Podcast Drop Date: 1/25/23
Gavin Guard, PA-C, MPAS, CISSN, Pn1 believes that the average doctor visit is not giving patients the time and support they deserve. Gavin graduated summa cum laude from Whitman College with a bachelor’s in biochemistry before completing graduate medical school training at the University of Colorado. His main clinical focuses include gastrointestinal disorders, thyroid and hormone health, as well as metabolic disease like diabetes, high cholesterol, and heart disease. Aside from patient care, Gavin is also publishing medical literature in the functional medicine field. He wakes up every morning to help patients find lasting solutions to their health so that they can experience hope and feel restored. When not in the clinic or reading papers, you can find him spending time with his wife and two young girls or pumping iron in the weight room.
Gavin's specialties include: - Digestive concerns (IBS, SIBO, reflux, bloating, diarrhea, constipation, IBD) - Longevity and metabolic health (heart health, blood pressure, blood sugar, cholesterol, weight loss) - Mold illness and toxicity - Thyroid health - Hormones (testosterone, menopause, female hormones) - Autoimmunity - Brain fog, fatigue
In this episode, Gavin Guard, PA-C and host Amber Warren discuss the following topics:
- Why do we care about Gut Health?
- Protocols to optimize Gut Health
- 70% of the immune system is found in the gut
- What is Leaky Gut?
- Imbalances of the Microbiome
- Testing
- Thyroid health
- Vagus nerve
- Gut/Brain Connection - And More!
Transcript:
Amber Warren, PA-C: Welcome to Functional Medicine Foundations podcast, where we explore root cause medicine, engage in conversation with functional and integrative medicine experts and build community with like minded health seekers. I'm your host, Amber Warren. Let's dig deeper. Welcome back, everybody. I'm here with Gavin Guard, physician assistant with Functional medicine of Idaho. Gavin Guard believes that the average doctor visit is not having patients, not giving patients the time and support they deserve. Gavin graduated summa cum laude from Whitman College with a bachelor in biochemistry before completing graduate medical training at the University of Colorado. His main clinical focuses include gastrointestinal disorders, thyroid and hormone health, as well as metabolic diseases like diabetes, high cholesterol and heart disease. Aside from patient care, Gavin is also publishing medical literature in the functional medicine field. He wakes up every morning to help patients find lasting solutions to their health health so they can experience hope and feel restored. When he's not in the clinic or reading papers, you can find him spending time with his wife and two adorable little girls. I can vouch for that. Or pumping iron in the weight room. Gavin has multiple specialties, some of which include multiple digestive concerns IBS, SIBO, reflex, bloating, diarrhea, constipation, IBD, longevity and metabolic metabolic health, optimizing blood sugar, heart health, high cholesterol and weight loss, mold, illness and toxicity, thyroid health, hormonal health, autoimmunity and brain fog and fatigue, to name a few. Welcome, Gavin. Thanks, Amber. So Gavin's been. Yay! Gavin's been a part of our team since June. This past June. We were able to swipe him from the state of Washington at least part time, where he spends time in Idaho seeing patients in person.
Amber Warren, PA-C: So we're just going to go ahead and dig right in. You know, the crux of what we do in functional medicine is really gut health. That is our bread and butter. Sure, we all take a lot of pride in in knowing the gastrointestinal system and the microbiome really well. But you take it to a new level and we've been so thrilled to have you present to our practitioners during our dedicated study time just some of the techniques that you've studied, some of the protocols that you've been able to just really optimize and just your approach and just let alone with some of the papers that you've published on gut health and connections there. So let's just for some of our listeners that may be gut health, that whole concept is somewhat new to them. Let's kind of start there. Why why do we care about gut health? Why is it important? Why functional medicine? Is that our focus?
Gavin Guard, PA-C: Yeah, I mean, so functional medicine is not much different than conventional medicine. We do a lot with conventional medicine does. We use medications, we diagnose, we order labs, all that. I see functional medicine more of a comprehensive, just good integrated medicine where we expand our toolkit. We're using nutritional science, sleep physiology, distress, tolerance or stress management supplements or nutraceuticals medications and exercise or movement. And we try to layer or pepper in these therapies in a very informed manner to create a more comprehensive plan for someone. With that said, functional medicine is a very diet and lifestyle focused medicine that's kind of like the base of the pyramid. You could use, quite frankly, all the medications or supplements that you want. But if you are not moving, you're not sleeping and you're not following a good diet, we're really not going to get anywhere. So with that said, again, functional medicine, diet and lifestyle focused. Paradigm, if you will. One layer above that on this pyramid model would be gut health. And there's a few reasons. That is one of which is that our gut is kind of like the epicenter by which inflammation occurs. And as good functional medicine providers, we're more or less all inflammation specialists. There's this process called inflamm aging. This theory that aging can be considered or perceived as a disease that could be halted or just mitigate or blunted with the rate of by which it occurs. So inflammation is something that we don't want and chronic inflammation is associated from anything like degenerative joint disease, autoimmunity, brain fog. There's new research from very prestigious neurologists and neuroscientists to show dementia and depression, anxiety. All have this common element or theme of inflammation at its core. So in conventional medicine, we kind of have these silos, if you will.
Gavin Guard, PA-C: You know, you are a heart doctor or you are a gut doctor, or you just focus on joints. But no one's really putting these pieces all together. I think that if you are to optimize one thing, apart from just diet and lifestyle, your gut is going to be the next thing that you would want to focus on because of how it. Then kind of contributes to inflammation, which then affects all of these diseases. And the research, you look at what are called these axes or this axis. That's just to explain how one thing affects another thing. There are terms called the gut brain axis, the gut skin axis, the heck, the gut thyroid axis, which I'm sure we'll talk about here soon. That just explains how your gut health can affect these other systems and symptoms. So maybe going back a little bit to the anatomy and how your gut can contribute to inflammation, your gut is exposed to the outside environment, Right. Much like how your skin is. So we have these two defense mechanisms, our skin and our gut health. Now, our immune system is has high concentrations of immune cells in our skin, in our gut. And normally our immune system is able to tell what is good or bad, right? But when we have things like infections, bacterial imbalances, maybe you're eating things that you shouldn't be, you're stressed out or sleep deprived. Our immune system kind of goes haywire and it really all starts in the gut. 70% of your immune system is around your gut, most specifically around your small intestine. That's because your gut is exposed to the outside environment. So it has to be able to defend from outside.
Amber Warren, PA-C: We describe it as our first line of defense. First line really is that interaction.
Gavin Guard, PA-C: Yeah. So, you know, normally your gut cells are packed nice and close together. They have these proteins holding them together. They're called tight junctions, and that usually allows the good things to come through. And so, for example, the protein, calories, carbohydrates to come through and keep the bad guys out, all the inflammatory things, all the things that are toxic in nature and that could be produced by bacterial imbalances or overt infections. Now there's this phenomenon called increased intestinal permeability. The lay layperson term is just called leaky gut, and that's where these gut cells start to become kind of withered away. They don't have that nice glue holding them together. So when you don't have this barrier anymore, now you have this open barriers, kind of like how there's holes in the the wall separating one town from the next or one city from the next. And so behind these gut cells, you have your immune cells, you have macrophages and dendritic cells, and there's some other things. And when they see things that they shouldn't be, they get a little freaked out. When they get freaked out, that could lead to chronic inflammation. It can lead to autoimmunity. And that's why we see a connection between gut imbalances and things like thyroid autoimmunity and brain fog.
Amber Warren, PA-C: Which let's be honest, that the autoimmune piece, that's an epidemic in and of itself.
Gavin Guard, PA-C: Oh, for.
Amber Warren, PA-C: Sure. I mean, Dr. Brus and I talked about that in our episode. He's seeing he's seeing Hashimoto's and kids under one.
Gavin Guard, PA-C: Yeah.
Amber Warren, PA-C: He's seeing thyroid antibodies being produced.
Gavin Guard, PA-C: Thyroid antibody is the prevalence there. It's found in about 19% of the population. 19 or one in five individuals have these antibodies directed towards your thyroid gland. That's where our immune system is. Kind of like this case of friendly fire. Your antibodies are usually directed against pathogens or infections, things that shouldn't be there. But when your immune system from usually there's some type of genetic predisposition, but then there's these environmental triggers, one of which is, you know, not only stress and all these diet lifestyle things that we talk about, but poor gut health we see, for example, H. Pylori, this bacterial infection, I should say colonization, because a lot of people have and don't have problems with it. But when that becomes overgrown, we see higher rates of thyroid autoimmunity with H. Pylori. And not only that, but treating H. Pylori leads to a drop in these thyroid antibodies. And so there's been a nice study. They took a group of individuals with thyroid autoimmunity as well as H. Pylori infections. They treated half of them and they didn't treat the other half. The group that they treated, the H. Pylori infection. They eradicated that bacterial colonization. They saw an average of about 2000 drop, a point drop in their thyroid antibodies, which you know, is providers. Anything past a couple of hundred like we're starting to get a little worried. So to see this as pretty phenomenal of not only this association, that's one thing, but also to suggest that treating the gut can directly improve things like inflammation and autoimmunity.
Amber Warren, PA-C: Mm hmm. Mm hmm. So we talk a lot about this concept or this term of dysbiosis. Yeah. So this overgrowth of of Helicobacter pylori is one one example of dysbiosis. What are other examples? Maybe you can just describe a little bit of what dysbiosis is a loaded term. I know. Sorry. Maybe we just start with with.
Gavin Guard, PA-C: Well, it's a good question.
Amber Warren, PA-C: Yeah. Maybe like testing, looking at dysbiosis. I mean.
Gavin Guard, PA-C: Dysbiosis is kind of a generalized term to describe in balances of the microbiome. And maybe we take one step back to explain what the microbiome is.
Amber Warren, PA-C: There you go.
Gavin Guard, PA-C: We we have I don't know, it was like 10 trillion cells. Human cells. Yeah, 10 trillion human cells. That's probably a rough estimate. We have ten times that in magnitude when we're talking about the small live microorganisms that live within or around and in us. And the highest density of this kind of microorganisms that live in us is within the gut. And that's called the microbiome, the GI microbiome. Now that just doesn't just include bacteria, but also includes some viruses, some parasites, some things called amoebas, which are kind of alien, like little creatures that can live in us and frank infections that we need to pretty quickly get rid of with things like antimicrobials. So that is the microbiome. And it exerts pretty widespread effects not only within the gut, but again, this gut has effects elsewhere in other systems. So dysbiosis is explaining how there can be kind of these shifts in the microbiome over time. Now the microbiome becomes somewhat stable by the age of three years old, and that's where we talk about how whether your vaginal or a C-section deliver, whether you're breast or bottle fed, how many rounds of antibiotics that you received as a kiddo, how this can affect your microbiome that can then predispose you to some of these inflammatory conditions later on.
Gavin Guard, PA-C: That's what we do well with in functional medicine. But there's also a lot of things that can impact your microbiome after it's become established at a young age. Things like your diet, whether you travel a lot and are exposed to infections, stress, sleep deprivation. So going back to dysbiosis, it's this term that explains how the microbiome can become somewhat altered. Now it's kind of hard to measure because there's so many variables to look at. You know, you've got all these thousands, probably tens of thousands of different species of bacteria alone, not to include also the virome, the viruses. There are some validated tests to give us an idea of how much of dysbiosis is occurring in the gut or the quantity of which it is occurring, One of which is from a company out in Norway is called the A Map Dysbiosis Index. And that's something that we are doing here at the clinic. Yeah, it's a validated test. It's a stool test, not a fun test. I will say you'll never look at French fries the same way. So there are some validated tests that we can use to gain understanding of how maybe your gut is affecting things like your joint pain, brain fog, anxiety, fatigue, and you may not have any direct GI symptoms.
Amber Warren, PA-C: I think that's really important for our patients to understand. Yeah, you don't have to have digestive discomfort, constipation, bloating to have a GI microbiome issue to experience, to have dysbiosis, or a diagnosable issue within within your gut.
Gavin Guard, PA-C: Absolutely. I mean, of course, if you have these frank symptoms of loose stools, constipation, heartburn, you're fearful of your food because you don't know how it may impact your your day or maybe your week. But like you said, also these other non GI symptoms, I've seen plenty of cases of acne and rosacea clear with the GI focused approach. Joint pain, brain fog, hormones. That's something that's kind of new and upcoming is something that we're trying to gain a better understanding of. But yeah, certainly you're going to have these GI elements and symptoms, but then the non GI symptoms are also something to keep an eye on for and we have some nice test to kind of act as another data point to fill in this overall complete picture of how we can start to move the needle with one's health.
Amber Warren, PA-C: Yeah, and we don't I mean, I think you and I can both sit here and say, we've been doing this long enough. We don't always have to test. There's protocols are things we can implement in the beginning and then see how much we're moving, moving the needle. Is that kind of your approach to know?
Gavin Guard, PA-C: I'm so glad you brought that up. Functional medicine has become a very testing heavy model and and I'm not bashing, testing. I think testing is very necessary. Yeah, but instead of it being the only thing that you base your treatment off of, that's one thing. How I see it right now is one of four different therapies or data points, rather, that we can use to make some informed treatment decisions. So one of which I always start with a patient's history. How do these symptoms come on? What exacerbates it? What makes it better? We look at past medical history, family history. If someone has a big family history of autoimmunity, we know that there is going to be a higher predisposition to autoimmunity in that individual. We have prior treatment response, and that's something I usually spend some time on, Like, Hey, have you ever tried probiotics in the past? Yeah, you did. How was that? Did you do well with it? Was there no response or did you have reactions? I use that as a data point to then inform my treatment model or the the how I prioritize these therapies in a stepwise fashion. And then finally, we have testing. Yeah, right. That is that 25% of the information we could use to kind of fill in the gaps. And what I always do when I'm seeing a patient, I kind of lay out what are the potential problems and then I rank order those, right? So I say, okay, their diet mismatch up here, that's number one.
Amber Warren, PA-C: Yeah.
Gavin Guard, PA-C: And then we're going to work on maybe some more movement patterns and gut health. And then with that I then layer on or correspond that with the sequential therapy that will fix that problem. So we work through this in a stepwise fashion. I don't just kind of shotgun approach it, but I do in a very informed manner based off of all of those four data points.
Amber Warren, PA-C: Okay, wonderful. Let's talk a little bit about the stool testing. What are the the the the markers you're looking at? What else besides kind of the this dysbiosis the imbalance of bacteria? What else are we looking at on the stool testing.
Gavin Guard, PA-C: Okay. So I would break it down into best second best and not so great testing. Yeah. Let's start with a not so great testing. There are some direct to consumer tests that I kind of warn patients against getting because they get this 4050 page report.
Amber Warren, PA-C: Now you can go online and get any kind of test food sensitivity testing, stool testing. Yes. It's pretty remarkable what you can go, which.
Gavin Guard, PA-C: Is somewhat good. We want to empower patients to take control of their health and do a lot of research. Right. On the other hand, it can lead to kind of this this like noodle soup of not knowing like where to go because of all the information that comes back. But there are some microbiome testing that actually sequences out your stool microbiome. And this is not saying that we are trying to detect pathogens like bacteria and parasites shouldn't be there. These microbiome tests are saying you have X amount of this lactobacillus species strain XYZ, and then you say you have this much, and I'll do that for like hundreds of species, and then it will say, with this information you need to do X, Y, Z, maybe take a probiotic. Well, they spent $400 to tell them that they should take a probiotic. Right. But also there I warn patients against this because recently there's a few companies that got in trouble. There was actually an FBI raid in one of the companies because they were using bad reference ranges. Their reference ranges were based off of dog feces and oh, my goodness, Yeah. And so they got in big trouble because they're, you know, making millions of dollars on this test. That's not it doesn't even have an accurate reference range.
Amber Warren, PA-C: And the average consumer would have no idea where their where their how they're coming up with these reference ranges or the assays that they're using or.
Gavin Guard, PA-C: They would have no idea. And it's not really clinically impactful to get these tests because I get a lot of patients coming to me with these tests and I unfortunately tell them like, this is not.
Amber Warren, PA-C: That helpful.
Gavin Guard, PA-C: For us. So that's the the one kind of area of testing that I say don't use. Yeah, there are some kind of better test, one of which is the Sebo breath test. And now I don't say it's one of the best tests for a few reasons, which I'm sure we'll get into. What is CBO? Maybe.
Amber Warren, PA-C: Let's start there.
Gavin Guard, PA-C: Yeah, let's start there. Define CIBO because that's a new term. Yeah. Sibo stands for Small Intestinal Bacterial Overgrowth or SIBO. So SIBO, it is associated with conditions such as irritable bowel syndrome, which is characterized by abdominal pain and a change in stool frequency and or stool consistency as well as we were just doing a study time, maybe even things like Gastroparesis where your stomach is not emptying out its contents as it should be. So SIBO has direct impacts on things like IBS and gastroparesis your bowel habits, but there's also been research to show that SIBO is associated with things like rosacea. There is a study with post menopausal woman and they show like, I don't remember, it was like either 90 or 100% of them had SIBO and they all had rosacea.
Amber Warren, PA-C: What is rosacea?
Gavin Guard, PA-C: Rosacea is a skin disorder. It's more or less like acne with some different elements to it's usually treated with some topical antibiotics such as Flagyl. So there's a connection between SIBO, Rosacea, SIBO, restless leg syndrome, SIBO, prostatitis, even so, and even brain fog and fatigue. So again, gut has non gut symptoms. So there's a breath test that we could do for this. And I get a lot of patients that kind of look at me weird, like how are we going to test our gut when looking at our breath? So again, this is a condition where the bacteria and the small intestines start to become overgrown. Normally the bacteria, the microbiome is really localized to the large intestine, large intestine, small intestine. Even though they're connected, they're separate organs as part of this global GI organ system. So when you have things like hypothyroidism, which I'm sure we'll talk about more impaired stomach acid, your guess, just not moving properly. You have a lack of these defense mechanisms, bacteria just like a stagnant pond. They start to become overgrown and the bacteria in the small intestine can disrupt that immune system where 70% of your immune system lives around your small intestine. You start to create more gas, bloating and altered stool habits and some systemic inflammation. So we give patients this glucose or lactulose this sugar solution to ingest. We feed that potential bacterial overgrowth and then that bacteria produces two gases, methane and hydrogen.
Gavin Guard, PA-C: And there's actually a third one, hydrogen sulfide. And that gas gets into the bloodstream, travels to the lungs, and then we breathe that out. And we have patients after drinking that sugar solution, breathe out or. Really just blow into these tubes every 15 minutes over the course of 3 hours, and then we can start to graph what's going on. So that is a breath test and it's been well validated as endorsed by many professional gastroenterology associations. I say it's maybe not the best because the treatment for those antibiotics. Right. There's FDA approved medication called rifaximin, non absorbed antibiotic. However, we now have three studies to show that herbal anti antibiotics or I should say antimicrobials, because they don't just affect the bacteria, but also parasites. Herbal antimicrobials can also clear and eradicate SIBO pretty effectively, almost as equivalent to rifaximin. Now. In the studies, it looks as though even if you don't have CBO, your CBO negative, you could still benefit from antimicrobials. And that's why I say it's again, one data point, but it's not the end all. Be all. Even if I have someone who CBO negative, I may still reach for antibiotics or antimicrobials. If someone has a GI condition. Yeah, but I may be quicker if they have CIBO positivity and that's where it is somewhat prioritize our therapies a little bit differently, but it's not.
Amber Warren, PA-C: Absolute because the SIBO, you're focusing on bacteria, but sometimes you forget that there's fungal overgrowth in there. I mean Candida, I thought we were just CFO Yeah, we were talking about.
Gavin Guard, PA-C: Yeah. Or small intestinal fungal overgrowth. There's not a great test for that right now. The best test that we have for that is a aspiration and culture. They'll go in with an endoscopy, a scope going through your mouth, going into the small intestine, and they will take a sampling out of the small intestine, grow it out and see if any bacteria or fungus grows on a petri dish. Not a lot of patients are going to be signing up for that, right?
Amber Warren, PA-C: Yeah.
Gavin Guard, PA-C: So we just really treat empirically. Maybe we've used rifaximin. Maybe you got some benefit, but not all the way. Maybe we try to also target things like fungal organisms, right?
Amber Warren, PA-C: And I think SIBO is a little bit of an interesting diagnosis and unique in what we diagnose in functional medicine with regards to gut health because we have to make sure we're taking care of root cause. How did the bacteria or the fungus get there in the first place? And you mentioned low stomach acid as being one of those root cause factors. What else do we see that that is a root cause for why somebody might have SIBO or C.F.O.
Gavin Guard, PA-C: Yeah. So stomach acid is one. Stomach acid is anti bacterial or antimicrobial in nature. If someone has chronic constipation, it's kind of this two way street where if your gut is just slower. Yeah, that can predispose you to SIBO, which can then make you even more constipated. And this is positive feedback cycle and we were just showing or kind of going over some research to show that hypothyroidism is one of the strongest risk factors for SIBO. So having low thyroid may be a predisposing factor and maybe causing SIBO or seeable may be causing thyroid in this positive feedback.
Amber Warren, PA-C: And what's the mechanism there, Gavin? Is it that we see our hypothyroid patients having slower transit time and dealing with constipation and that's that's more allowing the bacteria to grow.
Gavin Guard, PA-C: A couple fold there. Yeah. And I don't know if it's the chicken or.
Amber Warren, PA-C: The egg, right.
Gavin Guard, PA-C: But your thyroid is kind of like your metabolic gas pedal for a lot of different things. It helps elicit or kick any gear, stomach acid production. So maybe there's this thyroid stomach acid, SIBO connection. We also see that it stimulates GI motility or the movement, this peristaltic movement of your gut, this kind of wave like movement that gets all the bad stuff out and out through the stool. So that could predispose you kind of to this stagnation that could lead to bacterial overgrowth. And one of the hallmark symptoms of hypothyroidism is constipation. So I'm not sure about the mechanism or whether it's the chicken or the egg. There's probably a couple fold there.
Amber Warren, PA-C: Yeah. Can we talk a little bit about the vagus nerve and the role that plays in stomach acid production and SIBO? Yeah, because that's a that's fascinating. Our vagus nerve is such a fascinating nerve in our body.
Gavin Guard, PA-C: Sure. Yeah. And maybe the mechanism there would be better spoken to by Doctor Mutchnick. Yeah. Know, he's like the vagus nerve guy.
Amber Warren, PA-C: He's really good at that.
Gavin Guard, PA-C: Yeah, but the vagus nerve is this nerve that has both afferent and efferent signals, meaning it both sends signals from the brain to the gut, and then whatever's going on in the gut sends signals back to this brain. And maybe what I could speak to is kind of this gut brain connection. But yeah, really quickly, I mean, the vagus nerve stimulates hydrochloric acid production. So if you're eating your meals on a freeway, going 70 miles an hour and never really getting into that rest and digest day, you're probably going to have a hard time digesting things.
Amber Warren, PA-C: And I think that that is such an important topic. We call that eating hygiene and we actually have a really good handout we give to our patients. Are you preparing your body to have appropriate digestion and absorption of nutrients of your food? So many of us don't chew our food. You just mention they eat in the car. They're not saying a prayer or breathing before they eat while they eat. Sure, they're drinking a ton of water just prior to to a meal or in between meals that might impact digestion. It's it comes back to kind of what you mentioned in the beginning. You can take all the supplements in the world, but if you're not giving your body just the. Basic foundational tools it needs to de-stress, to increase resiliency, to absorb food. We can't move that needle.
Gavin Guard, PA-C: Yeah, it's called this cephalic stage of digestion, where before you even take a bite, your brain's sensing the smells, the sounds, your environment around you starts to prepare your body for digesting that meal. You start to and we've all experienced it as you start to salivate more inside your small intestine and your stomach. Your body is sending hormones to secrete things to help you digest protein and fat. So it's a really key part of one's digestion that often goes overlooked. Yeah. And, you know, going back to how your nervous system affects your gut. I've seen a lot of patients who, you know, they're on all the right supplement medication plan. They're eating really well, They're moving really well. They are sleeping really well and they're still having symptoms. And what I explain to them is maybe from a history of past trauma, whether neglect or abuse as a kid or whether just from, you know, genetic predispositions or families social dynamics, they're nervous system. How I explain it, it's just ramped up to the nine they're stuck in this fight or flight state long term and you know your nervous system is not an on and off switch it's more like a dimmer switch. We want to go from rest and digest and fight or flight.
Gavin Guard, PA-C: And we all we want to be constantly toggling between the two. If you're going out for one rep, max, squat or deadlift, you do not want to be, you know, kind of like having a sensation of like you're drinking martini at the beach. You want to be like, Let's go, let's get some weight pulled off the ground. But similarly, or I would say on the opposite end of the spectrum, we also don't always want to be in that fight or flight being in that what's called that sympathetic or that fight or flight state of your nervous system is really going to have long term and downstream effects that is really going to be taking a toll on your gut. So we just we oftentimes the patients I just take a moment to just acknowledge this. And patients, when I do acknowledge this, oftentimes patients really start like nodding their heads and like, yes, you just explained to me, that's why I need to work on, okay, what do I do about it? What I explain to them is sometimes it's what I'm not saying is that it's in their head. I'm not saying you're making up these symptoms or that this is fabricated.
Amber Warren, PA-C: Or they need an antidepressant.
Gavin Guard, PA-C: Or you need an antidepressant. I mean, in conventional medicine, there are a lot of antidepressants used for things like irritable bowel syndrome because of this gut brain connection. But we are using some, I would say, lower risk therapies, one of which is like some hypnotherapy. There are some nice IBS self guided hypnotherapy applications that could be used. And it's not the hypnotherapy. You know, someone's dangling something in front of your eyes. Really. We're just trying to detach how your nervous system is affecting your physical symptoms, right? So there's an app called the Nerva App and Irva. It's been used in clinical studies to show benefit in irritable bowel syndrome. There are some limbic retraining programs to help reroute some of that neurological threshold that's occurring in the subconscious part of your brain called the amygdala, that fear processing center. So we have a lot of tools at our disposal here, but again, trying to highlight how our nervous system could be affecting our gut. And it's not until we really address that nervous system that we get optimal results.
Amber Warren, PA-C: That's huge. And we could probably spend an entire episode talking about just that. The nervous system and the autonomic nervous system and the fight or flight versus rest and digest, I think we did heard a little. Let's bring it back to some of the testing, because you started talking about the breath testing. What are other ways that we're evaluating, you know, the gut microbiome and imbalances.
Gavin Guard, PA-C: Yeah, Yeah. Thanks for bringing me back.
Amber Warren, PA-C: I got you. I got you.
Gavin Guard, PA-C: Yeah. So we've talked about Sebo breath testing. We've talked about those microbiome testing, The DYSBIOSIS index. Some of the best testing is stuff that's used quite a bit in our practice and things that are conventional. Gi collies would not even bat an eye at things like endoscopy and colonoscopies. Everyone doesn't want to get them. I know they're not fun, but they are absolutely critical in some situations to really identify Is there anything anatomically or something we could see with a naked eye going wrong? We don't want to be treating someone with who we presume to have IBS when it's really colon cancer, for example. We which.
Amber Warren, PA-C: Is on the.
Gavin Guard, PA-C: Rise, which is on the rise and unfortunately affects a lot of people later in the stage of development of that cancer. So I send out a lot of people for endoscopy with colonoscopies along in conjunction with what we are doing. So is. On either or. Yeah, it's an end. So endoscopy is colonoscopy is absolutely critical for certain individuals. Next would be some stool test to look for things like infections. Do you have any parasites there? And we could do that by looking at some DNA tests. If there's DNA fragments of parasites and bad bacteria and other microbial elements, that should not be there. We do that with the DNA test in the stool. There is something called Calprotectin. This is a stool test that looks for this marker Calprotectin, and it gives us an idea of gut derived inflammation. And this can help us kind of piece apart. Is this IBS or is this inflammatory bowel disease or something else?
Amber Warren, PA-C: And biomarkers like Calprotectin help us know what protocols we need to use for this patient, right? Because there's some amazing anti inflammatory herbs that we can give our patients to calm down GI inflammation. That's really helpful for.
Gavin Guard, PA-C: This inflammatory in nature. And like you just said, there's some really nice natural anti-inflammatories that can be used and maybe this is done in conjunction with conventional care or I've had a lot of cases where we've put inflammatory bowel disease, which includes Crohn's disease, ulcerative colitis and remission with a diet lifestyle, natural, minimally invasive, GI focused approach. So that's a really great test, well validated. Again, our colleagues were not bad an eye on it because they do it all the time too. Yeah. There's also something that we can get is called a last case. One is this enzyme that is produced by your pancreas, this spongy like organ that sits behind our stomach and our pancreas produces hormones. And then this enzyme and many other enzymes that help with our food breakdown. So a last taste, one if low, can point to what's called exocrine pancreatic insufficiency, this condition where a pancreas is not pumping out enough enzymes to help break down certain components of our food, and that can present as loose stools and and bloating and things that look like IBS. In fact, epi exocrine pancreatic insufficiency has been noted to affect about 6 to 10% of those with IBS. Wow. So there's some of these conventional stool tests that we could do.
Gavin Guard, PA-C: There are some blood tests that we could do to look for what's called post infectious IBS. And this is something to be noted in 12% of EIB's cases. This is where there's a situation, let's say someone has a flu like illness, nausea, vomiting, diarrhea, and it's usually from some type of parasite, say, giardia, maybe a virus or a bacteria. One of the most common ones is called campylobacter jejuni. And that acute infection elicits an autoimmune response. This autoimmune response, again, our immune system is attacking our own tissue. It produces antibodies that can affect our gut motility, our gut movement, and that could lead to loose stools or constipation, abdominal discomfort. So there's a blood test for that. Yeah. So I'm not and I don't get all of this test right out of the get go, right? Usually I go based off of their symptoms, how all of this started. So if someone didn't have this flu like illness that preceded their disease activity, then I won't do this blood test. So it's really kind of a mix and match, if you will, of what tests that we get to fill in the gaps.
Amber Warren, PA-C: Yeah. Yeah. That's it's, that's so great. Is that kind of cover it as far as some of the GI testing you're doing. Yeah.
Gavin Guard, PA-C: Yeah. I mean there's some other antibody testing that we could do to look for autoimmunity against the gastric lining, but that's really the mainstay. There's some nutrient testing to see if there's some type of malabsorption going on, but I would say that's the majority of it.
Amber Warren, PA-C: So nutrient testing is that through the blood, looking at blood testing, looking at just nutrient deficiencies. Yes. Yeah. And so instead of saying, oh, you're a low and zinc, you're low in magnesium, you might be low in some B vitamins. Let's take a good mix of all these supplements. Maybe we're thinking, wait, there's a mal absorptive state, maybe this is gut health, right. And you just don't need to replete these nutrients.
Gavin Guard, PA-C: Yeah. Um. So you always try to treat in functional medicine. What's the most upstream root cause going on that's causing all these downstream symptoms? So even if you do get some nutrients, let's say they're low in X, Y, Z, why is that? It's usually a result of three different causes. They're not eating enough. They have impaired absorption or increase loss. You know, for take for example, B 12 or iron deficiency. Yeah, they could be vegetarian or vegan, but if they're not and they have some GI symptoms, it's maybe a cause of some type of GI imbalance. Right? We see about 40% of those with low thyroid and some type of GI issue are deficient. And B 12 we see that in celiac disease, about 50% upon initial diagnosis also have iron deficiency. We see deficiencies and things like magnesium, some fat soluble vitamins like A and DD with that pancreatic condition that we talked about extra in pancreatic insufficiency, H pylori can cause iron B12 deficiency. So it's always trying to treat the upstream root cause and a lot of times it's diet, lifestyle, gut focused approach.
Amber Warren, PA-C: Yeah. So you were pleading those nutrients. The supplements are really important, but we don't want to have to have you on these these nutrients long term. Fix the root cause. Fix the root cause. It's great. You know, we're we're going to spend another episode kind of digging into some of the treatments, and we have to pull nutrition into this conversation. That's like, you know, no talk about gut health and functional medicine is complete without nutrition. But with regards to some of the testing and the workup on some of these GI conditions. I like to end each one of my episodes with what? What's the advice you give or the recommendation you make that moves the needle the most? And what would you say with regards to just your your kind of casting a wide net approach to trying to look at some of these GI imbalances or or gut diagnoses?
Gavin Guard, PA-C: Yeah, Again, we always want to work in a foundation up model where we use the lowest risk and highest amount of benefit therapies first. For example, we would not start with a fecal microbiota transplant where we give you someone else's stool, which is, you know, has.
Amber Warren, PA-C: Incredible data.
Gavin Guard, PA-C: On that after you approve. Now for recurrent C diff infections and even some inflammatory bowel disease infections. But we don't start with that. If someone's eating fast food every day. So we start with the lowest risk therapies first and work our way up in this iterative and stepwise fashion. And that's what I think we do a good job of, of my approach is not shotgunning it. I'm not going to say, here's ten things that you do right here and now I'll see you in three months. I say, Here are the three most important things I think you should do in the next 4 to 6 weeks, and that makes that pun intended digestible for patients to actually apply and be consistent with.
Amber Warren, PA-C: Yeah.
Gavin Guard, PA-C: And then we gather some more information. How are you feeling? What's getting better with skiing? Same with skiing. Worse. Okay. Maybe your skin improved. Maybe we're brain fog for two, but you're improved. But now you're still feeling a little fatigued. Maybe we need to take a deeper dive into your sleep. Or do you have sleep disordered breathing? How is your exercise? Have we checked your thyroid, your iron? Maybe we need to use things like probiotics and iron supplementation. And then we use some of this. I would say more like a buckshot approach. We do a few things at a time. And again, the model is really based off those four data points, their symptoms, their history, prior treatment response, and then the labs. So it's always a game of mix and match. You know, there's not one set protocol, if you will, that the.
Amber Warren, PA-C: Art of medicine.
Gavin Guard, PA-C: Yeah, it's the art and science. And I hate to say it, but there's really no absolute medicine. It really is a game of statistics and chances, right? You could always be wrong, but you really just go based off of as much information that you can gather. And that's the beauty of I think having 40, 60 minute visits with individuals is like, we can dive deep.
Amber Warren, PA-C: Oh my goodness, here are their story.
Gavin Guard, PA-C: We take those last 10 minutes to understand their childhood history. I'm like, Oh, man, you've had some trauma. No wonder you're not getting better with all these therapies. We need to kind of pivot and look at your your nervous system. So that's why you.
Amber Warren, PA-C: Might not even start with a probiotic.
Gavin Guard, PA-C: Yeah, not even start with supplements or medications. Let's start with kind of maybe we need to get a counselor on board and really support your social environment and your nervous system first.
Amber Warren, PA-C: Absolutely. Well, Gavin, so many good tidbits there. I can't wait to dive in and talk more about kind of our treatment approaches in other players. Thank you so much for your time today.
Gavin Guard, PA-C: Yeah, thanks, Amber, for having me.
Amber Warren, PA-C: Thank you for listening to the Functional Medicine Foundations podcast. For more information on topics covered today, programs offered at FMF and the highest quality of supplements and more. Go to Fun Med Foundations dot com.