I intervene with diet and lifestyle 100% of the time.
KH: I’m Dr. Kristi Hughes with the Institute for Functional Medicine. I have the opportunity to talk with one of our faculty physicians and clinicians today, Dr. Tom Sult.
Dr. Sult, welcome to the conversation. I’m very excited to gather some information from you today about what it is you are doing in your private practice as it relates to patients that you’re seeing with GI concerns. Where I’d really love to start is, when we think about your full practice, what amount of patients—or maybe percentages—would you ballpark that are walking in the door, are presenting with GI complaints today?
TS: Where I’d like to start is to say that I’m really surprised when a patient doesn’t have GI complaints, so virtually all of them.
KH: All of them?
TS: Virtually all of them.
KH: No matter what condition or disease or diagnosis they’re walking in with?
TS: If you really ask the questions, virtually all of them. If you simply start by, not start, but when you get to the GI component, if you ask, “Do you have what seems like unreasonable amounts of constipation, diarrhea, abdominal pain, bloating?” everybody says yes. When they’ve been chronically unwell, everybody says yes. Obviously, healthy people don’t have those things. But the chronically unwell almost always have GI complaints.
KH: So your answer was “all,” right? What I’m wondering is, are there ways that you’re seeing problems in the GI tract even if that’s not the dominant symptom. Are you seeing that imbalances in the GI tract are systemically presented in certain ways?
TS: Yes, there’s this teeming ecology of bacteria in our gut; we call it the microbiome. The microbiome is becoming more and more important in our understanding of health and disease. When you have gut issues, your microbiome is disordered. When your microbiome is disordered, you can have low-grade inflammation in your gut.
I’m not talking about a degree of inflammation that causes inflammatory bowel disease. I’m talking about a minimal amount of inflammation that causes issues with the tight junctions between cells that line the intestinal lumen. That leads to abnormal interactions between the immune system and the gut luminal content. That can have systemic consequences. It’s very common.
KH: How are you finding that information in your patients? Is it through the history, the conversation, or laboratory tests? How are you arriving at some of those conclusions?
TS: I always start by having my patients construct a timeline. It’s interesting, when they construct this timeline, it’s almost like a ramp up, right? There’s no symptoms. Then all of a sudden there’s more and more and more and more symptoms. I want to look at that inflection point of where the symptoms really started. I want to really explore that. I want to ask a lot of questions about what was going on in their life:
- Were they traveling?
- Did they have a stressful event, did something happen?
The first place I really want to understand, is there a definable origin to their disease process? From that timeline, then we fill out something called the Functional Medicine Matrix, which is just a tool we use to try to understand from a systems biology point of view where have things gone haywire. Do they tend to have a lot of symptoms that relate to immune function or detoxification function or endocrine function or whatever it might be… or psychosocial or spiritual issues? Wherever it falls on this Matrix, I really want to study that and think about that as it relates to the person I’m talking to.
Then, I really want to verify my thoughts by telling the story that I just heard back to the patient. I want to sort of have this conversation about their story because people haven’t thought of it the way we’re thinking about it. They come to the doctor; they want to be briefed; they want to be succinct. Because they’ve been trained by us to be interrupted within 15 seconds of their story. I really want to explore because I want to understand the underlying causes and issues, not just the symptom. My first visit is really all about listening and retelling the story. I get 90% of what I need from that.
I usually will intervene then with diet and lifestyle treatments. When those diet and lifestyle treatments either don’t get us all the way home or don’t get us the direction I thought they would, then I might think about ordering tests. When I order a test, I happen to like specific tests that tell us a lot about how well somebody digests and absorbs their food, how well somebody utilizes vitamins and minerals and amino acids and fatty acids and antioxidants, how well they detoxify. It tells us some information about their microbiome and the health of their microbiome. By looking at that in a sort of broad general way again, I get more information about how we might intervene on a diet and lifestyle level to normalize their physiology.
KH: Did you always do it this way? What was it like for you in your pre-Functional Medicine model versus your integration model where you now work through the philosophical approach to finding the cause of disease? What’s changed for you, or how is it different than when you were taking more of a conventional or standard approach to GI concerns?
TS: I’m a conventionally trained physician. I’m board certified, residency trained in family medicine. Somebody would come to me, and they would have depressive symptoms, and I would diagnose them with depression and give them an antidepressant. They would have irritable bowel, and I would treat them for irritable bowel. They would have arthritis, and I would work them up and treat them for arthritis whether it was rheumatoid or psoriatic or whatever. These people had these different diseases.
In Functional Medicine, we’re really trying to understand what went haywire at a more fundamental level that led them to have GI issues and joint issues and depression. Often, we can come to some very fundamental underlying clues that lead to very simple interventions. Simple, not necessarily easy. Because sometimes we ask people to do some strange diets at least for a short period of time. But nonetheless, simple underlying causes that have dramatic impacts on how people feel without having to have them on polypharmacy.
KH: I guess I’d love to ask how often are you changing the diet or making dietary recommendations in your patients with GI distress?
TS: I intervene with diet and lifestyle 100% of the time.
KH: Let’s talk about some of the dietary approaches that you have found do work. Are there certain things that you do first with many of your patients? Or how would you say you move through your clinical decision tree to figure out which foods might be causing problems or if you’re going to recommend they stick with?
TS: The gold standard for trying to understand if somebody has food sensitivities is an elimination/provocation diet. That’s really the first diet I use.
Virtually all of my patients who come in, chronically unwell, will be placed on a comprehensive elimination diet. This is a diet designed to eliminate foods that are commonly found to be sensitizing, not necessarily from an allergy point of view but from just a food sensitivity point of view. Remember that food allergy, at least in the United States, we consider food allergy to be IgE-mediated food allergy. I’m not necessarily looking for that. In fact, I would say I don’t find that very often. But I do find many people who just have other food sensitivities. Maybe sensitive to say wheat or gluten even if they don’t have celiac disease. They may be sensitive to some other food.
Putting them on this elimination diet, for a finite period of time, I usually do this for 6–8 weeks. Then, reintroducing foods one food at a time as specifically as you can, looking for anything that may be triggering symptoms. Now, the good news about this is I’m going to put them on other things to try to help them heal. Many times they introduce foods, they feel better on the elimination diet.
In fact, most people come back at their first visit, and they say, “Boy, that was a really hard diet, but I feel so good I’m never going off of it.”
And I say, “Well, wait a second. You don’t have to stay on it forever. We will reintroduce foods one at a time and see if anything bothers you.” Because we’ve healed their gut in the meantime, when they reintroduce foods they actually get back on a healthy diet. Now, I don’t want them to go back to their previous diet because it was probably not very healthy, but I want them to go back to a healthy diet.
KH: When you say “heal their gut,” what does that mean to you? What are you doing with them that is helping support that, either leaky gut pattern or help support that healing process?
TS: First, eliminate things that are maybe irritating. So that’s the elimination diet, trying to get rid of sensitized foods. It’s not that the food is bad; it’s that there’s an abnormal immune system food interaction that’s going on. Eliminating the food short-term brings down the level of inflammatory molecules. Then giving nutrients that I know are going to help heal the gut, whether it’s a colostrum product or something like glutamine or a probiotic or a prebiotic kind of food or supplement.
KH: Let’s talk a little bit more about how you assess that microbiome. Are there resources or tools that you are using to get a better understanding of what your patient’s GI tract may hold as it relates to those various different bacteria, yeast, etc.?
TS: There are many companies that do assessments of microbiomes, ranging from culture techniques to PCR techniques and even genetic probe techniques. I typically start fairly simple. I use a test that uses organic acids to try to assess the gross balance of the microbiome in terms of good and bad bacteria and yeast and fungus and so on. I use fairly high-level interventions, and by high-level, I don’t mean sophisticated; I mean not very granular. I use diet change. I use prebiotic food changes. I use some high-count probiotic supplements.
If we don’t get where we want to go, that’s when I’m probably going to order more granular tests. To see if there’s a specific pathogen that I need to eliminate or if there’s some specific imbalance that needs to be more specifically addressed. That would include probably a PCR technique where we can look at anaerobic bugs that are much harder to culture. I sort of do this stepwise.
In Functional Medicine, it is really an iterative process where I’m going to see you; we’re going to make an intervention and see what that does. You might get better. That’s of course what everybody wants. That’s great. But you might not get better, or you might get worse. Both of those things give me important information that help me make the next decision.
In Functional Medicine, what we are really doing is this iterative process of doing an intervention, seeing how you respond to it. If you respond well, we’ll do more of the same. If you respond poorly, we’re going to try to understand why you did poorly and what that means in terms of the next intervention.
KH: You’re talking about a lot of sometimes challenging things you’re asking your patients to do. To change their diet, to change their lifestyle. These are not easy things. If we go back to your practice model, you clearly can’t be the person doing this over and over all day long with your patient volume and the capacity that you have to manage. How do you support your patients? How does your practice operate or function in a way that you are able to help people with their questions, their need for recipes or food ideas? It’s not an easy thing to change your lifestyle.
TS: Right. I like to tell my patients that I do what the Lipitor commercial says to do. After a trial of diet and lifestyle, consider Lipitor. All through medical school, we were all told, you know, “diet and lifestyle, diet and lifestyle,” and everybody summarily dismissed it and ignored it and went straight to the Lipitor, right? Doctors get the idea that, “Well, patients won’t change their lifestyle.”
They won’t if you don’t give them the tools. Just like they only take the medicine you give them 30–60% of the time, right?
We have to create tools to help them change their diet and lifestyle. In my practice, we have my longest standing nurse: she’s been with me for something like 17, 18 years. She’s now—it sounds like a demotion, but it’s really a promotion to our phone triage. She knows what I think before I think it most of the time. She answers the phone, and she answers most of the diet and lifestyle questions.
Then we also have a health coach. The health coach, either virtually or in person, sits down with these patients and helps them, coaches them through the diet and lifestyle changes and helps them understand not only the what but the why and most importantly the how.
KH: I know you’re practicing in the Midwest, and you’re practicing out in a rural-type community. There isn’t a Whole Foods around the corner for your patients to go to. How do you find your patients are handling some of these recommendations? These are huge changes to say, “Let’s reduce or eliminate the wheat and gluten from your diet. Or let’s take away dairy.” You’re surrounded my dairy farmers! There are dairy farmers and fields surrounding your practice. How do you get them to make these changes? How do you get them to find the food?
TS: The queen for the dairy industry is known as Princess Kay of the Milky Way, and I once took care of her. There was obviously many of them over the generations, but this particular one was allergic to dairy.
As soon as we discovered that, she said, “You cannot tell anybody!” So I didn’t tell. Nonetheless, yes, it’s a big issue because Princess Kay of the Milky Way is at the state fair, and she’s got her bust carved in butter. It’s a big deal in Minnesota, right? But it’s fundamentally not difficult.
It’s a struggle because it’s a change, and all change is hard. You can go to almost any diner anywhere in the world and say, “I would like a grilled chicken breast and vegetables.” It turns out, that’s on the diet. You can go almost anywhere and say, “I need this salad, hold the croutons.” Because again, you know, “hold the croutons” might not be good enough for somebody with celiac disease, but we’re not usually talking about celiac disease. We’re really talking about a dose-dependent issue. Getting rid of 99.9% of it is good enough for what I’m trying to do. If you have celiac, that might not be good enough.
We need to not throw the baby out with the bathwater. We need to allow good enough to be good enough. I always talk about my emergency meal. What’s my emergency meal? It’s not McDonald’s because that would be bad. Instead, I have frozen vegetables in the freezer all the time, and I have frozen chicken breasts in the freezer all the time. What can do you do for an emergency meal? You can rip open one of those bad boys and stir fry it. That is a really healthy good meal. You’ve got fresh frozen vegetables and a chicken breast…
If you have someone to help you like a health coach and if you have the mindset that this is the right thing to do, it’s infectious. Patients want to do the right thing. They want to be healthy and people will self-select to come. People who only want to be given a medicine? They don’t see me anymore. They don’t want to be seen by me anymore because that’s not what I do.
In fact, sometimes people come in and say, “Gee, I didn’t do what you said.”
And then, “Ok, why not?” Usually, that’s the key. I always tell people, when people don’t do what you ask and you explore why, that’s the magic. That’s the magic of medicine. But when it becomes recalcitrant, and they say, “Gee, I didn’t do it,” then I have to say, “You came to someone who treats disease with diet and lifestyle, and you’re unwilling to do either diet or lifestyle. So what’s next for us?”
KH: Could you pull this all together and give me a summary list of the things you find are the primary causes of much of the GI stress that you see in your practice? Are there things that rise to the top? Or do you have a top 3 list that you are now seeing as a Functional Medicine provider through that lens?
TS: Our frenetic, all-yang-all-the-time society is the primary cause of GI issues in my practice. The primary intervention is going to be listening and then helping them understand how to get out of fight or flight.
KH: So you’re talking about stress when you say primarily yang? You’re meaning the stress load?
TS: I’m meaning the stress load. I’m meaning everything from just the 12 things I have to do in the next 10 minutes to the guy who cut me off on the way to work to the letter I got from the IRS to all of these things. They’re all causing stress.
All of those stressors are resulting in a shift away from rest and digest to fight or flight.
If you’re in fight or flight, you’re not digesting your food well.
Your peristalsis has changed. That’s changing your microbiome: 70% of your immune system lines your gut, so you’re shunting blood away from your gut in fight or flight, so you’re not absorbing your nutrients well, and your shunting blood away from a significant fraction of your immune system.
KH: Stress is at the top of your list. What are some of the other key causes that you’re seeing?
TS: Diet. Eating fast food under fast conditions. Eating in your car. If you’re eating in your car, you are not helping. You’re not helping yourself. Eating nutritionally poor foods. Eating foods that are not nutritionally dense, that’s the next big piece. Not eating vegetables. I mean, I can’t tell you how many times I say, “How many vegetables do you eat in a day?” and they say, “… a day? How about if we do it by the week. I might get one or two a week.” That’s really a problem because we need fiber. Probably the single biggest nutritionally deficient thing is fiber. If you’re not eating your fruits and vegetables, you’re not getting fiber.
KH: Thank you. We really appreciate all your clinical wisdom today, and thank you for sharing what you’ve noticed unfold over the course of your journey in Functional Medicine.
TS: It’s my pleasure to be here. Thank you.
KH: Thank you for your time.