The Antisocial Doctors Podcast

Episode 8: Is the Autoimmune Protocol (AIP) Diet Helpful?

• Sonia Singh MD • Season 1 • Episode 8

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0:00 | 1:03:28

In this episode, we talk about why the Autoimmune Protocol (AIP) diet is trending—especially alongside new U.S. dietary guidelines—and what makes highly restrictive “inflammation” messaging so compelling. We tease apart the appeal of “natural” fixes versus “toxic medications,” the illusion of control many of us seek when diagnoses feel uncertain, and how social media can intensify guilt, shame, and anxiety around food. We also preview the difference between evidence-based anti-inflammatory dietary patterns and rigid elimination protocols, why nutrition research is complicated, and why restrictive approaches may carry real risks—especially for people with nutrient deficiencies or a history of disordered eating.

00:00 Podcast mission
01:21 Why this topic now
01:47 Patient story behind AIP
02:41 What AIP claims
04:11 Why it goes viral
08:10 Natural vs toxic trap
11:07 Diet and inflammation evidence
16:30 Anti-inflammatory pattern basics
19:16 AIP elimination and reintro
24:22 Sensitivities vs blanket bans
27:40 AIP research so far
31:28 Diet Autoimmunity Evidence
32:24 Nutrient Deficiency Risks
34:23 Adherence and Disorder Risk
40:00 Gluten Dairy Reality Check
42:46 Patient Case and Placebo
50:13 Clinician Counseling Approach
53:19 Big Picture Nutrition Mindset
59:01 Don’t Delay Medical Care
01:01:24 Wrap Up and Disclaimer

📖 Read the full episode summary, sources, and resources on our Substack:
 👉www.theantisocialdoctors.com

Sonia Singh MD

You are listening to the Antisocial Doctors Podcast, hosted by me, Sonia Singh, a board certified internal medicine physician with a Master's in nutrition and a special interest in health anxiety

Rebecca Berens MD

and me, Rebecca Barons, a board certified family medicine physician with a special interest in disordered eating.

Sonia Singh MD

We're also a millennial women anxious moms and curious humans navigating social media. We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.

Rebecca Berens MD

This podcast is meant to be the antidote to your doom. Scrolling, a, solve for the anxiety, stress, guilt, shame, and confusion. That comes from social media's messaging around health. In each episode, we discuss a health related talk trending on social media with curiosity, nuance, evidence, humility, and compassion.

Sonia Singh MD

This is not your average debunking podcast. We wanna explore not just what is trending on social media, but why? Why are so many people drawn to this? What is the nugget of truth here? What are the facts? What can we learn from this as patients and doctors? No shame. No blame, no snark.

Rebecca Berens MD

We're so glad you're here.

Sonia Singh MD

Hi Rebecca.

Rebecca Berens MD

Hi Sonia.

Sonia Singh MD

So the topic today is one that we were just discussing is topical, given that there's been newly released dietary guidelines for US Americans. So it's serendipitous that we chose to record this today. We're not gonna get deep into the new guidelines, but I think this is tangentially related and, it's a good time to talk about this specific thing. So tell us about the patient story that inspired us covering this topic and what the topic is.

Rebecca Berens MD

Yeah, absolutely. So I'm gonna change a few details here just for this patient's anonymity. But, and I'll be speaking a little bit in generalities, but essentially there's this patient who had a history of an eating disorder but also had an autoimmune condition that had been diagnosed and had symptoms that they suspected were related to another autoimmune condition that was still being evaluated. And they were concerned that they were developing all these autoimmune conditions. And had read about the autoimmune protocol diet and had been recommended to do that by some friends and family members. And decided they were gonna try to do that, to try to control all these autoimmune diseases and try to avoid having to be on more medication to manage these diseases.

Sonia Singh MD

Honestly, when you suggested this topic, I actually thought it was like a general topic of what should I eat for autoimmune disease? And I was not familiar with this actual, that there's a very specific protocol. So it was like a new concept to me. I don't know how many of our listeners would've heard of this specific protocol, but what is the claim that they make about the protocol?

Rebecca Berens MD

So basically it's a claim that by doing this again very specific dietary protocol as we discussed, can reduce inflammation, improve gut health naturally. And it's based on eliminating quite a lot of foods and then gradually reintroducing them so that you can see which ones are the ones that are inflaming you and then avoid those foods. And this is done in like a looser sense in more popular fad diets. Like the whole 30 is another example. It's not as strict as the pure autoimmune protocol, but I think this idea in general is, is commonly discussed. And the autoimmune protocol is just one of these. And I think the other claim that sort of goes along with this is that you can use this protocol instead of the toxic medications that we use to treat autoimmune diseases, to manage those symptoms. So then you can avoid being on medication. And I think that sort of is a separate claim that's made implicitly in in the marketing of this protocol.

Sonia Singh MD

Yeah, for sure. I wanna, I'm making a note to myself'cause I wanna come back to that particular concept.'cause I think that's really, so basically the general idea is that people must be consuming something dietarily that is inflaming them or causing this inflammation that is driving their autoimmune disease. So if they can just figure out what those foods are and start avoiding those foods strategically, then their issue will be improved or resolved.

Rebecca Berens MD

Yeah, essentially. Got it.

Sonia Singh MD

Okay. So what do you think makes this particular idea, this protocol viral and appealing to people?

Rebecca Berens MD

Yeah, so I think obviously as we've talked about before, there is this idea of natural is better and I wanna avoid being on a medication. That I think plays into a lot of why people are seeking out alternative. Things. And autoimmune conditions are relatively common. They have a huge impact on day-to-day life function, pain, overall wellbeing, like energy levels. They do also disproportionately affect women. Which as we've talked about in prior episodes, tends to feed into some of the discussion about these alternative factors for a variety of reasons that we've already gone into. The other thing is, it's. Really difficult to get a diagnosis for an autoimmune condition, especially initially, A lot of times the symptoms can start off pretty vague and difficult to tease out. And there's a lot of overlap of different symptoms with different diseases. And then on top of that, the medications can have a pretty significant side effect profile and can be very expensive. And so there is a, people who do struggle with these conditions have a very strong incentive to not have to take these expensive and side effect producing medications. Some patients are having to go in for monthly infusions. Some patients are taking pills that cause significant GI side effects on a regular basis. There's a lot to that. So the disease itself has a, Impact on day-to-day life. And then also the treatment has a big impact on day-to-day life. So it's feels a lose situation I think a lot of times to patients who are struggling with this. I think the other thing is inflammation in general is implicated in a lot of our, most common morbidity and mortality causing diseases like type two diabetes, cardiovascular disease, cancer, cognitive disorders. There's inflammation is implicated in this and inflammation now is a buzzword on the internet, yeah. And so I think there's this idea too that oh, if this, if there's something I can do with my immunity that's causing these diseases and it works for autoimmune disease, it would also work for these other diseases that are also very common, and difficult to, and so I think it's also this idea that people come to this is something I can do to prevent these diseases. And if it works for an autoimmune condition, it'll definitely work for this. Yeah. So it's like conflating the idea of managing an autoimmune condition with also managing all these other very chronic conditions. So it can apply to a lot of people, even someone who may not have an autoimmune condition.

Sonia Singh MD

Yeah, and I think the other thing is that we talked about this with respect to thyroid disease too, is with a lot of autoimmune conditions, we can't nail down one root cause. If there are certain people, practitioners that will tell you they know exactly what the root cause is, when you look at the medical data as a whole, I don't think we a hundred percent with certainty can say in each individual case, for some people there is genetic predisposition, and that's obvious from family history. For some people there is none. And it seems like there's some complex, perfect storm or combination of factors including lifestyle, including exposures, including environment, including str, including so many different things that are probably playing into the presentation and, manifestation of the disease. But. It sucks to not feel like you understand why you got something or why it's happening to you, and it didn't happen to your sister, or it didn't happen to your brother or your mom or whatever, and so I think a common theme we keep talking about is illusion of control, and so I think it's appealing to say it's just certain foods that are triggering this inflammation. And if you can just figure out what those are and remove those from your diet, you have control. You can resolve this thing. And that's the reason, it's oh my gosh, I I've just been eating onions for all these years and I didn't know that they were causing my inflammation, and I do think. I do. Okay. I guess this is a little bit more in the negative truth category, so I'll pause there, but, okay. Yeah, so I think there's so many different reasons and I think autoimmune disease and hormone related disease, hormonal conditions are two big categories where there's so much gray and nebulousness that, there it's fertile ground for these types of false claims and things to arise. So yeah, totally agree. And then I wanted to point out that. Like you said in the case of autoimmune diseases hard to pin on a diagnosis. Sometimes it starts out and you don't really meet the diagnostic criteria, and then a few years later you do meet the diagnostic criteria. And I'm sure that's such a frustrating journey for the patient to be on. Or if you're there and you're getting this diagnosis and it feels like this huge shock, I've definitely had a lot of patients call me crying after a rheumatol, like a first rheumatology visit and say oh my God, they think I have lupus, or they think I have RA and they wanna put me on this med. And they said it's gonna be, I have to go get all these tests beforehand that, and it's so overwhelming. And so then I think, again, this false dichotomy is almost comforting to say either you can go the natural route or you can go the toxic medication route. When in fact, I think, if you just step back and think about it rationally, probably there's evidence that the medicine is going to be beneficial, can help you, and there's probably evidence for some lifestyle and dietary methods that will help you. And if you use them in combination, that's probably gonna be even more helpful. It does not have to be one or the other, and I really think in a lot of the wellness content, I see it, it's presented very much as a, oh, like you don't wanna do, that toxic thing? Why would you wanna do that to myself? It was so funny. I actually, this is like tangentially related, but. I got head lice from my preschooler when I was freshly postpartum with a, I had a two week old baby and I was like, oh my God.

Oh,

Rebecca Berens MD

excellent timing. Wonderful.

Sonia Singh MD

Yeah, great timing. And I asked the school nurse told us do the promethrin shampoo and, whatever. She told us the regimen and then you're supposed to come comb it out with the knit comb. And I was trying to comb it out with the knit comb. I have a lot of hair and I just was like, oh my God, I don't know if I'm gonna get them all out. And so then I called one of those lice clinics and a lice lady. And the lice lady was like, oh. And I told her that I was nursing at the time, and the lice lady was like, do not use permethrin. Why would you wanna put those toxic things on your head? You should not do that. We use these all natural I forgot what the main oil is in their magical potion that they use. She was like, it's all natural ingredients and we comb it through whatever. And it just struck me in that moment, how strongly she was saying like, either you go that route or you go this route. And it gave me so much anxiety.'cause I was like, I already used the permethrin on my hair and I washed it all out. But I don't know. My baby's two weeks old. Aw. And in reality, now I've been through it twice now. I use the Permethrin shampoo and then I call the Ice Lady and I have her comb it all out. So I just do both and then I feel really well assured. I can tell the nurse I did the treatment and I also have it all combed out. It's just a reminder. It doesn't have to be both. And sometimes presenting it that way is just guilt and anxiety producing more than it's helpful.

Rebecca Berens MD

Yeah, absolutely. And I think as with everything that we talk about, it's the nuance, right? There's not, it's not one side or the other. It's, there's a middle ground and that's where often the answer probably is. So yeah, so we'll we can move on to the negative truth to talk about that and then and then get deeper into this. Negative truth, there is evidence that certain dietary components can influence our inflammation levels. And there's quite significant evidence about this actually. And I have a couple of studies here. What I will say it was, very difficult to pin down nutrition research in general. It's just difficult to do nutrition research and we'll talk about this when we talk about these studies. But I think. It's hard. I will just start off with saying that, and I think that's where a lot of the confusion around nutrition comes from and why you hear so many different things from different people is you can probably find research to support just about anything when it comes to nutrition. Yeah. Because most of the time with nutrition, we're not like. Putting someone in a randomized controlled trial where they're, we're controlling every aspect of their diet and behavior and activity and everything. It's just not practical to do that. Yeah. So it is just different types of studies that are not the gold standard that we typically think of. So I just wanna preface this by saying that, but the, so there's one study that's published in jama. It's called Intake and Sources of dietary Fiber, inflammation and cardiovascular disease in older US adults. And so in this one dietary intake was acce assessed by a food frequency questionnaire, which again, you're relying on the recall and self-reporting of the patients who did not, and these patients did not have prevalent cardiovascular disease. And this was co collected at baseline and then followed over time. So the data was evaluated from 1989 through 2015, so this is quite a long study and had over 4,000 people in it. So it was a large study but again relying on recall and self-reporting. And then they assessed inflammation using blood samples at baseline and then also looking at outcomes. And they, assessed this against the association with dietary fiber intake. And so among fiber sources there's cereal fiber, which is the insoluble fiber and fruit and vegetable fiber, which is a soluble fiber. Serial fiber was consistently associated with lower inflammation and also associated with lower cardiovascular disease incidents.

Sonia Singh MD

Are they just referring to insoluble fiber as cereal fiber, or do they mean like fiber consumed from cereal products?

Rebecca Berens MD

They're talking about any fiber from ac, like not just cereal products, but like cereal fibers. Yeah.

Sonia Singh MD

Like

Rebecca Berens MD

basically any

Sonia Singh MD

insoluble

Rebecca Berens MD

fiber, insoluble versus soluble fiber was my understanding as I read it. Okay. And then, so that was interesting. And it the same was not actually true of the soluble fibers, which I thought was very interesting. But they were, again, they were looking at this based on cardiovascular disease incidents, and then also some inflammatory markers including interleukin 18 C-reactive protein. So yeah, so this was interesting. And I think this is where a lot of the, like American College of, or American cartilage of cardiology or American cardiology society, this is where a lot of those cardiovascular disease guidelines come from is this this sort of study. And so this is clear evidence here of a dietary component that has an influence on inflammation levels. Yeah. There's also a very large. Summary of evidence study that I looked at from the British Journal of Nutrition that was published in 2024. It's called Overview of Anti-Inflammatory Diets and their Promising Effects on non-communicable diseases. And I, this one I liked'cause it just summarized everything.'cause like I said, it was a lot. Yeah, it's a lot to, to dig through. But essentially they looked at a variety of dietary components that across many studies, over a lot of time have shown some anti-inflammatory effects. And then said what are the effects that have been seen? And so there's a really nice table that I just used here as like a summary of what those things are. So Omega-3 fatty acids. Monounsaturated fatty acids, which is what you think of in Olive oil, avocados antioxidants that you find in fruits and vegetables, nuts and seeds spices polyphenols, which you find in olive oil, nuts, seeds, dark chocolate, legumes dietary fiber phytochemicals again in like spices, probiotics and things like yogurt and fermented foods. Vitamins and minerals. And then also low glycemic foods, meaning whole grain ve whole grains legumes and non-starchy vegetables that have a lower glycemic end index. So all of these things have a variety of anti-inflammatory properties that were determined in these studies. And we can put a summary table of this in our show notes for people to look through. I don't wanna get too deep into the weeds here because there's a lot to talk about, but but. All that to say, there's evidence for anti-inflammatory properties of some of these things. There's also evidence for some inflammatory properties of some foods. And things like processed meats, alcohol there there's evidence for that. I didn't get all, all as much all into that here. But point being, we have evidence that supports the idea that our diet has an impact on inflammation levels. And so that is true.

Sonia Singh MD

Yeah. This is a really nice table for summary and so I'm glad that we're gonna put this somewhere in the show notes so that people can, and access this. I think. You did a nice job emphasizing, all these things that we know are anti-inflammatory. Because I think as we've talked about before, like in the eating clean episodes, sometimes there's overemphasis on all the things you need to avoid. And even the structure of what, what you told me so far, like I have not independently looked at like a full description of the autoimmune protocol, but it sounds like it really leans heavily on restricting foods.

Rebecca Berens MD

Yes. And so we will definitely get deep into that when we talk about the facts with the context and nuance here because that I think is the key difference here between when we say an anti-inflammatory diet versus an autoimmune protocol. So just getting into the facts, what is the difference between these two things? So there is an anti-inflammatory diet, which is. I hate the word diet, but when we talk about diet, what we're talking about,

Sonia Singh MD

dietary pattern, I like to

Rebecca Berens MD

use the word dietary

Sonia Singh MD

pattern. Dietary pattern,

Rebecca Berens MD

diet pattern. Yes. Phrase. But when we say the word diet, we're talking about dietary pattern. We're not talking about a fad, diet specific diet that you go on.

Sonia Singh MD

Went on. Yes.

Rebecca Berens MD

But so in anti-inflammatory dietary pattern, there is evidence for that sort of dietary pattern, reducing inflammatory markers, improving metabolic outcomes, and improving ca cardiome vascular incomes. And this is the stuff that you hear all the time, pretty consistently from most expert bodies worldwide, just a diet, prioritizing whole foods, lot of plants, fruits, vegetables, whole grains, fatty fish, unsaturated fats, fermented foods, like the Mediterranean diet is the classic example that I think is the best studied and is most well known. And they show beneficial effects. And this is again, a dietary pattern that is. Relatively easy. No, I'm not gonna say easy, but relatively easy. Yeah. To integrate into your life, assuming you have access to food, time to prepare food, all the things that we've, the socioeconomic factors that we talk about that are very

Sonia Singh MD

important. I, so I disagree. Compared to what you're gonna probably describe about the autoimmune protocol, I'm sure it is easier, which is why

Rebecca Berens MD

I say relatively

Sonia Singh MD

Yes. Relatively, it's easier and more feasible compared to that. But it is not the way the majority of Americans eat

Rebecca Berens MD

right now. Correct.

Sonia Singh MD

Despite the fact that it is like the boring humdrum advice that we give all day, every day. It is not the way the vast majority of people eat. Correct. Yeah.

Rebecca Berens MD

But like you can follow, assuming you have the resources to do

Sonia Singh MD

yes.

Rebecca Berens MD

You can do this and live a relatively normal life without having to weigh your food aggressively read nutrition labels. All that sort of stuff that goes into these very restrictive diets. You can go to a restaurant. And be able to order something that probably generally fits into this diet because part of the diet too is it's not a hundred percent, it's a dietary pattern, right? So this is this doesn't mean you never eat any refined sugar and you never do.

It

Sonia Singh MD

is not a

Rebecca Berens MD

vegan diet, right? This is a, most of the time we integrate most of these foods and we still can have some of those other things, but most of the time we're following this general pattern, right? Yes. So it's not a strict diet. So that to say if you have the resources to do you can probably follow it. Which again, a lot of people do not have the resources to do and and so I think, point being this is a dietary pattern that is anti-inflammatory and probably has a lot of benefits and whether you have an auto autoimmune disease or at your risk of cardiovascular disease or metabolic. Problems. This is a dietary pattern that makes sense, that probably has an evidence based behind it to probably influence your outcomes with those conditions.

Sonia Singh MD

Yeah.

Rebecca Berens MD

A IP is very different. Yeah. So it is extremely restrictive. It involves an elimination phase in which you eliminate grains, legumes, nuts, seeds, nightshade, vegetables, eggs and dairy.

Sonia Singh MD

Ooh.

Rebecca Berens MD

And generally that's for 30 to 90 days or until symptom relief,

Sonia Singh MD

legumes, nuts and seeds. I

Rebecca Berens MD

know. I'm like, what do you eat?

Sonia Singh MD

Oh, that makes me so sad. Okay.

Rebecca Berens MD

Yeah. And so it, that is very difficult to follow.

Sonia Singh MD

Yeah.

Rebecca Berens MD

I doubt, I actually don't know what you would eat. I was trying to think about this. I was like, what would I eat?'cause this is all I eat all the time. And

Sonia Singh MD

well, and importantly, those are a lot of the things that are actually part of, a healthy plant-based Mediterranean diet. Yes. And like the grains, legumes, nuts, seeds, vegetables, eggs. Very.

Rebecca Berens MD

Yeah. And it really does eliminate a lot of things. It's very challenging to follow and it's very strict about elimination too. Like the cross contamination concerns and all these things are also an issue. So the it's not just oh, just try to li limit these things. It's no, 100%, none of these things.

Sonia Singh MD

Well also 30 to 90 days, 90 days well done, or until symptom relief. That could be a really long time,

Rebecca Berens MD

you, but

Sonia Singh MD

then you hear

Rebecca Berens MD

about

Sonia Singh MD

this, you have no effect.

Rebecca Berens MD

Yeah. And so this comes up with the FODMAP diet too, right? Which is often recommended for IBS, which is a similar thing Yeah. Of there's an elimination phase and a reintroduction phase. But I've seen a lot of patients who've had this issue too with that when they're recommended for IBS is like, the elimination phase never ends.

Sonia Singh MD

Yes.

Rebecca Berens MD

Right. If the symptoms. Especially GI symptoms. Like when do you say you never have a GI symptom, it can become really difficult.

Sonia Singh MD

Also, I think it's really important to point out that okay, so the diet we just discussed, which is appears to be the dietary pattern we just discussed. Which appears to be not only the most anti-inflammatory, but also appears to be the best for cardiovascular risk, best for cancer prevention. That is the dietary pattern that I am pushing most patients towards generally in life. So if that is the ideal that we're working towards, and then you super impose on that all of these restrictions, you don't have a lot left. No, you eliminated a lot of the satisfying, in a plant-based meal, nuts, seeds, and legumes are a big part of how you make it filling and satisfying without putting a bunch of meat products or refined carbohydrates in there. I, I. I just think for somebody I can't imagine somebody going no, I can't imagine. I'm sure it happens that some people go on the autoimmune protocol and yeah, they're eliminating these things, but potentially they're still not making very healthy choices or they're still choosing things that are not particularly nutritious or serving them, but they're sticking to the protocol. But if you're trying to eat generally healthy, according to the evidence, and then you do this also, you're really limited in what you can consume.

Rebecca Berens MD

Yeah. Yeah, I was thinking about it and I actually do not know what I would eat. I don't know how I would

Sonia Singh MD

compose,

Rebecca Berens MD

what would I eat for any of my meals? How, and especially for example, I eat my breakfast in the car, I drive my kids to school. I eat my breakfast in the car as I'm driving to work. I eat lunch at my desk while I'm working, and then I cook dinner when I get home. Okay. So two of those meals are not eaten inside my house.

Sonia Singh MD

Yeah.

Rebecca Berens MD

I'm like, what is a portable.

Sonia Singh MD

You can't have eggs, you can't have yogurt, you can't have a grain.

Rebecca Berens MD

Yeah. And I was like, you could eat chicken, and

Sonia Singh MD

yeah, this, I

Rebecca Berens MD

don't know what probably

Sonia Singh MD

make you lean pretty heavily on proteins and like animal-based proteins. Yeah. Which depending on which ones you choose could be pro-inflammatory,

Rebecca Berens MD

And just in terms of the the practicality of like actually preparing and eating this meal in a modern world, I just don't know how it would be done. And even even outside of a modern world, in the past, grains have been like a pretty heavy staple of world worldwide diets for a long time. I'm just curious. I just don't even know what I would do. So yeah, so like I said, 30 to 90 days or until symptom relief, you're on this very restrictive diet and then there's a reintroduction phase in which you reintroduce these foods one at a time, five to seven days apart, so that you can correlate the symptoms to which food caused them.

Sonia Singh MD

What would be your sources of fiber? Doesn't mean,

Rebecca Berens MD

I guess there's, I guess there's non, there are some non nightshade vegetables that you could eat.

Oh,

Sonia Singh MD

I see, okay. It's just the nightshade vegetables.

Rebecca Berens MD

Yes. It's just the nightshade vegetables. So there would be some non nightshade vegetables and then there would be meats, and that's pretty much all I could come up with. That you would be able to eat.

Sonia Singh MD

Yeah. That's

Rebecca Berens MD

rough. So yeah. But even the reintroduction phase so you've done this for 30 to 90 days, which was super difficult, not compatible with any sort of normal life. Socializing anything. And then every five to seven days you have to introduce these foods and then perseverate on what did I feel today, how it is this, from this feel. Yeah. And so this is many months of reintroduction, between the, initial elimination and the reintroduction. This is a long process. Yeah. So this is a significant portion of your life where you are not able to eat normally. Socialized normally. You have to be very hyper-focused on your food and your body. This is very challenging. Yeah. Very challenging.

Sonia Singh MD

So I wanna take a moment to pause and say I think maybe part of the why they've chosen these particular things dunno about nightshades as much, but like nuts and eggs and dairy. Dairy is a thing that a lot of people don't tolerate. So I can understand. There's a lot of people that come to me with digestive vague digestive things and I'm like, have you tried, cutting out dairy for two weeks depending on what they're describing? And that's not an unreasonable thing to do. Eggs and nuts are common allergens. So I'm, I wonder if that's kind of part of the rationale for including those. But allergy and sensitivity are very different. And the point I wanna make is just that I don't want somebody to list to listen to this. And for them to be like eggs make me feel terrible. You're saying they're not pro-inflammatory. That's not a thing. And I, food sensitivities are absolutely real. Allergies are a very specific type of physiologic response. And, they can be evaluated and tested for sensitivities are a little bit more nebulous, but they're real. They happen and they're real. And there is a food that makes you feel bad. By all means, if you notice that it's okay to decide, you're not gonna eat that thing. And I always remind my patients if it's just a sensitivity and it's not classic allergy response we don't need a test to validate us. If you feel terrible when you eat that thing it's not a, it's not a major restriction for you and it's not something that's, gonna cause a lot of problems for you to eliminate from your diet nutritionally then eliminate it, i, think I have a garlic sensitivity and I swear my joints hurt when I eat garlic. I get a headache, I get, and it doesn't make a lot of physiologic sense from a medical perspective, but I swear it's happening and so I'm gonna avoid it. But I think this idea of just of like with the fom not diet too, it is just avoid all of these things and then reintroduce them. I can understand maybe that in a research setting, but in practical, real life that is really hard. I with FODMAPs, I recommend I always educate people about FODMAPs who have IBS. And then I share resources that talk about what FODMAPs are and what foods are high and low in FODMAPs. And I tell them to use it like a list of likely suspects and to try to notice, keep a food diary and notice perhaps if there's a pattern with one of those high FODMAP foods. But I rarely recommend they go on the actual FODMAP diet because it's just, it's again, in a research setting, maybe it would make sense, but for an actual human being, living a real life, I think it's hard. And then again, you have to take into account what are that person's other medical needs? What is their history? Do they have a history of disordered eating? Do they have other things that they need to work on nutritionally, and yeah, I just, yeah, food sensitivities are real, but this idea of blanket elimination of multiple categories of food is problematic.

Rebecca Berens MD

Yeah, and I think, we're definitely gonna dig into everything else that you just said, but I think the, even with the FODMAP diet, I think it is always assumed that is done under the supervision of a dietician if you are gonna do these strict elimination, right? And we'll get into this later. I think this is the key thing that, that is really not explained in these, internet. It's oh, just do this diet. Like it's no big deal. If you are someone who truly does have to do a strict elimination diet, and there certainly, I'm sure are cases where it is appropriate, clinically it does require close supervision and monitoring. And we'll get into that. But I think all that to say the point being here, this is really hard and probably not practical for most people. Yeah. I wanna talk a little bit about the evidence for and against a IP meaning what are the potential benefits, what's the evidence of potential benefit? What's the evidence of potential risk? Because these are the important things for us to talk about when we're talking about any intervention. So there's really limited evidence directly studying a IP and any evidence that there is from a very small trial or an uncontrolled trial, like pilot level stuff. There was one trial that I found efficacy of the autoimmune protocol diet for inflammatory bowel disease. And this had 15 patients, so pretty small who had active Crohn's disease or ulcerative colitis. Seven of those 15 were taking biologic medications. Also. Okay. So they were not only doing the diet to control this, they were also taking medication. And they followed a six week elimination phase followed by five week maintenance, which I'm assuming by maintenance they meant the reintroduction. It was a little unclear to me. There was clinically significant increased improvement in disease activity scores. So improvement in how they clinically felt from baseline to week 11. And there was some endoscopic improvement on, in only seven patients, but only seven of the 15 actually went under endoscopy, was what I could tell. So like the seven of the 15 that went under endoscopy had improvements, but not all of them went under endoscopy. Okay. There was no significant change in CRP or fecal cal protection levels. And there was no comparison group either. So small sample size, no comparison group. Limited. Outcomes. So not great quality evidence here. It's interesting it, warrant, maybe warrants more study, but not something that you would certainly make a clinical recommendation to a patient based on this alone.

Sonia Singh MD

I always wonder why a study like this even happens. How hard would it have been to have a control group, to just be like, here's 15 other people with IPD that we're not gonna put on a diet. They didn't do a very strategic job selecting these people. Some are on med, some are not on med, some are okay with getting an e gb, some are not. So why not just, you gotta wonder why somebody even conducts such a low quality study.

Rebecca Berens MD

Yeah. I didn't dig too deeply into that. That's an interesting question that I

Sonia Singh MD

would, how hard is it to have another group that you do not do the intervention on and you just compare how they all look in, nine weeks or whatever, 11 weeks.

Rebecca Berens MD

Yeah. I wonder if this is almost like someone is has a hunch and they're like, lemme try it for some of my patients and see what happens. And then they report it.

Sonia Singh MD

Yeah, okay. See you. And you don't know that it's like

Rebecca Berens MD

a case report.

Sonia Singh MD

You also don't know how these patients are selected. Maybe they're people who already were like, doctor, tell me what diet I can go on to help me with this. In which case they're primed to, have belief that it's going. Yeah.

Rebecca Berens MD

And that's the thing, you cannot blind this study.

Sonia Singh MD

Right, which

Rebecca Berens MD

is why a control group is so important because you cannot blind yourself to you went through this intervention. If you are expecting it to help you, and then your clinical disease activity score is improved. I don't know what to make of that. Because yeah, there's no there's no blinding, you can't be blind to this.

Sonia Singh MD

Also it's okay, so let's say they had selected like 15 other people in their clinic with IBD who were doing whatever the other treatment. You don't know if these 15, they were like these people are on our study, we gotta bring them back and make sure their medicines are titrated and make sure they're like, like you just, you have no idea, how those people were treated differently compared to somebody who was not, in this study. So I, I just think it's hard to really draw any conclusions from this in 15, 15 people. And then this is just, this is Crohn's are ulcerative colitis. So this is a very different disease than Hashimoto's thyroiditis or,

Rebecca Berens MD

right. Yeah. Because this is a GI disease, right? So like you would think, okay, if there's a food thing, it would make sense to me clinically that nutrition may have more of an impact. Impact on a GI thing, right? Yeah. So which, which again, maybe this is maybe this is the early stages and this is how. Research is conducted. The initial studies are maybe not huge, fully funded big things like they're little Yes. Interest. It's starting point. This is interesting.

Sonia Singh MD

Yeah.

Rebecca Berens MD

This is a point, this is interesting. I'm interested, but I'm not making a recommendation based on this study. Exactly. It, it warrants maybe further investigation. There's also some theoretical mechanisms that have been described linking autoimmunity to diet, and that's via the effect on the microbiome and some food antigen, cross reactivity and things like that. But there's not really a lot of evidence clearly connecting that to an outcome. I actually couldn't even find that many studies, if I'm being honest. This was just challenging. There was one study that was looking just at gluten-free diets for multiple sclerosis, psoriasis type one diabetes and autoimmune thyroid disease. And this was just gluten-free. This wasn't an autoimmune protocol. Yeah. And it actually had like mixed. Outcomes. Some people got better, some people got worse. So you know, all of that to say not a ton of evidence. There's maybe something to this, it's not to say that there's nothing about this protocol that could be beneficial, but it's just we don't have good evidence for it. And then I wanna go on to what are the risks? So anytime we're talking about an intervention, we always say this, you should know what the benefits are, you should know what the risks are, and you should know what the evidence is, supporting the benefits and the risks, because that's the only way you can make an informed decision, right? Yeah. So what are the risks? So the main concern is obviously nutritional deficiency.

Sonia Singh MD

Yeah.

Rebecca Berens MD

Based on just what can you even eat? Can you eat enough food? Are you able to eat enough food? And are you able to eat enough of the different nutrient types from the food since you're limiting so many food groups? So in that IBD trial that I talked about, there were baseline assessments, I identifying deficiencies that required repletion in vitamin D and iron. Yeah. So we already know that patients with autoimmune diseases, particularly these GI ones that affect absorption of nutrients, may have a compromised nutritional status at baseline. Yeah. And then we put dietary restriction on them that's just gonna compound that effect. And it's pretty it's pretty difficult to ensure that a person is getting adequate nutrition and meeting all of their nutritional needs when they're restricting so many food groups. And that's why, again, this is designed to be done under supervision of a dietician and close monitoring, not to be casually carried out. For funsies in that,

Sonia Singh MD

in that IBD study, did they track the nutritional deficiencies after they completed the protocol?

Rebecca Berens MD

So they were tracking them and repleting them.

Sonia Singh MD

Oh, okay. Okay. Also a little suspicious, how many people who do this in real life are having somebody track their nutritional deficiencies and replete them as needed?

Rebecca Berens MD

And that's the thing, if you're gonna do it, I think the point here is you should

Sonia Singh MD

Yes.

Rebecca Berens MD

Right. You should, because this is a known risk of this. It's a known risk of your baseline condition.

Sonia Singh MD

Yes.

Rebecca Berens MD

And it's a known risk of we're cutting out a bunch of food groups, so it might be hard for you to eat enough of all the things you need. So we should monitor that. So I think, this is not something that you are going to accomplish with an ebook or a blog post that tells you what to do. This is something that if you are gonna do it, if it truly is gonna have a clinical benefit for you, it's gonna need some monitoring and to make sure that everything is appropriate. There's also, as we've talked about, ad nauseam. We know that it's gonna be difficult to adhere long term to a restrictive diet. It's just gonna be hard to do. I don't think we need a study to tell us that. There probably are lots of studies that would tell us that, I think we have to be aware of the adherence to something like this because the adherence is the key aspect to how the mechanism of how this may work is like we remove this thing and then now you're not getting that inflammatory effect. So if we are not able to adhere to it, what was the point? And I think that's that's an important thing for us to to be thinking about. There also was some direct evidence that linked dietary restriction in general. A IP again not as specifically'cause there's just not a whole lot of study on that specifically, but. Potentially increasing risk of eating disorders. Now this was actually mixed. There was some studies saying yes, there's some studies saying no. But there were was specifically studies showing exclusion diet history associated with over three times the odds of having arfid, which is avoidant restrictive food intake disorder symptoms. And so for anyone who doesn't know, ARFID is a type of eating disorder that is not so much based on wanting to control body size and shape. But concern about eating food. And sometimes it's related to oh, I choked before and now I'm afraid of swallowing. Or sometimes it's like I had an allergic reaction, so now I'm afraid to try any foods. Sometimes it's, I have GI symptoms and so I'm worried about eating all the time and it, and it can spiral. And this study was interesting because, these were self-initiated exclusion diets often. Yeah. I think it was like 66% of the cases were self-initiated, so they were already excluding things. So it's a chicken or egg thing. Did they already have a risk for AIT? And they were already having AIT before they went into, so again, hard to see. I think point being that the more that you are thinking about and focusing on what you're eating and monitoring for how you feel in your body after you eat something, that just becomes a big focus in your brain. And so it's of course going to have an influence on. Your eating behaviors and your thoughts and feelings about eating and your experience of eating, and that's gonna have an impact on your day-to-day life. There's also been a study of patients with celiac disease showing that between 14 to 57% of individuals with celiac disease might meet criteria for arfid depending on which screening tool you're using. And again, someone who has celiac disease does have to follow a very strict elimination diet of eliminating gluten. And that is a requirement for the treatment of that disease, right? That's just something that those patients have to do. And it's very rigid and that just compounds the effect that those patients have about that. That's just with gluten. If you're also having to restrict all these other things, you can just imagine that it becomes a bigger component. There's also an interesting study that indicated there's a bidirectional relationship between eating disorders and autoimmune diseases. That's interesting. Which I think again, probably goes back to that multifactorial cause. There's a lot of overlap of those multifactorial causes when it comes to both autoimmune diseases and eating disorders. There's genetic predisposition, there's socioeconomic factors, there's trauma, all of these things that are contributors to both of the development of both of these disorders. And so it makes sense that there's overlap between the two. But again, if you're someone who already has struggled with some disordered eating and then you are now focusing on food and eating all of the time. It's easy to see how that could become something that spirals out of control.

Sonia Singh MD

Yeah. Going back to our fit really quickly, I'm sure some people would wonder okay, so in Celiac where somebody legitimately has to really strictly eliminate gluten exposure and cross-contamination, all of that, how would that be afi And, I think the point to make here is I believe that, to qualify for a fit, it has to be either le, the restriction has to be to the level that it's causing them to not meet their nutritional needs, or it's causing functional impairment or psychological psychosocial distress. Correct. Something. Correct.

Rebecca Berens MD

Yes. I should clarify that. So yeah, obviously with, so this is a DSM diagnosis, right? So anything in the DSM, like it has to be causing you a problem.

Sonia Singh MD

Yeah.

Rebecca Berens MD

You have the syn, but it's not affecting your function or your health in any other way. It's,

Sonia Singh MD

yeah,

Rebecca Berens MD

just

Sonia Singh MD

the, some people might say, oh just like I have a few patients with I have one patient with very refractory. Celiac and he has to be very strictly avoidant. And it's really hard for him. It's very hard, and we've had to watch his nutritional deficiencies really closely, and do I think he has arfid? Probably not, but may, yeah, I can see how that would develop, because,

Rebecca Berens MD

and so that may be where it depends on the criteria you're using, right? Which screening tool you're using. But I think that also comes to that person. Yeah. Certainly if they're not able to meet their nutritional needs because of how restrictive they are and they are, but

Sonia Singh MD

they have a malabsorption issue, so it's

Rebecca Berens MD

I know. And so it's easy to overlap, right? And so I think it becomes a question of okay, are they able to meet their needs at all? And if not, are they distressed by that? Yeah. Or is it yeah, this is hard, this is a horrible thing that I have to do, but I'm managing it, I'm coping. I think there's definitely patients who, it becomes something so overwhelming that it prevents them from being able to work a normal job, being able to have normal social relationships. They're just functional

Sonia Singh MD

impairment.

Rebecca Berens MD

Yeah. So functionally impaired by it, or so, nutritionally impaired by it, that they are not able to maintain their nutrition status. That, they're losing weight, they're having the complications associated with restrictive eating disorders, like they're having bradycardia, they're, all these things. They're having that as a result of their restriction. Not just oh yeah, we're having to keep an eye on this and monitor, and you gotta take these extra supplements to make sure your needs are met. So yeah that's where, when we're talking about any eating disorder, the functional impairment and the nutritional status is a key part of that diagnosis.

Sonia Singh MD

Yeah. Okay. I guess we talked a lot about the, so that's a good summary of all the downsides of, doing some of these restricted sites. I feel like I hear a lot about. Just gluten and dairy in the context of autoimmune disease. Yes. And I have so many patients and friends who have just casually been told by somebody oh, you have an autoimmune disease avoid gluten and dairy. And I just, I try to remind patients that like I would never say something so casually to somebody without really solid evidence, because to eliminate even just those two things is not a super easy thing to do for a lot of people. And it, it may involve you eating a different meal than your spouse or your children or your friends or, not eating at a party when what's served does not fit those criteria. And those are all, yeah, those are really big deals, and you don't wanna improve one thing marginally or slightly and pay a huge price in some other category of your quality of life. Yeah.

Rebecca Berens MD

Yeah. And I think in gluten specifically, the cross contamination part is so key. And I think a lot of times when I hear about people eliminating gluten. They're not actually eliminating gluten, they're significantly reducing their gluten intake, but they're still potentially getting cross contamination. They're still occasionally, and it's is it. Is it worth doing all the restriction if you're not gonna all the way do it? Because then you're just restricting a lot, but you're still not getting the benefit of having restricted it.

Sonia Singh MD

To be honest with you, a lot of the patients that I talk to that are like, oh, I stopped gluten and I feel so much better. I usually ask them what were you eating before that you eliminated? And so many of them, it's not like they were eating Bulgar and Farrow and Right. They were eating, they, they were eating. Like a lot of refined carbohydrates. Yeah. Because that was easy and quick for them. And so yeah, maybe they felt better when they weren't doing it. But do they need to like now avoid soy sauce and do they need to now make sure that, the pots don't touch with other stuff that's, probably not. So it, can mean so many different things when people say I'm avoiding glu, like people say I'm avoiding gluten and I'm eating this gluten-free donut. Or I have these gluten-free bars, and, the nutrition. Yeah.

Rebecca Berens MD

It's like

Sonia Singh MD

the nutrition nerd in me is just is that better though? Is it really better?

Rebecca Berens MD

And that's the thing, like it's, if you truly need to avoid gluten, then yes. But if you're just like, oh, it's, this is healthier'cause it's gluten-free. This is gluten free, it's not It's still a processed food, which is fine. Yeah. But it's not different. Just because it's gluten-free, it's more expensive probably. But it's not significantly nutritionally different. Unless there's a true need for you to actually. Avoid, exclusively avoid gluten. And so that's the thing, it's it's very, it's, it is used very casually, like you said. And it really should not be, like, if this is something that's truly needed, it does require a lot of careful consideration.

Sonia Singh MD

Consideration and

Rebecca Berens MD

thought and supervision and monitoring

Sonia Singh MD

and exploring what you're currently Yeah. And I'm thinking that same thing with the autoimmune protocol. Is that I always, actually, I guess we'll get into this more about in our, how we kind of approach patients on this topic. But actually before we move on to that how did your patient do with their Yeah. Autoimmune protocol?

Rebecca Berens MD

Yeah, so my patient did, they did do it. They, I had suggested that if they were gonna do it, that I recommended that they work with a dietician because I was concerned about the the eating disorder history and just the restrictiveness of the diet anyway. Yeah. They unfortunately were not able to afford. To work with the dietician. So they just did it on their own. So unfortunately they, it wasn't as supportive of a trial as we had hoped. They did initially feel like it was working really well and they felt like their symptoms got better, but they experienced a lot of cravings for sugar. They experienced a lot of guilt and shame around the cravings they were experiencing. And they had times where they had something anyway'cause they were craving it and then they felt a lot of guilt and shame afterwards. And they ultimately were not able to sustain it. And after the fact they did say, that they felt like it really had a bigger mental impact on them that they realized at the time.'cause initially they were like, oh yeah, this is going really well. And then gradually the longer they were doing it, it was Devolving. And and yeah they did say that they felt like it, it made their mental health worse and they were concerned about a relapse. So that's, they had decided to stop pursuing the trial.

Sonia Singh MD

I bet. A really common experience. When you do any intervention, whether that's a diet or a supplement or a medicine, and you have really strong belief that it's going to work, there's a possibility for some placebo effect to happen. And so I bet you there's a lot of people that have the experience of going on one of these protocols feeling better because they're sure that it's going to make them feel better. And that's not imaginary. That's yeah, your, it's real. Your body interprets sens, it filters everything you're experiencing and sensing through your brain. And so your brain has this incredible power to turn the volume up and down on all kinds of symptoms. And so I bet you there's a lot of people who have this initial improvement and then. That placebo effect starts to wear off at some point, or maybe they try reintroduction and everything feels like it's making it worse. And I bet you a lot of those people maybe were not following it a hundred percent and then blame themselves that, oh, it's not working because I'm just not following a hundred percent. And so then they try even harder to follow it a hundred percent. Or maybe they try reintroducing and every time they reintroduce they feel terrible. And then they're like I guess I have to avoid all of these things, so when you do something and it's not working, there's a lot of different ways like you can interpret that, and I sadly think probably a lot of people, it just drives them further in, in the wrong direction, when Yeah. They feel that it's no longer working.

Rebecca Berens MD

Yeah. And I'll say, I've seen this exact scenario play out so many times, not necessarily with a IP, but with any sort of restrictive diet, the number of patients that I have seen and that my colleagues, eating disorder therapists and dieticians that I've worked with have seen who. Started off on some sort of restrictive diet because they were working with a functional medicine practitioner, or they had read about something that they were trying to, something for their health. Totally with full intention of this being a healthy change in their life to try to help with some symptoms they were having and it ending up in a clinically significant eating disorder.

Sonia Singh MD

Yeah. Yeah.

Rebecca Berens MD

So many stories and and it is, it's just the, it is that guilt and shame of this was the thing, the only I can't even control this one thing. And it becomes like a self blame, like we talked about the beginning of the episode this is the thing that people feel like they can control for whatever horrible situation they're going through with a diagnosis. And they can't do it. Which, who could do It's so hard. Yeah. But it becomes a self blame and it's this is my fault. And it just spirals so quickly. And a lot of times, the patients that I've seen, the practitioner they were working with is they just, their advice is always just double down, just try harder. Just if you would just do this what you wouldn't have. And they're getting that same messaging back. And I think that's also what's happening on social media. People are just seeing these posts over and over again and they try, their January, new year, new you thing. Even if it's not as strict as a IP if it's some huge lifestyle overhaul that they can't sustain. It becomes this shame spiral so quickly. But I think that's such a common experience and and it's really unfortunate and I think that's why, as we'll talk about you and I try to have a different approach to it.

Sonia Singh MD

Yeah. Yeah. And this, this is not just a thing that I think happens among patients. I see this happen with fellow healthcare providers. I see it happen with people in the nutrition space. And so it's really just the human condition. Yeah. I don't wanna make it seem like it's just an informational thing, or it's if you just knew better or something. I just think it's such that these are all just like such human. Responses and compulsions, that they can literally happen to anybody.

Rebecca Berens MD

Yeah.

Sonia Singh MD

Okay. So what can we take from this, you think, as doctors and just as humans?

Rebecca Berens MD

Yeah, I think that was really what you just said was my main takeaway is people are willing to do drastic things when they have these severe conditions or just for their health in general. People are, people care about their health and they're willing to do drastic things. And they're willing to put in the work. Which I think is like the opposite of what we're also always oh, people are just lazy. This is why people are having these problems. Yes,

Sonia Singh MD

right.

Rebecca Berens MD

But it's not truly this happens so much because people really do care and people really are willing to put in the work, but it just is not possible to sustain at that level. But, and as you said, the human condition is then to like spiral down and then just try again, and it just, it. It really is difficult to to sustain these sort of really drastic changes long term. And there's true risk involved with that. It's, I think that the thing we're also taught or hear a lot about these drastic changes is like, it's just a lifestyle change. Lifestyle changes have no risk. You can just do this thing. And it's, there actually is true risk involved, particularly in making these very drastic changes. There is true risk to that. Yeah. And so it's important to, to come at this from a perspective that is nuanced. And I actually, the placebo effect comment that you made earlier was another one that I thought about was like, is is it because you did something so drastic that you get such effects initially because you were expecting

Sonia Singh MD

to, right? Yes.

Rebecca Berens MD

Yes. And the incremental changes, of course, you don't expect them to overnight change how you feel so you don't overnight change how you feel. And then you're like, why am I doing this? I don't feel any different. It's yeah, you won't immediately.

Sonia Singh MD

Right?

Rebecca Berens MD

But that's I think it's self-reinforcing that I did this drastic thing and now I feel great and then. And then the guilt and shame spiral falls. But if you make the incremental change that's like a little bit hard, but you're doing it every single day and you're just not seeing the return. You're like, why am I doing this?

Sonia Singh MD

Yeah.

Rebecca Berens MD

And so that's also hard to sustain for its own reasons.

Sonia Singh MD

So there, there are studies about how the placebo effect is stronger. Depending on how, like for the, for a more invasive intervention, the placebo effect becomes stronger. Yeah. Which

Rebecca Berens MD

makes sense.

Sonia Singh MD

Getting an injection has a stronger placebo effect for people than getting a shot and getting a sur a sham surgery has a bigger placebo effect than getting a shot. I think in a similar way, when we're giving people these, recommendations to just move towards a more whole food, plant-based diet and move their dietary pattern a little bit more in line with that, and to maybe add some of these things that we know have some anti-inflammatory benefit, that there, that I think the likelihood of that having a placebo effect Yeah. Is very minimal. But when you do this drastic thing where you're like, tomorrow I am cutting out these, four different food groups and everyone's gonna notice and I'm gonna be, loud and proud about it. That is definitely much more at risk for making you think something is happening when in fact it may not be, yeah. So yeah, I totally didn't mean to no,

Rebecca Berens MD

that was, but

Sonia Singh MD

I to the same, did not read the whole outline before we started. Okay. So I guess how would you talk to patients about this in the future? Yeah, if they're considering these

Rebecca Berens MD

products, like I said, if someone's considering a protocol like this I always discuss the evidence

Sonia Singh MD

yeah,

Rebecca Berens MD

this is the potential evidence that we have, which is not a lot, this is the potential risks that I see, which are substantial. And then it's it's always patient autonomy, right? If you wanna do it, okay, let's make it as safe as possible. So let's get a dietician involved. Let's follow up more closely. Let's monitor how you're doing. Particularly for someone who may have a risk factor for disordered eating or for another nutritional deficiency. If you have IBD and you're already deficient, we gotta be really on top of it, yeah. And in general, I do always try to steer more towards small, sustainable changes and building on those gradually. But like I said if a patient really wants to move forward with a protocol like this and after a discussion of the risks and benefits is still wanting to move forward with that, it's just the monitoring and making sure that we're keeping them as safe as possible. Yeah.

Sonia Singh MD

Yeah. The patients I've had that have been really seeking some type of intent isn't there like a diet that you can put me on? Oftentimes I feel like they're against a wall where like the rheumatologist is yeah, it's time to go on one of these medicines. And so I think there's this pressure where they're like, no, I don't wanna do those small incremental changes. I wanna try this thing Yeah. For a month and see if I feel better.

Rebecca Berens MD

Yeah.

Sonia Singh MD

And only if I do not will I go. And I think there's this perception that the sense I've gotten from some of those patients is if I go, it's if you. If you go to a surgeon, you're gonna get a surgery. If you go, if I go to the rheumatologist, they're gonna give me a med.

Rebecca Berens MD

Yeah.

Sonia Singh MD

So I'm gonna first try this stuff on my own because I already know that if I go there, they're not gonna talk to me about diet and they're just gonna tell me to go take this terrible toxic medication, and I think to a certain extent that is true. If you go to a doctor with one of these autoimmune diseases and the most effective intervention for that autoimmune disease is a medication if that is what we know, the evidence points to you as the most effective intervention, that is what they're gonna offer you. And that is what they're gonna talk to you about. Now, I think a lot of people's complaint is the doctor didn't even mention I see this all the time. On posts in our Heights mom group or other groups that are like. I got diagnosed with thyroid disease, I got diagnosed with psoriatic arthritis, I got diagnosed with my doctor. Didn't even mention diet or nutrition or anything besides medication that is a very common refrain that you see in those forums. And I believe them. I totally believe that yeah. Happened. But I think part of the reason it happens is because the advice is so humdrum boring. What we feel, if you look at the news right now, they believe doctors have not been saying this at all. But I feel that I am a broken record talking about the Mediterranean diet, talking about whole foods, plant-based diet, talking about increasing vegetables and fiber in the diet. And I, I, it's, it doesn't feel I guess because it lacks specificity or this feeling that it's personalized for you and your condition that I think people feel like, oh they're not telling me anything helpful. And it's I think as doctors we can do a better job. I'm not a rheumatologist, so I don't wanna tell them how to do, I'm not a rheumatologist, I don't wanna tell them. But, I think for my patients with autoimmune disease who are very lifestyle focused, I really always try to start the conversation with the first step of this is just optimizing your baseline lifestyle and health factors. Whatever the diagnosis is, whatever the treatment plan is optimizing your nutrition, your sleep, your stress management, your movement, your hydration, all of those things can only help, yeah. Supporting this. And this has actually been, I think a big shift that I've consciously made over time after seeing how framing advice more as what to avoid, like what the consequences of that are, which are, I would see a lot of people just having fear around a lot of different foods and. Ending up, not really replacing them with anything better.

Rebecca Berens MD

Yeah.

Sonia Singh MD

And so now even if I'm talking about reducing cholesterol, I focus really heavily on what can we add here? Yes. Because when you tell people to avoid something, you just don't know what they're replacing it with or if what it replaces, or, if they're replacing it with anything at all, they're not gonna eat. In place of that thing that they were eating before. Whereas when you're telling people to add more vegetables, to add more nuts and seeds to add, like literally all the stuff that's,

Rebecca Berens MD

yeah.

Sonia Singh MD

Like when you're telling people to add more fermented foods, which we know are anti-inflammatory, my hope would be that crowds out some of the less nutritious things and it's much less likely to result in deficiencies, and I guess maybe, I don't even think it's a real fear to think oh, they're just gonna be eating too much then. I don't think that really happens.

Rebecca Berens MD

You're not gonna eat too many beans, you will stop.

Sonia Singh MD

Yeah. It's hard to eat too many vegetables, honestly. Yeah. It takes a lot of chewing and work for most

Rebecca Berens MD

people. Although I'll say sometimes there are people who do eat only those things. That's because they're like, these are the good things and I shouldn't eat anything. I don't wanna say that no one could do it but on average, if we focus on what we can add. I think it's also psychologically different.

Sonia Singh MD

Yes,

Rebecca Berens MD

totally. Because if you're saying like, this is a positive action you can do add this thing. Yes. Versus stop doing this, it just like psychologically that's different. Yeah.'cause it's more positive action focused than fear focused, like you're saying

Sonia Singh MD

And it's like a mindset of a abundance. Yes. I honestly think. When our brains feel that we are in a restrictive state, even if you have not actually restricted, I really think there's a bunch of hormonal and metabolic things that probably happen just from the,

Rebecca Berens MD

it's

Sonia Singh MD

the

Rebecca Berens MD

threat

Sonia Singh MD

sentiment that you are restrict Yeah. Of restriction, and so I think keeping yourself in a place of abundance where you're like, all right, if I feel like having the food, I'm gonna have the food. It's just a completely different psychological and probably metabolic experience for you, navigating meals and food than if you're constantly like, oh, gotta avoid this, gotta avoid that. Gotta, I can't eat this, can't eat that. That's a, such a different way to live your life. Yeah, I feel like I've really tried I think people mostly come to you asking like, is this thing bad? Is this thing good?

Rebecca Berens MD

Yes.

Sonia Singh MD

And, I also think honing in so specifically on specific ingredients is almost always problematic. And we chatted about this before we started the episode, which is that I did a master's in nutrition before I went to medical school, and I'm glad I did that because, there isn't a ton of training on nutrition. But honestly, part of that is because nutrition is such a murky science, and a lot of patients will come to me and be like, are eggs good now? Or are eggs bad? Okay, good or bad, or a lot of foods there's not honestly that many foods when I'm like, it's just plain bad. There's a few, but most things, fall somewhere in the middle. And it's really, you have to ask yourself so many other questions. It's what is your goal? Good for what? What are you going to achieve? Yeah. And you have to put it in that context, and then you have to put it in the context of the person's entire diet, and their preferences and their palate and what their family's eating and what their lifestyle allows for, and so I think we're so focused on specific foods and ingredients and avoidance that. We kinda lose sight of that big picture. And again, when your doctor is not giving you hyper specific advice, I honestly don't think it's because they just don't know. Like I think most doctors know like the basic fundamentals of decent nutrition. It's often because it's just the stuff that we know to be true is boring and most people know it already. And the other stuff that feels more specific is just the data's not that strong to really recommend it, and for it to be part of guidelines and to be part of our treatment recommendations for specific diseases. For a lot of, not everything, but for a lot of things. And yeah, I think it's just, it's an, it's the nature of nutritional research, which is so much of it is based on population data, on epidemiological studies, on recall studies, as you mentioned, dietary recall, which is so flawed in a lot of ways. And we see these things in populations and we don't know is eating this food really what's leading to the outcome? Or is it just that's a marker for people who do other healthy behaviors?

Rebecca Berens MD

Yeah.

Sonia Singh MD

And then, you would think okay, the solution is isolate that food or isolate that ingredient or that nutrient and study that in a lab, or study it in a test tube or study it in a really highly controlled setting. And sometimes you do that and it doesn't have the same effect at all. And why is that? Probably because in the context of that food or the actual whole food, it had some other, co-factors and other things involved in that, that were present in that food that led it to have that outcome. Or maybe as part of a broader diet, someone's broader dietary pattern, it led to that outcome. But then when you isolate it, it doesn't and it's such a common theme that, you do those big population studies and you say, oh man, vitamin A, it's great. And then you put it in a pill and you give it to people and you're like, Ooh, increases, cardiovascular risk, that's not good. Yeah. And I think. Keeping your perspective broad and focusing on kind of an overall pattern and not focusing on this kind of single ingredient, hyper restrictive, super specific for my disease is really more in line with what we know about nutrition.

Rebecca Berens MD

Yeah. And I would add to that, in keeping it broad, one of the other key things I wanted people from, to take away from this is you should not delay evaluation or treatment of an autoimmune condition or symptoms that you have that you're concerned about, autoimmune condition to see if the diet will help. Because really this should be an adjunctive thing, yeah. And the way I would view it as like this is an adjunctive thing that you can do that could help your body better manage inflammation, could affect inflammation levels, whatever. There's also. Evidence-based treatments for that. Yeah, we can use them together. Let's get everything under control. And then maybe you wean off the medication after you've had some time of doing the lifestyle changes. It feels more sustainable. It's something that you're doing. Maybe you need less medicine. Yeah, maybe you're able to come off of a medicine. But I wouldn't, I don't think it's fair to expect yourself to be able to like, while you're feeling terrible from this condition that is out of control, do this whole big thing and magically reverse it when there's an evidence-based treatment you could use right away. Get it started, get the fire under control, do the sustainable stuff, and then wean off This should always be a big picture. Using everything together. Use all the tools at your disposal. And yeah,

Sonia Singh MD

and I

Rebecca Berens MD

think,

Sonia Singh MD

Doing that, going to a consultation with a doctor and hearing about the pharmacologic treatment options and their risks and benefits is part of you just making an informed decision about what you wanna do. Yeah. No one's gonna go and, jab you with the Humira when you walk in for the consult, like it is going to be up to you for sure. And I always try to remind people just go, I think people have this, again, they have this feeling. They're like, I'm gonna go there and they're gonna just tell me I have to do the medicine and they're gonna scare me, and they're gonna tell me all the bad things are gonna have, I don't do the medicine and, my doctor the doctor doesn't even know about all of this, autoimmune stuff and the dietary, effect on inflammation and all these things. And, but it's that's fine. Even if you think all of those things are true, at least having the information is beneficial for you in truly making an informed decision about whether or not you wanna pursue, one of these protocols. So yeah, I totally, absolutely, and I have definitely had multiple patients who delayed care for years with an autoimmune disease, trying natural solutions and fearing that they were gonna end up on a medicine. And in that time. They had their disease, go outta control and y many of those patients I think could have had remission, if they were treated appropriately at the right time. So anyway alright for more info we're gonna put a few different resources and citations in the show notes. And we'll also put a few experts that may be helpful to follow if you're interested in autoimmune disease and diet and the relationship between those two. Okay. That's the end of the episode. Thanks Rebecca.

Rebecca Berens MD

Yeah, thank you.

Sonia Singh MD

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