Welcome to the Art of medicine, the program that explores the arts, business and clinical aspects of the practice of medicine. I'm your host, Doctor Andrew Wilner.

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Pas and NPS at locum story.com. And now to my guest today I would like to welcome Courtney Cowie. Courtney is a nutrition therapy and functional diagnostic nutrition practitioner.

She helps people struggling with chronic and mysterious digestive problems when conventional medical approaches fail. Disorders such as irritable bowel syndrome are not well understood.

And Courtney is going to tell us how her approach can help. Welcome Courtney Cowie. Thank you so much, Andrea. It's a pleasure to be here. Courtney, thanks for joining me.

I see there are a lot of letters after your name. No, I've accumulated a few, but. And no one ever knows what they mean. So let's start with your background in training.

Yeah, absolutely. Yeah. So, my original training in the field of nutrition was through the Nutrition Therapy Association. I got certified as a nutrition therapy practitioner, which was an excellent start.

And I still use those skills to this day. Really deep dive in using whole foods, ancestral diet type templates, nutritionally speaking, to try to restore chronic health issues and support the body with a vitamin A nutrient dense diet.

I was originally trained to do even a little bit of, lingual neuro testing, which comes originally from like osteopathy, chiropractic decades ago. So that was really cool.

And then years after that, I got into running functional lab testing. And so the certification I got that gave me the skills and know how to do that was through functional diagnostic nutrition.

So that led me to become certified as a functional diagnostic nutrition practitioner. And that was really helpful because I was starting to see in my practice a lot of clients that would test well for certain, say, supplements, if I was doing lingual neuro testing, but then I'd send them home.

They would try these things that have adverse reactions, complications, and just generally these people were showing up in a more complex picture. So I felt as deep down I need to do some more black and white kind of data data gathering on them to really understand the full picture.

So that's what kind of led me to that. And then more recently, I went and got training as a health coach through Precision Nutrition. And that was a really excellent program as well.

And it kind of helped me get a skill set around how to really motivate and coach clients to sustainable behavior, lifestyle, diet change, which, believe it or not, I really think is underrated in the holistic health sphere.

I think a lot of clients really need support in that area and don't have a good resource for how to do that, and if those behaviors aren't in place, it can be really, really hard.

No matter how good your testing is, no matter how much great nutrition education or advice you're giving, if people don't know how to sustain, those things are ultimately going to fail time and time again.

Well, knowing and doing. It's like exercise, right? Everybody knows they should exercise. But how many people actually show up at the gym, you know, five days a week, right.

So and food well we're going to get into that. You know, I mean there's two classes of food, right? I mean, there's healthy food and there's junk food.

Yeah. But there's a lot of gray there. You know, in between that I think people don't, appreciate. Now, before we get into this, I, I saw a New York Times article.

I think it was yesterday. Yesterday or the day before that was indicting the ultra processed food industry as basically poisoning us. And everybody's overweight because we eat ultra processed food.

And it's not really your fault because that's the food that's out there. And we need to label ultra processed food, you know, as toxins. I'm paraphrasing a little bit, but this that was the gist of the article.

But it dawned on me at the end of this, and this is where you come in this. I don't think I even know what an ultra processed food is. I know it's not a carrot, right?

Yeah, but beyond that, I mean, what are they talking about? Yeah, that's such a great question. And I don't know that there is a real hard and fast definition to that.

But it's interesting you're asking me this because, in my work with clients, I actually write in the beginning and spend time teaching them what processed foods are.

And it can be surprising. I would honestly qualify processed foods, not ultra, but just regular processed foods as anything you find in the grocery store that has a wrapper or packaging on it.

I mean, simply put, right, like it's something you can't go out into your backyard garden and get you can't source it direct from an animal you get from the farm.

And in some of these processed foods are higher quality and more nutrient dense, to be sure. And then I think within that processed foods range, you're right, Andrew, like there's this whole spectrum of foods that are really pretty toxic that have a lot of just artificial fake, even in some cases, ingredients that just have not been put in food ever in the food supply in them.

And those are the scariest of the processed foods. Right. So now, should we avoid all processed foods? In other words, if it comes in a package, is it still okay?

What about a package of, you know, cookies? Cookies are okay or you need to bake them yourself? Yeah, that's such a great question. So I take a very, like, practical and, human centered approach to my work with clients.

Right. And so I think, realistically speaking, most people in today's world don't have the bandwidth to cook every single thing that they consume from scratch.

Right? So, really, the way I approach that with clients is very individualized. And so I sort of start with where people are at. If someone's eating mostly processed foods, we talk about simple ways to start to incorporate some easy prep real foods.

And it could even be things like couple servings of fruit, a couple servings of vegetables that are easy to just whip up and have ready to go with a meal.

And then within the spectrum of convenience or processed foods, I spend quite a bit of time educating clients on how can we upgrade the processed foods.

You're already eating to higher quality choices that don't cost you any time, but they're going to be an automatic increase in nutrient density and the quality of the food.

So I feel like most of us can live in that space where there is some processed foods we can rely on to make our meal prep time more efficient and not cost as much time.

But ultimately, yes, we do need to have as many real foods as we can realistically incorporate into our diets every day. And the question is just like person to person, how much is that possible?

Right. All right. I think we're going to get back to this. But I don't know, I'm a little embarrassed, but I don't know what a functional diagnostic nutrition practitioner is.

Yeah. Okay. Yeah. So that training essentially is a functional nutritional training course. Right. That aims at teaching the foundational the FDA and foundational labs.

And so those specific labs are looking at what's going on with the digestive system. So we we get trained in a very specific foundational stool test called the GI map.

We tend to learn adrenal profile testing. And there's different ways to do it too. Andrew, just kind of speaking very simplistically here, to look at the body's stress response through the HPA axis.

I know that's a fancy term, but we'll just say stress response for simplicity's sake. Hormone balance in the body. And then we also look at factors like whether or not the body is breaking down protein properly, digestive function in other capacities, oxidative stress, which can give us an indication of accelerated aging and DNA damage and breakdown of the body, and then leaky gut profile, which tells us whether or not within the gut we've got, you know, mucosal barrier breakdown, which can then set the stage for systemic inflammation issues, whether that's chronic pain, headaches, autoimmune stuff, kind of the whole nine yards.

And so that's sort of the the backbone of that training. And then from there there's additional training that FDA and practitioners are offered to be able to increase the labs that they understand and can run with clients.

And of course, like a lot of functional training. And so there's a lot of education in, you know, using nutrition and diet to support client, health outcomes, teaching them, behavioral change, you know, how to optimize sleep, how to manage stress on a, on a basic level, right.

We're not diving deep into, you know, specific types of, like, stress techniques per se. But, that's how I would I would qualify that training that on the FDP side now in medicine, you know, as a medical, as a physician, when we use the term functional, it often, implies psychiatric, in other words, that it's not anatomical, it's not physiologic, it's functional that, I don't know how that word sort of emerged, but we say, well, this is a functional problem.

That means everything checks out fine. Yeah. Now, but you're using it a different way. You're using it actually as a body function that you're measuring.

Is that right? Yeah. That's right. And I don't know that there's like one right way to really like, describe these tests. Sometimes I'll just describe them as specialized lab testing.

It's hard to kind of give them like a specific name that makes it clear to everybody you're talking to. Right? Because a lot of people, just regular people out in the world, think a test is a test. This is a test.

And so often I'll have to explain to them, these aren't the types of tests that your doctor would would run for you because they often, most of the time aren't covered by insurance.

And so then we have to talk about like, what are the data points that these tests are looking at. Like why aren't they covered? Like what is the difference?

And so yeah, I'll sort of rotate terms between specialized testing and root cause testing, functional testing, kind of all of those really to describe them.

So I mean, just to be clear, these are a little outside the mainstream of accepted science. Is that right. So I wouldn't I wouldn't necessarily say that.

I would say that within, what's kind of been deemed the norm in the conventional medical setting. Right. These wouldn't be tests that doctors necessarily would always give credence to or be trained to run because, you know, and again, without going into like, what does insurance cover and why do they cover certain things versus others, right.

Like these would be tests that go more so into looking at, data points that maybe aren't as relevant or considered as relevant in the conventional medical sense.

And so in that regard, a lot of times doctors don't really have an interest in running them or don't think they're they're going to be worth much of much, or insurance companies aren't willing to cover them because they can't connect back to, you know, specific diagnoses.

And that's really the difference between, functional health and nutrition practitioners is that we're not diagnosing and treating anything. We're generally looking to help clients, you know, connect their symptoms to imbalances that make sense to explain the symptoms and, you know, walk back that that unwell this state they're in to a better place of health.

Right. So it's it's it's that kind of fine line that we're walking in the, in the nutrition holistic health sphere here. Okay. Well let's talk about irritable bowel syndrome.

Yeah I remember I had some patients with that and they they were just miserable, you know, and a lot of them sort of were you know, they they always had stress and psychiatric symptoms.

And it was always kind of hard to sort out because you could see how somebody who, you know, some of them would say, you know, wherever if I go anywhere, first thing I do walk into say, I don't know, I'm going to, a wedding or I've got some event.

It's like, where's the bathroom? Yeah, like that's number one. And so, you know, they have this heightened anxiety and, it's kind of a vicious cycle, right?

They're anxious because, you know, they never know when they're going to have a cramp and have to go to the bathroom. And then that anxiety can also aggravate the, the, the GI problem.

And, they become miserable. So where are we, though? That was a long time ago in medical school. I'm a neurologist, so I usually stay, pretty much above the neck these days.

But, where are we with understanding, irritable bowel syndrome? Yeah. I mean, I can't speak as much from the conventional medical side of things other than as a patient in the system.

Obviously, for many years before I got into doing the work I do now. But I, you know, to my understanding on that side of things, I think there's still a lot of lack of understanding of what's really driving that, really.

It doesn't really have the specific diagnostic criteria. When traditional testing like endoscopy, colonoscopy is done. They're not really seeing abnormalities that would explain any disease state.

So the symptoms are there. But there's nothing that can really be, you know, attributed to. So, you know, on that side of the spectrum, that's where that IBS label or diagnosis will often come in.

You know, on the functional side of things, that's where running some of these different tests can sometimes show different data points that, you know, when we're trained to look at, you know, how do these different data points correlate with different functions in the body, can actually relate back to like, oh, this would explain why you're having all this bloating or this bowel urgency.

And so that can be very helpful. And then I think the other big piece of that whole puzzle is the nutritional guidance piece. Right. And that's where at least my experience in the, conventional medical system is that a lot of doctors didn't have a deep training or understanding of how to advise their patients to eat to remedy those symptoms or support those symptoms.

And so I think that's where there's a there's a big opportunity for like nutritionists to come in and help support and say, look like here are some approaches that are shown to work well, other than maybe some standard handouts they could give, like the low Fodmap handout for Monash University.

That certainly is possible in the GI doctor realm, but like usually it doesn't go very deep there. And so one of the things that is really, just fulfilling in the work I do with clients is really helping them navigate, like, here are the foods you're eating, and these are some of the possible reasons why you could be having those symptoms.

Let's start to create a plan to maybe make some adjustments here to get you some symptom relief. So I think nutrition is really foundational first and foremost to help those people with IBS for sure.

I wonder if, I'm just thinking out loud here if, migraine is, parallel. You know, when you do patients a migraine, they'll all the testing is always normal.

You know, MRI is beautiful. And, but, diet and, triggers are different for every patient, and, and that's why they can be hard to, to identify, because, if you go, you know, if you Google migraine triggers, there's hundreds of them, but they all don't apply to every patient.

And also they all don't apply every day. And now we're at some patients made a piece of dark chocolate and get a headache. But only three out of five times, you know, the fourth time and the fifth time they might get away with it.

But, so it's kind of hard. You have to really study your diet to identify, the triggers. Wine, cheese. You know, these are the classic ones, but, you know, airplane aviation fuel.

There's all kinds of wild things that will trigger a migraine in certain individuals. But. And then why that is, still kind of a mystery. So I wonder if in, the bowel sort of setting, there are triggers that are difficult to identify because maybe they don't trigger every time.

Yeah. Did you do you find that so I yes, I do think it can be hard to identify these things like point blank. And I think the body is interesting because I do think that there's a compound effect of some of these food triggers to where, you know, in combination, if there's a number of them.

And over that period of time that that client is eating all those foods, they're more likely to potentially have an overt reaction. The other thing that we also think about, too, is just like delayed sensitivity reactions, which can be harder to track because sometimes the the food trigger is consumed.

But then there isn't this immediate, you know, response or symptom that gets created within an hour or 2 or 3 of having it. And so it is hard. And one of the things I tend to tell my clients is that, you know, if we're looking at this from like an immune activation against these foods standpoint, some of these antibodies will actually stay elevated for a long time in the system.

If you're eating these foods continually and your body doesn't like them, right. So it's it's an interesting thing. I feel like there's adaptability and some of that signaling and an ability to perceive those triggers does get a little bit, sort of confused or dampened when they're always being eaten and consumed.

It's like they're creating problems, but the person's ability to sense what's connected to that is less versus when they remove the food trigger. If they suspect it for a period of time and then reintroduce it.

A lot of times, it's like the slate gets wiped clean and they'll be like, oh my gosh, now that I haven't had, you know, say chocolate for three weeks and I'm trying it again.

Wow, I really notice I'm not feeling so hot. So that can be an interesting experiment is to run with clients to kind of validate is this a problem? Is this not a problem? Right.

Can healthy food be triggers? In other words, could it be an apple? Could the apple? Actually, even though it's pretty wholesome, could an apple be? In other words, it's not just a matter.

We're talking about ultra processed foods earlier. It's not just a matter that these are, quote, toxic or, you know, synthetic or additives that it could even be, healthy foods that are triggers in some individuals.

Is that right? Yeah, 100%. Yeah. Exactly. And that's the hard part about conditions like IBS and IBD is a lot of times those folks intuitively have tried to, improve their diet and choose better foods because they've not had a great diet potentially historically.

And it's a lot of those very foods, whether it's because like an apple, for example, is high Fodmap food, right? So a lot of what what was it like to use, high Fodmap, high Fodmap.

So the, the low Fodmap diet is is kind of the the quintessential diet that's often out of the gate recommended to people with IBS. And it's these certain like sugar components that are in some of these carbohydrates, fruits and vegetables that in higher amounts in some of these foods can trigger these IBS symptoms.

And so there's this entire, you know, Fodmap containing foods list. A lot of GI docs will just have these handouts on on hand if clients or patients come in.

And so, you know, the case of the Apple is a great example. It's a high Fodmap food which could potentially actually be more triggering to somebody with IBS.

And if they've got a really inflamed gut, it could be potentially the fiber content of the apple. If they're having trouble digesting fructose, that could be a component too.

So it can be hard to even know with a given fruit food, what is that specific thing that food contains that's actually triggering the gut? Because with the apple, I could think of three possibilities right there that might be setting a person off. Right.

All right. Let's do some definitions. IBS and IBD. What's that? So irritable bowel syndrome is IBS. And then inflammatory bowel disease is IBD and Fodmap.

Fodmap is you're going to really try to see how those ships are used to these acronyms. I want to say it's, fructose oligosaccharides, disaccharides, monosaccharides and polyols I believe is what the acronym stands for.

Well, I think the point there is that food is complicated, right? Yes. That's the, there's a lot going on there with, food. Just to segue a little bit, do you, do you deal any with children who are picky eaters, for example?

You know, there are kids who just won't eat this or won't eat that when they should. And maybe it's the texture, or maybe they're just stubborn. I mean, who knows?

Is that fall into your, area? I don't know if I would necessarily say that that's IBS, unless they're having actual, like, digestive symptoms on top of that.

But certainly that's, an aspect that has come up before in my work, whether it's a parent that's wanting their child to do some work with me and then always, you know, inevitably the parents also doing the work too, at that age, if they're really young. Right.

But I would definitely suspect that there could be some degree of digestive dysfunction or imbalance going on in the gut that could be driving some of the picky eating behaviors, because kids are pretty, pretty intuitive eaters.

Now, I feel like a lot of that is also the model they get at home. And you know that early start to life. Are they introduced with whole, nutrient dense foods?

Are they given a lot of processed foods that can obviously shape their food preferences as well? So, I wouldn't say it's necessarily an IBS type of scenario, but it certainly could be a part of it.

What about excessive weight gain or weight loss? Do you is that part of what you do? Yeah, I've definitely dealt with that as well. I would say that mostly it's the the weight gain issues that I see, not surprisingly, right, in the United States with my client population.

And what some people don't realize is that that can play a direct part in having, imbalanced gut function or abnormal gut function, particularly nutrient absorption, because if someone isn't breaking down their food well or absorbing their food well, typically their body can't get the nutrition it would normally and normally when that happens, metabolic rate slows down to compensate because that nutrition just isn't coming in to feed the cells, to work at their, you know, optimal capacity.

And we know when metabolic rate slows down, that's where the body starts to conserve energy and hold on to extra weight. Right. And so, even though a person might not be having any digestive symptoms, I could certainly be playing a role and could be a piece of the puzzle and trying to help them.

Right. It does seem to be the snowball rolling down the hill that the more weight you put on, the harder it is to lose, and the more weight you tend to put on.

Because it's hard to exercise when you're heavy and you're sort of in the habit of eating, and then your body, as you say, is metabolizing even more slowly because now you're bigger.

And, so everything is sort of working against you the bigger you, get. Yeah, exactly. So that that's a big, challenge, so huge. So. All right, tell us a success story.

You had a patient who was X and Y happened. Yeah. So, names, no names, no names, of course. Yes. Very much specific client that I'm thinking of who is very health oriented, too.

She was, in her, like, part time fun job. She was a trainer for other people and was in a group of, of like a Facebook group with these other trainers.

And they were together doing like, I think it was some sort of like, plant based diet challenge. And she was trying to do that for a while and was feeling worse and worse and worse and was connected with me on Facebook.

And so she finally reached out and she's like, I don't know what's going on. This is working for everybody else. It isn't working for me. Decided to start working with me, and she was having a lot of the classic IBS symptoms, you know, urgency, having to run to the bathroom potentially multiple times a day, the bloating, the stomach discomfort, especially later in the day, which is common with these things because as food doesn't get digested, it sort of ferments and bacteria ferment it.

And then that bloating gets worse and worse and worse. And so she, you know, started and we looked at her diet. And of course, I guided her through some diet changes that weren't plant based because obviously she had tried that didn't work for her.

And she started to get some relief. And then on top of that, we did run some, some specialized testing on her to get some data points. And sure enough, on the stool testing I ran, I could see she had overgrowth of certain bacteria in the gut.

And I said, you know, this is probably a part of the puzzle for you, because if we've got too many bacteria in the gut, that's where they can really go.

Have a party and ferment your food and create all this bloating and, you know, bowel issues. And so we we put together a strategy to try to support, balancing that out.

And by the end of that process, I would say generally it takes a few months of working with someone to kind of slowly make these changes, have the body respond.

She was feeling much better. Her bowels were normalized. She sent me a text like at one point, in the latter half of our process saying, oh my gosh, I can't believe how much energy I have.

I'm not on the couch anymore. At the end of the day, totally fatigued and exhausted in pain. So. So that was huge. That was a huge, huge change. And of course, she was a mom and she had a full time job on top of that too.

So just to be able to help somebody get back to that level of function and just enjoyment of life was really, really fulfilling. So it it wasn't one thing, you know.

Yeah, it was multiple things like and she like I said, she was a pretty good eater, I'd say, compared to the average person. She was ahead of the curve.

But there were some foods that in her situation with the way her GI was working, weren't working well for her. So we had to help work on that to give the symptom relief and then look for deeper data points or issues that would explain why she wasn't digesting her food well or absorbing it well, and try to work on those factors as well to get that that level of resolution.

Okay. Well, I think that helps answer my last question, which is who should go to a functional diagnostic nutrition practitioner? You want to wrap that up for me?

Yeah, absolutely. I would say if you've been struggling with a chronic issue of any sort. But I mean, we're talking digestive particularly today. So if you've if you've got a chronic issue and you've been down the conventional road of trying things, trying medications, trying diet, change yourself, maybe even trying supplements and you're not getting the relief you want and you still want to get to the bottom of this and hopefully try to resolve it without being dependent on a medication for life to help manage it.

That's the perfect person, really, to kind of look into this type of work and, and go down this process. And how can people get in touch with you? Best way would be through my website, which is super easy.

Just my first and last name, Courtney cowie.com. Oh, good for you. You got you got in there got in there early. Well is there anything you'd like to add Courtney, before we close?

Just that if you're listening and you have IBS or you have IBD and you're looking for a simple, easy starting point that's nutrition oriented, I do have a free PDF guide.

If you go to my website that you can download. And, I've gotten a lot of rave reviews on it. So I would encourage you to check that out as a resource.

Very generous of you. Courtney Cowie, thanks for joining me on the Art of medicine. Thank you so much for having me, Andrew. It was such a pleasure. And now a final thanks to our sponsor, Locum Story A.com locum story.com is a free, unbiased educational resource about locum tenants.

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Thanks again to Locum story.com for sponsoring this episode of the Art of medicine. I'm Doctor Andrew Wilner. See you next time. This program is hosted, edited and produced by Andrew Wilner, MD, FRCP, FAA, and guests receive no financial compensation for their appearance on the Art of medicine.

Andrew Wilner, MD, is a professor of neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Views, thoughts and opinions expressed on this program belong solely to Doctor Wilner and his guests, and not necessarily to their employers, organizations, other group, or individual.

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Holistic Nutritional Health with Courtney Cowie, LBT

Andrew Wilner, MD, FACP, FAAN

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