Latest / The Antisocial Doctors Podcast / Episode 8: Is the Autoimmune Protocol (AIP) Diet Helpful?

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Episode 8: Is the Autoimmune Protocol (AIP) Diet Helpful? · The Antisocial Doctors Podcast

1:27
Sonia Singh MD: You are listening to the Antisocial Doctors Podcast, hosted by me, Sonia Singh, a board certified internal medicine physician with a Master's in nutrition and a special interest in health anxiety
1:38
Rebecca Berens MD: and me, Rebecca Barons, a board certified family medicine physician with a special interest in disordered eating.
1:43
Sonia Singh MD: We're also a millennial women anxious moms and curious humans navigating social media.
1:48
Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
1:56
Rebecca Berens MD: This podcast is meant to be the antidote to your doom.
1:58
Rebecca Berens MD: Scrolling, a, solve for the anxiety, stress, guilt, shame, and confusion.
2:02
Rebecca Berens MD: That comes from social media's messaging around health.
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Rebecca Berens MD: In each episode, we discuss a health related talk trending on social media with curiosity, nuance, evidence, humility, and compassion.
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Sonia Singh MD: This is not your average debunking podcast.
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Sonia Singh MD: We wanna explore not just what is trending on social media, but why?
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Sonia Singh MD: Why are so many people drawn to this?
2:20
Sonia Singh MD: What is the nugget of truth here?
2:21
Sonia Singh MD: What are the facts?
2:23
Sonia Singh MD: What can we learn from this as patients and doctors?
2:25
Sonia Singh MD: No shame.
2:26
Sonia Singh MD: No blame, no snark.
2:27
Rebecca Berens MD: We're so glad you're here.
2:44
Sonia Singh MD: Hi Rebecca.
2:46
Rebecca Berens MD: Hi Sonia.
2:48
Sonia Singh MD: So the topic today is one that we were just discussing is topical, given that there's been newly released dietary guidelines for US Americans.
2:57
Sonia Singh MD: So it's serendipitous that we chose to record this today.
3:00
Sonia Singh MD: We're not gonna get deep into the new guidelines, but I think this is tangentially related and, it's a good time to talk about this specific thing.
3:07
Sonia Singh MD: So tell us about the patient story that inspired us covering this topic and what the topic is.
3:14
Rebecca Berens MD: Yeah, absolutely.
3:14
Rebecca Berens MD: So I'm gonna change a few details here just for this patient's anonymity.
3:18
Rebecca Berens MD: But, and I'll be speaking a little bit in generalities, but essentially there's this patient who had a history of an eating disorder but also had an autoimmune condition that had been diagnosed and had symptoms that they suspected were related to another autoimmune condition that was still being evaluated.
3:33
Rebecca Berens MD: And they were concerned that they were developing all these autoimmune conditions.
3:36
Rebecca Berens MD: And had read about the autoimmune protocol diet and had been recommended to do that by some friends and family members.
3:43
Rebecca Berens MD: And decided they were gonna try to do that, to try to control all these autoimmune diseases and try to avoid having to be on more medication to manage these diseases.
3:54
Sonia Singh MD: Honestly, when you suggested this topic, I actually thought it was like a general topic of what should I eat for autoimmune disease?
4:01
Sonia Singh MD: And I was not familiar with this actual, that there's a very specific protocol.
4:07
Sonia Singh MD: So it was like a new concept to me.
4:08
Sonia Singh MD: I don't know how many of our listeners would've heard of this specific protocol, but what is the claim that they make about the protocol?
4:15
Rebecca Berens MD: So basically it's a claim that by doing this again very specific dietary protocol as we discussed, can reduce inflammation, improve gut health naturally.
4:25
Rebecca Berens MD: And it's based on eliminating quite a lot of foods and then gradually reintroducing them so that you can see which ones are the ones that are inflaming you and then avoid those foods.
4:35
Rebecca Berens MD: And this is done in like a looser sense in more popular fad diets.
4:39
Rebecca Berens MD: Like the whole 30 is another example.
4:42
Rebecca Berens MD: It's not as strict as the pure autoimmune protocol, but I think this idea in general is, is commonly discussed.
4:49
Rebecca Berens MD: And the autoimmune protocol is just one of these.
4:51
Rebecca Berens MD: And I think the other claim that sort of goes along with this is that you can use this protocol instead of the toxic medications that we use to treat autoimmune diseases, to manage those symptoms.
5:03
Rebecca Berens MD: So then you can avoid being on medication.
5:05
Rebecca Berens MD: And I think that sort of is a separate claim that's made implicitly in in the marketing of this protocol.
5:12
Sonia Singh MD: Yeah, for sure.
5:12
Sonia Singh MD: I wanna, I'm making a note to myself'cause I wanna come back to that particular concept.
5:16
Sonia Singh MD: 'cause I think that's really, so basically the general idea is that people must be consuming something dietarily that is inflaming them or causing this inflammation that is driving their autoimmune disease.
5:27
Sonia Singh MD: So if they can just figure out what those foods are and start avoiding those foods strategically, then their issue will be improved or resolved.
5:37
Rebecca Berens MD: Yeah, essentially.
5:37
Rebecca Berens MD: Got it.
5:38
Sonia Singh MD: Okay.
5:39
Sonia Singh MD: So what do you think makes this particular idea, this protocol viral and appealing to people?
5:46
Rebecca Berens MD: Yeah, so I think obviously as we've talked about before, there is this idea of natural is better and I wanna avoid being on a medication.
5:53
Rebecca Berens MD: That I think plays into a lot of why people are seeking out alternative.
5:58
Rebecca Berens MD: Things.
5:58
Rebecca Berens MD: And autoimmune conditions are relatively common.
6:01
Rebecca Berens MD: They have a huge impact on day-to-day life function, pain, overall wellbeing, like energy levels.
6:08
Rebecca Berens MD: They do also disproportionately affect women.
6:10
Rebecca Berens MD: Which as we've talked about in prior episodes, tends to feed into some of the discussion about these alternative factors for a variety of reasons that we've already gone into.
6:18
Rebecca Berens MD: The other thing is, it's.
6:19
Rebecca Berens MD: Really difficult to get a diagnosis for an autoimmune condition, especially initially, A lot of times the symptoms can start off pretty vague and difficult to tease out.
6:29
Rebecca Berens MD: And there's a lot of overlap of different symptoms with different diseases.
6:33
Rebecca Berens MD: And then on top of that, the medications can have a pretty significant side effect profile and can be very expensive.
6:40
Rebecca Berens MD: And so there is a, people who do struggle with these conditions have a very strong incentive to not have to take these expensive and side effect producing medications.
6:49
Rebecca Berens MD: Some patients are having to go in for monthly infusions.
6:52
Rebecca Berens MD: Some patients are taking pills that cause significant GI side effects on a regular basis.
6:56
Rebecca Berens MD: There's a lot to that.
6:58
Rebecca Berens MD: So the disease itself has a, Impact on day-to-day life.
7:01
Rebecca Berens MD: And then also the treatment has a big impact on day-to-day life.
7:04
Rebecca Berens MD: So it's feels a lose situation I think a lot of times to patients who are struggling with this.
7:08
Rebecca Berens MD: I think the other thing is inflammation in general is implicated in a lot of our, most common morbidity and mortality causing diseases like type two diabetes, cardiovascular disease, cancer, cognitive disorders.
7:22
Rebecca Berens MD: There's inflammation is implicated in this and inflammation now is a buzzword on the internet, yeah.
7:26
Rebecca Berens MD: And so I think there's this idea too that oh, if this, if there's something I can do with my immunity that's causing these diseases and it works for autoimmune disease, it would also work for these other diseases that are also very common, and difficult to, and so I think it's also this idea that people come to this is something I can do to prevent these diseases.
7:45
Rebecca Berens MD: And if it works for an autoimmune condition, it'll definitely work for this.
7:48
Rebecca Berens MD: Yeah.
7:49
Rebecca Berens MD: So it's like conflating the idea of managing an autoimmune condition with also managing all these other very chronic conditions.
7:56
Rebecca Berens MD: So it can apply to a lot of people, even someone who may not have an autoimmune condition.
8:00
Sonia Singh MD: Yeah, and I think the other thing is that we talked about this with respect to thyroid disease too, is with a lot of autoimmune conditions, we can't nail down one root cause.
8:09
Sonia Singh MD: If there are certain people, practitioners that will tell you they know exactly what the root cause is, when you look at the medical data as a whole, I don't think we a hundred percent with certainty can say in each individual case, for some people there is genetic predisposition, and that's obvious from family history.
8:23
Sonia Singh MD: For some people there is none.
8:24
Sonia Singh MD: And it seems like there's some complex, perfect storm or combination of factors including lifestyle, including exposures, including environment, including str, including so many different things that are probably playing into the presentation and, manifestation of the disease.
8:40
Sonia Singh MD: But.
8:41
Sonia Singh MD: It sucks to not feel like you understand why you got something or why it's happening to you, and it didn't happen to your sister, or it didn't happen to your brother or your mom or whatever, and so I think a common theme we keep talking about is illusion of control, and so I think it's appealing to say it's just certain foods that are triggering this inflammation.
9:01
Sonia Singh MD: And if you can just figure out what those are and remove those from your diet, you have control.
9:06
Sonia Singh MD: You can resolve this thing.
9:07
Sonia Singh MD: And that's the reason, it's oh my gosh, I I've just been eating onions for all these years and I didn't know that they were causing my inflammation, and I do think.
9:16
Sonia Singh MD: I do.
9:16
Sonia Singh MD: Okay.
9:16
Sonia Singh MD: I guess this is a little bit more in the negative truth category, so I'll pause there, but, okay.
9:20
Sonia Singh MD: Yeah, so I think there's so many different reasons and I think autoimmune disease and hormone related disease, hormonal conditions are two big categories where there's so much gray and nebulousness that, there it's fertile ground for these types of false claims and things to arise.
9:37
Sonia Singh MD: So yeah, totally agree.
9:38
Sonia Singh MD: And then I wanted to point out that.
9:40
Sonia Singh MD: Like you said in the case of autoimmune diseases hard to pin on a diagnosis.
9:44
Sonia Singh MD: Sometimes it starts out and you don't really meet the diagnostic criteria, and then a few years later you do meet the diagnostic criteria.
9:49
Sonia Singh MD: And I'm sure that's such a frustrating journey for the patient to be on.
9:53
Sonia Singh MD: Or if you're there and you're getting this diagnosis and it feels like this huge shock, I've definitely had a lot of patients call me crying after a rheumatol, like a first rheumatology visit and say oh my God, they think I have lupus, or they think I have RA and they wanna put me on this med.
10:06
Sonia Singh MD: And they said it's gonna be, I have to go get all these tests beforehand that, and it's so overwhelming.
10:11
Sonia Singh MD: And so then I think, again, this false dichotomy is almost comforting to say either you can go the natural route or you can go the toxic medication route.
10:20
Sonia Singh MD: When in fact, I think, if you just step back and think about it rationally, probably there's evidence that the medicine is going to be beneficial, can help you, and there's probably evidence for some lifestyle and dietary methods that will help you.
10:33
Sonia Singh MD: And if you use them in combination, that's probably gonna be even more helpful.
10:37
Sonia Singh MD: It does not have to be one or the other, and I really think in a lot of the wellness content, I see it, it's presented very much as a, oh, like you don't wanna do, that toxic thing?
10:47
Sonia Singh MD: Why would you wanna do that to myself?
10:49
Sonia Singh MD: It was so funny.
10:49
Sonia Singh MD: I actually, this is like tangentially related, but.
10:52
Sonia Singh MD: I got head lice from my preschooler when I was freshly postpartum with a, I had a two week old baby and I was like, oh my God.
10:59
Oh,
10:59
Rebecca Berens MD: excellent timing.
10:59
Rebecca Berens MD: Wonderful.
11:00
Sonia Singh MD: Yeah, great timing.
11:01
Sonia Singh MD: And I asked the school nurse told us do the promethrin shampoo and, whatever.
11:05
Sonia Singh MD: She told us the regimen and then you're supposed to come comb it out with the knit comb.
11:08
Sonia Singh MD: And I was trying to comb it out with the knit comb.
11:10
Sonia Singh MD: I have a lot of hair and I just was like, oh my God, I don't know if I'm gonna get them all out.
11:15
Sonia Singh MD: And so then I called one of those lice clinics and a lice lady.
11:18
Sonia Singh MD: And the lice lady was like, oh.
11:20
Sonia Singh MD: And I told her that I was nursing at the time, and the lice lady was like, do not use permethrin.
11:25
Sonia Singh MD: Why would you wanna put those toxic things on your head?
11:27
Sonia Singh MD: You should not do that.
11:28
Sonia Singh MD: We use these all natural I forgot what the main oil is in their magical potion that they use.
11:33
Sonia Singh MD: She was like, it's all natural ingredients and we comb it through whatever.
11:36
Sonia Singh MD: And it just struck me in that moment, how strongly she was saying like, either you go that route or you go this route.
11:44
Sonia Singh MD: And it gave me so much anxiety.
11:45
Sonia Singh MD: 'cause I was like, I already used the permethrin on my hair and I washed it all out.
11:48
Sonia Singh MD: But I don't know.
11:49
Sonia Singh MD: My baby's two weeks old.
11:50
Sonia Singh MD: Aw.
11:50
Sonia Singh MD: And in reality, now I've been through it twice now.
11:56
Sonia Singh MD: I use the Permethrin shampoo and then I call the Ice Lady and I have her comb it all out.
12:01
Sonia Singh MD: So I just do both and then I feel really well assured.
12:04
Sonia Singh MD: I can tell the nurse I did the treatment and I also have it all combed out.
12:09
Sonia Singh MD: It's just a reminder.
12:10
Sonia Singh MD: It doesn't have to be both.
12:11
Sonia Singh MD: And sometimes presenting it that way is just guilt and anxiety producing more than it's helpful.
12:17
Rebecca Berens MD: Yeah, absolutely.
12:19
Rebecca Berens MD: And I think as with everything that we talk about, it's the nuance, right?
12:21
Rebecca Berens MD: There's not, it's not one side or the other.
12:25
Rebecca Berens MD: It's, there's a middle ground and that's where often the answer probably is.
12:29
Rebecca Berens MD: So yeah, so we'll we can move on to the negative truth to talk about that and then and then get deeper into this.
12:34
Rebecca Berens MD: Negative truth, there is evidence that certain dietary components can influence our inflammation levels.
12:41
Rebecca Berens MD: And there's quite significant evidence about this actually.
12:44
Rebecca Berens MD: And I have a couple of studies here.
12:46
Rebecca Berens MD: What I will say it was, very difficult to pin down nutrition research in general.
12:52
Rebecca Berens MD: It's just difficult to do nutrition research and we'll talk about this when we talk about these studies.
12:55
Rebecca Berens MD: But I think.
12:57
Rebecca Berens MD: It's hard.
12:58
Rebecca Berens MD: I will just start off with saying that, and I think that's where a lot of the confusion around nutrition comes from and why you hear so many different things from different people is you can probably find research to support just about anything when it comes to nutrition.
13:11
Rebecca Berens MD: Yeah.
13:12
Rebecca Berens MD: Because most of the time with nutrition, we're not like.
13:15
Rebecca Berens MD: Putting someone in a randomized controlled trial where they're, we're controlling every aspect of their diet and behavior and activity and everything.
13:23
Rebecca Berens MD: It's just not practical to do that.
13:24
Rebecca Berens MD: Yeah.
13:24
Rebecca Berens MD: So it is just different types of studies that are not the gold standard that we typically think of.
13:29
Rebecca Berens MD: So I just wanna preface this by saying that, but the, so there's one study that's published in jama.
13:33
Rebecca Berens MD: It's called Intake and Sources of dietary Fiber, inflammation and cardiovascular disease in older US adults.
13:38
Rebecca Berens MD: And so in this one dietary intake was acce assessed by a food frequency questionnaire, which again, you're relying on the recall and self-reporting of the patients who did not, and these patients did not have prevalent cardiovascular disease.
13:51
Rebecca Berens MD: And this was co collected at baseline and then followed over time.
13:55
Rebecca Berens MD: So the data was evaluated from 1989 through 2015, so this is quite a long study and had over 4,000 people in it.
14:03
Rebecca Berens MD: So it was a large study but again relying on recall and self-reporting.
14:07
Rebecca Berens MD: And then they assessed inflammation using blood samples at baseline and then also looking at outcomes.
14:12
Rebecca Berens MD: And they, assessed this against the association with dietary fiber intake.
14:16
Rebecca Berens MD: And so among fiber sources there's cereal fiber, which is the insoluble fiber and fruit and vegetable fiber, which is a soluble fiber.
14:24
Rebecca Berens MD: Serial fiber was consistently associated with lower inflammation and also associated with lower cardiovascular disease incidents.
14:32
Sonia Singh MD: Are they just referring to insoluble fiber as cereal fiber, or do they mean like fiber consumed from cereal products?
14:39
Rebecca Berens MD: They're talking about any fiber from ac, like not just cereal products, but like cereal fibers.
14:45
Rebecca Berens MD: Yeah.
14:45
Sonia Singh MD: Like
14:45
Rebecca Berens MD: basically any
14:46
Sonia Singh MD: insoluble
14:46
Rebecca Berens MD: fiber, insoluble versus soluble fiber was my understanding as I read it.
14:49
Rebecca Berens MD: Okay.
14:49
Rebecca Berens MD: And then, so that was interesting.
14:51
Rebecca Berens MD: And it the same was not actually true of the soluble fibers, which I thought was very interesting.
14:55
Rebecca Berens MD: But they were, again, they were looking at this based on cardiovascular disease incidents, and then also some inflammatory markers including interleukin 18 C-reactive protein.
15:03
Rebecca Berens MD: So yeah, so this was interesting.
15:05
Rebecca Berens MD: And I think this is where a lot of the, like American College of, or American cartilage of cardiology or American cardiology society, this is where a lot of those cardiovascular disease guidelines come from is this this sort of study.
15:16
Rebecca Berens MD: And so this is clear evidence here of a dietary component that has an influence on inflammation levels.
15:21
Rebecca Berens MD: Yeah.
15:22
Rebecca Berens MD: There's also a very large.
15:25
Rebecca Berens MD: Summary of evidence study that I looked at from the British Journal of Nutrition that was published in 2024.
15:30
Rebecca Berens MD: It's called Overview of Anti-Inflammatory Diets and their Promising Effects on non-communicable diseases.
15:35
Rebecca Berens MD: And I, this one I liked'cause it just summarized everything.
15:38
Rebecca Berens MD: 'cause like I said, it was a lot.
15:39
Rebecca Berens MD: Yeah, it's a lot to, to dig through.
15:41
Rebecca Berens MD: But essentially they looked at a variety of dietary components that across many studies, over a lot of time have shown some anti-inflammatory effects.
15:50
Rebecca Berens MD: And then said what are the effects that have been seen?
15:52
Rebecca Berens MD: And so there's a really nice table that I just used here as like a summary of what those things are.
15:57
Rebecca Berens MD: So Omega-3 fatty acids.
15:59
Rebecca Berens MD: Monounsaturated fatty acids, which is what you think of in Olive oil, avocados antioxidants that you find in fruits and vegetables, nuts and seeds spices polyphenols, which you find in olive oil, nuts, seeds, dark chocolate, legumes dietary fiber phytochemicals again in like spices, probiotics and things like yogurt and fermented foods.
16:19
Rebecca Berens MD: Vitamins and minerals.
16:20
Rebecca Berens MD: And then also low glycemic foods, meaning whole grain ve whole grains legumes and non-starchy vegetables that have a lower glycemic end index.
16:28
Rebecca Berens MD: So all of these things have a variety of anti-inflammatory properties that were determined in these studies.
16:34
Rebecca Berens MD: And we can put a summary table of this in our show notes for people to look through.
16:38
Rebecca Berens MD: I don't wanna get too deep into the weeds here because there's a lot to talk about, but but.
16:42
Rebecca Berens MD: All that to say, there's evidence for anti-inflammatory properties of some of these things.
16:46
Rebecca Berens MD: There's also evidence for some inflammatory properties of some foods.
16:50
Rebecca Berens MD: And things like processed meats, alcohol there there's evidence for that.
16:55
Rebecca Berens MD: I didn't get all, all as much all into that here.
16:57
Rebecca Berens MD: But point being, we have evidence that supports the idea that our diet has an impact on inflammation levels.
17:05
Rebecca Berens MD: And so that is true.
17:08
Sonia Singh MD: Yeah.
17:08
Sonia Singh MD: This is a really nice table for summary and so I'm glad that we're gonna put this somewhere in the show notes so that people can, and access this.
17:16
Sonia Singh MD: I think.
17:17
Sonia Singh MD: You did a nice job emphasizing, all these things that we know are anti-inflammatory.
17:22
Sonia Singh MD: Because I think as we've talked about before, like in the eating clean episodes, sometimes there's overemphasis on all the things you need to avoid.
17:29
Sonia Singh MD: And even the structure of what, what you told me so far, like I have not independently looked at like a full description of the autoimmune protocol, but it sounds like it really leans heavily on restricting foods.
17:43
Rebecca Berens MD: Yes.
17:43
Rebecca Berens MD: And so we will definitely get deep into that when we talk about the facts with the context and nuance here because that I think is the key difference here between when we say an anti-inflammatory diet versus an autoimmune protocol.
17:58
Rebecca Berens MD: So just getting into the facts, what is the difference between these two things?
18:01
Rebecca Berens MD: So there is an anti-inflammatory diet, which is.
18:05
Rebecca Berens MD: I hate the word diet, but when we talk about diet, what we're talking about,
18:08
Sonia Singh MD: dietary pattern, I like to
18:09
Rebecca Berens MD: use the word dietary
18:10
Sonia Singh MD: pattern.
18:10
Sonia Singh MD: Dietary pattern,
18:11
Rebecca Berens MD: diet pattern.
18:11
Rebecca Berens MD: Yes.
18:11
Rebecca Berens MD: Phrase.
18:11
Rebecca Berens MD: But when we say the word diet, we're talking about dietary pattern.
18:14
Rebecca Berens MD: We're not talking about a fad, diet specific diet that you go on.
18:17
Sonia Singh MD: Went on.
18:17
Sonia Singh MD: Yes.
18:18
Rebecca Berens MD: But so in anti-inflammatory dietary pattern, there is evidence for that sort of dietary pattern, reducing inflammatory markers, improving metabolic outcomes, and improving ca cardiome vascular incomes.
18:31
Rebecca Berens MD: And this is the stuff that you hear all the time, pretty consistently from most expert bodies worldwide, just a diet, prioritizing whole foods, lot of plants, fruits, vegetables, whole grains, fatty fish, unsaturated fats, fermented foods, like the Mediterranean diet is the classic example that I think is the best studied and is most well known.
18:54
Rebecca Berens MD: And they show beneficial effects.
18:56
Rebecca Berens MD: And this is again, a dietary pattern that is.
19:00
Rebecca Berens MD: Relatively easy.
19:02
Rebecca Berens MD: No, I'm not gonna say easy, but relatively easy.
19:04
Rebecca Berens MD: Yeah.
19:05
Rebecca Berens MD: To integrate into your life, assuming you have access to food, time to prepare food, all the things that we've, the socioeconomic factors that we talk about that are very
19:15
Sonia Singh MD: important.
19:15
Sonia Singh MD: I, so I disagree.
19:16
Sonia Singh MD: Compared to what you're gonna probably describe about the autoimmune protocol, I'm sure it is easier, which is why
19:21
Rebecca Berens MD: I say relatively
19:22
Sonia Singh MD: Yes.
19:22
Sonia Singh MD: Relatively, it's easier and more feasible compared to that.
19:24
Sonia Singh MD: But it is not the way the majority of Americans eat
19:27
Rebecca Berens MD: right now.
19:27
Rebecca Berens MD: Correct.
19:28
Sonia Singh MD: Despite the fact that it is like the boring humdrum advice that we give all day, every day.
19:33
Sonia Singh MD: It is not the way the vast majority of people eat.
19:35
Sonia Singh MD: Correct.
19:36
Sonia Singh MD: Yeah.
19:36
Rebecca Berens MD: But like you can follow, assuming you have the resources to do
19:39
Sonia Singh MD: yes.
19:40
Rebecca Berens MD: You can do this and live a relatively normal life without having to weigh your food aggressively read nutrition labels.
19:48
Rebecca Berens MD: All that sort of stuff that goes into these very restrictive diets.
19:51
Rebecca Berens MD: You can go to a restaurant.
19:54
Rebecca Berens MD: And be able to order something that probably generally fits into this diet because part of the diet too is it's not a hundred percent, it's a dietary pattern, right?
20:02
Rebecca Berens MD: So this is this doesn't mean you never eat any refined sugar and you never do.
20:06
It
20:06
Sonia Singh MD: is not a
20:07
Rebecca Berens MD: vegan diet, right?
20:09
Rebecca Berens MD: This is a, most of the time we integrate most of these foods and we still can have some of those other things, but most of the time we're following this general pattern, right?
20:16
Rebecca Berens MD: Yes.
20:16
Rebecca Berens MD: So it's not a strict diet.
20:17
Rebecca Berens MD: So that to say if you have the resources to do you can probably follow it.
20:21
Rebecca Berens MD: Which again, a lot of people do not have the resources to do and and so I think, point being this is a dietary pattern that is anti-inflammatory and probably has a lot of benefits and whether you have an auto autoimmune disease or at your risk of cardiovascular disease or metabolic.
20:35
Rebecca Berens MD: Problems.
20:36
Rebecca Berens MD: This is a dietary pattern that makes sense, that probably has an evidence based behind it to probably influence your outcomes with those conditions.
20:43
Sonia Singh MD: Yeah.
20:43
Rebecca Berens MD: A IP is very different.
20:47
Rebecca Berens MD: Yeah.
20:47
Rebecca Berens MD: So it is extremely restrictive.
20:48
Rebecca Berens MD: It involves an elimination phase in which you eliminate grains, legumes, nuts, seeds, nightshade, vegetables, eggs and dairy.
20:56
Sonia Singh MD: Ooh.
20:56
Rebecca Berens MD: And generally that's for 30 to 90 days or until symptom relief,
20:59
Sonia Singh MD: legumes, nuts and seeds.
21:01
Sonia Singh MD: I
21:01
Rebecca Berens MD: know.
21:01
Rebecca Berens MD: I'm like, what do you eat?
21:03
Sonia Singh MD: Oh, that makes me so sad.
21:06
Sonia Singh MD: Okay.
21:06
Rebecca Berens MD: Yeah.
21:06
Rebecca Berens MD: And so it, that is very difficult to follow.
21:10
Sonia Singh MD: Yeah.
21:10
Rebecca Berens MD: I doubt, I actually don't know what you would eat.
21:12
Rebecca Berens MD: I was trying to think about this.
21:13
Rebecca Berens MD: I was like, what would I eat?
21:14
Rebecca Berens MD: 'cause this is all I eat all the time.
21:17
Rebecca Berens MD: And
21:17
Sonia Singh MD: well, and importantly, those are a lot of the things that are actually part of, a healthy plant-based Mediterranean diet.
21:23
Sonia Singh MD: Yes.
21:24
Sonia Singh MD: And like the grains, legumes, nuts, seeds, vegetables, eggs.
21:27
Sonia Singh MD: Very.
21:28
Rebecca Berens MD: Yeah.
21:29
Rebecca Berens MD: And it really does eliminate a lot of things.
21:32
Rebecca Berens MD: It's very challenging to follow and it's very strict about elimination too.
21:36
Rebecca Berens MD: Like the cross contamination concerns and all these things are also an issue.
21:39
Rebecca Berens MD: So the it's not just oh, just try to li limit these things.
21:42
Rebecca Berens MD: It's no, 100%, none of these things.
21:45
Sonia Singh MD: Well also 30 to 90 days, 90 days well done, or until symptom relief.
21:50
Sonia Singh MD: That could be a really long time,
21:52
Rebecca Berens MD: you, but
21:53
Sonia Singh MD: then you hear
21:53
Rebecca Berens MD: about
21:54
Sonia Singh MD: this, you have no effect.
21:55
Rebecca Berens MD: Yeah.
21:55
Rebecca Berens MD: And so this comes up with the FODMAP diet too, right?
21:57
Rebecca Berens MD: Which is often recommended for IBS, which is a similar thing Yeah.
22:01
Rebecca Berens MD: Of there's an elimination phase and a reintroduction phase.
22:04
Rebecca Berens MD: But I've seen a lot of patients who've had this issue too with that when they're recommended for IBS is like, the elimination phase never ends.
22:11
Sonia Singh MD: Yes.
22:11
Rebecca Berens MD: Right.
22:11
Rebecca Berens MD: If the symptoms.
22:13
Rebecca Berens MD: Especially GI symptoms.
22:14
Rebecca Berens MD: Like when do you say you never have a GI symptom, it can become really difficult.
22:19
Sonia Singh MD: Also, I think it's really important to point out that okay, so the diet we just discussed, which is appears to be the dietary pattern we just discussed.
22:26
Sonia Singh MD: Which appears to be not only the most anti-inflammatory, but also appears to be the best for cardiovascular risk, best for cancer prevention.
22:34
Sonia Singh MD: That is the dietary pattern that I am pushing most patients towards generally in life.
22:39
Sonia Singh MD: So if that is the ideal that we're working towards, and then you super impose on that all of these restrictions, you don't have a lot left.
22:46
Sonia Singh MD: No, you eliminated a lot of the satisfying, in a plant-based meal, nuts, seeds, and legumes are a big part of how you make it filling and satisfying without putting a bunch of meat products or refined carbohydrates in there.
22:58
Sonia Singh MD: I, I.
23:00
Sonia Singh MD: I just think for somebody I can't imagine somebody going no, I can't imagine.
23:04
Sonia Singh MD: I'm sure it happens that some people go on the autoimmune protocol and yeah, they're eliminating these things, but potentially they're still not making very healthy choices or they're still choosing things that are not particularly nutritious or serving them, but they're sticking to the protocol.
23:16
Sonia Singh MD: But if you're trying to eat generally healthy, according to the evidence, and then you do this also, you're really limited in what you can consume.
23:25
Rebecca Berens MD: Yeah.
23:25
Rebecca Berens MD: Yeah, I was thinking about it and I actually do not know what I would eat.
23:30
Rebecca Berens MD: I don't know how I would
23:32
Sonia Singh MD: compose,
23:32
Rebecca Berens MD: what would I eat for any of my meals?
23:34
Rebecca Berens MD: How, and especially for example, I eat my breakfast in the car, I drive my kids to school.
23:39
Rebecca Berens MD: I eat my breakfast in the car as I'm driving to work.
23:41
Rebecca Berens MD: I eat lunch at my desk while I'm working, and then I cook dinner when I get home.
23:45
Rebecca Berens MD: Okay.
23:45
Rebecca Berens MD: So two of those meals are not eaten inside my house.
23:49
Sonia Singh MD: Yeah.
23:49
Rebecca Berens MD: I'm like, what is a portable.
23:51
Sonia Singh MD: You can't have eggs, you can't have yogurt, you can't have a grain.
23:55
Rebecca Berens MD: Yeah.
23:55
Rebecca Berens MD: And I was like, you could eat chicken, and
23:59
Sonia Singh MD: yeah, this, I
24:00
Rebecca Berens MD: don't know what probably
24:01
Sonia Singh MD: make you lean pretty heavily on proteins and like animal-based proteins.
24:05
Sonia Singh MD: Yeah.
24:06
Sonia Singh MD: Which depending on which ones you choose could be pro-inflammatory,
24:10
Rebecca Berens MD: And just in terms of the the practicality of like actually preparing and eating this meal in a modern world, I just don't know how it would be done.
24:20
Rebecca Berens MD: And even even outside of a modern world, in the past, grains have been like a pretty heavy staple of world worldwide diets for a long time.
24:29
Rebecca Berens MD: I'm just curious.
24:30
Rebecca Berens MD: I just don't even know what I would do.
24:32
Rebecca Berens MD: So yeah, so like I said, 30 to 90 days or until symptom relief, you're on this very restrictive diet and then there's a reintroduction phase in which you reintroduce these foods one at a time, five to seven days apart, so that you can correlate the symptoms to which food caused them.
24:47
Sonia Singh MD: What would be your sources of fiber?
24:50
Sonia Singh MD: Doesn't mean,
24:50
Rebecca Berens MD: I guess there's, I guess there's non, there are some non nightshade vegetables that you could eat.
24:56
Oh,
24:56
Sonia Singh MD: I see, okay.
24:56
Sonia Singh MD: It's just the nightshade vegetables.
24:58
Rebecca Berens MD: Yes.
24:58
Rebecca Berens MD: It's just the nightshade vegetables.
24:59
Rebecca Berens MD: So there would be some non nightshade vegetables and then there would be meats, and that's pretty much all I could come up with.
25:04
Rebecca Berens MD: That you would be able to eat.
25:05
Sonia Singh MD: Yeah.
25:06
Sonia Singh MD: That's
25:06
Rebecca Berens MD: rough.
25:06
Rebecca Berens MD: So yeah.
25:07
Rebecca Berens MD: But even the reintroduction phase so you've done this for 30 to 90 days, which was super difficult, not compatible with any sort of normal life.
25:14
Rebecca Berens MD: Socializing anything.
25:16
Rebecca Berens MD: And then every five to seven days you have to introduce these foods and then perseverate on what did I feel today, how it is this, from this feel.
25:22
Rebecca Berens MD: Yeah.
25:22
Rebecca Berens MD: And so this is many months of reintroduction, between the, initial elimination and the reintroduction.
25:30
Rebecca Berens MD: This is a long process.
25:32
Rebecca Berens MD: Yeah.
25:33
Rebecca Berens MD: So this is a significant portion of your life where you are not able to eat normally.
25:38
Rebecca Berens MD: Socialized normally.
25:41
Rebecca Berens MD: You have to be very hyper-focused on your food and your body.
25:46
Rebecca Berens MD: This is very challenging.
25:47
Rebecca Berens MD: Yeah.
25:47
Rebecca Berens MD: Very challenging.
25:49
Sonia Singh MD: So I wanna take a moment to pause and say I think maybe part of the why they've chosen these particular things dunno about nightshades as much, but like nuts and eggs and dairy.
26:00
Sonia Singh MD: Dairy is a thing that a lot of people don't tolerate.
26:02
Sonia Singh MD: So I can understand.
26:04
Sonia Singh MD: There's a lot of people that come to me with digestive vague digestive things and I'm like, have you tried, cutting out dairy for two weeks depending on what they're describing?
26:11
Sonia Singh MD: And that's not an unreasonable thing to do.
26:13
Sonia Singh MD: Eggs and nuts are common allergens.
26:15
Sonia Singh MD: So I'm, I wonder if that's kind of part of the rationale for including those.
26:20
Sonia Singh MD: But allergy and sensitivity are very different.
26:23
Sonia Singh MD: And the point I wanna make is just that I don't want somebody to list to listen to this.
26:27
Sonia Singh MD: And for them to be like eggs make me feel terrible.
26:30
Sonia Singh MD: You're saying they're not pro-inflammatory.
26:32
Sonia Singh MD: That's not a thing.
26:32
Sonia Singh MD: And I, food sensitivities are absolutely real.
26:36
Sonia Singh MD: Allergies are a very specific type of physiologic response.
26:39
Sonia Singh MD: And, they can be evaluated and tested for sensitivities are a little bit more nebulous, but they're real.
26:45
Sonia Singh MD: They happen and they're real.
26:47
Sonia Singh MD: And there is a food that makes you feel bad.
26:50
Sonia Singh MD: By all means, if you notice that it's okay to decide, you're not gonna eat that thing.
26:54
Sonia Singh MD: And I always remind my patients if it's just a sensitivity and it's not classic allergy response we don't need a test to validate us.
27:00
Sonia Singh MD: If you feel terrible when you eat that thing it's not a, it's not a major restriction for you and it's not something that's, gonna cause a lot of problems for you to eliminate from your diet nutritionally then eliminate it, i, think I have a garlic sensitivity and I swear my joints hurt when I eat garlic.
27:14
Sonia Singh MD: I get a headache, I get, and it doesn't make a lot of physiologic sense from a medical perspective, but I swear it's happening and so I'm gonna avoid it.
27:22
Sonia Singh MD: But I think this idea of just of like with the fom not diet too, it is just avoid all of these things and then reintroduce them.
27:31
Sonia Singh MD: I can understand maybe that in a research setting, but in practical, real life that is really hard.
27:37
Sonia Singh MD: I with FODMAPs, I recommend I always educate people about FODMAPs who have IBS.
27:41
Sonia Singh MD: And then I share resources that talk about what FODMAPs are and what foods are high and low in FODMAPs.
27:46
Sonia Singh MD: And I tell them to use it like a list of likely suspects and to try to notice, keep a food diary and notice perhaps if there's a pattern with one of those high FODMAP foods.
27:55
Sonia Singh MD: But I rarely recommend they go on the actual FODMAP diet because it's just, it's again, in a research setting, maybe it would make sense, but for an actual human being, living a real life, I think it's hard.
28:08
Sonia Singh MD: And then again, you have to take into account what are that person's other medical needs?
28:12
Sonia Singh MD: What is their history?
28:13
Sonia Singh MD: Do they have a history of disordered eating?
28:14
Sonia Singh MD: Do they have other things that they need to work on nutritionally, and yeah, I just, yeah, food sensitivities are real, but this idea of blanket elimination of multiple categories of food is problematic.
28:26
Rebecca Berens MD: Yeah, and I think, we're definitely gonna dig into everything else that you just said, but I think the, even with the FODMAP diet, I think it is always assumed that is done under the supervision of a dietician if you are gonna do these strict elimination, right?
28:40
Rebecca Berens MD: And we'll get into this later.
28:41
Rebecca Berens MD: I think this is the key thing that, that is really not explained in these, internet.
28:47
Rebecca Berens MD: It's oh, just do this diet.
28:48
Rebecca Berens MD: Like it's no big deal.
28:49
Rebecca Berens MD: If you are someone who truly does have to do a strict elimination diet, and there certainly, I'm sure are cases where it is appropriate, clinically it does require close supervision and monitoring.
29:00
Rebecca Berens MD: And we'll get into that.
29:01
Rebecca Berens MD: But I think all that to say the point being here, this is really hard and probably not practical for most people.
29:07
Rebecca Berens MD: Yeah.
29:07
Rebecca Berens MD: I wanna talk a little bit about the evidence for and against a IP meaning what are the potential benefits, what's the evidence of potential benefit?
29:14
Rebecca Berens MD: What's the evidence of potential risk?
29:16
Rebecca Berens MD: Because these are the important things for us to talk about when we're talking about any intervention.
29:19
Rebecca Berens MD: So there's really limited evidence directly studying a IP and any evidence that there is from a very small trial or an uncontrolled trial, like pilot level stuff.
29:29
Rebecca Berens MD: There was one trial that I found efficacy of the autoimmune protocol diet for inflammatory bowel disease.
29:35
Rebecca Berens MD: And this had 15 patients, so pretty small who had active Crohn's disease or ulcerative colitis.
29:41
Rebecca Berens MD: Seven of those 15 were taking biologic medications.
29:44
Rebecca Berens MD: Also.
29:45
Rebecca Berens MD: Okay.
29:45
Rebecca Berens MD: So they were not only doing the diet to control this, they were also taking medication.
29:49
Rebecca Berens MD: And they followed a six week elimination phase followed by five week maintenance, which I'm assuming by maintenance they meant the reintroduction.
29:54
Rebecca Berens MD: It was a little unclear to me.
29:56
Rebecca Berens MD: There was clinically significant increased improvement in disease activity scores.
30:02
Rebecca Berens MD: So improvement in how they clinically felt from baseline to week 11.
30:06
Rebecca Berens MD: And there was some endoscopic improvement on, in only seven patients, but only seven of the 15 actually went under endoscopy, was what I could tell.
30:15
Rebecca Berens MD: So like the seven of the 15 that went under endoscopy had improvements, but not all of them went under endoscopy.
30:21
Rebecca Berens MD: Okay.
30:22
Rebecca Berens MD: There was no significant change in CRP or fecal cal protection levels.
30:25
Rebecca Berens MD: And there was no comparison group either.
30:28
Rebecca Berens MD: So small sample size, no comparison group.
30:31
Rebecca Berens MD: Limited.
30:33
Rebecca Berens MD: Outcomes.
30:34
Rebecca Berens MD: So not great quality evidence here.
30:36
Rebecca Berens MD: It's interesting it, warrant, maybe warrants more study, but not something that you would certainly make a clinical recommendation to a patient based on this alone.
30:44
Sonia Singh MD: I always wonder why a study like this even happens.
30:47
Sonia Singh MD: How hard would it have been to have a control group, to just be like, here's 15 other people with IPD that we're not gonna put on a diet.
30:55
Sonia Singh MD: They didn't do a very strategic job selecting these people.
30:58
Sonia Singh MD: Some are on med, some are not on med, some are okay with getting an e gb, some are not.
31:03
Sonia Singh MD: So why not just, you gotta wonder why somebody even conducts such a low quality study.
31:09
Rebecca Berens MD: Yeah.
31:09
Rebecca Berens MD: I didn't dig too deeply into that.
31:11
Rebecca Berens MD: That's an interesting question that I
31:12
Sonia Singh MD: would, how hard is it to have another group that you do not do the intervention on and you just compare how they all look in, nine weeks or whatever, 11 weeks.
31:21
Rebecca Berens MD: Yeah.
31:21
Rebecca Berens MD: I wonder if this is almost like someone is has a hunch and they're like, lemme try it for some of my patients and see what happens.
31:26
Rebecca Berens MD: And then they report it.
31:28
Sonia Singh MD: Yeah, okay.
31:28
Sonia Singh MD: See you.
31:29
Sonia Singh MD: And you don't know that it's like
31:30
Rebecca Berens MD: a case report.
31:31
Sonia Singh MD: You also don't know how these patients are selected.
31:33
Sonia Singh MD: Maybe they're people who already were like, doctor, tell me what diet I can go on to help me with this.
31:38
Sonia Singh MD: In which case they're primed to, have belief that it's going.
31:41
Sonia Singh MD: Yeah.
31:42
Rebecca Berens MD: And that's the thing, you cannot blind this study.
31:44
Sonia Singh MD: Right, which
31:44
Rebecca Berens MD: is why a control group is so important because you cannot blind yourself to you went through this intervention.
31:49
Rebecca Berens MD: If you are expecting it to help you, and then your clinical disease activity score is improved.
31:56
Rebecca Berens MD: I don't know what to make of that.
31:59
Rebecca Berens MD: Because yeah, there's no there's no blinding, you can't be blind to this.
32:01
Sonia Singh MD: Also it's okay, so let's say they had selected like 15 other people in their clinic with IBD who were doing whatever the other treatment.
32:08
Sonia Singh MD: You don't know if these 15, they were like these people are on our study, we gotta bring them back and make sure their medicines are titrated and make sure they're like, like you just, you have no idea, how those people were treated differently compared to somebody who was not, in this study.
32:21
Sonia Singh MD: So I, I just think it's hard to really draw any conclusions from this in 15, 15 people.
32:26
Sonia Singh MD: And then this is just, this is Crohn's are ulcerative colitis.
32:29
Sonia Singh MD: So this is a very different disease than Hashimoto's thyroiditis or,
32:33
Rebecca Berens MD: right.
32:33
Rebecca Berens MD: Yeah.
32:34
Rebecca Berens MD: Because this is a GI disease, right?
32:35
Rebecca Berens MD: So like you would think, okay, if there's a food thing, it would make sense to me clinically that nutrition may have more of an impact.
32:41
Rebecca Berens MD: Impact on a GI thing, right?
32:42
Rebecca Berens MD: Yeah.
32:43
Rebecca Berens MD: So which, which again, maybe this is maybe this is the early stages and this is how.
32:47
Rebecca Berens MD: Research is conducted.
32:48
Rebecca Berens MD: The initial studies are maybe not huge, fully funded big things like they're little Yes.
32:53
Rebecca Berens MD: Interest.
32:53
Rebecca Berens MD: It's starting point.
32:54
Rebecca Berens MD: This is interesting.
32:55
Sonia Singh MD: Yeah.
32:55
Rebecca Berens MD: This is a point, this is interesting.
32:56
Rebecca Berens MD: I'm interested, but I'm not making a recommendation based on this study.
32:59
Rebecca Berens MD: Exactly.
33:00
Rebecca Berens MD: It, it warrants maybe further investigation.
33:02
Rebecca Berens MD: There's also some theoretical mechanisms that have been described linking autoimmunity to diet, and that's via the effect on the microbiome and some food antigen, cross reactivity and things like that.
33:14
Rebecca Berens MD: But there's not really a lot of evidence clearly connecting that to an outcome.
33:20
Rebecca Berens MD: I actually couldn't even find that many studies, if I'm being honest.
33:23
Rebecca Berens MD: This was just challenging.
33:24
Rebecca Berens MD: There was one study that was looking just at gluten-free diets for multiple sclerosis, psoriasis type one diabetes and autoimmune thyroid disease.
33:33
Rebecca Berens MD: And this was just gluten-free.
33:34
Rebecca Berens MD: This wasn't an autoimmune protocol.
33:35
Rebecca Berens MD: Yeah.
33:36
Rebecca Berens MD: And it actually had like mixed.
33:38
Rebecca Berens MD: Outcomes.
33:39
Rebecca Berens MD: Some people got better, some people got worse.
33:40
Rebecca Berens MD: So you know, all of that to say not a ton of evidence.
33:44
Rebecca Berens MD: There's maybe something to this, it's not to say that there's nothing about this protocol that could be beneficial, but it's just we don't have good evidence for it.
33:52
Rebecca Berens MD: And then I wanna go on to what are the risks?
33:55
Rebecca Berens MD: So anytime we're talking about an intervention, we always say this, you should know what the benefits are, you should know what the risks are, and you should know what the evidence is, supporting the benefits and the risks, because that's the only way you can make an informed decision, right?
34:05
Rebecca Berens MD: Yeah.
34:05
Rebecca Berens MD: So what are the risks?
34:06
Rebecca Berens MD: So the main concern is obviously nutritional deficiency.
34:10
Sonia Singh MD: Yeah.
34:10
Rebecca Berens MD: Based on just what can you even eat?
34:12
Rebecca Berens MD: Can you eat enough food?
34:14
Rebecca Berens MD: Are you able to eat enough food?
34:15
Rebecca Berens MD: And are you able to eat enough of the different nutrient types from the food since you're limiting so many food groups?
34:20
Rebecca Berens MD: So in that IBD trial that I talked about, there were baseline assessments, I identifying deficiencies that required repletion in vitamin D and iron.
34:28
Rebecca Berens MD: Yeah.
34:28
Rebecca Berens MD: So we already know that patients with autoimmune diseases, particularly these GI ones that affect absorption of nutrients, may have a compromised nutritional status at baseline.
34:36
Rebecca Berens MD: Yeah.
34:36
Rebecca Berens MD: And then we put dietary restriction on them that's just gonna compound that effect.
34:42
Rebecca Berens MD: And it's pretty it's pretty difficult to ensure that a person is getting adequate nutrition and meeting all of their nutritional needs when they're restricting so many food groups.
34:50
Rebecca Berens MD: And that's why, again, this is designed to be done under supervision of a dietician and close monitoring, not to be casually carried out.
35:00
Rebecca Berens MD: For funsies in that,
35:02
Sonia Singh MD: in that IBD study, did they track the nutritional deficiencies after they completed the protocol?
35:07
Rebecca Berens MD: So they were tracking them and repleting them.
35:10
Sonia Singh MD: Oh, okay.
35:11
Sonia Singh MD: Okay.
35:12
Sonia Singh MD: Also a little suspicious, how many people who do this in real life are having somebody track their nutritional deficiencies and replete them as needed?
35:20
Rebecca Berens MD: And that's the thing, if you're gonna do it, I think the point here is you should
35:23
Sonia Singh MD: Yes.
35:24
Rebecca Berens MD: Right.
35:24
Rebecca Berens MD: You should, because this is a known risk of this.
35:27
Rebecca Berens MD: It's a known risk of your baseline condition.
35:29
Sonia Singh MD: Yes.
35:29
Rebecca Berens MD: And it's a known risk of we're cutting out a bunch of food groups, so it might be hard for you to eat enough of all the things you need.
35:35
Rebecca Berens MD: So we should monitor that.
35:36
Rebecca Berens MD: So I think, this is not something that you are going to accomplish with an ebook or a blog post that tells you what to do.
35:43
Rebecca Berens MD: This is something that if you are gonna do it, if it truly is gonna have a clinical benefit for you, it's gonna need some monitoring and to make sure that everything is appropriate.
35:51
Rebecca Berens MD: There's also, as we've talked about, ad nauseam.
35:53
Rebecca Berens MD: We know that it's gonna be difficult to adhere long term to a restrictive diet.
35:58
Rebecca Berens MD: It's just gonna be hard to do.
35:59
Rebecca Berens MD: I don't think we need a study to tell us that.
36:02
Rebecca Berens MD: There probably are lots of studies that would tell us that, I think we have to be aware of the adherence to something like this because the adherence is the key aspect to how the mechanism of how this may work is like we remove this thing and then now you're not getting that inflammatory effect.
36:17
Rebecca Berens MD: So if we are not able to adhere to it, what was the point?
36:22
Rebecca Berens MD: And I think that's that's an important thing for us to to be thinking about.
36:26
Rebecca Berens MD: There also was some direct evidence that linked dietary restriction in general.
36:32
Rebecca Berens MD: A IP again not as specifically'cause there's just not a whole lot of study on that specifically, but.
36:37
Rebecca Berens MD: Potentially increasing risk of eating disorders.
36:39
Rebecca Berens MD: Now this was actually mixed.
36:41
Rebecca Berens MD: There was some studies saying yes, there's some studies saying no.
36:44
Rebecca Berens MD: But there were was specifically studies showing exclusion diet history associated with over three times the odds of having arfid, which is avoidant restrictive food intake disorder symptoms.
36:55
Rebecca Berens MD: And so for anyone who doesn't know, ARFID is a type of eating disorder that is not so much based on wanting to control body size and shape.
37:04
Rebecca Berens MD: But concern about eating food.
37:06
Rebecca Berens MD: And sometimes it's related to oh, I choked before and now I'm afraid of swallowing.
37:10
Rebecca Berens MD: Or sometimes it's like I had an allergic reaction, so now I'm afraid to try any foods.
37:14
Rebecca Berens MD: Sometimes it's, I have GI symptoms and so I'm worried about eating all the time and it, and it can spiral.
37:20
Rebecca Berens MD: And this study was interesting because, these were self-initiated exclusion diets often.
37:25
Rebecca Berens MD: Yeah.
37:25
Rebecca Berens MD: I think it was like 66% of the cases were self-initiated, so they were already excluding things.
37:29
Rebecca Berens MD: So it's a chicken or egg thing.
37:30
Rebecca Berens MD: Did they already have a risk for AIT?
37:32
Rebecca Berens MD: And they were already having AIT before they went into, so again, hard to see.
37:35
Rebecca Berens MD: I think point being that the more that you are thinking about and focusing on what you're eating and monitoring for how you feel in your body after you eat something, that just becomes a big focus in your brain.
37:48
Rebecca Berens MD: And so it's of course going to have an influence on.
37:51
Rebecca Berens MD: Your eating behaviors and your thoughts and feelings about eating and your experience of eating, and that's gonna have an impact on your day-to-day life.
37:59
Rebecca Berens MD: There's also been a study of patients with celiac disease showing that between 14 to 57% of individuals with celiac disease might meet criteria for arfid depending on which screening tool you're using.
38:11
Rebecca Berens MD: And again, someone who has celiac disease does have to follow a very strict elimination diet of eliminating gluten.
38:18
Rebecca Berens MD: And that is a requirement for the treatment of that disease, right?
38:21
Rebecca Berens MD: That's just something that those patients have to do.
38:23
Rebecca Berens MD: And it's very rigid and that just compounds the effect that those patients have about that.
38:27
Rebecca Berens MD: That's just with gluten.
38:28
Rebecca Berens MD: If you're also having to restrict all these other things, you can just imagine that it becomes a bigger component.
38:34
Rebecca Berens MD: There's also an interesting study that indicated there's a bidirectional relationship between eating disorders and autoimmune diseases.
38:41
Rebecca Berens MD: That's interesting.
38:42
Rebecca Berens MD: Which I think again, probably goes back to that multifactorial cause.
38:47
Rebecca Berens MD: There's a lot of overlap of those multifactorial causes when it comes to both autoimmune diseases and eating disorders.
38:52
Rebecca Berens MD: There's genetic predisposition, there's socioeconomic factors, there's trauma, all of these things that are contributors to both of the development of both of these disorders.
39:01
Rebecca Berens MD: And so it makes sense that there's overlap between the two.
39:04
Rebecca Berens MD: But again, if you're someone who already has struggled with some disordered eating and then you are now focusing on food and eating all of the time.
39:13
Rebecca Berens MD: It's easy to see how that could become something that spirals out of control.
39:17
Sonia Singh MD: Yeah.
39:18
Sonia Singh MD: Going back to our fit really quickly, I'm sure some people would wonder okay, so in Celiac where somebody legitimately has to really strictly eliminate gluten exposure and cross-contamination, all of that, how would that be afi And, I think the point to make here is I believe that, to qualify for a fit, it has to be either le, the restriction has to be to the level that it's causing them to not meet their nutritional needs, or it's causing functional impairment or psychological psychosocial distress.
39:42
Sonia Singh MD: Correct.
39:42
Sonia Singh MD: Something.
39:42
Sonia Singh MD: Correct.
39:43
Rebecca Berens MD: Yes.
39:43
Rebecca Berens MD: I should clarify that.
39:44
Rebecca Berens MD: So yeah, obviously with, so this is a DSM diagnosis, right?
39:46
Rebecca Berens MD: So anything in the DSM, like it has to be causing you a problem.
39:50
Sonia Singh MD: Yeah.
39:50
Rebecca Berens MD: You have the syn, but it's not affecting your function or your health in any other way.
39:54
Rebecca Berens MD: It's,
39:54
Sonia Singh MD: yeah,
39:55
Rebecca Berens MD: just
39:55
Sonia Singh MD: the, some people might say, oh just like I have a few patients with I have one patient with very refractory.
39:59
Sonia Singh MD: Celiac and he has to be very strictly avoidant.
40:02
Sonia Singh MD: And it's really hard for him.
40:04
Sonia Singh MD: It's very hard, and we've had to watch his nutritional deficiencies really closely, and do I think he has arfid?
40:10
Sonia Singh MD: Probably not, but may, yeah, I can see how that would develop, because,
40:14
Rebecca Berens MD: and so that may be where it depends on the criteria you're using, right?
40:18
Rebecca Berens MD: Which screening tool you're using.
40:19
Rebecca Berens MD: But I think that also comes to that person.
40:21
Rebecca Berens MD: Yeah.
40:21
Rebecca Berens MD: Certainly if they're not able to meet their nutritional needs because of how restrictive they are and they are, but
40:27
Sonia Singh MD: they have a malabsorption issue, so it's
40:29
Rebecca Berens MD: I know.
40:29
Rebecca Berens MD: And so it's easy to overlap, right?
40:31
Rebecca Berens MD: And so I think it becomes a question of okay, are they able to meet their needs at all?
40:35
Rebecca Berens MD: And if not, are they distressed by that?
40:37
Rebecca Berens MD: Yeah.
40:37
Rebecca Berens MD: Or is it yeah, this is hard, this is a horrible thing that I have to do, but I'm managing it, I'm coping.
40:43
Rebecca Berens MD: I think there's definitely patients who, it becomes something so overwhelming that it prevents them from being able to work a normal job, being able to have normal social relationships.
40:53
Rebecca Berens MD: They're just functional
40:53
Sonia Singh MD: impairment.
40:54
Rebecca Berens MD: Yeah.
40:54
Rebecca Berens MD: So functionally impaired by it, or so, nutritionally impaired by it, that they are not able to maintain their nutrition status.
41:02
Rebecca Berens MD: That, they're losing weight, they're having the complications associated with restrictive eating disorders, like they're having bradycardia, they're, all these things.
41:09
Rebecca Berens MD: They're having that as a result of their restriction.
41:11
Rebecca Berens MD: Not just oh yeah, we're having to keep an eye on this and monitor, and you gotta take these extra supplements to make sure your needs are met.
41:17
Rebecca Berens MD: So yeah that's where, when we're talking about any eating disorder, the functional impairment and the nutritional status is a key part of that diagnosis.
41:26
Sonia Singh MD: Yeah.
41:27
Sonia Singh MD: Okay.
41:28
Sonia Singh MD: I guess we talked a lot about the, so that's a good summary of all the downsides of, doing some of these restricted sites.
41:34
Sonia Singh MD: I feel like I hear a lot about.
41:36
Sonia Singh MD: Just gluten and dairy in the context of autoimmune disease.
41:38
Sonia Singh MD: Yes.
41:39
Sonia Singh MD: And I have so many patients and friends who have just casually been told by somebody oh, you have an autoimmune disease avoid gluten and dairy.
41:45
Sonia Singh MD: And I just, I try to remind patients that like I would never say something so casually to somebody without really solid evidence, because to eliminate even just those two things is not a super easy thing to do for a lot of people.
41:58
Sonia Singh MD: And it, it may involve you eating a different meal than your spouse or your children or your friends or, not eating at a party when what's served does not fit those criteria.
42:07
Sonia Singh MD: And those are all, yeah, those are really big deals, and you don't wanna improve one thing marginally or slightly and pay a huge price in some other category of your quality of life.
42:17
Sonia Singh MD: Yeah.
42:18
Rebecca Berens MD: Yeah.
42:19
Rebecca Berens MD: And I think in gluten specifically, the cross contamination part is so key.
42:22
Rebecca Berens MD: And I think a lot of times when I hear about people eliminating gluten.
42:25
Rebecca Berens MD: They're not actually eliminating gluten, they're significantly reducing their gluten intake, but they're still potentially getting cross contamination.
42:31
Rebecca Berens MD: They're still occasionally, and it's is it.
42:34
Rebecca Berens MD: Is it worth doing all the restriction if you're not gonna all the way do it?
42:38
Rebecca Berens MD: Because then you're just restricting a lot, but you're still not getting the benefit of having restricted it.
42:42
Sonia Singh MD: To be honest with you, a lot of the patients that I talk to that are like, oh, I stopped gluten and I feel so much better.
42:47
Sonia Singh MD: I usually ask them what were you eating before that you eliminated?
42:50
Sonia Singh MD: And so many of them, it's not like they were eating Bulgar and Farrow and Right.
42:55
Sonia Singh MD: They were eating, they, they were eating.
42:57
Sonia Singh MD: Like a lot of refined carbohydrates.
42:58
Sonia Singh MD: Yeah.
42:58
Sonia Singh MD: Because that was easy and quick for them.
43:00
Sonia Singh MD: And so yeah, maybe they felt better when they weren't doing it.
43:03
Sonia Singh MD: But do they need to like now avoid soy sauce and do they need to now make sure that, the pots don't touch with other stuff that's, probably not.
43:10
Sonia Singh MD: So it, can mean so many different things when people say I'm avoiding glu, like people say I'm avoiding gluten and I'm eating this gluten-free donut.
43:16
Sonia Singh MD: Or I have these gluten-free bars, and, the nutrition.
43:19
Sonia Singh MD: Yeah.
43:19
Rebecca Berens MD: It's like
43:20
Sonia Singh MD: the nutrition nerd in me is just is that better though?
43:23
Sonia Singh MD: Is it really better?
43:24
Rebecca Berens MD: And that's the thing, like it's, if you truly need to avoid gluten, then yes.
43:28
Rebecca Berens MD: But if you're just like, oh, it's, this is healthier'cause it's gluten-free.
43:32
Rebecca Berens MD: This is gluten free, it's not It's still a processed food, which is fine.
43:37
Rebecca Berens MD: Yeah.
43:37
Rebecca Berens MD: But it's not different.
43:38
Rebecca Berens MD: Just because it's gluten-free, it's more expensive probably.
43:41
Rebecca Berens MD: But it's not significantly nutritionally different.
43:43
Rebecca Berens MD: Unless there's a true need for you to actually.
43:45
Rebecca Berens MD: Avoid, exclusively avoid gluten.
43:47
Rebecca Berens MD: And so that's the thing, it's it's very, it's, it is used very casually, like you said.
43:53
Rebecca Berens MD: And it really should not be, like, if this is something that's truly needed, it does require a lot of careful consideration.
43:59
Sonia Singh MD: Consideration and
44:00
Rebecca Berens MD: thought and supervision and monitoring
44:02
Sonia Singh MD: and exploring what you're currently Yeah.
44:04
Sonia Singh MD: And I'm thinking that same thing with the autoimmune protocol.
44:07
Sonia Singh MD: Is that I always, actually, I guess we'll get into this more about in our, how we kind of approach patients on this topic.
44:13
Sonia Singh MD: But actually before we move on to that how did your patient do with their Yeah.
44:18
Sonia Singh MD: Autoimmune protocol?
44:19
Rebecca Berens MD: Yeah, so my patient did, they did do it.
44:22
Rebecca Berens MD: They, I had suggested that if they were gonna do it, that I recommended that they work with a dietician because I was concerned about the the eating disorder history and just the restrictiveness of the diet anyway.
44:32
Rebecca Berens MD: Yeah.
44:32
Rebecca Berens MD: They unfortunately were not able to afford.
44:34
Rebecca Berens MD: To work with the dietician.
44:36
Rebecca Berens MD: So they just did it on their own.
44:37
Rebecca Berens MD: So unfortunately they, it wasn't as supportive of a trial as we had hoped.
44:41
Rebecca Berens MD: They did initially feel like it was working really well and they felt like their symptoms got better, but they experienced a lot of cravings for sugar.
44:47
Rebecca Berens MD: They experienced a lot of guilt and shame around the cravings they were experiencing.
44:52
Rebecca Berens MD: And they had times where they had something anyway'cause they were craving it and then they felt a lot of guilt and shame afterwards.
44:57
Rebecca Berens MD: And they ultimately were not able to sustain it.
45:00
Rebecca Berens MD: And after the fact they did say, that they felt like it really had a bigger mental impact on them that they realized at the time.
45:06
Rebecca Berens MD: 'cause initially they were like, oh yeah, this is going really well.
45:08
Rebecca Berens MD: And then gradually the longer they were doing it, it was Devolving.
45:12
Rebecca Berens MD: And and yeah they did say that they felt like it, it made their mental health worse and they were concerned about a relapse.
45:17
Rebecca Berens MD: So that's, they had decided to stop pursuing the trial.
45:21
Sonia Singh MD: I bet.
45:21
Sonia Singh MD: A really common experience.
45:22
Sonia Singh MD: When you do any intervention, whether that's a diet or a supplement or a medicine, and you have really strong belief that it's going to work, there's a possibility for some placebo effect to happen.
45:32
Sonia Singh MD: And so I bet you there's a lot of people that have the experience of going on one of these protocols feeling better because they're sure that it's going to make them feel better.
45:41
Sonia Singh MD: And that's not imaginary.
45:43
Sonia Singh MD: That's yeah, your, it's real.
45:44
Sonia Singh MD: Your body interprets sens, it filters everything you're experiencing and sensing through your brain.
45:49
Sonia Singh MD: And so your brain has this incredible power to turn the volume up and down on all kinds of symptoms.
45:53
Sonia Singh MD: And so I bet you there's a lot of people who have this initial improvement and then.
45:58
Sonia Singh MD: That placebo effect starts to wear off at some point, or maybe they try reintroduction and everything feels like it's making it worse.
46:05
Sonia Singh MD: And I bet you a lot of those people maybe were not following it a hundred percent and then blame themselves that, oh, it's not working because I'm just not following a hundred percent.
46:13
Sonia Singh MD: And so then they try even harder to follow it a hundred percent.
46:14
Sonia Singh MD: Or maybe they try reintroducing and every time they reintroduce they feel terrible.
46:18
Sonia Singh MD: And then they're like I guess I have to avoid all of these things, so when you do something and it's not working, there's a lot of different ways like you can interpret that, and I sadly think probably a lot of people, it just drives them further in, in the wrong direction, when Yeah.
46:33
Sonia Singh MD: They feel that it's no longer working.
46:35
Rebecca Berens MD: Yeah.
46:35
Rebecca Berens MD: And I'll say, I've seen this exact scenario play out so many times, not necessarily with a IP, but with any sort of restrictive diet, the number of patients that I have seen and that my colleagues, eating disorder therapists and dieticians that I've worked with have seen who.
46:50
Rebecca Berens MD: Started off on some sort of restrictive diet because they were working with a functional medicine practitioner, or they had read about something that they were trying to, something for their health.
47:00
Rebecca Berens MD: Totally with full intention of this being a healthy change in their life to try to help with some symptoms they were having and it ending up in a clinically significant eating disorder.
47:11
Sonia Singh MD: Yeah.
47:12
Sonia Singh MD: Yeah.
47:12
Rebecca Berens MD: So many stories and and it is, it's just the, it is that guilt and shame of this was the thing, the only I can't even control this one thing.
47:19
Rebecca Berens MD: And it becomes like a self blame, like we talked about the beginning of the episode this is the thing that people feel like they can control for whatever horrible situation they're going through with a diagnosis.
47:28
Rebecca Berens MD: And they can't do it.
47:31
Rebecca Berens MD: Which, who could do It's so hard.
47:33
Rebecca Berens MD: Yeah.
47:33
Rebecca Berens MD: But it becomes a self blame and it's this is my fault.
47:35
Rebecca Berens MD: And it just spirals so quickly.
47:37
Rebecca Berens MD: And a lot of times, the patients that I've seen, the practitioner they were working with is they just, their advice is always just double down, just try harder.
47:44
Rebecca Berens MD: Just if you would just do this what you wouldn't have.
47:46
Rebecca Berens MD: And they're getting that same messaging back.
47:48
Rebecca Berens MD: And I think that's also what's happening on social media.
47:50
Rebecca Berens MD: People are just seeing these posts over and over again and they try, their January, new year, new you thing.
47:56
Rebecca Berens MD: Even if it's not as strict as a IP if it's some huge lifestyle overhaul that they can't sustain.
48:03
Rebecca Berens MD: It becomes this shame spiral so quickly.
48:05
Rebecca Berens MD: But I think that's such a common experience and and it's really unfortunate and I think that's why, as we'll talk about you and I try to have a different approach to it.
48:13
Sonia Singh MD: Yeah.
48:14
Sonia Singh MD: Yeah.
48:14
Sonia Singh MD: And this, this is not just a thing that I think happens among patients.
48:19
Sonia Singh MD: I see this happen with fellow healthcare providers.
48:21
Sonia Singh MD: I see it happen with people in the nutrition space.
48:24
Sonia Singh MD: And so it's really just the human condition.
48:27
Sonia Singh MD: Yeah.
48:27
Sonia Singh MD: I don't wanna make it seem like it's just an informational thing, or it's if you just knew better or something.
48:32
Sonia Singh MD: I just think it's such that these are all just like such human.
48:35
Sonia Singh MD: Responses and compulsions, that they can literally happen to anybody.
48:40
Rebecca Berens MD: Yeah.
48:40
Sonia Singh MD: Okay.
48:41
Sonia Singh MD: So what can we take from this, you think, as doctors and just as humans?
48:45
Rebecca Berens MD: Yeah, I think that was really what you just said was my main takeaway is people are willing to do drastic things when they have these severe conditions or just for their health in general.
48:56
Rebecca Berens MD: People are, people care about their health and they're willing to do drastic things.
49:01
Rebecca Berens MD: And they're willing to put in the work.
49:03
Rebecca Berens MD: Which I think is like the opposite of what we're also always oh, people are just lazy.
49:05
Rebecca Berens MD: This is why people are having these problems.
49:07
Rebecca Berens MD: Yes,
49:07
Sonia Singh MD: right.
49:08
Rebecca Berens MD: But it's not truly this happens so much because people really do care and people really are willing to put in the work, but it just is not possible to sustain at that level.
49:17
Rebecca Berens MD: But, and as you said, the human condition is then to like spiral down and then just try again, and it just, it.
49:23
Rebecca Berens MD: It really is difficult to to sustain these sort of really drastic changes long term.
49:29
Rebecca Berens MD: And there's true risk involved with that.
49:31
Rebecca Berens MD: It's, I think that the thing we're also taught or hear a lot about these drastic changes is like, it's just a lifestyle change.
49:37
Rebecca Berens MD: Lifestyle changes have no risk.
49:40
Rebecca Berens MD: You can just do this thing.
49:41
Rebecca Berens MD: And it's, there actually is true risk involved, particularly in making these very drastic changes.
49:46
Rebecca Berens MD: There is true risk to that.
49:48
Rebecca Berens MD: Yeah.
49:48
Rebecca Berens MD: And so it's important to, to come at this from a perspective that is nuanced.
49:53
Rebecca Berens MD: And I actually, the placebo effect comment that you made earlier was another one that I thought about was like, is is it because you did something so drastic that you get such effects initially because you were expecting
50:04
Sonia Singh MD: to, right?
50:04
Sonia Singh MD: Yes.
50:05
Rebecca Berens MD: Yes.
50:05
Rebecca Berens MD: And the incremental changes, of course, you don't expect them to overnight change how you feel so you don't overnight change how you feel.
50:11
Rebecca Berens MD: And then you're like, why am I doing this?
50:13
Rebecca Berens MD: I don't feel any different.
50:14
Rebecca Berens MD: It's yeah, you won't immediately.
50:16
Sonia Singh MD: Right?
50:17
Rebecca Berens MD: But that's I think it's self-reinforcing that I did this drastic thing and now I feel great and then.
50:23
Rebecca Berens MD: And then the guilt and shame spiral falls.
50:25
Rebecca Berens MD: But if you make the incremental change that's like a little bit hard, but you're doing it every single day and you're just not seeing the return.
50:31
Rebecca Berens MD: You're like, why am I doing this?
50:32
Sonia Singh MD: Yeah.
50:33
Rebecca Berens MD: And so that's also hard to sustain for its own reasons.
50:36
Sonia Singh MD: So there, there are studies about how the placebo effect is stronger.
50:41
Sonia Singh MD: Depending on how, like for the, for a more invasive intervention, the placebo effect becomes stronger.
50:46
Sonia Singh MD: Yeah.
50:47
Sonia Singh MD: Which
50:47
Rebecca Berens MD: makes sense.
50:47
Sonia Singh MD: Getting an injection has a stronger placebo effect for people than getting a shot and getting a sur a sham surgery has a bigger placebo effect than getting a shot.
50:55
Sonia Singh MD: I think in a similar way, when we're giving people these, recommendations to just move towards a more whole food, plant-based diet and move their dietary pattern a little bit more in line with that, and to maybe add some of these things that we know have some anti-inflammatory benefit, that there, that I think the likelihood of that having a placebo effect Yeah.
51:17
Sonia Singh MD: Is very minimal.
51:19
Sonia Singh MD: But when you do this drastic thing where you're like, tomorrow I am cutting out these, four different food groups and everyone's gonna notice and I'm gonna be, loud and proud about it.
51:28
Sonia Singh MD: That is definitely much more at risk for making you think something is happening when in fact it may not be, yeah.
51:34
Sonia Singh MD: So yeah, I totally didn't mean to no,
51:36
Rebecca Berens MD: that was, but
51:37
Sonia Singh MD: I to the same, did not read the whole outline before we started.
51:40
Sonia Singh MD: Okay.
51:41
Sonia Singh MD: So I guess how would you talk to patients about this in the future?
51:45
Sonia Singh MD: Yeah, if they're considering these
51:47
Rebecca Berens MD: products, like I said, if someone's considering a protocol like this I always discuss the evidence
51:51
Sonia Singh MD: yeah,
51:51
Rebecca Berens MD: this is the potential evidence that we have, which is not a lot, this is the potential risks that I see, which are substantial.
51:59
Rebecca Berens MD: And then it's it's always patient autonomy, right?
52:00
Rebecca Berens MD: If you wanna do it, okay, let's make it as safe as possible.
52:04
Rebecca Berens MD: So let's get a dietician involved.
52:06
Rebecca Berens MD: Let's follow up more closely.
52:07
Rebecca Berens MD: Let's monitor how you're doing.
52:09
Rebecca Berens MD: Particularly for someone who may have a risk factor for disordered eating or for another nutritional deficiency.
52:15
Rebecca Berens MD: If you have IBD and you're already deficient, we gotta be really on top of it, yeah.
52:19
Rebecca Berens MD: And in general, I do always try to steer more towards small, sustainable changes and building on those gradually.
52:26
Rebecca Berens MD: But like I said if a patient really wants to move forward with a protocol like this and after a discussion of the risks and benefits is still wanting to move forward with that, it's just the monitoring and making sure that we're keeping them as safe as possible.
52:40
Rebecca Berens MD: Yeah.
52:40
Sonia Singh MD: Yeah.
52:41
Sonia Singh MD: The patients I've had that have been really seeking some type of intent isn't there like a diet that you can put me on?
52:47
Sonia Singh MD: Oftentimes I feel like they're against a wall where like the rheumatologist is yeah, it's time to go on one of these medicines.
52:52
Sonia Singh MD: And so I think there's this pressure where they're like, no, I don't wanna do those small incremental changes.
52:57
Sonia Singh MD: I wanna try this thing Yeah.
52:59
Sonia Singh MD: For a month and see if I feel better.
53:01
Rebecca Berens MD: Yeah.
53:01
Sonia Singh MD: And only if I do not will I go.
53:04
Sonia Singh MD: And I think there's this perception that the sense I've gotten from some of those patients is if I go, it's if you.
53:11
Sonia Singh MD: If you go to a surgeon, you're gonna get a surgery.
53:13
Sonia Singh MD: If you go, if I go to the rheumatologist, they're gonna give me a med.
53:15
Rebecca Berens MD: Yeah.
53:16
Sonia Singh MD: So I'm gonna first try this stuff on my own because I already know that if I go there, they're not gonna talk to me about diet and they're just gonna tell me to go take this terrible toxic medication, and I think to a certain extent that is true.
53:27
Sonia Singh MD: If you go to a doctor with one of these autoimmune diseases and the most effective intervention for that autoimmune disease is a medication if that is what we know, the evidence points to you as the most effective intervention, that is what they're gonna offer you.
53:40
Sonia Singh MD: And that is what they're gonna talk to you about.
53:42
Sonia Singh MD: Now, I think a lot of people's complaint is the doctor didn't even mention I see this all the time.
53:47
Sonia Singh MD: On posts in our Heights mom group or other groups that are like.
53:50
Sonia Singh MD: I got diagnosed with thyroid disease, I got diagnosed with psoriatic arthritis, I got diagnosed with my doctor.
53:54
Sonia Singh MD: Didn't even mention diet or nutrition or anything besides medication that is a very common refrain that you see in those forums.
54:03
Sonia Singh MD: And I believe them.
54:05
Sonia Singh MD: I totally believe that yeah.
54:06
Sonia Singh MD: Happened.
54:07
Sonia Singh MD: But I think part of the reason it happens is because the advice is so humdrum boring.
54:13
Sonia Singh MD: What we feel, if you look at the news right now, they believe doctors have not been saying this at all.
54:18
Sonia Singh MD: But I feel that I am a broken record talking about the Mediterranean diet, talking about whole foods, plant-based diet, talking about increasing vegetables and fiber in the diet.
54:26
Sonia Singh MD: And I, I, it's, it doesn't feel I guess because it lacks specificity or this feeling that it's personalized for you and your condition that I think people feel like, oh they're not telling me anything helpful.
54:39
Sonia Singh MD: And it's I think as doctors we can do a better job.
54:42
Sonia Singh MD: I'm not a rheumatologist, so I don't wanna tell them how to do, I'm not a rheumatologist, I don't wanna tell them.
54:46
Sonia Singh MD: But, I think for my patients with autoimmune disease who are very lifestyle focused, I really always try to start the conversation with the first step of this is just optimizing your baseline lifestyle and health factors.
54:59
Sonia Singh MD: Whatever the diagnosis is, whatever the treatment plan is optimizing your nutrition, your sleep, your stress management, your movement, your hydration, all of those things can only help, yeah.
55:09
Sonia Singh MD: Supporting this.
55:10
Sonia Singh MD: And this has actually been, I think a big shift that I've consciously made over time after seeing how framing advice more as what to avoid, like what the consequences of that are, which are, I would see a lot of people just having fear around a lot of different foods and.
55:28
Sonia Singh MD: Ending up, not really replacing them with anything better.
55:32
Rebecca Berens MD: Yeah.
55:33
Sonia Singh MD: And so now even if I'm talking about reducing cholesterol, I focus really heavily on what can we add here?
55:39
Sonia Singh MD: Yes.
55:39
Sonia Singh MD: Because when you tell people to avoid something, you just don't know what they're replacing it with or if what it replaces, or, if they're replacing it with anything at all, they're not gonna eat.
55:49
Sonia Singh MD: In place of that thing that they were eating before.
55:51
Sonia Singh MD: Whereas when you're telling people to add more vegetables, to add more nuts and seeds to add, like literally all the stuff that's,
55:58
Rebecca Berens MD: yeah.
55:59
Sonia Singh MD: Like when you're telling people to add more fermented foods, which we know are anti-inflammatory, my hope would be that crowds out some of the less nutritious things and it's much less likely to result in deficiencies, and I guess maybe, I don't even think it's a real fear to think oh, they're just gonna be eating too much then.
56:16
Sonia Singh MD: I don't think that really happens.
56:18
Rebecca Berens MD: You're not gonna eat too many beans, you will stop.
56:19
Sonia Singh MD: Yeah.
56:20
Sonia Singh MD: It's hard to eat too many vegetables, honestly.
56:22
Sonia Singh MD: Yeah.
56:23
Sonia Singh MD: It takes a lot of chewing and work for most
56:25
Rebecca Berens MD: people.
56:25
Rebecca Berens MD: Although I'll say sometimes there are people who do eat only those things.
56:28
Rebecca Berens MD: That's because they're like, these are the good things and I shouldn't eat anything.
56:31
Rebecca Berens MD: I don't wanna say that no one could do it but on average, if we focus on what we can add.
56:36
Rebecca Berens MD: I think it's also psychologically different.
56:38
Sonia Singh MD: Yes,
56:39
Rebecca Berens MD: totally.
56:39
Rebecca Berens MD: Because if you're saying like, this is a positive action you can do add this thing.
56:43
Rebecca Berens MD: Yes.
56:44
Rebecca Berens MD: Versus stop doing this, it just like psychologically that's different.
56:47
Rebecca Berens MD: Yeah.
56:48
Rebecca Berens MD: 'cause it's more positive action focused than fear focused, like you're saying
56:50
Sonia Singh MD: And it's like a mindset of a abundance.
56:52
Sonia Singh MD: Yes.
56:53
Sonia Singh MD: I honestly think.
56:54
Sonia Singh MD: When our brains feel that we are in a restrictive state, even if you have not actually restricted, I really think there's a bunch of hormonal and metabolic things that probably happen just from the,
57:07
Rebecca Berens MD: it's
57:07
Sonia Singh MD: the
57:07
Rebecca Berens MD: threat
57:08
Sonia Singh MD: sentiment that you are restrict Yeah.
57:10
Sonia Singh MD: Of restriction, and so I think keeping yourself in a place of abundance where you're like, all right, if I feel like having the food, I'm gonna have the food.
57:17
Sonia Singh MD: It's just a completely different psychological and probably metabolic experience for you, navigating meals and food than if you're constantly like, oh, gotta avoid this, gotta avoid that.
57:27
Sonia Singh MD: Gotta, I can't eat this, can't eat that.
57:28
Sonia Singh MD: That's a, such a different way to live your life.
57:31
Sonia Singh MD: Yeah, I feel like I've really tried I think people mostly come to you asking like, is this thing bad?
57:36
Sonia Singh MD: Is this thing good?
57:36
Rebecca Berens MD: Yes.
57:37
Sonia Singh MD: And, I also think honing in so specifically on specific ingredients is almost always problematic.
57:45
Sonia Singh MD: And we chatted about this before we started the episode, which is that I did a master's in nutrition before I went to medical school, and I'm glad I did that because, there isn't a ton of training on nutrition.
57:54
Sonia Singh MD: But honestly, part of that is because nutrition is such a murky science, and a lot of patients will come to me and be like, are eggs good now?
58:01
Sonia Singh MD: Or are eggs bad?
58:02
Sonia Singh MD: Okay, good or bad, or a lot of foods there's not honestly that many foods when I'm like, it's just plain bad.
58:07
Sonia Singh MD: There's a few, but most things, fall somewhere in the middle.
58:11
Sonia Singh MD: And it's really, you have to ask yourself so many other questions.
58:13
Sonia Singh MD: It's what is your goal?
58:14
Sonia Singh MD: Good for what?
58:15
Sonia Singh MD: What are you going to achieve?
58:17
Sonia Singh MD: Yeah.
58:17
Sonia Singh MD: And you have to put it in that context, and then you have to put it in the context of the person's entire diet, and their preferences and their palate and what their family's eating and what their lifestyle allows for, and so I think we're so focused on specific foods and ingredients and avoidance that.
58:32
Sonia Singh MD: We kinda lose sight of that big picture.
58:34
Sonia Singh MD: And again, when your doctor is not giving you hyper specific advice, I honestly don't think it's because they just don't know.
58:41
Sonia Singh MD: Like I think most doctors know like the basic fundamentals of decent nutrition.
58:46
Sonia Singh MD: It's often because it's just the stuff that we know to be true is boring and most people know it already.
58:53
Sonia Singh MD: And the other stuff that feels more specific is just the data's not that strong to really recommend it, and for it to be part of guidelines and to be part of our treatment recommendations for specific diseases.
59:05
Sonia Singh MD: For a lot of, not everything, but for a lot of things.
59:07
Sonia Singh MD: And yeah, I think it's just, it's an, it's the nature of nutritional research, which is so much of it is based on population data, on epidemiological studies, on recall studies, as you mentioned, dietary recall, which is so flawed in a lot of ways.
59:19
Sonia Singh MD: And we see these things in populations and we don't know is eating this food really what's leading to the outcome?
59:24
Sonia Singh MD: Or is it just that's a marker for people who do other healthy behaviors?
59:28
Rebecca Berens MD: Yeah.
59:28
Sonia Singh MD: And then, you would think okay, the solution is isolate that food or isolate that ingredient or that nutrient and study that in a lab, or study it in a test tube or study it in a really highly controlled setting.
59:38
Sonia Singh MD: And sometimes you do that and it doesn't have the same effect at all.
59:41
Sonia Singh MD: And why is that?
59:42
Sonia Singh MD: Probably because in the context of that food or the actual whole food, it had some other, co-factors and other things involved in that, that were present in that food that led it to have that outcome.
59:54
Sonia Singh MD: Or maybe as part of a broader diet, someone's broader dietary pattern, it led to that outcome.
59:58
Sonia Singh MD: But then when you isolate it, it doesn't and it's such a common theme that, you do those big population studies and you say, oh man, vitamin A, it's great.
1:00:05
Sonia Singh MD: And then you put it in a pill and you give it to people and you're like, Ooh, increases, cardiovascular risk, that's not good.
1:00:10
Sonia Singh MD: Yeah.
1:00:11
Sonia Singh MD: And I think.
1:00:12
Sonia Singh MD: Keeping your perspective broad and focusing on kind of an overall pattern and not focusing on this kind of single ingredient, hyper restrictive, super specific for my disease is really more in line with what we know about nutrition.
1:00:28
Rebecca Berens MD: Yeah.
1:00:28
Rebecca Berens MD: And I would add to that, in keeping it broad, one of the other key things I wanted people from, to take away from this is you should not delay evaluation or treatment of an autoimmune condition or symptoms that you have that you're concerned about, autoimmune condition to see if the diet will help.
1:00:44
Rebecca Berens MD: Because really this should be an adjunctive thing, yeah.
1:00:46
Rebecca Berens MD: And the way I would view it as like this is an adjunctive thing that you can do that could help your body better manage inflammation, could affect inflammation levels, whatever.
1:00:56
Rebecca Berens MD: There's also.
1:00:58
Rebecca Berens MD: Evidence-based treatments for that.
1:01:00
Rebecca Berens MD: Yeah, we can use them together.
1:01:01
Rebecca Berens MD: Let's get everything under control.
1:01:03
Rebecca Berens MD: And then maybe you wean off the medication after you've had some time of doing the lifestyle changes.
1:01:08
Rebecca Berens MD: It feels more sustainable.
1:01:09
Rebecca Berens MD: It's something that you're doing.
1:01:10
Rebecca Berens MD: Maybe you need less medicine.
1:01:11
Rebecca Berens MD: Yeah, maybe you're able to come off of a medicine.
1:01:13
Rebecca Berens MD: But I wouldn't, I don't think it's fair to expect yourself to be able to like, while you're feeling terrible from this condition that is out of control, do this whole big thing and magically reverse it when there's an evidence-based treatment you could use right away.
1:01:30
Rebecca Berens MD: Get it started, get the fire under control, do the sustainable stuff, and then wean off This should always be a big picture.
1:01:36
Rebecca Berens MD: Using everything together.
1:01:37
Rebecca Berens MD: Use all the tools at your disposal.
1:01:39
Rebecca Berens MD: And yeah,
1:01:40
Sonia Singh MD: and I
1:01:40
Rebecca Berens MD: think,
1:01:40
Sonia Singh MD: Doing that, going to a consultation with a doctor and hearing about the pharmacologic treatment options and their risks and benefits is part of you just making an informed decision about what you wanna do.
1:01:51
Sonia Singh MD: Yeah.
1:01:51
Sonia Singh MD: No one's gonna go and, jab you with the Humira when you walk in for the consult, like it is going to be up to you for sure.
1:01:57
Sonia Singh MD: And I always try to remind people just go, I think people have this, again, they have this feeling.
1:02:02
Sonia Singh MD: They're like, I'm gonna go there and they're gonna just tell me I have to do the medicine and they're gonna scare me, and they're gonna tell me all the bad things are gonna have, I don't do the medicine and, my doctor the doctor doesn't even know about all of this, autoimmune stuff and the dietary, effect on inflammation and all these things.
1:02:14
Sonia Singh MD: And, but it's that's fine.
1:02:16
Sonia Singh MD: Even if you think all of those things are true, at least having the information is beneficial for you in truly making an informed decision about whether or not you wanna pursue, one of these protocols.
1:02:29
Sonia Singh MD: So yeah, I totally, absolutely, and I have definitely had multiple patients who delayed care for years with an autoimmune disease, trying natural solutions and fearing that they were gonna end up on a medicine.
1:02:40
Sonia Singh MD: And in that time.
1:02:42
Sonia Singh MD: They had their disease, go outta control and y many of those patients I think could have had remission, if they were treated appropriately at the right time.
1:02:51
Sonia Singh MD: So anyway alright for more info we're gonna put a few different resources and citations in the show notes.
1:02:58
Sonia Singh MD: And we'll also put a few experts that may be helpful to follow if you're interested in autoimmune disease and diet and the relationship between those two.
1:03:06
Sonia Singh MD: Okay.
1:03:06
Sonia Singh MD: That's the end of the episode.
1:03:07
Sonia Singh MD: Thanks Rebecca.
1:03:08
Rebecca Berens MD: Yeah, thank you.
1:03:11
Sonia Singh MD: Hey guys.
1:03:11
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1:03:15
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1:03:19
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1:04:40
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1:04:41
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