Abstract
Liz Lipski holds a doctorate and two board certifications in Clinical Nutrition and is the founder of Innovative Healing, a nutrition education company. Dr. Lipski is an educator for the Institute for Functional Medicine's GI Module, an advisor for the Accreditation Council for Nutrition Professional Education (ACNPE) and recently retired from Maryland University of Integrative Health where she was a Professor and the Director of Academic Development for the graduate programs in clinical nutrition.
Another thing that shaped me in terms of my career was my mom's love of cooking. She took lessons from Chef Francois Pope, who had a TV show on WGN, the public TV station in Chicago. My brother, mom, and I would watch these cooking shows. And then I would watch my mom cook. It was her main creative outlet. I'd sit and watch her make strudel from scratch, or tiny pecan pie cookies. She loved to entertain, and once made a Cantonese dinner for 40 people. My brother is a sculptor, and one day he said, “You know, I think it was mom's cooking that inspired me to be a sculptor.” And I said, “I never really thought about it, but I bet she's why I'm a nutritionist and why I love to cook.”
Finally, on Sunday mornings, my aunts and uncles and whoever else showed up came for brunch. My mom would cook, and my uncles would bring bagels and lox. I saw week after week how family could come together and hang out around a table for hours. I learned that family and food are intertwined.
One evening in the middle of teaching a class, I had an insight which changed my life direction. “Wow. I love herbs so much, but they aren't foundational to health. People need food and movement, and sleep and friends.” The next thought was: “I need to find a place where I can study nutrition, because this is what I really want to do.”
I searched for an English language school somewhere in the world where I could go to study whole foods nutrition to help people optimize health. How do we work with people who just don't feel as well as they'd like to? How do we work with people who already have a diagnosis of diabetes or hypertension or obesity, or they're recovering from cancer therapies? I found Donsbach University. Kurt Donsbach was an MD who was an early pioneer in integrative clinical nutrition. I enrolled in their master's program and they sent me a box of books and a box of tests and said, “Read these books, and take these tests. Then when you're done, write a thesis.” I never spoke to a single person at this college. My master's thesis was on infertility and nutrition. And 40 years later it's still informative.
I knew that wasn't enough, so I added two more components to my self-directed MS degree. I started volunteering at White Bird Sociomedical Aid Station in Eugene, Oregon, which was, and still is, really a model low-cost or free clinic for the country. At the time, there was a medical clinic, peer counseling, legal counseling, and a dental clinic. We also had a hotline and a 24-hour, mobile Bummer Squad. People called us if someone was overdosing on drugs, and they wanted to identify what drugs had been taken. People would call if they were feeling lonely, if they were feeling suicidal or had a friend who was suicidal, to report domestic disturbances, or as in one case when I was on the hotline, there was a naked man on someone's front porch and they didn't want to call the police. White Bird staff and volunteers worked to deescalate many situations that aren't necessarily criminal, but of concern. If there was a need, we'd send two of our staff to talk with the people, assess the situation and to help find a solution.
This program later became a partnership with the Eugene Police Department that has been operating since the early 1980's. It's called Cahoots and has been a model for the country. I live in Portland, Oregon, and in the last couple years we have teams doing the same thing.
I volunteered 20 hours a week at the White Bird medical clinic. Drs. Harry Krulewich MD, Basil Freedman MD, and Daniel Hardt, ND mentored me. They trained me to be a client advocate, which I think is still a really useful role that I haven't really seen implemented in clinics. The purpose was to make sure that our clients (never patients, the docs didn't want people to be “patient”) understood all of their options and had their questions fully answered. Also, to discuss these with the client to see what resonated with them and if they thought that they could make the plan work.
I got to sit in with every patient, and work as a medical assistant, helping with pap smears, pelvic exams, assisting with home births, in-office surgeries, and giving allergy shots. We had an in-office lab and I saw first-hand how to do metabolic panels, hematocrit and hemoglobin. I also worked there as a pregnancy counselor, in the days before there were home pregnancy tests. I also worked front desk. The five years I spent at White Bird helped me to learn the business and the compassion of being in my field. I loved all of it!
As a third prong of my education, I took a bunch of pre-med courses, pathology and microbiology and pathophysiology and anatomy and physiology at the community college. I started going to conferences sponsored by supplement companies, such as Standard Process, NutriDyn, etc. With the MS program, volunteering at White Bird and taking academic courses and going to conferences, I was able to create a robust master's program. Bob, when you and I were learning, there wasn't any formal way to learn what we wanted to learn.
Along this journey, in about 1980, I met Jeff Bland. He was my first nutrition teacher. He was an associate professor at the University of Puget Sound and was teaching weekend workshops, and my friends at the clinic and I would go. He was the first person to teach me anything about nutrition other than what I was reading on my own. I was so fascinated. He was also the first person to teach me about research, that there's research on these things. Up until then, I'd been reading popular press books.
I created my own program with the help of my doctoral committee, which was comprised of four PhDs, an MD/RD, and Doctor of Nursing. In this program I was able to integrate clinical nutrition with functional medicine, my love of herbs, immuno-toxicology, energetic aspects of healing, and more. I was able to learn organically in a way that I really loved.
About 20 years ago, I was part of a group of integrative practitioners who were asked to meet with the University of Hawaii medical school to discuss how to add integrative medicine to their curriculum. I told them that it needed to be integrated into the curriculum, not added in separate courses like frosting. There is already so much that needs to be covered in medical programs and for people to be able to pass the boards, so it's understandable that integrative care isn't at the top of the list.
As an example, I told them about a client of mine who was two and a half and was having grand mal and petite mal seizures. The pediatric neurologist recommended antiseizure medication, yet the parents were reluctant. Before her first scheduled visit, her mother called me from the emergency room and told me that the physicians were willing to order any testing I thought could be useful. This little girl was the third child in a vegan family. I asked them to do all of their normal testing plus to add an amino acid panel and a homocysteine level. I was concerned about whether she was getting her protein, and B-complex vitamins needs met on the vegan diet. At the time, there was already much in the pediatric literature about the role of B-vitamins and seizure disorders. When her results came back, indeed she had low amino acid status indicating that she needed more protein in her diet. The real surprise was her homocysteine level. Normal for a child her age was 3. Hers was 24, extremely high for anyone.
Her physician prescribed vitamin B-12 shots, we added a chewable B-complex, and she began eating animal protein: beef, lamb, bison, poultry, and fish. Her seizures resolved and her overall health improved. She remained seizure free.
This is why we need multi-disciplinary teams. I'm not suggesting that MDs become nutritionists, rather that nutrition professionals have a different perspective than physicians do. This is true for all of the disciplines: specialty medicine, physical therapy, psychology, etc. I rely on doctors for their many superpowers including differential diagnosis, acute medicine, use of pharmaceuticals, surgery, etc. This is critically important.
I have a different model of healthcare in my mind, and I call it the “dental hygiene model of medicine.” When I see my dentist, I typically only see the dental hygienist. Once a year, the dentist check in. If I had a current important issue, then I'd see the dentist.
Basically, my model of medicine is this: If you have an acute or chronic issue, you'll see your physician. And then also work with the nutritionist or the health coach or whoever that person is in the office who sits you down and says, “Tell me about your life. Show me your food diary. Show me your sleep journal. Show me your exercise journal. Let's talk about your life. What gets you out of bed in the morning. What gives you a sense of meaning and purpose in your life? Tell me about your relationships. Tell me about your job.” The other day I was talking with one of my mentees. She said, “I realized from this class, I don't like my job.” She works for herself. So, she's in a perfect position to say, “how can I change my job so that it gives me pleasure?”
We know that 80% of why somebody seeks medical care is due to lifestyle, but we never focus on it. Do we have a person in the office who can really sit down and hold somebody's hand and say, “Okay, tell me about it. Now let's talk about some of the directions you might be able to take to work on this.” A nutritionist, health coach, or other designated staff person has the gift of time to sit and really talk with patients that often isn't the best use of a physician's time.
There are so many different ways that we can work with chronic health issues and give much more support than we do with traditional medicine. I think when we have this kind of a focus in a clinic, we can substantially change people's health. We can be proactive and make recommendations that can prevent or ameliorate disease. Medicine will change because people will be proactive about “Oh, it's the nine cups of coffee I'm drinking every day that are keeping me up at night.” Or, “Wow, the food that I'm eating is inflammatory, and I didn't realize that I had a gluten or egg or, whatever it is, sensitivity that was causing my depression.” Or, “My sugar addiction was causing my depression and my low energy.” So, I think medicine needs to be flipped so that in chronic care MDs and DOs and nurse practitioners and PAs might be the primary person, but they're not necessarily the day-to-day caregiver.
I was also struck by a statement that Brian Bouch, MD said to me in my office one day while he was showing me a stool test, “These tests are going to change all of internal medicine.” I was super curious and wanted to know so much more. I was told, there wasn't more, so I decided to write a book about it.
The very first functional medicine meeting was held in 1993 on Maui. I introduced myself to Dr. Steven Barrie, ND, who founded what's now Genova, and said, “I want to write a book on the gut, on dysbiosis, and leaky gut and the systemic issues with poor digestive health.” And he said, “Oh, boy, do we ever need one, but we're all too busy to do it.” He offered to help and sent me cassette tapes of all of their lectures that they had ever given, and he sent me some papers. And from there on in, I spent about nine months writing a book proposal. Many of the early nutrition books that influenced me were published by Keats' Publishing.
I had this idea in the back of my brain one day that someday I was going to write a book and Keats was going to publish it. You know how one thing leads to another. Bob, I think this is another mentoring tip—be open to opportunities that are in front of you that you might not even notice. For example, I was talking with a physician who was going to be on a panel at a nutrition conference that I was chairing. We had a good connection so I told him that I had just finished writing a book proposal and asked if he happened to know any agents or publishers?” And he says, “Nathan Keats is one of my best friends. Tell him I told you to send it to him.”
So, I sent Mr. Keats my 80-page proposal, and he asked to send him the first three chapters, which I hadn't written yet! I wrote them, and then I went to meet with them. They had lowered my expectations of the meeting, but when I arrived, they offered me a book contract. I received the first copy at the 3rd IFM conference in Vancouver, BC when I checked into the hotel.
At the time I was writing the first edition of Digestive Wellness, I was just someone who was curious and who had begun using what I had learned in my practice. I had to pay for PubMed, which was brand new, not terribly expensive and so very cool to be able to use. I also went to several medical libraries. For the first edition, there wasn't that much research or much clinical data. And honestly, I wasn't any sort of expert in this. Once the book was published, people began calling from all over the country and world wanting to do phone consults. By time I'm wrote the third edition, which I wrote while I was getting my doctorate, the field was expanding and we had more labs, more data, and hundreds of clinicians with clinical expertise, of which I was one.
For example, one day Dr. Patrick Hanaway and I were on our way to a conference sitting in an airport, and he insightfully said to me, “You know, I think there are only really five underlying mechanisms of digestive disease.” He listed them off to me. Because Patrick is so insightful and balanced and brilliant, I started rolling his insight around in my head over the next couple of days. And I came back to him and I said, “How about DIGIT or DIGIN as an acronym for this model??”
So that's how the DIGIN model was born to help us prioritize where to begin. D is for digestion and motility. Can this person sitting with me actually digest the food that they're eating? Can they absorb that into their bloodstream selectively? Can they utilize nutrients, and can they get rid of waste? So that's the D.
The first I is for intestinal permeability? Do they have leaky gut?
The G is for the gut microbiome because we know that dysbiosis underlies pretty much every single disease process and we're starting to better understand those patterns.
The second I in dig in is for immune and inflammation, which we can see all the way from the gums to the anus. So how does inflammation, autoimmune and immune dysfunction play a role?
The N stands for the enteric nervous system and the gut brain.
This is a great diagnostic tool when you're sitting down with somebody one-on-one to think about how to look at this person? And maybe there's two or three of these areas that jump right out at you, which gives you a place to begin.
The fourth edition of Digestive Wellness had the DIGIN model included in it. The fifth edition expanded on that because we just know so much more about the microbiome and its role in cardiovascular disease, fatty liver, obesity, metabolic syndrome, diabetes, glaucoma, kidney disease, immune and autoimmune conditions, and so much more about the gut brain and the role of the vagus nerve.
For me, the learning has been, and remains, an evolutionary process of learning and using and learning and using.
Another example is that of calprotectin. It was included in functional GI stool tests for more than a decade before it was used in conventional circles.
I think that there's a lot of shift, but I think that there's so much more that needs to be happening.
Fortunately, we now have biologic medication for people who have inflammatory bowel disease (IBD), and I think that's fantastic. But we know also that diet plays an enormous role in IBD. I think that that is less-well utilized. Dysbiosis plays an enormous role in IBD, whether fungal, bacterial or parasitic, yet that's not as well being explored or treated as it might be.
I recall a client from long ago. He had ulcerative colitis and had been taking steroids for many years to help control it. I ordered a comprehensive stool test. It indicated that he had amoebas. I faxed the results to his GI doc and asked if he would be willing to treat him for amoebas. He did. That along with diet and lifestyle changes enabled him to remain ulcerative colitis free for over 10 years, after which time I lost contact with him.
Gastroenterologists and patients rely only on the costly biologics as kind of be all end all, and think that they are remarkable drugs, but there's so much more that people can do on their own to enhance their health, and I think that isn't being embraced all that well. I learned from gastroenterologist Dawn Beaulieu, that taking people with IBD off of their biologic medication can cause that medication to stop working when they begin taking it again. That provides gastroenterologists even more reason to do a full-work-up before they begin biologics.
Can you see everything you want to see in a stool test, no. Can you see enough to help make clinical decisions, yes. Often, researchers need more data before they recommend clinical use. Most of us in the functional medicine world just cannot wait. We need clinical tools now. These have been available since the early 1990's.
I have enormous respect for Dr. Knight and his lab. His lab has assembled probably the world's largest database of microbiota through the American & British Gut Projects. They collected over 25,000 samples from mainly the United States, Great Britain, Australia, and to a lesser extent countries around the world. Up until the COVID epidemic, anyone could send in their own stool or saliva sample for $99 to become part of the project (this project was put on hold due to COVID-19. At the moment, they aren't accepting stool samples). They were primarily looking at which microbiota were there, which were missing, and how these varied from country to country. How did the microbiome of people living in undeveloped countries differ from those in industrialized countries. They were also exploring how diet changed the diversity of the microbiome, finding that eating a larger quantity and variety of plant foods was beneficial and that medications such as antibiotics had a negative effect on diversity. Their current research focuses on how the microbiota in people with various diseases differs from those of healthy people. The goal was never to use the data to diagnose disease or for clinical use.
The doctors who are reading this article, or reading your journal, or going to integrative medicine conferences, or functional medicine conferences, or restorative medicine conferences are curious. Curiosity keeps us as life-long learners who are always looking for more tools to help people.
In conventional medicine, as Dr. Sid Baker said, “We name it, blame it, tame it.” But in functional medicine, we look for root cause issues, and how are you eating, how are you sleeping, what are your relationships like, are you moving your body, do you find meaning and purpose in life, do you spend time in nature? All these things are critically important, and do you have an underlying infection that nobody's noticed? Are you being exposed to mold or chemicals that nobody's asked questions about? Or do you have a magnesium insufficiency? Perhaps you're not getting enough magnesium in your food, which is causing you to be constipated, uptight, anxious, irritable, and have twitching eyelids or muscle cramping.
If working with someone with IBD in a flare-up, they need steroids and/or other medication to bring down inflammation. But we have so much research on the role of probiotics in IBD. We have good research about the role of diet in IBD, including the Mediterranean diet. And so much of this is being ignored. The right diet at the right time can turn someone around in two to three weeks.
My ideal diet for everybody is a whole foods Mediterranean diet that's culturally appropriate. So, for example, if you grew up in Central America, it's going to look a little different. It'll have a lot more rice, and beans, and salsa in it. Or if you grew up in Asia, it's going to have more rice, and more stir-fried meals.
A good whole foods diet is really my dietary goal, whether that leans towards a meat-based or plant-based diet. But when I'm working with somebody with GI issues, I rely on comprehensive elimination diets, anti-fungal diets, low-FODMAP diet, Specific Carbohydrate Diet, 6-Food Elimination diet, or an Elemental Diet. Someone who has IBS, or food sensitivities, for example will need a more restrictive diet until we figure out what specifically is causing the inflammation and work at healing their leaky gut, and balancing their microbiome, and getting them on firm footing so that maybe someday they can eat everything again. The body of research on using GI specific therapeutic diets is getting more robust every year.
Another area where we have new understandings is in IBS. It used to be a catch-all phrase for any type of functional bowel issue. Now, it's known that IBS has so many underlying causes, and a low-grade infection, whether that's fungal or bacterial, affects about 70%. We're just starting to get good research on small intestinal fungal overgrowth (SIFO). There is a paper by Erdoğan and Rao that shows that in people with IBS 40% had small intestinal bacterial overgrowth (SIBO), 25% had SIFO, and 36% had both simultaneously. 5
So, if we're only using antibiotics, then we're going to miss that. Right? Dr. Gerry Mullin has an herbal protocol he published research on that basically has aromatic oils like oil of oregano, and antimicrobials and antifungals, such as berberine. 6 When we're using herbs as antibiotics and antifungals, they also contain anti-inflammatory compounds, whereas drugs have only one mechanism of action.
I recently read a 2018 paper 7 about a year ago that fascinated me. They studied 36 men who had non-erosive gastroesophageal reflux disease and who were also eating less than 20 g daily of fiber. The participants were told to include 3 tsps daily of psyllium seed husks to their diet for 10 days. Incidence of heartburn began at 93.3% and was reduced to 40% in 10 days. The total number of reflux episodes was reduced from 67.9 to 42.4 and the timing of episodes was reduced from 10.6 to 3.7 minutes. This was such a simple intervention with profound and fast results.
In the last couple minutes of this discussion I want to talk about a shift that happened in my career about 15 years ago. I went from being a clinician to being an educator. I realized that as a clinician, I could see many people, yet if I taught, I could help to train the next generation of nutrition professionals. Teaching for IFM and for the Metabolic Medicine Institute also enabled me to train physicians and other clinicians as well. Bob, you know this, because you do a lot of teaching and lecturing. My own mentors, of which I have mentioned several, have influenced my thinking profoundly.
I've been lucky enough to design the first two integrative and functional Doctoral Programs in Clinical Nutrition (DCN), one at Hawthorn University and the other for Maryland University of Integrative Health (MUIH;
I think for me this is giving back by helping actually grow the field of personalized nutrition. The master's program that I co-directed at MUIH was only the second one in the country that was integrative and functional. We now have seven programs I'm aware of. This is an expanding profession.
For clinicians who want to add a layer of nutrition in their work, there are a couple of programs at MUIH and Western States that offer certificates in nutrition.
Nutrition is not rocket science. For many people who follow an elimination diet, often within two weeks, their symptoms are 80% improved. If we had a drug that could do what an elimination diet could do, it would be the best-selling drug of all time.
To Contact Dr. Liz Lipski, PhD, CNS, IFMCP
Liz Lipski, PhD, CNS, IFMCP
Innovative Healing Inc.
Faculty Educator Institute for Functional Medicine
E-mail: