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Adapted from episode 104 of The Perfect Stool podcast hosted by Lindsey Parsons, EdD, Gut Health Coach with Hope Pedraza, FDNP, certified Hair Tissue and Mineral Analysis expert, and edited for readability.

Lindsey: 

So since you’re a certified hair tissue mineral analysis expert, we’re going to talk a lot about minerals today and their role in digestion. So let’s start with the big four minerals.

Hope Pedraza: 

Yeah, I love that; jumping right in. Yes. So the big four are the macro minerals, the ones we need the most of, are calcium, magnesium, potassium and sodium. It’s important to know, especially when we’re looking at hair tissue mineral analysis, that the individual minerals are important. But then also, the relationships between all of the minerals are important. So they all play off each other, right? Some work synergistically with others, some work antagonistically against other. So this is why the right mineral balance is so important, because so often, if we’re not directly addressing what the mineral imbalances are, we could potentially be making things worse, because then we’re taking more of these, when really taking more of these is going to mess these up. So in the big four, the relationship between all four of those is important as well. So when we’re looking at the big four, the the macro minerals, all of those play so many roles in the body, including digestion, how your thyroid is working, how we’re pushing things in and out of the cells. A lot of these also work alongside other minerals as precursors to different hormones and enzymes that are related to digestion, the formation of other hormones. And so the right balance of these four is crucial. I don’t know if you want to go through each one of them individually . . .

Lindsey: 

Yeah, why not?

Hope Pedraza: 

Okay, cool. So I’ll start with calcium. So talking about calcium, calcium is a structural mineral, right, we need it for our bones and our teeth. And really 99% of it is supposed to be in our bones and our teeth. But it’s also needed for your thyroid hormone. So it helps with your metabolism and how your thyroid is working. Now with calcium, I find, at least in doing the labs that I run, that excess is far more common than deficiency. And so when you’re seeing an excess on an HTMA, on a hair tissue mineral analysis, and I should probably explain what that is, too. So if those who are listening, if you don’t know what an HTMA is, it’s a hair tissue mineral analysis. You’re literally sending in some of your hair. And so when you’re looking at your mineral levels, if you’re getting a blood panel, and really honestly, I believe this with just about any blood panel, but especially with looking at minerals, a blood panel is literally just a blip in time, right? It’s like what’s going on right now in your body. And so in a lot of instances, it’s not all that helpful.

And when you’re looking at mineral levels, I find that it’s really not all that helpful. Because it’s like what’s happening now. So it’s not even a look at what’s going on, right, you could take the same lab test in two days, and it’s going to look different on the blood test. Because it’s just what’s going on right now. It’s going to be affected by what you ate last night, what you ate this morning and what you drank yesterday; it’s just going to be so variable. And when you’re looking at mineral levels, the HTMA, we’re looking at what’s going on chronically; what’s going on over the last three to four months. Not only that, but a lot of minerals that we’re looking at, and some of these big four that we’re talking about are intracellular, meaning they’re supposed to be in your cells. So when you’re looking at your blood levels, it’s really not an accurate look at what’s going on at a cellular level, like how your cells are utilizing these minerals. So I wanted to say that upfront, just so people who are listening understand what we’re talking about. We’re talking about the HTMA.

Lindsey: 

Let me stop and say this. So people will see calcium, for example, or magnesium, on the comprehensive metabolic panel, which is one of the common blood tests that’s run. And that is not the same as getting one of these hair tissue mineral analyses. That’s basically saying that your body is functioning at the minimum level possible such that your glands are properly regulating these very important minerals. It’s not saying are you getting sufficient amounts in your diet over time?

Hope Pedraza: 

That’s exactly it. And if we’re talking about the difference between functional labs and conventional labs, that’s the main difference, right? With conventional labs, the reference range is like, “Okay, are you alive?” Like that’s the basic, like why you’re not dead . . .

Lindsey: 

Are you near death, do we need to intervene with an IV instantly?

Hope Pedraza: 

Exactly. That’s exactly it. So with functional labs, we’re looking at optimal levels, right, like, how do we live optimally? So yes, you may make a great point. So yeah, it’s totally different. And so we’re looking at calcium levels on an HTMA. This is what’s being pushed out into your tissues. So the issue here and I mentioned that typically excess is more common than deficiency on these labs when it’s being pushed out into your tissues. This is when we know it’s a problem because it can get to a point where there’s so much being pushed out into your tissues that it’s building up what’s called a calcium shell around your cells and around your nerves. And it’s going to cause the issues with cellular permeability, like how things are getting in and out of your cells, it’s going to cause issues with how your brain is functioning, because now you have this calcium shelf building up around the nerves and stuff in your brain and brain fog.

And I’ve had clients with this massive calcium shell that think – they’ve literally been told they have ADD – well, no, actually, we just need to fix your calcium levels. Literally, we fix your calcium levels, and all of a sudden no more brain fog, and I can concentrate now. It’s wild. So calcium levels are an interesting one. And I mean, sometimes there are symptoms of of calcium excess, but a lot of times they’re not what you think because sometimes you could have calcium buildup in the body, right? If you have like cysts or like bone spurs, kidney stones, that kind of thing.

Lindsey: 

Hardening of the arteries . . .

Hope Pedraza: 

Yes, exactly, calcification inside the arteries, but it doesn’t always show up that way. And it’s like for this client that I was mentioning, she’s always the first thing that comes to mind. Her numbers were literally off the charts. But for her, it wasn’t blatant things like that, it was ADD, trouble concentrating. All these things were big for her, it was more of that kind of thing, like how her brain was functioning, and her thyroid was functioning, because the thyroid wasn’t able to get in the cells because you have this buildup. So calcium is always an interesting one for people and looking at how that shows up.

Lindsey: 

Yeah, in my experience, it’s showing up as high for people that I see as well.

Hope Pedraza: 

Yeah, really?

Lindsey: 

Yeah.

Hope Pedraza: 

Do you find that they have the symptoms? Or is it kind of just like this underlying thing they’re not really aware of?

Lindsey: 

Oh, to be honest, I never knew that brain fog might be a symptom of ADHD or excess calcium. That’s why I have you here to teach us.

Hope Pedraza: 

Yes, totally. And again, just so people listening know, this is a different thing than calcification of the tissues that we’re talking about. And that’s just sometimes how it shows up when it’s pushed out into the tissues. So another one is magnesium. And magnesium is one of those, and I’m sure you talk about magnesium all the time, too. It’s involved in so many processes in the body: digestion, how your hormones are functioning, enzymatic reactions, like with everything that’s going on in the body, magnesium is used. It’s so easily depleted I think because it’s used in so many reactions in the body, that’s how it gets so easily depleted. And I think the number now is between 70 and 80% of us or something like that are deficient in magnesium. I think this is why, and so many of my clients are like “but I’m taking magnesium”.  But we’re doing the lab and I’m like, how’s your magnesium levels?

And they’re taking a supplement but your body is just running through the stores of it. It’s stress, your adrenals, especially when your adrenals are working in overdrive, it’s just pushing through your magnesium stores. Magnesium is one of those that’s responsible for helping us with cell permeability, how things are getting inside of the cells. It helps with muscle contractions, relaxation, like the relaxation of muscles. It’s important for your heart, it’s important for inflammation. And so when we’re deficient, which a lot of us are, things can show up like depression and hypertension, and a lot of times PMS and just inflammatory things. PMS, maybe aches and pains, osteoporosis, maybe arthritis. And a lot of times too in my clients, it may not even be as blatant as that, but it’s just like overall dysfunction in the body. It’s just not functioning optimally, because again, your supplies are running so low. Now, sodium is interesting.

Lindsey: 

Before we go on to sodium, let me just stop you and ask, in your experience, for people who show up as deficient, what kind of repletion levels are you needing on daily basis to get them back to sufficiency?

Hope Pedraza: 

Good question. So it depends on the person and it depends on a few things. But typically, I like to say five times your body weight in milligrams is what you want to shoot for. I feel like a lot of times it’s why people are so deficient. This is one of those that I really like to work with supplements and with food because we’re so deficient. And if you look at most of the supplements on the shelf, they’re like 150-200 milligrams. I just think nothing’s happening with you taking 150 milligrams.

Lindsey: 

But it takes up a lot of space. So you’re taking a lot of pills if you’re going to take it.

Hope Pedraza: 

Right, totally. So if you can find magnesium glycinate, it’s always my number one recommendation; your body absorbs that one the best. It’s easiest on the gut. If you want a laxative, you take magnesium citrate, otherwise don’t take it. But, but a lot of times too, I find, especially with my clients that are super depleted in magnesium, I’ll give them a combination of a few different forms that they need. And we’re going to add in the food on that one. So it’s going to be five times your body weight. So for an average human adult, it would be between like 500-700 milligrams, and so if we shoot for at least that 500 milligrams, I feel like we can be doing a good job of getting us closer to where we need to be. And then again, if somebody’s super deficient, we’ll do a combination like glycinate, maybe a malate, a threonate, putting a few different ones together, even doing some transdermal, like doing some soaks, right? You could do an Epsom salt bath; you could do either magnesium sulfate or magnesium chloride. So doing the transdermal soaks, you sometimes can absorb that a little bit better, and then adding in some food sources too, right?

Lindsey: 

What are some good food sources?

Hope Pedraza: 

Yeah. Think leafy greens, nuts and seeds. I love pumpkin seeds. And I work a lot with women and their hormones, too, so there are a lot of benefits for women’s hormones. But adding in pumpkin seeds . . .

Lindsey: 

I put them on every salad.

Hope Pedraza: 

Yes, totally, me too. I eat them all the time at my house, we eat a ton of seeds. Yes, nuts and seeds. Legumes can be. But I’d say that my top recommendations are typically leafy greens and the nuts and seeds. I feel like that’s the best way to get the magnesium. Yeah. So moving on to sodium, sodium is an interesting one. Because speaking of digestion, this one is actually really important for digestion, because sodium is needed to make proper stomach acid levels. So people that have chronically low stomach acid typically have issues with sodium. And so it never fails that my clients that are low on sodium, which is a lot of them, they have chronic bloating, and it’s because their food’s not being digested properly because they have low stomach acid. And there’s typically other factors at play, but the sodium piece always plays a role in that.

I could literally talk about sodium all day; there’s so much to talk about. And sodium, it’s one of those I find these days, like carbs, where like carbs were villainized for so long, so everybody’s afraid of carbs. And I feel like sodium is the same. You know, you hear from your doctor and everybody else, sodium causes high blood pressure and stroke and all things and eat a low sodium diet and watch yourself. And yes, you can say some of those are true, but in my experience, the way I see it, our sodium problem, especially here in the Western world, I can’t speak for the whole world here. But at least in the Western world, the sodium problem, all these issues that we think sodium is causing is not a sodium intake problem. It’s a sodium retention problem. Because where are we getting the salt from? It’s from processed foods, right? It’s from table salt.

Table salt is the equivalent of white sugar, right? It’s had all these chemicals put in it to strip every nutritional value from it, and you’re literally left with the sodium chloride. That’s it. And so when you’re looking at comparing that to unrefined salt, my recommendation is always Celtic sea salt*. It’s just so rich in so many trace minerals you’re looking at. To compare it, you’re looking at like anywhere from 85 to 95 other trace minerals in Celtic salt versus table salt, which is literally just sodium chloride. And so when you’re eating unrefined sea salt, you’re getting all these other trace minerals along with the sodium. So all these other minerals are pushing this sodium where it needs to go, it’s pushing all these other minerals where they need to go versus when you eat the table salt, just that refined salt from processed foods, your cells just soak it up. And then again, it’s a sodium retention problem. So yeah, when you eat the standard American diet, the salt intake is going to affect things.

So when I’m doing the HTMA, I would say deficiency is far more common than excess in sodium. And it’s typically for this reason, well, first of all, a lot of it has to do with your adrenals. Your adrenals use more sodium than any other part of the body. So our overworked, stressed-out adrenals are zapping through your sodium stores just like what’s happening with your magnesium stores. It never fails. When I have somebody who has adrenal insufficiency or their adrenals are just totally shot, they’re bloated all the time. Well yeah, your sodium levels are in the toilet and your body’s not digesting food. Your stomach is not functioning right, you know? Your stomach acid is probably barely existing. And so yeah, your digestion is going to suffer.

So it’s just like this chain reaction with the minerals. Which again, I love minerals so much and your listeners have probably heard that minerals are called the spark plugs in the body, right? But if you really think about that, nothing happens in the body without the minerals, or what’s going on at a cellular level. And this is what’s causing every reaction in the body: your digestion, your hormones, your glands; everything going on starts with the minerals. So yeah, I think understanding this kind of chain reaction, especially when we’re talking about digestion, the sodium piece is always a big one there.

Lindsey: 

Cool, yeah. Yeah, I know. I know. It’s because we are dealing with, well, I don’t know if you, but in my clients, I’m dealing with a certain subset of people who are already on a super-healthy, non processed food diet. They’ve already cut out the gluten and the dairy, so they’re all dialed in. So it’s that kind of diet where you precisely can end up with these deficiencies, sodium.

Hope Pedraza: 

Yeah. Right. For sure. Yeah. And my mom, for example, I use my mom as an example. I’ve read some labs and yeah, granted, she also grew up in a generation where the doctor makes you terrified of salt. So she’s not putting salt on anything. And she’s wondering why she has headaches all the time. And I kept telling her, your sodium levels. And then it wasn’t until her friend who’s a nurse was like, oh, yeah, your daughter is probably right, that she starts adding some salt to her diet. And sure enough, things start shifting. But yeah, it definitely affects things in a way that I think we just, again, I think we’ve just been so scared of it for so long, because we don’t want to have a stroke or heart attack. It’s like we avoid the sodium. It makes a difference.

Lindsey: 

Now I’m super curious what my sodium level was on my on my hair. Yeah. Let’s see where it was. It’s a little bit low.

Hope Pedraza: 

Yeah. Probably. Yeah

Lindsey: 

It’s 30. And the range is 20 to 250. So it’s normal, but it’s not great.

Hope Pedraza: 

Yeah, trending low. Yeah, that one is super common. And that usually surprises people, the sodium thing usually surprises people. Okay, so the last one of the big four is potassium. And this is one of those intracellular minerals that 99% of it, it’s in your cell. So a blood level or blood panel, tor me, it’s not really an accurate look at potassium, it’s just not. So really, and I’ve actually I’ve had a couple clients with this, they’ve gone to the doctor and their blood levels are actually elevated. Well, that actually is a bad thing. Because that means the potassium is in your blood and not in your cell. So this is like a loss, like your body’s not using it in the right way. So potassium is one of those that helps with your blood pressure, it helps with helping things in and out of the cells. What I find most important for potassium is it is responsible for how sensitive your cells are to your thyroid hormone. And so a lot of my clients who are struggling with their thyroid, their potassium is super low. And I find a lot of times too, this can also affect your digestion. Deficiency on this one is far more common. I mean, honestly, I can probably count on one hand the number of clients I’ve had where their potassium levels are where they’re supposed to be. Everybody is low, like it doesn’t matter what . . .

Lindsey: 

I’m deficient in potassium, and yeah, even if I add up all my food in Cronometer, I’m deficient in it, what I’m getting from the diet for sure.

Hope Pedraza: 

It’s hard to get, it really is hard to get it and we were supposed to have like 4500 milligrams a day. That’s a lot. It’s a lot so it’s not hard to be deficient in it. So this is another one like magnesium where I really like to do the supplement with the food, where . . .

Lindsey: 

You kind of have to because you can only get 99 milligram supplements, right? So yeah, what foods are . . .

Hope Pedraza: 

The best foods, my top three that I always recommend, especially for my thyroid clients: bananas, avocados and coconut water. For me those three are like top three.

Lindsey: 

I just can’t stomach coconut water.

Hope Pedraza: 

I can’t either, my gosh, it’s like you’re expecting it to taste different than it does. I don’t know what it is. So for my clients I’m like throw it in a smoothie where we’re covering it up with other things because I’m the same way.

Lindsey: 

Mix it with fruit or something; it’s just too sweet.

Hope Pedraza: 

Exactly, it is. I can’t.

Lindsey: 

I just like water.

Hope Pedraza: 

Exactly, exactly. Yeah, no, I can’t do it either. It kind of grosses me out but if you know can cover it up with other things or mix it with something else. But really those three, in my opinion, are the highest. And you can put all three of those in a smoothie and you’d be getting a whole lot in just one serving, one meal.

Lindsey: 

Yeah, I also found that just a glass of orange juice has 200 milligrams of potassium. My mom was deficient and I’m just like, have a second glass of orange juice a day. Let’s not overthink it.

Hope Pedraza: 

Exactly. Make it easy. Totally. Yeah, those fortified juices like that for sure. It’s a great way to get it and I find, hypothyroidism and constipation go and in hand. So there’s a lot of links there. But the constipation part is pretty common with those who are deficient in potassium. Constipation, a lot of times fatigue, I had clients who have irregular heartbeat situations going on, super tired and not able to tolerate exercise, unable to recover from extra exercise, muscle weakness. So a lot of those are are signs of pretty substantial deficiency in potassium. And then if you know that you have a sluggish thyroid or you know that you’re hypothyroid, it’s one of the best things you can do. And of course, you know, about the selenium and iodine and stuff, but potassium is one of those I feel like isn’t talked about enough for the thyroid. It really does make a big difference. We can get those levels up to a good . . .

Lindsey: 

Yeah. Yeah. And I keep thinking about how can I get more potassium personally.

Hope Pedraza: 

It’s a tricky one.

Lindsey: 

I definitely don’t want to drink smoothies. So I’m being sort of a pain in the butt, but I love my egg and my vegetables and the stuff that I’m eating for breakfast, I just love that routine. And if I have to have a smoothie, that’s replacing that.

Hope Pedraza: 

Totally, just add some extra avocado on it. You’ll get some with that.

Lindsey: 

But it’s so fattening.

Hope Pedraza: 

I know, you have to weigh it out.

Lindsey: 

Digging it down to the actual problem, the problem is that I want to eat that half a gluten-free English muffin with my breakfast, and that’s eating up some calories and some stomach space. And if I’m adding in avocado and all that, there’s just no more room.

Hope Pedraza: 

It’s so true. It’s a tricky one, it is.

Lindsey: 

Okay, so we’re done with the big four.

Hope Pedraza: 

Yeah, the big four. That’s it.

Lindsey: 

Okay, awesome. So, one of the minerals we need at lower doses, zinc, which is often recommended to support the immune system. Of course, if you have Hashimotos or autoimmunity, it’s important. And then the form of zinc carnosine, in particular, is recommended for gut health issues. So can you dig in a little on zinc and its forms? And how and why to supplement, and of course, its relationship with copper.

Hope Pedraza: 

Yeah, yeah. So zinc is another really important one, it helps again, it’s kind of one of those along with sodium that helps with stomach acid for healthy levels of stomach acid. It’s a precursor to quite a few digestive enzymes. And so it’s important for proper formation, creation of digestive enzymes. And zinc and copper have a really important relationship. And this is one that we look at on the HTMA, that relationship between zinc and copper, because they can work with or against each other. And this is typically one that I look at is in terms of hormone, it’s kind of the hormone ratio, the zinc to copper ratio.

And so copper can stimulate the production of estrogen. And so when there’s too much copper, not enough zinc, this starts to look like estrogen dominance; it can cause a real problem with the hormones. And so that’s when the zinc and the copper are off. And a lot of times too, copper toxicity is something that I see, and you might see this a lot with your clients too. But copper toxicity is something that shows up a lot with my clients. And so often, there are multiple issues here. A lot of times it is a zinc situation, where the zinc is just so low, and it could be an immunity thing. It could just be that their diet is just off and they’re just not getting enough zinc. But a lot of times too, it’s just from exposure to actual copper itself. And so I would say, probably 7 out of 10 of my clients have copper toxicity.

Lindsey: 

From pipes, or where are they getting it?

Hope Pedraza: 

Well, a lot of times, a lot of times it’s from birth control, either birth control or an IUD. Prolonged use and sometimes it doesn’t even have to be prolonged use. I think it’s like parasites, right? Like, sometimes you’re just a hospitable host to a parasite. That’s how it happens. And I think sometimes with copper, it’s the same thing. It’s like, well, maybe your vital functions were a little bit down and then your body just harbored it right? Because a lot of times I have clients where I wasn’t even on it for that long and sometimes it just happens that way. So I find sometimes it is copper pipes and I have actually only had a couple of clients where that was the case. For most of my clients, it’s a birth control situation or IUD.

Lindsey: 

Are you talking about the copper IUD in particular or from just other birth control?

Hope Pedraza: 

Either just because the stimulation of estrogen in the body is going to actually mess with this copper to zinc ratio as is birth control in and of itself; it depletes zinc in the body. A lot of minerals that are depleted by taking birth control and so when you’re depleting zinc, then copper naturally.

Lindsey: 

Yeah, yeah. Okay. And so they’re on different scales. And like I have an example of my mineral analysis. And copper is on a scale on this one from 11 to 37, zinc from 20 to 140. So how do you work the ratio?

Hope Pedraza: 

Yeah. So if you’re looking at, let me see if I can put one of mine in it that I just did the other day, because she had a really crazy ratio. And here’s the other thing about the HTMA. And this is why, it’s always good to have somebody who knows how to read them, because you can look at an HTMA at face value. And you could read it like 25 different ways. Because you can look at it, you can look at the the individual minerals, like, “Oh, this one looks kind of slow”, or whatever. But then if you look at the ratios, looking at the ratios changes how you interpret the whole thing. And so that’s how it is with zinc to copper ratio, because a lot of times it can look like “Oh, my zinc and my copper aren’t too far out of the reference range.” But in comparison to each other, they’re really off. So like my client, we had a session other day, her copper was a little low. But her zinc was so much further off than the copper. So now we’ve got this messed up zinc to copper ratio. So it’s really just looking at them in relation to each other, not not the individual zinc level and copper level, you really have to look at at the . . .

Lindsey: 

Yeah, like on my test. It does show at the bottom the ratios. Zinc to copper, the range is four to 20. Mine is 15.

Hope Pedraza: 

Yeah, yeah. So just a little bit elevated. Yeah, yeah.

Lindsey: 

Oh you’d call that elevated?

Hope Pedraza: 

A little bit. A little. It’s like trending elevated. Do you know which lab?

Lindsey: 

Mine is Doctors Data.

Hope Pedraza: 

Okay, I use Trace Elements. I think their ranges are a little bit different. Because basically over 12 is considered elevated in theirs, but I wouldn’t be too alarmed at 15.

Lindsey: 

I don’t take any copper in any capacity.

Hope Pedraza: 

Yeah. Also, I’ve had clients who, and it’s not all the time, but some who are, if you’re on a vegan or vegetarian diet, and you’re eating foods that are higher in copper, your copper can be really elevated from eating predominantly plant-based food and not being balanced out with the zinc. So yeah, that can happen that way. Yeah.

Lindsey: 

But I also see the opposite, which is, occasionally I do see people who seem like they may be low on copper because I don’t know if you’re familiar with the whole conversion of dopamine to epinephrine, norepinephrine requires vitamin C and copper, and I’ll see people with high dopamine, but then low epinephrine and norepinephrine. So that’s a potential copper deficiency. So I’ll see that a good bit. And people do tend to supplement with zinc, people who are aware of it helping your immune system. So I mean, they might be taking 50 milligrams of zinc a day, and eventually you’re going to end up with a copper deficiency.

Hope Pedraza: 

Totally, exactly. That’s so true. Yeah. And you know, it’s funny, you say that. It was in my FDN group, I think somebody was having conversation about that. Because throughout COVID, everybody was downing vitamin D and zinc. And all these things are trying to boost our immune system. And we were talking about how we’ve seen a lot more clients than normal have really high zinc levels, because they’re taking zinc like all day, every day, which is also going to be a little harsh on your stomach, by the way, so be careful. Yeah.

Lindsey: 

So did you mention anything about zinc carnosine?

Hope Pedraza: 

Just in terms of like which form to take it in? Yeah, I think I don’t have strict stipulations on what form that I give it in. A lot of times the form that I use, so when I do my mineral protocol for my clients, I use Vykon, which is a lab that basically customizes it to your HTMA. And therefore, most the time, it’s zinc picolinate. And that’s usually the form that it’s in. I think, the form for zinc to me, I’m not a stickler about the form on that one as much as others, especially magnesium and potassium and those. So I’d say the form, I just don’t find it as important.

Lindsey: 

Yeah, the zinc carnosine is just something that that’s used often when there is H. Pylori to help out with gut issues. So that’s why I wanted to bring it up. But moving on. So what other minerals do we need in smaller quantities? And what role do they play in digestion?

Hope Pedraza: 

Yes. So let’s see. So if you get the HTMA, it’s going to measure a few different, well, it depends on the lab, usually, it’s anywhere from like 20 to 24 different minerals. So let’s see, manganese is one. And I don’t want to say it’s directly influencing digestion, but it’s important for mitochondrial energy production in the cell. So because the mitochondria, the energy parts of the cells, and we need that for every part of the body and every function in the body. So I think manganese is one that can be really important just for overall function of the body, but with you know, thyroid function, digestion, just overall mineral balance, manganese can be important one.

I find that chromium, and chromium typically you hear that talked about in terms of blood sugar regulation, but I find that it does help. Again, it’s kind of one of those, it’s all a chain reaction, right, they’re all connected. And so it’s hard to pick which one because they’re all affecting so many things with chromium. It’s important for blood sugar regulation and insulin control, and your insulin and your cortisol are so related, and that’s going to affect your adrenals. There are so many things tied to how chromium is working. And the other part of that, linking a little bit more to digestion is a lot of times the more deficient in chromium, we have more sugar cravings and carb cravings. And it can lead to dysfunction that way, just because we’re eating things that we might not normally be eating just because those levels are low.

Cobalt is another one and there’s like many schools of thought about cobalt, like some people, some experts say it should be as low as possible. But we do need some levels of cobalt, we have to; it’s this precursor to B12. We have to have that intrinsic factor in the guts to make B12. So all of that is related to gut function. And it’s also related to liver function. Super low levels and super high levels of cobalt typically indicate low stomach acid or a stomach acid issue. Super high levels typically, in my experience, simply indicate some sort of liver stress. And so when I see super high levels, actually my client the other day, where I was just talking about her lab, her cobalt was really high. And we saw some other labs, there was definitely liver stress. She had H pylori, so affecting her stomach acid. So there’s a lot of signs, and the high cobalt was a red flag. So something’s going on with your gut and liver with the cobalt. So cobalt is one of those that I like to look at. Let’s see, I’m trying to think of a few more.

Lindsey: 

Well we should talk about iron for sure. Because that’s one a lot of people are deficient in and you can get high iron.

Hope Pedraza: 

Yes, exactly. Yeah. And I will say the HTMA is not – you should never use the HTMA alone for iron levels; you really need to get your blood ferritin levels checked. If you really want an accurate look at what’s going on with your iron levels. On an HTMA, when I’m looking at it, I never look at it in isolation. Like in isolation, it’s not really going to tell you a whole lot, but you can look at it in relation to some of the other minerals. But just in general, definitely get your iron levels checked. But if your serum levels are, you’re getting your ferritin checked for deficiency, right? Chronic Candida is common with low levels. Obviously, your thyroid, we need we need good iron levels for your thyroid. And then too much is a breeding ground for potential pathogens, right? We have too much iron, it can feed pathogens. So yeah, iron is one of those that the healthy balance is really important.

Lindsey: 

Yeah, I’ve been struggling with trying to get enough iron all my life. And I’ve had this problem with fragile cracking nails for a long time. And then it suddenly got significantly worse. And I have been borderline anemic for most of my life. And more iron deficient at the moment, but at various points also B12 deficient, because I at one point had pernicious anemia. But you know, I take the methylcobalamin sublinguals. So B12 is not an issue now. Yeah, but anyway, I got my ferritin numbers up significantly. And I switched from taking ferrous sulfate, which was the cheap drugstore form to the iron bisglycinate, which has been much more effective and at much lower doses. But anyway, the sudden decrease in the hardness of my nails made me wonder if I did have heavy metal toxicity or something. And my hair was falling out in buckets. So I got the hair tissue mineral analysis. Yeah, it was probably about four or five months ago at this point. And it showed, despite the fact that I was measuring high in blood, you know, my ferritin was very normal, it shows still showed a deficiency, but you’re saying maybe trust the blood more than the than the hair.

Hope Pedraza: 

I would trust the blood, yeah, for sure.

Lindsey: 

Okay. But then I was listening to this webinar, and the doctor giving it was pointing out that iodine, iron, magnesium and calcium all compete for absorption. And I was taking iron supplements at the same time I was taking my iodine. And my iodine came up fine on my hair. So I said, I’m going to stop taking the iodine and I’m going to take my iron supplementation and put it on an empty stomach just with my vitamin C. So it helps absorb it. And away from the calcium, magnesium, and it seems like my nails have been getting better since then.

Hope Pedraza: 

That’s awesome.

Lindsey: 

I’m wondering what other minerals or things could be playing into the nails and the hair?

Hope Pedraza: 

Yeah, yeah. I think a lot of times it’s what’s competing with what in a sense, because calcium obviously is a structural mineral, like I mentioned, like it’s in the bones, the teeth, that kind of thing. But I think a lot of times it has to do with these other minerals competing and vitamins too, vitamins and minerals. Because calcium competes with magnesium, it competes with phosphorus, it competes with a couple B vitamins, but then it works together with vitamin A and vitamin D and vitamin C, magnesium. So I think a lot of times it has to do with the combination of vitamins and minerals working together that can affect the hair and the nails. Because the nail thing isn’t super common, but the hair thing, I have quite a few in here. It’s like their hair is thinning, or it’s coming out. But a lot of times it’s those thyroid minerals, right, and that’s kind of one of the signs of a thyroid-ism. Right. So we’re looking at selenium and iodine and iron, like we said, and potassium is another of those thyroid minerals.

Lindsey: 

Yeah, maybe I need to dig in on the potassium. Because I’ve checked all the others.

Hope Pedraza: 

Eat some more bananas. Maybe you can add more bananas into your life without the fat of the avocado.

Lindsey: 

Okay. I’ll work on the bananas. How about plantain chips?

Hope Pedraza: 

There you go. Don’t want to eat any more bananas?

Lindsey: 

No, I’m really a pain when it comes to diet. If my clients were as bad as I am, they’d never get better.

Hope Pedraza: 

That’s hilarious.

Lindsey: 

So yeah, I was also low in phosphorus and chromium in my thing and have now twice been low on chromium on different tests. So I’ve just finally sucked it up and started supplementing with chromium. Because if that’s bringing down my blood sugar awesome, that’s nothing but positive.

Hope Pedraza: 

Totally, totally. Yeah, for sure.

Lindsey: 

But I did. I did read on the analysis that phosphorus, it’s not good to measure phosphorus in your hair. That that’s not the best way.

Hope Pedraza: 

Yeah, not the best way. Yeah, I mean, I’d say for phosphorus, it’s one of those I don’t ever really look at in isolation. I look at it in relation to calcium. Like the calcium/phosphorus ratio is like your nervous system ratio, kind of how your nervous system is functioning. But yeah, I’d say looking at it in isolation is not too accurate.

Lindsey: 

Yeah, what’s the chemical signal symbol for phosphorus? It’s P. Okay so I see, CA/P: 9.5; 1 to 12 is the scale.

Hope Pedraza: 

Oh yes, right in the middle.

Lindsey: 

Okay, good. Any other minerals that you want to mention?

Hope Pedraza: 

I think we hit the heavy hitters.

Lindsey: 

Okay. Well, should we talk about iodine for a sec?

Hope Pedraza: 

Okay. Yeah. Yeah. Let’s talk about iodine. Yeah, iodine is a good one. This is one that I look at a lot because I’ve worked with a lot of women who have different thyroid-isms and that kind of thing. And iodine, of course, is really important for the thyroid. And iodine and selenium are the two that we look at the most. Well, yeah, potassium, like I mentioned before, but iodine and selenium are the ones you look at the most in terms of thyroid function. Now, I will also say about iodine, hair tissue mineral analysis is not the best way to look at iodine either. Because it’s excreted in the urine and not in the tissue. So you really want to get an accurate look at iodine, you want to get a urine test. Now, I admit there’s a lot of controversy around iodine and giving people iodine protocol or not to give people iodine protocol, because there is such thing as too much right. There is such thing, especially if you have a thyroid-ism.

Lindsey: 

Hashimoto’s in particular, you don’t want to overdo the iodine.

Hope Pedraza: 

Yeah, exactly. You don’t want to overdo it. So I always lead with caution with the iodine. If I’m getting recommend things, I very rarely ever do an actual iodine protocol where we’re loading the body with liquid iodine. Typically, it’s like, take a kelp supplement. If you take a kelp supplement, it’s lower doses. And it’s safer that way, especially again, if it’s Hashimoto’s, so we’re not overloading the body.

Lindsey: 

Yeah. I usually stick to the RDA (recommended daily allowance), no more, and then think about what’s in your food too. And then, less than the RDA.

Hope Pedraza: 

Exactly. Because if you’re already eating sea vegetables and sea products, then you’re already getting some.

Lindsey: 

Right, and then also people are often taking multis, which have the 150 micrograms, the RDA.

Hope Pedraza: 

The RDA, yeah. And that’s why if I really suspect a really, really bad deficiency, then let’s do a different test. Like I’m not going to look at the HTMA. Like let’s do the urine test to make sure. Otherwise, let’s support just basic levels because you can look at potassium, copper, selenium, you can also look at mercury and look at certain ratios of those and where those numbers are to get an idea of if you’re iodine deficient or not. And you can look at calcium; I don’t know if I mentioned calcium. But if you look at where those minerals are, you can get an idea if there’s deficiency in iodine. And so if those are red flags, they’re looking at your lithium or potassium or calcium, all those, then yeah, let’s do a urine test to see where your iodine levels are. But if I’m not getting a bunch of red flags, then I’m not going to go overboard. Let’s say, just the normal levels that you would get in a multivitamin.

Lindsey: 

Right, right. Okay. So since we’re talking about minerals for gut health, I wanted to ask about two of the big supplements that are often recommended for healing the gut lining, collagen and l-glutamine. Do you use those in your practice? And if so, in what situations and dosages?

Hope Pedraza: 

Yeah, I do. Recently, at least in my FDN group, there’s been discussions on l-glutamine, like to use glutamine or to not use glutamine. For me, well, it depends on the person, like how much gut lining healing that we’re doing. I really find that collagen can be a good support for that. So I do recommend collagen for most, just kind of as a maintenance thing ongoing. I think it’s something that’s okay to take every day, taking in a good quality form. Like I think was a type one and three are supposed to be the best ones to help with the gut. So I do use those. L-glutamine, I typically don’t use it in isolation. Like if I use l-glutamine, it’s in conjunction with other things that are helping with the gut lining. So there’s cat’s claw. There’s like a bunch of botanicals mixed in with . . .

Lindsey: 

. . . like aloe vera and marshmallow and DGL and all that right? Yeah, like GI benefits, or GI Response.

Hope Pedraza: 

Yeah. And there’s the the Mega Mucosa. Yeah, yeah.

Lindsey: 

Okay. Do you use butyrate at all in your practice? I ask, because I just launched a supplement and I’m kind of obsessed with butyrate at the moment.

Hope Pedraza: 

I do. Yeah, I mean, that’s one of those I I’ve included here recently with some some clients. So yeah, I have been looking at that. Yeah. Yeah, that’s awesome.

Lindsey: 

Okay. Let me see if I’ve asked you everything. Oh, yeah, the heavy metals. So I, you know, I did my analysis to look also for heavy metals, not just for the minerals. And it showed me as kind of high in uranium and silver. And I’m like, what do about that?

Hope Pedraza: 

You know, it’s funny about the uranium. Now the one that I use doesn’t measure silver. So that’s not one that shows up on mine. But uranium is. It’s funny.

Lindsey: 

I know, like, where the heck am I getting that, is it maybe in my shampoo? I’m hoping that’s where it’s coming from, like, not from inside my body.

Hope Pedraza: 

Now, most of the time, and this has been true for two of my clients, the other one, it was still a mystery. Like, I still can’t figure where it came from. For two of my clients, it was well water. And that was where it was coming from. So typically, you’re finding uranium in granite rock, right? So if you’re drinking well, water, if you’re eating vegetables grown in a place with high granite rock or not washing them, then that could be it. But I’d still find that a couple of my clients, it’s been a mystery, like, where’s the uranium? Like, you’re not working in a mine anywhere?

Lindsey: 

I know. And I’m using that Zero Water filter and changing them every two weeks. No, it is not my water.

Hope Pedraza: 

That’s hilarious.

Lindsey: 

 Yeah. Then I have again, no idea. And unless the silver’s coming from my jewelry, which I suppose it could be leaking from jewelry because I wear silver jewelry all the time.

Hope Pedraza: 

Yeah, it’s possible. It’s possible. Yeah, the heavy metals are funny. So I would say mercury and aluminum are probably the ones that show up the most often. And honestly, in some levels, it’s going to show up. Like I don’t know if I’ve yet to have a test that aluminum doesn’t show up at least a little bit. Now, if it’s above a certain range, it’s like, okay, let’s talk about how we can reduce your exposure to aluminum. Mercury and aluminum are probably the ones that show up the most often.

And then there’s all these, I feel like they’re obscure. I mean, I guess they’re not because we most of them are ones we’ve heard of. Some more obscure elements and heavy metals that come up are bismuth and titanium and strontium, these random minerals. And most of the time, it’s coming from your makeup and from your personal care products. And so I have my clients who have these random, like,”What’s the bismuth from?” I’m like “Oh, you know bismuth is an ingredient in a lot of concealers and foundations and stuff.” So it’s, it’s the personal care products and the cosmetics and all the things that a lot of times really go overlooked in terms of how it’s affecting our health. Your body, your skin is absorbing all of that.

Lindsey: 

Yeah, well, who knows? Maybe that’s where I’m getting my uranium and/or my silver. But they were both in the yellow so I’m not sweating it too much.  Back to aluminum though, I did catch high aluminum levels I think in both of my parents and sent them off to drink five liters of Fiji water, a liter a day, because it has high levels of silica, which chelates aluminum. And of course high aluminum being a risk for Alzheimer’s. And it successfully brought the levels down.

Hope Pedraza: 

That’s amazing. I love that.

Lindsey: 

I don’t drink Fiji water all day because it’s expensive, but I do keep it by the side of my bed and that’s how I refill my nightly water bottle just because there are so many sources of aluminum that keep coming back in, with your aluminum foil and my wok is made of aluminum and various people use pans with aluminum.

Hope Pedraza: 

 Right, right. It’s true. Yeah, I love that; such a good remedy.

Lindsey: 

Yeah, I know there are some multis that have silica in them too, though. And you can just buy silica pills as well.

Hope Pedraza: 

Yeah, yeah. It’s easier to drink the water though.

Lindsey: 

I know it’s more fun. I feel very fancy.

Hope Pedraza: 

Exactly. You feel all bougie drinking your Fiji water, right?

Lindsey: 

My kids are like,”Oh, can I have some?” They think it’s a super special thing. And I’m like, “Sorry, that’s mom’s Fiji water.”

Hope Pedraza: 

Fiji water. That’s awesome.

Lindsey: 

Okay, so tell me where folks can find you.

Hope Pedraza: 

You can find me on Instagram; I’m @thehopepedraza on Instagram. And then you can visit my website. It’s hopefulandwholesome.com with everything you need to know about what I do and what I offer.

Lindsey: 

Okay, awesome. And I will include links for that in the show notes. Any parting thoughts?

Hope Pedraza: 

Yeah, you know, I am a proponent of the HTMA. I’ll just say that, even if you’re not doing A full panel of functional labs. HTMA, really, and I’m not getting paid to say this; I don’t get paid by the labs. I’m saying this just from just from my heart here. It really is the cheapest functional lab you can do to give you some of the most helpful data. I mean, the one I run is like 50 bucks. It is super cheap. And it does all of this, all of the heavy metals and the heavy hitters, all the big minerals, and it gives so much data. And so if you’re looking for a simple way to start making meaningful changes and wondering just overall function in the body, I really feel like the HTMA is the best way to go. And that’s the easiest in the end, it’s just hair. You don’t have to poop in anything. You don’t have to pee on anything. It’s just hair. So I find it’s pretty simple and inexpensive.

Lindsey: 

Yeah, I will see if I can add that to my Rupa Health Lab store*. Yeah. And that way people can find it there off of my website. But in any case, I definitely do have the one on there, the Hair Elements by Doctors Data on there right now, which isn’t isn’t 50 bucks, but it’s like $120 or so. It’s not too bad.

Hope Pedraza: 

Yeah, exactly. Yeah. It’s a cheap way to know what’s going on in your body.

Lindsey: 

Compared to all the other functional medicine tests, yeah, that’s a bargain.  Okay, well, this was a fun conversation. And I learned a lot because we actually haven’t talked about minerals at all before on the podcast. So, so this was great. Thank you so much.

---

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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. 

Adapted from episode 103 of The Perfect Stool podcast hosted by Lindsey Parsons, EdD, Gut Health Coach with Andrea McBeth, ND, Co-Founder of Thaena, and edited for readability.

Lindsey: 

So why don’t we lead off with a description of what Thaenabiotic is so that people have some context of what we’re talking about, since this is such a new and different product. And then we’ll get some background and then finish up with the research and uses and such.

Andrea McBeth: 

Sure. Thaenabiotic is a postbiotic, but specifically, the postbiotics that we extract from healthy human stool through a process that involves autoclaving, which is high heat and pressure sterilization, and then freeze drying.

Lindsey: 

And what is a postbiotic?

Andrea McBeth: 

We’ve heard of probiotics–those are the live organisms that either are cultured in food, and we eat and they confer a health benefit. Sometimes we also think about the microbes in our gut and microbiome. The food that they eat are the prebiotics, which we have also started to hear about, so fiber, vegetables and things like that. And the postbiotics are the molecules that the bacteria make when they consume those prebiotics. So the food that the bacteria eat gets converted through metabolism into small molecules that we’re now starting to look at and think about and call postbiotics.

Lindsey: 

Right? So, for example, short chain fatty acids like butyrate?

Andrea McBeth: 

Yes.

Lindsey: 

Okay. So I think people have some familiarity with at least that because I have a butyrate supplement that was recently put on the market and have talked a lot about it in my podcasts. How do you screen your donors for Thaenabiotic? Are you doing metagenomic sequencing of their microbiomes to ensure they have good protective bacteria? And if so, how often? And how often do you screen for other things like STIs?

Andrea McBeth: 

So we derived this from work we were doing in a fecal transplant stool bank setting. We both are doing all the infectious disease testing and whole genome sequencing and defining health through a series of history, intake and surveys. So beyond “do you have bad bacteria, are you healthy, have you had histories of infection or exposure to antibiotics or other medications?” we also consider, “what do you eat, what is your lifestyle, were you vaginally born and were you breastfed?” We still don’t have a really clear definition of health. But basically, our approach has been to take everything we do know and to the best of our ability identify and filter out people–super poopers–that meet all the characters of a healthy microbiome, with the caveat that we don’t know exactly what a healthy microbiome is. There’s nuance there, but we’re doing the best we can. We had a person working for us for a while who was really concerned about plastics. So, we added a question about using plastic water bottles, because that’s one of the places where people get really high concentrations of plastics in the diet, and that’s a disqualifier for us.

Lindsey: 

Okay. But specifically, are you checking to see if they have all the keystone species of a healthy microbiome, for example?

Andrea McBeth: 

We have gone back and forth on how to characterize that. We look at their alpha and beta diversity, we look at the species, but we don’t actually have explicit exclusion criteria, because what we’re concerned about is what metabolites they’re making. And as we know, Akkermansia, for example, can be a beneficial bacteria and is important. But if you don’t have the most Akkermansia, that doesn’t mean you don’t have the enzymatic genes within the microbiome to make the metabolites we care about. So although we are looking and collecting that data and thinking about it, we don’t have explicit inclusion and exclusion, good guys and bad guys amongst the commensals. But we are trying to classify these people as both healthy in lifestyle and history and healthy in microbiome diversity, at least.

Lindsey: 

And how often would you screen somebody for infectious diseases?

Andrea McBeth: 

So we screen every six months, and we also have a continuous conversation with our donors with the contractual agreement that anytime they sneeze or have a period of grief or anything that would perturb their microbiome in any way, we communicate and put them on pause, and then we retest before bringing them back on.

Lindsey: 

And are you getting pooled donations? Or are you getting a product that’s just coming from one person?

Andrea McBeth: 

Yeah, so we have multiple donors, and what we’re doing is identifying within a certain sub-batch a group of their individual persons’ stools and pooling those. And then, we can have a fingerprint of their metabolites, the end product, and then we pool those with other donors so that we’re getting a diverse array of metabolites. But we’re not pooling their bacteria, if that makes sense. We’re autoclaving as the first step, so everything is getting killed. But at the end, it is a mixture of multiple people’s metabolites.

Lindsey: 

I’m not sure I understood exactly the distinction there. So you’re pooling a smaller group, and then you’re pooling it into a bigger group?

Andrea McBeth: 

Were subclassifying it so that we can verify that we’re working within a single donor. Another part of this project is to start to understand the characteristics of metabolites that are coming from different people at different time points. So we’re collecting samples along the way, the end product is pooled between multiple donors and many, many stools.

Lindsey: 

Okay, so are the dead bacteria gone too, or are the dead bacteria in there?

Andrea McBeth: 

There are. It really is a prebiotic/parabiotic/postbiotic in its entirety, because it is whole stool that’s autoclaved. We do some processing to pull and save short chain fatty acids, but we’re not filtering everything out. The end product is a mixture of a little bit of everything.

Lindsey: 

So it does have dead bacteria. And how do you pull out fecal material then from the mix? Or is it still in there?

Andrea McBeth: 

Well, fecal material is a mixture of prebiotics and bacteria and dead cells and all that stuff.

Lindsey: 

So I guess maybe what I’m trying to get at is, like a typical fecal transplant, if you did it in capsule format, you might be taking 50 capsules or something. Right? So how does what’s in one capsule encapsulate enough of what you need?

Andrea McBeth: 

So early on, we were like, well, is this going to do anything, right? Our idea was, what if we could pool the postbiotics specifically in a small amount and put it into a supplement format. And when you think about fecal transplant, you think about 30 capsules, or a whole bunch of stool. What we’re doing here is, one capsule is roughly equivalent to about a half a gram of stool, so not very much at all, when we get to the end product, which is about 100 milligrams of the powder. But, it does seem to have a physiologic effect in terms of just the anecdotal observations we’ve been having as a nutrient or benefit, not in the same way that you would get bacteria engraftment from an FMT or grams of butyrate from a butyrate supplement, for example, but a mixture of thousands of these small molecules, and a really small amount that are working synergistically to support motility or interact with mitochondria or interact with the native microbiome and shift it from really subtle cell signaling. To the best of our preclinical and clinical observation, it’s doing something related to small molecule nudging–of less so the short-chain fatty acids. There are some, but it’s a relatively small amount of short chain fatty acids. Our basic mechanistic understanding and thought right now is that it’s the combinatorial effect of lots of these postbiotics in synergy at small concentrations.

Lindsey: 

Well, we’ll get into a little bit more about what the postbiotics are in a minute, but I just wanted to dig in a little bit on what got you interested in gastrointestinal conditions and treatments.

Andrea McBeth: 

I love the microbiome, I think it’s the coolest way to frame nutrition and environmental medicine, and why what we eat, drink and think matters in the world. My passion has always been chemistry and molecular biology. After doing some work in the cancer space and having a family member who had cancer and going through that on the patient side, my hope was to find a way to not do that again and have prevention. I think that the microbiome is the answer to us trying to figure out how to create a world that we can live and thrive in, because it’s such an important organ; it’s the canary in the coal mine of the environment we’re interfacing with. So I think, without going on too long about my passion for the microbiome, in short, I was working in research, had an experience with a family member with cancer, became a naturopath and wanted to connect all the cool things I was learning in nutrition and preventative medicine with the chemistry and the cellular biology. And the microbiome really was that bridge for me.

Lindsey: 

I’ve also been fascinated with the microbiome for a long time. So I think I heard on another podcast maybe that your original hope had been to offer FMT on a wider scale or a purified FMT product on a broader scale, but that the FDA put the kibosh on that. Is that the case?

Andrea McBeth: 

Well, we have been doing FMT for C. diff that was not responding to therapies for a long time. There was always a hope that we could understand mechanistically what it was about FMT that was so special, and address the infectious disease risk, scalability and some of the other things that were the limiter for using this really powerful tool, because you can provide FMT to a C. diff patient who isn’t responding to antibiotics, and their lives change in 24 to 36 hours. It’s not just that their diarrhea goes away– they feel better, they have less fatigue, and there’s all these really fascinating gut-brain axis components. The autism study that came out of ASU in 2017 and the follow up in 2019 was really profound for us and our practice. So people would call us and ask us and we would have to say, “no, it’s not accessible.”

We work with nutrition in support of things all the time as functional gastroenterologists, and it was really a moment of “what if it’s not just the bacteria or phages or viruses?” Maybe there’s another component of compost in the secret sauce of FMT that is safe and really is a food derivative or is like a probiotic, that we could provide patients in a different setting in a different way, change the paradigm and look left when everybody was really focused on what were the good bacteria and the bad bacteria. And so I think for us, it was just a moment of, well, what if theoretically, it was the small molecules? And then COVID happened, and then we couldn’t provide FMT because we couldn’t screen for COVID. That was a really good reason to put the poop in the autoclave. And so that’s kind of how it started. From there, we’ve gone down this path of developing something that is safe, tested, food-derived and fits more into this classification of dietary supplement. So there’s another tool in the toolbox to modulate the microbiome in the same way that early probiotics were brought to the market.

Lindsey: 

So when did it come on the market?

Andrea McBeth: 

So we’ve been providing it as a pilot through clinical practice for a few years, and relatively recently, in the last year, it’s a physician-only dietary supplement that’s on the market.

Lindsey: 

Okay. So I didn’t get a straight answer though, in the sense of, was there a conversation with the FDA about about wider stool transplant distribution, and did they reject the idea?

Andrea McBeth: 

Well, I think I’ve been to most of the conferences and listened to FDA Q and A’s and had a couple off the record conversations and the clear articulation was infectious disease risk is a concern, and that makes logical sense. When I pitched things like, well, “what if we did autologous FMT?” They’re like, nope, that’s definitely still FMT. And then I said, well what if we autoclave it and look at it like food, they were like, great, go do that. That’s going to be really helpful. That’s not a thing that we’re concerned with anymore because you’ve eliminated that component of concern in the infectious disease.

Lindsey: 

Yeah, I think that whole situation in the US is very frustrating to a lot of people. I just went on the web and searched a little bit. There was a study, I think, of more than 5000 courses of FMT, in which there was a total of five deaths, and I think most of those could have been prevented if there have been proper donor screening.

Andrea McBeth: 

I mean, I’ve always been fascinated with FMT. It works no matter who your donor is, so it can’t be this one magic bacteria. There’s got to be something about it that’s modulating the ecosystem. And I’m really excited about the Rebiotix product that’s out on the market, and we’ve shifted to using that clinically for C. diff, the approved by FMT enema they have.

Lindsey: 

Oh, I’m not familiar with it.

Andrea McBeth: 

Rebiotix is the first approved stool-derived FMT for C. diff. It’s on the market and insurances are starting to cover it; it’s huge that it’s now available. So we’re not going to do FMT anymore clinically for C diff. But Thaenabiotic is a bridge. It’s like the next generation in probiotics. It’s not fecal transplant, and I want to be really clear about that, but it came from that idea of observing what was happening in FMT, thinking about how the microbiome is signaling health through these small molecules, and what if we could take a snapshot of a healthy donor and would that impact a recipient who has dysbiosis or doesn’t have those good bacteria? You’re not engrafting or causing trouble necessarily with giving somebody something that you can’t get rid of or could cause an infection, but you are providing that complex ecology that some people have, that others, just because of the way they were born, their environment, their diet, or their antibiotic exposure, don’t have access to.

Right. So let’s talk about some of those postbiotics. So what are the different types of postbiotics that are found in Thaenabiotic?

Andrea McBeth: 

Yeah, it’s really hard for me to choose my favorite. So every day, I find myself with like a different list, but the broad classifications are a good place to start. So short-chain fatty acids, as you mentioned, are a really good category, because butyrate is well characterized, and has a ton of benefits. It’s a really interesting molecule because it does things that provide energy, but it’s also an HDAC [histone deacetylase] inhibitor, right? So it changes the way that genes are read, there are good things about acetate, propionate. But then, if you have them out of balance–or there’s some data that shows if you have too much of one–it might be a bad thing, right. But broadly, they’re really interesting because they’re sort of the powerhouse of the energy of the metabolism.

And then there’s things like indoles and tryptophan derivatives that are in lower percentages, but they bind T-cell receptors. There’s all this interesting work being done looking at how these small molecules can make profound impact, even at low concentrations, throughout the body by interfacing with our immune cells that sit at that Peyer’s patch in our gut. That mucus layer keeps the bacteria out, but these small molecules are transferring across the mucus layer and across the epithelium into the blood, into the lymphatic and interfacing with those. There’s other groups like the sphingolipids. The reservoir of our sphingolipids are housed in the microbiome, and they get broken down and then rebuilt in the cell walls throughout our body and our brain. I’m really excited for the future of research in the microbiome to start to look at where do all these molecules that the bacteria make get distributed throughout our body? And so I think those ones are really interesting. There’s medium-chain fatty acids, there’s bile acids. I don’t know if you have a group of post-biotics that are your favorite, but…

Lindsey: 

Doesn’t everyone?

Andrea McBeth: 

Yeah–ornithine and citrulline. I have a running list of my favorites that are in our product. Someday, I’m going to write a synopsis with my team.

Lindsey: 

I think what you need is a one-a-day calendar, you know, you just tear off the page.

Andrea McBeth: 

But I do think we have this treasure trove of small molecules that we’ve been coevolving with since the beginning of time that we haven’t looked at yet. And it turns out, they’re hormones. They bind and interface with our whole body in the same way that hormones from other organs do. And it makes sense, because the microbiome is kind of like a hormone organ that we just never saw and didn’t know what’s there. But feel free to keep me reined in, because I get really excited about the wonky chemistry. The big picture step away is that a healthy microbiome is making a huge diversity of small molecules that are being used to transmit signals throughout the body and interface with all the different parts of our organs, not just the other microbes.

Lindsey: 

Yeah, so where is Thaenabiotic meant to start dissolving? In the small intestine?

Andrea McBeth: 

So, we put it in a capsule to get it enteric coated, but the powder, if you open the capsule up and take it orally, it still seems to work. I think a component of that is that these small molecules aren’t just working locally in the colon; they are signaling molecules that get absorbed into systemic circulation. And that was a pretty big paradigm shift even just a year ago. But now, there is evidence that bacterial drug metabolites are in our serum, and that is a part of the mechanism of how the microbiome is interfacing. So I think it’s actually not as important where these get delivered as long as they’re getting delivered to the GI tract. There is a component of the Thaenabiotic that is insoluble fiber and those prebiotics, but it’s a very small amount. So it’s not like taking a prebiotic supplement with like, 10 grams of ‘whatever’.

Lindsey: 

Right, and you said it’s 100 milligrams worth of product. So just thinking comparatively, the butyrate supplement I created is 750 milligrams of butyrate alone. So it would only be a very small portion of any one thing–it’s just a combo of a bunch of things the bacteria would be producing. I’m just curious, because somebody said at one point, I can’t recall if it was on my podcast or in some other context, “we’re absorbing all our nutrients in the small intestine and then only water in the large intestine.” But yeah, you’re nodding, no. And I’m thinking, yeah, that doesn’t make any sense with what you’re telling me because other than the short-chain fatty acids that may be feeding the lining of the large intestine, there, obviously, are other molecules that are being absorbed from the large intestine.

Andrea McBeth: 

So that statement is true in our old paradigm of free microbiome nutrition, right? So if you were thinking about metabolism from a human-centric space, without any accommodation for the reality of this extra organ system of the microbiome, yes, that’s true. Our nutrients that are digested–I like to think of the GI tract, mouth to anus as an orchestra–so a component gets digested when you chew, and our salivary glands secrete things that help with digestion, and then you get stomach acid, HCl in the stomach that digests and breaks things down, and then a component like the amino acids get absorbed in the small intestine. So in our digestion and metabolism, things get absorbed. But there’s all kinds of stuff happening in the colon that’s related to microbiome metabolism that wasn’t included in that paradigm before.

Now, we have to really ask what we thought we knew and reassess how metabolism works in human health with the context of what the microbiome is contributing to the system, because a calorie in is not a calorie out. We’ve seen that with the work done in fecal transplant and my studies. We know, thanks to the Weizmann Institute and fecal transplant studies they’ve done in Israel, that my blood sugar response to rice and tomatoes may be completely different than yours, because our microbiomes are changing the way things get metabolized and impact blood sugar response. So I love that this product is intuitively contrary to the traditional paradigm, but the fact that it does anything is kind of a miracle and a testament, similar to how FMT was originally, that the microbiome is so much more important than we thought it was.

Lindsey: 

So what kinds of conditions or symptoms are people trying Thaenabiotic for?

Andrea McBeth: 

I think our framing of it as a dietary supplement very intentionally is to not treat disease. But we are piggybacking on the work that has been done, looking at how microbiome not being healthy can impact many symptoms and aspects of life. You can think about how our GI system works. It’s really interesting to see this impact motility, which is the way that our gut moves poop through the system and helps people have more frequent bowel movements. But it also makes people have less loose bowel movements, in some circumstances.

And the other place that we’re really interested is that it seems to impact fatigue and how people feel in their brain, which kind of makes sense when you think about the gut/brain access and all the evidence we have from fecal transplants and the role that probiotics and nutrition can play. We are very much at the beginning stages of working with physicians and functional medicine doctors to ask the question, “does your patient have a dysbiotic microbiome? And could they be missing some of this basic signaling because their ecosystem is depleted?” And if so, would this super-nutrient impact that? The general response is that, yes, it does seem to be a super multivitamin that can help rebalance some of those things that are caused by a lack of, not a certain species per se, but the metabolism that some of those important species are doing to make something like butyrate, which, for example, is pretty well covered and at a high concentration, but that same idea applies to other lower concentration and really important molecules, like the indoles, or any of the amino acid derivatives and specialty bile acids.

Lindsey: 

Yeah, I think that’s the follow up question that I was thinking of when you were talking about where absorption is happening. As you mentioned, l-citrulline is an amino acid, but I guess it’s not an essential amino acid. It’s derived from arginine.

Andrea McBeth: 

This is where I apologize if it’s too much philosophy, but I come back to this concept of how we evolved as an archaea and a bacteria being endosymbiosed. And if you think about human and eukaryotic multicellular organisms, we have not been around very long. Bacteria were here way before us for much longer. So we just hijacked the metabolism of bacteria and copied it for our own purposes. And so it makes total sense that in the same way, we think about human cellular metabolism–breaking down amino acids, taking things from food and all that stuff–bacteria are doing the same thing. They are interacting with these molecules at all the different steps of the biochemical pathways that we traditionally think of as a human cell pathway. They’re breaking apart amino acids, adding things to them, changing bile acids and breaking apart fats. You’re ending up with this really complex milieu of intermediate molecules that, again, are similar to what we think of as traditional human biochemistry pathways, like the Krebs cycle and things like that. But that’s mitochondrial remnants of our bacterial cells themselves, so that is all happening on the bacterial level within the microbiome. It’s a sea of all these nutrients that are used for all kinds of things,

Lindsey: 

Just in case people are having trouble absorbing what we’re actually talking about, I want to kind of condense this down. So basically, what you’ve done is you’ve taken FMT, you’ve killed the bacteria, and now you’ve put it into a pill. That pill is full of all the stuff that the bacteria were already doing in a healthy colon. But if you don’t have a healthy colon or healthy microbiome in your colon, you’re not doing all those things, and you’re not producing all those things. Maybe you’re producing some of those things because everybody still has some bacteria left, but you’re not producing all of them. And so now in one pill, you get a mixture of everything that a healthy person’s microbiome would be producing.

Andrea McBeth: 

Yeah, we think about it like an ecosystem. So it’s the entire ecosystem instead of one or two culture derivatives. So if you have a postbiotic from lactobacillus, that’s like a subset of postbiotics. This is the entire ecosystem of a healthy human. Instead of using a kombucha to ferment, you’re using a colon to ferment. They’re the same basic idea, it’s just that one is much more complex than the other.

Lindsey: 

Yeah. So I know, obviously, you have to avoid the health claims, but I’m just wondering if there are any anecdotal stories from users or reviews…?

Andrea McBeth: 

Unfortunately, not.

Lindsey: 

Are the reviews up on the website, though?

Andrea McBeth: 

I mean, we’re the only people autoclaving poops that are being really conscientious about this being something that is to support microbiome health. We have some really interesting data in longevity and longevity is not a health claim. So that’s really fun. We have a C. elegans model, which is a little worm that researchers use to study. There’s a bunch of genes that they have that we have, and there’s some analogy. So they’re a really nice model, because they’re easy to use, and they’re well characterized. What’s interesting is we have looked in C. elegans; we can make them live longer and wiggle and they’re more vital, and their health spans better, even compared to rapamycin, which is a really common longevity drug, and resveratrol, which is what we think of when we think of red wine being good for you or polyphenols. So Thaenabiotic works better than those in the C. elegans model for making them wiggle longer. And then when we look at the genes, it’s doing things related to oxidative stress and mitochondrial health. And so by proxy, you think about everything in our body that’s related to oxidative stress. This is a really potent antioxidant. That’s another framework for us to start to think about how we can support patients with things that are happening with them on a nutrition level to support antioxidant or oxidative stress.

I was really excited. I didn’t expect to have data come back from the RNA sequence we did, which is a way of looking at the genes in the worms. When we gave them the antibiotic, it really impacts their mitochondrial genes, which is, again, the powerhouse of cells, and they’re bathing in it, which is different than us eating it. But when we think about mitochondrial health, longevity and “inflamm-aging” if you want to make up a word that is thrown around a lot, that’s all related to oxidative stress and mitochondrial health. Again, with mitochondrial bacteria, whenever I hear longevity, people talk about mitochondria, just copy and paste that into microbiome. They’re the same thing.

Lindsey: 

Do you have any clinical trials planned or underway?

Andrea McBeth: 

We’ve got an IRB approval to work with these partner physicians in open black box observational pre/post testing and clinical data collection. So we’re at the really early stages of case studies and case reports kind of like Dr. Bredesen did with the Alzheimer’s work, where our hope is, we can collect enough data to then write the grants to fund real clinical trials. We’ve written many, we just don’t have the money to fund them.

Lindsey: 

There’s not a placebo in this case?

Andrea McBeth: 

No. It would be great to do a placebo-controlled study, early on that was like our first proposal, but we’re a small startup. We really are optimistic with the C. elegans data, that we’ll be able to start to write grants. And if we have enough clinical case observations, we might be able to fund a proper pilot study. We have not yet, but we are very hopeful. Anecdotal data is what it is. It has some value, but it’s limited. And I’ll be the first to admit, from the early days, I was like, “is there any way that this is actually doing something?”, and it’s taken me many years to be convinced that something as small as 100 milligrams of sterilized poop powder from a healthy person would significantly impact people. But there does seem to be a set of really strong responders. There are people that it does nothing for, but the people for whom it shifts stuff, it definitely makes a significant impact in the way that a dietary supplement that’s effectively utilized really can change people’s lives. So I’m cautiously optimistic, we’re going to keep learning.

Lindsey: 

Yeah. So I think then the assumption would be that if you already had a super healthy microbiome, and you were doing everything great that it probably wouldn’t be a big benefit to you. It’s more for people who have a dysbiotic microbiome.

Andrea McBeth: 

Yeah, the longevity data is so interesting. Before we had that, I would say “don’t take things for the sake of taking things” in general, and “eat food as medicine” has always been my mantra. But there’s something about a healthy microbiome for somebody like me that I can’t get anywhere else. So it does seem to help just as a baseline, for me to take it every day as a supplement in the same way that I tried to eat vegetables, but I was born via C-section, I have chronic disease, so I’m like a whole host of things. Even though I’m not acutely ill, this seems to be a support. I think the cost-benefit conversation is there no matter what we’re talking about, like, “is it better to go get a massage or try a new supplement?” I mean, I think that’s an individual decision on cost-benefit. But it’s nice as a clinician to have this as a tool in my toolbox.

Lindsey: 

Thinking about the cost-benefit analysis and long term supplementation, I think the frustration that a lot of people have with gut-based treatments, especially if they have some kind of a condition like I do, post-infectious IBS, where I’m going to have this for life likely, is, of course, that you have to do it indefinitely in order to get results. So I’m just wondering what you think the expected course of treatment for Thaenabiotic would be, and if people can get off of it, not perhaps if they’re using it for longevity, but say they’re using it for diarrhea or constipation or bloating or something like that?

Andrea McBeth: 

Yeah, totally. We have asked that question from day one. And what we’ve observed so far based on anecdotal and several thousand patients trying this is that you have to take it for at least a month, a few months, sometimes six to nine months. And like all things, it depends how you got there, right? If it’s 20 years that led you to something acute, that’s different than if you had diarrhea traveling. But it does seem to shift the microbiome enough or impact the neural immune modulation enough that you don’t need it anymore. And so people will try it for a while, stop it if their symptoms come back, then try it a little bit longer. It’s in increments of 30 capsules per month dose, and then we have a 90 cap bottle that’s three months. So in general, after three to four months, if it’s working and helping, try it for that long, go off of it, and then hopefully you’re at the point where whatever the underlying issue is, you’re more tolerant of food, you have more diversity in your microbiome, your immune system is less reactive, and your motility is better. You don’t have to keep on it indefinitely.

That said, we do have a handful of patients that have been on it for a really long time or they go off of it, but then they keep it around for acute flares. My business partner and I were asked one time, “is it for benders or is it for prevention?” I said benders, and she said prevention at the same time. So it’s great if you want to be resilient in the world to have a pizza and a beer, but that’s not something you normally can tolerate. At the same time, you can approach it the way my business partner does, where it’s a prevention thing. I think it just depends, again, on that cost-benefit and where people are at. It’s not something that you have to take indefinitely because the microbiome is such a dynamic environment, that if you can get it back into a state of balance with the immune system interface, that’s my theoretical position; we’re reducing the leaky gut, histamine, etc., enough that you can then be maintained and at a better place. So when you think about functional medicine, your patients, my patients and our own IBS, you can get to a place where you’re good and then you plateau. Then you don’t have a tool, you’re doing everything right.

Lindsey: 

But you’re still having diarrhea every month or week or so. Yeah, I’ve certainly heard that with a lot of people.

Andrea McBeth: 

And then you try something like this that’s another tool that gets you to the next place. It gets you off that plateau, or it helps you be resilient to that next perturbation. Like all the other tools in our toolbox, it’s not going to be a magic bullet or one-size-fits-all. It’s definitely not FMT, but it does have something in it that’s a little bit different than traditional food or herbal or probiotic supplements. It’s just a complex mixture of stuff that we couldn’t really synthesize any other way.

Lindsey: 

How did you settle on the 100 milligram dose?

Andrea McBeth: 

We tried high dosing. Originally, we tried to mimic FMT exactly and just autoclaved an FMT dose and it just didn’t seem to do as much. I’ve had a couple really interesting conversations about this. So you think about FMT, and its mechanism is probably a combination of the bacteriaphages, (the viruses within our gut that infect other bacteria), bacterial engraftment, fungal, and postbiotics. Of all of those, postbiotics are going to be working at a low and slow dosage, as opposed to phages, which are a big, strong punch short term. What we found is after we autoclave and all that stuff is dead, all that’s left are these small molecules. High doses don’t seem to have any added benefit, but low doses over time do seem to shift stuff. So we tapered people down and saw where you could still get benefit, not really have any side effects and then maintain dosing, and that’s how we got there. I would love to do a proper, controlled dosing study. But I think for us, we were at 50 milligrams for a long time, and then we increased it to 100 milligrams, because of that trade off of like, “would a little bit more help?” Sometimes patients take two caps, but I’ve definitely taken 10 or 30 caps at a time, and it just doesn’t seem to do anything extra. We tried that with patients in the early days, and it didn’t seem to do anything, so we moved away from that recommendation strategy.

Lindsey: 

Okay, interesting. So I understand that you’re sending me a bottle, so I can give it a try. I’ll have some time before I publish so I’ll be sure to include in my exit comments what happened and how it impacted me. I’m excited to try that.

Andrea McBeth: 

Yeah, I would say some of the interesting things we have observed is that it’s very mild. Generally, the biggest concern people have is that it does nothing. We’re working towards a money back guarantee so you could try it for 30 days. And if it doesn’t do anything, you don’t spend a bunch of money. But hopefully by the time this goes live, we’ll have that set up. And then there are a small set of side effects people have reported, because we have an adverse event reporting, is people who have constipation. This can cause transient cramping as their gut starts to move, but it doesn’t last very long. So it’s like, day three to five people will get an increase in motility and report cramping.

We’ve had some people report an increase of stomach acid, which was great in the context of turning that orchestra on, especially if you’ve had chronic IBS and dysregulated GI nervous system patterning. I have patients that take tons of HCl and digestive enzymes. If we could just get that turned back on organically, and not have to take all that supplemental support with every meal, that’s great. So that’s actually giving us some hints towards what the mechanism might be, with motility and gastrin. I have a lot of scientific research questions that someday I’ll have money to answer.

Lindsey: 

Yeah, if only our system worked a little bit differently so that these new, interesting things got research funding.

Andrea McBeth: 

Maybe there’s some of your listeners that are researchers that want to do collaborations with us. We would love to do more academic collaborations. I will ship poop powder to anybody who wants to throw it on their in-vitro models.

Lindsey: 

Great. So if readers purchase Thaenabiotic through me, you’ll be supporting the blog and podcast. Are there any other things you want to mention or places to go or links?

Andrea McBeth: 

I’m happy to share. We’re really trying to create a microbiome education system around this. In particular, if you’re a provider and you sign up, we have tons of continuing education content. We are building the newsletters and the ecosystem type things that you do.  I’m happy to share my X, which is where I bookmark all my microbiome studies. But I’ve always been really passionate about teaching about the microbiome and how our health, our decisions and the environment around us impact it. So I would love to hear from people and you can reach out to me through X. It’s @DreMcBeth, my name is Andrea Macbeth, I’ll send that to you too. I appreciate the time and the space! I love your podcast. Like when I started googling podcast/fecal transplant many years ago, it was always great to listen to your interviews because it’s such a cool paradigm shift to be a part of, right?

Lindsey: 

I mean, those are some of the funnest ones because, obviously FMT doesn’t work for everybody, but for the people for whom it works, it’s miraculous in what it can do. I wish it were more accessible, but I’m pretty excited about your product and how that might be a substitute for FMT for people who are struggling.

Andrea McBeth: 

Yeah, and check out Rebiotix, the REBYOTA product that is going to be on the market, hopefully Seres Therapeutics-approved relatively soon. There’s a company out of Australia that has a product approved in Europe called BiomeBank. So the tide has shifted. There are more of these out there. The US actually just approved a phase three trial for a company out of France called MaaT. They’re an FMT company that works specifically with cancer patients going through bone marrow transplants, and it’s amazing. Their data on this part of bone marrow transplants called Graft vs. Host disease is really incredible. So I’m optimistic–the last three years have been crazy, but hopefully we’ll start to see more and more tools for different people across different components of the spectrum.

Lindsey: 

Yeah, I’m excited for that too. Well, thank you so much for coming on and sharing about Thaenabiotic. Thank you so much.

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If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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. 

Adapted from episode 102 of The Perfect Stool podcast hosted by Lindsey Parsons, EdD, Gut Health Coach, and edited for readability.

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Today, I’m going to be talking all about colon cancer, its prevention, colonoscopies, endoscopies and diet changes to consider if you have a colon cancer diagnosis. I thought this topic might be important because I do see a number of clients who have gut health issues but haven’t yet been to see a gastroenterologist, so I wanted to highlight when and if that is recommended. 

One of the most prevalent health risks for men and women alike as they head into middle age is colon cancer. Colorectal cancers are the third-most-commonly diagnosed form of cancer in the United States and they typically begin with the benign growth of polyps in the colon or rectum. Polyps are an abnormal accumulation of tissue on the inner membrane of the large intestine (aka the colon), which, again, are not cancerous from their inception. However, if left unattended for months or years on end, these polyps can mutate into cancerous growths and become colon cancer. 

What are some symptoms of colon cancer?

Symptoms of colon cancer include persistent changes in bowel movements, including constipation, diarrhea and narrow stools, rectal bleeding or dark brown or black stool from bleeding coming from further up in the intestines, a feeling of incomplete elimination, chronic abdominal pain or cramping, unexplained weight loss, unexplained anemia, or even fatigue and general weakness. Unfortunately, once you’ve moved from benign polyp to symptomatic colon cancer, you may already have metastasized cancer cells in your colon, which would necessitate a more severe line of treatment. However, if caught at an early stage, polyps can be removed, and then there are many diet and lifestyle changes you can implement that contribute to staving off colon cancer. So it’s important, before attacking any functional GI issues with a functional medicine provider or a gut health coach like me, to get screened for colon cancer with a gastroenterologist if you’ve had any symptoms like the ones I just mentioned. 

How can I prevent colon cancer?

In the past half century, western diets have become increasingly conducive to developing colon cancer and other malignant conditions in our GI tract. Foods high in saturated fats, sugar, and processed meats are the biggest known culprits of colon cancer in our diets.   Because cancer-causing foods have become so prevalent in many Americans’ diets–this link between nutrition and GI tract cancer may be partially responsible for the staggering rate of increase in young adults developing these conditions. Diagnoses of advanced stage colorectal cancer in people under 55 years of age grew from 11% in 1995 to 20% in 2019, which means one in five people under 55 will have this diagnosis. 

Standard nutritional advice often puts red meat in the same category as processed meat as a colon cancer risk factor, but of course I draw a distinction between grassfed or pastured-raised meats and conventionally-raised beef and lamb, which is used in the research comparing diets including red meat, especially if it’s done in the US. And in fact, in the World Health Organization paper that examined 800 studies to determine the likely carcinogens in our diets (and the nearly 500 page monograph based on it) determined that while the risk was elevated for both processed and red meat, they could not rule out chance, bias, or confounding variables because no association was found between colorectal cancer and red meat in several of the larger studies. Furthermore, they also found that cancer risk was likely mediated by cooking methods, such as pan frying, which was associated with an increased risk of colorectal cancer in one of the larger studies. 

You may have heard of TMAO or trimethylamine N-oxide as something that’s found in red meat (meaning beef, pork and lamb) as well as eggs and dairy products that contributes to colon cancer. What you may not have heard is that salt-water fish and shellfish also are very high in TMAO but are supposed to be good for us. So what gives? What actually is in red meat, eggs, and dairy are l-carnitine, choline, betaine and lecithin, the precursors to a substance called trimethylamine or TMA. Your microbiome converts these precursors into TMA, which is then taken up by the liver and converted to TMAO, which increases colorectal cancer cell proliferation and angiogenesis, or the development of new blood vessels which feed cancer cells. And TMAO has also been associated with other inflammatory conditions, including heart disease, chronic kidney disease, liver disease and type 2 diabetes. 

And because TMAO is produced from substances in meat like l-carnitine, which is an amino acid that’s particularly high in beef and lamb, people who eat vegetarian or vegan diets don’t have the microbes that take part in this conversion, so will produce less TMAO in response to eating the same foods as omnivores. A 2014 study found a positive correlation between colorectal cancer risk and higher TMAO levels. But before you jump to the conclusion that one should avoid red meats entirely, I have to warn you that I see many clients on vegan or vegetarian diets or who eat exclusively fish and poultry who are either having trouble losing weight or suffering from fatigue. I run an Organic Acids Test on them and lo and behold, they have elevated markers that indicate that they are not bringing fats in their diets into the Krebs cycle to produce energy. The reason is usually because they are deficient in l-carnitine (which in addition to being found primarily in red meats is also made by the body from the essential amino acids lysine and methionine). They may also be deficient in vitamin B2, which along with l-carnitine is necessary to bring fats into the Krebs cycle for the production of energy. So when you have a deficiency in one of these nutrients, this means is that after the carbs and protein from a given meal run out, you have no way to use up your stores of fat for energy, resulting in fatigue and fat accumulation. And so what I do for those people teach them about supplements that will help restore the proper functioning of the beta oxidation or metabolism of fats: l-carnitine and a B complex, and when they use those, the fatigue turns around quite quickly. So the message here may be that the poison is in the dose when it comes to red meat.  

And to return to seafood, unlike red meat that just contains TMAO precursors, seafood actually is one of the highest sources of free TMAO as well as TMAO precursors. TMAO is what helps fish stay buoyant by acting like antifreeze and protecting proteins in their tissues–hence, deep-sea fish and shellfish are higher in TMAO. And that fishy smell from seafood is the smell of the conversion of TMAO into TMA. One study found that TMAO levels in the blood were significantly higher following consumption of seafood versus beef or eggs, 62 times higher in fact. Given how healthy seafood has been shown to be, it’s not totally clear whether TMAO is a sign of inflammatory conditions or the result of it. 

And to add some complexity to the story, all this is mediated by the microbiome, so high producers of TMAO have a higher ratio of Firmicutes to Bacteroidetes, typically 2:1 versus 1:1 for low producers. In addition, the high TMAO producers often had no archaea, which you may be familiar with as the kingdom which includes methane producing bacteria like Methanobrevibacter smithii and Methanosphaera stadtmanae, which are overgrown in IMO or intestinal methanogen overgrowth, which causes bloating and constipation. So these archaea actually convert TMA and TMAO into methane, decreasing TMAO in the gut. Unfortunately, I’m one of these people who have no archaea in my gut. But the exciting news is that some scientists are proposing archaeabiotics as a new type of probiotic to help reduce TMAO levels, which means that someone out there is likely working on this as their newest money-making venture. 

As I’ve observed when working with clients who have IMO or methanogen overgrowth, inevitably, diets rich in complex carbohydrates like beans and lentils and starchy vegetables (like vegan diets) increase archaea, whereas Methanobrevibacter abundance is negatively associated with recent fat consumption. And this isn’t because methanogens eat the carbs, as they don’t have the enzymes to do so, but rather that they eat the byproducts of carb consumption of other bacteria like Bifidobacteria bifidum, which has been shown to work with M smithii to produce methane from glucose. And it appears that people whose guts contain more methanogens also contain more Bifidobacteria, which are associated with a host of health benefits, including inhibiting pathogens, producing vitamins, regulating the immune system, repressing carcinogenic activity of other microbes, improving gut barrier function, improving glucose tolerance, reducing low-grade inflammation, and reducing endotoxemia resulting from high fat diets, as well as increasing longevity. Bifidobacteria also are helpful in reducing gas because they produce lactic acid, not gas, so higher Bifido levels lead to less gas and digestive issues. 

All this is to say that the microbiome is an important mediator of TMAO levels, and one of the best things you can do to make sure that your microbiome is rich in the archaea and bacteria that decrease TMAO is to eat a variety of complex carbohydrates and foods high in resistant starch, like starchy vegetables (and by that I don’t just mean potatoes, but sweet potatoes, root veggies and winter squash), and then resistant starch powerhouses like beans and lentils, as well as whole grains like brown rice, quinoa, millet, sorghum and buckwheat. It appears that the combination of resistant starch and other dietary complex carbs (as opposed to resistant starch supplementation alone) is important for getting fiber down to the distal colon or end of the colon where they promote the production of short-chain fatty acids like butyrate, which is protective against cancer. 

I should also mention that there are other substances in red meat and in cooking methods frequently used with meats that are connected with cancer development. This includes N-nitroso compounds (NOCs), whose effects can be mediated by eating green vegetables with your meat, heterocyclic amines from the char on red meats, which according to studies can be mediated by marinating and spicing up your meats with a variety of substances including turmeric, rosemary, Caribbean spice blends, honey, olive oil, lemon juice and garlic marinade, red wine marinade, as well as eating cruciferous vegetables along with your meat. So those are some dietary interventions for being able to eat your red meat in a safe way, but let me get back to conventional prevention methods for colorectal cancer.  

Along with diet changes, changes in your lifestyle that reduce stress have been correlated with reducing intestinal inflammation and lowered risk of developing colorectal cancer. These include meditation, yoga and/or regular exercise, spending time outside to take in Vitamin D, reducing electronic usage before bed, and getting adequate sleep, which is 7-9 hours a night for adults.

Supplements that are helpful in preventing and treating colon cancer include vitamin D3 combined with K2 (I like the Adapt Naturals one as it has the mk4 form of K2), curcumin (I like Curapro, available in my Fullscript Dispensary), resveratrol and quercetin. For the vitamin D, you want to get your levels to the 50-80 ng/mL level, which usually means taking 3000-5000 IU/day of D3. And I prefer the K2mk4 form of K2, which is the only form of K2 that our bodies produce endogenously (although the mk7 form is produced by our gut microbiome). 

And finally, I should mention that there is a marker on the GI Map Stool Test that can identify a risk for colon cancer, called beta glucuronidase, and when found, there are dietary and supplement interventions I can recommend to reduce it. Plus doing a functional medicine stool test to rule out and address any gut infections and correct a state of dysbiosis will reduce your risk of cancerous growths. 

When Should I Get a Colonoscopy?

Because of the high prevalence of colon cancer in the U.S., in tandem with the increasing rate of individuals developing colon cancer at a young age, many health practitioners are now recommending endoscopic colon screenings (also known as colonoscopies) at the age of 45. From that point forward, patients who do not have any polyps or abnormalities developing in their colon are advised to get follow-up colonoscopies every ten years. 

For individuals with risk factors that contribute to their likelihood of developing colon cancer, many healthcare professionals suggest screenings far earlier than they are typically done, as an extra preventative measure. Many risk factors are associated with genetics and hereditary traits, which ought to be considered on an individual basis when deciding whether to seek out a colon screening before the age of 45. These risk factors include an individual’s family history of colon cancer, inherited syndromes like Peutz-Jeghers Syndrome or polyposis, or even one’s racial or ethnic background, as people with African or Ashkenazi Jewish heritage are at an increased risk of developing colon cancer.

Other risk factors for colon cancer include Inflammatory Bowel Disease (or IBD), Type 2 Diabetes, and other diseases with implications on gastrointestinal health. Studies have also highlighted the connection between insulin resistance in diabetic patients and the onset of colon polyps, whereby insulin-resistant cells in the colon begin the process of carcinogenesis, consequently leading to full-blown colon cancer if left untreated. Some lifestyle factors that put individuals at a high colorectal cancer risk include over-eating/obesity, smoking and heavy alcohol use. Smoking in particular has been noted as a significant risk factor for colon cancer, as the chemicals found in cigarettes are known to release free radicals and spurn on DNA damage, creating cell damage and mutations, which can lead to polyp overgrowth.

The reality of colorectal cancer is that many people in the early stages of the disease will be asymptomatic. So it is all the more essential that you get a preventative colonoscopy or endoscopy even before symptoms arise if you’ve hit 45 or earlier if you have risk factors, but even more important if you are having symptoms and have never had these procedures. 

What are colonoscopies and endoscopies?

The general procedure for testing for colon cancer and other GI tract conditions are generally known as endoscopies because they are done with an endoscope, which is a thin, flexible tube with a light and a camera at its tip to look inside the body. If you’re looking at the esophagus, stomach and duodenum, or the first part of the small intestine, it’s called an upper endoscopy or esophagogastroduodenoscopy or EGD. If you’re looking at the colon, it’s called a colonoscopy.  Endoscopic procedures map out a certain area of the gastrointestinal tract using an endoscope inserted through the mouth for an EGD, or through the rectum for a colonoscopy. Endoscopies can surveil your entire GI tract, looking for abnormalities anywhere from the esophagus down to the rectum. The endoscope allows doctors to capture real-time images of the internal structures on a video monitor. 

Before a colonoscopy, your doctor will have you consume a bowel prep kit to completely empty your bowels the day beforehand. These will include osmotic laxatives and electrolyes to keep you from getting dehydrated. 

For low-risk individuals, rather than jumping straight to colonoscopies, there is the Cologuard option, which is a much less invasive stool DNA test for colon cancer. It’s not advised for high-risk individuals, including people who have IBD or a family history of colorectal cancer. And according to GI Alliance, Cologuard can miss up to 8% of colon cancer and more than 50% of pre-cancerous polyps, so you need to take that into account.  I chose to do a Cologuard instead of a colonoscopy when I turned 50 but decided I’ll go ahead with a colonoscopy soon now that it’s been 3 years, the interval for repeating Cologuard, just to be safe, since I since learned one of my parents had had a polyp found on a colonoscopy. 

Upper endoscopies or EGDs look for cancerous and precancerous growths in the esophagus, which is called Barrett’s esophagus in the esophagus, and in the stomach or upper intestines. They also look for gastritis or inflammation of the lining of the stomach, ulcers, narrowing of the esophagus, blockages, and can include biopsies for celiac disease and H pylori. An upper endoscopy can help to find the causes for heartburn, trouble swallowing, excessive burping, bleeding, nausea and vomiting, pain and unexplained weight loss. 

What diets do functional medicine practitioners recommend for colon cancer? 

Functional medicine approaches colon cancer from a holistic perspective, aiming to address the root causes of the disease and the terrain, which is like thinking about the soil rather than the individual plant, rather than solely focusing on killing cancer cells and symptom management. 

Three possible dietary changes that functional medicine practitioners may recommend to those with early-stage colorectal cancer (in addition to treatments like chemotherapy, immunotherapy, or surgery, that address the cancer directly) are low-carb diets, anti-inflammatory diets and ketogenic diets. Anti-inflammatory diets aim to limit foods that induce chronic inflammation in the intestines, thus lowering your risk of developing malignant growths and mutant cells in your intestinal lining. This involves eliminating refined sugar, refined oils, gluten, processed meat, among many other foods (that tend to be high in saturated and trans fats). Alternatively, these diets promote fruits and vegetables, fermented foods, grass-fed animal products and healthy fats, like those found in olives and avocados. 

Low-carb diets would eliminate many of the same foods and can go hand in hand with anti-inflammatory diets, with the extra restriction of only having 35-50 grams of carbohydrates a day. 

Along similar lines, ketogenic diets promote a very low-carbohydrate diet that forces the body into the process of ketosis, in which the body acclimates to burning fat as a primary source of energy as opposed to readily available carbohydrates. A 2017 systematic review of ketogenic diets in animal models found that in nine of 13 studies that were eligible for inclusion a ketogenic diet inhibited malignant cell growth and increased survival time. This review included colon cancer and gastric cancers as well as 5 other types of cancer. However, there is no data yet on humans. This is likely mediated by the fact that ketogenic diets produce ketone bodies like beta-hydroxybutyrate, which can substitute for butyrate produced by the microbiome when it ferments carbohydrates, which is protective against colon cancer.

If you do choose a ketogenic diet, you should do it carefully with the help of an experienced ketogenic diet coach or other practitioner as there are many potential adverse side effects and some people just do not tolerate super high levels of fat in their diet, which is required on a ketogenic diet in the range of 70% of calories. 

A well-studied alternative to ketogenic dieting is intermittent fasting, which has been identified as a good counterpart to those undergoing chemotherapy for colorectal cancer. Cycles with short periods of fasting have been found to reduce malignant tumor growth. Typically, functional medicine practitioners will advise that you align your fasting period with your sleep schedule, in which case, you may fast from after dinner through to breakfast or lunch the following day, and this may be scheduled in particular in advance of chemo treatments and will reduce the damage that the chemicals given to you have on your own cells. Based on an individual’s ability to tolerate periods of fasting in their daily routine, they can certainly fine-tune their fasting schedule to assure that they aren’t compromising their health or their ability to work, exercise, and otherwise feel sufficiently fueled throughout the day. These partial fasting methods may involve working caloric drinks into your fasting periods to tide you over and limit sensations of fatigue. If you’re dealing with cancer, I’d recommend listening to my episode 26 with Nasha Winters from July 30, 2020. We get into fasting schedules and interacting with chemo on that episode. 

I wanted to mention colonoscopies and endoscopies as an important step for people with new and persistent gut and bowel issues, so if you haven’t yet seen a gastroenterologist, I’d recommend making an appointment and going through that process before seeking out functional medicine interventions. 

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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. 

Adapted from episode 101 of The Perfect Stool podcast hosted by Lindsey Parsons, EdD, Gut Health Coach, and edited for readability with Jonathan Scheiman, PhD, Co-Founder & CEO of FitBiomics, sponsor of this episode.

Lindsey: 

Yeah, it’s my pleasure. So I know that your mission–the mission of your company–mixes sports and the microbiome. So can you tell me a little bit about how you got into that combo?

Jonathan Scheiman:

Absolutely. It’s just a story of my background, and I guess you could say my life and career. I grew up in New York City as a basketball player. I did go to FAME High School for Performing Arts–I was a tuba player. But then I played basketball at St. John’s, won a Big East Championship but didn’t make the NBA, so I’d always say my backup was getting a PhD in biomedicine. And that’s how I became a scientist.

Lindsey: 

Like all basketball players.

Jonathan Scheiman:

Exactly. That’s just a natural evolutionary path. And evolution is a key theme in what I believe in. Then I did a lot of work on molecular biology, genomics, engineering and biotechnology. Then I think when I was at Harvard doing my postdoc, I thought it would be amazing to mix these two fields together using cutting edge technology, with athletics as a form for understanding optimal health, wellness and physiology. And that’s how FitBiomics came about – decoding super performers to develop next-gen health solutions for broader populations.

Lindsey: 

Cool. So what got you interested in the microbiome as a field of study in particular?

Jonathan Scheiman:

Yeah, I think in general, working as a scientist and a researcher, I tend to be drawn by understanding underlying codes that elicit health benefits. I’m a big believer in form fits function/genotype to phenotype. So you probably know, we’re as much bacteria as we are human, and we have trillions of microorganisms in our body, collectively known as our microbiome. Most of them predominantly reside in our gut. You probably also have heard that we have 100 times more bacterial genes in our body than we do human genes. 70% of our immune system interacts with the microbes in our gut. So just in the notion of what is actually programming human health, functionality and longevity, the microbiome plays a huge role. I think that’s something that excited me to get into the field.

Lindsey: 

So I understand that you had the opportunity to start your career as a research fellow at Harvard under the mentorship of George Church, who’s the father of modern day genomics. Tell me about that experience.

Jonathan Scheiman:

Yeah, so it was actually my postdoc, I got my PhD from NYU. I’m a New Yorker, so I always have to shout out New York before we get to Boston, but that’s just me. George was an amazing mentor. So the Wyss Institute for Biologically Inspired Engineering–it’s a specialized Institute in Harvard. Really, as its name implies, it’s looking at solutions through nature and evolution, and how can we understand those solutions and use that to engineer and solve the major human and climate challenges of our time. I think it’s an institute and it was a lab that was really focused on disruption, and developing technology, but then not just developing it, but ultimately translating it to have real-world societal impact. So it was a great time of learning. It was a great time of development and hypothesis for FitBiomics, but then ultimately, validating it through science and publications and IP.

Lindsey: 

So in this podcast, we talk a lot about the microbiome, but down to the nitty gritty of like, when it’s going wrong and what to do if you’ve got, say, diarrhea. But going bigger picture, can you just talk a little bit about the function of the microbiome and the human body and its impact on human health?

Jonathan Scheiman:

Yeah, I think there’s one question, what does the microbiome do? I think a better question is ‘what doesn’t the microbiome do?’ And I think it’s actually something we’re learning more and more seemingly every day. I’ve mentioned briefly the notion of the immune system. So think about just energy metabolism, protein metabolism, neurology, immunology; the microbiome impacts all of this on our body. So first and foremost, whatever food we eat, we actually don’t digest most of it– the bacteria in our gut does that, and it breaks it down into macromolecules and nutrients that our body could absorb. So think about that in terms of energy and protein, neurotransmitter biosynthesis. There’s a famous anecdote that 95% of serotonin is produced by the bugs in our gut, so that gut-brain axis has huge implications for neuronal functionality. As we mentioned, just in terms of immunology and inflammation, that can have all sorts of applications for anything from autoimmune disease to even immune oncology and therapeutic applications. So I guess I was all over the place, but what I’m trying to convey is how impactful the microbiome is and everything it does.

Lindsey: 

So tell me what led you to start FitBiomics in particular, and how it’s different from other companies that are producing probiotics?

Jonathan Scheiman:

Yeah, so I think this goes back to my origin. If you look at the current paradigm in biomedicine, one, it’s studying disease physiology and phenotypes to understand what’s broken, what doesn’t work and can we correct it to promote health. But again, I’m a big believer in form fits function and natural selection/evolution. So what FitBiomics is doing is the exact opposite. Let’s look at what does work in the most fit and healthy people in the world. What is driving optimal physiology? We mentioned energy metabolism, protein metabolism, neurology and immunology for elite athletes; that’s basically endurance, strength, mental toughness and recovery. So let’s learn what works in them from a microbiome perspective and then translate that in next generation probiotics, so things that the world hasn’t seen, and novel functional applications for not just gut health, but sleep health, fatigue, recovery and things of that nature. So that’s what separates us– the source code and how we’re translating that for different health applications.

Lindsey: 

So I know that for endurance athletes especially, they can have issues like IBS and such. So I assume you’re not just taking excellent athletes, but excellent athletes who are in excellent health as your models?

Jonathan Scheiman:

Yeah. Athletes are superheroes in many ways, but they’re not necessarily perfect. So you might have an athlete that has a lot of muscle development and strength phenotypes. Yeah, they may have GI issues, but we could still learn what microbes in their gut are driving, let’s say, protein synthesis, amino acid degradation, or bone and muscle strength. Conversely, you could have ultramarathon runners that run 100 miles at a time, and we could identify, which we have, microbes that eat lactic acid and things of that nature. So it’s just really dependent upon which type of athlete you’re working with.

So what kinds of things specifically have you been looking at as you study the microbiomes of these elite athletes?

Yeah, so a couple of things, we work with athletes in a longitudinal manner. So what that means is, we look at their microbiome pre and post exercise to see how it changes from performance to recovery phases. And from there, we could see how athlete microbiomes are different by sport, or we can see how they’re different compared to non athletes. I mentioned that we published in Nature Medicine the discovery of this microorganism called Veillonella. We isolate it from ultramarathon runners to identify this microorganism that enriches in their gut after a strenuous exercise, eats lactic acid, converts it to short chain fatty acids and promotes endurance and run-’til-exhuastion assays. So that’s one example.

Then, we have another product on the market called Nella*. This is beneficial for gut health, but also has been clinically validated for sleep, and improved quality of sleep. And think about that for a second; sleep is almost the number one performance-enhancing drug. So, we’re effectively decoding athletes that have optimized sleep patterns, and now turning that into a probiotic capsule that can help everyone with their sleep.

Lindsey: 

So is the lactic acid that you produce in your muscles after exercising going into your gut such that a microbiome can then transform it?

Jonathan Scheiman:

Yeah, think about our GI tract is this huge interfacing fermentation facility. Everything we eat goes through it, a lot of things in our blood passage through it, and our immune system interacts with it. So to your point, lactic acid is produced by mitochondria in the muscles, it’s used as an energy source. Basically, when we produce more than we could utilize, there’s lactate threshold, and it’s associated with fatigue. Some of it goes to the liver for gluconeogenesis, but some of it actually filters into the gut. That’s where it can interact with the microbiome and become an energy source, where it’s now converted into different sorts of metabolites that confer benefits to the host.

Lindsey: 

That may explain why butyrate is increased and there’s better gut function in people who exercise.

Jonathan Scheiman:

Yeah, diet plays a huge role in microbiome composition. And by the way, if you look at Western diets, (high fat, high sugar, high salt, high antibiotic usage), it’s depleting and wiping out beneficial microbes, right. So that’s a problem. But like you said, I think active lifestyles–the notion of lactic acid buildup–that’s now serving to promote growth and abundance of beneficial microorganisms. So, healthy diets and healthy physical activity have this positive feedback loop on microbes that produce beneficial metabolites like short-chain fatty acids.

Lindsey: 

So are you doing metagenomic sequencing on the stool of these athletes? Is that how you’re studying this?

Jonathan Scheiman:

Yeah, I spend most of my time dealing with shit, both literally and figuratively. When I was in Boston as a postdoc at Harvard doing this study, the joke is I spent two weeks driving around Boston, eight hours a day in a Zipcar, literally collecting stool, and that was our initial study with marathon runners. So it’s a dirty job, but someone’s got to do it. But there’s a lot of interesting molecular cues we could find in stool. 60% of stool is actually bacteria. So you have millions of microorganisms. We can extract their genetic material and basically understand what’s going on in someone’s body, how that changes over time and how we could use that information now to develop next-gen probiotics for everyone to benefit from.

Lindsey: 

And what’s the other 40%?

Jonathan Scheiman:

That’s a good question. Probably debris, unprocessed food, I guess things we don’t even really want to know what it is. Actually, if you take a stool sample and put it in a little Eppendorf tube, you collect a stool sample, we resuspend it in phosphate buffered saline, put it into liquid suspension. Then, if you take a little bit of that and put into an Eppendorf tube, if you centrifuge it, actually, you could precipitate all of that junk, like the undigested food or debris in there, and then supernatants will have the bacteria and all that stuff in it.

Lindsey: 

I thought I’d mention that there’s some yeast and viruses, phages and archaea of course…

Jonathan Scheiman:

Oh, of course. To your point, it’s an umbrella; microorganisms of all these things you just mentioned. Yeah. Not just bacteria.

Lindsey: 

Okay. I was curious because I wondered what percentage of the stool might be, say, Candida, because I deal with people who have Candida issues all the time.

Jonathan Scheiman:

Yeah. Like you said, low abundance for things like that. But sometimes they spike out.

Lindsey: 

Right. So tell me about what you’ve learned in studying these elite athletes’ stool?

Jonathan Scheiman:

The one thing I want to continue to convey is that elite athletes, for us, are a model for understanding optimal physiology. You know, it’s kind of provocative. There’s this notion of like ‘Be Like Mike’, and obviously, what that’s done for Nike in terms of fashion and sneakers, and what it’s done for Gatorade in terms of energy drinks. And now if you just look by-and-large in society, how influencers and ambassadors basically determine economic decisions and nutritional decisions. But think about that from a biological perspective: What really is in Mike, and what if we could actually decode that and turn that into nutritional interventions for broader people?

I guess what we’ve learned is that these are a very distinct populations. It’s the .01% of humanity; we’re seeing microbes that are unique in their gut, we’re seeing microbes that are enriched in their gut, and we’re seeing microbes that spike in abundance after strenuous exercise that are helping them perform and recover better. So really, what we have validated is that elite athletes are a great discovery platform to understand the secrets behind health. And that’s really what FitBiomics is doing– understanding that and now translating that and making it accessible to broader populations.

Lindsey: 

And how do you know that the microbes that are spiking in these athletes are going to be useful to other people who aren’t necessarily doing exercise?

Jonathan Scheiman:

Here’s another provocative term. It’s almost like, what if you could get the benefits of exercise without exercise? First of all, let me also just say, we don’t believe in magic pills, we believe in science pills. And that’s what biotechnology and research do. It converts science fiction into science fact. So we isolate this microorganism that eats lactic acid. Okay, it’s beneficial for people that run 100 miles at a time. But what about people in their everyday lives, people on the grind, doing nine-to-five, like entrepreneurs, single moms at home? What about people dealing with chronic fatigue? What about people dealing with long COVID or fatigue in that regard? What about people that need exercise as medicine, and it’s not about running 100 miles, but you know what, “I want to be more active, so this could help me with glucose and insulin resistance.” So these microbes could confer benefits to everyday people. And that’s actually what our goal is; it’s not to make better athletes, it’s to improve human performance.

Lindsey: 

Did you have any big surprises when you looked at the microbiomes of these athletes?

Jonathan Scheiman:

That it worked! I think, in science, about this continual, iterative process. The reality is most of your hypotheses are wrong. Most of the experiments you run don’t work. But we had this crazy idea that we could look at the microbiome and we could look at the stool, we can look at the poop of these elite athletes, and we’re actually going to be able to find differences in them. And then we’re actually going to be able to isolate those differences from a microbial perspective and functionally validate that they’re conferring a benefit. And that’s what we’ve done from a preclinical and a clinical perspective, like our probiotics are functionally validated. So I would just say the big surprise is that this crazy idea actually worked–and we’re helping thousands of people today in their health journeys from gut health to sleep and fatigue–we could rapidly translate it into real world solutions.

Lindsey: 

How long have these products been on the market?

Jonathan Scheiman:

We’re early stage. So Nella, our first product has been on the market for two years now. But last year was our first full year on the market. We’re actually getting set to publish some clinical studies’ results that we did, which is very exciting. So they’re still somewhat new. But the point of this is now creating awareness so more people could benefit.

Lindsey: 

So what’s the difference between, say, the probiotics that you’re producing and the ones you find at the grocery store? Or say through me?

Jonathan Scheiman:

Yeah, great question. Again, everything is form fits function. Most of the probiotics today on the market are decades old. A lot of the products you see, they all contain pretty much the same strains. They’re just based on formulation. At FitBiomics, we’re not a formulation company, or an innovation company. Most probiotics either come from food, baby poop, animals or the environment. What we’re doing is we’re naturally sourcing our probiotics from, we like to say, the finest microbiomes on Earth, so probiotics that naturally function in peak performers to help drive their physiology. And then the other thing I’d say, too, is there’s that innovation, but also it’s the application. Most probiotics are just for gut health. So yes, Nella supports gut health, but it also supports sleep health. That’s a very distinct application for probiotic Veillonella, our second product, that’s for lactic acid metabolism, fighting fatigue and promoting endurance. That’s a very different application for a probiotic. And I’ll just say, that’s what the science and the technology does, it leads to rapid disruption, because now we could accelerate discovery and translation.

Lindsey: 

Okay, let’s dig in a bit more on those products. So Nella, tell me about the strains. Tell me about the research on the strains.

Jonathan Scheiman:

Yeah, so most of the probiotic market today, 90% of it, consists of lactobacillus and bifidobacterium. Again, most of these are isolated from food, and the industry knows how to grow them, but again, there’s not a lot of innovation. So Nella actually consists of three proprietary strains of lactobacillus that we isolate from elite athlete microbiomes. We formulated them into this capsule. This is something that we started with an open-label study before bringing it to market. 250 participants consumed Nella on a daily basis for two weeks, and they basically provided us feedback before, during and after consumption. Almost 95% of them reported at least one functional benefit that ranged from better digestion, to better sleep to better energy. We then followed that up with a placebo-controlled clinical trial with a professional soccer club. And lo and behold, the results showed statistically significant benefits in better digestion, better sleep and better energy. So that’s actually what we’re getting ready to publish. I’ll also just say, in that clinical study, we collected stool, blood and urine. What we’re seeing is, Nella is actually conferring benefits towards reducing oxidative stress and reducing inflammation. Again, I think it’s part of this holistic health that’s now driving benefits in sleep and energy. That’s what we’ve seen with Nella* and that’s why we’re so excited by it.

Lindsey: 

I’m sure that my listeners have heard the term oxidative stress before, but I’m not sure anybody’s ever explained it to them. So maybe you could just elaborate on what that means.

Jonathan Scheiman:

Yeah, I think in our environment and in what we eat, there’s a lot of things that create these free radicals that basically lead to cellular aging, DNA damage, and you could track the abundance of those reactive oxygen species, if you will, in the blood. So you might imagine that what we eat can determine those reactive oxygen species’ abundance, as well as how much we exercise, and we’re producing things to combat those and sequester them. So basically, what we found is that Nella as a probiotic is conferring these anti-inflammatory benefits and is also reducing these reactive oxygen species. And again, that has benefits for things such as cellular aging, DNA damage, stress and inflammation, which in turn could lead to better sleep or better energy levels. So that’s the gist of it.

Lindsey: 

And how is Nella taken? Is it one a day or more?

Jonathan Scheiman:

Right now it’s a daily capsule, we sell a 30-cap supply, so on a monthly basis. One-a-day in the morning with a glass of water before breakfast. That’s how most of our consumers enjoy its benefits. It seems to be working pretty well for a lot of people.

Lindsey: 

Great. And what about Veillonella? Tell me more about the strains in that and the benefits that you’ve studied.

Jonathan Scheiman:

So as we mentioned, Nella is really a variation of probiotic species that are currently in the market, from lactobacillus. Veillonella is something completely different. It’s actually a different genus of probiotic bacteria. You can’t find variants of those in the market. This is something as I mentioned, we isolated from ultramarathon runners. We did in vitro testing, and we did preclinical testing. So when we published in Nature Medicine, we found that animals that consume Veillonella, on average show a 13% improvement in run-’til-exhaustion. We then did a lot of translation, a lot of manufacturing and a lot of regulatory work. But we also did human clinical work. We completed a small, double blind placebo-controlled study that looked at Veillonella effects on V02-max performance. What we found is that, in fact, people that consume Veillonella are protected against performance decline in these run-’til-exhaustion assays. That’s something we also submitted for publication. Veillonella has taken a lot of time to translate from Nature Medicine to real world product, but what I can say is, actually, we’re bringing it to the world later this year in the fall.

Lindsey: 

Okay, so it’s not on the market yet.

Jonathan Scheiman:

Veillonella is not on the market yet. What I can say is, we have done some interesting, really cool early access, if people do want to try Veillonella before it comes to market, you can actually go to our website now and sign up for something we’ve called Project V. It’s basically providing Veillonella early access to very diverse populations, to see how it’s benefiting different people. Everything we do is constant evolution and iteration and seeing how our innovations could help broad, diverse people.

Lindsey: 

What is the strain in Veillonella?

Jonathan Scheiman:

It’s actually what it is. It’s Veillonella atypica. Yeah, so we’ve made it very literal, the product is Veillonella, and that’ll be coming out later this year. But I would encourage everyone to go to the website and sign up for Project V, if they are interested.

Lindsey: 

And did you name it?

Jonathan Scheiman:

No, that’s its scientific name. Veillonella is something that’s been out there just like Lactobacillus has been out there. But again, the discovery of how it’s enriched in these elite athletes and how it’s actually confirmed these benefits in fighting fatigue and endurance, that was a novel discovery.

Lindsey: 

Okay, I just thought because the name Nella and Veillonella have “nella” in them. Did you name the other after the strain?

Jonathan Scheiman:

So actually, I think Nella is in a lot of different sorts of bacteria genera, but you hit it on the head. When we were at Harvard, our first discovery was Veillonella, we published it in Nature Medicine, and that was basically the validation of our crazy hypothesis. Because it was so influential in our company, we took the root of it–”Nella”–and we felt like all of our products should be befitting of this discovery. And what we like to say, it’s not about next generation, it’s “Nella” generation. We stuck to our roots in discovery and science, and we’re using that to name our products.

Lindsey: 

And is that slower to come to market just because it’s a novel strain?

Jonathan Scheiman:

Yeah, so that one, actually, is a strict anaerobic microorganism. So you might imagine that manufacturing at industrial scale levels is not a small feat. The reason why 90% of the current probiotic market is Lactobacillus and Bifidobacterium is because the industry knows how to grow them; you can isolate them from food. That’s the real power of biotech microbiome research genomics and culturomics. Now, it’s enabling development of all these other microorganisms that before weren’t really possible to develop.

Lindsey: 

How quickly do you think people might actually notice a difference in their health when trying Nella or Veillonella?

Jonathan Scheiman:

Yeah, so we know for Nella, people see benefits as early as within seven to ten days. Microbiomes are different. There’s a lot of variability, I think. There are some really good responders within a week. There’s some folks for whom it takes a month, right? There are some people that don’t really notice the difference until they stop. The notion of probiotics, it’s not like instant gratification. It’s not something like, one day, you’re going to see a difference. But people do see noticeable differences fairly rapidly. And by the way, they’re very discreet measurements; bowel movements and quality of sleep. Those are two things people could readily measure. For Veillonella, when we did our clinical trial, that was in a two week time span. So two weeks of daily consumption, that’s when we saw the benefits in V02-max. We haven’t tested it in shorter resolution times. But with Project V, that’s something we’ll also uncover as well.

Lindsey: 

Okay, so I’m sure people who listen to sports podcasts know about V02-max, but maybe not all my listeners. So can you explain that term?

Jonathan Scheiman:

Basically, in layman’s terms, it’s effectively how long you could run on a treadmill until you pass out. That’s essentially what it is. So when you use that as a measurement for fatigue and endurance, it’s basically consuming Veillonella: How long can it help promoting us at maximal energy expenditure and keeping us going.

Lindsey: 

So it’s more for endurance than, say, for powerlifting.

Jonathan Scheiman:

That’s how we test it in this assay, we isolate from ultramarathon runners, so we want to test it in an endurance capacity. But obviously, the notion of fatigue endurance, you could sort of trade them off. We are starting a clinical trial this summer that’s more focused on recovery, looking at not necessarily how long can we keep going, but how quickly can we get back up and running again. I say running figuratively, not necessarily literal here. So I think something like Veillonella could have all these interesting benefits from fatigue, to endurance and recovery, and we’re just continuing to expand what those applications are.

Lindsey: 

And are you testing it then in athletes?

Jonathan Scheiman:

So for instance, the clinical study we did was not with athletes. They were healthy individuals that maintained some level of physical activity. So we weren’t studying couch potatoes. But we weren’t studying high intensity athletes. Because again, our goal is not to make better athletes, it’s to make a healthier population. In Project V, that’s something where it’s a wide distribution of the population. So that’s where you can have people that are maybe more sedentary, people that maybe are more endurance athletes or people that are in between somewhere.

Lindsey: 

And so you mentioned with Nella that there were potentially benefits for stool quality. What kind of things were you hearing about that? Or digestion?

Jonathan Scheiman:

Here’s a fun fact for you. Around 60% of the US population report having GI distress on a weekly basis. A lot of that could be just in frequency of a bowel movement. A lot of it could be constipation. And then there could be other things like IBS. So what we’re seeing is that people that take it are having better and more frequent bowel movements.

Lindsey: 

So more with regularity for people who are constipated, say, than people who have loose stool.

Jonathan Scheiman:

Yeah, I think that’s correct. But again, there are different forms of, let’s say, IBS. I think it’s helping people that have IBS, and there are different types. You could have a constipation-IBS, or a diarrhea-IBS, and I think it’s helping both categories.

Lindsey: 

So have you received any feedback from athletes who use your products?

Jonathan Scheiman:

Oh, yeah, for sure. So first and foremost, our products are field tested. We actually had two Olympic athletes utilize Nella during the Tokyo Olympics recently and won Olympic medals in historic fashion.

Lindsey: 

Well, there we go!

Jonathan Scheiman:

So it’s funny, you mentioned about consistency. One of these athletes, Adeline Gray, she’s by all means the greatest wrestler of all time as a six-time world champion and an Olympic silver medalist. When she travels internationally as anyone, you might have issues with regularity and digestion. So actually, Nella is something that’s helped her when traveling. And then we had another athlete, Krista Palmer. When we met her, she was having issues not only with her GI but also sleep. And she started taking Nella, loved it, qualified for her first Olympics, and then became the first US female diver to medal in over 20 years in the Olympics. Now, obviously, we’re not saying that’s all from Nella, but what we are saying is that even at the pinnacle of human performance, people are benefiting, and they’re utilizing it in these all-world competitions to help them be at their best. So whether you’re an Olympian or whether you’re an entrepreneur, a scientist or a single mom, sleep and gut health could benefit you.

Lindsey: 

So what other kinds of feedback are you getting on the products?

Jonathan Scheiman:

For Nella, because it’s on market, another big thing we’re seeing is just improved energy levels. And that makes sense, by the way, right? If you have better digestion, you could better absorb nutrients, and you could better release what’s not wanted. And then if you have better sleep, you have better energy. So that’s the big thing we’re seeing as well. There’s this interesting synergy between bowel movements, sleep and energy that people are really responding to.

Lindsey: 

When you say sleep, are we talking sleep onset, sleep maintenance, or the number of hours or the depth of sleep? What aspects of sleep?

Jonathan Scheiman:

Primarily the quality. In our clinical studies, a lot of this was survey data. However, again, as mentioned, we do have some of those molecular insights from the stool and blood. Anecdotally, we’re seeing from people using Whoop or Oura that there are less disturbances in the night, and we are seeing that certain stages of sleep are being improved upon as well, too. That’s something that in future studies we’re looking to dive deeper into.

Lindsey: 

Yeah, not everybody owns an Oura or Whoop.

Jonathan Scheiman:

Yeah, exactly. I think a lot of what we’re hearing is just better quality, less interruptions, and maybe more of a deeper sleep.

Lindsey: 

So are these products available just in the US or in other countries as well?

Jonathan Scheiman:

Up until recently, mostly available just in the US. But we just now started shipping to Canada and other parts of the world as well, like Europe. You can go to our website FitBiomics.com*. You can learn more about our company, you can learn more about Project V, the science, and you could also go to our shop page and purchase Nella. Actually, we’re doing a promotion now for summer and things of that nature. Right now, if you go to FitBiomics.com*, you could purchase a month’s supply of Nella as a subscription customer for $49 a month. So you’re talking about less than $2 a day, which is cheaper than coffee, or prebiotic sodas or protein drinks and stuff like that. So we definitely want to make this affordable and accessible to everyone.

Lindsey: 

Great. Any final thoughts before we wrap up?

Jonathan Scheiman:

I think what we touched upon earlier is the motivation behind this. I think we’re very motivated by accessibility and democratizing bioscience and democratizing health. And even if you think about the concept that .01% of the human population have these superpowers in terms of physiology and health, and how we’re now decoding that and translating that to make it available to everyone. I think that’s something that really motivates us. We don’t consider ourselves a probiotics company. We consider ourselves as a generational health company. The notion of generational wealth, but we feel this is just the fundamentally, radically different approach to health, health care, how we’re decoding health, how we’re recoding health. I’m sorry, you kind of got me now super passionate. But if you look at society, the health and wellness industry, by the end of this decade, will be a $7 trillion a year market globally. The majority of people that are in this wellness generation buy products to confer a health benefit. This is the reality of health in America; 60% of US adults have at least one chronic disease. It’s the leading cause of death in this country, it costs the country up to $4 trillion a year in health care costs. According to the CDC, two of the leading drivers for chronic disease are poor nutrition and sedentary lifestyles. So basically, what we eat and our lack of exercise are killing us far more effectively than anything out there. There’s a $7 trillion health and wellness industry, and yet 60% of US adults have chronic disease. There is this chronic disease crisis. And what I want to say is, yes, there’s athletes, yes, there’s probiotics. But really, we’re about is solving that crisis, and how we’re rapidly translating the biological health of the super-fit people into solutions for broader populations. That’s what Nella is, that’s what Veillonella is and that’s what our innovation platform is designed to do for years to come. So that’s my parting word and the big picture of what we’re doing.

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.

Adapted from episode 100 of The Perfect Stool podcast and edited for readability with your host, Lindsey Parsons, EdD, Gut Health Coach, with Roy Steinbock , MD, and Debbie Steinbock, HHC, of Mindful Family Medicine.

Lindsey: 

Can you just start by describing to people what an elemental diet is and what it’s used for? 

Dr. Roy:

Sure. So elemental diets are basically liquid diets, they’re shakes or formulas that you can buy, or there are some prescriptions. A truly elemental diet has all the nutrients broken down into their simplest form, so it would be amino acids, carbohydrates in the forms of simple sugars, or  very mild complex sugars like tapioca, maltodextrin, things like that, as well as fats, and some vitamins and minerals; the things that you need to survive. You can survive on these diets for a couple of weeks. People do them from two to three weeks, typically. But sometimes for more serious conditions like Crohn’s and colitis, people can stay on them for longer periods of time, obviously, with the supervision of a physician or someone who guides people through those kinds of conditions. And the diets are very hypoallergenic. They’re anti-inflammatory, they starve the gut bacteria and give your gut rest, so they can be used in a variety of conditions because of those different reasons. 

Debbie: 

What I’ll add to what Roy said is that they’re liquid formulas, but they’re usually sold in powdered form that you then mix in with liquid to make a liquid formula. We did a “Q&A” earlier today, and someone was like, “why are they called elemental shakes when they’re really like elemental water?” (because they’re not thick). We think of smoothies when we say shakes. They’re generally much thinner than that. 

Dr. Roy: 

And it’s certainly not like a milkshake. 

Debbie:  

Yeah. And then when I spoke about starving the bacteria, it mostly starves the small intestinal gut bacteria. We have such prolific large intestine gut flora, that while that may be impacted on an elemental diet, relative to the bacterial amounts in the small intestine versus the large intestine, we’re having a larger influence on the small intestinal bacteria, as we understand it. 

Lindsey: 

So what brought you into work on digestive issues and a focus on the elemental diet in particular?

Debbie:  

So I have been a nutrition counselor for going on 24 years at this point. I actually learned about elemental diets very early on in my practice, because of my focus in working with clients with inflammatory bowel disease. So I’ve used elemental diets for more than two decades in my practice, but mostly as an adjunct treatment to other things with clients who had inflammatory bowel disease or were going through other treatments. But in the last six or seven years, as elemental diets gained more popularity in the SIBO (small intestinal bacterial overgrowth) community, I started using them more as complete or full elemental diets, doing them with clients for an extended period of weeks. And that led me to other conditions that I use elemental diets with, in addition to SIBO in my practice, and I’m sure we’ll get into those, but we’ve used them for pain conditions, skin conditions, things like that, and autoimmune inflammatory conditions. At that time, about six years ago, when I got really interested in doing more with elemental diets, we did a full elemental diet ourselves together, because we really wanted to have that experience before we took others through it.

Dr. Roy: 

We frequently like to experiment with ourselves before we’ll recommend something, so that was a good opportunity. Debbie really wanted to do an elemental diet, and I tagged along for the heck of it. 

Lindsey: 

That’s very brave of you, because I have sent clients on them. But I can’t say that I ever have done it myself, because I’ve heard that at least the Physicians’ Elemental is not that great tasting, and you can go into a little bit more about that in a minute. But I wanted to ask whether you’re using the elemental diets as a first line therapy for SIBO, or once anti-microbials have failed? 

Debbie:  

It’s little bit of both. We’re in a very unique position in our practice in the sense that we have people reaching out to us interested in doing elemental diets. So sometimes they just know of the efficacy of them, and it’s something that they want to try first. Other times, like you said, it’s because other treatments have failed. 

Dr. Roy: 

We have a pretty unique patient population, especially here locally in Boulder, but once you get a reputation for doing something unusual, like elemental diets, people do seek you out. And so a lot of our clients who maybe don’t do well on medications, have fear of taking medications, or have a difficult time with herbs, it’s a great opportunity for them to do something that’s incredibly powerful, effective and super safe. It does take some commitment and determination, but that tends to be our clientele in general. We’re rarely needing to convince people to make changes; we have a relatively intense clientele, I would say. 

Debbie:  

I once got asked, “how do you convince people to do such a hard treatment?” I’m like, “I’m not really convincing anyone, they’re calling me!”

Dr. Roy: 

I think the other part of why we don’t need to convince people is because a) we did it ourselves, and b) we’ve had so much success doing it. Debbie’s walked hundreds of people through elemental diets successfully. And I think when you really believe in something, when you’ve seen the positive effects that it can have, and you have that under your belt, it’s pretty easy to “sell it”, because you know how effective it is, you know the challenges, and you know how to walk people through the challenges. That’s exactly why we created the program that we have.

Lindsey: 

I have to say that for me, it’s been less of a first line treatment, unless, of course, I see someone who says, “okay, I’m sensitive to all these different potential supplements, I can’t do this, and I can’t do that.” And they’re on a bunch of stuff already, so how could I possibly suggest they go on something else? Then, okay, elemental diet, that just simplifies things. It pops into my head in that respect, but because it is sort of hard core, I think, two to three weeks of just eating a powder would be really hard for me, and admittedly, a lot of my clients, too, who are on super restrictive diets anyway. Then I’m thinking, if you’re only eating six things anyway, how much of a big deal is going on this powder for a few weeks? So I’m curious how long you have clients stay on the diet?

Debbie:  

Yeah, so I would say two weeks is the average for many people. Occasionally, people will stay on for three weeks. We definitely have had clients who feel so good on the elemental diet, and that starts to kick in into the process. And they’re like, “is it okay if I stay on another week or another five days?” Then with some more severe conditions, people can stay on an elemental diet for more weeks than that, maybe for up to six weeks. However, I generally will transition people to a partial elemental diet at that point, so that they do have food in their system as well. Because as I like to say, there’s only a certain amount of flavor fatigue that people can endure on an elemental diet. 

Dr. Roy: 

For most people, there is a degree of fatigue of being on that. We tolerated it for two weeks, but I was ready to be done when we got off of it. 

Debbie:  

Roy also says “it needs to be tolerable but it’s not fine wine.” 

Lindsey: 

Right. So one thing where I’ve been using them more recently is, in particular, with IMO (intestinal methanogen overgrowth). So I’m curious if you find it to be equally effective for hydrogen SIBO versus IMO or methane SIBO, and I’m also wondering about hydrogen sulfide SIBO. 

Dr. Roy: 

Exactly. Well, one thing you mentioned, we also don’t use that as a first line treatment for most things. Obviously, we use a more holistic lifestyle approach for all the conditions that we’re treating. It’s usually by the time someone’s gotten to the point of considering an elemental diet, they’ve been through that with us or through that with some someone else. And so with conditions like SIBO, we will try other things first, but elemental diets are so effective and simple that people oftentimes sign up to them.

Debbie:  

We’ve used it for all three conditions with really good success. I know that in the research, it’s really only been studied for hydrogen SIBO, but we found it very successful with intestinal methanogen overgrowth, as well as hydrogen sulfide SIBO, either diagnosed or suspected with a flatline breath test. 

Lindsey: 

Okay. So in my case, I’ve had a couple of clients for whom antimicrobials did nothing; it was not responding to the IMO. Then I got them on the elemental diet, and it broke the bloating a little bit, but it was not like everything was better afterwards, even that was not enough.

Debbie:  

Well, you speak to a good point; is eradication of symptoms always correlated with the negative breath test? And as clinicians, we know that while some people feel amazing, there’s oftentimes layers and other things that are going on. Then sometimes, we eradicate SIBO, but somebody’s not feeling great still, and there’s other layers to their health that still need to be addressed. 

Lindsey: 

Right. So what other things might be causing the bloating if it were not the SIBO or the IMO?

Dr. Roy: 

Yeah, well part of it can be things in the large intestine as well. So a lot of times, people have imbalances of gut bacteria in the large intestine, or they just might not be digesting their food well, which could then lead to fermentation. Maybe it’s not overgrowth, but it certainly could lead to fermentation that would cause them to have gas and bloating. Those are a couple of things.

Debbie: 

Food allergies or sensitivities too. Or even sometimes just foods that are in their diet that are not necessarily working for them. An example I see really frequently that just came to mind when you said bloating is people that drink a lot of carbonated beverages, and they’re chronically distended, bloated, or have a lot of reflux. Then, when I look at their diet, it’s like, oh, you’re drinking 40 ounces a day of carbonation? Stress can exacerbate all GI conditions as well, so there’s a long list of other things that could be going on. 

Lindsey: 

So when you recommend that people go on an elemental diet, do you tell them to go off other supplements while they’re on it? Or is it safe to continue them? Or might those other supplements be providing food for the microbes? 

Dr. Roy: 

Yeah, we often joke that we’re elemental diet purists. When we put up someone on an elemental diet, typically, we’re just recommending being on an elemental diet with the shakes. That being said, we do recommend some supplements; something to maybe quell any potential fungal overgrowth, if that’s an issue. For people with methane SIBO, sometimes we’ll recommend using something like Atrantil, because Debbie had some clients that we used that with and actually found some really great results, both for symptom relief and gas reduction. But in general, what we’ve seen is that people don’t really tolerate a lot of supplements, because there’s no solid food in their digestive tract. Like sometimes we’ll recommend magnesium if someone’s has constipation, but usually they’ll need a smaller dose or be able to tolerate a smaller dose than they could when they were eating solid foods, so your digestion is a little more sensitive when we don’t have food in our belly. 

Lindsey: 

Yeah, I thought about the Atrantil. I know that those are polyphenols, and polyphenols promote the growth of certain kinds of microbes. So I was thinking, is that cheating? 

Debbie:  

Yeah, we say it’s always like a cost-benefit analysis of anything you add into the system, while you’re on an elemental diet. Do the benefits of adding it in outweigh the negatives of adding those prebiotic fibers or starches or whatever it is that you’re adding in even in a veggie cap or something like that? 

Lindsey: 

So I’m familiar with the Physicians’ Elemental diet, which people can find in Fullscript. I know Michael Ruscio has the semi-elemental diet formulas available on his website. Are those both good choices? Or would you say one’s better than the other? Or are there others that you recommend? 

Debbie:  

So we like to think about which elemental formula to choose based on which condition somebody is coming into the elemental diet with. We, of course, like most practitioners, have ones that are more tried and tested that we’ve used again and again with clients, with really great results. What we’ve also learned in working with so many people is that there’s some that work better for others. For example, there are some formulas that contain tapioca maltodextrin, that are typically lower in sugar than the ones that have glucose, dextrose, fructose. So some people do a lot better for blood sugar regulation and energy with those types of formulas, which a couple of companies have now. And then there’s some people that will do better with the shakes where they have to add their own source of fat to, because some of the fats that are contained in the formulas might not work well for them.

Then there’s the difference between elemental shakes and semi-elemental shakes. There’s some uses for both of them in this field. So we try to personalize it and teach people how to do so in the course that we have, by what condition they’re treating, or what their main concerns are. Or what’s the formula that’s going to best suit their needs? But to speak to your point, we keep saying that year after year, more and more shakes are coming onto the market, and that’s pretty cool, because it just shows us that there really is a need for this type of treatment. And at least in the 20 years that I’ve been tasting these, they have improved so greatly. The ingredients have improved too, to the point that we were willing to finally say, “okay, let’s try this ourselves”. This is not like drinking a hypoallergenic baby formula anymore.” 

Dr. Roy: 

To directly answer your question, we do use the Physicians’ Elemental a lot. They had a jumpstart on the market in terms of stuff that you could get from a practitioner or online, like Fullscript as you mentioned. We’ve not had a lot of personal experience with the Ruscio formula, but we’ve heard some good things about it. We’ve sampled a lot of different ones, and it’s on our list of ones to sample at some point. And we use Absorb Plus a lot, which is Jenny Patel Thompson’s formula, and that balance is great. She’s got a bunch of flavors and a bunch of different options. 

Lindsey: 

Is she a functional medicine person?

Debbie:  

No, not at all. She actually formulated Absorb Plus for her own personal health. She had Crohn’s disease, used an elemental diet for six weeks to get out of a widespread flare and then created Absorb Plus. Interestingly, semi-elemental formulas were what were considered elemental diets way back then, 25 years ago. The distinction has changed. So now when we say elemental, we mean an amino-based formula. But actually, what she has educated me about over the years, is that most of the studies that you read on elemental diets have actually used semi-elemental formulas that were done all these years ago. So now, when we say semi-elemental, we mean that the formulas have amino acids, simple sugars and fats. Well, you have to add fats if they don’t have them. But they also have small proteins, like dipeptides, or tripeptides, whereas the “true” elemental formulas are the amino-based formulas that don’t have any peptides in them. 

Lindsey: 

Right. And the reason that they do that is because it tastes better if you put them in that format?

Debbie:  

I don’t know if that was the original reason why. I don’t know that it was necessarily for taste; I think it was the populations that they were being used in. If you look back at when elemental shakes were originally used, it was definitely with IBD. They were actually developed for NASA for astronauts to limit the fecal matter while they were in space. For both of those populations, maintaining muscle mass is really important. And there is some thought that the semi-elemental formulas are better at helping to build or maintain muscle mass than just the aminos.

Lindsey: 

Okay. So tell me about your use of elemental diets with IBD and how successful that’s been. 

Debbie:  

So that’s what I’ve been using them for the longest, but like I said, until I had done an elemental diet fully myself, I was really hesitant to get somebody fully off food and onto elemental shake formulas. And so for many years, I just used them occasionally. There was a study, a pretty big one, that talked about how using a half-elemental diet with inflammatory bowel disease was a very effective treatment. So oftentimes, I would have clients use elemental shakes as an adjunct for calories and easily absorbed nutrients, and I still use them that way. But sometimes now, when somebody’s initially starting, like a flare, if they have Crohn’s or colitis, we might have them do elemental shakes as an initial bowel rest treatment; so short term, or a couple of weeks, depending on what’s going on.

Dr. Roy: 

In that population and in general for inflammation, these are formulas and shakes that are hypoallergenic, particularly the true elemental shakes with its amino acids. Normally, what we get allergic reactions to or sensitivities is more often due to the protein. And so when it’s broken down into these really simple forms, for most people, though there’s always exceptions, it’s going to be really hypoallergenic, and that can have an effect on everything from arthritis to colitis. They’re also so easily absorbed so high up in the intestine, that it really gives your bowel rest. So intestinal rest is incredibly important. It’s kind of like if you break or sprain your ankle, you want to give it rest. And when we eat three to five times a day, that’s creating a lot of digestive strain for people. So it can really help in terms of that. 

Debbie:  

Yeah, the reason that it’s used for SIBO and IBD, there’s an antimicrobial element and we know there’s an antibacterial action to them. That probably plays a part in the IBD population as well, whether or not somebody was diagnosed with SIBO or dysbiosis. We assume by nature of the condition that that exists there. 

Dr. Roy: 

There’s always these new popping-up studies showing that there’s an association between this bacteria and that bacteria, or Crohn’s, colitis and arthritis. Even in the study where they were using it for rheumatoid arthritis where they were able to induce remission for people as effectively as with using steroids, they proposed whether or not rheumatoid arthritis really starts in the gut. Obviously, all holistic practitioners know that or at least have thought that for many years, but it’s interesting to see Western science catch up with that.

Debbie:  

Just to finish up answering that question, the other ways that I’ve used it with clients who have inflammatory bowel disease is sometimes, I don’t know if you see this with your clients, but I’ve certainly had the clients who can’t get off of steroids. They’re on steroids, and then every time they wean down to whatever dose it is, they flare up again. So if their doctor is on board with it, I’ve had quite good success helping somebody through using an elemental diet during the weaning off of steroids and had several cases where somebody who had many failed attempts at getting off of steroids was able to use an elemental diet to assist that process.

Lindsey: 

But then did you slowly take them off the elemental diet with partial food?

Debbie:  

Exactly, and then bringing in really good foods and good supplements to support them after that process.

Dr. Roy: 

One of the things that we’ve seen that is really useful with the elemental diet is it’s virtually an elimination diet as well, because you’re really eliminating all your foods, and so it’s a good opportunity to see what really does affect you in a negative way. You obviously have to take into account that you’ve closed down your digestion for two or three weeks. So we have to fire that up properly, because that could create some digestive symptoms just by starting to eat after not eating for two to three weeks. But once we get that going, it’s a good opportunity to see, like, are strawberries really the thing that’s causing you to get bloated every time you eat them? Or was it more generalized?

Lindsey: 

So when people go on an elemental diet, do they typically have stool on a daily basis? Or do they tend to have problems with diarrhea or constipation or any of those things?

Debbie:  

It really varies so greatly; there’s such a wide range of what’s normal on an elemental diet. Educating people about that is important, because some people do have liquid breastfed baby poops. And that’s not diarrhea, that’s normal for people who are on an elemental diet, while other people have very little stool volume at all and could go a few days without stool and then when they pass stool, it actually looks quite formed. That’s been fascinating for us to see, even for Roy and I who have the same diet. We have some variation between the foods that we eat, even though we eat all of our meals together, mostly. But on an elemental diet, everything we were doing was exactly the same. And to see, even between the two of us, the difference in how our stools were on an elemental diet was pretty dramatic.

Dr. Roy: 

We tend towards different types of bowel movements to start off with. And Debbie always says, and I think this is very true, it’s like people tend to go towards where their challenge is. I tend to have slower bowels, so I had less bowel movements. Though I wouldn’t have called it constipation on the elemental diet, I had normal bowel movements, they were just smaller and less frequent, whereas Debbie tends to have more frequent bowel movements. 

Debbie:  

And so they were on the elemental diet. Exactly. Sometimes people surprise us where I think I know which way it’s going to go for some of my clients, given their health history, and it surprises me. I’m like, “oh, that’s how their body reacted to the shake.” And it can change over the weeks as well. Remarkably, for some people who are constipated, or have really high methane SIBO, and they’re having a struggle with bowel movements on an elemental diet, they might have one every day. And those are people that are like, “I want to stay on this a little bit longer.” 

Lindsey: 

So if somebody went on an elemental diet with SIBO, when they’re coming off of it, do you have one of the many SIBO diets that you recommend as a transition? 

Debbie:  

Yeah, so food reintroduction is really quite individualized for the person. But typically, what we do is we give people a very low residue diet to do for the first five days to really minimize any symptoms that they have. Then, we teach people how to use the different diets that are on the market for SIBO to really customize and learn what works best for them. So the diet that’s best for Debbie is different than Roy, and Lindsey, and that’s really the take home message here. While all these diets are great guides that were created with great intentions, most people don’t need to follow them to a “T”. But as Roy said before, sometimes after an elemental diet or after healing dysbiosis, or SIBO, they have a much wider tolerance of foods. We’ve seen that again and again in our practice. So what we don’t want to do is have somebody transition off an elemental diet and onto another restrictive diet when they’ve actually gained tolerance to foods back. So there’s a way that we teach people how to test that out in a systematic way, where they try the foods that they’re least likely to react to first and then test foods with higher fermentation or things like that down the line.

Dr. Roy: 

Or foods that have been challenging for them down the line. 

Lindsey: 

I was just going to say, it’s challenging sometimes when people have very restrictive diets and then start doing treatments that in theory should get them into a less restrictive diet. It’s tricky getting them to try new foods, and I’m curious how you handle that. 

Debbie:  

Yeah. I think that speaks to also that there’s a lot of a fear around reintroduction. That’s really important to note because after an elemental diet, especially if somebody feels a lot better after their treatment, they might be very reluctant to try new foods and are very afraid of symptoms coming back as well. I feel like I missed a part of your question. 

Lindsey: 

Well just how do you handle that? 

Dr. Roy: 

Well, we give suggestions in our course of how to do that; if you’re going too slowly, what happens if you go too quickly, if you have a relapse, or how to go backwards, we talked about all that. But for the really complicated people who have a lot of psychological and emotional connections to food and challenges with food, that’s probably more based on a one-on-one treatment protocol for them and helping them through that. This goes back to your other question about like, what do you do if someone’s still bloated or not feeling? Well, a lot of times we found, despite people doing all the right things, they’re still not feeling well, and it gets harder and harder to figure out what’s going on with them. At some point, what we realize is that a lot of that is immune-nervous system connection, fight or flight state and really working on that. And there’s some good programs to work on that as well. So you’re really helping people deal with some of their emotional issues around food. Their past history or their trauma around it can be an incredibly important part of their healing. 

Lindsey: 

Right. So are you using breath tests before and after elemental diets to check on people’s progress?

Debbie:  

Yeah, I would say 80 to 90% of people want that for SIBO. We generally recommend it. If they have a before breath test, we generally will do an after breath test, unless there’s financial concerns for somebody. But there’s also clients that are like, “if I don’t have SIBO, I know I still want to try this for just the break and the bowel rest.” So we’ve definitely had people who do that as well. We’ve had clients who have tested for calprotectin or sed rate or CRP before and after elemental diets as well. But for many of the conditions, there’s not much testing you can do before and after.

Dr. Roy: 

Right. And usually, by the time we’ve gotten someone to do an elemental diet for something that’s not SIBO, they have gone through a decent amount of testing already to try to figure out what’s going on with them. Sometimes it is a little bit of a “Hail Mary” pass after we’ve tried a lot of things. We know this has helped such a random concoction of different conditions, so people will try it. Oftentimes, we’ve had really good success, even when it’s not SIBO or something obvious. 

Lindsey: 

So tell me a little bit about some of the unusual conditions that you’ve seen it successful with – like you were mentioning pain and autoimmune and inflammation. 

Dr. Roy: 

Yeah, some with people who have arthritis, maybe not even specifically rheumatoid arthritis but arthritic conditions, chronic pain–it’s been really helpful for some. We’ve also treated a few people with some serious skin conditions like rosacea, and had pretty dramatic results. Now usually, these are people also having some digestive symptoms as well. It’s not just only for arthritis, though we certainly would do that. I just don’t think we’ve had someone specifically come to us for that. 

Debbie:  

We’ve done multiple food intolerances like eosinophilic esophagitis and had some really good successes there. And then we use partial elemental diets with all different kinds of conditions, from cancer to HIV. 

Dr. Roy: 

Those are for clients who just need easy, absorbable nutrition, we’re not necessarily trying to kill anything. And it’s not even necessarily for the anti-inflammatory process, but just to be able to get really easy-to-digest nutrition when they have damaged gut lining. We want it to get absorbed up real high so they can get all the essential nutrients. 

Debbie:  

Yeah, it’s because the gut affects so many things. Elemental diets clearly have never been studied for mental health conditions, but of course, you have to wonder how useful they would be with a lot of different conditions that they have yet to be studied for. 

Dr. Roy: 

We’ve seen improved brain fog and difficulty concentrating, or sleep as a positive side effect for people when we’ve treated other conditions. Again, it wasn’t one of the primary issues that we were dealing with, but we’ve seen improvements with that. 

Lindsey: 

Could you back up a little bit and just explain to people what eosinophilic esophagitis is? Because I don’t think any guest has ever mentioned that before on the show. 

Dr. Roy: 

Okay, sure. So basically, eosinophils are the type of white blood cells that produce IgE, which is the antibody that creates allergies. It turns out that you can have a higher concentration of eosinophils pretty much in any tissue. Thus, eosinophilic esophagitis is in the esophagus or the connection between your mouth and your stomach. And usually it’s a diagnosis where people are having a difficult time swallowing, consuming foods, or they can be bloated. It can be associated with SIBO, and it’s often times pretty uncomfortable for people. It’s a relatively newer diagnosis, and you can find eosinophils everywhere; there’s eosinophilic gastritis, there’s eosinophilic colitis, so you can find your eosinophils everywhere in the gut. The treatments in terms of Western medicine are pretty limited. It’s mostly steroids. It’s interesting in the Western world, I just find that so many Western doctors are just so terrified to tell a patient that they can’t eat a food, but you know, that can be very effective. And the ultimate elimination diet, like I said, is this elemental diet, and that can be quite effective at decreasing the inflammation. Sometimes that’s permanent, and sometimes that’s temporary. But for a lot of patients with something like this, or something recurring chronic, like maybe rheumatoid arthritis, if you can’t completely halt it, just having another tool, maybe even in addition to using steroids sometimes can be incredibly helpful. This can help decrease the total body burden of steroids and maybe lower the doses.

Lindsey: 

Are you using functional stool tests to diagnose that?

Dr. Roy: 

Well, not specifically for eosinophilic esophagitis. We do use stool tests, breath tests, and different functional medicine blood testing for other conditions. Eosinophilic esophagitis is generally diagnosed by esophageal endoscopy, and you have to have a certain number of eosinophils, more than 30 per high-power field, to be considered positive. Now, there’s also the gray zone of like, what if you have 25 and not 30? We see that as well. And that’s beyond the scope of this conversation, but it can be treated beyond just steroids and elemental diets as well. Elemental diets can be a very effective tool, at least squelching that inflammation.

Lindsey: 

Right. But in general, that then would be something that was diagnosed by a gastroenterologist?

Dr. Roy: 

Correct. That would be a diagnosis made by a gastroenterologist unless someone else is doing endoscopies.

Lindsey: 

Right, because I know, like on the GI map, there’s the eosinophil protein X, and I’m wondering if that is indicative of some type of eosinophilic process.

Dr. Roy: 

I think it is–it is indicative of some kind of eosinophilic processes. For example, people who have really severe allergies might have very elevated numbers of eosinophils floating in their blood. And that can be a tip off to “oh, these people might have eosinophilic esophagitis.” That being said, I’d say the majority of patients that I’ve seen with eosinophilic esophagitis don’t have elevated eosinophils in their blood or even elevated eosinophil protein X in their stool. Certainly one is not diagnosing the other, but it certainly points in the same direction, which is an issue with eosinophils or immune regulation, kind of like you see in allergies and asthma and eczema. They’re all part of that same immune dysregulation family. 

Lindsey: 

So I know that (and you mentioned already) that the elemental diet powders need to have fat added to them. I know that at least the semi-elemental, (the Dr. Ruscio ones) do. Does the Physicians’ Elemental diet also have to have fat added?

Debbie:  

Those have fat included into the product. 

Lindsey: 

So when people do have to add fats, I know some of the recommended ones are like Udo’s 3-6-9, or MCT oils. Do you have a preference for a particular type of oil?

Debbie:  

Yeah, it depends on the person. It’s really what oil they can tolerate the best. We’ve had clients that have added fish oil. I can’t imagine downing fish oil several times a day in my elemental formula, but for some people, that’s what they tolerate best. But all the ones you mentioned certainly can be added to somebody’s diet depending on their taste tolerance and how well they can tolerate fats and how many calories they can tolerate from fats as well.

Lindsey: 

Right? Because I know that MCT oil is known for causing diarrhea.

Dr. Roy: 

Right. Drinking oil in general can cause diarrhea.

Lindsey: 

We just don’t normally do it. 

Dr. Roy: 

Exactly, but I also I think it’s less likely to cause that when it’s mixed in with their amino acids or proteins infused in a semi-elemental and carbohydrates as well. We’re designed to absorb food in that way. Obviously, this is a little unnatural, it’s not whole foods. But we’ve not seen a lot of people who have oil diarrhea from it.

Debbie:  

Not at all. But there are some people that can’t tolerate MCT oil and some of the oils added into products that do better with less fat or specific kinds of it. We don’t have people add oil into the formulas that contain oil in them. That just feels a bit excessive. 

Dr. Roy: 

And there’s some conditions where it might make a difference to add more or less oil, for example, things like pancreatitis or gallbladder disease, where that can cause some issues–you might need to use less oil. When it gets to the point where you’re really trying to figure that stuff out, working one-on-one with a practitioner makes more sense. 

Lindsey: 

So tell me about your Elemental Diet Success Plan* and where people can find it.

Debbie:  

So the Elemental Diet Success Plan* course was borne out of all the work we’ve done coaching clients one-on-one through elemental diets. And in that process, we really learned the most commonly confusing questions that people had, where they really needed the most support in the elemental diet process and I personally have been the person seeing the clients in our practice through elemental diets through all of these years. So we put this course together, it’s really like a course for clients or patients, who are interested in getting additional support while going through their elemental diet. So the elemental diet success plan is composed of 14 different video lessons, which take people through planning or preparing for the elemental diet, implementing the elemental diet and then transitioning off the elemental diet successfully. And so we say that all of our lessons are little bite-sized lessons, where they might be as short as five minutes or as long as 25 minutes.

What we want is for people to be able to take an overview of the course. But then as they’re in each phase, they can go back and re-listen to that lesson again when they’re in it and they really need that additional support. Then what we also have as part of the program is some different guide books that take them through the process as well, so like a program timeline that helps them keep track of their progress through the program, a workbook that we say is kind of like the virtual handholding from us through the whole process that helps them through their calorie calculations, making their shake schedule, figuring out what foods they’re going to go back to after the elemental diet, troubleshooting symptoms, whether that’s psychological or physical symptoms of the elemental diet. 

Dr. Roy: 

It also helps with figuring out their inspiration for why they’re doing an elemental diet, how to stay on an elemental diet and how to persevere through an elemental diet.

Debbie:  

Or the mindset part of the elemental diet. Then we give them a detox support guide to support them through more challenging days to make symptoms more bearable, as well as transition diet recipes to help them through those first five days especially, and really the first two weeks of food reintroduction. So that’s the overview. Did I miss anything?

Dr. Roy: 

No–what I would say is that, like many doctors, I’m not walking people through elemental diets. It’s really Debbie’s experience of walking hundreds of people through elemental diets. We always joke in our family that for Debbie, if she was a superhero, her superpower would be organization and the overview of everything. She really just knows how to put things together for people and how to really guide people from beginning to end. Her amazing observational skills over these years have put together a program, initially one-on-one for her clients, but then turned it into a self-led program that really helps people be successful. That’s why we named it the elemental diet success plan, because we were thinking about what’s the purpose of it? It was that Debbie has guided hundreds of people successfully through an elemental diet with virtually a 0% attrition rate. I mean, there’s people who give up before they start, but anyone who has started and gone through the work with Debbie has made it through an elemental diet and many people already through the Elemental Diet Success Plan, self-guided. 

Debbie:  

We always say we can’t guarantee someone’s success with the results they’ll get from anything, but we can guarantee that we can successfully guide them through all the things they would need to have the greatest likelihood of a successful elemental diet experience, and therefore, a successful experience with their health as a result. 

Dr. Roy: 

And a pleasant experience, because despite there being some challenges during an elemental diet, for the most part, it’s really doable for the majority of people who want to do it. 

Debbie:  

And we don’t stop people white knuckling it. 

Lindsey: 

During this process, do they have access to some type of community or some online source such that they’re not totally alone?

Debbie:  

Yeah, the videos take them along this– we’ve built out and continue to do so, like with our participant FAQ inside the course. At this point, there’s not an interactive forum, but we actually did a Q&A this morning for our current program participants right now, which was so wildly successful that we’re considering the idea of doing little pop up Q&As along the way so we can catch people at different phases of their process. But with that said, what I’ve also done is quite a few hybrids, where a lot of the people that worked with me one-on-one, now that we have the Elemental Diet Success Plan*, they might buy the course and then say, “Hey, I just have a few things that I want to check in with you and make sure I got this right, I’m doing this right for my health, and you don’t have anything else you’d add to the mix given your experience.” And that’s worked so beautifully for people to have a little one-on-one but also have the course materials to take them through. 

Dr. Roy: 

Yeah, it really makes that part more affordable, so you can learn the basics from the course and then get one-on-one with Debbie. Our support staff will answer some very basic clarifying questions, but we can’t do one-on-one consultations in that way through email with people whose health information we aren’t privy to.

Lindsey: 

Yeah, every time I get a client question, I’m just like, “Okay, now let me go back to my database, reread all the notes I have about your conditions, look at the supplements you’re taking, and okay, now I can answer it.” So I can totally understand that. Any final thoughts before we head off? 

Debbie:  

No, that’s it. It’s a pleasure to meet you, and it’s nice to get to sit down and talk to you. Thank you so much for having us! 

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.

Adapted from episode 99 of The Perfect Stool podcast and edited for readability with your host, Lindsey Parsons, EdD, Gut Health Coach. 

Today, I’m going to be describing all the different functional medicine tests I use and when and why I choose certain ones, including stool, blood, urine, and even hair tests, which cover things like organic acids, fatty acids, amino acids, heavy metals, and nutrient levels. As you read, it might be useful to open up my Rupa Health Lab Store*, and open up the tests I’m talking about so you can see what I’m referring to. On every test, after selecting it, if you scroll down and select View Report, right under Sample Report, you can see an example of the test report.

Which functional medicine stool tests do you like the best?

To start with, the primary stool test I use is the GI Map from Diagnostic Solutions. Like most functional medicine stool tests, the GI Map uses polymerase chain reaction or PCR testing to quantify the microbial DNA present your stool. This is newer technology than culture-based tests, which favors the microbes that grow well in culture, and is no longer a valid measurement technique given the newer PCR technology available. The GI Map, like other tests, covers commensal bacteria and bacteria that may overgrow. This includes Methanobrevibacter smithii, one of the two primary microbes involved in IMO or intestinal methanogen overgrowth, and Desulfovibrio species, which are overgrown in hydrogen sulfide SIBO. Additionally, the test includes bacterial and viral pathogens, quantities of the two major phyla in the gut: bacteroidetes and firmicutes, quantities of yeast, fungi, parasites. Intestinal health markers are also part of the test, including markers for fat in the stool, pancreatic enzymes, beta-glucuronidase (which relates to estrogen dominance and heightened risk of breast and colon cancer), fecal occult blood, secretory IgA (your gut immune defense system), and anti-gliadin IgA (a marker of gluten intolerance). Finally GI Map tests include levels of Eosinophil Activation Protein, a marker of gut inflammation, and calprotectin, a marker of active inflammatory bowel disease.

Pros for the GI map are that among bacteria it tests, it includes Helicobacter pylori, along with its virulence factors, which indicate whether the strain you have could cause stomach cancer or ulcers, whereas this is an add-on test for some other companies and doesn’t include virulence factors. You can also get the H. pylori profile as a separate test, incidentally, from Doctor’s Data for $131. The other big pro is that it’s lower cost at $381, if you get it from my Rupa Health Lab Store* (or a little less for my active clients if they get it directly through me), which is less than some other functional medicine stool tests.

The biggest cons for me about the GI Map are that it doesn’t measure the different short-chain fatty acids in stool. Additionally, it does not compare the levels of the other important phyla, namely proteobacteria and actinobacteria. In addition, Lucy Mailing, one of my gut health mentors, sent a stool sample split in half to Diagnostic Solutions and got two very different results on calprotectin, so the reliability of that particular marker is somewhat in question. Although arguably, one part of the stool could concentrate certain things, so it’s hard to be sure this questions the reliability of that marker for Diagnostic Solutions. I have generally seen it correlate well with clients diagnosed with IBD.

The Genova GI Effects Comprehensive Profile is the second stool test that I’d be most likely to order if doing a functional medicine stool test. I’d be more likely to choose this one if there were no symptoms of H. pylori like reflux, nausea, constipation, or if someone had done a prior PCR stool test for H. pylori and it was negative. I might also choose it if I suspected there was an issue with producing sufficient butyrate, like when I see loose stool, unresponsive to antimicrobials or antibiotics or with IBD. It’s also one that Lucy Mailing has found reliable in her split stool experiments.

With the GI Effects, there is a 3-day stool sample and a 1-day stool sample option for the same price, so if clients are game for taking stool samples for 3 days, that would likely be more accurate.

What are the key differences between the GI Effects and GI Map tests?

The main differences between the GI Effects and the GI Map are that there are 5 markers for fecal fat on the GI Effects as opposed to only one on the GI Map, plus all the short-chain fatty acids. This is helpful for assessing if there is a gut barrier issue in the colon as well as dysbiosis. The GI Effects also provides a marker for the products of protein breakdown, indicative of incompletely digested protein in the colon, which could come from low stomach acid, for example. The GI Effects shows you the relative abundance of all the major phyla of bacteria, yeast and archaea in the gut, which I like because people often have overgrowths of proteobacteria.

There is still a culture section on the GI Effects which feels a bit dated, so I basically ignore that section, unless it happens to catch yeast; in which case, it’s helpful because if anything is found growing in culture, they do provide a sensitivity section of that microbe to various antibiotics and antimicrobial herbs, which can guide can help determine which herbal preparation to choose. The GI Effects also include Reflex Subtyping for Blastocystis hominis, because only subtype 7 is considered pathogenic, and subtype 4 has even been shown to even be beneficial in studies (as an add-on test). So this might be a good follow-up stool test for someone who originally did the GI Map and got a positive result for blastocystis. The GI Effects will run you $507 in my Lab Shop, so as I said, it is more expensive, which is one reason I usually recommend the GI Map for most people.

Those are the two primary stool tests that I use, but sometimes, rarely, I come upon someone whose symptoms all scream H. pylori and nothing else, like if they have no bloating but they’re constipated and have reflux or nausea, or if money is a real issue. In that case, I may choose to recommend just the H. pylori profile from Diagnostic Solutions or use it as a follow-up test after working with someone on H. pylori.

When should I consider using a SIBO breath test?

Sometimes, I choose to use SIBO breath testing with people, perhaps when their primary symptoms scream SIBO to me but nothing else, like with lots of bloating, and then either loose stool or constipation. Reflux may also be an issue. If they have loose stool, I’ll recommend the trio-smart, as it’s the only test that includes all three gases, hydrogen, methane and hydrogen sulfide, especially if they have visceral pain and sulfury-smelling stool. That’s $349 if you get it directly from the manufacturer. If someone’s stool is loose but doesn’t smell at all, then I generally assume it’s likely hydrogen and a SIBO/IMO breath test either with lactulose or glucose is best. That’s $261 in my lab shop, but honestly, you can find it cheaper elsewhere if you’re using glucose as the measuring substrate. However, you can get it with the lactulose from my shop, as they have a physician review service in the ordering that allows for lactulose, as it’s only available with a prescription in the U.S.

Glucose and lactulose, by the way, are the substances that people drink before taking the test. Lactulose is definitely more useful if you’re looking at IMO and constipation, as IMO can be anywhere in the digestive tract and glucose is absorbed early in the digestive tract. If someone has loose stool and bloats immediately after eating, then glucose may be the better choice. If they have alternating constipation and loose stool, then lactulose is probably the better choice. 

However, I will say that I don’t use breath testing that often; I generally use a combination of a stool test, symptoms and history to decide whether it’s likely a case of SIBO or IMO or neither. Now I should mention that there is also something called the Food Marble, which is an at-home breath testing machine. For someone with super recurrent/recalcitrant SIBO or IMO, I often wish I had suggested they order this at the beginning, as it would be more helpful because you can retest and the equipment includes two glucose kits and costs as much as one SIBO/IMO test. But you can’t get lactulose without a prescription if you’re using the Food Marble, so it’s not so great for IMO in the large intestine, unless you’re not in the U.S. and can get lactulose. And you never quite know who is going to have a tough case of IMO until you’re usually one stool test and at least a couple rounds of antimicrobials into the problem. One other nice thing about the Food Marble is you can also get a food intolerance test kit for the other things you can test on breath, like lactose, fructose, sorbitol and inulin, which many people are sensitive to. You should reach out to me at lindsey@highdeserthealthcoaching.com to order a Food Marble, if you’re interested, as I can get you a discount.

Finally, when someone has recurring symptoms of SIBO that seem to come back after trying antibiotics like rifaximin or antimicrobial herbs, generally with diarrhea or loose stool, then I also think of the ibs-smart test, which tests for the antibodies for vinculin and CdtB, which tells you whether your IBS or SIBO is the result of food poisoning and will be an ongoing issue for you, necessitating prokinetics and lifestyle interventions to help you manage it and delay recurrences. You can get that for $220 direct from the manufacturer.

What do you think of food sensitivity testing?

I’ll also briefly mention that I put the Grain Zoomer test by Vibrant Wellness in my Rupa Lab Shop* because I have had a number of clients who are eating strictly gluten-free and have gotten a positive anti-gliadin IgA on the GI Map. In this case, it usually indicates there’s some cross sensitivity to grains, so if they’re positive and there’s no gluten slipping in, then I recommend this test to see if they’re reactive to other grains–that’s $304. If they’re eating grain-free too but are eating dairy, then I may recommend the Dairy Zoomer test by Vibrant Wellness instead to see if they’re reacting to dairy. I don’t generally do food sensitivity testing, but sometimes there’s clearly inflammation in the gut that’s coming from something, and if you get that positive anti-gliadin IgA, you know it is food-mediated, then you know there is some cross-reactivity between gluten and other grains or dairy–that’s also $304.

What does an Organic Acids Test cover?

Another test I use frequently is the Organic Acids Test. I typically use the Mosaic version, which changed its name recently from Great Plains Lab. Episodes 74 and 77 of my podcast go into great depth on the interpretation of this test, so if you want more details, check those out. I usually add that in for gut health clients if I hear symptoms of fungal overgrowths or candida, like heavy antibiotic use, a turn in health after antibiotics, a white coating on the tongue, frequent UTIs or urgency, vaginal yeast infections, or household mold issues, because there are multiple markers on that test for fungal overgrowths.

I also add in the Organic Acids Test if I hear about anxiety or depression, as there are markers for neurotransmitters. It also covers markers in the urine of bacteria and specifically, clostridia overgrowths, as well as oxalates, Krebs cycle metabolites, markers for energy production from fatty acids, carbs and proteins, and markers for the status of various B vitamins, vitamin C, and CoQ10. Markers of detoxification include two markers that assess glutathione sufficiency, which is your master antioxidant. So, it’s also useful for people with low energy, chronic fatigue, likely toxic exposures, poor liver function, etc. That’s $337 in my Rupa Lab Store*.

What does the Genova NutrEval® test for?

Now for clients who have health issues that go above and beyond gut stuff and maybe some light mental health issues, like chronic fatigue, any type of autoimmunity, any type of inflammatory bowel disease, or fibromyalgia or complex, long-standing health issues, I often suggest the NutrEval®. There are two versions, FMV or plasma, and I think plasma is preferable for the most accurate amino acid levels. The NutrEval  is both a blood and urine profile that evaluates over 125 biomarkers. It includes an Organic Acids Test, the Genova Organix version, which is similar to the Mosaic OAT but only has 3 markers for yeast and fungal overgrowths. Then on top of that, you get all of the amino acids, all of the fatty acids, so you can see if people are low in Omega 3’s or over supplementing–and sometimes, you find they’re low in Omega 6’s.

The NutrEval also accounts for some minerals, including copper, zinc, magnesium, potassium, manganese and selenium, measured in the best way recommended, as well as heavy metals, including lead, mercury, arsenic and cadmium. It has markers for all of the B vitamins, vitamin D, CoQ10 and markers of oxidative stress that relate to fat-soluble and water-soluble antioxidants. So it’s an amazing all-over-body test that helps you figure out where functionally something is going wrong in the body. That’s $507 in my Rupa shop*. So for an extra $170 you get a lot more stuff over the Organic Acids Test.

The last test that I have used with people before is the Doctor’s Data Hair Elements test, which measures all of the essential elements, meaning minerals, in hair, and then all of the potentially toxic elements, 17 in all. I would use this with extreme hair loss or with known or suspected toxic exposures, or perhaps as a follow-up to check for removal of toxins that were identified on the NutrEval. I actually have a podcast coming up on minerals and hair and tissue mineral analysis so stay tuned for that one. The nice thing about this test is at $137, it’s very inexpensive but gives you a lot of information.

So those are the primary tests I use with clients, just to give you an overview. You can order them yourself in my lab store*, but if you’re thinking of working with me, I give clients a slight price break, so best to have me put in the order for you.

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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. 

*Links are for affiliate web sites, thanks for your support of the podcast and blog by using them.

Adapted from episode 98 of The Perfect Stool Podcast and edited for readability with Vincent M. Pedre, MD, Medical Director of Pedre Integrative Health and President of Dr. Pedre Wellness.

Lindsey:  

Before we launch into today’s topic, why don’t you give us a short synopsis of your own gut healing journey?

Dr. Pedre:

So that goes back to when I was a kid. As far as I can remember, I had a very sensitive stomach. I actually suffered from pretty severe constipation when I was a child. I think it was mainly due to not such a great diet; it was pretty devoid of vegetables. And I hated eating salad greens, so any insoluble fiber, that was deficient in my diet. But it was really in my early teen years where my gut started being very problematic. And coincidentally, around the same time, probably dating to the age of 10, maybe as early as eight years old, it was very common to go to the doctor with a cold, with an upper respiratory infection and be prescribed an antibiotic. So I don’t think I ever went to the doctor without having left with an antibiotic prescription. That probably happened more than once per year, from the age of 10 all the way through my teenage years.

I remember at times, not being able to recover from an infection like one time I had a severe bronchitis, which almost felt like an ammonia, and I wasn’t responding to the antibiotics. My mom would take me to the clinic, where I doubt that this is done anymore. This was back in the 80s. They would give me an injection of gamma globulins, so pooled globulins from the blood supply. And after I got those gamma globulins, I always felt better within a day. So it was almost like my immune system wasn’t working properly. And the pediatrician would say I need to be on a multivitamin and gave me these big horse pill multivitamins that I had to take. But that didn’t help me not get sick as often. And it really took me about two decades to fully understand. It’s part of what motivated me to become a doctor: Why do I get sick so often, and how can I not get sick? And what is the underlying root cause?

Along the way, I discovered a couple of things. Just by self-experimentation, when I went to medical school, I took dairy out of the diet because I just didn’t have the time to sit and eat cereal with milk in the morning; I had to run out the door. Dairy became less of a presence in my diet, maybe I had the occasional ice cream. In college I had gotten sick so many times, so I was always really observant of any changes I made and how they affected my health. And what I noticed was that within a month of cutting out or not having as much dairy, and actually incorporating more healthy fats at the same time, (I was eating more olive oil and avocados), I stopped getting sick as often. I didn’t feel that fear I had about being around sick people. And it was the first fall where I only got a minor sniffle but didn’t get anything too major. I started making this association, even though I was in a traditional Western medical school where nutrition was given maybe one day out of the four years. I grew up in a household where my dad was very focused on nutrition and had done allergy testing, like food sensitivity testing. And this is, again, back in the 80s when it was not very common to see that. So that was infiltrated into my mind. Even though I was a child, I grew up around this. So I always thought that there must be something in nutrition, that there was some power to the way that we ate. So, I changed that in my diet. I stopped getting sick as often but I still had a lot of gut issues and I couldn’t figure out what it was. What was going on?

Little did I know that the antibiotics had led to leaky gut, had decimated my gut microbiome and led to sensitivities to the top big food groups that I was eating, which were gluten and dairy. Even though I had cut back milk and stuff like that, I was still eating occasional pizza and cheese, so dairy was still leaking into the diet. It wasn’t like a complete avoidance. But it really wasn’t until I had finished my medical training. And I was still suffering from IBS. You can imagine long hours at the hospital, sometimes they fed us pizza, getting a sandwich, not making the best food choices in the hospital where there really weren’t that many healthy food choices to begin with. And so, it wasn’t until after I completed my training that I started looking for other answers and other ways to look at things. And that’s when I discovered functional medicine. And when I learned about the microbiome and leaky gut, I started realizing that what I was dealing with was IBS or irritable bowel syndrome, which really was just an umbrella term for something that had many causes. For me, it was an imbalanced diet, eating too much gluten, still eating some dairy and having a decimated gut microbiome. So I started working on that.

I was in my 30s at the time and was so surprised that even within two weeks of cutting out gluten, I felt so different, my energy levels increased. By then, I was working, I had my own private practice and some days could be really long, it can be a 12 hour day, and I struggled in the afternoon. If I went and had a pizza for lunch, if I had a sandwich, I literally felt like I had been drugged. At 3 p.m., I was struggling to keep my eyes open while seeing patients. So I was looking for a solution that would just allow me to have more mental clarity, more energy, more focus. And within two weeks of taking gluten out, my energy shot up; the afternoon crash that I was having disappeared. And I thought wow, there is something to this. I was still early on in functional medicine, still somewhat of a skeptic, but looking at the science, trusting that the science was there. But at the same time, I was my own guinea pig. What I thought was going to be a life sentence of sensitive stomach, never knowing when I ate out if I was going to have to run to the bathroom if something was going to disagree with me, was really all about food choices and rebalancing the gut microbiome.

We cleaned out the diet and became a gluten-free household, limited dairy. I figured out which dairies I could have, like low-lactose cheese, but staying away from things that had a lot of lactose. Eventually, I figured out that I can seasonally eat dairy. So I’ll eat dairy in the summer, because I love cheese. But I avoid dairy fall, winter, spring. And this was after a couple of years of experimenting and realizing that even a little bit of cow dairy, specifically, in the fall, winter and spring, predisposed me to getting sick and more mucousy. When spring rolled around, I would get allergies. And when I took dairy out, all of that disappeared. And honestly, there were years when my patients were coming in with all sorts of allergy symptoms in the spring, and they’re always saying, “Oh, this is the worst allergy season ever”. And I honestly didn’t know that. The only way I could know more mechanically was on the worst days when there’s a high pollen count in the air. And inevitably, the pollen gets trapped in your eyelids and your eyes get a little bit irritated. That’s when I would feel it on those days. But otherwise, no more respiratory symptoms.

So, I became really fascinated with gut health and how it affects our overall health and started becoming very curious when patients came in with any sort of gut health issues and really paying attention not just to their gut health, but also curious about what other conditions or symptoms they were experiencing that went with gut health issues. They would come in with IBS and migraines, they would come in with IBS and allergies, IBS and asthma. I started making the association between the two and working with patients on their gut health issues, having at the same time been working on my own gut health issues and seeing that what I thought was not reversible after two decades or more of my life, actually was something that you could get under control with the right types of interventions.

Lindsey: 

Yeah, awesome. That actually sounds a lot like my journey. I also discovered gluten and dairy were very detrimental to my health. So, you’ve already hit on a couple of the big ones, but what other things can disrupt the gut microbiome? That is, if you can’t easily track it back to something like heavy antibiotic use or food poisoning that led to SIBO or parasites.

Dr. Pedre:  

Yeah, obviously, those are some of the big things that might be gut disruptors. But there are other things that maybe we don’t think of as things that cause food sensitivities, but sugar is a big gut disrupter because it can cause overgrowth of Candida. And for people who are mold sensitive, mold toxins can be big gut disruptors; living in a moldy home. And that’s the thing that I find so fascinating about the gut is that the symptoms might be the same between two people, or there might be a lot of similarities in how two people present. But the actual underlying reason why they’re having those symptoms can be very different.

Sometimes it’s a combination of things; it could be that they had been on antibiotics at one point, that they traveled to India, and they picked up a parasite, but they’re also mold sensitive, and they live in a moldy house, and that’s also affecting their gut and causing leaky gut and all sorts of problems. Or, maybe they are sensitive to lectins, and they’re eating legumes or they don’t know how to prepare legumes properly to reduce the lectin content and reduce the irritation of the gut lining. There’s a lot of other ones, including glyphosate pesticide, that can become a gut disruptor, because it’s basically a chelating agent that acts like an antimicrobial. So if you’re eating wheat that’s contaminated with glyphosate, that’s a double hit. So you’re getting the gluten, which increases gut permeability, and you’re also getting glyphosate, which is going to cause alterations in the gut microbiome.

There are things that people do every day, and they don’t think too much of it, because it’s part of our normal society. Some of the things are over the counter medications that you can take, and you think, well, if it’s over-the-counter, it means that it’s been FDA cleared, it’s fine, it’s not going to cause any sort of problems in the body. And yet, all of these come with warning labels, but none of them warn specifically about the fact that they can cause leaky gut. Ibuprofen increases gut permeability. Acetaminophen also can do it; not directly by affecting the gut lining, but by having an effect on the gut microbiome. And that then leads to increases in gut permeability, or what we call leaky gut. And lastly, people don’t think about this, but alcohol is a big gut disrupter. Probably, someone who’s listening might think back, sometimes we don’t notice things until you really put your nose on it and start paying attention. But maybe you might notice that you go out drinking, and maybe you have a couple of drinks the night before, and the next day, your gut isn’t feeling so great. Maybe you’ve got to run to the bathroom at some point. If you’re not connecting the two things, you might think that they’re unrelated.

But, we know now that alcohol also disrupts the gut microbiome. And anything that disrupts both the good and bad bacteria in the gut is going to result in having downstream effects on the gut lining, which increases gut permeability and leads to leaky gut, which then leads to all sorts of inflammation and increases inflammatory signals in the body. So there are a lot of gut disruptors that are part of our normal day to day existence. That’s why it takes so much education for people to understand how these things have these downstream effects that, starting with the gut, affect so many other aspects of our health.

Lindsey:  

So specifically, what is alcohol doing to the gut? Is it killing bacteria?

Dr. Pedre:  

It’s killing bacteria. Just think, what do we use to disinfect surfaces? We use alcohol. So when you’re drinking alcohol, and of course it depends on the type of alcohol, it’s going to wipe off some of your good bacteria. And that disrupts the gut. Now, depending on the drinks, maybe you’re having a sugary cocktail, maybe you’re having wine, maybe you’re having beer, there’s going to be carbohydrates. There are sugars related to that. There might be some yeast that is going to feed yeast overgrowth, so not only is the alcohol going to wipe down your good bacteria, but it’s also going to promote the growth of yeast in the gut. And for somebody who’s already sensitive because they had to go on a course of antibiotics that disrupted the gut, then adding these other gut disruptors is only adding more fuel to the fire.

Lindsey:  

Obviously, alcohol is a big part of life for a lot of people. And I’m curious, how much drinking is too much? Because surely, there’s all sorts of things we do that upset our gut microbiome every now and then, like, even I eat a pizza every now and then because you’ve got to live too. So what do you think is a reasonable limit for someone who is used to social drinking?

Dr. Pedre:

That’s a debate, because what they found is that maybe we can work backwards, that one drink a day, for women specifically, increases the risk of breast cancer. And that’s only a couple of milligrams of alcohol. So there’s got to be some sort of happy medium there. But knowing that every time you’re having a drink, you’re causing some level of gut disruption. If you’re having one drink daily, you’re also increasing your risk for cancer. But if you have less than that, maybe you’re having two to three drinks per week socially, then that’s having less of a weighted effect, right? Because the more you have, the more of an effect it’s going to have. Now, the thing is that alcohol is also going to increase inflammation in the body, because alcohol increases the release of inflammatory markers like IL-6 and IL-10. So it’s having an effect at some level.

I think that’s why when I’ve had people do an elimination diet, one of the things that we take out along with wheat, dairy, and some of the other disruptors like corn, soy, legumes and nightshades is alcohol. Because, again, it’s a gut disrupter, and sometimes you don’t really notice what something is doing to you until you take it out. And then you reintroduce it. So, I think that it’s important to make these wise decisions and understand what your body matrix is, how you’re feeling in general, and if you already have ongoing chronic inflammation, if you have mental health issues, if you’ve got some brain inflammation, then alcohol is only going to make that worse.

The interesting thing is, now looking at it through the lens of the gut, understanding that alcohol has some toxicity to the brain neurons, but it also is toxic to the gut microbiome. By doing that, it’s altering the good microbes in a way that will increase gut permeability. And whenever you increase gut permeability, you’re going to increase the influx of inflammatory substances, whether it be bacterial DNA, (bacteria actually has been found to get into the circulation), or products from the bacterial cell wall like endotoxin, that then stimulates your white blood cells and causes the release of more inflammatory mediators, eventually leading to things like insulin resistance that scrambles your insulin signal. So you start producing more insulin, which tells your body to convert carb calories into fat. You start gaining weight in the middle, and then that fat in your belly starts to produce its own inflammatory signals, and then it becomes a cascade. So you have to understand where you’re at, because we’ve thought of alcohol as liquid calories, and why some people have difficulty losing weight if they do a pretty strict diet, but they’re still drinking one to two drinks per day. And it’s probably not just the calorie effect from the alcohol, it’s also the inflammation-inducing effect of the alcohol, that’s not allowing the body to shed the fat.

So, I’m not going to say that everyone should give up drinking alcohol, but I am going to say, depending on your own underlying issues, it’s definitely something to consider or to really pull back on, especially if you have certain health goals that are not compatible with drinking alcohol, in those situations, because of the disruption that it’s going to do to your gut. Namely, the increase in inflammation and the problems with brain health. I know we’re talking about gut health but given the rising rates of dementia and Alzheimer’s in the country, alcohol is the enemy of brain health.

Lindsey:  

Okay. So you mentioned endotoxemia in that last bit. Can you talk a little bit more about that and about dieting as it relates to endotoxemia?

Dr. Pedre:  

Yeah. So endotoxin is a lipopolysaccharide. It’s a lipid/sugar short chain carbohydrate molecule that is made as part of the outside of the cell wall of gram-negative bacteria like E. coli. Everybody’s probably heard of E. coli that lives in the large intestine. And the interesting thing is, when it was discovered, they called it endotoxin, because they thought it was retained, and the only time it was released was when the bacteria died, and it was shed. But it turns out that these bacteria actually release endotoxin, and that endotoxin can be absorbed into the circulation. Obviously, the more endotoxin is going to get through, the more leaky the gut is, and the more permeable the gut barrier is. Now, endotoxin has the ability, because it is a part lipid molecule, to get through cell membranes. And one of the areas that it can get through is the blood brain barrier, which is a protected circulation that keeps the brain circulation separate from the rest of the body. But anything that’s fat soluble is going to be able to get through there, and lipopolysaccharide, another name for endotoxin, can get through.

What endotoxin does, and in a variety of tissues in the body, not just the brain, but also the liver, muscles and pancreas, is it increases the expression of an inflammatory genetic pathway inside the cells.  When this pathway is activated, the cell is producing more inflammatory chemicals and releasing inflammatory signals to its environment. So it does this in the hypothalamus in the brain, in the liver and muscle tissue. And part of the effect that this has is increasing insulin resistance, insulin being the hormone that tells your body to push the sugar from your circulation into the cells where the sugar is going to be used for energy production, and sugar is coming from the breakdown of carbohydrates in the diet. And we know that insulin is probably one of the most powerful aging molecules in the body. So, you don’t want too much insulin. Insulin will raise blood pressure, and it increases the likelihood of more calcifications and plaque formation inside the arteries. So the higher your insulin, the more accelerated heart disease you’re having. And it also is a signal that tells your body that it needs to conserve energy as fat. So your body will take the calories when insulin is high, and start packing them in your belly as fat, and you start to accumulate visceral fat, which then becomes a feed forward cycle. So the visceral fat also will increase insulin resistance and more insulin resistance causes more fat in the belly.

So now you can visualize this process, that there’s a trigger that’s coming from environmental aspects, whether it’s over the counter meds, antibiotics, poor diet, too much sugar, over processed foods, leading to an increase in gut permeability, or leaky gut. And as a result, there’s more endotoxemia coming in, more endotoxin that gets into the circulation, which activates white blood cells, signals inflammatory cascade in a bunch of tissues in the body and starts to cause a weight gain in the person. Now we also know that there is endotoxemia that tends to follow eating. And it seems to happen more with inflammatory oils. So nuts and seed oils are going to have more endotoxemia. The one that has the least amount of associated endotoxemia is olive oil.

However, there is a certain element of endotoxemia that happens after a person eats, and it’s interesting, because there’s a doctor that specializes in cardiovascular health, Dr. Mark Houston, and I heard him present on endotoxemia and do an experiment where they gave somebody a meal–I think it was like a burger or something like that–a pretty inflammatory meal, and they measured endotoxin levels post meal. You can also measure things like anti-endotoxin antibodies, which is one indirect way to see how likely does a person have leaky gut. But what they did is they replicated the meal. So they did one without and one with broccoli. And when they gave people broccoli, it actually reduced the endotoxin load. That was really fascinating. So this was a plant-based diet being protective against endotoxemia while an inflammatory diet with lots of starches, sugars, heavy on meats can cause more endotoxemia, especially with saturated fats, which are going to pull that endotoxin through the gut barrier into the circulation, and even worse if you have leaky gut.

Lindsey:  

So you mentioned an animal-heavy diet causing endotoxemia. You also mentioned lectins and preparing legumes properly. And, of course, if you are not eating a lot of meat, then you need to be getting some of your protein probably from beans, lentils and such. So tell me about how people can eat those things safely.

Dr. Pedre:  

The important thing to know is that traditionally these foods are obviously not eaten raw, initially. One thing that we’ve done in Western society is we’ve shortened the time interval, so we’ll take a raw bean and then we’ll just cook it outright and not have soaked it. There are several things that can help reduce the the gut-irritating effects of lectins on the gut from beans and legumes. The main thing is soaking them overnight, and then rinsing them out and using fresh water to cook them the next day. Another thing that is really helpful is to cook them in a pressure cooker. That’s also going to help reduce the lectin content by another 30% to 50%, just by cooking them in a pressure cooker. You can also add a little bit of sodium bicarb to reduce the gas-producing effects from the sugars in the beans. Or you can add kombu*, which is a seaweed that you don’t necessarily eat but you use it during the cooking process, and it also helps to make the beans more digestible. Now, there are certain beans that are a bit easier on the digestion like mung beans* and adzuki beans*. They’re good for people who have trouble digesting regular beans. The other thing that you can do with beans if you have the patience, or you can also in some health food stores find them this way, is sprout them. So you can get sprouted beans that have been soaked and sprouted. Now their nutrients have been activated, and they also have been made much more digestible. So you can get easier access to the nutrients in the beans, like the protein, the minerals and all the other great nutrients inside. It also makes it easier on the digestion for people who are really plant focused.

Lindsey:  

Obviously, we know that gluten is inflammatory and has issues, but do you think everyone should avoid gluten or just the people who are sensitive to it?

Dr. Pedre:

It’s a really great question. And there was a study that was done a couple of years ago that actually looked at the effects of gluten on three groups of people. One group was people who had a diagnosis of celiac disease. That’s an autoimmune intolerance to gluten, and that’s about one to 2% of the population. The next group was what we call NCGS–non-celiac, gluten sensitive. And this represents anywhere between 2 and 10% of the population. Probably, I would suspect, it’s much on the larger end. And then the third group were people who are considered normal. They didn’t have any signs of gluten sensitivity. They didn’t have celiac disease or celiac genetics. So they looked at the effects of gluten on their gut permeability, and as expected, people with celiac disease when exposed to gluten had the greatest increase in gut permeability. When people with non-celiac gluten sensitivity, who we know are still sensitive, though they’re not as extreme as celiac, they also had an increase in gut permeability, but not as great as people with celiac disease. The mechanism is that when you have gluten It breaks down into its protein molecules and gets absorbed by the cells that line the intestines, gluten actually triggers the release of zonulin, which is like the dimmer switch that controls gut permeability by increasing or decreasing it, depending on how much zonulin is getting expressed in those cells that line the intestine.

So you would think that someone who is normal would have zero increase in gut permeability from being exposed to gluten. But that’s not what they found. What they found is that even people who were “normal” actually had a small, but still measurable increase in gut permeability. So, depending on genetics and predisposition, one thing that can happen for people is that this could be a lifetime hypothesis. Maybe you’re fine when you’re young, and then a lifetime of exposure to gluten augmented by maybe having had to go on antibiotics for an infected tooth, and then you get a UTI or pneumonia, and you have to go on antibiotics again, and then you’re still eating gluten. So you’ve had other things that increased gut permeability. Or, maybe you hurt your knee and you were taking ibuprofen. So now you’re adding factors that are increasing gut permeability, and they’re allowing more of that gluten to get through.

Eventually, if you have a genetic predisposition, it’s very possible that you would develop some sort of condition, like an autoimmune disease, for example, that could be triggered by the environmental trigger of gluten. This was the research that Alessio Fasano did, where he was looking at what is the pathway to autoimmune disease, and he hypothesized that autoimmune disease starts in the gut, and it involves three important things. One is a genetic predisposition. The second is an environmental trigger. So the environmental trigger that he was looking at was gluten, because from his research and findings, the surface of the gluten molecule can be confused by the body as if it were a foreign bacteria. So it’s perceived as an invader, especially if it’s not broken down properly, so it’s a more intact protein. Then it’s going to be very antigenic, and it’s going to provoke an immune attack. And then the third factor that he found was necessary in this pathogenesis of autoimmunity was leaky gut. So if you have a genetic predisposition, you have an environmental trigger and then you have leaky gut, it’s very possible that you could develop an autoimmune disease somewhere down the road.

Interestingly, when I went to medical school, we initially learned that celiac disease was a diagnosis in pediatrics, and it would be something that you would pick up early in life. We never really thought that celiac disease could start later in life. And yet, I had a patient who came to see me–she was 52 years old. And she was having a lot of gut issues, but she also tested positive for autoimmune markers for thyroiditis (for autoimmune thyroid), and she just didn’t feel well. We decided, because of her history and her background, to do celiac genetic testing, and we found out she was positive for celiac genetics. Not only was she positive, but when I sent her for an endoscopy, she had positive findings on endoscopy for celiac disease. And she was 52 years old at the time. So you wonder, did she have celiac disease all along? Was it something that she maybe developed younger, but didn’t know? I don’t think so, because when I’ve seen younger individuals with celiac disease, it hits them pretty hard, and they suffer a lot when they eat gluten. So, we could hypothesize based on the fact that we know that gluten can increase gut permeability, even for people who are normal who don’t have any autoimmune disease, that a lifetime of exposure eventually could reach that threshold level, where it’s the straw that breaks the camel’s back that finally triggers the Pandora’s box of autoimmunity to get this condition. And again, this is a byproduct of multiple factors; namely, genetics, environmental trigger, and leaky gut.

Lindsey:

Yeah, I think that is a path I see people on frequently with Hashimoto’s Disease like I have, but fortunately I got my antibodies down to zero.

Dr. Pedre:

That’s great, and that was my motivation. When I decided to take gluten out of my diet, which was in 2007, (obviously, a lot of it was related to looking to fix my gut issues), but my mom had been diagnosed with rheumatoid arthritis, and my older sister has multiple sclerosis. So I was learning about the connection between gluten, leaky gut and autoimmunity. Part of my motivation was to fix my gut, but also, part of my motivation was to prevent the development of any autoimmune disease later in my life. I was about 34 years old at the time and I thought I can do without gluten if it means investing in my future and investing in my future health.

Lindsey:

Yeah. So are canned beans already soaked? Or no?

Dr. Pedre:

No, very unlikely. Canned beans are more often than not going to be quite irritating to the gut lining, and depending on the can, also, I think a lot of them have been replaced and are now BPA-free. BPA is quite an irritant for the body and actually activates the immune response and has been found to be a trigger for autoimmunity in and of itself. A lot of these cans are lined with BPA now you have “BPA-free” cans, but even other forms of PA, like non Bisphenal A, could potentially be toxic. So again, like anything, the best is to make food the most natural way possible and the more homemade that you can. Yes, it is an extra step. Yes, you have to buy the dried beans or the sprouted beans. 

Lindsey:

And you have to remember to start soaking them the night before. 

Dr. Pedre:  

Yes, and you have to soak them and then remember to rinse them out. But it doesn’t take that long to put beans in a pot and soak them overnight.

Lindsey: 

And same thing for lentils? Or are those okay?

Dr. Pedre:  

The same thing you should do with lentils, although with lentils, you can usually get away with soaking them less than overnight, you can soak them for a couple of hours and they’ll be fine. And dal, actually, is another thing that’s easier on the digestion. So mung beans, adzuki beans and dal are ones to think about if you want to incorporate beans, but you want to test them out and you know that you don’t react well to regular beans. But know that if you eat out and beans don’t agree with you, those beans were probably not soaked and rinsed and cooked in a pressure cooker before. And they probably didn’t have added bicarb or kombu seaweed to reduce the gas promoting effects of the beans.

Lindsey:

So do you think that a diet without dairy requires some amount of calcium supplementation? Like what’s the evidence for that?

Dr. Pedre:  

Yeah, that’s the thing that I think led me down the wrong path growing up, because so many commercials would say “dairy does the body good” and “dairy makes your bones strong”, and if you don’t have dairy, you’re not going to have strong bones. The truth is that dairy actually causes leaching of calcium out of the bones. I don’t know if you’ve ever read the China study or looked at the research behind it, where they looked at the diets across the world, and they found that the highest bone densities and the lowest risk for osteoporosis, even postmenopausal, were in regions of the world where they actually ate very little dairy, and the highest incidence of osteoporosis is in the western world where dairy consumption is quite high. So it has to do with the the alkaline and acid balance. It’s really about eating a plant-rich diet, which is going to be very alkalizing, and it’s going to allow your bones to retain that calcium, especially for women as they go through menopause. But men also are not free of risk. They might not be as high risk at 50 years old as women when they’re going through menopause, because in those first two years is when a significant portion of the bone masses can potentially be lost. But men need to think about osteoporosis leading into the 70s.

Lindsey: 

So what is the best diet overall for having a diverse microbiome?

Dr. Pedre: 

That’s a great question. There was a study that Stanford University did in 2021. They looked at a high fiber diet versus a high fermented foods diet in a group of women over a 10-week period. They had done microbiome testing at the beginning and then at the end, without altering any other behaviors. When we think about a high fiber diet and functional medicine, we talk about eating the rainbow, like eating a variety of plant-based foods that are rich in all sorts of soluble and insoluble fibers. And we think of that as what feeds the microbiome and will create diversity, right? Because fiber is basically our indigestible carbohydrates. We also call them resistant starch that feed our microbiome and produce a whole bunch of really important post-biotic products like short-chain fatty acids.

When I heard about this study, and I was reading it, I was thinking for sure, the high fiber group has to be the one that’s going to gain the most microbial diversity. But it wasn’t. It was the high fermented foods group, and they were eating about two to four servings of fermented foods like sauerkraut, pickles and yogurts every day. Not only did it increase microbial diversity in their gut in this 10-week study, but it also lowered 19 inflammatory markers. Now if you’re you’re listening to this, you may be wondering in your head, are you telling me, Dr. Pedre, that I should now start eating fermented foods and not eat so much fiber? Well, it’s not quite clear. And that’s why in my book, The GutSMART Protocol*, I designed a quiz that separates people into mild, moderate or severe categories, because what I found is that if you have severe gut issues, you’re not going to be able to tolerate fermented foods. There’s no one size fits all. But within that, it’s important to know that ultimately, as you heal your gut, the goal is to start incorporating fermented foods.

Now, I want to say something about the high fiber, because we need to consider that fiber is protective of colon cancer, it’s important to keep your poop moving through. So you want to make sure you’re having daily bowel movements. Fiber is a very key part of that. But what they did find in the study, and it seemed to have a better effect, depending on the baseline microbial diversity of the person, the high fiber diet helped create some level of immune modulation that controlled the immune system, keeping it from being over-reactive. And even though the high fiber group didn’t experience a drop in the 19 inflammatory blood markers that they were looking at, they did see that there was some level of immunomodulation. So from this one study, it’s a small study, it was only women, and it was a short study, I think we need to expand the study and look across ethnic groups, men and women to see if this is something that’s reproducible.

I think the takeaway here is that the best diet for gut health incorporates more fermented foods than probably most people are used to having. And once you heal your gut, if you take the GutSMART quiz in my book*, and you come out at severe, you can’t eat fermented foods. Once you get to moderate, you can only dip your toes in them. It’s not the American way, where if a little is good, a lot is even better, you’ve got to be really careful about when you’re incorporating fermented foods to start with small doses, even like a quarter teaspoon and slowly work your way up.

But the best diet, based on this study’s findings and other studies that we’re starting to hear about, in terms of the effects of combining of fiber and fermented foods, is that it also has a very positive effect on mental health, anxiety and depression. So, I think the answer is in between. We can’t say that fiber is the solution for everything. But I think in a society where we don’t eat enough fiber to begin within the United States, the average person needs 10 to 14 grams per day–the goal is anywhere between 25 and 35 grams a day. There are more primitive societies like the Hadza hunter-gatherers of Tanzania that eat up to 50 grams of fiber per day. So we’re getting a fraction of what our ancestors ate in fiber because of all the processed foods, so in general, everyone could use a bit more fiber in their diet. But along with the fiber, they need some fermented foods. And to find out if you’re able to eat fermented foods, they can check out the GutSMART quiz in my upcoming book, the GutSMART Protocol*.

Lindsey:  

Okay. So I’m wondering, because I have post-infectious IBS, and periodically I’ll have rounds of SIBO, if probiotic foods are contraindicated for someone like me, or say people with histamine intolerance? 

Dr. Pedre:  

Yeah, those are other very important contraindications. Someone who has histamine intolerance or someone who has SIBO is going to have a very difficult time tolerating probiotic supplements in general and may even have a lot of trouble with fermented foods. Now, they might be able to have a very tiny amount of kraut juice where they can have a quarter teaspoon at a time, and that might be okay. But they do have to be really careful. Obviously, SIBO is an imbalance in the gut, an overgrowth of bacteria in the small intestine that needs to be corrected and might have a number of underlying issues. It could be hydrogen, methane, or it could be hydrogen sulfide gas, depending on the underlying reason the solutions are slightly different. Someone who has histamine intolerance or mast cell activation disease is ultimately going to have a gut microbiome imbalance and leaky gut, and part of the reason that they have histamine intolerance is because their gut barrier has been compromised. So the focus would be on healing the gut.

There’s good research showing that spore-based probiotics like Bacillus coagulans and Bacillus subtilis might actually be okay in small doses and slowly increasing for these patients, because they help reestablish the gut terrain. They help promote the growth of the right bacteria, but they also inhibit the growth of the wrong bacteria in the wrong location. Because when you have SIBO, it might not be that there’s bad bacteria; it might just be bacteria in the wrong place in your gut. There’s some evidence that the spore-based probiotics can help improve gut permeability as well, or reverse leaky gut.

Lindsey:  

So if you got into your gut issues because of an extremely stressful period in your life, I’m wondering whether you think dealing with your stress and decreasing your stress could restore your gut microbiome, or in your experience, does it take more than that?

Dr. Pedre:

Well, I always like to say that you can’t out diet or out supplement a stressed out lifestyle. I’ve certainly had those patients over the years that were checking off all the right boxes. They were following the right diet, they were taking all the right supplements, but they live their life in a straitjacket of stress, running from meeting to meeting. They just wanted the solution to be mechanical, but not address all of the other underlying issues, which are really important because stress is like an attack on the gut and stress also will increase gut permeability. And that’s the reason that I included a section in my book that has a very strong focus on diet and how to heal the gut through diet. I have a section called turbocharging your results, for the very reason that the mind-body connection is very important, not just the gut to the brain, but the brain to the gut through the vagus nerve. Incorporating things like mindfulness meditation and breath work are also key components of the healing process, because when you do these activities, when you do specific breath work and meditation, it helps activate the vagus nerve. When your ventral vagus is activated, it tells your body that it’s safe, and when your body feels safe, your body can heal itself. So it’s very important. Not only that, but when your body is in an activated ventral vagal tone, it’s in a parasympathetic state, which means your body is relaxed, and it can digest and absorb nutrients more easily.

Lindsey:  

Okay, well, we’ve covered a lot of different topics in here. Thank you so much for sharing your knowledge with us. I really appreciate your time.

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.

Adapted from episode 97 of The Perfect Stool podcast and edited for readability with George Nikias, MD, Gastroenterologist practicing with Hackensack Gastroenterology Associates.

Lindsey:  

So, I understand liver disease is your specialty. Can you give an overview of the things that go wrong with the liver and what the signs and symptoms are?

Dr. George Nikias:  

Sure. Liver disease is a subspecialty of gastroenterology, and it’s a growing one. And the patients will see that liver disease will range from a person who feels well that has abnormal blood tests related to the liver, perhaps identified by their primary doctor, or primary health care professional, to someone with severe liver failure, jaundice, life threatening illnesses and everything in between, including persons with chronic liver disease, that are suffering the complications of that and may need evaluation for liver transplantation. We can talk a little bit about the common liver conditions that people hear about or read about as well as the less common ones. But ultimately, hepatologists or physicians who have specialty training in liver disease deal with all of these very conditions that affect the liver. 

Lindsey:  

Yes, let’s talk about those different conditions and how they come about.

Dr. George Nikias:  

Why don’t we work from a common everyday scenario in the clinic that we often deal with, and we can expand from there? Very often, we’ll see individuals that come to the office or the clinic with no complaints other than being told by their primary health care provider that they have abnormalities in their liver tests, and often they will seek further evaluation on the computer and learn of potential causes. At the same time, this can also be a point of alarm for people with fears that perhaps their liver is failing or not functioning. But very often, it’s not the case. So a common scenario would be somebody who feels well, perhaps has some other health conditions, who has elevations in the typical liver chemistries, the AST and the ALT, as we typically define them on the health panel, or the metabolic profile, that’s done as part of a routine health care visit. Very commonly, those liver tests can be elevated. And one of the very common reasons in this country, and for that matter worldwide, is a condition called fatty liver, or as it is now being described, non-alcoholic fatty liver disease, which has now evolved into something that’s described as metabolic liver disease, because we’ve learned that fatty liver really is part of a process that involves physiologic changes across the entire body. And the implications of that is important with regards not just to liver disease, but overall health and longevity. 

Lindsey:  

And how does this come about? 

Dr. George Nikias:  

Well, the common scenario, or the common condition that exists with fatty livers, typically, is a weight above normal, or elevated body mass index, as we call them. The common theme seems to be central obesity, or abdominal fat, which we’ve now learned isn’t simply a storage platform per calorie, but an active area for physiologic functions in the body. So fat isn’t just an energy source in our body, but fat cells have a role in metabolic performance. That being said, individuals who are heavy are at risk for fatty liver disease. With the presence of fatty liver comes a condition called insulin resistance, which we now know, and I think many people recognize, eventually can lead to risk of diabetes. Those conditions (fatty liver, diabetes) can coexist with other findings, including elevated circulating lipids and elevated high blood pressure, which all make up a condition called metabolic syndrome. So metabolic syndrome is a physiologic change in the body that very routinely exists with fatty liver. Fatty liver can be the prequel, if you will, to the development of metabolic syndrome, diabetes, and potentially systemic changes in the body, or complications in the body occurring from that physiologic change. So the evolution is from individuals developing fatty liver disease, if not risk for diabetes, metabolic syndrome, high blood pressure, associated high lipids, and complications from that, particularly cardiovascular and other vascular diseases.

Lindsey:  

Will you typically see blood sugar or fasting glucose or A1C rise before you see the liver enzymes rise? Because I’ve seen a lot of that without elevated liver enzymes.

Dr. George Nikias:  

I think that’s the important caveat. If you have someone with elevated hemoglobin A1C, a diagnosis of diabetes, even if liver chemistries are normal, fatty liver very commonly exists. So there’s really an umbrella that covers everyone’s fatty liver. There are those that have normal liver chemistries that have fatty liver. There are those that have abnormal liver chemistries that also can. And then within that umbrella, there’s a subset of individuals who have risk for liver disease, including hepatitis, liver scarring, and the complications of scarring, which would include cirrhosis, and the complications of cirrhosis. So the way I view it is, it’s this iceberg or this all encompassing term, fatty liver, and then within it, a subset of individuals with true risk for significant liver disease. And so, to go back to answer your questions, you can have normal liver tests and have fatty liver. Then the bigger question is, are those persons at risk or not at risk for liver disease? The answer is they are, but probably less so if they have normal liver tests, but not always. That’s where it gets a little bit tricky.

Lindsey:  

Obviously, you’re talking about the metabolic fatty liver and/or non-alcoholic. But I’m wondering, I hear a lot of separation of the non-alcoholic fatty liver disease and alcoholic fatty liver disease. I’m wondering if they play out differently, other than the cause, and if the things that can mitigate or reverse the conditions are any different other than obviously, one requires stopping drinking, and the other one, probably changing your diet?

Dr. George Nikias:  

Yeah, I think that it’s a good question. A lot of the problem with fatty liver in general is that we don’t have good treatments. And so it behooves us, if someone is over-using alcohol, to counsel them about reduction, if not elimination of alcohol. If they have fatty liver in general, or risk factors for fatty liver, meaning if they’re diabetic, if they have high BMI or high central abdominal girth, and they have excess alcohol use, we will intervene in that situation and counsel them. So then the natural history or the evolution of non-alcoholic fatty liver, and it can become –  the tricky case is the individual that has maybe casual alcohol use, but also has risk factors for non-alcoholic fatty liver and has abnormal liver tests. How do we counsel them to make changes to determine that we’re having an effect on the other condition? Like you said, Lindsey, stopping alcohol or reducing alcohol is one very effective intervention for alcoholic fatty liver, but how do we counsel someone regarding modest alcohol use if they have fatty liver, incidentally? So this becomes a tricky thing to work through.

Lindsey:  

Yeah. So what do you tell patients about reversing fatty liver? Because I know how hard weight loss is, and that for some people it just seems to be they’re on and off diets their entire lives until they finally just reconcile themselves to their current weight, because they realize the futility of that or adopted a more healthy attitude that their health is what their goal is, not their weight. So I’m just curious, when people have disordered eating, it’s so complex.

Dr. George Nikias:  

I think first of all, the key is to is to have them set goals that are realistic. What we do when we see them first and tell them they have this condition, first of all, we reassure them that the vast majority of people that have fatty liver will not die of liver disease. However, this is important, what we tell them is that you are at risk for vascular complications. So the goal here is, as you said, total body health and achieving that. If you look at this in a two-pronged way, if we look at the evaluation of liver disease, there are measures we take to stratify risk, to identify if they are at risk for significant liver disease, and we can do that very simply. From looking at the blood tests, we can come up with a risk profile, what’s called a non-invasive index. And if it looks like there’s concern that the blood tests can’t clearly exclude significant liver disease, then we have technology in our office that allows us to determine if there’s a risk of significant liver disease using something called elastography. Elastography is technology that uses ultrasound to determine the stiffness of the liver. So sound is transported through the liver. A harder liver, a harder substance transports sound quicker. The speed of which the echo of that sound is transferred through the liver is measured. If the speed is faster, then the liver is going to be harder than the fibrosis index, or the E score is higher on that FibroScan test. If that’s identified, then we have a discussion about that risk, and really begin to talk to them about the possibility of a liver biopsy to confirm it, or really have a distinct discussion about intervention. Now, going back to that intervention, in terms of your initial goal, is giving them tangible, actionable goals to shoot for in terms of weight loss, because the vast majority of these individuals have above normal body weight. So the numbers we’ll use that have been shown in studies to affect change in terms of liver fat and liver scarring are 7% of body weight and 10% of body weight, respectively. So we tell them that the goal here is not dropping huge amounts of weight in a short period of time, but rather, aiming to lose 7% of your body weight, which is, I think, realistically achievable for many people. And that’s been shown to reduce liver fat. Along the same lines, 10% body weight loss has been shown to have impact on liver scarring. So, I think the goal is to really create a paradigm for success with a tangible goal, and then the extension of that is, we’ll ask what diet we should do. And there’s been some work in this. There’s still, I think, a lack of clarity as to what the ideal diet is for fatty liver, but data seems to suggest that a Mediterranean diet really stands forward as the ideal diet, both from the standpoint of weight loss, weight maintenance and potentially heart health. So I generally endorse a Mediterranean diet for these individuals. 

Lindsey:  

I know I have seen people who are able to lose a lot of weight on a ketogenic diet and maintain it. But the problem that I’ve also noticed is that after a while people are just dying for carbs. So that’s just unrealistic as a long term plan, but an easy way of losing a lot of weight fast.

Dr. George Nikias:  

I think you’re right, and I think that I don’t like to use the term “diet”. Because diet, to me, implies short-term intervention, which is not pragmatic. And we know that any short-term intervention is bound to fail. So what I say is, look, just don’t think about this as something you need to do for three months, or six months, or even a year. Think about it as something you’re going to do permanently, so make it achievable, change is slight. And the other big thing is activity and encourage them just to go out. If you don’t walk, just walk five minutes the first day and walk 10 minutes the next week after that. So my view is that, what I want to espouse is lifestyle changes that are permanent, but in order to be permanent, it has to be achievable. So if we set up unrealistic goals at the outset, then they’re doomed to fail. And I think that’s the way they should view the condition as long as it’s not going to impact them anytime soon. So the intervention should be something for life, because this condition moves slowly and is correctable provided the results are achievable for the long term.

Lindsey:  

Can you explain a little bit the different terms and stages of liver disease? So you have fatty liver and I know there’s cirrhosis, fibrosis: How does that progress?

Dr. George Nikias:  

Sure. Let’s look at the condition of fatty liver, because fatty liver is sort of all encompassing. The vast majority of persons with fatty liver have nothing other than fat in the liver. So if you took a specimen of liver, from someone’s fatty liver straight with just fatty liver and looked at it under a microscope, you would just see globules of fat, they can be large or small in size, but no associated inflammation. So that’s an individual with fatty liver, but without hepatitis, so you’ll often hear the term NASH used to define non-alcoholic steatohepatitis. In that case, that represents about 25% of the total group of individuals with fatty liver. In that case, there is fatty change associated with inflammation. From within that group, there is the highest risk of fibrosis, which is the term used to define scarring of the liver. Then, fibrosis is graded along a well defined staging score that moves from stage one to stage four, stage one being minimal fibrosis and stage four being cirrhosis. So cirrhosis, and all the pejorative connotations associated with it, really is simply a way to define the end stages of a defined scarring pattern across all liver disease, not just fatty liver. And individuals with cirrhosis can have an absolutely normally functioning liver. But what individuals with cirrhosis have is a context in their liver that puts them at risk for liver problems from a variety of insults.

Lindsey:  

Is cirrhosis or fibrosis evenly distributed throughout the liver or is it like there’s a section of liver that starts to go bad and then it spreads?

Dr. George Nikias:  

No. Cirrhosis is something that impacts the whole liver. And that’s often one of the big discussions when somebody comes, and they need liver surgery. They’lI say, I have this problem, can we just cut the liver out, because I’ve heard that the liver can just grow back? That’s like the mythological story of the guy who stole fire from the gods and then he was doomed to have his liver eaten, but the bird would come back and eat his liver as it would grow back. That happens with a healthy liver. So if you have a healthy liver, and you lose half of it because of surgery, for example, it will grow back to reoccupy the space that had existed before. A liver that’s cirrhotic doesn’t have that same capacity. That’s because cirrhosis is a uniform scarring process across the whole liver.

Lindsey:  

And fibrosis too, that’s throughout the whole liver?

Dr. George Nikias:  

So yeah, so fibrosis is, think about fibrosis as this very spidery scar tissue that intersperses its way through the liver, and cirrhosis is simply that spidery scar tissue becoming more dense, so dense to the point that normal liver tissue becomes encircled by it. Thick bands of it have now encircled the liver. And that nodule appearance of the liver that we associate with cirrhosis is expansion and densening of the fibrosis to become cirrhosis.

Lindsey:  

Okay, and can you tell about the stage of liver disease from the ALT and the AST markers on the blood test?

Dr. George Nikias:  

Now, what the ALT and AST markers do is tell us whether there’s potentially a liver disease or liver condition at play. So these tests are, if you will, screening tests for a potential liver condition. The level of elevation of the test doesn’t tell us how severe the liver disease is. The level of elevation doesn’t tell us whether or not cirrhosis is present, although there can be certain patterns that might alert our attention to that. But someone can have normal liver tests and still have significant liver disease. So sometimes they just confuse you, there’s a disconnect there. If an individual comes to the office and says I’ve been told I have cirrhosis, but my liver tests were always okay or maybe just a few points off, how could this happen? It’s because it’s not as straightforward as a link between the level of elevation of those tests and risk.

Lindsey:  

Are those tests testing how much the liver is currently being damaged as opposed to how much it has progressively been damaged?

Dr. George Nikias:  

Right, that’s a good question. So intuitively, you think that a higher elevation in those tests corresponds to more liver damage, and that can be the case. Let’s say somebody has hepatitis because they ate contaminated food and developed hepatitis A, for example. Well, those liver tests can rise dramatically. Very high. Let’s say normal ALT for healthy adults is between 25 and 30. For someone with viral hepatitis that number can rise as high as 1000, which is not something that’s characteristic of fatty liver. So the level of elevation gives us a clue as to the cause, but not necessarily the severity, because someone with hepatitis A can have a dramatic elevation in their ALT level and at the same time can have a normally functioning liver. And there’s somebody that can have cirrhosis and liver failure, and their ALT levels can actually be normal or minimally elevated. So we get insights into the cause of liver disease by the pattern of elevation and the degree of elevation. But it doesn’t always give us insight into the severity. 

Lindsey:  

Well, obviously, it sounds like it’s not something that’s consistent across people, but I’m just curious what kind of numbers you see on ALT or AST before people have complete liver failure, or is it just completely random, depending on the cause?

Dr. George Nikias:  

Well, the diagnosis of liver failure isn’t predicted by the AST or ALT. So the diagnosis of liver failure is predicted or is raised, or the consideration is raised, by a collection of symptoms and lab tests, including tests like the bilirubin, which is a byproduct of red blood cell destruction, that the liver is responsible to metabolize and handle. The serum bilirubin, it’s part of that metabolic profile that we talked a little bit about, that chemistry panel. So the bilirubin can be elevated, which gives us insights into the way the liver functions normally. There is also albumin, a circulating protein in the blood that’s produced by the liver. Lower levels of albumin suggest reduced synthetic ability, so the liver begins to fail, the ability to make albumin goes down. These are factors together with other symptoms, or other findings, that can raise the concern about liver failure. But the ALT can be normal or near normal, and someone can have liver failure.

Lindsey:  

So with transplants, the donor base, I’m guessing, is probably somewhat larger if you can cut off a piece of a liver and still have it regrow. So if somebody gives up a piece of their liver, they might still be perfectly fine?

Dr. George Nikias:  

Well, yeah, in terms of a donor, yeah that’s the motivation is a living donor liver transplant. So the opportunity to donate a portion of a liver to another individual works from that very virtue, which is that healthy liver will grow back. So you can donate a portion of your liver to someone else, because you don’t need a whole liver to to have a healthy life. And that tells you that it will grow over time.

When you do a liver transplant, I assume you completely remove the diseased one and you put in the new one?

Yeah, with liver transplants, the whole organ is removed and replaced with a new liver. That’s because, the diseased organ, the complications of liver disease, are many fold besides just not functioning in terms of the metabolic demands of the body. One of the other big problems of the liver is the problem with high pressure in the main vessel and main vein that feeds the liver called the portal vein. One of the complications of cirrhosis is high pressure in that vein. So, in order to correct that, the native organ needs to be taken out, because you’d think if you have a liver that’s failing, why don’t we just put a new liver and not take out the old one, but you have to take the old one out in order to address that other problem.

Lindsey:  

Okay, so is reversal of fibrosis or cirrhosis of the liver possible? Because I actually just published an episode, Episode 89, with Dr. Barrie Tan, who did a study on tocotrienols* (available in my Fullscript dispensary), which are the most active form of vitamin E. And in his fatty liver study, they did show fibrosis scores going down. So I’m curious if in your experience fibrosis scores can go down and if you’ve used the tocotrienols?

Dr. George Nikias:  

It’s such a great question. It’s actually an area of very intense study, not just in fatty liver, but across across liver disease in general, because cirrhosis represents, as we’ve said, the end stage of the scarring or fibrosis process. If we can interrupt or reverse fibrosis, then we can essentially eliminate the risk of cirrhosis and the complications of cirrhosis. So is fibrosis regression possible? The answer is yes. And this has been shown across multiple liver diseases, including hepatitis B, where patients that have cirrhosis will have the cirrhosis regressed. The thought was always that scar tissue is permanent. Like if you ever cut your arm and a wound forms and it’s fine, but that’s fibrosis, right? It’s a response to injury. Well, the perception was always that fibrosis in the liver, that response to injury, was permanent. That actually has been shown to not be the case, that fibrosis in the liver is a dynamic process. So if you can correct the underlying cause, if the fibrosis is present and early, it’s reversible. Again, we talked about this fibrosis to cirrhosis evolution. There is probably a critical point at which cirrhosis becomes so dense, there’s so much scar tissue, that despite the elimination of the cause, that cirrhosis may not reverse, and we see this in a number of conditions. So hepatitis B, you can have cirrhosis, but if the cirrhosis is advanced and dense, treatment of the hepatitis, where you have control of the agent that’s driving inflammation, will still not allow the cirrhosis to reverse. But, and this is actually really interesting, if you have somebody with hepatitis B and liver failure, for example, and you put them on treatment, if they respond to their treatment and the liver failure is controlled, there can eventually be liver healing. There’s other conditions for example, like autoimmune liver disease, which is a hepatitis that can look just like a virus but it’s actually our own body damaging our liver. Autoimmune liver disease, if controlled, fibrosis there regresses and shrinks away. So yes, fibrosis is a dynamic process, and it’s reversible. Cirrhosis, the end stage of fibrosis, is also dynamic. So early cirrhosis, right, that spidery scar tissue, not too dense, reversible, shrinks away. When it is very dense, to the point that the liver begins to have problems with blood flow through it, and some of the other physiologic changes associated with cirrhosis, that may not be reversible. And this poses the question of when do you go over that cliff? When is one of the changes irreversible or permanent? There’s some very interesting work going on with that trying to better identify people who are on that cusp to intervene more readily so that we can reverse it.

Lindsey:  

What causes gallbladders to stop functioning properly and create stones?

Dr. George Nikias:  

Well, gallbladder stones are the result of a change in the solubility of the contents in bile. Gallbladders don’t stop functioning, but rather they suffer the consequences of their contents, which are stones or sludge. So bile is a solution. It’s 95% water and the 5% is comprised of a variety of substances. The biggest component is something called bile acids or bile salts. They’re really critical in a variety of body functions, principally fat absorption, fat- soluble vitamin absorption, as well as other metabolic processes. Bile is composed of bile salts, cholesterols, phospholipids, proteins, potassium, sodium, and things like that. And this all exists in the solution. The theory is that for a variety of reasons, the solution falls out of its stable state, and things begin to precipitate out. It’s those precipitants for example, cholesterol, or other components of bile, that begin to lead to the production of stones. And stones, which can often exist without symptoms, can rest in the gallbladder where they just exist and there’s no issues. If an individual has a stone, and as a result of normal eating, the gallbladder squeezes to try to expel bile to assist with digestion, the stone can become stuck in the neck of the gallbladder. This is the source of the pain. The pressure in the gallbladder itself causes biliary type pain or gallbladder pain. 

Lindsey:  

And where will you feel that? 

Dr. George Nikias:  

The most common place is actually underneath the breastbone but often radiating to the right-upper abdominal area of the right flank. So often, it will be 30 to 45 minutes after a fatty meal. People can often have symptoms at night, which is kind of curious because you’re not eating then. People often complain of similar kinds of pain waking them from sleep. Again gallbladder pain is a sign of not so much a gallbladder spasm, but a pain related to gallbladder malfunction, if you will. If it’s not treated, then the gallbladder can become inflamed or infected, which can lead to serious problems at that point. Yes, that’s what is called cholecystitis. That’s the consequence of that issue. 

Lindsey:  

And so how can people intervene at the first sign of problems to prevent it from escalating to where they have to have their gallbladder removed?

Dr. George Nikias:  

Well, that’s the tricky thing, because recurring attacks that are suggestive of gallbladder pain typically warrant gallbladder removal, and the whole paradigm of gallbladder removal really was changed about 30 years ago when laparoscopic surgery redefined how the gallbladder is removed. So it turned an operation that used to have an obligatory long hospital stay, or risk of complications into a straightforward operation that now is almost done on an outpatient basis. People will come in in the morning and go home in the afternoon with a gallbladder gone. So laparoscopic surgery simplified the intervention for gallbladder problems, but there are people who will ask about non-operative interventions. We’ll talk to them and we’ll say, look,  weight loss can sometimes facilitate gallstone dissolution. Interestingly, paradoxically, rapid weight loss results in gallstone formation. So they’re looking to lose weight, which goes back to this whole idea that there’s no quick fix for anything. It should all be gradual, and sort of reasonable. But weight loss can help with gallstone dissolution. The other thing I will tell them is that if you have no symptoms, you don’t need your gallbladder removed. So, the presence of stones doesn’t require gallbladder removal. There is medication that is approved that has been around for a long time that is actually a component of bile called ursodeoxycholic acid. It’s one of the bile acids present in circulating bile, but it actually has the ability to dissolve gallstones. The problem is that it’s not reliable. In doing so, you’d have to be on it indefinitely. So it doesn’t serve as an easy management option if somebody’s having pain from their gallbladder. 

Lindsey:  

What about diet changes or eating things that help thin the bile? 

Dr. George Nikias:  

There’s no diet specifically that will change bile composition. Urso, that supplement, will change the composition of bile. As far as diet, typically fatty food will trigger gallbladder attacks; we will counsel people to perhaps have a lower fat diet. But it’s not a durable fix, if you will. 

Lindsey:  

Okay, I want to back up and ask about treatments for liver disease, because you did mention obviously, that it is possible to reverse the fibrosis. So what kind of traditional and/or non traditional treatments can you point to? 

Dr. George Nikias:  

I think that’s an important question. So we talked a little bit about the common one, which is fatty liver. And the way to reverse fibrosis by the liver is again aiming for weight loss. Weight loss does have the ability to interrupt or even reverse fibrosis in individuals with fatty liver disease. I think the key component in figuring out how to reverse fibrosis, first and foremost, is looking for the cause, identifying the cause of liver disease. So when someone comes to the office, and we see significant liver disease, it becomes critical to look for potential causes and a lot of that is achieved or excluded relatively quickly. It’s a predetermined panel of blood tests. So to your question of how we improve fibrosis, the answer is identify and treat the underlying cause. Now, in terms of modifiable factors, there obviously, is weight management, which we discussed already, interruption or reduction in alcohol consumption is important. If somebody has cirrhosis, we will have a meaningful discussion about stopping alcohol use altogether. And, again, that’s another modifiable risk factor. But then beyond that, it’s a matter of identifying if there is a viral cause present, if there’s an immune driven cause present as in autoimmune liver disease. Is there consideration this could be someone with overload of iron, or copper, in terms of describing other liver conditions, because there are. So there are other less common liver diseases, but the key, the uniform goal is identifying the cause of liver disease. 

Lindsey:  

Okay. And can you explain a little bit more about what bile is, where it comes from, and the purpose it serves in the body.

Dr. George Nikias:  

So bile, I said, is produced in the liver. The biliary system is a system that’s unique to the liver, it originates in the liver. So you have to think about the liver as not just this factory that is responsible for producing clotting factors for our blood, making proteins and helping with the metabolic handling of our body, but also a critical component of digestive function. Because bile serves as the pathway to digestion of fat, as you said, absorption of fat, fat-soluble vitamins because when we eat, everything we take into our intestines is absorbed into our circulation, it passes it through our liver first. And so the liver identifies and is responsible for processing foods that we eat, including fats, anything that we eat that’s foreign, and these substances will be identified and handled in the liver. So the biliary system, the bile system, handles fat absorption, handles excretion of toxins that are not excreted through the kidneys. So we get rid of waste in a couple of different ways, right? We can pee it out through our kidneys. But if the kidneys can’t do that, waste has to be removed another way and that’s often through the biliary system and the stool. So things that circulate within us that we don’t need are excreted through bile. Now, bile is formed in the liver, in the liver cells, and is passed from the liver cell into something called the canaliculus, which is this tiny, little microscopic pathway in between the liver cells, because the liver cells are stacked next to each other. But in between them, bile is excreted and passes it into tiny little branches, almost like branches in a tree. Envision the biliary system or the bile system like you would a tree. The main trunk of a tree is the bile duct, which attaches to the gallbladder, like a piece of fruit off the tree. So you have this piece of fruit, which is the gallbladder attaching to a branch, the trunk of the tree, which is the bile duct, which is the repository for all these tiny branches, receiving bile from all the liver cells, which is where the leaves of the tree would be. So bile is produced and passes down into the bile duct, and is stored in the gallbladder. The gallbladder stores bile until it’s needed. The gallbladder squeezes in response to a meal. So that’s the facet of digestion involved using the biliary system. So bile and bile salts have the unique ability to help solubilize or help digest fat, because fat is normally not able to be dissolved into water, and most of our body is water. So how do we get fat into our body through bile? Because bile can form something called micelles, which solubilizes fat, and allows for us to absorb fat and fat soluble vitamins like vitamin D, which is so important. Now everyone talks about vitamin D, we get vitamin D through the biliary system. So bile serves that purpose. Bile salts and bile acids, make their way through the circulation, continued digestive process and through the small intestine until they reach the end of the small intestine called the ileum. In the ileum, the brain of the small intestine, we have what’s called enterohepatic circulation. So those bile substances are reabsorbed into the bloodstream, and they make their way back into the liver. It’s a cycle. Some of them leave and go into the large intestine, the colon and they actually get further broken down there into other kinds of bile acids. A small amount actually gets excreted into stool, most of it is circulated through this enterohepatic circulation. So we recycle all our bile acids, our bile is part of this continuously self-feeding factory. The bile acids that enter the colon, interestingly, get further broken down by bacteria in the colon, into secondary bile acids, and they actually have an impact on our body as well, which ties into the microbiome and all this. You can’t talk about GI illness anymore without somehow involving the microbiome. And it applies in liver disease as well. So bacteria that live in the gut, in the colon, metabolize the bile acids into into secondary bile acids or, different types of bile acids, and they actually have an impact not just on digestion, but other physiologic processes in the body. So the biliary system, is a completely independently functioning system, separate from the liver itself. The machinery of the liver is really the critical part of not just digestion, in terms of absorption of fat, but also a variety of other processes. And it’s also a source where things can go wrong as well. So the same way the liver cells can be damaged with something like hepatitis, viral hepatitis, for example, there can be disorders of bile function, bile production, bile transport, that can have an adverse impact on the liver itself as well.

Lindsey:  

And does the bilirubin marker on a blood test tell us anything about the bile function?

Dr. George Nikias:  

Yeah. So the way I like to think about this and express this to people is to think about the bilirubin level as a marker for factory integrity. Because we talked, Lindsey, about the AST and ALT; those are an indication that maybe there’s a factory problem. But factory integrity, liver function, is really often predicted based on the bilirubin level. So the higher the bilirubin, the greater the potential for liver malfunction. That’s not always the case. But if a bilirubin level is elevated, and there’s concerns about liver disease, due to context changes, it becomes a bit more urgent. 

Lindsey:  

Okay. So why might somebody have insufficient bile? 

Dr. George Nikias:  

Insufficient bile from the standpoint of inability to excrete bile?

Lindsey:  

Inability to digest fats or trouble digesting fats? Is that usually because of insufficient bile or more like clogged bile ducts?

Dr. George Nikias:  

So fat soluble vitamin malabsorption can happen in situations of insufficient bile excretion. And those conditions are not common. But an example of that would be something like a condition called primary billary cholangitis, PBC. It used to be called primary biliary cirrhosis, but it’s now been renamed primary biliary cholangitis. That’s a condition that occurs more commonly in women that results in destruction of the bile ductuals. We mentioned those branches on the tree; the tiny branches are affected. The ability to produce bile is impacted. And if you can’t make bile, if the bile can’t be excreted into those little ducts, then over time, there’s a rise in the bilirubin level in the blood. And if you have insufficient bile production, then you’ll have a consequent reduction in that absorption, and also, more importantly, fat soluble vitamin absorption. So individuals with that condition, PBC, that have elevated bilirubin levels can be at risk for fat soluble vitamin deficiencies.

Okay, and so then what would cause clogged bile ducts or too thick bile?

Bile thickness is impacted mainly by the concentration of bile. So bile that’s thick, is typically bile that would be more concentrated in the gallbladder. Otherwise, bile is the same consistency, but clog bile ducts can happen because of something that damages the production of bile or movement of bile through the ducts. So that condition PBC is one example. There’s a condition called primary sclerosing cholangitis, PSC, which is a condition of bile duct damage involving the larger ducts. We mentioned PBC involves the tiny ducts or the ductuals. PSC is an inflammatory disease damaging the larger ducts. You can have the inability to have bile flow. At the liver normally in that situation, you would develop jaundice, you could be at risk for cirrhosis, and all the complications and consequences because of cirrhosis and other causes. 

Lindsey:  

And is that autoimmune?

Dr. George Nikias:  

PBC and PSC are both felt to be immune-driven conditions. The way to think about it is that autoimmune conditions are never necessarily just autoimmune, but rather combinations of a multi hit hypothesis. So it would be somebody who inherits a predisposition to immune disease, and then something triggers it to result in the event. And what’s interesting about PBC as an example, is its predilection for women nine to one over men. So autoimmune conditions is an autoimmune tendency, with some sort of environmental trigger, whether it’s an infection, dietary or an external agent. There’s an interesting theory that in PBC, one of the environmental triggers might be something in cosmetics, that there’s a link. It’s interesting, I just read this, nail polish remover was thought to be a risk factor for PBC. So there may be a substance that’s absorbed that triggers the immunity forward and drives that process. PSC is a condition that coexists very often with another intestinal condition called inflammatory bowel disease. So immune diseases coexist. And the same can exist across body systems.

Lindsey:  

I had not heard about the nail polish remover. On some of them they have a label that says there’s no – I’m trying to remember what is not in the nail polish remover –  I assume it’s the ones that don’t have that that barely work that are the ones you should be choosing.

Dr. George Nikias:  

I just happened to come across this because they I was reading the new guidelines. And it’s something that we don’t tell people about, and these are simply based on epidemiologic studies looking at individuals with the condition. So it’s hard to counsel people what to do, but I think it just proves that for a lot of these a lot of these immune driven conditions, it doesn’t necessarily have to be something like an infection. It could be something exogenous.

Lindsey:  

Yeah, I just looked it up, it’s acetone. It’s the ones you’ll see bottles that say “no acetone”, so I assume that must be the bad thing.

Dr. George Nikias:  

I’m not sure. I’m not sure. But I think it’s a hard thing to study. Because there’s so many other components, it’s so heterogeneous.

Lindsey:  

Sure. So this is a bit out of left field of the topic of liver disease and bile but I do see clients all the time who get negative biopsies for H. pylori during an endoscopy, but they’re clearly symptomatic for it, they have reflux or they have constipation. And then I run a GI Map on them, which is a stool test and they show high levels on this PCR test. So I’m curious why there isn’t more testing for H. pylori beyond biopsies by gastroenterologists.

Dr. George Nikias:  

Well, you mean using other methods to . . . 

Lindsey:  

Urea breath tests or stool antigens?

Dr. George Nikias:  

The answer to your question is, first of all, we try to be efficient. So if we’re doing an endoscopy on somebody who has symptoms, and it’s appropriate to have an endoscopy done, then we will certainly do a biopsy for H. pylori, and there’s a couple of important things to keep in mind. First of all, a biopsy should be done from two spots in the stomach to confirm it, because you can have a biopsy be positive in one area and negative in the other. So we will commonly take a biopsy from what’s called the antrum, which is the lower stomach, which is where H. pylori likes to be, but also do it from the body of the stomach, because often one would be positive and one would be negative. The other thing that’s also really important is that acid suppression, particularly with something called a PPI, or proton pump inhibitor, which is of these drugs that would include Prilosec, Nexium, Prevacid. Acid suppression impacts the environment for H. pylori propagation or the milieu. The bug likes acid, so if you suppress acidity in the stomach, you will reduce the ability to identify H. pylori. So, if we suspect H. pylori, and we don’t see it on a biopsy, that’s often one of the things that we’ll consider. Did we miss it because either sampling or because they got their biopsies done while taking acid suppression therapy? Keep in mind that breath test cannot be done if someone has been using a PPI or an acid suppression using a proton pump inhibitor. So to go back to your initial query, I would say if we suspect H. pylori, we should look for it in an efficient way and a biopsy is very efficient, if they need an endoscopy. And if an endoscopy is not necessary, a breath test or stool antigen are equally effective in making the diagnosis. 

Lindsey:  

Okay, and obviously if you’re having a PCR test, you’re just looking at H. pylori anywhere in the intestine. So is it only problematic when it’s overgrown in the stomach and/or has virulence factors?

Dr. George Nikias:  

Well, we don’t typically do a PCR test for H. pylori. 

Lindsey:  

Right, that’s a test I use a lot though for my clients. So that’s why I’m mentioning it.

Dr. George Nikias:  

So H. pylori is a bacteria that’s found in the stomach. That’s the milieu. That’s its area of identification. 

Lindsey:  

It’s not hanging out in other parts of the intestine? If it’s high, it’s coming from the stomach?

Dr. George Nikias:  

So if we identify H. pylori, it’s by definition, an H. pylori gastritis. So you can identify H. pylori in the stool, you can look for the antigen in the stool, but that’s the result of a bacteria that was shed in the stool from the stomach. I hope that was clear. 

Lindsey:  

Yeah. Okay. So yeah, basically, H. pylori lives in the stomach, that’s the part of the digestive tract that it prefers.

Dr. George Nikias:  

H. pylori is the most common pathogenic agent worldwide. Half the world has H. pylori. Yeah, that’s a whole other . . . I know, we got off topic about the liver, but it’s important nonetheless, and probably a subject for a whole other discussion. H. pylori is a worldwide epidemiologic issue, responsible for the vast majority of all ulcer disease involving the duodenum, peptic ulcer disease of the duodenum, the small intestine, responsible for the majority of ulcer diseases involving the stomach. And, it’s an established risk factor for cancer of the stomach. It’s something called MALT, which is a lymphoid tumor of the stomach, as well as being responsible for other health conditions, the link of which many aren’t clear and other potential health conditions. So it’s an issue. 

Lindsey:  

Okay. Well thank you for that. We’re run out of time, so I’ll have to do a different show on H. pylori entirely, which I actually haven’t focused a single episode on. So that’s probably a good next one. Thank you so much for coming on. Any final words before we close out? 

Dr. George Nikias:  

No, thank you. I think that the important thing is that, the liver has been lost in the mire of intestinal conditions. And I’m glad to hear that it’s getting its rightful place in the discussion, and I appreciate the opportunity to talk a little bit about it. 

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.

Adapted from episode 96 of The Perfect Stool podcast and edited for readability with your host, Lindsey Parsons, EdD, Gut Health Coach.

As a gut health coach coming from a functional medicine perspective, I believe in treating the root cause of disease rather than just masking symptoms. And when it comes to gut health, fiber is one of the most important factors to consider.

First of all, fiber plays a critical role in maintaining regular bowel movements. With a standard American diet full of sugar and processed foods, you definitely don’t get enough fiber. And without enough fiber in your diet, you may get constipated or at minimum have a less healthy gut microbiome, which may be one of the reasons that people who are constipated have an increased risk of gastrointestinal cancers, as well as breast, ovarian and other cancers, in particular in the year following constipation, although the direction of causality is not definitive in the studies, and undiagnosed cancer could be causing constipation as well. But the theory is that stool sitting around has toxins that get reabsorbed into the body.

So fiber is good for you because it serves as food for the trillions of bacteria that reside in our gut microbiome, which plays a critical role in our immune system, our metabolism, and our mood, as well as our gut health. Research has shown that a diet high in fiber can reduce inflammation, improve cholesterol levels, and even lower the risk of chronic diseases such as heart disease, diabetes, and certain types of cancer. So I recommend that most of my clients prioritize their fiber intake, except when it’s contradindicated, which I’ll discuss later. Normally I suggest this in the context of diet, but for those who may struggle to get enough fiber from their diet alone, fiber supplements can also be a useful tool to consider.

What are the different types of fiber?

So you’ve probably heart that there are two main types of dietary fiber: soluble and insoluble, and a healthy diet will give you some of both types. Soluble fiber dissolves in water and forms a gel-like substance in the digestive tract, which can help slow down the digestive process, which is beneficial in particular for those with blood sugar concerns or while you’re eating anything sugary. Soluble fiber is also known for its prebiotic effects, which means that it feeds the beneficial bacteria in the gut. This will support a healthy gut microbiome and reduce inflammation in the body. Good sources of soluble fiber include oatmeal, beans, peas, lentils, and fruits like apples and citrus.

On the other hand, insoluble fiber does not dissolve in water and passes through the digestive system mostly intact. This type of fiber promotes regular bowel movements, prevents constipation and supports healthy digestion and nutrient absorption by adding bulk to stool and preventing it from becoming too loose. Good sources of insoluble fiber include whole grains, vegetables like broccoli and carrots, and fruits like berries and kiwi, although most foods have a combination of both types of fiber.

Resistant starch is another type of dietary fiber that resists digestion in the small intestine and reaches the large intestine intact. In the large intestine, it acts as a prebiotic and feeds the beneficial gut bacteria, promoting a healthy gut microbiome and in particular higher butyrate production, which is important for feeding the cells lining the large intestine or colonocytes. Resistant starch has been linked to improved digestion, reduced inflammation, improved insulin sensitivity and lower blood sugar levels. It may also promote feelings of fullness, leading to a reduced calorie intake and potential weight loss.
Sources of resistant starch include foods such as green bananas, legumes (beans, lentils, chickpeas), oats, some whole grains and cooked and cooled potatoes or rice. When cooked and cooled, potatoes and rice undergo a process called retrogradation, which changes the structure of the starch, making it more resistant to digestion. My favorite way of getting resistant starch is just making a large batch of jasmine rice and putting it in the fridge to eat with leftovers. If you eat it cold or don’t reheat it too much, you retain much of the resistant starch.

Which fiber supplements are best for gut health?

I often recommend that my clients incorporate fiber into their diets to support recovery of a healthy gut microbiome, because for some reason, pathogenic bacteria tend to like things like sugar and white flour and commensals or beneficial bacteria, like fiber. I think about this particularly during treatment for H pylori, which typically causes reflux and constipation, but not so much bloating, either through diet or through supplements, and after SIBO treatment, especially for diarrhea or soft stool, to help restore butyrate producers in the colon.

Here are some types of fiber supplements you may want to consider.

Psyllium husk is a type of soluble fiber that comes from the husks of plant seeds and is one of my favorite to recommend. Research has shown that psyllium can help to reduce constipation and firm up stool for those with softer stool. What’s more, psyllium has been shown to help reduce LDL cholesterol levels, making it a potential adjunct therapy for those with high cholesterol. My husband swears by his daily psyllium husk. You can build up slowly to a tablespoon of psyllium husk powder in 8 oz. of liquid, but drink it fast because it gums up quickly. Or put it in less liquid but follow it up with the rest of 8 ounces of liquid. It’s best to do this away from any supplements you take as it may impede absorption of the supplements. You can also take it in capsule format, but it takes 6 to get to a tablespoon, so it’s a bit impractical. By the way, Metamucil is primarily psyllium husk, but it’s got other non-beneficial chemicals, so I’d avoid it and get a pure psyllium husk product.

Inulin* is a type of soluble fiber that is found in many plants, including chicory root, Jerusalem artichokes, asparagus, garlic, onions and leeks and can also be purchased as a supplement. Studies have shown that inulin can help to improve gut microbiota composition and reduce inflammation in the gut. Inulin may also have potential benefits for those with diabetes, as it has been shown to help regulate blood sugar levels.

Guar gum* is another type of soluble fiber that is derived from the seeds of the guar plant and is used as a thickening agent in many gluten-free foods. Research has shown that guar gum can help to improve stool frequency and consistency in individuals with chronic constipation. Additionally, guar gum has been shown to have potential benefits for those with high cholesterol, as it can help to reduce LDL cholesterol levels. Partially hydrogenated guar gum (PHGG) or Sunfiber (which you can find in my Fullscript Dispensary*), however, is particularly used in IMO (Intestinal Methanogen Overgrowth) as a beneficial fiber to help with constipation. It’s a type of guar gum that has been partially broken down enzymatically, making it easier to digest and less likely to ferment in the gut. PHGG has been shown to have similar benefits to regular guar gum, such as improving stool frequency and consistency, without the risk of worsening symptoms in individuals with SIBO or IMO.

Acacia fiber*, also known as gum arabic, is a type of fiber derived from the sap of the Acacia Senegal tree. It is commonly used as a food additive to provide texture and stability, but it can also be taken as a dietary supplement. Acacia fiber is a highly soluble fiber that is fermented slowly by gut bacteria, producing short chain fatty acids that can support gut health. Research has shown that acacia fiber can have a range of health benefits, including improving gut barrier function, reducing inflammation, and supporting healthy immune system function. Acacia fiber is a better choice in SIBO as it’s less likely to cause bloating.

Pectin* is another type of soluble fiber that is commonly found in fruits and vegetables, particularly apples and citrus fruits. It is also used as a food additive to thicken and stabilize products like jams and jellies. Pectin is fermented quickly by gut bacteria, producing high levels of SCFAs that can support gut health. Studies have shown that pectin can have a range of health benefits, including reducing inflammation, promoting healthy gut barrier function, and improving lipid metabolism. Modified citrus pectin* is also used in particular to help with chelation of heavy metals.

Glucomannan* is a type of soluble fiber derived from the root of the konjac plant. It is commonly used as a dietary supplement to aid in weight loss, as it has been shown to promote feelings of fullness and reduce appetite. Glucomannan is fermented slowly by gut bacteria, producing SCFAs that can support gut health. Research has shown that glucomannan can have a range of health benefits, including improving glycemic control and reducing constipation.

If you’re not dealing with bloating, you may want to try a combination fiber product like Thorne FiberMend or Pure Encapsulations PureLean Fiber, which you can find in my Fullscript Dispensary*. When starting any new fiber product or adding fiber to the diet through sources like beans and legumes, be sure to start slowly and build up so that your microbiome has time to adjust to avoid gas, bloating or constipation. Aim to increase fiber intake from food or supplements by 5 grams per day until you reach the recommended daily intake of 25-30 grams per day. I like the tool Cronometer, which is an online nutrient, calorie and macro checker, to see how you’re doing with your current levels of not just fiber but all nutrients. You can even enter your supplements in there to see if you’re getting the recommended daily allowances.

How can I get enough fiber from my diet?

If you want to avoid fiber supplements, my best advice for a diet high in fiber is to eat beans and legumes. I know they’ve gotten a bad rap because of lectins, saponins and phytic acid but I don’t find that most people are sensitive to lectins, and you can do things like soak them and cook them slowly to get rid of most of those problematic substances. And I’ll provide a link on how to do that. Unfortunately, most canned beans do not undergo pre-soaking so it’s best to make them yourself from dried beans.

While fiber is found in a variety of foods, including fruits, vegetables, whole grains, nuts, and seeds, beans and legumes really stand out for their high fiber content, and in my opinion, it’s very hard to hit the RDA for fiber (25-30 grams of fiber per day, based on your calorie intake) without eating them. Overall, beans contain more fiber per serving than any other type of food.

For example, here’s a comparison of ½ cup of the highest fiber beans with many other fruits and vegetables:

•             Black beans: 7.1 grams of fiber

•             Kidney beans: 7.3 grams of fiber

•             Pinto Beans: 6.9 grams of fiber

•             Lima Beans: 6.6 grams of fiber

•             Chickpeas: 5.3 grams of fiber

Compare that to:

•             Raspberries: 4.2 grams of fiber (but think about how expensive raspberries are and realistically, who ever eats an entire ½ cup of raspberries at a sitting? That’s like the entire container)

•             Artichoke: 4 grams of fiber

•             Broccoli: 2.3 grams of fiber

•             Blueberries: 2 grams of fiber

•             Carrots: 2 grams of fiber

•             Green beans: 2 grams of fiber

•             Cauliflower: 1.5 grams of fiber

•             Cooked cabbage: 1 grams of fiber

•             Raw Spinach: 0.8 grams of fiber

•             Romaine lettuce: 0.5 grams of fiber

One way I recommend getting more beans and legumes into your diet is adding them to breakfast. Just make a batch and use them as your breakfast carb. Start with a tablespoon and work your way up. Or do a combo of rice and beans. That was a common breakfast that went great with an egg with a soft yolk over it when I lived in Costa Rica. They called it gallo pinto there, but there are many varieties of this from different Latin American countries. I’ll include that recipe in the show notes. I suggest breakfast because most people don’t vary their breakfasts a lot, so it makes it easier to make it a habit.

Nuts are also another good source of fiber but for a ¼ cup serving, it’s still only 2-4 grams of fiber. And of course it’s important to note that fruits and vegetables also provide a wide range of other important nutrients, such as vitamins, minerals, and antioxidants, that are important for overall health, so it’s best to get some of your fiber from other fruits and veggies, and balanced diet will include a variety of fiber-rich foods, including fruits, vegetables, nut and legumes.

Should I take fiber with IBS or IBD?

So as I mentioned earlier, there are some contraindications for taking fiber or getting much fiber in your diet in certain gut health conditions.

If you are in an active flare of inflammatory bowel disease, meaning Crohn’s Disease or colitis, studies a show that a high fiber diet will cause increased inflammation and disease activity. Therefore, low-fiber diets like the Specific Carbohydrate Diet, low FODMAPs or IBD-AID are recommended during times of active cramping or diarrhea. However, slowly introducing fiber once your symptoms have settled and could be described as mild or not present, one food at a time, is recommended to help keep your condition in remission.  In human studies, psyllium husk, inulin and germinated barley foodstuff all showed positive results for decreasing remission rates, while wheat bran showed no benefit.

If you’re suffering with IBS-like symptoms, in particular bloating and gas after eating, or have diagnosed SIBO (small intestine bacterial overgrowth), it’s also recommended that you decrease your fiber, and avoid prebiotics like inulin, fructans and GOS (galacto-oligosaccharides), because they are high in FODMAPs, aka Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols, which feed the bacteria and archaea that are typically overgrown in SIBO. So for people with active SIBO, I usually recommend either a low FODMAPs diet, Nirala Jacobi’s Biphasic Diet or Marc Pimentel’s low fermentation diet. If you do want to continue fiber supplementation to help with bowel movements by either bulking up the stool and decreasing diarrhea or to help promote more frequent bowel movements during a low fiber diet, acacia fiber* is a SIBO safe fiber, and partially hydrogenated guar gum or PHGG, aka Sunfiber (find in my Fullscript Dispensary*) is helpful in IMO or methane SIBO.

Because fiber can be irritating in certain conditions, one way I help people get the microbiome benefit of fiber without the irritation of it, while healing from gut health conditions, is to recommend supplemental butyrate or tributyrin, the preferred form of butyrate, while healing. This is something I tend to recommend only to people with soft stool or diarrhea, as it can be constipating. It’s one of the short-chain fatty acids that people tend to most lack when they have conditions like SIBO-D and IBD, which tend to go along with overgrowths of proteobacteria, which do not produce butyrate. And I’m sure you’re heard that I have my own tributyrin supplement called Tributrin-Max, which you can get for 15% off your first order with the code INTRO15 or super exciting, I now finally have it for sale on Amazon, and discount code TMINTRO15 will get you 15% off your first order there.

You may be asking yourself about prebiotic fibers too beyond traditional fiber supplements, and I have done another podcast on that, which may have some overlapping material, episode 28 Prebiotics and Fiber.

And of course if you’re struggling with some type of chronic disease, chronic inflammation, bloating, constipation, diarrhea, soft stool, acid reflux, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.

*Links are for affiliate web sites, thanks for your support of the podcast and blog by using them.

Adapted from episode 95 of The Perfect Stool podcast and edited for readability with Dr. Laura Brown.

Lindsey:  So today we discussed that we would talk about bile. I don’t think we’ve really had anybody on the podcast to talk about that topic. Let’s start out with what is bile and why do we need it.

Dr. Laura Brown:  Really good question. I did a little bit of recent research. It’s been a while since I had dipped into this topic myself. We always take bile for granted. Bile is something that our liver makes, our gallbladder stores. And then upon a trigger, which comes from an enzyme in the small intestine, the gallbladder releases bile to help us digest fats. But there’s so much more to it, as we’re going to talk about today. Even if somebody has their gallbladder removed, the liver still makes bile, and it releases it as needed. It doesn’t have the chance to store it and concentrate it in the gallbladder. So the body has backup plans, like Plan B, to help us digest our food, especially fats, which we use bile for. But we’re finding out so much more about bile acids, which we’ll also talk about today.

Lindsey:  Great. So isn’t the base of bile dead red blood cells?

Dr. Laura Brown:  Yes, there are red blood cells in there as well. There’s also cholesterol, and other components. We’re learning more and more about what’s in there and what it’s used for. Our interest today is more on the gastrointestinal tract and what these things are doing. Bile acids are a big component of this, and when we first touched base together, you mentioned TUDCA, which is a secondary bile acid created through processing with the gut microbiome and the recirculation of bile. Bile is released, but it’s also brought back into circulation. We only excrete about 5% of it through our stool, and then 95% of it comes back up to be reused. As it’s going through these processes, it goes through a number of different chemical reactions. There are about four different kinds of primary bile acids, which are initially released from the liver, and then they get turned into secondary bile acids by the gut microbiome when they reach the large intestine. Those get changed and recirculate, and they have different purposes. TUDCA is one of them, and there are a lot of studies on mice right now, and they’re starting to do more in humans. They’re looking at a lot of the neurodegenerative diseases like Alzheimer’s, ALS, Huntington’s, Parkinson’s, and they’re seeing some positive results or influences with TUDCA* (access products using my patient direct code: I0rdLMOm) acting as an antioxidant or preventing that misguided protein folding that we see so often in Alzheimer’s. It’s really early in this type of research, so there are lots of mice studies and starting human trials. So I think before we stop the presses on some of the other drugs that they’re doing, but to continue the research on the synthetic TUDCA and TUDCA stands for Tauroursodeoxycholic acid. It’s a bit of a mouthful, so they call it TUDCyondA.

Lindsey:  Yeah, exactly. So what are some of the things that can go wrong with the bile and the organs that produce and store it?

Dr. Laura Brown:  Well, there are lots of things that can go wrong. For instance, if you have issues with your liver and it’s not making proper bile, then we have an issue. So we have to address liver health in that case. The liver makes the bile in one area and receives the recirculated bile acids in another area of the liver. There can also be issues with the gallbladder in the storage of bile, which I often see in clinic with patients coming in. It’s always sad when somebody says, “Oh, I had to have my gallbladder removed.” I wonder if they really had to because we see a lot in celiac and non-celiac wheat-sensitive patients. And I’m like, what’s going on?

What’s going on is that wheat is affecting us. None of us have the digestive enzymes to break down wheat. It’s a fiber that goes through our digestive processes and gets fermented in our large intestine. And that’s why they’ve always promoted whole grain products to help feed the microbiome and promote bowel regularity. However, for some people, for most people, they will have damage in the small intestine from eating wheat or gluten. Wheat has over 100 different proteins, gluten being one of them. The wheat damage happens in everybody and is usually healed up within 20 minutes. But for those who are celiac or non-celiac wheat-sensitive, the damage can last for up to five hours. And then typically, it’s time for the next meal. And usually there’s gluten in it again, right? Like if they’re not knowing, right, undiagnosed.

This repeated damage prevents the enzyme called cholecystokinin or CCK from releasing. When that doesn’t release, the bile isn’t triggered to be released. And if the bile sits around because the liver makes the bile, sends it to the gallbladder, and the gallbladder condenses it, then it can get sludgy and form gallstones. These gallstones are like prickly little things and can be centimeters in size. I had somebody walk in yesterday, two centimeters, can you imagine this two centimeter stone sitting in this tiny little organ, they can be bumping up against the sides of the walls and as they roll around, they can create scar tissue, which can cause inflammation in the gallbladder. So now we have cholangitis right, so we have the inflammation of the gallbladder, or inflammation of the ducts.

So you’ve got these little stones or the sludge sitting around too long, or bumping against the walls and causing damage. And now we have those nice little ducts getting damaged. And we also see a kind of blocking up of the ducts, it gets sludgy and it blocks it up. And then that can backflow and block up the duct that comes down kind of in the same neck, the same wire, kind of an intersecting highway, where the pancreas sends down its enzymes Okay, so then we get back up of the enzymes from the pancreas with all this, this blocked duct stuff going on, and this is all because bile isn’t moving freely, right? It’s not flowing. And this can cause issues with the gallbladder, inflammation with the gallbladder, gallstones, the duct blockage, and this all can happen from a trigger. And it’s not the only trigger, the wheat, right? It’s not the only thing that can cause all this. But that’s one thing that I often think about. And when we do a wheat-free, sugar-free, an anti-inflammatory diet, essentially, you know, no alcohol, no wheat, no sugar, low dairy, and then just lots of vegetables, that seems to help the cause. Of course, everybody’s individual and we’re not giving medical advice today. We’re just kind of talking and educating about what can happen here.

Lindsey:  That’s interesting. I didn’t know that there was any relationship between wheat and gallbladder issues. So that’s great to know. If you do have thick bile, what kind of foods can help you thin it and get rid of that sludge?

Dr. Laura Brown:  Yeah, so we want bitter foods to help trigger bile release, right? All of our bitter foods will stimulate all of our digestive juices. And it’s not just bile that starts, so I want you to picture a nice bright juicy lemon, okay? And then I want you to picture taking a knife, cutting that lemon in half, and now taking that half a lemon and then just squeezing it into your mouth. And I bet that you’ve already got digestive juices flowing in your mouth.

Lindsey:  I do.

Dr. Laura Brown:  Even the thought or the imagery of a bitter food gets that going and flowing in your mouth. But not just getting the salivary juices flowing, you’re now stimulating the whole digestive tract including the bile release to get things moving and get things ready for digestion. So having a hot cup of lemon water in the morning, I think most people have kind of heard like, oh, what did we do that for? So that can help stimulate or a nice bitter green salad: the endives, radicchio, that kind of thing.

Lindsey:  Arugula…

Dr. Laura Brown:  Arugula. That can, yep, dandelion. Those bitter teas. And then sometimes in naturopathic medicine, we use tinctures of gentian* or bupleurum*, or things like that are really bitter, that helps stimulate the digestive tract. Even a cup of chamomile tea or dandelion root tea are nice and bitter. They can stimulate as well.

Lindsey:  That’s what bitter aperitifs are for, right?

Dr. Laura Brown:  Right. You got it. You got it. Yeah. So these things can help stimulate the bile to keep it flowing and the digestive juices to keep them flowing. Because anything that becomes stagnant, obviously doesn’t flow so well, right?

Lindsey:  And so what are the symptoms of gallstones?

Dr. Laura Brown:  So lots of sharp, intense pain, usually it can be under the right breast, you can feel it there. Your liver, if you’re to take the palm of your hand and kind of nestle it up under your right breast, that’s kind of where your liver sits, is kind of there. And then your gallbladder, the ducts and stuff come off of where your index finger would be kind of in that area. So sometimes you get pain right there. But unusually, you can get pain in your right shoulder and have pain in the right shoulder. So that can be part of it as well. Nausea, vomiting, those can be issues. If it’s extreme, and you have blockage, you can end up with jaundice, that will show in the whites of the eyes, yellowish skin, sometimes you can end up with diarrhea. Okay, so some issues there. So those are some of the some of the symptoms: nausea, not feeling well, pain, diarrhea, that you can think, oh, what’s going on here? Oh, that might be a gallstone kind of kicking around.

Lindsey:  So are there some early signs on any of the functional medicine tests that you do with patients that tell you that there may be a bile issue?

Dr. Laura Brown:  That’s a good question. Some people suggest looking at small intestinal bacterial overgrowth to see if something’s going on there. We see different things in stool tests. Those with inflammatory bowel diseases have imbalances of Firmicutes and Proteobacteria, which affects how we shift bile acids and that affects the recirculation. So that’s something to watch for. You can also look at liver enzymes and things like that. But, you know, often you have to have severe inflammation or something really strong going on before the liver enzymes rear their head. Often it’s caught inconsequently, maybe on an ultrasound image, if somebody’s having it done for something else. It could be that indigestion, sometimes people will complain of indigestion or that little bit of pain, sort of watching for those kinds of complaints, family medical history of what’s going on, food sensitivities, understanding what’s happening there. So just picking up on different things, as far as screening tests and trying to look at bilirubin and things like that. But again, it you’d have to be pretty far down the road before those things would be red flagging.

Lindsey:  And where would you find the bilirubin test, that’s part of a CMP (Comprehensive Metabolic Panel)?

Dr. Laura Brown:  You can do that through blood. You can do that through looking at the urine; the urine is more measuring how the kidneys are functioning. So kind of looking at the blood tests.

Lindsey:  What about markers for fat in stool? Are those indicative of bile sufficiency?

Dr. Laura Brown: Sometimes. Like a floating stool might indicate that we’re not releasing enough bile to digest fats. I don’t think I’m talking about on the test though.

Lindsey:  Like steatocrit the GI map, for example.

Dr. Laura Brown: Yeah, you can use that as a clue. I don’t think it can be diagnosed from that. I would put together other symptoms and other things going on. That’s just one way the body’s talking to us when you’re looking at it that way. It’s like, okay, you know, let’s look at the bile. What’s going on there? Yeah.

Lindsey:  So what does total bilirubin on a blood test mean?

Dr. Laura Brown: Bilirubin is your breakdown product of your red blood cell. And it is a part of bile. So you’d be looking at how much is there? And do you have enough? Is it too much or not enough sitting there? Usually you’re more concerned if it’s not releasing, right? If there’s blockage, depends on what’s going on, right? If there’s blockage, your stool might even look whitish or grayish, right? If your bile ducts are blocked, because you’re not getting any, you’re not getting into that red blood cell breakdown product or bilirubin into the stool, which is typically    what makes it look kind of brown. So if you have a clay colored stool, and floats. Yeah, let’s think about that. Right? Let’s see, is the bile being blocked? And then why is it being blocked? Is it because the liver is not making enough? Or is it because something’s clogged there? Or are we trying to pass a stone? So there’s different things that could be going on. So you are always taking things as clues. Right?

Lindsey:  Right. So what are the different supplements that one uses to deal with bile issues and what types of situations might warrant their use?

Dr. Laura Brown: So the different types of supplements that I look at: vitamin C seems to be helpful vitamin D seems to be helpful. Then I look at Malic Acid*. I found this that was very interesting. So malic acid, which is in crab apples, there’s a great gemmotherapy, and gemmotherapy is where you take the  twig in the springtime of the plant that has the new fresh buds on it. And then you crush the buds of the leaves, which would have all the genetic material to help it grow and do its thing, and you would crush that down and soak it in alcohol, glycerol and water. And then that’s extracting the components that would be dissolvable in alcohol and water and glycerol. And then so you make a tincture or syrup out of that. And when you do that with the crab apple or the May apple, you’re able to create a medicine that helps dissolve the gallstones. So that can be helpful.

Lindsey:  That’s called malic acid?

Dr. Laura Brown: Malic acid. Also berberine, which is found in Oregon grapefruit, hydrastis canadensis. Berberine is really great for the health of the liver. It’s good for blood sugar control, good for the gut. It’s anti-microbial in its physical form, or in a homeopathic form I’ve used for addressing gallstones and bile. If you want to just stimulate bile itself, as we mentioned, bitter tasting foods and tinctures can stimulate what’s going on there. If you’re trying to look at the health of the liver, Mary’s thistle, or milk thistle is always great to help the health of the liver. So that would maybe indirectly help the production of bile.  And then if we want to stimulate new bile, we take bile acid sequesterants, which would be fiber essentially, maybe some psyllium or something to help pull that out of the system so that we have less recirculating, so it forces us to make more fresh bile. So that’s sometimes helpful to help reset the system a little bit there. So there’s lots of different things that I think about. It’s kind of like where we are at, what seems to be the issue because we want to balance; we don’t want to overproduce this stuff.

We know when we eat too many fatty foods, then we end up with too much bile acid being released. And this can be an issue as well. It’s acid. And when it’s a primary bile acid or when that’s initially released, it’s an acid so it can actually cause damage. And that’s why the body quickly throws you know hydroxylase to add some kind of chemical to buffer it a little bit. So it’s not so damaging. And that’s what’s a secondary bile acid is. But if we end up with too many secondary bile acids, this can be damaging as well. So we want to balance right and the balance is key. So it’s not just more is better or less is better. It’s the balance between the primary and the secondary. And that means having a good balance of the right gut microbes, so having a good balance of the Firmicutes and Proteobacteria, so that we’re actually changing the primary bile acids into the secondary bile acids. Those with inflammatory bowel disease have this issue, they have low levels of Firmicutes and Proteobacteria. So they’re not transforming as much of the primary bile acids into the secondary bile acids. So then this is causing inflammation, or this is contributing to the inflammatory picture; it wouldn’t necessarily be the only cause.

Lindsey:  That’s interesting. I had never heard that about IBD. And so do they tend to have high bacteroides, then?

Dr. Laura Brown:  That would be separate, right? And you would look at the different families within that. So because you break down all of the different components of the Firmicutes, it’s just the family, right?

Lindsey: Phylum. Yeah, those are the phyla.

Dr. Laura Brown:  So you’re looking at what’s in there. So sometimes, that’s where you see when you get your results back from the GI map or the GI 360 test, you’re getting that breakdown of the six or seven families that are common, you can get the breakdown within them, and you could see what’s high, what’s low, we’re looking at those greater families. And you could have less or more of different phyla within the families.

Lindsey:  Yeah, no, I wish the GI map would list Proteobacteria, but it doesn’t list Proteobacteria. So you kind of have to extrapolate from the overgrowth of individual bacteria, whether that’s an issue,

Dr. Laura Brown:  Look up the GI360 and see if that solves what you’re looking for. Yeah, might be something of interest.

Lindsey:  I like the GI Map, because it has H. pylori on it. And it’s an issue for a lot of people.

Dr. Laura Brown:  Yes, you can add that to the GI 360. In Canada, at least in Ontario, we’re not allowed to add that in. But I think it is an option. We may be able to.

These harmful effects of the primary bile acids, as I mentioned, can be seen in inflammatory bowel disease, other gastrointestinal diseases, obesity, type 2 diabetes, liver diseases, cardiovascular diseases, and neurological diseases. So this gets down to some pretty nitty-gritty details of what’s going on, especially when you have four different ways that a primary bile acid could be modified, chemically modified. And then how the secondary bile acids work, and how they go into the system. So it branches out and then branches out. It’s like they told two friends and then they told two friends. It’s a lot of branching out of what can happen. A big domino effect comes back to often diet and often our standard American diet, which is high in processed foods, high in processed sugar, and processed wheat.

Lindsey:  I don’t eat gluten or dairy. And sometimes, if you’re in the situation where you have to eat a meal in public, like an airplane meal or a cocktail party, it’s just shocking how dominant gluten and dairy is.

Dr. Laura Brown:  Incredibly, and you know, it’s something you’ve probably had to learn to navigate. To navigate all of that, because it can be challenging and you want to boil it down. I would just focus on the people, eat something before you go, or just smile and say, no thanks.

Lindsey:  Or just go and eat more carrot sticks and hummus.

Dr. Laura Brown:  Yeah, and hope for the best.

Lindsey:  Exactly. Okay. So when is actual supplementation with bile acids like ox bile recommended or not? Because I know there’s some types of SIBO for which it’s contraindicated.

Dr. Laura Brown:  Yeah, tell me what you know about that. The SIBO and the contraindications with the ox bile. What is it? Where is your thinking on that?

Lindsey:  I’m not sure. Let me let me dig up this piece of information. Okay, so ox bile is good for methane SIBO not good for hydrogen sulfide SIBO.

Dr. Laura Brown:  Okay, right, that’s what you’re saying.

Lindsey:  Yeah, that’s what I heard.

Dr. Laura Brown:  Did they say why?

Lindsey:  I’m not sure.

Dr. Laura Brown:  Okay. It’s not something I have at the tip of my tongue. To be honest, I’d have to look that up. I use digestive enzymes sparingly. I use them with gallstones and to help with digestion. I’ll often start with bitters or 2 tablespoons of apple cider vinegar with a bigger meal to help the stomach make that hydrochloric acid so they can be more acidic, so they can stimulate what’s going on. So that we can suggest to help the body because, as you know, when you’re introducing, I’d like to find ways to remove the obstacles and then to support the body in what it naturally does. So when we’re putting the ox bile down there, yes, it could be helpful in some situations. But I like to see the body do what it does naturally, because it does it better than we can, right? And so supplements short term, when someone doesn’t have a gallbladder. If they don’t have a gallbladder and you’re having a higher fat meal, yes, you use it, use your digestive enzymes with the ox bile* in it, but also teach them how to have small meals or meals that are less fatty. So they’re not always taking an enzyme every time they eat.

Okay, the liver is still producing bile, so it can handle amounts of it. And you’ll see this, you may see the issue with people with short bowel syndrome, I see that as well. So if somebody has issues with short bowel syndrome, they’re not reabsorbing their secondary bile acids as much. And they’re probably having issues absorbing in what small intestine they do have. So it’s helping them out with that. So yes, so there are some situations where you would supplement and then we’re looking at what we talked about before the TUDCA, or the secondary bile acid that is being used in some of the research to help with the barrier function to help with cognitive regeneration. That’s something that I’m going to follow that research and see where that leads, it’s not something that I’m going to pull out of my pocket right now and say, to my patient, that I would trust in this not giving you Alzheimer’s. No, but it’s something I’m going to follow up because it’s very interesting.

We’ve been using bile supplementation for 1000s of years, the Chinese medicine reparatory uses it. In many different uses, 1000s of years they used the bile from bears in order to help with digestive disorders. So it’s not new. It’s just picking in and knowing some of these more detailed research studies that are coming out, to be able to understand what we might use it for, other than just, okay, we don’t have a gallbladder, we’re eating a fatty meal, we’re giving it, we’ve got a gallstone. We know that ox bile* can help dissolve cholesterol-based gallstones. We’re having issues digesting. So maybe we take a little bit, maybe we try that apple cider vinegar first. Get the diet under control and reduce the wheat, the dairy, the sugar, the alcohol, right, those types of things. Get the obstacles out of the way instead of throwing band aids and stuff.

Lindsey:   

Yeah. So I’m wondering since bile is so important in digesting fat, how much fat is too much in the diet? Like I know people, and I think it kind of happened to me that when they tried to ketogenic diet, they started having sharp abdominal pains and I’m thinking maybe they were gallbladder pains.

Dr. Laura Brown:   

Yeah, likely they were because some people can’t handle it, especially those with their gallbladders. removed. Right? They can’t handle that bullet.

Lindsey:   

 Oh, yeah. For sure if they’d had it removed. Yeah.

Dr. Laura Brown:   

Right. So it’s spreading that out throughout the day. Sorry, the question again . . .

Lindsey:   

. . . was how much fat is too much in the diet? Because like a ketogenic diet is supposed to be 70% fat?

Dr. Laura Brown:   

Yeah, I mean, it’s individual, right? I mean, there’s no one right diet for anyone and no one diet for any of us for life. So it’s finding out what works and what doesn’t work. And you might find the keto diet is not for you. So maybe you just modify it a little bit. And then you’re okay. But just be watchful for those symptoms, like the sharp pains, or the nausea, or the gray and floating stools, or the pain in the shoulder, maybe it’s the right shoulder that you’re getting that pain in. Or you’re just not feeling well  when you’re eating that level of fat. It’s not for everyone.

Lindsey:   

Yeah, no, I discovered it. It definitely wasn’t for me, because I love carbs too much. But it also wasn’t for me because of the pain. So how do constipation or diarrhea relate to bile? Is there one more than the other that might point to an issue related to bile if other causes are ruled out?

Dr. Laura Brown:   

I mean, there’s bile acid diarrhea, right? That’s something that we know is part of IBS-D, it could be bile acid diarrhea. And that is, essentially you don’t have the bile to break down the fat. So you’re getting that immediate kick. And it sometimes happens with people with undiagnosed celiac disease, the problem is that they’re not digesting the fats. And it’s just like quickly getting exited because the body is going and we can’t digest this here. Right. So it’s a fast exit. So that could be part of what’s going on.

Lindsey:   

So in that case, it probably be likely there would be fat in the stool, and there’d be diarrhea.

Dr. Laura Brown:   

And you got it. Yeah, yeah.

Lindsey:   

Okay. And what does the research say about the impact of saturated fat on the microbiome?

Dr. Laura Brown:   

Well, different people handle saturated fats in different ways. We know too much fat is inflammatory, and there’s some saturated fat that we can handle little bits of, other people not so much. We know saturated fat in some people, especially with the familial hypercholesterolemia. So high cholesterol runs in the family, these people tend to absorb more saturated fats from their diet easier, and then they end up driving up their cholesterol and it affects them. For others, the saturated fats don’t affect the cholesterol so badly. So in moderation, they’re okay. But we know too many fats of any kind, especially the saturated, or the hydrogenated or the industrial seed oils are inflammatory, they promote the arachidonic acid cycle, which is inflammatory. So this is affecting the gut barrier, and sorry, my brain just kind of going into different things, because the bile acids hit vitamin D receptors, and there’s a lot more there to unpack, that I’m just getting into now. So there’s different ways that that high fats, affecting more primary bile acids being released, if we have more primary bile acids being released, so we end up with more secondary bile acids, some secondary bile acids are helpful, too much are now inflammatory and not helpful. So that can cause issues as well. So it’s a lot about balance, right, starting with what we put on our plate, and what we put in our mouth.

Lindsey:   

I guess the best thing a person can do is experiment with what feels good, right? Like I know personally, that if I eat a pork belly, that I’m not going to feel good. That’s a guarantee. I better take some digestive enzymes, I better do something because it’s just going to be too much.

Dr. Laura Brown:   

Right? So you’ve learned.

Lindsey:   

I’ve learned yeah, but I can handle a couple slices of bacon, it’s not going to make me feel bad. So I think our bodies give us clues as to what works.

Dr. Laura Brown:   

I always say the body sends us lots of messages, like 1000s of messages. And if we’re quiet enough, we can hear the whispers. Sometimes it even screams, right? Sometimes the body just screams at us. And we just have to know what the body’s telling us and or at least relay what the body is telling us. So people come in my office and they’re trying to find words for what’s going on. I’m like, just give me the motions just just like because the body doesn’t speak in words, the body speaks in messages, right? Or hand gestures, things like that. So I just try to get people to explain, it doesn’t have to be a real word. Because this is often how the body speaks is in gibberish, because it just can’t get it out. And then that is such a great clue to what’s happening and what’s going on. And then we keep pulling on the loose strings to figure out the puzzle.

Lindsey:   

So are there dangers of following a super low fat diet following a gallbladder removal?

Dr. Laura Brown:   

That’s a good question. I think you have to introduce the fat slowly to help train the liver, right. So I wouldn’t go out and eat a bacon and avocado sandwich with cheese, right? Or a really high fat meal  immediately after having gallbladder removed; you would slowly reintroduce the amount of fat so that your body would acclimatize to its new reality.

Lindsey:   

I just know that I hear I hear people who’ve said “I had my gallbladder removed, so I just can’t eat fat anymore.” And so they literally are avoiding it. Very purposefully, no added fat to cooking. And I imagine that you could end up deficient in some of your fat soluble vitamins if you went super low.

Dr. Laura Brown:   

Well, exactly and you want to trigger some of that bile to come out because you need it in order to help dissolve the fat soluble vitamins or as you said, you’re not going to absorb them. And if you’re missing out on even your essential fatty acids, what’s your body going to be making your cells out of? Every cell in the body has a phospholipid bilayer, which means it’s made of fats. And if it doesn’t have healthy essential fats, like omega 3s from fish or walnuts or flax seeds or things like that, then it’s going to make it out of whatever it can. And when it’s not making it out of the more fluid fats, it’s going to make it out of other stuff. And typically, that membrane ends up being a little more rigid. And if it’s more rigid, it’s not going to let the toxins out or the nutrients in as easily as if it were more fluid. So you still need some fat, it’s not a no fat diet, it’s a low fat or kind of a trickle fat. But you know, it’s adjusting, and acclimatizing and just retraining the liver to deliver it just in time, right? You want that bile to be delivered just in time.

Yeah, you’re right, your vitamins A, D, E, and K are all your fat soluble vitamins. And you need to have them with some fat and you need the bile to be able to go in and emulsify or break it apart, just like the dish detergent does in the sink – takes those bigger fat droplets and breaks them all into little smaller ones so that it can be absorbed in the small intestine. And then if we’re not absorbing those things, you’re not getting the fat or getting the bile to help digest that, we’re going to miss out on those key nutrients, which is important. But you have to think, lots of foods that we might not think have a lot of fat. Sometimes just a little bit of fat can be enough for somebody. So nuts and seeds, for example. Sometimes people don’t think of them having a lot of fat, but they are they’re pretty high in fat, right? It’s sometimes thinking that, oh, I didn’t realize that had fat in it. They’re just thinking the overt pouring oil on.

Lindsey:   

Right, right. And meat and fish, those have fat too.

Dr. Laura Brown:   

Yeah, absolutely. Like salmon, right? Or fatty fishes with your essential fatty acids. Those are key. Yeah. So you’ll be getting some of that. So the body learns; it’s very resourceful.

Lindsey:   

Right, very resourceful. I know. You can take out any number of pieces of our body and it still manages to function, perhaps not optimally, but it functions.

Dr. Laura Brown:   

Exactly. Yeah, exactly.

Lindsey:   

So we’ve been focusing very much on bile, but what else is involved in fat digestion?

Dr. Laura Brown:   

So we’re looking at those enzymes, we’re looking at that fat coming in. I’m not sure what you’re getting at, because we’ve talked about those things, as well. What do you think, what are you thinking?

Lindsey:   

Oh, I was just thinking, you know, the other digestive enzymes like lipase and such that are involved in that digestion and that process.

Dr. Laura Brown:   

Right, and the lipase coming from the pancreatic area. And those types of things are often included in a digestive enzyme as well. It’s not just ox bile, that type of thing. So if we’re having issues digesting, those would come with it. Yeah, so the digestive enzymes are coming from yes. . . for starches it starts in the mouth. And then stomach is meant to kind of break things down chemically. And also with the acid, but then we’re needing the bile, and then the digestive enzymes from the pancreas to do that first breakdown. And then obviously the microbiome, as we talked about before, changes those primary bile acids into the secondary bile acids. So that’s part of our digestion for fats too, in order to help do things that way. Most of the fats are ideally absorbed in the small intestine, the first part of the digestive tract. Okay.

Lindsey:   And so earlier you mentioned you use digestive enzymes sparingly. So I’m wondering why so sparingly and whether what kind of situations you use them in?

Dr. Laura Brown:   Well, I say sparingly, because I don’t like to use anything unnecessarily. And I believe everything has a time and a place for it. There’s some people that have issues with their pancreas, sometimes, advanced celiac disease, patients need a digestive enzyme with every meal. We know that there’s different types of digestive enzymes, not just ox bile, there’s papain, there’s bromelaine, there’s other types of ones that help break things down. There’s ones that cystic fibrosis patients might use to break down mucous. And the types of things that you would use those in those cases, if you’re using something, to act systemically not to digest food, you would take it away from food, right.

So that might be a different use of a digestive enzyme, or you might call it more of an enzyme, not just digestive. Because an enzyme is really something that helps a chemical reaction occur without consuming itself. So that is what an enzyme is. So it helps a chemical reaction occur. And we have lots of different chemical reactions happening in our body all the time. So the digestive enzymes taken away from food can help break down mucus, can help bring down inflammation, can help with inflammation in joints, arthritic conditions, gout conditions. So that’s one area to use digestive enzymes between meals or away from food on an ongoing basis to help with that type of thing.

If you’re using it to help digest food, or is there some kind of physical roadblock to our own digestive enzymes? Is the pancreas damaged? Is the gallbladder removed? Is the liver damaged? Can we heal the liver? You know if the gallbladder is just sludgy, can we clean it out first, right, or while we’re cleaning it out, take the enzymes, but then when we’re done, we don’t need them anymore. There was some thought with the secondary bile acids, some of them might help heal some of the pancreatic cells. So there were some ideas there that I saw in some of the research, you might use them to help the healing. But then when you get the healing done, or when you using them in the meantime, while you’re doing healing with other things, then when you’re done, you’re done. Right? So as I said, using it sparingly. There’s a dose at a time and there’s a duration. It’s not in all circumstances that once you start it, you have to be on them forever.

Lindsey:   

Do you think they’re useful in SIBO? Because I have I have post infectious IBS. So I’m always getting bloated after a time. I mean, I can take antimicrobials and then it starts over again. So my thinking was I take a digestive enzyme with each meal just because I want to make sure everything’s getting digested and everything’s not hovering for the bacteria to grow.

Dr. Laura Brown:   

So then I’d look at what’s the mechanism of the recurrent SIBO? And what’s going on there. And what can we do to prevent that? And is there something that we can do to halt the presses on that? Often I see food sensitivities that impact the ileocecal valve, which is the valve between the large intestine and the small intestine. And it gets a little grumpy when it gets constantly irritated by foods it doesn’t like, so then it gets lazy, and lets the bacteria that’s supposed to stay in the large intestine up into the small intestine. This is small intestinal bacterial overgrowth. And our large intestines are designed to ferment foods. And if it’s sitting up in the small intestine, it starts to ferment and it goes crazy because it’s where you get more of the sugars and things like that. So it starts to ferment and that’s the bloating, the gas, an uncomfortableness, but it was looking at food sensitivities and what’s going on there. We also know there’s things like, Levothyroxine can promote small intestinal bacterial overgrowth. So if it’s something that you need to be on because you have hypothyroidism, then maybe every once in a while we’re doing that maybe once a year, we’re doing a gut cleanup and, and doing some antimicrobials. Just to help prevent that from happening.

There’s a nice little move that I do in the clinic to help shut the ileocecal valve. And that can happen. So I’ll do that for some people. I had a lady walk in one time, just off the street. I’ve had this pain for two years, can you do something about it? I’m like, okay, you’re just telling me about it. Okay, lay on the table. And then I’m just poking around, you know, just to the right of the bellybutton and over a couple inches, depends on the person. So I’m feeling around that you could tell that there was some irritation there. So I just do the move that helps close the ileocecal valve. And, her appointment was over, and I said “let me know how you feel”, and I never hear from her. So, some time goes by, and I reached out to her and I thought maybe I offended her. She didn’t like that or it felt weird or hurt or whatever. And I said, “Oh, was everything okay after your last appointment?” And she goes, “yeah, I walked out of there with no pain.” She was in pain for two years. It’s gone. And it’s never come back. Yeah, I mean, that doesn’t happen every day in practice, but I mean, it’s like, hey, this is great. It’s not bad for business, but great for the patient.

So so many things like that can be helpful to watch out for. But then it’s looking at the diet, looking at the food sensitivities, looking at why do we have this recurrent SIBO going on. And that’s individual for the patient to dig into that. So that we can get moving forward, and sometimes it is food restriction. Sometimes it is antimicrobials on a rotating basis. Sometimes it’s fasting just to give that whole digestive engine a break, right, just a rest. Sometimes that’s as good as anything, and it’s finding what works for you, as an individual, what works for you to help reset. You know, I kind of find my little arsenal of stuff and, and know what works like I love bitters*. I know things get slow for me, I’ve got a lovely bitter formula that I put together. And it’s Chinese bitters. And I mean I’m lucky that I don’t have a strong bitter receptor. Some people do. So I can get it past my mouth. And it’s not an issue. But I find that it can be really helpful for me and it doubles as an antimicrobial. But if I think fine, things are just kind of slow to digest. I feel like foods kind of sitting there too long, because you get that sensation, right? It just feels like the things aren’t moving through, it’s sluggish. So I find for me, bitters are a really awesome way to get things flowing and going.

Lindsey:   

In my case, I have elevated vinculin antibodies. So I know I’m going to be getting SIBO over and over again. So it’s just a matter of continuing to, to chip away at it. So prokinetics and trying not to eat constantly. I’m not a big fan of fasting, though.

Dr. Laura Brown:   

And it’s fine. And there’s no one right way to fast. You could just extend to, maybe it’s a 12 hour fast.

Lindsey:   

I shoot for 12 hours at night. Shoot. I’m not sure I always hit it, but I shoot for it.

Dr. Laura Brown:   

And then maybe every once in a while you make a bunch of bone broth, or you just have something that’s a little more simple to digest. Or you have like I’m going to eat vegetables all day today. Right? That kind of thing. Just to give the body a break from heavier stuff. Digesting heavier things. So you give it a break from the fat and the protein and the heavy carbs. You just eat vegetables all day. Nothing wrong with that. Right? You can do it for a day or a morning, right? Maybe you don’t want to do it all today. So yeah, just to give a little digestive break. I can tell my brain that I’m doing a digestive break. But if I say I’m not going to eat the first thing I want to do is eat. So but a digestive break, that’s fine, because it’s a whole engine. Right? We talked about how things start when we think about it. We thought about that lemon, and boom, what happened? We didn’t even eat a lemon and we were just thinking about it and everything started to flow.

Lindsey:   

Yeah, right. So it’s amazing the power of the mind.

Dr. Laura Brown:   

Our experience with food starts when we think about it. It’s intensified when we see it and smell it and that is the beginning of our digestive process. Then we eat it, then it starts to go down through that whole process. So sometimes we do need to give it all a bit of a break.

Lindsey:   

Okay, so we’ve sort of covered this in a roundabout way. But just concretely, if somebody is staring at a suggested gallbladder removal, what would you tell them to do, to try and avoid?

Dr. Laura Brown:   

Depends on how far along we are, how much damage has been done? Is the gallbladder intensely inflamed? Are we in a lot of pain? Are we able to eat? So we kind of take those things into consideration, if I have somebody that has some gallstones, and the doctor said, well, let’s just remove it. It’s bothered them. Now, they’ve been to emergency a couple of times, but we’ve kind of figured out that’s when they eat pizza, and a lot of biscuits or something. It’s like, okay, hey, let’s change up the diet. Right, let’s get the gluten and the processed foods out of there, and the sugar. Let’s get that out of there. Let’s hold up the alcohol. And these sometimes are stepping stones or can be roadblocks for some people. So it’s helping them understand how to do that. And then getting more vegetables, lots of cabbage-based family vegetables, getting some bitters in there, getting some of maybe that hot lemon water, or the chamomile tea or the dandelion root tea, just getting some of these things into the diet. And then seeing maybe using some of that malic acid tincture that I talked about, or some of the homeopathics. Or maybe we’re using some ox bile or some combinations of these things. And then we’re giving it a month or so to see how we’re feeling. Are we feeling better? Do we have less pain, and are we not doubling over anymore? We’re able to eat and feel fine. And then usually they’ll go back for an ultrasound or something to see if there’s further inflammation or whether gallstones are out. So we can see oh, do we have this under control? Okay, sounds like a good plan.

Lindsey:   

Well, that was all the questions I had about bile, anything you would care to add.

Dr. Laura Brown:   

Just that there is ongoing research on what the secondary bile acids do for us, the secondary bile acids are a byproduct of the gut microbiome in the large intestine. So it makes three different things, it makes things made from the short chain fatty acids, and it makes the secondary bile acids. And then there was one other thing, I think it was a taurine-based byproduct that it also makes. And it’s taking a look at what these things are responsible for in the gut and just understanding and appreciating the complex interaction of the gut microbiome, its byproducts, and our human immune system, our gut lining, and not only the gut lining, but the blood brain barrier, and just how those things go together. And just appreciating the health of the gut and how it affects the rest of the body. I mean, this is why I wrote a book on it, that book I wrote is called Beyond Digestion*. And it’s just I found so many things started in the gut, and just appreciating that if we take care of our gut, it’s going to take care of us, our microbiome is is huge 99% of the genes that we carry around with us on tests that our microbiome, and if we take care of it, we’re going to be much healthier, and we’re learning this more and more and more. And it comes first and foremost with diet, what we’re putting on our plate and then how we’re treating ourselves. Stress is huge, finding ways to manage that. There’s many different things that affect the health of the gut. It’s been great talking about bile and it was interesting doing a deep dive on some of the more recent research, so I appreciate that stimulation Lindsey to bring that to light and just know that some of these things like the TUDCA is of great interest for the neurodegenerative diseases. And just to keep following up on that if you have family members with Alzheimer’s or Parkinson’s or Huntington’s or ALS. This might be something that would be really helpful in the future where we have little to offer otherwise, but everything comes back to the data and food is medicine.

Lindsey:   

Yeah. Okay, awesome. Well, thank you so much for doing that deep dive on bile.

Bile Acids PDF prepared by Dr. Brown

If you’re struggling with  bloating, constipation, diarrhea, soft stool, acid reflux, IBS, IBD or any type of chronic disease, etc. and want to get to the bottom of it, that’s what I help my clients with. You’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my 3- and 5- appointment health coaching programs 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.