How to Choose the Best Diet for Gut Health

In this episode of Functional Medicine Research, I interview Dr. Liz Lipski in a discussion about how to choose the best therapeutic diet for gut health.  We discussed the low FODMAP diet, comprehensive elimination diet, Simple Carbohydrate Diet (SCD), GAPS diet, Paleo diet, histamine, pancreatic elastase and low HCL levels.  Liz discussed why we would choose each one of these diets for an individual and what each diet entails.  I use all of these diets in my practice so it was nice to have an overview of each diet from one of the top experts in gut health.

Best Therapeutic Diet Liz Lipski

Dr. Hedberg: Well, welcome everyone to “Functional Medicine Research.” I’m Dr. Hedberg. And I’m really looking forward to my conversation today with Dr. Liz Lipski. And Dr. Lipski, she’s a Professor and the Director of Academic Development for the Nutrition Programs at Maryland University of Integrative Health. She has a PhD in Clinical Nutrition, two board certifications in nutrition, one in functional medicine, and she’s a fellow of the American College of Nutrition. She’s the author of the fantastic book “Digestive Wellness” which I highly recommend. And she’s the founder of the Innovative Healing Academy. She’s on faculty for the Institute for Functional Medicine and the Metabolic Medicine Fellowship in Integrative Medicine. She’s been a pioneer in the field of functional nutrition for four decades. Liz, welcome to the program.

Dr. Lipski: Thanks, Nick. It’s so nice to be with you today.

Dr. Hedberg: Yeah. This is gonna be a great talk. We’re gonna be talking about how to choose the best diet for gut therapy. And why don’t we start by just a general question about, you know, what is the best overall diet for GI health? Do we really know, based on the research at this point, what the vast majority of the population should follow? Do we have any insights on that?

Dr. Lipski: I do. I think a lot about what’s different between people who are healthy and wanna work on tweaking their health or preventive health, and then people who are already in a deep hole where already their health is compromised. And hands down, when we look at research, it looks like a whole foods diet based on a Mediterranean-type diet is the very best diet. When we look at it, cancer rates go down and diabetes rates go down and cardiovascular disease rates go down, but we also have some research on GI.

And one of the main issues in the way that we’re eating… And I know you see this in your practice, Nick. What we see is, when you ask people, “Well, how do you eat?” And what do they tell us? They say, “I eat pretty well.” Right? Don’t you hear that all the time?

Dr. Hedberg: Yeah. Yeah.

Dr. Lipski: And then you look at somebody’s food diary and maybe they do, but usually they don’t. And so for me, steering somebody at first to a whole foods diet is the most important thing because what we know is that according to a recent study based on kind of looking at every food that has a barcode and it represented, you know, any food company that had more than, you know, a tiny share of the market, they looked and they said 70.9% of the foods that we Americans are eating are ultra-processed. Ultra-processed.

And so we now have other studies that say, “Well, if you have more than two servings a day of these ultra-processed foods, we have a 62… For each 10% increase in ultra-processed foods, we increase our risk of cardiovascular disease by 12%, and heart disease by 13%, and strokes by 11%.”

So, we also have some research on cancers as well. And so, you know, it’s not that we can have a treat. It was just my son’s birthday and I made a cake and we all had cake. It’s not like, you can’t have some treats, but at least I made the cake. I knew every ingredient that was in it. And most of us are just eating, the majority of our food is fast, easy, cheap, and filled with all kinds of additives and highly-processed foods. And so the first step is moving towards a whole foods diet and trying to make at least 80% of what you eat every day as real food and cooking.

And so that’s kind of a long answer to, like, what’s the best diet for GI? So, for people who are healthy, you know, tons of vegetables and fruits and legumes and nuts and seeds and whole grains and good-quality proteins. That’s really what our diet should look like. And for the most part. But then, when we’re sick, we have to do different things.

Dr. Hedberg: Right. Right. It’s such a confusing topic for the consumer. We’re talking about colonizing Mars and we can’t even figure out what to eat, you know, on our own planet. But we can wade through some of that, especially when we’re talking about specific therapeutic diets. Why don’t we jump into this area and go through a few specific therapeutic diets? Why don’t we start with the elimination diet? This is a diet that I’ve used quite a bit over the last 16 years. And so can you tell us, you know, how do you choose the type of patient to use an elimination diet with and what does that diet look like?

Dr. Lipski: Okay. When both of us started, this was pretty much our only therapeutic diet. And so, like you said, you have a lot of experience with it, I have a lot of experience with it. And I’ve said over and over that if you can take somebody who has inflammation, maybe even somebody with autoimmune disease, and put them on a comprehensive elimination diet, within two weeks they often feel at least 50% better. And so I think that this is one of the greatest reducers of inflammation of all time is dietary change because eating is the most inflammatory thing we do, depending on what we’re eating and who we are.

So, the comprehensive elimination diet, I think about it for somebody who has a lot of pain, somebody who has migraines, somebody who has arthritis, somebody, again, maybe if they have autoimmune disease and they’re not ready to kind of turn their lives 100% upside down.

And what you can eat on an elimination diet is you can eat poultry, preferably organic. You can eat bison and meats that aren’t eaten that often. You can eat fish. You can have fruits and vegetables. You can have non-gluten containing grains like rice and wild rice and buckwheat. You can have seeds like amaranth and quinoa. You can have other seeds like sunflower seeds and pumpkin seeds. And you can use oils like avocado oils and olive oil and walnut oil and sunflower oil. You can use herbs and spices. And that’s pretty much what comprises it.

One of the things I like about the diet a lot is you can pretty much walk into most restaurants and be able to find something that you can eat. You could have a salad or you can have grilled chicken with some vegetables and baked potato. What’s not on this diet is alcohol, sugar, gluten, dairy, eggs, soy. Unless somebody is a vegetarian, I don’t include any legumes because legumes, as people know, can cause a lot of gas and bloating if people aren’t used to them. But if they’re already part of somebody’s diet, we can talk about that. One of the big deals that I typically make is if somebody is a big coffee drinker, we negotiate on that. Do you do that too?

Dr. Hedberg: I do. Yeah. Because cold turkey on coffee can be very, very hard for some people.

Dr. Lipski: Yeah. It’s not the most… We know that coffee has, you know, probably a couple of hundred different components to it and some of those are really anti-inflammatory and antioxidant and helpful for us. So, usually, it’s not caffeine, is usually not somebody’s biggest issue. It’s usually, usually, usually in 80% to 90% of cases, it’s gluten, dairy or eggs. But I really like to start with a pretty, you know, broad-brush because what I’ll ask somebody to do is to do this diet 100% for two weeks and then come back into the office and then we reevaluate where they are.

If they have zero benefit, then it’s kind of like, “There is zero benefit? Well, maybe we are barking up the wrong tree.” Right? But for most people, I’ve seen people come in who had arthritis, depression or have mental health stuff. This works so amazingly well for depression, anxiety. And I’ve seen people come in, they’re fatigued, they’re not sleeping well, they’re depressed and anxious and they have pain. And they come in after a couple of weeks and they go, “Oh, my gosh. I feel like a different person.”

And that’s when I say, “Do you think you could do this two more weeks?” Because I’d like to give a longer period of time. We know that the half-life of antibodies is about 21 days. So, if we can have somebody stay on this diet for at least three or four weeks 100% then we can kind of tamp down that antibody response. And then when they actually reintroduce foods, they get often a big kind of kick that says, “Uh-oh, my symptoms are coming back.”

And how I like to do this, and everybody does it a little bit differently, is I like to have people, for example, if they’re gonna add eggs back into their diet, I would like them to have eggs at least a couple of times that first day and a couple of times the next couple of days. And if they have any negative reaction, sometimes people have a negative reaction immediately, then eggs are off their list, and they know that. But if they don’t really notice anything, I want them to keep eating eggs for a few days in rather high amount to see what happens. Because often somebody feels fine the first day and it’s a second or third day, all of a sudden, their symptoms kick back in. I’m sure you’ve seen that too.

So, that’s kind of the comprehensive elimination diet. And it always used to be my first go-to diet. And it’s still one of my main first go-tos and I think it’s because people can wrap their heads around it pretty easily and because it works remarkably well so often.

Dr. Hedberg: And you’re doing around three weeks to start or do you do it a little longer, a little bit shorter?

Dr. Lipski: Well, I have them do it for two weeks and then come back into the office. And then based on where they are, we do it another two weeks, is my recommendation.

Dr. Hedberg: Okay.

Dr. Lipski: What I find is if you tell me to do something for a month, I may not be able to do it 100%. But if you have need to do something for two weeks and tell me to do it 100%, I can do that.

Dr. Hedberg: Agreed. Yeah. That’s a great point.

Dr. Lipski: So, this is more compliance. Yes, I want them to be on this side for at least four weeks, but I can’t tell people that right to begin with because it’s too hard for a lot of people.

Dr. Hedberg: Right. Right. And the majority of the time, they’re doing better on it, and so there’s motivation to continue once you check in with them again in a couple of weeks.

Dr. Lipski: Yeah. Yeah. And then sometimes, if they feel really great, sometimes people are like, “I am not ready to add food, and anything back.” And sometimes people say, “I am desperate for a piece of bread.” Right? Or, “Please give me back my pasta.” Right. And so, in those cases, what we do is we kind of look at it and we got, “Okay. Well, do you think you can like make it one more week? And then, let’s start adding this back in.” Because most often the foods that people are sensitive to are the ones they crave the most.

Dr. Hedberg: Exactly. And so your reintroduction recommendations. So, you use the example of eggs. So, will you have them eat that particular food just by itself in a meal or do you mix other foods with it?

Dr. Lipski: They can mix other foods with it. So, for example, they can make an omelet or they could have, you know, some eggs with some home fried potatoes or, you know, have a bake… However, you eat them. Or maybe you can have a gluten-free pancake mix, which isn’t my favorite, but, you know, I put an egg in it and see what happens if everything else that’s in that gluten-free pancake mix is also on your diet.

I had a client when I was living in Asheville when you and I were friends, you know, when I was there and she followed everything that I said to the tee and she had amazing results. In two weeks she came back and she was glowing. She had lost some weight and her skin was way improved and her energy was really high and her depression was gone and her arthritis was gone. And she had followed everything that I’d said except that she was a great teacher to me because she went out and she bought gluten-free cookies and gluten-free everything that she could find that was in line.

And so she was still eating a ton of processed foods. And so she was a great teacher to me because she did get better. And she got so much remarkably better and yet she was eating a lot of junk food, a lot of like chips that fit the diet. So, she was eating a lot of potato chips with, you know, organic potato chips. So, you can still get great results even if you kind of bend the rules a little bit.

Dr. Hedberg: Have you used the pulse test, the Coca pulse test for reintroduction? You check the pulse and then eat the food and then check the pulse after that, and if it increases by more than 10 or decreases by more than 10 then that’s a sign of a reaction. Do you buy into that or do you not use that?

Dr. Lipski: Coca, it’s a really great hypothesis. And I have worked in clinics where they’re actually doing provocative testing right in the clinic and they’ll use that. And so, you know, you can. I have used it in the past with people. And sometimes people really notice that their pulse changes and sometimes they don’t. Sometimes they might get flushing or they might feel a scratchiness in their throat or they might feel almost like itchy or, you know, other different kinds of things. And so it’s one of the things that can be used. How do you use the Coca test in your practice?

Dr. Hedberg: Yeah. I do recommend that to patients who I put on an elimination diet. I have just an instructional handout that I give them and then I do have them just test at home. And they seem… I mean, most of the people that have used it seemed to like it a lot and they found it useful. And it seems to have correlated with their suspicions as well. So, if they were just kind of suspicious about eggs or almonds or whatever, it seems to do work well for that.

Dr. Lipski: Yeah. I kind of forgotten about that. It’s a good one and it puts that in between their hands. I think that, along with looking for any other kind of provocation of other symptoms, together, that would give a really complete picture.

Dr. Hedberg: Right, right. So, let’s talk about the FODMAP diet. So, this diet has emerged quite a bit over the last few years, especially, because of the emergence of SIBO, not that SIBO hasn’t been around but it just has gotten a lot more press and more attention and more research and for good reason. So, the FODMAP diet, how do you select the individuals to put on the FODMAP diet? And what are some of the general guidelines for that diet?

Dr. Lipski: So, I’m looking at the research. And what the research demonstrates right now is that the low FODMAP diet is great for people who have irritable bowel syndrome, especially people who have IBS characterized by a lot of gas and bloating. And you and I both know that the research also indicates that more than half of people with IBS have small intestinal bacterial overgrowth.

What we don’t have is a lot of papers yet demonstrating that people with SIBO do really well on a low-FODMAP diet. But if we know that people who have IBS with all of the signs and symptoms of SIBO, which is gas and bloating and discomfort, do really well on a low-FODMAP diet. And now we have all kinds of review papers. If we look at that, then we can say, “Well, once we do start getting papers on SIBO and the low-FODMAP diet, they’re going to be positive.” We just don’t have them yet.

And I think one of the reasons, the main reason why this diet has, as you say, kind of mushroomed on the scene is that the original developers of this diet, Dr. Sue Shepherd and Peter Gibson from the University of Monash in Australia, you know, one of their main things is that they started doing research immediately on the diet. And so we started getting research, which is what we don’t really have for other diets.

And so now, I think the original hypothesis was that this would be a really useful diet for Crohn’s. And it hasn’t really been that effective relatively for inflammatory bowel disease. Some people will benefit but most people don’t. And so, you know, when I think about this diet, I think definitely irritable bowel syndrome, people with gas, bloating discomfort, people who’ve been on a gluten-free diet but they don’t seem to get better. So, that’s the population group.

And I think for me, the most important thing about these FODMAPs, like, what is a FODMAP? Okay? And a FODMAP is… I’ll go through what they are in a second. But each one of these is a prebiotic-rich food. It’s a prebiotic category. And prebiotics are the food that feeds the microbiota. And these are typically insoluble fibers, they’re resistant starch, they’re sea vegetables. And they’re food for the microbiome.

But when we have dysbiosis, we have to starve the microbiota. And so this is one of the low-carbohydrate diets that we use for dysbiosis that starves the microbiota. And so we remove all kinds of really great foods. So, if it’s fermented, it’s gone. Okay? So, there goes beer and wine. But there also goes, you know, a lot of things like yogurt or kombucha or sauerkraut or kimchi. Anything that’s like fermentable, it’s gone.

Oligosaccharides. Well, that’s just another name for a large group of prebiotics. We see those in supplements all the time, in probiotic supplements. Why? Because they’re food for the probiotic microbes. Disaccharides, the main one they’re concerned about in this diet is lactose. Monosaccharides, fructose, and so fruits are restricted and not all fruits but the high-fiber fruits are restricted. And then what was known as polyols which are the sugar alcohols. So, sorbitol, mannitol, maltitol, xylitol, isomalt, things like that. And we normally think of those as being in, you know, just like protein bars and protein drinks and things like that, but what we know is even some foods like asparagus and avocados have amount enough of the polyols to kind of throw people off.

So, this is a low-prebiotic diet. So, what they allow is, you know, they’ll allow… They don’t allow dairy products unless they’re lactose-free or really hard cheeses, or lactose-free yogurt, or… So, some of the big no-no fruits are things like bananas, which is the number one fruit that people eat, and melons and grapefruit and oranges and apples and… Oh, I’m sorry. Those are low-FODMAP. But apples and cherries and mangoes, pears, watermelon, those are all high-FODMAP.

So, there’s charts. And whenever I’m recommending this diet, I recommend that people spend $5 or $6 and get the app from the University of Monash because they can look up every single food and it gives them green, red or yellow. And so they know that they can eat it or they can’t eat it. And if it gives them a yellow, then it’s like, okay, well, this…you can have three, you know, two sprigs of asparagus. And it’s like, “Well, who’s gonna eat two stalks of asparagus?” So, it gives you the amounts that you can eat. And if you look and it goes, “Almond,” Sorry, no, those are red.

I just had a client who…an old friend who called me and she said, “Give me the name of a referral to somebody in my area.” And so I did and I said, “Her first visit is $750.” She goes, “I don’t care. I’m so miserable.” I’m like, “Well, before you see her, just tell me what’s going on.” And she’d had IBS-diarrhea type with gas and bloating for 15 years. And about three weeks prior, she and her husband, this was in early March, they come with some friends away for the weekend and they had wined and dined. And when she got back onto the airplane, she spent the entire time, including all the seat belt time, in the bathroom having diarrhea. I’m like, “Okay.” So, it sounds like she got food poisoning without doing any testing or anything fancy.

And the morning she talked with me she had gone to see her doctor and her doctor said, “You think maybe it’s a bladder infection, but let me just put you on an antibiotic that will help with food poisoning and if it’s also a bladder infection.” And so she had just started taking that. And it wasn’t Rifaximin which is usually the antibiotic that’s used for small intestinal bacterial overgrowth, but I looked it up and it was something that was a second-line therapy. So, I’m like, “Okay.” And he didn’t do any testing, but I recommend the low-FODMAP diet.

And she got the University of Monash app and she started doing the diet and she did amazingly well. And she was on the antibiotic for about 10 days. And I said, “Well, stay on the diet.” Because, typically, what you wanna do is have somebody go on the low-FODMAP diet for 4 to 6 weeks 100% and then start adding categories of foods back in. So, let’s add some fructose in. Let’s add an apple or two and see how somebody does. Let’s add a little bit of dairy and see how somebody does. Some milk or some ice cream or custard or yogurt or let’s add some, you know, beans or broccoli from the fructans category or, you know, let’s add some beans and galectins category and let’s just kind of look at all of this and see how people are doing.

And so she was doing amazingly well. She did not wanna add any foods. And one day, somebody gave her a salad with nopales cactus at work. And she ate it and all of her gas and bloating came back. And then she looked on the app, she goes, “I never even thought about cactus as being a high-FODMAP food.” She lives in Texas where people eat, you know, cacti. And most of us, it’s just not even on our radar.

So, actually, one time, when we did a phone visit, her husband got on the phone. He’s been doing all the cooking for her. He said, “Thank you for giving me my wife back.” So, these diets are life-changing. Actually, she… I told her, I said, “Don’t be surprised if some of your symptoms come back after a while.” And after about maybe five weeks, they did. And so I followed up with her with some antimicrobial herbs to help just kind of balance her microbiome a little bit better. And she’s been doing amazing. Now she’s about five months into it.

Dr. Hedberg: Excellent. That was…

Dr. Lipski: Yeah. So, I wanna talk a little bit about some of the downsides of this diet too. It changes your metabolome really fast. Okay? It also changes the gut microbiome. If the point of it is starving out the microbes that are causing gas and bloating, then it also, what we know that in four weeks, the bifidobacteria levels just plummet. So, this is not a diet we want people to stay on long-term.

One of the other kind of benefits of it is that it reduces histamines. So, if you’re working with somebody who’s really allergic or somebody who’s having a lot of histamine responses to various foods, or even somebody… We don’t have any research on it, but I would look forward to it. Somebody who has eosinophilic esophagitis and also has allergies. This reduces histamines eight fold. So, it’s not something that’s really marketed about this diet, but I’m looking forward to seeing some more research on that.

On the other hand, hypnotherapy and yoga both work just as well as the low-FODMAP diet for people with IBS.

Dr. Hedberg: Interesting. I can see how it make sense in a number of ways, actually. Okay. So, we’ve covered the elimination diet and the FODMAP diet. And next on our list is the Specific Carbohydrate Diet. And correct me if I’m wrong. That’s pretty much identical, if not very similar to the GAPS diet. Is that correct?

Dr. Lipski: It’s not exactly the same.

Dr. Hedberg: Not exact. Okay.

Dr. Lipski: No. I think that what Dr. Natasha Campbell-McBride did with the Gut and Psychology Syndrome diet called the GAPS diet is she took the Specific Carbohydrate Diet and then she coupled it along with kind of nourishing traditions, Sally Fallon traditional foods diet. So, they’re very, very similar, but there are slight differences.

Dr. Hedberg: And so let’s talk about that. So, there’s Specific Carbohydrate Diet. I’ve mainly used that in inflammatory bowel, but can you expand on who you would use that with and what’s included in that diet?

Dr. Lipski: Sure. So, the Specific Carbohydrate Diet, we have maybe about 20 studies so far, and most of them are about pediatric Crohn’s disease. And so if you had a child with Crohn’s disease, this would be your absolute number one go-to. We also have a few studies on adults with both Crohn’s disease and ulcerative colitis demonstrating that this is the diet. So, just like you, this is the diet that I use for somebody who has inflammatory bowel disease.

And there was a recent paper by, I think, Vincenzi that put the low-FODMAP diet and the Specific Carbohydrate Diet head to head for people with irritable bowel syndrome and the low-FODMAP diet one hand, you know, heads over. So, this isn’t… Even though some people feel better who have IBS, it’s not really an IBS diet. It’s really an IBD diet.

And what’s allowed on this diet are all your non-starchy vegetables, honey, all fruit, and juices. Just like the low-FODMAP diet it allows really low lactose dairy products. So, they allow homemade yogurt and hard cheeses and dry curd cottage cheese. Pretty much all kinds of animal protein is allowed. Nuts and seeds.

So, for example, my son just had his birthday and I made him a lemon torte, which instead of using flour, I used almond flour. So, if you’ve ever made something with almond flour or you’ve made things with cashew flour or these really came a lot out of the Specific Carbohydrate Diet. And then you can have all kinds of foods that are fatty like avocado and coconut and olives and ghee. And then one of the main kind of tenets and bases of this would really be a lot of bone broth as well.

When Elaine Gottschall first put this diet together based on what Dr. Sidney Haas had given her own daughter who had ulcerative colitis, she allowed string beans and lima beans and white beans. Right now, they’re considered kind of second-line foods in this diet. But that’s pretty much what the diet looks like. There’s some great cookbooks out there. And there’s also, if you go to the Specific Carbohydrate Diet website, which is, they have a whole list of, you know, legal and illegal foods. So, again, you can just look up any food and see like where is it on your diet. And there’s some great cookbooks out there too.

Dr. Hedberg: Yeah. I found when people started, it’s difficult the first week. They’re very, very tired because of the carbohydrate intake is so low. Have you seen that as well? And do you have any tips for people during that first week or do they just need to stick it out?

Dr. Lipski: I think people need to kind of stick it out. I have seen that, but I’ve seen that with all of the diets. And I think one of the main things that happens over and over is that often people really don’t know what to eat the first week. And so sometimes they’re not eating enough. And so, you know, I would say, “Here’s a recipe for a specific carbohydrate muffins. Make these.” Or because they feel like people are eating a lot of carbohydrate because they’re loaded with honey and fruit and almond flour. And so they feel like bread.

I’ve made out of “Grain-free Gourmet” by Jodi Bager and Jenny Lass, I’ve made their blueberry muffins and cranberry muffins over and over for guests and people at my house and I don’t say anything. Nobody notices that they’re grain-free. So, I think really encouraging people and make sure that people are eating enough calories is really important because people, you know, if they just think, “Well, I can’t just eat almonds. Well, how many almonds are you gonna eat or walnuts?” But if you can make those into scones or you can make them into a kind of almond bread, then people have something that they can really eat that seems familiar and delicious.

Dr. Hedberg: Excellent. And so you said that the subtle…or maybe not subtle, but some of the small differences between the SCD diet and the GAPS is just some more of the nourishing traditions type recommendations?

Dr. Lipski: Yeah. I wish that we had research on the GAPS diet. We don’t. We have lots of anecdotal evidence, but we don’t have any research. And there have been some pretty wild claims for it. Anyway, I’m not gonna come to that. But there have been some pretty wild claims. And so I would like to see that. I think one of the most difficult things about the GAPS diet is that, you know, 100% of everything is homemade.

And so I’ve heard Dr. Campbell-McBride speak and she’s like, “So, it’s best if you have chickens in your own yard or you have a neighbor who has chickens and, you know, go to somebody who raises beef and get a side of beef and go and get, you know, a butchered pig and…” Because she wants everything to be organic and, you know, amazing, you know, like, the best quality ever. And people are spending a fortune on the food which, you know, we Americans, we don’t spend a great percentage of our income on our food as compared to other countries.

But it’s a little bit more difficult. You always have to have broth, you know, ready. You need to make everything from scratch. Where I think the Specific Carbohydrate Diet, there are now some products out there that people could buy that make it a little bit easier. So, I think the two are really similar, but what we have research on is Specific Carbohydrate Diet and not GAPS.

Dr. Hedberg: Excellent. So, the next diet is the Paleo diet or Autoimmune Paleo. There’s a few differences between those two, but the Paleo diet is another one of those diets. It’s very popular. It’s also kind of an elimination diet in many ways. So, who would you choose the Paleo diet for, and what’s included in that diet?

Dr. Lipski: So, the Paleo diet is basically the comprehensive elimination diet minus all grains. And we have… I mean, I’m sure everybody who’s a clinician listening to this, they have so many people who’ve come into their offices on a Paleo new diet that they’ve put themselves on. It’s a very popular. And often, there’s also no nightshade family foods, so there’s no potatoes, tomatoes, eggplant or peppers. And usually, no nuts and no seeds, but sometimes nuts and seeds there isn’t anything that’s… Again, we don’t have a lot of research.

We have one paper on using an autoimmune diet for inflammatory bowel disease. It was done by Konijeti, et al. And they took 15 people with IBD who’d had it for at least 19 years. And about half of them were using biological meds. And nine had Crohn’s, six had ulcerative colitis, and for six weeks they put them on a Paleo new diet that eliminated grains, legumes, nightshades, dairy, eggs, coffee, alcohol, nuts, seeds, refined sugars, oils, and food additives. Think caveman diet. And they allowed fresh foods, bone broth, fermented foods. And 73% were in clinical remission at six weeks and that was maintained at 11 weeks.

And what we see, you know, often in diets, especially Specific Carbohydrate Diet in children, the long… Even up to a year, you see those remissions gone. And so what they said is these results are equal in benefit to most drugs that are used for inflammatory bowel disease. And you can still use the biologics and other drugs.

There were two people in the study of the 15 who had ileal strictures that got worse. So, if somebody had ileal strictures, I’d probably…this would not be one of the diets because it’s a pretty low-fiber diet. So, I’d look at that. And one of the other diets that… And again, you know, what we’re doing is we’re taking out the big three. We’re taking out eggs, dairy, gluten, and then we’re taking out sugar, alcohol. I once was teaching and I had a group of students who decided they were gonna go off sugar for eight weeks. And the results were amazing just from taking away refined sugar. One woman’s migraines that she’d had for 12 years were gone. One man lost 20 pounds. People were sleeping better. Their energy was better.

And so, you know, I have colleagues who will just put people on a sugar-free diet. I’m like, “If I’m gonna make their life miserable for a few weeks, I’m gonna do the whole thing. I’m gonna take a real diet and I’m gonna do the whole thing. Recommend the whole thing.” And the reason is, is because we’ll get better results.

So, there was one diet I did not put down on my list for you, but I wanna talk about and that’s the six food elimination diet, which looks kind of… It looks a lot like the comprehensive elimination diet except it’s less strict. And this diet, we have over 40 papers on for people with eosinophilic esophagitis. And so if you’re working with somebody with eosinophilic esophagitis, I would choose a six food elimination diet or I would use a comprehensive elimination diet.

And I might even consider a Paleo immune diet. And the Paleo immune, I really think about it for somebody who has autoimmune conditions. And it’s also really good for people who have dysbiosis. Even though we don’t have the papers on it because it restricts carbohydrates so much. Again, when we think about dysbiosis, we think about carbohydrate restriction on all levels.

And so, you know, because we’re trying to rapidly change the gut microbiome so it can come back to balance. And these diets that we’re talking about, these are therapeutic diets. You wanna use them for…to have somebody on them for, you know, 4 to 8 weeks 100%, and then you wanna start that reintroduction phase, food by food and see, like, what’s provoking those symptoms because you can get a lot of nutrient deficiencies with any of these diets and you can also, really, they’re so restrictive that we can really trigger kind of orthorexia and eating disorders in people because I’ve worked with people who they’re still on a diet years later and they’re afraid to try anything new.

And so there are a lot of these different diets we’re gonna be seeing more research. The Specific Carbohydrate Diet, I’m very excited that next year, I think next summer a year from now, we’re gonna start seeing results from a 46 center, multi-country study on the Specific Carbohydrate Diet in Crohn’s disease compared with a Mediterranean diet in Crohn’s disease. So, there is a lot of research that’s starting to go on all these different diets and I’m really looking forward to seeing more and more of that.

Dr. Hedberg: Excellent. And I also wanna ask you about histamine, a low-histamine diet, avoiding that. What particular population are you thinking about when you try to limit histamines?

Dr. Lipski: So, add if I’m forgetting anything, but for me, when I’m thinking about a low-histamine diet, I’m thinking about somebody who has classic allergies, so, eczema, asthma, you know, seasonal allergies. I’m also thinking about possibly and, again, we don’t have any research on it, but possibly a low-histamine diet for somebody with eosinophilic esophagitis.

And I’m kind of saying that from personal experience. My husband has eosinophilic esophagitis and he completely normalized his eosinophil biopsy count and the strictures that were in his esophagus by going on a six food elimination diet. But he’s also somebody who’s really allergic. And he found cow’s milk and dairy products were his big nemesis, but he also found that, you know, the little bits of beer and wine that he loved to drink a few times a week triggers symptoms. And so I’m really curious, I’d love to see somebody to use a low-histamine diet on people with eosinophilic esophagitis or eosinophilic gastritis.

And then the other people that I think about immediately are people who say, “I can’t eat any fermented foods. Probiotics make me feel really sick. I can’t eat leftovers.” When I hear people who… And people who have trouble eating fish. People with histamine reactions, they don’t do well with leftovers, they don’t do well with anything that’s fermented, so beer or wine or kimchi or, you know, any of the wonderful fermented foods that we’re now, you know, promoting to people to keep well. And so, you know, those are the people I think of. Are there any other people that you’re using a low-histamine diet for?

Dr. Hedberg: Yeah. Chronic pain would be at the top of the list since histamine is often involved in that process. So, that’s another one that I would add in.

Dr. Lipski: Yeah, makes total sense. Yeah. And again, the low-FODMAP diet reduces histamine eight fold. So, again, we don’t really have any studies comparing the two. And I wish we had more studies just on a low-histamine diet. We don’t really have a lot of studies on that.

Dr. Hedberg: Right. And so when you see, say, on a stool test a low pancreatic elastase or you suspect maybe low HCl production, compromised pancreatic exocrine function, what are you…? Are you always using HCl and digestive enzymes? Do you like to use herbal bitters to stimulate those? And what kind of populations would you use those HCl and enzymes on? And do you subscribe to some practitioners who are using extremely high doses of HCl, you know, upwards of 5,000 to 6,000 milligrams of betaine HCl with each meal? So, how do you approach that?

Dr. Lipski: Okay. So, on a stool test, if I see pancreatic elastase levels or elastase levels less than 400, I’m going to want to recommend that someone take a good quality digestive enzyme product. If I see somebody with levels less than 200, there’s really a pancreatic exocrine insufficiency that probably needs further investigation. And that person may need to be on digestive enzymes lifelong. And sometimes, you’ll see that in somebody with, you know, kind of a low-grade chronic pancreatitis. So, I will often refer, if I see really low levels, because I’m not a physician. But we’ll definitely start recommending digestive enzymes.

And I have not seen any negative indicators for use of digestive enzymes when they’re taking, you know, like, a good quality enzyme that has protease, amylase, lipase. It’s well balanced. I haven’t seen any problems with them. The only problems I’ve seen is sometimes when people are taking pancreatin, which is desiccated pancreas usually from pig, is that sometimes that can be a little bit irritating to people and they feel like heart burning, they don’t feel good from it. So, that’s kind of, you know, one of the things.

Typically, we could talk about different kinds of enzymes for a long time, but, you know, I think that enzymes are always really supportive. And a lot of the signs of enzyme insufficiency are, again, they look a lot like IBS. The digestive system doesn’t have a lot of ways of registering its displeasure. You’ll also, if you ask people, they’ll say that they see undigested food in their stool and so on. And so, you know, people who have a lot of gas and bloating, you kind of think, “Well, why don’t we give them an enzyme? Maybe it’ll help them digest their food better.”

So, as far as HCl, first of all, I’m not in clinical practice anymore. I’m teaching all the time and writing and lecturing. But when I was in practice, I would have people do kind of an HCl challenge test and I would have them, you know, with a meal with protein take one capsule of betaine HCl and see how they feel. If they feel like a heartburn, I’ve had people who say their neck bothers them or they got a headache or they got diarrhea or their back hurts. No matter what the negative kind of sign is, I’ll say, “Okay. Experiment over.”

But in a healthy person who has plenty of stomach acid, it ought to make you feel uncomfortable. It might feel a little heart burning. More recently at IFM, we’ve been recommending that people try something different and that is to just take about a quarter to half a teaspoon of baking soda in some water on an empty stomach and then asking people to notice what happens over the next five minutes. And if somebody has plenty of acid in their stomach, they ought to start burping. And so it’s kind of a more benign way of doing it and a little bit maybe, possibly more accurate. These are all empirical tests that we do.

And so, you know, like with HCl, if somebody doesn’t notice anything, then you kind of keep increasing and say, “Well, you know, increase it two at the next time you have a meal with protein, or take three and see when you find that your heartburn goes away or that your pain goes away or your gas and bloating goes away. When do you start feeling better?”

And more and more, when I was in practice, I started using Swedish bitters. Instead of HCl, I started using umeboshi plums. And the reason for that is that I had one client who…it was easier for her to remember to take her betaine HCl all at one meal. And so she just would take six or eight at one meal and none at the other meals and she started having horrible pain because she was giving herself ulcers. You are actually putting acid in your stomach.

And I had another client who called me one day and she said, “I’m at the hospital. I’m having all this burning. Could it be the calcium I’m taking?” And I’m like, “Well, how much betaine HCl have you been taking?” And she was taking huge amounts. And what I had no idea was that she was also anorexic. She was in a new marriage and her husband was constantly on her because every time she would gain an ounce, and so she was doing food avoidance eating and taking tons of that betaine HCl. And she actually had a stomach ulcer from it.

So, I am very cautious about it these days. That said, I’ve worked with, you know, hundreds of people who’ve taken small doses of betaine HCl over a long periods of time with meals with protein, and they feel like a million bucks. So, if somebody can be responsible and take one with a meal or two, take, you know, 250 milligrams or 500 milligrams or 750 milligrams, most people can do great with that, but I’m not in favor of huge amounts. Nick, what are you finding in your practice? What do you recommend in these days?

Dr. Hedberg: Well, I test antiparietal cell antibodies. And if those are positive and the patient has significant signs of low HCl, those patients definitely just do really well with very, very high doses of betaine HCl because, obviously, their parietal cells, which, for our lay listeners, those are the cells in the stomach that produce acid. So, if your body is making antibodies against them and they’re being destroyed, then that individual is usually gonna do really well by supplementing with a lot of acid.

But I agree with you. You have to be careful. If there’s any kind of gastritis, history of ulcers, if they just kind of tend to have a very sensitive stomach and things like that, then sometimes, even just a single capsule can cause burning and pain. But I will say, there are some people that do well on those really high doses. But most people are going to do okay on just a few capsules of the betaine to strengthen digestion. And I also like to use a lot of bitters like you did and I have them take those for a few months to just start to get things stimulated and working again.

So, that’s kind of my take on it. And like you, I’ll also use an enzyme blend just sometimes with just has the pancreatic enzymes, the amylase, the lipase, and the protease. So, just like, you know, in practice, everything is gonna be patient-specific and so you just have a lot of different tools that you use for the individuals.

So, the last thing I just want to ask you about, we were talking about this before we started, was why do we need all of these special diets all of a sudden? What do you think is breaking down? Because there’s so many now, so many gut issues, so many health issues, so many different diets. Do you have any insights on to why we need so many these days?

Dr. Lipski: Yes and no. I wish we had some research on it, but I’ve just seen over time, because I have been doing this a long time. I’ve just seen, you know, when you look at graphs of autoimmune diseases, they’re on the rise, the amount of people with IBS is pretty constant, actually, 12% to 15%, but big. But even the ketogenic diets, which we don’t have any research on, GI and ketogenic diets yet, you know, they’re really low-carbohydrate. So, they’re also gonna dramatically change the microbiome, which we do see in studies.

But why do we have to keep limiting and limiting and limiting and going to smaller and smaller amounts of food? And I think that it’s because we have so much dysbiosis that our gut microbiomes are so out of balance. And they’re out of balance from the, you know, 100 pounds of refined sugar that the average person eats, the low fiber, the processed foods, the alcohol that people drink, the drugs we’ve taken, antibiotics. There are antibiotics in people’s water. There are drugs in their water. I think EMFs, we have no idea what role they play. There’s something new, I think all the glyphosate-enhanced foods. We have, you know, GMO foods that are slipped even into the organic food sources. And I also think that exposure to heavy metals, molds, and then just kind of the high stress in our lives of, you know, the way that we live and especially now there’s so much stress in people’s lives on top of everything else.

I don’t know but it’s a big question. And when I was first studying nutrition and wellness, I read “High Level Wellness” by Don Ardell. And he told this story that has always stuck with me. And he said, “There was a community and they lived on a river. And every day, there would be people floating down this river and they got really great at rescuing people out of the river. And they could label it and they had teams and emergency teams and they could get somebody out of the river, you know, 97% of the time, and they could get them within 6 minutes and, you know, they were really proud of this until somebody once said, ‘Why are all these people in the river? Why are all these people floating down the river?'”

And I think that’s where we are right now is that we are a population that’s floating down a river and we’ve gotten really good at emergency rescue. But I really think that basics of diet and lifestyle are the main reason why so many of us are floating down the river. And I think that making sure you get seven to nine hours of sleep a night. Personally, I need 9 to 11 hours of sleep to feel great. Making sure that you’re moving your body. Less than a quarter of us get regular exercise, 150 minutes of exercise a week, eating at least 5 to 9 servings of vegetables and fruits a day. Making sure we’re getting enough fiber. Eating whole foods. Doing things that are fun and give you pleasure. Having good relationships. Having meaning and purpose.

These are why we’re all floating down the river because we’re so busy, like, worried about making money or taking care of sick family or whatever it is or getting ahead in whatever way that we’re not paying attention. So, it’s like how do we keep people from falling into the river? And I really think that the roots of the tree are really diet and lifestyle.

Dr. Hedberg: Yeah. That’s really well said. I completely agree. So, this has been great, Liz. Thanks for coming on. Why don’t we just talk briefly about how people can find you online? What are your websites? Where would you like people to go?

Dr. Lipski: Okay. So, my main website is If you liked what you heard today, I have a course, an online course that’s self-paced and that is And I hope that you’ll sign up for that. If you are a nutrition professional or health professional, you can receive continuing education credits for it.

And then I have another site And you’ll find free goodies on all of these. And if you’re curious about your own health, you can go to my website, it’s called And there you’ll find the digestive health appraisal questionnaire where you can kind of pinpoint, “Do I have leaky gut? Or should I suspect celiac or gluten intolerance? Or is my microbiome imbalanced and other things?” It categorizes for liver and gallbladder and all kinds of things. And you can do a little self-test on yourself. So, those are my websites. And I hope that you’ll join me in one of them.

Dr. Hedberg: Fantastic. Well, thanks for tuning in, everyone. This is Dr. Hedberg. You can go to and search for Dr. Lipski and you’ll see a full transcript of this interview with all the links and resources that we talked about. So, take care, everyone. Thanks for tuning in and I will talk to you next time.

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