Is a healthy and stable gut microbiome difficult and possible to risk among the following types of patients: (1) people in the study that I mentioned in which three or more generations on a low-fiber diet led to permanent loss of key microbes; (2) individuals that have never been colonized normally, like people who were born [via] a C-section or [were] formula-fed; (3) individuals whose mucosal microbiome and immune system vigilantly exclude newcomers resulting in unsuccessful causation [2:47]​ of probiotics.

A really great question, Ariel, and I think the answer to that is we don’t know for sure. But I also think it’s fair to say that we could expect it to be significantly more challenging in those situations. I also think, and this is maybe not a popular thing to say in the Functional Medicine world, but not all problems are solvable. I think we need to be honest with ourselves and with our patients about that. Some patients come in with extremely complex conditions, and [they have been] sick for many, many years and have taken 40 courses of antibiotics and lots of other medications, and have lots of other stuff going on. If their expectation is to get back to 100 percent function or what they remember from when they were 25 years old before they got sick in the first place, that can be a setup for disappointment and even despair.

I think the art of being a practitioner is helping to work with patients to set expectations. It doesn’t mean you give up. It doesn’t mean that they can’t continue to work to improve their health, but if you got in a car accident, for example, and shattered your leg, you probably wouldn’t expect to get back to, like, 100 percent perfect function of that leg, probably ever. I mean, you can restore a lot of function. You can do physical therapy and rehab and a lot of stuff to improve the function of the leg, reduce pain, [and] reduce inflammation, but it would probably be unrealistic in that scenario to expect to get back to, let’s say, perfect function, assuming that that was even present before, but that’s often the expectation, in some cases, with internal conditions. I think that we need to help patients to shift out a little bit in these kinds of situations, so great question.