The Carbohydrate Malabsorption Theory of Acid Reflux

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

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, 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

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.

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