Q & A

Q & A

This page as an open thread for reader questions, especially questions about personal health concerns.

I am putting this page up as a way to share knowledge — my knowledge with questioners, but also so that others with similar concerns can read the conversation, and readers with relevant knowledge can chip in with their own thoughts.

Please keep in mind that I can’t research questions in any depth, so my answers should be considered tentative, incomplete, and subject to later correction. Also, I am not a doctor, and nothing I say should be construed as a substitute for medical diagnosis and treatment. I am only sharing opinions about disease origins and general therapeutic strategies which may or may not be applicable in any given case.

To get the page started, I’ll put up a few questions from recent emails. Here is an index by disease, with clickable links:

And here are my answers.

Chronic Lymphocytic Leukemia (CLL)


Been following your work on the PHD before the publication of the book and commented on my CLL and the usefulness of Vitamin D once on your blog and you responded to keep an eye on my Vitamin K intake, which I do now.. Am fortunate in a way to have my form of CLL as it indolent which gives me the opportunity to experiment without the pressure of undergoing conventional treatment. The PHD, I think, is helpful in this regard.

Wonder if you could point anything out to me that may be useful. Anything at all. And I will be happy to share with you my results.

Surely you know of the helpfulness of green tea with CLL. You may not be familiar with research that points out that those with low levels of Vitamin D need treatment for CLL far sooner than those with elevated levels.

Feel strongly that your version of a ketogenic diet would be helpful but also feel I need some direction in this area. Do you have any suggestions?

Warmest Regards,


Hi A,

I remember your comment, thanks for writing back. I’m glad you’re enjoying our diet and wish you the best.

Thanks for the tips about green tea and vitamin D. Neither one surprises me.

Most likely CLL is caused by a viral infection. So enhancing viral immunity is probably a good idea. Good strategies may include: (1) low-protein dieting, which inhibits viral reproduction and can promote autophagy; (2) maintaining high vitamin D levels; and (3) intermittent fasting, which promotes autophagy.

Some food compounds have been reported to have antiviral effects. An example is green tea catechins, eg http://pmid.us/16137775, http://pmid.us/18313149, and http://pmid.us/18363746, and this could be why green tea is helpful against cancers, http://pmid.us/21595018, which are usually viral in origin.

I might search Pubmed for herbs and spices with antiviral effects, and use them abundantly in cooking, along with antiviral foods. Turmeric / curcumin is a good choice, this needs to be taken with black pepper to enter the body. See http://pmid.us/21299124, http://pmid.us/20434445, http://pmid.us/20026048.

Coconut oil / lauric acid also has some antiviral properties, so inducing ketosis with coconut oil could benefit you even aside from the ketosis. You could also try monolaurin supplements which may enter the body better and which some people have reported to help viral infections.

You might also try HDL-raising tactics as discussed in this series: HDL and Immunity, April 12; HDL: Higher is Good, But is Highest Best?, April 14; How to Raise HDL, April 20.

Another possible tactic is high-dose riboflavin with UV exposure on the eyes. This requires going outdoors at midday and not wearing glasses or contact lenses. Riboflavin+UV is toxic to blood-borne viruses, and the retina is a location where UV can reach circulating blood cells. Sun exposure will also help you optimize vitamin D.

That’s a few ideas, at some point I’ll do some research to come up with more and do a blog post. Do keep me posted on your results!

Best, Paul

Bloating, acid reflux, anxiety, depression, hypoglycemia, hypothyroidism, fatigue

Just came upon your website and had a question for you. I have had some health concerns for the last four years, bloating, acid reflux, anxiety, depression, hypoglycemia symptoms, female complaints (I am in my forties), thyroid antibodies at 333, weight gain around my middle and too tired to work out like I once did. I used to be fikiiled with energy and great health no depression or anxiety. My doctor thinks these symtoms are all from peri-menopause and wants to treat me with Zoloft.

Needless to say I have tried to avoid the Zoloft. I have tired every avenue out there to cure myself. Most recently the Primal type diet. When I eat no grains or dairy I get horrible hypoglycemia symptoms and don’t feel great like everyone else on a low carb diet. I feel weak and more anxious. Do you think your diet would be easier for me with the addition of rice and potatoes?


Hi G,

Yes, I do think our diet will be better for you. You should eat enough starches to avoid hypoglycemia.

The key thing for you is treating the infections which are consuming so much glucose and making you glucose-deficient if you don’t eat enough carbs. Whatever pathogen(s) this is, it seems to have infected your gut and caused the various gut problems; circulating pathogen-derived toxins and immune cytokines are probably responsible for the anxiety and depression. Hashimoto’s hypothyroidism may be either due to circulating toxins or a thyroid infection.

I would suspect some kind of protozoal or parasitic infection due to the hypoglycemia, but what I really recommend is getting your doctor to have a stool sample analyzed for pathogens. Metametrix has a good test. Once you know what pathogen to treat, and get on a better diet like ours, you should improve quickly.


I am writing on behalf of my mother … We live in Dhaka Bangladesh …

Before her illness, my mom was 105 lbs, 5 feet tall and always 10ft tall in spirit…. When she was diagnosed with Lupus at the age of 30, we were all overwhelmed and out of our depths. My beautiful, athletic mother was in a wheelchair and given 6 months to live….

The doctors has advised her to eat literally nothing, minimum protein (1 small piece of chicken/fish, limited to 20g protein per day), only 2-3 types of vegetable and 2-3 fruits and of course lots of carbs to apparently compensate for her failing KIDNEY and LUPUS. She is on tons of medication, no food except the wrong foods (carbs) and in chronic pain. She currently weighs 139 lbs.

Please advise. — S

Hi S,

I believe lupus is a catch-all diagnosis for a variety of conditions which are probably caused by undiagnosed infections. In the US the infections are usually bacterial. I’ve known several people with diagnosed lupus who were cured by antibiotic treatments – in one case the problem was Lyme disease (Borrelia). I have no idea what the likely pathogens would be in Bangladesh. If she does better on low carb and coconut oil, that indicates bacteria; if she does better on high-carb, that indicates protozoa.

A healthy diet is very important. It is very bad advice to “eat literally nothing,” it is essential to be well nourished. Protein is necessary for healing and immune function, and 20 g/day is too little. Fasting is good, but it should be intermittent – not starvation! She needs healthy fats, more protein, and lots of micronutrients. Eggs, shellfish, seafood, bone broth soups, vegetable soups, and fermented vegetables may all be helpful. Coconut milk is probably good for her. You should basically follow the program in our book.

I would try to put her on a good diet, give her a little time for kidneys and other tissues to heal, and then try antimicrobial medicines. Usually, if they’re not working, then you don’t notice an effect. Any strong effect, good or bad, means they are working. Bad effects mean that pathogens are dying and releasing a lot of toxins as they disintegrate. If this occurs, detox aids (salt, water, and one of cholestyramine/charcoal/bentonite clay; also glutathione supports and vitamin C) will help.

Please stay in touch and let me know how things go.

Best, Paul


Jersie wrote:

I’ve suffered from depression for decades. A few months ago, I decided to try the Dr. Kruse protocol for jumpstarting leptin sensitivity and 2 interesting things happened.

When I went very low carb – below 50 gm -. I had half-day periods where the depression suddenly lifted (something that has rarely happened otherwise). However, I also suffered from darker than normal periods.

I stopped the Dr. Kruse protocol after 6 weeks, and went back to regular paleo (approx. 200 – 300 gm. Carb/day). I’m now generally more depressed than usual, without the good periods.

These changes seem to indicate that I can have an influence on my depression with diet, but not sure what diet to try. Thoughts?

Hi Jersie,

I think your experience on very low carb is diagnostically telling.

I would interpret it this way:

  1. Your depression is caused by an interferon-gamma mediated immune response in the brain, probably caused by a viral or bacterial infection. This leads to tryptophan being directed away from serotonin and toward the kynurenine pathway. So you have a serotonin deficiency and kynurenine excess.
  2. A ketogenic diet is both therapeutic (promotes immunity against bacterial and viral infections) and mood-improving (clears kynurenine).
  3. However, you are at risk for hypoglycemia in the brain (especially if the infection is bacterial) and hypoglycemia causes irritability/anxiety and can aggravate depression.

So the very low-carb diet had mixed effects (ketosis, hypoglycemia).

What I would do is follow our ketogenic diet advice. Eat at least 50 g/day carbs from starches to get sufficient glucose, plus sufficient protein to reach 600 calories/day protein+carb, but add in large amounts of MCT oil or coconut oil. Also, do intermittent fasting – eat all the carbs within an 8-hour window; eat at least half the MCT oil in the 16-hour fasting window.

Once on a good diet, I might experiment with antibiotics to see if they relieve symptoms.

Please let me know how things go.

Leave a comment ?


  1. Hi Paul,

    You missed a few of us a bit further up so I wanted to repost my question for you here ;-).

    In response to your reply, I have been following the PHD for several months now and have seen many improvements in body composition, overall well-being and energy levels. However my testosterone levels are still coming in borderline low, and I’d like to bring these up as much as possible.

    Would it help to emphasize carbs more, or stick with the fat emphasis?

    Anything else I can try that you’ve had success with in the past?



    Hi Michael,

    I haven’t forgotten you but I need to do a little research.

    However, let me give you just an off-the-cuff unresearched response. I would expect things that promote growth hormone release and muscle growth to promote testosterone. This could include resistance exercise several times per week, with higher carb and protein consumption on the days exercise is performed.

    I would also expect circadian rhythm therapies to be helpful.

    I’ll try to come up with more when I have time.

    Best, Paul

  2. Hello Paul

    As Michael mentioned, you may have missed my question posted on dec. 5

    How would you approach a fungal + bacterial infection? How do you balance carb intake? Which one should I tackle first? For more details including my diet scroll up to comment #41377


  3. New Chapter doesn’t source its raw materials from China, according to their web site. It’s quite a pricey brand, though, but for those worried about such things it might be worth it. I don’t know if there are other supplement makers following similar policies. I’ve been a member of consumerlab until recently, and the problems with lead contamination that they found were usually on little-known brands. The only other problems they typically found were things like a product having 10% less of a certain vitamin than stated on the label or something like that. I’m still not sure about the safety of taking supplements every day for the rest of my life, but the major brands appear to be pretty harmless.

  4. Thank you Craig for the info re coconut oil. I hadn’t ever heard anything before about its killing off friendly bacteria so, Vincent, if you’re out there, would it be possible for you to demystify me re your post and why you need to limit coconut oil.
    Thank you.

  5. @Sheep Counteress. “Also, a general question: does anyone have experience getting very strong-willed family members on board with PHD, especially those who already have very rigid conceptions of what the correct diet is? I would greatly appreciate your tips!”

    I prefer to verbally barage them into submission. :0 J/K. What i mean is my dad has needed many many repeated explanations about why wheat isn’t good and the rest of the PHD concepts since they are opposite of many food ideas by the gov and vegs. The other day he got a latte at McDonalds and said he got low-fat milk in it because of what I said??? “What! Let’s start from the beginning dad.”

  6. Paul: Thanks very much for your thoughts about fats. I appreciate the suggestions.

    Frances: I was probably guilty of misunderstanding something Paul said about coconut oil and bacteria in another thread. See his response to you above.

    I have found that doses of more than about 1-1.5 tsp of coconut oil give me very loose stool, followed later by mild constipation (which disappears as soon as I eat fermented vegetables). I concluded that such doses of coconut oil harm my gut flora, but perhaps other forces are at work, or I am not digesting the coconut oil properly. Perhaps the diarrhea that follows big doses of coconut oil, rather than the coconut oil itself, is responsible for my subsequent constipation. I do not know. In any case, I do not think others should read too much into my rather idiosyncratic experiences. 🙂


  7. @Michael

    For testosterone, also make sure sleep is good, make sure you getting zinc, Vitamin A, and that your thyroid is in good shape. Training + recovery is needed for optimal testosterone as well.

    How are your D levels? Make sure D is optimal as well. This is personal, but morning wood and erections? Do you get those? If you are supplementing melatonin, I would stop… this lowered my T.

    Make sure you are eating enough too! Calorie restriction lowers T.

  8. Sheep Counteress

    Hi Paul,

    Thank you for the explanation regarding starch level. With the sour tastes, I don’t think it is a preference for sweet so much as an inability to handle sour. The article you linked says, “Elevated taste thresholds (ie reduced sensitivity) for sweet, sour, salty…occur in healthy older individuals.” Both he and I have an extremely sharp sense of taste, though I have noticed that his is not as sharp as it used to be. But that should make him tolerate sour foods more, not less? He isn’t even that old; only in his 60’s, but not too healthy physically and older than his years in disposition. I’m hoping getting him on board with PHD can change that.


    Thank you for the info about the supplements. I take some of Paul’s recommended supplements despite lingering questions about origin, but am at a loss when dealing with someone who thinks anything that might be from China is like the plague.


    Thank you for the encouragement and funny story! Have you gotten your dad to read the book? I believe things are much easier for people to swallow when they read for themselves. My dad doesn’t read English too well, and translation of this type of material would be a huge task for me. With all the work the ebooks took, and a second edition on the way, I’m sure versions in other languages are farther down the list of Paul and Shou-Ching’s priorities. So in the meantime, I will keep at the repeated explanations!

  9. @Sheep Couteress. He doesn’t read especially diet books. He wants to skim and get the gist. Then, he doesn’t digest things fully so he reverts to what the doc says like statins. He gives me a headache!

  10. Thank you Vincent for taking the time to get back to me, that’s helpful.

    There’s a lot of stuff on here that maybe looks idiosyncratic but I think that there are a lot of people out there with symptoms that mainstream doctors don’t know what to make of.

  11. Frankie Rodriguez

    Where can i get organic Taro and Sago online?

    I don’t know, I’ve never seen organic taro or sago.

  12. Frankie Rodriguez

    Would properly prepared beans be considered safe? Since my Ancestory is predominantly Hispanic.As a kid, I could remember, my Grandma soaking beans and serving it with white rice,platains and avocado.I will be starting this diet shortly once I find out of the do’s and dont’s.Before reading about this diet I thought that the Western A Price Diet was the know all, be all diet.Also what breads are considered safe?Since i will have to give up sourdough rye.

    Hi Frankie,

    Well prepared beans – soaked overnight and then thoroughly cooked – are moderately but not entirely safe. I don’t have a strong objection to them, but I don’t encourage them either. For breads I would stick to gluten-free breads made with rice flour, potato starch, and tapioca starch.

    Best, Paul

  13. Sorry, Paul, it is me again on the issue of cod liver oil. I have just purchased a liquid brand and intend to have, just as you recommended (I absolutely do not eat liver) to have a teaspoon/day. As CLO also naturally contains vitamin d, I do not know how much vitamin d3 I shouöd supplement additionally, as well as how much vit. k2. The label on the CLO-bottle warns against taking it (the CLO) when already substituting with vitamin d, but this seems to be a standard safety advice but I am confused on how much vitamin d3 to add or if I should stop taking it altogether…
    Thank you very, very much!

    Hi Iris,

    I believe 1 tsp CLO has only about 400 IU vitamin D, which is not enough to worry about. Normally about 2500 IU/day is a reasonable amount to supplement in the winter, but individual needs vary. It’s helpful to get serum 25OHD levels tested once in a while to guide you. Aim for 40-45 ng/ml = 100-112 nmol/l.

    Best, Paul

  14. Paul, Iris’ question above about cod liver oil is timely for me too. I’ve been taking about a Tbsp/day in my morning smoothie for several weeks to a month and have been having indigestion and seem to smell it even though it’s not on my clothing or my person.

    I also take 2000 mg/day vit. D3.

    I’m thinking of stopping the cod liver oil altogether. We eat liver probably no more than two or three times a month.

    What say you?

    Hi erp,

    I think a tbsp is quite a lot. I think a teaspoon is sufficient. I might take a break for a while, and then try again with a smaller dose.

    Best, Paul

  15. Hey paul, me again! I recently got some more strips for my blood glucose monitor after quite a few months (I don’t know if you remember but I asked almost a year ago about my blood sugar values which seemed extraordinarily high even after moderate amounts of carbs). Well I’m sure you’ll be glad to know that after a while of eating according to the PHD and upping my carbs, I haven’t recorded my blood sugars going over 140 at all even after eating lots of carbs at once.

    However I noticed a weird phenomenon the other day. I had been baking some cakes (gluten free, low in fructose ofcourse!) for a xmas party. I did alot of tasting and ended up eating probably around 200g worth of carbs. I tested my sugar and instead of rising and falling it seemed to jump around. I ate the stuff over the course of an hour or so finishing at 5:30pm. Here is what I recorded:

    5:30pm – 130
    6pm – 90
    6:30pm – 111
    7pm – 118
    7:30pm – 90

    I recorded the last 4 on another monitor as well to be sure it wasn’t just something wrong with the monitor I was using, and got more or less the same values.

    Is this normal? What causes the blood glucose level to fall and then go up again despite not eating any more in between?

    Thanks very much!

    Hi remo,

    It’s not usual, but I don’t think it’s worrisome either. Managing a large dose of glucose is a complex task which starts with insulin but then needs other hormones to help maintain blood glucose levels. It looks like you issued a lot of insulin manage the abnormally large glucose intake, then blood sugar started to go low, so some other hormones kicked in to raise blood glucose back again. It may be that you have a few minor delays or excesses in the blood glucose regulation system, or that this abnormal amount of carbs in a short period of time posed an unusual challenge for your body that it wasn’t prepared for. Regardless, since blood glucose stayed in a normal range throughout, I wouldn’t worry about it.

    Best, Paul

  16. Any ETA on the acne post Paul ? Also how does one know if he has a fungal or a bacterial infection ?

    Thank your for making our health better 🙂

    Hi Mik,

    No ETA, it depends on when I have time to research the literature and synthesize it with my own experience.

    It’s not easy to know what the pathogen is if the infection is mild. As the symptoms become severe it gets easy. Fungal infections tend to affect skin/epithelial surfaces the most, so skin, ears, sinuses, mouth, urinary tract, and digestive tract. On the skin they tend to create ringworm type red rashes; in the mouth, thrush. They tend to have slowly varying symptoms. They don’t respond to antibiotics. Fatigue and mild hypothyroidism are common symptoms.

    But fungal and bacterial infections can coincide, they can form biofilms with both types present. Such co-infections may be very common.

    Best, Paul

  17. Hi Paul,

    Help me choose between two different multivitamins; is one of these forms of Vitamin A worse than the other: Retinyl Palmitate or Retinyl Acetate.

    I have seen both of these listed depending on the brand of multivit.

    Wikipedia gives the impression that Retinyl Palmitate is synthetic & Retinyl Acetate is natural?
    What wikipedia says;
    “Retinyl Palmitate is a synthetic alternate for retinyl acetate in vitamin A supplements”
    “Retinyl acetate (retinol acetate, vitamin A acetate) is a natural form of vitamin A which is the acetate ester of retinol”

    Thanks, Darrin

    Hi Darrin,

    I’m not aware that there’s a significant difference between them.

  18. Thanks Paul.
    & it looks like they are both synthetic after all, the wikipedia info threw me.

  19. Frankie Rodriguez

    Would gluten free Whole Quinoa and Whole Millet bread be ok?

    Hi Frankie,

    I would definitely avoid millet. Quinoa is tougher to judge, see http://perfecthealthdiet.com/?p=582.

    Best, Paul

  20. Hi,

    From reading your book, which I love, I know that you aren’t a fan of B vitamins. I have a short luteal phase and failed to ovulate regularly before taking my current vitamins (ProCycle PMS) which are high in B vitamins. I started taking these vitamins two years ago, after reading “Fertility, Cycles, & Nutrition) by Marilyn Shannon. The formulation of the vitamin reduces estrogen levels and increases the levels of progesterone (“The effect of a nutritional supplement…on premenstral tension syndromes” in the Journal of Applied Nutrition 1985, 37:1-11). Shannon states that no toxicity has been reported due to the balance of micronutrients in the supplement (“Role of nutrition in managing the premenstrual tension syndromes” Journal of Applied Nutrition 1987, 32:405-422).

    B1 (Thiamin HCl) 25 mg
    B2 (Riboflavin) 25 mg
    B6 (Pyridozine HCl)300 mg
    B12a (Hydroxycobalamin) 62.5 mg

    Any thoughts? I like having “normal” cycles but I don’t necessarily like that the way I’m achieving that may be risky.

    Thank you for your time and input. It is greatly appreciated.

    Hi Shannon,

    Actually, we are fans of B vitamins in pathology (with the exception of niacin and folic acid), we don’t recommend them as routine supplements mainly because we don’t want people to think they need to take a lot of pills, and the long-term effects of very high doses aren’t well known.

    I think the B1 and B2 doses are excellent and could be coupled with B5 (pantothenic acid) and biotin too. The B6 and B12 need to be paired/balanced with each other. Those are very high doses – pharmacological doses. There is a potential for side effects at those doses.

    I’m not prepared to endorse such a high B6/B12 dose – 100 mg B6 and 5 mg B12 are more normal therapeutic doses – but will look into the paper you cited when I have time. Thanks for letting me know about Shannon’s work.

    A good summary of possible negative effects of too much B6 or B12 can be found at the Linus Pauling Institute information center: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminB6/ and http://lpi.oregonstate.edu/infocenter/vitamins/vitaminB12/. Note especially this on B6:

    Although vitamin B6 is a water-soluble vitamin and is excreted in the urine, long-term supplementation with very high doses of pyridoxine may result in painful neurological symptoms known as sensory neuropathy. Symptoms include pain and numbness of the extremities and in severe cases, difficulty walking. Sensory neuropathy typically develops at doses of pyridoxine in excess of 1,000 mg per day. However, there have been a few case reports of individuals who developed sensory neuropathies at doses of less than 500 mg daily over a period of months. Yet, none of the studies in which an objective neurological examination was performed reported evidence of sensory nerve damage at intakes below 200 mg pyridoxine daily (24). To prevent sensory neuropathy in virtually all individuals, the Food and Nutrition Board of the Institute of Medicine set the tolerable upper intake level (UL) for pyridoxine at 100 mg/day for adults (see table below) (7). Because placebo-controlled studies have generally failed to show therapeutic benefits of high doses of pyridoxine, there is little reason to exceed the UL of 100 mg/day.

    Best, Paul

  21. Paul, just to double check – your response to Ashley said that 5mg B12 is a more normal therapeutic dose. You do mean mg and not mcg, right? I only ask because the Linus Pauling institute recommends quite low doses (2.4mcg) of B12 for adults and I wanted to make sure I am understanding your recommendation correctly.

    As for balancing B6/B12 is there a rule of thumb for that ratio? I am currently taking 50mg/500mcg daily.

    Thank you.

    Hi SGW,

    50 mg/500 mcg is what we recommend in the book. I think that’s a good dose. I don’t think it’s known what the optimal therapeutic B12 dose is. 5 mg will have big effects – it will make hair and nails grow very fast. Some people think the effects are beneficial. I don’t know. But I think if we’re already seeing big effects at 5 mg, I would be cautious about going above that without good clinical data.

    2.4 mcg is a good dose for avoiding known deficiency conditions. I would characterize that as a normal supplemental dose, 500 mcg and up as therapeutic doses.

  22. @Ashley – If this is the supplement you’re taking, it contains only 62.5 mcg, not mg, of B12. http://www.restorehc.com/product/procycle-pms-formula

  23. Hi Paul


    I came across your exchange on Judy Tsafrir’s blog, v interesting.

    So could you please clarify something for me, still on the subject of how to get sufficient glucose without too much bloating or inflammation (ankylosing spondylitis). Could squashes, beetroots and carrots as per GAPS diet, provide sufficient glucose for long-term good health? I can’t tolerate honey or too much fruit but I can manage some cooked squash etc.

    Thank you.

    Hi Frances,

    Beetroots and carrots are sugary vegetables, so if you don’t tolerate honey or fruit then these are probably problematic in any quantity. Presumably the fructose is poorly digested and is feeding your pathogens. Squashes are lower calorie and mixed sugar-starch usually, thus more tolerable.

    In addition to fructose, the other most problematic components are FODMAPs and various fibers.

    Glucose is generally the most tolerable carb. Glutamine, an amino acid that gut bacteria can metabolize, can sometimes make large amounts of protein problematic.

    So dextrose or near-dextrose foods like rice syrup are usually the best tolerated carb sources.

    Best, Paul

  24. @SGW – You’re right. That should be 62.5 mcg of B12a. I guess it’s time to get a new prescription. 🙂

    @Paul – Thanks for the info. I’ll have to read over those links.

  25. Thank you Paul for that prompt and detailed reply. I’ll give your recommendations a go.

  26. This is a general question for everyone. How often, if ever, do you break your diet? For example, stuffing at Thanksgiving or cake for your birthday. I know all of these things can be made with safe starches, but I’m wondering how often you eat foods with sugar or wheat flour. I still crave/miss certain things and don’t mind “splurging” on special occasions but that’s a lot harder to do now that I know what those things are doing to my body. Just curious what others do….

  27. Ashley, I’m pretty careful, so I haven’t knowingly eaten anything forbidden (except a very occasional pistachio hot fudge sundae) mainly because I’m afraid if I make an exception, I’ll go back to the bad old days. After 15 months, I no have cravings and am actually repulsed by bakery smells.

    I do use cream liberally and that makes up for a lot. ;-}

  28. Honestly, English really is my native language.

  29. Great topic, Ashley. Makes me wish PHD had a forum.

    For my first 7 months of Paleo-ish dietary change I followed the 90/10 rule and ate whatever I wanted once a week. This would typically be a restaurant meal including sugar and wheat. I coped with the 90/10 thing just fine.

    After learning more about gluten’s effect on the immune system, and not being able to rule out the possibility that it might play a part in my lingering symptoms, I cut it out entirely about a month ago.

    I’ll still eat sugar or food cooked in omega 6 oils occasionally.

    To be honest, I’ve been surprised and disappointed by the amount of stress going 100% gluten free has caused me. I don’t think it’s a wheat addiction thing, either. It’s more about lack of flexibility, how it impacts my social life and stress relief – eating out and socializing (which seemed to always involve food) were signficant sources of pleasure and stress relief before. I now find them stress-inducing. Parties, social events, dinners out or at friends’ houses… all minefields I do not enjoy traversing. I pass up invitations much more often now, and that doesn’t seem good for health.

    So I’m working on how to make gluten free less of a killjoy.

  30. Off topics — We have been advised by our county health department and at our school to get the pertussis vaccine because about a half dozen of our 1200 students have been diagnosed. I have been told that at least one of them is a student in my alphabet. Advice? thanks.

    @ Ashley, I rarely “cheat,” although I have a daughter-in-law who despises me because of my weird food issues, so there’s a cost. Until Wise Traditions in Dallas, I had (mostly) not eaten wheat in nearly 20 years. I was told the bread at the conference was made with soaked wheat which is safe or safer. During the three days in Dallas I ate 6 slices of genuine sourdough bread and experienced no joint pain. But then I started reading Paul’s book. Oh dear, even “properly prepared” wheat is unsafe? No huge loss since I’ve gone without it for so long. Starting GAPS to “heal and seal” my gut and don’t want to mess that up.

    Would PHD “heal and seal” as well?

    Hi Dale,

    I don’t feel I can give advice about vaccination because I haven’t researched that.

    Re the gut, I would expect our diet to work well at restoring gut barrier integrity, but much depends on the composition of your gut flora. I would say if your flora is good ours is the best for the gut; if you have pathological flora then more restricted diets may be needed.

    Best, Paul

  31. Frankie Rodriguez

    Is fermented beeet kvass and kombucha acceptable?Also i found an organic rice flour bread online.Do these ingredients seem resonable? White rice flour, rice sourdough starter, potato starch,tapioca starch,rice bran, organic Non-hydrogenated palm fruit oil,rice malt, unrefinde sea salt, guar gum,

    Hi Frankie,

    Yes, beet kvass and kombucha are acceptable, but people with fungal infections may want to be wary of yeast fermented beverages.

    The ingredients of the rice flour bread are excellent. The only one that gives some people trouble is guar gum, which is a kind of fiber and can feed certain gut pathogens. Chris Kresser has written on this. But most people have no trouble with it, and like the texture it gives.

    Best, Paul

  32. Paul,

    I have been searching for the literature but can’t find any evidence for this hypothesis… but are apples and carrots somewhat antifungal like cranberries? The three of them seem to be particularly resistant to molding and when they do go bad they seem to just rot rather than mold over. Even the organic ones.

    Hi Bill,

    I have heard that carrots are an excellent antifungal food, probably all in-ground vegetables are as they are exposed to fungi there.

    But I have no idea why apples would be antifungal.

    Best, Paul

  33. Hi Paul

    Have decided to go for the rice syrup option as you suggest – had a bad flare-up of AS inflammation last night after eating about twice the amount of squash that I normally have (someone else giving me v generous portions).

    So I have a couple of questions, I hope you don’t mind.

    1. If I omit all other sources of glucose (fruit, rice, potatoes etc) do I need to eat 400 cals of brown rice syrup a day ie just over a 1/3 jar?

    2. Does it have to be eaten with meals at the same time as the protein or is it ok to have it mixed with coconut oil as snacks? I have adrenal fatigue and hypoglycaemia so I need to be careful.

    3. Could you explain why GAPS/SCD/ankylosing spondylitis diets favour honey and fruit (ie fructose) as opposed to glucose (I know they’re not your diet but curious).

    Thanks again.

    Hi Frances,

    1. If carbs are giving you problems I probably wouldn’t eat so much rice syrup. Aim for 200 calories of glucose a day from the syrup, just to avoid glucose deficiency issues, and try to squeeze in other carb sources as you feel able.

    2. You can have it both ways, but most should come during meals. Combine it with fats and vinegar or lemon juice or the brine from fermented vegetables (which will supply lactic acid as well as probiotic flora). This will help control blood sugar excursions. And divide the dose so not so much at once.

    3. I think GAPS/SCD focus primarily on colonic dysbiosis and fructose in most people is absorbed in the small intestine, so doesn’t feed colonic pathogens. However, some people have fructose malabsorption or small intestinal dysbiosis, so there are no guarantees. In general, honey and fruits are low in fiber and toxins. Honey also has antimicrobial compounds which can improve the composition of gut flora. I think the preference for honey and fruit was developed primarily through trial and error, it works for the majority of people with bowel ailments. AS has been linked to Klebsiella and starch components that aren’t digestible by humans, so starch avoidance may work well for AS patients.

    Best, Paul

  34. Ashley, interesting question. As I have autoimmune and get nasty symptoms, I’m very strongly motivated to stick to anything that works.

    But sometimes it’s impossible to stay strict and my experience (for myself, I’m not assuming that everyone would react in the same way) is that the more strictly I adhere to a diet, the worse I feel if I ever deviate from it. So, depending on your point of view, that’s either an argument for never deviating or for never being strict in the first place.

    But I don’t think of deviating as cheating because that implies rules. I regard everything just as useful information which may turn out to be partly or wholly incorrect or incomplete anyway eg the famous food pyramid with grains and beans at the base).

    I don’t much like the SCD terminology of legal v illegal foods but I appreciate the clarity of it, which I assume is the reason for it.

  35. Frankie Rodriguez

    What would be a good brand of bread maker to purchase?

  36. Hi Paul,

    I’m a big fan of your book and blog and had some success with the diet and supplements. Once I started working towards a more ketogenic diet, my neurological symptoms (ms like, but not ms according to all the specialists I’ve seen) started to subside. Last week was the best week I’ve had in a year and a half. [Symptoms started a few weeks after a trip to Florida during which I was covered with no see-um bites–probably some kind of infection, I’m imagining).

    But there’s a wrinkle. Just as my neurological symptoms were vanishing, I developed very dry mouth and dry eyes. I immediately started consuming more glucose, which brought back the neurological symptoms. My doctor now says I have Sjogrens syndome and wants to test me for lupus (test came back negative a year ago).

    I’m imagining I’ve probably had Sjorgens for a while, since I’ve had dry eyes of and on for years but never thought anything of it. So here’s my question. Is it possible I have two different kinds of infections, one of which does well on ketogenic and one not? I hate to abandon the ketogenic approach, since it was helping with the neurological symptoms. But my body is definitely telling me something is wrong (and right).

    As a side note, I did take doxycycline for 3 weeks, probably too early in the diet (two months in). Might have helped for a the first 10 days, then the neurological symptoms got worse for the last bit. Since the neurological symptoms come in a 3-4 week cycle, it was hard to tell if the antibiotics were effective or I was just having the normal cycle.


    Hi Kate,

    Most likely the dry eyes and dry mouth were due to a glucose deficiency, maybe augmented by a vitamin C deficiency. I recounted my own experience with those symptoms here: http://perfecthealthdiet.com/?p=1077.

    The way to square this circle is to add just enough glucose to avoid dry eyes, eat more protein as well, and maintain ketosis by eating more MCT oil or coconut oil. Daily intermittent fasting may also help with the neurological issues.

    It’s also possible that you have a gut dysbiosis that is fed by carbs. In that case you may want to reduce vegetables/fiber, add fermented vegetables and yogurt, and experiment with low-carb and ketogenic dietary combinations to find what works best.

    For autoimmune issues balancing vitamins D/A/K2 is very important, so be sure to do that, and don’t be deficient in the antioxidant minerals or vitamin C.

    Best, Paul

  37. Hi Paul

    Thank you very much for that detailed reply.

    I had 1tsp rice syrup yesterday and have had sharp burning pains in my stomach for the last 24 hours. This is interesting for me as it’s very similar to the symptoms I used to get if I ate honey, which i haven’t done for years (except that the pains would be much worse and last for only 3 hours). I assumed that I was allergic to honey but now I’m thinking it’s to do with the sugar.

    Anyway, I’d be interested to know if you have any thoughts on this.

    So it’s back to the squash, beetroots and carrots ie GAPS/SCD. Could you advise how much I’d need to eat of these every day to get adequate glucose (as I’m not eating rice, potatoes etc).

    Kate, I have every sympathy as I am also in a double bind with regard to starches exacerbating some symptoms and ameliorating others. Actually, I know that there are many people with autoimmune in the same boat, having a ragbag of symptoms that seem to require conflicting. It would be really lovely to come up with some solutions that work in the long-term ie healing the gut and then inplementing full PHD, which seems intuitively right as well as having some sound science behind it.

    Thank you again Paul, it’s immensely helpful to have your guidance.

    Hi Frances,

    You might want to buy dextrose powder, or perhaps this tapioca syrup (http://www.amazon.com/dp/B000NQBZWS?tag=perheadie-20&camp=213381&creative=390973&linkCode=as4&creativeASIN=B000NQBZWS&adid=1WGRQ3E3FXVFVPZBMR5M&&ref-refURL=http%3A%2F%2Fperfecthealthdiet.com%2F%3Fpage_id%3D1066), to make sure it’s actually the glucose that is the problem and not something from the rice bran.

    Re quantities, I would try to get at least 200 calories of carbs per day, at least 600 calories carb+protein. Since each food has differing amounts of carb calories, it’s best to have a kitchen scale and look up calories at nutritiondata.com or a similar site for a few days until you know how much of your favorite carb containing foods you need.

    Best, Paul

  38. Sorry about the typos/omissions, I meant conflicting strategies.

    Frankie, we have had our Panasonic SD-253 breadmaker for years and it’s brilliant. We researched carefully, it was the Good Housekeeping Institute Best Buy at the time and I know lots of other people who have it and love it. It’s probably been superseded by another model by now but I think that Panasonic are generally good.

  39. Thank you, Paul. The more I read this blog the more questions I have.
    So to anyone who has the answers — the recent crop:
    -where can I find your bread recipe?
    -how can I learn the condition of my gut flora? Culture through my ND?
    -I am confounded by your recommendations of 600 calories of this, 200 calories of that. If I use a food chart will that give me the information I need? For example, does the calories in an orange tell me the number of calories of fructose in that orange, or would that be a different number? Counting calories is really a pain.
    -finally, I was a few minutes late to your talk in Dallas and missed hearing anyone pronounce your name. Please help me out with this, as I think it compromises my credibility when I share with friends and family and say, “Jam-in-et or Jam-in-ay or something like that.”

    Thanks again and again. I’m going to see about reactivating my paypal account to help out with this generous blog.

    Hi Dale,

    We haven’t posted a bread recipe yet … but we’ve made bread twice and are getting better at it. You might search the Recipes post for bread links, or just search the web for gluten-free bread recipes that use PHD safe starches.

    The condition of your gut flora – I usually recommend DNA tests of stool, eg one by Metametrix which costs $180 or so. However, this is for people who have some clear pathology.

    I recommend visiting nutritiondata.com for information on foods. They’ll tell you the breakdown of calories in an orange, and you can weigh your orange on a kitchen scale to translate it into grams of food. It’s a little bit of work but it will educate you about your food.

    My name is pronounced Jam – Inn – Ay.

    Best, Paul

  40. Hi Paul,

    I was reading about your posts about bacterial infections when I noticed you mention oral thrush. I have a similar white blotches on my tongue- does that mean a candida infection. I can’t seem to find any recommendations about what to do in this case on the site, any suggestions? Thank you =)

    Hi Steven,

    I don’t know. You might consult a doctor. They can do a scraping and have it cultured to see if it is fungal; or may be able to diagnose it visually.

    Best, Paul

  41. Paul,

    Was wondering if you could point me towards the literature concerning l-glutamine feeding pathogens. It seems to be widely touted as “the leaky gut” supplement… but its seems based on your knowledge that this is a misconception?

  42. Frances, regarding the rice syrup reaction, I also cannot tolerate honey or the brown rice syrup. White rice is ok for me though, as long as I rinse it first. I am pretty sure I have a fructose problem, as honey and apples really bother me – they make me super groggy in the morning and also cause GI problems if I have too much (also overly ripe bananas). I tried brown rice syrup (Lundberg brand, the only kind I can get locally), and I also had the morning grogginess problem. It could be you have a fructose problem (fructans are in brown rice). Or it could be the way its made, it is fermented with enzymes, sometimes barley, but Lundberg uses some fungal enzymes so its truly gluten free: http://www.lundberg.com/products/syrup/Organic_Sweet_Dreams®_Brown_Rice_Syrup.aspx

    I would love to try white rice syrup but cannot find a source.

    Hi Naomi,

    Our source for white rice syrup at Amazon seems to be unavailable at the moment but tapioca syrup which should be equally good is available. Dextrose powder is another alternative.

    Best, Paul

  43. Hi Paul,

    I was hoping if you could elucidate as to whether taking VSL#3, a probiotic with an average serving of 300-450 billion cfu is dangerous for a someone without the severe pathologies listed on the website (http://www.vsl3.com/pdf/VSL3Patientbrochure.pdf)

    I have problems with my digestion and overall malaise, trying storebought probiotics hasn’t helped, and i’m not yet at the point of seeking a fecal transplant. I figured i’d try this but just wanted to make sure the dose of bacteria wouldn’t be dangerous. Thank you for any advice on the matter =)

    Hi Michael,

    I doubt it’s dangerous. The colon has trillions of bacteria, so each pill adds a few percent to the bacterial population. What can happen is that with a leaky gut you can get a temporary infection for a few days after introducing the tablet. I don’t think this should be severe, and after your body adapts to the species in the pills it should be OK. But I haven’t tried this supplement and I make no guarantees. I think it may be worth a try, it is easier than a fecal transplant. However, eating fermented vegetables and dairy will give a wider array of species and might be an even better bet.

    Best, Paul

  44. Thank you Naomi, that’s interesting. I was trying rice syrup in the first place because I have a problem with starch but I have been wondering about eliminating everything dodgy except for white rice, just as an experiment, as I assume that it’s the least fibrous and most pure starch of all the PHD safe starches (and I like it the best).

  45. @SGW I agree that eating this way can be stressful. We usually look over the menu online ahead of time and see what we can eat. Usually we have to make substitutions or have them “hold” something. For example, at a Mexican restaurant we had the taco salad – didn’t eat the taco shell, added guacamole, and used the salsa as dressing (the rest was like a normal salad). It’s not always perfect but we try to do our best. It’s a lot harder though when going to someone’s house for dinner.

  46. The plateau range for Vitamin C is around 400g per day. In a traditional diet without supplementation how would one acquire this amount of vitamin c and not go over PHD low fructose guidelines? In times of increased stress (modern day) 400g isn’t even adequate. It takes an average of 2 pounds of various fruits and berries to reach 400g of Vitamin C.

    Thanks for making eBooks available Paul. I purchased my copy yesterday. 🙂

  47. Hi Monte,

    Many fruits and vegetables have about 1 mg vitamin C per gram, so 300-700 mg per pound. I think 400 mg per day would be a pretty typical intake in the tropics, as long as they didn’t cook fruits and vegetables too much.

    But it’s true, vitamin C needs are highly variable and grams or tens of grams may be appropriate during infection, wound healing, or stress.

    Has it been shown that the chronic stress of modern living significantly raises vitamin C needs? I would be interested in evidence.

    Best, Paul

  48. Hi Paul,

    You have provided greatly appreciated advice about solids for my daughter’s seven month old twins. I have just seen the twins for the first time; although they are the same weight (both now average) one twin is tall, strong and has an easy going temperament and good digestion, while one looks much smaller and shorter, sleeps badly, is much more difficult and cannot tolerate eggs, dairy or potato. She often gets rashes around the mouth and in the last twenty four hours she has developed excema on her legs after eating potato the day before.

    She may have been getting mainly formula and the other twin having the lion’s share of the breast milk. She is fine with banana and with rice cooked in diluted bone broth – undiluted bone broth makes them both cry with stomach ache for twenty minutes.

    I have heard stories of children’s eczema being cured when given cod liver oil and also with coconut oil. Would you advise trying the smaller twin with a few drops a day of cod liver oil or coconut oil, say a teaspoon a day? The twins haven’t been given any coconut oil yet.

    Thank you so much for your help and Merry Christmas to you and to Shou-Ching.

    Hi Francesca,

    Well, the problem is probably mainly due to bad gut flora, one of them just has worse gut bacteria than the other.

    I’m not an expert in infant nutrition so it’s difficult for me to give advice. What I would advise for older children would be:

    1. Yogurt and probiotic cultures rich in Lactobacillus and Bifidobacterium species
    2. In low doses, fermented vegetables – maybe drink a bit of the brine
    3. A diet that mimics our food plate

    At seven months immune function is most of the way toward normal, so it should be possible to start migrating their diets in this direction, but cautiously. The concern is that adding external bacteria could create infections. The parents need to be attentive to what foods cause trouble and try to find ways to give good nourishment with minimal side effects.

    Also, I would try to get the infants some mid-day sun exposure on bare skin for vitamin D. Balancing omega-6 and omega-3 is important, minimize the omega-6 (this may require avoiding store baby foods) and provide some omega-3. Balance D/A/K2 — a 100 mcg K2 supplement may be worth considering, maybe grind up a bit of liver in her food for A, aim for 500 IU per day of vitamin A. If she does get cod liver oil get one without vitamin A and give only small amounts, a teaspoon is a lot for an infant.

    I wish I knew more infant nutrition, but I hope this helps.

    Best, Paul

  49. Paul,

    I have a friend that told me she was diagnosed with a benign tumor on her thyroid last spring, which might explain her overweight issues. Although she said the dreaded…I follow a “plant-based diet.” Code: vegetarian. Connection to her health? I responded, I follow a mostly plant based diet too! (by weight) And then told her to buy your book. 🙂

    Should I point her toward your anti-cancer diet article or is the low thyroid, Hashimoto articles more relevant? Both?

    Any diet advice..ketogenic lower levels?

    Last one, another person doesn’t want to eat potatoes because of his previous kidney stone issue?

    Replies can wait until after the holidays of course, but I just wanted to get in line. 🙂

    Merry Christmas and Happy New Year!

    P.S. FYI, I’ve had about 2 dozen friends, acquaintances and relatives go to the site to read about my weight loss article and asked about the diet. Thanks again for the opportunity!

    Hi Jay,

    There are various types of tumor. Often in thyroid nodules develop on the way to Graves disease / hyperthyroidism. I would have a hard time giving advice giving the variety of possible tumors, her doctor must know more. Sending her to a cancer article might be unduly frightening, although our cancer diet advice is good in general.

    In general, I would just advise a healthy diet. Sending her to our food plate and lending her our book would be good. I see no reason to specifically guide her to a ketogenic diet.

    The hypothyroidism category would be the best articles to send her to. I think she should supplement selenium and low-dose iodine. Try to optimize thyroid health.

    The not eating potatoes because of kidney stones has me baffled. I think potatoes should be a good anti-kidney stone food. You might send them to our kidney stone post – see the kidney stone category.

    I’m glad your story is spreading! You’re a great role model. I don’t know many people with your dedication.

    Best, Paul

  50. What’s the verdict on butternut squash, also Bragg’s liquid amino acids? I’m pretty sure the Bragg’s is unacceptable, not being fermented, but am wondering if it’s a real problem used in small amounts. So many of my recipes call for it, and I just don’t like soy sauce as much.

    On another topic, down .6 of a pound in the first two days and am sure loving what I’m eating.

    Hi Judy,

    Butternut squash is an excellent food – we just made soup with it for Christmas day. The liquid aminos should be OK I think; the soy toxins are proteins so if the proteins have been broken down to amino acids it should be detoxified. However, in a quick search I don’t see details of the preparation process so I don’t guarantee it. I think in small amounts it should be fine even if it does have a few toxins.

    Happy to hear you’re enjoying the diet and losing weight!

    Best, Paul

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