In this episode we discuss:
- Treating autoimmunity in two steps
- Foods that prove difficult to reintroduce
- Dietary changes alone are often not enough
- Regulating and balancing the immune system
- Reintroducing foods successfully
- How do we define health?
- The ability to live your dreams
- The downsides of lengthy dietary restriction
Chris Kresser: Hey, everybody welcome to another episode of Revolution Health Radio. This week, we have a question from Mikaela, so let’s give it a listen.
Mikaela: Hi, Chris. This is Mikaela. I have a question for you about the autoimmune protocol. Well, and actually, really, in the elimination diet. I have been following the autoimmune protocol for Crohn’s disease to control my symptoms since 2012. And I have had success, but I’m not 100 percent better. And I’ve had very limited success in reintroducing foods. So my question is, when you’re following an elimination diet, if you are unable to reintroduce foods, does that mean that you’re not healing? Or do you think that some foods are just off the table for good? I’d love to be able to sit down and have some salsa or maybe scrambled eggs. And I’m wondering if that’s just something I’m going to have to live without. Thanks for an awesome podcast and looking forward to hearing your response.
Chris: Thanks so much for sending in your question, Mikaela. It’s a great one. We receive some kind of variant of this question pretty regularly, and in some ways it’s the million dollar question because there are so many people out there who are doing elimination diets like autoimmune Paleo (AIP) or low FODMAP or even just a 30-Day Paleo reset or a Whole30, and they are wondering the same thing, “Will I have to be on this diet forever?” or “Will some healing take place that allows me to recover my function and be able to eat some of these foods that I’ve taken out of my diet?”
Now of course, if you’re removing things like Twinkies, Cheez Doodles and Super Big Gulps, unfortunately, you’re never going to (at least that’s as far as we know) acquire any magical properties that will enable you to better tolerate those foods because they’re just nutrient poor and calorie-dense, and we have really no business eating them in the first place. But certainly there are other foods that are healthy otherwise, and they’re well tolerated that are removed from things like the autoimmune Paleo protocol—nightshades, eggs, nuts, and even full-fat or fermented dairy. I would argue they’re perfectly healthy. A lot of research supports their benefits but may not work for some people because of certain conditions. I am generally a believer that our diet should be as broad and diverse within that Paleo template—or “Paleo-plus” kind of template that might include some full-fat and fermented dairy and even properly prepared legumes and some grains or pseudo-grains if they’re tolerated in moderation—because the broader and more diverse we can make our diets, the greater the nutrient density and the wider variety of nutrients it will get. I’m always by default an advocate for eating the broadest diet that we can tolerate, but there are obviously conditions in which we may have to restrict our diet, in some cases pretty significantly, at least to begin with, while we’re in the healing process.
Two steps to healing that can help you eat your favorite foods again
As is often the case with these types of questions, the answer is, “it depends.” I don’t think there really is a single answer to Mikaela’s question, but I can share my experience working with thousands of patients at this point. And what I would say is that diet is an absolutely crucial factor and sometimes the most significant factor in the healing process, but it’s certainly not a panacea. Sometimes dietary changes will be enough on their own to get somebody back to where they want to be, but often additional steps are necessary above and beyond diet.
Treating Autoimmunity in Two Steps
Since Mikaela’s talking about Crohn’s disease, that’s an inflammatory bowel disease, which is autoimmune in nature, let’s discuss an overall functional approach to autoimmunity as it relates to Mikaela’s question.
For me at least, this consists roughly of two steps. Step one would be removing triggers that provoke or exacerbate a dysregulated immune response, and then step two would be taking specific actions to regulate the immune system if removing the triggers wasn’t sufficient to bring it back into line. The AIP falls into the first category of removing triggers, and more specifically it would fall into the category of removing dietary triggers. If for a particular patient the primary trigger for them was dietary in origin, things that they were eating that were provoking an inflammatory response and really wreaking havoc on the immune system, then removing that trigger for that person could settle their inflammation and lead to long-lasting healing. That healing could itself lead to being able to tolerate that same dietary trigger, those same dietary triggers that originally caused the problem.
If you think of it like—let’s think of an analogy here. If you have an injury, for example, or let’s say you were playing soccer and you got injured. While you’re injured, playing soccer is probably going to be painful and difficult and possibly even make the injury worse, but there’s no reason that once you heal the injury, you can’t go back to playing soccer. That’s kind of a similar idea here. If food triggers originally provoked a response, in some cases but not all—I’ll come back to that—removing the trigger may allow the body to heal sufficiently such that you can actually even return to eating that food trigger that initially caused the problem without any difficulty.
Foods That Prove Difficult to Reintroduce
However, there are a lot of exceptions and caveats to what I just said. Probably the biggest one is gluten. In many cases, no matter how much healing happens, a patient who is significantly gluten intolerant will never recover the ability to eat gluten without problems. There are always exceptions to the rule and I’ve actually seen that happen in some cases, but at least in my experience, it is the exception and not the rule.
There are also some other dietary antigens like eggs and dairy that seem to have more of a persistent effect over time even after gut healing takes place, less so in kids. I think kids can tend to outgrow these things and move on from them more so than adults. But with adults I don’t see as many people fully recovering their ability to tolerate eggs and dairy if they haven’t been able to tolerate them at all, although there are some shades of gray there. For example, if somebody is lactose intolerant rather than intolerant to the proteins and dairy, there are some studies that suggest that consuming fermented dairy can actually restore lactose tolerance, and I’ve seen that with some patients. I’m qualifying everything I say, which can be irritating, but that’s really how it is in clinical practice and working with patients. Everybody is different and everybody responds in a different way, and so it’s really hard to make general statements about this stuff without providing those qualifications.
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Dietary Changes Alone Are Often Not Enough
Okay, so let’s get back to this framework we’re looking at here where we’re talking about step one of removing triggers, and we’re talking about dietary triggers, and that in some cases, removing these dietary triggers can be enough to heal and even lead to being able to eat some of those same foods that were removed in order to heal in the first place. That may happen in some cases, but in many cases I found that diet, although it’s really important, isn’t enough on its own to resolve a problem. We have to start looking at other things that could trigger and exacerbate an immune response, and these include:
- Gut issues like SIBO, dysbiosis, intestinal permeability, disruptive gut microbiome
- Stress, which I think is absolutely huge with autoimmune disease. I think it’s the elephant in the room that’s often not addressed despite the fact that there are many, many studies showing that stress is a common trigger across every single autoimmune disease that we know about, and I’ve just seen that be such a huge factor in all of my patients with autoimmune disease.
- Sleep and physical activity—not enough or too much
- Lack of social support
- I think another really key factor in autoimmune disease, the role of environmental toxins like heavy metals, mold, etc., infections like latent viral infections or tick-borne illnesses like Lyme or Babesia, Bartonella, intracellular infections
- Methylation issues, mitochondrial issues, etc.
All of these things can trigger or exacerbate immune dysfunction, and some of these things can be explored and regulated without any testing, such as the sleep and stress management, physical activity, social support, but others will require some testing, particularly the gut issues, screening for environmental toxins and infections, methylation and mitochondrial issues.
This, as you can gather, there’s quite a bit of work that goes into this, and in some cases it will probably need to be done with someone, a functional medicine specialist who knows how to do this kind of testing, and it can take months or even longer. This is why our conventional medical model, which is really geared towards single patient, single disease, single treatment and you’re done, it doesn’t really work that well in this world of complex chronic illness that we live in.
This exploration will often take some time and often requires some testing, and in some cases, if you just remove all of the triggers and you address all these things that can exacerbate immune dysfunction, that will be enough to restore normal immune function.
Regulating and Balancing the Immune System
But in other cases, you have to go onto step two, which is taking specific actions to regulate and balance the immune system. This includes relatively simple things like optimizing vitamin D levels, optimizing glutathione status, optimizing short-chain fatty acid production, particularly butyrate, which has an immunoregulatory anti-inflammatory role, considering more advanced nutritional interventions like therapeutic fasting, which has been shown to have an immunoregulatory effect, and some really interesting recent studies by Dr. Walter Longo out of USC, using botanicals or nutraceuticals that play an immunoregulatory role, and even low doses of medication like low-dose naltrexone, which I have spoken about before for immune tolerance and regulation. These things can play a really vital role in helping to get the immune system back into that range of tolerance from where it’s easier to maintain itself in that range.
Reintroducing Foods Successfully
What I can tell you is that when a more comprehensive two-step approach is used like that, removing the triggers and then taking specific actions to regulate the immune system, many people are eventually able to reintroduce foods successfully in their diet. But that said, some sensitivities in some foods often persist. Let’s take someone who is on AIP, and they have to be very strict, the most typical response that I see is after a comprehensive functional medicine protocol where we explore all of these triggers and we do things to regulate the immune system, maybe they’re able to start eating some dairy products and nightshades, but eggs just continue to be off the table, or maybe they’re able to tolerate eggs and nightshades but they just never recover their ability to eat dairy. Or let’s take someone who’s been on a low-fat diet to prevent recurrence of SIBO. Once we address the SIBO and then perhaps we find that they’ve got an underlying mercury toxicity that is probably was causing their SIBO to recur over and over again and we address the mercury toxicity and their SIBO kind of resolves once and for all, that person might typically be able to start eating FODMAPs in fruits. Maybe they’re fine with the higher fructose. Maybe they’re fine with sugar alcohols. Maybe they’re fine with most classes of FODMAPs, but they just never really recover an ability to eat a lot of onions and garlic, particularly raw onions, and those just still trigger them despite feeling better in every other way and having addressed all of the issues that have been identified. That’s just the lingering effect for that person. That is probably the most typical response.
How Do We Define Health?
If we take a step back and think about this a little bit further, it leads us to interesting questions, which are: What is the goal of treatment? What is health? What are we actually hoping to achieve?
In some cases, I see patients who quite understandably have a memory of what it was like to feel really really good, the last time they felt just perfect and had no complaints, and maybe this was in their early 20s or something like that and they really have it in their minds that they want to get back to that particular feeling and now they’re 35 or 40. The reality is, in many cases, it may not be possible to return to that exact feeling that somebody had 15 years ago or 20 years ago, the last time they remember feeling perfectly well because the body changes over time and there are some changes that we have considerable control over, and there are some changes that we have less control over, particularly if there was an infection or an accident or something that had a profound impact on the body. We know that many autoimmune diseases are triggered by viral infections or other infections, for example, and once that process of autoimmunity gets going, it can be managed very effectively without drugs, with diet and changes and this whole process that we’re talking about.
But in many, if not most, cases, that doesn’t mean that the condition will be completely cured. That person may always produce some antibodies to whatever tissue they started producing them to, and if we remove the triggers and take specific steps to regulate the immune system, that person may be able to live symptom free or mostly symptom free, but they may never return to that feeling that they had prior to the infection and the autoimmune disease. They may never be able to eat some of the foods that they were able to eat prior to that infection or autoimmune disease, and they may reach a new level, a new place of balance in equilibrium and homeostasis that’s possible, given circumstances and the state of their body at that particular point in time rather than going back to some idea of our memory of the way things were 15 or 20 years ago.
For me, this is a really interesting question. I’ve written about it before and talked about it before. What is health really? How do we define it? Do we define it as the absence of symptoms? That can be problematic as a definition, of course, because it’s the absence of symptoms when and in what circumstances. Is there an absence of symptoms when we eat whatever we want? Or does it mean an absence of symptoms when we eat a specific diet? Or does it mean an absence of symptoms when we mostly follow a specific diet but sometimes go off the reservation a little bit somewhere in between? It gets tricky if you use the absence of symptoms as a definition.
The Ability to Live Your Dreams
I have long argued for a more inclusive definition of health that comes from Moshe Feldenkrais, who is the creator of the Feldenkrais Method that you might be familiar with. It’s a pretty amazing method of reprogramming the nervous system, body-based intervention, and his definition of health is the ability to live your dreams. I find that to be at the very least provocative and a great topic for discussion because it doesn’t refer to anything at all in terms of symptoms, energy levels, pain or anything like that, a lot of the things that most people would use to define health. It simply refers to the ability to live your dreams.
When you think about it that way, someone that has perfect physical health, if that exists, it’s hard to even quantify what that would be, but if we think about it as a spectrum where on the left is perfect and on the right is death, maybe they’re closer to the perfect health side. But let’s say that person is miserable, they have terrible relationships, they are in a working a job that they hate and they’re just really unhappy in their life. Is that person healthy? Versus perhaps somebody who has an autoimmune disease maybe they have Hashimoto’s or rheumatoid arthritis and maybe they are on a fairly restricted diet, but they take really good care of themselves. They have really positive relationships. They are doing work that’s meaningful to them. Perhaps they’re helping other people with a similar condition to recover. They wake up feeling excited and happy to face the day, and sure, maybe there are times during the day where they don’t feel like they have quite as much energy as they would like to have, or they have some pain that flares up occasionally, especially if they’re exposed to foods they don’t typically eat, but overall they’re living a meaningful, rewarding, and fulfilling life. Who is healthy? Is that first person with that perfect physical health but everything else falling apart healthy? Or is that second person who has some physical challenges but still really living their dreams healthy?
I think you know what my answer would be, but I encourage you to think of your own answer because the answer to the question “What is health?” really provides an important context and framework through which we interpret our experience. I think that is really important and something that’s often overlooked for anybody that’s dealing with chronic illness. How we hold ourselves in that place when we have chronic illness, whether we see ourselves as somebody that is fundamentally healthy but dealing with some physical challenges or whether we see ourselves as someone that is broken, sick, ill, and it is a person that has a chronic disease can really make all the difference in the world in terms of how we relate to ourselves and the world around us. I think it’s a very, very important thing to consider and look at for anybody that’s dealing with ongoing symptoms.
Okay, so in summary here, I think elimination diets are often an important part of the treatment, but they’re often not the only important thing to look at. In my practice with patients, we go beyond and look at that two-step framework of removing triggers that provoke or exacerbate immune response and then taking specific steps to regulate the immune system if necessary after that.
The Downsides of Lengthy Dietary Restriction
The other thing I want to mention before we finish is that I am definitely wary of too much dietary restriction for too long, and there are a few reasons for that. One big one concerns about nutrient deficiency. As I mentioned in the beginning of the show, I advocate eating the broadest diet within the Paleo type of template as possible because that will expose us to the widest range of nutrients and that’s very important, of course, for health.
But there are also other issues that can happen with diet that’s really super-restricted, like social isolation, not having enough fun or play, not being able to go out and enjoy dinner or meals with friends. And as I mentioned earlier, that kind of stress and social isolation, I think, is a major factor in autoimmune disease and also just with chronic disease in general. I have many, many stories of patients with whom I have gone through the entire process, the functional medicine process, doing all the labs, doing the diet restriction, identifying and addressing triggers, regulating immune system. And ultimately, the thing that made the biggest difference for those patients was not any of what I just described but actually turning their attention to their social environment, actually loosening some of the restriction on their diet, making sure they’re spending more time with friends and getting support that they need, making sure they have more fun and pleasure in their lives, getting a regular massage, taking a hot bath walking on the beach, spending time in nature, developing some deeper friendships of people where they can share what’s going on in their life.
A lot of times these things can seem less tangible. They can seem less important. We all kind of pay lip service and tend to think that more tangible things like taking supplements or medications or making dietary changes will have a bigger impact. But the reality is, when you look at the research, a lot of these less tangible things actually can have a greater impact on quality of life and even symptoms in people who are dealing with autoimmune disease, and I have definitely found that to be true in my work with patients, and this is a growing focus.
I hope that was helpful, Mikaela, lots of information there. I hope you can make sense of that and it helps you and others who are listening in some way, and please do keep sending in your questions to chriskresser.com/podcastquestion. Even though I’m not able to answer all of them, they help me understand what you’re thinking and what you want to know about and they inform my ideas for blog posts in addition to podcasts and other content that we’re developing, so please do keep sending in your questions. Enjoy your weekend and I’ll talk to you soon. Take care.
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