Efficiently Navigating the Available Diets & Sulfur Intolerance with Heidi Turner

This was a great discussion with Heidi Turner.  Heidi and I first discuss how to efficiently navigate the sea of available diets. We also detail what I think may be the most important diet to consider after one has tried paleo, autoimmune paleo and low FODMAP – the low sulfur diet.  The good news is that you can run this experiment in just a few days.

In This Episode

Episode Intro … 00:00:39
Elimination Diets To Try … 00:05:00
Low Sulfur Diet … 00:09:30
Foods That Are Problematic … 00:14:35
Low Oxalate Diet … 00:19:40
Sulfur Intolerance … 00:26:26
Factors That Drive Sulfur Intolerance … 00:37:27
Low Sulfur Diet … 00:45:48
Treatment … 00:50:17
Episode Wrap-up … 01:03:00

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Episode Intro

Dr. Michael Ruscio: Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I am here with Heidi Turner, who I was quite impressed with the presentation she gave at the SIBO symposium last year in Chicago. And I’ve been looking forward to picking her brain. She did a great presentation on the SIBO, sulfur, and joint rheumatoid arthritis connection. So she did a really good job with that, and I’ve been looking forward to picking your brain. So Heidi, welcome to the show.

Heidi Turner:  Thanks for having me. It’s great to be here.

DrMR:  Absolutely. It’s good to have you here. Can you tell people a little bit about your background?

HT:  Sure. Let’s see.

DrMR:  Where to start, right?

HT:  Where to start, yeah. I was born…No. I’ll just say my past life, before I got into nutrition, was in theater. And I was a contributing editor at Conde Nast Traveler Magazine for 12 years. So that encompassed the first 30 years of my life. And then at a certain point, I decided I wanted to start using a different part of my brain. And decided to go into nutrition.

I went to Bastyr University to get my master’s degree. And for those of you who don’t know, Bastyr is a college of naturopathy. And they also have an excellent nutrition program, but the focus is food as medicine. I spent a few years there and got my more allopathic training as a registered dietician/nutritionist. And I kind of brought those two things together. I had the fortune, after I graduated, of meeting a rheumatologist named Steven Overman who really had been a rheumatologist for years and was really getting to the point in his life where he realized that medication wasn’t enough in terms of treating his patients. And that other lifestyle factors, nutrition being one of them, was a really critical piece.

So he asked me to start seeing his patients. And after a couple of years of doing that, the Seattle Arthritis Clinic was formed, and I was asked to be a provider there. And that was about 10 years ago now. So I’ve been working with rheumatology patients, autoimmune, and inflammatory arthritis patients now for the last 10 years. And adjusting the diets. Addressing issues related to microbiome. Whatever I can do to get in there and reduce the inflammatory process in an effort to reduce their pain and inflammation.

DrMR:  Love it. So in the clinic that you’re in now, you’re working along side conventionally trained rheumatologists.

HT:  Oh yeah. Absolutely. 7 of them.

DrMR:  Ok, which is cool.

HT:  Yeah. I’m kind of the, I’m the weird one. It’s a full on medical establishment. So we’re working with all of the biologics. We have infusion rooms. DMARDs. Every possible way medication that you could think of that could suppress the immune system. So yeah, I’m the one that either, I’m seeing a lot of patients who are either not responding to their therapies. Or, are only partially responding. Or to patients who have been referred to a rheumatologist but they really don’t want to go down that pathway of medication.

And I’m lucky to work with doctors who are open minded enough to say, look. We have a nutritionist here. Go see here and see what you can do. And if things aren’t working out, then I’m here with my medication. Come on back. So it’s a great atmosphere to be in. They’re very respectful of what I do, which is lovely, as well. And I’m respectful of what they do. So it works really well together. It’s been a really good relationship.

DrMR:  Great. Great. I think that’s a nice fit. And that’s the way it should be. It should be this merging between the two and not this one or the other but not both. So totally there with you on that.

There’s a lot that we have to talk about today, and I have a feeling we’re going to depart from my normal kind of line of inquiry because I want to try to get as much big picture information down in this podcast as we can.

Elimination Diets To Try

So let me start off with kind of a big picture orientation, to help the person listening to this or reading this, orient themselves or navigate, “Do I do paleo? Do I do autoimmune paleo? Do I do low FODMAP? Do I do SCD? Do I do low FODMAP with SCD? Do I go GAPS? Do I do low histamine? Do I do low oxalate? Do I do low lectin? Do I do low sulfur?”

It can be maddening. So it’s helpful to at least have some guiding principles to walk you through this. So I’ll offer just a few off the top of my head. And I’d like to get some of yours, also, to contextualize the listener or the reader to this.

I like people starting off with a paleo type diet. It’s not the only place to start, but I think it’s a decent place to start. It’s going to get rid of many inflammatory foods. Using that term loosely. And from there, one can progress to maybe a trial of the autoimmune paleo or the paleo low FODMAP, just depending on what they have going on. If someone’s got more digestive issues, like gas, bloating, abdominal pain, especially if they have loose, frequent stools, or more on the diarrheal end of things. I like steering someone more toward the paleo low FODMAP, which is essentially just combining a paleo diet with the low FODMAP diet rules.

If they have more neurological, rheumatological symptoms, then I may next go more so to the autoimmune paleo diet. And the autoimmune paleo diet and the low lectin diet in my mind have a lot of similarities. And one of the things I’m always looking for when I hear about a new diet, is how different is this from XYZ? Because what I’m always trying to do is consolidate to the fewest diets, rather than adding the most nuance and having the highest number of diets. So in my mind, the autoimmune paleo diet and the low lectin diet are very similar. So I think if you go on the AIP diet, you can check the box of low lectin. Not perfect, but it’s pretty proximal.

If you then, and sorry, Heidi, to be long-winded here. So from there, especially if digestive symptoms are predominant, then you can go to the low FODMAP. And an evolution of the low FODMAP diet or another level of rigor could be the low FODMAP plus SCD diet, which in my mind is also very similar to the fast tract diet that Norm Robillard has, I think, done a great job with. Very similar to that diet. And also we’ll establish a low-fructose diet for those who are wondering about that. To the most part, if you do low the FODMAP with SCD combination diet.

There’s a couple of other things in there to consider, which is a low histamine diet. And this is something that someone could do a week trial. They could just look for a low histamine diet handout and try that diet for about a week. And oftentimes, that can be an additional benefit. Now, the low FODMAP diet will decrease dietary histamine, but sometimes a paleo diet, because of the fermented foods and things like avocado and aged cheeses if they’re eating dairy, can have high histamine. So that’s not a bad one-off that, in my experience, people can notice response to fairly quickly.

And then there’s a couple of other’s left. The low oxalate diet, open to that. But the one thing from the interview with Sally Norton, who I appreciate everything she’s doing. Was the recommendation that someone may need to be on that diet for about three months before they start to notice an improvement. And that to me just seems, I need something better than that before I can really get behind something. I’m open to it, but there are other therapies I would try to improve gut and immune function before that because of that three-month window before an improvement would need to be seen.

And then we have the low sulfur diet. I’m not really sold that any of those previous diets adequately achieves a low sulfur intake. Now, I could be wrong because I haven’t really looked at all of these diets relative to a low sulfur diet list, and seen which diet is most proximal. But from my cursory glances, it seems that the low sulfur diet may not be adequately encapsulated into any of these other diets.

So I’m definitely curious to get your opinion on all of that, Heidi. Sorry to give you a super long question and lead in. But most specifically that end piece in terms of, do you think if someone has done those other diets, they could say they’ve adequately done a trial on the low sulfur diet.

HT:  Well, I’ll just answer that question and then I would say, it’s true. That if you’ve done all those other diets, you have not likely done a low sulfur diet. Is one of the ones that’s kind of the bottom of the pyramid to consider trying.

Low Sulfur Diet

And I’ll kind of take you through my thought process that I apply, and we can kind of bring that to a low sulfur diet because you started this conversation as, what do you apply? Do you do this, this, this, or this? And I’m like, yeah. Yes. Yes. You know, I apply all of those things. People come in, the first thing they come in for and they say, I’m here for an anti-inflammatory diet. And I’m like, ok, I’ve got like 12 of them. So we have to sit down and talk. And my focus is on the food. It’s not on anything. It’s on everything else, but the food is how I treat. I’m a dietician/nutritionist. The food is how I treat.

So I’m really looking for the patient to guide me in terms of what’s going to be the most appropriate protocol because from my perspective, they all work. Depending upon the individual. I can have one person come in. And I see a lot of RA, a lot of rheumatoid arthritis. It’s one of the primary diagnoses that I see. And I will see someone come in with RA. I’ll put them on autoimmune paleo or a paleo type of diet and they’ll do remarkably well. They’ll feel amazing and inflammation down.

And I’ll take the next person coming in, and it completely inflames them. And it makes them that much worse. So I never, I really don’t start from any particular. When someone comes into my office, I don’t start from any particular, we’re going to start here. It’s got to be this. I caution practitioners against that, that it has to be this particular thing.

Now, that said, I would say to your point is that I would say most people who come in will benefit from starting with a paleo type of diet. Absolutely. And that speaks to, first of all in a paleo diet, whether it’s AIP or it’s paleo, you’re taking out more of the problematic foods that I would sort of put at the top of that pyramid. You’re taking out wheat, you’re taking out dairy, and you’re taking out sugar. And I consider those the trifecta. Those are my top trifecta of foods that tend to be the most problematic and the most over consumed.

So if somebody has come in. And it’s really dependent upon the patient because sometimes the patient’s come in, and they’ve never done anything with their diet. In which case, ok. Where are we going to start? I like when the patient comes in and they’ve actually done a few things already. You know? There’s this thing called the internet that people like to go to for dietary recommendations. And when they go, by the time most people have come in. I’d say 90% of people that come in have already tried a gluten free diet and a dairy free diet and they’ve reduced their sugar.

So I would say if you haven’t, that would be certainly a lovely place to start because in many cases, those three foods are problematic. And I would say as practitioners, we’re all pretty hip to that already. But if the patient hasn’t done it, then absolutely look at those three things.

If they have done that. It also depends upon what they’re willing to do, as well. Where is the patient at? What can they do? I’m not going to put them on an AIP diet if they don’t know how to cook and they’ve got six kids and they’re working full time and they’re already highly stressed. I may not necessarily send them down that road. We may need to start slower and to start with a few foods. Right?

So start at the top. Gluten, dairy, sugar. If the patient hasn’t done that yet. If they have, then I’m going to start looking at the symptoms. What’s the patient telling me about their symptoms? Most of the time there’s going to be gut stuff going on. Ok, so we might move them down that road of a paleo type of diet. Where we’re shifting down, not just the gluten, dairy, and sugar, but also the grains as well. And the beans. So we’re shifting that down. And again, in most cases, we’re going to see some benefits in term of that shift.

Now, if the patient is telling me that, “well I did a Whole30.” A lot of people have done the Whole30. A lot of people have tried paleo. “And I felt so much worse on that diet.” I’m always trying to find, what have they done already and how did they feel when they did it. So if they did the Whole30, they did paleo, and they felt horribly on it. Their gut was killing them. Their joints were much worse on it.

Then I’m going to start thinking about, what about that diet is potentially problematic to the patient? And then I’m going to start to think the next rung down is where we start thinking about FODMAPS and histamines because those diets are very high in plants. And they’re very high in meats. And people tend to eat bacon and sausages, more fermented meats and things like that, and tomatoes. We tend to eat a little bit more in terms of histamines, and we also tend to eat a little bit more in terms of FODMAPs.

Foods That Are Problematic

So, ok. Now I’m going to start asking them, tell me what foods do you find to be problematic, if any. How do you do with say onion and garlic? “Oh my god, I can’t tolerate onion and garlic at all. It makes me crampy. It makes me gassy and bloating. It gives me headaches.” Ok, alright. So we know that that’s probably, how about the crucifers? “Oh yeah, no. I get really gassy from those.” How about beans? “I get really gassy from beans, too.”

Ok. So I’m hip to the fact at this point that FODMAPs are going to be problematic for this person. And I’m also looking at this point at other symptoms that might kind of help me to determine which diet to kind of go with, as well. So if the patient is telling me that FODMAPs are problematic for them, then I’m going to guide them a little bit further down that road, and we might try a FODMAP diet at that point.

If I’m seeing that the patient not only has joint pain, but they’re also working with those histamine type of symptoms. So they have severe allergies. They’re snotty and sneezy and they’ve got runny eyes. Or they have urticaria. Or they have anxiety or insomnia.

DrMR:  Brain fog. Do you find that one fairly common, also?

HT:  Brain fog is in everything.

DrMR:  Good point.

HT:  I just assume they have brain fog. I don’t know. I mean, histamine, FODMAP, paleo. All of it causes brain fog. So I stopped trying to track that one after a while. But sure. Are they have trouble sleeping? I just kind of try to go down things that might indicate that there are some histamine issues going on. But we also know that might indicate that I might want to put them onto a histamine diet.

We know from research that a low FODMAP diet can reduce histamine load in the body. So I’m usually on the fence, kind of going back and forth between whether to go down the histamine road or whether to go down the FODMAP road. And oftentimes I’ll take a look at what’s in the diet. If they’re drinking a lot of wine or kombucha or fermented foods. Or if they are eating a lot of FODMAPs, and they know those to be problematic, then I might kind of steer them down one or sometimes both of those diets, depending on what they’re willing to do.

And those things are just indicative to me, if I see a histamine intolerance, and I see a lot of histamine intolerance in rheumatology. Particularly with rheumatoid arthritis. But I see a lot of histamine intolerance. Then I almost invariably will order a hydrogen breath test to rule out bacterial overgrowth as one of the sources of their histamine intolerance. I’m kind of diverting here a little bit, but I just want to kind of rule in some of my other thought processes when I see that histamine intolerance.

I look at foods as, they’re not diagnostic, but they can give me a sense of pathways that are being triggered in the body. So if I’m seeing that histamine intolerance is present, I have to be thinking, ok. What are all the pieces that are going to trigger histamines in the body? I look at stress. I look at hormonal fluctuation. I look at the diet. And then I also look at the gut. And I consider bacterial overgrowth as a significant contributing factor in that sense.

If I see that FODMAPs are more problematic, I too might start to think around dysbiosis, or imbalance of bacteria. I have seen it with yeast, and I have also seen it with SIBO. So when I’m working those angles, then I’m going to be thinking more around, what do we need to do to kind of mess with the microbiome a little bit here.

Ok, I’m going to keep going. Any questions yet?

DrMR:  No, no, that’s great. Please. You owe me one, so go for it.

HT:  Alright. Then we kind of get into these other, let’s say we’ve applied all of this and we’re still. I work a lot with SIBO in my clinic. My doctors are well attuned to it. They are recommending hydrogen breath tests themselves. I work a lot with bacterial overgrowth because I started working with it about 5 years ago, and really saw a significant reduction in my patient’s symptoms when I would treat their overgrowth.

Some patients we wouldn’t see any change in their arthritic pain, but we would see their gut kind of calm. It really depended upon the individual, but I spend a lot of time with SIBO. So if I see a lot, if I’m seeing that, and we’re working the microbiome. And yet we’re still not getting any benefits to the joints. That’s when I’m going to be starting to think about these other food sensitivities. That’s where I might go down the road of oxalates. And I’ll talk to you about that in a second. Sometimes salicylates. And sulfur. And that’s sort of the newest thing that I’m working with a little bit more at this point.

Low Oxalate Diet

I’m going to speak to your oxalate comment. I totally agree with you, that it can take a while. And I agree, I’ve seen it take up to 6 months to really get full benefit or resolution of symptoms from a low oxalate diet. So I am more likely to order 24-hour urinary oxalate tests. I would ask my doctor to do that for me. Ask one of my docs at the clinic to do that for me. This is a test that you can get at any hospital. Any lab will do that. You don’t have to go through, you can certainly go through an organic acid test. But you can just as easily have your primary care doctor order it for you.

And you basically, you pee in a jug for 24 hours. And they measure your oxalates. Doctors use this for kidney stones to see if you’re producing a lot of oxalate in the urine. And that, I find to be, I will usually, if I’m thinking oxalates, I will usually ask that test to be ordered first because that diet takes so long to really know if it’s going to benefit you. And it’s a hard diet to follow. Especially if you’re already low FODMAP, low histamine. And we’ve kind of taken you through the gamut. Recommending low oxalates is…

DrMR:  That’s really where I struggle. If something is going to take that long, it’s just, there’s got to be no other alternative for getting at that. And in this case, I think there are other ways of getting there. But to your comment about the lab, that’s brilliant. Now, are you using, I’m assuming an out of the box, LabCorp, Quest, 24-hour urine.

HT:  Yep. That’s it.

DrMR:  Ok. And are you using the same ranges that will be reported via the lab?

HT:  I am. You know. The ones who are really in a lot of pain, they’re way outside the range. I think the lab range is in the low 40s. 40, 44. That LabCorp uses. Or at least the Mayo clinic uses, anyway. Those who are going to benefit, it’s way outside that range. Like I saw a 48 the other day, and I’m like, I’m not. I don’t know. I’m not there. I don’t know. We’re not quite there. And she’s been doing all of these crazy diets. It’s hard on the patient. When you’re like, let’s do low histamine. Let’s do low FODMAP. Let’s do paleo.

For me to ask them to kind of shift over to a low oxalate, I need to be a little bit more clear in that we’ve actually exhausted all avenues for me to do that. But one patient I had, we saw, and there are other things that can kind of indicate. Her GFR was down to 31. All of a sudden it just dropped, and they couldn’t figure out anything that was going on with her kidneys. They tried every test imaginable. Except for an oxalate test. Couldn’t figure out why her GFR was dropping so dramatically. We ran a urinary oxalate, and she was 133.

So, with a 42, 41 range. Ok, that’s going to work. I have no problem asking that patient to take oxalates out of the diet. Her kidneys are failing. And she has pain that we have not been able to get to, doing anything. Doing low histamine. Doing low FODMAP. Treating her SIBO. Her back pain is constant. And once those kidneys told us that there was an oxalate issue, we get those oxalates out, her back pain is just, it’s taking months. But bit by bit, it’s coming down slowly. And we’re seeing a resolution of that back pain, through the omission of those oxalates.

DrMR:  That’s fantastic. That, to me, was worth the call right there because again, I really struggle with things that can’t get people results in a more timely fashion. So that to me is going to be what I start doing now, is running that 24-hour urinary oxalate. And just to clarify, and say it one more time for the audience. If you’re seeing only a slight elevation, you would not use that as justification for the diet, correct?

HT:  I wouldn’t start there. But if I’m seeing other things. Other symptoms that you look for. Interstitial cystitis, vulvodynia, and obviously a history of kidney stones where calcium oxalate was the issue. And we have this pain. And there’s maybe a slightly elevated oxalate. And we’ve tried other things that we’re just not getting anywhere. Ok. Then I might go down that road.

And the other thing is to also look at the history. This particular patient had been on antibiotics multiple times over the course of her life. And you know, that potential deficiency of Oxalobacter formigenes, and the thing that helps her to break it down, is more likely. So you have to kind of look at the full picture. But this 48, I don’t know. I’m not sold on it yet. And she has some sulfur issues, so I’m going to stick there first, I think.

DrMR:  And again, the upper level cut off is 40 to be into the positive?

HT:  I think it’s like 42. And it depends upon the lab, as well. I’ve seen an organic acid test where it’s much higher, and I don’t know what they’re using for that. And our lab, which we’re using Mayo through U-dub. It is 43, 42-43 I want to say. It’s low 40s. But she was 133.

And a low oxalate diet, what’s funny. I’ll just say this. Within three weeks, a month on that low oxalate diet, she was down to like 20 on her oxalates. But her symptoms hadn’t really changed. It’s taken three months, four months, to see her GFR start to come back up again. So it takes a long time. Absolutely.

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Sulfur Intolerance

DrMR:  So very helpful there. And if you have anything else, please feel free to finish that thought. But I’m curious to kind of transition into the sulfur piece now.

HT:  Yeah. So this is interesting. So, I’m going to just give you a little bit of a story and kind of take you through my experience with this thus far. So about 10 years ago, I had a patient come in and she – severe – what I noticed in looking. I’m always looking for the patterns in the food. What are the things that each of these foods has in common. What constituents could indicate the pathway we need to be working on.

She had some mast cell issues, but was doing fine with high histamine foods. But what I saw was everything sulfur she couldn’t tolerate any kind of sulfur compounds in her foods. And 10 years ago, there was nothing on this. You go to PubMed and look at the research, there was very little on what to do with a sulfur intolerance.

And you now, Epsom salt baths. What were things we could potentially do? And Epsom salt baths were helpful. But we ended up kind of working other pathways with the microbiome. Got her to a better place, but weren’t really able to move her out of that low sulfur diet.

So you get distracted over time, and working on histamines, and FODMAP, and SIBO, and focusing there and not really thinking about sulfur intolerance. Just not really knowing what to do with that. So fast forward maybe two years ago. It’s always kind of stayed in the back of my mind. So we fast forward to two years ago, and a patient of mine with SIBO. We had been treating her SIBO. And whenever she would stay on her antibiotics, whether it was antimicrobials or rifaximin, she felt great. She was an RA patient. And everything came down. Gut stuff came down, joint pain came down, she felt really good. And as soon as we would take them out, everything came back up again.

All GI tests were fine. No history of food poisoning. All the things that you go through. She was clean. She was really clean. And it’s like, why do you have SIBO? So we’re just focusing on her stress more than anything, trying to shift that around. But she has major food intolerances. And when she takes in a food that she’s reacted to, it goes on for a week or two. It’s a really significant RA flare when she has it.

So I start looking at her diet, and seeing that we’ve had her on low FODMAP for a while, because she can’t get her FODMAPs back in. But I was noticing that she was doing just fine with pears and apples and avocados and mushrooms and blackberries. These other non-sulfur FODMAPs, she was doing just fine with. And I’m kind of looking and like, what’s the difference here? Between this FODMAP and that FODMAP? Why are you ok with this, and why are you ok with that?

So she all of a sudden starts getting headaches. She moves into a place that has well water. And she starts getting severe headaches. So she got a water report, and it was very high in sulfur. So, I asked her to come off of her water, and within a couple of days her headaches reduced and we saw some of her joint pain reduce, as well. And I start looking at these two food categories and going, oh, that’s sulfur, that’s not.

So then I start looking, again. Kind of going back to the research on sulfur. Again, not a lot in terms of the research, but now we have websites kind of popping up around CBS and genetic issues and sulfur oxidase genetic issues. People who have a difficult time converting their sulfur compounds into the usable form, sulfate. So that we can actually use that for detoxification and cellular communication and all the things that we use. Digestion. All the things that we use sulfur for.

So, we took her off, I identified other sulfur foods, and took her off what I could find. Took her off, and it was this immediate, headaches went away. Gas and bloat went away. Constipation went away. We had been working with her constipation for a year trying to get things to work. All of a sudden, she was going every single day. Everything just shifted down. Her pain shifted down. It was like everything just kind of deflated on her. And I went, oh my god. Here we go ok. Now we’re back to sulfur metabolism issues. Ok.

And I’m just going to take you over to one other thing and talk to you about what we were doing. So one other person comes in, and she and I had been working SIBO. And she, again, she does really great on her antimicrobials, as soon as she takes them out, everything comes back up again. Now she has MCAS, EDS, and POTS as some of her cofactors in addition to spondyloarthropathy. So she’s got a lot going on.

But we decide, she said, I’ve always felt the best on those antimicrobials. Can we just try them again? And I said, sure. I’d like to add in Alamax because there is a certain amount of methane you’ve got there.

DrMR:  Oh boy.

HT:  Yeah, right. You see what’s coming, right? We added Alamax, and we’re going to add in a little NAC as well because, that will help with die off. So, she comes back in a week later, and she had exploded.

DrMR:  For the audience, both of those are very high in sulfur.

HT:  High in sulfur. Just yeah, so you know. She had exploded. She had gained 15 pounds. I could barely recognize her. Her face was swollen. Her eyes were swollen. She had a headache. Her skin had broken out. Her gut was bloated. She was majorly constipated. Everything had just swollen up on her, and I didn’t know what was going on. I said, ok let’s stop everything that we’re doing.

So we shifted everything down, and everything started to deflate again. But only to a place because she still had quite a lot of sulfur in the diet. And I had just seen this other patient. The lightbulb had gone off there. And I said, hey! I just gave you a bunch of sulfur!

And the other thing I wanted to mention around symptoms for her that I’m also hearing is that she smells ammonia. On her breath and in her urine. So she always has this sense that she smells like ammonia. She feels toxic. She looks toxic, she feels toxic. And these are all symptoms that I’m describing to you while I’m presenting to you is because, these are all symptoms that I’m seeing being very common among those who have this sulfur intolerance. There’s a toxicity that’s there. There’s a swelling. There’s a weight gain. There’s a gas and bloat.

Sometimes it’s diarrhea, but more often than not, there’s a constipation. There’s an eye inflammation. And I’ve seen varying degrees of that. So I’m always kind of looking for that at this point. But there’s also that smell that doesn’t always apply to everyone. But I have seen in a few patients that they say, I smell like ammonia. What is that?

So. This has led me down the road to working and really identifying these sulfur intolerances.

DrMR:  So, great presentation, by the way. Thank you for that case presentation to kind of bring that to life. Let’s recap some of the key indicators because the thing I really try to harp on for people listening to this is, what are the few lifelines in terms of symptoms that they may want to look out for, that may tell them that this is something that’s afflicting them. And I know sometimes it’s challenging, because sometimes the presentation and the symptoms are very nonspecific.

But you had said swelling, weight gain, this feeling of inflammation, gas and bloating. Sometimes an ammonia-like smell.

HT:  Constipation. Headaches. I really do look at the brain a lot. I look at the headache. I look at the eye inflammation. That’s another indicator. Like, I get headaches from garlic and onion. I get headaches when I eat, that’s part of the presentation often. This one patient that I’m talking about also, she was more prone to shingles. I don’t think that’s as common, but certainly skin issues. Urticaria or eczema, I might see that.

Now, unfortunately, a lot of these look like histamine responses. And I’m guessing there’s a correlation there. There’s likely a stimulation of histamine in all of this through this sulfur intolerance. So it’s a little hard to differentiate between the two. I don’t know how else to describe it. There’s a toxicity to the patient. They feel toxic. They feel exhausted and they feel toxic when these things flare. And there’s joint pain, and there’s gut issues, and there’s bloat. Severe bloat.

DrMR:  Now, do you find that gastrointestinal symptoms are always present? Are the present in the majority? In half the cases? In the minority of cases?

HT:  That I’ve seen, it’s been all of the cases. And I think it speaks to, in those patients that I’ve really seen this with, we were treating their SIBO and they always felt better. When we had them on an antibiotic or an antimicrobial. They just, like they can function when that’s going on. And there’s a question about hydrogen sulfide producing bacteria. And whether that is increasing symptoms. I would anticipate more diarrhea there, but most of these patients are prone to it.

But I do see that rifaximin especially works really well in this population. But definitely more of the, obviously not the allium but more of the berberines and oreganos and things like that, where you might target that hydrogen producing bacteria. Those typically are going to be, they’re good responders to those, basically. So I would say, I don’t know. If I think about it right now, I haven’t see a sulfur patient that doesn’t have GI issues.

DrMR:  Gotcha. Ok. And without getting too far field into the academics, what do you think is driving this? I’m assuming foundationally that if people do not have healthy gastrointestinal tracts, that for a number of reasons, potentially because of inflammation, because of intestinal damage, because lack of enzyme being able to be secreted, that there’s not going to be optimum function, just like there is for histamine, for example.

Factors That Drive Sulfur Intolerance

What do you think, to put it simply, are some of the main factors that are driving this?

HT:  So there’s the diet, obviously. If we’re doing a higher sulfur diet, then that’s going to be more problematic. And that might be more problematic on a paleo or an AIP type of diet, just for those who aren’t doing so hot on those.

So the dietary intake of high sulfur foods, nuts, eggs, all of the crucifers, onions and garlic, kale, greens. Vegetables. Not fruits. Not so much in the way of fruits. But all of those foods that we typically might eat on a very healthy diet.

Dr. Michael Ruscio:  Which is why I try, not to cut you off, which is why I remain openminded to the fact that the paleo diet, as healthy as it can be, is not the only healthy diet. There are some people that, I think some people have gone to diets that are higher in carbs, kind of like your Paul Jaminet-esque paleo Mediterranean, whatever. And they’re feeling better because they’re eating less of these problematic vegetable foods, and more grains. And it’s not necessarily the carbs, but it’s their reduction of some of these high histamine, high oxalate, high sulfur foods. I think that’s the reason why they’re feeling better. So it’s just important to bear in mind, just because there is some evidence showing the paleo diet to be very healthy, it’s not to say that it’s the only healthy diet. And for some people, it may actually be a bad maneuver.

HT:  Exactly. You got it. So, other underlying causes to this. There’s the dietary piece. I do question water source. Certainly anyone who is on well water, I always question because I think there’s going to be a higher sulfur content, likely. Unclear if you’re seeing red rings around your faucets and things like that, then there might be a higher sulfur content in your water. So be aware of that. If you are taking in a lot of that, that’s going to be problematic.

Medications and supplements. We do a lot of detox stuff that has, most of the detox supplements, ALA, MSM, NAC, if we’re doing a lot of detox powders of supplements or some of these multivitamins include a lot of detoxification supplements in there, then we’re going to be, again, increasing the amount of sulfur that’s coming through.

Certain medications, like sulfa medications. And that would be another good thing to be looking at, does your patient have a sulfa allergy. They’ve tried sulfasalazine and failed it miserably. If they have a sulfa allergy, that might be another indicator that there could be some sulfur intolerance issues going on. So there’s supplementation. A lot of people take garlic during the winter season, as well. So just be careful of that.

There’s also indication that there can be hydrogen sulfide bacteria in our water. Not just in our water system, but in our pipes. So we might be getting a little bit more of those bacteria coming in via our water. And let’s see, what else? Environment. Fossil fuels. We’re getting sulfur as one of the byproducts of fossil fuel. So we’re going to be breathing it in. So that is potentially, depending if you’re in the cities and in greater concentrations where you’re going to be more exposed to that. That could be problematic.

I’ve seen some people who have sulfur issues that when they get out into the country, or they get out to the water, they get away from the city, it’s like they can function again. It’s like all of their symptoms just shift because all of a sudden what they’re taking in, what they’re breathing in can be more problematic.

One thing I’ve been listening to some of the work of Dr. Nigh and his team down in Portland recently and they’re kind of looking at things. Looking at glyphosates as potential contributing factors that are found in roundup and some of our pesticides as not as necessarily having sulfur, but binding molybdenum, which is basically one of the key cofactors in converting sulfur oxidase into sulfate, so we can use it effectively. So that’s another question around environment. And also discussing the possibility that heavy metal might also be potentially binders in that situation, as well.

And I have to say that some of my patients who are doing better, we’ve taken and made sure that they’re doing all organics. And that’s everything, environment. That’s environmental organics in their home but also what they’re taking. And really making sure that we’re cutting down on the amount of chemical coming through to reduce toxicity in that sense.

I think those are the things that I have seen the most as the contributing factors. And that by cleaning up their environment, getting them off of the supplements that are sulfur based. Oh and then bacteria in the gut. If you’re producing hydrogen sulfide bacteria, sometimes if we can shift down on the amount of sulfur coming through, then I’ve seen that basically we don’t see as much of the gut symptoms. The gut might calm down a little bit more.

And it might speak to, by shifting down sulfur potentially. If the body isn’t producing sulfate. If we can’t convert all of the stuff that’s coming through into sulfate, which is our useable form of sulfur, then the body might try to make it other ways. And hydrogen sulfide bacteria, those bacteria. They’re there for us. It might be a way that they can think to increase our sulfur production so that we can actually build that sulfate.

DrMR:  Sure.

HT:  But what I will see is when we take down that dietary sulfate, often times the gut starts to calm down again and we’re at a much better place. The gut issues disappear. It’s like, oh, it was a sulfur issue. So now we need to work on those pathways. What do we do to upregulate your ability to manage the sulfur that’s coming through? Because you need sulfate. You need to be able to detoxify. You need to be able to help your cells work. So how do we not just reduce the amount of sulfur that’s coming through, but also upregulate the pathways that are going to help you to make that conversion happen.

DrMR:  Sure. And I want to come to you, dietary strategies, and several mental strategies for helping to detoxify and process sulfur in a moment. Before we go there, are there any tests that you have found helpful to guide people with this. Or to indicate this might be an issue.

HT:  I haven’t. No. I don’t do a lot of testing in my practice. I’ll just let you know, just to start. I don’t do a lot of testing. Outside of breath testing and then that oxalate testing. But I don’t know of any. Maybe there are organic acids test. I don’t know. Maybe there’s something that you might have an idea around that more than I would. But nothing that I’ve been tuned into where that sulfur intolerance might be more problematic. Other than maybe you have a flatline hydrogen breath test. That would indicate that you are working with higher levels of hydrogen sulfide producing bacteria.

DrMR:  OK. And let’s go into some diets. What the keystone dietary recommendations are. But also, I’m wondering if there might be a good link or website where there’s a breakdown of high sulfur foods compared to low sulfur foods. And also, if there are AKAs because I was doing a little bit of searching around, and it seems like this may also be described as a low-thiol or a low ammonia diet.

HT:  Yeah.

DrMR:  So how can the user try to navigate this.

HT:  Yeah, that’s a really good question. And I haven’t been able to find any studies that are going to say, “We’ve measured the sulfur in this food.” It’s kind of like histamine foods. It’s going to be about 10 different sources online. And unfortunately, I think I’m early enough in this whole process where I don’t think we have enough research on that to really say this absolutely has this much sulfur and this doesn’t.

Low Sulfur Diet

So I basically, go to my online sources. I think Dr. Jockers is the one who I got his low-sulfur diet from. And you start there. So I basically found one that I felt like was potentially beneficial, and potentially what I was seeing clinically as far as what was problematic to my high sulfur patients.

So you start there and then you kind of build it yourself, basically, from there. And I work a lot with the diet, so I might see, coconut is considered low, and yet I see my sulfur patients not do well with coconuts. So I’m going to put that onto the no list. So there are certain things. Beef is ok in small amounts, but I see a lot of my patients not do well with beef. So I’m going to take that off the list. So I’ve basically started with one, and then kind of narrowed it down from there basically, based on my experience with it.

DrMR:  So, did you say that’s available on your website? Or was there somewhere else?

HT:  It is not, no. I think where I first started, there’s a doctor, DrJockers.com. And he works a lot with the CBS mutation and works a lot with a low sulfur diet. And I felt like he had a good resource there as far as which foods were high, which foods were low. There is the question around whether it’s a sulfur or a thiol issue. It’s a high in cysteine, methionine, or just sulfur. High in sulfur. I will take the thiols out. I took everything out, basically. And then rebuild from there.

So we try to really take out everything, including grains for those who have SIBO. Even though those are not high sulfur. I will shift out grains. I will shift down on the meats. It’s primarily low sulfur fruits and vegetables. It’s a very non-sustainable diet. All you’re doing is basically shifting down on the concentration of the sulfur to see if you’re working with the correct pathway. And when you shift this down, you’re going to know within 3 to 5 days whether this is benefitting the patient. I have seen the deflation happen within a day or two. Sometimes it takes a little bit longer. But it’s really fast. It’s not like your oxalates. It’s a really fast reduction in terms of those results.

And if that’s the case, then you want to start rebuilding. Can you do beef? Can you do some of these other higher thiol vegetables? What can we do to kind of build this up as much as we possibly can while we’re supporting these other detox pathways, without using sulfur-based compounds.

So, it’s really just kind of starting with one. Again, it’s choose one and apply. And in most cases, you’re going to reduce the amount of sulfur that’s coming in. If you’re already on a low FODMAP diet, you’re already about halfway there. But then you have to go further as far as, no 20 almonds. There’s no almonds. You know. No eggs. Your meats are going to have to really shift that down. Fatty meats are going to better. Fish is going to be better than a higher protein situation. And you’re shifting down on the amount of meat that you’re eating, as well. So if you’re paleo, you’re going to be taking that way back.

It’s a really intense, it is not a sustainable diet. I’m just going to let you know. It is not a fun diet to do, and most people are going to have a certain level of threshold of tolerance. Kind of like histamines. You just take them all the way down, see if it’s the right pathway, and then you build it up from there and see what the tolerance is.

Dr. Ruscio Resources

Hey, everyone, this is Dr. Ruscio. I quickly wanted to fill you in on the three main resources that are available to you in case you need help or would like to learn more. Of course, I see patients both via telemedicine, via Skype, and also at my physical practice in Walnut Creek, California.

There is of course my book, Healthy Gut Healthy You, which gives you what I think is one of the best self-help protocols for optimizing you gut health and of course understanding why your gut is so important and so massively impactful on your overall health.

And then finally, if you are a clinician trying to learn more about my functional medicine approach, there is The Future of Functional Medicine Review, which is a monthly newsletter. Which is a training tool to help sharpen clinical skills. All of the information for all three of these is available at the URL  drruscio.com/resources. That’s D-R-R-U-S-C-I-O. And in case you are on the go, that link is available in the description on all of your podcast players. Okay, back to the show.

Treatment

DrMR:  You know, if we can have a fast response like that, it’s really a lot easier to work with. So that was my two next questions were, how long to see a response. You answered that, 3 to 5 days. And then, do you reintroduce? And you answered that also. Kind of a one-ish food at a time, trying to establish what foods are ok and what someone’s tolerance is.

HT:  Exactly.

DrMR:  And then I’m assuming that what will probably happen, just for clinicians. And patients also. But the better you feel, the less you’re going to think about this. And then at some point, you may go, wow. I feel like crap today. So take stock of what you’ve been eating. You may need to ratchet things back down for a little while, and kind of recalibrate. And that happens with histamines sometimes. It happens with FODMAP sometimes. So just remember that that happens sometimes. It doesn’t mean something is irreparably wrong or broken if that happens. Sometimes when people start drifting into too much FODMAP, the come in the clinic, and they go, oh my god. This is SIBO relapse. Does this mean I’m never going to… and they freak out.

It may be. Alright, that it could be. But in a lot of cases it’s not nearly as dire as sometimes people overreact into thinking that it is. So just a little bit of a note there.

HT:  Absolutely.

DrMR:  What about supplements that can help with this. And how are you using those.

HT:  Yeah, so this was really tricky because again, not a lot of research to help support this. I was using, some of the things that I use are Epsom salt baths. That I’ve been using for a while. Those are really beneficial. They are sulfate. And that’s really what we’re looking to help the patient produce, is sulfate. So that really just kind of helps to shift down some of that more toxic feeling that they’re experiencing. This is obviously in addition to the dietary change. But that could be beneficial.

I’ve also been working with trace minerals that also have sulfate in them. Trace Minerals Research has one that’s called ConcenTrace that has magnesium and calcium and a few things, but it also has a little bit of lithium orotate as well as sulfate. People do really well on that.

DrMR:  That’s ConcenTrace by …

HT:  Trace Minerals.

DrMR:  Trace Minerals.

HT:  Yeah. They really do well on that. I don’t know, maybe there’s something about the lithium as well, I don’t know. That’s what I was working with. I was also, for a while, working more around, especially my patients who smelled like ammonia, working with some calcium d-glucarate and for ammonia detox, magnesium cofactors for everything. Sometimes l-glutamine was beneficial as well.

If you go too far down into those more of the genetic, all of the cofactors and related to the genes, it’s a little bit hard. I don’t do genetic testing, and I certainly, I get the whole idea of it, but it’s certainly not my specialty. So for me to kind of go, you have the CBS genetic enzyme issue. There’s lots of things you can do to help support that. If you go too far down that road when you’re kind of working with different websites or practitioners, I haven’t seen it really benefit using chlorella things like that. I haven’t seen it really benefit, ornithine, arginine. Those type of things. I just haven’t seen it really do anything.

DrMR:  I’ll agree with you there. I think the gene testing has been way overinflated in terms of it’s potential benefits. Open to it, but I think it’s been way overstated.

HT:  Agreed. I’m totally open. I think it’s fascinating. But I just, it’s not my specialty. If someone is interested in it, I will certain refer out. I’ve seen some remarkable things, I will just say before I move on. I have seen some remarkable things for those who do specialize in it, and where I could not get the patients, especially in mast cell issues where I could not get the patient anywhere down the road and they were able to do it. So there’s something there. I don’t apply.

So those are the things I’ve been working with, I would say, marginal success. But certainly some benefit.

DrMR:  So then if you had to compare the diet compared to the supplements, how would you say they rate in terms of percentage of improvement that each one may yield?

HT:  Well, hang on, I’m going to do a couple more supplements here.

DrMR:  Ok sorry. Please.

HT:  No that’s ok. I think these are actually ones that I’m seeing more benefit from. And this is coming from the work of Dr. Nigh out of Portland, as well. And he’s really focusing a lot on that cofactor of conversion into sulfate. And how things like environmental glyphosates, environmental toxins might be leading to molybdenum deficiency, and how molybdenum is a really major cofactor in that conversion into sulfate.

I have used molybdenum for years in working with histamine intolerance because it too is part of that, that metabolism of histamine that we would see deficiency when someone has a salicylate or a histamine intolerance. So, looking at his work and in that thought process, how do we upregulate this conversion? And apply molybdenum, I’m seeing some pretty impressive results in bringing that in, as well as hydroxocobalamin as well.

So those are two that he works a lot with that he has mentioned. And they’re ones that I have worked with before for other conditions, but am now applying them to this population and seeing early indications there are some good benefits to them. And I could get a little bit further down the road. And it’s allowing us to actually add more sulfur back into the diet. And that’s always been the issue with sulfur, with sulfur issues, once you take them out, it is hard to get them back in. Depending upon how long this has been going on and how toxic the individual is.

So, those are the other two that I’ve been working with. And I’m finding early indications are beneficial.

DrMR:  Are there doses for each one of those that you’re using?

HT:  I don’t have them off the top of my head.

DrMR:  That’s ok. Would you mind emailing them over to me if you have a chance?

HT:  Yeah, sure.

DrMR:  Ok, because I’d love to include that for people.

HT:  Absolutely.

DrMR:  Because I know that people will ask. I’m just going to preempt that now. Ok. And so, then if you have more please continue. But if not, I’m curious to get your comparison in terms of supplements versus diet. Relative contribution from each one.

HT:  In terms of sulfur?

DrMR:  In terms of how much you feel like they help. Just because sometimes I find that people may over emphasize the importance of supplements. Not taking anything away from them, but I just want to try to contextualize how important each one may be.

HT:  Ok. I just want to make sure I understand, you’re talking about with sulfur specifically? Or you’re talking about just in general?

DrMR:  Yes. I’m sorry. With sulfur intolerance specifically. How important do you find that the diet compared to the supplements in terms of the contributors towards resolution of symptoms.

HT:  I think they’re necessary. I mean, the diet is going to help you feel better. You’re going to do it, and you’re doing to feel better on that diet. But you’re going to have to stay on that diet. In order for you to get better, you’re going to have to do more. You’re going to have to likely go back in and shift gut microbiota around. So we might have to do another SIBO treatment. We might have to do some probiotics. We might have to supplement from that perspective.

And again, I don’t know where I’d be without the trace minerals, the Epsom salt baths, and now I’m adding in molybdenum and B12. Those have really kind of moved me forward in terms of helping these patients.

And obviously, you have to shift down. Not just in the diet, but also environmentally. What can you do to shift that down, as well? So I feel like you need it all. I don’t feel like it’s just a matter of, do the diet for a while and then bring it back in. Like you could do with FODMAPs. Right? You could take the FODMAPs out for a period of time, really get a major benefit from it, and be able to bring those back. You could do the same thing with histamines. You could do that with other types of diets. With this one, it’s a really sensitive population. Again, there’s a level of toxicity going on, and severe inflammation going on. So you really have to throw, I think, as much as you possibly can at that.

DrMR:  Gotcha. So this tends not to get better with time unless there’s some kind of support, essentially is what you’re saying.

HT:  I think so. Yeah. I haven’t been able to build the diets back as easily without that support.

DrMR:  That makes sense. That’s good to know. One other thing I wanted to ask you, just kind of quickly. How long you feel is at least an adequate preliminary window to gauge whether a diet is working or not. Now, for the sulfur diet or low sulfur diet, you had said about 3 to 5 days. I’m wondering how you feel about that same question for histamine, which I’ve found to be fairly quick. And for FODMAPs, which I’ve also found to be maybe two-ish weeks. Maybe a skosh longer. But what are some guiding timeline principles?

HT:  I would agree. Everything you just said I would agree with. Sulfur, give it two weeks. But you’re going to notice changes within a few days. But just say, I’m going to give this two weeks. But it will likely happen a lot earlier for you. Histamines I say two weeks. Let’s see, FODMAPs I say two weeks. And again, you’re probably going to notice benefits earlier than that.

When I do elimination diets, like for gluten and dairy and things like that, I typically see more three weeks on that. I tend to not go much longer than that. Some people are doing stuff, their doctors are saying to do it for 6, 8, 10 weeks. I find adherence just goes out the window. Especially when you’re trying to kind of figure something out. What you don’t want to do is ask them to do it for too long because really, I look at this as like a little science experiment. Take it out, how do I feel. Add it back in, how do I feel.

DrMR:  Well said. I agree completely.

HT:  You go too long on that, you’re going to lose your data, you know because a party is going to come up, or a dinner is going to come up, and you’re going to lose it. And eventually they go, eh. Forget it. I can’t stick to it anyways. It’s just too hard.

DrMR:  Yep. I agree.

HT:  So yeah, I’m right there with you. I’d say that’s long enough. And you might not. What I’ll just add to that, say a gluten free diet. Some people say you don’t get the full benefits for three months or six months or a year. Right? So that might be true. It is possible that three weeks is not going to be long enough to get the full benefit from a gluten free diet.

But it’s enough to calm a response down. It’s enough to shift things down so that when you add it back in, you’re going to get a response. You’re going to see that reaction. And that’s really what I’m looking for. I’m looking for the return of the food back in. Especially in my clinic because we’re always, I’m working with the docs, and they’re not waiting for me to make diet changes. We’re going to start the methotrexate, and the Humira. We’re going to start all of these things.

So when I’m also changing the diet at the same time. Or if you’re adding a lot of supplements in. So you’re doing a lot of things at the same time. You don’t have that opportunity to really get a sense of what’s working. I want to take those foods out for a period of time. What I’m really looking for is when I add them back in. So I’m looking for the benefit, but I’m also looking for the return of that food. To see what that immune system does.

DrMR:  Yep. Makes a lot of sense. Two final questions for you. One, I already kind of know the answer to, because we were talking about it pre-roll. But in terms of the state of research here. I know you were saying it’s kind of it in its state of infancy. So I’m assuming there’s not a lot to cite in terms of randomized control trials or other interventional studies.

HT:  In terms of sulfur?

DrMR:  Yes, I’m sorry. Regarding a low sulfur diet.

HT:  I have not seen it. There’s a lot on sulfite because there’s a lot of sulfite sensitivities. But I have not seen it. I’m looking forward to it, but I have not seen it.

Episode Wrap-up

DrMR:  Gotcha. And then final question. If people wanted to read some of your work and just follow you, is there a good website or somewhere else where people can learn more from you?

HT:  Sure. I have a relatively low profile online. I have a lot going on in my life. It keeps me from doing too much online. However, I do have a Skype-based practice. Here in Seattle. And I’m at FoodLogic.org. and if you’re in the Seattle area, I’m at the SeattleArthritisClinic.com.

DrMR:  Awesome. Is there anything you want to make your closing remarks to the audience before we move to a close?

HT:  I think I’ve said everything. I would just say…And I know that you profess this, as well. When you’re looking to make dietary changes, if you’re a practitioner or if you’re the patient, just start with one place. Start with one place and see what your body does. If that’s a paleo diet…Whole30 is really popular and it’s a great thing because a lot of people are willing to do it with you. Start from just one perspective and see how you feel. And if things get better. Then you’re on the right track. And if things get worse, use that information to help propel you to the next step.

DrMR:  I like it! Well, Heidi, thank you so much for taking the time. This has been a great conversation.

HT:  Thanks for having me.

DrMR:  My pleasure.