Long Covid, Gluten and Mold with Dr. Peter Osborne

Episode 90:

Long Covid, Gluten, and Mold with Dr. Peter Osborne and Evan H. Hirsch, MD

Evan H. Hirsch, MD 00:09

Hey everybody. Welcome back to the energy MD podcast where as you know, we help

people with chronic fatigue long COVID and M casts get their lives back by finding and

fixing the real root causes, which are heavy metals, chemicals, molds, infections and

trauma. So really excited because we're going to be talking with my good friend Dr. Peter

Osborne. Today we're going to be talking about long COVID And what he is seeing so I'm

sure he's going to drop some great nuggets, some great tips on what we can be doing to

support ourselves better if we have long COVID. So let's learn a little bit about Peter first.

So Dr. Peter Osborne is the Clinical Director of origins healthcare in Sugarland, Texas.

He has a Doctor of Chiropractic, a doctor, a functional medicine doctor of pastoral

science, and a board certified clinical nutritionist, often referred to as the gluten free

warrior. I love that Dr. Osborn is one of the most sought after functional medicine

doctors in the country. His practice is centered on helping those with painful chronic

degenerative and autoimmune diseases with a primary focus on gluten sensitivity and

food allergies. He is the founder of glue of the gluten free society, the author of the best

seller, no grain no pain, and the host of the gluten ology masterclass series, The

Ultimate Guide on going gluten free. Dr. Peter, thanks so much for joining me today.

Dr. Peter Osborne 01:29

It's a pleasure to be here. Thanks for having me. Of course,

Evan H. Hirsch, MD 01:32

always a pleasure. So let's talk a little bit about long COVID. So can you frame this for us,

can you just give us a definition of long COVID At this point in time,

Dr. Peter Osborne 01:44

the layman definition pretty simply as somebody who's been diagnosed with COVID. And

instead of having a general recovery, where they you know, they run its course of

anywhere from seven to 14 days and recover. They just don't recover, they stay tired.

Fatigue is really probably one of the biggest things that we see in people with long

COVID fatigue and complete exercise and tolerance. So if they if they tried to start

exercising or doing anything physical at all, that tremendous shortness of breath, and

muscles kind of rejected the idea of any kind of physical activity through the either the

production of pain, or just the the weakness as a general rule. So that's what we see, in

the vast majority of people that we we've seen in the clinic with, you know, they've been

diagnosed with long COVID.

Evan H. Hirsch, MD 02:33

And I've noticed that some people get COVID. And then their symptoms persist. And

some people get COVID, their symptoms go away for a period of time, sometimes

months. And then they come back and there's all sorts of weird symptoms. What are

you seeing in your clinic?

Dr. Peter Osborne 02:48

Yeah, it's interesting on that, on that first part, what we're seeing a lot of is that people

when they go home, because they're sick, they have mold in their home. And so when

they're at home sick, they never really recover, and they just stay sick because the mold

is an immunosuppressant and comes with its own, you know, battery of inflammatory

chemicals and mycotoxins and other things. In the ladder statement that you made. One

of the observations that we're seeing is that having COVID The virus itself is damaging

to the intestines. And so what we're seeing is kind of a post infectious, leaky gut that

sets in and it triggers a number of food reactions, food sensitivities that didn't exist

before the illness. And so now they've become actually reactive to the foods they're

eating. And those foods are creating similar types of responses that you know, lead to

chronic fatigue and lack of ability to recover. There's actually some interesting research,

I reached out to the researcher in Germany published in a paper, it was an opinion piece.

But he was looking at the chemical inflammatory pathways of COVID, as well as gluten

sensitivity and found some pretty strong connective corollaries there. Another group of

researchers recently published on their speculation that they're gonna see a massive

rise in the incidence of celiac disease post COVID, because of the viral induced damage,

and we already know that one of the risk factors for developing Celiac disease is a viral

infection and interroll Viruses can can actually increase the risk for the development of

it. And I think COVID is just it falls in that category. So when you have somebody post

viral infection, who develops villas atrophy, you know that now they're going to start

suffering with malabsorption and gastrointestinal dysfunction, which leads to

malnutrition? And of course, nothing's more important for the body to be able to heal

and repair itself and maintain itself then, you know, then the essential vitamins and

minerals that come from our food.

Evan H. Hirsch, MD 04:57

So can you for those who are familiar Can you define celiac disease for us. Sure,

Dr. Peter Osborne 05:02

yeah, celiac disease is an autoimmune condition of the small intestines, where when

exposed to gluten, the individual will develop antibodies against the lining of the GI tract.

And so that that damage occurs it flattens the folds of the GI tract, this folds are called

villi. The small intestine has a surface area of about the size of a tennis court, not

because you know, it's 20 foot long, but it's the size of a tennis court because of all

these folds, those those those folds called villi get flattened out, so the surface area

then dramatically reduces. And so when you have somebody with celiac disease, the the

reason the surface area of the intestine is so great is because you need a lot of surface

area to do the work of digestion and absorb the vitamins and the minerals as they're

passing through. And so when you cut down on that surface area with celiac disease,

you get malabsorption syndrome. So now that person is not absorbing adequate

quantities of vitamins, adequate quantities of minerals in one of the hallmarks is

actually fat malabsorption. So if you if you're looking in the toilet bowl, and you see like

a clay colored stool, or a tan colored stool or your stools are floating, you know, post

COVID, you might suspect that that is something that's happening is fat malabsorption.

Evan H. Hirsch, MD 06:25

Now, and in the in the stool will float, right because it's got more fat in it. Yep. Yeah. And

then what's the difference between gluten sensitivity and celiac?

Dr. Peter Osborne 06:36

So everyone with celiac, is gluten sensitive. Not everyone with gluten sensitivity has

celiac. Hence the term you know, if you do a deep dive in medical research, you'll find a

term in CGS and that that's an acronym for non celiac gluten sensitivity. So the the

debate is hot around this area because some believe that you can't have celiac disease.

Or rather, you can't have gluten sensitivity, unless you are a celiac. But more and more

this gets studied, the more and more realize that more people have non celiac gluten

sensitivity than actually have celiac disease. So the studies show that about 1% of the

population has celiac. But they show that six to 14% of the population has non celiac

gluten sensitivity. So it's actually much more prevalent. The biggest differences are in

the area of damage. So when we're talking about celiac disease, the area of the

autoimmune reaction is generally isolated. Not always, but generally speaking, is can be

isolated to the GI tract. So what happens, you go to the GI doctor, they do a couple of

different kinds of tests into a scope to look for that villus atrophy that we were referring

to earlier. And then they also do what's called serology. So they're looking at different

antibodies that a person might produce to gluten. So there's there's anti gluten

antibodies or anti Gliadin antibodies, and then they're also antibodies that show up

when the when the intestines are being damaged. So that would be like anti endomysial

antibodies and tissue transglutaminase antibodies. So those are, you know, to diagnose

celiac disease, you have to have two things be true, you have to have those positive

antibodies, but you also have to have that positive villous atrophy that that a GI doctor

would find on an on an upper GI on a scope. Whereas non celiac gluten sensitivity can

impact or affect pretty much any tissue in the body. And, and so examples of that would

be somebody who develops rheumatoid arthritis. A lot of these individuals we can find

that have RA, for example, will will will completely go into remission when they follow a

gluten free diet. And if we look in their blog, we'll find gluten antibodies in their blood

along with the other hallmarks of rheumatoid arthritis like positive rheumatoid factor.

We'll see the same thing with Hashimotos which is an autoimmune thyroid disease,

which you know, there's there's a strong correlation have been about 350 studies now

that have shown that people with Hashimotos actually react very well to gluten free

diets and have a reduction in their circulating antibodies in many cases have

symptomatic recovery. So, there have been about 100 different manifestations of what

we would call non celiac gluten sensitivity that had been reported on in the literature. So

everything from you know psoriatic arthritis, ankylosing spondylitis, to rheumatoid

arthritis to Hashimotos to scleroderma to to Addison's disease. If you have an

autoimmune condition, and you don't know why you have it. The likelihood that you are

gluten sensitive is very, very strong. As a matter of fact, gluten is the number one most

well researched cause of autoimmune disease and we have that ofs as a specific truth

ever. In other words, everyone agrees that gluten causes celiac disease. It's just that

we've had this resistance in medicine for doctors to say, let's look at gluten as it relates

to other autoimmune diseases too. This is actually when I trained in did an internship in

the VA hospital in the rheumatology department was one of the first questions that I

asked is why are we not looking for gluten sensitivity because the research is robust on

gluten causing other forms of autoimmunity beyond celiac disease. And I was really

basically just told to be quiet. Because I was an intern. So I don't know if I answered your

question. But those are the biggest differences is that people with celiac disease

generally have the autoimmune condition where they have a lot of intestinal pain, gas,

bloating, diarrhea, sometimes they have vomiting, kids, if they have celiac will fail to

thrive, they will grow, they'll have delayed puberty, women cycles can be can be thrown

off, especially again, the younger, whereas when we have non celiac gluten sensitivity,

it's usually some form of autoimmune disease, or autoimmune inflammation expressed

in other tissues of the body beyond the small intestines.

Evan H. Hirsch, MD 11:14

Okay, and it seems like a lot of the diagnosis of celiac is missed, you know, a lot of

people come to me and they say, Well, I don't have celiac. So then I can eat gluten. And

that's not really kind of like how it works, right? In terms of the diagnosis, it's really the

severe end of the spectrum, like you have to have this really blunted the blunted villi. Is

Is that true? And how do you? How do you coach people on that? Yeah,

Dr. Peter Osborne 11:39

for sure it's true. The worst I've ever seen, was a woman who had 90 Negative biopsies.

And the 20th, one was positive, it was like a 45 year journey through doctors before the

test. So think of celiac disease. Positive biopsy, is like end stage disease. It's very

similar to diabetes, you don't eat sugar, and tomorrow you have diabetes, right? It's you

eat, you eat over abundantly, you don't exercise and you eat too many carbohydrates

over a period of 30 to 40 years before your body breaks down to the point where it can

no longer processed sugar, at which point they're calling that diabetes. But at which

point, were you actually developing problems, you know, and so it's the same thing with

gluten by the time you have illis atrophy, the problem is so extensive that you've allowed

decades of damage to occur. And now you have to dig out of those decades of damage.

Whereas if you can catch it early, you can you can stop a lot of the damage from ever

happening. My favorite way to look at gluten sensitivity is that it's a state of genetics. It's

not necessarily even a disease. Don't think of gluten sensitivity as a disease per se.

Think of it as a genetic predisposition. There are certain gene patterns on the HLA DQ

alpha one and HLA DQ beta one gene, that if a person possesses these different

patterns, then there's a they're predisposed to react to gluten should they eat it. And if

they do eat it, it doesn't mean there'll be super sick tomorrow or even super sick

immediately, it means that their body will perceive that gluten to be a poison, there will

be an inflammatory response as a result of that exposure. And so it's a matter of dose

exposure over time, the more exposure you get, the more damage is done, eventually,

you reach a point where your body can't repair faster than You're damaging it from your

diet. And that's when symptoms really start to ensue. And when people seek out doctors

and seek out a diagnosis, and that's why gluten sensitivity as a as a as a recognition. It

just fails oftentimes to get to get diagnosed because people just don't are doctors in

many cases, unless you have Frank overt celiac disease just don't even consider gluten

as a potential possibility.

Evan H. Hirsch, MD 14:03

And so since gluten is involved in so many different disease processes, and I know you

talked about the genetics and how there are some people who are more predisposed,

but should anybody be eating gluten?

Dr. Peter Osborne 14:18

I think it's arguable. I mean, I hear my my experience on this is extremely biased

because in my practice, I'm not going around to Healthy People saying go gluten free.

What's happening as very sick people are coming to me who have you know, multiple

forms of autoimmunity. And we're finding that these individuals, pretty much all of them

are gluten sensitive. So So Should everyone go gluten free? I don't know. I don't know

that anyone has, you know, could answer that question. Honestly, I you know, but my

biased experience is that if you have autoimmune disease or chronic inflammatory

illness of an unknown origin, it will absolutely not hurt you to go gluten free, and it might

absolutely help you tremendously to go gluten free.

Evan H. Hirsch, MD 15:08

So there was some research maybe about, I don't know, 10 years ago, that that I heard

about peripherally? I haven't seen this research. But there was a question about when

avoiding an antigen or an allergy, that you potentially become more sensitive to either

that allergy or other or other allergy. And in this particular case, I think that it was

actually might have been peanuts. But I don't know whether it's extrapolates to gluten,

because you said, you know, there's no harm and going off of it. But is there? Is there

anything out there that suggests that if you're not consuming it, then you're decreasing

the immune systems relationship to it? And that when you do consume it, then

potentially you could have an issue with it? And then can you extract that to or

extrapolate that to any food allergy?

Dr. Peter Osborne 16:01

It's a great question. You know, they've done studies now with gluten specifically to see

if you know, delaying the introduction of gluten into the diet of a child would increase or

decrease the risk of the development of celiac disease and found that delaying is

actually probably better, although the studies aren't super definitive either. But that

delaying it is probably better. There's some studies that have been published that show

that part of the problem with gluten in individuals is not necessarily that it will even

stimulate the immune system per se, but that the protein itself is so hard to digest, that

if you use it as a staple food in someone's diet, you create digestive distress, and that's

different than say, creating an immunological reaction that is autoimmune in nature. So

and if you look at like infants and children, what do we do when they're born? You know,

generally, well, depending on the doctor, many doctors recommend breastfeeding

nowadays. But we went through a period of a few decades where you know, formula

was being really pushed actively, even by pediatricians and OB Gen, Doc's. And, you

know, one of the number one ingredients and formulas grain corn, specifically corn

syrup, and you know, beyond the soy and some of the other bases, but then once a baby

reaches the age of three to four, the general recommendation is, is grain based cereals,

right? So you've got like rice and malt and or barley and wheat based cereals. And so

what what, what we see in those situations, is is is with the advent of those cereals, and

I know causation and correlation aren't the same thing. But we see with an advent of

those cereals becoming a primary staple in the diet of infants, we see an increase in

type one autoimmune diseases like eczema, atopy. And, and allergies, and asthma. So,

you know, again, causation and correlation aren't aren't the same thing. But I find those

things to be, in my experience, very true that when we have children that have those pre

existing types of conditions, that taking them grain free, very often leads to resolution of

those problems. As far as other foods are concerned, I haven't seen anything in the

scientific literature, it doesn't mean it doesn't exist. But I haven't seen anything that is

compelling enough to say that by avoiding a certain food, you actually will have worse of

a reaction when you are exposed to that food. My own belief, from clinical experience,

but also from most of the immunological research that I've read, is a lot of the reasons

people react to things has to do with the way their immune system is predisposed to

react to those things. So everybody's unique in that regard, right where the N equals one

in a sense, but the other is just in general, how how healthy or robust is the health of an

individual and this is particularly true of their gut. So I guess a child if they were born via

cesarean section, and so they didn't ever properly get vaginal colonization of their

microbiomes those people we know through research are more prone to autoimmune

development and more prone to food allergies. We also know that a lot of what we're

calling food is I wouldn't call food you know, if you look at if you look at a lot of the

infant cereals, you know beyond gluten, look at the cadmium contamination and the in

the lead contamination of rice based cereals, and wheat based products. It's through the

roof and then when you when you couple that with the 3000 what are called grass

generally recognized as safe chemical food additives that have never been properly

studied. And they've never been properly studied, especially in conjunction with

synergism amongst each other. So if you are eating a food that has five or six additives,

maybe they claim that additive is safe if you just had a certain amount Have that

additive, but what happens when you add that additive to six other additives? Is there a

synergism that has the potential to create an immune dysregulation in a human? And

I'm of the belief that that is absolutely what's happening is it's a combination of, we're

calling fake food food. And we're recommending that people eat that or consume that

on a regular daily basis. And then we're also subjecting, you know, we're being are being

subjected to a number of new chemicals that are, you know, just part of technology and

part of, you know, our life. And so there's this assault on the immune system that exists

in the last 70 years that really didn't exist prior to that. And that's another reason why I

think we're seeing a lot of kids and adults, you know, develop more and more

immunological responses to the things they're thinking are normal. It's not normal to eat

processed food and food dyes and food preservatives, and glyphosate and Atrazine.

Like that's not food, but it's in our food. And if we can come to the realization that those

things do have a meaningful impact on our immune system and do our best to avoid

them, eating whole foods, eating organically, I think we see that people's as a general

rule of thumb, I'm sure you've experienced this in your own practice, but I'm certain that I

have and that people generally get healthier, and they have less symptoms, and their

autoimmune diseases miraculously start to go away. And it's like, okay, I know, we're not

supposed to say that you can cure autoimmune disease, or that it can go into remission.

But, I mean, I've been practicing 22 years, and I've seen over 10,000 cases of

autoimmune disease go away. And that's just simply with diet and lifestyle change. So I

know my observations are not are not unique to me. I mean, doctors like yourself, and

and many of our other colleagues have I've talked to have seen very, very similar types

of outcomes. So I just say that all of that was a long about way to say, to answer your

question is that No, I haven't seen compelling research that says that by not eating a

food, you become more allergic to it should you be exposed to it.

Evan H. Hirsch, MD 22:02

So you talked about the chemicals that are in the food that we're being exposed to. You

know, I know that autoimmunity and the sensitivities to these food allergies, including

gluten can come from, you know, anything that's in the body that the immune system is

trying to get rid of. Right. So heavy metals, chemicals, molds, and infections. We talked

about COVID. And you talked about some of the other infections that can kind of trigger

some of these, you know, autoimmunity allergy spectrum, I guess you can call it. So if

that's the case, if having these toxins in the body triggers a gluten sensitivity and other

food allergies, can you remove a gluten sensitivity? Or decrease it significantly by

removing the toxin the COVID? Heavy Metal the chemical?

Dr. Peter Osborne 22:52

Make sure I understand your question that by removing the chemicals that you could

improve a person's ability to tolerate gluten. Is

Evan H. Hirsch, MD 22:59

that okay?

Dr. Peter Osborne 23:03

perceptually Yes. But in reality, no. And here's what I mean by that perceptually, if you

remove toxins from a person's diet, they're going to feel better. And so they're going to

become more resilient and more adaptive to anything that they do to themselves that

might not be healthy, right. So when you take a person who's chronically ill, and they

make some great lifestyle, and diet changes, like sunshine, and sleep, and good, clean,

whole real food, and exercise and good supportive care around them, they're going to

feel better, no matter what their situation, no matter what their condition, and by feeling

better, they're becoming more resilient, more adaptive to the environment. And so when

you take away, let's just say 20 poisons, but keep one poison in, you're still going to feel

better, right? And so that's what I mean by perceptually. Yes, is that you're reducing a lot

of the problems that are also contributing to the core of that person's problem. But if a

person is gluten sensitive genetically, and I've seen this happen repetitively, clinically

speaking, where they do all the right things, and then they try to reintroduce gluten at a

later point. And what ends up happening is, you know, if their health started, maybe like

here, like a visual, and then we got them here, right? And then they wanted to

reintroduce gluten and then what we see is that their health starts to do this again, and

it starts to slowly decline. And that's true of people where I've tested them for gluten

sensitivity gene patterns. I can't say that's true of everyone, but it's certainly true of

people that have those genetic markers or those genetic predispositions.

Evan H. Hirsch, MD 24:40

And I promise we'll come back to long COVID but I'm just really enjoying this

conversation about gluten right now. So what about gluten in other countries? I found

that when I traveled to India and HaCha potties and recently I went to Germany and and

and had some some gluten products there I didn't react as I have reacted before in the

past when I've been in the States.

Dr. Peter Osborne 25:06

That's a great question too. So there's a lot of variable amongst the different strains of

grains that are grown. You know, whether they're heirloom type grains, or whether they're

hybridized grains, a lot of our hybridized strains contain more gluten in them than non

hybrid strains. But what we also see is the way they're grown. So like in the US, you

know, most most grain crops are sprayed twice with glyphosate. So you spray, you know,

when you're planning, but then you also spray as a desiccant, at the end of the of the, of

the growth of the plant. So what you're trying to do with with glyphosate as a desiccant,

as you're drying the crop out before you combine it, it just makes the process easier. So

it's like a double dose of poison on the US stuff. Now we're seeing that change, I think, in

Europe, they've just approved glyphosate for the next 10 years. And so, you know, I'm

concerned by that, because a lot of people report exactly what you just did, which is I

can get away with it better over there than I can here. But there's another part to this too

beyond life, per se, it's when you're on vacation, you're happier, you're not at work, there's

not the stress load, you're generally your dopamine is much higher. So there's a there's a

anti pain effect of the neuro chemistry of being on vacation. And the reason I bring that

up is because we've we've also seen this with gluten, I'm gonna I'm gonna backtrack just

a little bit for a minute. One of the things that we know about gluten is that when it's

broken down in the intestine, there's a sub protein or type of protein that's produced

called gluteal, morphin. And gluteal. morphin behaves like morphine, it actually can

attach to morphine receptors. So there's some evidence that shows that gluten can

actually mask its own toxicity, by being broken down into a morphine like substance that

can blunt the inflammation and can blunt the pain that would otherwise produce. So so

there's that but then when you're on vacation, you have this psychology of lack of stress

or of reduced stress, which can also impact neurological pain mechanisms. And so it

can reduce the level of symptomatology that a person might have in that regard. There's

also differences in nitrogen fertilizer use utilization. So one of the things that's

interesting, the more nitrogen fertilizer, and I'm talking about synthetic haber bosch style

nitrogen fertilizer, not not like bird poop, or you know, or cow poop as fertilizer, but actual

synthetic. Nitrous nitrogen production from what's called the haber bosch method is

which is where you extrapolate nitrogen from the air versus, you know, versus using

poop as a source of nitrogen. But there's some evidence that shows that the higher

levels of nitrogen used in grain based products, the greater the quantity of we have

wheat, and this has been found in wheat, the greater the quantity of gluten that we

actually see. And so part of that may have to do with how much nitrogen fertilizer

they're also using within the soil itself. So So you know, there are a lot of different

variables there. My advice to anyone is, if you are confirmed gluten sensitive through

genetic testing, or if you are confirmed as celiac, you shouldn't try to eat European grain,

even if you don't feel as bad when you're eating it, because it's 20 parts per million is the

rule of damage with gluten, that means it for you to receive an inflammatory mediated

response, you only have to be exposed to a breadcrumb. And that that gluten How long

does it take for gluten to leave the system once you are having an immune response to

it that the antibodies that that gluten causes your body to produce, they have a half life

of any anywhere from 30 to 60 days, so it takes at least that long for an exposure, you

know, to calm down. So if you're thinking about, Okay, I have this chronic inflammatory

disease. If I just cheat on gluten once a week, right, then I'm having this antibody

response that has an infinite inflammation that can last for several months. And it may

not be as much of a response as if I ate pizza every night or if I ate pasta every day. So it

is a dose issue as well. But if we're trying to overcome a chronic inflammatory disease

and we're in we see somebody hitting a plateau because they're cheating periodically,

maybe not they're they're on a gluten less diet but not a an absolute zero tolerance

policy, gluten diet. A lot of times we'll see those people plateau out, and they'll start even

in some cases start digressing backwards. We call that gluten free whiplash when they

start going backwards in their health because they're not being strict or rigid enough

with their diet.

Evan H. Hirsch, MD 29:51

And what are generally people missing when they when they go gluten free, and they're

still having issues. I've heard you give this talk before what Other foods have gluten or

gluten type proteins that are triggering that inflammatory response that people don't

think to remove out of their diets. Yeah,

Dr. Peter Osborne 30:11

great, great question. So in the US, and I think this is true in the European Union as well.

Gluten in a food level is defined as wheat, barley and rye. And so you can have, for

example, an oatmeal, or an oat product, or corn or rice product that is labeled legally

gluten free. But what a lot of people don't realize is that the corn in gluten is called Zayn.

And by concentration, it's about it's almost 60% of the total protein concentration of

corn. And that there have been a number of research studies that show that corn gluten

actually stimulates the same type of immunological response that wheat gluten does.

As a matter of fact, there was a study in 2012, that showed that people with celiac

disease reacted worse to corn than they did to wheat. And we've seen similar studies on

rice, although the type of gluten and rice is different. It's it's called origin. And by by

concentration of protein, it's only about 5% of the protein found in rice. So it's a much

lower density or concentration. So some people have reported that, hey, I can tolerate

rice a little bit better. But I've seen cases where rice really, really triggers people with

gluten sensitivity in a big way. So rice and corn are two, probably two of the biggest. And

then the other one would be quinoa, there was a study published, oh gosh, it's probably

been 15 years now, where they looked at Kmart cultivars and found that two of the

proteins in qinhuai were so close to Gliadin. Like they were resembling of Gliadin, which

is the type of gluten found in wheat that that they got and these were these were not

human studies. Just to be clear, these were these were more culture cell studies where

they found inflammatory reactivity. With quinoa and I see a lot of people react to quinoa

as well. So it's just one if you're if you're doing everything well and you're 100% grain

free, but you're eating like quinoa and buckwheat are amaranth which are which are

technically not grains, they're pseudo grains. But you're still struggling, I would

encourage you to look at those and eliminating those is your next kind of first logical

step to see if you improve.

Evan H. Hirsch, MD 32:18