Gut Health, Hormones, Anemia and Autoimmune Disease: Finding a Root Cause

Adapted from episode 46 of The Perfect Stool podcast with Dr. Ian Hollaman and edited for readability.

Lindsey: 

So why don’t you tell me a little bit about your journey to wellness?

Dr. Ian:

Well, of course. Wellness is a moving target for sure, especially with all the challenges that we face on a day-to-day basis. But what got me started was back in grad school when I was going through what we would call a hell quarter. That just basically meant we had a lot of tests, a lot of pressure on us academically at the time. And unfortunately, I was also breaking up with my girlfriend of four years. So what happened is everything fell apart, and I started to have a lot of brain fog, and just really felt like I was floating. I started developing some neurologic symptoms as well, and then on top of that, lack of focus and concentration, some insomnia, and then some chronic fatigue. I got really concerned about that, because it really dramatically impacted my performance as a grad student. I was your typical type A student, in front of the class, asking all the annoying questions. And then then I kind of went to the back of the class because I was embarrassed about what was going on with my body and I wasn’t understanding what was going on. I actually started to do really poorly.

I started going from practitioner to practitioner. This is probably super familiar to a lot of your readers. What happened was people would say, well, you know, you need this or you need that. I was being fit into people’s boxes, rather than when I met with the ninth practitioner who said, hey, let’s take a look at your diet, let’s look at your lifestyle, let’s look at your nutrient status, let’s actually do some blood chemistry on you. The amazing thing was he really dialed me back into where I was feeling optimal wellness within about three-four months. I didn’t realize it, but at the time, that was probably one of the most important events in my life, because I realized that was the kind of doctor that I wanted to be. I just didn’t understand that that’s not how doctors are taught. I started to realize that we’re taught to learn clusters of symptoms, and that equals a diagnosis. And then you treat the diagnosis, and you’re not actually treating the person. So that launched me into the functional medicine world of trying to understand the root cause and it’s really ignored so much. We’re told if you have anxiety, you need to take an anxiety pill, if you have leaky gut, you need to take a leaky gut formula. We’re not actually asking the question of why. And I think I annoy my clients sometimes because I ask that question to them. And many times they know the answer, but you just have to give them enough opportunity to self-reflect on what’s actually going on in their life.

Lindsey: 

I’ve heard very similar stories from many of my clients who have seen many practitioners. I think I was lucky because I had my autoimmune stuff diagnosed before it really impacted me. I have Hashimoto’s. I had an enlarged thyroid, and the doctor caught that. So I went for an ultrasound, and then they saw the damage from the Hashimoto’s on the thyroid. And this was well before my TSH was even far from optimal levels.

Dr. Ian:

Right, so you’re in that thyroiditis experience and not quite the hypothyroid. I mean, how many millions of people are actually out there dealing with that issue? And of course, many times doctors aren’t listening or they’re not doing a physical exam, or maybe your thyroid isn’t enlarged, right? The crazy thing is, the American endocrine society specifically says TSH should be between 1 and 2.5. Then if you have a four and your doctor is saying, you’re within the normal range, I guess you’re okay. Then you wonder if they’re comparing you to all these other sick people or through standard chemistry analysis? Or are you actually looking through the lens of optimal chemistry?

Lindsey: 

So tell me about what autoimmunity has to do with gut health.

Dr. Ian:

Oh, nothing. No, I’m just kidding. It has everything to do with gut health. So Alessio Fasano is the dude who figured out the mechanism behind celiac disease. If you aren’t aware, celiac disease is this condition where when you’re consuming gluten, your gut becomes permeable or leaky. Then you actually get confused on what is your self, versus what is non-self, so you actually start going after and targeting your own tissue. Alessio Fasano is kind of now considered the godfather of celiac disease and he’s the one who discovered the mechanism behind what it takes to have an autoimmune disorder. There’s three things that go into this. So there’s a genetic component, and I have celiac. So there’s this HLA-DQ2 and 8 gene, and yes, you can test them. But you need a genetic predisposition. There are environmental issues as well, and so for example, being exposed to pesticides, being exposed to glyphosate, like Roundup. And then there are these triggers, which can be traumatic events in your life, auto accidents, after you gave birth, a divorce or something like that. You put all these three things together, and it turns on your genes, which is actually all occurring in the gut, where you start to create this leaky gut, or intestinal hyperpermeability. And that’s why so many of us as healthcare practitioners try to understand people’s symptoms, but we’re going to look at the system and the gut is where 70- 80% of the immune system is. That’s why we make that connection there, and why we want to look to that as the root cause.

Lindsey: 

So when you have somebody who has an autoimmune disease, and they have no gut symptoms at all, will you still test their gut?

Dr. Ian:

100%. About 60% of my clients don’t have gut symptoms, and you do not have to have IBS, you do not have to have colitis or Crohn’s, you do not have to have a single gut symptom. One is because your body may actually be accommodated to those symptoms. But the fascinating thing is that there are over 100 different autoimmune conditions, and over 26 cancers that are associated with autoimmunity. I’m just quoting the experts, and Dr. Fasano specifically says that to have an autoimmune disorder, you have to have leaky gut, because our ability to express, modulate and quench inflammation goes to the gut. So even if you have zero gut symptoms, I’m still going to look at your gut and try to understand if there is a way that we can leverage that piece to actually help your health.

Lindsey: 

Okay, so now thinking about what Dr. Fasano revealed as the action of zonulin in opening up the intestines and making them leaky, in particular in celiac, whereas I guess a normal person might have an opening that that is very brief from zonulin, someone with celiac has a very long one.

Where gluten sensitivity fits in with that I’m not sure. Can you help me with that?

Dr. Ian:

Yeah, absolutely. So if you look at what is commercially available, you can do panels that will look at about six markers for celiac disease. There’s actually another 18 that I can commercially get right now for gluten sensitivity. These are different and separate conditions that manifest in different ways. And why this is so important is that gluten sensitivity can trigger the leaky gut process. You don’t have to have celiac disease to have a leaky gut. You actually may not have the genes for celiac disease. So you can actually do a blood test and check these antibodies and see if you’re reacting to gluten. You can have three reactions to gluten. You can have a typical allergy, which is how we think about peanut allergies, where you’re getting an immediate response, we call it an IgE reaction. You can have celiac disease, and that’s the autoimmune process where gut tissue is broken down because you’ve been exposed to gluten. And again, there’s the genes and other triggers there. Then, you can actually also have gluten sensitivity. Why that’s so important is that it is an underlying facet behind so many chronic disorders. It’s very, very commonly not tested. So when you go to your doctor and ask about celiac and they test for it and it’s negative, it’s because maybe they ran one or two antibodies for celiac, not the full six. And that’s usually tissue transglutaminase antibodies, but if it’s negative, they’ll say it’s okay to eat wheat. And that might be 100% absolutely not the truth. If you leave that other part out and you get exposed to gluten, you can have inflammation for months with just one exposure. So it really is a game changer for people and it’s why so many clients or just people that you know will cut out gluten and have it change their lives.

Lindsey: 

And so are you talking about the Cyrex arrays?

Dr. Ian:

I’m using Vibrant Labs, I used to use Cyrex. They’re both really good companies, and it kind of just came down to price. I tend to use Vibrant more often. I believe they’re a spin off of Cyrex. They’re both very good companies. I love them both. Cyrex is headed by Aristo Vojdani, who’s one of the most preeminent immunologists in the world. The panel that I probably do the most with him is something called a gluten cross-reactivity panel. It’s number three if you go on to their website, and it tests, I believe, 24 or 26, different foods that cross-react to gluten, meaning, if you eat that food, your immune system may be mistaking it as gluten. And then your body’s freaking out, because you ate dairy, tomatoes, corn or rice. There’s just enough of an overlap between the amino acids in those structures where your immune system flares up and is saying you ate gluten, when you actually ate a gluten free grain, but you still have a reaction to it.

Lindsey: 

So Vibrant Labs, what’s the test that you run then for celiac and gluten sensitivity?

Dr. Ian:

Yeah. It’s their gluten sensitivity and celiac disease panel is what they call it. It’s a comprehensive test to 24 different antibodies.

Lindsey: 

So I find that there’s often budget constraints. And, this is one of those things where an elimination diet usually does the trick to tell you whether that’s a factor. So I’m curious how you think these compare?

Dr. Ian:

Yeah, so you can test and treat or treat and test. A lot of my mentors said, hey, you’re going to run into these situations where people don’t have thousands of dollars to spend, and sometimes you don’t really need to, so you can absolutely do it in different ways. The only caution I give to people is if you really do have celiac disease or autoimmunity, and you’re going to go back and rechallenge gluten, just be aware that the inflammatory cycle kicks back up and can induce other autoimmune conditions and can really put you backwards. So I love elimination diets, we do them all the time, but I also ask what’s the end result? What kind of condition are we working with? If you’re working with a colitis patient, and they’re going to lose gut tissue, or an MS patient, and they’re going to lose eye tissue because they’re back on gluten, I would rather you spend a couple hundred bucks and have you be 100% compliant, than have you take the risk of actually losing tissue as a result of the autoimmune disease kicking back up. That’s just me. People get to make their own choices, of course, and we want them to. We want people to own their health. But I just say, what do you guys want to do? Would you like to test for it? Or would you like to just make sure that you’re going to be 100% compliant, and be able to get yourself off of that? And see if we can actually see an improvement?

Lindsey: 

Yeah. And are they coming to you still eating gluten? Because I find everybody by the time they find me, eats like meat, vegetables and fat.

Dr. Ian:

I get a smattering of people, you know, it’s pretty diverse practice. I do get the super complex and chronic and people that have been to all these different pratitioners. And then just two weeks ago, I was working with this colitis patient, and I was like, have you ever done a gluten free diet? And she’s like, well, I kind of tried it for a month. And I’m like, okay, so not really.

Lindsey: 

To run these tests, they have to be eating gluten, right?

Dr. Ian:

Typically for testing celiac disease, they have to eat roughly about a piece of toast for about 30 days, and then test. But again, do you really want to, especially if you’ve already gone gluten-free? Do you really want to go back and tempt the devil here, is that worth it? The other thing that I would also stress to the readers is that many times people switch to a gluten-free diet and bring on these other products, which are refined and processed. And they’re like, I feel worse with these gluten free products, because they’re feeding simple sugar to bacteria, which then grow and produce toxins, chemicals and byproducts, and all of the sudden, your inflammation levels go back up and you get brain fog, joint pain, aches and fatigue again. It’s nice to be able to have some of those things once in a while. But the question is, what kind of flexibility does your body have for that?

Lindsey: 

Yeah. So I wonder whether the origin of leaky gut may be different for each individual, but whether its origin is in SIBOs and the SIFOs, the fungal overgrowths, or if it’s in the food sensitivities? For example, in my case, I went off gluten and dairy and then also went through protocols to clean up SIBO and SIFO. And now, my Hashimoto’s antibodies are down to normal. I think perhaps the SIBO and the SIFO, from so many rounds of antibiotics, were what caused that sensitivity to gluten and dairy. But now if I take some enzymes, and I eat those foods, I don’t see any big reactions. So I kind of wonder which came first?

Dr. Ian:

Well, again, chicken and egg, right? And I think it’s potentially both, but I think for probably a lot of the patients that I’ve seen, a common trigger is antibiotic use, and people don’t realize how much of an asset and how valuable the diversity of our gut microbiome is. When I say diversity, I mean the amounts of species that are essentially taming these inflammatory chemicals and processes, so that we can also absorb really efficiently. When you knock all that out, the fungus, he’s thrown his party hat on, because now he has less competition and can continue to grow. And they’re actually the ones that now have predominant control in the gut. When we expose ourselves to standard American diet foods on a regular basis, we are eroding our immune system, and then eventually, at some point, you trigger the leaky gut process. What’s crazy is a head trauma has been shown to actually significantly cause intestinal permeability within an hour after a traumatic brain injury. So that’s something that’s not really appreciated.

Lindsey: 

I actually had a speaker on electrogastograms (Dr. Corey Deacon, episode 20).

Dr. Ian:

Uh huh. That’s a fascinating issue. A lot of times people develop leaky gut after concussions. They get hormonal disturbances, and this whole vicious circle basically starts at that point. But for so many people out there, they just get used to it, or even their doctors are telling them, oh, it’s just arthritis, right? Or it’s just normal to be 50 and postmenopausal and have an absolutely miserable life. And I don’t know if I actually believe that because I have lots of my clients who are 100% thriving after they get their food sensitivities handled, after they get the bacteria handled, after they are actually getting their immune system rehabilitated. And that’s really important. And I do want to say this, before I forget, that one of the most important things I learned in my master’s program, from a man named Dr. Alex Vasquez. He basically said, what you’re going to find is even if you deal with these triggers, people are still going to have a wound up immune system. You know, even when you find the gluten, you find the dairy and you remove the bacteria and the fungus, people are still going to have an immune system that’s now conditioned to give the same response. That’s when you really need to employ some therapies to stimulate specific subsets of cells called T regulatory cells. If you can do that really efficiently, and you get the diet, exercise and stress and all these other things, but if people are still having issues, that’s when I really start to think something kind of got broken there. And then we want to use some therapies and strategies to stimulate those cells in the right direction again.

Lindsey: 

How do you do that?

Dr. Ian:

So there are different nutrients out there, and that’s one of the ways to do it. I can give you six, maybe seven different things that I use. One is fibers. There are different kinds of fibers out there that can do this, one of them being prebiotic based fibers: inulin, XOS (xylooligosaccharides), there is a product that’s called Sun Fiber, which is a modified guar gum. Sometimes guar gum gives people issues, but this is actually a modified guar gum, and it does not seem to cause the same gas and bloating issues as other fibers do. But vegetables do this too, right? So, do we need to take that a step higher? Beyond that, vitamin A, D and K, as far as nutrients, alpha lipoic acid, green tea, or green tea extracts, and you can do it as a decaf version. And the other one is actually probiotics, and what they’re doing is stimulating certain chemicals. The chemical that I’m most interested in is called interleukin 10. And there’s different kinds of probiotic strains that can stimulate interleukin 10 to then actually stimulate those T regulatory cells. For example, we want your vitamin D level to be about a 50, with a normal range being anywhere from 40 to 60. A lot of research is pointing to 50 being the optimal chemistry. You can ramp a lot of those nutrients up for short windows of time. Then, you can come back and check those thyroid peroxidase antibodies, check the thyroglobulin antibodies, check the anti-endomysial antibodies or the zonulin and see if you’re actually now able to quench that inflammation, get your immune system regulated.

Lindsey: 

Now, is there any measure of inflammation other than looking at the specific markers for any given immune disease? Like CRP (C Reactive Protein)?

Dr. Ian:

Yes, there are for sure. There are different kinds of CRP. There’s more of a nonspecific kind, then there’s more of a very specific, or cardiac kind, and high sensitivity is always the one that we want to choose. That’s going to be the most common commercially available inflammatory marker. There are other ones out there something called ESR, which is not really in vogue anymore. It’s not used as often. I mean, there’s a condition called polymyalgia rheumatica. And ESR is appropriate for that. There are what we call cytokine panels. And these are a little bit more advanced but quite frankly, they don’t dramatically change the recommendations I give for care. So again, going back to the budgetary concern, it’s deciding between test and treat or treat and test. And if I know that in general, people should be on a good nutrient dense diet, taking the crap out of their diet, they might need to do nutraceuticals for a short period of time, maybe they need a stool test, and maybe that’s going to change the recommendations. That’s usually what I’m going to focus on. For inflammatory bowel diseases, I will actually add a marker called calprotectin, which is very, very sensitive as it relates to the differential diagnosis, or the decision between inflammatory bowel disease or irritable bowel syndrome. So if your calprotectin is really high, we know you have a much higher chance of having colitis or Crohn’s, which is a much more serious condition than something like IBS. You can check zonulin, and  you can check antibodies to zonulin. And that is a great way to tell us if you actually have leaky gut. And like I was saying, I’m not a rep for Vibrant, I take no kickbacks from them. Again, it’s the cheapest lab that I can find that actually gives really good data on that gluten sensitivity and celiac disease panel, and they run anti-zonulin antibodies. So if you have a high anti-zonulin antibody, you know you have leaky gut. If you really want to, you can go back and retest it and verify that those markers have decreased, and it’s probably going to correlate with you getting better anyways. So most the time, I don’t rerun it. But if I’m managing an autoimmune condition, and I’m helping people to know if it’s really under control, I do like to repeat the standard anti-thyroid peroxidase antibodies in the case of Hashimoto’s. I would repeat that maybe every three to four months, because there needs to be enough time to actually allow your immune system to calm down.

Lindsey: 

And so if somebody is testing the zonulin antibodies, and they ate something like gluten ahead of time, I imagine that would cause it to be elevated. Do you tell them to be careful about what they’re eating prior to the test?

Dr. Ian:

Hopefully, the idea here is that they’ve been behaving. And of course, we can all get exposure, we can all get cross contamination. I mean, I’ve had plenty of times when I’ve had people just so upset because on a stool test, they’ve got a gliadin antibody. And they ask, “How the heck did that happen?” You know, it’s shared equipment, or they traveled or something came up. It’s usually not that someone said, you know, well, screw it. I’m just going to go eat pizza. That happens too, sometimes, right? But what we want to do is test normal conditions. It’s this therapeutic trial we’ve been doing. Let’s see if this is actually working for us.

Lindsey: 

So in other words, they’re normally off gluten, they take the test. And you will see over time, that in theory that would go down.

Dr. Ian:

Well, yes and no. So in the case of celiac disease, we know that 60% of celiacs on a gluten-free diet have absolutely no improvement in their intestinal microvilli. They studied a group of celiacs and they had them on a super strict 100% gluten-free diet. One year later they came back and did another biopsy on their gut, and they found specifically that they did not have any significant healing to the brush border. And so why that’s so important is it goes back to what you’re saying, did they actually have other food sensitivities, did they have another autoimmune disorder, did that celiac turn into colitis? Was there a high burden of chemicals that we weren’t aware of, were they under a massive amount of stress, and they were secreting cortisol, which was degrading all their healthy bacteria in their body. These are the mechanisms we have to look at because this is why we’re seeing a higher rate of mortality with people with autoimmune disorders. It’s the same reason my grandfather got Parkinson’s after he was diagnosed with celiac. And I am convinced at this point, because everyone that I work with so far, in my practice, who I’ve tested for autoimmunity with Parkinson’s, they have autoimmunity. And so if I could have tested his blood, I can almost guarantee you he would have been autoimmune. He was so strict on his gluten-free diet. My grandmother was so good on that, bless her heart. But he had an inflammatory issue that was never really fully controlled, even after he actually removed gluten from the diet. And that’s what’s so frustrating, because Western medicine is, on average, 15 to 20 years behind published research. And, there’s no drugs to treat leaky gut. I mean, that’s the sad reality right? They haven’t developed anything. Then you get this issue where there’s no incentives for them to train people to actually help heal people.

Lindsey: 

Yeah. When you’re thinking about your grandfather, are you thinking there were maybe other food sensitivities, or there were gut infections that went untreated?

Dr. Ian:

Well, really a couple things. My guess was because of the Parkinson’s, and one of the other key pieces of that is environmental chemical exposures. He was a world war two veteran, he was in the Battle of the Bulge, and he was exposed absolutely to persistent organic pollutants on a very high level. And no one said, hey, you might want to do some detoxification of those chemicals. They’re associated with cancer, they’re associated with autoimmune disease, they’re associated with increased mortality. It’s like that diagnosis just kind of lands on them. And then all sudden, he started having this tremor. And it’s like, oh, you have Parkinson’s, we want to give you a dopamine medication now, because that’s going to help you with the symptoms, rather than looking at why did it happen in the first place?

Lindsey: 

I wanted to talk a little bit about anemia with you, because we talked a little bit about that beforehand. So I was first diagnosed with your basic iron deficiency anemia around age 16. And there seem to be a lot of different types of anemia. So there’s iron deficiency, B12 anemia. And then I know there’s megaloblastic and pernicious anemia. So first, let’s just go over what is anemia, and whether there are some autoimmune routes to anemia?

Dr. Ian:

Sure. So one thing that’s really important to kind of stop and think about is that there are certain things when they’re present. I call them deal breakers. And for me, there’s three things that are deal breakers. One of them is anemia. Another one is blood sugar handling issues. And the third one would be gut infections, or really any infection to the mucosal surface. Those three are probably the most common things I see in my practice that really, really dysregulate the immune system. So anemia, by definition, means the inability of the body to produce and actually distribute oxygen to tissues. What we most commonly think about is iron deficiency anemia. And that’s what we call a microcytic anemia, meaning that the red blood cell actually starts to become smaller. Now, there’s also macrocytic, and that’s when the red blood cell starts to become larger. There’s some other kinds of anemia out there, there’s something called anemia of chronic disease. There are things like sickle cell, which is more of a genetic-based or a familial base anemia. We have different categories and classifications, but anemia in general is going to mean that you cannot deliver oxygen to the tissues. That means that the tissue is going to essentially start to starve and die off and at the same time, it also means you can’t bring nutrients to those tissues because blood flow is going to be compromised. Lack of iron is what is most commonly thought to be the root cause of microcytic anemia, and as a result of menstruation and heavy menstruation. I actually don’t agree with that.

Lindsey: 

I was going to say, I never had heavy menstruation, so that always rang kind of false to me.

Dr. Ian:

Yeah, actually the most common form of microcytic anemia is going to be small intestinal bacterial overgrowth, because a lot of times people will be eating meat and getting enough iron and being told that they actually have an iron deficiency anemia, so clearly the solution is to have a transfusion. But the solution here is to look back at the gut and figure out what’s missing. There’s a good chance that the bacteria that are becoming overgrown are actually using your iron before you get to use it. And that then creates a chronic cascade of issues. In menstruating females, this is also very, very common, so I always look at that piece. The most common cause hormonally, if it is truly a hormonal mechanism, is going to be endometriosis or fibroids. If there’s really, truly an estrogen-dominant condition, causing the growth of this tissue, iron can actually feed that tissue, and then it can present as an anemia. Especially if we start talking about hormonal symptoms, you really need to do a good workup. There needs to be a transvaginal ultrasound, and we need to actually see if there’s tissue growth going on in there. Because if you give people iron in those conditions, it will actually make their hormonal issues worse. And I speak of that from experience. I have made my clients worse, right. And this is why we call it practice. People don’t really think that’s how it works. But you know, I am light years beyond where I was when I first started functional medicine, because I’ve actually worked with clients now. And I’ve seen that happen.

Lindsey: 

Okay. This is blowing my mind because I had endometriosis. And I started taking iron, probably around the age in which I was diagnosed with iron deficiency anemia, probably around 16. And then at some point, eventually, when I couldn’t become pregnant for a second time I was diagnosed with endometriosis and had surgery. So if you don’t give iron, what do you do?

Dr. Ian:

We’re bypassing the gut, and actually doing an iron transfusion. Then you will hopefully not cause nearly the same level of damage. So if it’s a critical issue, and it’s a medical issue, you’re going to have to get the iron somehow. And most people are not that bad, right? They don’t actually have to go to those heroic extremes and get hospitalized and actually have a transfusion. For the majority of people, what’s actually happening is they probably had a bacterial overgrowth going on, which then actually triggered a hormonal dysregulation, which is actually now feeding back into the gut. So to break that cycle, I would typically want a nutrient dense diet, I want them consuming foods that have iron, but I’m not going to actually go to iron supplementation initially. I’m going to actually use compounds like diurnal methane or DIM*. I’m also going to want to use things like broccoli seed extracts or sulforaphane. That’s actually a great way to create an estrogen detox. The other main way to actually detoxify estrogens would be through something called methylation, which requires specific B vitamins. Methylation is another topic that gets into genetic issues. The vast majority of people with autoimmunity actually have these genetic issues where they don’t methylate right, and so what happens is we’re told to take folic acid, which can make us worse because we’re not taking the methylated versions, which is 5-MTHF* (for folic acid) or methylcobalamin* (for B12). But that is another way that we detoxify estrogens. On top of that, the main way that people are actually regulating hormones is through birth control. Well, guess what, that actually creates a bigger burden on the methylation of your B vitamins. So this is why we’re seeing side effects with people that are on birth control long term, and they don’t really understand it and they’re doing it for the right reasons. But unfortunately, they’re creating a bigger issue by actually doing that. That just comes back to an education process to figure out what’s going on. But again, just to tie back to the endometriosis piece, if it is really at a point where it’s grown to a size, there’s limitations to the natural stuff. There may actually be surgery required, but for me, I’m always going to try to be conservative first. You can actually give people broccoli seed and a whole container of that once a day is actually pretty therapeutic. And then on the DIM side, you can get that from cultured, cruciferous vegetables, so if you’re getting your brassicas, and something like sauerkraut or kimchi, which has a lot of this DIM* compound in there. If you hate those things, and you can’t tolerate them, you can get it in supplementation form as well. And there’s plenty of companies out there that carry this stuff.

Lindsey: 

Now, that’s funny, because I was just looking at the DIM in the health food store I go to. There you go, because I was shopping around for something to help with my hot flashes that have turned up again. Well, I saw that and then I saw the sulforaphane. And I said, Wait a second, I have some at home. I’m just going to take that.

Dr. Ian:

Yes. I think that would be like, first line for me if anyone with hot flashes to deal with. I very commonly find hot flashes can stem from blood sugar handling issues. So I would always ask people, you know, are you getting any fatigue after meals? Are you getting any sugar cravings after meals? Or are you getting shakiness, irritability or lightheadedness in between meals? And the reason why that’s important is because there’s blood sugar spikes and dips, and those will actually start to spike your catecholamines, adrenaline, norepinephrine, these are stress hormones, and so that can actually then go to your brain and trigger those hot flashes. Especially if those hot flashes are happening at nighttime.

Lindsey: 

So I think I need to back down on the L-tyrosine.

Dr. Ian:

Yep, yep. Good idea back down on that one.

Lindsey:

That may be why they restarted.

Dr. Ian:

Two of the things that I use very frequently and pretty successfully would be black cohosh*, and then also chase tree berry*, which is progesterogenic. So it actually increases progesterone activity in the body. And then the black cohosh is an estrogen mimicker. I don’t exactly know why black cohosh works, but it definitely definitely helps. I think partly because part of hot flashes, you see a cycle of up and down. People think it’s just this estrogen excess, but it’s a drop, your immune system freaks out, and then you spike estrogen up again. So then your immune system gets confused, and it doesn’t know what to do, and it starts giving you those hot flash symptoms. So important, because so many hormonal issues lead into autoimmunity, right? So for example, if you talk about Hashimoto’s, for every one man who has Hashimoto’s, there are 10 women. And one of the things that heavily influences the immune system is testosterone. And so if women start to become estrogen dominant, a lot of obesity, they’ve got fat build up, their insulin is making estrogen, and they’re starting to throw off the ratio of estrogen to testosterone. That is very, very important as it relates to their autoimmunity. That’s something I think that everyone needs to be looking at. I personally use a test called a Dutch Test. It’s a dried urine test for comprehensive hormones. And you can look at all three of your estrogens, you can look at multiple testosterone markers, you start to get more of a comprehensive look at what is going on with the hormones. I mean, hormones are so important, right? From the cortisol rhythm issues, to the estrogen- and testosterone-based issues, to the gut issues. All of those are tied into these vicious circles that people have such a difficult time getting themselves out of with autoimmunity.

Lindsey: 

I’m going to ask you about the cortisol in a second, so don’t let me forget that. I do want to go back to the autoimmune roots of anemia. Did we fully cover that?

Dr. Ian:

No, and the other big topic is if you really want to start talking about the ability to look at labs, you really need to get very good training on that, because it’s a serious condition. If you have a good provider, that is going to be able to actually say, hey, look, it is really this specific anemia. Here’s what we’re going to do, we’re going to come back, and we’re going to retest, just to make sure that we’re improving things. Your life is on the line, when you’re talking about this kind of stuff. There are serious issues. The other category was this macrocytic, or enlarged red blood cell issue. That is going to show on the complete blood counts, or CBC’s that are run. That will show up as a high MCV or high elevated mean cell volume. And why that’s important is that your body is making an adjustment because your red blood cells are not replicating at the rate that we need them to. What that means is that your cells are enlarging or becoming macrocytic. That is a good indication that you’re probably lacking B12. You could be lacking B9 or folic acid or the active form of folic acid. The other issue that this brings up is called pernicious anemia. About 25% of Hashimoto’s patients have this condition. And pernicious anemia means that your body is attacking two different kinds of tissues. One is called a parietal cell, which is found in your stomach. And then another tissue is called intrinsic factor, an intrinsic factor helps you absorb the B12. And this is one of the big buzzwords around energy. And if you have chronic fatigue, and especially if you have autoimmunity, I don’t care what kind of autoimmunity it is, I really would want to screen someone for that parietal cell antibody and the intrinsic factor antibody. And if either those are positive, we know that there’s pernicious anemia, which means from a management perspective, you can give someone all the oral  B12 you want, and it’s not going to work. At that point, that’s where an injection is necessary.

Lindsey: 

What about the sublingual?

Dr. Ian:

So here’s the thing, if you have intrinsic factor antibodies, it’s not really going to work. If you have parietal cell antibodies, you can bypass and you can use the sublingual form. That’s the kind of differential between those two. Sometimes it works, sometimes it doesn’t. But a lot of times, I’ll say you might want to go get something called a Myers cocktail. It’s like a B vitamin infusion, or you may want to get a prescription for a B12 shot. My only caution with that for people, because again, people get excited about this stuff, and they’re like, okay, I’m going out, I’m going to do this stuff, and it’s going to be great, is that I highly recommend that you don’t use cyanocobalamin. Cyanocobalamin is derived from cyanide. Methylcobalamin is a little bit more expensive, you know, like maybe $2 or $3 more per injection, but you don’t have to worry about it actually creating a problem for you in the long run.

Lindsey: 

Yeah. So when they discovered I had B12 anemia, it’s funny, I had one shot at the beginning, because I was down in the hundreds. It’s a wonder I even had any feeling at the end of my hands. But I was beginning to have some signs. I can do the sublinguals. And after our conversation, the other day, I went back to look at my records. I didn’t see any tests for parietal cell antibodies. But I did see that the intrinsic factor, like they couldn’t quite tell, so it was borderline. But I’ve been taking sublinguals and my B12 levels are great, both on the Organic Acids Test and on regular tests.

Dr. Ian:

And that brings up a really important point. If you are running labs, and you are suspicious that there’s a B12 issue, you can have a normal cytic, normal chromic anemia, meaning you can have a normal MCV, and you can have a normal B12 level, the actual test for B12. Another more sensitive test is called methylmalonic acid. That can be normal, and yet, you can still be B12 deficient. That’s one of the things I vividly remember. There’s a case series that we looked at in my master’s program. It was a presentation of a man with neurologic symptoms. He had psychosis. He had again numbness and tingling, he had every single symptom of B12 anemia. But homocysteine, B12, methylmalonic acid, they were all normal. And they gave him an injection of B12. Guess what happened? All of his symptoms went away. So when you suspect that there’s an issue, treat it, especially when you’re talking about a B vitamin. It’s cheap. It’s readily available. There’s no side effects, except for yellow urine. And I get it, people get frustrated. They say, you’re trying to sell me these expensive vitamins and my urine is yellow and it means that I must be not absorbing these B vitamins and that’s not what’s happening. It’s a normal biochemical reaction to see that yellow urine. It’s pretty standard when you take any vitamin complex that you’re going to see that. But what is so important is that people go through this workup process, and they go to these specialists, and they can’t find anything. And then many, many times, they’re told it must be psychosomatic. It must be in your head. You must be crazy. And it’s like, you know what, maybe you’re crazy. But the reality is, they’re not giving you a very good explanation of why you’re having these issues. So I just want to tell those people don’t give up hope. Find someone that has more tools in their tool chest to actually help you figure out what your root cause is and get you back on track.

Lindsey: 

So with cortisol, I hear different things going on in the functional medicine community. I hear some people saying the whole adrenal fatigue thing doesn’t exist, that there’s no scientific backing to this.  And when we test the adrenals, we did stuff with the cortisol, the pregnenolone, the DHEA and nothing happened. And then I hear other people who still are clinging to this, like this is a basic thing in their protocol. What is your take on it all?

Dr. Ian:

So I would have to say that there is scant research on something called adrenal fatigue. What I would say is there is absolutely a condition called chronic fatigue syndrome, also called myalgic encephalitis. And there is absolutely an adaptation that your body goes through when you’ve been exposed to either a high levels of acute stress or long term chronic stress. Our body has a natural mechanism by which it switches cortisol production into cortisone, done explicitly to save our tissue. So what very commonly happens as a result of another root cause trigger being overlooked, like an absorption issue, leaky gut, they’ve got a brain issue going on, they’ve got chronic stress, there’s issues with their spouse, there’s something going on again, that’s usually not being addressed. A gut infection would be another thing that would actually require a lot of cortisol to manage, your body starts to kind of turn the faucet down. And now all of a sudden, your cortisol levels do drop, we’ve classically said, even when I was trained back in the day, that it’s adrenal fatigue. And that really is not, I think, the most accurate way of looking at that. I think it’s saying to look for the conditions that are present, and issues that that person has, that the body is smart enough to realize, if we keep pumping out cortisol at this level, the pipes are going to start to break, right? And so what happens is it goes back to actually working someone up in that root cause model with functional medicine to figure out how do we get the body to start making that cortisol over again. Now, some people will actually have antibodies against their adrenal glands, that actually can happen, so you can actually get subtle autoimmunity against the adrenal glands. And that is Addison’s, which is adrenal autoimmunity. Cushing’s is when you have a hyper excess of cortisol. And so for Addison’s, the antibody is 21 hydroxylase. That’s the antibody that you actually have to test. And that’s what typically is targeted. Now, to go back to that Dutch test, that actually looks at cortisone and cortisol, and the circadian rhythm of cortisol. If you can get cortisone to start pushing back into cortisol, many times, people are going to start to actually feel a lot of relief, and a lot of times their energy will start to come back online. The main component that does that is licorice. And it’s whole licorice root* that will actually do that. Now, for some people who are already hypertensive, you have to be careful, it also stimulates another hormone, it’s called aldosterone. That actually can start to change your retention of sodium and it can actually increase your blood pressure. So you just have to be cautious with that if you know someone that has higher blood pressure. But I can tell you that I think I’ve changed some people’s lives just by giving them whole licorice root. And they were just down in the dumps for so long. Now, again, you can’t just give some licorice, that is then just a bandaid, you still have to go back and figure out, what are we going to do to maybe help you get out of this adrenal fatigue? One of the ways that I’ve done that for people is high intensity interval training. And not P90x, not CrossFit. Like, you’re not just going to jump into 60 minutes of CrossFit or you’re just going to jump into the insanity workout. But what I mean is that there is something called a cortisol response, or the cortisol response system, and it’s a neurologic mechanism by which, right after you wake up, within one hour, your cortisol will double. That actually comes from the hypothalamus, also the hippocampus. And so those two areas in the brain are actually getting the adrenal glands up and going to actually secrete the cortisol so that you can get up and move and you can go chase whatever you need to go chase to get your calories. So one of the ways to actually help improve and reregulate that is that within 30 minutes of waking up, you do high intensity interval training. I’ve had so many clients who’ve said, Oh my gosh, this is great. I really do feel this way. Now again, the caveat is if a little is good, a lot. . .

Lindsey: 

. . . isn’t better.

Dr. Ian:

Yeah, it’s sometimes a disaster. I mean, look, our clients are 40s 50s 60s, not 21 anymore, they’re not spring chickens and are not going to just bounce back if they pull a hamstring. So we’ve got to be gentle and easy in how we actually introduce this. I mean, I really do get some consistent results from people that are able to three to five times a week actually integrate that. And you start really slow and low, and then you build up. You know, see what your tolerance is and what you can handle. And then you kind of go from there, put in the licorice, combining a good anti-inflammatory, Mediterranean diet, if you’re addressing the root cause issues. I mean, this is the stuff that I’ve been doing for 12 years that other people just never figured out. They’ve been to all these other practitioners, you know, but this is what really is why we show up on a regular basis. Yes, okay, Money can be great as a doctor, but honestly, I think there’s a perception that we’re gazillionaires and it’s really not the truth.

Lindsey: 

Not the natural doctors.

Dr. Ian:

Yeah, not so much. Right. Yeah, you start talking about orthopedic surgeons, and, you know, neurologists and yeah, they’re going to be billing crazy.

Lindsey: 

And they may be the David Jockers, and the David Perlmutter’s and stuff.

Dr. Ian:

Yeah, 100% those people, and God bless them, we need all those people, right? The reality is, is that we’re in the trenches, and we’re working with people on a daily basis. And the gift that we get on a regular basis is “Thank you”. It’s the gratitude, right? It’s the fact that you can actually give people hope. I call it “vitamin H”, but you can give people hope that you know what, maybe if we give this one more shot, this can turn things around.

Lindsey: 

Okay, now, yeah, that would have been the perfect moment to go, “You know what, that’s a great note to end on.” Except I still feel like there’s something in the autoimmune stuff maybe that we haven’t talked about. And probably not something small.

Dr. Ian:

Oh, man, there’s so much to actually really talk about.

Lindsey: 

Keep in mind, I’ve already had shows on almost every individual topic that relates to the gut.

Dr. Ian:

I think one of the best tips that I can actually give people is that blood sugar stability is actually gut stability. The reason why I say that is that if you are straying from a good diet, and you’re actually creating a blood sugar handling issue, we start seeing some pre-diabetic issues or some hypoglycemic problems. You actually will start to create more problems for your gut as a result of: 1) the foods that you’re actually consuming, they’re creating the blood sugar handling issues which are going to be stressful to your gut. But also, as you start to change hormones like cortisol, you actually start to change the healthy versus unhealthy bacterial load. So if you are having to put out inflammation, because you’re eating pro-inflammatory foods, cookies, pastas and pastries and even gluten-free, all these wonderful things that are out there, you actually will start to recruit more cortisol, and it actually starts to starts to degrade the diversity of bacteria in your gut, which creates more stress, more inflammation, and it creates more vicious circles. So for me, what I do personally is I have a protein and fat rich breakfast every morning. And I do that because when it stabilizes my blood sugar, my cortisol stays stable, I don’t get energy crashes in the afternoon. And then as I go through the day, I’m actually bringing in more vegetable content. I will do some more protein in there, but much more of the carbohydrates that I consume. And I’m a super high energy guy. I play soccer, I do CrossFit, I’m putting a lot of calories out on a regular basis. And I’m still going to use vegetables as my carbohydrates, you know: yams, potatoes, squash, those kinds of things, because they’re clean. They’re green. And I know that they work for my chemistry. So I think if we can, again, go back to the basics of good fat, protein in the morning, good carbohydrates in the afternoon, evening. You know, it doesn’t have to all be carbohydrates. We get good fats in there as well. Olive oil, coconut oils, those kinds of things. That goes a long way when you actually look at what a long term diet can be. Or should be.

Lindsey: 

Okay. Well, then, I guess with that, we will wrap it up. I really appreciate you coming on and sharing all this information. This was awesome and detailed. And you know, it’s like my own personal health appointment. I’ve dug into all my health stuff, so that was great. Where can folks find you?

Dr. Ian:

The website is https://drautoimmune.com/. And I would just encourage people to go there. We’re on social media channels, you can go to Facebook, Instagram or Twitter.

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