Thank you for posting this man’s case here. I am in agreement with the thoughts you have on recommending the removal of gluten and dairy from this man’s diet, given his symptoms when he has them. I also agree that allowing yogurt and butter to remain in the diet at this time and looking at the more likely contributors to his symptoms first is appropriate, and less restrictive so he is more likely to be compliant. You also may want to consider recommending a comprehensive digestive enzyme for gluten and dairy for the times when he may still encounter these things such as meals out.
I am assuming from your details that he has had the standard comprehensive metabolic panel with liver function tests, as well as an abdominal ultrasound to assess for the possibility of gallstones. If these things have NOT been assessed, they would be things that should be by his general practitioner. If they have, and have been shown to be normal, it is unlikely they would follow up with further testing given the lack of more significant gastrointestinal symptoms. The comprehensive stool assessment would be the first I also would elect as this will show how well he is digesting fats, his pancreatic function, as well as the flora balance. I generally add on parasitology when I do this test, due to the minimal cost increment I feel it is worthwhile to also rule this out.
In my practice I use the CDSA with parasitology (x3) test from Doctor’s Data – http://tinyurl.com/q4256rk – which is available from Regenerus labs; Genova Diagnostics also offers a Comprehensive Digestive Stool Analysis / Parasitology ™ – http://tinyurl.com/p6gopyt.
I also would elect to do some additional gallbladder support given that his symptoms do sound like what we typically see with gallbladder stasis, despite the lack of labs or imaging indicating this. In addition to the artichoke complex, phosphatidylcholine is important for healthy bile flow as well as the elimination of toxins from the liver. The diet of many is deficient in phosphatidylcholine. It also can support a more balanced stress response and mood, as it provides choline, a precursor to acetylcholine.
Of course, we must always consider the gut when we support the brain. Leaky gut often comes with an increased permeability of the blood brain barrier as well as systemic inflammation, both of which can increase central inflammation and agitation, contributing to obsessive through patterns as well as anxiety and depression. Certain strains of probiotics support the reduction of anxiety and the stress response in the body, especially when taken on a longer-term basis.
Ait-Belgnaoui A, et al. Probiotic gut effect prevents the chronic psychological stress-induced brain activity abnormality in mice. Neurogastroenterol Motil. 2014 Apr;26(4):510-20. http://tinyurl.com/pz3z7ya
Dinan TG, Cryan JF. Regulation of the stress response by the gut microbiota: implications for psychoneuroendocrinology. Psychoneuroendocrinology. 2012 Sep;37(9):1369-78. http://tinyurl.com/pl387g2
On the other hand, it is worthwhile to consider that his stress levels, anxiety, and obsessive-compulsive tendencies may be contributing to his digestive symptoms, as well as his concerns about them. Imbalances with glutamate are associated with obsessive compulsive disorder, and working to address this possible imbalance may improve obsessive behaviours. N-acetyl cysteine has evidence for reducing obsessive compulsive behaviors in many studies pertaining to addiction.
Pittenger C, et al. Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment. Pharmacol Ther. 2011 Dec;132(3):314-32. http://tinyurl.com/nsb2lef
Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009 Jul;66(7):756-63. http://tinyurl.com/oepm2xr
Egashira N, et al. N-Acetyl-L-Cysteine Inhibits Marble-Burying Behavior in Mice. J Pharmacol Sci. 2012;119(1):97-101. http://tinyurl.com/ofbd9y9
Vitamin B6, magnesium, trace minerals, and ascorbic acid are important for neurotransmitter metabolism as well, and are particularly important to include for individuals who experience anxiety at a higher level than depression. I usually start with the B6, magnesium, and vitamin C and then add in the B12 and methylated folate gradually with individuals who have anxiety and find this to be better tolerated than starting with B12 and folate.
Atmaca M, et al. Serum folate and homocysteine levels in patients with obsessive-compulsive disorder. Psychiatry Clin Neurosci. 2005 Oct;59(5):616-20. http://tinyurl.com/pkf8spp
Mitchell ES, et al. B vitamin polymorphisms and behavior: evidence of associations with neurodevelopment, depression, schizophrenia, bipolar disorder and cognitive decline. Neurosci Biobehav Rev. 2014 Nov;47:307-20. http://tinyurl.com/z3z4jfa
Moretti M, et al. Ascorbic acid treatment, similarly to fluoxetine, reverses depressive-like behavior and brain oxidative damage induced by chronic unpredictable stress. J Psychiatr Res. 2012 Mar;46(3):331-40. http://tinyurl.com/njzh8ch
A garum armoricum Ling-fish-based food concentrate has been shown to balance adrenal function or dysregulated HPA function under stress as well as supporting mood and sleep. Although I also use phosphatidyl serine for this purpose in my practice, I see a slightly greater benefit for individuals who also have anxiety with this supplement. This food concentrate (http://tinyurl.com/pntrrf4) contains polypeptides that act as precursors to neurotransmitters such GABA, encephalins and endorphins. They can exert a regulatory effect on the nervous system, potentially enabling the organism to adapt to stressful conditions. It also contains the essential omega-3 fatty acids, DHA and EPA. These are precursors of the prostaglandins and prostacyclins, cellular chemical mediators which help regulate the main biological functions of the body, including the noradrenergic functions of the central nervous system.
A variety of herbs are useful for calming digestive upset, as well as reducing anxiety. Fennel, lemon balm, and chamomile are calming to the nervous system, and have a gentle essence yet effective action of reducing digestive upset. Each of these herbs can be taken as a tea brewed double strong (or other form) to help reduce stomach bloating and flatulence, also supporting the reduction of anxiety which can be a contributing factor. Less specific acting but still helpful, probiotics and fermented foods are healing to the digestive system and support the reduction of anxiety as they also support levels of GABA. Encouraging the introduction of foods such as yogurt, kombucha, kimchi, or sauerkraut is a good food-based therapy to support. Although GABA is not available as a supplement in the UK any longer, it is found in kimchi and Pu-erh teas.
Topical castor oil to the abdomen and right upper quadrant of the liver is very supportive for gastrointestinal symptoms, liver/gallbladder support, and also supports relaxation. Dr Todd Born recently wrote about the many benefits of castor oil which can be read here – http://tinyurl.com/kqsrfga. I generally instruct clients to use a simplified castor oil pack by simply massaging castor oil into the region, applying a cotton cloth to protect other garments from the oil, and using the body heat to draw the oil internally. Generally, the use warm water pack is also often recommended for a period of 15 – 20 minutes.
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Tea: To drink through the day: Chamomile, fennel, lemon balm.
Phosphatidyl Choline (ARG): 2 softgels twice daily. https://tinyurl.com/l6rnsh5
(or use Biotics Research Phosphatidylcholine if out of stock)
To support mood:
NAC (ARG): 3 – 4 tablets once daily away from food. http://tinyurl.com/c96mjpy Supports reduction of obsessive-compulsive behaviours.
In addition to B complex, magnesium, and vitamin C consider:
Pyridoxine P5P (ARG): 1 capsule (275mg) in evening before exercise or before bed. http://tinyurl.com/j3drsl8
Please do consider the following, if you do not see desire outcome with Phosphatidyl Serine:
Stabilium® 200 (ARG): 4 capsules once daily on an empty stomach for 4 weeks, decreasing to 2 -3 capsules after this. http://tinyurl.com/pm5ou44 Garum armoricum concentrate that reduces anxiety response under stress and supports healthy sleep.
Digestive support to consider:
Full Spectrum Digest (ARG): 1 capsule shortly before meals. http://tinyurl.com/p4p65vh
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
Registered Nutritional Therapist Helen Perks is collaborating with Clinical Education to bring you the first-ever Functional Medicine book club for Practitioners.
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