Your leaky gut tests aren’t fixing you [PODCAST]

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A teacher came in for migraines and weight loss with a stack of leaky gut test results and a diagnosis that never fixed her. Shiv K. Goel is a board-certified internal medicine and functional medicine physician who argues that leaky gut is not a diagnosis but a physiological response, and that the upstream driver is often chronic stress and a dysregulated cortisol rhythm. This episode is based on his article “Why your leaky gut tests aren’t fixing your symptoms,” published on KevinMD. You will hear why a normal scope and an IBS label can still leave a patient uncured, why no single permeability test is reliable on its own, and why objective results still matter because they drive patient adherence. He explains why he reaches for sleep, stress reduction, and targeted support over a generic supplement stack, and why you should neither dismiss patients with normal labs nor over-order unvalidated panels. Press play to hear why the fix starts with the story behind the symptoms, not the next panel.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Why your leaky gut tests aren’t fixing your symptoms.” Shiv, welcome back to the show.

Shiv K. Goel: Thank you for having me, Kevin. Thank you.

Kevin Pho: All right. What made you write this latest KevinMD article?

Shiv K. Goel: I wrote this article because of the kind of patients I see in my practice, and I wrote specifically about this patient I give the name of Irene. Usually the patients who come to my clinic either already have a bunch of testing done by these functional lab companies, things like serum zonulin panels through direct-to-consumer labs, and they are convinced that more testing equals more answers and a matching pill to fix it.

Or I see the patients who come in with something unrelated. They do not even know what leaky gut is. They may have irritable bowel syndrome or IBD, or any stress-induced GI cramping, dysbiosis, or something unrelated. Like Irene, she came in with the complaints of a migraine. She is a 36-year-old teacher who had already had an extensive GI workup done.

She was already diagnosed with irritable bowel syndrome. She had been scoped two times. She was found to have a diffuse inflammation. She came in because she wanted to lose some more weight, and that is when the story started to unfold. I decided to write it because I thought that there is so much misinformation out there about leaky gut syndrome, whether it is really a diagnosis, what tests are available for it, and how we deal with it. Even with a well-documented gastroenterology chart, we can still miss what is driving it, what is upstream of the leaky gut, because leaky gut is not a diagnosis as such.

It is a physiological response, where our gut has increased permeability. So that is why I wanted to write this article.

Kevin Pho: So give us some context on leaky gut, and as you alluded to, it is a controversial term. There are a lot of conventional physicians who dismiss the term and say leaky gut is purely a functional medicine term and that it is not real. Now, you are both internal medicine and functional medicine. For those who are not familiar with that concept, from your perspective, what is leaky gut?

Shiv K. Goel: So leaky gut, to be honest, is not a diagnosis, and it is what you make of the symptom. It is a physiologic finding we document. Like in Irene’s case, her full panel showed an elevated serum zonulin level, positive LPS antibodies across IgG and IgA, a depleted secretory IgA level, and an elevated fecal calprotectin.

So why do a lot of GI physicians not consider it? Because it is not a diagnosis, it is like a physiological response, such as in conditions we can name like a chronic inflammatory bowel disease, Crohn’s disease, or anything which inflames. It increases the gut permeability, which causes inflammation, which causes endotoxins from the gut bacteria to go into the system, which in turn results in issues.

So the GI doctors, they do not mirror those things, so for them it is a chronic inflammation. From their point of view, it does not matter to them. But there are studies done across the board about how we can fix it. It is not about doing a test or giving a pill which can fix it. There is not a solution. Testing is just to confirm whether there are underlying physiological changes which are happening in your gut, and what the upstream root cause of those changes is, and how we can fix it.

Kevin Pho: So you mentioned that the GI physician did scope her and found some inflammation. What do you say to those colleagues who argue that the scope already gave the answer to the diagnosis?

Shiv K. Goel: The scope showed the inflammation, but it does not mirror what the inflammation is actually doing to the patient. Is every inflammation which happens causing you to have leaky gut or increased permeability, or not? How do we know that? That is why, because it does not mirror your zonulin level, or whether bacterial endotoxemia is happening or not. That is why we check your LPS translocation, and then we check the underlying cause of it, because they found that the inflammation is happening. If we do not know why the inflammation is happening, and in order to know that the inflammation is causing this issue, then we can know what the upstream cause of that is.

Like in her case, she has a severely dysregulated HPA axis. Sustained high cortisol throughout the day is kind of a flat curve. There are studies, and a lot of research has been done about it, about how sustained cortisol levels can cause your secretory IgA level to go down, and it can also cause a dysbiosis. It can cause increased permeability of the gut and inflammation.

So all of that is a downstream effect of something which is happening. And just by naming inflammation, inflammation can happen without you having the leaky gut as well.

Kevin Pho: So you mentioned some of these tests, and these are not tests that physicians typically order outside of functional medicine. Zonulin, LPS antibodies, secretory IgA, those are tests to check the permeability of the gut that functional medicine prescribes. So if those tests come back positive, like you said, what are some of the next steps? Because you said it is not as simple as giving a pill. So what do you do with that information?

Shiv K. Goel: So that is where it is a story. It is the patient. We have to find out what the real cause happening is. That is what I believe in. We do not treat a symptom, because even the leaky gut is happening because of underlying reasons. So that is when we did further testing. We did her cortisol curve and everything, and we found out that she has a severe stress.

When I listened to her and everything, it took me time. It is not that the first time only I decided that everything was there. It took me time to understand her story when she came in for the follow-up, and then I ordered her the testing to understand, because the GI doctor, they found the inflammation, but she was not cured. Her issue did not go away. And irritable bowel syndrome is also not a real diagnosis as such. It is like, I do not know the cause of it, so it is something like an idiopathic inflammation.

Kevin Pho: So once you have that information, you mentioned that you talk to them once they get the data back. Now, from that patient standpoint, if their gut is more permeable, what are options that they can do? What are some treatment options outside of conventional medicine that they can do?

Shiv K. Goel: So one is first the cortisol level, through circadian rhythm anchoring and HPA axis support. What does that mean? That means finding out first through the history what the patient’s stress pattern is. Are they having good sleep or not? What time do they wake up, what time do they go to bed? What is the quality of their sleep? Do they get any sunlight or not? Are they going to bed at the right time, or are they waking up at certain times? And by fixing those issues, and by incorporating certain exercises such as deep breathing exercises, such as mindfulness, such as relaxation techniques, and by giving certain supplements, and there is evidence for that, such as L-glutamine, zinc carnosine, magnesium, and some Saccharomyces boulardii, and sodium butyrate.

So they all help in putting your gastric lining together, as well as curing the underlying issue with that too. And also, sometimes we do a targeted antimicrobial treatment for the dysbiosis, which we guide by their GI Map sensitivities.

Kevin Pho: So by decreasing the cortisol level through some of the things that you mentioned, sleep, decreased stress, deep breathing exercises, that can improve the permeability of their gut. Is that what I am hearing?

Shiv K. Goel: Not just that. That actually only helps with that one reason, high cortisol, if it is a persistent high cortisol which is causing so much stress on the adrenal gland. Because if you see in the adrenal axis, from DHEA to pregnenolone, it is like a downstream of everything, whether it goes through the cortisol, whether it goes through the hormones or the immunity or everything.

So when we have severe stress continuously happening in our life, acute stresses or chronic stress, then it kind of goes in one direction. So your immunity goes down, our insulin resistance increases. We start having weight gain, metabolic syndrome, more GI issues start to happen. And so all of these things happen because of that.

So by fixing that thing, and by also curing and taking care of the leaky gut at the same time, we are not just taking care of what the leaky gut is, but also curing what the root cause of it is. If we just take care of this and we do not take care of the underlying issue, it is not going to go away. So that is why we incorporate zinc carnosine, L-glutamine, or we have this antimicrobial treatment for the dysbiosis and everything else along with that.

Kevin Pho: Now, what do you say to the critics who say that there is just not a lot of evidence that shows that these diagnostic tests and measuring these things for leaky gut, there is just not a lot of evidence that backs it up? So what do you say to those critics who say that?

Shiv K. Goel: So here is the thing about all the testing, and I agree with that. There is no one best test, because the zonulin test is not even the best test. What the evidence is, is that we should be measuring the pre-haptoglobin 2 level, but instead what the lab companies measure, they measure the haptoglobin 2 level or the C3 level, which is not exactly the same as what zonulin is, which is pre-haptoglobin 2.

And that is why we have the other tests, such as the lactulose-mannitol ratio urine test for that. But even that is also not very accurate. But that is why we do every other test like LPS antibodies and everything, just to have a map of everything, whether the person really has it, and along with that we see what the patient’s personal lifestyle is.

Everything in medicine we do, we are doing to make sure that what the patient is telling us, their story, correlates with what we see in the testing. We do not have to do any test. The point is that if we do not do any test and we do not show it to the patient, their own adherence to the treatment plan would not be that effective.

If we tell somebody, “OK, you have to do this, this, and this. This is what I think it could be,” me thinking something is not going to be a solution. We have to give them some objective evidence for that.

Kevin Pho: So are you saying that sometimes the relationship that we have with a patient goes beyond the evidence? Sometimes patients need to see objective measures to support the narrative behind their symptoms, even though those measures themselves have not been rigorously studied?

Shiv K. Goel: No, they have been rigorously studied. It is like when we check a GFR. We do a blood test and we check the serum creatinine level. Is it the most sensitive test to determine the GFR? No. But almost every time it gives us a fair idea, OK, this GFR should be around this.

We check people’s lipids, like a normal lipid panel, and we see that, OK, this is their LDL, this is their HDL, this is the ratio. And 90 percent of the physicians, based upon that, if the LDL/HDL ratio is OK, they think that the patient does not have much cardiovascular risk. Now, the evidence shows we have to check their ApoB level, because that is the one which actually decides it.

So the point is not that we have to check. The point is that it gives us a fair idea about what is happening. And when we follow up, suppose we started all the treatment protocol, how would we know that it is actually benefiting the patient? Number one is by their symptoms, that they will clinically feel better. But just their feeling clinically better does not mean that the exact issue has gone. So that is why sometimes, one or two times, we can repeat the test to make sure that it is going in the right direction.

Kevin Pho: We’re talking to Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Why your leaky gut tests aren’t fixing your symptoms.” Shiv, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Shiv K. Goel: Yes. So my take-home message is for the physicians out there: Listen to your patients. We do not have to order the test every time. The treatment should target the identified driver first, whether it is gluten elimination for celiac disease, whether it is disease-specific therapy for IBD, or stress reduction strategies like sleep, movement, or mindfulness-based approaches for stress-driven dysbiosis and cramping, rather than defaulting to a generic gut-repair supplement stack.

And do not dismiss the patient with the normal labs, or those who have been told that their scope is normal. And you do not have to over-order unvalidated zonulin panels for patients either, because permeability testing has a really narrow role in a specific diagnosed condition. But a single blood marker on a functional medicine panel is not a reliable way to diagnose or chase the leaky gut in isolation.

Kevin Pho: Shiv, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Shiv K. Goel: Thank you for having me, Kevin. Thank you.

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