IBS Case Study: Functional Medicine Series

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Dr. Andrew Wong 

Welcome friends to a special series on the Capitol Integrative Health podcast. I’m your host, Dr. Andrew Huang. And this is a podcast that is dedicated to exploring the root causes of both disease and wellness. I am honored to be a co founder of Capitol Integrative Health Clinic in Washington DC area with a mission to create a global revolution in health care by educating, leading and inspiring people towards optimal health and true well being. One of the key modalities we utilize in our clinic to help patients and be of service is functional medicine. We’re excited to offer you this series is an insightful look into functional medicine, otherwise known as root cause resolution medicine, and walk me through case studies that emphasize how we think about and approach holistic care with our patients. So let’s introduce you to our person today. Her name is Sarah and she’s a 35 year old female and her main issues are actually gut issues. So she Sara’s been struggling with digestive issues for the past five years. She has an s history of antibiotic use for recurrent urinary tract infections in her early 20s. She was also diagnosed with irritable bowel syndrome or IBS by a gastroenterologist three years ago. And she also has a family history of some autoimmune diseases. These are diseases where the immune system is actually attacking proteins and structures and in her own body, you might have heard of some of these, including celiac disease and Crohn’s disease in her family. Sara symptoms includes that she frequently experiences bloating and gas and redownload discomfort after meals. These are not really convenient things especially if she’s socializing or with her family or loved ones. She also is regularly constipated, and has a bowel movement once every two days. So typically, we would say you know, having a daily bowel movement is a good thing to eliminate toxins and kind of keep things moving. She does in addition to the constipation have occasional loose stools, for no known reason. So from like conventional perspective, we would identify this patient Sara as someone with IBS mixed picture someone that has both kind of alternating constipation and diarrhea. She also has some mild eczema so she has also what’s called atopic dermatitis, she has some rashes in different areas like on her elbows are on her on her thighs, sometimes on her belly. And then she does have low energy this is something that’s also going on kind of concurrent with with the bowel symptoms over the last five years. She’s been also experiencing the last couple years acid reflux symptoms. These are typical heartburn symptoms where she feels a little bit of a burning little bit of a sour throat. And this often happens after meals and she often takes over the counter and acids like toms and things like that for relief from that for at least partial relief. In terms of lifestyle factors which we typically ask every patient in terms of functional medicine on her diet and nutrition she does often eat on the go. She you can see on the the middle part there of this slide that she actually works as a paralegal at a busy law firm, so I’m sure they’re working really hard. So she’s eating on the go, she’s eating through lunch, things like that she’s not really stopping to sit down, maybe she’s actually walking down the hallway processing emails while she’s you know, one hand on the on the iPhone or cell phone and one hand on the on the on the snack that she’s eating on the muffin and things like that. She’s relying on pre packaged processed foods and sugary snacks are energy. And she has limited fruit and vegetable intake. In terms of stress, again, working as a paralegal, she’s writing her stresses at eight out of 10. She is in a long distance relationship, and is often traveling to see her partner across time zones, which is also a stress on on the body’s physiology going across time zones. And in terms of movement. She’s focusing mainly on cardio movement, things like treadmill or elliptical does run two to three times a week and tries to get outside at least once a week. So we can talk first about how we would approach patient like this from a functional medicine perspective. Again, just to recap this patient has been struggling for with digestive issues for about five years. We know that hypocrisy said that the gut is the root of health and the root of disease to paraphrase Socrates and we know that you know, we know that Hippocrates you know what was is correct, because really, when you look at the gut, it is the main sort of barrier gatekeeper between the the outside world the outside of the body and the inside the body. The digestive tract is a hollow lumen in which you know, things get processed through not only things like food, but also medications and supplements and even toxins and bacteria and things like that. So things that are gonna get in past that first barrier that gut lining will then go into the bloodstream. And then in the bloodstream, it can actually activate your immune system that is different parts of the immune system, but essentially can cause both inside the gut but also outside the gut in terms of different body symptoms, systems, rather different symptoms. So she has really, we kind of can look at this as kind of two, two buckets of symptoms. She has gastrointestinal symptoms, which are things like the typical things, you would you would see gas bloating, abdominal discomfort, after meals, reflux, she has alternating constipation and diarrhea, although more constipation for her, but then she also has some extra GI or extra gastrointestinal symptoms, meaning that likely the inflammation and the imbalances are actually starting to spill outside the gut, so to speak, into the bloodstream and to the immune system activation. So this is where things like eczema would come up, or energy, other people might have joint pain, or headaches or things like that. But she clearly has some systemic symptoms that are not just gastrointestinal, because again, the gastrointestinal tracts can affect really, the entire body. And this is one of the tenants of functional medicine is that the entire body is connected, right? When you ever played that game, as a kid, for instance, operation, I think it’s your operation. And like the hip bone is connected to the knee bone, and you know, the toes connected to the calf and things like that, right. So this is kind of what the body truly is made of is all these connections and connecting the dots of physiology is what functional medicine is all about. So I would ask this patient, Sierra, really, a couple of things starting from the beginning of her life, was she born by C section was born vaginally. And also another thing from a childhood history perspective is to share frequent ear infections or throat infections, again, having some sort of antibiotic use there, both the antibiotic use and potentially C section use or kind of not having as much breast milk as as a child would potentially predispose to having less beneficial bacteria, things like lactobacillus bifida bacteria, other bacteria that helped to help to balance the immune system. So basically, there’s the gut, and then there’s the immune system, and about 70% of your immune system actually ends up living in your gut. So if the gut microbiome is off, so to speak, if there’s an imbalance in the gut bacteria, if there’s too many inflammatory bacteria, not as many of the kind of good or anti inflammatory bacteria that can lead to immune system issues, and immune system issues can actually lead to gut symptoms, or even like I said, extra GI symptoms like eczema, or fatigue. So that’s the first thing is kind of some more things about the history. We want to ask her, you know, did she take probiotics with the antibiotics and sometimes probiotics can help to rebalance the gut bacteria. After after taking antibiotics, typically, we would recommend often to take probiotics for at least a month, after after a course of antibiotics, for instance, we do want to ask her a little bit more about her diet, she’s on what we would call in. In our country here, a SAD diet or a standard American diet sad.

Dr. Andrew Wong 

We could call it a SAD diet, because really a sad diet is bad diet, bad diet is low in fruits and vegetables, low in fiber. It’s usually not very high in healthy fats and healthy proteins as much, but it’s high in inflammatory and processed foods. You know, what we often call it even Ultra processed foods, things that have a high glycemic index where the blood sugar goes up, where maybe there’s there’s conventionally grown foods as well, which might have glyphosate which will potentially damage the gut lining as well through something called the shikimate pathway, which affects the microbiome health. And then also we have to look at the type of food she’s eating, you know, is she eating foods that tend to be highly allergenic? Are antigenic things like gluten and dairy or sugar are kind of the top three that we often think of? There may be other ones as well. So kind of seeing, you know, basically, if she can take a food journal or a food diary, or at least write some things down, you know, are there correlations that she can start to come up with that might be able to impact her future behavior in terms of her nutrition? For instance, if you said, Well, I do you know, good with a salad and salmon and I do pretty well I have less bloating, but then if I eat, say something with dairy or gluten like a pizza, right, and then I have digestive issues after that so she can start to kind of get this get a sense of what may be causing her more more inflammation. We can also look at because she has a family history of celiac and Crohn’s disease, we may want to start to you know, rule that out or at least investigate that there’s some lab tests we can do that look at IBD extended panel which is kind of inflammatory bowel disease extended panel, also celiac comprehensive panel. We do want to ask her also with the history of reflux does she have Have any, any significant abdominal discomfort after meals in that situation, you have to think about all sirs and you want to, you want to make sure that, you know, a lot of times with acid reflux in the functional medicine world, there’s actually a sense of, okay, maybe she has too little stomach acid in the stomach. And that’s actually opening up the lower esophageal sphincter and making the acid go up. reflexing more I would say, in the esophagus and the larynx, which can cause things like heartburn and hoarse voice and sour mouth and things like that. So one of the things is, we often will look at things like treating the patient with things like bitters, or apple cider vinegar, or even even hydrochloric acid or stomach acid supplements. But we may want to do this, if she’s having this reflex for several years, maybe only after going for her to see the GI doctor, the gastrointestinal doctor, again, to do an endoscopy to look at that. So these are some of the questions kind of we would look at. I think the biggest things are trying to figure out some of the antecedent things that might have preceded some of her illness, some of the triggers some of the foods some of the some of the stress to write she has a lifestyle factors of, of stress working as a paralegal, which I think is inherently stressful, but also that she’s not really eating and sitting down and eating, relaxing, activating that relaxation response, or the vagus nerve, which is a big part of that that relaxation response that will activate the digestive enzymes in the motility that’s needed to digest the food effectively. So another big thing is not only what is she eating, but how is she eating, who she eating with? And sometimes even and this goes a little bit beyond this case, but why she’s eating? Is she eating for emotional nourishment? Is she eating kind of what’s called Emotional eating to mitigate the stress? Or is she eating for nourishment of her body? So these are just some questions that we would often ask. We may want to ask her, you know, we talk about nutritional counseling about okay, she’s not eating any fruits and vegetables, vegetables right now, is it because of the stress is because of the time limitations or food prep limitations. And if she were to eat that in a perfect world, if you had unlimited time and resources, you could buy what she wanted? What kind of fruits and vegetables would she be eating? What are her favorites, right? So we want to try to work with the patient and personalize this kind of nutritional plan and lifestyle plan for Sarah. So it worked for her and not for some, you know, cookie cutter sort of recommendation that’s based on sort of a guideline that doesn’t take Sara into account, it’s more patient centered that way. In addition to that, I would say on the lifestyle. The other thing is movement, we know that a combination of cardio and resistance training is better than cardiac alone for many things, including booting up muscle mass, and I think we can see that when you build muscle, you also help with gut motility. Um, this is a bit more of an aside, but looking at going up the abdominal muscles and things like that would often help motility and she does have constipation. We know that one of the strongest anti inflammatory treatments is actually exercise. But I think that, you know, sometimes cardio can actually exacerbate stress. If it’s what is called in some circles, chronic cardio where there’s too much aerobic activity and not a lot of resistance training, then you basically have what favors a candidate catabolic to anabolic ratio with the body and the bones and everything and muscles are breaking down. And you want to have this balance where you have some catabolic activity like cardio, and then some anabolic activity where things are building up like bones, muscles, etc. And giving your body a chance to build those, build those muscles and bones up again. So these are some of the questions that that we would ask her. We often could ask her also what tests that she’d done before Has she had any workup from her conventional GI doctor has she had a workup from her conventional as a primary care doctor as she had lab tests done so that way we can kind of again, personalize the recommendations and we’re not repeating some of the things that have already been done. So lifestyle factors, what lifestyle factors would we give this patient now it’s interesting that when we look at functional medicine, functional medicine often has a reputation for using testing and deep dive lab testing often this can be the difference between someone you know getting better and then still kind of wandering in the dark what’s going on. However, that being said, lab tests do have limitations. So we do start with lifestyle recommendations for all of our patients because often lifestyle is really putting that person as Sarah here in charge of her own health. We often say here that, you know Sarah, Hey Sarah, you’re the CEO of your own health and your immune system and your gut. And your ability to heal innately naturally, is really the strongest treatment you can have. So some of the things that are kind of lifestyle recommendations like getting more sleep, reducing stress, you know, improving her nutrition, improving your movement, these things actually have a again a very powerful inflammatory, anti inflammatory effect, a powerful and immune balancing effect. And we’ve seen some people in our clinic like, like Sarah, for instance, that have had irritable bowel syndrome for years, and often it’s with the lifestyle recommendations alone might be some of the biggest kind of results, you know, from from the lifestyle change. So I think it’s really important to emphasize, to the, to patients and to Sarah hear that, you know, a lot of these things are within her control, or at least, you know, she can try to start with these. And, you know, often again, these small changes can make, you know, outsides differences in her health outcome. So, lifestyle recommendation, I would start with something that’s very simple in terms of breathing again, when you breathe deeply, and especially when you breathe kind of either as much or more on the exhale than the inhale, I start with something called a 555 breathing, which is five seconds in five seconds holding the breath, and then five seconds out. And if she does it for six cycles, that’s going to help balance your autonomic nervous system, which basically translates to say that it’s going to help her gut, it’s going to help her digest. So if she can do this breathing, ideally in the morning, in the evening, but then also before her meal would be really nice. Again, activating that relaxation response, getting that digestive system online. Again,

Dr. Andrew Wong 

if you think about your digestive tract as a, maybe like a computer, as you know, something that’s helping you out, you wouldn’t want to use your computer if you didn’t turn it on already, right. So you want to turn it on by activating that relaxation system by breathing. That’s the first thing you know. And then I think the second thing is really chewing her food, you know, chewing the food can activate the digestive enzyme amount by 20%, it can activate the salivary amylase, and that also brings the same signal down to your stomach, increasing stomach acid return is going to increase some of the downstream enzymes like amylase and lipase and also help release the bile from the gallbladder which stored. So again, these things are going to be helpful really to digest carbohydrates and fats. And then of course, the stomach acid is very helpful. And stomach acid is suppressed with stress. So Samak is going to help digest proteins, break them down to amino acids that can be used for many things like neurotransmitters, or amino acids that are going to be helped to build up your muscles are enzymes that are going to help to run your entire system. So no proteins, no amino acids, no amino acids, no building blocks for you to survive and thrive. So you really want to have, you know, we’re gonna say to Sara, you know, she really wants to have the stress under control, so to speak, so that she can really digest your food effectively, whatever she is eating, whether it’s a salmon salad, or whether it’s a pizza. Either way, you know, you manage that stress is going to help, I would think about you know, movement during lunchtime if she can, you know, get up for a walk as well after lunchtime, that would be nice, as a minimum and then kind of continuing her cardio but then adding some resistance training to help build her muscles and bones and give give her that kind of that building back of anabolic activity in addition to the catabolic activity that she’s already getting with the cardio on the running. And then often we recommend something called elimination diet and functional medicine, this can be very helpful. And there’s different forms of this. And I’m not really an expert in this, but I would often refer out for this to one of our team. But an elimination diet is going to eliminate some of the top foods that might be inflammatory that might be causing her irritable bowel syndrome. And often this alone with lifestyle nutrition is enough to reduce her IBS symptoms and reduce her things like eczema and increase her her energy. Now let’s talk real quick about eczema. Because you know, I know that we’re all very interested in skin health here. And there is actually gut skin connection, there’s the health of the gut microbiome influences the health of the skin, microbiome. And the levels of inflammation in the gut often correlate with the levels of inflammation in the whole system, including the skin. So we often see that eczema, or psoriasis, or acne or things like that get better with nutritional changes with gut microbiome improvements. So it’s important to know that from a functional medicine lens, when you have a skin issue, you automatically have to think about your gut health as well. So those are some of the lifestyle recommendations just to kind of keep it simple and wrap up on this. I would say, you know, breathe a little more slowly, before a meal, maybe give some gratitude if that’s if that’s helpful. And then I would, I would do that and then I would also consider chewing, you know, 20 to 30 chews per bite just to slow down that digestion and improve the enzyme and digestive capacity for that person. And then consider an elimination diet we typically talk about at least at the minimum gluten, dairy sugar, there could be other factors other foods like eggs and nuts and egg different things for different people but I think those are some of the top things and then we would often refer to to some of our team here. In terms of testing, there’s a lot of different tests that that we could do with bloating and sort of upper tract symptoms, upper GI tract symptoms, we think about a test called a SIBO test or small intestinal bacterial overgrowth test. So this is a breath test, it’s usually utilizing a sugar, such as lactulose, or glucose. These are basically of substances that you drink, and they do taste sugary, I’ve tried this test before myself. And basically they, they help to kind of activate the bacteria that are in the small bowel, and the small bowel bacteria are going to then produce some gas. So there’s two major types of gases that are on the test. One is called hydrogen one’s called methane. There’s another test that we use that that uses those two class gases, and then adds a third gas called hydrogen sulfide, which we often use if someone has say, IBS or suspected SIBO. But those two gases on that first test are negative, we’ll use that third test, and that has three gases. But basically, that’s a test we could consider for her. Based on her symptoms, or her history of antibiotic use, she likely has low stomach acid based on her reflux, she has some bloating and gas. And we know that a lot of the symptoms are of, of IBS are actually caused by gut microbiome imbalances, which can be affected by nutrition and stress and all the other things, hormone imbalances, etc. So SIBO test would be something I would I would consider, we also know that she’s regularly constipated. And so constipation is actually something that can be caused by McDonough bacteria, which is type of methane producing bacteria think it’s called Mithuna, vectors smithii i. So don’t ask me to spell that on spelling bee. But that’s basically what it is. And then we can also look at some functional testing, we’ll look at often what’s called a functional stool test. It’s basically a stool microbiome test, that also analyzes things like enzyme activity, and inflammation and immune health markers, really taking a deep dive into the gut microbiome as a whole. That’s a stool test is a poop test that you do at home, kind of joke with people that you just take this French fry basket that they give you and you put your stool on there in the privacy of your own home. And then you basically take a sample of that you want to get it from, I think different parts of the stool. So if you do that test at home, you’re getting it from the edge you’re getting from the center of the stool you’re getting from different areas. But that can be a really, really helpful test. The one we use is typically it uses something called PCR technology or Polymerase Chain Reaction technology. So to look at DNA sequences of various bacteria, viruses, and other organisms and amplify that, that’s called PCR. So that’s, that can be a very helpful test to you to use from a perspective of, you know, basic labs, we often will get a basic lab panel things like liver test, kidney test, we’ll look at maybe markers of inflammation, maybe CRP, which is C reactive protein, which is an inflammatory marker. Certainly, like I said before, celiac markers, Crohn’s markers, you know, things like that to see if there’s any potential for inflammatory bowel disease there or celiac disease respectively. And then I think I would also consider thyroid testing for the patient with constipation and bloating and gas, low thyroid are also got hypothyroidism can often cause some of these same symptoms that she might have low energy and constipation and bloating and kind of not moving things through kind of the slow metabolism, slow metabolism, right? That’s, that’s considered, you know, a potential hypothyroid series of symptoms. Reflux can also be caused by hypothyroidism as well. So I think all these things can be really, really helpful. Kind of down the line, maybe in round two, we might think about something called food sensitivity tests. So these are tests that look at potentially both food allergies, which are IGE mediated, which is an antibody called IgE, otherwise called immediate hypersensitivity, but also IgG, which is delayed hypersensitivity. There’s also another marker that we’ve started using now called a C three d, which is complement three D, and it’s another type of immune reaction. So basically, the the bottom line is the immune system is complex. And there’s a lot of different types of reactions that can happen with foods and sometimes it’s hard to really understand or figure out you know, what someone’s reacting to some, some foods may trigger reaction and zero to four hours, which is considered immediate, some are considered you know, more delayed, which is four to 72 hours classically, so there’s there’s all these things happening. I think the only other thing I would think about would be potentially probably after gastrin get a GI or gastroenterology referral for endoscopy would be a Heidelberg test, which is a stomach acid test that can look at whether the stomach acid is high or low whether there’s Pyloric insufficiency, which is another issue that might be causing some of the issues for her. So a lot of Deep Dive test. And the bottom line is, you know, usually these gut symptoms are not random, the body’s all connected, we have to look at the gut, but also the rest of the body to take a really comprehensive approach of functional medicine approach to treating to diagnosing and investigating and treating Sarah. And then, you know, we also use a team approach, one of the most well known one of them, who’s considered the founder of Functional Medicine, Dr. Jeff bland, actually famous,

Dr. Andrew Wong 

he’s famously said at one of the conferences I attended, he said, never treat a patient in isolation, don’t think you can be a cowboy or cowgirl or cow person, meaning that we’re going to pilot, you know, we’re going to do everything for that patient, or, you know, we’ll be the only practitioner. So I think it’s really important to stay humble and realize that there’s a lot of different integrative practitioners, conventional practitioners, that could really benefit Sara here. So certainly a GI doctor, making sure she has a primary care doctor on the conventional end, I think functionally a functional medicine specialist, a functional nutrition specialist could be really, really helpful for Sarah. I think from a stress management and immune perspective, I would consider for sure, acupuncture and my official release, which is a special type of soft tissue and Mind Body practitioner, that can really help people to balance their immune system and their energy and things like that. So there’s a lot of people that we could consider, certainly physical therapy as well, because physical therapy can be really helpful, especially if someone is more in that chronic cardio category and not really doing a bunch of strength training or may not know how to use the weights and the deadlifts and things like that. So I think all these practitioners work in harmony and synergy with each other, to really help treat Sarah and proactive, preventative and personalized way. And then what are your take home points for Sarah? So I would say, you know, people, including myself, can only remember three things at a time, you know, and that’s why that’s why I think, you know, keeping it simple is really important, because for retention of information, and so that she has a sense of what she can actually do, you know, practically. So maybe maybe for her from a lifestyle perspective. And maybe she’s really, you know, maybe her boss is working her too hard. And she’s really stressed out and she can’t let’s pretend that she can’t, she doesn’t want to change her diet, or doesn’t have the time and energy to do that. So if she does, maybe we’ll just say one thing, which is to take out sugar, okay, we’ll just do one thing like that, refer her to function nutritionist. But if she even can’t do that, then we’ll just say, Okay, Sarah, well, let’s just have you chew your food and sit down while you eat, and see if that helps your IBS symptoms. So I think the first thing to do is to be more mindful of, of the nutrition and maybe take a little bit of a breather, literally a breather. So she’s taking a deep breath before breathing and chewing, deep respiratory eating, I should say, and then chewing her food, and potentially eliminating sugar and see if that helps reduce the IBS symptoms. So I think sort of lifestyle change would be would be the first thing number two, I would say because she has a history of reflux, and IBS and things like that, you know, maybe we do want her to go to see a GI doctor to get an endoscopy to rule out all sirs, especially with abdominal discomfort after meals, at least just to get that evaluation. Again, we work with conventional medicine and we do some of that ourselves, you don’t kind of work against the medical system, it’s all about what is in the best service of the patient. So I think that’s that’s a second thing. And number three, I think on the functional you know, aspect is really a toss up for me between SIBO and, and a stool test. I tend to favor a stool test a little more than Siebel because it to me, it gives us more information and often can give us underlying reasons why someone might have SIBO. So I would favor a functional stool test in the situation. And then based on that you can kind of take some other steps that are kind of based on the testing and how how Sarah is doing when you do the follow up with her in terms of lifestyle changes, and we’ll see how she’s doing with that. So making sure she sees her, her practitioners making sure that she kind of gets a functional so test and then having her do some simple lifestyle changes is what I would do first after that, because I know I know we’re talking about the top three, but you know, we do we do want to look at things like some basic lab tests, like liver tests, kidney tests, thyroid tests, you know, all of those type of things. So, and that’s another thing sometimes again, people were very busy, and you know, they can’t deal with even lifestyle changes. So I might just say to Sarah, hey, just go get your labs done. And then we’ll follow up with that. So little baby steps again, the The journey of 1000 miles starts with a single step. And it’s really that single step to take that, you know, starts that healing journey for Sarah. So I hope this was helpful for you and kind of giving an intro to kind of how we think about in from the functional medicine world for gut health, and we’ll see you soon on another episode. Thank you so much. Thank you so much for joining us today for this episode of the capital Integrative Health podcast. A quick reminder that the information we share on this podcast is meant for educational and informational purposes only. It’s not a substitute for professional medical advice, diagnosis or treatment. We highly recommend that you speak to a qualified health care provider before making any medical or healthcare decisions. If you enjoy this episode, please take a few moments to subscribe and leave us a review. Your reviews help us reach more people and continue to offer innovative insights and information to better optimize your health and wellness.