Adapted from episode 145 of The Perfect Stool podcast edited for readability with Will Bulsiewicz, MD, gastroenterologist and Adjunct Assistant Professor of Medicine at Emory School of Medicine and the Founder of 38TERA*, a gut health supplement company, and the bestselling author of “Fiber Fueled*” and “The Fiber Fueled Cookbook*”.
Lindsey:
I’m sure my listeners would be interested in hearing how your own health issues brought you to where you are now in the search for root causes for gut health issues. Can you tell us about that?
Will Bulsiewicz, MD:
Yeah. I think that this is an important part, it informs many of my personal motivations in terms of the way that I approach health. So, I think, as a background an allopathic medical doctor, it was my lifelong dream to become a medical doctor, and I went through medical school and residency basically looking up at these people who were before me as. These are my heroes. This is what I want to be like. And then it all was quite sobering when I started to have health issues myself. Essentially, what happened is that the things that were bad patterns, bad habits that I had from my childhood and carried into adulthood, that I think I doubled and tripled down on during times of stress, or when I was short on time, or things like this, which I frequently was in my 20s going through my medical training, it ultimately came to a head where I found myself in my early 30s and I was unwell and I was having a crisis of health, and I was 50 pounds overweight. I had high blood pressure and high cholesterol, but even more importantly, I didn’t feel well, I was depressed, I was anxious, and also I had tremendously low self esteem, and I knew I wanted to feel better.
Yet in that moment when there I was, I was a board certified internal medicine doctor. At that point, I was in my specialty training as a gastroenterologist. I had won many awards. I was the top award recipient at Northwestern among 60 doctors. And yet, I didn’t want what I was trained to do for myself. I wanted something that would address, “Why do I feel this way? Why do I have these issues?” I don’t want to take a blood pressure pill for blood pressure, and take a cholesterol pill for that, and then, take something else for these other feelings. I want to repair the person, starting with the inside and working my way out and I didn’t really know how to do that, because that’s not what I was trained for. I tried to exercise my way out of things. There were definitely things that were beneficial from exercise, but it didn’t really fix the problem, to be honest.
Lindsey:
I always say you can’t exercise your way out of a bad diet.
Will Bulsiewicz, MD:
That’s exactly right, and I didn’t understand that, right? This seems obvious. It seems obvious, and yet there I was in it, living it, and not seeing it. And anyway, it was changing my diet that really changed everything for me, and the realization that, oh wow, not only do I feel better, my gut feels better.
Lindsey:
What was your diet? And what is it now?
Will Bulsiewicz, MD:
This period of time that we’re talking about, I’m now in my mid 40s, right? And we’re talking about a period of time that was on the on the order of 12 to 15 years ago. And leading up to that, when I was in high school, my parents were divorced, my mom was at work, and I would come home from school, and I had two brothers, and we grilled hot dogs almost every single day. And we loved going to fast food joints and drinking soda. If you had some money, that’s what you would spend your money on. Then I went to college and medical school, and I’m independent now I have my own life. What do you think I ate? Exactly, wow.
Or imagine this, I work a 30 hour shift, right? This is, literally what would happen every fourth night during my residency in my 20s. I would work a 30 hour shift, not sleep, come home around one in the afternoon, completely exhausted, stop at Taco Bell, grab $15 worth of food, which is a lot for Taco Bell back then, and basically, devour it and then pass out and wake up the next day and go back to work. I had a very unhealthy lifestyle, but again, I didn’t see it or understand it, and so, anyway, you asked me, how do I eat now? I want to give the caveat that, how I eat now is a build. And I’ve always been working on ways to try to improve little things, not trying to be perfect, trying to tweak and work my way up. I feel I’m in a great place now in terms of the balance between it all. But where I started was the first thing was drinking smoothies. And it was almost drinking smoothies as a supplement. And it had fiber and polyphenols, phytochemicals and all kinds of good stuff. But that was my way of having something that I could prepare quickly, effortlessly, and still feel I was doing something decent for myself. That’s where I started, and it really, made a difference.
Lindsey:
Yeah. Where did you end up now? What do you do now? Do you cook for yourself? Do you eat lots of fiber?
Will Bulsiewicz, MD:
I eat lots of fiber. Yes, I try to cook for myself when I can, on the weekends. I’ll have breakfast. Breakfast for me could be avocado toast. That’s one of my favorites. And also, I should say I have four kids, and my kids, the age range is between, right now, once she turned one, my youngest, and then my oldest is 10. And anything that I prepare for myself, I have to prepare for my kids at the same time, right? I’m looking for solutions that are quick and healthy and also delicious, because that’s what my kids want. Avocado toast is a family favorite. Yogurt, I might do a plant-based yogurt, but I’m not opposed in any way to regular dairy yogurt, if that’s what people prefer. And a yogurt with nuts and seeds, specifically hemp seeds and berries, that would be a classic on the weekend. During the week, I typically don’t consume breakfast. I usually don’t, to be honest. I probably should, but I don’t, and I drink coffee and then I have lunch.
For lunch, soups, salads, sandwiches. A big kick that I’ve been on recently has been to take soup and add an entire can of beans to it. And I choose the beans based upon which type of beans fit the soup profile. Certain ones, I’ll use garbanzos. Other ones I might use kidney beans or black beans, depending on what the style of the soup is. But, again, I’ve worked my way up to this. If you have gut issues, this is not a starting point. This is where you get to eventually. And then dinner time varies, we cook for the family, and it varies by day of the week. We have typical family foods. Taco Tuesday as an example, and we’ll put out the taco spread, and then the key is, we have all the accouterments, and you pick and choose which ones you, and then add it to your taco, and it’s pretty nice. Another example of something that I would do for dinner is, I love making a bowl and including some whole grain and some legume or lentil, and then adding toppings. Depending on the flavor profile, whether it be Mediterranean or a burrito bowl, you put out that spread, add that stuff in, make it taste really great, and then acknowledge that this is a healthy meal.
Lindsey:
Yeah. I’m hearing the emphasis on the beans and the lentils, which is what I tell all of my clients who are eligible for that. There are some that are not, but all of the ones that are ready for beans and lentils, I would say, quarter to half a cup a day minimum, because you’re never going to hit your fiber requirements without it.
Will Bulsiewicz, MD:
They’re powerhouse foods. When it comes to the gut microbiome, there’s nothing more densely packed with fiber, resistant starches, and they also have polyphenols too. We’re talking about something that was strategically designed by nature, basically, to feed the gut bacteria. And I totally agree with you. They’re not for everyone, and for people who do struggle with gut issues, the starting point could be something like, for example, lentils which are soaked and typically, the smaller ones will be a little more tolerable.
Lindsey:
Yeah. One of the things we wanted to focus on today is Crohn’s disease, which I haven’t had anybody speak about in a while. Can you talk about the different types of Crohn’s and how you might approach them differently?
Will Bulsiewicz, MD:
Yeah, so we think of Crohn’s in terms of phenotypes, and I think in the future, we may be able to get more specific with this, because we’re taking this label of Crohn’s disease, which for the listeners at home, this is a form of inflammatory bowel disease. You can think of it in the same family as ulcerative colitis, but to me, as a gastroenterologist, these are distinct health conditions, and with Crohn’s disease, what makes it unique is that it can affect anywhere from your lips all the way down to your bottom, anywhere in between, and it can be in one spot and nowhere else, or it could be in different locations and skipping around and be involved. Some people are just the small intestines. Some people are just the large intestine. Some people are both.
That’s very different than ulcerative colitis, where ulcerative colitis is the colon, and how much of the colon is involved, is the question. But it’s always the colon, and it always starts in the rectum, with ulcerative colitis. Now, when it comes to Crohn’s disease, given this varied presentation, I think that in the future, we hopefully are going to be able to get more specific at looking at these specific types and then studying them and unpacking them further. But the main distinction that we will make is that there’s some people that have what’s called stricturing Crohn’s disease, where they form scars, and those scars within the intestines get tighter and tighter and tighter, and it closes off, and it affects the ability of food to flow through. And the issue with this, with the type of dietary pattern that I recommend, is that this can be trouble for a person who’s eating a lot of plant based foods, particularly the skins. In my mind, I’m thinking about an apple and a pepper and things of this variety that have a skin. Those skins don’t digest and they remain intact. You might chew them, but they’re still quite large. They can bunch up like a meatball and cause a blockage, right?
Now, on the flip side, if we’re talking about a smoothie, it’s a completely different thing, because the smoothie is so particulate, so small, it’s not going to form a clump inside your intestines. That’s not possible. We tend to, with these people, be very cautious with how we approach fiber, but I hope that the listeners are hearing me when I make this distinction between highly refined, particulate, plant-based foods versus things that are closer to whole foods that have a skin and therefore may be problematic for a person who has one of these strictures. I’m happy to talk more about the strictures because there’s two main elements to strictures that people need to know. One is inflammation, and inflammation, if you properly treat it, that will go away. And the second is scar tissue. Scar tissue is not going away. If a person does have a blockage, in theory, it may be possible to resolve the blockage in the hospital. The patient, treating the condition, getting the inflammation under control, you may be able to do it, but there are some people that do require surgery for this.
And then the second major type is what we call penetrating Crohn’s disease, which basically means that the inflammation is severe that it may make connections to other parts of the body, and when it forms a connection, we call that a fistula. A fistula is an inappropriate connection between two parts of the body, so, Crohn’s disease may connect to the bladder, or it may connect to another part of the intestine, or it may connect to a woman’s vagina, and all of these things then will have potential manifestations and consequences. These two types, though, stricturing and penetrating, these are different phenotypes, typically people aren’t both at the same time. Typically they’re one or the other.
And when it comes to penetrating disease, I don’t share the concern that I mentioned a moment ago with the skins and fiber of that variety. All patients with Crohn’s disease have deep dysbiosis. What that means is a very damaged gut microbiome and fiber is unique, because while it is incredibly healthy, it also is the food that requires our microbiome in order to process and digest it. This creates an issue for people that have a very deeply damaged gut. The thing, paradoxically, that they need the most, is also the thing that’s hardest for them to receive. In both cases, I apply rules, but I take them to an extreme. I apply rules that I would use for people that have irritable bowel syndrome or other forms, other manifestations of dysbiosis, but with the acknowledgement that in inflammatory bowel disease. These are typically the people with the most damaged microbiome. The rules are that I use typically, when it comes to these types of foods, are I will start very gentle, and then I will slowly ease into it. I tend to use, in this context, a low FODMAP diet. And Lindsey, I know that your listeners are quite facile, FODMAPs, is this something that I should explain? Or how do you feel about that? Do you want me to get into that?
Lindsey:
Briefly. I’m sure they’ve heard about it on another podcast.
Will Bulsiewicz, MD:
FODMAPs, it’s an acronym. It’s super nerdy. It stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. And basically what this is referring to is the fermentable parts of our food, and specifically fermentable parts that are carbohydrate. They’re carbohydrate based. Now this doesn’t make them bad. In fact, they’re good. They’re good because the vast majority of them are what we would describe as prebiotic, meaning they feed and fuel our microbiome.
But that being said, anytime we use the word fermentation, it’s never a human biological phenomenon, that’s always our microbes. Microbes are what ferment things, whether it be in a jar and we’re making some kimchi or sauerkraut, pickles, or whether that be inside of our own intestine, and our gut microbiome is processing and digesting these foods. Fermentation is done by these microbes. The point is that for people that have a damaged gut, their microbiome, those microbes, they’re not in a good spot. And by going low FODMAP, it allows us to give them the space that they need to heal and be gentle. We don’t want to do low FODMAP in perpetuity, right? But for a period of time, you make this play. And the intent is to gently ease into feeding the microbiome, as opposed to aggressively doing it and stuffing it.
And there’s been data for many years on irritable bowel syndrome. Anytime we talk about irritable bowel syndrome, if you have inflammatory bowel disease, you almost certainly also have irritable bowel syndrome underlying it. It’s an overlap. There’s data with irritable bowel syndrome, but now there’s also data more recently, with people with inflammatory bowel disease. Two things. One was a six-week study where they had people with inflammatory bowel disease follow a low FODMAP diet, and they improved the measures of gut inflammation. That’s a beautiful thing.
And then the second was, among these people with inflammatory bowel disease, they discovered that they had improvements of their symptoms and improvements of quality of life. The point being that if I were to take a person who has Crohn’s disease and I look at them, and what I see from my perspective, is a person who has a damaged gut microbiome, because their gut microbiome is damaged, their gut barrier is broken, and this has activated the immune system inappropriately, and the immune system is on the attack. And when the immune system goes on the attack, people think about things like autoimmune disease. What’s interesting is that inflammatory bowel disease, I don’t consider to be autoimmune.
Lindsey:
Really?
Will Bulsiewicz, MD:
Very similar, but I think worth pointing out, because it’s more than semantics. It’s understanding what’s happening. In an autoimmune disease, your immune system is attacking you, in inflammatory bowel disease, your immune system is attacking your microbiome. It’s a rejection of your own microbiome, and your intestines get stuck in the middle.
Lindsey:
Interesting.
Will Bulsiewicz, MD:
And the inflammation that manifests is the result of the inflammatory process manifesting in the lining of your intestines. But your immune system is not trying to attack your intestines. It’s trying to attack the microbiome. And the way that we heal this broken, damaged gut microbiome, broken gut barrier and confused immune system, the way that we ultimately want to heal, this is by healing the gut microbes. Because if we can do that, if we can reverse dysbiosis and move back to a normal, healthy, balanced microbiome, which the term is eubiosis for that, if we can do that, then that balanced, healthy microbiome will allow us to repair and restore the gut barrier, which is how we accomplish that. And when you repair and restore the gut barrier, then you simultaneously are going to give the immune system the space that it needs in order to manage itself, to heal, to stop attacking.
Lindsey:
Yeah. And are you using comprehensive stool testing to assess the microbiome?
Will Bulsiewicz, MD:
So with Crohn’s disease, I haven’t found comprehensive stool testing to be something that I would allow to lead; I find it to be a complimentary piece. I don’t yet believe that these tests are in a position of being ready for prime time, in the sense that what I want to know, with a patient with Crohn’s disease, I want to know how they feel. The expectation is that symptoms are present as a result of their condition. And, I should say it’s not universally true, but generally speaking, symptoms are present in response to their inflammation. When the symptoms improve, it is because you are improving the inflammation. I want to get them into a symptomatic remission. That would be the first step. And then the second step is to get them completely free of disease so that you can’t tell them from another person who doesn’t have inflammatory bowel disease.
Lindsey:
And are you talking about interventions with diet, or are you talking about using the immunosuppressive drugs?
Will Bulsiewicz, MD:
So, the way that I see this interplay is, I guess, let me put my general philosophy as a medical doctor out on the table, which is that what I care about is people being better, right? And to the best of our ability, addressing the root of the issue and not covering it up. Because I feel like when you cover it up, you might get them better temporarily, and then they get worse again. With this in mind, the answer to your question depends a bit on the intensity of the of the health condition. For people that have mild Crohn’s disease and it’s not severe in terms of the effects of inflammation or in terms of the symptoms, then we have more. We wait. We have more give, rebuilding and repairing the gut microbiome. It takes time. To me, what we’re talking about here is not a four-week process. I don’t even know that it’s really a four-month process. In my mind, generally, people that have inflammatory bowel disease, to really get to where I would want them to be, we’re talking about something on the order of, minimum of six months, most likely 12 months, somewhere in the range of 12 to 18 months, to truly get there.
I won’t sit back and have a person progress to the point of requiring surgery with Crohn’s disease while we’re waiting for diet and these things to kick in. When it’s appropriate and medically necessary, absolutely I would treat them with medication. My issue with medication is not the fact that they exist, because I’m glad that they’re there and they can really help people. My issue with medication is that we have built a healthcare system that almost entirely is focused on providing the medicine with absolutely no acknowledgement that these other aspects, which are the root issue, are relevant. That to me is the problem. And this is an interesting thing, which is that I would have drug reps that would come into my office, and they did not like me, and the reason why is because I literally said to them, I know that’s not you, but your company has created a drug that they’re charging people 1000s of dollars per month, and you’re asking me to prescribe this, but then you don’t teach me or provide the clinical study necessary for us to know how to stop and I don’t think that’s fair, because you’re making a ton of money. You should be not only funding a study to start the drug. You should be required to fund the study to stop the drug.
Lindsey:
Yeah, that’s not their business model.
Will Bulsiewicz, MD:
That’s not what they’re going to do, right? But that’s a problem because at the end of the day, I feel that should be a requirement for approval of particularly these drugs. The issue with Remicade or Humera, right, Infliximab, those are the two classics when it comes to treatment of inflammatory bowel disease. The problem with these things is that if you stop it, and you’re wrong, they will form antibodies to the drug, because the drug is a biologic, the immune system can react to it once you withdraw it, and then you won’t be able to put it back on board. And that’s a serious issue, because the data are very clear that the first medication that you receive that’s in this class is the best that you’ll ever do, and then the second one will be not as effective. And my point is that I understand why doctors don’t want to withdraw these drugs, because they’re afraid of losing the drug and not being able to bring it back. But it’s not fair, because the drug companies, they know how much money they’re making.
Lindsey:
As you’re intervening in the meantime on diet, how are you correcting microbiome? Are you familiar with the research of Mahmoud Ghannoum at Case about the plaques and Crohn’s and the presence of Candida and H. pylori in some of these plaques and such?
Will Bulsiewicz, MD:
So I am familiar with Mahmoud Ghannoum and to me when it comes to Candida, and I believe that he would agree with this, it’s been a couple years since I couple years since I talked to him, but he and I used to be in contact. I think that he would agree with me saying that when it comes to fungal infections, this is at least what I see in the data, that when we empower the healthy bacteria, they suppress the inflammatory yeasts. And we can see this quite readily, because for the vast majority of people, thrush, which is candida infection in the mouth, or esophagitis from Candida or vaginal yeast infection, these manifestations of yeast, they are number one when the microbiome is weak, right?
And classically, number two, occurring with antibiotics, because of course, the microbiome is non-existent in that moment because you’ve suppressed it and they come up, they flourish. From my perspective, the solution is not necessarily to attack the Candida. I believe that the solution is to focus on building the beneficial bacteria. Because when we do that I believe that the key to inflammatory bowel disease and many of these dysbiosis-based conditions, is ultimately to restore healthy microbes and then feed them with prebiotics and allow them to release the short chain fatty acids, butyrate, acetate and propionate, because then those are what help to suppress inflammatory microbes, help to suppress inflammatory yeasts, rebuild and restore the gut barrier, and also simultaneously, they have direct effects on the immune system.
Lindsey:
And at what point in the Crohn’s healing process is it safe to add fiber?
Will Bulsiewicz, MD:
I believe that it’s very early in the process, but I think that there’s a strategic approach. I guess let me, let me talk through. Let’s pretend that we have a person for a moment who has moderate to severe Crohn’s disease. All right, if they’re actively flaring, right now, I am not trying to put out their flare with fiber, right? And because they’re actively flaring, the addition of fiber is going to be a mess and may make their symptoms worse, because they’re not in a position of being capable of handling that. Ultimately, we need to get this person into remission, which may require medication in order to do that. When they get into remission, this, to me, is when our process of healing begins.
And the analogy that I would make Lindsey is, gosh, and I feel weird even saying this. I hadn’t even processed this until now, but, we obviously have the fires that are happening in California, I hate that, but I feel this is still the best analogy for me to describe this, please forgive me. And let’s separate from that, if we could, but if you have a fire that’s burning, you don’t plant new trees in the midst of a fire, right? You have to put the fire out, right? That’s step one. You put the fire out, and then when the fire is put out, there is damage that’s there, and the forest has been reduced down to not much. But there’s also an opportunity to regrow, acknowledging that opportunity to regrow does require time and patience, but it’s possible. And you put the fire out, and then you replant the seeds, and you allow those seeds to grow and mature, which takes time. With that analogy and applying it to Crohn’s disease, a person’s having an active flare, I want to use medication when appropriate, put the flare out, whatever is the least medicine necessary once they’re in remission.
That, to me, is when we really start to introduce the fiber-based approach. And my preference would be going back to what we were discussing a moment ago. I would generally start with a low FODMAP diet, and then over time, progress from low FODMAP to moderate FODMAP, and then working our way up to less restriction over time and simultaneously, from a fiber perspective, I would absolutely use a fiber supplement within that context. And so, Lindsey, I started a company called 38TERA*, right? And I’m happy to talk about 38TERA supplements. But I think there’s also this broader conversation that ignoring for a moment that I have a prebiotic supplement, acknowledging, what is the role of a prebiotic supplement within this setting? The answer is that it’s targeted for the microbiome. It’s not the same as food. It’s not meant to be the same as food. It’s not meant to be a replacement for food. It’s meant to be a way in which you can confidently influence the microbiome and have control over that dial. You can start with a very small amount, and then you can work your way up slowly over time. And what I would opt for within that setting is I would absolutely opt for a low FODMAP prebiotic, because low FODMAP once again, still is prebiotic, still feeds and fuels the microbiome, but is going to be more gentle to this person who has a damaged gut.
Lindsey:
Yeah. In terms of foods, you were talking about smoothies, and how, if they’re blended up, the fiber is not difficult for somebody. Is that an early way of introducing fiber? Would higher FODMAP foods that were in the context of a smoothie be acceptable where they might not be otherwise?
Will Bulsiewicz, MD:
Ultimately, it depends on how they feel. Yeah. If they if they were to do higher FODMAP and they feel totally fine, cool, you’re good. And if they struggle with that, then we have to back it down and move towards something that’s more simplistic. And while we’re in FODMAP content . . .
Lindsey:
Is the struggle going to look pain in the context of Crohn’s, or is it going to be loose stool or diarrhea or constipation? What are the primary symptoms that people are going to be suffering from?
Will Bulsiewicz, MD:
It really depends on the individual. And it depends, because the issue is that the disease can manifest in many different locations with varying degrees of intensity. Small bowel disease manifests in a rather different way. For example, the discomfort with small bowel disease will typically be felt around the belly button. If you have small bowel Crohn’s disease and you’re having intensification of discomfort around your belly button, what’s going on there? Whereas colonic Crohn’s disease, the colon basically frames the abdomen around the outside. Right, lower quadrant, right, upper quadrant, left, upper quadrant. These are different places depending that could manifest.
And again, I think it’s understanding your own disease, where you typically manifest it, and and what symptoms you experience. The lowest, most common symptom is bloating. Anytime the gut is struggling to process and digest food, you get bloating. And it’s not to say that the smallest amount of bloating should be something that scares you. That’s not the way that I feel about that, but it’s the acknowledgement that ultimately, what we’re trying to do is get you to a place where you’re comfortable, and then grow from there. Because if we can start with you being comfortable, then we have our baseline, and then from the baseline will continue to push over time.
Lindsey:
You mentioned the crossover of IBS with IBD. In some of these cases, this bloating could be caused by SIBO, conceivably?
Will Bulsiewicz, MD:
Definitely.
Lindsey:
All right, are you testing for SIBO then and treating that?
Will Bulsiewicz, MD:
Potentially, but SIBO, I guess the thing with SIBO is I’m a bit sensitive when it comes to SIBO. And I’ll admit that my fear is over treatment, because typically the treatment for SIBO is antibiotics, right back to overgrowth. Therefore, we must reduce the volume of the bacteria. We must cut them down. And antibiotics are a routine part of care with these people that have inflammatory bowel diseases, including Crohn’s disease, and they’re highly effective. But the issue, though, is that ignores the root of the issue, which to me, is dysbiosis, a damaged gut. I believe that dysbiosis is at the heart of Crohn’s and other forms of inflammatory bowel disease. I believe that it’s at the heart of irritable bowel syndrome. And I believe that SIBO is quite simply a manifestation of dysbiosis. It’s a form of it. And my concern with this particularly, is that I don’t want to rush to be put into a position where I feel that I have to treat a person with antibiotics because the test is positive. There are people who need antibiotics. There is no doubt. There are people who definitely have SIBO, and ultimately we have to get there. But my fear is that we’re paying a price where in the short term they are better, in the long term, not making them better.
Lindsey:
Yeah, but there’s definitely approaches that don’t involve antibiotics, serum bovine immunoglobulins or herbal antimicrobials that are more selective, like pomegranate husk or, gosh, there’s heaps of them, like turmeric, andographis, lots of things. How about those approaches?
Will Bulsiewicz, MD:
Those approaches, it depends on, to me, I would have to take a look at the specifics of what we’re talking about. An example oregano oil, I would have concerns about.
Lindsey:
Oh, yeah.
Will Bulsiewicz, MD:
So, because if we’re talking about broad spectrum anti-microbial, and I understand it’s not an antibiotic, it’s the same thing from my perspective, right? Whereas when we’re talking about something that’s more on the spectrum of garlic, or you mentioned pomegranate husk, or you mentioned turmeric? The thing that’s interesting with these things is that’s not an isolation antimicrobial; that’s in combination with prebiotics. Curcumin is a polyphenol and the health benefits that we receive from turmeric are the result of the gut microbiome and the effects that turmeric has on the gut microbiome. And the same is true with pomegranate in terms of ellagic acid and other prebiotic polyphenols that exist naturally. I have less concerns about those things, because basically what we’re talking about here is a prebiotic being packaged with something that we talk about being anti-microbial, right? But more selectively, and I’m seeing this not as an anti-microbial. I’m seeing this as a prebiotic building, right? Because my fear is that we’re not building; that’s my fear, right?
Lindsey:
Yeah, so the building process is ultimately going to take care of the cutting process? That you’re going to feed the good microbes, and they’re going to outgrow the bad ones without having to break down the bad ones.
Will Bulsiewicz, MD:
Yeah, and there’s healthy foods, as you’ve already pointed out, and then I would put my stamp on that there’s healthy foods that do have anti-microbial or antiviral effects that have been demonstrated, yet that’s not in isolation. We wouldn’t characterize them as an anti- microbial. We would say that they have that effect. It’s in combination as part of a package that also is many times prebiotic and therefore good for the microbes.
Lindsey:
Tell us about your supplement and what’s in it and how it’s helpful? And is it helpful, in particular, in Crohn’s? Was that in your mind as you developed it, or was it generally developed for building up good microbes?
Will Bulsiewicz, MD:
The way that I was thinking about this is, I guess, to frame the context, I have had incredible success treating people with prebiotic supplements for many years, but the thing that always troubled me is that the standards that I hold, I’ve never felt the supplements were there, never fully fulfilling those standards. And this led me to want to create my own because I, with confidence, believe that there is a role that exists for optimizing the gut microbiome and then receiving the effects and the benefits that come from the production of short chain fatty acids. To me, the general approach was, I wasn’t necessarily thinking about a specific disease state, per se. It’s more to say that, what we know, with 100% clarity, is that when you put prebiotic fiber or resistant starch or polyphenols in the mouth and swallow, we know where they’re going to go, we know what they’re going to do, right? It’s the because there’s no place else for them to go that you’re going to come into the context with the microbes.
Then those microbes will ferment them and create short chain fatty acids. But what I felt was missing is that many of the fiber supplements that exist are mono fiber, one single type. And in some cases, people advocate for using them at ridiculously high doses, 15 or 20 grams. And what happens when we only consume one type of fiber? You only feed certain microbes, and there is such a thing as too much, and this is part of my concern with, for example, inulin. Does it have studies to say that it’s beneficial for a microbiome? Yes; there’s also studies that say that it can be inflammatory and problematic if you do too much. I wanted to create balance. I wanted to create something that had multiple different forms of prebiotics, different types of fiber, also resistant starch and also polyphenols, and I wanted them, whenever possible, to come from something that has been clearly studied in humans with randomized control trials demonstrating that.
Number one, if you take this product at this particular dose, here’s the effect that it’s shown to have on your microbiome. Number two, it will affect your bowel movements, right? That, to me, is part of the proof that we’re achieving something of benefit is if you’re if your bowel movements are not the same, the proof is in the poop. And then number three, benefits beyond this, such as the improvement of gut symptoms, bloating. As I pieced together the formula, there’s seven different prebiotic ingredients, and they include resistant starch, which comes from potatoes. By the way, it’s a bit of a unique thing. It’s not the same resistant starch that you get by heating and cooling the potato. This is the resistant starch, RS2 that’s innate to the potato if it’s uncooked, and kiwi fruit, mango, beets, lingonberry and acacia and baobab. So, all right, it’s seven different and again, it’s a combination of fiber, resistant starch and polyphenols. And I see these as being synergistic together.
We have a clinical study that’s occurring right now that we should have the results in the next few months. And part of what we’re doing with this study is to demonstrate the synergy that exists when you take resistant starch and you add fiber and then subsequently polyphenols, because my expectation is that this is priming the pump, getting the microbiome organized and preparing to basically create these short chain fatty acids. Right now, as it relates to Crohn’s disease or these different health conditions, irritable bowel syndrome or even small intestine bacterial overgrowth, a few of the things that we did specifically and strategically. Number one, it’s low FODMAP. This is uniquely and strategically formulated, and it’s certified as low FODMAP. It’s intended to be gentle on the gut. Number two, it is certified glyphosate free. But it’s also taken much further than that. One of my concerns with, for example, gluten containing products, or oats or many of the things that people worry about is maybe it’s not the actual plant itself. Maybe it’s what we’re putting on the plant, glyphosate. Because to me, if you go to Italy and you can eat the food, which a lot of people say, it’s not the actual wheat. That’s the problem. It’s the way we’re treating the wheat. The product is certified glyphosate free.
But then beyond that, I’m really proud of the fact that we have extensively tested every single batch for more than 50 different pesticides, and it’s been negative every single time on every single test. We third party test far beyond this. This is a big part of what I was hoping to accomplish by creating my own brand, is that we’ve run over 100 different tests. That includes heavy metals, it includes microbes and pesticides. It also includes unique things that I literally have to get the laboratory to figure out how to get this done, histamine and salicylates and methyl salicylate. In essence, what we’re doing is we’re basically looking at things that can cause food intolerances that are specific to people with gut health issues. And for any batch that you purchase, you can find on the packaging, on the bag, here’s the lot number. You go to our website, you enter that lot number, and entire report is downloadable for you to see the results specific to that batch.
Lindsey:
Yeah. I’ve been trying it since you sent it to me, and I will vouch for the fact that it is light and fruity, and you add to some water, and it makes a light fruity beverage that tastes good and isn’t overly sweet. What sweetener is there in there? Is it stevia or something?
Will Bulsiewicz, MD:
It’s got monk fruit.
Lindsey:
Monk fruit, okay. Because I normally don’t like monk fruit. Monk fruit, to me, can be overbearing and sometimes weird, but it I didn’t detect any bitterness or bad aftertaste at all. It was light and pleasant and not too sweet. A lot of these things, the electrolyte formulas and whatever, it’s way too much. It was not that. I will vouch for the taste, and also the fact that if it didn’t come up, it wasn’t a typical fiber supplement.
Will Bulsiewicz, MD:
Yeah, it dissolves pretty well. You’ll see a little bit of white granular powder, and that white granular powder is the resistant starch. And that’s because resistant starch is unique, because it’s not soluble fiber yet. It’s still prebiotic fiber.
Lindsey:
Yeah. One thing I was wondering about, though, on the label, it says, I think was it maybe 5.9 grams of fiber per two teaspoons. But then it breaks it down, and it says 2.6 grams. I was confused. Which is it?
Will Bulsiewicz, MD:
Yeah, yeah. The actual serve is 5.6 grams, all right. And when you dig into the amount of actual fiber, it’s less than this, which, by the way, to me, is reassuring. And the reason why is because these are whole food ingredients. This is taking whole food ingredients, deriving a powder and then putting it into the formula, as opposed to some chemical extraction process where you are isolating the fiber and nothing else. What you end up with is that you end up with less than the 5.6 grams as actual grams of fiber. But the key, from my perspective, to addressing our fiber deficiency is not about grams. To me, it’s about a variety of different foods and feeding and fueling the microbiome to an adequate level. What we have, for example, is we have two ingredients that have human clinical trials to show what they do. And the cool thing about it is they both have been shown to improve the health of the microbiome. An example is Solnul™, which is the resistant starch, increases akkermansia levels by 317%
Lindsey:
Wow. At what dose, at 3.5 grams?
Will Bulsiewicz, MD:
Per day, which is the dose that is in a single serve of this product. Basically, we wanted to meet the standard of that trial, we included that precise amount of Actazin, which is the kiwi fruit. A very small dose has a very powerful effect. So 600 milligrams of Actazin per day, because the kiwi fruit fiber is quite powerful, is able to achieve an improvement in Faecalibacterium.
Lindsey:
prausnitzii?
Will Bulsiewicz, MD:
Faecalibacterium as a genus, not necessarily prausnitzii specifically. And then they also, more recently, published a paper discovering that it also increases Akkermansia levels, and now Akkermansia, I’m sure that your listeners have heard about Akkermansia, but this is a powerful, anti-inflammatory bacteria that protects people from inflammatory bowel disease, and there are companies that are selling probiotics, and those probiotics may be alive or they may even be dead, and they’re extremely expensive. And my argument is nothing against those companies. If they help you, they help you. That’s what I care about. But my argument is that if we could feed target and feed our own Akkermansia and help that to grow, that’s ultimately what we want. We don’t want something from the outside that passes through us. We want something that sticks. Yeah,
Lindsey:
Yeah and interestingly, I have seen clients and you see on a stool test, or on a metagenomic sequencing that they have no Akkermansia, no Faecalibacterium prausnitzii, and then it’ll come back. And sometimes this will be having not, of course, taken a probiotic for a Faecalibacterium prausnitzii, and sometimes not having taken the Akkermansia probiotic, but it can come back by feeding it even though it was below detectable levels. It doesn’t mean it’s not in there somewhere. It’s hiding up in there, maybe in the appendix somewhere, right?
Will Bulsiewicz, MD:
Oh, I totally agree. Yeah, that’s a great point on the appendix. I hadn’t even thought specifically of that. That’s a good point in my mind. The way that I thought about these things, is that because it’s not detectable doesn’t mean it’s dead, doesn’t mean that it’s totally gone but that it is below the ability of our tools to detect, which have their limitations.
Lindsey:
Yeah. Are there any other lifestyle or supplement or non-conventional interventions that are your regular go to’s in Crohn’s.
Will Bulsiewicz, MD:
I think that there’s other supplements that can be beneficial in Crohn’s disease. You mentioned the turmeric. I’m of the belief that turmeric is something worthy of consideration for all people that have inflammatory bowel disease. The starting dose can be as gentle as 500 milligrams once a day, but that’s a starting dose, and then we start to ramp it up, and quickly get to 1000 milligrams a day, and potentially more than that, potentially up to 2000 milligrams per day. I also am a believer in vitamin D. And the beauty of Vitamin D is that it can be a test-informed and targeted approach; you’re not blindly taking the supplement. You test and then you address the level. Yeah, and the goal for people that have Crohn’s disease, typically for me, I would target numbers of 40 to 60. And my observation is that vitamin D levels are consistently low in people that have dysbiosis, because there’s a connection between vitamin D and gut barrier function.
Lindsey:
My observation is that they’re consistently low in anybody who’s not supplementing, because nobody gets enough sun.
Will Bulsiewicz, MD:
Yeah, that’s true. Most people don’t get enough sun. But I also think that we are living in an epidemic of dysbiosis these days, and I think that’s part of what feeds into this as well. The other thing too, that’s interesting about vitamin D is it’s a fat soluble vitamin. Vitamins A, D, K and E are fat soluble vitamins. What that means? A few things. Number one, when you take your vitamin D supplement, take it with a fatty meal, it will improve absorption. But number two, in the context of obesity, you can have lower vitamin D levels as a result of obesity, because basically it spreads out throughout the body, and it can end up in fat cells, where it’s not even functional. It’s not helping you. Yeah. Vitamin D, again, I would target 40 to 60. But if a person were not doing testing, then I would probably, most people talk about 2000 international units per day. I’m more of the belief that we need to go higher and harder than that, because I don’t think that’s adequate. I typically would probably go at 5000 and as high as potentially 10,000 if there were a need, per day, yeah, and . . .
Lindsey:
Then testing every six months, every three months? How often would you test it if you were supplementing at that level?
Will Bulsiewicz, MD:
Trying to get them up to goal, then I would test more frequently, probably three months would be the target there. Once I have them at goal, then you make an assessment, how hard was it to get them there? Yeah, if it was hard, then you might test them a little more often, to make sure you’re maintaining it. But, over time, you hopefully settle in, you find the amount that you need, and then you stick with it. And then I also am a believer on some level, on the importance of adequate Omega 3 intake, specifically EPA and DHA. And, unfortunately, the vast majority of people; this is again, another one that you can test. It’s the Omega 3 index. And the Omega 3 index, basically, it’s a percentage, and it tells you what percent of the total body fat that’s detectable is made up of these types of omega 3s. A few things on omega 3s, real quick. Omega 3s are anti-inflammatory fats. They’re polyunsaturated fatty acids, PUFAs. When I hear people trashing PUFAs, I get a little bit bothered, because omega 3s are PUFAs. They’re good for you, whereas Omega 6s it’s a different story. And we can talk about that if you want to, we get plenty of omega 6s.
Most people don’t get enough omega 3s, and it leads to an unhealthy balance between those two fats. We want to reduce our omega 6 intake, but we really want to increase our omega 3 intake. There’s three main types of omega 3s: ALA, EPA and DHA. And the issue is that if you eat seeds, which, by the way, can be a source of Omega 3, it’s chia seeds, flax seeds, hemp seeds and walnuts, it gives you ALA, but the conversion rate is extremely poor. And ultimately, I’m of the belief that, look, if you can get your Omega 3 index up to goal, which, for a normal person, is eight to 12% and if you have Crohn’s disease, I would want you at 10 to 12%.
If you can get there up to goal without a supplement, I’m happy for you, but a lot of people cannot. This is where the choice that’s on the table is, we want an EPA and DHA supplement, and you can do fish oil, which is less expensive, or you can do an algae-based supplement. I tend to, when possible, opt for a high quality, algae-based supplement. I tend to favor the algae-based supplement for purity reasons. You can create that and it’s the Omega 3. And the problem is that when it’s fish oil, it’s not the fish that’s creating the Omega 3. It’s storing it, but it’s also storing other stuff. Unless we know that it’s pure, I have concerns. Anyway, the dosing for a person that has complex inflammatory conditions like Crohn’s disease is very high. Typically, we would start off in the range of 500 to 1000 of EPA plus DHA. But with these complex inflammatory conditions, you work your way up to two or 3000.
Lindsey:
And are we talking about krill oil now at this point, or what is the algae based one?
Will Bulsiewicz, MD:
Krill oil could suffice, basically all these things come from the ocean. Yeah. This is the long chain Omega 3s, but algae-based is not krill. Krill is an animal, and it’s own, unique thing, Whales eat a lot of krill. Algae, though, is the plant, and it could be grown in a farm and still produce high quality EPA and DHA.
Lindsey:
Yeah, so, I know with the vegan sources, it’s really hard to get much EPA or DHA without taking tons of it. It’s really expensive to get there.
Will Bulsiewicz, MD:
I think it’s becoming increasingly available, the ability to get the vegan, long chain. Again, what I’m looking at is, I’m going to turn the label, I’m going to look at it, and I want to see how much EPA and how much DHA, and I’m going to add those two together.
Lindsey:
Yeah. Is there one that you are familiar with that’s high because I’ve looked for this for clients who are vegan, and I can’t find anything that’s more than like 300 of the two of them in a whole pill.
Will Bulsiewicz, MD:
I mean, I don’t know the brand off the top of my head, I have seen them that are about 1000*.
Lindsey:
Oh, really?
Will Bulsiewicz, MD:
Yeah, no, yeah, it might be two. It might be two pills per serve, and that gives you 1000.
Lindsey:
Yeah, I use the ProOmega 2000* a lot, because one pill is 1000 EPA and DHA. It’s done.
Will Bulsiewicz, MD:
No, that’s great. And for these people, so 1000 EPA and DHA for the vast majority is a sufficient amount, but for people that have complex inflammatory issues, you’re looking for an anti-inflammatory dose, and that’s where you have to push it a little bit higher.
Lindsey:
Yeah, this has all been super interesting, but unfortunately, we’re running out of time. I do want to ask number one, where can people find your supplement, and mention that they did make a discount code for my listeners, that was PERFECTSTOOL for 10% off.
Will Bulsiewicz, MD:
Yep, the code is PERFECTSTOOL, and caps or no caps. It should work either way. If you have trouble, let us know. Yeah, if anyone’s looking to try out 38TERA, use that code. You’ll save 10%. Our website is 38TERA.com*, and you’ll find it there. And, on our website, we have a ton of resources if you want to check it out. We have a Science page, we have laboratory results. We also have a product guide that walks people through the specifics of how best to get the most out of our product. But nonetheless, go to the website, check it out. And honestly, I hope that it helps people, and if it doesn’t let us know.
Lindsey:
Awesome. Thank you much for coming here and sharing your knowledge with us.
Will Bulsiewicz, MD:
Thank you, Lindsey.
If you’re dealing with gut health issues of any type (diarrhea, constipation, bloating, SIBO, IMO, H2S SIBO/ISO, IBS, IBD, gastritis, GERD, H pylori, diverticulitis, candida, etc.) or have an autoimmune disease and need some help, I see individual clients to help them resolve their digestive issues or reverse autoimmune disease naturally, You’re welcome to set up a free, 30-minute breakthrough session to see if you’d like to work with me. I also have my own two products, Tributyrin-Max, which is particularly helpful for loose stool and diarrhea as it slows your motility and firms up your stool, and SBI powder, which is an all around gut pathogen binder, which is super safe and won’t harm beneficial bacteria, and is usually the first line of treatment I educate my clients about in order to avoid stronger antimicrobial herbs.
*Product and dispensary links are affiliate links for which I’ll receive a commission. Thanks for your support of the podcast by using these links. As an Amazon Associate, I earn from qualifying purchases.
