Male patient, 52 years old, three years out from traumatic brain injury after a skiing accident with three prior concussions. How do I treat balance and ringing in the ears as his primary complaint. Wanted to continue to eat gluten, so I ran Cyrex 4 and didn’t come back with anything. His cholesterol is low at 135. LDL is 77, HDL 41. I told him about fat and cholesterol for the brain. Can’t convince him to go Paleo, low carb, or do food elimination like an elimination diet. How do I convince him to get rid of the gluten? He won’t eat any red meat. His thyroid hormones are normal except for low free testosterone, high levels of AST, MCV and creatinine although question dehydration. Micronutrient testing low in B12 shown by no red meat and high MCV, also low folate B2 and B5 even though he’s on a B complex in addition to B12 methyltetrahydrofolate. Plasma levels show low glucose insulin interaction. I asked him to start adding protein to breakfast, having veggies with every meal. He says he’s compliant, but the labs aren’t showing absorption. Am I missing something with fat and B absorption? He’s heterozygous for the FAD1 and 2 SNP. I tried the absorption issue and Perlmutter but he’s not convinced. Please advice on what I’m missing or what I can add as far as treatment.

Dr. Amy Nett: If I’m looking for gluten sensitivity, I would actually run Cyrex Array 3, so that might just be a typo. Cyrex Array 4 does include the gluten-containing grains like rye, barley, spelt, kamut, but if you’re really wanting to look for gluten sensitivity or intolerance, then I would actually go ahead with the Cyrex Array 3. If you haven’t done that, that’s a more comprehensive test. If someone does come back with no markers out of range on Cyrex Array 3, depending on their symptoms, I’m not necessarily strict about having them remove gluten completely. Somebody who has tinnitus and some vestibular symptoms, which we certainly wonder whether or not there could be some degree of inflammation here, you could try to approach it from that perspective, but again, I would suggest maybe a 30- to 60-day gluten-free trial. It sounds like he’s pretty resistant to that, but it is hard if you do that Cyrex Array 3. That’s one downside. You do a Cyrex Array 3, and none of the markers come back out of range. You do lose a little bit, I think, in terms of making an argument for “look you need to be very strict about this.” It’s nice if it comes back with markers out of range if you’re trying to get that patient off gluten. That’s a little bit tricky.

HDL is low, so that’s a risk factor for cardiovascular disease.

The resistance to diet limits, of course, what you can do. I mean, all you can do is educate the patient. But, of course, it’s going to be his decision in terms of what he wants to do. Again, it’s up to him ultimately, and the question is, does gluten cause inflammation? If so, then maybe a 30- to 60-day trial diet – but look, if patients don’t want to do this, this is their health, and it’s up to them. We can’t make them do anything.

That’s okay that he won’t eat red meat. I think we can still work with patients even if they’re not eating red meat hopefully. It sounds like he probably won’t eat organ meat, but that would be something to think about if you would do like a chicken liver pâté perhaps if he’ll consider chickens.

I think you just mean they’re not showing absorption because he has low B vitamins.  I think you mean the low cholesterol. Is he not absorbing dietary fat and that’s influencing his cholesterol? Possibly. It could be genetic. The first thing to ask is what do the cholesterol profiles look like for his parents or siblings.

We’re talking about FADs, so for those who don’t know, we’re talking about the fatty acid desaturase genes. The fatty acid desaturase genes, these produce proteins that desaturate omega-3 and omega-6 polyunsaturated fatty acids. Of course, these are going to be involved in catalyzing the final step in the formation of EPA and arachidonic acid. I don’t see any mention for him of the EPA or arachidonic acid. I’m not sure how to include that information with what I’m seeing here. Again, you’re on the call, and you want to clarify that.

As I said, make sure you do Cyrex Array 3 if you only did Array 4. If he’s not absorbing B12, think about testing for pernicious anemia. Maybe he has an autoimmune condition where he’s not absorbing vitamin B12. If that’s the case, he may actually need injectables, so subcutaneous or intramuscular B12 and/or folate injections. I’d run testing pernicious anemia. I would also do stool testing to look for GI inflammation. You want to see what is the lysozyme, lactoferrin, and calprotectin. Make sure you’re not missing a case of gut inflammation. Maybe just addressing the gut will improve his absorption because you need to think about both supply and demand. There’s absolutely the absorbtion piece. There is something that’s preventing his absorption, but then there’s also the demand like, what if you know what are his stress levels like, etc. Is his demand for B vitamins just that high? You want to think about gut inflammation and what else is preventing absorption. When is he taking the B vitamins — with meals or without — maybe tweak that a little bit. See if taking the B vitamins with meals improves absorption or something like that. I would also consider digestive enzymes. You didn’t mention any digestive symptoms, but maybe he’s just having trouble breaking these down. Maybe his stress response is too elevated, so maybe he’s just not digesting foods very well. Consider something like a Digestzymes, get a little bit of betaine HCl so that the foods that he is eating are broken down more efficiently. Hopefully, that gives you a few different places to add on to what you’ve already done there.