LET’S “TALK” ABOUT

SIBO
3 EXPERT TALK TRANSCRIPTS
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Post-Infectious IBS and
SIBO: The Cause and Effect
Shivan Sarna with Mark Pimentel,
MD
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The Issue that Keeps
Coming Up: GERD and SIBO
Shivan Sarna with Steven
Sandberg-Lewis, ND, DHANP
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If You Build It, They Will

Come: The Biology of the
Microbiome Shivan Sarna with
Jason Hawrelak, PhD
Click here to watch this interview!

Shivan Sarna: We are here in LA
with Dr. Allison Siebecker, SIBO
specialist, and Dr. Mark Pimentel.
Thank you so much for joining us.
Dr. Mark Pimentel: It’s a
pleasure to be here.
Shivan Sarna: Well, in case you
haven’t noticed, my voice is funky.
And so, Allison graciously agreed to
join me on this interview, so that we
could give as much information as
possible, but also because my voice
is funky.
And by the way, you’re in for a treat!
Dr. Mark Pimentel: I feel like it. I’ve
got two interviewers.
Shivan Sarna: We’re going to try to
uncover as much as possible. No
pressure!
Okay, Dr. Pimentel, thank you so
much for being here. So, I hear you
have a new title at Cedar Sinai?
Dr. Mark Pimentel: Yes, I do. I used
to be the Director of the GI Motility
Program. And now I’ve turned that
over to another physician. I’ve
moved up in a different position.
It’s called the Executive Director of
the Medically Associated Science and
Technology or MAST Program.
But essentially, it’s a new endeavor
at Cedar because of all the work
Post-Infectious IBS and SIBO:
The Cause and Effect
Shivan Sarna with Mark Pimentel, MD
Click here to watch to this interview!
The purpose of this presentation is to convey information. It is not intended to
diagnose, treat, or cure your condition or to be a substitute for advice from your
physician or other healthcare professional.
we’ve been doing in motility
disorders and SIBO-related
disorders. My time is more focused
on developing the technologies and
the treatments for SIBO. So it’s very
exciting. And it’s a good time for
everybody.
Shivan Sarna: Oh, that’s fantastic!
Yeah, okay. Find out those answers
please.
Dr. Mark Pimentel: I’m doing my
best. One step at a time, but this is
a big step because this program, its
entire effort is for this. So that’s a
good thing.
Dr. Siebecker: …to find solutions.
Dr. Mark Pimentel: Yeah, that’s right.
Dr. Siebecker: Thank you! Thank
you, Cedar. Thank you, Mark.
Okay, let’s start with the first
question everybody really wants
to know—well, that we talk to. Can
someone with SIBO be cured? Can
they get better?
Dr. Mark Pimentel: It depends on
the SIBO. I mean, one of the things
that we see at Cedar’s because
I’m like the referral center is we
often see people who have gotten
multiple therapies and they failed.
So the kind of patients I see now
versus what I saw 10 years ago, I
see the ones who’ve tried multiple
things and it’s not working.
But looking at clinical trials, it
essentially is that a third of patients
respond to treatments and don’t
relapse. I mean, I see people at the
mall, for example—I know this is
kind of a side story. But I see people
at the mall where they say, “You
treated me, and I’m still better,” and
it’s 10 years later. So, I know that
there are some people who just get
permanent relief.
But again, it’s not that common.
Maybe 70% don’t. And then, it’s a
chronic maintenance and kind of a
nagging problem for them.
Dr. Siebecker: Wow! People like
yourself and like me, we see these
chronic people. And I have noticed
that it’s like there are two groups of
physicians. There are the ones that
see the people that resolve quickly,
and there are the ones that don’t.
And each group thinks the other
is crazy when they’re talking about
SIBO. It’s like there are two different
types of SIBO.
Dr. Mark Pimentel: The problem
with SIBO is that it can be a catch
all for everything because SIBO
symptoms can be in the gut,
beyond the gut. And the symptoms
can be manifested as skin things.
But mostly, the gut is the primary
issue for which I see the patients.
But because of that, doctors are
maybe overusing the term SIBO.
And that causes some trouble
for that term. And patients will
encounter trouble because the
doctor will say, “Well, everything is
SIBO.” Well, not everything is SIBO.
And one of the things that we do at
our centers when people come with
a SIBO diagnosis or seeking that, I
tell them, “My job is to prove that
you don’t have SIBO first. But if you
do, then we need to prove why you
have SIBO because I don’t let it rest.
I want to know, and I want to make
sure that I know why. Because if I
know why, number one, I know how
to treat. And number two, I know
you have SIBO because the why
also implicates SIBO.”
But in the community, I think it’s
becoming very cliché, the term SIBO.
The second part of that question
is that SIBO can be caused by a
lot of things. If you have a bowel
obstruction from a tumor, you can
have bacterial overgrowth. And
you don’t ever want to rest on SIBO
being a diagnosis.
SIBO is caused by something.
Figure that out because if you’re
missing a critical issue like cancer
or something like that, you’re not
really treating SIBO, and that is not
the answer. Treating the cause of
the SIBO is the answer. And I think
that doctors overlook that as well.
Dr. Siebecker: It can be so hard
to find the underlying cause. And
often, we do need to refer to
specialty centers like you.
Let’s just jump right to that for
a moment because one of the
underlying causes physiologically is
deficiency in the migrating motor
complex. Can you describe the
testing? How would we know?
Dr. Mark Pimentel: So, as you’ve
said, Allison, one of the most
common causes of SIBO is that
the cleaning wave of the gut—
otherwise known as the migrating
motor complex, another term is
housekeeper wave. They’re all the
same thing. But every 90 minutes,
when you’re not eating, there’s a
gurgling sound that you hear and
somebody says, “Oh, you sound
hungry” or you’re embarrassed
because you have that sound.
First of all, don’t be embarrassed.
Shivan Sarna: Don’t! It’s like,
“Yeah!”
Dr. Mark Pimentel: Yes, it’s like the
greatest thing to have because it’s…
Shivan Sarna: “My migrating motor
complex is happening.” [05:01]
Dr. Mark Pimentel: It’s the
dishwasher. It’s cleaning up your
small bowel. So you need that so
that the bacteria don’t build up on
those debris and slime from the last
meal.
And so not having that wave has
been known for decades that it can
cause bacterial overgrowth because
you’re not cleaning. And so all that
stuff is left there, and the bacteria
start fermenting and growing, and
they’re very happy about that.
But the migrating motor complex
can be measured. And one of the
ways we measured it is with an
antroduodenal manometry which is
a tube through the nose all the way
down into the small intestine under
x-ray guidance. And then, you
leave it there for six hours, and we
measure it on a computer system.
Shivan Sarna: That does not sound
like a fun test.
Dr. Mark Pimentel: It is not a fun
test which is why we reserve it for
special patients who really need it.
Eighty percent of the time, that’s the
cause of SIBO. So, we don’t need
to do it all the time because, more
than likely, that’s the reason for
most patients. But in certain special
situations where the patient is more
severe or we really can’t sort out
what the issues are, we’ll still do the
test to be sure.
Shivan Sarna: And don’t you do
something special at the end with
erythromycin?
Dr. Mark Pimentel: Yeah! So
we actually do a stress test on
the cleaning wave. The cleaning
wave is triggered by a drug called
erythromycin. But it’s not really
erythromycin that’s doing it.
Erythromycin mimics a normal
hormone in the gut called motilin.
And motilin is produced by the
stomach, and then it actives the
cleaning wave.
And erythromycin is a motilin-
agonist. It activates the cleaning
wave. And so, we give 50 mg.
intravenous. And shortly after
that, five minutes later, you get a
cleaning wave—or you don’t.
Now , if you don’t, it means that the
problem is deeper or even more
problematic.
So, what we like to see is a nice
cleaning wave afterwards. Even
if you don’t have cleaning waves,
seeing one means we can make
them happen. Not seeing one
means it’s going to be harder to
make it happen. And it’s going to be
harder to treat that patient.
Shivan Sarna: So, when we’re
taking the prokinetic that is LDE…
Dr. Siebecker: Oh, that’s just low-
dose erythromycin.
Shivan Sarna: Right! It’s not 50 mg.
though, right, is it? What’s that low
dose?
Dr. Mark Pimentel: So, anything
over 150 or in the 250 range. Let me
start going backwards.
The reason we know that this drug
has this effect is because the 2000
mg. a day dose that was used for
lung infections caused people
to be very nauseated. So Abbott
Pharmaceuticals had commissioned
some trials to see why it happens,
why you get nausea from
erythromycin and at what dose
does it happen.
And so, as they decreased the
dose, they started to see cleaning
waves form at the very, very low
dose of 50 mg. But at the high dose,
you get backward contracts of the
stomach—which is bad. You don’t
want backward contractions.
So, erythromycin actually has two
phases of effect on motility. We
want the cleaning wave phase, not
the others. And honestly, 50 mg. is
the correct dose. As soon as you go
higher than that, you start to get
the wrong effect which would make
it worse.
Shivan Sarna: Oh, that’s good
information.
Dr. Siebecker: Okay. So what about
the smart pill?
Dr. Mark Pimentel: So, the smart
pill really doesn’t measure stomach
emptying. It is a surrogate of
stomach emptying in the sense
that it correlates with stomach
emptying.
So, the way the stomach works is
you eat food, it mixes and churns
and gets it to a small size, so it
exits the stomach. Nothing can
exit the stomach greater than 1
millimeter during the eating phase
of digestion.
The smart pill is about an inch long
or three-quarters of an inch. So it’s
not getting out of the stomach until
all the food is out of the stomach. It’s
also not getting out of the stomach
until the cleaning wave comes.
So, the cleaning wave is a sign
that you’re done eating because
cleaning waves only come on an
empty stomach. So what the smart
pill does is it tells you when food
has finished being digested in the
stomach. And now you’re entering
the cleaning phase.
And that’s why the smart pill
stomach emptying is four hours.
But when you do a nuclear test, it’s
an hour and a half, half emptying
time. So the food emptying is a lot
faster than the smart pill ever will.
So again, it’s not measuring the time
to emptying of the stomach. It’s
measuring the time to first cleaning
wave.
So, let’s say you’re an IBS patient or
a SIBO patient, and you don’t have
many cleaning waves, the smart
pill may take six hours to empty. It
doesn’t mean your stomach is not
emptying food correctly. It means
that your cleaning waves aren’t
coming fast enough. So that’s the
problem with that.
Now, when the cleaning wave does
come, it will detect it. But it’s like
a surfer on a wave. So the pill will
always stay ahead of the waves that
are coming like a surfer riding a
wave. So if you think of the surfer,
the surfer doesn’t ride on top of the
wave; he rides halfway down the
front of the wave.
So, you can never measure the
intensity of the cleaning wave
because you’re not riding the top.
You don’t know how much pressure
it’s creating.
The other thing is, once that wave
is done, you’re down and out. You
won’t catch the next wave. You’ve
got to ride all the way back. It’s not
going backwards. So it will only
pick up the one generally speaking.
And then it won’t pick up any more
cleaning waves after that because
it’s already through all the way
down the bowel. Does that make
sense?
Dr. Siebecker: Mm-hmmm…[10:13]
Dr. Mark Pimentel: So it’s good for
detecting that first one after a meal.
But unless you were to have a string
on it to hold it, it’s not going to
detect every cleaning wave for the
next 10 hours.
Dr. Siebecker: I see. And so that’s
what we really need to see. You
might have one wave, but you
might not have another one for
10 hours. And then a person will
have a deficient migrating motor
complex, but their smart pill test
looks like they have, “Look, you
have a migrating motor complex.”
Dr. Mark Pimentel: Ideally, it
should be tethered—which would
be a little awkward—through the
nose or something. But you’d have
to hold it in one place…
Dr. Siebecker: …so you can keep
seeing the waves, yeah.
Dr. Mark Pimentel: …so you can
keep seeing the waves, and it would
work. But they don’t have anything
like that.
Dr. Siebecker: That’s such an
important point because so many
patients are given—well, I don’t
know how many. But many are
given the smart pill test by their
gastroenterologist as a way to see
whether their migrating motor
complex is functioning well or not.
And that’s not the best use.
Dr. Mark Pimentel: That is not the
correct use of the smart pill. And I
don’t even think they advertise it for
that purpose, the company.
Shivan Sarna: What is the proper
way?
Dr. Mark Pimentel: The proper
way is that tube for six hours which
is a very uncomfortable…
Shivan Sarna: Oh, yeah, the one I
don’t want to do.
Dr. Mark Pimentel: Yeah, the one
you don’t want to do, yes. I don’t
blame you.
Shivan Sarna: Could you
pronounce that for us again
because it’s a lot of words there…
Dr. Mark Pimentel: Oh, sure, the
antroduodenal manometry. Antro
means stomach; duodenal means
duodenum; manometry means
pressure measurements. But it’s
a tube that you place through the
nose. You freeze the nose a little bit
with some jelly that has xylocaine in
it. You pass it down. They swallow
the pill. And we slowly pass, pass,
pass, pass. And then, under x-ray,
we make sure it doesn’t coil up in
the stomach, but that it actually
gets into the duodenum.
And once it’s there, you hook it up
to the machine. And for six hours,
you’re measuring.
But about partway through it,
you give erythromycin to see if
it generates a wave. And then,
right at the end, we give a meal to
make sure that the stomach goes
from fasting or non-eating mode
to eating mode, which is totally
different. It’s sort of a lot of mixing
motions and all sorts of things that
the stomach needs to do to get the
food processed.
Dr. Siebecker: It’s a very functional
test. It’s really testing function.
Dr. Mark Pimentel: It’s testing the
actual physiology, that’s right.
Shivan Sarna: Are you lying? Is the
patient lying down?
Dr. Mark Pimentel: The patient
will be semi-upright because they
have to eat as part of the test.
And they would usually bring their
iPad because it’s a boring test—
although having that thing in your
nose for six hours is somewhat
uncomfortable.
Shivan Sarna: It’d be worth it. It’d
be worth it.
Dr. Siebecker: One other thing I
wanted to ask you since we’re on
the subject is, when you’ve detected
obstruction, you can kind of tell
obstruction from—
Dr. Mark Pimentel: Yes. So,
the bowel wants to overcome a
blockage. It’s like if you want to
push your car to the gas station,
you just keep pushing and pushing
and pushing and pushing until you
get it to the gas station if you run
out of gas, for example. Same thing
with the bowel obstruction. Things
are not going through. So what your
bowel does is a mechanism. It does
cleaning wave after cleaning wave
after cleaning wave. But they’re
really short and aggressive.
And so, if you get these repetitive
what we call cleaning wave-like or
MMC-like waves, we can tell that
somebody is obstructed using
this test. It doesn’t always. It isn’t
perfect. But when you see that, it’s
a classic sign.
Shivan Sarna: That’s something to
think about.
Dr. Mark Pimentel: Complicated,
it’s complicated.
Dr. Siebecker: One of the most
frustrating things I think is that
we don’t have this available. Most
clinicians don’t have it available
to them. Where can we get it, the
antroduodenal?
Dr. Mark Pimentel: So, the
antroduodenal manometry is only
available through a few centers in
the west. I mean, we’re one of the
few that does it routinely. I think
they’re doing it in San Francisco at
Cal Pacific Hospital. But other than
that, I’m not sure. Mayo Clinic used
to do it. I’m not even sure that they
do a lot of them these days. They
do a lot of scintigraphy, a special
capsule that they use for looking at
transit time.
Shivan Sarna: So that’s different
than the smart pill?
Dr. Mark Pimentel: It’s very
different, yeah. But just a handful of
places in the country do it. It’s very
limited.
Dr. Siebecker: Sometimes, it
feels nerve-wracking to make the
assumption. You were saying, 80%,
we think that’s the reason, the
underlying cause. And it can feel
nerve-wracking. Like are we sure?
What else…?
Dr. Mark Pimentel: Well, this is a
problem with SIBO altogether and
IBS (as IBS and SIBO have overlaps).
How do we know for sure? How do
we know for sure this is what we
have?
And so, anything we can add to
the building of the case for SIBO
or building of the case for the
diagnosis is helpful to the patient.
This is something I say in my
lectures all the time. The patient
is doctor shopping because they
don’t feel like one doctor is doing
the right thing, they’re not getting
better, and therefore, they’re
wondering if the diagnosis is
correct. And that’s frustrating for
patients.
Dr. Siebecker: Let’s go back to what
you’re saying earlier about we’ve
got to find the underlying cause
which is so hard. [15:01]
Dr. Siebecker: What are the most
common underlying causes or
causes you’ve seen just in your
career of treating SIBO?
Dr. Mark Pimentel: Well, the
association between IBS and SIBO
is very clear. I would say probably
70% of IBS has SIBO. That, we’ve
established. There’s a lot of papers.
I think that’s very clear now. And
then, that is from the migrating
motor complex.
So, to go back a little bit, food
poisoning we think is the
one thing that damages the
migrating motor complex. So if
you got gastroenteritis on a trip
somewhere, and that’s when
your IBS or SIBO started or your
symptoms started, we see that
association very clearly.
The problem with that association
is that patients come to me and
they’ve had 20 years of symptoms,
they don’t remember the first few
days. They’ve had diarrhea all along
on and off. But the first two days
of diarrhea, the food poisoning,
they don’t remember. They don’t
remember what happened.
But for some patients, it was
apocalyptic. They went on a trip.
The whole trip was ruined. They
had blood on their stool. They
were admitted to the hospital and
needed IV. You’ll remember that.
But some of the more milder cases
which still triggered this event, they
may not remember.
But in any case, food poisoning
does this damage to the cleaning
wave or the migrating motor
complex. And then, you get the
SIBO. And that’s the most common
cause.
But of course, if you’ve had
surgery—let’s say, for example,
you’ve had tubal ligation or your
gallbladder taken out—and then
they’ve created scar tissue, that
scar tissue can kink the bowel. That
will probably be the second most
common cause of SIBO that isn’t
easy to treat. They have these scar
tissues and some bends or elbows
in the bowels that…
Shivan Sarna: Adhesions…?
Dr. Mark Pimentel: Yeah. When
the adhesions pull on the bowel. It
creates an elbow like a bent hose
(you know, your hose for like hosing
the lawn). And when it’s bent, the
water doesn’t come through. It’s
the same thing. You get this food
kind of building up, and then the
bacteria grow there.
And then, it starts to go to more
obscure things. Ehlers-Danlos
syndrome is now being recognized
as a cause.
Shivan Sarna: Yeah, that’s like my
signature move.
Dr. Mark Pimentel: See? So those
are kinds of things that the bowel
just doesn’t move correctly because
the physical structure of the bowel
is impaired by the genetics of
Ehlers-Danlos syndrome.
And then, tumors. And narcotics
is a big—of course, right now,
these days, narcotics is a big issue
nationally. If you’re on morphine,
you’ll have SIBO, guaranteed.
Shivan Sarna: If you have one dose
of morphine?
Dr. Mark Pimentel: No, you have
to take it—the study that were done
in the 90s is that if you took normal
people and put them on morphine
for a period of two weeks, almost
all of them would eventually have
SIBO.
Dr. Siebecker: Two weeks is not
long.
Dr. Mark Pimentel: No, it’s not
long. But it’s not one pill either.
Dr. Siebecker: Right!
Dr. Mark Pimentel: So, if you had
surgery and you took a couple
of doses of narcotics to get you
through the first couple of days,
that probably isn’t going to be
enough to do it. And if your cleaning
waves recover nicely, don’t worry
about it. It’ll probably go away.
Shivan Sarna: And that’s because
the narcotics slows down or stops
the MMC?
Dr. Mark Pimentel: …blocks the
MMC. It stops everything. So that’s
probably the reason.
Dr. Siebecker: So, the most
common ones that you see are
food poisoning-induced post-
infectious IBS, and then adhesions
or structural issues that might come
from surgery or other causes.
Dr. Mark Pimentel: Right!
Dr. Siebecker: And then, getting
morphine.
Dr. Mark Pimentel: And
sometimes, it’s obscure. For
example, I had a patient. I’ve had
this probably five times in the
last 20 years. They’ve never had
surgery—and we do a barium, the
barium shows an adhesion in the
right lower quadrant right down
where the appendix is.
It turns out, when they go in
and look, the patient had had
appendicitis but it recovered. And
it created a scar. Sometimes, the
appendix is wrapped around the
ileum or weird things like that. And
they’ve never had their appendix
taken out.
And they do remember abdominal
pain when they were a kid after
the fact and they come out of
it. You say, “Did you ever have
appendicitis?” “No, but I had this
really bad pain when I was like
15. The doctor thought maybe it
was appendicitis, maybe not. But I
seemed to get better.”
And so, we see weird things like
that. We just have to watch for that.
Dr. Siebecker: I remember when
I was observing with you, you saw
one of those, we saw one of those.
We saw a lot of weird stuff.
Dr. Mark Pimentel: I see weird
stuff, yes. I don’t see the simple
SIBO that responds to treatment
and you see at the mall now that
are doing…
Dr. Siebecker: “Thank you!”
Dr. Mark Pimentel: They don’t see
me now. Some doctors, at least a
minority, they know how to treat it
fairly well. And so they get past the
first phase of people. So now I’m
seeing only the tough cases where
nothing seems to work.
Dr. Siebecker: Let’s talk about that.
That’s a perfect segway.
So many of us are seeing really
tough cases. Lots of people also
aren’t. But for those of us that are
seeing them, what are some of your
suggestions?
I guess it’s a two-pronged question.
First of all, what should we be
thinking about? And what have you
seen help in cases where you’ve
tried most of everything, and
they’re not responding? So they’re
recalcitrant, and the test is positive,
what do you do?
Dr. Mark Pimentel: I mean,
treating SIBO, there’s a menu of
items or a menu of things you can
use. I don’t know if you want me to
go into that during this question.
But there’s a menu of things
you can try. And if you’ve kind of
funneled through that, and you feel
like you’re very frustrated, we get
the same frustration. [20:08]
Dr. Mark Pimentel: So, we see
patients where the breath test is
still positive, or it’s negative and
their symptoms are still there, and
then now they’re debating whether
it’s SIBO or not.
But one of the problems we
run into—and this is why we’ve
been pushing so hard to get the
hydrogen sulfide, is because we’re
missing a gas. Hydrogen sulfide is
critically important.
We have three abstracts that went
into the DDW. And I can’t talk about
them because…
Dr. Siebecker: Oh, for this year?
Dr. Mark Pimentel: Oh, yeah.
Dr. Siebecker: Because you had
one too for last year?
Dr. Mark Pimentel: We have one.
And it was just the preliminary. But
this is the full validation of it. And
it’s very exciting.
Shivan Sarna: Can you explain
what the event is that you’re
referring to?
Dr. Mark Pimentel: So, DDW is the
major event for presentation of GI-
related research. It comes up this
time in June of 2018. But what I can
tell you from what we’ve presented
so far is that hydrogen sulfide is
critically important. And it’s the
missing piece that we didn’t have
before.
Now, knowing it is so important
especially in patients where we’re
not getting good responses. Look
at methane and hydrogen, for
example. Hydrogen is needed to
make methane. That’s the path.
So, the more methane you have,
the lower the hydrogen is on the
breath test. If I treat methane
and get rid of it, just those bugs,
hydrogen goes up because now
hydrogen is not being used by the
methane. So, sometimes, we treat
a breath test that’s a flatline. And
after treating them, the hydrogen
goes up. So how did we get there?
Because we’ve given an antibiotic,
it should go down—but it goes up.
That’s because we’re getting rid of
hydrogen sulfide which is using the
hydrogen.
So, if we don’t know all three
gases—methane, hydrogen and
hydrogen sulfide—we don’t know
how to treat these patients fully up.
So, next year will be the magic
because we’ll be able to see the
whole thing, and then better be
able to determine what therapies
they need for these difficult cases.
I personally think that’s a big
missing link.
Dr. Siebecker: And so, what you’re
thinking is it’s not just the flatline
breath test then? It’s some of these
tough cases where you’re seeing
positive SIBO.
Dr. Mark Pimentel: We’re not
just seeing hydrogen sulfide in the
flatline, that’s the point.
Dr. Siebecker: Yeah, the point
being like these complicated cases
may have hydrogen sulfide that we
cannot detect.
Dr. Mark Pimentel: Correct!
Dr. Siebecker: Wow!
Shivan Sarna: So, in terms of
interpreting a breath test, you have
a breath test, it shows hydrogen or
it shows methane...
Dr. Siebecker: …or both…
Shivan Sarna: …or both, and it
could still be hydrogen sulfide. Is
that what you guys are saying?
Dr. Mark Pimentel: Correct.
Generally, methane and hydrogen
sulfide fight for hydrogen. So they
don’t like to be together because if
methane is there, hydrogen sulfide
is starving, and if hydrogen sulfide
is there, then methane is starving.
So they’re not mutually exclusive,
but they tend not to be together,
all three. One is dominating. We’ll
show all that at the big meeting.
Dr. Siebecker: More to be said
later. “Stop asking me questions.”
Shivan Sarna: So, you have the
diagnostic tool. And so I’m assuming
you have an answer as well.
Dr. Mark Pimentel: I can’t talk
about it—not today, not today.
Dr. Siebecker: I bet he does, I bet
he does.
Shivan Sarna: Okay.
Dr. Siebecker: Oh, okay. I’m looking
at my notes here. I have another
question I want to ask.
For the people that are not chronic,
do you call them acute or do you
call them not chronic? Do you call
them easy? What do you call them?
Dr. Mark Pimentel: Tell me how
you define “not chronic” because
I’m trying to understand the
question.
Dr. Siebecker: Like the 30% of SIBO
that is not—the people that you see
at the mall, “Thank you! I had the
one treatment, and I’m all better!”
Dr. Mark Pimentel: So, because
sometimes acute could mean
you’ve only had it for a year…
Dr. Siebecker: I know!
Dr. Mark Pimentel: So, one of the
questions patients ask me is “I’ve
had this for 20 years. Am I less likely
to respond?” The answer is no. I
don’t see any difference whether
you’ve had it for one year or 20
years in terms of your likelihood of
response. Now, that’s if I’m seeing
them naively meaning they haven’t
seen another doctor, they haven’t
tried other therapies.
So, acute could be they only had it
for a year. The food poisoning is a
year ago.
But what you’re saying is the
patients who respond and don’t
relapse…
Dr. Siebecker: Yeah.
Dr. Mark Pimentel: We need to
study those more carefully because
I don’t really know. I don’t know
why, for some people, it’s one-
and-done, and some people, it’s
multiple therapies (we got to keep
treating over and over and over
again), and others, nothing works!
And we’re dissecting that, but I don’t
have good answers for that, and
probably won’t for another year.
Dr. Siebecker: Well, I never know
what to call those people except
blessed or something. So I often say
“not chronic” because acute often
means intensity of symptoms, and
maybe they do, maybe they don’t.
All I mean is one-and-done. Maybe
we’ll just call them one-and-done.
Shivan Sarna: Yeah, right.
Dr. Mark Pimentel: Yeah, that’s
what I call them, one-and-done. I
love those! Except what happens is
my clinic has now accumulated the
not-done.
Dr. Siebecker: Forever and ever…
Dr. Mark Pimentel: Yes, never
responding to things. We’re able
to manage their symptoms, but it’s
more complicated. [25:13]
Dr. Siebecker: Okay, so for a SIBO
patient who we don’t know what
they’re going to be, what type
they’re going to be, just all across
the board, what’s the typical timing
that a patient would start to feel
better.
Dr. Mark Pimentel: It varies. But
for example, if we’re giving an
antibiotic like Rifaximin (which
is what we typically do as a first
line), they will start to feel better
sometimes three days, sometimes
eight days. But it’s a 14-day
treatment.
There are patients where they
take the drug, they’re finished, and
it isn’t for 5 to 10 days after that
they don’t feel the benefit. I don’t
understand why that happens for
some people, but it varies.
But let’s go back for a second to
the one-and-done because, I have
to say, it must be frustrating for
physicians who treat SIBO regularly,
like yourself, where you see the
toughest cases all the time, and you
start to get disappointed or almost
dejected about it.
Well, when I travel the country, and
I’ve done these numerous talks
in the last two months, and I’m
talking to gastroenterologists in my
case, and they come to me after,
and they say, “You’ve changed my
practice. My patients are getting so
much better on this. Not everybody
gets better, but a lot of them get
better,” those were the patients I
was treating 10 years ago because
nobody knew.
So, what we’ve done in terms of
educating about SIBO, what we’ve
done in terms of developing the
therapies for SIBO have helped
a lot of people. We just don’t see
those first line people anymore.
So we feel frustrated like “What
are we doing?” But in the front
lines, a lot of what’s going on in the
educational sessions like this are
helping those frontline doctors to
get the right therapy to the patient.
So I’m reassured by that, although it
is frustrating in our clinics.
Dr. Siebecker: Such a good point.
Thank you so much for making that
point. It’s so good.
Well, in these summits that we’ve
been doing, we do have a lot of the
chronic sufferers that are watching.
I’ll turn to that then. What are some
of the things you’ve seen help the
chronic sufferers best? What does
management look like for them?
Dr. Mark Pimentel: Right! So if
you’re a chronic sufferer, and a lot
of things are not working—well,
there are two types. There’s those
that, for example, in the case of
Rifaximin, going back to that, where
I give them Rifaximin and they get it
three times a year, and every time
they get it, three months of benefit,
and they just keep getting that over
and over. And that’s not a problem
because you don’t get resistant to
Rifaximin (at least according to the
data that’s been published so far).
But if you don’t respond to that,
and then you don’t respond to the
next thing and the next thing, then
it’s really management. So we do
a three-pronged approach. We
want to try and make the migrating
motor complex work as best as it
can. So we put them on a prokinetic
to a tolerable level. We manage
them with diet on top of that. And
we generally can get even the
toughest cases 50%, 60% or 70%
better by doing this very intensive
approach.
And we might use natural
remedies, turmeric, for example, or
peppermint and a lot of different
things to try and chronically keep
the bacteria as low as possible. And
we’ve done an okay job there. But
the patients still come to clinic, still
say that they have some bloating,
that they have some symptoms.
So it isn’t a cure. It’s more of a
management strategy at that point.
Dr. Siebecker: So really, it sounds
like what most docs now have
learned which is diet, prokinetic,
maybe some ongoing antimicrobials
like peppermint or something like
that, or meal spacing—even meal
spacing, right?
Dr. Mark Pimentel: Oh, meal
spacing is important because if
you’re noshing all day or having
little, small meals, you never get
a migrating motor complex. So
remember, when I say “caveman,”
I don’t necessarily mean Paleo
(because that comes up), but back
in the day, we ate, and because we
didn’t have a refrigerator, you killed
the animal, you ate the animal,
store what you could, but it doesn’t
store for long. So it’s like feast, and
then you don’t eat for a few days.
And that’s the way our digestive
system evolved. It didn’t evolve with
a refrigerator and potato chips in a
bowl in front of you at a desk. While
you’re doing a job, you’re snacking
all the time. Every time you snack,
you stop the cleaning wave. So it’s
better to space your meals as best
as possible.
Shivan Sarna: And how many
hours?
Dr. Mark Pimentel: I have that
argument with so many patients
because they’re always negotiating
a smaller window.
Dr. Siebecker: They’re trying to
negotiate it down. They need the
potato chips!
Dr. Mark Pimentel: It drives them
crazy. And then, they ask me, “What
can I have? Can I have water? Can
I not have water?” And I know that
you probably have questions about
that as well.
But spacing is important. And
I usually say four to five hours
between meals. So it’s tough.
Dr. Siebecker: You used to say
three. You changed it to four.
Dr. Mark Pimentel: Yeah, because
the meal takes about three hours
to complete digestion. So you
really don’t enter the cleaning
wave until three hours. So if you
do three or four, you’re right at the
edge of when the cleaning waves
are coming. And if you’re already
impaired in the cleaning wave, just
give it a couple of hours to have
one. [30:15]
Dr. Siebecker: Right! So if you ate
at four, you might have an hour of
cleaning waves.
Dr. Mark Pimentel: Right. And you
only get one for every hour and a
half that you’re not eating. So you’d
be lucky to get one.
Dr. Siebecker: Ah, so it’s really five
then? It’s really five.
Dr. Mark Pimentel: Yeah, it’s
almost got to be five.
Shivan Sarna: Okay, can I have
water? Will the water impact my
MMC?
Dr. Mark Pimentel: The interesting
part about that is that the gut
contains a lot of water all the
time. So theoretically speaking, if
you were to have water, it’s not a
problem.
Now, if you were to drink a liter
of water, you will stretch the
stomach and convert to fed state
by mechanical triggering of fed
state. So stretching the stomach
makes the stomach think food has
arrived. But if you just were to have
like half a glass or a glass of water,
especially if it’s over half an hour
just sitting in your desk, that’s not
going to do anything.
Dr. Siebecker: This is a good tip. So
sipping, sipping water.
Dr. Mark Pimentel: Sipping is
better than gulping or guzzling…
Dr. Siebecker: …or all at once.
Dr. Mark Pimentel: Yeah. Large
quantities is probably not a good
plan.
Shivan Sarna: So, sip your water
perhaps for the five hours? During
the five hours, you can sip. But
don’t have a liter.
Dr. Siebecker: Yeah.
Dr. Mark Pimentel: It’s very
dangerous to get so specific…
Shivan Sarna: I know, I get it.
Dr. Siebecker: People ask!
Dr. Mark Pimentel: I know, but if
you “you can take a glass of water,”
and you tell people, “You can only
sip it gradually over five hours…”
Dr. Siebecker: I know! They’re
going to go, “No…”
Dr. Mark Pimentel: But basically,
what I’m saying is you don’t want to
shoot back two cups of water all at
one time. If you do it over a half an
hour, that’s plenty. You don’t have
to sip it over hours and hours.
Dr. Siebecker: Okay. So then what
about caloric items?
Dr. Mark Pimentel: So, coffee is a
big question, “Can I have coffee?”
The answer is you can have coffee,
you can have tea as long as there’s
no milk and there’s no calories in it.
Dr. Siebecker: Like no sugar.
Shivan Sarna: Did you hear that,
everybody? Okay! We’re going to be
wrapping this up, but this is one of
those times where we save one of
the most important things that you
ask about so much till the end. Say
it again.
Dr. Mark Pimentel: So, if you’re
going to have coffee or tea, it’s okay
in those four to five hours between
meals. But nothing in it except
for the coffee and the water, not
sweeteners.
Shivan Sarna: So herbal teas are
okay.
Dr. Mark Pimentel: Herbals are
fine. It’s just nothing with calories.
Dr. Siebecker: So no calories at all.
That would answer the question of
people like, “Well, could I have one
bite of something? Could I have…”
whatever.
Dr. Mark Pimentel: Yes, you can.
But the answer is you shouldn’t.
Dr. Siebecker: I’m like, “You can do
whatever you want, but…”
Dr. Mark Pimentel: Yes, because
it’s free-range living. But one thing
I’ve learned over the years is that
people come back to me and they
say, “I follow your diet.” I say, “Okay.
And how is it working?” They say,
“When I cheat, I feel bad.”
Shivan Sarna: Yeah.
Dr. Siebecker: Mm-hmmm… yeah.
Dr. Mark Pimentel: And the
literally say, “Every time I cheat,
I feel bad. So I know your diet is
working.”
And again, there are days where
you’re with your friends, you’re with
your family, it’s Thanksgiving or
whatever, and you’re not going to
behave according to the diet. That’s
okay because that’s life. But you
want to try and do it as much as
possible.
Dr. Siebecker: Okay, wait. I know
you want to wrap up, but this is
really important.
Shivan Sarna: Do it!
Dr. Siebecker: People ask us all
the time, if they cheat, have they
screwed everything. How much
trouble is Thanksgiving?
Dr. Mark Pimentel: Perfect! First
of all, Thanksgiving is a disaster for
everybody.
Shivan Sarna: …for a lot of reasons.
Dr. Mark Pimentel: Yes, weight
gain between now and the
next month. It’s a disaster. But
Thanksgiving is the highest time
point of the year for food poisoning
because the food is not properly
cooked or it’s sitting out for hours
and hours and hours or days
and days and days. We’re eating
leftover, leftover, leftover. And so
it’s literally the worst time of the
year for my patients. And I counsel
them and counsel them. And
inevitably, one comes back and
says, “I got really sick during that
time period.” Anyway, it’s a bad
time.
But remember the morphine story
I told you earlier. You have to be on
morphine for two weeks to cause
overgrowth. One day of cheating is
not going to bring your overgrowth
back. You may not feel great the
next day, but it’s not bringing
everything. All the cards not falling
down. So just give it a couple of
days. Usually, it resolves.
Dr. Siebecker: That’s similar with
the breath test. People are worried,
“Oh, if I drink lactulose which is
meant to feed the bugs, won’t I just
give myself SIBO again?”
Dr. Mark Pimentel: Yeah, but if the
bugs are in the colon, you’re just
going to make them grow more, but
you’re not going to make them grow
in the small bowel if they’re not
there. So you’re not going to make
SIBO by doing it (unless you were to
guzzle it every day).
Dr. Siebecker: One test is not a
worry. A lot of people are like, “I
don’t want to take the re-test. Will it
bring it back?”
Dr. Mark Pimentel: The answer is
we’ve never seen that happen.
Dr. Siebecker: I never have either.
People get really worried about it.
Shivan Sarna: Understandably so,
right?
One thing, I did watch your video on
Twitter about Thanksgiving which I
thought was fantastic.
Dr. Mark Pimentel: Okay. I tried
to be funny. I’m not sure it came
across that way, but…
Shivan Sarna: Hysterical!
Dr. Mark Pimentel: Okay, that’s
better than funny. I’ll take that.
Shivan Sarna: It was mainly me just
going, “Oh, my gosh!” I’m leaping
because Thanksgiving is my favorite
holiday. And I did throw up at this
Thanksgiving. So who knows what
was happening to me.
Dr. Mark Pimentel: Sorry.
Shivan Sarna: Thank you. [35:18]
`But you made some really good
points about eat the food that’s on
the hot plates versus leaving some
of the other stuff that’s perhaps at
room temp for a little too long. So
go to the hot plates first.
Dr. Mark Pimentel: Yes. Club med
classic. All you can eat. You go to
these resorts, all-inclusive, all you
can eat and all you can drink also.
Shivan Sarna: Cruises too.
Dr. Mark Pimentel: So they usually
have these buffets out for lunch
and for dinner. And you go there.
And the burner is sitting right
here, but the metal is this big. So
the stuff on the edge is perfect
temperature for getting the kind
of bugs you don’t want. But right
over that burner, right above that
burner, that’s the hottest point. If
it’s steaming when you scoop it out,
and that’s the stuff you’re taking,
you’re probably find all the time.
It’s stuff like that. And same thing
with Thanksgiving. Some people
have—what do they call those?
Shivan Sarna: Little trivet, like the
hot plates?
Dr. Siebecker: The hot burners.
Shivan Sarna: Burners, yeah.
Dr. Siebecker: Okay, I have one
more that loops into this…
Shivan Sarna: Alright!
Dr. Siebecker: …because it ties in
and people ask it all the time. What
about the part where they’re doing
food reintroductions? They’ve been
very strict. But now, they’ve had
treatment, and they’re feeling so
much better. They’re starting to
tell they can tolerate more foods,
and so they’re doing experiments
to find out what they can tolerate.
And then, they get worried, “Well,
while I’m experimenting, might I be
bringing it back? If I try a little bit, it’s
fine. And then, I try more, and then,
ooh, I get a symptom.”
And then they keep going with
these experimentations over time -
are they bringing it back?
Dr. Mark Pimentel: So, the
answer is if it’s going to come back
eventually anyways, yes, they could
be slowly be bringing it back. So
that’s always a worry.
This concept is more important
for the low FODMAP diet which is
very popular these days, because
the low FODMAP diet is unhealthy.
Now, some of your viewers may not
like me saying that. But even those
who purport the low FODMAP diet
or discover the low FODMAP diet
recognize that you have to have
a reintroduction phase because
it’s going to hurt people over time
potentially.
And the first abstract ever that
describes this was presented
at the American College of
Gastroenterology about a month
and a half ago where they showed
the people who were sustained
on a low FODMAP diet for more
than three months started to have
measurable nutritional deficiencies.
So, you can’t stay on low FODMAP
forever, period.
Dr. Siebecker: And even the
elimination phase. They say do
like five or six weeks low, and then
begin…
Dr. Mark Pimentel: But there are
some patients who, once they’re
on low FODMAP, they feel so good,
they don’t want to come back or
start introducing. They get very…a
Dr. Siebecker: Most, I would say.
Dr. Mark Pimentel: They hang on
to it with dear life. But you can’t
because you will get nutritional
deficiencies. That’s very clear now.
But the way we did our low
fermentation diet was there are
things that are no, no, no…
Shivan Sarna: No onions, no
garlic…
Dr. Mark Pimentel: No, not for
ours.
Lentils and beans and those types
of things, the non-digestible sugars
are just no forever because of the
risk that they incur. And dairy, like
lactose, would be a no.
But there are other things like we
don’t like people eating too much
roughage or fiber. And those are
soft no’s. So, the soft no’s can come
back in, but the hard no’s, probably,
forget about it.
Shivan Sarna: If someone wanted
to find that diet, how can they find
it.
Dr. Siebecker: It’s online. The link’s
on my website because he let me.
Dr. Mark Pimentel: Yes, I gave you
permission.
Dr. Siebecker: He gave me
permission. And it’s in his book.
Dr. Mark Pimentel: Correct! And in
a modified version in the book. It’s
not as well laid out as you have now
with the newer kind of description.
Dr. Siebecker: Yeah, you’ve done
an update. That’s important for
people to know, that the link on my
site is your updated version.
Dr. Mark Pimentel: And you can be
on that diet indefinitely because we
made it very balanced. And it’s not
as restrictive as the low FODMAP.
But the point is I’m always happy to
re-introduce. And I have no problem
negotiating that with patients. But
there are certain things that are
negotiable and certain things that
are non-negotiable.
Dr. Siebecker: So, you are a little
bit worried about some of the
non-negotiables—you wouldn’t
suggest the non-negotiables
being re-introduced. You would
be concerned that might hasten
relapse.
Dr. Mark Pimentel: Yes, yes.
Dr. Siebecker: Yup!
Dr. Mark Pimentel: There are
studies, for example, in Japan where
they feed red kidney beans—kidney
beans is a non-negotiable—to rats.
And they all get overgrowth just
from eating red kidney beans.
Dr. Siebecker: Wow!
Dr. Mark Pimentel: Nothing else.
Shivan Sarna: Why? Does anyone
know why?
Dr. Mark Pimentel: Because red
kidney beans, what they do, they’re
so hard to digest, they make the
bowel think it’s always in fed state.
And it lingers and lingers and
lingers and lingers. And basically,
because of that, you get no cleaning
waves because you’re always fed
state, fed, state, fed state. It takes
12 hours for it to get through the
bowel. And so the bowel is just
constantly trying to break it down,
but it’s hard to break down. And
eventually, the bacteria build up—at
least that’s the hypothesis. [40:07]
Dr. Mark Pimentel: So, lentils will
do that, kidney beans, garbanzo
beans, hummus. I keep talking
about this being on an airline, and
they gave me a snack box. And it
was lentil chips with hummus dip.
I’m like, “Do you want to kill our IBS
patients with this? They will die!”
And then, you add a soda to that,
you’ll have to peel me off the ceiling
with bloating.
Dr. Siebecker: Plus, they’re on a
flight.
Dr. Mark Pimentel: And they’re on
a flight. So terrible!
Shivan Sarna: So, the flight plus the
carbonated beverage… no good!
Dr. Mark Pimentel: No bueno. No
good. No, no good.
Shivan Sarna: …because we’re
going to just be under that
pressure. We’re going to turn into a
fermentation balloon.
Dr. Mark Pimentel: Well, not
to mention what they do is they
pressurize the airplane to 10,000 ft.,
not to 0,not to sea levels. So you’re
already like you’re on a mountain
of 10,000 ft. height. That’s the
pressure. So your gut is already
distending.
And then, you add to that the lentil
chips and the hummus which
will start to ferment very quickly,
and then you add carbonated
beverage to that, you just get so
distended, you can’t even clear it.
And of course, it’s hard to clear it
on a plane because there’s people
around you, and you know…
It’s awkward for the patient and
awkward for the…
Shivan Sarna: Awkward is a good
way of calling that.
Dr. Siebecker: I just opened my
water bottle on a plane coming
here. Pop! So you can see it
pressurizing it.
Shivan Sarna: Yeah, the pressure.
Dr. Siebecker: Okay, I keep saying
one last time, but it is one last
Shivan Sarna: Okay.
Dr. Siebecker: What about the
person who is one-and-done? Can
they just eat whatever they want or,
still, there are non-negotiables?
Dr. Mark Pimentel: If they’re one-
and-done, generally, I see them at
the mall…
Dr. Siebecker: Right! You’re not
seeing them again over and over.
Dr. Mark Pimentel: And they’re at
the food court eating what they like.
So I’m pretty sure the one-and-
done’s, once they’re a year past the
one-and-done, they’re done, and
they feel good. And that’s a good
thing.
Dr. Siebecker: I just heard you say
a year past. Would you suggest
that for some amount of time and
then…?
Dr. Mark Pimentel: Yeah. And
again, because I don’t see them,
and they’re gone, they tend to go
free range. I’m definitely not walking
around food courts pointing out the
bad food items people are eating.
I have other things to do with my
free time than…
Dr. Siebecker: You’re not stalking
your past patients to see what
they’re eating?
Dr. Mark Pimentel: I am not
stalking my patients. Although,
sometimes, I think my patients stalk
me at the mall. But that’s a different
story.
Shivan Sarna: See you later! Okay,
we will wrap on that. Thank you so
much.
Dr. Mark Pimentel: Thank you.

Shivan Sarna: Dr. Sandberg-
Lewis is with us today. So we love
to learn from him. And what that
means is that we have, as I’d like to
say, 40 years of gastroenterology
experience in an hour. And he
has contributed so much to
the community of naturopathic
understanding of the digestive
system with all of his SIBO work.
And today, we’re also going to talk
to him about GERD.
And he is here with us, coming in
live from Portland, Oregon.
Hello, hello.
Dr. Sandberg-Lewis: Hi!
Shivan Sarna: Hi. So Dr. Siebecker
and I were talking about what
we wanted to do for the summit
and the topics that we wanted to
discuss. And of course, GERD was
on the top of the list. She was like,
“You’ve got to talk to Steven about
that.”
So, if you would, for people who
are like, “GERD? Doesn’t that mean I
have to take TUMS?” would you just
describe what GERD is and what
some of the negative ramifications
are? What’s the problem with
GERD?
Dr. Sandberg-Lewis: There are a
number of problems with GERD. So
GERD is short for gastroesophageal
The Issue That Keeps Coming
Up: GERD and SIBO
Shivan Sarna with Steven Sandberg-Lewis, ND, DHANP
Click here to watch to this interview!
The purpose of this presentation is to convey information. It is not intended to
diagnose, treat, or cure your condition or to be a substitute for advice from your
physician or other healthcare professional.
reflux disease. Some people have
reflux—in this case, it means
backward movement of fluids
through the lower esophageal
sphincter, which separates the
stomach from the esophagus. And
that reverse flow will bring really
irritating substances—assuming the
person can make stomach acid—
it will bring very irritating acid,
possibly bile, because some people
also have reflux that goes from the
small intestine into the stomach,
and then into the esophagus. We
can talk about that later. That’s
called DGER, because you’ve got the
duodenum in there.
And all those irritating substances
can cause lots of symptoms in
the chest, and in the throat. And
they can also lead to more serious
diseases like reflux esophagitis,
Barrett’s esophagus, dysplasia and
even a cancer of the esophagus.
There are other kinds of reflux too,
which we’ll maybe talk about some
other time, the ileocecal valve,
where you have ceco-ileal reflux,
going from the large intestine into
the small intestine. And that causes
problems too like SIBO.
Shivan Sarna: And then you were
talking about that there’s even a
third one.
Dr. Sandberg-Lewis: When I talked
about DGER, that’s duodeno-
gastroesophageal reflux. And that’s
when there’s reflux of fluid from
the small intestine up through the
pyloric valve that separates the
stomach from the duodenum, and
then if that further reflux is from
the stomach into the esophagus,
gastroesophageal reflux, then
you’re getting bile and acid and
enzymes coming up into the
esophagus. And that is a real
serious list of irritants.
Shivan Sarna: How could someone
get any of these conditions?
Is it physical, like adhesions,
or is genetic? What is usually
predisposing people to having any
or all of those GERDs?
Dr. Sandberg-Lewis: There is a
myriad of causes. Probably the
easiest way to describe it would
be either a problem with the lower
esophageal sphincter, that little
round tubular muscle thickness
at the bottom of the esophagus
isn’t staying closed properly, then
you’ll get more reflux from the full
stomach up into the esophagus.
That’s one thing, and there are a lot
of things that can do that, that can
cause that laxity of that muscle.
And then the other big thing is
more pressure in the abdomen
than in the chest. And SIBO,
unfortunately, is one of those
things that causes a lot of pressure
from all the gas, pushing up against
the diaphragm, and creating more
of a tendency for things to rise
upward, instead of to go downward.
Shivan Sarna: So that leads to—if
that’s the problem, what do we do
about it? With PPIs, or proton pump
inhibitors being just handed out like
candy, and I say that from my own
personal experience because I was
on them for seven years at least,
and prior to that, I would eat TUMS
like it was nacho chips. I was just
piling through a couple of bottles a
week. [05:11]
So what’s the typical way that
people in, let’s say, America or
around the world, deal with it, and
then what are some alternative
ideas to maybe have a healthier
approach?
Dr. Sandberg-Lewis: So first of
all, there’s the antacid, like you
were talking about TUMS, that are
calcium carbonate, other forms
of minerals that will absorb acid.
The problem with TUMS and other
calcium carbonates is that calcium
salts, along with dairy protein and
the calcium in the dairy are some
of the most potent stimulators of
gastrin.
Gastrin is a hormone that’s
produced in the stomach that
actually stimulates more acid
production.
So when people eat calcium
carbonate, TUMS, it takes a lot of
acid to absorb calcium carbonate.
So it absorbs acid, and symptoms
improve. But then the calcium
carbonate stimulates gastrin
production, so that we produce
more acid, and you get into this
vicious cycle of producing more
and more acid. It’s called rebound
hyperacidity.
The same thing happens with a
proton pump inhibitor, or the older
medicines—things like Cimetidine,
Tagamet—those were the first
ones that were introduced after
the calcium carbonate, the TUMS.
Those would inhibit the H2 receptor
on the parietal cell.
The parietal cell is the type of cell
in the stomach that produces acid.
The parietal cell responds to three
different stimuli—one is gastrin,
one is the H2 receptor, which
means H stands for histamine,
which a lot of people get a lot of
interest in, and study, in the SIBO
field.
Histamine is also a stimulator to
acid production, specifically, the H2
receptor. There’s the H1 receptor
that has more to do with the more
allergic reactions on other tissues.
And then there’s acetylcholine,
the major neurotransmitter in the
parasympathetic nervous system,
which is the rest and digest nervous
system.
So either acetylcholine, histamine
or gastrin, all three of those things
can stimulate acid production.
In different times, different drug
companies have gone and tried
to attack different mechanisms.
So they’ve done the H2 receptors,
things like Tagamet. They’ve done—
they’ve not attacked acetylcholine
really directly for reflux, but the
calcium carbonate was just an initial
phase to just try to neutralize acid,
but it actually stimulated more
gastrin, so gastrin got involved in
that one.
So what can you really do about
it? These medicines have their
place. Usually, we use them for
short periods of time, six to eight
weeks to help heal ulcers, or
reflux esophagitis, when someone
has a lot of irritation, redness
and inflammation in their lower
esophagus. So sometimes we use
these things.
But what else can you do?
Well, you can treat the cause. That’s
what I like to do—treat the cause
and then gradually withdraw the
medicine. We have to talk about
causes. Can I do that?
Shivan Sarna: Yes, let’s do that.
Dr. Sandberg-Lewis: So like I
said, the two main mechanisms
are either the lower esophageal
sphincter is having a good tone,
maybe pyloric valve at the base of
the stomach isn’t having a good
tone either.
And then there’s pressure that’s
higher in the abdomen than in the
chest.
The diaphragm, this dome-shaped
muscle, it separates everything
that’s in the thorax or chest from
everything that’s in the abdomen.
[10:01]
And if the pressure up against the
diaphragm, if the intra-abdominal
pressure is greater than the
intrathoracic pressure, you’re going
to have things being pushed up
instead of moving down.
And the third piece which I think
has been talked about a lot in this
series is peristalsis or motility.
So if someone has poor motility—
for instance, the most extreme case
is gastroparesis. Has anyone talked
about that yet in this?
Shivan Sarna: Not so much. Not
enough.
Dr. Sandberg-Lewis: Gastroparesis
is—paresis means weakness. It’s
not total paralysis where things
won’t move at all. Weakness
and gastro, of course, being the
stomach. So when the migrating
motor complex, the first phase of it,
and everybody in your group here
knows about—
Shivan Sarna: Let’s just put
definition because we have new
people all the time.
Dr. Sandberg-Lewis: Migrating
motor complex is a reflex that is
very important in prevention and
treatment of SIBO and most other
problems in the gut. It starts in
the stomach, and then it contracts
things, contracts the stomach
to empty the stomach, and then
once the food gets into the small
intestine, it contracts different
phases of it. It contracts the small
intestine to move food all the way
down, food and bacteria, all the way
down to the ileocecal valve, the very
end of the small intestine.
So it’s actually moving things about
18 to 20-feet through the digestive
tract.
Remember, Dr. Siebecker and I, and
Dr. Shaver, we all teach a course
called advanced gastroenterology at
our university. And I wanted to call
it the small intestine is not small.
We call it that as a subtitle because
the small intestine, it sounds small
because of its name, but it is the
longest and—it’s not the most
important because the whole thing
is important. But it’s extremely
important, and it’s 18 to 20-feet
long.
The migrating motor complex is
moving food and bacteria and
debris and fiber all the way down
from the stomach to the ileocecal
valve, at the end of the small
intestine.
And when that first phase isn’t
working properly, the stomach can
hold onto food for many, many
hours. Normally, the stomach is
about 91% empty by four hours.
And it’s really dramatically more
than half empty within two hours.
In gastroparesis, or delayed gastric
emptying, it can—I have one
patient, it seemed like it took about
10 hours for him to empty his
stomach. And those patients, when
they have extreme gastroparesis,
they have terrible nausea and often
vomit their food because the meal
that they ate last time and perhaps
the meal they ate before that is
still in their stomach when they eat
another meal.
So they won’t really want to eat.
They have very little appetite.
This is caused by a lot of things, but
probably the most common one
is either post-infectious, like post-
infectious IBS when we talk about
anti-vinculin antibodies and things
like that or blood sugar problems
(diabetes and prediabetes).
We see people whose
autonomic nervous system—
the parasympathetic is part of
that—doesn’t work properly. It’s
called autonomic neuropathy.
The nerves have a pathology and
it’s the autonomic nerves, the
parasympathetic nerves, that are
not working properly. And it doesn’t
empty.
And then, of course, motility in the
small bowel might also be pretty
poor. That’s why it’s come up over
and over again that blood sugar
problems like diabetes are a major
cause of SIBO, and until you get to
the blood sugar working right, then
nerves aren’t going to work right,
and you’re not going to get rid of
your SIBO. You’re just going to keep
having it because of poor motility.
Shivan Sarna: So one more
time, if you have the diabetes
or prediabetes, that affects your
nerves, and then that affects your
motility, like if you have post-
infectious IBS, meaning after a bout
a food poisoning, and how the MMC
is then inhibited because of the
nerves. Is that right? [15:13]
Dr. Sandberg-Lewis: Exactly.
Shivan Sarna: I know this is
going to sound crazy because you
know I’ve done about a hundred-
hours of these interviews. I don’t
remember—I do have brain fog
sometimes, but I really don’t
remember ever hearing about the
connection between blood sugar,
diabetes and gastric emptying.
Maybe we just really haven’t talked
about that level or that height of
the digestive system, but that is so
interesting.
Dr. Sandberg-Lewis: Yes. That’s
really essential. And then if you
want to put something on there
that often goes with type 2 diabetes
and pre-diabetes, not always, and
sometimes goes just by itself. And
that’s abdominal obesity.
Apple fat or visceral fat puts a lot
of pressure on—this is not the
subcutaneous fat that’s just under
the skin. This is deeper. It’s around
the viscera or the organs in the
abdomen. And not only does it
create lots of havoc in terms of the
physiology and the functioning of
the liver and other organs in the GI
tract, but it also increases the intra-
abdominal pressure by pressing
against those organs.
And that increases the risk of reflux.
So when you can reduce the
amount of visceral fat, that can
really be a cure for reflux.
Shivan Sarna: So when you hear
about people who’ve lost weight
and, therefore, their reflux is
diminished or goes away, is that
usually the driving force behind
that?
Dr. Sandberg-Lewis: Well, it
could either be they have blood
sugar problems and losing weight
help normalize their autonomic
neuropathy that they had from
the blood sugar issue, or it could
also be that the intra-abdominal
pressure is lower, and it could
be that once you lose the weight,
your SIBO improves, and then you
don’t have as much pressure from
the gas being produced within the
lumen of the intestine.
Shivan Sarna: So how is weight
loss—I think I know the answer
to this, but how is weight loss
related to an improvement in small
intestinal bacterial overgrowth? Is
it that the visceral fat has shrunk
and so, therefore, it’s less pressure,
therefore the valves won’t open as
much in the backwash?
Dr. Sandberg-Lewis: I think that
makes sense, but I’d probably put
it more into the nerves and the
sugar. Now, think about it. When
a person’s blood sugar is elevated,
there’s going to be elevation of
secretion in the GI tract as well,
which feeds the bacteria and yeast.
Shivan Sarna: I’m making lots of
faces. What? That sucks.
Dr. Sandberg-Lewis: That’s why
diabetic women are very prone to
vaginal yeast infections because
their vaginal secretions have more
sugar in them too, and that feeds
the yeast. Yeast is always there. It’s
a normal inhabitant of the vagina,
the digestive tract, but it overgrows.
Your initial question was why would
losing weight lead to improvement
in reflux.
So change in pressure and then
also change or improvement
in peristalsis, migrating motor
complex, all those functions that
occur through the enteric nervous
system, and the parasympathetic
tone of the enteric nervous system.
Shivan Sarna: When a woman is
diabetic or not—let’s say a woman’s
estrogen levels change in a certain
age, and they start getting the
abdominal fat from perimenopause
and menopause. Does that also
lead to what we’re talking about?
[20:02]
Dr. Sandberg-Lewis: Age is one of
the risk factors for type 2 diabetes.
Kids have it now, unfortunately.
One out of three kids born after
2000 will have diabetes. But if
we just look at the way things
have been for a long time—the
interesting thing is if you look at
some of the literature that talks
about the way estrogen functions,
one of the major ways that estrogen
functions and does all of the
things it does is it affects serotonin
receptors.
There are seven or so different
types of serotonin receptors, two of
them in the gut control motility in a
large way. And that’s the 5HT3 and
5HT4 receptors. And it’s thought
that estrogen really modulates
or controls the function of those
serotonin receptors.
So that’s how estrogen does a lot of
what it does is by interacting with
serotonin. And we know serotonin
is the major thing that controls
motility in the gut besides motilin
and then some others that it works
along with.
So when you go through
menopause and your estrogen
levels are coming down, number
one, Datis Kharrazian has talked
about this very eloquently,
especially when estrogen levels
drop precipitously, rapidly. That can
trigger a lot of inflammation in the
central nervous system.
And inflammation in the central
nervous system does not shut off
easily. Once it’s started, it just keeps
going.
That will affect motility in the gut
as well because part of motility
is, at least there’s an input from
the central nervous system to the
enteric nervous system for that.
There’s a lot of cross-talk between
the two.
Going through menopause, there
are a lot of mechanisms, maybe
more than I should even get into
because I’ll get too nerdy about it.
But there are a lot of mechanisms
that could turn on problems
with blood sugar and, therefore,
digestion.
Shivan Sarna: So that leads me to
antidepressants. I know this is a
rabbit hole, but I’m okay with this
because I really think a lot of people
are dealing with this. Are they called
SSRI? Is that what they’re called?
Dr. Sandberg-Lewis: That’s the
original group, and now, we have
the SSNRIs also that affect not just
serotonin but norepinephrine as
well.
Shivan Sarna: So is the SSNRI, is
that Wellbutrin?
Dr. Sandberg-Lewis: I believe so,
yes. So those things modulate
serotonin receptors as well. At
least they affect the reuptake of
serotonin from the interneuronic
space, and make a stronger
serotonin effect.
Shivan Sarna: Is this possibly one
of the connections between the
brain and gut? Is this where they’re
saying that people—this is such a
reach, but people with the altered
microbiome could be more prone
to depression and mood disorders?
Is that the same deal?
Dr. Sandberg-Lewis: It’s a real
thing. It is true that even—yes.
Digestive problems can definitely
cause or add to depression
and anxiety through many
mechanisms—which I love to get
into if you want to, but maybe you
don’t want them. There are some
mechanisms, but we’ll try to make it
more practical.
Shivan Sarna: Would it also be
the reverse? So you are depressed,
and that leads to more digestive
problems. You have digestive
problems, that can lead to you
to being more depressed. That’s
depressing. That whole thing that I
just said is depressing. [25:01]
Dr. Sandberg-Lewis: We call it
crosstalk. It goes both directions—
from the central nervous system,
to the gut, and the enteric nervous
system, and the enteric nervous
system is interacting very intimately
with the microbiota that make up
the yeast, the bacteria, the viruses
that make up the GI microbiome.
Shivan Sarna: So let’s say you are
diabetic, you’re pre-diabetic, you
might be a menopausal woman or
perimenopausal woman, what’s
your best advice for improving the
digestive system, and then we’ll
circle back to GERD. But what’s your
best advice in this lane, about how
to help your digestive system?
Dr. Sandberg-Lewis: Well, first of
all, it would be to do the things that
make your blood sugar healthier,
your blood sugar balance healthier.
So that’s going to be daily exercise,
something light to do, preferably.
Walking is terrific, especially walking
where you’re not carrying anything
and your arms can swing, cross-
crawl because that does a lot of
beneficial things.
There’s actually a book called
Walking Your Blues Away by
Thom—he is a psychologist who
has written a lot of books. This one
is just how to use walking as a way
to clear emotional trauma, just
as you might use EMDR with eye
movement, this is using your whole
body in a cross-crawl movement to
help clear trauma and unresolved
emotional states.
Thom Hartmann, I just remembered it.
And yes, we do these kinds of
things.
So walking has a lot, and any cross-
crawl exercise has a lot of benefits.
By the way, riding a bike is not
cross-crawl because your arms
don’t swing, unless you ride without
holding the handlebars, which I
don’t recommend.
Cross-country skiing is terrific, and
any of the machines that do that
whole body, get the arms moving
opposite the legs, stair-steppers
and stuff like that.
That’s one really important thing
that helps blood sugar, it can help
with weight loss.
Another really important thing
is the thyroid renal, which is
something I made up. Thyroid
gland and the adrenal glands are
so important in normalizing blood
sugar, maintaining bone mass,
helping with mood and energy and
blood sugar, very, very important,
and blood pressure as well.
Those glands are so important
for the maintenance of normal
function. And so often, in standard
medicine, the only time you really
look at the adrenals is when there’s
90% of their function gone. That’s
called Addison’s disease. It’s very
rare. It’s an autoimmune disease.
Or when a person has Cushing’s
disease, which is when their stress
hormone, cortisol levels are so high
that everything goes haywire, and
we can actually die from it. Very
serious condition, which is a little
more common than Addison’s.
But in naturopathic medicine and
other forms of natural medicine, we
like to look at the adrenals before
they’re 90% gone because many
people have a lot of dysfunction
there, and you can’t really—in my
book, you can’t really separate
thyroid from adrenal. They work so
closely together.
So that’s my suggestion is balance
your adrenal and thyroid function,
so that your blood sugar can
normalize, so that you can lose the
weight around your waist because
that’s one of the better ways that
we have of measuring abdominal
fat or that apple fat.
The waist circumference for
women, over 35-inches is too much.
For men, over 40-inches is too
much. [30:02]
And so it’s easy enough to say, “Oh,
lose that waist circumference. Bring
it down. Just get to it.”
Well, that can be almost impossible.
If your insulin levels are very high,
and your DHEA levels are very low,
and your cortisol is very high, that’s
the worst group of hormonal levels
that can lead to a waistline that just
gets bigger and bigger.
You could lose weight all over your
body. Your face might look amazing,
but you can’t lose the weight
around your waist. And that’s the
weight that’s controlling the whole
blood sugar issue, which causes
GERD and causes SIBO and other
digestive problems.
So the thyroadrenal, if you would,
gland is really important there.
Shivan Sarna: How do you spell
your new word?
Dr. Sandberg-Lewis: We probably
don’t want to make it a real word.
It’s not. It’s just my way of letting my
student doctors and my patients
know that—it’s my way of thinking.
It’s a little superficial to be treating
somebody’s thyroid and ignoring
their adrenal or vice versa. You have
to look at both. Even just to improve
the conversion of T4 to T3, T3 being
the active thyroid hormone, T4
having a little bit of activity.
Just in order to make that
conversion, you have to have a
good balance of DHEA and cortisol.
So that’s really important.
Shivan Sarna: It seems like hypo
and hyperthyroidism or thyroid
scenario is practically an epidemic
these days.
Dr. Sandberg-Lewis: Hypo
is. Hyper, I don’t know if it’s a
10th or a 12th of the amount,
but yes, they’re both big deals.
And that’s in part because of
our environment because we
know that xenoestrogens and
other environmentally produced
hormones often from plastics and
phthalates, those are ubiquitous in
our environment, and they tend to
affect the thyroid.
If we could just do one shout-out,
if this has not happened before in
your series here, men and women,
especially women, please don’t
drink water out of those crinkly-soft
plastic bottles.
Don’t do that. Don’t do that.
Stop doing that. You’re getting
phthalates, you’re getting
plasticizers that make the plastic
soft and pliable, you’re getting those
when you’re drinking it, especially
if it’s sat out in the sun and got too
warm. And even if you cool it off
again, you’re getting factors that are
throwing your hormone balance off
in a major way.
And it’s totally avoidable if you can
avoid those kinds of plastics as
much as possible.
The other big piece of reflux is diet.
Even if you don’t have SIBO causing
all that intra-abdominal pressure,
diet is a big factor. And so there’s
a book called No More Heartburn,
and I’m really forgetting author
names today.
Shivan Sarna: That’s okay. That’s
what Amazon is for.
Dr. Sandberg-Lewis: I’ll think of
it in a minute. It’s not my favorite
book, but the first chapter is on
heartburn. The first chapter is quite
good. And I have adapted some of
this information—Sherry Rogers is
an M.D. who wrote this book.
And I have adapted some of this
information in my textbook, and
eventually, I’m going to be writing a
book on reflux in the next couple of
years. I’m just getting started on it.
She has a little mnemonic called
“Cut out the Crap.” Cut out the crap,
C-R-A-P. And I’ve expanded what
those things mean a little bit as
well. But I thank Sherry Rogers for
this really nice foundational idea.
So the first C, the things you want
to cut out, the first C is cigarettes,
tobacco, and cola or other soda.
[35:07]
We know that’s a big factor,
especially with the high fructose
corn syrup, and even if it’s sugar-
free.
And then C also stands for
chocolate because all the
methylxanthines that include
theobromine in tea, caffeine in
coffee, I didn’t say coffee yet, did
I, and theobromine in chocolate,
all those methylxanthines can be
factors that irritate the stomach and
trigger more reflux.
So chocolate, coffee, cola,
cigarettes. And then the R in
Cut out the crap is for refined
carbohydrates. Even though we tell
people, if you’re losing too much
weight and you’re treating your
SIBO, try using some white rice, and
see if you tolerate that.
There are some white rices that are
not as processed, just polished a
little bit, as opposed to white flour
and things like that.
And really, on my cut out the
crap handouts, I say, refined
carbohydrates or too much
carbohydrates.
We know that a low carbohydrate
diet can really almost instantly
improve reflux in a lot of people.
And maybe that’s because you’re
not feeding your overgrown
intestinal flora as much, substrate
to make hydrogen and methane
and hydrogen sulfide from. But
whatever the mechanism, a
lowering of total carbohydrate
seems to help reflux in a lot of
people.
And A in cut out the crap, is Aspirin
and other non-steroidal anti-
inflammatory drugs like Ibuprofen,
Aspirin, Naproxen.
You could also put A for alcohol.
It doesn’t mean people can never
have alcohol without having a
reflux, but it’s definitely a factor that
affects the tone of the sphincters,
and it’s irritating to the entire gut
when it’s too concentrated.
And then P, P is for processed food
in general. You can put soda pop
there, instead of under C because
it’s not just cola.
I also added packing in food at
bedtime under P because if you eat
food, much food, within three hours
of laying down at night, remember,
I said it takes about four hours
for the stomach to be completely
empty if a person doesn’t have
gastroparesis.
And so three hours gives you
time for a good 70% to 80% of the
stomach to be empty for most
people. And so there’s going to be
less pressure when they lay down,
for there to be reflux into their
esophagus from their stomach.
So cutting out the crap, getting
your thyroid renal working so
that your blood sugar normalizes,
and exercising in a way that you
enjoy, and that is rhythmic and
sustained—those are some big
deals.
And then, when we say cut out
the crap, we really should have—
one of those should be eating too
much at a time. So maybe A is for
appetite. Listen to your appetite,
and after you have one helping of
food, wait at least 20 minutes. Go
do something that takes 20 minutes
before you decide if you’re still
hungry enough to have seconds.
And slow down.
If you eat your food slowly and
chew it slowly and thoroughly until
it’s liquid, and then swallow it—by
the way, if you haven’t done that,
you’ll find that your muscles will
naturally be trying to swallow the
food really way before it’s liquid.
[40:00]
And you have to think about it, the
first few times you do it, and really
concentrate on not swallowing the
food until it’s fully liquid.
My wife, who is a stress
management coach, she has a
really smart saying, and that is,
you have to fool your body into
thinking you’re safe. And the best
way to fool your body into thinking
you’re safe, so it doesn’t got into a
fight or flight response while you’re
eating is to chew your food slowly
and thoroughly until it’s liquid
because your brain stem, the base
of your brain, is always monitoring
the environment to see, “Is this
dangerous? Do I actually have time
to chew and swallow my food, or do
I need to run because something is
going to kill me?”
Your brain stem, it’s very simple-
minded. It’s very primitive. And it’s
just always thinking about that sort
of thing, and trying to control heart
rate and breathing and all these
other things.
And so you can fool your body
into thinking you’re safe, so that
it will allow your parasympathetic
nervous system to get the gastric
acids flowing, to get the pepsin
flowing, to get the mucus flowing, to
get the pancreatic enzymes flowing,
everything working, and motility
working, if your body thinks you’re
not about to die.
And your brain stem really
responds to that. If you’re chewing
your food really slowly, it figures,
“Oh, this person’s got all the time
in the world. I guess there’s no
predator around. I guess we can
really focus on digestion” instead of
fight or flight.
“Let’s get the hell out of here, or kill
whatever wants to kill us.”
Shivan Sarna: If you are in fight or
flight, isn’t one of the first things
that happens is your body just
stops digesting to use that energy
to be able to run away?
Dr. Sandberg-Lewis: Yes, it shunts
the blood to the brain and the
muscles in your arms and legs,
so that you can do those things
instead of having almost 50% of
your blood pulling your abdomen,
dealing with the food.
Shivan Sarna: So do you need to
train your brain every time you eat,
or is it one of those things where
it’s a muscle and it starts to have
more and more experiences of
being relaxed when you eat, and
then it’s easier to have that relaxed
sensation when you eat? Or is it
every single time you need to train
it?
Dr. Sandberg-Lewis: Well, it
depends on your life. I’ll tell you
this. When I am in the middle of
my day seeing patients—I’ve seen
my morning patients, and I go
and I take a half-hour to eat, or
40 minutes to eat, when I first sit
down, the food’s there, it’s ready, I
first sit down, I have to check in with
myself.
A simple way to do this is just to get
a sense of, “Am I feeling the chair
that I’m sitting in against my body?
No, I’m still hovering,”
I’m just tight.
And so what I’ll do is take a few easy
belly breaths again, again, thank
you, Kayla Sandberg-Lewis for
teaching me all these things over
the years, and then I’ll just sit—I
know how to meditate, so I’ll just do
that for even one or two minutes
until I feel my body settle down,
where I can actually feel like I’m
supported by the chair.
Then I know, “Okay, now, I can eat.”
Also, another really simple thing
you can do that’s very effective,
if you don’t meditate or want to
do this in addition, you just think
of one or two things you’re really
grateful for.
Grace before meals sounds like a
religious thing, and I guess it is, for
some religions, but it’s also—they
came up with it because they knew
it was good for digestion, and
heart math, the folks that study
parasympathetic tone, and the way
that you can encourage it, they say
that feeling a sense of gratitude
is one of the most potent ways
to stimulate the parasympathetic
nervous system.
So I just sit down and I think, “I’m so
glad I have all of my four limbs, and
they all work. I’m so glad that my
patients keep coming to me, and we
have this great time interacting and
helping them.”
It could be the simplest little thing.
It doesn’t have to be complicated.
Shivan Sarna: The first time I met
you, we were at Gary Weiner’s
office. [45:02]
We were there for all afternoon,
and you were like, “Okay, I got to go
eat lunch now.” And you went into
another room. I don’t know if you
remember this but I do because I’m
very visual. I remember you were
in the other room, you were just
sitting there, you had your glass,
not Tupperware, but it was glass
because no plastic, thank you.
And I think it was a chicken breast
or something. You had your cute
lunch box, and then you had your
glass, and you were eating slowly,
but not like overly slowly. It was
just like you were present with your
food.
And you don’t know this, but there
have been many times that when
I have been trying to be more
present with my food, I’ve actually
thought of you at Dr. Weiner’s
office, in that exam room that
nothing was going on except you
were eating your lunch.
I have thought about that so many
times.
Dr. Sandberg-Lewis: That’s
great. I think that a good doctor is
sometimes playing the role of Jiminy
Cricket, being your conscience on
your shoulder. “I remember, I’m not
supposed to eat this way. I think I
would rather do it this other way.”
See my goofy little face when you’re
sitting down to eat, and you’re
thinking, “I should slow down. I
want to slow down.”
Shivan Sarna: Yes, Jiminy. Just so
you know, random act that you
didn’t know had such a big impact.
I wanted to circle back around in
terms of GERD. There’s the whole
take HCL/apple cider vinegar
approach. Weigh in on those things,
if you would, because they are very
common DIY home remedies, and
controversial, at least when I went
to my ear, nose and throat doctor,
the one who put the scope down
there and said, “You’re pre-Barrett’s,
Shivan Sarna.”
And I was like, “No, I feel fine.”
“No, no, no. Your entire esophagus
is cherry red down there.”
And I was like, “Really?”
And then I started to think about it.
“Okay, yes, I guess I do eat a lot of
TUMS.”
He had to tell me what I was feeling
which was super strange.
And I asked him about the HCL,
hydrochloric acid. And he’s like,
“There is no way that HCL will
be strong enough to produce, in
capsules, a change in your acid
levels. Plus, that’s adding acid, so
no.” He just totally pooh-poohed it.
So then, three times I attempted
it, and the third time’s the charm.
It actually did work, and I was able
to get off my little purple pill after
seven years.
So what was that? A fluke? I hear
people do get a lot of success with
it. What do you think? What’s your
experience with that?
Dr. Sandberg-Lewis: So
hypochlorhydria is one the causes
of heartburn, and it’s a complex
mechanism, and no one knows
exactly what the right mechanism is
that does that, but it could be that
having adequate acid production
in your stomach affects the tone of
the lower esophageal sphincter we
think it does.
Also, having enough acid in your
stomach helps to speed up the
emptying of the stomach by
triggering certain other chemicals.
If you have gastroparesis, almost
always you’ll find that people have
achlorhydria or hypochlorhydria,
more commonly. They have low
levels of stomach acid production.
And their stomachs stay full a long
time.
It’s possible to have high acid and
also have your stomach not empty
properly. But often, if acid levels are
extremely high, the stomach will
empty prematurely. Again, there
are lots of possibilities with this
physiology, but I would just say that
having the right amount of acid can
help with the tone of the sphincters
and with gastric emptying and,
therefore, to have a big effect on
reflux.
I don’t usually give patients with
Barrett’s esophagus and reflux
esophagitis—I don’t usually start
them off with hydrochloric acid.
We have in our office at 8 Hearts a
Heidelberg machine, which is a way
to directly measure stomach acid
levels.
And interestingly enough, if
someone does have decreased
stomach acid production during
the test, my resident who does
the test with a patient, they will
give him a capsule of hydrochloric
acid, and see what that does to
the pH because you get an instant
response to the computer from the
stomach. [50:17]
You can see what the pH is at
all times. And see how many
milligrams of betaine hydrochloride
does it take to normalize the
stomach acid level, to bring it where
it belongs.
And so yes, capsules do, within a
matter of minutes, change the pH
of the stomach. We see that every
day in our office.
So I disagree with what the
gastroenterologist said, but yes,
stomach acid—
Shivan Sarna: He was an ear, nose
and throat guy.
Dr. Sandberg-Lewis: Ear, nose and
throat doctor. They deal with reflux
a lot too because there’s something
called laryngopharyngeal reflux or
LPR, which is interesting because
often, those people, they don’t
have heartburn. They just have
symptoms in their throat, so it could
be hoarseness, it could be having
to clear your throat all the time, it
could be a cough, a chronic cough.
It could be swollen tonsils. It could
be swollen larynx or voice box.
So that’s a whole different kind of
reflux, but it can be caused by reflux
as well.
And one thing we haven’t talked
about is hiatal hernia. So hiatal
hernia is a major cause of reflux
and heartburn and LPR, all these
things. It’s when the stomach
moves up through the hiatus of
the diaphragm. Remember, the
diaphragm is a dome-like muscle.
It separates everything that’s in the
abdomen, from everything that’s
in the thorax or chest. And it has a
little hole in the middle called the
hiatus.
And that’s what allows the stomach
that lives underneath here, to
attach to the esophagus through
that hole, the hiatus.
If you have a hiatal hernia, that’s
either a hiatus that’s wider or, for
some reason allows the upper
portion of the stomach to come up
into the chest.
Now, you have a space-occupying
lesion in your chest. You have
something pressing against your
heart, which can cause arrhythmia,
including atrial fibrillation. You
have something pressing against
your lungs, which, if enough of the
stomach is in the chest—I saw one
of my patients had shortness of
breath, and it was due to collapse
of her left lower lobe of her lung,
because so much of her stomach,
almost her entire stomach was in
her chest.
That’s rare. I’ve only seen three
patients like that in my career,
where their entire stomach is up in
their chest. But it’s very common for
two or three centimeters of upper
stomach to be in the chest.
And what does that do?
I’ll try to keep this as friendly and
simple as I can. But the diaphragm
is a muscle. It’s a big thin, wide,
dome of a muscle. In fact, for
people that eat meat, or have been
to a butcher shop, it’s called skirt
steak. You know, it’s really thin, skirt
steak. That’s diaphragm.
And so this muscle, it’s smooth
muscle. It’s not like muscle that
you control voluntarily. But it’s
smooth muscle that’s under
parasympathetic tone control and
other tone from other parts of the
nervous system.
And it acts as the outer sleeve of
the lower esophageal sphincter.
The lower esophageal sphincter
is, it’s the muscles that are
thickened right at the bottom of
the esophagus where it meets the
stomach. But in addition—is that a
cat?
Shivan Sarna: Yes, she’s hungry.
Dr. Sandberg-Lewis: In addition—
we’re talking about food. In
addition, the diaphragm, being
a muscle, surrounds that hiatus
right at the same level as this lower
esophageal sphincter.
So I like to call the diaphragm the
outer surface. It’s the outer layer of
the lower esophageal sphincter.
So if you take your stomach, which
is normally here with the lower
esophageal sphincter, and the
esophagus right at the base right
there, everybody’s happy, they’re
working together. And you move
the stomach up three centimeters,
now, the lower esophageal
sphincter is at the top of my fingers.
[55:01]
And the diaphragm is here, so they
can’t work together. So if you can
bring it back down in its normal
position, now you a full lower
esophageal sphincter. And a lot
of what pushes the stomach up
is everything we talked about—
increased intra-abdominal pressure,
SIBO, holding your breath.
Did you know constipation can
cause hiatal hernia?
Shivan Sarna: What?
Dr. Sandberg-Lewis: When people
have constipation, they often will
have to strain to have a bowel
movement. Or if you’re having a
baby, if you’re a woman having a
baby, they take, “Push, push, push,”
and if you hold your breath when
you’re pushing, to push something
out, a baby or a stool, you’re greatly
increasing the intra-abdominal
pressure.
So I train my patients, after we do a
manual correction with a deep, slow
massage technique that brings the
stomach back down, and then I tell
my patients, “You need to breathe
before you contract your abdominal
muscles.”
So if you’re lying down, you can sit
up. Take a breath first and breathe
out as you sit up because you’re
going to have to contract your
abdominal muscles to do that.
If you are going to have a bowel
movement, especially if you’re
constipated, and you’re going to
be bearing down a lot, first, take
a breath. Breathe out as you bear
down.
If you run out of air, stop bearing
down, take another breath.
You’ll find that that doesn’t allow
you to get as much pressure, but
that’s exactly what we want—is not
to build up the pressure so much
that you create hemorrhoids, hiatal
hernia, intra-abdominal hernia, all
those things.
And then the third time that you
really want to be conscious of
your breath is when you’re lifting
something. So if you’re lifting
something more than 5 or 10
pounds, take a breath first then
exhale as you do it.
Shivan Sarna: This makes sense.
How can someone find out if they
have a hiatal hernia? Of course,
because I’m the poster child for all
of this, of course, I have one too.
And I found out when I did a scope
this way. And my doctor said, a
different doctor, it’s not bad enough
to have surgery, but it’s enough to
be uncomfortable. How is it’s going
to be find out if we have that?
Dr. Sandberg-Lewis: So the
ways to find out if you have a hiatal
hernia, one would be a Barium
swallow, or an upper GI Barium
study. The other way is upper
endoscopy like you had.
Very rarely I have seen—it’s
suggested that there was a hiatal
hernia on an abdominal ultrasound
if they went a little bit above into
the chest. That’s not a really reliable
way to do it apparently, but it’s
very interesting enough, I guess
somebody could possibly see it
there.
And it could be seen on a CT if
they were looking for it. Although,
usually you get either an abdominal
CT or a thoracic chest CT. But some
people are getting both at the same
time, and so it might show up there
as an extra bit of organ in the chest
that doesn’t belong there.
Shivan Sarna: So a physical
maneuver can help that. You do
it the old osteopath move that
some chiropractors still know. A
visceral manipulation therapist can
help with that too. Is that the only
way that you can address a hiatal
hernia?
Dr. Sandberg-Lewis: As
you discussed with your
gastroenterologist, there is a
surgery, and there are two other
newer forms of treatment that are
endoscopic surgery procedures.
The most common one is called
Nissen Fundoplication. And it’s a
technique that’s really interesting
where they take the fundus or
upper portion of the stomach, and
wrap it around the back of the
stomach, and then sew it to itself,
around the front.
It’s like creating a little turtleneck
sweater around the top of the
stomach. And it does hold it in
place, and it mimics what I was
saying about the diaphragm
because normally, the diaphragm
creates a little turtleneck sweater
around the top of the stomach.
So remember, anything you can do
to strengthen your diaphragm could
also help with reflux and with hiatal
hernia staying in place. [01:00:03]
Singing loudly, gurgling—things
that you can do, especially loud
swinging and speaking loudly. I
don’t usually speak very loud but
it could be an exercise to—and
breathing exercises, learning to do
diaphragmatic breathing.
There’s a really simple, elegant
exercise where you take one sheet
of toilet paper, and put it on the
wall in front of you, at the height of
your face. And you stand 12-inches
away, and you practice each day,
and see how long you can hold
the toilet paper against the wall
just with your breath because you
have to use exhalation, prolonged
exhalation and keep the force up, in
order to keep the toilet paper from
falling to the floor.
And that’s a really nice little exercise
for the diaphragm.
Anyone who has asthma, reflux
and asthma, are like a cycle that go
around and around and around for
many reasons, interesting reasons.
But being able to become proficient
in the use of your diaphragm
muscles can help with asthma, as
well as helping with reflux.
Shivan Sarna: So when you talk
about the gargling and the loud
singing, that reminds me of Dr.
Kharrazian’s exercises for helping
strengthen the vagus nerve. That’s
a super duper double whammy
bonus to help the diaphragm help
the vagus nerve. And would visceral
manipulation, other than my little
idea about the hiatal hernia, would
that help with reflux as well?
Dr. Sandberg-Lewis: Visceral
manipulation, in order to help
with the mobility of the organs
and the abdomen, meaning, their
ability to move with respect to each
other, move around each other,
as well as motility, to move things
through the lumen or the inside
of the tube, yes, that’s a big part
of what it’s all about, especially
bringing the stomach down back
into the abdomen and keeping
it there, and keeping that lower
esophageal sphincter in line with
the diaphragm, so they can work
together. That’s really important.
That’s really effective.
Shivan Sarna: So it’s interesting
that we’re talking about, of course,
because these topics are very
interesting, especially to anyone
who has issued, but quickly, a
little story about my visceral
manipulation session that just
happened two weeks ago. We’ve
been working on a lot of different
stuff, and my therapist, I call her a
living CAT scan machine, because
I’ll ask her, “What’s that body part?”
And she can tell me and she’s like,
“Oh, your ileocecal valve is slightly
rotated.”
She came at my stomach from a
different way. When I say came up
my stomach, she was just palpating
around and feeling around. It hurt
a little bit more. Usually, it doesn’t
hurt. None of her work seems to
really hurt, which is fantastic.
And she’s like, “Wow, I really feel a
lot of—”
She described it as tight, dry—these
are just her descriptive words, not
being literal, like fascia underneath.
And then it explained my left
shoulder blade pain, and then it
also explained why—I was a yoga
teacher, so I would do this, and I
was always stretching my psoas
muscle because I always felt so
compressed here.
I was always like, “My psoas is so
tight.”
It was actually probably from 1991
when I was in a car accident and
the car came at me from this way,
the seatbelt dug into me, and I went
like this, and it probably caused a
lot of adhesions and stuff under
the stomach. That’s my working
hypothesis right now, but since
we’ve released that, holy smokes,
I feel like I can breathe, I feel like I
can do this, which doesn’t seem like
a big deal to people.
If you can’t do it, and it doesn’t feel
good, then it is a big deal.
And I just feel shockingly, totally
transformed.
Dr. Sandberg-Lewis: Happy to
hear that.
Shivan Sarna: Thank you.
Dr. Sandberg-Lewis: Fascia is a
much ignored part of the body that
has multiple functions. I’m trained
in structural integration, so I’m
intimately involved with the fascia.
It’s amazing what can change so fast
when you relieve an adhesion in the
fascia, so that you don’t have a little
spot weld anymore, can open up,
and things can move and be as long
as they’re supposed to be, instead
of being all shrunken up like that.
[01:05:11]
Yes, it’s great. And left shoulder is a
common place for stomach, gastric
stomach problems to reflux.
Shivan Sarna: So I’m just sharing
that with everybody because I’ve
been getting body work since the
80’s, but the final frontier and the
constant frontier, for as long as
I can remember, has been that
left shoulder blade. And I’ve had
acupuncture needles in there. I’ve
been rolfed three times. I’ve been
structurally integrated.
I’ve had it all done. And for the
first time ever, since my memory,
I finally felt relief, and it was
after that she gently released the
adhesions underneath my stomach.
I’m just throwing that out there
because if I took so long to figure
that out for me, and this has been a
part-time job, VisionQuest, for me,
for most of my adult life because
I’ve been in such discomfort. I hope
this helps somebody out there, to
save them a lot of time.
Dr. Sandberg-Lewis: Yes, there
are so many layers to issues that
people have, and I know people
have come to me and said, “Yes, I’ve
had visceral work, and it just didn’t
help.”
Even if you ask how many times you
went, “Well, I had 20 sessions.”
That’s a pretty good number of
sessions. That’s a lot of sessions.
But it could be at the 21st session.
It’s just right and the practitioner
finally notices what’s going on with
that one little piece. You never
know. It’s a different day. You don’t
step in the same body twice.
Shivan Sarna: Yes. It was probably
about our 30th session too. And
I’ve received tremendous help. And
she’s like, “I’ve been in this area
before but was never drawn into it.”
And I never really felt the difference.
It wasn’t like, “That’s a hotspot or
anything like that.”
It was just like, “Oh, yes. That’s my
stomach.”
And it was just, like you said,
right time, right place, answered
prayer, whatever, but there it was.
Persistence is my super power, my
secret super power.
Good luck, everybody, because I
know this does takes persistence in
feeling well.
Dr. Sandberg-Lewis, thank you so
much.
Dr. Sandberg-Lewis: It’s been fun.
Thank you. I appreciate it.
Shivan Sarna: You’re brilliant, sir.
Thanks so much. And I know you’ve
just helped so many people expand
their brains and first step, get that
blood sugar level balanced out. It
seems to be a fabulous idea for so
many reasons.

Shivan Sarna: Dr. Jason Hawrelak
is with me. This gentleman is one
of the most prolific writers in
the world of probiotics and the
microbiome. And he has graciously
agreed to talk to me for you about
microbiome, about SIBO, about FMT
and what that stands for. “Huh?
Who’s transferring what? Wait! I
don’t know.”
So what we’re going to learn about
is his approach to microbiome,
is a supplement going to actually
impact us by taking a couple of
capsules a day, or do we need to do
more drastic things.
I’m going to stop talking, so we can
start listening to him.
Thank you so much for being here.
Dr. Jason Hawrelak: Thank you
for the invitation. It’s a pleasure to
be here. I can chat about gut stuff
and microbiome for days on end, so
it’s nice to have a captive audience
who’s interested.
Shivan Sarna: So right now, you’re
in Tasmania?
Dr. Hawrelak: Tasmania, yes,
which is a small island on the south
of the Mainland Australia. And
it’s fairly isolated with a relatively
small number of people. We have
the cleanest air on earth, and the
cleanest rain on earth. So there’s
If You Build It, They Will
Come: The Biology of the
Microbiome
Shivan Sarna with Jason Hawrelak, PhD
Click here to watch to this interview!
The purpose of this presentation is to convey information. It is not intended to
diagnose, treat, or cure your condition or to be a substitute for advice from your
physician or other healthcare professional.
very many plusses to be down here.
But we do get lots of Antarctic sea
breezes which are perhaps less
positive — but the air is clean, if
cold.
Shivan Sarna: Wow! Just a quick
aside, how did you end up there?
Dr. Hawrelak: Well, I was born in
Canada. I grew up in Calgary. And
then, I did what many young people
do when they finished high school.
I wanted to travel the world as a
backpacker.
And I did, but I didn’t get very far.
I got to the east coast of Australia,
and arrived in the subtropics, fell
in love with the coastline, and the
warm weather, and the beach. And
I essentially stayed there which
is where I did my naturopathic
studies. And I subsequently did my
honors and PhD in that same area.
But my partner’s family is from
Tasmania, so we left the subtropics
and beautiful rainforests and
beaches to move down to
Tasmania, which is beautiful in its
own way, just far colder.
Shivan Sarna: Got it! That’s
interesting. Back to the microbiome
we go.
So, people with SIBO—we’re going
to talk about specific strains and
everything, I know. But people with
SIBO, we have a huge question.
When should we, if we should, start
introducing a probiotic supplement?
So what is your perspective on that?
Dr. Hawrelak: My perspective—
and as is the way I practice too—is
I will often use probiotics from
the—in fact, I almost always do
use probiotics from the first bit of
diagnosis.
So, when I do the breath testing, I
take their history and I work out,
“Okay, yes, it’s SIBO. That’s the main
cause of your symptoms,” I will be
using probiotics at that time and
point.
I suppose I was lucky enough that
I did my PhD looking at the role
of dysbiosis in irritable bowel
syndrome. And I started this project
back in 2000. So it was before the
SIBO literature sort of became more
well-known. And I had the chance to
see that grow from a small bubble
to what it is now.
But because I had that comfort
level with using probiotics for
irritable bowel syndrome, and
people were talking about SIBO
being the main cause of IBS, I
never had any hesitation about the
use of probiotics in IBS because I
was doing clinical trials on these
patients, treating patients in clinic
with IBS with generally good results
already at that point. So I didn’t
have that same hesitation that I
think you could get at a certain
time or point where probiotics
were like, “Ooh, they’re a no-go for
SIBO patients.” So, I think that was
certainly part of my background
that led me to where I’m at.
And also, having a chance to
evaluate the literature, I think if you
look objectively at the probiotics
in SIBO literature, the evidence is
overwhelmingly positive in terms of
trial outcome.
There’s a handful of trials that
showed those particular strains
weren’t useful, but the vast majority
have been shown to be useful in
either helping with eradication,
or at the minimum, decreasing
symptoms significantly.
Shivan Sarna: Well, top of the line,
first question out of the gate, what
are the strains that help people
with SIBO, or brand names, or like
making sauerkraut? What is it that
we can do as SIBO patients to help
ourselves?
Dr. Hawrelak: That’s a good
question. Sadly, some of the strains
that have been used in the research
aren’t commercially available at this
point in time. And I think this is the
biggest issue in the realm of SIBO.
And I see this as a probiotic
researcher all the time when I’m
reading through the literature
they come up with, “Ah, that’s a
new strain being useful for this
condition.” It’s not commercially
available, and it may not be for five
years.
And sadly, some of this has been
happening similar with the SIBO
literature that, yes, there’s been
some strain s researched essentially
from the early 2000s in SIBO, but
most of which are commercially
available.
In North America or Australia, there
are some like Enterogermina which
is available in Europe, which is this
specific strain of bacillus clausii.
[05:04]
And there is saccharomyces
cerevisiae variety, boulardii,
Biocodex, which is available in
North America as well as many
parts of the world which actually
has positive results in one study,
and I’d say more equivocal results
in a second study (although the
second study compared it to
antibiotics specifically). There was
a substantial decrease in both
hydrogen output even after seven
days on this particular probiotic
strain. But it wasn’t as effective as
the antibiotics. But still, it was more
effective than placebo.
Shivan Sarna: What about doing
them together, the antibiotics and
the strain?
Dr. Hawrelak: Yes, good question.
And I think there’s been little
research. In fact, I’m not aware of
any research that’s done that in
exactly that way. There has been
some research that’s used—
There’s one interesting study where
they gave antibiotics for the first
two weeks of every month, and
then they gave probiotics for the
subsequent two weeks of every
month. And that was more effective
than people who didn’t take their
probiotic the subsequent week in
terms of eradication rates.
And that’s probably the closest
study that’s been done to what
you’ve got in mind.
There certainly has been some
research using a specific prebiotic
alongside Rifaximin, for example,
which did significantly improve
eradication rates.
Shivan Sarna: And what was that?
Dr. Hawrelak: That was partially
hydrolyzed guar gum.
Shivan Sarna: Oh, yeah.
Dr. Hawrelak: Yes. And partially
hydrolyzed guar gum, interesting
substance in that if you look at the
broader irritable bowel syndrome
literature—and I did a systematic
review looking at all the research,
looking at, we’ll call it PHGG
because it’s far easier to say, in
irritable bowel syndrome patients.
And there are eight clinical studies,
all of which showed a benefit to
IBS patients in terms of reduced
symptoms.
So it didn’t surprise me necessarily
that it worked as an adjunct to
antibiotics. And it’s got a pretty
unique capacity to actually decrease
methane output. And I would say
that’s what makes it somewhat
unique as a substance.
You will know, and many of your
listeners will know, that you
can generally divide SIBO into
hydrogen-dominant or methane-
dominant. And those that are
methane-dominant, it’s wonderful
that we’ve got another tool that
specifically addresses that.
Shivan Sarna: So, partially
hydrolyzed guar gum, what exactly
is that? I know it’s a fiber, it’s a
prebiotic. Is it the sap of a tree?
What is this stuff?
Dr. Hawrelak: It comes from the
guar bean. They would isolate out
the gum. And that’s when you use
it I suppose as a thickener aid and
as a dietary fiber for hundreds of
year. But the hydrolyzation process,
they chop it into smaller bits. And
that process is important because it
actually ferments differently. So you
can’t assume that normal guar gum
will work the same.
In fact, we have research showing
that normal guar gum increase
methane gas output, whereas
partially hydrolyzed guar gum
decreases methane output. So it’s
important to keep track of that.
And also, the microbes that are
capable of eating PHGG are actually
different too, and that we tend to
have an increase in numbers of
butyrate-producing bacteria, as
well as bifido bacteria when people
consumer partially hydrolyzed guar
gum.
Shivan Sarna: Would you call PHGG
partially hydrolyzed guar gum?
Dr. Hawrelak: Yes.
Shivan Sarna: I understand now.
Go back in time with me about
three minutes, and say slowly—I’ll
try to put you on the spot. Just if you
can, we’d love it. Tell me the names
of those strains that studies have
been done to show being helpful for
people with SIBO.
Dr. Hawrelak: Okay. It was
bacillus clausii. And the product
was an Italian probiotic called
Enterogermina. I have to close my
eyes to visualize that one to get that
one. And it is available in Europe
and has been for a long time. It’s
just not widely available outside
that realm.
And the saccharomyces one is
available easily in North America as
Florastor.
Shivan Sarna: I thought that was
SB.
Dr. Hawrelak: Ah, well, yes, good
question in that we now know
that there is no such thing as
saccharomyces boulardii.
I probably have to take a step back
in that there’s a microbiologist in
Southeast Asia I think in the 1920s
called Henry Bollard. And he was in
Southeast Asian village where there
was some cholera going through,
and there’s people dying of horrible
diarrhea.
But he noticed that some of the
locals were making a drink from
lychee skin tea. And he was a
microbiologist. These people were
getting better and/or weren’t
getting sick. [10:03]
So he was curious and said, “Okay, I
wonder what microbes are available
in that lychee skin tea.” And he
found a yeast, which is a type of
a saccharomyces, which he, as
microbiologists often do, named
it after himself, saccharomyces
boulardii. And he sold that to a
French company called Biocodex
in the 1940s. And it’s been sold
around the world as a probiotic
since that point in time.
But we now know that there’s not
actually a separate species. It’s
actually so closely related to baker’s
yeast and brewer’s yeast. That’s
actually classed within that same
species. So it’s saccharomyces
cerevisiae which is the baker’s
yeast species. But it’s just a unique
cultivar. They’re called the variety
boulardii. And it’s the Biocodex
strain. There’s a number of different
strains of boulardii which, again, are
similar genetically, but also a little
bit different.
And all it takes is a gene turned off
or on that makes the yeast good for
fermenting wine versus champagne
versus beer versus other things.
So yes, I think the gene tweaks are
important.
Shivan Sarna: And so, a yeast
which ferments is okay for people
with SIBO?
Dr. Hawrelak: Yes. That particular
yeast is a pretty phenomenal
yeast actually when you look at
the clinical trials and so on. It
tends to decrease Candida counts
in the gut. It’s helpful against
protozoal infections like Giardia and
blastocystis as well. It helps heal
the gut when it’s damaged because
of its capacity to release these
compounds called [polyenes] as it
traverses to the gut.
So it’s got a number of actions and
they get immensely useful. And I
use it a lot in my clinical practice
because of the range of actions
it actually has. But yes, it does
seem to help in SIBO as well. And
I particularly use it in hydrogen-
dominant SIBO.
Shivan Sarna: And it’s called
Florastor. So in the States, you can
get it at Walgreens, CVS, the names
of the most popular—
Dr. Hawrelak: Yes. Who would
have thought? That’s the exact one
that Henry Bollard isolated from the
skin of lychees.
Shivan Sarna: And when you’re
saying lychees, are you saying
lychee fruit? Is that what you’re
talking about, a lychee fruit?
Dr. Hawrelak: Yes. I would
pronounce it lychee. But yes, the
fruit, the subtropical fruit that’s red
and absolutely delicious, yes.
Shivan Sarna: And it’s interestingly
almost gelatinous with that big
seed. And it has the red skin that
has little pokies on it. Very scientific
right there.
Dr. Hawrelak: Yes, but you’ve got it.
You described it beautifully.
Shivan Sarna: That is so
interesting. Let’s continue to talk
about—I’m going to get some
Florastor, I’m going to get some
hydrolyzed guar gum (also known
as partially hydrolyzed guar gum,
PHGG), how much are we talking
about? A tablespoon, a teaspoon?
Dr. Hawrelak: Most research with
PHGG uses 5 g to 7 g per day, which
is generally around a tablespoon.
And that’s probably an Australian
tablespoon which, strange enough,
is different from an American
tablespoon. So you might have to
weigh that out a bit.
But most of them will come in a tub
with a scoop that has the actual—
one scoop equals six grams. It’s
pretty typical. And that would be a
typical serving dose.
Shivan Sarna: And you just put it in
water?
Dr. Hawrelak: Yes, it mixes really
well. There are some fibers that are
really gluggy and really unpleasant
to take. This one slightly thickens
the beverage, but you can add
it to hot drinks, you can add it
to cold drinks, you can add it to
breakfast cereals or smoothies. It
is really easy to take which is rare.
As someone who uses a range of
natural medicines, it’s something
that’s actually palatable. And to be
honest, a better spectrum [13:41].
Shivan Sarna: Okay! So the
question that I have which I don’t
really need to know, I’m just glad
we found something that’s going to
help us when we take our Rifaximin,
so whether we’re taking Rifaximin
or not, this is a helpful thing for
people with SIBO?
Dr. Hawrelak: Yes. I would use it
across the board in my methane-
dominant ones primarily (but I’d
used it in my hydrogen-dominant
ones as well).
Shivan Sarna: What is the function?
What does it do? It’s a prebiotic, but
I thought that one of the reasons
why partially hydrolyzed guar gum
was helpful when people took
Rifaximin was because it helps with
bile stimulation. Is that true? Or is
that just so wrong [14:27].
Dr. Hawrelak: I would see that as
very unlikely, that it would actually
impact bile output. As I’ve said, we
did the systematic review looking
at PHGG in IBS because there’s this
idea that it only helped because it
actually fed microbes and they’re
formidable (they’re more receptive
to antibiotic killing). And our review
showed that that wasn’t the case.
Certainly, when prescribed on its
own, it would often have amazing
effects about normalizing bowel
patterns. So people that went from
having two bowel movements
a week went to having five.
Those who went from 35 bowel
movements per week went down to
having 9 just from ingestion of that
particular substance.
Shivan Sarna: What’s the
mechanism? [15:07]
Dr. Hawrelak: A number of
mechanisms. I think that’s the key
thing. We now know that, yes, it
suppresses methane and it speeds
up whole gut transit times. That
would explain how it could be
helpful for constipation type IBS.
But it also has that capacity to
decrease inflammation from a gut
healing and up-regulate butyrate
production. And butyrate is a pretty
amazing substance. And there
may even be other people in the
SOS talking about the wonders of
butyrate.
But one of the things that it does do
is it decreases gut inflammation and
decreases visceral hypersensitivity.
And visceral hypersensitivity, we
know, is one of the key underlying
issues with irritable bowel
syndrome patients that make them
react to this much gas instead of
most of us that would react to that
much gas.
So think it’s probably how it works
as well. And it seems to have an
effect about minimizing diarrhea
stimuli as well.
Shivan Sarna: That’s amazing.
That was truly amazing. Is there a
brand that you prefer? Do you have
a brand that you like? I know in
Tasmania, I don’t know if they have
a lot of brands.
Dr. Hawrelak: We’re relatively
small. Up until recently, we couldn’t
get it in Australia. So I was using an
American product that makes the
well-researched one worldwide.
And it was Healthy Origins’ partially
hydrolyzed guar gum. It was
relatively inexpensive, maybe $10
or something for a month’s supply.
I like things that are effective,
inexpensive, easy to take. They get
three ticks for me and my patients.
Shivan Sarna: We like that too.
We like that too. So I’m getting
Florastor, I’m getting partially
hydrolyzed guar gum. Next,
what else should we be looking
at and thinking about in terms
of probiotics, specific strains,
supplements? Yogurt versus
sauerkraut? What should we be
thinking about?
Dr. Hawrelak: I tend not to use
sauerkraut as a therapeutic tool. I
do encourage patients, in the right
scenario, to make it, and I think it’s
part of that healing process. It’s
pretty amazing to be involved with
making something that’s getting
yourself better.
I think there’s some gut healing
properties with sauerkraut as well,
which are wonderful. It tastes nice
[17:18].
However, it’s a wild ferment
because we don’t necessarily know
what strains it contains, we don’t
know amounts it contains, it usually
contains a strain of lactobacillus
plantarum at a therapeutic dose.
One teaspoon will usually have at
least a billion CFU or colony-forming
units, so a billionth microbes per
teaspoon, which should make it
therapeutic dose-wise. It’s just the
fact that it’s a wild strain.
So, some nice sauerkraut that I’m
making here will actually contain
different strains of the same species
compared to yours in your house
which would be different than your
neighbors unless you use the same
batch of starter culture.
And I think it’s the differences
in these wild ferments that, for
me, may take them out of the
therapeutic realm and put them
in the adjunct treatments, but I
wouldn’t rely on them on the same
way.
Yogurts can be in that same
category, but then they can also
be different too because you
can get commercially available
yogurts where they actually add in
therapeutic strains in therapeutic
amounts, so you know exactly what
you’re getting.
Mostly, but there are ones that
are called therapeutic or probiotic
yogurts.
Whereas with supplements, they
can differ in quality too, and they
can differ in labeling. Someone
will have actively chosen the right
strains with therapeutic effects
to help people; whereas other
companies would have chosen the
other path which is shovel a bunch
of random microbes in there from
a cheaper supplier and hope that
they do something.
But I don’t use those. I use the ones
that are well-researched. And there
are strains like bifidobacterium
lactis HN019,which we know speeds
up gut transit time. So it’s one
that I use in my, both constipated-
type methane and SIBO patients,
but also just my constipated IBS
patients, and even my patients with
functional constipation as well.
Sometimes just giving them that
one strain, all of a sudden, they’re
doing poo every single day, and
they’ve been doing poo every three
or four days before that. Just that
small, little thing, and that’s strain
has been shown in research even
in just two weeks to speed up that
transit time from 50 hours down to
20 hours, which is a pretty massive
change.
Shivan Sarna: That’s huge. What is
the name of that one more time?
Dr. Hawrelak: Bifidobacterium
lactis HN019, and it’s the HN019 is
the strain designation.
Shivan Sarna: And how can we get
that?
Dr. Hawrelak: That one’s available
in a number of products in the US,
but I can’t remember [them] off the
top of my head. I know Xymogen,
ProbioMax has got it because
they’re one of the first that had
it in a relatively higher dose, but
it’s becoming more widespread,
so there’s probably other parts
available in the US market that have
it now too. [20:00] dose because we know it works.
Shivan Sarna: So, speaking of
dosages, we see the CFU, there
seems to be all kinds of different
measurements for the strength
of probiotics. Is there something
we should be—they don’t seem
to correspond with each other.
I don’t know. Can you educate
us for a moment about what we
should be looking at in terms of the
currency, or the way we describe
the potency, or look for the potency
of a probiotic?
Dr. Hawrelak: It certainly would
be CFU. Each CFU is one bacterium,
essentially. This area is complicated
by the fact that the exact dosage
that’s therapeutic differs by strain.
So for some strains, like the
lactobacillus reuteri DSM 17938—
very catch names, I know—that
particular strain, we know that
100 million (so 10th to the 8th) is a
therapeutic dose.
But for most probiotic strains, that
would be too little. In fact, we know
from the overall set of research,
we’re looking at 10 to the 9th,
or 1-billionth CFU as a minimum
therapeutic dose. And I think that’s
where I would go for.
You don’t need to have
100-billionth, I think, is the
minimum therapeutic dose for
most strains is that. But you have
to ensure that if you’re using a
multi-strain product with 10 strains,
they can’t just add up to a billion
or up. Each of those strains, if you
want to have a chance of it being
therapeutic, essentially, has to
contain 10th to the 9th CFU in that
particular product that the dose
that you’re taking.
There are exceptions like the
Lactobacillus reuteri DSM 17938
which is used at a much lower
dose. And commercially, you’ll often
find it available at a much smaller
So the people that put it together
in supplement form just used the
dose that the clinical trial shows
works [21:53].
Shivan Sarna: Would that particular
strain be helpful for people with
SIBO?
Dr. Hawrelak: Interesting question,
and I’d say yes. There’s some
research—probably it’s just this
year—looking at people who are
methane-dominant constipated
patients which, when you look at
the methodology, it would have
included people that would be
diagnosed with methane-type SIBO
for sure. And they just gave that one
fecal strain and there was a massive
reduction in methane output,
including clearance of methane in a
while since I read the study. I think
there were over 50% of subjects.
Shivan Sarna: What is the name of
that again? I know it ends with DSM
17938. What was the first part?
Dr. Hawrelak: Lactobacillus, which
should be easy, and then reuteri,
which is R-E-U-T-E-R-I. And that
one is available in the US, which
is as BioGaia, and Canada, and
throughout Europe, and even
Australia. So we’re lucky that that is
one of the few strains that has got a
good research base in this area, and
is commercially available for most
of us.
Shivan Sarna: So I have found the
BioGaia, and it was for babies, and
then the little squirty thing.
Dr. Hawrelak: Exactly. So it’s
used for colic as well. So there’s a
number of clinical trials showing it
helps with even child colic. That has
been the main marketing pitch so
far, but there’s other clinical trials
for other applications too. It can
be used alongside triple antibiotic
therapy for helicobacter pylori, and
it helps improve the eradication
rate and decrease side effects.
But they’re not marketing it that
way because there’s a huge market
of colic in babies, and a good
research background, so that
makes sense and do work for that.
But the more recent study was—
there are a number of studies
showing it works for constipation.
We’ve known that for years, but
we didn’t necessarily know the
mechanism until there’s the tie-in
research study that was published
this year showing that it worked at
least in part by decreasing methane
output.
Shivan Sarna: This is amazing. Where
have you been all my SIBO life?
Dr. Hawrelak: In Tasmania, which
is very far away from you, I think.
Shivan Sarna: Clearly. So I have the
little squirty bottle of the BioGaia,
and how much should I be taking
because it’s like a baby’s dosage?
Dr. Hawrelak: Interestingly
enough, the dose that was used in
the trial from memory was 10 to the
8th CFU twice daily. That’s it. From
memory, I think it’s five drops twice
daily is the therapeutic dose of
most of those liquid versions.
And I think we’ve been brainwashed
and hoodwinked a bit to this idea
that we have to give hundreds of
billions of CFU to get a therapeutic
effect.
Now, that’s clearly not supported by
the broader probiotic literature.
Shivan Sarna: It just depends on
the strain.
Dr. Hawrelak: Yes, it does. And
some strains do have a dose-
dependent effect like the HN019
strain that I mentioned before does
work better at a higher dose of 15
billion instead of 1 billion. It sped
up things more quickly, so there is
a rationale for some of that. But I
think sometimes they’ve taken that
a step too far and anything below
100 billion is useless. And that’s
clearly not the case. You can have a
strain like this one, the reuteri one,
that 10th to the 8th CFUs is enough
to have a therapeutic effect that
many people would argue is quite
a potent therapeutic effect as well
based on that research. [25:01]
Shivan Sarna: More controversy
to clear up. Refrigerate or not
refrigerate, that is the question.
Dr. Hawrelak: It depends on, again,
on the strain in that for the last 20
years, when people were trying to
develop new probiotic strains, they
essentially put them through what
I’d call a probiotic obstacle course.
So they will essentially—most of
these have been isolated from
people’s guts or essentially, from
some healthy person’s poo.
It might start off with 200 or 300
different strains of lactobacilli
or bifidobacteria in that fecal
specimen. Then they’ll isolate those
out, and then essentially put them
through an obstacle course.
Which one survived stomach acid?
Which one survived bile source?
Which ones can adhere to your
intestinal cells? Which ones can
stick around for a while? Which
ones produce selectively-acting
antimicrobial compounds which can
kill off pathogens but be harmless
to the good bugs that we want?
Which ones survived room
temperature storage?
That’s the obstacle course. Out of
that 200 strains they started with,
they often end up with one or two
that actually take all the right boxes.
So these days, you’ll find there’s
a number of probiotics coming
out that actually don’t need
refrigeration. Whereas in the older
days, before they probably did the
obstacle course in the same degree
of rigor, particularly when it came
to stuff like storage capacity, then
refrigeration is important for some
preparations.
Shivan Sarna: And Florastor,
by the way, does not need to be
refrigerated.
Dr. Hawrelak: That’s right. That
one actually says don’t refrigerate
on the label.
Shivan Sarna: Well, that’s
interesting because the last bottle I
had, I kept in the fridge next to the
other one, so good to know.
Dr. Hawrelak: Yes, because that
one is—the way it’s freeze-dried in
preparation is a bit different from
the other preparations. And also,
the fact that it’s yeast as well, so I
think humidity is more of an issue
with that one, in terms of starting
its regeneration cycle rather than
temperature.
Shivan Sarna: I believe that if we
all do what you’ve said so far, we’re
going to be vastly improved. But I
know this group, I know what it’s
like to have SIBO, and to feel like I
might not ever hear from you again.
So I have to keep asking these
questions.
What else, and forgive me because I
know I’m just repeating myself, but
what else—we’ve tried that. Let’s
say we get some improvement,
or no improvement, what else for
people with SIBO and IBS should we
be at least investigating or trying?
Dr. Hawrelak: I certainly treat lots
of patients with SIBO, so I concur
that often just a single approach
or a single agent is unlikely to
necessarily—in some people, it
might make a massive life-changing
change. But yes, in most cases, no.
For me, I would certainly use
probiotics, I would use prebiotics.
But I’d use herbal medicines as a
core component of how I would
treat too (as well as using probiotics
and anti-inflammatories, et cetera).
It is a condition that I think is
complex. As I’m sure you and
everyone who’s got it know it’s not
as simple as, “Take this one pill for
five days, and you’ll be right.” It’s
not.
Sometimes, you can take a pill for
five days, or a herbal agent, and if
you’re one of those lucky people,
you can have a dramatic shift in
that first week. But then if you stop,
everything right then and there,
it generally doesn’t last that long
before symptoms actually come
back when they haven’t got a bit
deeper.
So I think this is an area where
really working with a clinician that’s
got adequate experience and the
skillset in this area makes a world
of difference because they can go,
“Okay, let’s try this bit, and let’s do
this. Let’s look at your breath test
results more closely.”
Generally, when I’m assessing for
the first time, I would do lactulose,
fructose and glucose breath tests—
all of that in one first go. And I’d get
these different bits of information
from that than I would if I just relied
on lactulose as a breath test tool.
And that can actually dictate how
I treat things too, so that’s where I
think the nuance is coming about,
the tailoring of specific treatment
for that person. So yes, we can talk
about what things work in clinical
trials and that work on—the same
as Rifaximin works in a certain
number of people, but not a whole
bunch of others.
But the clinical trials show yes,
it’s effective. But upon systematic
review, it’s showing a 50% efficacy
rate, which is not better than none,
but it’s not fantastic either.
So it’s a matter of tailoring things
and trying to work out what the
best approach is for that person.
And I think this will get easier in the
future too when we start getting
tools that can actually assess the
specific microbiota imbalance that’s
in the small bowel because at the
moment, we often don’t really know
what’s there. We just know, “Okay,
you get a raised breath test result.
We’re going with these agents. So
we hope we’ll target those things.”
But if we actually knew specifically,
“Okay, you have an overgrowth of
streptococcus on E. coli,” we can
actually tailor our treatments far
more specifically at that time.
So I’m hopeful that will change
things in the next 5 or 10 years
when we develop a special sort of
smart capsule, for example, that will
actually be able to sample as it goes
through the small bowel. And then
we can use a DNA sample to work
out what microbes are there and
what quantity they’re there.
But I don’t think we’re quite there
yet. [30:15]
Shivan Sarna: So that smart pill is
not actually available yet?
Dr. Hawrelak: No, that smart
pill is “do go through and have a
good look at the entire gut,” which
is great. And you do have some
smart pills, I think, that are used
in research settings to take some
samples that we could assess
through DNA.
But as I’ve said, I think, over
the period of 3 to 5, technology
will improve to a point—and
accessibility will improve—that
we might be able to actually start
assessing patients in a much more
detailed way.
Shivan Sarna: Very cool! I want
to move on to a couple of other
questions. But before we leave this
with the strains, is there anything
else that we should at least “nothing
else has worked,” or “by all means,
try this every single time,” anything
else for a SIBO patient in terms
of strain that is available in the
marketplace at this time?
Dr. Hawrelak: Yes. That makes
it a bit trickier. I’m trying to rack
through my brain of the other
clinical trials that showed product
results that sadly aren’t available.
Now, there were some interesting
case studies from the late
1990s, and these were children
hospitalized with severe SIBO. So
they weren’t just a bit of bloating or
distension. They were really, really
unwell.
Non-responsive to antibiotic
treatment. And I think they
had results using lactobacillus
rhamnosus GG which is available
as Culturelle and others in the US
market. And other cases responded
well to lactobacillus plantarum
299V, which is another probiotic
with a number of positive studies
in irritable bowel syndrome more
broadly as well that is available in
most markets around the world.
So I think those would be worth
experimenting with as well.
Shivan Sarna: So Culturelle, which
is the market name for it, but
then what was the other one for
plantarum?
Dr. Hawrelak: Lactobacillus
plantarum 299V. And it’s the 299V
which is the strain designation. So
I know in the US, Jarrow, I think
in their Ideal Bowel Support have
got it. But I’m sure there are other
products on the market over there
too. But that one is pretty wildly
available worldwide—very positive
results pretty consistently within
the irritable bowel syndrome
broader literature as well.
So yes, that would be one that’s
worth experimenting with too.
And then there’s the
bifidobacterium infantis 35624
which, again, has got some
positive results in IBS—not in SIBO
specifically. And that one is a line in
the US.
Now, there are some ingredients
in that one that I think is perhaps
less than ideal, and I haven’t used
that one personally because it’s not
available here. I use the other ones
that have the bit what I would call
cleaner ingredient list first before
actually going to the line. But there
is some positive research in IBS,
and specifically working on visceral
hypersensitivity or low-grade gut
inflammation.
Also, what’s interesting, animal
research suggesting it actually is
able to increase the amount of
tryptophan, I think, actually in the
bloodstream too. So therefore, it
might work a little bit by having sort
of a mood lifting effect as well.
Shivan Sarna: Very nice! What’s not
to like about that?
Dr. Hawrelak: That’s right.
Shivan Sarna: So, thank you. Those
are all incredibly valuable. Let’s
move to the other—I have two
other magic questions which is:
When we take an antibiotic—I
realize Rifaximin has been studied
to basically stay in the small
intestine. So I’d love to hear your
take on that. But let’s say we’ve
taken penicillin, we’ve taken
tetracycline, whatever these broad
spectrum antibiotics, how does that
impact our microbiome? And what
should we and could we do about
it?
Dr. Hawrelak: A couple of very
good questions. Rifaximin is
interesting because there is that
idea that it’s very selective in the
small bowel. But there are clinical
trials using it for diverticular disease
which is a colon infection. And I
think even for another infection
of the colon that I can’t remember
right now. So there is evidence
showing that it works in the colon
as an antimicrobial as well. I
wouldn’t necessarily agree that it
only works in small bowel based on
the data that we have.
That said, the data that we have
does suggest that it’s far more
selective in its collateral damage
compared to typical antibiotics. So
I think that’s very much a positive
in that scenario. It makes me worry
less about that as a treatment
approach compared to most
antibiotics.
And I think the research in
antibiotics and the gut microbiota,
and this has been interesting to
watch in this area because as I’ve
said before, for me, this started
late 1999 when I would’ve started
writing my literature review looking
at microbiota research.
And in 2004, I think we did a
systematic review where we
gathered every single study that
looked at antibiotics and looked
at what impact they had on
the microbiota. And there are
hundreds. [35:00]
So it’s a massive task and took
weeks to actually pull out all the
information. But looking at that—
and some of the information at
that time, the late 90’s, early 2000’s
suggested that antibiotics had
relatively short-lived impact on the
microbiota.
And that was surprising to me at
the time.
I was like, “Okay, if it only takes
two weeks or four weeks for the
ecosystem to normalize afterwards,
then maybe I shouldn’t be so
worried about that.”
But, there’s a big but here, but when
we changed technology from using
culturing to using DNA techniques,
we were able to see things in far, far
more detail. And instead of seeing
only small portions of what was
present, we were able to see the
broader spectrum focus there.
And that really blew our minds
because all of a sudden, antibiotics
weren’t just damaging the
ecosystem for two weeks or four
weeks, we’re talking a couple of
years, we’re talking permanent
alterations to every single course of
the antibiotics.
Yes, the core ecosystem, the bugs
over there, and most amounts
tend to rebound to some degree.
Sometimes it takes six to nine
months, depending on the
antibiotic. But there are others that
actually get wiped out through that
process.
And I think that’s the thing, is that
we could argue that every single
course of antibiotics actually
diminishes your gut diversity a
little bit more. And I think that’s
problematic.
And sometimes, what we’re losing
is microbes that were on the
periphery, bugs that made up a
small portion of your ecosystem,
some of which we don’t even
know what they do, some of which
weren’t even probably named or
just recently been named that
we’re actually losing when we take
courses of antibiotics.
So what’s the significance of this?
A lot of it we don’t know. But you
can take a microbe like oxalobacter
formigenes. Oxalobactger
formigenes, it’s in very small
proportion in your gut. It’s close to
0.01% of the ecosystem. It’s tiny.
When we take an antibiotic cocktail,
like we do for helicobacter pylori
or sometimes for eradicating more
full-on infections (or even, some
people are using it for some sort
of possible gut infections at this
point in time), two-thirds of people,
that microbe goes extinct from the
ecosystem—gone for good.
Does that matter? Well, it turns
out that that fecal microbe, what it
does is it eats oxalates. It eats the
oxalates from your diet. And by
eating the oxalates, it prevents you
from absorbing them. So when that
microbe is gone, we start absorbing
the dietary oxalates we otherwise
weren’t. And that increases our risk
of kidney stones.
And now, there’s a whole bunch
of theories about other impacts of
oxalates we’re actually having.
And okay, we didn’t talk about these
things 20, 30, 40 years ago because
I don’t think they happened.
They’re happening now because we
wiped out the entire species from
the gut that was present before
an entire human evolution was
present. That’s not there. There are
consequences to that.
Even though it’s a tiny player,
0.01% of the ecosystem, when it’s
gone, there are consequences. And
interestingly enough, if that was a
mom before she was giving birth
to her kids, she can’t pass that on
to her kids because the bug is gone
from the ecosystem. It’s extinct.
So that means her whole family line
will be the increased risk of kidney
stones and having oxalate issues
just from that one intervention for
a microbe that we didn’t even know
existed 20 or 30 years ago.
So I think there are consequences,
and we really do have to think
strongly about the use of
antibiotics, and try to reserve
them for—they save lives. And in
those situations, they’re amazing
medicines. And if we save them
for that for as much as we can,
we’ll do our own health good, we’ll
do our generations of microbiota
good, and as well as a society as a
whole because we get less antibiotic
resistance with microbes too.
But I think we’ve got to be cautious
about using it as port of call for
more functional gut conditions.
Depending on the severity that
some people with SIBO would have,
then I would be hesitant to use
antibiotics as the first number of
treatment options. I’ll be going with
options that are less damaging to
the ecosystem or something like
partial hydrolyzed guar gum that
actually encourages a healthier
gut ecosystem as a consequence
of its use rather than detrimental
changes that are permanent.
Shivan Sarna: So the other typical
approach to eradicating the
bacteria that is overgrown in the
small intestine is, of course, the
herbals—the berberine, the Neem
Plus, the things that we’ve talked
about a lot on the summit. So we
don’t need to spend time talking
about that, what they are.
But how do those impact the
microbiome?
Dr. Hawrelak: That’s a very good
question. I’d say we don’t have
as much data on this as what we
would like. As part of my PhD I did
do some preliminary data-looking
at this. We tested berberine and
enteric coated essential oils, we
use coptis and goldenseal, oregano
essential oil, citrus seed extract, et
cetera and look to see what impact
they had on those common gut
microbes that we could grow at that
point. [40:12]
So, this was in-vitro methodology,
which means it’s a little bit more
limited. I would have loved to have
the finance to do human trials at
that point. But we didn’t have that.
What I could do is this in-vitro data.
And it certainly showed that some
of these antimicrobials, herbal
antimicrobials, caused collateral
damage. Certainly, the top of the
list would be citrus seed extract and
grapefruit seed extract. That pretty
much kill everything at even tiny
doses—which actually was scary.
It’s even more potent than the
Clindamycin, which is our positive
control.
And then when we start looking at
what the ingredients are in some
commercially available citrus seed
extracts, which is your bentamine
chloride and triclosan, which are
hospital-grade disinfectants, it
makes you see, “Okay, that’s why it’s
such a potent antimicrobial agent.”
But even things like oregano
essential oil, it was able to quite
effectively kill bifidobacteria as
well as a range of pathogenic
microbes—but was less so on
lactobacilli. So lactobacilli can
tolerate a bit of oregano pretty
well except for in very high
concentrations.
And berberine itself and herbs
containing it did seem to have
collateral damaging effects,
particularly bifidobacteria. So in
my research, bifidobaceria was
the most knocked about beneficial
group by herbal antimicrobials.
But there’s a bunch that we didn’t
test like [lycopene], for example,
or thyme essential oil or clove—a
whole bunch that I would love to
be able to do that again in a much
more systematic approach using
DNA stool analysis that would give
us a much clear picture of what’s
going on.
Shivan Sarna: So, I’m going to take
my Rifaximin, let’s say, I’m going to
take my partially hydrolyzed guar
gum, I’m going to take some of the
probiotics you’ve just talked about,
and then I’m going to continue with
these probiotics after the treatment
period is over. Is that a reasonable
approach?
Dr. Hawrelak: Certainly—taking
a step back from SIBO specifically
and looking at restoration of the
ecosystem. And I think that’s the
way we have to look at the gut
microbiome. It’s restoration, not
receding.
The receding thing is actually a
myth. It goes back a long time. It
goes back to the 1900s. They said
that we could ingest yogurt bacteria
and they would permanently stay
in our gut and prevent protein
putrefaction and keep us healthy
and help us slow down the aging
process.
That idea has been around for a
long time, but we’ve got 30 years of
clinical trials showing that for the
vast majority of probiotics that we
actually ingest, they’re temporary
visitors. They’re there for a few
days. And in three, five, seven days
afterwards, they’re generally gone.
So it’s not a matter of receding,
and I think the idea that we can
easily recede the ecosystem, I think
cheapens it.
If you could just regrow your finger
really quickly, you wouldn’t really
care about much. You can just chop
it off and regrow it.
I think it’s the same thing that if all it
took was just taking a bottle of pills
from the fridge to restore or just to
recede your gut, you wouldn’t worry
so much with antibiotics. And I think
that’s part of the problem now—
when you realize that the species
that are going extinct are ones that
we don’t have in probiotic capsules
or powders.
And that even the ones we do have
in capsules and powders made
from lactobacilli bifidobacteria are
temporary visitors at best, it makes
you sort of want to be much more
of a custodian of that ecosystem
and care for it in a different sort of
way.
So yes, taking the right probiotic
during antibiotics can help minimize
the damage it caused, and taking
prebiotics after antibiotics can help
restore the healthier ecosystem,
but some species will still go extinct
from that process. There is no easy
way to restore bar FMT.
Shivan Sarna: So before we talk
about FMT, I talked about Rifaximin
and how I would do the probiotics
with it. And I think what you’re
saying also is whether you’re doing
Rifaximin or you’re doing the
herbals, do the same thing.
Dr. Hawrelak: Yes. It does make
it slightly more complicated in a
SIBO patient because if I’ve got a
patient that doesn’t have SIBO, then
I’ll often use two or three different
prebiotics, and I’ll use a range of
dietary fibers to make sure the
ecosystem is restored more quickly.
And I do stool sampling before and
after. You can see the effects. It’s
pretty marked.
But it’s more complex when you’ve
got some SIBO patients. And this is
where the individuality aspect we’ve
come onto. You’re going, “Okay.
Well, let’s see if we can tailor the
regime based on your test results,
what you’re doing, what we know
what the impact of those herbs or
that antibiotic, and see if we can
minimize that.”
And we can potentially do a stool
exam afterwards to see what’s
been disturbed by that and how we
can best restore it as well. There
are some things we can take like
polyphenol, like grape seed and
skin extract. It’s not grapefruit seed
here, it’s grape skin, and grape
seed which does have the capacity
to nourish a number of beneficial
microbes. But it doesn’t have the
same gas-forming effect that you
would get with classic prebiotics
like inulin or fructooligosaccharides.
[45:09]
Shivan Sarna: Very cool! FMT, tell
everybody what it is, if you would
please, and what’s the deal, man?
What’s the deal?
Dr. Hawrelak: FMT is fecal
microbial transplant, and it is, as
the name suggests, taking poo
from someone else, and taking it in
yourself as a way of receding. And
this does do that. You can certainly
recede using someone else’s feces.
There is a way of doing it, it’s just
more complex than just taking a
probiotic capsule. And there’s a
couple of different ways in research
circles, and not to say that—it’s
unclear at this point which way is
superior.
There are some people who will
send a scope down your stomach,
and secrete essentially dilute,
watered down feces into your small
bowel. And there will be others who
do it by colonoscopy where it goes
up the other end and squirt feces in
your colon. And that’s the process.
So, there are still debates about
which way is most effective.
Most research to date has looked at
Clostridium difficile which is a very
horrible gut infection to actually
get. It can be life-threatening that
commonly occurs after antibiotic
usage, particularly sorts of
antibiotics, and even more so if
you happen to be in a hospital and
taking antibiotics there. Clostridium
difficile everywhere in a hospital
setting sadly.
Usually, it’s not a problem if your
gut ecosystem was intact. But
as soon as it’s not, it becomes a
problem. It can grow into this space
that becomes available.
Yes, the most research on FMT
has looked there. But there’s a
burgeoning area of research looking
at FMTs for other conditions. And
this, I think, is quite exciting as well
because there’s research looking at
metabolic syndrome.
For example, people that had
blood sugar issues, weight issues,
essentially took some poo from
healthy, metabolic healthy people,
one application down the upper
tube, and their blood sugar
regulation improved dramatically.
No change in diet, no change in
lifestyle, 50 more species were
present from a fecal transplant than
what there were before.
So we’ve got the capacity to
decrease diversity pretty strongly,
and low diversity is one of
the biggest buzz words in the
microbiome world because it seems
to be a risk factor for a whole
range of chronic ill health than
conditions that we see in western
countries, and our diversity scores
are generally very poor as well
because we’ve often had C-section
births, and we are formula-fed, and
we took lots of antibiotics as a kid,
let alone one or two or three course
a year for our entire adult life, and
we’re eating a western diet that’s
so low in fiber that we don’t have
much diversity left.
But we know that there are people
with obesity, or type 2 diabetes
have got less diversity than even
typical western population.
Shivan Sarna: So people who
are losing weight and people who
are gaining weight, can they both
benefit from a supplement or FMT
of a probiotic?
Dr. Hawrelak: There’s been some
very good preliminary research
using probiotics to help with obesity
and type 2 diabetes and metabolic
syndrome and prebiotics as well.
There’s some great research
using fructooligosaccharides and
inulin as a tool that actually help
improve blood sugar control quite
dramatically.
And some probiotics, including the
bifidobacterium lactis HN019 that I
spoke about before, has got some
research helping with obesity as
well and decreasing systemic body
wide inflammatory markers.
So there’s a building area of
research using probiotics and
prebiotics for those conditions.
As far as where no one has looked
at, people that lose weight too
easily. It’s such a small proportion
of the population that I don’t think
people bothered looking at it to
date—but that might change.
Certainly, there’s a lot of effort
going into the obesity of side things.
And it wouldn’t surprise me in a few
years’ time if FMT would be a more
widely offered treatment approach
for obesity, metabolic syndrome
and type 2 diabetes given how
impressive the early results have
been, and also given, I suppose,
that it doesn’t seem to require
lifestyle or dietary changes to work
in the short-term.
Now, that’s the issue because if
you keep eating that same western
diet, it was lovely and beautiful
right after the FMT, but it’s going
to deteriorate rapidly and become
the same one that it was before
because it’s really very much
dependent on what we’re eating as
to what species thrive and which
ones don’t.
So, you often see things shift pretty
dramatically after FMT depending
on people’s diets. It’s been shifting
this very much in a very beneficial
way by choosing the right foods
and the right prebiotics, et cetera.
But then you see patients who had
a beautifully resistant post-FMT go
down the gutter because they’re
eating a really restricted diet which
is has got so many healthy fiber-
rich, polyphenol-rich, prebiotic-rich
foods. [50:05]
Shivan Sarna: Why is why everyone
talks about not staying on a low
FODMAP diet forever.
Dr. Hawrelak: Yes.
Shivan Sarna: Almost there. Almost
there. Thank you by the way. This
has been very illuminating. What
stool tests do you suggest, do you
work from, do you utilize to see
what the terrain is like?
Dr. Hawrelak: So, it has to be
essentially DNA-based. I think that’s
the biggest thing. Culturing is old,
outdated technology for assessing
the microbiota composition.
It still has its strong points
for determining antimicrobial
sensitivity of pathogens and finding
certain pathogens, yes. But when
you’re trying to assess the health
of the ecosystem, you have to use
technology that’s capable of seeing
that ecosystem.
And culturing doesn’t. The old
technology where we take some
poo, put them in a petri dish and
see what grew could only grow
maybe 30% of what’s there which
doesn’t tell us very much about that
ecosystem.
And most tests that we, as clinicians
or the public had access to was
even less than that 30%. Then they
tell us about four different species
and we’re trying to guess the health
of the ecosystem based on that. I
think that’s extremely problematic
and can’t be done. You need to get
an overall picture.
So, places like the American Gut
Project or uBiome (which are both
easily available for most people
and fairly affordable too for that
matter) could actually give us a
much broader picture of what the
ecosystem looks like.
They do take more work
interpretation. You have to
have a practitioner that’s skilled
and knowledgeable about the
microbiota composition, about
what percentages they should be,
and how we can manipulate it to
do the best thing by those results. I
think that’s what’s required.
Now, there are tests like the Genova
GI Effects stool profile that does a
bit of—they do some DNA testing,
which is great. And then they give
you a much broader picture of
digestive function, inflammatory
markers, et cetera, which I think
is a great too, but it’s also—for my
patients, around $700.
So it is a significant cost whereas
uBiome is $100 or something like
that. It doesn’t get me all of the
same types of information, but if all
I’m after is a snapshot of the health
of the ecosystem, then that could
be absolutely wonderful.
And then you can do some
interventions and see what impact
you had by doing a retest in two
months or four months. And I do
that frequently, so you can see
how well you actually are doing
in restoring that ecosystem to a
healthier composition.
Shivan Sarna: This has been an
action-packed hour, my friend.
Thank you very, very much. If
somebody wants to work with
you, someone wants to get that
poop tested, and they’re doing the
uBiome or whatever, and what’s the
other one?
Dr. Hawrelak: The American Gut
Project.
Shivan Sarna: How could someone
work with you? How could someone
send you this test and you would be
able to help them out based on the
test?
Dr. Hawrelak: So, I do see patients.
I wear many hats. I do some
research scientist work. And I’m a
clinician. And I do lecturing work.
So I do practice a couple of days a
week. And my clinical practice is in
Hobart, but I have patients all over
the world. So my clinic is Goulds
Natural Medicine. And I’m basically
working with gut, more gut, cases
these days.
Shivan Sarna: We appreciate it.
You’ve cleared up a ton that we’ve
had questions about. Yes, there’s
more to research and more to
find out like, “What was he talking
about?” Of course, it does create
more questions as well, but it’s
one thing when you’re on a wild
goose chase. We’ve all been
there. And then to be able to have
someone who’s like, “Hey, it’s over
the mountain. And this is a couple
of the paths that you can take to
get over the mountain.” It’s very
comforting, and is definitely for
those of us with SIBO, we have a lot
of anxiety about it, we’re confused,
we’re frustrated. I don’t need to say
that because everybody knows.
But definitely having this guidance
is extremely, extremely helpful.
So thank you. Continue your good
work, sir. We need you.
Dr. Hawrelak: Thank you. I will
continue to do, so don’t worry.
Shivan Sarna: No pressure.
Dr. Hawrelak: Luckily, I love this
stuff. I could speak for another four
hours on the gut microbiome, gut
bugs without any issue.
I still get a thrill out of finding new
research paper that then I can start
using on patients and seeing how it
actually works.
Shivan Sarna: Very exciting. Thank
you very, very much, Jason. I really
appreciate it.
Dr. Hawrelak: You’re very
welcome. A pleasure to be here
and chat with things about gut and
microbiome. [55:21]
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