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Understanding these triggers of inflammation can also help you to partner more easily with your child’s doctor to find the root of illness more efficiently.

  CHAPTER 3

  leaky gut vs. healthy gut

  I LIVED IN A HOUSE with ten girls in college. Somebody was always waiting for me to get out of the bathroom. My constipation was ever-present. Each time I needed to move my bowels, it felt like childbirth. And it was always touch-and-go whether or not it would happen. Wow, I cannot believe I am writing this—if you see me around town with a bag on my head, you’ll know why.

  I also had stomach discomfort almost every time I ate, but just thought that was how everyone felt after eating. I didn’t know any different. On top of that, I was diagnosed with an autoimmune condition, Hashimoto’s hypothyroidism, as I was starting medical school. I had no idea at the time that food could be playing a role in my constipation, abdominal discomfort, or thyroid issue.

  Fast forward to my integrative medical training, and I began understanding nutrition and health. I started advising parents how to deal with constipated children by removing dairy from their diets, but somehow, I still wasn’t connecting the dots in my own life. I had a bowel movement every day, so I didn’t think my bowels and the time and effort it took to go were even a thing.

  I was taking patients off gluten and dairy and seeing magic happen. Bowels were beginning to function properly, lifelong stomachaches were going away, the allergy march diseases were improving (eczema, allergies, asthma), and, as an added bonus, behavior, focus, and sleep were improving. Parents were noticing fewer meltdowns, outbursts, and mood swings.

  Around this time, my sister (who also has hypothyroidism) took gluten out of her diet and felt a whole lot better. I decided to take the plunge. It was remarkable, as if someone took a bag off my head. Suddenly (within days), I had a clear head, I had no energy slumps after eating, and my bowel movements were so much easier (but they still took a little while). In addition, my stomach stopped hurting after every meal, and my skin took on a new glow. I had been through all of this schooling and training—four years of traditional medical school, three years of pediatric residency, two years of integrative medical fellowship—in addition to five or six years of clinical practice, and I was just now figuring out I had a food sensitivity much of my life?

  I actually think my constipation started in college. I don’t remember having bowel issues or recurrent abdominal pain in childhood. When I think back to my cup of college inflammation, I had a significant increase in gluten, dairy, and processed foods (that my mother did not keep in our house), in addition to increased stress and lack of exercise (a big stress reliever for me). My cup was overflowing.

  SHEILA’S CUP OF INFLAMMATION

  The longer I remained off gluten, the better I felt. It made me realize that I had previously become one of those people who eats because I had to eat, not because I enjoyed food.

  About a year after I went off gluten, I attended a medical conference where one of the speakers said, “Bowel movements should only take you the same amount of time it takes you to urinate.”

  Wait, what?!

  She was discussing the role of nutrition and how it impacts the gut—no pun intended! In particular, she was extolling the virtues of a gluten-free, dairy-free diet for some people.

  The concept that moving your bowels should be quick, easy, and without strain did not even compute with me. But this doctor had said it, and it made sense when I thought back to what I knew about the physiology of our GI system. As I listened to this lecture on bowel movements and thought about the notion that they should be quick and easy, I thought once again about the connection between my bowels and my diet. Should I also be off dairy? I’d adjusted to losing one delicious food group in removing gluten. Was I prepared to lose another?

  Dairy was a different story than gluten for me. Cheese was one of my favorite foods, and as a busy pediatrician, cheese was easy. There was no cooking or preparing; I could just grab a slice on the go and feel satiated for another couple of hours.

  Nonetheless, I decided to give it up. Although my bowel movements had gotten tremendously easier since I had gone off gluten, when I went off dairy as well, I could get in and out of the bathroom with the speed and efficiency of a NASCAR pit crew. The disco ball dropped out of the ceiling again, and I had my own private dance party.

  Disco ball - my AH moment!

  I really didn’t know bowel movements could be so easy. And then I was in for another surprise six months after I went off dairy. I did a brief cleanse with a like-minded group. For three weeks we took gluten, dairy, sugar, all animal products, caffeine, and alcohol out of our diets. From a bowel movement perspective, doing this cleanse was like heaven, and I felt fantastic. However, I couldn’t keep up that level of elimination for much longer than three weeks, but it served an essential purpose: It showed me how my body could function and helped me establish a different baseline of eating. It also gave me great insight into how I could further help my patients and their parents understand what was going on.

  What I have learned from my practice and from my own health is that bowel rhythms give us a window into inflammation and gut health. From an integrative medicine perspective, the gut is the body’s powerhouse—the system that can set the tone for the body’s other systems.

  I have remained off gluten and dairy for many years, but over the past couple of years I have been able to loosen up the reins on dairy. I eat Kerrygold grass-fed butter almost daily, and occasionally I will have regular cheese on a gluten-free pizza. I can do that now because I gave my gut time to heal. My GI system, skin, energy, and ability to think clearly after eating a meal have remained significantly better than when I was eating a lot of gluten and dairy on a daily basis.

  Not everyone has an issue with gluten and dairy, which is why I recommend doing a selective elimination diet to test out the waters. They are both yummy foods and if your child’s system can handle them, there is no need for her to be strictly off of them. The best way to find out is to remove them one at a time (as we do in the program) and monitor symptoms to see if there is a change. For me, gluten is more problematic than dairy and I find it is often the case that one or the other makes more of a difference with many kids as well.

  THE SCOOP ON POOP

  My first and highest priority when working with a child is to get her gut in order. We want daily, easy, formed stools. Review the Bristol stool chart I have included for handy visualization. It categorizes stool quality; the goal is a 3 or 4—like a sausage or a snake—I know, gross. Stools should be quick and should not not be a major, foul-smelling event. They will be stinky, yes, but not clear-the-room foul. Daily easy stools are one of our first indictors of a healthy gut.

  What do we mean by the gut, exactly? The entire length of the GI tract—everything from the esophagus to the stomach to the small intestine, colon, and rectum—and the activity that begins the moment food is placed into the mouth and continues until it hits the toilet, constitutes the gut.

  The gut is the hub for about 70 percent of our immune system. This might surprise you until you consider that it regulates the breakdown and absorption of food, it is often where skin issues stem from, and of course it governs our waste removal and detoxification.

  A well-functioning GI system does more to keep the immune system—and the body itself—in balance than any supplement or medication could ever hope to. Fermented foods, fiber, and nutrients from our food, as well as being outside in nature and playing in the dirt, contribute significantly to the health of our GI tract. Together they enhance the content and diversity of the bacteria in the gut (also called the microbiome). This sets the stage for a strong, well-functioning, well-balanced immune system. We will discuss the microbiome in more detail later in this chapter.

  LEAKY GUT (INCREASED INTESTINAL PERMEABILITY)

  A connection exists among the environment of the gut, inflammation, environmental allergies, food allergies, food sensitivitie
s, and autoimmune diseases (recall my diagnosis of Hashimoto’s hypothyroidism) that I didn’t learn about during medical school and residency. Here’s how it works.

  We have a single layer of cells along our GI tract, and the health and integrity of this layer of cells, called our epithelial cell layer, is critical for our overall health and immune system. Each cell is cemented to another by something called a tight junction. When these tight junctions begin to break down, the medical term is increased intestinal permeability. But most people have come to call it “leaky gut,” which describes an unhealthy gut lining and gut environment.

  If we expose our gut and microbiome to certain foods (artificial dyes, processed foods, refined sugar), medications (antacids, unnecessary antibiotics, steroids), or environmental toxins (herbicides or pesticides), this interferes with the growth of beneficial bacteria in the gut and also creates inflammation. This inflammation damages the epithelial cells and the tight junctions, making the gut more permeable. The body then begins to absorb things into the bloodstream that shouldn’t be there. Once these runaway molecules from the gut hit the bloodstream, they set off a cascade of inflammation because the body treats them as invaders.

  When the gut is inflamed, our bodies struggle to effectively and efficiently absorb all the nutrients from our food. If this inflammation goes unchecked, it leads to nutrient deficiencies such as low iron, and it also spreads to many different systems. This inflamed or leaky gut lining is part of the reason children who have asthma also have eczema, bumps on the backs of their arms and cheeks, chronic runny nose, constipation, recurrent ear infections, and sometimes lots of meltdowns.1 In conventional medicine, we look at all of these symptoms as separate illnesses, but in integrative medicine, we look at them as chronic, unchecked, systemic inflammation.

  INFLAMMATION IN THE GUT IS INFLAMMATION EVERYWHERE

  We don’t have fences in the body, so when we have a leaky gut and undigested food particles are triggering a cascade of inflammation into our bloodstream, all our other systems can be affected, including our brain and nervous system.

  For example, children who have constipation often have behavior and mood problems when they get to day two, three, or four of not having a bowel movement. The buildup of metabolic by-products resulting from poor digestion and excess inflammation can contribute to behavior issues. This can look like meltdowns in the younger kids and mood swings or emotional outbursts in older kids. The next time you start to discipline your constipated child, pause and look at the last time they pooped. See if you can get their bowels back on track with the HKHM program. Lean toward improving their digestive function and let’s see if we can restore some semblance of harmony in your home!

  The graphic “Healthy Gut vs. Leaky Gut” is a great illustration of how an unhealthy or leaky cell leads to a leaky gut, which leads to inflammation affecting the brain and central nervous system. When I first started using the selective elimination diet in my patients, we kept seeing these added perks of improved nutrition and digestion. The kids were sleeping better and more restfully, their meltdowns or mood swings improved, and some kids were able to focus better.

  INFLAMMATION-LEAKY GUT-ILLNESSES

  HEALTHY GUT VS. LEAKY GUT

  HEALTHY GUT VS. LEAKY GUT

  Concept creation in conjunction with Deborah Allen, RPh, as an adaptation from the book Leaky Cells, Leaky Gut, Leaky Brain, with permission from the authors, Jess Armine, DC, and Elizma Lambert, ND.

  Our world today is much more sterile than it was even twenty years ago—in some ways that is good. We die far less often from infectious diseases (except unfortunately during a pandemic), but our chronic diseases have skyrocketed. Could that in part be due to our increasingly sterile lives? Strong cleaning products, along with antibacterial soaps and hand sanitizers, are in widespread use. According to the FDA, exposure to triclosan, an ingredient in hand sanitizers that was banned in 2017 (as were twenty-three other ingredients), possibly contributed to making bacteria more resistant to antibiotics. It also poses other health risks, including thyroid hormone disruption and skin cancer. (See https://www.fda.gov/consumers/consumer-updates/5-things-know-about-triclosan.)

  Hand sanitizers remain ever-present. Yes, it’s important to keep our hands clean, but soap and water may be the best option for killing harmful bacteria and viruses, while maintaining the integrity of our skin and not creating bacterial super-strains that become resistant to antibiotics.

  THE MICROBIOME

  You know by now that the gut microbiome is the teeming ecosystem along the GI tract made up of bacteria, yeast, and other microorganisms that play a critical role in your child’s overall health. Keeping these microscopic creatures alive and well fed is important to our overall health, although we did not learn about this in medical school.

  This ecosystem is highly dependent on how we live our lives, what we eat, and what we are exposed to (our environment, stressors, medications). Take two children, one with a diverse and beneficial microbiome, the other with an unhealthy one. Expose them to the same classroom environment. One child might get the sniffles for a couple of days, but not miss a single day of school. The other might get sick and be out for a week every other month, often on rounds of antibiotics.

  An analogy to gardening makes this easy to understand. A gardener wants nutrient-rich soil and uses clean water to encourage green, healthy plants to grow and thrive. A healthy gut microbiome helps us bounce back more quickly after being exposed to a virus or bacteria, just like a healthy plant can withstand an occasional dry spell.

  GUT HEALTH

  FACTORS THAT MAY IMPACT OUR MICROBIOME

  Poor-quality processed food.

  Hand sanitizers and strong cleaning agents with bleach.2 Living in such a sterile environment may actually be impacting the diversity of bacteria in our gut and therefore our overall health (referred to as the hygiene hypothesis).3

  Herbicides (containing glyphosate) that kill weeds and microorganisms in the soil. Widespread global use of glyphosate has increased dramatically since 1996 (fifteenfold).4 It is used by the farming industry on crops and for nonagricultural use such private yards and schools.

  Antibiotics that kill bacteria causing an infection but also kill the beneficial bacteria in the gut. There were 270 million antibiotic prescriptions written in 2015; this is equivalent to about 838 antibiotic prescriptions for every 1,000 people.5

  Antibiotics used in food-producing animals have contributed significantly to resistant bacterial strains that impact human health (3,500,000 kg of tetracycline was used in 2017, predominantly in the cattle and swine industries).6

  The high C-section rate in the US (up to 30 percent in some areas, a 60 percent increase from 1996 to 2011).7 A C-section baby enters the world through a sterile surgical incision and does not descend through the birth canal. Therefore, the baby does not ingest the beneficial Lactobacillus bacteria from the wall of the vagina.

  research on leaky gut and celiac disease

  This groundbreaking concept of leaky gut has been understood by naturopathic doctors for years. It has only been more recently introduced to the conventional medical world by Alessio Fasano, MD, an Italian physician at Harvard, who is the head of pediatric gastroenterology and nutrition. His research has shown that patients with celiac disease (an autoimmune condition where gluten attacks the lining of the gut, causing damage) have higher levels of a molecule called zonulin. Zonulin damages the tight junctions between the cells that line the gut.8

  Dr. Fasano’s research also found that gluten triggered the zonulin elevation even in individuals who don’t have celiac disease.9 Some of you reading this book may have experienced this. I certainly have. My celiac test results through bloodwork are completely negative. I did not have an endoscopy since the bloodwork was negative and my symptoms all went away quickly and easily when I went off of gluten. I note this here because so many kids I see have a gluten sensitivity, but they don’t have celiac disease. I test kids before taki
ng them off of gluten, but I put in the caveat that if the test findings are negative, I do still often recommend we do a trial off of it to see if it makes a difference.

  HEALING A LEAKY GUT USING THE 5 R APPROACH

  This simple mnemonic, the “5 R Approach,” will help you remember the process we go through to heal a leaky gut. It is the foundation of my HKHM program.

  Remove foods that drive inflammation

  Replace vitamins, minerals, fats, fiber, protein

  Reinoculate with prebiotics and fermented foods or a probiotic supplement plus digestive enzymes

  Repair with this regimen for three to six months consistently and monitor symptoms as the gut repairs itself

  Reintroduce foods that have been eliminated slowly, one at a time (except for the processed foods)

  I will walk you through the 5 Rs, including the exact supplements I use in my practice, in section II. Barry’s case is a great example of how the 5 Rs can be a powerful treatment tool.

  CASE STUDY

  BARRY

  SYMPTOMS: CHRONIC CONSTIPATION AND ENCOPRESIS (BOWEL ACCIDENTS)

  Barry was eight years old when I first met him and his mother. I was doing primary care pediatrics at the time. He had chronic constipation that had started when he was about six months of age. It was so bad that it developed into something called encopresis. Encopresis is when stool leaks out of the anus, soiling underwear and causing a foul odor to surround the child. Constant soiling of your underwear is embarrassing for an eight-year-old child. It also concerned me, his pediatrician, and his parents.