Bile, Digestive Support and the Microbiome: A Conversation with Dr. Laura Brown

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.


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.


 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 . . .


. . . 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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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?


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.


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.


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.


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.


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.


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.


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.


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.

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