Dr. Amy Nett: This is a great question because we would love to see patients improving with only dietary and lifestyle changes. Based on my experience, I would say that at least for the people who end up coming to CCFM, diet and lifestyle alone are often not enough to make changes, and again, that’s because what we just talked about in terms of how chronic infection can actually affect lipid profiles, and it’s causing a cascade of changes due to inflammation and immune dysregulation.
What I would do with this patient is I would explain that diet and lifestyle are absolutely a core piece, but two things come into play when we don’t see improvement. One is that there are cyclical changes. Depending on how many times you measure those TPO and thyroglobulin antibodies, you might see that at sometimes they increase and at other times they decrease, so it’s important to monitor parameters at several different points and not just look at one follow-up draw because we always explain to people that with functional medicine and the way we approach things, we expect to see periods of improvement, you may worsen a little bit, you may hit a plateau and then improve again a little bit. It’s sort of this stepwise progression of improve, plateau, improve, plateau, sometimes inevitably with times of worsening. Make sure you have multiple measures to know whether it’s really an upward trend or whether you just caught elevated antibodies.
The other thing I would explain is that when we’re approaching disease from a functional medicine perspective, you really need to think about peeling the layers of the onion. Again, diet and lifestyle is the first piece, but then you need to start looking at what else is causing the immune imbalance. Unfortunately for her, it sounds like diet and lifestyle are not quite enough. So what is the next step? Well, I would probably look at the gut next. I would do stool testing, SIBO breath testing. If those are completely normal and there’s no chronic infection, then you need to think about metals testing or mood exposure testing, but keep looking at—HPA axis testing, of course, that should be in there—but keep looking at what could be contributing to the immune imbalance, what exposures are throwing off her immune system. Is it possible that even on an AIP Ppaleo diet she’s still eating something that’s triggering her? It’s rare, but unfortunately some patients do need to be on a very restricted diet, so know that even on AIP, some of those foods could still be triggering her. I have patients who can’t eat coconut or avocado, so think about digging into foods. Is there a way to do more of an elimination diet? I understand that gets very restrictive, and if you’re uncomfortable doing that strict of a diet, maybe have her work with a nutritionist, but just keep thinking about anything that could be throwing off the immune system because that’s why those antibodies are going up.