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Adapted for readability from my interview of Dr. Norm Robillard from The Perfect Stool podcast. Listen to Episode 41 of The Perfect Stool.

Lindsey: So I am very interested in your work and your bio and all the peer reviewed papers that you’ve published. And because you published on the Bacillus species, I have to go a little off track of our main topic and ask you what you think of spore based probiotics that are Bacillus probiotics?

Dr. Norm: Yeah, interesting. Well, you know, my, my doctoral thesis was on Bacillus anthracis. So there’s one you can check off the list. That wouldn’t be a very good probiotic.

Lindsey: That’s anthrax, right?

Dr. Norm: Anthrax, right. And there’s some other Bacillus species that wouldn’t necessarily be good.Bacillus cereus is linked to foodborne illness and so forth. But there are many other species that are very well studied, that are in natural food products. For instance, Bacillus subtilis is in natto, and that’s been used for hundreds, if not thousands of years in Japan. A couple of good things about the spore based probiotics: they won’t be killed by stomach acid so you don’t need a lot of fancy encapsulations. If you give people the spores, of course, they have to germinate and grow in the gut to impart their benefit. They do, as a group, produce a lot of antimicrobial agents of their own, natural antibiotics, bacteriocins, things that modulate other bacteria, competitors. So there could be some benefit there. So in terms of probiotics in general, I think there are so many studies on them, and the results weren’t quite as positive as I think a lot of people, especially people that produce and sell them, were hoping, and there might be many reasons for that. But even a full complement of a new microbiome from a healthy person through fecal microbiota transplantation, for instance, hasn’t really proven to be very good so far, in IBS studies. And I think that there’s been one or two on constipation, which might have shown some benefit, which is a great thing if there was, but it’s been a little bit challenging to really find the benefits. Some certain specific studies for some strains for certain indications, perhaps, and so I recommend some of those as well. But I really, I personally think if you don’t fix the diet and other factors, if you have any number of other underlying causes that might throw you into any number of forms of dysbiosis, that a probiotic is not going to be a magic bullet. And of course, the only probiotics that are available for the most part are aerobes that are easy to grow and lyophilized and put in capsules. So we don’t have probiotics for the anaerobes, which are probably the more important type of organism to look into.

Lindsey: Yeah, one of the things that that strikes me with the research on probiotics in particular, thinking about that recent study that basically said, you know, it takes longer to recover your natural microbiome if you use probiotics following antibiotics, is that they’re looking at people who maybe were starting with a healthy microbiome to begin with. But the people that I’m working with are not starting with a healthy microbiome, and they don’t want to return to that microbiome. So typically, we’re using antimicrobials and then following with probiotics, because we want to set a new microbiome that’s healthier. So in that context, I feel like those studies don’t really apply.

Dr. Norm: Right. And they don’t and if you looked at a comprehensive stool test, and you looked at which organisms were really kind of off, and chances are almost 100% of the time, it’s not going to be a quick fix with probiotics. A lot of people are deficient in lactic acid bacteria, but does that mean they have a deficiency in the large bowel where the fecal material is forming? It’s not going to really say much about the small intestine. So let’s say you have no detectable levels of Akkermansia Muciniphila, right, an anaerobe that lives on the gut surface and feeds exclusively on mucus and cross feeds other organisms and has been linked to leanness and perhaps turnover of mucus in a good way. There is no supplement for that. Again, I think you’re back to, what are the things that create an anti-inflammatory environment, and that give your microbes the opportunity? I personally think (and some people think my requirements are a little bit restrictive) but I do think that less is more in terms of resetting the gut. Marlene Remely, an excellent biologist in Austria, did a short-term study on fasting. He found that some of these gut lining microbes, and those are the ones that are probably more even more important, that there was some stabilization of Faecalibacterium prausnitzii, and some of the other gut lining microbes, with fasting. And so if you fast a little bit, if you cut back on your calories, and specifically carbohydrates, I do think that it’s less of a population for your immune system and motility, stomach acid, bile and digestive enzymes to manage. So these control mechanisms, I think, could have an easier time for it, if you took some steps to quiet things down. And I think that’s why the elemental diet, for instance, has shown to be pretty effective for some forms of dysbiosis.

Lindsey: Do you want to talk a little bit more about what an elemental diet is, just because I don’t know that I’ve had anybody discuss that much on the podcast?

Dr. Norm: Sure. You know, I’ve a proposal for a better one too. An elemental diet is essentially a diet, and it can be given orally, you can drink the solution. It can be given through a tube for people that can’t take foods orally and it can be given by IV, but in every case, it’s fully digested nutrients. So there’s three foods: proteins, fats and carbohydrates. And so instead of fats, you’d have fatty acids. Instead of proteins, you’d have amino acids. And instead of carbohydrates, most of these formulations just include either dextrose, powdered glucose, or a starch type molecule like maltodextrin, that’s very quickly broken down to glucose. So essentially, glucose. And the idea is to have those nutrients very quickly and efficiently absorbed so they won’t feed the gut microbes very much at all, because the nutrients get absorbed into your bloodstream. So for people with a weight loss issue, you’re going to have a better chance to absorb more of the nutrients yourself. And for people with various types of overgrowth, you’re going to be able to quiet down, rest the gut, so to speak. However, I’m a little surprised that there aren’t more efforts to make formulations that have more fat, because most of these elemental diet formulations are very little fat.

Lindsey: Yeah, like you’re just supposed to add fat at the end. I think it’s just a little impractical, maybe to ship things that are in a powder form with lots of fat in it. It makes it really quite heavy.

Dr. Norm: And like my friend, Mike Rucsio, out there in Walnut Creek, he’s got some formulations. He was working on one that was low carb. I don’t see it in the store lately.

Lindsey: I’ve recommended that to clients.

Dr. Norm: Yeah, and it’s semi elemental, but he cites some data (semi elemental means the protein’s not fully broken down into amino acids, peptides), he cited some data that those might be absorbed just fine, if not better. So he’s looked into this, and I do think, for a lot of people, an elemental diet with more fat and few fewer carbs, and even in some cases, you know, carbohydrates are not a required food source. I mean, we don’t need them to survive. So I think for a lot of people less would be more just in terms of metabolic health, even if it’s rapidly absorbed. But beyond that, some of this glucose could feed bacteria, if you had an advanced case of SIBO.

Lindsey: Right. Yeah, I had a client who was diabetic, and I can’t remember, maybe his low carb option wasn’t available at the time. And then the elemental diet just completely spiked her blood sugar, not type two diabetes, type one.

Dr. Norm: Right. Good point. I think there are some formularies that would do that kind of thing. But the other thing is, it could feed SIBO. And the reason we know that is because many hospitals use glucose for hydrogen breath tests, and for people that are positive for SIBO, that means that glucose is feeding some of those bacteria, right?

Lindsey: Of course. Okay, that was just a little bit of diversion. Let’s get to the main topic. Tell me a bit more about your own reflux and how that led you to develop the Fast Tract Diet.

Dr. Norm: Sure, yeah. That’s, that’s going back a ways now. I’m happy to be free of that, except occasionally, a tiny bit around holidays when I go off the rails. Yeah, it was 15-16 years ago. I had chronic acid reflux for many, many years. And it was really impactful on my life in general, work and play, and even at night sleeping. I was getting aspiration reflux and waking up with my lungs on fire. What the heck is going on? And I wouldn’t have done anything with it, except what most people were doing, trying to take some proton pump inhibitor (PPI), swallow a lot of Tums. And I just happened to go on a low carbohydrate diet for other reasons, just to lose a few pounds. But I when I realized the dramatic improvement in my reflux, essentially, it went away on a very low carbohydrate diet. I was just amazed and started doing a little research and trying to understand, why would cutting out carbohydrates have that effect, because it seemed to go against all of the current research and theories on what was causing acid reflux. And, you know, without making that story too long, it turns out, and this is why I’ve written three books, well, two, one on reflux and one on IBS. Because it turns out, there’s a lot of evidence for why carbohydrates actually drive acid reflux. And so it does have to do with carbohydrate, malabsorption, excessive fermentation of gut microbes, and whether that’s in the small intestine, we’re looking at that now in a study of 90 patients. Or whether it’s an overgrowth in the early part of the large bowel? But there’s no question in my mind that too many carbohydrates, for people that aren’t digesting and absorbing them well, will create blooms of gas-producing bacteria and that gas pressure builds up and is driving the acid reflux, which is a completely new way of looking at that. So we’re still pursuing it in in the clinic to find the proof or not for this theory, but I’m pretty sure we’re right on this. Whether it will be SIBO or LIBO, or another form of dysbiosis still remains to be determined.

Lindsey: LIBO meaning large intestine. . .

Dr. Norm: . . . bacterial overgrowth – it’s kind of a loose term, don’t go on PubMed, you won’t find it. There is a lot of evidence that LIBO is a real thing. I call it that, for lack of a better word, large intestine bacterial overgrowth. But, yeah, there’s a couple of studies with pH capsules, showing significant increases in the acidity of the early large intestine for populations of people with IBS. And the only reason that could be happening is because bacteria are fermenting more carbohydrates, making more short chain fatty acids, and that’s driving the pH down.

Lindsey: Okay, so why are people not digesting their carbohydrates? Well, from the stomach on down?

Dr. Norm: So the million dollar question. In many cases we know it is for specific reasons. Pancreatitis, pancreatic insufficiency, right? So if the pancreas is not producing or releasing an adequate supply of digestive enzymes, that of course is protease, lipase, amylase, there’s some other ones, elastase, which they measure in a stool test. But those three major ones, and especially the amylase, that could be one reason, right? Then there’s the brush border enzymes. So sucrase and maltase and other enzymes that break down disaccharides. And those are really important not only for breaking down simple disaccharides, as the name implies, but also the final breakdown of starches. Because don’t forget amylase enzyme, whether you’re talking about amylose, starch, or amylopectin, the two types of starches, you do get these final breakdown products. And those are finished off with the brush border enzymes. And so most research has focused on genetic deficiencies in these brush border enzymes. But I wish they would have, and there was a company up in New Hampshire that tested for this, but I contacted them and right now they’re only doing that testing for research studies. But I wish it would be more widespread because I think a lot of people might benefit. It might be beyond a genetic deficiency. A lot of people have brush border enzyme issues, and you can imagine why they might for instance. With SIBO, all bacteria are releasing proteases that scavenge for nitrogen sources. And they need nitrogen so they’ll go after proteins, break them down and absorb them. And if they happen to be up in where these villi and microvilli are releasing these brush border enzymes, right at the tip of the microvilli, they could break down our disaccharidases, in addition to the inflammatory damage on these delicate villi and microvilli. So there’s a couple of reasons. I wonder to myself, since so many people like myself get these functional GI issues a little bit later in life, 30s, 40s, especially and older, and I wonder if there could just be a general, your digestion is not working quite as well as it did when you were 18.

Lindsey: Yeah, or maybe just too many years of stuffing in too much bread and pizza and pasta, pastries.

Dr. Norm: Or excesses. I’m a fan of moderate alcohol, but some people really go overboard.And sothere are a lot of things. I think, for a lot of people, you won’t necessarily be able to put your finger on it. But you can come to a reasonable conclusion that they’re not breaking down carbohydrates as well as they did when they were younger.

Lindsey: Right, right. And so for some people, maybe just digestive enzymes would be sufficient if you get a good enzyme that has both the brush border and the pancreatic enzymes?

Dr. Norm: Right, sure. And by the way, we didn’t really have a chance to talk about the other source of carbohydrate degrading enzyme, the amylase in our saliva. And there’s been a number of studies in the last five or six years, showing that that there’s a gene copy number issue, some people have many gene copy numbers for salivary amylase, and up to 60% of the protein in the saliva is amylase. So that they really get started digesting starches, just by chewing before they swallow. And other people may have very few copy numbers. And they may not digest starches as well. And it is an evolutionary thing, because people with these high copy numbers that that are able to break down starch well by chewing, they also seem to be better adapted or equipped to control blood sugar in the bloodstream.

Lindsey: Interesting. Of course, that’s assuming they chew, unlike my son who swallows his food whole.

Dr. Norm: Oh, I know. And you know what? He’s young, he can.

Lindsey: He can afford to. Right, so I keep telling him it’ll hit you in your mid-20s.

Dr. Norm: Right, but good point. Chewing really well, eating really slowly, it’s probably the best thing you can do. And just assume that maybe if you have trouble with starches, you may be one of those people that doesn’t have a real high number of amylase gene copy numbers.

Lindsey: Yeah, it seems like there’s some people that do really well on a keto diet. They feel great. They have energy. I tried that for about a month. And it was a disaster for me. I was just beaten down. I’m just one of those people that has to have some starches in my diet.

Dr. Norm: Even if and I’m not pushing it, but I’m just kind of curious. Do you consume more fats when you’re on a keto diet?

Lindsey: Well, yeah, I was definitely trying to pound the avocados as much as I could. But you’ve got tofill in the calories with something.

Dr. Norm: So there you go, though. Hold on, right. You’re getting a lot of fats with the avocados. But you’re also getting a lot of fiber with those. And so there’s a lot of fermentable material in avocados. I personally, and most people I consult with, I probably wouldn’t ever have more than a third of an avocado and maybe less. There’s other fiber, it’s a superfood and the fats are great, but it has a good bit of fiber in it.

Lindsey: Yeah, I probably was having one a day I would guess.

Dr. Norm: Are you a vegetarian? I’m just curious?

Lindsey: No, I just have no gluten, no dairy. So that’s pretty much what I do right now. Omnivore. Well, let me dig a little bit more into the Fast Tract Diet. So what does it consist of?

Dr. Norm: When I first had that experience, and did a little research and wrote my first book, it was basically just go on a low carb diet. And that’s the answer. And that’s still a great answer for many today. And it just so happens that, while that diet might not be a great fit, like a keto diet for you, for a lot of people it is, it turns out, in study after study, it’s making great headway in randomized control trials for controlling blood sugar and reducing cardiovascular risk and inflammation. So this is a huge amount of positive research on the general health aspects of low carb diets. And I just lucked out with that, because for me, it made my reflux go away. So that was all I needed to know. But long term, I’m happy to say I really think the research for metabolic disorders, diabetes, weight loss is pretty good for low carb and ketogenic diets. So it could have stopped there. But I did want to figure out what was the most important part of diet for these functional GI issues for controlling these, what I’m calling, malabsorptive disorders. And so I was talking to a guy named Mike Eades (he and his wife Mary Dan Eades wrote “Protein Power”) one day. We lived not far from each other in Southern Cal. And he asked me a really important question. He says, “Well, I read your book. I believe you’re right.” He had heartburn himself that low carb really helped. He says “Which carbs do you think are really the problem?” I’m like, “Oh, okay. That’s a good question.” And so I’ve I ended up with a list of five: fructose, lactose, resistant starch, fiber and sugar alcohols. And I know that’s a lot but, don’t forget my final approach. You don’t have to eliminate them. You just need to limit them to the point where you can control your symptoms. So those were the five. The real challenge and what took me actually a number of years to work out was, how do you control those? If you can hold up any piece of food and say, I have no idea how much of these things are in this food, right? Like avocado, there’s more fiber. And fruits, there may be more of some starch, and bananas, but also certain disaccharides, and other fruits. And then starches, we talked about there being two different types of starches: amylose, which is hard to digest, and amylopectin, which is easy to digest. So how do you know how much of these five types of carbs are in all of these different foods? It was really a perplexing problem. But I felt I couldn’t come out with a diet book unless I understood a way for people to get at this question. Because otherwise, it was a research problem for every kind of like the FODMAP diet. There’s a lot of research papers on how much of these FODMAPs are in all of these different foods. It’s a huge effort. And I wanted people to be able to circumvent that. So I did finally come up with an approach that was based on the glycemic index and the nutrition facts. Because we know the glycemic index is a measure of how quickly carbohydrates from any food enter the bloodstream relative to glucose, which goes in the quickest, right? And so when you have the nutritional facts, the total carbs, sugar alcohols if they’re added to that food, you have the serving size, and you have the glycemic index or a good estimate of the glycemic index, say based on a very similar food, then you can calculate this value that I call the fermentation potential – FP. So you hear a lot of people on my different forums and so forth saying, “Well, how many FP points are in this?” And that is really a measure in grams per serving, of how many in total of these types of carbohydrates are in that food. So a lot of people treat it as kind of symptom potential.

Lindsey: How do you calculate it?

Dr. Norm: So it’s a manipulation of the glycemic index formula.

FP = (100 – GI) (Total carbs – fiber) + fiber + added sugar alcohols
…………………………..100               

Lindsey: And so then that number you get is your FP points?

Dr. Norm: Then that number is the FP points, right.

Lindsey: Okay, and you want to have fewer FP points, not more?

Dr. Norm: Well, right. More would be more like more prebiotic, right? And so less if you have a lot of symptoms that come from bacterial overgrowth, a lot of bloating and gas and these functional GI issues. Chances are you’re consuming too many.

Lindsey: Okay, so I’m really curious, an apple, how many FP points?

Dr. Norm: So an apple, let me see. So I, in addition to the writing the Fast Tract digestion books, one on heartburn and one on IBS, I also came out with the Fast Tract Diet mobile app. And so I have it with me right here. So in the search, apple . . .

Lindsey: I asked, because when I eat apples, I’ve realized that I can’t or shouldn’t be eating an entire apple. But that’s it just like too much whatever for me.

Dr. Norm: It’s fiber. It’s funny you should say that. In fact, in in this mobile app, we put in serving sizes that are a little bit smaller than some people might be used to. But it’s just our way of saying, you know, less is more when if you’re having these problems. So for instance, for an apple, I list an apple and the serving size is one half of a medium fruit. Right? And that’s 91 grams of apple, a half apple. The glycemic index is only 40. So you’ve got this low glycemic index. So that’s great for diabetes. It’s bad if you’re trying to put your microbes on a diet. And then it has total carbohydrates of 13 grams. Not too outrageous, right, but with a glycemic index of 40. And then add on two grams of fiber. There are no unnatural sugar alcohols. You come up with an FP or a fermentation potential of nine grams.

Lindsey: That’s a lot!

Dr. Norm: Well, it is a lot, right. It’s the weight of nine paperclips or whatever. But it’s a lot if you think in terms of how few grams of carbohydrates it takes bacteria to produce gas, right? For 30 grams of unabsorbed carbohydrates, bacteria can produce 10 liters of hydrogen.

Lindsey: Wow.

Dr. Norm: The beginning of the molecular food chain. Thirty grams equals 10 liters of hydrogen gas. So for your situation with that half of an apple, that would be a little over three liters of gas. So and your body is dealing with that, right? Some of that gas may be converted to hydrogen sulfide, some may be converted to methane, and that reaction reduces the volume. Some of it will be absorbed into your bloodstream and exhaled through your breath. So your body’s always trying to manage and deal with it. You might belch, you might have a little flatulence. All of these ways your body’s trying to manage that gas. But if you’ve got too much to manage, maybe a couple apple slices might be better than half of an apple.

Lindsey: So how many points do you recommend people restrict themselves to or is it more just a matter of figuring out “well, I felt bad at 30 points, so maybe I need to make sure my meals are no more than 15?”

Dr. Norm: Yeah, well, if you had the tool, and were doing it, then that would be great. It would be an empirical determination based on your symptoms. I guess at the beginning, people have no idea. So it’s good to have some basic ideas of what to do. First of all, for a very small person, they would have even less than a very large person. Everything’s scalable, right?

Lindsey: Right.

Dr. Norm: But generally, we’re on probably a fifth printing on the Fast Tract digestion books now, but when I initially wrote that book, I was saying oh, 25 to 30, 45 or even more. If you’re feeling great, even more points, and that’s where it was. Now people, our readers, and people that have joined us on the Fast Tract Diet official Facebook group (and I recommend to your listeners if they if they want to know more, they can just join this Facebook group – there’s over 11,000 members now and everybody’s chatting it up and helping each other out and here’s recipes and all this stuff.) But they are telling us, “Hey, hey, hey, when I have LPR”, which is particularly challenging condition, right, laryngopharyngeal reflux. Very subtle, but a persistent irritation of the throat, the vocal cords, you can have respiratory aspects of it, you can have plugged eustachian tubes. It’s very challenging to get rid of this, right. So they were starting to tell us, “You know what? For this, your 25 grams is out the window, I really needed to go under 20.” And some people said “I went 15” somebody else “I went 12”. So we started listening to the experience of our readers. And when we were working out the details for a protocol for this collaborative study we’re doing on 90 people with chronic acid reflux going off PPIs, we went in and reprinted the manual, reducing these points a little bit based on what people were telling us. So to make a long story short, I’d say maybe 25 is a place to stop. But if you’re really having problematic symptoms, maybe going lower.

Lindsey: And that’s per meal, right?

Dr. Norm: That’s per day, per day.

Lindsey: Wow. So you are talking about seven or eight per meal? Don’t you, you were the one that pointed out how many grams of fermentable material that is.

Lindsey: So is that basically putting people on a keto diet?

Dr. Norm: Well, no. But keep in mind, hold that thought. Keto and other means, fasting, there’s a whole lot of different troubleshooting things you can do. So for some people that are really in the throes of this thing, there’s some troubleshooting sections in the book. And in the mobile app, there’s a bunch of mini chapters in the mobile app that have some troubleshooting techniques, and one of them is just in general, a low carb diet or a ketogenic diet or some fasting. But because even when you’re low in points, there are some higher carb foods that are very low in points. And that’s because they have a very high glycemic index.

Lindsey: So you can eat white bread, right?

Dr. Norm: White bread is right, relatively low. And you know, unless you have celiac disease, or sensitive to gluten, or jasmine rice and Asian sticky rice or sushi rice. They’re very low and points because they have a very high glycemic index. So don’t eat too much if you have blood sugar issues, but they are lower in points. Now, here’s where the troubleshooting section can come into play the FP calculation. It’s a very good way to compare one food to another in terms of which one would be easier to digest, and how many carbs and how many points. However, what we don’t know right now is how well people with digestive health issues, what would the glycemic index be if we tested them in those people? Because right now to get one of these glycemic index values, a single food is tested in 10 healthy people where they give them glucose first and then they measure all their blood levels of glucose. And then they give them the test food, and then they measure their blood sugar levels over time. And then they compare the area under the curve of the test food to the glucose to get a glycemic index. But if it was a person with IBS, SIBO, LIBO, SIFO, dysbiosis, pancreatitis, cystic fibrosis (they also have trouble releasing enzymes from the pancreas), the glycemic index might be lower for those people. So that’s why in the book, and in the app we do with caution and that’s why we say half a cup of rice, try a half a cup of rice. Make sure it’s fresh, make sure it’s moist and fluffy. That’s the best chance you have. And make sure it’s either Jasmine or sushi or one of the lower FP rices. Eats really slowly and chew really well. And see if you have symptoms because you may not be ready for it if you have some issues with say, one of the things we talked about, brush border, pancreatic enzymes, salivary amylase, etc.

Lindsey: Okay, I want you to tell me again, the five sugars that you’re supposed to be wary of?

Dr. Norm: Yes, they are lactose. And of course some people are lactose tolerant, right.

Lindsey: Not me!

Dr. Norm: Not me either.They’ve got the gene stuck in the on position. But you know, well over half the world’s population is lactose intolerant, adults, so lactose, fructose and fructose malabsorption is well documented again, many, many people around the planet are fructose intolerant. Lactose, fructose resistant starch, which is several types of starches, and some types of resistant. And the amylose type we talked about is one of the more resistant types. It behaves like a fiber, so resistant starch, fiber, and there’s many, many different forms of fiber, as I know, from listening to some of your podcasts, you know all about, and with many different qualities and properties. So all fiber, initially to get symptoms under control, is included, as well as sugar alcohols. And sugar alcohols are also well documented, just go to the FDA website, you can read about those, how many problematic digestive symptoms you get.

Lindsey: Oh, yeah, I know all about it, but I put up with it anyway.

Dr. Norm: But there’s one exception. Erythritol is a sugar alcohol. But it’s not metabolized by bacteria. There’s been some good studies looking at that. And so most of it is excreted unchanged from the body.  So for sugar alcohols, it is an exception, and natural sugar alcohols, you know, we do recommend those as one of the low FP sweeteners. You could use that and monk fruit and stevia and things like that. But erythritol is a good one. Now, not everybody agrees with everything I said. We had a reader just the other day write to me and say, “How could you have erythritol in your diet? I just can’t believe it. It’s terrible.” And so I wrote back and I said, “Well, here’s a link to a paper, it talks about how bacteria don’t ferment it, and so forth.” And she came back with another paper. And she said, “But you do know this paper shows that it impacts and reduces how well fructose is absorbed.” So it’s interesting, we continue to learn from our readers. Fructose, at least according to this one study that she sent me a reference on, fructose is absorbed twice as slowly in the presence of erythritol. So yes, we’re learning from my readers. But I still think erythritol is a great choice, as long as you’re not consuming a lot of fructose.

Lindsey: It’s funny because I feel like I don’t really do well on erythritol at all. Like it kind of makes me feel nauseous. But I do better on xylitol.

Dr. Norm: Lindsey, that’s really interesting, because in studies that looked at erythritol with other sugar alcohols, the other sugar alcohols were just way worse in terms of gas and diarrhea and bloating. Erythritol had none of that. But I do happen to remember that some people in that study with erythritol did feel a little nausea. So that may be something. Yeah, I, for some reason, don’t have any problem with it. But that’s interesting you said that, because I do remember that in the study.

Lindsey: Yeah. And if you if you have to choose your poison, I’ll take a little bit of a soft stool over nausea.

Dr. Norm: Yeah, nausea’s a real uncomfortable feeling.

Lindsey: Yeah, it kind of makes you not want to eat your dessert that you’ve carefully crafted. Okay, so I want to dig a little bit more into LPR because I think that that is what I had. Now 30 years ago, I saw a doctor and had a constant cough and no acid reflux feeling. I never felt acidy in my throat, but I did eventually start to feel my voice changing and that kind of thing. You know, I was on PPIs for 15 or 20 years straight.

Dr. Norm: I didn’t know that. Wow.

Lindsey: Yeah, at the very beginning, they were giving me asthma inhalers and that kind of stuff because of the cough and looking for causes of the cough. And then finally, somebody said this may be acid reflux, but is LPR a new diagnosis? Because back then nobody had name for that.

Dr. Norm: It’s been around for some time. Jamie Coffman, doctor in New York City, she’s also done some research, published least a couple of papers on it. She has a different diet approach. It’s a low acid diet to deal with this idea that when people have reflux, some of the the pepsin from the stomach, an enzyme that breaks down protein, will stick to the tissue in the throat and can become even intracellular. And then when you eat very acidic foods, you can turn it on. It’s only active at acidic pH, so she recommends a low acid diet and this Acid Watcher Diet is the same idea. So yeah, it has been known. Maybe it hasn’t been as popularized as acid reflux, but it is quite common. Of course the Fast Tract Diet is a different approach, right? It’s saying yeah, go ahead and sip some alkaline water if you want to take advantage of those ideas, with the pepsin. But really, you want to eventually stop the reflux so that you won’t get pepsin and other things up into your throat, and your lungs and your airways and your eustachian tubes and so forth. Thanks for pointing out some of those symptoms, right? Yes. Cough, sore throat, feeling like there’s a lump in your throat that drives you crazy, even though they  look down there and say there’s nothing there.

Lindsey: Oh yeah, that was me with any kind of lactose.

Dr. Norm: Yeah. And by the way, these respiratory issues, asthma, COPD, also strongly linked with acid reflux. So no surprise there.

Lindsey: Interesting. So I assume on the Fast Tract Diet, there is a period of time in which you’re kind of going super low FP so that you can get some of those bacteria to die down, and then you maybe ease back up. Is that sort of how it goes?

Dr. Norm: Yeah, so people, practitioners, and so forth, that worry about people being on a low carbohydrate diet, they’re a little more quick to say, “Okay, you’ve been on this two weeks, you need to really expand your diet, you need more carbs, and eat more of this and that.” I don’t have that kind of fear. Because I do think, just from my 15-16 years in this area of study, being close to the low carb keto community, I really do believe low carb and keto is a safe and healthy diet. So I don’t worry that much about people rushing to get to add more carbohydrates. I do recommend a good variety of lower carb, low FP plants, and fresh herbs. And if you were to look at the Fast Tract Diet mobile app, it has all of these different categories for foods, and if you look at it, I just clicked on the vegetable table, they’re all listed by FP points. And you would see that there’s probably about 50 that are under three or four points, so that there’s a huge diversity of vegetables at a low FP. And then they gradually do start going up and then you get to the more starchy ones and more fibrous ones, and you get to plantains, they do get to be higher and higher. So I do still recommend people eat a lot of plants, but lower carb, green leafy, lower FP, and there are great numbers to choose from. Also, by the way, if you’re into legumes, sprouted legumes are also very low. But I let people ramp up on their own, when their symptoms allow it. I just want them to trust this method to control the symptoms. And once they get that down, I really feel like they can manage, you know. Then they say, “Alright, well, I feel better, I’m gonna. . .”, and then they try all these things and go out for a weekend and eat French fries, and this and that, and at home they’re going to be like, “Oh, man, that was wrong.” But they’re able to, I think, do it on their own. When I consult with people, I provide extensive written recommendations. So the first session, people might get six to eight or nine pages of notes. Usually, I’ll consult with somebody, at least, maybe two or three sessions, give them notes for every one. So they’ll always be able to go back to those notes, no matter what happened, or when they’re on holiday or seeing the family, they can just always kind of regroup and say, all right, I need to really kind of go back to the basics.

Lindsey: So I wanted to ask about low stomach acid, because that is, you know, in the functional medicine community, one of the causes that is often cited for acid reflux, as opposed to high stomach acid. Do you think that that has validity? Or do you think that it’s just a misdirection?

Dr. Norm: I do. In fact, one of the first things that I do when I work with people is I do an assessment. You know, of course, if every drugstore had a Heidelberg acid test, and you could just bring it home and take it and just okay, just do that. But as you likely know, there’s not a lot of practices that do this, unfortunately, because I do think it’s a hugely important test, with a dangled the pH capsule on a string. You swallow the capsule, but it’s still dangled in your stomach, but it’s being held there by a string so it doesn’t move, right. And that capsule is radioing out pH activity in your stomach to a receiver and a laptop on the practitioner’s desk. And so for most people, it’s going to say the pH is one or two, it’s very, very acidic. And then they give you three or more bicarb challenges, right? We drink this solution of bicarbonate and then you can see the pH. Just watch it on the laptop. The pH goes from two, goes flying back up to seven or eight. And then the question is, how long is it going to stay high like that? That’s what they want to know. If you re-acidify quickly and you can do that several times, you don’t have low stomach acid, right? If you’re very slow to re-acidify, or you have a not a very acidic stomach to begin with, or it takes too long to re-acidify, then you will almost certainly be diagnosed with hypochlorhydria, or even achlorhydria. So that’s what you want to know. But how to get at it when a lot of people don’t have easy access to practitioners that have that test? So what I do is a risk assessment. And I look at what are the potential causes for low stomach acid? Right? And from listening to your stuff I think you’re aware of these too, right? But here, these are the questions I ask because a lot of people will know the answers to most of the questions and if not, they can be tested. So first of all, do you have any autoimmune conditions? So a lot of people may have Hashimoto’s, or this or that. But autoimmune conditions don’t tend to occur in isolation. And so if somebody has an autoimmune condition, then I might suspect pernicious anemia, right? Autoimmune atrophic gastritis, where your own immune system is attacking the parietal cells that produce this acid. And those same cells produce intrinsic factor for absorbing vitamin B12. So if somebody had a significant autoimmune reaction, it would make me wonder about that. And there’s a quick blood test you can get for that, by the way, it’s not as far as the Heidelberg test.

Lindsey: Pernicious anemia, you mean?

Dr. Norm:  B12 levels. But you could have versions of autoimmune atrophic gastritis, where for one reason or another, your B12 levels are okay, and some people are supplementing and all of this, but you want to know whether your parietal cells are being impacted. And so there is an anti-parietal cell antibody assay, it’s a blood test. So it’s available. So that’s one. Next one is, of course, H. pylori, right, because most people won’t know if they’re infected with this bacterium. But it burrows through the mucus in your stomach, it attaches to the lining, and there it sits in these little colonies. So it’s not a diffuse infection. It makes little colonies and where those colonies are, over time, your stomach lining gets damaged. So if they happen to be in the area of your stomach with these parietal cells, chances are you will get atrophic gastritis eventually, if not an outright ulcer, and the inability to produce adequate stomach acid. So for so many reasons, beyond just stomach acid, I do always recommend if people are H. pylori positive to go ahead and suck it up and take that antibiotic treatment to get rid of it. Because you just don’t, especially older people, and I’m putting myself in that bucket, we don’t want to have that bacteria as we’re getting older. So that’s the second one. The third one is, are you taking a lot of NSAIDs, non steroidal anti-inflammatories, because they will irritate the stomach. They can lead to gastritis for that matter. They can also lead to NSAID enteropathy, make tears and damage the small intestine as well. But in terms of the low stomach acid, you have people that are abusive with these NSAIDs, they may want to be checked again with something further like a Heidelberg acid test. The other one is alcohol. And I’m not talking about moderate alcohol, but people that have really done a lot of binge drinking or alcoholics; that can certainly have an impact. And then things that most people won’t have; any kind of bypass or stomach surgery or stomach cancer. But that’s usually where I where I start, and I just want to know if they’re at risk for it or not before wasting time pursuing that further.

Lindsey: Now, the NSAID piece surprises me a little only because I know that when I, because of my sciatica, had to take NSAIDs and there was nothing else I could do, I was in too much pain and was taking like six a day against all my best knowledge and wisdom. But I was taking about six a day and ultimately started feeling pain in the same place in my stomach every time I took them and I knew I had to stop because I was on my way to an ulcer if not already there. And then the recommendation at that point is to go on acid reducing drugs to try and just heal up your stomach lining.

Dr. Norm: Right, I know that’s been explored. And unfortunately, many things are wrong with long term use of acid reducers but that’s right.

Lindsey: Right and I didn’t use them long term in this case, I used them until the pain went away basically and then some Culturelle probiotics.

Dr. Norm: Oh there’s another interesting area of research and by the way with NSAIDs you know the other thing people can do if they must take them, it’s just make sure you always have plenty of food in your stomach when you take them.

Lindsey: Yeah, which isn’t possible when you’re trying to take one right before bed and you’ve got it   scheduled three times a day, right? And they only last eight hours at the longest.

Dr. Norm: Another area of research that’s very interesting and you know like a lot of people, I’ve been looking over the last few years into what’s this hydrogen sulfide all about. People seem paranoid about it and, are my bacteria, the sulfate reducing bacteria, are they making all this hydrogen sulfide gas? My farts stink, I must have it. And oh, I’ve heard it’s going to give you chronic diarrhea and all of these problems with it. And so most people and practitioners have this big concern about hydrogen sulfide. But there is another side to this molecule. First of all, bacteria make it in our gut and not just the sulfate reducing bacteria, some proteobacteria make it, some bacteroidetes organisms produce it. So a lot of organisms have the pathway to use this trick to take hydrogen as fuel. Instead of making methane, they make hydrogen sulfide. But aside from this worry about, do I have pathological levels of hydrogen sulfide, there’s a whole other side to hydrogen sulfide, in terms of its ability to help heal wounds. It is a regulatory molecule in the body. There’s a lot of research going on to see that they might be able to come up with hydrogen sulfide releasing or promoting supplements that would help people when they have to take NSAIDs, prevent the bad side of them. So that I think is really still just an area of research. But I think it’s one that’s really great to follow. What’s the positive side of hydrogen sulfide, by the way? When hydrogen sulfide gets out of the gut, it’s very, very quickly changed into something else other than hydrogen sulfide, because it is a toxic molecule at high levels. But the body has mechanisms for dealing with that. Quite effective.

Lindsey: Yeah. So, you know, I’m always struggling, back to the whole stomach acid issue, though, like with the idea that you may have someone who’s absolutely convinced that they have high stomach acid, that the doctors have told them, they put them on PPIs. They feel burning in the chest, Barrett’s esophagus, this kind of stuff. And then to say to them, I think you may have low stomach acid. Take more stomach acid. It’s a tough sell.

Dr. Norm: Yeah. And I’m glad you’re a good interviewer, because you pull things back to LPR. I tend to drift. So you got us back on topic there. Yeah, let’s talk about PPIs and stomach acid in terms of LPR, because the most common prescription for LPR is a PPI? Yeah. And you will find a person here or there that says, well, it does seem to help helps my LPR to be on a PPI. But most people will say no, it’s not helping. And in fact, when you look at the studies, and if people go to digestivehealthinstitute.org, I wrote a couple blogs on LPR, but one of them in particular is talking about PPIs, and their ineffectiveness for LPR. So this question has been studied very well. PPIs for LPR are no better than placebo. There’s  studies on it, there’s metaanalyses of studies on it, it is no better than placebo. And so why is that? And it may be the same reason. PPI drugs, acid-reducing drugs are also no help for asthma. Asthma is another reflux linked condition. In a way a lot like LPR. There was one study in kids that showed 80% of children with asthma have chronic acid reflux. So with LPR and COPD, and as we know, there’s a strong connection with reflux, right. But there was a study done called The Sarah Study. A thousand kids were in the study with asthma centers all over the US, and they put them all on Nexium. And they had to come out at the end and say, “Hey, everybody listen up,” something like 120 authors on this paper, “Hey, I gotta tell you y’all, didn’t work at all for asthma.” Right? And so you can read this paper on The Sarah Study, it’s crazy. The final conclusion was, Nexium did not help asthma, so acid reflux must not be the cause of asthma, which I thought was just such a bogus conclusion.

Lindsey: Right, or, Nexium doesn’t help acid reflux.

Dr. Norm: But here’s the thing. All they had to do was look at some other studies on, for instance, fundoplication operations when you tighten the LES (lower esophageal sphincter). And it’s invasive, I’m not recommending it, but it’s a proof of principle.

Lindsey: Okay, wait, before you go on, can you define a little bit more what that means?

Dr. Norm: Yeah. So there are various ways to tighten the muscles, the group of muscles right at the top of the stomach, called the lower esophageal sphincter muscles. So the bottom of your esophagus, before food goes into your stomach, it has to go through this group of muscles called the LES, and they relax when you swallow. They relax and let the food go through, and then they tighten up again. But for some people, there’s a thought that well maybe it gets looser and so forth. Well, I have a different theory for that, that it’s being driven by gas pressure, as I told you. But people that do have reflux, and in this case, asthmatics with reflux, when they did fundoplication operations that tighten up these muscles and don’t allow you to reflux much, they did better, and they could reduce the medicines. So that proves there is a connection with reflux. And so I think what the study did prove is that acid might not be the most important thing in the refluxate, either for LPR, or for asthma, that it’s something else. And what are those other characters, what are those suspects? And I think that you can look at bacteria, bacterial end products, digestive enzymes and things from our own gut. But I think one of the chief suspects in my mind is bile. And bile wasn’t focused on that extensively in reflux by a lot of people. And possibly because it’s released in the duodenum, past the stomach and thought, well, why would that much bile even be the reflux? But when they look, they find it. And of course, with my theory of reflux that is basically saying it’s from carbohydrate malabsorption, gas building up in your intestines, that that theory basically entails reflux starting at a much lower point in your intestines. And so you would expect bile and other things from your digestive tract to be in the refluxate. And it is.

Lindsey: Yeah.

Dr. Norm: So first of all, I think they should get off the PPIs. And try the Fast Tract Diet. That’s my first advice. Or work with myself or somebody to really go look at these 25 to 30 potential underlying or contributing causes of reflux and other functional GI disorders. But just a quick tip, based on that idea, is you and your doctor, maybe just bring up the topic of bile acid sequestrants. If you think you have a bile issue, there are drugs you can take. Prescription so I couldn’t prescribe them, but a doctor could, that tie up some of this extra bile. Maybe that would help. But I think in the long term, what you really want to do is get control of reflux.

Lindsey: Yeah. Now I can attest to the fact that when I had reflux, and I coughed up, like my sputum in the morning was brownish, like bile. So I don’t know if that’s what that was. But anyway, I remember that, but it’s been so long since I had that. And really, for me going off dairy was the main contributing factor to it going away. And that allowed me to go off PPIs.

Dr. Norm: And you know, with dairy, it’s not just the lactose.

Lindsey: Yep. It’s casein.

Dr. Norm: You know all about these oligosaccharides in milk?

Lindsey: Yeah. No, I had I had issues with all sorts of things in dairy.

Dr. Norm: Yeah. Right. Well, there’s lactose, there’s oligosaccharides. And then there’s intolerance. It’s to the proteins themselves, which is less common, but maybe you did have them.

Lindsey: Yeah. Well, you know, we have gone a bit over time, so I probably should not take any more of your time.

Dr. Norm: Really? Wow. Man. I really like talking to you, time flies.

Lindsey: I know!

Dr. Norm: This has been a pleasure for me. Thank you.

Lindsey: Yeah, well, so obviously, I see you sell your books and your app and your programs and you see individual clients like I do for gut health issues. So we’ll link to all that stuff in the show notes. Anything else you want to mention before we go?

Dr. Norm: No, I think you did a great job. I’m open to, there are so many great studies, and I’m open to talking about all of them to see if we can really as a community increase our understanding. And like I said, we learn a lot from people on our Facebook group, from readers, from feedback, from working with people one on one, so I really feel lucky to be able to do this with my career at this point. Plus it got me out of the corporate realm. Again, just remind people, they can join us at the Fast Tract Diet Official Facebook group, 11,000 members, so a lot of good stuff going on there, and they can find all of our information or links to it on digestivehealthinstitute.org.

Lindsey: Okay, great, I’ll link to that in the show notes. Well, thank you so much. I appreciate you coming on the show.

Dr. Norm: My pleasure, Lindsey.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

Excerpts from my podcast Interview with Dr. Russell Jaffe, MD, PhD, founder and chairman of Perque Integrative Health LLC. Listen to Episode 40 of The Perfect Stool.

Life Guard Multivitamin, How Much B-Vitamins Should I Take and Avoiding Genitourinary Issues

Lindsey: So I actually heard you speaking on another podcast before your folks reached out to me. And I realized that I was already taking a Perque product. It’s the Life Guard Multivitamin (find at Fullscript). And I was really happy because when I heard the way you talk about your supplements, it made me feel like I’d be a fool to be using products from any other company.

Dr. Jaffe: We did a double-blind, placebo-controlled trial to show that our Life Guard Super Multivitamin, which actually replaces more than one product for most people, is more bioavailable because it has more active, more enhanced uptake, and less what I would call binders, fillers, flowing agents, glues and other stuff that is in most supplements for reasons of profit, not reasons of value.

Lindsey: Yeah, and it’s not unreasonably priced either. So it was a good choice for me. And I think the reason I selected it was that it had a high level of the active B vitamins.

Dr. Jaffe: Right. So it’s a super B complex, complete B complex, and a super mineral, which is usually a separate formula. It’s got 40 active ingredients in meaningful amounts because you need them all.

Lindsey: Yeah, I take two a day and I feel good about that.

Dr. Jaffe: And hopefully you keep your urine sunshine yellow, while being well hydrated.

Lindsey: It’s the B vitamins that turn your urine yellow, right?

Dr. Jaffe: Oh, yes, it’s specifically riboflavin. And I want your urine to be sunshine yellow. If it’s glass clear, you’re deficient in something, right?

Lindsey: So what you’re seeing is the excess B vitamins coming out in your urine that you don’t need?

Dr. Jaffe: No, no, not excess! B vitamins that protect your kidneys and your bladder and your genitourinary system. There’s a lot of problems that happen in later life in the genitourinary system. And you can avoid them if you bathe it in the right kind of nutrients for life.

Lindsey: Ah, okay. So I always thought that that was because I was taking too much. But you’re saying that’s just like a good healthy thing?

Dr. Jaffe: Yes. I’m saying that you want to protect your kidneys, your bladder and the rest of you. And the answer is, yes, most of us are deficient. And when deficient is common? Well, we go around saying “well, everyone’s deficient, who cares?” I do care and it makes a difference.

Food Sensitivity Testing with the LRA/ELISA Tests

Lindsey: I wanted to start with a question about an area that comes up with a lot of clients of mine, which is food sensitivities. Can you tell us about the technology that you invented to test for delayed reaction sensitivities, including food sensitivities?

Dr. Jaffe: Right, so the reason that we brought together cell culture, and amplified reactions in a single system, after many people tried and didn’t, was we needed an ex vivo (meaning outside the body) test:  reacting in the laboratory just as things happen in the body. So we needed an ex vivo specimen and we needed to validate the procedure. We did that in the early 1980s. We’ve done over 80,000 cases. We’ve done over 25 million cell cultures. We are the gold standard for functional immunology, especially T cell reactions, which turned out to be more important than the antibody V cell reaction.

Lindsey: And so that’s the technology that you use for the ELISA test? Yes, it’s ex vivo, which means in the laboratory, cells react just as they do in the body. It’s a cell culture; it’s not red and blue and dead. It’s not stained, it’s not dried. It’s not something can just put out your hand and take a specimen and get a result. Because a number without a meaning is meaningless. We produce meaningful results over 30, 40 years now. We want to provide the meaningful results for what you should eat and drink, what you should think and do based on what each of us needs, because that is kind of personalized.

Lindsey: So can you touch a little bit on the difference between a food sensitivity and food allergy?

Dr. Jaffe: A food allergy typically means an immediate reaction. For example, the bee stings you and you drop in anaphylactic shock. And I say, well, you must have a hymenoptera venom hypersensitivity. That’s type one. But then there’s Gell and Coombs, two guys who basically articulated the language of the immune system along with a guy named Lujerne. They all got Nobel prizes. So dumb, they were not. And they pointed out that there are antibody reactions. These are from B class cells. B cells become plasma cells that produce antibodies. Now, are those antibodies helpful and neutralizing and memory? Or are they complement fixing and harmful? When you do a serum test, you don’t know; only when you do a cell culture test to distinguish good from bad B cells. But more importantly, you also get immune complexes and T cells in the same cell culture. And that was our pioneering effort, so that we could open up the black box of the immune system. Because what we knew when we started was that if the immune system is happy, you’re happy and you live long and well. And if your immune system is unhappy, we can whack it, like with dexamethasone, which may or may not be helpful.

Lindsey: So would you recommend the ELISA/LRA test to a person who has a highly reactive gut and seems to be reacting to everything they eat? Or would it be better to try and heal up what’s likely a leaky gut before testing for food sensitivities using the LRA?

Dr. Jaffe: I think that’s a very appropriate question for someone like me, because you would think I would say everyone needs what I do. But I’m not going to say that. I think you can start with 4 self assessments, you can start with betterlabtestsnow.com, which is a consumer portal to get information, inspiration and accurate interpretation of where you are. What if your hemoglobin A1C, for example, is less than 5%? What if your high sensitivity C reactive protein is less than 0.5? What if your homocysteine is less than 6? Well, then I would interpret your results differently than if the only thing I had was food sensitivity. Now we have the gold standard of delayed allergy. But delayed allergy is only a big part, not the entire part, of digestive issues. And John Hunter, very important guy in the United Kingdom, pointed out that there are intolerances. For example, let’s say you acquire a lactose intolerance to milk sugar. That’s not immune. But it will make you unhappy. That’s for sure.

Lindsey: I’ve got that. And I can tell you it makes me unhappy.

Dr. Jaffe: Haha, yes, unless you take lactose free milk. So you could put an enzyme called lactase on a column, pass the milk through that, the lactose becomes something else, but not lactose. And now it’s okay. And I’m pretty sure in most healthy markets, there is a little section called lactose-free milk. And by the way, I actually recommend you make your own almond milk at home or cashew milk – after you ferment your own cashews.

Lindsey: Okay, so at betterlabtestsnow.com you’ve at got these tests, but what should people look for first at that website?

Dr. Jaffe: Well, I think where they should go is predictive biomarkers. Tell me where you’re strong. And I’ll celebrate. Tell me where you’re weak. And I’ll tell you what to do.

Lindsey: I actually found on that website, the LRA test and saw that they ranged in price from about $397 to $1725 for the most Deluxe one, but all of them included foods, environmental chemicals, food additives and preservatives, molds and food colors.

Dr. Jaffe: If you want the everything test, it’s at the higher end, if you want selective testing, that’s an option. We provide the best quality of the best testing; you decide how much testing you need.

Probiotics, Prebiotics and Symbiotics

Lindsey: So tell me about some of the products that you designed for gut health and the research on their ingredients.

Dr. Jaffe: Well, in regard to gut health, we’re talking about prebiotics, probiotics and symbiotics. Prebiotics is fiber. Probiotics are bugs, but alive. Symbiotics is recycled glutamine. And now I’m going to paraphrase Dr. Denis Burkitt. He first won the Nobel Prize for Burkitt lymphoma. And then he had so many invitations to talk to journalists and others that he actually disconnected his phone and he went to Kenya. He became a missionary, a medical missionary, Nobel laureate. How many Nobel laureates do you know decamped to Kenya? And what he noticed he taught me personally. He said, “You know, when people there (like East Africa), when they live a traditional diet, which is high fiber, it’s somewhat subsistence, it’s feast and famine. There’s no irritable bowel syndrome. There’s no ulcerative colitis, there’s no mucal enteritis. There is no leaky gut, there are no digestive problems. It’s when they move to the city. And they have the challenges of the toxins of urban living. That’s when these problems occur. So we need 40 to 100 grams of fiber. That’s the prebiotic fiber, 40 to 100 grams a day of unprocessed fiber. And we need 40 to 100 billion healthy bugs. Isn’t that interesting: 40 to 100, 40 to 100. Different a little bit, but not much. One is fiber, and the other is bugs. And then we need recycled glutamine.

Lindsey: And what is recycled glutamine?

Dr. Jaffe: Well, glutamine is a very important amino acid. It’s the source of energy for your enterocytes, the cells that line your intestines, and make your leaky gut go away. But glutamine goes to glutamate unless you recycle it. So we actually pioneered how to recycle glutamine about 10-fold. So now you give 1.5 grams rather than 15. You give that on rising and before bed because it’s an amino acid recycled by PAK. PAK is called pyridoxyl alpha-ketoglutarate, if any of you are biochemists.

Lindsey: And so what is the product that you sell that is the recycled glutamine?

Dr. Jaffe: Yes, thank you. It’s called Endura/PAK guard (find at Fullscript).

Lindsey: And if you are eating plenty of protein, would you need something that provides glutamine?

Dr. Jaffe: The amount of protein that an adult human needs is 60 to 70 grams a day. And when you go above 60 to 70 grams a day, you add acid. Because the excess amino acids become keto acids, you’ll lose ammonia, that ammonia is lost in the urine, sweat. And still, it’s part of why people sweat in ways that are, shall I say, unpleasant?

Lindsey: So your probiotic product, I noticed that it doesn’t list the strains, but I presume that you’re using those strains that are numbered and researched?

Dr. Jaffe: First of all, we do have 10 billion active CFU (colony forming units). Ten active strains, between acidophilus and bifidus and strep thermophilus. What we do not include are the individual, proprietary, and shall I say manipulated strains, because we follow nature and nurture and wholeness. (Find Digesta Guard Forté 10 at Fullscript). We don’t follow vogue. And I don’t mean just Vogue magazine, I mean, scientific vogue. I mean, the fact that today people are looking for the magic probiotic that they can patent. I don’t think that’s actually a good idea. I think that that probiotics, prebiotics and synbiotics should be available to promote healthy intestinal digestion, assimilation and elimination.

Lindsey: Okay, so in other words, the strains that you’re using are more sort of general?

Dr. Jaffe: Not only they’re more general, more active. We actually harvest our strains in what’s called log phase, which means doubling. Wouldn’t you like a more potent probiotic? Well, most of what you get in almost every other probiotic is yogurt, freeze dried, or dried, and then powdered, and then put in a capsule. And by that time, by the time you get to plateau, by the time you get to too many organisms and too little nutrition, they’re cannibalizing each other. And when you cannibalize each other, you immunized the probiotic, so many people who are taking probiotics (and so need probiotics) are actually getting immuno probiotics, which we really, really, really don’t recommend.

Lindsey: And so you said they’re in a log phase. Can you explain a little bit more what that means?

Dr. Jaffe: Log phase means doubling 2, 4, 8, 16, 32, 64, 128, 256. I can’t go much above that. But doubling. There is a point where when you grow the organisms in the culture medium, they double, double, double, double, and then they plateau. When they plateau it’s easy to harvest the maximum number of bugs but they’re mostly dead and not only dead, they’re immunizing dead, and that’s a double harm.

Lindsey: What does that mean they’re immunizing?

Dr. Jaffe: Oh, immunizing means that they’re cannibalizing each other to the point where they leave remnants behind that will burden your immune defense and repair system, including endotoxins that my friend Ron Alene pioneered in the 70s. If you know about endotoxin, look up limulus crabs. My friend Ron, who still is a friend and a colleague, would go out once a year to San Diego –  La Jolla, which we all thought was a nice place to visit, in order to harvest limulus crabs to get their fluids so that he can have a year’s worth of endotoxin assays back at the National Institutes of Health.

Lindsey: What are assays?

Dr. Jaffe: Oh, assays mean tests.

Lindsey: What’s the prebiotic product that Perque makes?

Dr. Jaffe: The prebiotic that Perque makes is multiple sources of unprocessed fiber called prebiotic fiber (Regularity Guard – find at Fullscript), because it nourishes the beneficial bugs in your gut. But it’s not bugs. Those are the probiotics.

Lindsey: Okay. And there has been some research of late that pointed to the idea that taking probiotics after antibiotics might not be a good idea because it takes longer to return to your base microbiome. But the people that I’m dealing with as clients already have a very disturbed gut microbiome that probably we don’t want to return to. So can you just comment on that research? And when it’s appropriate to use probiotics?

Dr. Jaffe: When I explain it, this is my answer. None so blind, as those who will not see. What I mean by that is you have very smart microbiologists and other scientists who are pathology oriented and not physiology knowledgeable, and they don’t know their elbow from a hole in the ground in regard to what we’re talking about. Because the whole conversation has changed in the last two or three years, because we’ve actually learned a bunch in the last two or three years. And so if you go back even five or 10 years, you can actually make recommendations than I am very sure will harm and not help. So this notion that oh gosh, we need antibiotics. Oh, and let me stop at that point. I’m a licensed medical doctor, at least in several jurisdictions like New York and California. I have never had a problem with my medical practice, because people have gotten better and not worse. And no, I haven’t given antibiotics in the last 30 years, probably more, because people didn’t have an antibiotic deficiency. What they had was a deficiency of the good stuff. So we give the good stuff, in sufficient amounts to crowd out the bad stuff. And guess what? That works.

Lindsey: So say somebody had a urinary tract infection, what would you give them?

Dr. Jaffe: Again, such really astute questions. Now say you have a person, more likely a woman than a man. But let’s say you have a person with a UTI, or a urinary tract infection, the first thing I would give them is a simple sugar called mannose. Why? Because there is science. And by the way, there’s good science and there’s bad science; I only want to talk about the good side. There is good science that says if you give this simple sugar called mannose, then some of the harm of a urinary tract infection can be reduced, while hopefully you restore the imbalance of the immune defense and repair system.

Lindsey: I actually have some of that mannose in my in my cupboard, and I’m curious what kind of doses do you need to actually begin that process?

Dr. Jaffe: Again, very good question. Let’s say you have a UTI and you’re irritable, for whatever reason, in that region of the body. I’m pretty sure that if you if you don’t take half a gram twice a day, it’s almost homeopathic, which may or may not work. And there are people who will give you 5 grams. And I don’t think that’s a harmful thing because mannose is one of those sugars that’s not metabolized. It’s not like glucose, it’s is not like fructose, it’s not a harmful sugar.

Lindsey: And how does it work? Does it attach to the bacteria and carry them out?

Dr. Jaffe: It prevents the bacteria from connecting with the wall of your genitourinary tract and therefore irritating it. You know, it prevents the connection. It basically pushes things away.

Lindsey: And so that on its own could clear a UTI?

Dr. Jaffe: Let me say three things about that. First of all, most urinary tract infections are not accurate. When you have a count of 50,000 bacteria in a urine specimen in regard to a urinary tract infection, I am 100% sure from running the labs at the NIH, that that means you didn’t have a clean catch. You didn’t have a sterile specimen. Only when you have a lot of bad bugs and not just bugs, you have to have a lot of bad bugs. If you have a lot of bad bugs, I want to get them out. If you only have a few bugs, I’m not sure. In fact, I’m very sure I wouldn’t treat a result without a meaning.

Lindsey: Given you have an accurate test, is mannose sufficient to clear UTI at appropriate doses?

Dr. Jaffe: Without question, mannose will reduce the symptoms. It is not alone sufficient.

Lindsey: And so would you add probiotics to that?

Dr. Jaffe: Well, since I’m a physiology before pharmacology physician, since I’m a scientist and not just a mystic, everyone, in my experience needs prebiotics, probiotics and symbiotics.

Lindsey: And if you are eating a sufficient amount of fiber, then you probably don’t need to take prebiotics, but few of us are actually doing that right?

Dr. Jaffe: 40 to 100 grams of prebiotic fiber means you’re chewing chili, and curry, and dal at almost every meal.

How to Help My Sciatica (and deal with inflammation in general) and Should I Take Curcumin Supplements?

Lindsey: So I actually have been going through sciatica and . . .

Dr. Jaffe: Is it really sciatica or is it? There’s an alternative, which is . . .

Lindsey: Yeah, it’s not piriformis syndrome, it’s really sciatica.

Dr. Jaffe: Okay, now, if it’s sciatica, you have an antioxidant deficiency, a magnesium choline citrate deficiency, and polyphenolic deficiency. Take them for three weeks and I want you to report back.

Lindsey: Okay, so I’m already taking vitamin C, but maybe not enough.

Dr. Jaffe: Based on a weekly C cleanse?

Lindsey: No, I’m not doing anything like to bowel tolerance.

Dr. Jaffe: What you’re thinking, my friend Bob Cathcart recommended bowel tolerance. I can tell you don’t do that. But do follow our recommendation for the C cleanse, one of the four personalized predictive biomarkers.

Lindsey: Right. And then magnesium, I’m already taking magnesium glycinate, 400 milligrams a day.

Dr. Jaffe: And your urine pH after rest is what?

Lindsey: I don’t measure that.

Dr. Jaffe: Until you do, you’re flying blind.

Lindsey: Okay, so what am I shooting for on my urine pH if I’m taking enough magnesium?

Dr. Jaffe: Six and a half to seven and a half – that’s only based on 1,227 studies.

Lindsey: Okay, that sounds like a sufficient number. And then the polyphenols, I have been taking the Perque product called Repair Guard (find at Fullscript). And I didn’t know what it was for, but I knew I was going to be interviewing you and it just caught my eye and I bought it. So is that something that’s useful in the polyphenol department? I know it has quercetin.

Dr. Jaffe: Well, it has quercetin dihydrate. So there’s quercetin, of which you should be concerned, and then there’s quercetin dihydrate, of which you should not be concerned. So for the last 35 years, we have combined quercetin dihydrate with soluble OPC. We have published multiple requested chapters and review articles showing that you can have good or bad polyphenolics, flavonoids and flavonols. And we want the good and we don’t want the bad.

Lindsey: Okay, so quercetin dihydrate is the safe format is what you’re telling me.

Dr. Jaffe: And let me give you another little anecdote. So my friend Bob calls me up and he says, Well, have you ever heard of resveratrol? And I said, “Yes. If you drink about 400 glasses of red wine, you’ll get a meaningful amount of resveratrol.” He says, “Yes, what do you think? I said, “Well, I think quercetin and soluble OPC.” He says, “Well, you know, I own the patents globally on resveratrol.” I said, “Sell them,” and he did.

Lindsey: Okay, so you thought they weren’t worth keeping?

Dr. Jaffe: When you have the better, stay with the better, if you need the worser, that’s your problem. Is that clear?

Lindsey: Yeah. Okay, so anyway, back to my sciatica. So you think I’m nutrient deficient, but I was just wondering about the products in terms of Repair Guard or Pain Guard Forté, would either be useful in helping with my sciatica pain?

Dr. Jaffe: In regard to your or anyone’s sciatica, you start with the 4 personal self assessments, you move on to the eight predictive biomarkers, interpret your best outcome values, and then you’ll be fine. My father had sciatica, I cured it.

Lindsey: I’ve been having it for like eight months. So it’s getting a bit urgent. And I’ve been taking every supplement anybody recommends. .  .

Dr. Jaffe: . . .and they have been treating the back end of an ass. Forgive me for saying it that clearly. They’re not looking at the causes, they’re looking at the consequences. I understand that; most professionals do. So throw curcumin in that has lead. What value does curcumin from turmeric have when it has lead contamination? Negative. Oh, but I didn’t know it had lead. I actually thought it was curcumin. Well, it’s not. Because curcumin has to be heated and has to be met with piperine. It has to be part of dal or curry or other foods. So that’s why we start with what you eat and drink, think and do and then we don’t let you be dehydrated.

Lindsey: So if I have USP verified curcumin with bioperine, could I feel safe that that’s not lead contaminated?

Dr. Jaffe: It’s two points. First of all, when you start with a pepper corn, and you grind piperine onto a food, it lasts about one hour. And I’m pretty sure it’s been more than one hour before that piperine was exposed to whatever it was that you got in the supplement. And so it was a false, as in illusion, promise.

Lindsey: So would it be better to just grind up some pepper myself right then as I take my curcumin?

Dr. Jaffe: And not only fresh ground pepper, or fresh ground peppercorns, which I buy. And I buy the white, the black, the pink; it’s really very pretty. But I put them in a simple copper, as an Italian copper, grinder. And why do I do that? Because that keeps them away from mold and problems. And how do I grind them? Fresh. Because the piperine in my kitchen lasts one hour. In your kitchen, the piperine lasts one hour. When you have piperine in a product? It’s an illusion, because it’s not what you want.

Lindsey: And the reason that they put it in, in theory, is to extend the . . .

Dr. Jaffe: Oh no, no, the theory is that consumers are smart enough to know that the word piperine should be associated with the word curcumin, or turmeric, if you want better uptake. Except what the consumer doesn’t understand is time.

Lindsey: And so is there a Perque product that has curcumin?

Dr. Jaffe: Never.

Lindsey: Okay, so you think we should just be eating it fresh?

Dr. Jaffe: Yes, make a curry once or twice a week. Make a dal once or twice a week, make a chili once or twice a week. Do it with whole foods if you can. We want you to start in the kitchen. And we don’t want you to start with the supplements. We have supplements. They’re necessary. But they have to start after the kitchen.

Lindsey: Yeah, and I do like curry. Of course for people whose kids don’t like it, it’s more challenging to have it twice a week.

How to Get Your Kids to Eat Healthy

Dr. Jaffe: Well, no, no. Let’s talk about that for a minute. What I would do with children for a dal or a curry is noodles. But they would be bean curd noodles. Kids tend to like noodles. You know like slurp slurp slurp. I must tell you that my children were never very neat and we didn’t care. We just wanted them to eat. We just wanted them to enjoy what it was that we were eating. And by the way, there were times when my children said “I’m not going to eat that”. And we said, “What do you want to do?” And they said, “Call in for Uber” (Dad actually can do that). Well, maybe Dad can. But we’re not going to do that. We only have this and that and the other thing from the kitchen. “Well I don’t like you”. “I don’t care, I still love you.” “Oh, well, I’m hungry.” And then they would sit down and eat. If the children are in charge, it’s actually a problem.

Lindsey: Yeah, no, my kids eat curry. Just to say, it’s not my kids. I was referring to someone else’s kids.

Dr. Jaffe: No, I appreciate your point. You want to make it savory. You want to make it aromatic. You want to make it something that’s appetizing. You do not want to force them to eat something that you think is healthy that they hate you for. I promise you that will not end well.

Lindsey: Yes. No, it’s not fun to have battles at dinnertime with the kids.

Dr. Jaffe: No, but start with I’m tired and hungry, and then they’ll eat.

Which Vitamin C is Best? Is Liposomal Vitamin C a Superior Form?

Lindsey: Yeah. Okay, so let me ask about the Perque vitamin C because I heard you talking about it on another podcast and you made it sound like the way it’s made, that any other vitamin C supplement would be essentially useless. But I’m guessing that that’s probably an overstatement. So could you compare Perque’s vitamin C to others? And why are they different in terms of efficacy, like a percentage difference? Or how would they compare?

Dr. Jaffe: So most of the commercial vitamin C, which is 95 plus percent of the vitamin C you would buy in any store from health food to other, including online, is damaged. It is partially ascorbate. It’s partially diketogulonic acid, it’s partly dehydroascorbic acid. It is deficient. It’s not distilled under nitrogen. It is not nature’s vitamins. Since 1987, and for the last 30 plus years, we have provided nature’s vitamin C. Safer, uncontaminated, more effective, documented in clinical outcome studies, multiple, and documented for the last 35 plus years. It’s safer, more effective, when you use nature’s form. (Find it at Fullscript)

Lindsey: Okay, and by nature’s form, you mean if you were to say, eat an orange, you would get vitamin C in the same form as the Perque vitamin C supplement?

Dr. Jaffe: Good point. However, do you know the average orange moves more than 1000 miles by the time it goes from being picked to your eating it? It has 10% or less of the vitamin C that it started with. That’s a fact, that’s not an opinion. If you live in an area where you have your own citrus garden, and you pick your own tangerines, and you pick your own oranges, and you pick your own citrus fruit, Hmm, that’s a blessing.

Lindsey: Yeah, I planted a mandarin tree two years ago, and the first year it got decimated by a horrible – some sort of butterfly or the worm form. And then this year, I’ve got two mandarins on it. And boy, I’m watching those things grow so anxiously. I’m hoping one day I’m going to have a voluminous tree.

Dr. Jaffe: As long as the roots survived. I’m currently growing a nectarine and a tangerine that we think are going to survive in our zone seven.

Lindsey: I’m in Arizona, Tucson, so we can do citrus.

Dr. Jaffe: You absolutely can do citrus but it should be xeriscape. You have to drip the water in.

Lindsey: Yeah, that we have to get that set up. We have yet to have to put in drip irrigation. Okay, so tell me about what you think of liposomal vitamin C?

Dr. Jaffe: Well, since our recrystallized ascorbate gets 100% uptake and since most ascorbate gets a fraction of that, how much more than 100% do you think you could get on God’s green earth?

Lindsey: Okay, so in other words, no point in investing in liposomal, because the Perque is the best one. That’s sort of the end story?

Dr. Jaffe: To be really clear, liposomal ascorbate includes a significant fraction of the ascorbate that is not ascorbate. It is the liposome, and it is there on the premise that you can’t get the beneficial ascorbate in. And since we have documented over many decades 100% uptake of the recrystallized under nitrogen ascorbate that nature provides, we’re pretty sure that compromising that is really not a good idea. In fact, we’re very sure it’s a bad idea.

Lindsey: So I also noticed that Perque’s vitamin C pills are 1000 milligrams and I have read multiple times that you can only absorb 500 milligrams of vitamin C at any time.

Dr. Jaffe: You listen to people who don’t know their elbow from a hole in the ground, and are pathologists rather than physiologists, who are my friends, and I specifically mean Mark Levine at the National Institutes of Health. I specifically mean the Food and Drug Administration, who has for many years obscured, not clarified, the issue of how much do you need. Because if you want to avoid scurvy, I mean, scurvy, if you want to avoid your teeth falling out when you sail on the Pacific, or the Atlantic Ocean, oh, you only need a dusting, as in an orange or a lime. They were called limeys for some reasons. Haha, that has nothing to do with health. If you want to know how much ascorbate you need, you’ll have to do a C Cleanse. It’s one of our four personalized assessments, followed by eight predictive biomarkers, interpreted to best outcomes values, if you want to be well and healthy in the 21st century.

Perque Brain Formula

Lindsey: Okay, I got it. So is there anything that Perque or you are working on right now, any new products that might be coming out soon?

Dr. Jaffe: Again, thanks for asking the question. We have long needed, and now have perfected, what we call Perque brain formula, brain like cognition, you know. Like, I’m not going to take periwinkle, I’m going to take something a little more effective. And I think you know this – I’m no longer a spring chicken. So I actually want my brain to work. At least for as long as it does. I cannot control when a piano might fall out of the sky, or when the good Lord is going to take me. In the meantime, I don’t lose my memory. If you can’t remember your loved ones, it’s really not a very pleasant place to be.

Lindsey: And so is the brain formula already out then?

Dr. Jaffe: It’s coming out very soon.

Lindsey: Does it have a name?

Dr. Jaffe: Yes. It has a very interesting name. It’s called Perque Brain Formula.

Lindsey: Okay. So it’s very transparent. We can keep our eyes out for that.

Dr. Jaffe: And you can place orders now because it’s really coming out very soon. It’s in production. Now, we have pioneered a better formula. And yes, we’re very proud.

Lindsey: What kinds of ingredients?

Dr. Jaffe: Everything you would like and nothing you wouldn’t.

Lindsey: Okay. I guess people can look at the label.

Dr. Jaffe: Haha, there’s more than one thing on the label.

Lindsey: Yeah. Okay. It’s a multi-item formula.

Dr. Jaffe: Right. synergistic.

Lindsey: Is there anything that you wished I had asked you about the topic of gut health that I didn’t?

Dr. Jaffe: You’ve asked so many good questions. No, I think I’ve had a chance to say my “truth”. I think, as you know, I came as a skeptic, but I’m now here. I think physiology before pharmacology, I think nature and nurture and wholeness. I think living in harmony with nature. I think knowing what you can eat, assimilate and digest and eliminate without immune burden is a stepping stone toward lifelong health and well-being. And I want to be dancing at 120 with folks like you, because if I’m the only one dancing at 120, it’s lonely.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

*Product links in this article are affiliate links on Fullscript or Betterlabtestsnow. Thanks for your support of the podcast and blog by using my links!

Adapted from episode 39 of my podcast, The Perfect Stool: Understanding and Healing the Gut Microbiome.

There are tons of special diets meant to help reveal food sensitivities, address physiological imbalances or reverse autoimmune disease or other chronic conditions. I’ll cover 11 of them in this article. This may give you a starting point for trying a more targeted elimination or other special diet. Or if you’ve already done the elimination diet thing with no luck, even one as strict as the paleo autoimmune protocol or AIP and it didn’t help you, this may give you some completely new ideas, because there are many diets for different health issues that are not a subset of the AIP.

Gluten-free Diet

So let’s start with the most basic: gluten-free. Gluten is commonly known as the protein found in wheat of all kinds, including einkorn, durum, khamut and semolina, as well as barley, spelt, triticale and rye and frequently oats because of cross-contamination. However, gliadin is actually the subfraction of gluten that’s found in the grains I just mentioned and that has received the most attention. And it’s hidden in tons of foods, like soy sauce, soups, salad dressings and spices, so you’ll need to find a thorough list of potential sources and stay away from processed foods with questionable ingredients while you try it. This is step 0 for anyone with gut or autoimmune issues of any type. I did a whole podcast episode on this (episode 21) if you want more detail. However, before you give up gluten, please go to your doctor’s and get tested for celiac disease, which is an inflammatory condition of the small intestine. If you do a lot better on a gluten-free diet and you haven’t been tested, the only way to get tested is to start eating gluten again, and if you’re feeling much better, you won’t want to do that. But having that celiac diagnosis will make you take the diet a lot more seriously and requires a much higher level of vigilance, like separate cutting boards and removing personal care products with gluten in them. Of course, you may not have celiac but could have non celiac gluten sensitivity (NCGS), which you’ll find out by giving up gluten and seeing how you do. If you are gluten sensitive and you just ignore it and eat gluten, you can end up with autoimmune disease, osteoporosis, asthma, mental health issues, fibromyalgia or chronic fatigue.

Another big subset of people that the evidence shows should try a gluten-free diet are those who have already been diagnosed with an autoimmune disease, especially Hashimoto’s thyroiditis (the most common cause of hypothyroidism) and Grave’s disease. This is because the protein in gluten looks a lot like your thyroid cells. This type of autoimmune disease is believed to start when you have a leaky gut (which may be because of the gluten or for some other reason like a gut infection) and the undigested gluten proteins escape into your body, creating an immune attack to remove these proteins. Then because of molecular mimicry, or the resemblance of gluten and thyroid cells, your body attacks your thyroid. But really experts recommend cutting out gluten for any type of autoimmunity.

So I’m not going to lie: cutting out gluten is tough and may seem impossible, but I’ve gone mostly gluten-free for about 7 years now because I was diagnosed with Hashimoto’s thyroidits, and honestly it’s a relief, mainly because it keeps me from eating things that make me feel bloated and terrible like bread and pasta, and encourages me to eat more nutrient-rich foods. And it keeps me from indulging in so many unhealthy, sugary things that have gluten in them. Although I have to admit that I do cheat about 6 times a year, eat pizza and take enzymes to digest it now that my Hashimoto’s antibodies are down to normal levels.

But when first faced with the prospect of going gluten-free, you might be thinking: what about a chewy delicious pizza crust, or a sandwich on beautiful toasted ciabatta bread, or your favorite bowl of pasta? Fortunately, there are lots of great alternatives to those foods now and gluten-free bakeries in most cities. Although, I’ve always been of a mind that you’re better off looking for recipes that are naturally gluten-free, like with a lot of Asian recipes that are naturally gluten-free (provided you use tamari or gluten-free soy sauce instead of soy sauce).

But if you’re looking for good alternative flour options, two of my favorite low-cost and neutral-tasting, grain-based ones for baking are sweet sorghum and millet (which I combine, and then you need to add a starch like cornstarch or tapioca starch as 1/3 of the mix). I don’t add binders like xantham gum to my gluten-free flours. Rather, I look at any individual recipe to see if that addition is necessary and try to use more natural binders like flax or chia seeds, ground up and mixed with water.

My favorite grain-free flours are almond and cassava flours, and then I use tapioca starch (or arrowroot starch) as my starch, which is just the starch from cassava flour, but it’s much less expensive than whole cassava flour. And there are tons more grain and grain-free options including: amaranth, arrowroot, buckwheat, millet, cornmeal, flax, chia, coconut, oat, quinoa, rice, mesquite, bean flours (garbanzo, fava, etc.), tigernut and many more. And if you’re looking for amazing angel hair pasta that’s gluten-free (and very hard to find), I love the BGreen Millet Angel Hair*.

One caution about going gluten-free is not to just switch to gluten-free junk foods with additives and fillers (and often a lot of sugar), or based mostly on rice flour. They have found elevated levels of arsenic in people eating gluten-free because of high rice consumption so think more about following a whole foods diet minus gluten that includes other sources of starch, like root vegetables, nuts and other grains besides rice.  

A final note that while it’s well-known that gluten causes celiac, it’s less-known that gluten can cause inflammation in other parts of the body including the mouth, esophagus, stomach and small and large intestines. I had one client who came to me for weight loss who was also hypothyroid. I had her do an elimination diet including gluten. Wouldn’t you know, after she had been working with me for about 4 months, she saw her dentist, and all of 4’s and 5’s with the depth probe were now healthy 3’s. So she had all this inflammation going on in her body that wasn’t super obvious but cleared up after eliminating gluten. So given gluten is connected to inflammation, and inflammation to most chronic diseases, eliminating gluten is a viable option to address many different conditions, not just celiac.

Grain-free Diet

So if you start with gluten and that doesn’t seem to be enough, you may want to go the whole way to grain-free. More restrictive than the gluten-free diet, the grain-free diet(as the name suggests) involves cutting out all grains, which technically are the seeds of grasses. The reason to try this is because you may not just be sensitive to gliadin but to other prolamines found in other grains traditionally considered gluten-free, like corn, rice, millet, oats, wild rice, fonio, job’s tears, sorghum, millet and teff. So if you find that you’re 75% better off without gluten but not all the way, you may be sensitive to all prolamines in grains and should give a grain-free diet a try.

Anti-inflammatory diet

So the next diet I wanted to cover is an anti-inflammatory diet. Reducing inflammation, as I’ve mentioned, can be a powerful way to reduce your risk of illness and reverse a chronic illness you already have. Chronic inflammation is linked in research to heart disease, arthritis, cancer, diabetes, depression and Alzheimer’s. Since I’ve heard the term anti-inflammatory diet floating around on the internet quite a bit, I wanted to include what that was, but quickly realized that there is no set definition of an anti-inflammatory diet. Pretty much everyone agrees that it eliminates added sugars, deep fried foods, partially hydrogenated oils (which are mostly out of the food supply thanks to the Obama administration, as long as a serving has less than ½ a gram, which will be labeled as 0 grams), ultra-processed foods, and refined carbohydrates like white bread, pasta and desserts. Then depending on who you’re talking to, it may reduce or exclude red meat, saturated fat, processed meats, gluten, dairy, soy and/or processed seed oils. And then also important is what you do focus on, which is getting lots of servings (think 5-9) of fruits and vegetables/day, with a particular focus on green leafy vegetables, cruciferous vegetables like broccoli, cauliflower, cabbage and Brussels Sprouts; alliums like garlic, onions, scallions and leeks, fats like olive oil and avocado oil, nuts, fatty fish and seafood with lots of omega 3 fatty acids (like sardines, anchovies, salmon or tuna, but be sure to choose only brands of canned tuna that boast low mercury like Vital Choice* or Safe Catch*) and anti-inflammatory spices like turmeric, ginger, cloves, rosemary and thyme. And of course you should choose organic and/or pasture-raised foods and for meats, dairy and eggs. And then it’s also important on an anti-inflammatory diet to get lots of fiber, so that can come from fruits and veggies, or whole grains if you’re eating grains, or nuts, for example. Or dark chocolate – that’s one of my favorite sources of fiber.

Basic Elimination Diet

Next item up, the basic elimination diet. So for my clients, if they are having digestive issues and haven’t already done it, I often suggest a basic elimination diet. Because if you’re showing signs of leaky gut, like migraines, brain fog, joint pain, or skin issues, not to mention GI issues, it is often a combination of foods, not just one food like gluten, that’s causing you to react. Eliminating only gluten or only dairy or just those two and not feeling better could leave you with the false conclusion that those foods are fine for you, when in fact the issue is that you are sensitive to several foods.

So generally, I suggest a whole-foods elimination diet for at least a month that excludes gluten, added sugar, dairy, soy, caffeine, alcohol, processed foods and seed oils. Then each item (except crappy processed foods and seed oils, which you shouldn’t reintroduce at all, and the sugar, which should remain limited) should be reintroduced alone for a couple of days Eating the reintroduced item at least 2 servings a day until you feel a bad reaction, or if not, wait a couple days after that for any delayed reaction. Now of course if this isn’t enough for your symptoms to improve, you can start excluding additional foods, like nightshades, nuts or legumes, or go for a full autoimmune protocol, which I’ll get to later. I think this kind of elimination diet is a good start for people who aren’t prepared to try something as extreme as the autoimmune protocol or AIP. I know that when I found out I had Hashimoto’s thyroiditis and saw the AIP, I was like, “No way!” It was just a nonstarter for me because it felt like there would be nothing left for me to eat. But when I tried this pared-down elimination diet, my symptoms improved and I was able to isolate gluten, dairy and soy as the most problematic foods for me. So if you have an autoimmune disease that isn’t profoundly impacting your health yet, this may be a good start.

Paleo

If you haven’t been living under a rock, you’ve likely heard of the paleo diet, which was developed by Robb Wolf. Formerly a research biochemist, Wolf is the bestselling author of The Paleo Solution: The Original Human Diet* and Wired to Eat*. And along with the paleo diet is a whole school of thought known as ancestral health, approaching lifestyle and nutrition from the perspective of our hunting and gathering ancestors, who if you pull out high rates of infant mortality, lived long and healthy lives. And spent a heck of a lot less time working that we do to maintain it. So generally, you can pretty much figure out the foods that would have been accessible to hunter gatherers: meats, animal fats, coconut oil, seafood, root vegetables, other fruits and vegetables in season, nuts and seeds and natural sweeteners like maple syrup and honey in limited quantities.

Processed foods of any kind are out, unless of course they’re made to be paleo, as is alcohol, all dairy except clarified butter or ghee, all grains, starchy vegetables like potatoes, corn and peas, factory farmed meats, beans and legumes, including peanuts and soy, refined or processed sweeteners and processed seed oils. One of the biggest brands of paleo products is Primal Kitchen, which makes very nice dressings* made from avocado oil and now has frozen entrée options for people who don’t cook. I aspire to the paleo diet, except I’m too weak to eliminate all grains when my family eats them in front of me, and fakish foods like sugar alcohols because at the end of the day I have found that added sugar in any form, even if it’s ancestrally okay, causes me to gain weight. Not to mention alcohol, and legumes, which I believe are healthy, high-fiber foods for most people.

On the Paleo diet, ideally you should be eating a wide variety of proteins from as many animal sources as possible. This means not relying on standard cuts of meat and lean meats, but including the fatty meats and organ meats, not shying away from saturated fat in meat or coconut oil, and including bone broth and other good collagen sources. If you’re a baker, paleo baked goods typically use cassava flour or coconut flour, as well as arrowroot or tapioca starch or other non-grain flours. In addition to meat, vegetables, nuts and seeds, avocados, olive oil and fish oil are staples in a Paleo diet. And root vegetables, including sweet potatoes and winter squash, are the primary sources of starches. The paleo diet has been shown to be anti-inflammatory, promote weight loss, reduce digestive issues, and reverse or decrease the likelihood of developing chronic diseases.

Paleo Autoimmune Protocol (AIP)

Next up, AIP or the Paleo Autoimmune Protocol. So if you’re tried the paleo diet and feel better but not all the way better, you may want to implement the AIP, which includes an elimination diet designed to reverse autoimmune disease by addressing the nutritional resources required for immune regulation and tissue repair as well as removing inflammatory factors from your diet. The protocol also focuses on your lifestyle. So what’s involved in AIP? The AIP addresses four areas known to contribute to autoimmune diseases, which are: nutrient density, gut health, hormone regulation and immune system regulation. Meat, seafood, copious amounts of vegetables, fruit and healthy fats are AIP-approved. You might be thinking: isn’t that the same as the Paleo diet? It’s sort of like the paleo diet on steroids and further eliminates eggs, nightshades (which include potatoes, tomatoes, peppers, chilies, eggplant, tomatillo, goji berries and ashwagandha), seeds, nuts, ghee, chocolate, caffeine and seed-derived and nightshade-based spices.

The AIP diet has been attributed to Dr. Loren Cordain, PhD, a scientist responsible for discovering that certain foods trigger inflammation in people with autoimmune disease. Other leading experts in the AIP field are Robb Wolf, for his contributions in The Paleo Solution, and Dr. Sarah Ballantyne, PhD, who researches and writes extensively on autoimmunity and diet. Her research-heavy tome on autoimmune disease is called The Paleo Approach*. The main thing to remember about AIP is that it’s an elimination diet, which involves the removal and systematic reintroduction of potential problem foods, but that it is meant to last a lot longer than a typical elimination diet – pretty much as long as it takes for gut inflammation to settle down. I would generally consider recommending it for someone with an autoimmune disease that involves bad joint pain or other significant pain or disability or potential for future problems, along with gut testing and healing of gut infections that could be at the root of food sensitivities.

Low-Oxalate Diet

The next diet I’m going to talk about is the Low-Oxalate Diet. So if you’ve been rattling around the world of functional medicine for any length of time, you may have heard about oxalates. You probably even know they’re in spinach. What I’ve discovered since I’ve started using the Organic Acids Tests to uncover gut and other health issues, is that pretty much any client who has a high level of yeast metabolites also has a high level of one of three markers of high oxalates, because oxalates are produced by yeast. Oxalates are crystals that can cause kidney stones, most of which are made of calcium oxalate, but are also less known for their role in fibromyalgia, vulvodynia or vulvar pain, autism, anemia, urinary tract infections, interstitial cystitis and crystal formation in other places like bones, joints, blood vessels, lungs, thyroid and even the brain. Wherever they’re found, oxalate crystals can cause pain and damage and increase inflammation.

The first thing to know about starting a Low-Oxalate Diet is that you should reduce your oxalate intake slowly. So for example if you’re eating over 500 mg of oxalate each day, you should be reducing at a rate of no more than 5 percent per week. Basically that means reducing about 25 mg each week. If you’re eating 500 mg or less of oxalates, you can come down 10 percent each week. This is to avoid a phenomenon called oxalate dumping, which is a horrifying thing where oxalate crystals start coming out of your body wherever they are present. So you might be asking at this point, what foods are high in oxalate and how would I even know if I have an oxalate toxicity issue?

Foods that are high in oxalates include:

• beer
• beets
• beans
• berries
• coffee
• dark green vegetables
• nuts
• oranges
• spinach
• soy milk
• soda
• tofu
• wheat bran
• sweet potatoes
• black tea
• rhubarb

This might seem like a random list, but if you’ve noticed difficulty with some of these foods in the past (or perhaps all of them), or you have any of the conditions I mentioned before, it’s possible you have an oxalate toxicity issue. If you suspect oxalate toxicity might be your issue, or you just want to learn more about the Low-Oxalate diet and what’s involved, there’s a great website with recipes and a chart of oxalates in various foods from actual studies measuring oxalates in these foods. They also have a Facebook group called TryingLow Oxalates. Also, one way you can help remove oxalates from your body or diet is by eating a full serving of dairy or a calcium citrate supplement* with meals, which will absorb and usher oxalates out in your urine.

Low-Histamine Diet

Next up is the Low-Histamine Diet. If you have allergies, I’m sure you’ve heard of “anti-histamines,” which are drugs like Claritin, Benadryl and Zyrtec that treat allergic rhinitis and other allergies. But what is histamine? A histamine is a compound released by your MAST cells that plays a part in your body’s immune and inflammatory responses. So when your immune system is triggered by a potential threat, histamine is released through your bloodstream. Then your blood vessels dilate and this creates an inflammatory response with common allergy symptoms like sniffling, sneezing, coughing, tearing up or itching. Histamine intolerance occurs when high levels of histamine are chronically built up in your body. Common symptoms of histamine intolerance include irritability, depression, brain fog, dizziness, rash, flushing, hives, headache, tissue swelling, altered bowel function, nausea, vomiting, abdominal cramps, non-celiac gluten sensitivity, runny nose, difficulty breathing and insomnia.

There are two reasons why histamine can become chronically elevated: either there’s something producing high histamine levels in your body or an inability to clear histamine from your body. So what causes high histamine levels? It could be allergies (as I mentioned), but it could be other things too, for instance gut dysbiosis, environmental mold exposure, a leaky gut, GI bleeding, alcohol, genetics and histamine-rich foods. Foods high in histamine or that cause a release of histamine include:

• avocados
• eggplant
• tomatoes
• sauerkraut
• papaya
• pineapple
• dried fruit
• strawberries
• citrus
• all nuts and peanuts
• fermented dairy products like yogurt and kefir
• coconut yogurt
• aged cheese
• cured or old meats
• shellfish
• smoked fish
• soy sauce
• miso
• mayo
• pickles and olives
• sauerkraut
• kimchi
• relish
• soy sauce/tamari
• chickpeas
• soybeans
• aged cheeses
• chocolate
• alcohol
• energy drinks
• black and green tea

Leftovers are also high in histamines, which build up the longer food ages.

Low-histamine foods include:

• herbal teas
• leafy herbs
• coconut oil
• olive oil
• freshly cooked meat
• poultry (frozen or fresh)
• eggs
• coconut milk
• rice milk
• hemp milk
• almond milk
• gluten-free grains
• fresh fruit
• most vegetables

If a Low-Histamine Diet works for you, then you will probably want to figure out whether there’s a root cause you haven’t addressed, or if you have something called Mast Cell Activation Syndrome, which includes not just a release of histamine but also other inflammatory mediators, of which histamine is one.

Low-Sulfite Diet

The next diet is a Low-Sulfite Diet. One more potential allergen that could be causing your problems are sulfites. Symptoms of a sulfite allergy are typical allergy symptoms, including hives, itching, trouble breathing or swallowing, GI symptoms like an upset stomach, diarrhea and vomiting, flushing, dizziness and a drop in blood pressure. Sulfites are preservatives widely used in the food industry to prevent discoloration and browning of processed foods. Depending on the manufacturer, foods that may (or may not) contain large quantities of sulfites are:

• molasses
• jams and jellies
• tomato paste
• corn starch
• potato starch
• guacamole
• gelatin
• fruit and vegetable juices
• fish
• crustaceans and shellfish
• dried fruits and vegetables
• lunch and processed meats
• condiments
• canned and frozen fruits and vegetables
• bottled lemon and lime juices and concentrates,
• alcoholic and nonalcoholic cider
• wine and sparkling wine
• vinegar

Look for a sulfite-free label to be sure. Sulfites can also be found in medications and personal care products. So if that group of foods speaks to you, you may want to look into a Low-Sulfite Diet.

Low-Salicylate Diet

Next up is a Low-Salicylate Diet. Another potential source of dietary sensitivities may be coming from salicylates. A big tip off to this would be a sensitivity to aspirin or other non-steroidal anti-inflammatory drugs. Reactions can range from the urinary/gastrointestinal, like diarrhea, urgency or stomach pain, to fatigue, to the mental, including depression, memory loss, hyperactivity or trouble concentrating, to typical allergy symptoms like burning or itchy eyes, trouble breathing, tinnitus, headaches, rashes, rhinitis and swelling of hands, feet, eyelids, lips or face.

If you’re sensitive to salicylates, foods you’ll want to try reducing or eliminating include:

• tangerines
• pineapples
• oranges
• most berries
• herbs and spices (including cinnamon, rosemary, thyme, oregano, turmeric and mint)
• nectarines
• green apples
• black tea
• asparagus
• all dried fruits
• fruit juices

You also will want to avoid topical and inhaled exposure, because salicylic acid is easily absorbed through the skin and lungs. Many household items and toiletries typically contain substantial amounts of salicylates or salicylic acid, including: wart and callus removers, topical creams, toothpaste, soaps and cleansers, shaving cream, shampoos and conditioners, muscle-pain creams, mouthwash, lozenges, hair products, fragrances, detergents, cosmetics, cleaning products, chewing gum, bubble baths, breath mints, Alka-Seltzer, air fresheners, acne products, drugs for IBD and supplements containing willow tree bark extract.

Low-Sulfur Diet (for CBS Mutation/Sulfation Issues or Hydrogren Sulfide SIBO)

The last diet I wanted to cover was a Low-Sulfur Diet, which is indicated for someone with what’s called a CBS mutation, which causes issues with sulfation (one of the essential processes for detoxification,  also involved in hormone regulation, cell signaling and molecular recognition). When you eat sulfur compounds, your body produces ammonia as a byproduct, which is toxic, but is usually eliminated through the urine. If you have a CBS mutation that’s high firing, you may end up with excess ammonia, which can cause symptoms like lethargy, fatigue, shortness of breath, tremors, seizures, poor coordination, lack of muscle control, visual disturbances, headaches and nausea. In addition, you could have an overgrowth of microbes that produce ammonia as a byproduct that’s exacerbating your condition. I had a client who had these kind of symptoms every time he ate sugar or carbs and had to go to the urgent care for a three-drug cocktail just to handle it. When we did his Organic Acids Test and I saw his orotate level was elevated, in conjunction with these symptoms, I suspected a CBS mutation. Sure enough, he did a 23andme and confirmed that he did have the mutation. Educating him about supplements to reduce ammonia-producing microbes (including candida) in his gut has greatly improved his condition, as has strategically using certain amino acids. For people with this mutation, Dr. Jockers recommends a diet consisting of 70% fat, 10-20% carbohydrate and 10-15% protein or under 50 grams/day and limiting sulfur intake by removing garlic, onions, cruciferous veggies, eggs, legumes and all protein-rich dairy. And it’s also recommended that you add in one root vegetable, particularly known for removing ammonia, which is yucca, also known as cassava. It’s actually used in aquaculture to control ammonia levels and fed as a supplement to fish and shrimp. Also, in my client’s experience, removing sugar and carbs was a really essential component to feeling better because candida feed on sugar and carbs and were adding to his ammonia load as a byproduct of their metabolism. Lucy Mailing, PhD also recommends a similar diet for people diagnosed with an overgrowth of hydrogen sulfide producing bacteria. Your tip-off that this may be an issue is when your gas smells like rotten eggs. Her recommendations include a diet void of animal foods and dairy for 3-4 weeks, low fat, only olive, avocado and coconut oils, and avoiding sulfur-containing vegetables if they cause symptoms.

So that’s a lot of information, I know, but hopefully it may have given you a place to start on understanding the variety of potential diets that can be used to address gut and health issues.

When I’m working with clients, I help them understand what dietary protocol might be best to try, along with simultaneously testing the gut through the GI Map or Organic Acids Test to see if there is another root cause of their symptoms.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

Listen to episode 39 of The Perfect Stool: Understanding and Healing the Gut Microbiome.

*Product links in this article are affiliate links on Amazon. Thanks for your support of the podcast and blog by using my links!

Adapted from my interview with Esther Blum, RD, on episode 37 of the Perfect Stool: Understanding and Healing the Gut Microbiome.

1. Eat plenty of fiber. One common cause of constipation is not getting enough fiber. Esther Blum, RD, recommends getting at least 20 to 40 grams of fiber per day — 20 grams at first because it’s important to start slow. If you’re not eating any fiber and you suddenly start eating a lot, you could experience gas, bloating and discomfort, so you have to build up your fiber intake over time. It’s also very important to increase your hydration as you increase your fiber.
2. Hydration. Wondering how much water you should drink? Here’s a trick: take your body weight, divide it in half, and convert that number to ounces. So, for example, if you’re 160 pounds, you need 80 ounces of water. In addition, for every 20 minutes of intense workouts, you need another eight ounces, and for every cup of caffeine, you need another eight ounces.
3. Magnesium. Try taking 400-800 milligrams of magnesium at night before bed to keep your bowels moving. Magnesium citrate is known for its help in moving bowels (decrease your dosage if your stools end up too soft).
4. Wake up and walk first thing in the morning. This is a wonderful way to gently massage your intestinal tract and keep things moving.
5. Water with lemon. Drinking warm water with lemon upon arising gives your gallbladder and liver a good flush.
6. Celery juice. There isn’t a lot of clinical research to support celery juice as a remedy for constipation. But anecdotally, in her practice, Esther Blum has seen it work really well, because, like with lemon water, it gives the liver a good flush. First thing in the morning, cut the base and tips off of an entire bunch of celery, wash the stocks, then run them through a juicer. Drink the juice on an empty stomach. Wait 20 minutes, and then carry on with your morning routine.
7. Toilet hygiene. Practice sitting on the toilet in the morning for 20 minutes and reading. This will train your body to have a bowel movement first thing in the morning.
8. Exercise. The human body is not designed to sit all day. It’s supposed to be moving and active. If you’re lying in bed or sitting all day, your intestines are not moving around or getting stimulation.
9. Chew your food well. Most people don’t realize that digestion begins in the mouth. You really have to chew your food until it’s a slurry. It should be the consistency of baby food before you swallow it. The better you chew your food, the better chance you have for smooth digestion.
10. Stress-management. Stress is a leading cause of constipation. If you’re holding things in and holding on to your stress – you can become very constipated. Developing regular stress-management activities for yourself during the day can be a great tool for alleviating constipation – and for improving overall wellness, too!

If none of the above solve your problem, a good polyphenol-based product called Atrantil has been successful for some of my clients in improving constipation. You can find it in my Fullscript Dispensary.

And if none of this helps your constipation, you may have a more serious gut health issue that requires testing and more advanced interventions. I can educate you about both. To tell me more about what you’ve been struggling with and hear about my 5-appointment gut health coaching program and decide if it is a good fit for you, you can set up a free, 30-minute Breakthrough Session with me (Lindsey). Individual 1-hour consultations may be scheduled directly here.

Listen to episode 37 of the Perfect Stool: Understanding and Healing the Gut Microbiome.

IBS, or Irritable Bowel Syndrome, is a digestive disorder which affects more than 10 percent of the world’s population. This article explores traditional and functional medicine approaches to treatment of IBS; testing; and the relationship between IBS, SIBO and IBD. And if those initials don’t mean anything to you, don’t sweat it, they’re all covered in this article.

So… what is IBS?
IBS is a cluster of symptoms that include abdominal pain, cramping or bloating that may be alleviated by a bowel movement; excess gas; diarrhea, soft stool, constipation or alternating diarrhea and constipation; and mucus in the stool. Other symptoms of IBS might include changes in texture and color of stools, nausea, acid reflux, easily feeling full or loss of appetite.

There are also non-digestive symptoms of IBS, which people might be less aware of. These can include anxiety or depression, difficultly sleeping, fatigue, headaches, an unpleasant taste in the mouth, muscle aches, sexual problems, body image issues or heart palpitations.

For most people who suffer from IBS, symptoms are worse at certain times, improve at other times, and even disappear altogether for periods of time. For some people, IBS symptoms are not severe, and can be managed with diet, lifestyle and stress management; but for many others, they can significantly impact their quality of life, make it hard to leave the house because of urgent runs to the bathroom with diarrhea, may involve accidents necessitating a change of clothes, and may impact people’s ability to work or be seen as reliable at work or in their social life. And unfortunately, many suffer in silence and don’t get the help they need because of the stigma or embarrassment.

IBS presents itself differently in different people. Clinicians organize the syndrome into three basic types: constipation-predominant (called IBS-C), diarrhea-predominant (IBS-D), or alternating constipation and diarrhea or mixed (IBS-M). According to Dr.Jockers.com, as much as 12 percent of the U.S. population suffers from IBS, or nearly 40 million people, and women and people under the age of 45 are more prone to IBS.

What’s the difference between IBS and SIBO?
SIBO, or Small Intestinal Bacterial Overgrowth, is believed to be the most common cause of IBS, with some experts citing the figure of approximately 60-70% of IBS being caused by SIBO. And the symptoms of SIBO (bloating, constipation, diarrhea, flatulence and abdominal pain) overlap with IBS, so in some sense, one could reasonably say that they’re basically the same thing, but IBS is more of a traditional or allopathic diagnosis, while SIBO is used more in the functional medicine world, although more and more gastroenterologists are using the term SIBO, the American College of Gastroenterology has put out clinical guidelines for treating SIBO, and some gastroenterologists are now using some of the same testing methods as functional medicine practitioners. And like with IBS, SIBO has traditionally been divided up into SIBO-D, SIBO-C and SIBO-M.

However, the nomenclature of SIBO and the issue of whether symptoms are coming from general bacterial overgrowth has been called into question because the testing that has been used to diagnose it, that is hydrogen and methane breath testing, has neither been shown to be terribly reliable, in particular with the hydrogen part (meaning that if you test at one time, do no treatment, and test two weeks later, you get different results), nor has it been shown to be valid in at least two recent studies (Cangemi et al., 2020), (Saffouri et al., 2019), meaning that if you compare aspirates (or suctioning of) bacteria in the small intestine, it doesn’t correlate with what’s showing up on breath testing or with patients’ symptoms. And an article published out of Dr. Mark Pimintel’s lab out of Cedars-Sinai Hospital (a leading SIBO researcher), seems to validate the lack of validity of the hydrogen breath tests in the abstract, where it says that at the 90-minute time point on the lactulose breath test (which is considered the cutoff time for measuring gases coming from the small intestine), 4/7 SIBO subjects had a rise in hydrogen (H2) ≥ 20 ppm above baseline, which would mean they had SIBO, as compared to 2/13 non-SIBO subjects. So first, those are small sample sizes so it’s difficult to call these results definitive, but at least in this study, the hydrogen breath test only correctly identified SIBO 57% of the time, and 15% of the time gave a false positive for SIBO in someone without it as compared to the results of the duodenal aspirates (or sampling of cells in the first part of the small intestine, or duodenum). This is one of the main reasons I never recommend breath testing to my clients.

There is some interesting information coming from that study, however, including that subjects with bloating had a relatively higher abundance of bacteria from the family Enterobacteriaceae, while people experiencing urgency with bowel movements had a relatively higher abundance of bacteria from the family Aeromonadaceae. Also, the subjects with what they were calling SIBO (based on the quantity of the bacteria in their small intestine) had a 4.31-fold higher relative abundance of the phylum Proteobacteria (averaging around 37%) and a 1.64-fold lower relative abundance of the phylum Firmicutes. They also reported that subjects with SIBO also exhibited greater urgency with bowel movement than non-SIBO subjects (P = 0.022), which was the only symptom they seemed to be able to correlate to overgrowth, which again in my opinion calls into question the definition of SIBO as a state of general bacterial overgrowth. And, a brief aside for people who have studied statistics, the p value on that last item was only. 0.022, versus 0.0001 for the relative abundances by family and phylum. So clearly the more statistically significant issue shown in that study is the predominance of proteobacteria, and in particular, Enterobacteriaceae and Aeromonadaceae. And further, they also found that SIBO subjects had relatively more bacteria from the genera (which is the plural of genus by the way) Klebsiella, Escherichia/Shigella, Acinetobacter and a couple more unknown genera.

As a result, “SIBO” may not be the right word. Rather, the term “dysbiosis,” which typically implies that there is an overgrowth of a particular kind of bacteria (but maybe not bacteria in general) may be more accurate. Dysbiosis may be bacterial overgrowth in both the small and large intestines, or an overgrowth of yeast in your intestines (also known as SIFO, or Small Intestine Fungal Overgrowth), an infection with a parasite, a general lack of diversity, or underrepresentation of certain important species. However, in my experience looking at lab results of tests like the GI Map and Organic Acids Test, typically all three things are happening at once when you have symptoms of IBS. But that being said, I have a client now who has an IBS diagnosis and symptoms, and when we did her labs, there were no overgrowths of pathogenic bacteria, no yeast overgrowth, and it seems like the amino acids I educated her about to help bring up her dopamine and serotonin levels have already positively impacted her IBS, which points to anxiety and stress as a likely root cause in her case. So you never know what you’re going to find out until you test. That, by the way, is one of the benefits of doing an Organic Acids Test – it helps identify when things are going wrong with your neurotransmitters, which impact your mental health, which is often impacted when you have gut issues.

As I mentioned above, IBS is divided up by whether it involves diarrhea, constipation or both. For people with constipation, it’s usually caused by an overgrowth of methanogens, or methane-producing microbes. Rather than grouping that under SIBO-C or IBS-C, the newest term being used is IMO or Intestinal Methanogen Overgrowth, because the methanogens may be located in both the small and large intestines, plus the term SIBO has the word bacteria in it, and archaea are not bacteria. [All organisms on earth are separated into three domains: eukarya (which is where you find animals, including humans), bacteria and archaea]. Anyway, IMO can be another cause of IBS, especially if it involves ongoing constipation. 

Now some good news for people who have been suffering and can’t figure out exactly why: breath testing that includes a third type of gas in your small intestine, hydrogen sulfide, has just come online for commercial use. Prior breath testing was for hydrogen and methane, with hydrogen typically being associated with diarrhea and methane with constipation. But up until now, you couldn’t test for hydrogen sulfide in a commercial setting; it was only used in a research setting. This new test was developed by Dr. Pimintel. It’s called trio-smart™ and it’s is available from Gemelli Biotech. It looks like an overgrowth of hydrogen sulfide-producing bacteria is also typically associated with diarrhea. Breath tests can be done in a lab or using a home kit, which is what the trio-smart is. If you drink glucose and do any type of SIBO breath test, which involves breathing into a tube and saving the results, it covers the first part of your small intestine. If you drink lactulose and do the test, it covers the lower part of your small intestine. Dr. Pimentel also developed a blood test for IBS called Ibs-smart, which tests for autoimmune markers which impact your intestinal motility, which can be a root cause of IBS, originally brought on by food poisoning, which likely is the primary root cause of IBS.

But the long and short of it is, what you’ll find out by doing an ibssmart test is whether you have an autoimmune issue, which you’ll need to address after killing any dysbiotic micro-organisms, by using something called a prokinetic. That’s a drug or natural substance, like ginger, that helps the intestines to move. Some of the prescription medicines used as prokinetics are low dose erythromycin, low dose prucalopride and lose dose naltrexone and one neutraceutical one is called Iberogast*. So if you seem to have recurring problems even after SIBO or IBS treatment, try taking a ginger pill before bed, or have a cup of ginger tea in the evening after dinner to stimulate the migrating motor complex as you sleep. Or if those don’t work, you may need something by prescription to deal with your motility issues. Or you can skip the test, cure your IBS, wait and see if it comes back quickly, and if it does, you’ll probably need to take a prokinetic. And at minimum, once you’ve cleared up your IBS or dysbiosis, you should make sure you don’t eat more frequently than every 4-6 hours, you don’t eat at least 2 hours before bed, and you go at least 12 hours at night without eating, to allow your intestines to clear out and let the migrating motor complex do its job.

So if dysbiosis is a root cause of IBS, maybe even covering 60-70% of it, what about the rest? IBS can be related to other things, like adhesions or bands of scar tissue from a surgery, inflammation or an injury that’s keeping your intestines from moving properly. Or it could be from Ehlers-Danlos syndrome, which is a hyperflexibility condition that can impact your intestines. Or it could be from hypothyroidism, blood sugar issues, type 2 diabetes, drugs you’re taking or took, Lyme disease or various autoimmune diseases like scleroderma or rheumatoid arthritis. Or it can be from a traumatic brain injury, which can also impact your migrating motor complex.

What’s the difference between IBS and IBD?
Now just a brief interlude to address the difference between IBS and IBD, or Irritable Bowel Disease. IBD is an umbrella term which describes digestive disorders caused by inflammation of the bowel, and autoimmune issues that affect the gut and intestines, including Crohn’s disease, ulcerative colitis and microscopic colitis. IBD symptoms are typically more serious and less common than IBS symptoms. These might include: loss of appetite, blood in the stool and nutrient deficiencies brought on by malabsorption.

How is IBS diagnosed and treated?
Typically doctors will give a diagnosis of IBS once they’ve excluded everything else, including IBD, which usually involves an endoscopy (or where they put a camera down your throat to look at your esophagus, stomach, and the upper part of the small intestine), and a sigmoidoscopy or colonoscopy (where they put a camera through your rectum to look at your colon, or for a sigmoidoscopy further into your small intestine). That’s one of the reasons Dr. Pimintel has developed the tests mentioned above, to spare you having to have the entire length of your intestines scoped. But typically, if the endoscopy and colonoscopy are negative and gut symptoms continue, including abdominal pain for at least 12 non-consecutive weeks out of the precious year, characterized by a change in how often you have a bowel movement, and your bowel movements are not normal, then a diagnosis of IBS may be indicated.

If you see a functional medicine practitioner with an IBS diagnosis or symptoms, depending on your symptoms, you will likely either be asked to do a PCR-based stool test like Diagnostic Solutions’ GI Map or Doctor’s Data’s Comprehensive Stool Analysis with Parasitology, a SIBO breath test and/or an Organic Acids Test. The results of those tests will give your practitioner a lot more data about what’s actually at the root of your issues.

In terms of treatments, if you see a traditional gastroenterologist and have a positive breath test or just based on symptoms alone, you may be prescribed antibiotics, in particular one called Rifaximin or xifaxin, an antibiotic that only impacts bacteria in the intestinal tract. It’s super expensive though – last I checked it was about $1750 for a two-week course – so if your insurance won’t cover it or your doctor isn’t in the know, you may want to go the herbal antimicrobial route. There are also some other antibiotics that may be helpful, including neomycin, metronidazole, augmentin, bactrim and nitazoxanide. However, although antibiotics may reduce your symptoms in the short-term, many times they may further stress the gut lining and microbiome or cause an incidence or increase in fungal overgrowth, which will cause a relapse or even a worsening of symptoms in the long-term. Rather than an antibiotic approach, many naturopaths, functional medicine practitioners and experts in the field prefer antimicrobial nutraceuticals because they simultaneous address both bacterial and fungal overgrowths. Typical antimicrobial herbs used for dysbiosis include Berberine, Allicin from garlic, Oregano Oil, Thyme Oil and Uva Ursi. And hydrosol silver and bismuth are also used. One of my favorite protocols that kills both bacteria and yeast is using the Candibactin BR* and AR* products. But you’ll want to get help using them because the die-off or Herxiemer reaction can be unpleasant or even dangerous if you have severe overgrowths of bacteria or yeast. That’s when you have flu-like symptoms as you begin to kill stuff in your intestines. And then once you have dislodged the bacteria and yeast, you want to use prebiotics and probiotics strategically to help reset your microbiome in an effective manner.

Some additional supplements that may be effective in addressing IBS symptoms or root causes include Betaine HCl* and digestive enzymes*, especially if there is evidence of a lack of stomach acid or pancreatic enzymes, respectively, on the GI Map test. And if there’s evidence of leaky gut, like food intolerances, or low gut immunity (indicated by low secretory IgA on the GI Map) l-glutamine powder* and an IgG product like MegaIgG* or Megamucosa* can be helpful. And then there are some supplements that help soothe and lubricate or reinforce the mucus lining of the digestive tract, like aloe vera*, which also helps with constipation, as well as marshmallow root, DGL and slippery elm (which can be found in combination products like this one*). And Atrantil (find in my Fullscript Dispensary) is a great over the counter medication that’s very helpful with constipation and actually consists of various plant polyphenols. And another really good one for help with bloating is peppermint oil*, which is good to take prior to meals.

One of my mentors, Lucy Mailing, PhD, believes that treatment shouldn’t focus on quelling bacterial overgrowth by antibiotic means. Rather, she focuses on the depletion of the short chain fatty acid butyrate, which is the food for the cells lining the colon (while glutamine, by the way, is the food for the cells lining the small intestine). Antibiotics, gut infections, low-fiber intake, and stress are all factors that can deplete gut butyrate, causing oxygen leakage into the gut. This encourages gut dysbiosis characterized by an overgrowth of faculatative anaerobes like proteobacteria, which can survive in the presence of oxygen. Therefore, she recommends avoiding antibiotics, treating fungal gut infections, eating plenty of fiber, managing stress and getting plenty of regular exercise. Speaking of which, a study published in the American Journal of Gastroenterology in 2011 found that increased physical activity improves GI symptoms associated with IBS, and improves quality of life to such a great extent, that exercise should be utilized as a primary treatment for symptoms associated with an irritable bowel. If you’re thinking of supplementing with butyrate and some more advanced interventions that Lucy recommends, I’d suggest you do it under the care of an expert gut health practitioner, such as myself. I’ve personally found supplemental butyrate to be one of the most helpful things for me in keeping my bloating in check and my stool at a nice Bristol #3. In case you’re not familiar with it, the Bristol stool chart rates stool from 1 to 7. A 3 or 4 is considered normal, but I’d much rather a 3 than a 4, personally.  

In terms of diet, one of the most commonly recommended for IBS is a low FODMAPs diet (which stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols), which, along with eliminating gluten, dairy, and a wide selection of fruits and vegetables, eliminates the omnipresent ingredients garlic and onion and their powders. The low FODMAPs diet should not be used long-term or it may result in the extinction of vital gut microbes. Rather, it’s best used to precede treatment to reduce symptoms, as a self-diagnostic tool (if you do better on it, you know your issue is at least partially bacterial) and to temporarily deplete the microbes that cause problems, so your killing regime will be more successful. Or it can be used as an elimination and reintroduction diet to see which of those foodstuffs most affect you. There are also other diets out there that are even more restrictive like the specific carbohydrate diet or the biphasic diet, but honestly, I think low FODMAPs is already a lot to ask of people, so I generally go the route of treating the underlying cause of IBS symptoms quickly rather than playing out a difficult diet like FODMAPs. But honestly, by the time most of my clients find me, they’re usually reduced to a diet consisting mostly of vegetables, meat and fat in their desperation to find a solution to their problems, so I’m not inclined to ask them to restrict their diet even further. 

Could my gut issues cause or be the cause of my autoimmunity?
So if you have a mild case of what seems like IBS, you may just be toughing it out thinking the symptoms are tolerable, but be careful. My gut issues preceded my autoimmune issues, and I know they’re related. Dr. Alessio Fasano, a pediatric gastroenterologist, research scientist, and founder of the University of Maryland Center for Celiac Research, believes three factors are at the center of all autoimmunity issues. They are genetic susceptibility, antigen exposure and increased intestinal permeability. Given that you find increased intestinal permeability in IBS and dysbiosis, it is not surprising to find that they are common underlying causes and precede many autoimmune conditions. Although that association isn’t entirely clear, what it clear is that with its high likelihood of generating leaky gut, it is important to address IBS for the prevention and treatment of autoimmunity.

If you want more help with IBS or other gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

Listen to episode 36 of The Perfect Stool: Understanding and Healing the Gut Microbiome podcast.

*Product links in this article are affiliate links on Amazon. Thanks for your support of the podcast and blog by using my links!

Excerpts from my podcast “The Perfect Stool: Understanding and Healing the Gut Microbiome“. Edited for readability. L=Lindsey; I=Inna.

L: How did you get into this work on Crohn’s and colitis?
I: That was my long journey to healing. I got sick with Crohn’s in early 2000. I was originally diagnosed with colitis, and then properly diagnosed with Crohn’s. I tried all kinds of medications, and it didn’t bring me much relief. Being a pharmacist myself, I was also skeptical and worried about the side effects, which doesn’t help at all when you know them all. And I tried different methods. I went for different modalities of healing, and my nutrition was not at the point where it is now. But I tried changes and I did succeed to a degree, until I finally found functional medicine, which really brought me to a whole different level. That’s how I started the practice, because [functional medicine] helped me.

L: Were you already a PharmD at the time when all this started?
I: I was an RP, a registered pharmacist, at the time. The reason I [got a PharmD degree in 2017] is because I wanted to dig deeper into the studies and learn way more about evidence-based stuff. I was a pharmacist, then I took a lot of education and learned about functional medicine, integrative solutions. And then I decided, here’s the time to do my doctorate to be able to really extrapolate all the details and learn about the evidence-based studies.

L: What year were you diagnosed with?
I: –colitis, originally colitis, in 2000. And then, in 2003, I was diagnosed with Crohn’s disease, the final diagnosis.

L: When you see a Crohn’s or colitis patient in your practice, what is your first step in working with them?
I: I take them on a really long consultation, we discuss their history, we go all the way back, I listen to them, I need to hear their goals, I need to understand their gut story. And by the end of the session, I am more or less on top of what functional diagnostics they should run and what route they should take in order to heal.

L: Do you typically have to do some more testing with them or is a diagnosis of Crohn’s or colitis sufficient to start working with them?
I: For most of my clients, I recommend functional diagnostics. They really can open up and show us a whole different picture, especially the stool test with PCR technology right now—even other toxicity-related testing that doctors at this point don’t have an option or don’t have the education to dig for. That could be the root cause. And it’s great. It’s great to find out.

L: So what do you use for diagnosing toxicity?
I: Well, it’s really not diagnosing – I try to steer away from that term. But to recognize and to see and to get a lab check, I really love. First I would do an Organic Acids Test for a client. And sometimes just from that lab alone, we could see we have to dig in and see if there is metal toxicity. Then we’re going to do more extensive testing, for example, for metals, or for mold toxicity or other toxins.

L: Whose testing do you use for metals?
I: I love the Great Plains Laboratory. They’re great. I’ve just had really great success with that lab.

L: What kind of test do you use for mold?
I: Also, I love to use GPL for their mold testing.

L: And what’s that one called?
I: Multi-tox screen. I believe a full tox screen and then the Organic Acids Test.

L: Do you also do that through Great Plains?
I: Yes. For around 10 years. I’ve seen hundreds of these tests.

L: So what made you choose the Great Plains over the other labs?
I: I met the rep at an integrative healthcare symposium. They were very compatible to Genova. Genova at that point changed from Methometrix and a pharmacist’s license was no longer okay to order. And that was a perfect choice for me. GPL.

L: What kind of information will you see on an Organic Acids Test that will lead you to believe that it’s perhaps a metal toxicity issue?
I: It could be a combination of things. It could be the fact that we see that there’s a lot of issues with liver detoxification, a symptomatic presentation, along with a combination of things, plus the liver, plus the look of a client. It’s really at least a few different ways you could see and then go for metal testing. [A client with metal toxicity might have a “look”] that’s often a grayish skin, black under their eyes. They’re often feeling cold, cold sensations in the hands. Sometimes they have a metallic taste in their mouth – that’s the liver, unable to process. Again, if the bile ducts are congested, they usually have that color.

L: And would these be people who have had some knowledge that they were exposed to heavy metals, or people who were just sort of, “Oh, I have no idea how that happened?”
I: I often have someone that says, “Oh my goodness, I had no idea. I have so much lead. I have so much aluminum.” But I did have a client that was completely positive they had mercury poisoning. He goes “I went through so much sushi in the past couple months. Maybe I have mercury toxicity.” And here we go. There it was. That can happen.

L: And that I assume is primarily from fish like tuna?
I: Yeah, yeah, large fish. Again, some companies are very, very responsible and they can grab the fish before it reaches a certain weight. So there’s much less mercury in the tuna like Vital Choice. Yeah, it is BPA free and very, very sustainable and organic, very clean company.

L: Good to know. So we were talking a little bit about the mold. What kind of signs and symptoms might lead you to that or things on the Organic Acids Testing that might lead to you to suspect mold?
I: With my clients, it gets a little harder, because my clients usually are Crohn’s and colitis, and they’re very sick to begin with. So the symptoms can kind of mix in all together. So mold I will mostly recognize from the Organic Acids Test. And that’s like, right in the beginning of the test, we will get Aspergillus being high, the different Furan markers, or Tartaric or 5-Hydroxymethyl-2-furoic. If they’re really high numbers, we will really go straight for mold testing.

L: Okay. And then how often do you find that people with Crohn’s and colitis, the root cause is some gut stuff like Candida or bacterial overgrowth?
I: Super often. Very often. Many, many of my clients have candida overgrowth, many.

L: Have you begun to form theories about what the most common root causes are for Crohn’s and colitis?
I: That’s a question I’ve been asked recently a lot. A common root cause would you believe that it’s the personality? My common thing in my Crohn’s clients is type A personality. They push themselves. It’s a combination of course; it’s a multifactorial situation. There’s so much involved. Type A personalities; very common in Crohn’s patients. And they really push themselves – they’re one of those go getters that go without slowing down, and that can really get them in trouble. It’s a root cause for Crohn’s. It’s a multifactorial base, except that being in overdrive and not letting yourself relax enough and not remembering yourself and not prioritizing your health often is an issue.

L: Tell me how that relates to gut issues. What’s the physiological process there? I assume we’re talking about stress.
I: Sure, it’s adrenal imbalance. It’s the fact that, you know, the gut microbiome, this is something interesting, many people probably don’t know, if you haven’t got a perfectly balanced gut microbiome or as close as perfect as you could get. Probably no one is perfect, but as diverse because we want it to be very diverse, to be to be healthy, as diverse as possible. And overnight, there’s some kind of severe stress, a fire, major fights, something really horrible happening. The next day, if you tested that microbiome, it would show someone super sick; a really, really different microbiome. So the gut microbiome, of course, plays a major role. And so presumably, the stress releases cortisol, and then how do you think that impacts the gut microbiome? Stress, releasing cortisol, we don’t have the exact connection to how it affects the microbiome. When your cortisol is constantly high, you will have some kind of other hormone imbalance, sex hormone imbalance, that leads to possibly blood sugar instability. Now [you get] the release of insulin, now you’ll have the cravings that you’re not going to eat properly. It’s a chain reaction, and then you get indirectly to the gut microbiome imbalance.

L: When you work with clients, do you also test their adrenals?
I: I do. It’s part of fixing the entire body. I really appreciate that from the Kalish course from way over 10 years ago. I know there’s a lot of controversy with the adrenal fatigue diagnosis. Of course, I do not diagnose. But fixing, correcting things, is really helpful for those that have chronic conditions.

L: Tell me what kinds of things you’ll find when you test the adrenals.
I: All kinds of things. High cortisol for someone, super low cortisol for another one. If they’ve really been in severe chronic situations, DHEA falls down. For women sometimes, it affects their sex hormone health, like they’re symptomatic for low progesterone because of pregnenolone steal.

L: Pregnenalone steal?
I: Steal, yes, it’s a term with adrenal health. It’s what happens when you have that low cortisol for too long, when it reaches that point, when it really can’t go back high enough, because it’s exhausted, the adrenals, you cause a situation called pregnenolone steal. And from there you’re going to have trouble making a sufficient amount of sex hormones. And that creates other symptoms. A lot of my Crohn’s patients, for example, have low progesterone, young and old, at any age point, and therefore with low progesterone, it is harder to maintain pregnancy. So no wonder now they’re confused why they’re having miscarriages – low progesterone often leads to miscarriages.

L: I know all about that. That’s exactly what happened to me. So what do you recommend for that? And are you an herbalist type with the drops? Or do you get people to use the pills or?
I: I often mix but my favorite one right now is Adaptocrine from Apex Energetics. I’ve seen great results with it.

L: So is that a mix of different adaptogens?
I: Yes, mix of great adaptogens. But again, it’s a blanket adaptogenic herb combo, but if there is a need for more of plant-derived bioidentical hormone for just a short term, DHEA, pregnenolone, they work well.

L: I know that the adaptogens help both with low and with high cortisol, do you use the same thing in that case or something different?
I: Very often I do yes, more often with low cortisol activity. And if I see them overreact to them and if I see this is just a very recent case, and they’ll be able to fix it with a quick fix. But most likely it would be for both cases.

Q. Is there something different between Crohn’s and colitis in your treatment approach or in typical protocols?
I: It’s a very good question. I understand what you’re asking me. Not one of my protocols has been the same for the past good three or four years. Everything is so individualized for every single person. Like no Crohn’s patient is the same; more probably Crohn’s patients than colitis patients but not one wellness plan that I create looks the same as the other.

L: Do you typically use herbal products in helping people?
I: Herbal and neutraceutical supplements.

L: What kind of diet changes do you recommend for people?
I: Anti-inflammatory. That’s where I really focus on. As long as the diet is very anti-inflammatory and favorable for macro and micronutrients balance. I don’t restrict completely. The SCD (specific carbohydrate diet) diet. SCD can work for a short period of time for sure. Except completely without carbohydrates – usually, weak patients, Crohn’s patients in flares, they really need some carbs to flourish. I create for my clients usually a mix of a Paleo, with a little bit of carbs. I focus on properly-balanced plates, from macros to microbes. All thought out and colorful plates to get the most out of your nutrition, like not having them repeat meals all the time. Very important to rotate.

L: What grains do you recommend to people?
I: I concentrate on gluten-free grains like buckwheat. Many of my clients love buckwheat; actually, they haven’t used it before we speak. So that works.

L: That’s funny because I remember as a child being offered buckwheat pancakes and the first time I tasted them I’m like “this is the most vile thing I’ve ever had, what is this stuff?” And I eat gluten free but when I bake, I make a mix. I usually use sorghum and millet and cassava and tapioca starch as my starch or arrowroot. Sometimes tiger nut or coconut flour.
I: Those are all perfect; all in my pantry. I even managed to be able to make crepes; really, really thin pancakes. Yeah, it takes time. But yeah, you learn.

L: Almond flour of course, that’s my go to flour.
I: And the key is to rotate obviously, you don’t want to be stuck on one. Because then you might create another problem. You might create another food intolerance for yourself.

L: I think I probably live like 50% on almonds. What about elemental diets? Do you use those at all or semi elemental?
I: I try to steer away. Unless there’s a specific rare case. I would recommend that for really short term just to kind of calm everything down, but not for too long. Maybe a week or two.

L: And why is that?
I: Again, I won’t find an evidence-based study on this. Strictly from my experience with so many clients – when the stomach is empty for the first few days it feels great, though there’s no pain. When your gut is inflamed, what happens? Food passes, it creates pain. So food is associated now with pain; people are afraid to eat. This is common with Crohn’s and colitis patients. When you restrict them on chunky food, you will now decrease the pain so they feel better. For a couple of days to a week, things are great. What happens afterwards is that the microbiome cannot be really sustained and be really well-balanced without the chunky meal, or at least the smoothie. You need to feed the intestinal lining. You need to feed the gut microbiome. And, unfortunately, elemental diets won’t provide that in my opinion. With a decade of experience, people start to feel gassy. They will start losing natural probiotics in the gut flora. And they start to feel worse later, in pain. So yes, it’s very short term in my practice only. I’m not putting anybody’s practice down if they have success.

L: What about fiber?
I: Fiber again, very carefully, but it’s a must to reseed that flora. You can’t avoid fiber, but you’re going to have to be very careful and do a proper job putting down the fiber. I’ve learned that if there’s overgrowth of bad bacteria, no good probiotics and you give them fiber, they hurt. That’s gas, that’s pain. And in the beginning, it took me a while to understand how to gently, gradually put it back in.

L: When they’re flaring do you use fiber? Or do you wait until the flare stops?
I: Depends on the flare. If it’s a real flare, then yes, I would wait a little bit until they’re better.

L: And how do you gently introduce fiber?
I: Small amounts, little by little, pinches in the beginning only, and then we grow.

L: And then probiotics. Which probiotics do you use?
I: I really use a lot. I use probiotics depending on the results that I see on the GI map and other labs. I love Garden of Life original professional formulas and Multiprobiotic their soil-based I love. S. boulardii, depending only if there is a need. I love Probiomed from Designs for Health. I am very choosy. And I pick and choose for every case.

L: Will you typically have people do multiple kinds of probiotics, like the spore-based and the lacto-bifido and the S. boulardii?
I: It depends. Most of the cases I do not combine. Most of the cases I don’t. I’ve had a few where I had to, there was a need.

L: And so this is basically based on what you see on the GI map, you’ll decide what they’re most lacking in?
I: Yes, exactly. What they’re lacking in, what they would benefit from, for example, Megasporebiotic by Microbiome Labs for certain cases. But if there’s Bacilli overgrowing, of course, I won’t give that to our clients. So it has to be review and then recommend.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

Listen to the entire podcast episode with Dr. Lukyanovsky.

Gastritis
The problems I address in this article happen north of the intestines in the stomach or in the first part of the small intestine, called the duodenum. While some of these are dealt with effectively using traditional medical care, others will be missed by your traditional doctor, or will become advanced and require a functional medicine approach because they’ve been left so long unattended that they’ve provoked problems in your gut microbial balance or because their origins are bacterial gut infections that traditional doctors don’t know how to look for or treat.

Let’s start with gastritis. This is a first line problem where your stomach is bothering you. It can be asymptomatic or can have symptoms such as

• Indigestion
• Nausea or recurrent upset stomach
• bloating, pain, vomiting, including vomiting of blood or material that looks like coffee grounds
• Burning or gnawing feeling in the stomach between meals or at night
• Hiccups
• A low appetite, or
• Black, tarry stools, indicative of blood in your stool

All this means that you have inflammation, irritation and/or erosion of the lining of the stomach. And you can have an acute or sudden case of gastritis or it can come on gradually and last a while, which would be considered chronic. But either way is, if you catch it early, gastritis can be dealt with pretty easily. However, left untreated, it can lead to a severe loss of blood and may increase your risk of stomach cancer.

A lot of people will just figure out they have gastritis from the pain and do something about it without seeing a doctor. But if you have a chronic case and taking antacids isn’t doing the trick, you may see a doctor, who may do an upper endoscopy, and likely blood tests, such as checking your red blood cell count for anemia, or possibly check your B12 levels to see if you have pernicious anemia or a B12 deficiency, which can result from low stomach acid, which can give you some of the same symptoms as gastritis. And if you have evidence of blood in your stools like the black, tarry stools I mentioned, your doctor may do a fecal occult blood stool test. And if your doctor is on the ball, he or she will also check for H. Pylori or helicobacter pylori, which is a bacteria that can cause these symptoms. I’ll touch more on that later. However, your doctor’s test could miss H. Pylori, so often people will end up needing better testing to verify that their problem was H. Pylori all along.

Some of the causes of gastritis are within your control, so if you are using alcohol excessively, stopping or reducing your use is one treatment. If you have an eating disorder, chronic vomiting will also cause gastritis, so you may need to get professional help with that. And of course our old friend stress can also cause gastritis, so either eliminating your sources of stress or mitigating them may help. And taking NSAIDs or non-steroidal anti-inflammatory drugs, including acetylsalicylic acid, which is the drug in medicines like Aspirin, ibuprofen (which is in Advil and Motrin), diclofenac (which is a topical pain cream and is found in a product called Voltaren) and naproxen sodium, found in Aleve, is another way to end up with gastritis, so if you can stop those or reduce your use, that may help. You can take Acetominaphin without these negative side effects, although I’m well aware that it doesn’t take care of the same problems.
The last possible causes of gastritis that will require professional help are H. Pylori or other bacterial or viral infections, and bile reflux, which is a backflow of bile into the stomach from the bile tract (which connects to the liver and gallbladder).

If you are diagnosed with gastritis, one treatment you’ll likely be offered by your doctor is to take either antacids and other drugs (such as proton pump inhibitors, also known as PPIs or H-2 blockers) to reduce stomach acid. Some examples of these are Nexium, Protonix, Aciphex, Omeprazole, Prilosec and Prevacid, and these are offered over the counter, which makes them look innocent, but let me warn you, as someone who took them continuously for like 15 years, they are not innocent. These drugs will reduce your stomach acid by up to 99% and the end result of that can be the development of even worse gut bugs, maldigestion of protein, B12 anemia, leaky gut, and ultimately, autoimmune disease, all of which I believe I developed after long-term PPI use. The only one that wasn’t definitely diagnosed for me was the maldigestion of protein, but I had all the rest. If you have to take a PPI, my recommendation is to follow the instructions on the package that says not to take for more than 14 days. If your problem doesn’t resolve in those 14 days, you may need to look harder for your root cause. In my case, my root cause of bloating and an incessant cough that was coming from stomach acid in my esophagus, was an intolerance to dairy. I thought I was only lactose intolerant and dutifully took my lactose digestant tablets when I ate dairy, but it turns out I was also intolerant to casein. When I completely cut out dairy, my 15 years of acid reflux disappeared. It was a sad day, but as my French friend said to me about a year earlier, “if you have to take a pill to eat something, do you think you should be eating it?” Those words rolled around in my head for about a year before I was willing to face the loss of my beloved dairy, but I haven’t looked back and have learned to replace the creamy, salty, umami of dairy with avocado or just make different dishes that don’t require dairy. And I occasionally cheat and take many pills to digest gluten and dairy for Neopolitan pizza or burrata cheese, but that’s about it.

Back to treatments your doctor may recommend for gastritis, this could include recommending you avoid hot and spicy foods, eliminate gluten and/or dairy, which are two of the most likely dietary culprits for these kinds of issues, or if your issue if pernicious anemia, vitamin B12 shots or like I take, sublingual tablets. And finally, if your root cause is H. Pylori, and a traditional doctor finds, it, you’ll likely end up on a cocktail of several antibiotics plus PPIs, which may mess up your gut microbiome even more and cause you long-term problems, so I wouldn’t recommend that approach. And I’ll address the best way to deal with H. Pylori under the topic of ulcers.

Some more functional medicine type treatments for gastritis include taking DGL* or Deglycyrrhizinated Licorice before meals, which helps with the mucus production in your stomach and intestines and helps coat and protect them. And the probiotic Lactobacillus rhamnosus GG, which is found in Culturelle* and other probiotics, has also been found to help with gastritis.

But the good news is that most people with gastritis improve quickly once treatment has begun, so the moral of the story is, don’t ignore your body’s early signals that something is amiss in your gut because it can get worse.

Ulcers
Left unchecked, some gastritis, depending on its root cause, can turn into an ulcer, which is an open sore on the inside of your stomach (aka a gastric ulcer), or an open sore on the inside of the upper portion of your small intestine, or your duodenum, (aka a duodenal ulcer). Together, both of these are referred to as peptic ulcers. The main causes of these, like with gastritis, are H. pylori and long-term use of NSAIDs and/or taking other medications along with NSAIDs, such as steroids, anticoagulants, SSRIs (or selective serotonin reuptake inhibitors, which are prescribed for anxiety or depression), or the drugs Fosamax or Actonel.

Symptoms of ulcers include:

• Burning stomach pain
• Feeling of fullness, bloating or burping
• Intolerance to fatty foods
• Heartburn
• Nausea

And some more severe but less common symptoms are:

• Vomiting or vomiting blood — which may appear red or black
• Dark blood in stools, or stools that are black or tarry
• Trouble breathing
• Feeling faint
• Unexplained weight loss
• Appetite changes

You may not be old enough to remember this, but I do. They actually used to believe that spicy foods and stress caused ulcers, which we have since learned isn’t exactly true. Drs. Barry J. Marshall and J. Robin Warren, Australian researchers, discovered in 1982 that H. Pylori was in fact the root cause of more than 90% of duodenal ulcers and up to 80% of gastric ulcers, for which they were awarded a Nobel Price for Physiology or Medicine in 2005, after being ridiculed and ignored by the mainstream medical establishment.

But as I mentioned, one other primary cause of ulcers is prolonged use of NSAIDs, like Ibuprophen. I recently had the misfortune of experiencing this during my ongoing bout of sciatica because I can’t survive without some type of pain relief. I was taking 2 Ibuprofen every 4 hours (which was what my doctor described as the maximum safe dose, without any warning about ulcers, although of course I knew better). First it felt like an acidy feeling in my chest, then it felt like a burning or slight discomfort in a particular place in my stomach after taking Ibuprofen. I was so desperate for pain relief I kept taking Ibuprofen for at least 7-10 days after this sensation started, but eventually knew I had to stop or I’d end up with a bleeding ulcer. I have since had to switch to Acetominaphin, even though it’s not as good for my type of pain, but I really had no choice. Now I reserve the Ibuprofen for only my worst days. And the good news is that I was able to reverse this problem relatively quickly by taking a PPI, Omeprazole, for about 10 days along with the probiotic Culturelle, which is also recommended for ulcer prevention, and my symptoms resolved quickly. The bad news is, I’m on another drug to help relax my muscles called Tizanadine, which is starting to cause an acidy stomach, so I may have to dip back into the PPIs, or stop the Tizanadine, so I’ve got a bit of a dilemma, as I imagine many of you have when faced when you’re faced with the choice of taking your needed drug or having digestive issues, which was something I was a bit more flippant about when it wasn’t my body, and which I can now totally appreciate, as I try to control my pain while trying to resolve the root cause of my sciatica.

Getting back to our old friend, H. Pylori, which is the primary cause of ulcers, the dilemma is that it doesn’t always cause ulcers, and many healthy people have it in their systems with no problem. In fact, in developing countries, H. Pylori is found in over 80% of people, and about 20-50% have it in developed countries, but only 10-15% of people who have H. Pylori will develop peptic ulcers. Some strains of H. Pylori cause gastric cancer, but not all, so if you have it, it’s important to find out which strain you have and if it’s a problematic one, which you can find out through the GI Map Test, which costs about $400, and is used by functional medicine practitioners. Unfortunately, it’s not covered by insurance, but the information you get on it is worth its weight in gold. You can order it yourself online too, and I usually recommend it for my clients with upper GI issues, because it will tell you not only if you have H. Pylori, but if you have what’s called virulence factors, or the really bad strains of H. Pylori, and whether your amount of H. Pylori is abnormal, and will also test for all other known gut pathogens as well as signs of gut dysfunction originating in your digestive organs.

The way that H. pylori causes peptic ulcers is by attaching itself to the protective mucous coating of the stomach and duodenum, and weakening it, allowing acid to reach the sensitive lining beneath it, causing an ulcer to form. Left untreated, it can lead to stomach perforation and bleeding. Ironically, some studies show H. Pylori can be protective as well against gastro-oesophageal reflux (aka GERD) and oesophageal carcincoma, and the former is documented in fascinating detail in Martin Blaser’s book “Missing Microbes” that made me want to go out and get H. Pylori, because of the GERD that plagued me for years. Dr. Blaser, who had H. Pylori but was asymptomatic, cleared it out with antibiotics, then found himself with GERD, then reinoculated himself with it. It turns out that certain strains of H Pylori (cagA+ ones) can reduce the acidity of the stomach (thereby raising its pH) which can prevent GERD, Barrett’s oesophagus and adenocarcinoma (a kind of cancer) of the oesophagus.

However, what I have seen in clients with H. Pylori is a sequence of events that leads to problems. First you see a decrease in stomach acid. This is caused by the release of an enzyme from H. Pylori called urease, which breaks down in the stomach into carbon dioxide and ammonia, causing burping and bad breath that are commonly associated with H. Pylori, and which neutralizes stomach acid or hydrochloric acid, or HCl. HCL prompts the release of bile, which helps metabolize fat in the small intestine, so you can get fat maldigestion, which can lead to nutrient deficiencies. If your stool is pale or floating, that may be because you don’t have enough bile production.

As a result of low stomach acid, you get a rise in pathogenic bacteria or overgrowths of commensal or beneficial bacteria that are not killed off in an acidic stomach, such as Escherichia, including certain pathogenic strains of E Coli, Clostridia, including Clostridia Difficile, which you often see people getting after hospital stays and which causes explosive and frequent diarrhea, Enterococcus, including Enterococcus faecalis and faecium, streptococcus, and overgrowths of yeast such as candida albicans, candida glabrata or other fungi and a high ratio of the phylum firmicutes to bacteroidetes or other more pathogenic strains of H. Pylori. Eventually this can turn into an increase in stomach acid, which will also cause symptoms of acid reflux, bloating, gas, etc.

Low Stomach Acid
Now I want to stop for a minute to make sure you understand that low stomach acid can cause the same symptoms as too much stomach acid, but traditional doctors will almost always assume that your symptoms are coming from too much stomach acid, diagnose you will GERD and prescribe PPIs. The normal pH of a stomach for healthy protein digestion is 1.5-2.2. And that proper pH is a trigger for contraction of the lower esophageal sphincter, which is just above the stomach. This protects the soft, delicate tissue of the esophagus from the harsh acids in the stomach. If your stomach acid is too low, the sphincter may remain open, letting acid up into your esophagus, causing GERD symptoms like burning or an incessant cough, which often prompts people to take antacids or PPIs. These medications can exacerbate the problem by preventing proper digestion of foods, especially protein, which you need HCl to digest, and stressing the enzymatic system of the pancreas and other digestive organs, which are prompted to secrete enzymes in response to stomach acid levels. This can lead to calcium deficiencies, iron deficiencies, B12 deficiency, Vitamin A deficiency (which leads to increased inflammation and gut damage), and protein deficiency, all of which lead to other problems in the body.

When you have a low stomach acid situation brought on by H. Pylori or other reasons, like aging, you will often then see low pancreatic elastase 1 on the GI Map test, which is a digestive enzyme secreted by the pancreas. You can also see this decrease in pancreatic elastase 1 for other reasons, such as gallstones and a vegetarian or vegan diet.

Now back to the question of whether stress is a potential cause of ulcers. The reality is that it probably is, but indirectly. While H. Pylori may be ultimate culprit, given that so many people have H. Pylori and no ulcers, the question is, “why do some people get them?”. So here is the route that this commonly follows. First, our bodies’ first line of defense in the mucous membranes, segretory Immunoglobulin A or SIgA decreases in response to chronic stress. As a result, our gut defense systems are down, allowing the overgrowth of pathogenic or opportunistic bacteria like H. Pylori, which can lead to an ulcer. Or it can lead to decreased stomach acid and other overgrowths as I mentioned before.

So the better way to deal with H. Pylori, rather than taking antibiotics, is to take mastic gum* which is quite effective in treating H. Pylori, along with probiotics of various types, DGL*, and slippery elm*, to help coat your stomach. And if you can tolerate it and it appears you have low stomach acid, it helps to supplement with Betaine HCl*, or stomach acid, using a Betaine HCl challenge test approach, which I’ll describe in just a minute.
GERD

Okay, finally let’s finish up the topic of GERD or gastro-oesophageal reflux, which again is when the lower esophageal sphincter lets acid up into the esophagus. We’ve already touched on some possible causes, including low stomach acid and H. Pylori, so other possible causes are a hiatal hernia, pregnancy, scleroderma, which is an autoimmune disease, obesity, smoking, alcohol usage and certain prescription drugs. So it may be that you have excess stomach acid and not low stomach acid, in which case a short-term (meaning no more than 14 day) course of PPIs may be called for, but you should really only use them when necessary and symptomatic, and then start to try to figure out the root cause of your excess stomach acid and address it. So if you have no other possible root cause as I just mentioned and are negative for H. Pylori, you can start by trying the Betaine HCl challenge to see if you have low stomach acid. The way you do that is to start with one capsule per meal with animal protein (they typically are sold in the 500-750 mg range) then increase your dosage by 1 capsule/meal every 2 days until you feel heartburn or a warmth in your stomach (going up to as many as 5 capsules), then back down to previous dose. If you immediately feel a burning, then it may be you have excess stomach acid or perhaps a hiatal hernia or some other issue. You can take an antacid or some baking soda to neutralize the acid if it’s bothering you. But there are some contraindications for using Betaine HCl, which include Barrett’s esophagus, diagnosed malformation of the lower esophageal sphincter, a history of stomach ulcers, any diagnosed disease or pathology of the pancreas, or if you’re taking NSAIDs or have a diagnosed blood-clotting disorder. One alternative to taking Betaine HCl is to have 1-2 tbsp. of apple cider vinegar or lemon juice mixed in water 10-15 minutes before meals. But again, if you have a diagnosis of Barrett’s esophagus, esophageal strictures, or reflux esophagitis, you shouldn’t use these either. In that case, your best bet is just to try digestive enzymes* that don’t include Betaine HCl, but if you do want to try the Betaine HCl* approach, it’s best to find one with pepsin, which is an enzyme normally secreted by the cells in your stomach.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

This information isn’t intended to diagnose or treat disease but is for educational purposes only. Please consult with your health care professional before acting on any of this information.

*As an Amazon Associate I earn from qualifying purchases. Thanks for your support in using my links!

Mushrooms have been eaten by humans for thousands of years. There are tens of thousands of different mushrooms species, of which six are cultivated for food in North America. There are about ten “choice edibles,” wild mushrooms for which people forage because they’re especially tasty. In Asia, they cultivate approximately twenty different mushrooms. At any time, you might see at least a dozen of those in an Asian market.

Jeff Chilton, co-author of The Mushroom Cultivator*, founder of NAMMEX (North American Medical Mushrooms Extracts), and my most recent guest on The Perfect Stool podcast, introduced medicinal mushrooms to the supplement market in the United States in 1990. He started NAMMEX in 1989, at a time when no U.S. company offered mushroom-based supplements, even though mushrooms have been used in traditional Chinese medicine for thousands of years. This is partly due to the high cost of cultivating mushrooms in the United States. Developing mushroom supplements is even more expensive. For example, while fresh mushrooms may sell for $5 a pound, once they’re dried, it’s $50 per pound because the process of drying is more involved. Mushrooms, like a lot of vegetables, are 90% water. So the economics of mushrooms as supplements do not work in the United States. For this reason, no mushrooms are grown the United States for supplement use; NAMMEX grows all of its mushrooms in China.

The most important attribute for medicinal mushrooms is their ability to modulate the immune system. Mushrooms contain compounds called beta-glucans. In fact, their cell walls are made up of approximately 50 percent of these beta-glucans. A large body of scientific research has demonstrated that beta-glucans express immunological activity. Mushrooms are often working in the background – so when your immunity is low and you get frequent colds, that’s when mushrooms can stimulate the production of immune cells, including macrophages, NK cells, or T killer cells. The key takeaway is that mushrooms modulate our immunity, which means they help potentiate and strengthen our immunity when we need it; but if our immunity is fine, they don’t do anything.

This is why many people would call mushrooms adaptogens. Adaptogens are non-specific: they sit in the background, available to help when needed. That’s why it’s so important to either include mushrooms in your diet or supplement regularly to enjoy their benefits. It’s not recommended that you supplement with mushrooms for a week or two, stop for a week or two and then start again. Rather, Jeff Chilton recommends that before considering supplementation, everyone include mushrooms in their regular diet as a very healthy food.

There has not been a lot of specific research about gut health issues with medicinal mushrooms. However, chaga mushrooms have been used traditionally for gut issues. Chaga is interesting because it doesn’t even look like a mushroom. It is not cultivated, but wild-crafted. It comes about very irregularly from what is called a canker that grows off of trees when a fungus has attacked a tree. Jeff Chilton suggests chaga as potentially helpful for Irritable Bowel Syndrome or Crohn’s disease, for example. Mushrooms also have a very high level of fiber, which directly feeds the microbiome. Some species are so high in fiber that scientists have suggested they should be processed and sold as a fiber supplement. So that’s a key way in which they help the gut microbiome.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

Information in this article was adapted from my interview with Jeff Chilton on episode 33 of my podcast: The Perfect Stool: Understanding and Healing the Gut Microbiome.

*As an Amazon Associate I earn from qualifying purchases. Thanks for your support in using my links!