Adapted from episode 52 of The Perfect Stool podcast and edited for readability.
Lindsey:
Today, I’m talking with Dr. Miles Nichols about a couple topics that haven’t been covered at all or fully before on the podcast, including peptides for gut health, breathing, parietal cell antibodies, as well as having an in-depth discussion of recurrent SIBO and one potential cause, nasal infections. Dr. Nichols is a functional medicine doctor specializing in Lyme, mold illness, gut, thyroid, and autoimmunity. With a doctorate in oriental medicine, he has extensive training and expertise around herbal medicines and has developed formulations used by functional medicine doctors across the country. Dr. Miles and his wife Dr. Diane Mueller, who appeared on my podcast in episode 43, co-authored “Use Your Mind to Heal Your Mold and Lyme” and “Stress Resilience”. They founded the Medicine with Heart Functional Medicine Clinic in Colorado and also the Medicine with Heart Institute that trains other doctors in functional medicine.
So, we’re actually going to start by launching into a topic that no one including myself has so much as mentioned on the podcast so far (and I’ve been going since late 2018) and that is peptides. So, can you start with an explanation of what peptides are and then how they can be helpful to people with gut conditions.
Dr. Miles
Absolutely. Just like proteins are made up of amino acids, peptides are specific chains of amino acids that have specific effects in the body. And unlike a protein, which are bigger amino acid chains, they’re typically smaller amino acid chains, some of which are produced by the body. One of the most well-known peptides, it’s been known for many, many years, is insulin. Of course, people know that insulin can be lifesaving when someone has type 1 diabetes, because they’re not producing that anymore.
There’s many peptides that are made by different glands in the body, by the thymus gland for the immune system that starts to become more withered up over time as people age. It doesn’t produce those peptides as much anymore. Peptides can have functions that are a little bit like hormones, but they’re not quite hormones. In fact, some peptides can stimulate the production of hormones. So, there’s growth hormone releasing peptide, for example, which can stimulate the production of growth hormone in the body, and then that can lead to repair and that repair could be in the gut, it could be other areas of the body. As we age, we tend to produce less growth hormone, have less ability to repair the body. Peptides are one way to help restore almost like a youthful function in the body’s ability to repair and heal tissue with relation to the gut. In specific, we do have some peptides available that can have an effect directly on the gut by taking a peptide orally. A lot of times they have to be injected, but there’s, for example, one peptide called BPC-157* (25% discount at Tailor Made Health available as of 7/28/21 with code TMH25) that can be taken orally and stimulate tissue repair through the esophagus, stomach and intestines. We use it a lot for intestinal permeability, or for people who have acid reflux issues and are trying to get off of an acid blocker medication like a PPI, which can be very damaging to the gut. If they’re struggling with that, BPC-157 can be a real significant help to them in those cases.
Lindsey:
And do you also use it for things like IBD or Crohn’s?
Dr. Miles:
Absolutely. And there are some that have immune modulatory mechanisms that have been shown to be effective with certain autoimmune diseases because they’ll regulate the TH17 and the TH1 and TH 2 balance and also some that are highly anti-inflammatory in a similar way to steroids, but without suppressing the immune system on the beneficial side like steroids do. So, for example, KPV is one peptide that we’ll use that’s highly anti-inflammatory, that gives us some of that benefit that people might get from taking a steroid. But it actually doesn’t negatively impact the part of the immune system that defends against pathogens, and that helps with fighting off infections.
Lindsey:
Is KPV also available orally?
Dr. Miles:
It is available orally now as well, there’s actually very few that are available and have shown good data on that they metabolize well and have good effects orally. And luckily KPV is one of those that can also be taken orally.
Lindsey:
And how do you source peptides, do you use the Tailor Made Health BPC-157*?
Dr. Miles:
Tailor has a compounding pharmacy and then they also have a side that is starting on developing some supplements, and peptides are in this gray zone where in the pharmaceutical world they’re sometimes considered as a supplement. Depending on the size of that amino acid chain is part of how the FDA is regulating it and that’s changing rapidly. It keeps changing on what’s considered to be a peptide that can be even sold by compounding pharmacies. So there’s a lot of moving parts to how peptides are available. But I do use Tailor Made as one of the big suppliers. We’ll do their compounding pharmacy side for a lot of the peptides and then they also have the Tailor Made Health side, which has the supplements like the BPC-157 in capsules. KPV is not available on that health side right now. It’s only through the compounding pharmacy side.
Lindsey:
So is that only prescription for KPV?
Dr. Miles:
Right now, it’s only prescription. BPC-157: again, it’s in this gray zone and who knows what’s going to happen. Any day now it could change but right now it does appear that it can be considered a supplement at this point.
Lindsey:
And so, is that targeting mostly then the small intestine and the stomach? Because you mentioned things that I associate more with the upper part of the digestive tract – BPC-157 that is.
Dr. Miles:
So, BPC-157, there are some mouse studies that are looking specifically at that area, the esophageal area, but there are also studies that are looking at the heart and BPC-157, the brain and BPC-157. It does enter the bloodstream, and it becomes systemic and can affect stimulation of repair mechanisms throughout the entire body. So, it would impact the full intestinal tract as well as even other organs and tissues. It’s being used post-surgery for repair. It’s being used post traumatic brain injury, because it can cross the blood-brain barrier. And it can have some impacts inside of the brain as well.
Lindsey:
So, it’s kind of just an all-around body repairing peptide?
Dr. Miles:
It is, and as it touches the areas that it does touch it might have a stronger effect when it stimulates that repair mechanism. It might start local, but then it goes into the bloodstream and it becomes systemic.
Lindsey:
And so how long a course of something like BPC-157 and what dosage would you put someone on to really give it a good try and see if it would make a difference?
Dr. Miles:
Yeah, it really does depend on the condition and what all else is happening with the person. Usually we’ll do a two-month course, sometimes one month to get a feel for the impact that it’s having. Often if we’re using it for something like stomach lining and esophageal issues, it might even be shorter than that; we might not need quite as long. But if we’re using it to get to something more systemic, there’s been a lot of damage to tissue from an autoimmune condition like Crohn’s or Ulcerative Colitis, then we’ll probably want to see at least two months to get a good sense for if it’s going to have a positive benefit.
Lindsey:
And will you see for example, bloody stools clear up with IBD after using it? What kind of impacts have you seen in your patients?
Dr. Miles:
In particular, with KPV for IBD, KPV tends to be a little more of my go to although I will use BPC as well. In those cases, I almost always am going to also test for and treat other issues like small intestine bacterial overgrowth, so we’re doing other things at the same time. We might be using low dose naltrexone. I haven’t done enough solo KPV only and nothing else to give a good sense for what that’s doing independent of other treatments, but it does seem to enhance beyond where we were at prior to using it.
Lindsey:
And are those the only two that you’re using right now? Are there any others?
Dr. Miles:
There are many, many others actually. Also, thymosin beta is a really nice one. The thymus gland, I mentioned earlier, is a gland that’s part of the immune system, but it breaks down earlier in life. A lot of autopsies done on people who are even 30 or 40 years old find it shriveled up and looking kind of like a raisin, it’s not functional, it’s not producing a lot of those immune peptides anymore. And so, thymosin alpha and thymosin beta are two very strong immune peptides. Thymosin alpha is a really nice and strong immune system regulator. Sometimes we’ll see cytomegalovirus impacting the gut. And there’s a lot of studies on thymosin alpha one and chronic viral infections, even severe ones like hepatitis C, and we also see that it regulates the autoimmune side very nicely and helps on autoimmunity. That one recently has become less available. Thymosin beta is still available. Thymosin beta has similar function on immune regulation, but less than thymosin alpha. Where it’s stronger than thymosin alpha is on tissue repair. So sometimes thymosin beta plus something like BPC 157 together can be even stronger on the systemic tissue repair and repairing damage from auto immunity or other tissue damage from things like small intestine bacterial overgrowth that might have caused intestinal permeability, and then these things can help repair the gut very, very strongly.
Lindsey:
Thymosin alpha and beta, are those oral or are those injectable?
Dr. Miles:
Thymosin alpha is injectable. Only thymosin beta has become available orally. It can be used as a capsule, although I’ve only seen it through compounding pharmacies at this point. It is prescription but it is orally available to get it as capsules.
Lindsey:
So, when you have these prescription drugs, does this mean they’re FDA approved? Or is it because it’s bio identical, it doesn’t have to be?
Dr. Miles:
They are natural compounds that are produced in the body are some of them are getting the scrutiny of the FDA. At some point, you have to say it’s food or a supplement, because otherwise, you would just be regulating corn and broccoli and things like that. At some point, the amino acid chain has to stop. And they have to say, okay, that’s considered food. And they’ve been reclassifying where that chain stops to unfortunately take a number of the peptides that had been available and make them require FDA approval, which will mean that they get temporarily pulled off the market, and then some company would have to fund a lot of trials before they’d get put back on. Because these are identical to compounds that are produced in the body naturally, we see the safety profile is amazing on these things. From the mice studies, the dosage is well past what anyone would ever be able to achieve from taking a supplement with minimal to few side effects. There are a couple peptides that have some side effects that I see repeatedly, the biggest one really is nausea. And that’s from a peptide called PT 141 that’s used actually for sexual health in both men and women, for libido and for erections and things like that. And that gives nausea to people pretty commonly. But other than that, I really don’t see many side effects whatsoever from peptides and the safety data on them is incredible, in really, really high doses.
Lindsey:
You mentioned food and regulating food. And I’m just curious, do you know if peptides appear in certain foods, like x food is very high in this peptide? Or is it just assembled by our body from the amino acids we get from food?
Dr. Miles:
So, you could break down gluten to the peptide level, for example. And you could look at all the different peptides that constitute that gluten protein. Very, very sophisticated gluten sensitivity testing will break things down into the peptide level and they’ll be looking at gliadin and then they’ll be looking at lots of the different kinds of breakdown products of gluten. Peptides are all over the place. People are getting peptides in a sense through food.
But the peptides that we’re using medically are really ones that have very, very strong effects that typically are not found in foods, and they’re usually produced by the body to have specific functions. There’s a peptide that’s used in mold illness a lot, VIP. And that’s available as a nasal spray. We use that a lot to help restore the cognitive function we see. There’s a study on VIP nasal spray that gave it for about six months and did a neuro quant fMRI image of the brain and found that the areas that were damaged by mold toxins repaired over that six months’ time and a lot of the hormones improved.
And what I see with gut issues is there are a lot of people, especially people who are getting chronic and recurrent gut issues, so people who are getting repeat small intestine bacterial overgrowth that recurs over time many times in a row, we see this a ton in our clinic and part of where we see that that can happen is sometimes there’s an infection in the sinuses that keeps re-infecting the gut. So, first we treat the sinuses with anti-microbials and things to balance that Rhino biome out. And then we apply the VIP nasal spray to treatment after that to rebalance the brain and the hormone system. But I’ve seen sometimes that people don’t get results or they get temporary results. And then they’re feeling their gut out of whack again, when we haven’t dealt with something like an infection in the sinuses.
And, of course peptides can help systemically with infections on the immune system regulation site. They’re not just for tissue repair, they also help with infections because of that immune system bolstering impact. And in addition to the reduction of the auto immune side of the immune system, there’s also a bolstering and an improvement, especially from some of the thymosins. Like thymosin alpha 1 has a very strong improvement in the ability of the body to fight off infections as well that can then impact the gut and cause that multiple reinfection of the gut that we see very commonly in our clinic.
Lindsey:
Are you usually seeing bacterial infections in the sinuses or fungal?
Dr. Miles:
Both. Primarily bacterial is much more common than fungal. Occasionally there is a fungus growing. More often we see a multiple antibiotic resistant form of staff that’s coagulative negative. It’s called MARCoNS for short, which stands for Multiple Antibiotic Resistant Coagulase Negative Staphylococci. That’s a mouthful, so we just named it MARCoNS is the much easier way. MARCoNS is an infection that we see in about 95% of people who have struggled with chronic inflammatory response syndrome due to mold. We see it with a ton of people who have Lyme or cognitive dysfunction. It’s very linked with amyloid plaque in the brain as well. And we see people struggling with cognitive decline, Alzheimer’s, dementia, things along those lines, also having MARCoNS very frequently. So, that’s the biggest one that we find. But we find klebsiella in the sinuses, which is highly associated with gut dysfunction. And there are certain forms of klebsiella that are associated with ankylosing spondylitis, and other autoimmune issues. We also see some of those organisms as well in the sinuses occasionally.
Lindsey:
And are you testing the sinuses? How are you finding out what’s in there?
Dr. Miles:
Yeah, we do a sinus swab. Generally, it’s just called a MARCoNS sinus swab through a lab called Microbiology. And that needs to go real deep into the sinuses.
Lindsey:
Like the Covid test.
Dr. Miles:
Exactly. It feels like it’s way back, then we send that in, and the lab does a culture for multiple kinds of bacterial and fungal infections. And then it reports whether there’s an infection. If there is, whether it’s small growth, moderate or large growth, and then it runs an antibiotic resistance profile to see if it’s resistant to multiple antibiotics, which everyone has a little bit of staff in and on their skin and in their nose. And still staff isn’t necessarily a problem if it’s not multiple antibiotic resistant, but when it becomes multiple antibiotic resistant, that’s suggestive that it’s colonizing more so than would be beneficial. It’s crowding out some other organisms that would be beneficial organisms. So, we see people, some of them have chronic sinus issues, chronic sinus infections that are repeated. Some of them don’t have a lot of sinus issues and they would not expect themselves to have an infection. But they do and then when we clear it up, their brain feels much clearer, their sinuses often feel much clearer. And they have less recurrence of gut issues because we don’t have that dripping down of the dysbiotic bacteria from the sinuses going into the gut repeatedly.
Lindsey:
I’m curious about this because I have had a nose that has run since about age 15 almost nonstop. The only thing I’ve tried sinus-wise is using the Biocidin drops and making a spray out of that. What do you use for the antimicrobial sprays?
Dr. Miles:
A lot of times we like to nebulize because getting into the deeper sinuses is difficult with sprays alone. We’ve seen some effective treatments with a spray alone and Biocidin is one that I’ve seen sometimes be effective as a nasal spray. We use a lot of colloidal silver. We sometimes use a concentrated allicin from garlic called Allimed (available from my Fullscript Dispensary*) that’s a concentrated liquid form of garlic that we can add into sinus spray, and we’ll sometimes use spore based probiotics as well. Often we’ll be nebulizing Colloidal Silver of a certain mix of colloid and ionic silver that can go deeper and penetrate into the deep sinuses to get some of the deeper sinuses and then occasionally hydrogen peroxide can be used as well. I probably would recommend doing that under the guidance of a practitioner that knows what they’re doing in the right dilution ratios so you’re not damaging anything in there. But peroxide is a very strong oxidizer. And we’ve seen it to be very effective at clearing out some of these infections as well. Occasionally we’ll use antibiotic sprays. And there are a couple antibiotics together with EDTA that are put into something called Beg Spray. That spray, it can be very effective, but we usually don’t need it, we usually are able to achieve the clean MARCoNS test and clear out infections with things along the lines of Colloidal Silver, garlic, and sometimes some herbal extracts with Megasporebiotic (available from my Fullscript Dispensary*) are another spore based probiotic mix – just a tiny little bit in a nasal spray. And sometimes we use an Ion Biome*, which is something that’s been shown to clear out chemicals like glyphosate and also improve quorum sensing to have the bacteria talking to each other to try to improve the microbial balance there. There’s actually quite a few treatments that we’ll use because it’s not the easiest thing to treat. Even when we use the antibiotics, I’ll see people not clear it multiple times. And so, we often do have to do multiple different treatments to find the full clearing of that infection for people. But we’re pretty successful when we use the nebulizing to go a little deeper.
Lindsey:
Now I’m curious why something coming down from the sinuses would reseed SIBO because there’s got to be good number of bacteria just in the intestines in any case.
Dr. Miles:
There are. It’s going to depend on the person and their immune system function. When there’s dysbiosis in the gut, we often also find that people are having bacterial issues elsewhere in the body. Sometimes we find chronic infections, sometimes we find the sinus infection, and it’s vice versa. If we see a sinus infection, it may be just regulating the immune system to some extent. Stomach acid is a pretty good barrier; it kills a lot of bacteria. So even when you swallow down some of the bacteria from the sinuses, if you have a good healthy level of stomach acid it will probably take care of a lot of that. But unfortunately, we do see a lot of people who have suboptimal stomach acid production and then some bacteria are surviving through that stomach acid barrier. There’s really no research to say how many of the times the reinfection is due to bacteria migrating from the sinuses directly into the gut. I just have noticed a clinical correlation between people who have recurrent gut infections and who also have sinus infections and that may be more a pointer towards a systemic immune system issue that’s allowing for multiple infections in multiple areas. I can’t tell if it’s causative necessarily, but I have seen some cases of running a stool report and seeing, for example, staff overgrown on a stool report and then also seeing staff overgrown in the sinuses on people who have multiple infections. So, I just wonder, but I don’t know, there’s no research there to tell us, right?
Lindsey:
And so how do you know if someone has sub optimal stomach acid? Are you just trying them on Betaine HCl, you’re not running Heidelberg tests, I assume?
Dr. Miles
No, Heidelberg tests are a little bit difficult to run, we’ll do a gastrin test in the blood to see if there’s an elevation in gastrin, which could be an indicator that there’s sub optimal function in the stomach acid production. We’ll also run antibodies to parietal cells, and those parietal cells are the cells that make stomach acid. And they make intrinsic factor which is important for metabolizing vitamin B12, which is then important for energy and neurological function. So, the parietal cell antibodies, we see fairly frequently, I’m surprised actually at how much I find parietal cell antibody elevation.
I read some research on parietal cell antibodies that correlated that people who had hypothyroidism, which we know a lot of people with gut issues also have thyroid issues, that people who had autoimmune hypothyroidism, or Hashimoto’s, would have about a 20 to 40% chance of having elevated parietal cell antibodies, meaning the immune system is attacking the parietal cells, which are the ones that are producing the stomach acid. So again, it’s an indirect measure.
And when parietal cell antibodies are elevated, we don’t actually know how much damage has been done to the parietal cells, and how much that’s affected stomach acid. But it’s a clue that there could be an impaired ability for those cells to be making enough acid. So, when we do see parietal cell antibodies, or if we see elevated gastrin levels, those are pointers. And then we’ll also ask symptomatic questions. If someone feels like protein sits in their stomach, like a rock, they feel like if they have a heavy meat meal, they really are sluggish for quite a while. If they have very low appetite in the mornings, if we see a lot of low mineral levels on their blood testing, then some of these things can add up to be very curious about stomach acid being impaired.
And then occasionally, we will do a trial with the HCl. And we’ll see if people tolerate that. I don’t typically like the mega doses of working up super high until people get an acid reflux response. I respect people who do that. And there’s a time and a place, I personally haven’t found that to be very clinically effective. So, I don’t use that usually, we’ll just do one or two capsules with a meal. And occasionally we might go up to three, but usually one or two are sufficient in my experience to give. It’s sort of the minimum effective dose that people tend to notice. And if they don’t notice any negative effect, then often they are lacking in stomach acid. But that’s not even the perfect thing because I’ve seen people who are lacking in stomach acid who have a negative reaction to one cap of Betaine HCl because the stomach lining has been damaged, possibly due to an H. pylori infection or other issue where the stomach lining is really sensitive to acid, not because the acid has too much, but because there’s some other issue that’s causing inflammation there. And then even a normal level of acid might feel like burning for certain individuals. Unfortunately, there’s no clear cut answer to that, except that I think, a trial of some Betaine HCl ,one or two caps, except for people who have ulcers, or something along those lines, is reasonably safe, a reasonable idea that we do also on top of that lab testing.
Lindsey:
And is that in the 650-750 milligram range?
Dr. Miles:
Anywhere from 500 to 750 milligrams is a good starting dose and even doubling that to doing two of those caps. If people respond well to one cap, it can also sometimes increase the benefit as well. So up to a gram and a half, maybe even two grams in some cases can be helpful and beneficial. I usually don’t go that high or higher than that but occasionally we’ll go up to that amount for certain people.
Lindsey:
So, I’m really interested in all this stuff because this is my story. I had Hashimoto’s. I had two tests of parietal cell antibodies probably 10 years ago, with a very forward thinking hematologist. I don’t know if that’s pretty standard to run. And intrinsic factor, I think one was equivocal, one was high. Yeah. And I did take Betaine HCl for a while, not at his direction, but at some later point, ultimately reversed the Hashimoto’s but still have iron shortages and zinc shortages and such. So, probably need that stomach acid still.
Dr. Miles:
Yeah. And the parietal cell antibodies, there’s a lot of research. I don’t know if anyone was privy to this research who you were seeing who was able to share this with you, but there’s quite a lot of research suggesting that you can reliably lower parietal cell antibodies and reverse that immune system attack against the parietal cells with injectable B12. Was that ever shared with you?
Lindsey:
Well, I actually think somebody said that recently. I’ve been taking sublingual B12 for years, but I did get a first injection when they found my B12 level in the hundreds.
Dr. Miles:
The research is fascinating on B12 injection and parietal cell antibodies, because they tried using high dose oral B12, and they did not find a reduction in parietal cell antibodies, and then they tried injecting B12. And they found a reliable reduction in antibodies from injectable B12. This research takes a long time. So sometimes it’s weekly injections of B12. For six months, nine months, a year, two years in some cases, depends how elevated the parietal cell antibodies are, but they do reliably start to lower with weekly injections.
Lindsey:
This is not appealing. But if I have to do it, I’ll do it. You know, in the usual medical system I’m waiting three months for my specialist visit. As I rediscovered this whole parietal cell stuff, I’m going to get mine retested and see if they’re still elevated. I hope they’re down by now, but maybe not since I’m not digesting my iron and zinc. Of course, I was worried too that the extra iron might be feeding the SIBO.
Dr. Miles:
The parietal cell antibody research is very clear. And I have had patients who like you have not been thrilled by the idea of a weekly injection. I had one patient who said I’ll try anything to not have the injection and so I suggested that we try very high dose sublingual B12. So, we were doing ridiculously high doses of sublingual B12 with him holding it. . .
Lindsey:
Like 5000?
Dr. Miles:
No like 20,000 a day. We had 10,000 mcg tablets, and then he was doing two of those per day – methylcobalamin. And it stabilized the antibodies, they didn’t go up. But it did not make them go down. We were trying the liposomal form of B12 as well, and we just couldn’t get it to go down without injection. That’s an n of one. That’s one person, maybe other people are different. And I’d love to do a bigger study on that and try things like bigger doses of sublingual and high quality liposomals and I still have some promise and hope for that. But so far, clinically on the n of one, the person who I’ve tried it with, I have not yet found something that can equal injections in terms of its ability to lower parietal cell antibodies. And the research is clear on this. If you do weekly injections, almost everyone’s antibodies start to come down at different rates; some faster than others. But after a few months, they recheck and then they see where it’s at. So, we’ll do about 12 weekly injections, recheck parietal cell antibodies, see where they’re at.
The research study did it until they were symptom free and the research studies were looking at oral symptoms because a lot of people with parietal cell antibodies will have things like dry mouth, burning tongue, things in the oral region – symptoms there. They continued until they got a reversal of symptoms, but I like to see them ideally drop the below 10 to feel like okay, we can go on to maintenance and then maintenance is once per month an injection of B12.
Otherwise, in the studies the people who tried to maintain with oral and did not do injection for maintenance, unfortunately, it started climbing back up. There’s more though that can be discovered and the research really has looked at H. pylori being linked to parietal cell antibodies. So, it could be if someone had an H. pylori infection, and that got eradicated, that may already help prevent the rising of parietal cell antibodies. It’s not clear in research, there’s just an association that’s clear that says that people who have H. pylori are more likely to have parietal cell antibodies. It doesn’t say one’s causing the other, but mechanistically it seems reasonable to consider that H. pylori could be a localized influence on the immune system in the area triggering the response against parietal cells. So, there may be other things that could be treated, that could help, but the thing that’s very determined for sure in the majority of people to help from a research-based perspective are the weekly injectable B12. And then monthly to maintain once it’s normalized.
Lindsey:
I was convinced I finally figured out the source of all of my gut issues. I must have H. pylori that’s not terribly symptomatic, and I got my stool antigen test and it was negative. So I was kind of disappointed.
Dr. Miles:
Yeah, that is a little disappointing. Actually, on myself a while back, I had some thyroid issues, and there’s an H. pylori thyroid connection. So, I was testing H. pylori, and I did a stool sample and it came back negative. And about three weeks later, I did another stool sample and it came back positive through a different lab. And I thought, well, this is interesting that I found it with the same stool antigen. The stool antigen test is actually FDA regulated. The two labs were using the same antigen, but I think the handling was a little different. The one had a frozen sample, and I think it kept it frozen better, the way it was packaged. I’ve sometimes seen multiple tests necessary to identify H. pylori. Not all the time, but occasionally.
Lindsey:
I’ve seen tons of clients and that situation where they’ve had an endoscopy. They’ve had biopsies, they’ve had breath tests, maybe never a stool test. My father for one—40 years’ worth of gut health issues— finally sent him out to do a GI Map. Came back with H. pylori and a parasite.
Dr. Miles:
Yeah, we see that all the time, too. That’s classic.
Lindsey:
Yeah, I’ve got people who are always just like, I’ve already been tested for H. pylori. I’m just like, let’s just test it.
Dr. Miles:
You got it.
Lindsey:
I have found you can order just the H. pylori test from the GI Map as an independent test. And it’s not expensive at all. So, I think that’s worthwhile.
Dr. Miles:
Yeah. And I often run a blood antibody in tandem.
Lindsey:
Yeah, just to see if they’ve had it at some point.
Dr. Miles:
Yeah, absolutely.
Lindsey:
So, thinking about other causes for recurrent SIBO, you know, I look at the list of potential causes for recurrences, and probably the low stomach acid and parietal cell antibodies are one of them. But a history of endometriosis, abdominal surgery, I’ve had C section, I’ve had endometriosis surgery, the history of PPI use, although that was like 10 years ago, stress, supplementing with iron, Hashimoto’s. All of those things. When you have so many potential root causes, how do you even start to unpack these things?
Dr. Miles:
That’s a difficult question. But part of what I do together with my wife, Dr. Diane Mueller, we trained practitioners in functional medicine. So, we’re very detail oriented about how do people go about solving this kind of puzzle. And basically, we have a series of root causes with an approximation of likelihood and then a good history and you just gave us a very relevant history already. Most people don’t know to tell us if they’ve had abdominal surgery, they don’t think it’s something that is relevant to the fact that they’re having digestive problems now. For a clinician it’s really important to ask if you had abdominal surgery, because that’s going to lead to scar tissue. And that scar tissue can lead to the reoccurrence of small intestine bacterial overgrowth. In addition to low stomach acid you mentioned, we’re also going to look at the scar tissue abdominally like you mentioned, and then another one is the migrating motor complex damage due to an autoimmune cross reactivity from an infection that usually is a food poisoning type of infection.
Lindsey:
Right, the ibs-smart test?
Dr. Miles:
Yeah, so the post-infectious IBS, which you can get a test that measures the vinculin antibody and the cytolethal distending toxin B antibody. Basically, the immune system creates a reaction against a toxin that’s released by certain bacteria like Campylobacter jejuni, that can cause food poisoning and who hasn’t had food poisoning at least once or twice in her life? Then that toxin, the immune system can cross react and create that attack against the enteric nervous system that regulates the migrating motor complex that flushes the bacteria out of the small intestine. And so, that can be an issue as well that can be tested for so you can look at those antibodies to see if that’s the root cause. And that’s nice that you can look for that root cause.
Lindsey:
Yeah, I have one of those tests on the way. I’m very excited.
Dr. Miles:
That’s great. So, one strategy is to look at that test.
Lindsey:
And that would be indicative? Well, I guess you could have scarring in your abdomen that is totally unrelated to that and also hurting you migrating motor complex, right?
Dr. Miles:
Everyone wants the one smoking gun, but unfortunately, it’s usually a couple things.
Lindsey:
It’s a five shooter over here.
Dr. Miles:
You could have low stomach acid. And you could have a migrating motor issue due to the damage to the enteric nervous system from a post infectious issue, cross mimicry. And then you could also have scar tissue playing a role. Especially if we see high methane levels, we often do see some systemic chronic infection as well playing a role along the lines of Lyme disease, or one of the co infections for Lyme that we frequently see, especially with those methane-dominant SIBOs that don’t respond very well or keep recurring. Lyme is another one that we frequently see. And the sinus infection, like I mentioned, seems to be correlated. I don’t know if it’s causing it, there’s no clear research saying it is or it isn’t, but I suspect it could play a role. That’s something that that we’ll look for. And typically, the good case history is going to end the symptoms we talked about related to stomach acids. So, looking at those symptoms, in addition to the parietal cell antibodies, H. pylori, possibly the gastrin, fasting gastrin levels.
Lindsey:
I was just going to ask, does the gastrin level appear on any of the functional medicine stool tests? Or is that a separate thing?
Dr. Miles:
That’s a blood test, actually. Fasting gastrin in the blood can elevate in low stomach acid. It’s a marker that we’ll use sometimes. I wouldn’t say it’s incredibly useful. But it can be one tool in the toolkit to take a look at stomach acid potentially playing a role. It’s basically take a good assessment, and once we get a good assessment, then it’s a matter of saying, okay, you know, you have a parietal cell antibodies, so I’m really suspecting stomach acid is part of what’s going on for you. And then you also have this history of abdominal surgery. I might ask more in that case, when was the timing of when this came on? Because sometimes abdominal scar tissue, it can change a little bit over time, it usually doesn’t a lot. So, it can take some months to onset SIBO after an insult to the abdomen with scar tissue. But if it’s, for example, you had surgery after you were already, like you had gut issues since you were a teenager and your surgery was in your 20s, then I’m not going to think that that surgery scar tissue is, it’s definitely not the only root cause because you had those issues prior.
Lindsey:
Okay, good. Than I can cross that off my list, because I’ve had bloating and stomach issues since I was a teenager.
Dr. Miles:
Yeah, and I find that a lot, which isn’t to say that the scar tissue isn’t playing some role at this point. It may be but it wouldn’t top my priority list for what to treat first, given that there’s something that was underlying prior that was leading to there being an issue even earlier on. So, that kind of investigative work can help sort out where we might be looking at. If someone has a history of multiple bouts of antibiotics before two years old, we might be looking at okay, maybe there was some long standing dysbiosis that began in early childhood and then maybe there were a couple of rounds of food poisoning. Okay, now we might want to be looking at the antibodies to vinculin and cytolethal distending toxin B because there could be this post infectious issue with cross reactivity. And then prokinetics are going to be a much bigger player in the treatment plan in that case, versus if Lyme is a more significant player then we have different things that are going to be more at play for the long run prevention.
Lindsey:
Talk a little bit more about prokinetics and which ones, especially nonprescription, that you think are the best and maybe just explain what they are.
Dr. Miles:
The prokinetic is helping that migrating motor complex. It’s promoting the movement in the intestines. And that promotion of movement in the intestines will be a proxy for the function that’s supposed to be natural, that every 90 minutes or so in between meals when you’re fasting, the intestines, you might notice a little rumble grumble in the tummy. Borborygmus is the medical term for that, which I love that word, borborygmus, it’s just a wonderful word. So, that gurgling sound, that borborygmus is a sign that there might be that peristaltic wave that’s happening that’s moving the debris, the fibers, the bacteria, out of the small intestine into the large intestine. It’s like a peristaltic wave that flushes things into the large intestine. And when that is compromised, which in the case of what we’re talking about is a root cause of the cytolethal distending toxin B antibody, leading to cross reactivity with vinculin antibody. Vinculin is part of the smooth muscle. It’s part of the intestinal function of the enteric nervous system that helps that migrating motor complex, helps that flushing mechanism. When that’s damaged by the immune system autoimmune attack against it, then we want to use prokinetics, which can be herbal or pharmaceutical agents that can promote that peristaltic activity, that wave like activity in the gut, in the intestines.
Several of the prokinetics that are helpful are pharmaceutical, but several are natural as well. On the natural side, ginger is one of the classic ones that’s used. And I like ginger, I do think it’s useful, although sometimes it can feel hot in the stomach if we use real therapeutic doses of ginger. Some people tolerate it better than others. And I like to do bedtime dosing for prokinetics, because that’s the longest fasting period between dinner and breakfast. So, bedtime dosing is nice. And I like to use some ginger but not too much so that we don’t get the burning feeling in the stomach that might keep someone up or be uncomfortable.
There’s artichoke extract which is being used, and the studies on artichoke extract are really about gastric emptying, the stomach emptying. And they don’t say much about small intestine transit. I don’t know how effective it is for the migrating motor complex, but it’s reasonable to think it could be because it definitely increases the speed at which the stomach empties pretty significantly. When we see that increase in stomach emptying, we have to wonder. One of the waves of the migrating motor complex goes all the way from the stomach to the large intestine. There are phases and waves of the migrating motor complex and we don’t know for sure which wave it is that’s impacting when the artichoke extract is being used. But I do think it’s a good one to consider including as a prokinetic, because we at least know that it helps with stomach emptying, and it may help with small intestine transit as well. 5- HTP is a common one that’s used. And 5-HTP is a precursor to serotonin, and then later turns into melatonin. So it’s used sometimes for sleep, sometimes for mood and sometimes for prokinetic. And there’s a lot of serotonin that’s produced by the gut and the theory goes that the receptor sites for that on the intestines may be related to the migrating motor complex. 5-HTP is another one and some products have multiple of these in them. You don’t have to necessarily get different products for each of these constituents. But those are some of the ones that can be useful. HNO19 is a strain of Bifidobacterium that has been shown also to improve motility. I like to use that in high doses as well, in some cases.
Lindsey:
Which species?
Dr. Miles
Bifidobacterium lactis. So the HNO19 strain of bifidobacterium lactis is shown in at least one research study to impact the motility in a positive direction. There are some probiotics that are available with high doses. So sometimes we’ll use a probiotic that has 15 billion of that strain specifically, and one of them even has as much as 50 billion of that one. So sometimes we’ll use that in higher doses.
Lindsey:
Which ones are they?
Dr. Miles:
Zymogen carries Probiomax DF and Probiomax Daily DF. The Probiomax DF I believe is the one that’s the higher dose and then the Probiomax Daily DF is the lower dose, but both of them have a reasonable dose of bifidobacterium lactis HNO19.
Lindsey:
So, tell me, what does the breath have to do with things like gut issues?
Dr. Miles:
That’s a really interesting question. I think a lot of people, you don’t need a research study to say that when you’re stressed out, your digestion is impacted. I think that’s pretty common across the board; some people more than others. But it’s pretty common that if someone experiences an acute stress, they have digestive worsening, whatever their digestive picture is, it tends to get worse with stress. We know the nervous system regulates multiple functions that impact the gut. There’s a lot of research around the vagus nerve and how the vagus nerve innervates parts of the gut. A lot of people who are treating SIBO will sometimes prescribe vagus nerve calming the nervous system type activities to stimulate the vagus nerve. The theory is that like a prokinetic, it might help with the motility in the intestines and the appropriate signaling between the intestines and the brain.
And breath work has a strong nervous system regulating ability, certain breath techniques can very quickly regulate the nervous system and shift from the sympathetic kind of fight flight type stress reaction into the parasympathetic rest and digest. They even use those terms in describing the nervous system to say digest for the parasympathetic nervous system. Because when the body is not feeling acutely threatened, the body puts more resources, energy, blood flow into the intestinal area versus if you’re threatened and you’re feeling like you need to fight or run, the body puts more blood into the limbs to be able to run to fight and certain parts of the brain to be able to react quickly. If we can shift from that sympathetic stress response into a parasympathetic rest digest response, especially around meal time, and especially when feeling symptoms of gut issues or preventatively to digest appropriately when having a meal, that can be really impactful and really helpful from a digestive perspective.
And a lot of people who report acid reflux or bloating or issues with feeling like the food isn’t moving much in their intestines, once they’re shifting into more rest and digest state, they’ll actually start to feel those grumblings, there’s a lot of people who they lie down to rest or they lay down for a treatment of some sort— a massage or an acupuncture treatment, and immediately, their stomach starts rumbling and growling, and they start to hear their stomach growling because they’re just relaxing out of that go go go. And they lay down to relax and that relaxation really can do a great benefit to the digestive system. But unfortunately, it’s not easy every meal to go lay down for a massage or treatment of some sort.
Lindsey:
Don’t you get massages after all your meals?
Dr. Miles:
I wish, that would be nice. But you can easily do a short few minutes of breath work with every meal. That’s a fairly simple thing to implement.
Lindsey:
That’s something I tell a lot of my clients, especially weight loss clients about just doing some 5-5-7 breaths, five in, five hold, seven out. The exhale being longer than the inhale.
Dr. Miles:
Yeah, and that’s going to cultivate a little bit of CO2, carbon dioxide with a longer exhale, then inhale. And a lot of people think, oh, I need more oxygen, I need to take more deep breaths to get more oxygen. There are lots of issues with oxygen deprivation. There’s lots of sleep apnea out there where people are deprived of oxygen. So, oxygen is a good thing and you do need oxygen to the brain and the body to function. Absolutely. But there’s also a great need for carbon dioxide and it’s underappreciated. The carbon dioxide gas is actually needed to deliver oxygen to the tissues. Without enough CO2, the oxygen that’s in the blood won’t be appropriately delivered into the tissues to have its optimal effect.
CO2 also is involved in nervous system regulation. And so, CO2 gas will, as it increases, induce a parasympathetic nervous system response in many cases where a person will all of a sudden feel themselves relaxing. If there’s elevated blood pressure, it’ll go down. If it’s not elevated, then it’ll stay, it won’t push it down further than it being normal typically by just CO2. But if it’s elevated, it can increase nitric oxide and that can help blood pressure regulate. It also can help with the sinuses clearing up. By increasing CO2, the sinuses can clear and open and the lungs can open. If someone has asthma or breathing difficulties, the CO2 increase can help bronchodilate the lungs as well. So, the lungs can breathe easier, people can stop an asthma attack through a certain breathing technique that increases the vasodilation, increases the CO2levels that increases the vasodilation.
And so, what you’re doing with that breathing technique is you’re getting with that longer exhale a little more CO2. That little more CO2 can increase all of these things I just mentioned. But unfortunately, what a lot of people do when they think of breath work is they think, oh, let’s take a few deep breaths. Which is not bad, that has some good functions too. And there’s certain breath works that use that kind of deep, fast breathing for specific purposes. But when it comes to shifting into the parasympathetic nervous system, actually, what helps is slowing the breathing, and breathing less total volume of air per minute – not trying to get more air in, but less volume of air per minute. It doesn’t mean necessarily that you’re taking a shallower breath, it more means that you’re slowing the breathing, to breathe maybe 5, 6, 7 times in a minute instead of 12, 13 times in a minute. And not necessarily excessively deep breaths either. But moderate breasts that are into the belly. They’re not superficial or chest breasts, but they’re into the belly, and they’re slowing down the breathing rate. Maybe, like you said, also could be exhaling a little longer than inhaling or even holding after the exhale for a few seconds before inhaling again. And doing that sometimes several times can also induce that relaxed, parasympathetic state. Yeah, there’s several different breath techniques and videos that can help describe how to do the techniques. But I think there’s a lot of misinformation that just straight fast deep breathing is going to relax the body. That’s not necessarily true. In fact, some people can induce panic attacks if they go too fast with their breathing.
Lindsey:
And just quickly, what are some of those breathing techniques if people want to look them up?
Dr. Miles:
For this purpose of what we’re talking about today, Buteyko Breathing or Oxygen Advantage should be two that are more in this genre of increasing CO2 levels to regulate the parasympathetic nervous system response. There is also Wim Hof breathing, which is faster and deeper. And I do endorse and find it to be very helpful. In fact, I’m trained in it, but I wouldn’t do it as a way to relax the nervous system. In fact, it’ll increase adrenaline temporarily. It does a lot of interesting things.
Lindsey:
Well, that’s for another conversation. This has been really interesting. I’ve loved the depth we’ve gotten into on some of these things. So, tell me where readers can find you.
Dr. Miles:
Readers can find the clinic website, who are interested potentially in care in the clinic at medicinewithheart.com. And even if you’re not interested in care, we have a great blog, where we write about peptides, we write about some of the things that we’ve been talking about here in much more detail with cited references. If you want to take a look at more detailed information, medicinewithheart.com, and you can also get in touch with the clinic there. And then for practitioners, if there are any practitioners interested in the practitioner training program, that’s mindbodyfunctionalmedicine.com.
Lindsey:
Great. Well, I really appreciate you sharing your knowledge with my listeners.
Dr. Miles:
Wonderful, Lindsey. Thank you so much for having me.
If you’re struggling with Candida or other gut health problems and are ready to get some professional help, you’re welcome to set up a free, 30-minute breakthrough session with me. We’ll talk about what you’ve been going through and I’ll tell you about my gut health coaching 5-appointment program in which I recommend lab tests, educate you on what the results mean and the protocols used by doctors to fix the problems revealed. Or if you’re ready to jump in right away or can just afford one appointment at a time, you can set up an 1-hour consultation with me.
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