Chris Kresser: Most patients who get a case review with me get the full suite of gut testing plus the functional blood chemistry panel plus the DUTCH HPA axis test. That’s kind of the core group of tests that I prefer to order for every patient no matter what their symptoms are or what their goals are. Now, of course, I’m willing to make exceptions, and I will custom-tailor that based on the patient’s particular presentation and goals.
For someone who comes in and says, “My only symptom is insomnia and that’s it. I don’t have any other problems”—I can’t think of a single patient that I’ve ever seen that that’s the case for because insomnia will cause so many other problems, but let’s just use this as a hypothetical example—“And my financial resources are extremely limited. What can we do?” The first thing I’m going to do, actually, is say, “Well, have you done all this in terms of sleep hygiene, all the recommendations I make in my book,” everything that we’ve talked about in the exposome unit—optimizing sleep nutrition, optimizing sleep hygiene, optimizing exposure to light. If we go through all that and they’re not doing any of that, I might not order any tests. I might just say, “Do that and let me know how that works. If it works, great. I’m happy to have helped, and we don’t need to do a case review. If it doesn’t work, then, yes, I think we should order testing,” and I would start with the DUTCH urine test and HPA axis assessment, which we’re going to be covering in the next unit, for that patient.
And if that testing comes back and their diurnal cortisol rhythm is flipped and they have high cortisol at night and low in the morning and they have high overall cortisol, then we can just get busy with that and address those things. If the SIBO resolves after that and they have no other complaints, then they’re done.
I’m not a big fan of going looking for problems when problems don’t exist. At the same time, part of our job as functional medicine clinicians is to provide preventative care. If the insomnia could be a canary in the coalmine for a future problem, it might be good to do a more comprehensive panel, which is why I typically try to convince patients to do the full spectrum of testing, but like you said, not everyone can afford that and not everyone has bought into that approach yet, so you just take the approach that’s appropriate for each patient.
Oh, yeah, the other question of do I ever order a SIBO test without ordering a stool test, not commonly. It’s really quite impossible to diagnose SIBO only based on symptoms or to know that, for example, this person almost certainly doesn’t have SIBO, but they probably do have a parasite. So I would pretty strongly recommend doing a breath test with stool tests. I think the only times I don’t do them together is if a patient brings in a stool test and it’s pretty recent and it’s a lab that I like. I might not order another one. I’m trying to think if there’s any other situation. If they have a history of SIBO and they’re really pretty certain that they have it again because they know what it feels like and they’ve been tested with stool tests extensively in the past, I may not order it in that situation, although if they haven’t had stool tests in the past in that circumstance, I would strongly argue for one because I would say maybe there’s something going on in the colon that’s causing this SIBO to recur and we need to figure out what that is.