through there if you’re interested in getting the talks.

Steve Wright:  Yeah, I thought it was a great summit.  There was a ton of top-notch presenters who shared some really awesome concepts.  It took me, like, three days to download it.  There was so much info, so you definitely get your money’s worth.

Chris Kresser:  Actually, I guess, we could put a link to it in the show notes for this show, so rather than going and digging around my website, you can just check out the show notes and we’ll put a link in there where you can get the recordings.

Steve Wright:  OK, great.  Well, this was a heck of an intro, Chris.  Take a water break, and I’m gonna tell everyone about Beyond Paleo.  Now, if you’re listening to the show, we’re assuming that you’re into your health, you’re into optimizing your health, and you’re probably gonna want to check out what over 10,000 other people have already signed up for, and that’s what I talked about before called Beyond PaleoBeyond Paleo is Chris’ brainchild.  It’s 13 emails.  It covers everything from food to being happy, and all of these things together are gonna help you burn fat, boost energy, and prevent and reverse disease without drugs.  So you’re gonna want to get your hands on it if you haven’t yet.  Go over to ChrisKresser.com, and look for the big red box.

Chris, are you hydrated?

Chris Kresser:  I’m ready to go.

How to tell if digestive problems are caused by leaky gut, SIBO, or food intolerance

Steve Wright:  OK, let’s do this.  Our first question comes from Megan:  “Is there an easy way to tell if your GI problems are due to leaky gut versus SIBO versus general food intolerances, for example, FODMAPs?  Or is it more likely that these issues all overlap in someone with an unhealthy gut?”

Chris Kresser:  Yeah, it’s a great question.  I guess it depends on what you mean by ‘easy’ for the first part of your question, because there are tests that can be done for SIBO.  There are a couple tests that I’ll mention in a second.  And then there are also stool tests that can be done to identify gut pathogens like opportunistic or pathogenic bacteria and fungal infections and parasites.  And there are tests that can be done for fructose intolerance.  And then there are also tests for food intolerance and tests for leaky gut, though I think those are less useful, and I’ll come back to that in a second.  So let’s talk first about the tests for SIBO.  There are two main ways of testing for small intestine bacterial overgrowth.  And for those of you who aren’t aware of this is, normally the small intestine should be relatively sterile, meaning there shouldn’t be a lot of bacteria in it.  Most of the bacteria that resides in our gut is in the colon and, to a lesser extent, the very end of the terminal ileum, which is the end of the small intestine.  But in some cases, the bacteria can translocate from the colon into the small intestine where it doesn’t belong, and then that causes gas and bloating and pain and changes in stool frequency and consistency.

So there are two ways of testing for small intestine bacterial overgrowth.  One, and the most common one is a breath test, where you drink a solution that contains some simple sugars, which can be fermented by small intestine bacteria.  And then you blow into a little tube that’s attached to a balloon or a bag, and then you send that bag to the lab, and the lab tests it for certain gases that are produced by certain kinds of bacteria.  And if the levels of the gases are high, then that indicates you have an overgrowth of bacteria in the small intestine.  So that’s one way of testing for it.  Another way of testing for it is a urine organic acids test, and these are offered by labs like Metametrix and Genova Diagnostics, who just bought Metametrix actually last week, so they’re gonna be merging together.  And organic acids are byproducts of bacterial metabolism.  So certain types of organic acids, if they’re elevated in the urine, can indicate an overgrowth of bacteria in the gut and also an overgrowth of fungi.  So D-arabinitol is an organic acid that’s produced in fungal metabolism, and so if you have an overgrowth of D-arabinitol in the urine, then that can indicate a yeast overgrowth.

So those are the two main tests.  I tend to use the organic acids test more, and that’s partly because it has a number of markers that I find to be useful, and so I just can kill several birds with one stone, and I tend to order that more, but the breath test is also good.  One lab that’s pretty well known for the breath test is Metabolic Solutions, and it’s pretty affordable.  It’s like a hundred bucks, maybe 95 bucks or something.  At least, that’s what it costs me to order it.  I don’t know if they have different prices for clinicians and patients.  I think that same lab, Metabolic Solutions, they also offer a fructose intolerance test, which is very similar to the SIBO test, and that is one that you could do to identify any potential problem with FODMAPs.  If you test positive for fructose intolerance, then you’re almost certainly gonna benefit from doing the FODMAP approach since the FODMAP approach is based on reducing foods that have excess fructose or fructans or polyols, sugar alcohols.  So if you have access to that kind of testing and you have the resources to do it, they’re all pretty easy to do, and they can help you identify what the underlying cause of your problem is, and then maybe that can help determine what kind of action to take, both which diet would be most effective for you and then what other interventions might be effective.  For example, if you have SIBO, you’re probably gonna want to do some antimicrobial protocol in order to treat that.

As far as food intolerance testing goes, we’ve either talked about it on the show or I’ve written about it or both, but I don’t consider food intolerance testing to be very useful for a couple different reasons.  Number one, and I’m pretty sure I’ve mentioned this on the show, there have been some kind of blinded trials done anecdotally by clinicians, where they’ve drawn their own blood and put it two vials, you know, on the same day, same blood draw, and labeled the two vials with different names and sent them into the same lab and come back with completely different results for the two different vials of blood that came from the same person on the same day.  So that’s a little suspect.  And then number two, even if the test was completely reliable, the question is still what’s causing those food intolerances?  I mean, food intolerance is a symptom; it’s not a disease.  There’s an underlying disease or pathology that’s causing those food intolerances, and that would usually be SIBO or intestinal permeability or a parasite or a fungal infection or some other gut problem, maybe a gut-brain axis issue or maybe gluten exposure, undiagnosed gluten intolerance.  Those are mechanisms.  Those are problems that lead to symptoms.  So if you just remove the foods that the food intolerance testing shows that you’re sensitive to, certainly that will help with the symptoms, and there’s nothing wrong with that, but assuming you want to be able to eat some of those foods again, addressing the underlying problem is a much better approach.  So I don’t put a lot of stock into food intolerance testing for those reasons.

And then intestinal permeability, well, there are a couple of different ways to test for leaky gut.  And I actually want to talk to Dr. Fasano about this a little bit.  I’ll be curious to see what he has to say about it.  But there’s the lactulose/mannitol test, and that’s the one that’s best known.  And again, you drink a solution of lactulose and mannitol sugars.  They’re rather large molecules, and they shouldn’t pass through the gut when the gut barrier is intact.  And if they are detected in the blood, that means they’ve passed through the gut, and that means, then, that you have a leaky gut.  So that’s one way of testing.  A newer way of testing was developed by Dr. Aristo Vojdani.  I hope I’m pronouncing his name right.  But he’s the clinical advisor at Cyrex Labs, and they developed a test that screens for antibodies that are involved in the immune response that destroys the gut barrier.  So I think there are actomyosin antibodies, zonulin antibodies, and one more, which I can’t remember off the top of my head.  And that’s a completely different way of testing for leaky gut, but if we take Dr. Vojdani’s research at face value, it’s apparently much more effective and accurate than testing the lactulose/mannitol route, which some doubt has been cast upon in recent research.

The reason I don’t find myself testing for leaky gut very often is my benchmark for determining whether to run a test is whether it will change the outcome of the treatment, and usually with leaky gut it doesn’t, because if I get the test results back — Let’s say someone comes to me and they have a gut problem.  If we were to run a test for leaky gut and it came back and it said they didn’t have a leaky gut, well, I still have a person with a gut problem.  You know, I still need to figure out what’s causing their gut problem and what to do about it.  And if someone comes back with a leaky gut, I still need to figure out what’s causing that leaky gut.  So again, I look at leaky gut kind of more like food intolerance in a sense because even though it is an underlying mechanism to some extent, meaning it can contribute to and cause a lot of other problems, there’s still usually something causing leaky gut itself.  It doesn’t just come out of nowhere, you know, and that could be, again, like, gluten intolerance or a pathogen, some kind of inflammatory process, small intestine bacterial overgrowth, stress, gut-brain axis problem.  So there’s usually still more work to be done to determine what the underlying cause is, and I just think often it pays to just do that.  But the one area where I think the testing can be helpful is gauging the success of the treatment.  So if we do a bunch of treatment and the person is improving, then we might do the leaky gut test and see, OK, let’s see what’s happening to your gut barrier.  Is it still permeable or has it improved based on the treatment we’re doing?  And if it hasn’t, then we can adjust the treatment and make different choices.

So, yeah, I mean, there’s obviously a lot to talk about here too, and maybe as another announcement, for some time, you know, I’ve always known that I would write a book and probably several books, but I’ve really been struggling a lot over the past several months deciding what book I want to write and, you know, what my first book would be.  And I finally have decided, and it’s gonna be a book on gut health.  And specifically it’s gonna be a book that examines what the real causes of digestive problems are, because most of the diagnoses that we have for digestive problems just name the symptoms that people experience.  So think about it:  Irritable bowel syndrome, IBS.  Somebody goes in to the doctor.  They say:  Oh, my stomach hurts.  I have pain.  I have gas and bloating, and I have diarrhea or constipation.  And the doctor goes:  OK, well, you’ve got IBS.  And you know, it’s basically like the patient is like:  Well, isn’t that what I just told you?  My gut is irritable?  And you know, the same is true for heartburn and a lot of other “gut diseases.”  They don’t actually describe what’s wrong; they just describe the symptoms that people are experiencing.  So my book is gonna focus on the underlying causes of gut problems like SIBO, like parasites and other gut pathogens, like gut-brain axis problems.  And then, of course, talk about how to address those problems with natural remedies.  So we’re gonna be talking about this subject in a lot more detail in the next year because I’m gonna be up to my ears in it as I start writing the book, which I haven’t started.  I’ve outlined it.  I’m gonna start writing probably, I don’t know, in the fall once I get through these other projects I’m working on.

Steve Wright:  You’re signing yourself up for a lot of projects, man.

Chris Kresser:  I know!

Steve Wright:  We’re expecting this from you.

Chris Kresser:  Yeah.  You guys gotta remind me to take my own medicine and remember to, you know, take care of myself and lay down and take a nap every now and then.

Steve Wright:  Yeah.  You need to be sleeping.  I know you like to laugh when you say IBS, but you know, you need to be laughing outside of the podcast too.  We can’t forget the happiness piece.

Chris Kresser:  Not at all.  It’s a crucial part of my well-being.  That’s for sure.

Steve Wright:  Well, I’ll just throw a little plug in there for our Real Food Summit talk because Megan’s question was really the topic of Jordan’s and my presentation:  what to do when you go paleo or you go Weston A. Price and your gut problems don’t necessarily go away.  And so we tried to give some really practical tips that we’ve learned over the years.  So that might be a place to go, Megan, for more information until the thesis that is in Chris’ head is in our hands.

Chris Kresser:  All right, let’s do the next one.

What to do about Epstein-Barr Virus

Steve Wright:  OK.  This question comes from Teresa:  “Hi, Chris.  Thanks for the high-level discourse actually based on science.  Any suggestions for chronic acute Epstein-Barr?  Besides the obvious tenets of good health, sleep, good nutrition, smart exercise, good vitamin D levels, omegas, and the normal antiinflammatory steps, I tried a run of cat’s claw with no obvious results.  There’s nothing in the literature of help.  Can you help me?”

Chris Kresser:  Yeah.  So by chronic acute Epstein-Barr, I’m assuming she means a latent Epstein-Barr infection that was reactivated.  For those of you that don’t know, Epstein-Barr virus is extremely common in the sense that over 90% of North Americans have been exposed to it and then have IgG antibodies, which means we were exposed to it.  And once we are exposed to a virus like that, it usually doesn’t leave our bodies completely.  It can stay latent in our cells, and it can get reactivated when our immune defenses are down, often when we’re under great stress or possibly when we get another infection of a different type or if we’re eating an inflammatory diet or, you know, anything that can throw our immune defenses off.  To determine if you have this, by the way, it’s very important not only to get IgG antibodies tested since most people will turn out being positive for IgG Epstein-Barr, but to get IgM antibodies, which would be indicative of an active infection or chronic acute, which I assume is what she means.

So yeah, I do have some suggestions for working with this.  I have quite a few patients that are dealing with reactivated infections like Epstein-Barr or cytomegalovirus or herpes, HPV, or HHV, human herpesvirus.  The key thing in a general sense to realize when working with viruses, unlike bacterial infections or yeast infections, is that the number one thing you want to do is strengthen your own immune system’s defenses because while there are antiviral treatments, both drug and nondrug antiviral treatments, they’re generally not as effective as antibiotic treatments or antifungal treatments, and therefore the goal is to really boost our own innate immune defenses so that our immune system can do what it does best, which is eradicate these infections.  So the basics there, I think, she’s already doing, but would be antiinflammatory diet, high doses of vitamin C, so we’re talking about gram-level doses, several grams a day to bowel tolerance, maybe like 1 g three to four times a day.  You could even go that high.  Selenium and iodine are both important for the immune system.  Glutathione precursors like N-acetyl cysteine, lipoic acid, and then things that help with intracellular glutathione recycling like milk thistle.  Those are all really solid basic choices for supporting immune function.

But in terms of a natural antiviral that you might try, I like monolaurin, and monolaurin is an extract of lauric acid, which is a fatty acid that’s found in coconut products and in breast milk.  And when lauric acid is attached to glycerin, it forms a monoglyceride known as monolaurin.  And monolaurin works directly on the envelope coat of the virus by disrupting the conformation of the lipid bilayer, which in turn prevents its attachment or absorption to host cells.  So there actually is some research on monolaurin and its antiviral activity.  It’s also antifungal, and it has efficacy against gram-negative bacteria too.  The cool thing about monolaurin is that it’s pretty well tolerated and safe.  It doesn’t seem to have a negative impact on the beneficial gut flora.  And when compared with some other options in terms of natural antimicrobials, I’ve found it to be pretty easy to work with and not cause a lot of side effects.  So the sort of typical starting dose would be 1200 mg two times a day for an adult.  So I would definitely try that.

In my practice, I use some custom botanical formulas to treat viral infections, and I’ll customize them based on the specific presentation of the patient, based on the type of virus that they have, and you know, their own constitution and symptom profile.  But some of the medicinals that I will use are familiar, I’m sure, to a lot of you.  Echinacea is one; laurea; usnea, or old man’s beard — I love that name; dandelion; pau d’arco; astragalus; lemon balm.  It’s generally better rather than, you know, just going down to the store and getting a bunch of these and brewing them up, to work with an experienced herbalist if you can.  But some of these herbs, particularly echinacea and dandelion and lemon balm, are pretty safe and can be used at home.  You can just make teas or even buy teas with echinacea and some of these herbs in them.  So give that a shot, and let us know how it works out.

Does a furry tongue mean anything?

Steve Wright:  OK.  Let’s roll on.  This next one is from Anonymous:  “Hi.  I started the paleo/Perfect Health Diet at the start of this year.  All is generally going great.  I’ve lost weight and feel a lot better.  The only problem I’m having is a furry tongue.  It gives me horrible breath in the morning.  Throughout the day after eating sometimes it goes green.  I’ve been to the doctor, who gave me some antifungal lozenges to use for candida, but two of these lots have not worked yet.  The doctor said it was unusual to get unless you have a low immune system.  I haven’t been sick since going paleo, nor have I taken antibiotics.  Do you have any ideas what’s going on with my tongue?”

Chris Kresser:  My guess would be low stomach acid.  And I see this a lot on people who start a paleo diet coming from a diet with less animal protein.  We’ve talked about tons of times on the show.  Stomach acid, as you all know by now, is crucial to breaking down protein, particularly animal protein, and if you don’t have enough stomach acid, the protein can putrefy in the stomach.  And I haven’t seen any research on this from a conventional medical perspective, but certainly anyone who is familiar with Chinese medicine will know that they put a lot of stock into the appearance of the tongue, and a thick coating on the tongue is definitely an indicator of digestive disharmony.  And I don’t really know how to explain that with precision from a Western medical paradigm perspective, but I certainly have seen it to be, you know — In nearly everyone who has a digestive issue, there tends to be a coat on the tongue.  So that’s my guess:  low stomach acid.  It could also be small bowel bacterial overgrowth, and we talked earlier about how to get tested for that.  The easiest thing to do to test out the stomach acid hypothesis would be to just take some hydrochloric acid, that betaine HCl protocol.  We’ll put a link in the show notes to the post on my website where I discuss the protocol in detail and go through it step by step.  And if that doesn’t work, I would probably get tested for SIBO.  Or if you do the organic acids test, that will test for both SIBO and a fungal overgrowth, which would probably be an even better idea.

Steve Wright:  OK, well, that should get them started, and I’ll just add that back before I started my health reversal, I did have a white-coated tongue, and I did and still am getting over low stomach acid, so just my two cents that might help you do what Chris said.

How baby is telling you it’s time for different foods

OK, let’s move on to the next question from Thomas:  “Hi.  I purchased the Healthy Baby Code after the birth of my son.  He is now 6-1/2 months old.  We are trying to feed him egg yolks as his first food as you recommend, but he doesn’t seem to like them.  We’ve mixed it with breast milk, but it doesn’t seem to help.  Should we continue trying to feed him this or move on to other foods?”

Chris Kresser:  Definitely move on to other foods.  The guidelines for introducing first foods are general and will apply to many babies, but as any parent who has had more than one child will tell you, just like adults, babies have preferences and likes and dislikes.  So if your baby doesn’t like eggs, then yeah, just skip it and move on to the next thing and try something else and then maybe come back to it later.  It seems that some percentage of babies also can’t really tolerate egg yolks very well at that age, and I’ve had some reports of vomiting and just some bad digestive reactions.  I don’t think they’re mediated by allergy.   I just think that for whatever reason it’s maybe a little bit too soon to introduce that particular food.  So use the guidelines as a rough blueprint, so to speak, but feel free to improvise a little bit based on your child’s preferences and what’s available to you.  Some of the things that are — I mean, you wouldn’t want to skip too far ahead because the guidelines are laid out with particular stages of development of the digestive tract in mind, but certainly just going forward a little bit and expanding the options that way is completely fine and would definitely be recommended in this situation.

Steve Wright:  OK, well, I have nothing to add there, so glad you covered that.

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The specific Graves Disease Protocol to keep it in check… for good

Chris Kresser:  Steve, did we miss the Graves’ disease question or did I not put that in there?

Steve Wright:  I don’t see a Graves’ disease…

Chris Kresser:  Scroll down a little bit.  It’s in there somewhere.  If you can’t see it, we’ll come back to it in a different episode.

Steve Wright:  I copied down to the intermittent fasting one.  I don’t see it in there.

Chris Kresser:  Well, let me just kind of paraphrase it.  The question, I think, was essentially we’ve talked a lot about hypothyroidism and Hashimoto’s but haven’t talked much about Graves’ disease and how would I recommend approaching Graves’ disease.  Graves’ disease is certainly more rare than Hashimoto’s and hypothyroidism.  That’s one of the reasons I haven’t talked about it as much, but I do know quite a bit about it because my wife was diagnosed with Graves’ disease, and this was back when we were still trying to get pregnant with Sylvie and we were having some difficulty, and I was doing some investigation figuring out what was going on, and we discovered that she had Graves’.  And shortly after discovering that and treating her for that, she got pregnant with Sylvie.  So it’s something that I’ve done quite a bit of research into and I have obviously a personal motivation to stay up with it.

So for us, for my wife, the number one thing by far in terms of turning her health around was low-dose naltrexone, which we’ve discussed a few different times.  Low-dose naltrexone is a low dose of a medication called naltrexone, of course.  Naltrexone, if you look it up, you’ll find that it’s used for some things that have nothing to do with autoimmune disease and Graves’ disease.  Naltrexone at 50 mg is used for opiate and alcohol withdrawal.  You know, so basically it blocks the endogenous opiate receptors at that dose, which are our natural feel-good chemicals, so that if a heroin addict that was on 50 mg of naltrexone shot heroin, they wouldn’t feel a thing.  The problem at that dose was that not only did they not feel any pleasure from shooting heroin, they felt no pleasure at all at any other time in their life because their pleasure-producing chemicals were completely blocked.  So naltrexone was not very successful from that perspective, but a doctor in the ‘80s named Dr. Bihari found that if you used a lower dose of naltrexone and created a temporary blockade of the opiate receptors overnight, you could basically trick the body into producing more endogenous opiates.

And if you’re wondering how this relates to autoimmune disease, we know now that white blood cells have receptors for these endogenous endorphins, and that suggests that the endorphins have an immunoregulatory effect.  And sure enough, later research showed that low-dose naltrexone stimulates T regulatory cell function.  The T regulatory cells balance the immune system, and they turn off the inflammatory response once it’s turned on, and that’s a characteristic of autoimmune disease, is they’re often runaway inflammatory responses.  They’re basically inflammatory conditions run amok, where you get an inflammatory process and it just goes on and on and doesn’t get turned off.  So low-dose naltrexone, there are studies examining it in multiple sclerosis, in fibromyalgia, Crohn’s disease, probably the most well-known and best-designed trials, and it was remarkably effective for Crohn’s disease.  There was something like a 77% remission rate, which is just unheard of for a Crohn’s disease treatment, and with no side effects compared to placebo, which again, is unheard of because most of the drugs that are used to treat Crohn’s are pretty potent and can cause some pretty nasty side effects, like prednisone and Imuran and Remicade and some immunosuppressive drugs.

So low-dose naltrexone has not been clinically studied specifically for autoimmune thyroid disease, but many autoimmune diseases share common mechanisms, so it’s not that much of a stretch to think that if it works for MS and IBD and fibromyalgia that it could work for Hashimoto’s and Graves’, and sure enough, it does work very well for those conditions in my anecdotal experience and then the experience of a lot of other practitioners that use it and have hundreds of patients that are taking it for autoimmune thyroid disease.  So that would be absolutely my number one priority if I had Graves’ disease, is trying low-dose naltrexone.  There’s little risk to doing it.  There are no known long-term complications or risk associated with it at such a low dose, and especially when you compare it to the other treatment options in Graves’, which are basically having your thyroid radioactively ablated, or nuked, in layperson’s terms, or taking radioactive drugs like PTU or methimazole that have pretty nasty side effects including liver failure and death, I think low-dose naltrexone is a pretty attractive alternative.  I actually have a friend or a friend, or a friend’s mom, who had had Graves’ for 30, 40 years and had been taking medication, I think, PTU for that length of time, was extremely skeptical that LDN could help her because she had been on medication for so long.  But she heard about Elanne’s experience, and she decided to give it a shot, and now she’s off of those toxic drugs and she’s just taking LDN.  So it works even after that length of time in some people.

The next thing is that there are some studies, a couple studies, that suggest that L-tyrosine at pretty high doses can suppress the conversion of T4 to T3.  Graves’ disease is a hyperthyroid condition, and reducing the conversion of T4 to T3 can be helpful in those situations.  So the dosage that was observed in those studies to do that was around 1000 mg two to three times a day.

There’s some research that suggests that lithium orotate can help because it blocks the release of iodine and thyroid hormones, and in fact, it’s often used after radioactive ablation of the thyroid gland in Graves’ disease, when patients can experience a transitory increase in thyroid hormone after that ablation, and lithium is used to bring the levels down to prevent a thyroid storm or thyrotoxicosis.  So the dose, though, for that with lithium orotate is very low.  Some of you might be familiar with lithium as a treatment for bipolar disorder.  In the case of bipolar disorder, it’s used at a dose of, like, 800 to 2400 mg, but the way it’s used to bring levels down of thyroid hormone is a lot lower.  It’s about 120 mg.  I would not do this without supervision of a clinician who knows what they’re doing because lithium, if it’s not dosed properly, can have probably some undesirable effects, so it’s good to get some support there.

Those are the main ones.  Again, for us, I did some other things, like a custom herbal formula for my wife, but it’s difficult to give general recommendations for that because it’s really tailored to each person’s particular presentation.  But what happened is after she went on LDN, within two months she was pregnant, and then we had a very healthy baby girl who’s actually turning 1 in two days, three days.  This weekend we’re having her 1-year birthday party, which is gonna be fun.  So it can be quite remarkable, and really she’s been euthyroid the entire time since she’s been on LDN.  She’s never had to take any other drug.  And she’s healthy and doing great, so it’s definitely an exciting treatment for people who have that condition.

Steve Wright:  That’s a great story.  Are you inviting everybody to the birthday party?

Chris Kresser:  Yeah, c’mon over!

Steve Wright:  Hey, now, just to clarify, I’m assuming that you would also want to be gluten-free at least, if not paleo?

Chris Kresser:  Yes, definitely.  I mean, sometimes I think that that goes without saying, but of course, it doesn’t, so thanks for reminding me.  You want to eat a generally antiinflammatory diet, which means avoiding gluten because it can aggravate the immune system, and any other foods that can aggravate the immune system.  And another thing you want to be careful of is iodine.  I think iodine actually can be helpful in some cases of Graves’ disease, but you need to make sure that you have enough selenium if you’re taking iodine, and you need to make sure that you’re taking a very low dose of iodine to begin with and building up slowly.  And it’s probably a good idea to just get your iodine levels tested to see if you even need to take it, because if you take a higher dose of iodine right off the bat and you’re selenium-deficient, then iodine can, in that situation, exacerbate the autoimmune reaction.

Steve Wright:  OK, great.  Do you want to do one more?

Chris Kresser:  Let’s do the anemia question.

Everything you need to know about Anemia (and more)

Steve Wright:  OK.  It’s a bit long, so hang with me here.  This comes from Chris:  “About anemia, I heard you briefly mention during a podcast that something like 30% of your patients are anemic, and I was hoping that you would offer me some avenues for research into this problem.  I’ve been anemic for 15 years now, probably about the same amount of time that I’ve had intestinal/digestive issues.  Only in the last six months have I discovered paleo, Weston A. Price, and GAPS.  So I’ve finally gotten control of my depression/anxiety/psoriasis/gas/allergies/ asthma/fatigue/general immunity” — he’s got some things going on — “But the anemia persists.”  He lists some specific counts here.  We’ll skip over those, but basically it comes down to he’s borderline anemic, and it’s continuing to persist.  Chris, can you offer him some help?

Chris Kresser:  Yeah, I mean, if you want some avenues for research, I can keep you busy for the next five to ten years probably because anemia — There are few topics actually in medicine that are more poorly understood and more complex.  Anemia is one of those topics that, I think, is not taught well in any medical school, whether we’re talking about conventional medical school or the more alternative kind of medical schools.  A lot of clinicians just don’t really understand it very well, and I know this because I frequently see patients coming from all different types of clinicians, doctors, naturopaths, acupuncturists, whatever, and they tell me their history, and they show me their labs, and they show me what their clinicians did, and I’m often pretty shocked.  And you know, it is complex, as you’ll see.  I’ll go through some of the basics of anemia and the things that can cause it, and you’ll get a sense of why there is so much misunderstanding.  But on the other hand, it’s really frustrating because there are some things that are pretty easy to grasp that I think all clinicians should know, but I guess we just have to blame the schools because they’re not teaching it very well.

A lot of people can’t even agree on a definition of anemia.  That’s where the complexity and the problems start, is if you look up what is anemia, you’ll get all different kinds of responses.  One is a condition where the number of red blood cells in the blood is below normal.  Well, then, of course, there are different opinions on what’s normal.  And then another might be more specific, like hemoglobin level of below 12 in women or below 13 in men.  But my preferred definition is compromised ability of red blood cells to deliver adequate oxygen to body tissues, because that’s, in the end, what we’re really concerned about, is the capacity of hemoglobin to deliver oxygen to the cells, and all the cells in the body need oxygen to function properly.

So the causes of anemia can be basically split into four categories.  One would be insufficient production of red blood cells, hemoglobin.  Number two would be excessive breakdown of red blood cells.  Number three would be loss of blood.  And number four would be fluid overload.  So when we talk about insufficient production, that can be further broken down into stem cell problems like aplastic anemia or insufficient erythropoietin production; inadequate maturation of the red blood cells, which is usually in turn caused by nutrient deficiencies, specifically iron, folate, B12, or B6; myelodysplastic syndrome, or MDS, which was previously known as preleukemia; and then anemia of chronic disease, also known as anemia of chronic inflammation.  Now, when we talk about excessive breakdown, the second major group of causes, we’re talking mostly about the hemolytic anemias.  This generally will feature jaundice clinically.  You’ll see some yellowing and orange-bronzing of the skin and increased levels of an enzyme called lactate dehydrogenase on a lab test.  And these are often due to genetic mutations like sickle cell anemia and also enzymopathies like glucose-6-phosphate dehydrogenase deficiency, or G6PD.  The third category is blood loss, and short of trauma, you know, if you get in an accident and lose a lot of blood, we’re mostly talking in women about menstrual disorders like heavy periods or endometriosis or something like that, and in both men and women, gastrointestinal bleeding, so inflammatory bowel disease or ulcers, something like that where there’s significant ongoing blood loss.

And then the fourth category there is hypervolemia from excessive sodium or fluid intake, also sodium or water retention.  And it’s kind of a tangent, but it’s really important to point this out:  This hypervolemia happens naturally in pregnancy during the second and third trimesters as the blood volume expands to accommodate the growing fetus, and I see this a lot in my practice because I do a lot of fertility/pregnancy work.  A lot of women are misdiagnosed with anemia by their physicians or other health care providers during this period because a lot of clinicians, surprisingly, aren’t aware of this phenomenon, that the normal range for hemoglobin during pregnancy drops quite significantly.  So for example, the normal level for hemoglobin in nonpregnant women is between 12 and 16 g/dL, but the normal levels in pregnant women at 28 weeks are between 10 and 14 g/dL, and some research actually suggests that the lower end of that scale leads to better outcomes in pregnancy.  So if you’re pregnant and your hemoglobin is at 10.5, that actually pretty ideal and it doesn’t mean that you’re anemic.

OK, back to regular programming.  So I think you’re getting a sense now of how complex this is.  The typical thing is, like, you go in to the doctor and your hemoglobin is below the average level.  They’re just gonna give you an iron supplement, but iron deficiency is just one subtopic in one of those four categories of potential things that can cause anemia.  And certainly statistically speaking worldwide, iron deficiency is the major cause of anemia.  It affects about 2 billion people around the world, but it tends to affect more people in developing countries where iron-rich foods, particularly animal protein, is not available or not as readily available and in disadvantaged socioeconomic communities in the US for the same reason.  But iron deficiency anemia is more rare — I mean, I’m hard pressed to think of — I think I can recall maybe two or three patients that I’ve ever seen that have had iron deficiency anemia.  But as the questioner pointed out, I have a lot of patients with anemia.  Almost always the anemia is caused by something other than iron deficiency in my patient population.  And that might be unusual, but I frequently will get people come to me that have had low hemoglobin and their doctor just prescribed iron pills.  And the problem with that is that sometimes these patients are iron loaded, or sometimes they have something called anemia of chronic disease, which I’ll mention in a second, and giving someone who has anemia of chronic disease iron can really be problematic because anemia of chronic disease is caused often by an infection, and all pathogens utilize iron to proliferate and grow, just like most life on Earth.  And so if you give someone with an infection and anemia of chronic disease that’s caused by that infection iron supplements, you’re gonna make them much worse, and this actually happened to one of my patients.  It was quite sad.  Someone that I was consulting with in Texas, an older woman in her early 80s, and she sent me her blood work, and she did have anemia.  Her hemoglobin was low and her iron saturation was low, but — and this is really important — her ferritin levels were high, and that’s what distinguishes iron deficiency anemia from anemia of chronic disease, is the ferritin is elevated because ferritin is an acute phase reactant that’s elevated in the inflammatory response, and so that indicates that there’s some infection or inflammation, and also the body is trying to sequester iron and ferritin to keep it away from the pathogen.  So she sent me that, and then she ended up going to the hospital or to her doctor for some other reason, and the doctor saw that she had low hemoglobin, either didn’t test for or pay attention to ferritin, gave her iron pills, and she ended up spending a day or two in the hospital and nearly died.  It was really scary.  So this is a serious issue, and I think it’s important to grasp the complexity of it and to investigate these possible mechanisms because it’s often not simple.

So, let’s see.  We got a little lost there.  I guess what I would say is assuming some of those medical causes have been ruled out, like you don’t have stem cell problems, you don’t have myelodysplastic syndrome, you don’t have a hemolytic anemia, you’re not experiencing any blood loss, and you’re not hypervolemic, you don’t have excessive sodium or fluid intake, in that case then it usually does come down to a nutrient deficiency, and then we’d be looking at either iron deficiency on the one hand or folate, B12, or B6 deficiency on the other hand.  Luckily, it’s pretty easy to distinguish between those two, and the way you do that is you look at other markers that are included in a complete blood count, which he’s obviously had.  Usually when you test hemoglobin and red blood cells, that’s part of a panel called a complete blood count that measures some other markers.  So what you need to do is you look at MCV, mean corpuscular volume, and then MCH and MCHC, and if MCV is low, below the lab range, and hemoglobin and red blood cells are low, that’s usually indicative of iron deficiency anemia.  If MCV is high or high normal, then that’s a macrocytic anemia, and that’s indicative of B12, folate, or B6 deficiency.  So it’s fairly straightforward to do that, and of course, you can test your iron levels, doing an iron panel and ferritin to determine if you’re iron deficient.  And you can test your B12 levels using a standard serum B12 test and also urinary methylmalonic acid to see if you’re B12 deficient.  You can also test folate levels in the serum, but that’s a little less accurate.  The best way to test folate status is formiminoglutamic acid, which is one of the organic acids on the urine panel that I mentioned earlier.

So if your eyes have rolled back in your head and you’re just completely lost, don’t worry about it.  This is a complex topic.  I hope this was helpful for the questioner.  I would definitely get an iron panel and ferritin and then test for your B12, B6, and folate status.  Those are the most likely causes of ongoing anemia even after all of the kind of changes that you’ve made.  And if those are all normal, I would definitely seek out a practitioner who knows this stuff and can help you out.

Steve Wright:  That was a wealth of information that blew my mind.

Chris Kresser:  All right, we did it.  I think we made it through quite a few this time, huh?

Steve Wright:  Yeah, that was a good rapid-fire session right there.  OK, great.  Do you have anything to close with?

Chris Kresser:  No, just make sure to tune in next time for Dr. Fasano and then hopefully the time after that maybe — We’ll be AHS.  So we’ll either be taking a week off, one show off for a little summer break, or I’ve been talking with Jordan and Steve about the possibility of doing a kind of on-location, informal episode there if we can find the time and we can work it out technologically.

Steve Wright:  Yeah, we’re gonna do our best to see what we can come up with, and you definitely don’t want to miss the next show.  That’s for sure.

OK, great, so if you liked what you heard today, please head over to iTunes and leave us a review.  Leaving reviews really helps the popularity of the show, helps get the word out so other people can listen to it.  Please keep sending us your questions at ChrisKresser.com, and we’ll talk to you next time.

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Join the conversation

  1. I have aplastic anemia and do not want to use ATG from a horse or steroids or immune suppressant drugs. What can I do to get better? My MVC was 99 and ferritin high I also have MTHFR where Bs are a problem and I have hereditary hemochromatosis.
    I am almost 60 yrs old.

  2. After being ill for many years and chronic low CBC I hired a functional medicine doc and have been diagnosed with aplastic anemia megaloblastic anemia and have MTHFR mutations that are related to B absorption as well as hemochromatosis.

    She is not familiar with either of these but started me on a protocol but I would like to hear any input t.hat would be useful

  3. Take the bit out about food intolerances being just a symptom please, and not needing tests
    I did take a test and it was the best thing I ever did
    I had over 20 intolerances and had to cut them out for 3 months some a year..of course I found my other root causes, all 6 of them.. and all were treated, without that intolerance test I would of been up the creek…I will add I took two different tests to make sure they matched and they did

    • Which two tests from which labs did you take? would be interesting to know as my Dr has asked me to get this test done but Im worried ill be wasting my cash.

  4. Hey Chris, I have Graves disease and Thyroid Eye Disease. After reading your info on LDN as possible treatment I asked my Functional Medicine Dr to prescribe this for me. 4 months in, my TSH, T3, T4 and Trab readings are ALL back in normal range. I am now off Neomercazole which has been my Graves medication for the last few years. If N=1 – I am a success story for Graves treatment! ]

    PS – All of my practitioners – my GP, Opthalmologist, Endo and Functional Med doctor love it when I come in and tell them the latest thing I have found out from the Paleosphere. NONE of them prescribed this for me – only the Func Med Dr had even heard of LDN. None of them have ever prescribed me a diet and only again, the Func Med had heard of Paleo. It never ceases to amaze me how little general medical Drs know about new science.

  5. thanks for sharing all of your wonderful knowledge. You give hope to for those of us who are suffering. In your discussion about L-tyrosine and LDN for Graves disease did you mean L-Carnitine instead of L-tyrosine? I think I’ve read L-Carnitine helps with hyperthyroidism and l-tyrosine is for hypothyroidism. Please specify. thanks .

  6. Hi Chris! First, I can’t tell you what your research has done in helping troubleshoot my issues. You are a national treasure.

    I am preparing to take the Genova SIBO lactulose test. The instructions say to wait 2 weeks after taking any antibiotics, antifungals and antibacterials. However I’ve been on back-to-back rounds of Oil of Oregano and Macrobid for both sinus and urinary tract infections only until this week. My question to you is: would botanicals and herbals such as oil of oregano, raw garlic, olive leaf extract, GSE etc, be included in this list and affect the test results? It’s the height of flu season and I’m nervous to cut out my immune support for even another week to wait to take the test. Thanks!

  7. Hello, I’m trying to find out if taking LDN is necessary on a permanent or temporary basis for graves disease, ie, is it possible that it can be taken temporarily to turn off the inflammatory response, and then to wean yourself off LDN without the autoimmune response recurring? Or is the mechanism of action of LDN such that you have to keep taking it … forever…?

    Previously I have used ptu for approx 8 weeks, then weaned off it, and been fine, until after childbirth, twice. Now I am much more healthy, have a better diet etc etc, but I have the feeling the ptu may have to last longer than 8 weeks…. So, I’m looking at alternatives…

    Any help with understanding whether LDN has to be taken forever, or is just a temporary measure to reset your system, would be appreciated. Many thanks

  8. hi, i have been suffering with a diagnosis of ” severe IBS” for several years. i suffer with night fever and chills, inflamed upper torso, extreme nausea, gas, cramps, w hite coated tongue. bouts of diahroeah and constipation. i feel very dizzy most days. I recently had an ovarian cyst removed and my appendix. pains just gets worse. I feel like i have a virus of some sort in my gut. have had endoscopy’s, barium exrays, blood tests done…. do you think i have Epsein Barr virus, or SIBO, or leaky gut. who can i visit to help me establish what on earth is going on. I am majorly depressed and need help

  9. What a great source of information, I just got diagnosed with graves and my endocrinologist is already pushing 1 of the 2 options to get rid of my thyroid.
    I`m wondering what she says about your option of treating graves. I`m currently on methimazole, so I have a question related to that, would I be able to take LDN and methimazole at the same time until my thyroid levels normalize? I hope they eventually will. I don’t want to give up on my thyroid so easily.
    Thank you again for a great site.

  10. Hello Chris,
    Thanks for a great website.
    Thank you for letting us know about LDN as a treatment for Graves.

    What is the protocol with the taking of LDN, when pregnant or breast feeding?
    T & Cheers,

  11. Hi Chris, would you also recommend large quantities of goitrogenic vegetables (eg. brassicas – not soy because of its [other] problematic compounds) in hyperthyroid/Graves (i.e. as part of a treatment protocol that doesn’t entail thyroidectomy, etc.), or will that somehow just make symptoms worse if ever one tries to reduce one’s dose? Can’t find any definite recommendations on the internet.

    Pagan Cossack

  12. Thank you for so generously sharing your careful and in-depth research. You are truly helping many people attain much better health and get more out of life!

    Do you have any nutritional support recommendations for someone who has been diagnosed with MDS (myelodysplastic syndrome)? Platelets 20, red blood count as low as 4.5. Several drugs tried (including experimental), also megadoses of Vitamin K2 (45 mg MK-4 per day), with little or no effect.

    Thank you for any suggestions.

  13. thanks for the info on anemia, its really helpful. my situation does not seem to fit the high/lows you mention…rbc is high, hemoglobin is normal, mcv is low, mchc is low and rdw is high. ferritin is on the low end…

  14. Regarding baby foods, I gave my nearly 7 month old some raw guernsey cow’s milk (thinking I’d try the wapf raw milk formula with her soon). That night she had blood and mucus in her stool and the next day the poo was light green. I was shocked as since birth she is breastfed and hasn’t had any digestive issues (that I’m aware of). She’s certainly been more healthy than my previous children. Do you think she’s just not ready for it yet or is the reaction more indicative of an allergy?
    The reaction is surprising as I thought raw milk is meant to be easy to digest and the next closest thing to breast milk.

  15. I’m a bit late to the party here but I sure found this podcast useful. My health care practitioner things I may have chronic EBV and I’m pretty sure after getting food poisoning last year (fast food to be kept nameless and never visited again) I think I’ve experienced the wonderful effects of a fungal overgrowth (or I had it for a long time and after the poisoning it got everything out of whack. Felt crappy most of the year and tried paleo (although maybe too much protein) and other things as you mentioned.

    I just had one quick question however that I don’t remember seeing addressed here. If you have sibo, or a fungal infection I’ve read in various places that you shouldn’t eat fermented foods, I have tried and like Bubbies Kraut and Kombucha but am I doing more harm than good with these?

    Thank you Chris for all you do as it is making a huge difference for people.

    Stay well and prosper!


    • I realize this was years ago, but in my experience, if you have sibo and you can eat a thing, eat it.

  16. Regarding the Metabolic Solutions lactulose breath test, Metabolic Solutions sells only to licensed healthcare pracititioners :-(.