Adapted from episode 54 of The Perfect Stool podcast and edited for readability.
Lindsey:
Today I’m talking about the naturopathic treatment of inflammatory bowel disease or IBD with Dr. Steven Sandberg-Lewis, a practitioner of Naturopathic gastroenterology in private practice at Hive Mind Medicine in Portland, Oregon. He has been in practice for 40 years and in 1996 he joined the full-time faculty of the National University of Natural Medicine in Portland. Now adjunct faculty, he continues teaching, seeing patients and supervising student doctors in complex digestive disorders. His areas of special clinical and research focus include irritable bowel syndrome, SIBO, GERD, hiatal hernia, inflammatory bowel disease, biliary dyskinesia, the sterolbiome, gastroparesis and chronic nausea/vomiting. He is also the author of the textbook entitled Functional Gastroenterology: Assessing and Addressing the Causes of Functional GI Disorders
So today we’re going to be talking about inflammatory bowel disease. And I know you’ve got Crohn’s and colitis under that title, and that there’s different types of colitis, including ulcerative, microscopic and collagenous. So if you could just go over the different types of IBD, and how they differ in terms of what’s going on and the symptoms, just to start us off.
Dr. Steven Sandberg-Lewis:
Well, if you use the term colitis, you’re focused on the colon. And, of course, Crohn’s disease, can cause something called Crohn’s colitis, which is when Crohn’s disease is present in the large intestine. It can also be present anywhere else in the gut, and most commonly in the small bowel, but there is Crohn’s colitis. There’s also ulcerative colitis, which, by its name, is always in the colon. The big difference between these two main forms of inflammatory bowel disease in terms of the actual location and nature of the disease, the biggest one is that in Crohn’s disease, you typically have areas of colon that are completely normal. By biopsy, by visible exam on a colonoscopy or any other form of imaging, you have these areas that look completely normal interspersed with areas that are diseased. Whereas in ulcerative colitis, it’s a continuous process. It starts in the rectum, if it’s the mildest form, which is called ulcerative proctitis. And then if it’s going to get more advanced, it moves gradually up into the sigmoid colon, the whole left side of the colon, or even the entire colon, it’s called pancolitis. So they look very different in that you don’t have any areas that are spared, like Crohn’s colitis would have. There are a lot of other differences too, like one of the most striking differences in terms of lifestyle is smoking tobacco. It doesn’t even have to be smoked. It could be a transdermal patch, or some other delivery of tobacco, but tobacco actually reduces the risk of recurrence and severity of ulcerative colitis, whereas tobacco increases the risk for bad outcomes, the need for eventual surgery and general aggravation of the condition in Crohn’s, even though they affect the same areas and they’re both called inflammatory bowel disease.
Lindsey:
That’s interesting that you brought up the tobacco right off the bat. Because I sort of think of that like, okay, now we’ve tried absolutely everything out there, and then maybe say, hey, maybe a nicotine patch? Is that something that you use with patients?
Dr. Steven Sandberg-Lewis:
I’m not supposed to say that we do that. But I certainly remember very clearly a patient who was not responding to any standard medicines, or natural medicines, and she came in to see me. And after we talked, she started smoking five cigarettes a day, and it completely put her in remission. And she stayed that way for years. She could have used the patch, she could have done something else, but she thought that was cheaper, and just did that. So yeah, I’m not telling people to do that. We don’t tell people to do that. But an interesting finding is that the nicotine receptors in the gut do respond to nicotine and have opposite effects in Crohn’s and ulcerative colitis.
Lindsey:
Interesting, and so how is collagenous colitis different from ulcerative colitis, or microscopic colitis?
Dr. Steven Sandberg-Lewis:
Some writers and researchers still don’t put microscopic colitis in the same category as IBD, or inflammatory bowel disease. But I do, I make a little Venn diagram with Crohn’s and ulcerative colitis. And I put microscopic colitis over on the side as a separate circle. But I do call them all inflammatory bowel disease and the difference, microscopic colitis is the general term. And by the name, you can tell that it means you can only see it with a microscope. This is the kind of thing that gets biopsied for when someone, especially someone over 50, starts to have copious many times a day, non-bloody diarrhea. It can be very serious and can be a lot of weight loss and nutrition.
So microscopic colitis is a term for – it’s a normal colonoscopy for this kind of condition – but when you biopsy it, either the left or the right side of the colon, you take a biopsy, you will see microscopic inflammation, and that shows up as many lymphocytic white blood cells in the lining cells. And there’s two forms. As you mentioned, one is called lymphocytic because you just see those lymphocytes, and the other is called collagenous. You see the lymphocytes there, too. But in addition, there’s a thick layer of collagen tissue, which is a tissue that normally makes up most structural parts of the body, but a thickening of that collagen protein in the deeper layer just underneath all those lymphocytes.
And to the best of the research, it seems as if collagenous colitis is probably a later stage, because it has that same inflammation that you see with the lymphocytes, but now it’s starting to thicken up. Generally, what happens in the body when there’s chronic inflammation is there’s a thing called fibrosis, or you might call it scarring, where fibrous tissue is laid down to try to patch things when there’s long-term inflammation. And I mean, that’s one of the things that destroys the liver in cirrhosis. It’s actually the healing process that can affect the function of the liver because of this fibrosis. So that’s what’s happening in microscopic colitis, both collagenous and lymphocytic.
Lindsey:
Got it. And then in just regular ulcerative colitis, like on a colonoscopy, you’ll see visible ulcers along the colon?
Dr. Steven Sandberg-Lewis:
Right, you see either redness which is called erythema, you might see erosions, which are shallow denuding of the surface, or you may see actual ulcers, and bleeding and other signs.
Lindsey:
So, in terms of treating these diseases, functionally, which ones do you see the most success with, and which the least. Or are they all potentially reversible if patients are willing to stick it out and follow your treatment plans?
Dr. Steven Sandberg-Lewis:
Well, I used to say that I have a three-pointed approach. My latest lecture that I did a couple months ago, for our gastroenterology course I made it into a five-point star. But for most people, I like to just talk about a 3-point approach of treatment. So that involves number one, diet. The next one is some kind of immunomodulation, something that helps to balance the immune system in the gut, which is where most of the immune system is anyway. And then the third corner is stress and coping. I tell people that right away that these are the things we’re going to be focused on, you know, see if they want to buy into that kind of approach. I don’t like to leave out anything that’s essential if it’s there.
So what’s the most effective depends on the person. You know, I’ve had people who really needed to go to a counselor or have some hypnosis or self-hypnosis or mindfulness. And they put that piece off, and it just had to wait until they finally did that for things to really improve. If you’re walking on eggshells every day of your life because your boss is a jerk, or your primary relationship at home makes it so you don’t ever really relax, you always feel on edge and ready to jump. If you have old tapes playing in your head, and colon, from childhood or earlier in life, that haven’t been resolved, those are key things to work on. I teach a course at the naturopathic college within the university called gastroenterology lab. It’s a lab course, because we do things, physical things. I teach them how to use Emotional Freedom Technique to clear unresolved emotional states. And eye movement clearing techniques for the same thing. I teach them other physical techniques like ileocecal valve and hiatal hernia syndrome techniques and things like that – visceral manipulation. I just think it’s really important. I think of gastroenterology as a physical medicine process as well as emotional and organ based. That’s one thing. That’s one corner.
The other corner, like I said, would be diet. And the gold star, first, when you think of diet , would be either the Specific Carbohydrate Diet that was created by Sydney Haas back in the 1940s, New York pediatrician. Before they knew what celiac disease was, the Specific Carbohydrate Diet was invented by Dr. Haas as a way to treat celiac disease. Gluten had not been discovered; they didn’t know what caused celiac disease. Celiac means abdominal. So it was the abdominal disease. It’s not anything they knew. And gluten wasn’t really discovered as a substance until I think 1952. So kids were dying of malnutrition because of celiac disease. And he created this diet that had only specific kinds of carbohydrates, hence the name, ones that were not highly fermentable by intestinal bacteria. And that was extremely successful in treating celiac disease as well as IBD.
Lindsey:
Now why would that be for celiac?
Dr. Steven Sandberg-Lewis:
Because it’s a gluten free diet. Gluten is highly fermentable. And especially wheat because of the fructans in it. That’s the primo diet, and then other diets have been designed off of that. So there’s the GAPS Diet, the Gut and Psychology Syndrome Diet, which took the Specific Carbohydrate Diet and added Price-Pottenger types of high fat to support the brain and fermented foods and bifodobacter was added, before that only lactobacillus-containing foods were on the Specific Carbohydrate Diet. So just kind of advanced it to work more on autism and bipolar and depression and other mental conditions.
Also, the brilliant Dr. Allison Siebecker, who I work with a lot and teach an advanced gastroenterology course with, she put together the Monash University FODMAP diet together with a specific carbohydrate diet because we know based on research that both the FODMAP diet and the specific carbohydrate diet are very effective at treating both irritable bowel syndrome and inflammatory bowel disease and getting people out of flares.
So she put the two of them together into one diet and one set of charts, which is really helpful.
And then Dr. Nirala Jacobi took it a one step further in Australia, again, like a FODMAP diet, and she created what’s called the Bi-Phasic Diet, which is basically Dr. Siebecker’s diet. But it has two phases, one that’s a little stricter that you do first. And then the reintroduction phase is the second phase. Some diet of some sort like this is extremely important, and really helps in every way. It helps emotions, helps the physical structure, helps the microbiome. And it’s really hard to get around not using diet. Often you can use a diet all by itself and get excellent results.
And then the third piece, immunomodulation. In standard gastroenterology, this is all done by suppressing different parts of the immune system either with prednisone, which kind of lays down a blanket over the almost entire immune system and decreases its activity to bring down inflammation, or more specific types of immunomodulators. But they all are designed to suppress the immune system.
In my approach, if I don’t need to use something like that, because we don’t have time and there’s too much tissue damage going on, I’ll get them started on the diet, which can work as fast as prednisone in my experience. But also, if I have time, I’ll do something different. And that might be something like low dose naltrexone. It is a prescription drug, but we use it in 1/10th to 1/15th of the normal dosage. And it works to raise endorphin levels in the body which helps to balance the immune system’s function. I like to say to people that the opiate receptors, that’s what you’re stimulating with your endorphins in the digestive tract and in the nervous system. These endorphin receptors, when you block them for short periods of time with low dose naltrexone, it actually stimulates the immune system and the pituitary gland to make more endorphins. And when you have higher levels of endorphins, it helps to sort of orchestrate the whole immune system so that you don’t have one part overreacting and another part underreacting. It helps balance it by stimulating certain types of cells called regulatory T cells. And the low dose naltrexone is really good at doing that. So, we’ll use something like that. Or we’ll use herbal medicines such as turmeric or boswellia.
Lindsey:
So just to back up and sort of state the obvious. These are all autoimmune conditions?
Dr. Steven Sandberg-Lewis:
Right. It’s funny though, they’re autoimmune conditions, especially Crohn’s and ulcerative colitis – we know there are specific autoimmune markers that you can measure in the blood. The interesting thing is that a lot of textbooks of medicine still don’t admit that, in articles as well, it’s not known. We call it idiopathic inflammatory bowel disease, which means we don’t know the cause. Really, I think there’s almost overwhelming proof to say that these are autoimmune.
Lindsey:
And what are the markers that you look for with the various conditions?
Dr. Steven Sandberg-Lewis:
There’s a lab called Prometheus that specializes in GI tract and they do all kinds of advanced GI testing. They test interestingly enough for Crohn’s disease, upwards of 60 to 70% of people with Crohn’s disease will have a marker in their blood, which is an antibody against saccharomyces cerevisiae, which is baker’s yeast. So, they’re called ASCA, anti saccharomyces cerevisiae.
Lindsey:
They have that in a basic IgG panel even through Lab Corp now though.
Dr. Steven Sandberg-Lewis:
Other labs have started to do it. For me, this was the one that initially did it. And then in ulcerative colitis, a large percentage of people will have p-ANCA antibodies which is a substance made by neutrophilic white blood cells that you can have antibodies against, which is an autoimmune marker for ulcerative colitis. You can do this panel where you check for these. And there are other ones as well, but these are the main ones where you can check the blood for these different antibodies and see if there’s a pattern that looks more like Crohn’s or ulcerative colitis or neither.
Lindsey:
And in terms of your treatment, your natural treatments, does it matter whether it’s one or the other?
Dr. Steven Sandberg-Lewis:
It really matters. Now with the diet, not so much. Although, if we know someone who has Crohn’s, we’re going to make sure they don’t get gums and thickeners. I mean, that’s true for probably both conditions. But carrageenan is a definite no-no for people with Crohn’s. So, they want to make sure that’s not in their diet.
Lindsey:
Including thickeners, like partially hydrolyzed gaur gum? Or is that an OK one?
Dr. Steven Sandberg-Lewis:
Well see that one’s modified. It’s like modified citrus pectin. It’s different, rather than xanthan gum or carrageenan, or guar gum, which can really be problematic. The partially hydrolyzed gaur gum, as far as we know, is not fermentable the way regular gaur gum is.
Lindsey:
Oh, okay. So, that’s the issue is that it’s fermentable. So Crohn’s patients are more susceptible to having problems with those gums and things. This is like polysorbate 80, and other things, too, right?
Dr. Steven Sandberg-Lewis:
Well, there’s even some very fascinating research articles that look at the kinds of substances that help water and soap kind of sheet out in layers, like you use in your detergents. Detergents definitely often has surfactants in them. And there is some very interesting evidence from research that that may be a factor in either type of IBD.
You know, again, when we talk about the differences between the diseases, ulcerative colitis really appears to be a mucus problem. In Germany, they’ve done a series of studies to look at phosphatidylcholine, common name lecithin, normally produced in the last portion of the small intestine, the terminal ileum; it’s secreted there. And it becomes part of the mucus that then flows in through the ileocecal valve through into the large intestine. You know, the large intestine has a special kind of mucus, it has two layers of mucus, the stomach and the large intestine have these two layers of mucus because the stomach has to protect itself from acid so it doesn’t get digested because it produces acid.
And the large intestine, you really don’t want the billions of bacteria per gram of material in the large intestine to touch the mucous membrane to actually touch the cells that line the colon, because that could stimulate an immune reaction, which looks a lot like ulcerative colitis. So, the large intestine has a very dense, deeper layer right up against the cells that line the intestine that’s very dense and hard for bacteria to move through. And then it has a less dense, more superficial layer that some bacteria can live in it, especially things like akkermansia, a type of bacteria that really likes mucus. Then others live out in the opening in the air, so to speak, even though there’s no air there. It’s an anaerobic environment, but in the space. We think that, at least according to these series of German studies, that if you’re not having phosphatidylcholine, which is the stickiest gooey substance in the world, mixed in with your mucus, and then have that flow through your large intestine, you’re not going to have normal mucus in there, you’re not going to have these very important layers. And then bacteria are more likely normal flora, of which, like I said, there are billions per gram, in the large bowel it’s normal to have that much. They can actually end up touching some of the cells and that’s a no- no; that’s going to stimulate a big reaction by the immune system.
Lindsey:
Is that something that you tell people to supplement with?
Dr. Steven Sandberg-Lewis:
Well, we’re not doing that. Mostly because I think we would pull that out if nothing else was working, but we have to have it specially formulated and triple encapsulated.
Lindsey:
To get to the large intestine?
Dr. Steven Sandberg-Lewis:
Yeah, to make sure it isn’t absorbed too soon.
Lindsey:
So, in other words, if you’re eating processed food with soy lecithin, that’s not going to be helping you.
Dr. Steven Sandberg-Lewis:
That’s right, that’s good for your gallbladder, it’ll go to your liver and get used and put into your gallbladder to help prevent gall stones, but no, not otherwise. It’s also a good source of choline, which your body can turn into acetylcholine, which is a very important neurotransmitter for the gut. So, it’s really helpful thing, but not for the colon.
Lindsey:
Let me just back up and ask about the antibodies to S cervisiae because, you know, I think about Saccharomyces boulardii, which is Saccharomyces cervisiae subspecies boulardii, as a very common probiotic. Is that a problematic one then for people with Crohn’s?
Dr. Steven Sandberg-Lewis:
I’m not aware that it is. But certainly, yeast overgrowth in general and Candida and rhodotorula. Some of these other forms of yeast that can overgrow in the gut can definitely be a big problem. Bacterial overgrowth, normal flora, especially in the small bowel, as well as yeast overgrowth in the small or large bowel can be a big issue in Crohn’s, even more so than ulcerative colitis, right. I don’t tell people never take Saccharomyces cervisiae or boulardii because it will make your Crohn’s worse.
Lindsey:
But you do tell them presumably to avoid gluten as part of the SCD diet? Or which one? You sort of gave me a series of them, but do you use the Bi-phasic Diet then?
Dr. Steven Sandberg-Lewis:
Depends on the patient. One thing I want to mention too is I highly, highly, highly suggest that if they’re eating gluten on a regular basis, before they just continue it, get a thorough blood test for celiac, non-celiac and wheat allergy. Because you’ll never be able to get an accurate test again if you quit eating it.
Lindsey:
And a thorough test would go beyond just tissue transglutaminase. Or what all would you test to get a thorough test?
Dr. Steven Sandberg-Lewis:
So, a basic test that would test everything that would make it thorough. I mean, there’s some really thorough tests by Cyrex Labs and the Wheat Zoomer that’s done by Vibrant America that are incredibly detailed and check for every possible kind of reaction you could have to gluten. But the basics would be tissue transglutaminase, both IgA and IgG, deaminated gliadin peptide, IgA and IgG, and total Secretory IgA.
Lindsey:
And that’s to check if the immune system is working in the first place?
Dr. Steven Sandberg-Lewis:
That’s just to make sure they don’t have an IgA deficiency, which is quite common in celiac, right. And also, so you’ll know to forget, you’ll know to ignore the TTG IgA and deaminated gliadin IgA because they’re not accurate if total IgA is low.
Lindsey:
And they would then be low as well?
Dr. Steven Sandberg-Lewis:
Most likely, I mean, if they’re still high, then they’re high, but if they’re normal doesn’t mean anything. And that’s why you have the IgG to back it up. Also, if you wanted to check for non-celiac gluten intolerance, which I think is a great idea, you would do antigliadin antibody IgA, and IgG.
Lindsey:
And that’s blood. Right?
Dr. Steven Sandberg-Lewis:
These are all blood.
Lindsey:
Just because I know there’s in the GI Map, there’s an anti-gliadin from the stool. Is that worth anything?
Dr. Steven Sandberg-Lewis:
Yeah, there are two labs that I know of that do that, the GI Map, and then also the original lab that does all the testing from stool. It’s been so long since I saw one of those that I can’t even remember the name of it like, EnteroLab. I think It is. And they do the TTG in the stool as well, as well as anti-gliadin antibodies. So the last one if you want to check for wheat allergy is wheat IgE. That’s the only one that’s IgE because it’s an allergy.
Lindsey:
But do you think that the stool ones are useful markers?
Dr. Steven Sandberg-Lewis:
I don’t know. They’re not standard. I certainly take them to heart, but they’re not standard ways of diagnosing celiac. If it’s anti gliadin antibody that’s elevated, that’s pretty indicative of non-celiac gluten intolerance. And I think it makes sense to use saliva or stool rather than blood to do these tests. Because you’re in the right compartment. You know, you’re in the gut. But the standard tests are the ones to also do, and those are blood.
Lindsey:
Do you as a naturopath, do you do endoscopies and colonoscopies and that type of thing? Or do patients come to you having already typically seen an allopathic doctor and gotten a diagnosis?
Dr. Steven Sandberg-Lewis:
I don’t. Our license allows us to do that. But most gastroenterologists, they spend several days a week doing these procedures. And I just don’t think that’s the highest calling for a naturopathic doctor when we have so many tools for actually, once we have the diagnosis to treat it. But yeah, we could if we wanted to, in fact, Mark Davis, a former student of mine, who specializes in IBD in Bethesda, Maryland, he took the training, the 80-hour training, to do it. And he just decided after that, that he probably had other things that he should do. But yeah, we can do it. But we don’t.
Lindsey:
What is the typical functional testing regime for someone with IBD?
Dr. Steven Sandberg-Lewis:
The first thing I do, if I’m thinking, hmm, does this person have IBD? Let’s say they have Crohn’s, or they have the rare kind of ulcerative colitis where there’s no blood. And still, Crohn’s can have blood or not, ulcerative colitis almost always does, sometimes doesn’t. And you’re not sure, but based on their other symptoms, you’re really thinking about it. The first thing I do is a stool calprotectin. I think of calprotectin as a really good way to decide if somebody needs a colonoscopy and biopsy or not. And if the levels are under 50, then we’re thinking about other things besides IBD. Definitely, I think all labs at this point, for some reason, use that number 165 and above, seems to be a really accurate number for indicating someone’s in a flare. Definitely when calprotectin is over 250, that’s definitely an active flare of Crohn’s or ulcerative colitis. Anyway, levels between 50 and 100, usually repeated again in three or four weeks and see if it’s going down or up. Because it’s kind of in the equivocal, maybe range. I do that. And, again, if it comes back high. And if there’s not time, because someone’s really acute, you’re going to just start treating them as if, right?
But you can also get a stool sample and send it off, as you’re starting to treat them and see what the calprotectin is. I’ve had patients with calprotectin over 2000. That’s almost typically someone has a really severe flare. And so it’s a great marker, noninvasive. And I like to use the calprotectin. Once I start treating someone, I like to do it every six to eight weeks, to see if the treatment is working. You know, someone’s symptoms could be better, but they could still have pretty severe inflammation if you’re kind of controlling it with the treatment. So, I like to see if the markers actually coming down. Calprotectin is another immune substance produced by neutrophilic white blood cells. And it’s a really accurate marker for that. So how else do we diagnose? We send for colonoscopy if we think that’s what’s going on.
Lindsey:
Yeah, no, I’m saying assuming they have the diagnosis. They’ve seen someone, you know that you have some form of IBD. I’m talking about what kind of testing you might do to look for other things going on?
Dr. Steven Sandberg-Lewis:
Oh, yes. And that’s where stool testing can be really helpful. Like I said, I will use the calprotectin as a marker of inflammation but then also going to call for yeast, we’re going to look under the microscope for yeast, because it doesn’t always culture, if it cultures, the labs will give us culture and sensitivity, the sensitivity testing will check for natural substances that would kill that particular yeast as well as prescription. It will also check for certain kinds of viruses such as cytomegalovirus, which can really kick up inflammatory bowel disease in ulcerative colitis patients. If diarrhea is a strong component, we’ll do a Clostridium difficile toxin test, because you got to really treat that specifically. If they have that, they won’t get better until you do. And we’ll check for small intestine bacterial overgrowth, especially if they have significant bloating and abdominal pain, which in Crohn’s disease sometimes all you have is sort of a tendency toward constipation, bloating and abdominal pain, and abdominal pain can be the main symptom.
Lindsey:
And will you check for SIBO with a breath test like the triosmart?
Dr. Steven Sandberg-Lewis:
So, the breath test, of course, measures for hydrogen and methane. And the triosmart adds the third gas, which we had a lot of trouble getting a test for. They worked on that for over 15 years. And that’s hydrogen sulfide. And actually, I meet with physicians and researchers around the country, every third Wednesday of the month for an hour, and we talk about the triosmart tests that we’ve done in this previous month. And we’re trying to really understand how to use this and how to treat it, because it’s treated a little differently than other kinds of bacterial overgrowth.
Lindsey:
So, when you were talking about the stool testing, whose stool test do you use typically?
Dr. Steven Sandberg-Lewis:
Well, if I order it for a patient, or who has come to see me in Oregon physically, then they can actually be a patient, I can order lab work and prescribe medicines, I’m usually going to use Doctor’s Data. I like culture based testing. First of all, because like I said, you can get a sensitivity. If you can culture the organism, you can get a sensitivity, for a stool test, and see what would be most specific for treating that bug to bring the numbers down. You can’t do that if you just check PCR, the gene testing, the DNA testing. Many of the other labs have dropped the culture altogether and just do the genetic testing. Genova is probably the oldest lab. I’ve been using them since the 1980s. I think it was started by naturopathic doctors, which is kind of cool. But they still have options for doing culture, as well as testing for genes.
Lindsey:
So just to make sure people understand what sensitivity means, that is where it tells you which natural substances and antibiotics and such would kill the thing that you’re testing?
Dr. Steven Sandberg-Lewis:
I really need to ask how they do it. When I was being trained back in the 1970s, they would take the stool and spread some on a petri dish, and they would grow the bacteria or the fungus. And then once they grew it, they would put little paper circles that were impregnated with the different natural treatments or drug treatments, they lay those on top, and they’d see how big an area of clearing occurred around those treatment discs. And that’s how you knew if the bug was sensitive to it, and it would be killed by it or not.
Lindsey:
When it comes to culture, I’ve heard it argued that it’s not as valid as PCR, because it tends to just culture those bacteria that are aerobic, and those will grow and proliferate, whereas the anaerobic ones won’t.
Dr. Steven Sandberg-Lewis:
Yeah, it also grows the facultative anaerobes, the ones that can, like lactobacillus, live in some oxygen. But you’re right. If you want to check all the anaerobes you really have to do both kinds of testing. That’s what I would suggest until we know more about what to do with some of these dozens and dozens of fully anaerobic organism markers. I think at this point, you know, we have the microbiomes kind of mapped out for both the colon and now for the small intestine. We know how to test for all kinds of bacteria using their DNA. But the thing to know about the colon, when you’re looking at stool, you’re looking at colon. It doesn’t tell you about the small bowel. And according to researchers and all the textbooks, about half the bacteria in the colon are dead. So it’s like 50/50, living and dead. When you’re looking at DNA, you’re looking at dead and live bacteria. That’s what you’re looking at. When you do a culture. It won’t culture if it’s dead, you know, it’s only living that will grow. I still like that idea that I’m looking at what’s alive, and what’s able to grow, as opposed to everything dead and alive. Because I think it’s a real shame when doctors do PCR, this DNA testing on stool, they find something that’s high, and then treat it with strong drugs to try to kill it, or even strong herbs to try to kill it. I think they may be doing nothing, except maybe some damage, you know. They’re going after something that’s already dead, at least half of its dead. I just think that we have a lot of information about the microbiome. But we’re like little infants, you know, squashing bugs that they see on the floor. And we’re not really doing anything very intelligent, not that infants aren’t intelligent. But we’re not doing anything that’s maybe that meaningful or intelligent at this point by strictly using PCR. Until we have about 20 year’s experience with this, I think we’re probably going to be making a lot of mistakes. So I like to go with what I know is alive. That’s just my prejudice.
Lindsey:
Okay, do you find that there are certain root causes that you find commonly with Crohn’s and colitis, when you do these types of tests?
Dr. Steven Sandberg-Lewis:
I mean, there’s one piece and that is, almost all these stool labs will check the short chain fatty acid levels in stool. And we know that short chain fatty acids are produced by friendly bacteria, the microbiome, when they metabolize fiber, or mucus. They make short chain fatty acids and we know that butyric acid is the best understood, and probably, at this point, the most important of the beneficial short chain fatty acids produced in the large intestine. As a food source, you can actually get, I think it’s like 20% of your calories, from your own bacterial production of short chain fatty acids. And it does many things. We know that in research, it really seems to help reduce the risk of inflammatory bowel disease. So certainly, when you see someone who has very low butyric acid levels, that in itself isn’t the cause. It’s whatever’s not producing the short chain fatty acids, which might mean, they’ve got a really low diversity or low number of bacteria in the large intestine. So, they don’t have enough bacteria to produce it. Or maybe they don’t take in the right kind of fiber or enough fiber to give the bugs what they need. Or maybe they don’t produce enough mucus because they have some issue with them.
Lindsey:
That always strikes me as ironic that a lack of short chain fatty acids that are produced from eating fiber can be a problem. And yet the solution is eat less fiber and go on these diets like SCD that has virtually no fiber, right?
Dr. Steven Sandberg-Lewis:
I wouldn’t say it has virtually no fiber, and it depends how you do it. And I certainly recommend working with a knowledgeable nutritionist that can help you individualize the diet. But there can be plenty of fiber on these diets. It’s just specific carbohydrates. So it’s not all fiber, and it’s certainly not insoluble fiber like bran, because that’s quite irritating. You know, soluble fibers, some are less fermentable than others and certainly vegetable fiber. If someone is lucky enough to have the ability to process vegetables and fruit fiber in a healthy way, when they have IBD. These kinds of diets can have plenty of fiber from fruits and vegetables and nuts and seeds. You’re just choosing the lower FODMAP versions of those things.
Lindsey:
Which sort of points to the fact that an overgrowth of bacteria in the small intestine is likely at the top of the train – that stopping that fermentation in the small intestine is the beginning of trying to solve the problem in the large intestine.
Dr. Steven Sandberg-Lewis:
Right, the small intestine and the large intestine are a whole different world, like I say, they have different microbiomes, when you study them. Also, the small intestine isn’t small. It’s the largest part of the digestive tract, by about a factor of four or five, it’s 18 to 20 feet long, some say 22 feet long, and the large intestine is only about three and a half feet long. It’s all about the diameter of the opening, right? That’s why they call it small, as opposed to large intestine. And the small intestine is designed to have very low numbers of bacteria in it, because it’s got stomach acid, bile, and pancreatic enzymes, all dumping into the top of it, and really creating an adverse environment for the bacteria. So it really keeps their numbers down. And then the migrating motor complex that moves things through the small bowel also helps kind of flush out the bacteria, so they don’t just sit there and multiply. So the numbers in the small intestine shouldn’t be more than 1000 to 10,000 per gram of material, whereas in large intestine, you have millions or billions per gram. And that’s normal, it just depends whether you’re on the upside or the downside of the ileocecal valve, whether that’s going to be normal.
Lindsey:
Are you seeing then that the majority of people with IBD have either SIBO or SIFO?
Dr. Steven Sandberg-Lewis:
I think that those conditions are extremely common, especially in Crohn’s disease. But they can also be an aggravating factor in ulcerative colitis, and microscopic colitis. I’ve seen really good results by treating adrenal problems, which we haven’t talked about yet, as well as bacterial overgrowth in the small bowel in people with microscopic colitis as well.
Lindsey:
And so, I imagine some of your patients come to you already taking pharmaceutical immunomodulatory drugs and steroids and such. If that is the case, and you work with them, and they seem to be doing better, how do you know when it’s the right time to try and get off of those?
Dr. Steven Sandberg-Lewis:
In large part that depends on the patient. Not all patients come to me saying my goal is to get off this drug, right? Assuming they had that goal. Yeah, if they come in, they say, yeah, I want to get off my biologic or I want to get off my Pentasa, or whatever. First of all, I look at the fact, is the drug working? Does it do what it’s supposed to do? And sometimes it’s really not. So I have patients who are on biologics, which are injectable drugs at this point, either as infusions at an infusion center or self-administered every couple of weeks at home. And what I’ll ask them, say they’re on a biologic drug that has eight-week cycle, they have an infusion every eight weeks, I’ll say, “So how are you immediately, you know, the first week after you have the infusion?” And how are you the last week or two, when you’re needing the next infusion? And they say, no real difference, doesn’t get better after the infusion, and it doesn’t get worse, as it’s wearing off, then I’m going to figure you know, this drug really isn’t working.
That’s very different than someone who comes to me and says, oh, I just feel like I got my life back the first two weeks after I have my infusion, and the last two weeks while I’m waiting for my next one, I’m kind of wondering if I should go in early because I’m getting so bad. And then that’s a drug that’s doing something. So, it really makes a difference. If the drug’s not doing anything, there’s less need to worry about starting to withdraw it as long as we have something else in place. I always, if I can, like to get the diet in place. The emotional states starting to move in the right direction if it needs to, or coping with stress, as well as some kind of immunomodulator. And usually the first one is low dose naltrexone they’ll be trying because it’s often so effective. I’ll get that started. And then we’ll work with the doctor who prescribed the biologic to wean it.
Lindsey:
Okay, so one thing that I’ve found challenging with clients with IBD is that some of them just don’t believe that healing is possible because they come from that allopathic background in terms of who they’ve seen that they don’t want to stick it out, like they’re not willing to stick out the diet for an extended period of time. So I’m just wondering if you have any tips for patient adherence?
Dr. Steven Sandberg-Lewis:
You know, I have gotten less and less skilled at that, I think, because I don’t have to, by the time people see me. I have this one guy. He keeps telling me he’s seen 50 gastroenterologists before he saw me. I’m not primary. I’m not secondary. I’m not tertiary. I’m probably quaternary care.
Lindsey:
So you’re getting the people who really want to get better and will do anything.
Dr. Steven Sandberg-Lewis:
Yes, yes. So I’m probably not as good as a primary care doctor at getting people motivated.
Lindsey:
So, we talked beforehand that you have a song about the Bristol stool chart.
Dr. Steven Sandberg-Lewis:
Oh, doesn’t everybody?
Lindsey:
Yeah, but I’m wondering what your version is like. I’m looking forward to hearing the Bristol stool chart song. And just in case anybody doesn’t know what the Bristol stool chart is, it’s the chart of how your stool looks on a scale of one to seven that can help you determine what’s going on. Maybe you’re constipated or have diarrhea.
Dr. Steven Sandberg-Lewis:
We use it to just get a good, quick way to write it in the chart. So we know what the form of their stool is. Because one thing I could say about constipation and diarrhea, people will start talking about their condition. They’ll say, yeah, I’ve got constipation. So, I say so what, what’s the Bristol stool type? And you know, seven is liquid, and one is a little hard ball. And they’ll say, let’s see. They look at the pictures, and they say six or seven? And you think, well, wait a minute . . .
Lindsey:
What aspect of that is constipated?
Dr. Steven Sandberg-Lewis:
So the thing is, the definition of constipation, according to the Rome criteria, is it’s a number of things. It can be frequency of less than two to three stools per week. It doesn’t matter what the form is, right. And often, people who have constipation take a lot of vitamin C or a lot of magnesium or Miralax, or something else. And they end up overdoing it. And go from having a Bristol one hard round ball stool to having sometimes explosive diarrhea. If you were to just take their history, and not know that they were constipated to begin with, and start taking all these laxatives, you’d think they have diarrhea. There is also by the way, have you ever explained overflow diarrhea?
Lindsey:
No, but I know about it.
Dr. Steven Sandberg-Lewis:
So, for those who don’t know about it quickly, it’s when people have diarrhea, often children have diarrhea. But they’re really constipated, you have to treat them as if they’re constipated, because they have built up stool that can show up on CT or X ray of the abdomen, in the colon, and all that can get through that narrowed space, because of all that hard stool in there is liquid. And so the only thing they have is liquid stool. And that’s called overflow diarrhea. It’s not exactly straightforward all the time. But the Bristol chart does help us at least get a sense of what the form of the stool is. It doesn’t necessarily tell us whether it’s truly constipation or diarrhea. I’ll see if I can remember the chords (to the tune of Do a Dear):
One a ball, a hard-round ball
Two, a clumping form of one
Three, a log with three gold lines,
Four, a snake that’s smooth and done
Five an unformed bunch of flecks
Six, a pile of soft serve mess
Seven, a fully liquid stool
That will bring us back to one
Lindsey:
Wonderful. Well, thank you so much for sharing all your knowledge with us today.
Dr. Steven Sandberg-Lewis:
All right, it was fun.
If you’re struggling with IBD or any type of gut health problem and are ready to get some professional help, you’re welcome to set up a free, 30-minute breakthrough session with me. We’ll talk about what you’ve been going through and I’ll tell you about my gut health coaching 5-appointment program in which I recommend lab tests, educate you on what the results mean and the protocols used by doctors to fix the problems revealed. Or if you’re ready to jump in right away or can just afford one appointment at a time, you can set up an 1-hour consultation with me.
