Amy Nett: Second question also from Amy. She says, “This is a case study question about a 20-year-old college hockey player, and he has fatigue, insomnia, depression, brain fog, eczema bloating, occasional diarrhea, vomiting, and heartburn.” With that list of symptoms, I’m already thinking about gut. I’m thinking GI dysbiosis. I’m thinking that he’s probably eating some foods that are triggering his immune system because we’ve got that eczema in there. I’m also thinking about foods as triggers, particularly inflammation because he’s got the depression, and then I’m thinking that there’s some sort of disruption probably in that HPA gonadal axis as well, so thinking about hypothalamic-pituitary-adrenal-gonadal axis here because he’s got the fatigue and brain fog, that could be the inflammation of the food – so definitely thinking about gut, adrenals and foods as triggers. On the details here, she says, “Symptoms started last fall. He stopped playing hockey, cut his class schedule in half due to ‘exhaustion.’ He has insomnia and sleep studies.” Okay, no results on the sleep studies there. “Labs have been normal except a little low on glucose. He has trials giving up gluten without improvement. His mother is a dietitian but does not believe in Paleo or keto. He passes out/blacks out after intercourse. Now reports sometimes vomiting in the morning and some heartburn that results with Tums. He’s lived off campus for two years.”
Okay, so I’m still thinking gut, inflammation, adrenals. Unfortunately, you do still need to do, especially he has some improvement with Tums, so I would think about testing for small intestinal bacterial overgrowth. I would run a stool test. We’re now starting to run the GI-MAP stool test. I think that’s Diagnostic Solutions Lab, so the DSL GI-MAP. You can also still run the Doctors Data stool test. I think you’re still getting a lot of useful there and SIBO breath test.
I would think about running either the complete hormone profile or just the adrenal assessment on him. He’s a 20-year-old, so you know there’s still going to be some fluctuations and changes in that hypothalamic pituitary adrenal gonadal axis, but I think it’s still worth getting some idea. When you look at his blood work, so you’re saying that he’s had “normal labs.” I would want to make sure I take a look at those. I would be particularly interested in markers of inflammation. Look at C-reactive protein, ferritin. Maybe you want to run an ESR, an erythrocyte sedimentation rate. Look at zinc and copper levels. I would want a little more information I think on the bloodwork, making sure that we’re really looking at it from a functional medicine perspective, also making sure you look at thyroid. I understand that if he’s given up gluten without improvement, I would make sure it’s been for a minimum of 21 to 23 days because the half-life of the IgG antibodies is, I think, it’s 21 days or 23 days, so you want to make sure it’s been long enough to really get those antibody levels down. Even if he’s done the full three weeks, I still often tell a lot of my patients that making some of these dietary changes, this is not the one answer, and this is not going to be the only thing you need to get you where we want your health, but it’s one piece on lowering inflammation, and we have to approach this from all these different angles. Even though taking out gluten is not the one answer, I do think it’s a really nice piece for removing some potential inflammation, and more importantly, increasing nutrient density particularly phytonutrient because you’re replacing that gluten with things like sweet potatoes, winter squash, plantations, foods that actually have a lot of nutritional value beyond just the carbohydrate content.
I think with him, again, think about just starting with the basic and gut testing. Make sure you actually look at the blood panel and then look at the adrenals and/or sex hormones. The exhaustion, I would think about viral infections but not until you do the basic gut testing because he’s got the heartburn, the eczema, the fatigue, the insomnia. I would also look at the diet pretty closely with eczema. You might want to think about kind of optimizing essential fatty acids. Look at his omega-3. If he’s a college student, he may not be eating as much in the way of coldwater fatty fish, so is it worth supplementing with a nice fish oil, some cod liver oil? Cod liver oil giving you both the omega-3 and also some vitamin A for skin. It may be also getting some gamma-linoleic acid in there as well. If you want to use some GLA something like borage oil and if you’re using a GLA oil, make sure you get at least 500 mg of EPA in there, so it doesn’t convert down that arachidonic acid pathway in terms of looking at your omega-6 pathways.
I would think about essential fatty acids there as well, and again, this is a call a male college student. You’re going to have to see how open he is, how many supplements you have the option of giving him. But I’m thinking with the depression, the fatigue, there’s some sort of mitochondrial dysfunction here as well, so making sure your lipid membrane, your mitochondrial membrane, your cell lipid bilayer, all of those membranes are healthy, working well. Do some testing, but while you’re doing that testing, maybe think about optimizing essential fatty acids, doing what you can with his diet. Think about stress management too. He’s talking about depression and had to cut his school load back, yet to decrease hockey, so what are his social support? He’s not sleeping well. Again, thinking about stress management, maybe the cognitive behavioral therapy for insomnia program or CBTI. A lot of different places to start. Hopefully that gives you some ideas on where to start.
Amy also asks, “Should he follow the autoimmune diet or more of a 21-day elimination diet starting with the gluten and other primary known triggers like dairy and egg?”
Yes. In an ideal world, autoimmune Paleo would be awesome. A 20-year-old hockey player, I would not try to do that, especially if his mom already doesn’t even believe in like gluten-free. I just feel like that’s going to be such a battle. Not knowing him, I would probably start with just gluten-free. If you think you can get gluten-free and dairy-free, great. If you think you can get gluten-free, dairy-free, and egg-free, fantastic. I think taking out eggs in a college student is going to be kind of more trouble then potential benefits. I would say go for gluten-free. I think a 21-day elimination diet gluten-free, dairy-free is possible, but again, I think just given what you’ve said about his mom, and he’s already kind of like, “No, no. I did that. It’s didn’t do anything.” You got to start with something reasonable so that you can get compliance like he needs to buy-in.
Amy also said, “He’s been to Mexico many times, could that be an issue to encourage stool testing?”
He needs stool anyway. I mean, I think you said he has the vomiting. He takes Tums, and he feels better. He needs stool testing anyway, and if you have to bring up that he went to Mexico, that’s one more reason for it. I would fully support that. Do what you have to do to be honest. You need to get the buy-in from him, but he needs gut testing. I mean, he shouldn’t have so many symptoms at 20 years old. So yes, go ahead and use it. I don’t really know. I mean, if you’ve got an acute gastroenteritis in Mexico, then absolutely otherwise just having into Mexico, I’m kind of shrugging my shoulders, but I think you might as well use it. Use it for your cause.