Benefits of a Supplement Holiday

Patient Summary: 

Overview Context: 

• Karen is a 51-year-old former triathlon who came in seeking help for multiple symptoms. She had been diagnosed with MCAS and was being treated for MARCoNS (antibiotic resistant streptococcal infection of the sinuses) following mold exposure.

Visit 1 – History and Exam:

Symptoms and Concerns

• Chief Complaints:
  • “Attacks of body and facial swelling”
  • Facial and body eczema
  • Food intolerances
  • Eye pain, eyelid swelling, red eyes
  • Redness of the feet, hands and face

• Other Symptoms:
  • Anxiety, panic attacks
  • Headaches
  • Fatigue
  • 25 lb weight loss over previous year
  • History of chemical sensitivity: “couldn’t go down detergent aisle without holding breath, couldn’t use toothpaste” 

Onset, Timeline and History:

August 2018

• Began experiencing worsening redness on face with severe itching and swelling. She was put on prednisone and benadryl but felt worse. “Benadryl made it worse and made me panic – sudden onset each time I took it.”

Nov/Dec 2019

• Began seeing doctors. “Nothing helped, lots made me worse. Next year developed lots of food sensitivities that I could not figure out. The healthier I ate, the worse I got.”

Feb 2020

• Met with functional med practice – diagnosed with MCAS. Put on bromelain, quercetin, DAO, multivitamin and probiotics and unfortunately had severe reactions. 

March 2021

• Diagnosed with sulfur and salicylate intolerances. 

May 2021 

• Tested for mold toxicity in body and sinuses (MARCONS). Began treatment with cholestyramine and BEG spray. Feeling worse since these treatments were started.

Jan 2022

• Functional med doctor recommended glutathione for mold and milk thistle for elevated liver enzyme. This led to severe reactions – swelling, redness, joint pain, back pain, eye pain, skin sensitivity.  

Feb 2022

• “Feeling worse on sulfur supplements”

March 2022

• Feeling worse directly following BEG spray.

Past Medical History

• Medications:
  • Cholestyramine (CSM)
  • BEG nasal spray
• Supplements:
  • 
• Environmental:
  • Karen’s home was previously remediated for mold. She notes exposure to mold and chemicals at her office. When exposed to mold she experiences lightning bolt pain, headaches, dizziness, tingling.
• Prior Testing 
  • Positive RTL urinary mycotoxin testing Nov 2021.
• Prior Diet
  • Currently on a low histamine / low sulfur diet.
• Other Treatments
  • Limbic retraining program (DNRS) – helped

Initial Impression

• While Karen’s mold toxicity was correctly diagnosed, she was unfortunately placed on a treatment strategy that was too much for her system.
• Particularly of concern was the pattern of immediately worsening directly after using BEG spray and CSM.
• I suspect that Karen was mobilizing more toxins using these treatments than her body was able to process. 
• At the conclusion of this first visit, I asked Karen to simply stop everything in preparation for our next visit.

Visit 2 – Testing and Initial Treatment Recommendations

• At the beginning of this visit, (just a few days later) Karen was beaming and looked like a new person. She tells me that she stopped everything at the conclusion of our last visit. Two days later “I started feeling like myself again!” 
• Her eczema improved, and the rash on hands improved. Her anxiety dramatically lessened, and she realized that she wasn’t “constantly body scanning”. She noticed less chemical sensitivity as she told me that “I wore sunscreen on my shoulders for the first time in 3 years!”

Clinical Impression

• Karen’s response to stopping treatments confirmed that they were counterproductive, and were slowing her healing down. In functional medicine, when you are on the right track your patient’s response will let you know. Sometimes the best thing we can do as healers is to get out of the way.
• Moving forward, we will very slowly advance probiotics while continuing DNRS. It is likely that we will need to restart binders, but this will be done slowly, one at a time.

Cynical Takeaway: Consider asking your patients to take a supplement holiday.

• This is particularly useful in cases where patients have been on multiple treatments of unknown effect. To help make the patient feel more comfortable I ask the patient if there are any supplements that they are 100% sure they will feel worse stopping. I simply ask them to stop the remainder and follow up with me in 1 week. 
• In virtually all cases, the patient will stop the treatment and not go backwards symptomatically, which tells you that these treatments were not needed.

Functional Medicine Gone Wrong: “$40,000 - $50,000 in supplements and tests”

Patient Summary:

• Overview Context: 
  • Noah is an 18-year-old male with a history of epigastric pain previously treated by an overly zealous functional medicine nutritionist.

Symptoms and Concerns

• Chief Complaints:
  • Nightly stomach pain (epigastric region; 8/10) occurring after dinner and occasionally early morning (always postprandial).
  • Nausea 1-2x/week
  • Severe fatigue
    • Feeling fatigued usually in afternoons and thinks this is related to nightly stomach aches (as well as regurgitation and acid reflux) which has drastically shifted his sleep cycle
  • Bloating 9/10
    • Followed strict Elemental Diet for 2 weeks – Pain and bloating went away and then returned a week after stopping.

• Onset, Timeline, and History:
  • “I’ve had horrible gut pain (almost always at night) my whole life, especially during summers and traveling.”  For years at night he “popped Tums and Rolaids like candy.” 
  • Noah told me that he had been trying to get well for years, and that he had “spent between $40,000 – $50,000 in supplements and tests.”
  • In 2019 Noah was treated by an integrative nutritionist:
    • “My nutritionist told me not to eat red meat because of the E. Coli in my stool.” 
    • Noah hadn’t eaten red meat for years based on this comment from a nutritionist.
  • Noah was incorrectly diagnosed with Celiac at this time based on a non validated Wheat Zoomer test. 

Initial Supplements:

What Went Wrong?

• Impression:
  • This patient was tested unnecessarily, resulting in improper diagnosis and years of wasted money and time. Instead of living his life, this young man was left with a sense that he had significant dysfunction and major medical diagnoses.  
  • This case is a good reminder of how important our words can be. Choose your words wisely, patients listen to and hold on to what you say.

• A Better Approach:
  • Happily, this patient is doing significantly better on a simple program. After stopping the excessive and heavy-handed treatment program, we started a basic Paleo diet and triple probiotic therapy. At his last visit he reports that his GI symptoms have almost completely resolved. 
  • In addition to the fundamentals, Noah has been thriving on the Gupta Program, and I look forward to seeing his growth and improvement at every subsequent visit.

Probiotics’ ability to degrade aflatoxin

Title: Isolation, Purification, and Characterization of a Laccase-Degrading Aflatoxin B1 from Bacillus amyloliquefaciens B10

Methods

• In vitro study in which 74 strains of bacteria were screened for ability to degrade the mold toxin aflatoxin. 

Results

• A strain of bacillus (a soil-based probiotic) was found to secrete a novel enzyme (B10 laccase) with the ability to degrade aflatoxin.

Clinical Takeaways

• The ability of certain bacillus species (and possibly other strains) to produce enzymes capable of breaking down toxins may be one of the mechanisms by which probiotic treatment is helpful for patients with mold illness.
• Additional evidence for starting comprehensive probiotic therapy early in suspected mold toxicity cases. This adds to the body of evidence supporting the use of probiotic therapy in mold illness.

Probiotic protects against zearalenone-induced damage during pregnancy

Title: Zearalenone toxicosis on reproduction as estrogen receptor selective modulator and alleviation of zearalenone biodegradative agent in pregnant sows

Background

• The mold toxin zearalenone, and its metabolites, are known to have estrogenic effects due to their ability to bind to estrogen receptors. This study was conducted to investigate the toxic effects of zearalenone during pregnancy, and to see if these effects could be lessened with supplementation of the soil-based probiotic bacillus subtilis (as previous work by the authors has shown that this probiotic degrade zearalenone).

Methods

• First time pregnant female pigs were fed one of four diets:
  • normal control diet
  • diet contaminated with a low dose of the mold toxin zearalenone
  • normal diet + Bacillus subtilis
  • diet of low dose zearalenone + Bacillus subtilis

Results

• Significant increases in the vulva size and prolactin were found in the zearalenone group compared with the control group
  • “Feeding low-dose ZEA naturally contaminated diets disordered most of reproductive hormones secretion and affected estrogen receptor-α and estrogen receptor-β concentrations in serum and specific organs and led to moderate histopathological changes of gilts”
• The addition of a probiotic reduced the damage to the ovary, uterus, and mammary gland caused by the mold toxin. 
  • A Uterus (control group): a small amount of inflammatory cell infiltration in the inner membrane; capillaries are mildly hyperemic or stagnant.
  • B Uterus (mold group): a large amount of inflammatory cell infiltration in the inner membrane (small red arrow); severe bleeding in lamina propria (large red arrow)
  • C Uterus (mold + probiotic group): a small amount of inflammatory cell infiltration in the inner membrane; capillaries are mildly hyperemic or stagnant.
• 
  • “…histological structures of all the organs, including the ovary, uterus, and mammary gland, were observed to be normal and essentially lesion-free in the CO [control] group. In contrast, moderate lesions such as swelling, degeneration, inflammatory cell infiltration, hemorrhage, and necrosis were observed in the ovary, uterus and mammary gland to varying degrees in the Mo [mold] group. Very interestingly, our results revealed that the administration of MBA [probiotic] significantly ameliorated the lesion of ZEA exposure in the ovary, uterus and mammary gland.”

Interesting Notes

• Even at low doses, zearalenone acts as a profound endocrine disruptor, significantly increasing the female genital organ size and increasing prolactin levels.
• Mycotoxin exposure led to increases in multiple inflammatory cytokines and immunoglobulins, and this effect was ameliorated by the addition of probiotics. 
• The authors had previously shown that probiotic supplementation significantly improved zearalenone toxicity at higher concentrations in the animals feed (approximately 600-800 μg ZEA/kg feed). 
• This study not only showed detrimental effects of zearalenone at a lower concentration in animal feed (around 250 μg ZEA/kg feed) – but also that probiotic supplementation retained a protective effect.

PRACTITIONER TIP

Setting up a system for continuing education

Getting your medical license or other health care degree is just like getting your license to drive –  hopefully, you get better over time. But how many of us actually carve out time and a system to engage in continuing education? 

I’d like to share with you some of my current systems and how we think about continuing education:

1. Diversify your education sources

• Conferences and courses – These can be great but they can also be expensive and hard to do frequently. I like these especially as a way to meet other people in the field. 
• Podcasts/audiobooks – An easy way to plug into educational material while on a drive or on a walk. Some of my favorites are Dr Ruscio’s (of course), Peter Attia’s The Drive, Curbsiders Internal Medicine, and Sigma Nutrition Radio.
• Pick an expert’s brain – Consider reaching out to a mentor or clinician you admire to see if you could pick their brain. Offer to pay them for their time, but usually they don’t charge for this if they are passionate about what they do.
• Read research articles – This is where you can go in depth on a particular niche topic of interest. Consider subscribing to the FFMR Plus+ to get all the latest updates on new functional medicine research.

2. Set up a schedule

• We carve out 30-60 minutes every morning to dig into continuing education. It doesn’t have to be this much. Even 10 minutes every day adds up over months and years. The important thing is that you do it. 
• Set up a recurring time to reflect and integrate. Every Saturday, I spend 30 minutes reflecting on what I learned the week prior and integrate it into my practice and treatment model. I may update my snippets on my EMR or change the dose of a commonly used therapy according to a recent study. 

3. Know what you want

• We encourage you to write down questions/topics that you want to research. This will help you focus on the task at hand and not get distracted. Here’s an example of what that may look like from my latest project:
  
  

4. Teach it to others

• To help you better understand what you learned, consider writing a short article for your website, recording a video for your patients, or making a presentation for your community.

If you integrate these systems into your continuing education endeavors, then I’m confident that you will grow as a clinician, and ultimately, get better outcomes for your patients.