Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Microbiome with Kiran Krishnan: Rational Wellness Podcast 163
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Kiran Kirshnan discusses The Microbiome with Dr. Ben Weitz and the Functional Medicine Discussion Group.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

6:55  Among its other roles, the microbiome is responsible for the maturation and proliferation of immune cells like T cells, B cells, and macrophages, etc... Our bone marrow produces B cells and our thymus produces T cells, which is like producing 15 year olds to defend our country, but in order for them to succeed they must first go through basic training and learn how to fight and get their equipment, which is what the microbiome does. This has been studied in mice without a microbiota and you see very poor and complete attenuation of the development of their immune system. The microbiome also supplies the energetics, like butyrate, and the equipment for the natural killer cells, the macrophages, and the dendritic cells of the immune system that are continuously circulating around looking for pathogenic viruses and bacteria to attack or to use the compliment system to neutralize it. Everything inside our bodies is covered by a mucosa. This mucosal surface of the inside of our bodies are approximately 4,000 square feet, which would be a really large house to live in. It is in this mucosa where the viruses and bacteria interact with our microbiome and this is where all the sampling and action takes place. 70-80% of our immune system is centered around our gut and in such eubiotic mice, this never develops.

12:58  There is a Prevotella-to-Bacterides ratio that is reported on the Biome Fx stool test that Microbiome Labs is working with. When people consume a lot of meat and protein, you tend to start to lose prevotella and then you start to increase bacteroidetes. This imbalance tends to be associated with insulin resistance and the inability to be able to build glycogen storage, both part of prediabetes and metabolic syndrome. Such patients also tend to get lethargic and tired at some point during the day because they are struggling to produce energy.  Some of these people with lower levels of prevotella and higher levels of bacteroides will have blood sugar drops in the middle of the night and they may get awakened by this. Kiran mentioned a study that will be published soon that showed that by adminstering a prebiotic that raised levels of Akkermansia and bifidobacteria along with the spore probiotics, these obese patients exhibited 38% reduction in visceral fat mass along with improvements in blood sugar regulation.

18:47  Kiran is involved in a prediabetes study with UCLA using the prebiotics, the probiotic, and also berberine, which is a type of herbal bitters and could be looked at as a natural metformin.  Bitters like berberine can trigger peptides like YY and GLP-1, which are transducers that improve leptin response and increase fat burn by increasing something called cyclic AMP.  It stimulates all of the cells in your body to start burning fat for fuel, it improves gastric emptying and motility in the gut, and then it dramatically improves the insulin sensitivity as well. And prediabetes often results in diabetes in the next number of years and diabetes dramatically increases the risk of almost all chronic conditions.

23:42  In order to help with weight loss, the best thing to do is to do intermittent fasting.  You can start with 12 hours and build up to 14-15 hours. Intermittent fasting will cause Akkermansia and bifidobacteria levels to increase and the microbiome diversity will increase.  It’s complicated to explain, but this type of intermittent fasting can actually improve the microbiome and stimulate certain types of bacteria to grow and certain other species to become reduced. Also taking the right prebiotic or resistant starches will promote the formation of butyrate, which is important for metabolic health and which turns on the cyclic AMP process that causes all of your cells to burn fat. But taking oral supplements of butyrate does not work because it will get absorbed in the stomach or small intestine before it makes it to the colon. Butyrate enemas can work, because you are putting it into the large bowel, but even better when it is produced endogenously by having the right bacteria and feeding them the right prebiotics.

                                                                               



Kiran Krishnan is a Research Microbiologist and has been involved in the dietary supplement and nutrition market for the past 20 years, including hands on involvement in university research.  Kiran is a Co-Founder and the Chief Scientific Officer at Microbiome Labs, a leader in microbiome and probiotic research. He is a frequent lecturer on the Human Microbiome at Medical and Nutrition Conferences.  He is currently involved in over 18 novel human clinical trials on probiotics and the human microbiome. Kiran is also on the Scientific Advisory Board for 7 other companies in the industry. Kiran has published clinical trials in peer-reviewed, scientific journals and several global patents in his name.  The new stool test he has helped developed is the Biome FX

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



 

Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talked to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

                                Hi there, this podcast is a recording of our monthly Functional Medicine discussion group meeting, and it’s similar to the normal podcasts, and that it’s basically an interview style, in this case it’s with Kiran Krishnan of Microbiome Labs who sponsored this podcast. And the topic was the microbiome, and we were having an amazing discussion and it went on for about 90 minutes.  Unfortunately, I didn’t hit the record until about 30 minutes in, so I’m going to try to set this up for you so that it’ll make some sense. So I’m going to give some a little introductory remarks to set up the topic, and then just keep in mind that it’ll start with the speaker speaking and I’ll try to help with what he was talking about. So let me set this up. So as I just mentioned, the topic for today is the microbiome, which as many of us know is of crucial importance for our overall health and it’s no accident that many of us in the Functional Medicine world tend to start by looking at the gut as the most important underlying factor or one of the most important underlying factors in many aspects of our health.  Just to be clear, the more than one trillion bacteria, fungi, protozoa, and viruses that live largely along our digestive track, especially in our colon, but also in our small intestines as Dr. Pimentel explained to us last month, but also on our skin, in the vagina, in our nearly every mucous membrane that the body is referred to as our microbiotaThe microbiome is the genetic material of all these microbes. Now, the bacteria and the microbiome are incredibly important for our health as all of us know and we’re starting to learn about some of the importance of the fungi, and there’s even been some interesting data looking at the benefits of parasites. But we’re going to focus on the bacteria today and these bacteria help us to digest our food, regulate our immune system, protect against other bacteria that cause disease, and produce various vitamins, amino acids, short chain fatty acids like propionate and butyrate, and neuro-transmitters among other important substances.

                                The father of Functional Medicine, Dr. Jeffrey Bland once said, “The relationship between our diet and the trillions of bacteria in our intestinal tract is one of the most important features that regulates the way our genes are expressed.”  We now know that the concept of trying to map out the microbiome so that we can determine which ideal set of specific microbes determines a healthy microbiome is no longer a practical definition.  What I mean by that is we thought at one point that if we simply figured out exactly which set of specific bacteria map out a healthy microbiome, then we could just try to duplicate that, and now we know that it’s way more complex than that. There’s a huge amount of diversity in what constitutes a healthy microbiome and that’s between people living in different countries over the course of their life, and many different factors.  So unfortunately that simple definition is not going to work for us. So given that what are some of the factors that can help us determine if a given patient has a healthy microbiome? Or if their microbiome may be contributing to their disease or symptoms or imbalances?  For example, there’s growing body of evidence showing that having a more diverse microbiome is associated with improved health, and then the lack of diversity is associated with obesity, inflammatory bowel disease, obesity, diabetes, and many other conditions.

So Kiran Krishnan is here to enlighten us on some of these topics. And he’s a research microbiologist who’s been involved in a dietary supplement and nutrition market for the past 20 years, including hands on involvement in university research.  Kiran is a co-founder and the chief scientific officer at Microbiome Labs, a leader in microbiome and probiotic research. He’s a frequent lecturer on the human microbiome at Medical and Nutrition Conferences. He’s currently involved in over 18 novel human clinical trials on probiotics in the human microbiome. And he’s on the scientific advisory board for seven other companies and he’s published clinical trials in peer reviewed scientific journals.  So Kiran, we started off the discussion by me asking Kiran about what are some of the most important components to a healthy microbiome. And he talked about one thing that’s important is that there are certain key stone, super important species. He talked about akkermansia muciniphila, he talked about faecalibacterium prausnitzii, and he also talked about some of the ratios like the Firmicutes to Bacteroidetes and the Prevotella-to-Bacteroides ratio.  And now as the discussion starts, he’s talking about how the microbiome positively affects the immune system and how these microorganisms actually help with the maturity of our immune cells?  So with no further ado, we’re going to go right into discussion with Kiran Krishnan speaking. And I hope you really enjoy this, even though we missed the beginning, there’s some amazing, interesting information that he’s sharing with us.

Kiran:                    Maturation and proliferation come from the microbiome predominantly, right? So we have certain amount of machinery to make immune cells but we’re making baby naive immune cells. And it’s the role of the microbiome to train and mature, and then proliferate those immune cells in order for them to actually do their job. The analogy I give is like, we can make children that are immature and small and tiny, and we can’t send our, 15-year-old without any equipment to war, right?  If we want them to go out and defend the country they have to go through basic training and all the training, get the equipment and all that to actually be able to go and fight. So what our bone marrow and what our thymus is doing is actually producing children essentially, which are ineffective at fighting for us. And then our microbiome trains those soldiers. So without the function of the microbiome, you would not get maturation of those T cells, B cells and macrophages and so on.  And this has been studied extensively in no biotic mice, for example, the germ free mice, right? When you rear a mouse germ-free meaning it has no microbiome, you see very poor and complete attenuation of the development of their immune system. In fact, the amount of immune tissue in the gut, which is where about 70, 80% of your immune tissue exists, that becomes attenuated dramatically. So you don’t even develop all of that immune tissue in the gut.

                                A second part to that first claim is a lot of the energetics that the roving immune system requires in order to continuously circulate through. And then when they find something, attack it, eat it up, use the compliment system to neutralize it or the natural killer cells and their ability to use nitric oxide and all the super oxides, all of that equipment and energetics come from the microbiome.  So the microbiome produces the equipment for our defense cells to kill off viruses, bacteria infected cells and they produce the energy, like butyrate is a really important energy source, macrophages and dendritic cells who are circulating around trying to protect us. So again, that relationship is so intimate and the immune system would cease to exist and function if it wasn’t for the microbiome. Then the claim about the neighborhood watch, I’ve been trying to eliminate the importance of the microbiome for people using what I think are sensible analogy.

                                So think about inside the body, everything is covered by a mucosa. So we used to say that the skin, the outer skin was the largest organ in the body, it’s a huge barrier, it’s protecting us, but the skin is only about two square meters in surface area. The mucosa on the inside is about 400 square meters. So it is way larger in terms of area than the skin. And most people here are from the US, so translation of 400 square meters is it’s close to 4,000 square feet.   So imagine an apartment or a house that’s 4,000 square feet, we’d be pretty happy in that space. All of that is packed in as our mucosa. So a virus or bacteria basically enters through a mucosal layer, whether they’re going into the eyes, nose, mouth, they’re going in through your genital tract or even through the skin, they’re going to enter the mucosa.  So that’s where all the sampling and action takes place. Now, in this mucosa, you’ve got about 40 trillion microbes that already lived there, right? So imagine you’ve got 40 trillion microbes covering the space where new pathogenic microbes enter and it’s a job of the immune system to somehow sift through all of the 40 trillion to find the one or two that might be causing you a problem.  And in fact, to survey those 40 trillion or so microbes that already live in your system, you’ve got about 200 million immune cells that do that job, right? So it’s a 200,000 to one ratio.

Dr. Weitz:            Wow.

Kiran:                    It’s an absolute mind-boggling feat when you think about it. The analogy I give is imagine you’re at a music festival and it’s good to imagine it because it’s never going to happen again, or at least not for another year or more. But imagine where like a really fun music festival and it’s in a pretty big field and there’s 200,000 attendees there. So that’s a lot of people, it’s a big event.  Among that 200,000 attendees, you get word that there may be five that are potentially egregious, that could be toxic and somehow hurt some of the other attendees could bring all kinds of paraphernalia and drugs and really kind of cause issues. And you are the lone security guard in that sea of 200,000 people and it’s your job to find those four or five potentially harmful attendees, it would be an impossible task.  The only way you could do it is if the other 199,995 attendees are also keeping eye for you being a neighborhood watch and can radio you, should they see anything suspicious? That’s the only way you can serve it, that’s what occurs in your body. The sea of microbes that predominate cells, all of the cells in your body, they are the neighborhood watch for their immune system when they sense a new pathogen entering a system, whether it’s in the lung with the along microbiome or your sinus cavities in your gut, anywhere else in the body, the microbiota, the resident microbiota in that space signals to the immune system that something is going on, here you got to come pay attention, right?  That’s the only way the immune system can survey this amazing surface area that is already covered with potentially harmful microbes.

Dr. Weitz:            Somebody asked the question, I guess you had mentioned a Prevotella-to-Bacteroides ratio, and maybe you could explain what that is and its importance.

Kiran:                    Sure. Yeah. And what’s interesting, another interesting thing we’re seeing prevotella and bacteroides are also two file up. And this is not bacteroidetes which is the one we were talking about with firmicutes, this is bacteroides, so it’s very close in name but slightly different. What we’re seeing is that when people consume lots of meat and protein, you tend to start to lose prevotella and then you start to increase bacteroidetes. And again, not to confuse me, but this is not the bacteroidetes we were talking about earlier, this is bacteroides.  And what we start to see in this pattern is the formation of insulin resistance. There’s two things that occur, one is the inability to balance blood sugar levels, and then the second thing is the inability to build glycogen storage. So people that tend to have really low prevotella and much higher bacteroidetes tend to have blood sugar dysfunction, and then also tend to have, like get really lethargic and tired at some points of the day they can’t produce the energy.  This is really profound because they’re seeing this more and more in the Western world. And when we do the biome effects test, this is another one of those functionalities that we measure. What’s interesting about when I’ve done a consult, so one of the things that we offer for all of you guys that you should know when you start getting the test done for either yourself or your patients, we offer consults with either our biome effects clinical director, Dr. Sam Molt or we’ve got groups within our learning and development team that will go over the test with you so you get familiar with it, right?   But for some practitioners who are friends of mine, I’ve done it myself and they’ll send me their patients test beforehand and I’ll tell them, “Don’t tell me anything about the patient,” in the first few minutes I’m talking to you, I want to guess what they’re coming in to see you about, just from looking at their tests. And so far, I think it’s been five out of five that I’ve been able to guess.  And the last three have been this same issue like, are they having glucose metabolism issues? Which they may not know because they’re not necessarily pricking their finger and testing the glucose levels because they’re not diabetic. But the way it cycles is it causes massive drops in blood sugar levels in the middle of the night. Some of these people awakened because of that, they get a panic response, during the day, they have real big swings in energy levels.  And then when you encourage them to do a 24-hour glucose and insulin cycle, you see these massive swings up and down throughout the day, and they’re not diabetic, their A1C is may be a little bit of elevated but they’re not completely diabetic. And all of them have this diminished prevotella and really high bacteroides.

                                So that’s another function that dictates like, and it doesn’t have to be obese, like the last two people I talked to about this one was 110 pounds, so she’s not in any way shape or form obese and never has been. But because of multiple rounds of antibiotics and because she has SIBO like condition, she’s basically completely eliminated plant-based foods and she’s very high on the protein and that starts to cause that dysfunction.  So that’s another one that we tend to look at what people in metabolic dysfunction is, how do we bring back that ratio, get that akkermansia up. Between those two things, you’ll start to see a big change, we have a study publishing just on that recently, I’m sorry to keep running on about this, but we have a study publishing recently where we took obese individuals, so these are people, the BMI of 30, 30 to 31 somewhere around there.  So they’re not morbidly obese but they’re overweight. And we did full DEXA scans, we were looking at visceral fat, subcutaneous fat, we were looking at a whole bunch of metabolic parameters. There was a 90-day study, right? And what we did is all we added into their system, and this was a placebo controlled study was a little bit of a prebiotic that we know increases Akkermansia and bifidobacteria as well and then the spores, the spores that stopped the LPS, the leaky gut.  It was a 90-day study, we told them not to change anything about their diet, don’t add any exercise in that they weren’t normally doing. So they’re continuing all of the behaviors they normally continued that kept them overweight and kept them gaining weight.  And what we saw in that 90-day period with no changes in diet, exercise or anything was in the group that was getting that probiotic, prebiotic combination. We saw a 38% reduction in visceral fat mass, and that’s a really dangerous fat around the organs. We saw some weight reduction as well but weight is just not a great measure of metabolic activity, but doing the DEXA scan we saw real fat being lost quite dramatically. And we also saw an inching up of their lean mass, so they were putting on some lean body mass, and then we saw all of these beneficial metabolic changes as well.  So that just goes to show without even diet and exercise and those other aspects of it, just shifting the microbiome we can start shifting their metabolic profile. And then if you add diet exercise and all that to it, the results can be quite profound.

Dr. Weitz:            That’s amazing. Can this be used as an adjunct to working with a patient with diabetes or prediabetes?

Kiran:                  Absolutely, yeah. In fact, we’re starting a diabetes, a prediabetes study with UCLA right now on the same principles but in this case, we’re going to have the probiotic, we’re going to have components of the prebiotic but we’re also adding in bitters, in fact berberine. And one of the important…

Dr. Weitz:            Natural Metformin.

Kiran:                  Exactly, completely natural Metformin. And one of the things that’s really interesting about it and the professors that we’re working with already have published on some of the mechanism of action of bitters, we have bitter receptors right in the upper part of our GI, right where the stomach dumps out, and then in the lower part of our intestines as well, those bitters trigger things called peptide YY GLP-1, these are transducers or transmitters that actually improve leptin response, increase fat burn by increasing something called cyclic AMP.  So it stimulates all of the cells in your body to start burning fat for fuel, it improves gastric emptying and motility in the gut, and then it dramatically improves the insulin sensitivity as well. So simple thing like that and we know that, you guys all know that prediabetes is going to be one of the biggest health pandemics in the next couple of decades because not only do we have so many diabetics right now in the world, we have four times as many prediabetics as we do diabetics and almost 80% of them are going to become diabetics over the next 10 years.   And when they all become diabetics, morbidity and mortality for all of the chronic conditions increased dramatically with diabetes, including COVID right? The mortality rate for diabetes with COVID is seven-fold, seven times higher than a non-diabetic. And that’s scary because in the US we have lots of adults and even some children who are diabetic.

Dr. Weitz:            Absolutely, get into discussion with somebody about COVID, they go, “Well, it’s only people who have these high risk factors.” And when you look at the American population you’re talking about obesity, we’ve got 70% of people are overweight read in the number of people with diabetes and heart disease and autoimmune or immunological compromise. And then you add some cardiovascular conditions, you’re talking about a huge percentage of our unhealthy population.

Kiran:                  Per CDC data, 60% of US adults have at least one of those chronic illnesses falls under the high risk category, right? Hypertension, diabetes, cardiovascular disease, obesity, 60% or more. So yeah, we have a tremendously high risk population in general which goes beyond just the age factor.

Dr. Weitz:            Right. This should be one of the messages we get out of this pandemic crisis we’re in is we have a really unhealthy society and we’ve got to get do something about improving our overall health.

Kiran:                    Yeah, absolutely. That to me was, I’ve done lots of interviews so far on COVID and the pathology and so on. One of the first interview I ever did, I said, my point was that there is a silver lining here because when you look at this virus it’s developed the capability of taking advantage of our vulnerabilities. And that vulnerabilities, the ACE2 receptor, the ACE2 receptors is expressed in cases of chronic low-grade inflammation, which is a epidemic in our society.  And this pathogen has figured out a way to take advantage of that vulnerability. What it tells us is that we should have resilience against these kind of things, and many people do but it’s really painting a picture of how vulnerable we are as a population. Because the thing is, we’ll get through this one and it’s not as bad as it could be as other viruses could be. It doesn’t have the mortality rate as MERS did or the first SARS did, or Ebola does, it doesn’t have 15, 16% mortality rate.  But somewhere around the corner, that’s another one of these coming around and it could be as infectious but 10 times the mortality rate. Again, taking advantage of our vulnerabilities, so to me that is really the silver lining in all of this is like, we should realize that as a population, we are ill equipped to handle something like this only because our systems are vulnerable. Our immune system can take care of this kind of virus very easily if we are allowing it to function in the right way.

Dr. Weitz:            So, bottom line for patients who are overweight, a couple of people asked questions about this, what can we do now to help in terms of the microbiome to make it easier to lose weight?

Kiran:                    Yeah, so really important practical things and this is exactly what I do too and I’ll go through swings with my own weight, and I actually just saw my sister the other day and she’s like, “How did you lose?” I leaned down over the last two and a half weeks because I was like, “Yeah, I’m getting a little too pandemic chubby. So I got to lean down.” So what do I focus on when I do that? And what I think will be really effective to start stoking people’s metabolism. Number one is the fasting, right? If you can add in some intermittent fasting and yes, it will be hard for certain people to go 14, 15, 16 hours right off the bat, but you could totally taper them up.  If they can go 12 hours without eating 8:00 PM to 8:00 AM for the first week, have them do that next week, go 8:00 PM to 9:00 AM, start pushing them, right? If they can get to that 14, 15 hour range metabolic changes already start to happen. Akkermansia levels will increase, the microbiome diversity will increase, bifidobacteria levels will start to increase. Those will be profound changes for their microbiome.

Dr. Weitz:            So why will our microbiome flourish when we don’t eat anything?

Kiran:                    Yeah, so that’s a really important question. So part of it is about food utilization. So if you think about it, every meal that you eat takes about depending on your system but it will take eight to 12 hours before you deprecate that part of the meal, right? It takes that long to go through your system. Now, the way the microbiome is organized is there are many community structures that feed off of one another, there are primary digesters of the macronutrients that you take in, and then they produce secondary metabolites.  And then those secondary metabolites metabolized by another group of bacteria that then produce tertiary metabolites. And then another group of bacteria can eat those and produce another set of metabolites. So that’s part of the reason it takes so long, especially when the food gets to the colon for it to start passing through and all of the digestion that occurs in the colon to happen, or at least a fermentation to happen.  And the thing is when you have primary digesters, let’s say bacteria A is a primary digester of the carbohydrates that enter in as food products, right? Bacteria A seize the carbohydrates, it becomes really active and it starts digesting those carbohydrates.  When it is active it suppresses the growth and the functionality of vector B, C, and D, right? So it starts metabolizing and then it produces all of these secondary metabolites, its primary food is gone so it becomes, it starts lowering its activity. Then bacteria B jumps on these metabolites and starts producing bacteria B gets to flourish to a certain degree. When its primary food source has gone it pushes goes down the row, bacteria C starts to flourish.

                                So when you give your body time to digest the food and ferment the food completely, you actually get to flourish lots of groups of bacteria. What tends to happen is that bacteria A is digesting its primary food, and then that food is gone then it kind of takes a metabolic risk, bacteria B starts to digest the metabolites. All of a sudden the primary food comes back in, then bacteria A start getting active again, which suppresses this next group of bacteria.   So it’s this staircase type of metabolic process, hopefully that’s… I know it’s a little abstract to think about but hopefully that is understandable. So when you give your gut time to actually process all of the food, you get complete fermentation and digestion, and that completeness in fermentation and digestion allows more and more microbes to flourish that utilize different parts of the meal and diet. So that’s a really important thing to understand.  So if we just continuously keep feeding, we’re really only supporting certain categories of bacteria, others get suppressed, they don’t ever have a chance to flourish.

Dr. Weitz:            Would it be even better to fast for three or five days?

Kiran:                  So there can be some diminishing returns if you go too far, and we need more studies on that. There’s a lot of great studies on intermittent fasting, there’s some pretty good studies on 24, 48 hour fastings, but there’s very few studies so far in longer fast, like six, seven, eight days.  I would think that there’s a point in most people’s microbiome where you start losing the benefit and start gaining some dysfunction from that longer fast. It’s probably less typical for us as a species to go that long without eating than it is to go 14, 15, 16 hours. Our ancestors routinely went that long without eating because they didn’t always have food at the ready, they would wait for the hunger pangs to kick in, to motivate them to go out and start looking for food.  So I would say you push that, the longest I’ve ever done is about 30 hours. And I could tell for me, and I intermittent fast every day, pretty much and have been for the last three, four years. That 30-hour period was kind of, I could feel was not really producing much more benefit for me. So then I had small food, small meals, I started feeling great.

                                So that intermittent fasting becomes really important, that’s one of the easiest things to implement. If you could start getting some prebiotics into them, the illegal saccharides particular, the ones that we use is in that Mega Pre, the fructooligosaccharides that come from Kiwi especially are really important for increasing akkermansia and increasing bifidobacteria. Bifidobacteria is another group of bacteria that are inversely correlated with metabolic dysfunction.   Now, the question is, if I take high doses of bifidobacteria, will I achieve the same thing? In fact, you don’t, you don’t see studies that show high dose of bifidobacteria having metabolic impact. There is one bifidobacteria strain called Blp1 I think that when it’s dead will actually help induce some metabolic improvements. That’s again, one of those special cases where there’s something within that bacteria strain that when it’s killed and it opens up will actually provide a metabolic benefit.  So the prebiotic will do a lot more to increasing your endogenous bifidobacteria, giving that metabolic support. Using the spores can be very powerful to megaspores because it stops that leaky gut. So you want to stop the leaky gut, you want to use a prebiotic to increase akkermansia and bifidobacteria, you want to add in a degree of fasting, and then if you can get them to take additional things like resistant starches, that’ll help because one of the really important metabolites in the microbiome that controls body weight controls metabolism are short chain fatty acids.  Like butyrate is so important for metabolic health, butyrate is one of the main signals that turns on the cyclic AMP process that causes all of your cells in your body to burn fat. Butyrate also helps with the leptin response and the satiety signaling, so they’re really, really important. If you can just increase short chain fatty acids, you’ll start to see changes in weight.

Dr. Weitz:            Is it beneficial to take supplements in butyrate and short chain fatty acids?

Kiran:                   Yeah, that’s an interesting component of butyrate therapy because what they found is that butyrate is really useful in things like colorectal cancer or really severe colitis when you have inflammation in the large bowel, but when you take it orally, it doesn’t seem to help. So what they’ve started doing in hospitals is they all still do butyrate enemas instead to get it into the large bowel, so it actually has that function. So there’s a big question of whether or not orally supplemented butyrate actually will get to the large bowel where it needs to be, or does it get dissipated and absorbed in the small intestine, or maybe even the stomach.  So that’s the part that’s unsure, increasing your endogenous butyrate is not hard at all. Our study that we published last year showed that when we added the prebiotic and the probiotic in, we increase butyrate production by 150%.

Dr. Weitz:            One of the tricky things about using prebiotics since a lot of us have patients with SIBO and they’re very sensitive to prebiotics and fiber, and it tends to flare them up.

Kiran:                    Yeah. That is problematic. So we say with the prebiotic that we use, which are highly specialized oligosaccharides designed to make it to the large bowel so they should not have a lot of bacteria in the small bowel that can ferment it to create the gas and distension, but we tell them to test it. They can go as little as like an eighth of a scoop, mix it into a jug of water, shake it up and kind of sip it throughout the day.  We’ve even had some people that go as far as not being able to take it in orally, so then they do prebiotic enema to get some oligosaccharides into the large intestine, which is where the bifidobacteria acclimates are all there, so you can do a retention enema with the prebiotic mix. So that’s one way to start getting it in there. If you can, because if we can’t do it this way, you might try the other way.

Dr. Weitz:            So it’s interesting as some of these probiotics that are dead are actually more beneficial, myself and I’m sure a lot of the practitioners who are listening probably have probiotics in our refrigerators at our office, which we’ve made a big deal out of making sure that they will refrigerated the whole time thinking that we’re providing an extra benefit, because if the temperature gets too high the bacteria will die and these are more potent. Are we really helping our patients?

Kiran:                    Yeah. No, all of that work to try to keep it alive in the room is really all for nothing because the moment they hit 98.6 degrees in the body and pH a one and a half or something going through the stomach, they just obliterated. And we’ve tested that, we’ve tested 40 or so of the top retail probiotics and even the probiotics in the health space and all of them die going through the gastric system.  So the key is then finding ones that have shown studies that the dead versions are actually beneficial. And that’s specialized. Like for example, with rhamnosus GG, when you kill it and you administer it, it has all of these benefits but regular rhamnosus, the generic version of rhamnosus wouldn’t have that same effect.  You kill it, it’s just dead and it’s not really doing anything, you’re going to poop it out 12 hours later. So the metabolic response modifiers, the types of strains that when dead can have specific metabolic effect are very specialized to those subspecies of the strain, it doesn’t translate to the wild type version of this strain.

Dr. Weitz:            With respect to intermittent fasting, somebody asked the question, do you think it’s more beneficial to skip breakfast or to skip dinner?

Kiran:                  Ah, great question.

Dr. Weitz:            What do you think it matters?

Kiran:                  So yes, there are at least two studies that came out that showed that if your fasting window is basically from the afternoon till the morning that, that actually has a bigger impact on weight loss than the overnight to the afternoon fast. So if you’re fast with somewhere around like 12:00 or 1:00 PM all the way until like 8:00 or 9:00 AM, that seems to have a more profound effect on weight loss and fat loss than the overnight to noon fast.  Now that being said, the overnight to noon fast also has benefit, right? The problem I have, and I can’t do the other way around just because dinner becomes such a big important social thing. Whether it’s business related, it’s family, it’s friends, so it becomes really hard to skip dinner, just from the social side of it.  And so that’s why for me, I’ve not been able to do that kind of routine, I can do the skip the breakfast very easily. Now, the other advantage for me in skipping breakfast is that I can do my workouts in the morning and doing your workout in a fasted state really amplifies your growth hormone levels, and that has a huge metabolic impact as well. If you can fast through the late afternoon and evening and then throw in a workout sometimes somewhere in that evening period, that’s fantastic but a lot of people find it very hard to skip dinner. There are too many social things surrounding dinner.

Dr. Weitz:            Yeah, actually for me it’s easier because a lot of times I’m busy with patients and I don’t really have time. And a lot of patients want to come in after work, and so rather than eat late, a lot of times I’ll just skip dinner just because it’s easier.

Kiran:                    Yeah, that actually has a bigger impact metabolically than skipping breakfast. But if you can’t skip dinner, then skipping breakfast will help as well.

Dr. Weitz:            Is there ever going to be a probiotic, protozoa or fungus?

Kiran:                    Oh, fungus yes, so we already have saccharomyces.

Dr. Weitz:            Yeah. That’s true. That’s true.

Kiran:                    Well established. We will have, yeah, I believe we will, we’ll have potentially things like amoebas, we’ll potentially have protozoas, we may have organisms that we don’t even know exist yet. When prions became a thing with mad cow disease 20 years ago I was actually still in university and it was so interesting to see my immunology, microbiology professors like losing their minds as to what the hell is this weird alien thing.  Because imagine viruses are really fascinating all themselves, because they’re not even living creatures, viruses are technically not alive because they cannot create any sort of metabolic effect on their own, they can’t reproduce on their own, they’re just like a fatty envelope with RNA or DNA sitting in it or protein envelope with RNA and DNA sitting in it and just floating around.  And it just has this mechanism that allows it to bind to certain things, inject its RNA or DNA and hijack the cell. So that in itself is fascinating, then you think about a prion which doesn’t even have that sophistication, it’s just a strand of protein. And this strand of protein, it just so happens the prions that we know of right now are really devastating that’s what created the mad cow disease. So it creates the encephalitis, so basically bus holes in your brain, but it’s this tiny little thing of protein and there’s like no functional way of killing it, that anyone knows it can withstand all kinds of heat, it can withstand all kinds of acid, it’s really mind boggling.

                                So we may find organisms that we don’t even know exists right now that are really important therapeutics within our system. I think the next one’s beyond bacteria and fungus are likely going to be in the parasite family, the parasitic family, just because there’s so much work being done with that already in a fringe world, the helmet therapy and all is considered by many to be like really weird. But the data’s good and they’re showing real progress in certain parts of the world in treating allergies.  And when something like allergies becomes more and more of an epidemic in our country, we’ll start having to go towards those types of therapies.

Dr. Weitz:            Don’t we know that societies where worms are endemic have much lower rates of allergies and asthma and autoimmune diseases?

Kiran:                    Yep, absolutely. And there’s a double edged sword that there are certainly some worms that will then create all kinds of other problems down the road, but absolutely. And I think in part, what that speaks to, to me is it speaks to our disconnect from the natural world. So we’ve evolved to have a pretty intimate relationship with all of these organisms in the natural world.  And the more we disconnect from them, then the more susceptible we become because we’re missing key links to our function and our phylogenetic tree. And so understanding what those things that we’re missing are, and putting it back into our system, I think will be a really big part of microbiome therapeutics moving forward. We are engaged with lots of very big companies in the world and massive companies. What’s exciting about it and then many people are turned off by massive companies. I totally understand that, but massive companies like Nestle, for example, who’ve spent their whole lives feeding sugar to people and sugar to kids.  When you look at their new focus, they’re saying we’re going to de-invest from all of our candy sugar stuff and focus on health wellness and microbiome science. There are companies like Chris Hanson and ADM, Archer Daniels Midland, these are massive billion dollar companies and they’re all seeing the writing on the wall.  I get calls from these kinds of companies and I talk to the leadership within those companies, they’re all trying to figure out how do we focus and hone in on the microbiome. They all see the microbiome as like the big thing over the next several decades to really improve health and humanity. So it’s really exciting. I think we’ll see lots and lots of innovations.  One of the areas that we’ll start to see more and I’m always advising companies to disrespect is the microbiome modulation. We’re getting to understand more that A, if you have high risk for certain types of cancers, you have certain type of microbiome, there are certain features within your microbiome that are characteristic of that condition.  So as we can better monitor and understand and test for those features, we can hopefully modulate features as we go along to fix people’s ecosystems in a very precise way to improve their overall outcomes.

Dr. Weitz:            How does the microbiome change with diet? You mentioned that if we eat heavy meat diet, that that’ll influence the diet one way. And right now in the diet world, we have these really extremes, we have people eating meat only the carnivore diet, we have people only eating vegetables and everything in between.

Kiran:                    Yeah, absolutely, and that to me is one of the scary things in the whole world of wellness and functional medicine is the adaptation of real extreme and exclusive diets. We’re just not designed to function that way. I think one of the things that makes the human species really unique in the animal kingdom is our incorporation of a really large diversity of microbes into our system, which really gives us strong omnivore qualities.  And that omnivore quality actually is a big part of our evolutionary ascent up the ladder, because if you think about other species that we essentially we would be competing with that are obligate carnivores or obligate herbivores, they are very susceptible to environmental and other changes. If you think of a lion is as powerful and ferocious as a lion is, if there’s a drought and the wildebeest levels are low, or its main prey, the lion’s going to starve to death.  If a human is in that same drought, we can go and dig for roots and tubers, we can eat insects, we can eat plants, we can eat rodents, we can eat a whole bunch of different things and survive through that. The same with on the opposite end with the lions prey, the wildebeest was an obligate herbivore can only eat plants. And so if those plants are dead and the Savannah is dry, they’re going to die, they can’t just go and eat insects and they can’t just go and catch a muskrat and eat it.  So we’ve got this really unique capability of producing tools using these hands, we’re upright, we’re [bi-pi-to 00:44:50], we can move long distances and we can eat lots of different things. Our microbiomes are really designed to do that. So the moment we go to a very exclusive diet especially if we do it for long period of time, it’s going to have a long-term negative consequences. I think short-term, like if you’re really trying to change your metabolism and you’re going to go keto for a short period of time, that could be totally fine.

                                Because one of the big benefits of keto is you’re actually eliminating sugar, and that to me is where you get a lot of the benefits of keto. So you can go keto for a short period of time, but then get those vegetables and the plant-based foods back into your diet. You also shouldn’t be going vegan forever and not getting any complexity in your amino acid profile and so on.  So to me, it’s really about much more of a balanced diet and I think that’s how we’re evolved to exist.

Dr. Weitz:            It’s a really big current trend in the Functional Medicine world as you mentioned to talk about the dangers of eating lectins, the dangers of eating meat, because everybody’s going to get heart diseases. And it seems like everybody’s looking to the specialized diet that subtract certain types of foods as the answer to fixing people with certain types of problems.

Kiran:                    Totally, yeah, and that’s a problem because we’re not talking about enough is how do you build a resilient microbiome that handles all of these things? I mean, you talk about lectins, one of the types of diets have tend to a lot of lectins is the Mediterranean diet, they eat lots tomatoes and all that. It’s one of the healthiest diets ever, there’s more studies on the Mediterranean diet than any other kind of diet and we’re talking huge studies and we’re talking 50,000 patients longevity studies on it.  So clearly it has benefit and there’s a way of eating it and there’s a way of preparing it, and the people’s microbiomes are resilient to handle it. We have amazing capability of neutralizing things that are not actually good for us, the anti-nutrients people talk about. If we have a resilient diverse microbiome, we can absolutely neutralize those, we can neutralize glyphosate in our gut, not to say that we should have glyphosate in our food, but just to show the ability the resilience of our microbiome to protect us.  So to me and people always ask me, like what is your focus and goal with your microbiome? What do you try to do? And to me, my goal for health is about being resilient, because I don’t want to have to live a really structured control life in order to feel good. Like you talked a lot of people and you go, “How you feeling? How’s your gut doing?” “Oh, I feel great as long as I don’t eat this, this, this,” and they’d rattle off 17 things. “And I feel great as long as I don’t do this.”

Dr. Weitz:            That’s one of the biggest issues of a lot of us in the functional medicine world, we have these patients that come to see us for these severe gut problems. And gluten was a problem, they cut out gluten, they cut out dairy, they cut out this vegetable, we cut out that vegetable, we cut out, they went on a low FODMAP diet, so they cut out all the cruciferous vegetables and then they found out about the next category of foods to cut out and they come in and they’re eating two or three fruits and [crosstalk 00:48:19] anything.

Kiran:                    Yeah, absolutely.

Dr. Weitz:            And your gut has no tolerance to be able to eat these different types of fruits.

Kiran:                    And the thing is the elimination doesn’t do the healing, and that’s the important part that people need to understand. And in fact, speaking of gluten, there’s a really good study on this, and I think it’s fine for people to avoid gluten if they want to reduce the risk for that permeability. But you cannot avoid carbohydrates, you cannot avoid fiber because one of the big studies on gluten they showed that in the first year of gluten intolerant people going on a gluten free diet, their mortality rate almost doubles.

                                And you would think like, wait a minute, that makes no sense. So these are gluten intolerant people, meaning when they eat gluten, they get all this inflammation, they get all this intestinal permeability. Why is it when they go on a gluten free diet, does their mortality rate increase in that first year? And then it tapers off a little bit in second year, but in that first 24 months, their mortality rate almost doubles.

                                So the reason for that is in Western society and in our culture and our society, more than 85% of our fiber intake comes from wheat. So you’re getting all of this fiber, despite getting the gluten that’s also harming you, but you are getting the fiber component. So then also then you eliminate gluten and most people who eliminate gluten we’ll replace it with proteins and fats.

                                So you’re taking out fiber completely out of your diet and then you’re replacing it with fats and proteins. So now the expectation is what I removed the offending thing my gut should be healing. As it turns out, when they look at these individuals, the gut doesn’t heal at all, it stays susceptible and because you increase the intake of other things like fats that can increase endotoxemia, you are actually increasing your risk for other conditions.

                                So what you should do in that case is eliminate the gluten, that’s fine, but you have to replace it with other non-gluten sources of fiber and so on, because that is what drives the repair. Just eliminate, eliminate, eliminate is not going to cause a repair. We need to maybe temporarily eliminate foods that are clearly offending your system, but then make sure we’re getting things in there to provide some diversity, provide some resistant starches, some fiber, all of those things are really important.

Dr. Weitz:            Is there any way that people following a carnivore diet by eating the entire animal, every part of it. Is there any way they can have a healthy microbiome?

Kiran:                    So if they’re eating the entire animal then potentially, and that would include intestinal content. And we see that in hunter-gatherer tribes, right? So in the hands of tribe in Tanzania and the tribes in Papua New Guinea, when the hunters go out and they catch their prey like in, I think it’s in the one in Tanzania, the porcupine is like a delicacy for them.  And they’re not doing this often, even though they’re called hunter-gatherers, they hunt way less than they gather, they gather a lot more. But they do go out as hunting parties. One of the first things they do when they capture the animal, is they cut open the intestines and then they eat the intestinal content. Most of these animals that they eat are ruminant to certain degree, they’re picking up seeds and nuts and all that from all over the place.  They’re fermenting it in their guts and if you eat that intestinal content, you’re getting all kinds of amazing carbohydrates and resistant starches and so on. So you likely can, if you’re eating connective tissue and you’re getting different forms of collagen, you’re getting some of the glycoproteins from connective tissue, if you’re eating organ meat, if you’re eating brain, if you’re eating liver, you can get diverse enough macronutrient to maintain diversity within the diet.

                                But the unfortunate thing is in the US, when you’re saying, when someone’s saying the carnival diet, they’re just eating a steak and that’s about it. And I’ve met a lot of people like that. I mean, I get to speak at places like the paleo effects like I spoke last year. I met so many people at that show they go, “Yeah, I’ve gone full carnivore.” I’m like, “Okay, what do you eat?” “I eat two steaks a day. That’s it. And sometimes I’ll have a dollop of butter on the steak.”   And I’m like, “Okay, well, that’s not a good thing necessarily.” And also it depends on your microbiome in large part, because if you look at it, one of the ill effects of meat metabolism is the formation of TMAO. And there are certain types of bacteria that produce high levels of TMAO.  If you happen to be one of those people that have high TMAO producing bacteria, and you eat lots and lots of meat, it’s going to cause heart disease. There’s no if, and’s or but’s about it, the studies on TMAO are pretty clear. But if you happen to have very low levels of those bacteria, you can sustain this for a period of time until those bacteria grow because you’re giving it so much meat. So that’s another kind of catch that whole thing is what happens to the food when it enters your system.

Dr. Weitz:            I know this is kind of going off our topic, but I love to get your take on this TMAO thing, because those of us who are working with patients with cardiovascular risk factors we have found that certain supplements, like L-carnitine, incredibly helpful for mitochondria, for the strengthening the heart, and all need super important nutrients for liver health, for brain health.

                                And it’s really hard to, it doesn’t really seem to make sense, it doesn’t fit with our experience that patients who are eating foods or taking supplements with choline or L-carnitine are really putting themselves at increased risk of heart disease.

Kiran:                    Yeah, because of the potential of TMAO.

Dr. Weitz:            TMAO.

Kiran:                    [crosstalk 00:54:28] of TMAO.

Dr. Weitz:            Yeah. So I think the answer to the TMAO question is more about making sure we have a healthy microbiome than about not consuming L-carnitine or choline.

Kiran:                    Exactly. Yeah, because again, it comes back to that balance issue. So one of the things that we test in the biome effects tests is TMAO producing bacteria.

Dr. Weitz:            By the way, if everybody’s not familiar with this, why don’t you explain that Microbiome Labs is offering a stool test. And how can practitioners find out about this?

Kiran:                    Yeah, absolutely. So  the test is called biome FX, like the letter F and the letter X. It’s a whole genome sequencing test, just to give you a little bit about the difference between what we’re doing and what you have already experienced in the market. We started seeing a lot of issues with accuracy in stool testing. One of the big problems is most of the stool tests, in fact, all of the ones you’ve used use something called 16S sequencing, 16S sequencing if you’re not familiar with sequencing information, 16S is like taking random Polaroids of a single of parts of someone’s body, and then trying to piece it together and identify who that person is.   So it’s a really low resolution inaccurate way of identifying species level for the bacteria in your system. So it tends to have a very high error rate. And what the companies aren’t telling you when you look at your test results, and they’re showing certain bacteria that they’ve picked up, they’re not telling you that they have an algorithm in their bioinformatics pipeline that makes a prediction that this is likely the bacteria we found, it’s not absolute at all.

                                In fact, all of the big microbiome research organizations, the American Gut Project, the Human Microbiome Project have come out and said, you cannot use 16S to identify bacteria to the species level. So we saw that as a big problem, and so we wanted to make that in itself a change. So we started working with the top lab in this space called CosmosID on developing a whole genome sequencing test, which means that we actually have to sequence in bacteria’s entire genome from end to end in order to identify, we’re not looking at just little snippets of the bacteria.  So it’s a far more accurate, it’s 99% or more accurate. So you’re getting the most accurate species level information. Now, why is species level information so important? Well, because like we’ve been talking about with the microbiome, it’s really about what does that total ecosystem look like. Outside of the keystone strains you can’t necessarily just pinpoint singular bacteria and their levels as being problematic because everybody at the species level has most of those bacteria different frequencies.

                                And so what we look for is we look for really important trends, well-established trends because in the microbiome, one of the things I say is, it’s not who’s there, it’s who else is there, right? The function of certain bacteria are dictated by what other bacteria are in that environment and what are all of their relative abundances? That’s where the mapping becomes really important. So we can map out functionalities within your microbiome by understanding the species level, relative abundance data, and the best researchers who have done this is led by Rita Colwell.  Rita Colwell is the most decorated scientists in this whole world of microbiome mapping, she’s got 60 honorary degrees including a couple PhDs that she first earned and then 60 other degrees, she’s published 800 papers in this space in peer reviewed journals, which is a mind-boggling amount for any researcher doing work.

Dr. Weitz:            Isn’t it the case that the PCR, quantitative PCR testing is actually more sensitive and specific for picking out organisms? And if you go into a hospital and they suspect CDF, they’re not doing a whole genome sequencing stool tests, they’re doing a PCR test, right?

Kiran:                    They’re doing a PCR test and that’s important because the relative abundance of that pathogen compared to all of the other DNA may be really low. So for them, in order to find that bacterial DNA or viral DNA in the case of COVID or any other virus, they need to amplify that bacteria viruses DNA. And that’s what PCR does, the polymerase chain reaction amplifies the DNA. The problem with doing that in a stool test to try to understand your microbiome is it artificially amplifies the volume of that particular species DNA.  So it gives you erroneous relative abundance numbers, so we need to be able to get really accurate relative abundance numbers. And the thing is that the sequencing work takes longer, that’s another reason why, if you’re ill with something, they’re trying to figure out what is making you ill, they use PCR because it can be done pretty quickly. You can get PCR done in an hour or 35, 40 minutes.

                                The genome mapping using full metagenomics takes much longer than that. However, CosmosID, the lab that we’re working with are the only lab that are FDA approved to do whole genome sequencing for pathogen identification, because now we’re starting to see some issues with PCR, even in pathogen identification because you might go to a doc, or you might have diarrhea and your doctor, your infectious disease doctor gastroenterologists might say, “You might have C diff, this looks like C diff. So let’s take a stool sample and then we’ll look for C diff.” But they were using the PCR, they will amplify the C diff DNA and they’ll pick it up.  Now, C diff may not even be causing you the problem, because C diff may be there but its levels may be low enough that it’s not the one causing you the problem. And the PCR is absolutely focused on that one organism, it’s not like it’s amplifying everything to pick up whatever it can find, it’s going in, honing in on that one organism saying, “Hey, we found some C diff, that must be your problem so we’re going to give you vancomycin all day long.”  Well, that might not be the solution, right? So now the FDA and the infectious disease specialists starting to see that PCR may be problematic even in trying to identify an infectious agent, what may be better is sequencing everything that’s there and seeing what is just popped up at the highest that could cause those symptoms. So CosmosID is the only FDA approved lab in the country that can do that kind of work.  So we partnered with them to get the best sequencing data. And then our other thing that we focus on the stool test is we want to give you functionality, we want you to be able to tell what your patients microbiome tends to do and tends not to do. It’s not absolutes, there’s no absolutes within the microbiome, but you will have a guide for you to understand where the real issues may be within that patient’s microbiome that you can start honing in on to help.

                                And everything we test actually gives you actionable steps that have references. On lifestyle changes, diet changes, and even supplement changes that can help that particular area. Coming back to TMAO, that’s one of the things we test. So you could eat meat and choline there and L-carnitine all the time and be absolutely fine and it’d be very healthy for you as long as you don’t have really overgrown levels of bacteria that create TMAO.  And you may have that because of previous dietary choices, when you bring back balance of the microbiome, then you don’t have that issue. And so one of the things you can do is you could test your patient’s microbiome and say, “Hey, your TMAO levels are really producing bacteria really high, so let’s reduce these kinds of things for a period of time until that comes down, then we can bring them back into the system.”  Just another example of that sulfate reducing bacteria. Nobody would have really thought about it or heard of these things within functional medicine, but they’re so important because one of the things that they do is they take sulfate from sulfate rich foods, and they convert it to hydrogen sulfide in the body which then becomes really inflammatory to the bowels. And so many healthy foods are high in sulfates, seafood is high in sulfates, and the leeks and garlic and artichokes, all of these things, high in sulfate.  So you might have a patient that’s going, “Doc, I’m eating pretty clean. I’m eating healthy fish in a line caught fish, I’m eating these vegetables. I still have really bad diarrhea…”

Dr. Weitz:            I just had a patient today and she had a flatline SIBO breath test which is usually indicative of hydrogen sulfide.

Kiran:                    Yup, exactly. So, yeah, and then you will know from the bio effects test like, “Oh, okay. It’s because your sulfate reducing bacteria are really high, these categories of foods really are actually counterproductive in your gut. So let’s bring those down over time and you could see all of the recommendations that allow to bring that down, bring that down over time and then rebalance microbiome, then you can reintroduce foods like normal.”

Dr. Weitz:            So how do we order this stool tests and how much does it cost?

Kiran:                    Yeah. So the practitioners you can order, I think we sell them in bundles kits of four, there’s no cost to order them of course because you can order the kits and have it within your practice until you have the right patient to use it on. The price that we charge is 299, we leave it up to you if you want to mark it up above that, but that’s a price that we only talk to practitioners about.  So the patients don’t know what the cost of this is. We have a mix of practitioners, some that don’t mark up tests at all but then charge a consultation fee to go through it or some that double the price depending on how they’re set up. So we allow you to decide how to do that. So then the functionality of it is if you have patients coming into your clinic, you can hand them a test, you can either have you or your staff registered the kit for them.   It’s a very quick process maybe it takes two minutes and you can either put in the payment and then charge them back, or you can have them take the kit home and have them register it using your code in there and then they will pay for it directly too. So you can manage it however you want, they do this test at home, we’ve got a very painless sampling procedure. That was another thing that we really wanted to improve, we didn’t want people like scooping poop and doing all kinds of stuff.   So we have this piece of paper that actually sticks to the toilet seat that has a bowl in it and then you take care of your first void and then we give you a brush, a coring brush, and you kind of core through a few spots in the stool, stick the coring brush in the test tube, close it off, then that’s what you mail back the paper, you can actually just unstick it and flush it. So you’re not dealing with actually managing anything.

Dr. Weitz:            That’s cool. It’s always tricky trying to hold that with [crosstalk 01:06:13] basket.

Kiran:                    Exactly, yeah. And the brush, what’s cool about the brush is we even thought about this like, we don’t want you to get too close to the stool. So the brush actually has a long handle when you first get it and you can actually core through the poop sample. I think we recommend somewhere around like five or six times you core through it.

                                And we use a brush because one of the things we found was you’re not getting adequate sampling of the DNA from the stool when you swab the surface or when you scoop a tiny bit of it. The DNA and the bacteria in the stool is not homogenous, so the bacteria on one side is going to look different than the bacteria and the other side and their relative abundances can change. So we wanted you to be able to go through the whole core of the stool and use a brush with lots of bristles to pick up as much as we can.

                                The more you pick up the more accurate the data it would be. So the brush has a long handle, you core through it a few times, you put it into the test tube, and I think you just off the top of the handle and then screw the cap on it, then you’re just mailing it back in a prepaid envelope.

                                And here’s the exciting part about it is we now have an FDA approved COVID diagnostic in the stool tests, and it’s an actual diagnostic meaning you can diagnose COVID in the stool. And that’s really important because studies have shown that you can actually pick up COVID in the stool for up to two to three weeks longer than you can pick it up in the upper respiratory tract. So you might have a patient that was feeling pretty crummy.

                                And in fact, we just had this with one of our employees, she was feeling pretty crummy and she went and got the nasal pharyngeal test and it was negative. But there’s studies that show, you can get up to 50% false negatives with that test. And so she’s like sitting at home having lots of similar COVID like symptoms and doesn’t know if it’s COVID or not.

                            So we’re having to do the stool test instead and the stool test will come back in about four days for the COVID part. The sequencing takes a little bit longer, but the COVID part comes back faster. And if you had somebody that had COVID maybe a couple of weeks ago, I suspect they did, you could still pick it up in the stool test up to two, three weeks after symptoms go away.  So it’s a great way to do that diagnostic, and you can do it at home. You don’t have to go to a testing facility where you’re around a bunch of other people that also think that have COVID and you could kind of keep yourself just safe distance from all of that.

Dr. Weitz:            This has been an awesome discussion Kiran, and I could talk to you for hours.

Kiran:                  Thank you.

Dr. Weitz:            Thank you for being so generous with your time. And so I think we got to most of people’s questions.

Kiran:                  Awesome.

Dr. Weitz:            And I really appreciate it.

Kiran:                  Well, yeah. Thank you so much for the opportunity, I always treasure any opportunity to talk about this with people, because clearly everybody here are the people on the front lines, you guys are the ones making the difference out there. And nothing I do is meaningful until it translates to the work that you do, so I’m always grateful for these opportunities. So thank you, Tanya, so great to see you and thank you for getting this set up for us as well and really enjoyed it, really enjoyed it myself.

Dr. Weitz:            Excellent. And thanks to everybody.

Kiran:                  Yeah. Take care.

 

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Emotional Eating with Melainie Rogers: Rational Wellness Podcast 162
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Melainie Rogers speaks about Emotional Eating with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

5:22  Losing weight is difficult, which is why 70% of the population is overweight.  One of the problems is that many people overeat or binge eat for emotional reasons. When our clients are feeling anxiety, they tend to eat carbohydrate foods, which tend to increase the amount of serotonin in the brain.  And while we are in this global COVID-19 pandemic, we are seeing a lot of anxiety and lot of this type of overeating.

7:34  When working with a weight loss client, we have to try to help our clients to understand their eating behavior and then work backwards to try to understand what feelings are triggering their behavior.

9:12  Not everybody who’s eating for emotional reasons have an eating disorder, but many do.  A good acronym is HALT, which refers to eating for the following reasons: 1. feeling hungry, 2. feeling angry, 3. feeling lonely, or 4. feeling tired.  If you do this occasionally, this could be normal, but if you’re doing this two or three times per week and feeling out of control, this is an eating disorder.

10:18  The difference between overeating and binge eating is that if you ate a whole pizza and then felt really full, that would be overeating. But if you did it and felt out of control and great distress by doing it, that would be binge eating.

11:00  One of the best strategies is to sort out what is biological or physiological from what is emotional. If someone skips breakfast and eats very little for lunch, then it is biological to be extremely hungry and to overeat because of that.  If they binge at this time it would be considered a physiological binge. For patients with emotional eating problems it is important to eat consistently throughout the day.

12:20  Eating consistently is important for emotional eaters to break their cycle, but in the Functional Medicine world now the hottest trend is to skip either breakfast or dinner so that you 12-14 hours without eating, which is referred to as intermittent fasting, which is considered to have anti-aging properties. Melainie said that if intermittent fasting works for you and you don’t binge at the end of the day, then continue doing it.  But if you find yourself overeating during that 8 hour window, then that may not be the right program for you. During Ramadan where you fast from sunrise to sunset, they often gain weight, since they tend to overeat or gorge at night. 

15:22  The difference between physiological and emotional binging is that if the client is eating food consistently throughout the day and meeting their nutritional needs and they are still overeating or binging, this is emotional because they are hungry or angry or lonely or tired.  It is important to make clients aware of this.

16:26  Mindfullness is being aware of what you are eating. Paying attention to whether or not you are really hungry.  You should not eat when you are distracted, such as by watching t.v..  It can be helpful to jot down on a notepad how hungry you are on a 1 to 5 pt scale before the meal and how you feel after.  It can also be helpful to write down what you are eating throughout the day, so you are aware of how much you ate.

20:15  The app Recovery Record can be helpful for clients with eating disorders.

20:50  Negative body image can be the motivation for eating disorders, so it is important to work towards having a positive body image or at least get to body neutrality, which means I just appreciate what my body can do for me. I may not love my body, but I’m not beating myself up all the time. It can be very difficult in our society where we are bombarded with imagery around the thin ideal.

23:25  If we eat unhealthy foods, we deplete our bodies of necessary vitamins, minerals, and other nutrients such as protein, which may make us crave more food.  For example, craving sweets could be an indication that we are dehydrated or lacking vitamin C, while a craving for salty foods might mean that we’re deficient in sodium or calcium or magnesium or zinc.  Eating a lot of low nutrition junk food can lead to someone being overfueled calorically, but underfueled nutritionally.

25:40  Eating foods like breakfast cereals that are fortified with vitamins and minerals is not as nutritious as eating real, natural foods like fruits and vegetables that are naturally high in vitamin and minerals and many other phytonutrients that are important and others that have yet to be discovered and appreciated.  We are programmed to seek out variety in food so that we are more likely to eat all of these important nutrients and this can’t be replaced by a poor diet and a multivitamin.  Supplements can be most beneficial when they top off a healthy diet. 

27:21  A lot of people are feeling extra amounts of stress due to the current coronavirus pandemic and are more liable to eat unhealthy, processed foods that require minimal preparation. And such processed foods are actually less expensive per calorie than natural, healthy foods and many people are out of work or making less.  And such processed foods tend to have a longer shelf life if you are stocking up to avoid frequent trips to the grocery store.

29:56  A lot of people are confused about what to eat, since the science seems to be changing and there is so much misinformation on social media around food and wellness.  There are many wellness coaches and diet gurus with very minimal training in the science giving advise about the best way to eat.  We have completely opposite diets–the meat only carnivore diet and the vegetable only vegan diet both being promoted and discussed as the best way to eat, so it is not surprising that so many people are confused about what the best way to eat is.  The diet debate is as polarized as the political debate in the US right now.

32:52  We know that exercise has incredible benefits for mental health, physical health benefits, motility, flexibility, joint stability, bone density, etc.   But high intensity exercise or overexercising can be another form of obsession like an eating disorder.  This can be just as harmful as undereating.   Overexercising can be very harmful and is done for an underlying body image issue, so we need to find out what is underlying the motivation for their behavior. 

36:11  It is not unusual that clients who come to us for weight loss will tend to underreport what they are eating by about 50% because they feel shame and guilt that they have over not being able to do what we have asked them to do. Our job is not to shame them further, but to figure out how we can set them up to be more successful.

 



 

Melainie Rogers, RDN is a Certified Eating Disorder Registered Dietician and accredited supervisor in the treatment of eating disorders. She is the Founder and Executive Director of BALANCE eating disorder treatment center™ and Melainie Rogers Nutrition, LLC in New York City. Among her many affiliations Melainie is the founder and recent past president of the New York City Chapter of the International Association of Eating Disorder Professionals (IAEDP), an Advisory Board Member at the Center for the Study of Anorexia and Bulimia (CSAB) and a former Board Member of the Binge Eating Disorder Association (BEDA). She is also an adjunct professor in the Department of Nutrition and Food Studies at New York University. She recently published Redefining Wellness: The Ultimate Diet Free Guide, a free e-book that contains contributions from 150 experts, which can be found on her redefiningwellness.co website.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.

 



 

Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello Rational Wellness podcasters, Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who enjoy listening to this podcast, please give us ratings and review on Apple podcasts. If you’d like to see a video version, go to my YouTube page. And if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                            Today our topic is emotional leading with Melainie Rogers. I think I butchered your name, but there are many-

Melainie:              Oh, that’s perfect.

Dr. Weitz:            There are many reasons why approximately 70% of Americans are overweight or obese. There are genetic factors that make it difficult to get and keep your weight into a healthy range. We may be taking certain medications such as antidepressants that tend to make us overeat. There are various hormonal factors, many of which can be treated. Insulin is secreted when we consume foods with a lot of sugar, and a large insulin surge in response to eating a bowl of breakfast cereal or a doughnut will tend to drop your blood sugar making you crave more sugar.    By the way, I saw an executive from one of the companies that make cereal on CNBC, and he was bragging about the fact that, “Isn’t it so great that Americans now are eating cereal for dinner as well as breakfast?”

Melainie:              No. Wow.

Dr. Weitz:            Anyway, back to sugar and insulin. Every time we develop insulin resistance, so our pancreas needs to pump out ever greater amounts of insulin, which makes us crave more and more sugar, and more carbohydrates, and we end up in this vicious cycle that is hormonally related. In our society, inexpensive, highly processed, and addictive junk food is readily available. Such unhealthy food products have been specifically designed to be hyper palatable and addictive. And there’s aggressive marketing to convince us that eating such foods are good for us. And if we eat such high sugar, high fat, high salt foods regularly, we end up being depleted of necessary vitamins, minerals, phytonutrients. And so this may encourage our bodies to eat more to get those nutrients we need. Of course, being cooped up inside due to the COVID-19 crisis, which we’re currently undergoing with the stress and worries about getting infected and dying, as well as our loss of income, provide additional reasons for unhealthy eating.

                                Melainie Rogers is here to join us today. And she’s a registered dietitian and a certified dietitian and a certified eating disorder registered dietitian. She’s the accredited supervisor in the treatment of eating disorders. She’s the founder and director of BALANCE Eating Disorder Treatment Center in New York City. She’s the founder and past president of the New York Chapter of the International Association of Eating Disorders Professionals. And she is definitely one of the top experts in binge eating and anorexia, et cetera. She recently published Redefining Wellness: The Ultimate Diet Free Guide, which is a free ebook that contains contributions from 150 experts, which can be found on her redefiningwellness.co website. Melainie, thank you for joining us today.

Melainie:              It’s a pleasure, Ben. Thank you for having me.

Dr. Weitz:            Before we start the conversation, I’d like to start with a request or a comment. I know that, looking at some of your work and your blog posts, that you’re used to often speaking to a lot of women who may be more right brain in their thinking about emotional eating. I assume that they are probably a big part of your target audience. But I think most of my audience and myself are very left brain analytical focused. We talk about health and functional medicine. I think it’s important to deal with the emotional stuff, but if there’s a way that we can do it so that limited left brain people like me can understand it, that would be helpful.

Melainie:              Sure. As a left brain person myself, I’m trained in research. So we will definitely talk about the research, and then of course behaviors.

Dr. Weitz:            Very good. Losing weight is very difficult for most people, which is one of the reasons so many people are overweight. I think the latest statistics show in the United States, something like 70% of the population is overweight. I work with a lot of clients who are trying to lose weight and many of them have emotional reasons for why they eat. Can you explain some of the emotional reasons people have for overeating or binge eating?

Melainie:              Absolutely. Not most people, but many people, guys and gals, I know you mentioned women earlier, but for overeating and emotional eating, it’s about a 50/50 split between guys and gals. The reason for that is because we all, male and female, experience emotions, and a driving force behind the key emotion, which is anxiety, is actually our amygdala. Amygdala is a part of the brain that is responsible for that flight freeze response. And that’s the part of the brain that’s responsible for pumping out this feeling of uncertainty and anxiety, generalized anxiety.  What we know from emotional eating, Ben, is that most of our clients or general population, when they’re feeling anxious, they seek out carbohydrates, usually. They don’t usually seek out a chicken breast, right? The reason to that, my clients say to me, “My God, I don’t know what it is. Why am I addicted to carbs or sugars?” It’s not that you’re addicted to carbs or sugars. It’s that carbohydrates, specifically, when you ingest them increase the amount of serotonin in the brain.  Now, many of your viewers may know that serotonin is the chemical that reduces anxiety. So we’re talking about a neurobiological process here, that we call emotional eating, because we think it’s all about emotions, but it’s actually a whole chemical response and a domino effect that leads to overeating. And right now with COVID-19, we’re seeing so much more of this type of eating.

Dr. Weitz:            When we come in contact with someone who’s trying to change their weight, how do you determine what the underlying reasons are? Not everybody is willing or able to actually articulate why they’re overeating.

Melainie:              Absolutely. And a big part of that, too, is that, as a society, we’re not actually encouraged to check in with our emotions, and certainly there’s a gender bias there. Where guys are definitely not at all encouraged to connect with their emotions, they’re encouraged to be stoic and to pull yourself up by your bootstraps and just get on with it. Which that kind of a suppressed emotion just leads to a lot of things going sideways, hence we’ve got guys and gals, but more predominantly guys, who drink excessively, who have sex addictions, who gamble excessively. Those are behaviors that are working sideways; too many underlying emotions, which they really have lack of awareness around.  For us, what we try to do is help our clients understand, or at least start with the behavior because that’s very concrete, and then work backwards to, what’s the trigger around why you would do that? Often, for many people, that’s pulling back the layers to figure out what are those underlying feelings, which make people really scared. People get really scared to think about feelings. It’s amazing, actually, but yes, that’s the process.

Dr. Weitz:            So is everybody who’s eating for emotional reasons, do they all have an eating disorder?

Melainie:              No, not at all. But they probably have disordered eating. So it’s on a spectrum. For many of us at some time, we’re all going to eat out of emotion. A really good acronym that’s often used in the substance abuse world that we’ve adopted in the eating disorder world is HALT, hungry, angry, lonely, tired. The whole quintessential, I roll into bed or I crawl into bed with my pint of ice cream and binge, watch TV, Netflix, or whatever. So that’s emotional eating for comfort. Maybe there’s been a break up, or your boss yelled at, you or COVID-19. So it’s on a spectrum. And doing that occasionally just means you’re normal. But if you’re doing that two or three times a week and feel very out of control and can’t stop it, then by default of the frequency and the severity of it, then it may fall into the criteria of what is an eating disorder.

Dr. Weitz:            And then, what’s the distinction between emotional eating or overeating and binge eating?

Melainie:              Binge eating is when you eat a larger amount of food than other people would normally have. Let’s say you have two entrees for dinner. You eat very quickly, and you feel great distress doing it. It’s one thing to sit down and eat a whole pie of pizza, pizza pie, and be like, “Oh gosh, I’m really overfull. Wow, I ate all that.” But there’s not a distress attached to it. That wouldn’t be considered a binge. A binge is when people feel out of control and feel great distress by what they’re doing.

Dr. Weitz:            Okay. What are some of the best strategies and tips to help patients, clients avoid overeating or binge eating?

Melainie:              Number one thing we find is biological. My job as a registered dietitian is to separate out biological or physiological binges from emotional binges. How I would differentiate the two then is that, a physiological binge is when our clients get up in the morning, maybe they’ve binged the night before and they decide, “Oh, I’m going to skip breakfast this morning.” Or, “I’m not hungry for breakfast.” They get to lunch, and they decide that they’re going to have a tomato and a piece of lettuce, because they’ve got to make up for calories that they consumed the night before. And you guess it, by the time they get to the end of the day for dinner, they’re absolutely ravenous. That’s a physiological hunger.  Then when they sit down to dinner, they don’t just have their steamed chicken breast and a little portion of broccoli that they intended to have, they in fact, go on an outright binge and usually have fried this and fried that and fried this and feel out of control. So that’s a physiological binge. How we try to reduce that is by having people eat consistently throughout the day. That means you have to have a breakfast, you have to have a lunch, you have to have snack, you have to have dinner. Go ahead.

Dr. Weitz:            Yeah, I have to jump in here because this is a constant discussion we have in the functional medicine world. I’ve been working with clients with nutrition for over 30 years now. The big thing we started with was, people skip breakfast, they’re rushing around, they have a snack for lunch and then they overeat for dinner, and that’s why they’re all overweight. And the mantra was, “You have to eat breakfast, you have to eat within so much a period of time of waking up. You have to have small meals throughout the day.” For years we were preaching, “That’s the way to be healthy. That’s the way to balance your blood sugar.” And now the big thing in Functional Medicine is, the way to be healthy is to do intermittent fasting by skipping breakfast.

Melainie:              I know. I know, right. I know. Because it’s the goal of getting a 12-hour break on your body, right? 

Dr. Weitz:            Yeah, or 14 hours or 16 hours, and pressing your eating window into a narrow range It’s funny how it comes full circle, but anyway go ahead…

Melainie:              It’s so funny because… No, you’re absolutely right, because it used to be low fat and then it was no carbs, and now it’s, sorry, intermittent fasting. I don’t really advocate any one diet. What I do for my clients is try and figure out what works for them. But we do know conclusively that if you skip breakfast… Or let’s say you don’t do breakfast, I’m cool with that too. I’ll work with whatever the client wants to do in the sense of guiding them. But if you’re just eating lunch and then you’re eating dinner and you’re binging, I would suggest that you’re just not taking in enough calories for the day, and that’s a physiological binge. Yeah, those intermittent fasters out there, whatever works for you. But if you are binging towards the end of the day, then you may want to have a look at that.  What’s interesting about that, Ben, is that it used to be, “Don’t eat after 7:00 PM.” But I think that went out the window because with our current lifestyle, people don’t usually get to dinner until 8:00 or 9:00. So I think this is the new modification on that, which is just trying to create some kind of gap. But also it makes me wonder that, are people just there for binge eating or grazing through those eight hours that they can eat? During Ramadan, for example, when the Muslims fast for a month, people gain weight.

Dr. Weitz:            Is that right?

Melainie:              Because they starve and then they binge. I’m laughing. I’m sorry. It’s not a laughing matter. But we know that the-

Dr. Weitz:            No, no. I know that you’re laughing out of irony. Yeah.

Melainie:              Yes, out of irony. I mean, we know from the research that the number one way for people to gain weight is by restricting so excessively that they end up being out of control around food. That’s just a physiological fact.

Dr. Weitz:            If that’s the physiological or part physiological-

Melainie:              Yes, binge.

Dr. Weitz:            Then what’s the difference between the physiological and the emotional?

Melainie:              If a client is then eating consistent food intake throughout the day and meeting their nutritional needs, their fuel needs for the day, and they’re still finding that they’re getting out of control with eating and it’s not hunger-driven, we know it’s emotionally-driven. So then that becomes the big question of, what are those underlying emotions? So for people who are overeating it can be, the acronym I used earlier.  Well, hungry, we just eliminate it, because we’re having consistent eating. But now we’ve got angry, now we’ve got lonely, now we’ve got tired. And so it’s important for clients to then have a look at, “Why am I eating right now? I know I’m not hungry.” That brings into play mindfulness, which is just observing your behaviors and not judging, Ben, but just being curious. Like, “Why am I doing this? I don’t want to eat this. I’m not even tasting it.” So helping clients increase that awareness around their behavior.

Dr. Weitz:            What is mindfulness? Everybody throws it around. And when I talk to people, a lot of people are not really sure what it is.

Melainie:              Sure. Mindfulness from the definition or how we operate with our clients is really awareness. Just being aware that, “Hey, I’m reaching for the third or fourth, or fifth slice of pizza, and I haven’t checked in if I’m even hungry because I’m usually disconnected.” If we think most of us are disconnected like this from what our body is needing from a hunger and fullness perspective, that’s our internal regulatory system. Leptin, ghrelin, PYY, all those great feedback hormones are dictating that. What we really want to practice or get back into doing is checking in with our body and saying, “Gosh, I think I’m full. I don’t actually need that extra slice.”

Dr. Weitz:            What’s a practical tip for somebody who’s sitting down and they’re eating. Is there a little tool that they can use to be mindful while they eat?

Melainie:              Absolutely. There’s a lot of different ones. Some of them come back to the oldies but the goodies which is, “Don’t eat when you’re distracted.” And for many of us it’s for dinner anyway, sitting down in front of the TV or the computer and eating, and we look at our plate, “My gosh, gee, did I eat all that? I didn’t even realize it. The plate’s empty, I must have eaten it.” That’s distracted eating. First and foremost, try to reduce the distracted eating. Which means, turn off the TV, shut down the computer, sit there and be thoughtful and notice yourself eating your meal and check in with your body.  For some people, it can be helpful if they have a little notepad and just think, “Oh, how hungry am I?” And use a one to five point scale? “How hungry am I when I go in? How full am I at the end of the meal? So that they have a little bit more data collection that can feel more concrete for them around this process, so it doesn’t feel new and ethereal and not scientific. Those are just a couple of real simple things.  The other thing is when you plate a meal, if you go back for more check in, ask yourself, “Am I still hungry?” “Yeah, I’m still hungry. Maybe I’ve got some mouthfeel going on, so maybe I want some dessert to wrap up,” or something like that. It’s really checking in with yourself.

Dr. Weitz:            Okay. What are some of the other techniques we can use?

Melainie:              Some other techniques to use would be having a look at… Checking in, “Did I eat throughout the day today?” For some people, writing it down can be really helpful as a scientific experiment on themselves. So that-

Dr. Weitz:            You mean write down what they’re eating?

Melainie:              Yeah. Or even if you don’t want to write down what you’re eating, just write down the time that you ate throughout the day. So for some of us, we’re so crazy busy, Ben, and honestly, you can forget to eat. Your introduction earlier was about people who are just on the go, and you can really get delayed in eating consistently throughout the day. So if you even just decide that you’re going to write down what time of the day you eat throughout the day. It doesn’t matter what the food is for now for this example. Then you can just check, “Did I eat lunch?” “Yes, I did.” “Did I have a snack?” “Yes, I did.” “Did I have dinner?”   If on one particular day, you’re overeating at the end of the day and you go back to your notepad and say, “Why am I crazy hungry? Or why am I wanting to overeat right now? Did I eat today?” And you check back and go, “Oh, I forgot to have lunch.” It can happen. It could happen. Or, “I grabbed a snack for lunch instead of a real meal. And that’s why I’m starving right now.” That kind of data collection is important.

Dr. Weitz:            Do you have any apps for doing that?

Melainie:              Yeah, I do, actually. We don’t tend to use apps that have calories, because I find that that keeps everything external. I want clients to get back to their internal regulatory system with those hormones we talked about earlier. There’s a wonderful app we use called Recovery Record. And it’s really about logging what time, what you ate, but also hunger and fullness. Then of course, if we think about hungry, angry, lonely, tired, it can also tap into if there’s any kind of emotional eating going on as well.

Dr. Weitz:            What role does negative body image or body dissatisfaction play in? How can this be overcome?

Melainie:              It plays a huge role. Because usually what happens is that there is a dissatisfaction with your body and a desire to change it, which usually in our society now, which idolizes the thin ideal, that usually means weight loss, or for a lot of us it means beefing up. And so therefore there is usually an attempt to, in the weight loss case, there’s an attempt to lose weight and reduce calories. What we know is that when you reduce calories below a certain amount for an extended period of time, that physiological response we spoke about kicks in and then people end up overeating, they’re fallen off the wagon, they feel despair, they regain the weight plus some. So body image in our current society can be a huge trigger for dieting, weight loss, and weight regain.

Dr. Weitz:            How does somebody get a positive body image?

Melainie:              It doesn’t happen overnight. I would say it’s pretty tough to do in the current society where, Ben, we’re just bombarded with imagery around the thin ideal. What we work with with our clients on is, “Okay, let’s not go from negative body image and hating your body to, ‘I love my body overnight.'” I think that’s almost impossible. What if we just get to body neutrality, which means I just appreciate what my body can do for me? I may not love it. I may still think this about my stomach and my thighs, but I’m not beating myself up all the time. So we work on our clients trying to reduce behaviors that might add to the negative body image, which means unfollow on Instagram and social media accounts that have you comparing yourself to others.  In some cases, we even have our clients take up their full length mirrors and just have the mirror above your head, for example. Because if you can’t view your body without picking it apart, then maybe it’s time to just take a short break from doing that. And then there’s a lot of cognitive challenging of a lot of the thoughts that we all have, some challenging on those thoughts and some reframing of those thoughts to get to at least an appreciation of what your body can do for you.

Dr. Weitz:            Can you talk about how, if we eat unhealthy foods we tend to deplete our bodies of necessary vitamins, minerals, and other needed nutrients, such as, say, protein that may make us crave more food? In one of your blogs, you wrote that craving sweets could be an indication that we are dehydrated or lacking vitamin C, while a craving for salty foods might mean that we’re deficient in sodium or calcium or magnesium or zinc.

Melainie:              Yeah, absolutely. Well, we know that, and you alluded to this earlier, that if you’re eating a lot of what we call low nutritious food, which still has a role in an overall eating plan, but not if it makes up all of the eating plan. So foods that don’t have a lot of vitamins and minerals in them can ultimately lead to someone being overfueled calorically, but underfueled nutritionally, which means they’re deplete in vitamins and minerals. Then I think that blog really just speaks to cravings and how cravings can direct us. If you listen to your cravings, they can direct you in a way of what you might need a little bit more of.

Dr. Weitz:            But it says on that box of breakfast cereal that it’s fortified with vitamins and minerals.

Melainie:              I know. I know. Which is why maybe it could be a good dinner choice. Yeah, I know. Isn’t that crazy? Absolutely. We’re finding that out that the portion of the population that might be nutritionally depleted, even though we do have a lot of fortification, vitamins don’t necessarily, because we’re still doing the research on this, right? They don’t necessarily check all the boxes just as a sole entity. It’s a lot more complicated when vitamin C is detracted from a food source because of all the other elements that play along with the vitamin C, versus a synthesized vitamin C supplement, as we well know. Yeah.

Dr. Weitz:            When vitamin C is found in foods like oranges, there’s all sorts of bioflavonoids and other phytonutrients, many of which we’ve not even figured out what their role is. I’m a big believer in supplements, but supplements are topping off a natural diet. So you’re getting at least a good background of all those phytonutrients that are contained.  Just recently, one of the studies on COVID-19, we’ve seen some positive data on vitamin C, but the bioflavonoids have been shown to be super helpful. I mean, some of the ones particularly that are found in foods that have vitamin C, like hesperidin and rutin. And so I think it’s important that you have a phytonutrient rich, healthy diet with lots of different colors of fruits and vegetables. And then take your vitamin C on top of that, you’re going to get a different response than eating Cheerios that are fortified with vitamins.

Melainie:              Exactly. It’s amazing, Ben, because we’re actually designed to seek out variety in food. And this is the very reason for it. Because prior to us being able to actually identify that there are such things as vitamins and minerals, no one’s got a gauge built into their arm that says, “You’ve met your zinc intake and your magnesium intake for the day, et cetera.” Right? The way that our brains are structured is, we seek out variety of food to make sure that we’re actually getting in adequate vitamins and minerals throughout the day. Which is pretty genius when you think about it. And it can’t be replaced by just a simple supplement, as you rightly said.

Dr. Weitz:            Unfortunately, a lot of people now are stressed, so they’re eating some of these unhealthy foods because they don’t require a lot of preparation. But the reality is, is we really have more time now because people are at home to fix yourself a really good healthy meal with lots of fruits and vegetables and actually being involved in preparing it, and prepping it, and cooking it. It’s actually an important part of getting the benefits and enjoyment out of a meal. I encourage everybody to do that.  Now, on the other hand, I also understand that unfortunately, healthy foods are more expensive. You see at these food banks, you don’t see a lot of fresh produce being put into those boxes. You see boxes of cereal, and packaged foods and things like that. And because those are relatively inexpensive and ditto for junk foods, our fast food industry, which is probably still doing as much business as they were before because you can’t dine in but a lot of people do takeout anyway and it’s fast and inexpensive.

Melainie:              Right. That’s so true. Also there’s a shelf life on those items that you mentioned at the food bank. Those things can be put on a shelf or put in a box, easily and stored, whereas fresh fruit and veggies don’t and they spoil. It’s just logistically a lot tougher. And also what we find with food scarcity is that some of the more socioeconomically challenged areas, particularly I can speak for New York City, anyway, there’s not a lot of grocery stores in certain areas, but there’s hell of a lot of fast food chains in those areas. It’s also access to food. So there’s a lot of factors that play into it.  One other thing, Ben, is, yeah, some people are looking for what’s readily available. And this would be a good time to take the time to prepare some of these more nutritious meals and such. But I think honestly, it also comes down to motivation. I think so many people are feeling so flat right now with so much uncertainty that it’s just stressful. And when stress is high, your motivation tends to go low, which is counterintuitive to what would make you probably feel better. But we know about that, right? Motivation and behavior change is really tough as well.

Dr. Weitz:            It’s interesting that there seems to be more information and ever on food, and healthy eating, and nutrition, and yet, a lot of people are still confused. Can you comment about that?

Melainie:              Absolutely. I think it’s because there’s information overwhelm. They’re confused because, for example, we used to say that butter was bad, and then we went to margarine, and now maybe margarine is bad. So the science keeps changing and therefore consumers can’t keep up, is one thing. And now with social media, there’s such a plethora of information out there, it’s hard to even follow. And there’s so much contradiction out there as well. What my pet peeve is, is all the pseudoscience that is out there on social media.  There was one stat I saw recently, which suggested that between eight to nine out of every 10 comments and information out there on social media around food and wellness is actually bad science or even no science. I mean, I’m a registered dietician. I was medically trained. And so everything that we do is based upon what is the research. So it’s frightening to see a lot of wellness coaches out there who have no training and no understanding of the research spreading incorrect and inaccurate information.  I feel sorry for the consumer, because how can you possibly try to sort through what’s rubbish to fact? Then the facts actually do change as more and more research comes in as well. So it’s tough. I’m glad that I have the training that I have, but it’s still a lot of information to filter through.

Dr. Weitz:            Yeah. If you’re on social media, it seems to me that the biggest trend right now is the carnivore diet, which is meat only. All you eat is meat.

Melainie:              Right. Yeah. So a bit of caveman coming in there, but even caveman used to run around and get their root vegetables and fruits and berries from the trees and such like that. Yeah, it’s just another form of like the Atkins that was around a couple of decades ago, and it’s just the same thing-

Dr. Weitz:            Even more extreme, you know?

Melainie:              Yes, it is very extreme. It’s very extreme. The difficulty with that, and I know there are people who are pro; the difficulty with that, as we’ve seen with any of these eating plans, is that for a while it works for people until it doesn’t because taste fatigue, physiological needs are not met, et cetera. And then-

Dr. Weitz:            Starving the microbiome…

Melainie:              Exactly microbiome, and then people fall off the wagon. Then what’s so beautiful and brilliant about these diets is that when the consumer falls off the wagon, they blame themselves. They don’t look at the diet and say, “This diet was setting people up to fail.” Hence, it just perpetuates itself.

Dr. Weitz:            What do you think about high intensity exercise for emotional leaders? You see people who are obsessed with exercise, especially the gyms are closed, but I’m a gym person and used to seeing certain people at the gym for hours at a time. And that’s another form of eating disorder is over exercising. So how should people who have a tendency towards emotional eating approach exercise?

Melainie:              Exercise in moderation is really great for so many reasons. And you as a chiropractor and sports chiropractic person know this. I have a sports nutrition background as well, Ben. So you know that the mental health benefits, the physical health benefits, motility, flexibility, all of these things, we know exercise is really helpful up to a point. But what you’re speaking to is a behavior of obsessiveness and going above and beyond what actually technically is healthy. In fact, obsessive exercising is very unhealthy.  What we look at with what we do is not just people’s obsession around food, whether it be undereating or overeating, but that obsessive tendency carries forth in other areas. And one of them, as you said, is over-exercising, which can be really harmful. But what’s really interesting about that is that some people overeat, or express their emotions through other ways; over-exercising is a way that people are trying to manage anxiety. It certainly has health benefits and therefore, unfortunately, it’s pretty normalized in our society because it’s like, “Oh, I envy that guy. Look, they’re three hours at the gym.” And it’s like, “Uh-uh (negative), that is so unhealthy.” I wonder about the work ethic, and also wonder about their relationships, because if you’re three hours in the gym, you’re not going to have some pretty happy people at home.

                                What we try to do there is we treat the whole person. So it’s not just about the food. It’s about what is your relationship with exercise? And also what’s driving that, and often it’s a body image underlying piece is driving that. For the guys it might be the bulking up, because there’s an underlying body image issue, which is an underlying anxiety issue. I mean, I’m simplifying these concepts, but for the point of the illustration. So we try to get at the underlying reason that one might be over-exercising and try to pull that back.  Usually what happens is when you reduce, someone who’s an over-exerciser, when you reduce their activity, their anxiety goes right through the roof. Which is exactly what we want to see because then we’re like, “Okay, you’re self-medicating with exercise. So let’s get it, what’s the underlying anxiety about?” In the same way that someone might be drinking excessively, you take the alcohol out of the picture and you’ll see their anxiety going up. So we need to get at the underlying anxiety.

Dr. Weitz:            How about a few tips for those of us who’re working with clients with weight problems? How about the client who’s not being honest with you? You make recommendations for changing their diet and exercise and they come back and four weeks later, no change, haven’t lost a pound, maybe gained a pound and they claim that they’ve eaten nothing all day except a salad and some tuna fish and an apple and they’re doing excessive amounts of exercising. You just know it’s not the case. How do you approach them?

Melainie:              Well, there’s a couple of different things there. First and foremost, we know that for a lot of our clients, because of shame, and they want to be seen as doing the right thing, and they want to not do the right thing. They want to follow your recommendations. They want to please you, Ben, they want to please me. They’re coming in, they’re paying us money. And then they find they can’t. Then they feel great shame about their behaviors. And they also feel shame about the fact that they can’t do what you asked them to do. So they’re not always forthcoming with the reality.  We know with our clients that 50% of what they tell us is either true or not true in the sense of, for our under-eaters, they’ll report that they’re eating a lot more than they are by about 50%. And for our over-eaters, they’ll under-report how much they’re eating by about 50%. So we know that from the get go, that that is part of the shame. Our job is not to shame them further, but to figure out how we can set them up to be more successful. So maybe those goals were too ambitious. Or maybe, actually, this is not just occasional over-eating, but there’s a serious problem going on here that they’re not able to rein in on their own, and they actually need more help and more support around that. And maybe they need more therapeutic support to handle the emotional stuff that’s causing them to overeat and then lie about it.  Then of course, there’s the other piece… Sorry, Ben. The other comment there is, the lessons learned from the greatest loser is that people massively restrict and they’ve lost a lot of weight, even though they still may be in a higher body weight, their metabolic rate shuts down and all sorts of biochemical processes change. And that endures for up to six or seven years; we’ve seen from the research thus far. So-

Dr. Weitz:            What have we seen from the biggest loser? Can you go over there?

Melainie:              Yeah. From the biggest loser where they’re able to do research on people who’ve lost a hundred plus pounds and are able to follow up with them six and seven years later, all of them regain plus some. And what they actually found is that the weights they return to, their metabolic rates never recovered fully to what we would expect a person of their body weight to be. If you-

Dr. Weitz:            Wow. This is almost all of them, you’re saying?

Melainie:              Yes. If you look at the Biggest Loser, which I hate that show but for research I have to watch it. And I was horrified by the shaming and it’s just disgraceful. But if you remember, those contestants were exercising six and seven hours a day plus. So it wasn’t that a lack of exercise was affecting their metabolic rate, which is a common thought in the sports nutrition world, that’s for sure, that exercise will protect your metabolic rate. It’s not true.  Again, I guess what I want to say for our higher weight clients, it’s complicated. There’s so much that we still don’t know because of weight bias actually, Ben. There hasn’t been good research done because assumptions were calories in calories out. We now know that that’s not the case. That it’s much more complicated and nuanced and sophisticated than that. And so our higher weight individual, our clients, we don’t have good research to be able to advise them accordingly. So compassion is really important. And then making those recommendations more baby steps so that they can feel good, and they can feel that they’re succeeding.

Dr. Weitz:            What could you do? Let’s say you’re in with a client and this is somebody who’s trying to lose weight, and you know they’re not being honest about the food they’re eating, how do you coax it out of them? What kind of a conversation or what can you do? So, for example, you’re recommending that they need psychological counseling besides the nutrition coaching that somebody like myself can provide. But how do you even bring that up if they’re not even admitting?

Melainie:          Well, if they’re not admitting that means their shame is too great. Even if you were able to… So here’s the thing, previously, what I guess might’ve    been encouraged is to just say to them blatantly, “I don’t believe a thing you’re telling me and you’re lying because the scale tells me the truth.” So my question to anyone who would approach them in that manner is, A, “Will the client come back?” B, “Did you help that client in the future to seek out help?” What we find is that when clients drop out of treatment, it may take them two years to come back, if at all. And we know that higher weight clients disproportionately don’t seek out help because they’re ashamed about their body and their weights. So shaming is not a way to go.

                                We know that our clients are going to under-report how much they’re eating because they’re ashamed of it. I’m just going to keep that in my mind, but I’m going to work with what they’re willing to talk about. That might be, I’m not going to comment on how much they had for dinner or not. I’m going to say, “Okay, well, did we have that breakfast?” How did you go with trying to get that breakfast in?” Or, “How did you go trying to get that lunch in?” “You know how we talked about having to make sure we get some protein in there? How did you go with that?”  We talk about those one or two, or even three simpler ideas. Because the idea is if we can get food in and by food, I mean, you make sure you get your protein there, make sure you get your fat for satiety, make sure you get the carbs in there. I don’t want low carbs because you’re going to binge on those later. It’s a physiological response. If we can work on what we can add in at the times where there are gaps, then that can also help with overeating later on, even if they’re not reporting that.

                                I had one client that I worked with, Ben, for two years before she admitted that she was binging. I knew she was, but that’s part of her process. It’s like if someone’s drinking alcohol, and you know they’re drinking, but they won’t admit to it because that’s their process; denial. If you think of stages of change; denial, and then there’s pre-contemplation and contemplation. Motivational interviewing and thinking of stages of change with behavior can be really helpful as well.  Also managing our expectations as the clinicians, because we know that if you just follow what I tell you, you’re going to really just see some great results and you’re going to be healthy and you’re going to recover. Then when they don’t do it, it’s really takes away from our sense of accomplishment. And so we have to check our egos as well and pull back and meet the client where they’re at with their process.

Dr. Weitz:            How about when they come in for their first consultation and you’re somebody like me who just is super disciplined, and it’s like, “If this is healthy, then I’m going to do it. I can’t imagine why anybody wouldn’t do that.” You’re meeting a client and you know that they’ve had problems with weight for a long time. They may be told you that. How do you set them up for success? Because I know I’ve had the occasion more than once, unfortunately, of setting them up on a program and asking them to write everything down, and this is going to be so great. We’re all excited, and that’s it. Never saw them again.

Melainie:              That’s right. That’s absolutely right. Because you set them up, you’re like, “We’re going to do this.” Yeah, because it’s overwhelming. It’s overwhelming for them. I think what’s really, really hard is, and I encounter this too, because I’m a registered dietician, so therefore, I know what to eat and what not to eat and all that stuff. I studied it for seven years, and other things. We have to be a little bit careful, Ben, because we bring our enthusiasm for what we do but if our clients were wired in the same way that we’re wired with our interests and our level of passion for this, they wouldn’t need our help. We have to bring it down a notch or two or three.

                                I like to share with my clients occasionally whatever, that I love my Doritos and my glass of wine. And I have to make sure I have my Kit-Kat or my chocolate every day; to normalize it and come down to their level, and to be able to say, “Gosh, I know this is really hard.” And maybe even reflect what other clients struggled with and how they were able to overcome it. Because I think using us as a benchmark… We’re the supposedly expert and we’ve done, hopefully, all this study and clinical practice to get where we are, but we still have to moderate that to help the clients. And maybe their baseline is this. Maybe that’s as good as it’s going to be for them, and they’re thrilled with that because it was better than where they were.   But I hear you and I’ve been in the situation too. Beautiful plan and the client doesn’t come back, or they come in and they’ve done none of it. And that’s when you’re like, “Okay, those goals were way too big and overwhelming. Let’s just start with the basics.”

Dr. Weitz:            Good. Okay. That was great. Any final thoughts you have for our viewers or listeners?

Melainie:              I hope people have gotten out of this today just that, most people are doing the best that they can, and we can definitely help them to take that next step and take it in baby steps. Those extreme diets are usually not exactly what they’re cut out to be.

Dr. Weitz:            How can people find out about your programs and getting in touch with you and your clinic and-

Melainie:              Absolutely. Check us out on our website, which is balancedtx.com. And also we have a free 20-minute complimentary discovery call, Ben, for any callers who want to call in or sign in via our website. If you feel as though maybe you’re struggling or someone you love is struggling and you want to just get a better sense, “Is this disordered eating? Is this emotional eating? Is this an eating disorder?” We can help you sort through that.

Dr. Weitz:            How about practitioners? Let’s say somebody like myself who’s not typically focused on the emotional stuff, is there a way, if I’m working with a client and I’m working with the dietary stuff, can we interface with you and your office on emotional part?

Melainie:              Absolutely. I have a team of therapists and I have a team of nutritionists, so we have the medical piece and we have the psychological piece. Our whole philosophy is, gold standard of practices working collaboratively. So we would love to do that, Ben.

Dr. Weitz:            So as a practitioner, how would I approach that with sending one of my clients too, but making sure that I can continue to work with them on the nutrition part?

Melainie:              Oh, absolutely, that’s essential. Is if our clients come in with any kind of team member that they’ve been working with, our goal is to absolutely insist that they continue to see you because you know them the best. We want to hear from you what you’ve seen and observed so we can then set up the best care package for them with your collaboration and theirs. And then-

Dr. Weitz:            So as a practitioner, would I call or-

Melainie:              Absolutely. Just give us a call.

Dr. Weitz:            Okay. Awesome. Thank you, Melanie.

Melainie:              Thank you so much, Ben.

Dr. Weitz:            Melianie

Melainie:              That’s okay. It’s all good. Thanks, Ben. What a pleasure.

Dr. Weitz:            It was a pleasure for me as well. Thank you.

 

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Fasting with Dr. Daniel Pompa: Rational Wellness Podcast 161
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Dr. Daniel Pompa discusses fasting with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

2:37  Some of the smartest doctors in the Functional Medicine field just happen to be chiropractors.  The reason is because we share a major premise that the body has innate intelligence that heals itself if we just remove the interference for this. 

3:13  Dr. Pompa became interested in fasting in the 90s from his involvement with a vegetarian group that was inspired by some books by Herbert Shelton on fasting and he went to some of the seminars. At that time, fasting was not very popular.

4:15  Intermittent daily fasting is where you don’t eat for a period of time that could be 12 or 15 hours or even 24 hours.  Extended fasts are where you go without food for between 2 and 5 days. And there are certain conditions that will benefit from an even longer fast.  Dr. Alan Goldhamer, who I interviewed on episode 116, has patients do a 30 day medically supervised fast.  30 Day Fasting with Dr. Alan Goldhamer: Rational Wellness Podcast 116   

5:36  Dr. Pompa discussed a patient that he fasted years ago for a grapefruit sized tumor for about 26 days. It took that long to reduce the tumor to the size of a golf ball. She was detoxing and her tongue went from coated white to green to black and fuzzy her family had to cross ventilate their house since she smelled so bad.  When you do a 5 day fast, the magic happens after 3 days when you have lost your hunger and you get your energy back. Day four we hit max autophagy, which is when your body eats broken down and damaged cells, organelles, and even DNA and recycles these proteins and nucleic acids. So then you continue the fast one more day for 5 days to really take advantage of this autophagy and then you see a massive rise in stem cells to rebuild and massive rise in growth hormone as well. The benefits of a fast tend to decrease after 5 days, so multiple 5 day fasts is the way to go in order to maximize autophagy and allow the body to heal itself.

9:22  Dr. Pompa prefers to do water only fasts, but he often starts clients with a partial fast, such as using the five day partial fast developed by Dr. Valter Longo, which makes it easy. You just eat what’s in this box, nothing else, for 5 days. You can design such a program yourself and Dr. Pompa in his Beyond Fasting book explains how you can design a partial fast around the foods that you like.

11:12  With a partial fast you get a lot of the benefits of a full fast. You still get autophagy and stem cell production.  It is helpful to work up to a complete water fast by starting with a partial fast that contains between 500 and 1,000 calories, depending upon the person.  But such a fast does need to get the protein levels down to below 15-20 grams per day, depending upon the size of the person.  Many of the studies that look water only fasts do not see as many results as Dr. Pompa’s patients get because they prepare and train for the fast so that their body is fat adapted and ready for the fast, much as you would train to be able to run a marathon. He lays out a seven week program in his book, Beyond Fasting, for how to prepare to do a 5 day water only fast. With a water only fast you get energy divergent where your body uses it’s energy that does not need to help digesting food and this energy can be used to help the body to heal, whether it’s a knee or the kidneys.

14:18   Fasting can actually stimulate the immune system and that could be very helpful during this coronavirus pandemic. Back in the 90s fasting was considered to be harmful to immunity because during a fast you might see a drop in white blood cells, but this is actually part of autophagy and it is getting rid of old white blood cells which we call senescent cells that drive inflammation. Then, a month or so after the fast you will see an increase in the immune system to preventative levels.  With fasting we also see an improvement with patients with autoimmunity.

16:48  To prepare for a 5 day water fast, it is advantageous do a ketogenic diet to get your body to become fat adapted. If your body is fat adapted, you may start having autophagy on day one of your water fast instead of on day three.

18:12  The key to weight loss is to eat less often rather than eating less, according to Dr. Pompa.  If you eat too few calories for too long, your metabolism will slow down and your body thinks it is starving and it will hold onto fat but break down your muscle and turn it into sugar for fuel. Dr. Pompa noted that he eats only two meals per day in a 4-5 hour window and one of these meals he eats until he is a bit beyond full, which signals the body that you are not starving and you can burn fat for fuel.

22:32  For many years it was believed that the key to losing weight and being healthy was to eat breakfast and to have small, frequent meals throughout the day to keep an even blood sugar, so that you didn’t eat too large a dinner.  But by doing this, you never give your body a chance to burn its own fat because you are always feeding it.  And it’s a bit ironic that now one of the keys to losing weight and being healthy is to skip breakfast so that you are doing an intermittent fast. Dr. Pompa pointed out that because of the Dawn Effect, where you get a rise in blood sugar from the morning rise in cortisol, it is easy to have energy in the morning without eating anything. Hunter-gatherers in Africa usually just eat one meal per day. The men are up early and spend all day tracking down and hunting prey and they don’t eat until evening when they come back to the tribe in the evening and they would eat together.  And these hunter-gatherers were lean, ripped, and healthy.

25:48  On the other hand, Dr. Pompa said that if it works better for your schedule to skip dinner rather than breakfast, then that works as well. The key is giving your body time to go through autophagy by not eating for a period of time and it doesn’t really matter what meal you skip. 

26:33  When people follow a ketogenic diet for too long, the body will think it’s starving and will hold onto fat. We have to have periods of feasting as well as periods of fasting. And we should change our diet based on the seasons and environmental changes.

27:43  To measure cellular aging vs biological aging we can use telomere testing.  Telomere testing measures the length of our chromosomes and we now have DNA methylation testing. Looking at your telomere length is like looking at the tread you have left on your tires. To promote better cellular aging it is best not to do low carb or keto for too long.  It’s best not to do too much fasting since stimulating autophagy long term is not good. It’s also not best to do vegetarian all the time or to eat a bodybuilding high protein diet. For short periods, a high protein diet can be healing, but for long term, high protein will age you by stimulating the mTOR pathway. It’s best to alternate periods of fasting with feasting, moving in out of low carbs and higher carbs. The magic is in the change.

30:12  While a ketogenic diet has less fiber and stresses the microbiome, this will actually help to increase bacterial diversity once you come off the ketogenic diet.  By stressing your microbiome, you stimulate change and improvement, much like exercise stresses your system to make you stronger.

34:46  When you follow a ketogenic diet initially you start to burn fat for energy, so you produce ketones and during the first week or so you spill a lot of ketones into the urine and these can be measured with ketostix. But once your body gets used to using ketones for energy, when you become fat adapted, you will no longer spill a lot of ketones into the urine, so you need to measure ketones in blood instead of in urine.

 



Dr. Daniel Pompa is a global health leader and innovator on a mission to educate practitioners and the public on the origins of inflammation-driven diseases, cellular detoxification, fasting strategies, and diet variation principles.  Dr. Pompa is the host of Cellular Healing TV, and the author of the books Beyond Fasting and The Cellular Healing Diet. His website is DrPompa.com.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



 

Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz host of The Rational Wellness Podcast, I talk to the leading health and nutrition experts and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Hello, Rational Wellness Podcasters. For those of you who enjoy listening to The Rational Wellness Podcast, please give us a ratings and a review on Apple podcasts. If you’d like to see a video version, please go to my YouTube page. And if you go to my website drweitz.com, you can find detailed show notes and a complete transcript.

                                Today our topic is fasting with Dr. Daniel Pompa. Fasting is one of the oldest healing strategies in natural medicine. And it’s been advocated for thousands of years by alternative health care practitioners and utilized by almost every religion today that’s around. For years the medical community has essentially dismissed fasting as having no randomized double blind clinical trials, proving that fasting has significant benefits for reducing or curing diseases. But the studies have been accumulating especially on intermittent fasting. And Dr. Valter Longo of USC has been publishing a number of scientific articles and a book that have really been placing the spotlight onto fasting, highlighting some of the anti-aging benefits with his fasting mimicking diet program that involves eating a low calorie diet while eating only food products contained in his ProLon kit. That includes a low protein vegetarian nutrition plan.  Dr. Daniel Pompa is a global leader, and an innovator on a mission to educate practitioners in the public on the origins of inflammation driven diseases, cellular detoxification, fasting strategies, and diet variation principles. Dr. Pompa is the host of Cellular Healing TV, and the author of the books Beyond Fasting, which is going to be the focus of our talk today, and The Cellular Healing Diet. Dr. Pompa, thank you so much for joining me today.

Dr. Pompa:         Yeah, thank you for having me. I love these topics.

Dr. Weitz:            I just think it’s so interesting that I’m a chiropractor. You’re originally a chiropractor So many of the smartest people in the functional medicine world are chiropractors for whatever reason.

Dr. Pompa:         There’s a reason it’s because we share a major premise of the fact that the body has innate intelligence that heals itself and all we can do is remove interference and it does, right? And so fasting is one of those things that harnesses that innate intelligence and allows the body to heal itself, and that’s the magic. That’s why we all unite around that philosophy, honestly.

Dr. Weitz:            How did you get so interested in fasting?

Dr. Pompa:         It was back in the ’90s. I joke because I say it was just me and some natural hygiene society guys that were into fasting. That was a vegan vegetarian group, but they were all really big into fasting and there’s a guy named Herbert Shelton that read a lot of books on fasting and so I would go to the seminars. I was intrigued by fasting because again, it’s the philosophy of the innate intelligence, right? It’s like the body heals itself.   Yeah, I got very sick, so it was something I had to apply to myself but fasting does, it harnesses that innate intelligence and my fascination with it came out of that.  Back then it was very few people are into it.  And now it’s popular, I just had to stick around for 20 more years.

Dr. Weitz:            These trends in natural health world. So what is the definition of fasting? And then what is intermittent fasting? Because those are two terms you hear a lot, and I think there’s some confusion over exactly what fasting includes.

Dr. Pompa:         Yeah. So intermittent fasting daily is where you just don’t eat for a period of time, maybe it’s 12 hours, 15 hours, 24 hours, right? That’s an intermittent fast and you can do it daily. Now, extended fasts are when you take and you go without food beyond that, maybe it’s two days, maybe it’s three. I prefer and always have five-day fasts. And I believe there’s a magic number in that five days. But with that said, there are certain conditions that you will benefit fasting longer.  But there’s also a time to stop fasting and we talk about all those things but extended fasts has different benefits. Some of the same benefits is intermittent fasting daily, where you just do that 15 hours, 18 hours, whatever it is. So some of the same benefits you pick up even at a short fast like that, but certain conditions, certain health aspects, extending it longer is critical.

Dr. Weitz:            Yeah. I interviewed about a year ago Dr. Alan Goldhamer and he-

Dr. Pompa:         Yeah.

Dr. Weitz:            … puts people in 30 days medically supervised fasts.

Dr. Pompa:         Yeah, and there’s a time for that. Back in the day, I took some people through some really long fasts and they definitely have to have more body stores just to put it nicely. Certain tumors, a bit longer fasts. I fasted a woman, it was probably about 26 days, she had a grapefruit sized tumor and man it took that many days to bring it down to it was about a golf ball. And then she fasted like another week after three months and then she got rid of it completely.  But in that time, her first week was horrible. She was detoxing, her tongue went from coated white to coated green to black and fuzzy and her family literally had to cross ventilate the house. They had a fan on one side and they would open the windows and blow it through because she stunk up the whole house, right?

Dr. Weitz:            Wow!

Dr. Pompa:         In the first week, she came in complaining to the clinic everyday. Oh, my gosh. Right? And then after that she came bounding in every day with her reports of healing. So I’ve watched fasting really deep, deal with some incredible things and I’ve watched incredible things happen with the fast. But I learned through that process is shorter, five-day fast. You can achieve the same thing with a lot less pain, multiple five-day fasts. And why five days? Because look, it takes about three days for people to go, “Okay, I can do this. I actually lost my hunger. I actually have energy back.” So I would always carry them at least one more day, right? But again, three days is suffering. So day four was like, “Okay, it’s a good day.” So why not carry an extra day, day five, when they finally feel good to get that healing. Look, I didn’t know a lot of the science back then because there wasn’t any frankly on some of this.

                                Now, we know that some magic happens day four, we hit max autophagy. What autophagy is, is this happens during fast, the body to get energy eats. It’s so intelligent. Here’s that inborn intelligence thing right, that heals the body. It’s so smart, it wants to survive. It will eat only the bad cells of the body. It’s that smart to even know, here’s bad DNA, here’s a bad cell. It’ll take those out and not harm the good cells. So autophagy is the body getting rid of these bad cells and other debris and rubbish that it needs to get rid of. It’ll eat that first. That’s autophagy. So when I use that word autophagy, so think of auto automatic. Phagy as eating, so automatically eating the bad.  So what happens is, is during that this fast, day four we have max autophagy, meaning that all of a sudden the body’s just crushing bad cells, why would you cut it off then? And then day five, we see what we call max stem cell production. Because every time the body gets rid of a bad cell, it doesn’t just go, “Oh, you’re going to have to live without that white blood cell.” No, it stimulates and produces a new white blood cell via of the stem cell production. So about day five, we see this massive rise in stem cells.  And then after that, there’s a plateau effect. So if we do multiple five-day fasts, we maximize the autophagy, we maximize the stem cell production and we also maximize the hormones. We have this massive growth hormone rise that takes place day five. So multiple five-day fasts is how you can shut off autoimmune-

Dr. Weitz:           And a fast for you is water only right?

Dr. Pompa:         Yeah. I do prefer water only.  So you mentioned Valter Longo, right?  I love Valter and his group.  Pleasure to work with them.  I thank God for some of his studies because he really brought what we learned clinically years ago five-day fast is he’s the one that really spearheaded that max autophagy, max stem cell and some others have done that work too.  But so he’s brought a lot to this.  One of his studies was taking five months and this was an animal study, a rat study. Type 1 diabetic rats and fasting them. And really watching the beta cells regenerate because of the stem cell rise that takes place and after month four and five, we would see this the beta cells coming back and they were able to reverse the condition. So more and more studies, very exciting have been done, so I thank Valter for that.  But Valter and I definitely disagree in that I think that again, I train doctors on these topics. And clinically, I can tell you the most powerful still is a water fast.  Now, I still utilize partial fasting and I have for years.  So Valter’s fast where he boxed the foods for five days.  I’m a big fan.  I think it’s easy.  I think it’s a great partial fast, and I’ll explain what that really is because there’s a definition of partial fast.  I’ve used it for many, many years.  And oftentimes the first fast I’ll do with someone is in fact, a partial fast, and then move them to water fasting, which is a little more aggressive in getting rid of bad cells.  So I’m a fan of pure water fast.  But yet, I’m still a fan of partial fasting. Okay, so…

Dr. Weitz:            So partial fast, you’re not getting the same benefits as a full fast.

Dr. Pompa:         Yeah. You’re still getting a lot of benefits, you still get autophagy, you still get stem cell production. We have a way of measuring autophagy, and I talk about that in my book that doing your fast you can measure this in a very simple way. But we don’t see as much autophagy in a partial fast as a water fast.  And Valter really loves the partial fast. I have a lot of respect for him. But again, clinically, I just see, in a lot of the studies, they just put the average person into a water fast. It’s a mistake, you’re going to not see these major benefits. In my book. I have a seven week program. This is what you do five weeks up to the fast. Week six is the fast, week seven is breaking the fast. So it takes you through that whole process.  You don’t just run a marathon, you train for a marathon. So number one, you can finish it. And number two, you get the best result, right? So you don’t just do a fast. My book takes you through how to train for it. So a lot of the studies that just do look at water fasting or taking someone who’s not fat adapted, they’re not able to fast very well. So they’re not getting these benefits that I’m talking about right out of the gate.  So anyways, the bottom line is Valter has made the partial fast very popular, and he even boxed the foods that follow the rules of a partial fast. So what is a partial fast? If you have to get your calories, depending on body size down somewhere between 500 calories a day to 1000. Figure people can do a little more calories. Protein is important. You have to get your protein at least under 20 grams a day. The reason is, is if you have too much protein, it will knock you out of that autophagy. You won’t get any autophagy, so you have to get the protein down.

                                So a smaller person, you might need less protein, even under 15 grams of protein a day. So Valter put those in five boxes. So you have what it is you’re eating. In my book I give a partial fast, you can design it yourself around the foods you like, right? So I talk about that. But yeah, so partial fasting you still get the benefits, you still autophagy, you still get stem cell production. Water fasting, you get something a mass of what I call energy divergent, where your body has so much energy not eating any food, it has so much extra energy that it takes that extra energy and it just doesn’t sit on it and have a vacation. It takes it and all of a sudden the stuff that it wanted to heal, but it couldn’t because you never gave it a break. It takes energy and it starts healing it.  So maybe it was a knee problem from 20 years ago. All of a sudden, you get this knee pain, that’s the body healing it. It will divert these extra stem cells to the knee and start healing it. Maybe it’s kidney pain. Maybe it’s this pain, whatever it is, the body will take that extra energy, utilize its stem cells, and magic happens.

Dr. Weitz:            And of course, right now we’re going and at the time of this recording, we’re going through the corona virus pandemic. And fasting is actually something that can stimulate immunity.

Dr. Pompa:         Yeah, very much because, one of the things that back in the 90s was a criticism of fasting was it lowers your immune system. Because we would do blood tests, right? And you’d see this massive drop in white blood cells. Well, that can’t be good. But clinically, we’d say, “Wow! But we see the opposite.” We see autoimmune which is mean hyper immunity, which is really bad immunity, right? Where your body’s hyper responding, creating inflammation, sick people, people don’t feel well will have autoimmune even if you don’t diagnose, your body’s attacking itself, not good.  We see a lowering of the autoimmunity. And then we see this rise, especially a month or so after a fast of the good immune system would go up. Well, now, one of the Valter studies showed this drop in white blood cells is the autophagy, meaning the body gets rid of these old white blood cells, immune cells that are living too long. We call them senescence cells. They live too long, they cause mishit, they drive inflammation. They don’t work. They’re like union workers. I just insulted somebody out there. I didn’t mean to do that. I met like the bad union workers, the guys that sit around. The PennDOT guys or what are those? Government workers. There’s the word I was looking for, not union. Sorry, union people. My father was a union guy, didn’t mean that. The government workers they get paid anyway, so they don’t want to do anything.  So anyways, there’s probably better analogies out there but insult nobody. I don’t mean that. The point is, is these white blood cells that live too long, they just hanging around causing bad stuff to happen not doing their job. So what we learned is that drop in white blood cells, the body eats those guys out. And when we get rid of those, it stimulates a stem cell and it  creates a brand new white cell that is working and doing its job. So it’s like hiring the good employee again, right? It’s like, bam, doing everything correct. And so that’s how you end up with better immunity.  So right now, with this virus, I’ve recommended people to fast. My kids, they all fasted together, they did a five day water fast, and upregulated their immune system to preventative levels.

Dr. Weitz:            Cool. So, in order to do to get ready for the fast, in your new book you talk about putting people on a ketogenic diet. So what exactly does that consist of?

Dr. Pompa:         Yeah, so chapter one is fat adaptation, becoming fat adapted will get you into this autophagy instead of taking four days to get there, you can get there day one. And in the book I talked about, again how to measure that. We look at ketone levels, glucose levels, but there’s a ratio, but we can get there day one.  So chapter one is how to get your cells using fat for energy, because that will create more autophagy faster, and ketosis is that way of doing it. And then we take each chapter takes you through another step, then we start eating less often and we start doing some of that intermittent fasting. I call it mitochondrial fitness. We stress the mitochondria without eating in periods of time. Again, we’re training it for the fast that’s going to happen. And then I take you through some of my diet variation strategies, which is a whole nother subject, chapters four and five, really, how these various strategies take you to another hormonal level to become this efficient fat burning machine. So when you go without food, your body’s just crushing bad cells. So there’s a process there.

Dr. Weitz:            So in terms of weight loss, I know in your book, you say that the key to weight loss is to eat less often rather than eating less.

Dr. Pompa:         Yeah. Look, when we look at, especially in this country. We look at weight loss, you can’t flip a television on without a morning show anyway, talking about a calorie restricted meal, right? There’s a menu of low fat low calories, right? That is the cornerstone of weight loss still in this country, even though scientifically we know it doesn’t work. Now, when we say that though, people listening will say, “Yeah, okay. I want to believe you, but I restrict my calories, I lose 10 pounds.” And I would say, “You’re right, you do. And if you’re a bigger person, you may even lose 20. Gosh darn it, it works.”  Well, long-term it doesn’t because the weight loss ends up to be more muscle. Even if it’s fat, what happens is it’ll stop at a certain point because the metabolism gets lower and lower. As you restrict calories, the body eventually says, “I’m starving.” And when it says I’m starving, now it will start to use its muscle, break it down into sugar, it’s called gluconeogenesis. And then it will hold on to fat, which is not what you want. So therefore, now you can be down to 500 calories a day that used to work for you. Now you’re at 500 calories a day. And again, remember I said that a partial fast short-term, that’s great. But long-term, it’s very destructive to your metabolism and your health in general. So long-term caloric restriction does not work.   So how when we look at … we talked a little bit about anti-aging, right? You mentioned that I should say. When we look at that, there’s only one thing that really works for anti-aging, and that’s eat less. So you just said caloric restriction doesn’t work. So when we look at countries cultures that live long, healthy, we know they eat less, but they don’t do it the American way of pushing food away eating half your meal, caloric restriction. No, they don’t do that. They eat less by eating less often. And there’s our conversation of intermittent fasting daily.

                                So I typically eat two meals in a day in a very short window four to five hours. So I’m eating less often. At the end of the day, I eat less calories than the average American my age no doubt about it. But if I did the exact same amount of calories, but pushed my meals away, I still ate four meals a day or five meals or even three and I ate half of my meal my body would go, “You’re starving,” because you’re not eating too full. Something magic happens when you eat one meal to full a day.  So I always make sure I eat at least one meal to where I’m literally, even a little bit beyond full. The body likes that because it goes, “I’m not starving and I’ll keep using your fat.” If you start stopping meals and eating partial meals, the body will go, “I’m starving, and then it will start holding on to your fat.” So eat less often and eat too full would be the rest of that conversation.

 



 

Dr. Weitz:                            We’ve been having a great discussion, but I’d like to take a minute to tell you about the sponsor for this episode. I’m thrilled that we are being sponsored for this episode of the Rational Wellness Podcast by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturer of clinician designed, cutting edge nutritional products, with therapeutic dosages of scientifically proven ingredients, to help patients prevent chronic diseases and feel better naturally.

                                                Integrative Therapeutics is also the founding sponsor of Tap Integrated, a dynamic resource of practitioners to learn with and from leading experts and fellow clinicians. I am a subscriber and if you include the discount code Weitz, W-E-I-T-Z, you’ll be able to subscribe for only $99, instead of $149 for the year. And now, back to our discussion.

 



 

Dr. Weitz:              I think it’s so ironic that I’ve been doing this for over 30 years. And when we started, the big key to helping people lose weight was the fact that people rushed out of the house with eating breakfast, and then they would eat too much for dinner. And so for years, the mantra was, you have to eat breakfast. You have to eat within an hour of waking up. You got to have small frequent meals throughout the day.  And it’s just so ironic that now … so before then the key to being healthy was having breakfast, having small meals spaced throughout the day so you can keep an even blood sugar. And now the key is skipping breakfast.

Dr. Pompa:            You know it’s funny as I some years ago, I think it was 2005 was the first time I had the opportunity to go visit this hunting gathering tribe in Africa. And I was still a four or five meal a day person, like you’re saying, right? That philosophy, and I saw something completely different. I saw a tribe, I said, “Where are the men?” They were up and gone at like 4:30 in the morning when it was still cool off in their hunts, tracking down pray, and they’d be gone all day to three or four in the afternoon. “So how do they eat? What do they do?” “They don’t eat at all.” They’re out all day tracking down pray. So oftentimes jogging, running, right? It’s like, “And they do without food?” “Yeah.” And then I noticed the women never eat, even the ones that were gathering. They weren’t eating because they would wait and eat one meal together as a tribe. Now that meal may have lasted three hours, right? They’d start eating and start preparing but, a very European way of eating.  And I was fascinated by it because these people were lean, ripped. Amazing, right? Without disease, it was a pretty amazing experience. It made me question that, like, what are we doing? It’s like, because every time you’re eating, you’re basically not allowing your body to burn its own fat. But like caloric restriction, it works in the beginning. Because if you’re eating five meals a day, your body’s not eating its muscle, it will prevent that. So it maintains the metabolism that way, and people feel that but the problem is, we never give it a chance to burn it’s stored fat, that’s what our bodies are designed to do.

                                So long-term, you want to live long, healthy, eat less, but eat less by eating less often, and that’s what we see very healthy in the Hadza people did this. So were basically short cutting something that works short-term, not long-term. And that was the five meal a day thing. And by the way, eating breakfast in the morning, that’s the most natural meal to skip. And the reason why is because you get something called the dawn effect. In the morning, oftentimes you’re not hungry because your body releases glucose. If you test your glucose, the highest glucose you have all day long in the morning, because your cortisol rises to get you up. That’s what gets you up in the morning. Glucose falls cortisol. So that just means your glucose goes up. And that gives you your energy for several hours after you get up, right? So that’s why you’re not hungry because your glucose is high because of your cortisol level. So that dawn effect of glucose we’re meant to run on, and then again, you can run on that for pretty long time.

Dr. Weitz:            Yeah. I know for me, for some reason, I do better if I have a good breakfast. And if I’m going to skip a meal, I’ll skip dinner.

Dr. Pompa:         I was going to say this. So people always asked me, “Well, which meal should I skip if I’m going to eat two meals?” I said, “Whichever one works best for you and your schedule.” In other words, if eating dinner is important to your family you can’t skip, then eat dinner. Skip breakfast. If for you it’s the other way around, right? And some people for diabetics, I’ll have them skip dinner and eat the breakfast and skip dinner. So it’s whatever works. The key is, is just opening up that time giving your body time to go through autophagy, and giving it time to fast. It doesn’t matter what meal you skip, really.

Dr. Weitz:            When people follow a ketogenic diet or try to follow a ketogenic diet, what are some of the biggest mistakes they make? Why are they not successful? Can’t produce enough ketones? What are some of the mistakes that people make?

Dr. Pompa:         One big mistake is, first of all, I’m not a believer that there’s one diet, you should stay on your whole life, right? That tribe that I spent time with, they were constantly changing their diet based on what foods they have, environmental changes. So in my book, I talk about seasonal variation, how important that is, and weekly and monthly variation. And if you’re low carb too long, the body will think it’s starving, and we need times of feast and we need time to famine. And that balance is emulating these really healthy cultures. So it’s really key for hormone optimization. And that’s really how we age slowly, right? So, I’ve been able to measure my cellular age every way possible. And I spent some time sick some years ago, and my cellular age was much older than my actual age. Now-

Dr. Weitz:            What method for measuring cellular aging have you found to be the most effective or accurate?

Dr. Pompa:         Well, telomere testing has gotten better.

Dr. Weitz:            Right.

Dr. Pompa:         That measures … It’s the biological clock that, protects our DNA and the shorter they get the closer you are to death, simply put. It’s gotten better and better and more accurate, but now that we have DNA methylation testing.

Dr. Weitz:            Right.

Dr. Pompa:         If the given analogy, looking at your telomere length is looking at the tread you have left on your tires. DNA methylation is looking at the parts of the engine, how well are your organs aging, compared to your … Look, I’m a mid 50s, I’ll be 55 this year. I’m getting younger every year at the cellular level compared to my actual age. And I was the opposite. And again, everything I’m saying right now is what I do and how I’ve done it, amongst other things. But you will age according to your cellular health. Honestly, on the outside is what I’m saying.  Right anyways, so diet variation strategies is a anti-aging strategy as well. Shifting your diet is critical. So the answer to your question is one of the biggest mistakes for people is they try to stay in ketosis all the time or low carb, big mistake. And again I’ll throw criticism both ways. Staying vegetarian all the time big mistake. Staying keto, paleo all the time, big mistake. If you want to die sooner, eat a bodybuilding diet high protein diet will age you sooner, right? But eating high protein for short periods is very healing, right? So it stimulates a pathway called mTOR, mTOR long-term is bad for you. Low mTOR stimulation short-term very good for you, that means high protein or high calories that stimulates mTOR.

                                So too much fasting is not good that stimulates the autophagy pathway long-term is not good. So variation, you need autophagy to get rid of bad cells, you need mTOR to stimulate production of new cells. So feast famine, I talked about in my book and how to do feast famine. So when people do ketosis, the big mistake is just staying in ketosis. Big mistake, you need feast, you need famine, you need moving in and out of high healthy carbs, low carbs. The magic is in the change.

Dr. Weitz:            Cool. You also talk about how ketones when you’re following a ketogenic diet helps to heal the gut and helps to diversify the microbiome. But one of the traditional criticisms of the ketogenic diet is that there’s not enough fiber which typically comes from starchy vegetables, beans, grains, seeds, and so that a ketogenic diet tends to starve the microbiome.

Dr. Pompa:         Great question. Let’s make it even more extreme. First of all, with the improved testing on being able to measure the microbiome or like the types of bacteria, the amount of bacteria in our gut, right, we call that the microbiome. That’s not just bacteria, but viruses, funguses, right? It’s all of these pathogens and everything that’s included in our gut.

Dr. Weitz:            Right.

Dr. Pompa:         Okay, so we have better testing to measure. The one thing that we can take away from all of this testing really isn’t what we thought in the beginning we would get, we thought, we’re going to be able to be able to, “Oh, there’s these bad guys, you have this too many bad guys, you have too many this.” It really didn’t turn out like that, it turned out to be diversity. If we look at very healthy people, their microbiome on a test versus unhealthy people, the one thing that stands out is not what type of bacteria, it’s the diversity of the bacteria. The more diversity, the healthier the person.  So the question should be then how do we increase the diversity? Stress the microbiome, honestly, just like how do I get more fit and healthy? Exercise, what’s good exercise? You have to stress your body, right. If you stress it too much, you won’t recover. Not good, right?  And the more the better shape you are, the more you can stress.  So fasting is a stress. When you change your diet, it’s a stress to your microbiome.  So my point is going to be this.  Take a carnivore diet, that’s an extreme diet of eating only meat and fats. Zero fat, okay. It’s caught on out there, right? People are showing their pre blood and post blood tests, you would think eating only meat and fat? Oh, my gosh, their cholesterol must go up. Obviously, it’s the opposite. Their blood test transforms.

                                Now, the challenge that I propose is stay on that diet.  Maybe genetics carry you a year, maybe two. But now all of a sudden, you’re going to see massive changes the other way.  Now, let’s pick on the other side, you have the vegans, right?  So I got on the diet.  I felt great.  Stay on that diet, we’re going to start to develop certain deficiencies. The point is, I love being vegan or vegetarian for a period of time, I love being on a carnivore diet for a period of time. So to answer the question how you increase the diversity of your gut, do those extremes.  So going without fiber for a month on a carnivore diet, it stresses those bacteria, oh, they don’t die, they back up, they get stronger, they get resistant, and then you start eating again. And they’re just they take off and they get four. So we know that the change of diet, the more you change your diet, like the Hadza people, the more diversity you have in your microbiome.  So it’s magic.  It really is.

Dr. Weitz:            Now it’s tricky to change your diet. I know over the years, when if I change from eating more animal protein to suddenly eating more fiber, initially, you start getting GI upset and your enzyme system isn’t ready for that change. So …

Dr. Pompa:         Yeah. To your point, and you know what’s happening because here’s what, your body has to change its microbiome to make the enzymes that it needs to start breaking down. Eventually, it adapts. So the advice is just take it slow. Take it slow. If you just drastically change, your body will catch up, but you’re going to have to deal with symptoms. All right, so if you just go slower, then maybe when you first start eating more meat, you’d have to take some HCL, digestive enzymes, HCl or bile, the body will change its microbial and start producing more bile, it will start producing more HCl. It’s that smart.  It is, but it takes some time.  So your question or your comment really gives an explanation for why the diversity increases because it has to survive.

Dr. Weitz:            Right. So when patients try to follow a ketogenic diet, a lot of people will recommend that they use these urine Ketostix. And that’s a way to measure if you’re excreting ketones in the urine, but some people use those through their whole ketogenic program and that’s not really appropriate, right?  Why is that?

Dr. Pompa:         Yeah. Ben, you’re well read. Yeah, you’re right. And I’ve had good doctors say, “Well, my diet gets you in ketosis in two days.” I’m like, “Really? How are you measuring that?” “Urine.” Okay. You eat more fat in the diet, you’ll start producing more ketones. You’ll see them in the urine. So what happens is ketones, let’s back up. What are ketones? I don’t know how educated you’re listening audience is. But ketosis means that where your cells can use two things for energy, sugar or fat. So when we become fat adapted or going into a ketosis diet, we’re shifting the cells energy to where 95, 98% of the energy is from fat, not sugar, right? So we reduced our carbs down to so low that it has to eventually to survive use fat. When it burns fat, it makes something called ketones because your brain can’t use fat as energy. It can only use sugar or ketones. So when we drop sugar down, it burns the fat. The body uses the fat as energy, and then it makes ketones and your brain uses the ketones.  Okay, so just a little bit of chemistry there. So ketones have a major healing effect on the body for your brain. We know that keto diets would take people out of seizures, neurodegenerative conditions, alters people’s brains wake up. Hugely healing for the brain and the gut. That was one of your questions earlier.   We also know studies the ketones help heal the gut. Again, staying on the diet can create problems, down the road, but by shifting people over into this fat about the diet and making ketones, it’s magic. So the first week or so we see this urine rise up if ketones, and then we see it go away. Well, where did they go? Because now the body’s actually using the ketones and you don’t see them in the urine anymore. So it takes about two weeks for someone to fat adapt to become keto adapted. And one of the telltale signs is you don’t have ketones in your urine as much anymore. So means your body’s finally using. So we can’t use urine as a good measurement. You have to use a little blood.

Dr. Weitz:            Right. So let’s see. How long do you recommend people follow this ketogenic diet?

Dr. Pompa:         Again, it’s different for everybody, and it’s interesting, because one of the things that some of your viewers may be saying is, “I tried it, didn’t work for me.” And, well, that’s just that it works for everybody because the body is meant to go in these ketosis states. But when you’re really stuck in is a sugar burner, you meaning your cells can only use sugar, it’s oftentimes hard to break out of that. It’s very dangerous just to be in that zone, it can lead to cancer and other problems. But what we’ll do clinically, is we’ll take somebody and put them in a keto diet for like, two, three months. They’re hardly getting in whether you’re measuring your blood ketones, and you have to be above 0.5 to say, “I’m in ketosis, right?” And their 0.5, 0.6, 0.3, 0.2, they’re in they’re out, they’re barely in. What’s going on?  We’ll pull them out of a ketone diet after two months, put them on a healthy higher carb diet. Two months later, we put them back into a keto diet. And by the way, when they’re on keto, they’re not feeling good yet, right? They’re just not using the ketones, their brain’s not using them, they don’t feel good. We move them back to a higher healthy carb diet. Now they feel good because they’re using more sugar again. So then, two months later, now we put them back into ketosis. Now their ketone numbers go higher 0.8, 1.2, 0.3. I still feel great, but better, and then we’ll move them out again.  So we’ll do that a few times. And then each time they get more fat adapted, each time they get more grit. So we actually use that variation strategy to help people break through into this phase that everybody should be able to get into. So answer your question, sometimes two months, sometimes three months, sometimes six months, and but I always move them in and out of the state.

Dr. Weitz:            Are there some people based on their genetics and their lab values that maybe shouldn’t do a ketogenic diet? For example, maybe patients who have APOE-e4 variation?

Dr. Pompa:         Yeah. Look at our bodies, everybody can benefit from it. Why? Because it’s survival mechanism. It’s a survival mode. And during survival modes, the body turns off bad genes that have been turned on. it’s called epigenetics. It resets the microbiome, right? You get rid of bad cells, because bad cells don’t adapt to the stress of ketosis. So I believe that it’s a stressor that everybody can benefit. Fasting is the same way, meaning we’re genetically programmed to fast. The problem is today is we’re always in a feast mode, whatever diet you’re on. We always have access to food, it’s not healthy. We’re meant to go through these resets and fasting gives us that reset. Ketosis gives us a reset.

Dr. Weitz:            Right? But what about, let’s say somebody goes on a ketogenic diet, and then you say, do lab testing and you find out that there’s small, dense LDL is shooting up?

Dr. Pompa:         Interesting. So when I am in a state of ketosis, my particle numbers of cholesterol rise up, which I always educate people that total cholesterol doesn’t matter.

Dr. Weitz:            Right.

Dr. Pompa:         Typically, with total cholesterol, you’ll see that drop and triglycerides will drop typically in ketosis, right? But total cholesterol doesn’t matter but the particle numbers and the size do in fact, matter. It sounds like you know that. When I’m in ketosis, I’m in about a 20% group that actually sees a rise in my particles. And yet, all of my inflammation numbers drop dramatically. So I struggled with that for a while, what’s going on? And I found out that there’s 20% of people that that happens. And there’s theories around why that happens. But one of the things is they learned that it’s not a dangerous state, the body’s raising up the particles to carry more cholesterol, and it’s doing … it’s an adaptation mechanism. But the fact is, as my CRP drops, all of my inflammation numbers that we possibly measure drop down, showing that it’s really not an inflamed state, and I’ve done that with some others like myself, who get that phenomena opposite.   So the point is, is when most people go into ketosis, we see a drop in particles. That’s most people, 80% of the people.

Dr. Weitz:            Right.

Dr. Pompa:         But again, I would argue if you stay in that state too long, you could see a shift again, right? So we’re all genetically different. I think that’s the point you’re making. But one thing is, is that we all need variation. I don’t care what diet is best for you. All we need is variation. Now, how long you can stay vegetarian successful without creating certain deficiencies, genetics will determine that. How long you can stay in a carnivore or keto diet without creating problems, genetics will determine that, but we all need change.

Dr. Weitz:            Can you do ketogenic diet and be vegetarian?

Dr. Pompa:         Yeah. No, you can because the key to it is low carb. So and when we look at ketosis, the average with the way to get into ketosis is get your carbohydrates down below 50 grams a day. Now that’s net carbs. What that means is you minus the fiber, so think of it this way, and a cup of blueberries. Let’s say it has 15 grams of carbs and seven of them are from fiber, you minus the seven and you’re left with eight net carbs. So vegetables typically, some of them can have high carbs, but when you minus the fiber, you’re at a much lower net. So it’s very easy to lower your carbs below 50 on even a vegetarian keto. I put people in a vegetarian keto for different reasons. And sometimes I put people on high fat, with a higher meat, so there’s a lot of different ways to do ketosis. You can do ketosis on any diet really, except high carbohydrates.

Dr. Weitz:            Do you lose muscle when you fast?

Dr. Pompa:         No, here’s the funny thing, right? So I told the story in my book. My son, Isaac was like, “I want to put on muscle. Why would I fast?” I said, because you need to get rid of the bad muscle that’s not adapting anymore. That’s why you’re not getting gains in the gym anymore.” And so I gave him a challenge. So he fasted and he lost about eight pounds. Very typical, I would say, I told him you’d probably lose 10. Anyways, and, “Oh my gosh, I’m losing.” I said, you only lost bad muscle, the body’s too smart for that. Now watch what happens the next month. So the bet was that he would put on not only that weight, but he would for the next few months, he would actually gain weight and he did. Because the body, it really gets rid of the muscle cells that aren’t adapting causing problems, inflammation.  You remember, you don’t make gains in the gym. You make gains when you’re recovering. So by getting rid of bad cells via autophagy, the body will recover faster. Arguably his microbiome got better, his assimilation got better. But we even use fasting for people who can’t gain weight and they end up putting on muscle after a fast so typically a month after you’ve gained your your weight back and then some muscle.

Dr. Weitz:            So it’s really about stimulating the body, stressing it and then having the body adapt in a positive way, which is as you mentioned, what happens with exercise.

Dr. Pompa:         That’s right. Yeah, exactly right. Everything is about adaptation. So the key to the stress of fasting is creating a hormone optimization. Because of forcing the adaptation, how does the body adapt? It does it via hormone optimization. So when we look at that day five of a fast, I said, we see this maximum growth hormone rise. Even after one day of fasting, the body raises up the growth hormone and you know why? It’s holding on to its muscle. It knows I need it to fight or flight. It knows it needs the muscle, so it raises a growth hormone, and it stops the loss of muscle, and it only allows the loss of bad tissue.

                                And even your cells become more sensitive to hormones, which carries on after the fast. So I talk about in the book, how to hormone optimize using these strategies, even when you change your diet. Let me give me a great example with exercise because I think all of your listeners can understand this. If you start exercising, you always get a benefit. I don’t care what type of exercise you feel better, whatever benefit is, you feel better, you get a benefit when you start exercising. However, if you still do the same thing over and over again in the gym, it plateaus. Oh, and then now there’s a plateau, you actually start losing things and you’re like, “What’s going on?” Hire a good trainer and he goes, “Oh, you just have to change your workout,” and you start getting benefits again. Why? And then a good trainer changes your even every routine, he changes things, right?

                                So because the moment you change, the body has to readapt and then it does it by hormone optimization. So every time you force your body to adapt that it does you get stronger, you get better. Same with diet. So you start the new diet, whether it’s vegan vegetarian, carnivore, whatever it is, I feel so much better. And then not maybe like this first few days, you know how it is your body shifts around but eventually you feel better. So you become a firm card carrying paleo diet person, right? That says me because it helped me I’m a vegan, and I always will be because it helped me.

                                Now here we are a year later. “Yeah, I’m fatigued.” It’s not the diet because this diet helped me, right. But then someone comes along, convinces you to change your diet. It’s like, “Oh, my gosh, I feel so much better.” Don’t be a card carrier, the magic is the change like exercise, just keep changing the diet, keep changing exercise force the body to adapt, and your microbiome will change. You’ll turn off bad genes. I hormone optimize. All of that happens when you change your diet, just like exercise.

Dr. Weitz:            That’s great. Dr. Pompa, any final words for our audience?

Dr. Pompa:         Well look, at this time, as we said, I would argue all of it starts with mindset, right? It’s like, during this time of this Coronavirus, I’ve told my family, the doctors that I train, this is an opportunity to change our lives for the better. Or you could focus on the fear and your life will get worse. It will, you’ll get more sick, you’ll gain weight, you’ll feel worse, you’ll make less money, all these bad things.  My heart breaks for people who aren’t able to work, but out of these times is a soil ripe for change. You will come out of this stress just like fasting, making less money, being trapped at home, you will come out better, but you have to choose it. You have to think about it now, set the intention that this is an amazing time. Thank God for this time, out of it will come creativity, a job change you needed. You’ll look back if you create these intentions and say, “That was one of the greatest times in my life.”    So even though the adversity is hard now for us, and I believe that they are not minimizing your stress, but you have to change the intention to opportunity in what you can change. And believe me, fasting is another way of changing those intentions and creating new ones, because it just adds that stress. So I challenge you to fast and I challenge you to change your mindset.

Dr. Weitz:            That’s great. And how can our listeners and viewers get ahold of you and find out about your books and programs?

Dr. Pompa:         Yeah. The link is … if you go to it right now, that’s a first book. We really haven’t even have the hardcopy yet. So there’s still one more editing that goes back so you all are getting a special prelaunch right there. So if you go to beyondfastingbook.com you can get that prelaunch, beyondfastingbook.com and you can check it out. And then you can go just to my website drpompa.com. So Dr like doctor. D-R and then P-O-M-P-A.com. So there you go.

Dr. Weitz:            Awesome. Thank you Dr. Pompa.

Dr. Pompa:         Yeah, you’re welcome. Thank you for having me.

 

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Cancer, Incorporated with Dr. Ralph Moss: Rational Wellness Podcast 160
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Dr. Ralph Moss talks about Cancer, Incorporated, his latest book, with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

3:45  Dr. Moss shares some thoughts about the current coronavirus pandemic, including that if every particle of coronavirus were visible with a light, we’d be amazed how widespread it is. He likes the medicinal mushrooms, including shitake, maitake, and reishi, for immune system support.  Dr. Moss is intrigued by the concept of Superinfection Therapy, which has been used in the treatment of hepatitis B and C and for the seasonal flu and the concept is that one infection stimulates the immune system that knocks out another infection, such as with a poultry virus that does not cause any disease in humans.

12:29  Dr. Moss discussed the use of the BCG vaccine, which is used for TB, and this shows some effectiveness both as a treatment and for prevention for the SARS-COV-2 virus.

13:56  The areas where there are the highest amounts of fatalities from COVID-19 are occurring in areas with high rates of air pollution.

17:07  Dr. Moss’s latest book is Cancer, Incorporated, which talks about the war on cancer and the drugs and the financial ties between the researchers and the drug companies and the regulators.  One shocking fact is that when we look at some of the new targeted drugs, like the immune therapy ones like Yervoy, which are used for solid tumor cancers during stage four, on average these drugs only extend survival by 3 to 6 months.  On the other hand, some people are completely cured by targeted drugs, such as former President Jimmy Carter, who had melanoma that had spread to his brain.

21:59  These newer, targeted cancer medications tend to have much fewer side effects than traditional chemotherapeutic drugs. But there are a number of questionable ways that they were able to get some of these drugs approved, such as that some of them are approved not because of curing any cancer patients but because they improve some surrogate marker, such as a score on a test. For a drug to get approved for cancer it should either cure you or extend life in a meaningful way or improve the quality of your life.  For example, some drugs are approved because they extend disease-free survival or progression-free survival, which may mean that there is actually no increase in the rate of survival from the cancer.  And these drugs can have a number of uncomfortable side effects.

29:40  Immunotherapy for cancer includes drugs like Yervoy, Opdivo, Keytruda, and Tecentriq, which are heavily advertised to the public.  Cancer tends to confuse and turn down the immune system, so these drugs activate the immune system and they can be very effective in certain cancers like melanoma.  They are also often referred to as immune checkpoint inhibitors. But these drugs are very expensive, costing approximately $150,000 and it may be most effective to take two of these drugs at a time. There’s new drug, Kymriah, a CAR T therapy drug, also an immunotherapy, that costs $475,000 per injection, while the actual cost of production is $20,000.  One of the justifications from the pharmaceutical companies is that they spend lots of money doing research and development for these drugs. But Dr. Moss points out that most of the basic research is actually done by the National Institutes of Health, by the government, paid for by taxpayers. After the taxpayers pay for much of this research, it is then handed over to big pharma, who reap most of the rewards.

35:15  These pharmaceutical companies can no longer be taken to court for price gouging since congress passed the Medicare Modernization Act of 2003. It included in the law that the government, which means Medicare, Medicaid, and the VA could not contest the prices, could not negotiate over the price of the drug.  The sole reason why the same drugs are cheaper in Canada than the United States is simply because they have a universal healthcare system that goes through the government, and the government negotiates those prices down.  This same provision that we not negotiate to lower the price of the drugs was also written into the Obamacare legislation in order to keep the big pharma lobbyists from opposing the legislation and keeping it from passing. When they were passing Obamacare, there were three times as many lobbyists from big pharma and the insurance companies for every member of congress.

40:25  Dr. Moss’s book Cancer, Incorporated highlights how money flows from big pharma to the oncology profession.  A lot of money especially flows to the key opinion leaders, the most influential doctors, the ones whose names show up on the key clinical trial papers. In fact, if you go to a website called Open Payment Data, you can track all the money paid to doctors by drug companies. This database was part of the Obamacare bill and it requires that drug companies have to reveal all the money they give to doctors, universities, and hospitals.

           



Dr. Ralph Moss is the former science writer and assistant director of public affairs at Memorial Sloan-Kettering Cancer Center. He is known for his Moss Reports which are detailed reports on the most common cancer diagnoses for lay persons and he also provides informational and personalized consultations for cancer patients. Dr. Moss was a founding member of the National Institutes of Health’s Alternative Medicine Program Advisory Council, and of the Complementary and Alternative Medicine panel. Dr. Moss has written a number of books, including his latest Cancer, Incorporated.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



 

Podcast Transcript

Dr. Weitz:            Hey. This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest and cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello, Rational Wellness Podcasters. For those of you who enjoy listening to the podcast, please give us a ratings and review on Apple podcast. If you’d like to see a video version, please go to my YouTube page, and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                                Today, I will be talking to the medical writer, Ralph Moss, PhD, who has written or edited 14 books and collaborated on four film documentaries related to cancer research and treatment. We will be talking about modern cancer treatment, especially chemotherapy and some of the newer targeted medications. Dr. Moss is a former science writer and assistant director of public affairs at Memorial Sloan Kettering Cancer Center in New York back in the ’70s.  Since leaving Sloan Kettering, Dr. Moss has independently evaluated the claims of conventional and nonconventional cancer treatments all over the world, and he currently writes the Moss Reports, which are very detailed reports on the most common cancer diagnoses for laypersons, and he also provides informational and personalized consultations for cancer patients and their families. Dr. Moss was also a founding member of the National Institutes of Health’s Alternative Medicine Program Advisory Council, and he has served as a peer juror for a dozen medical journals.  Dr. Moss, thank you so much for joining me today.

Dr. Moss:             My pleasure.

Dr. Weitz:            So, I definitely want to focus our talk on your latest book, The Cancer Industry, but before we do-

Dr. Moss:             Cancer Incorporated.

Dr. Weitz:            Cancer Incorporated, okay. Sorry about that. Cancer Incorporated. Before we do, I wanted to ask you a few questions about the current coronavirus pandemic situation that we’re in. At the time of this filming, that’s what’s going on right now in the country, and you can tell from this mark on my nose from wearing a face mask almost the entire day, which is not something I’m used to since I don’t work in an emergency room. I’m in private practice.   So, I know that you’re an expert at cancer, but you’re also an expert at integrative approaches to cancer, and as I think about this pandemic, I think that the way I like to look at a viral epidemic like this is the key, I think, from my integrative functional medicine perspective is that we want to make the host, which is us, very inhospitable to the virus stinking root and growing. I think of integrative cancer care the same way. We want to make the terrain of our body hostile for cancer to be able to take root and grow.   So, from your perspective, what are some of the most important things that we can do to protect our bodies against this coronavirus that’s spreading around the world right now?

Dr. Moss:             Well, as you say, I’m not an expert on this topic with the other 320 million Americans trying to figure out how to survive in all of this, and given my age, and some of other health conditions, I feel personally that my wife and I are at increased risk. So, we’re very vigorously following the standard recommendation, and treating like it is already in our area, although I live in Maine, and we have not been hard hit in the rural parts of Maine, but, of course, if every particle of coronavirus were visible with a little light on it, we’d probably be amazed at how widespread this thing is.  Actually, that’s how we conceptualize it. So, we do take very seriously the need to wear a mask and gloves and all the rest of it. In our community, which is a very small community, the neighbors have gotten together and made a group plan where we’re all in touch via instant messaging, which initially was for helping each other do shopping, and we’ve utilized that, but it also is a way to keep in touch and know if anybody’s gotten sick and where are things then. The first notice we got of the lockdown of the state was through that little informal messaging system. I think this is going on all over the country. It’s very, very good. Oddly, the social distancing has led to greater closeness among neighbors in some parts, at least, and this has been very good.

Dr. Weitz:            That would be a great positive that could come out of this situation is it actually brings the country together to fight this common condition.

Dr. Moss:             No doubt. No doubt. I think history will be rewritten to be pre-COVID-19 and post-COVID-19. I see it as that. Let me just get rid of this call. So, as far as what one could do about it, I think of this in two different ways. One is what can you do personally and then the other one is what can you do society-wise. Personally, I’ve written a blog about mushrooms, medicinal mushrooms.  Why? Because the strengthening of the immune system and the healing healthfulness of the immune system I think is very important. So, the things you would normally do to keep your immune system healthy and keep the numbers in a high normal range would be beneficial, and the most neglected supplement in that regard, I think, are the medicinal mushrooms, which have a tremendous amount of research behind them in Asia, not so much in the US.   People go to my website, which is mossreports.com, they’ll find my blog about this and how you could prepare a soup out of medicinal mushrooms, especially shiitake, maitake, and reishi or oyster mushrooms. Amazingly, almost all of the exotic Asian mushrooms also double as immune modulators. So, I think that’s important.

                                A woman that I knew when I worked as a consultant to the National Institute of Health, Jennifer Jacobs, MD, has put out a blog about homeopathy and COVID-19, which I thought was very interesting. She’s a medical doctor. She’s had 40 years experience with homeopathy. So, I think her word should be taken seriously.

                                Then I think also from a societal point of view, the ideas that have intrigued me the most about potential treatments have been the ones that work on the immune system, and two in particular. I’ve written a blog about one of them. The other one is very much in the news, if people search for it.   The first one is called Superinfection Therapy. It seems like a contradiction of terms to give an infection on top of an already existing infection. This has been used in the treatment of hepatitis B, hepatitis C, and seasonal influenza, flu in Russia from the ’60s to the ’80s. Hundreds of thousands of people who got basically non-disease-causing superinfections were deliberately given this. Some of them were given, for instance, the Sabin oral polio vaccine.   So, what would that do? Well, there’s a funny thing called superinfection where if you have an infection, you give another infection on top of it, sometimes that second infection knocks out the first infection. It’s like they’re competing for the same ground. You could think of it that way.  The other idea is that the superinfection, the second infection stimulates the immune system in a nonspecific way that then enhances your ability to deal with the first one. Whatever the reason is, there’s a lot of potential to this, and it’s been shown in other situations. This may be applicable to SARS type of infections, coronaviruses, and so forth. There’s a petition at the White House. The White House has the petition process and we have started the petition basically to bring this to the attention of Anthony Fauci, who is a big top scientist on the president’s COVID-19 taskforce. So, we’re hoping.   It’s a long shot, but if you get 100,000 signatures on a petition to the White House, somebody in the White House has to respond to it. So, we’re trying. What else can we do, right? There isn’t much more. We’re trying to-

Dr. Weitz:            Just let President Trump know how he could personally make an investment in a company that provides this therapy and you’ll be golden. It will be on every press conference.

Dr. Moss:             My problem in life is I’m always trying to find the least expensive, least profitable treatments. To me, the most effective treatment would be water or something, something that was free.

Dr. Weitz:            Sleep, exercise, right, meditation.

Dr. Moss:             Walk in the pine forest in Maine might be the best treatment. You know what I’m saying is that … So, that’s a treatment that would be incredibly inexpensive because the one that they use in Europe experimentally is a poultry virus. These poultry viruses are very good because they are highly contagious and active, but they don’t cause any human diseases. There’s a couple of them.  So, one of them is currently being proposed as a treatment. We’re not asking for anymore than a fair test initially, like a pilot study, and maybe 10 patients to start, and then, of course, we’ll work through clinical trials, although the clinical trial system seems to be tremendously under stress now for the obvious reasons.

Dr. Weitz:            Oh, sure, but there are actually a huge number of clinical trials that the FDA is allowing without the normal controls because of the situation we’re in. So, actually, the scientific community is very excited about the ability to launch somebody’s treatments.

Dr. Moss:             The other treatment that interests me very much is BCG, bacille Calmette-Guerin, which is the standard TB vaccine.

Dr. Weitz:            They use that for bladder cancer sometimes, right?

Dr. Moss:             Correct. Correct. That was your first use medical, well, repurposed use in cancer, and it’s used at very high level, instilled into the bladder mainly to prevent recurrences of bladder cancer, which are relatively easy to treat, but very difficult to keep from coming back.   So, they use the BCG, instill it, but BCG has many uses. It’s been in literally over a billion people. It’s given to babies. It’s considered, of course, a very safe thing, and it seems to correlate with lower rates of viral infections, but more importantly, BCG is being tried in Europe as a way of actually treating people.  Again, I think the philosophy is almost identical to superinfection theory, therapy in that it makes a nonspecific stimulation of the immune system. That can be enough to help the person in the initial stages to keep that virus from taking over the lungs. So, I think that this is very important.

                                Another one more thing I’ll mention, which is, and it came out, I mean, there was an article about it today in the New York Times, but there have been hints of this all along, which is that the greatest number of fatalities from COVID-19 are occurring in areas with high rates of air pollution.   I thought about this because I, luckily enough, and not by accident, I live in an area with very little air pollution. I mean, we get what blows up the coast from Boston, and maybe Portland, but that’s about it. I mean, so if you-

Dr. Weitz:            So, it’s probably a great idea that the president right now is trying to reduce the fuel emission standards on cars.

Dr. Moss:             Well, nature is carrying out an experiment, which is to reduce air pollution. So, we got the green new deal, but we got in a way we never expected. All the industries shut down. Car manufacturing is all shut down and so forth. So, in a way, I mean, it’s ironic that it took that in order to get us to reduce our pollution of the planet, but I’m not saying … This is more like a longterm thing, but it also points to the fact that the health of the lungs proves critical in a surprise, surprise, in a respiratory disease.   So, whatever you can do to improve the health of your lungs, whether it’s through exercise or through supplements, through walking in the woods, whatever you need to do, that would be a beneficial thing.

 



 

Dr. Weitz:                            I’ve really been enjoying this discussion, but now, I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure scientifically-tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners and preservatives.

Among other things, one of the great things about Pure Encapsulations is not just the quality products but the fact that they often provide a range of different dosages and sizes, which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. For example, with DHEA, they offer five, 10 and 25-milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient.

                                                Now, back to our discussion.

 



 

Dr. Weitz:             Let’s talk about your book, Cancer Incorporated, which talks about the laws and the war on cancer and the drugs that ties between the researchers and the drug companies and the regulators.

Dr. Moss:             Yes. So, I wrote the book. It took me about a year to do this, and it just came out in January. Of course, then overwhelmed by our more oppressing problems, but the cancer problem is not going away, and it will-

Dr. Weitz:            In fact, patients who are currently undergoing some of these treatments for cancer actually at increased risk of COVID-19 infection and having a worse response as well.

Dr. Moss:             Absolutely. Absolutely. It’s a disaster especially for cancer patients, especially people with lung cancer. It’s a terrible situation. What I focused on in Cancer Incorporated, though, is the manner in which these drugs, these new drugs in particular have been presented to the public, and what I see as the corruption of the oncology profession, the leading cancer researchers in terms of approving drugs and getting the FDA to approve drugs that are not really effective.   I was led to this by the speech that James P. Allison of the MD Anderson Cancer Center gave upon accepting the Nobel Prize in December of 2018. He was contrasting a treatment that he invented called Yervoy, which is a immune therapy with all previous drugs I targeted, so-called targeted drugs, and he made a comment that I can’t quote exactly, but, basically, on average that these drugs extend survival by a few months. You push the envelop by a few months.    When I looked into this, I was startled. I hadn’t realized, as critical as I’ve been of the cancer industry, I hadn’t realized that it was that limited. When I looked into this, I found that it was in fact the actual increase in overall survival from these new drugs in stage four cancers. We have to specify. We’re not talking about pediatric cancers or relatively rare kinds of cancer, but on average, for the solid tumors of adults in the final stage, in the stage four, metastatic disease, is I think-

Dr. Weitz:            For those who are not aware, stage four means that the cancer has now spread from the initial organ where it was throughout the other parts of the body.

Dr. Moss:             Correct. So, it’s about 3.8 months. That’s what this clinical trial show. These are the actual benefit on average of all of these targeted drugs that are now the bulk of the drugs that are being approved or what we would call targeted drugs. Even with the immunotherapy, which I do believe in in general terms, it’s really only about five or six months on average.   Now, you hear about people being cured by immunotherapy. This is true. This is-

Dr. Weitz:            For example, former Vice President Jimmy Carter who was diagnosed-

Dr. Moss:             President, yeah.

Dr. Weitz:            Yeah, former President Jimmy Carter who was diagnosed with, I think it was metastatic. What was it?

Dr. Moss:             Melanomas spread to the brain.

Dr. Weitz:            Spread to the brain, and it’s been years now, and he seems to be doing phenomenal.

Dr. Moss:             Phenomenally well. He did have a pinpoint radiation to the brain, but especially in an older person like himself, and he’s I think in his 90s, you wouldn’t expect that to result in a-

Dr. Weitz:            He takes one of these targeted meds or took one of these targeted meds, right?

Dr. Moss:             He took one of the very first immunotherapy drugs. So, the targeted drugs could be divided into precision medicine, let’s say, and then a subset of that would be immunotherapy.

Dr. Weitz:            By the way, these are somewhat of an improvement over the traditional chemotherapy, which were basically drugs that just kill everything and are designed to kill the cancer cells and hopefully they don’t kill you. Whereas these targeted drugs don’t have as many of the side effects.

Dr. Moss:             No. That was the main selling point of that, but I go in great detail in Cancer Incorporated into what these drugs actually do, and the manner in which they’ve been approved. I was shocked by what I found because there’s couple of things.   One is that, now, we’re not talking about fraud here, which sometimes occurs, but I’m no saying that there’s actual making up of data. It isn’t that, okay? So, people can disabuse themselves of that notion. It does happen, but that’s not what I’m talking about. That’s not the general course of thing. What I’m talking about is that most of the time, the drugs are approved by FDA based upon a surrogate marker.  A surrogate marker means I can’t prove to you that the drug actually conveys true patient benefit, but I’ll choose something else like a score on a test or another. I’ll redefine what I mean by benefit, so that I can then get approval. The main scam going on here, and it is a scam, is a drug to be effective, for a cancer drug to be effective in stage four cancer, it basically has to do one of three things.  First of all, it could cure you. That would be great. You take the drug, you have a complete response to the drug, meaning that the cancer disappears, and you live out your normal lifespan. That would be a cure.  Second thing, it could extend your survival in a meaningful way. So, what would that be? Meaning that in the group as a whole, we’re not going to just consider anecdotes, individual cases, we’re going to consider the entire group being tested. They live months or years longer than they would have if they took a different treatment or if they took no treatment or they just have best supportive care. That would be increased overall survival, okay? That’s another palpable benefit of treatment.  The third one would be increased quality of life, but the vast majority of drugs do not cure. They almost never tested for quality of life, very rare or they don’t really extend the overall survival. So, how could it be then? How could the FDA, the Food and Drug Administration or the equivalent agencies abroad, how could they approve a drug without it showing any benefit?

                                The answer is that there are a dozen definitions of survival at the National Cancer Institute dictionary, cancer terms, and they usually substitute something like disease-free survival or progression-free survival. What does that mean? So, it means that between the time that they administer the treatment and the time that they first noticed that the cancer is in fact getting bigger, progressing, spreading to other organs, whatever, that period of time, the progression-free time is longer in the patients who get the treatment than in those who don’t.  So, now, when you read a headline that says, “Such and such drug increases survival in cancer patients,” most often, if you drill down and you’ll read, bother to read the article not just the headline, much less read the actual study that it’s based upon, not just the abstract but the actual study, you find that what they’ve done is they changed the shape of the curve. They moved it over so that some more time elapse between the time the person was first treated and the time that they first noticed the disease is progressing, but they didn’t increase the actual time the patient live.

                                So, I give an illustration on how that could be you. You have two people, patient A and patient B. So, patient A and B, they have the same disease, same stage, same type of cancer. They’re both treated on, let’s say, January 1st. One of them gets the experimental drug, and one of them gets no further treatment, okay?  So, at three months, there’s no sign of further progression in patient A, but patient B is going downhill. The cancer is still growing, it’s still causing a problem. At the six-month point, patient B, of course, is still going downhill. Patient A may detect that patient A actually now has an increase in progression of the cancer, and they both continued downhill from there, and they both died exactly one year after starting the treatment.  So, from a common sense or a patient or a laypersons’ point of view, what exactly was the difference between those cases? They both lived exactly to the day, one year from the time that they started the treatment. It didn’t make any difference. If you take the word survival, I mean, increased lifespan, which I think 99% of people would, it didn’t make any difference.    Did patient A have a better quality of life? That’s debatable? Patient A had a period of false hope, let’s say, a period of six months where she thought that she was maybe going to be cured, but during that time, she was getting this toxic drug. So, she may have spent that time in very, very difficult, uncomfortable or dangerous circumstances.  So, which is better? I don’t know. No one has ever figured that out because I think it depends on the person. Do you want that period of that false hope of six months and you can enjoy that and have a normal … or do you want to just accept your fate, not do anything, and slowly go down? I don’t know.

Dr. Weitz:            You know who benefits from that.

Dr. Moss:             Right.

Dr. Weitz:            The executives and the shareholders of the big pharma company that are making more profits supplying this drug that costs hundreds of thousands of dollars when you’re treating that.

Dr. Moss:             Right, and can have a horrendous side effect. Yes, it’s true that with chemotherapy, one of the most brutal treatments ever invented, chemotherapy, or probably the most poisonous that’s deliberately given to human beings since the bloodletting era or the mercury era, whatever you want to call it.  Yes, you don’t get that kind of … but you get other toxicities, some weird things. Even with the immunotherapy, which as I say, for the highly mutated cancers like melanomas and lung cancers, can be very effective, but the guidebook on the side effects of those new immunotherapy runs to, I think it’s 65 pages of fine print for what can occur following this kind of immunotherapy.

Dr. Weitz:            By the way, which are some of the examples of some of the immunotherapies and how do those drugs work?

Dr. Moss:             Right. So, it’s Yervoy, and Opdivo, and Keytruda, which are heavily advertised to the public, by the way, only two countries in the world.

Dr. Weitz:            Is it Yervoy, the drug that Carter was given?

Dr. Moss:             I believe it was.

Dr. Weitz:            Yeah.

Dr. Moss:             It was either that or, yeah, I think it was or it was Opdivo, but, yes, I think it was Yervoy because that was the first one to be developed, and then there’s Tecentriq, and there’s a few others, okay? The idea is a very good one. It’s based on a very, very important fact that Dr. Jim Allison and others discovered, which is that cancers have the ability to confuse and turn down the immune system.  So, the immune response can be inhibited by the cancer itself. So, it’s like a fifth column within the body that’s preventing your armed forces from being able to act, okay? So, the brilliance of what Jim Allison did, who discovered Yervoy, was to figure out a way chemically to block the interaction of the cancer cell with the immune cell, the crosstalk that goes on between the cancer and the immune system, and to block that, and then the immune system is able to be activated.  This can be very, very effective in melanoma. It’s something like 50% or 60% of the patients, melanoma stage four patients are now having these major responses and durable remissions from this drug. So, I understand the excitement and enthusiasm for it, but through not any fault of Jim Allison, the company, Bristol-Myers Squibb, which owns both Yervoy and Opdivo, set the price of the drug at around $150,000, and if they’re given in combination, which is the most effective way, the price can go up to a million dollars per person.

                                Some oncologists in Latin America analyzed the situation and they said … They were in Chile, country of Chile, and they said only 10% of the population would even be covered through insurance for this type of treatment. Forget about the people who don’t have insurance, but just of the insured population. In Peru, a less affluent country, only 5% of the population would be covered for that treatment.  So, you could be sure that 95% of humanity will be left out of that kind of treatment, that kind of pricing. It’s just out of this world. The height of absurdity came with a different type of immunotherapy called Kymriah. It’s what’s also called the CAR T cell therapy. That drug sells for $475,000 per injection, per injection.  We know from the inventor of that treatment who let the cat out of the bag because he said that the actual cost of production, it’s a living drug, it’s a very interesting drug, but it’s a living drug, he says that the actual cost of production is $20,000. So, 455,000 or about whatever that is 96% is profit.

Dr. Weitz:            Now, is there any justification for that based on the fact that I’m assuming to take a devil’s advocate position a drug company would say, “Look, we had to spend years researching this, and we spent years researching other drugs that didn’t work that we never got paid for.” The cost of running these trials is very expensive, right?

Dr. Moss:             Right. Right, but what most people don’t realize, if we want to talk about fairness, is that the vast majority, I think some people have said 100% of all new cancer drugs are basically researched by the federal government at taxpayer expense.

Dr. Weitz:            You mean, initially, the NIH is doing the basic research.

Dr. Moss:             Exactly. All the basic research of almost all the drugs, the taxpayer pays for to an amazing degree, sometimes up to actually the finished product, which is then handed over to a drug company on the very disadvantageous terms to the government. The taxol famous case of the derivative, the only herbal treatment, well, one of the few herbal, the derived treatments for cancer, Bristol Meyers was given a monopoly on the sale and distribution of that drug for an incredibly small amount of money compared to the billions that they made on it. It was a scandal that actually wound them up in court, eventually, in the old days when drug companies could be taken to court, but the basic-

Dr. Weitz:            Can they not be taken to court anymore?

Dr. Moss:             Not for what we’re talking about because they pay … I mean, for price gouging, and monopoly practices, no, it doesn’t happen, but basically, the drug companies through the corruption of the congress and the FDA, they’d pass the law in 2003 that we live with the consequences are called the Medicare Modernization Act of 2003.   One of the things that this did where they slipped in was that the government, meaning Medicare, Medicaid, and VA could not contest the prices, could not negotiate over the price of the drug. So, it’s like if you go to a plumber and you say, “You can charge me anything you want. Go ahead. Just whatever it is, I’m going to pay it and I have no recourse,” and the public is demanding that you give them that drug because of good public relations and complicity of the media.   So, they got that law passed. They got it passed at 3:00 in the morning by one vote in the senate, and emergency, they called a surprise vote, the proponents of the bill, 3:00 in the morning. A lot of the opponents were not there, and they pushed it through. We’ve lived with the consequences of this-

Dr. Weitz:            By the way, the sole reason why the same drugs are cheaper in Canada than the United States is simply because they have a universal healthcare system that goes through the government, and the government negotiates those prices down. That’s the main reason why-

Dr. Moss:             That’s right. I mean, I’m in favor of a Medicare for all system, but we wouldn’t have even needed a Medicare for all system. All we needed was for Medicare to have the right and the requirement to economize on behalf of the American public by negotiating over the price. It wouldn’t have been perfect, but we wouldn’t see 150, 175,000, much less $475,000 drugs. It would be impossible.  You know why? Because if you look at Great Britain, which has a special committee, they have national health service, so they have a special committee that judges the value of the drug. They have formulas that they work out and everything, but the basic bottom line is that set they will say, “No. We don’t want it.”  It’s not enough of an innovation over the previous drug, and it’s not cost-effective. Invariably, what happens is that the company then comes back and says, “All right. Well, how about half? Would you do half?”  Then they’ll look at it again, they run their numbers and they say, “No. Still no good.”    The company will come back, “All right. We’ll take a quarter,” because 95% of the price is markup. That’s business.

Dr. Weitz:            By the way, these companies just by partially by talking about how much they spend on research and development, and the fact is is these companies spend more money on marketing than they do on research and development.

Dr. Moss:             Overwhelmingly so. Overwhelmingly so.

Dr. Weitz:            That same provision was written into the Obama Care, Affordable Care Act that was written into the Medicare bill.

Dr. Moss:             Yeah, because if you look at opensecrets.org and you can see to the penny how much the drug companies are giving to the different campaigns, so-called of the congress people.

Dr. Weitz:            There are three times as many lobbyists for the pharmaceutical industry and the insurance industry than there are for every member of congress.

Dr. Moss:             Correct. There’s between … because this came out at the time of that bill, the Medicare Modernization Act, but also more recently, the precision medicine initiative, which was Obama’s pride and joy, 1,350 drug company lobbyists were creeping and crawling all over the congress, which is exactly what you said, three times, three lobbyists for each and every member of congress. The money just flows like water, and-

Dr. Weitz:            In defense of the congress people, that’s the system we have. They can’t get reelected unless they can raise millions of dollars.

Dr. Moss:             Well, Bernie Sanders did it. I mean, he didn’t win, but it wasn’t for lack of money. That’s a different issue.

Dr. Weitz:            Right, but that’s an exception. That’s not that easy to do what he did.

Dr. Moss:             There are other countries that have public funding of election that don’t allow that.

Dr. Weitz:            Absolutely. Absolutely.

Dr. Moss:             So, it’s a solveable problem, but the fact is that corruption is always good with people who are going to find an excuse for corruption, but the corruption is there. A big part of my book, of Cancer Incorporated, is concerned with how this money flows to the oncology profession, and I don’t just mean the profession individually, but individual payment to leading what I call key opinion leaders, KOLs, the key opinion leaders within oncology, the most influential doctors, the ones who show up first author, second author, and final author on the key clinical trial papers.   Most of those people are in the pay personally of the drug companies. This is public knowledge. There’s a website called Open Payment Data. It’s run by the Medicare facility. This is one good thing that came out of the Obama era, Obama Care era, and it basically stipulates that the drug companies have to reveal to the penny how much they’re giving to individual doctors, which is amazing because it isn’t just like, “Oh, we gave 10 billion to the oncologist.” No.  You can enter in the name of the doctor, the medical doctor, American medical doctor and see who they took how much from. It’s very interesting because most of the situations that I looked at and I looked at a lot of different clinical trials as you can imagine, it’s a pattern that the key researchers, the key opinion leaders, and many of the other people included in that paper as well, the top people, the top academics, a person taking personal payments.   I want to emphasize they were personal, they call these general payments. What that means is I think that’s euphemism, but what it means when not talking about the money they take for their lab or their clinic to do the research on these drugs, which is questionable in and of itself and undoubtedly you bring $12 million into your institution. You’re going to rise, you’re going to climb up that totem pole. I’m not talking about that.  I’m talking about how much money you took to put your kid through a fancy school or a fancy college or you took for the yacht or you took for the second or third-

Dr. Weitz:            Now, to play devil’s advocate again, I thought it was illegal for doctors to get direct payments from pharmaceutical companies.

Dr. Moss:             No. It’s not illegal, and it never was illegal in oncology. Oncology wrote its own rules, which is called the chemotherapy concession by which they could buy drugs wholesale and sell them to the patients and get reimbursed at retail rates. At one time, that constituted, according to one source, that constituted two-thirds of the income of oncologists in private practice.   The oncologist in private practice makes about, I think the average figure is $367,000, but that means that these people, these individuals were making the equivalent of a million dollars, two-third of which came from the sales of chemotherapy, the chemotherapy concession.   Now, that all changed also with changes to the Medicare reimbursement rules, and so I’m not saying that that’s going on to the same degree as it was because oncology changed from a private practice-centered profession to a group, I mean, to it working for hospitals, basically.

                                This is something else. What I’m talking about is something else. This is, I don’t even know how to describe it. It’s payments for what they describe as honoraria or speakers bureau fees or consulting, different names are given, but it’s money that flows for vaguely defined services right into the pocket or to the account of the doctor who’s involved oftentimes in evaluating the product of that company.   I don’t know how much more clear cut it could be, how much more grazen it could be. You’re evaluating a drug that people are going to make life and death decisions based upon your statements and your evaluations. You’re going to take up to $3 million from the company who produces that drug and then you’re going to make, you’re telling me that you’re going to make an objective evaluation of the efficacy of that drug.

                                I’m saying, again, they stay on the very side of the law by not lying about the results. I’m not accusing them of lying. It’s the interpretation of the results. In other words, it increased survival. Well, it did if you look up survival in the NCI, National Cancer Institute dictionary, and you want to define progression-free survival or disease-free survival as survival, they’re not lying, but the way you spin the results, the way you write it up for New England Journal of Medicine of JAMA Oncology or any of the other big journals, that’s critical because the average person is only going to read the headline of the story.    Some will read down into the story itself. Some may go look at the title or the abstract of the paper. Believe me, very few people actually read the entire paper through with a critical eye, but when you do that, you see there’s no, “There, there.” There’s nothing there. It doesn’t do anything. If they’re going to charge you $150,000, we have nothing. What are they sowing? Oh, the greatest commodity in the history of the world.

Dr. Weitz:            So, Dr. Moss, what are some of the solutions to the situation that we’re in?

Dr. Moss:             How about reforming the congress so that they don’t take any more money for coverage?

Dr. Weitz:            Well, I think there’s a lot of people who’d like to do that. The problem is is since the Supreme Court ruled on Citizens United, there’s no way that we could pass a law, even if we wanted to, because it would be overruled by the Supreme Court. So, the only two choices we have are A, to have a significant change in the Supreme Court, which is very difficult, and seems to be going the wrong direction right now or B, we would have to have a constitutional amendment that would go over the Supreme Court, and we never even passed the women’s rights amendment.

Dr. Moss:             I’m totally aware of that. So, I mean, I can only put forward Utopian solutions.

Dr. Weitz:            No, absolutely.

Dr. Moss:             At this moment, we’re just spinning our wheels. I understand that. I’m not saying that I have a solution that’s a practical thing that could be implemented right now because the problem is so pervasive. It’s so systemic.

Dr. Weitz:            No. I think it’s totally corrupted, all are on politics, and having public financing of campaigns and getting rid of lobbyists, absolutely has to be a goal how do we end up eventually accomplishing it.

Dr. Moss:             Yeah. A couple of chapters were written in conjunction with other individuals who I think I was very lucky to get their input. One of them was the final conclusions of the book, of Cancer Incorporated. I co-wrote or bounced back and forth with Wayne Jonas, who was my colleague at the Office of Alternative Medicine back in the ’90s, and was the director of the OAM office, now National Center for Complementary and Integrative Health. I was an adviser to that committee.

                                So, Wayne and I have kept in touch for decades now. He’s a brilliant thinker and has thought of many of these. Lives in Washington area, has participated in endless discussions at the governmental level. He and I came to the conclusion quite through our own surprise that we felt that the main recommendation we could make would be to nationalize the cancer drug industry.

                                We don’t go as far as to say nationalize the whole drug industry. That wasn’t our focus, and I don’t really know enough about other areas where drug industry maybe is better than it is on oncology, but we feel that it’s actually an impediment to the overall drug development in the United States that the NIH and the NCI already does the heavy lifting in terms of drug development and could do a better job, and by better job, what I mean is that they wouldn’t have the same pressures that the drug industry has to show increased profits every quarter because that’s the imperative of Wall Street, of capitalism.

                                So, we felt that scientists would still do their work. You don’t even need the patent system. You could reward people. You could give them amazing rewards for discovering new drugs and new treatments based upon actual benefit to people. I’m talking about large rewards. You could give 50 million or $100 million to people who discover and effective new treatment. Why? Because you’re ready. Every year, the world is spending about $120 billion on cancer drugs, most of which as we see probably 90%-95% of which is pure profit to the industry, and they’re spinning their wheels.

Dr. Weitz:            So, essentially, what you’re saying, doc, is right now, for those people who don’t realize it, National Institutes of Health does a lot of the basic research, they’re finding out maybe some of the mechanisms, some molecular processes, et cetera, and then that’s all done paid for by the taxpayers done by the National Institutes of Health, and then pharmaceutical companies cherry pick what they see as the more promising research and then do the last steps, and get all the money for the drugs. You’re saying just have the National Institutes of Health just finish the process and take those promising processes and develop the drug and market it, and not have those huge profits to the benefit of the taxpayers.

Dr. Moss:             Correct. I fully and freely admit, I didn’t come up with this idea. What happened was is that in the course of writing the book last summer, an article appeared in JAMA Oncology. JAMA is, for those who don’t know, is Journal of the American Medical Association, advocating exactly this for cancer drugs. I mean, it blew my mind, and Wayne Jonas’ as well because he’s the one who actually brought it to my attention. He said, “Look at this.” We haven’t even gone that far in our thinking.

Dr. Weitz:            Now, one of the immediate objections is going to be, “Well, we know that government can’t do anything well. They’re totally inefficient. The private sector always does things better.”

Dr. Moss:             So, we talk about immune checkpoint inhibitors, okay? Immune checkpoint are the most important advance in cancer treatment in at least 25 years came about by, entirely, by government funding, NIH, National Institutes of Health and National Cancer Institute grant to a salary employee of a public institution. James Allison was a professor of virology and immunology at University of California Berkeley, a public institution, which used to be free, by the way.

                                So, the entire development of the immune checkpoint drugs up until the point where he had to find a private firm to take it over, which eventually wound up to be Bristol Meyers Squibb. So, government-funded, government-run, government laboratory, government-paid, and the drugs were all invented there. I could tell you many other drugs. Adriamycin got developed by the government, had to be handed over to a private company that invent the private company because none of the drug companies wanted to touch it. It wasn’t profitable enough.

                                Taxol, entirely developed within NIH and then NIH funded lab in New York at a public hospital in New York City, which isn’t the case. The government functions very well in the realm of biomedicine, but nothing’s ever going to be public. I’m no saying that some Utopian era is going to dawn if the government … Of course, you always, in life, it’s you go from one set of problems to another one at a “higher level” but there’s still problems. You solve one problem and then you get another problem. I mean, that’s just the nature of reality.

                                So, yes, we will have issues if the government takes over the drug, but you know what? I felt this way when I was consulting for almost nine years for the government. As bad as it was, you still could drag somebody up before a committee and drill them and find out and investigate, and find out where the … There’s that potential for public exposure and disclosure, right?

                                I said about the government runs the website that lets us see the degree of corruption of the oncology profession. It doesn’t happen automatically, but I saw it happen with my own eyes. It can happen.

                                So, it’s always going to be a problem to administer a country of 320 million is never going to be easy, and much less a world with whatever, seven or eight billion people, but at least there’s some disclosure. What goes on inside the boardroom at Bristol Meyers Squibb? We don’t know. I don’t know, and we’ll never know or the boardroom at Memorial Sloan Kettering private institution. You’ll never know.

                                This is kept close to the vest, but one thing you can be sure of with the imperatives of a private corporation, especially a corporation that’s traded on the stock exchange and is competitive with other companies and so forth that their imperatives are profit and growth, and it usually is on the quarterly basis. They’re all racing to show how well they did because Wall Street will react even to one quarter downturn.

                                So, they’re kind of a cancer because they have to keep on growing and spreading and metastasizing, and that’s their imperative. You don’t have the same imperative-

Dr. Weitz:            It’s really the system, not the companies because as public corporations, they’re required to maximize profits, to maximize shareholder value.

Dr. Moss:             Right. Even if they weren’t, they’d still have to do it because who would invest in the company that was lagging? Sometimes you get the best results at privately owned companies, and I own a company, so I’m not saying that companies are necessarily bad, but my son and I, we’re in business together, we could decide, “Oh, well, this quarter, we’re going to focus on doing something that’s not immediately profitable, that maybe it’s an investment in the future or something.”  Nobody, except for our wives, nobody is going to criticize or have any word to say about this, but when you’re a publicly owned corporation, you’ve got the lash of profitability at your back and nothing can stop that. The really interesting thing was they held a meeting that this immune checkpoint inhibitor thing is just phenomenally big. I mean, it’s billions and billions. One drug alone makes, that’s Keytruda, makes over eight or nine billion dollars a year.

                                Everybody wants in on this, and the FDA last year held a meeting, and they brought together whoever wanted to come to discuss the development of new cancer drugs, and it was new immune therapy drugs. This was chaired by Richard Pastor, who’s considered the cancer Tsar in the United States. He’s the most powerful person probably at the FDA.  In the course of the meeting, he listened to the presentations from this company, that company, this company. At the end of the presentation, he said, “So, now, what you’re telling me is …” I’m paraphrasing, “You’re all basically creating the same drug.” They all were creating Keytruda, and Keytruda is another version of Opdivo. What does that mean?  It means that everybody wants in on the $8.8 billion Keytruda market. So, if I could splinter one little thing, I’ll take a cancer, a very, very small portion of that, maybe I’ll just take an angiosarcoma and I’ll run my drug against that drug, and I find that there’s some positive thing. Now, that’s not covered by your patent. I just cut away a little sliver. What can I do with that? The drug could be then extended into other kinds of cancer, become competitive with your big drug or I could sell it out to the highest bidder because even a sliver of the cancer market is worth billions of dollars. It’s so big. Huge market.   So, the head, basically, I call him the head of the FDA, I mean, the top most influential person in cancer in the FDA basically said, “It’s all the same, isn’t it? It’s all the same drug.” So, you got hundreds of companies competing to create a drug that already exists. In fact, it already exists in two forms. There’s no innovation going on there. They don’t want it. Innovation is too risky. It’s much safer to create a me-too drug and then cash in your chips three, five years down the road. That’s what’s going on.

Dr. Weitz:            Thank you, Dr. Moss. I’m going to have to bring the discussion to a close because I am still seeing patients at this time, and I do have a patient coming up. So, maybe you can tell everybody how they can get a hold of your reports, and find out more information about you.

Dr. Moss:             Right. So, our website is mossreports.com, and I’ll hold up a copy of my book, Cancer Incorporated. This book just 250 pages in length, including all the references is available for free as an ebook at our website. So, you just go to mossreports.com/cancerinc or Cancer Incorporated, and you download a copy of the book. We wanted to get this out to as many people as possible or you can get a paperback of it if you choose. That’s not free, but not expensive either.     In our Moss Reports, we have 38 diagnoses of disease, specific reports on different forms of cancer, and we have phone consultations as well. So, we’re busy. We’re active. I’ve been doing this for 45 years. Hopefully, we’ll do it another 45 years.

Dr. Weitz:            Thank you so much, Dr. Moss. Fascinating discussion and a great contribution.

Dr. Moss:             Thank you.

Dr. Weitz:            Thank you.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
New Developments in IBS and SIBO with Dr. Mark Pimentel: Rational Wellness Podcast 159
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Dr. Mark Pimentel speaks with Dr. Ben Weitz and the Functional Medicine Discussion Group meeting about New Developments in IBS and SIBO.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

9:15  The story about SIBO and IBS is similar to the story about peptic ulcers and H. pylori.  We’ve known about peptic ulcers since the 1980s and then they discovered that H. pylori is the cause of 60-70% of cases of peptic ulcers. We didn’t change the name to H. pylori disease. About 60-70% of IBS is caused by SIBO, but just like there are a bunch of people with H. pylori that don’t have ulcers, there are a bunch of patients with SIBO that don’t have IBS.  There could be narcotics or adhesions as the cause or something else.

10:49  Dr. Pimentel discovered that many cases of SIBO have an autoimmune origin. It starts with a bout of food poisoning related to a bacteria like E. Coli, salmonella, shigella or campylobacter. These bacteria can all secrete Cytolethal Distending Toxin, which can create a response from the immune system, creating antibodies. Those antibodies can cross react with a similar structural protein in the intestinal wall called vinculin and this can damage the ability of the nerves to control the Migrating Motor Complex, which produces cleansing waves that help keep the intestines clear of too much bacteria.  Thus by damaging this normal motility, there is an increased likelihood of bacterial overgrowth of the small intestines.  Dr. Pimentel has also developed a blood test to measure these anti-CDT and anti-vinculin antibodies, the IBS Smart Test. The higher the anti-vinculin antibodies, the more difficult the patient is to treat.

17:15  This cross-reactivity of anti-CDT and anti-vinculin antibodies proves that this model of cross reactivity of antibodies can lead to autoimmunity and in the Functional Medicine world we use this concept of immune cross reactivity to explain how reactions to gluten or dairy or to toxins or to infections can result in autoimmunity. Dr. Pimentel remarked that when he was conducting his Reimagine Study, where he and his colleagues mapped the microbiome of the small intestine, he was surprised that they found that patients who went gluten free but did not have celiac disease, tended to have lower cytokines in their blood and that they were less inflammatory.

20:05  In a recent paper, the ACG Clinical Guidelines for SIBO, you list 6 factors that are important for helping to maintain small bowel ecology and for preventing SIBO.  You talk about 1. hydrochloric acid, 2. digestive enzymes, 3. bile, 4. motility, 5. the ileocecal valve, and 6. the gut immune system.  Yes, acid kills bacteria, but acid blocking medications like PPI use is not necessarily associated with SIBO and Dr. Pimentel’s group did not find really significant changes in the microbiome in patients who took PPIs.  If you have IBS and you’re on a PPI, we didn’t see more SIBO. But if you’re a healthy individual with no GI symptoms, just GERD, and you’re taking a PPI, there is higher risk of getting SIBO.  But because methane organisms eat hydrogen, and because hydrochloric acid contains hydrogen, patients on PPIs had less methane SIBO.  Dr. Pimentel has found that GI motility is the most important factor in preventing SIBO.  The Migrating Motor Complex (MMC) refers to waves of peristaltic contractions that occur when you haven’t eaten for several hours and these help keep the intestine clear of too much bacteria. It is like a dishwasher. This MMC is what gets inhibited by vinculin antibodies or by opiate medications. There are drugs that stimulate this motility, like Prucalopride, Tegaserod or Zelnorm, and even erythromycin low dose can do it.

24:53  When intestinal motility is impaired you can have diarrhea rather than constipation. You would think that without peristalsis, without motility, you would have constipation.  But you can actually have diarrhea, since without the squeezing of the peristaltic activity actively slowing things down, the intestinal contents would just pour through. This is the case with scleroderma, where the bowel becomes thicker and the contents just pour through like water going through your plumbing pipes, since there is nothing holding it back. 

26:08  The Migrating Motor Complex controls the cleaning waves and this is separate from the peristaltic activity that happens when you eat food.  The eating mode is grind three times, four times, then stop and wait, let the food absorb, and then grind a little more, and then let the food absorb. Then keep doing that over and over again. The small bowel moves the food forwards and backwards and forwards and backwards getting it all mixed with enzymes and bile, like it’s mixing it up. Each section of the digestive tract–stomach, small bowel, colon–each section moves differently at a different time and each has separate neural control.  The only time they all come together is during the cleaning wave. The cleaning wave starts at the top of the digestive tract and marches down, squeezing things through in a very straight top to bottom way to strip everything out. Patients who are taking a Proton Pump Inhibitor (PPI). like Prilosec, which are acid reducing medications, the bowel thinks you don’t have as much food in the stomach and it goes to cleaning waves prematurely or sooner than you should.  Because when you eat, you’ve got a lot of acid and all that acid prevents the switch from switching from eating mode to cleaning mode. But when you’re on a PPI, you don’t have that signal. You switch to cleaning mode earlier and you actually get more MMCs or cleaning waves, which may reduce the likelihood of SIBO. There are patients who have neuropathies where they switch to cleaning wave mode when their stomach is full of food, which is not good. People think it happens because they get what’s called a gastrocolic reflex where they eat and then they’re running into the bathroom. But that’s not that meal.  But there are also people who never switch to cleaning mode and then that’s a problem because they never clean.

29:26  The Vagus Nerve. There are a number of prominent practitioners in the Functional Medicine world who talk about the importance of stimulating the vagal nerve to help patients with SIBO by stimulating motility.  The vagus nerve is the electricity coming into the house, but the problem is the wiring that goes to the light sockets and having more electricity going to your house will not fix the wires and not all the lights will turn on. Using a prokinetic is also a way to turn up the energy, so that the lights that are working can be brighter, but the only way to get the other lights working, to fix the motility, is to get rid of the vinculin antibodies.

30:57  Dr. Pimentel and his group have mapped out the microbiome of the small intestine for the first time with his REIMAGINE Study.  The Human Microbiome Project was published in Nature in 2007, but this only mapped out the microbiome of the colon.  But the microbiome of the small intestine is completely different from the colon. The density of microbes in the small intestine is much smaller than the colon, but the small intestine has a much larger surface area, so there are probably more total microbes than there are in the colon.  Unfortunately, the Human Microbiome Project has not yielded one bug, one disease, but Dr. Pimentel’s research looks like it will be discovering a number of one bug, one disease associations in the small bowel, which is very exciting.

33:57  Dr. Pimentel used to think that the bacteria that cause SIBO overgrew up from the colon, but now we know that they are likely already in the small intestine and have overgrown since the cleaning wave is not working. It’s basically E. Coli and Klebsiella and possibly Aeromonas. These are the bacteria that cause many cases of hydrogen SIBO.

35:28  While Dr. Pimentel used to think that there potentially was a different variant of SIBO in different portions of the small intestine, regional forms of SIBO, such as duodenal SIBO and jejunal SIBO.  But his study did not really find that there was much of a difference in the bacterial content as you get closer to the colon, as had been theorized, so there does not appear to be regional SIBO.

37:00  Dr. Pimentel and his group have now reclassified methane SIBO as IMO, which stand for Intestinal Methanogen Overgrowth, since it is caused by methanogens, which are not bacteria, and they are not necessarily overgrown only in the small intestine, but also in the colon.  Dr. Pimentel has been studying the beneficial effects of a non-absorbable form of Lovastatin that reduces methane production. 

38:52  The consensus by experts for the cutoff level for a positive for methane on a lactulose SIBO breath test is 10 and while Dr. Pimentel used to prefer a level of 3, he now feels that 10 is probably a better marker.

40:50  Methane SIBO is often more difficult to treat than hydrogen SIBO and Dr. Pimentel pointed out that this may be because the methanogens that cause it tend to be closer to the surface of the mucosa and drugs like rifaximin may not penetrate as well there. This is why Dr. Pimentel is working on possibly using a version of Lovastatin.  Dr. Sam Rahbar of LA Integrative Gastroenterology and Nutrition has noticed that methane SIBO may also have a coexistence of fungal overgrowth and he has pointed out that this may be one of the reasons that Lovastatin helps, since it appears to have antifungal properties as well.  I suggested that perhaps certain nutritional agents that are known to break up biofilms like bismuth and NAC, which is also a mucolytic agent (breaks up mucus) might be helpful, but Dr. Pimentel feels that there is not enough scientific evidence to know if these might work.  Dr. Pimentel also noted that the organisms that cause hydrogen SIBO, E. Coli and Klebsiella also tend to live in this mucosal layer. And this is one of the reasons that the work that Dr. Pimentel and his group did to sample the bacteria in the small intestine was so difficult. 

44:30  Hydrogen Sulfide SIBO. We think that hydrogen sulfide is causing diarrhea in SIBO patients. Methane causes constipation, hydrogen sulfide causes diarrhea, and hydrogen is just the fuel source for either direction.  Dr. Pimentel usually uses antibiotics to kill the bugs that cause SIBO, but he tries to use as few antibiotics as possible. He uses Rifaximin for hydrogen SIBO and Rifaxmin and Neomycin for methane SIBO and he’s not sure what to do for hydrogen sulfide. He is hopeful to have a new breath test out that will enable us to diagnose hydrogen sulfide SIBO.  He is hopeful that the data on Lovastatin will pan out and they can use that for methane SIBO.  If they don’t respond, they may use natural products like peppermint and berberine and allicin.  If they are positive on IBS Smart test for vinculin antibodies, then he will give a prokinetic.  Once they get rid of the SIBO, they place patients on a specialized diet like low FODMAP, but he prefers the low fermentation diet, because you will have a better quality of life.  He’s not sure if a low sulfur diet might be helpful for hydrogen sulfide SIBO.  He prefers not to use a low fiber diet until after the antibiotics treatment, since if you starve the bacteria, the antibiotics may not work as well.

48:30  Dr. Allison Siebecker and Dr. Steven Sanford-Lewis, two of the top integrative doctors who are experts on SIBO, both treat SIBO successfully by using Rifaxmin or natural antimicrobials and a low FODMAP diet simultaneously and they find that using both simultaneously is more effective. Dr. Pimentel will typicall treat with antiboitics first and then add in the low fermentation diet and often a prokinetic, and Prucalopride or Motegrity is his favorite one to use, though he may use low dose erythromycin because of the lower cost.

56:36  Lovastatin that’s on the market now is designed to be absorbed into your blood to reduce cholesterol. In order for Lovastatin to have the desired effect in the gut for methane SIBO, it will have to be non-absorbed into the bloodstream and slowly released in the gut, so Dr. Pimentel is developing a novel form of the drug, which is not yet available on the market.

59:07  Some patients with SIBO get brain fog and neurological symptoms. This could be caused by D-lactic acidosis, which Dr. Satish Rao has published on. Methane is a gas similar to halothane and isoflurane, which are gases used in the operating room to induce sleep. Methane is also associated with higher blood sugar and higher cholesterol, so methane is clearly a bad actor.

1:00:20  Dr. Felice Gersh, a gynecologist and women health expert in Irvine, California asked since a lot of cases of IBS and SIBO occur in women, how estrogen affects their enteric nervous system and their microbiome?  If you are a woman and you get food poisoning, you are almost twice as likely to get IBS as men. Women have more autoimmune disease. Dr. Pimentel explained that estrogens are growth factors for some bacteria but he does not have the answer yet as to how estrogen impacts the microbiome.

1:04:30  There is a study that shows that spore based probiotics containing bacillis strains performed better than either Rifaximin followed by conventional probiotics or Rifaximin followed by a low FODMAP diet. (Catinean A, Neag AM, Nita A, Buzea M, Buzoianu AD. Bacillus spp. Spores-A Promising Treatment Option for Patients with Irritable Bowel Syndrome. Nutrients. 2019;11(9):1968.)  Dr. Pimentel is excited about the potential for probiotics to be helpful, but most of the probiotic studies are small and we really need a large, well designed trial, like with 500 patients, to really answer this question.

1:06:18  If you have a patient with both SIBO and H. pylori infection, Dr. Pimentel would treat the H. pylori first, since it requires a larger trial of antibiotics and you might wipe out both infections, so you should repeat the breath test after the treatment for H. pylori to see if the SIBO is also gone. Dr. Pimentel is also exploring whether there could be parasites that are stimulating this autoimmune response in the small bowel that leads to SIBO and he pointed out that Giardia has vinculin in it and he is exploring whether that could that trigger vinculin antibodies.

1:10:48  SIBO could affect B vitamin status. You can get an elevation of folate with SIBO, since folate is produced by gut bacteria. You do sometimes see a vitamin B12 deficiency in SIBO.

 

 


 

Here are links to some recent important papers by Dr. Pimentel:

1.Pimentel M, Saad RJ, Long MD, Rao SSC.  ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020; 115(2):165-178.  (This is the paper where methane SIBO is recategorized as IMO.)

2. Leite GGS, Weitsman S, Parodi G, et al. Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison With Stool: A REIMAGINE Study. Digestive Diseases and Sciences (2020) 

3. Pimentel M, Lembo A.  Microbiome and Its Role in Irritable Bowel Syndrome. Dig Dis Sci. 2020;65:829-839.

4. Morales W, Rezaie A, Barlow G, Pimentel. Second-Generation Biomarker Testing for Irritable Bowel Syndrome Using Plasma Anti-CdtB and Anti-Vinculin Levels. Dig Dis Sci. 2019;64(11):3115-3121.

 

 



Dr. Mark Pimentel is a Gastroenterologist who is head of the Pimentel Laboratory and Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai, which is focused on the development of drugs, diagnostic tests, and devices related to condition of the microbiome, with a focus on IBS. Dr. Pimentel has published over 100 scientific papers and he speaks around the world at conferences, esp. about SIBO and IBS. Here is a list of some of Dr. Pimentel’s key publications: https://www.cedars-sinai.edu/Research/Research-Labs/Pimentel-Lab/Publications.aspx

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



 

Podcast Transcript

Dr. Weitz:                            Hey, this is Dr. Ben Weitz, host of The Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest and cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

Okay. Welcome everybody. Our topic for tonight is small intestinal bacterial overgrowth and irritable bowel syndrome. Our special guest at our Functional Medicine Discussion Group meeting tonight is Dr. Mark Pimentel. I’m Dr. Ben Weitz and I’ll start by making some introductory remarks. Due to such a large crowd, I’ll ask everybody to type in your questions and then I’ll try to call on you or I’ll ask Dr. Pimentel the question when it’s appropriate for the discussion. Let’s see. Unfortunately, I guess I have to keep manually admitting everybody as we go. If you’re not aware, we have a closed Facebook Page, the Functional Medicine Discussion Group of Santa Monica.  If you’re not on there, you should join so we can continue the conversation when this evening’s over. I’ll be recording this event and I’ll post it on my YouTube page and I’ll include it in my weekly Rational Wellness Podcast. If you haven’t listened, please check out my Rational Wellness Podcast and subscribe to it. It’s on Apple Podcasts and all the places you can get podcasts, Spotify, et cetera. If you do like listening to it, I’d appreciate if you give me a ratings and review on Apple Podcasts. We have many excellent interviews with many of the top doctors in the Functional Medicine world. We just posted a discussion of testing for COVID-19 with Dr. David Brady.

Tonight, Metagenics will be our sponsor. I’d like to tell you about a few products that they have that are awesome for gut health. CandiBactin-AR, which contains oregano and thyme oils along with sage leaf extract and lemon balm, and CandiBactin-BR, which contains a number of herbal sources of berberine, along with some Chinese herbs. This combo is really awesome for SIBO and many other forms of gut dysbiosis.  It’s been used in a study at Johns Hopkins by Gerald Mullins to be equally as effective as rifaximin, which is the gold standard antibiotic treatment for SIBO. Also, I wanted to tell you about one of Metagenics line of quality probiotics, UltraFlora Integrity. This contains Lactobacillus salivarius UCC118, which has been shown to support tight junctions and reduce intestinal permeability. In other words, it reduces leaky gut. In addition, a study was conducted at Cleveland Clinic that found that this particular strain of probiotic used daily for 90 days was effective in reducing symptoms of SIBO. Anyone who would like additional information or would like to set up an account with Metagenics please call or text our local representative Kaylee Ogaard at (310) 321-8785.

                                                Dr. Mark Pimentel is the head the Pimentel Lab and Executive Director of the Medically Associated Science and Technology program at Cedars-Sinai. He’s a very prolific researcher having published over 120 scientific papers. The Pimentel Lab research is irritable bowel syndrome, the microbiome, and many other gastrointestinal conditions. Irritable bowel syndrome affects 10 to 15% of people in the United States. For many years, prior to Dr. Pimentel’s research, IBS was thought to be a diagnosis of exclusion. Once inflammatory bowel disorders, celiac disease, parasites, and all the other causes of gastrointestinal disorders were ruled out, you were sometimes left with a diagnosis of IBS. Generally, there was not an organic reason for this condition. Dr. Pimentel has many accomplishments. He’s the first researcher to demonstrate that small intestinal bacterial overgrowth is the cause of IBS in a majority of cases and that SIBO could be diagnosed with a lactulose breath test. Dr. Pimentel also pioneered the use of rifaximin, a nonabsorbed antibiotic as a treatment for IBS, especially for IBS with diarrhea.   He’s developed an autoimmune model of IBS being caused by an episode of acute gastroenteritis, which most of us called food poisoning. He’s developed a blood test looking at antibodies to vinculin and cytolethal distending toxin to diagnosis this autoimmune cause of IBS. Dr. Pimentel has discovered that the methane producing organism Methanobrevibacter smithii causes constipation and that lovastatin can inhibit this methane production. Dr. Pimentel and his colleagues have recently renamed the methane version of SIBO as IMO, which stands for Intestinal Methanogen Overgrowth. Most recently with his Reimagine Study, Dr. Pimentel for the first time ever has mapped out the microbiome of the small intestine, a monumental achievement. Dr. Pimentel has really spurred the development of an entire SIBO community complete with SIBO testing, SIBO drugs, SIBO supplements, SIBO podcasts, and SIBO conferences. I hope one day we’ll be able to go to conferences again. But until then, we’ll have to do Zoom conferences like we’re doing now. Most importantly, Dr. Pimentel has given hope to millions of patients with IBS that they might finally be able to feel better and stay better. Thank you, Dr. Pimentel for joining us tonight.

Dr. Pimentel:                     Well, thank you, Ben. It’s a pleasure to be here and thanks for such a broad introduction. I really appreciate it.

Dr. Weitz:                          Before we get started with the discussion of SIBO and IBS, Allison Siebecker called me and asked me to ask you a question, which I’ll ask you in a little bit. I told her I was happy to finally be discussing something other than COVID-19 because I’ve been doing all these podcasts about COVID-19. She told me about your project to use UV light inside the body to kill the virus. I said, “I can’t believe that. I just saw president Trump talking about light inside the body to kill the virus.” You have to tell us about this project. Are you looking to replace Dr. Fauci? I’m just kidding.

Dr. Pimentel:                     Replace Dr. Fauci although he’s disappeared.  We had been working for about three or four years. Dr. Rezaie sort of came up with this notion of using light, Ultraviolet A light, to treat infections. We did a broad array of experiments. Some of this is public information because we presented at the European meeting of gastroenterology that a particular wavelength of light for 20 minutes to 40 minutes will kill most pathogens. Because our research was paused by COVID, one of the applications was to put it in the endotracheal tube to prevent a pneumonia from endotracheal tubes. Then we began to test it on coronavirus. That’s all I can tell you right now, but yes, we’re very interested in what we could do to maybe help save lives. Again, that’s all I can say for the moment, but stay tuned because we’re publishing the work that expresses or goes beyond that abstract at the European meeting. Yeah, just trying something different for the moment because we’re closed otherwise.

Dr. Weitz:                          Yeah. My understanding is, is that this is potentially something that might in the future be able to help with SIBO as well.

Dr. Pimentel:                     It could. We’re looking at ways to apply it internally. One of the bugs that we tested and was presented at the European meeting was C. diff is very susceptible to this light. Stay tuned, we’ve got a lot of things coming from that technology. Very exciting.

Dr. Weitz:                          Yeah, that’s very exciting because C. diff is a very difficult bug to kill. Before we get into some of your latest research, perhaps we can define some terms so everybody is on the same page. Can you explain what is IBS, what is SIBO and how should we rethink of these two conditions?

Dr. Pimentel:                     I’m explaining it just a little different these days. Maybe you’ve heard it from other podcasts, but I think it helps to understand because people are confused. Patients are confused as well because they say, “Well, is it SIBO or is it IBS?” The answer is, yes, because it’s both. The way I explain it now is, if you go back into the 1980s and look at peptic ulcer disease. Peptic ulcer was a ulcer in your stomach and you had pain and so forth and so on. Then they discovered that H. pylori was the cause of that ulcer, but it only caused about 60 or 70% of ulcers. We didn’t change the name to H. pylori disease. It’s still peptic ulcer disease, but H. pylori is the cause of 60 or 70%. Sort of a similar story here. It’s irritable bowel syndrome, and about 60 or 70% of IBS is caused by SIBO, I think. That’s basically how we frame it now. But like H. pylori, there’s a bunch of people with H. pylori that don’t have ulcers and there’s a bunch of people with SIBO that it isn’t IBS. There’s another cause.  There could be narcotics as a cause or adhesions as a cause or something else. Not just IBS and not just this post-infectious autoimmune thing. It’s just how the terminology is used.

Dr. Weitz:                            Okay. Can you explain your autoimmune concept of SIBO?

Dr. Pimentel:                     Yeah. I mean, to me, this is the most exciting stuff, because it may suggest we could be close to a cure if we can cross the next couple of hurdles. But essentially, food poisoning starts the process, it’s like a trigger. People don’t remember. I mean, they don’t remember two days of diarrhea two years ago and they now still have diarrhea. But sometimes you do remember. Sometimes it ruined your vacation or whatever, and ever since then, your bowels have never returned to normal. But that trigger is what trips you into a problem. We now identified that food poisoning, it could be E. Coli, it could be salmonella, shigella or campylobacter, they all share one toxin in common. This is what we sort of latched onto in the 2000s and said, “Well, could this toxin be a culprit?” Because they didn’t have anything else in common, but they had this toxin. We actually created a campylobacter without this toxin and infected rats, and they didn’t get IBS. But the rats infected with campylobacter got IBS. We’ve continued even to this day with that animal model.   Just at this past DDW, we had a huge abstract and presentation, but DDW didn’t happen. But the bottom line is that, toxin, CdtB creates antibodies in your blood that we can detect. Exposure to that toxin creates an autoimmunity to a protein in your gut called vinculin. Vinculin is important for the nerves to kind of connect. With attacking vinculin, those nerves are not connecting properly, the gut doesn’t flow correctly and bacteria build up. That’s how it works. We were supposed to present even more data that substantiates that story to a greater extent about two or three weeks ago.

Dr. Weitz:                            If somebody gets a bout of food poisoning, this is a question that Allison Siebecker asked me to ask you, is there a way to prevent them from this turning into SIBO? Is there some strategy they could use?

Dr. Pimentel:                     Well, let’s say you get food poisoning today. Well, one strategy that we tested in the animal studies was, let’s say you were going on a weekend trip to an underserviced area in an underserviced country to maybe build homes or something as a mission work or other things. And you were there for a short period of time in an underserviced area. If you took antibiotics with every meal, I know that sounds strong, you will prevent food poisoning and you will not get IBS. Our rat studies showed that. We do that in humans for some people who travel to very difficult areas. But I’ll explain another way we use that also. You can prevent. If you have food poisoning today, we used to say, let it go because it’s self-limited, it’s going to go away after a few days. But we now know based on all the meta-analysis and in fact Mayo Clinic did a beautiful 45 minute presentation that proves food poisoning causes IBS. What they found, was the longer the food poisoning, the more likely you were to get IBS and SIBO and all that stuff. [inaudible 00:14:07], then maybe you’re going to help you.   [inaudible 00:14:13] is [inaudible 00:14:20]. For example, now you had food poisoning, it’s gone and you want to [inaudible 00:14:24] to be able to [inaudible 00:14:25]. But the study was only 30 patients, so it wasn’t strong enough or powerful enough to show that it prevented. That jury is out on that, but to be honest….

Dr. Weitz:                          Hang on one second, Mark. I’m going to mute everybody and then unmute you again because I can’t find where she is. Okay. There we go.

Dr. Pimentel:                     Okay. Perfect.

Dr. Weitz:                          Okay. Good. Thanks.

Dr. Pimentel:                     The third thing is the steroid jury’s out, but I wouldn’t recommend steroids because of the side effects.

Dr. Weitz:                          Right. Okay. Then can you talk about the serum test that you developed and now you’re on the second version of it that helps us measure this autoimmune form of SIBO?

Dr. Pimentel:                     Yeah. We developed the first version, but it’s specificity and sensitivity needed some tweaking. The proteins, vinculin and CdtB are quirky, and so they need to be stabilized. We figured out a way to stabilize it, we call it epitope optimization. Now the new generation test is very specific, over 90% specific with either marker, and it’s called ibs-smart. Now ibs-smart helps me a lot in my clinic for anybody with diarrhea. Because, I’ll give you an example, I had a patient in my clinic. She was 19 or 20 years old. Her mother said she wanted her to have a colonoscopy and I would say, “This is 19 years old. You have no blood in the stool.” I did the test, it was negative. Then I said, “Okay, I will scope this one.” It was microscopic colitis. I wasn’t expecting that in a young person. In another case, it was a young man who was 23 years old. His mother has vinculin antibodies over three. So she’s super autoimmune. She said her son is having the same symptoms. I measured the antibodies and the vinculin was high, but not really high enough to be IBS.  Then he said, “Well, I’m going to Southeast Asia in about six months. What should I do?” I said, “Well, you can’t let those antibodies get higher because you’ll be harder to treat.” This is what we see in our clinic, the higher the anti-vinculin, the harder they are to treat. But the amazing thing with this young man was, he was in his early 20s. He’d had a colonoscopy already. He had a CT scan of the abdomen, the ultrasound, stool study. I mean he had a $4,000 workup. That’s his copay. That’s not how much the workup costs. Where he could have had the test and the test would have saved them all that copay because it was positive. We’re using the test not just to make patients feel comfortable that the diagnosis is correct because the test is very accurate, but also to guide prognosis and to save money for patients and for healthcare.

Dr. Weitz:                            It’s kind of exciting for us in the Functional Medicine world, because we see a lot of patients who have these autoimmune conditions and we find that food sensitivities and reactions to toxins and heavy metals and things like that seem to be factors. We’re always talking about this cross-reactivity model and here we have a very concrete cross-reactivity model that’s been thoroughly proven in this particular arena. It kind of gives more credence to that cross-reactivity model that we often utilize to explain how sensitivity to gluten or dairy can lead to autoimmune thyroid disease and things like that.

Dr. Pimentel:                     Well, two things to say on that. First of all, we think that these two markers, anti-CdtB and anti-vinculin, are not markers of the disease, they’re actually causing the disease. That’s the part that I’m really excited about because, particularly in anti-vinculin’s case, if we can get that out of your bloodstream, it’s possible we can cure IBS and SIBO. That part makes me very excited, but it’s also a little challenging to do that. The second part of what you said is, for me to swallow my tongue and say something I didn’t expect to say. Which is that I’ve sort of been on the fence about gluten. I’ve always said, “Well, I’m not sure …” Celiac disease is clear. Gluten sensitivity was always unclear to me. This Reimagine Study that we’re doing, we were supposed to present … It’s public domain now because the abstracts are published, but it was at the meeting, the DDW meeting. People who were gluten free and not celiac, their cytokines in their blood were much lower. They were less inflammatory. I was expecting to see nothing.

Dr. Weitz:                          Interesting, fascinating.

Dr. Pimentel:                     Well, now I have data. It’s not that I need to see my own data to be correct, but it’s more that I have a way of thinking through problems. As we thought through this problem, it’s clear there’s something there that needs further exploration and more objective evidence. But I’m convinced there’s something there in some people. I’m glad you brought that up because I needed to clear the air on my own conscious and say…

Dr. Weitz:                          That’s right.

Dr. Pimentel:                     … something to gluten.

Dr. Weitz:                          Interesting, yeah. Alessio Fasano and other researchers have found that 100% of patients who consume gluten on a regular basis have some evidence of leaky gut and other issues. So that’s interesting. One of your recent papers is the ACG Clinical Guidelines for SIBO. In those guidelines, you list six factors that are important for helping to maintain small bowel ecology. You talk about hydrochloric acid and digestive enzymes and bile and motility and the ileocecal valve and the gut immune system. I thought maybe we could talk about some of those and which ones do you think are most important in the etiology of SIBO?

Dr. Pimentel:                     All of those are what I call classic or traditional notions of what can prevent bacteria from getting in your gut. Yes, acid prevents bacteria from getting in the gut. Well, the irony of that is, we did present it at DDW and this paper is coming out just shortly, that people on PPI did not have too much of a different microbiome in the small bowel. That shocked me also because I was expecting PPI to radically change the microbiome, and it didn’t. There were a couple of small changes, but nothing as remarkable as I expected and definitely PPI was not associated with SIBO. This was a very large group of patients. Acid is funny because acid kills bacteria, but you don’t need much time with acid for it to kill. In five minutes with a pH of one, bacteria are pretty much destroyed.

Dr. Weitz:                          It seems like maybe your group has gone back and forth on the PPI because it actually states in the paper that PPI use is associated with higher risk of SIBO.

Dr. Pimentel:                     Yeah. Okay. Traditional studies had said that, and our paper hasn’t been published yet. Now in the Reimagine Study, we didn’t find SIBO. That hasn’t been published, so we couldn’t put it in there yet. It was only an abstract and they don’t like abstracts for guidelines because it’s not peer-reviewed as thoroughly as a paper. But we didn’t find it. But there’s two things that were happening that’s in the literature. Number one, if you’re IBS and you’re on a PPI, we didn’t see more SIBO even in published literature. But if you a healthy individual with no GI symptoms, just GERD and you’re taking a PPI, there was more SIBO. It’s a little confusing. The third sort of confusing leg of this three-legged stool of acid and bacteria is, methane organisms love acid. They can use hydrogen or acid hydrogen to make methane. People on a PPI had less methane overgrowth because they had less acid. Sometimes no acid is good depending upon if you’re methane, sometimes no acid is bad if you’re … Yes, the thing is confusing.

Dr. Weitz:                            Yeah. Interesting. Then digestive enzymes, I know that one of the things that you think is super important is this migrating motor complex and motility. Allison Siebecker was talking about it and she was explaining how the digestive enzymes and the bile are kind of like the soap as part of this process by which the MMC helps keep the intestines clear. For those, you who are not aware, the MMC is gastric contractions that occur in between eating. When you haven’t eaten for a while, you get these peristaltic activity that helps to keep the small intestine clear of bacteria.

Dr. Pimentel:                     Yeah. It’s like a dishwasher. It washes your small bowel in preparation for the next meal. To me, that’s the most important. Of all the factors for SIBO, not having that wave means SIBO or having a reduction in the frequency. That happens every 90 minutes when you’re not eating. Morphine causes SIBO and morphine’s a potent inhibitor of that wave. Anything that blocks that wave from occurring will cause a lot of SIBO. We think that’s what vinculin antibodies are doing, is that they’re impairing that cleaning wave. That’s based on the research in the animals.

Dr. Weitz:                            What other drugs inhibit that wave?

Dr. Pimentel:                     It’s mostly opiates that do that. Then there are drugs that stimulate that wave, like motility drugs, Prucalopride, Tegaserod or Zelnorm, and even erythromycin low dose can do it.

Dr. Weitz:                            Okay. Last time we talked, we were talking about motility and you explained something that was really fascinating and I think most people are not aware of. Which is that, without normal intestinal motility we’ll actually have diarrhea, not constipation. Can you explain that?

Dr. Pimentel:                     Yeah. It’s a little confusing because even when I train the fellows about motility, people think you don’t have stuff coming out because the gut isn’t moving. But the way that that actually works is, if your gut can actually squeeze and hold things in, that’s active slowing. But for example in scleroderma, if the bowel becomes thicker and can’t move because it’s so thick, it actually just pours through like going through plumbing because there’s nothing holding it back. You can actually have diarrhea if the peristalsis is thick and unable to perform its retaining function. Motility is kind of fascinating because there’s so many ways you can have symptoms based on the lack or presence of motility.

Dr. Weitz:                            Now, is the migrating motor complex, is that exactly the same thing as the peristaltic activity that happens when you eat food or are those separate things with separate neural control?

Dr. Pimentel:                     Yeah, they’re totally separate. It’s almost like you have a switch with two modes. You have the cleaning mode and then you have the eating mode. The eating mode is, grind three times, four times, then stop and wait, let the food kind of absorb and then grind a little more and then let the food absorb. Then keep doing that over and over again. The small bowel moves the food forward and back and forward and back and forward and back getting it all mixed with … Like it’s mixing it up. Whereas the cleaning wave, it starts at the top and goes choo,choo,choo, like marching down, squeezing things through in a very systematic, straight top to bottom kind of way to strip everything out. All the lettuce and things you can’t eat or can’t digest. They’re different mechanisms. Going back to acid, this is a funny part, people on a PPI, the bowel thinks you don’t have as much food in the stomach and it goes to cleaning waves prematurely or sooner than you should.  Because when you eat, you’ve got a lot of acid and all that acid prevents the switch from switching from eating mode to cleaning mode. But when you’re on a PPI, you don’t have that signal. You switch to cleaning mode earlier and you actually get more MMCs or cleaning waves. Again, another reason why SIBO may or may not be associated with acid reduction medication. Was that kind of confusing or …

Dr. Weitz:                          Yeah. Well, what’s the implication of that MMC happening earlier?

Dr. Pimentel:                     Well, in some ways it’s good. But there are patients for example, and this is not that common, who have what are called neuropathies. Where the nerves are irritated and the switch is not in the right position. The last thing you want is a cleaning wave when your stomach’s full of food, because then everything’s just going to go whoosh right to your colon and out. That doesn’t happen very often at all. People think it happens because they get what’s called a gastrocolic reflex where they eat and then they’re running into the bathroom. But that’s not that meal. This event that I’m talking about is very rare. But there are also people who never switch to cleaning mode and then that’s a problem because they never clean. There’s various forms of neuropathy that are out there.

Dr. Weitz:                          We have a slightly different neural control of motility in different parts of the track? Stomach is different than small bowel than large bowel?

Dr. Pimentel:                     Yeah. The only time they all come together is that cleaning wave. The stomach starts, then the small bowel, and then it gets to the colon and the colon sort of holds everything right after that to get everything dehydrated to make stool. Everything kind of activates during that cleaning wave to keep things moving along. It’s integrated only when you’re not eating. But when you’re eating, every part is moving separately and doing things in a different way.

Dr. Weitz:                          A lot of people talk about the vagal nerve, the gut brain connection and the vagal nerve is sending a lot of signals to control motility. What do we know about the importance of the vagus nerve? Is there a way to stimulate it to help with SIBO or motility problems?

Dr. Pimentel:                     Yeah. Stimulating the vagus nerve is a little challenging. There are neurostimulators and other things that could be used, but not well studied in SIBO particularly. Now the problem with SIBO is, the nerves are … It’s sort of like that … What I tell my patients is, “You have electricity come into the house. That’s your vagus nerve. Okay. The wires from the pole are coming to your house, but not all the wires are touching the light bulb sockets.” You’ve got half the lights. You turn on all the lights in the house, but only half are turning on. That’s the problem with SIBO. You could make the wires from the house push more electricity, but it’s not really working terrific. Now, again, that’s what the prokinetic does, is it turns the energy up so that all the light bulbs that do work are brighter and you get a bit of light. That’s why we use a prokinetic to kind of, whatever’s working, make it work better. But you can’t repair the phase until you get rid of the antibody. That’s the way I see it.

Dr. Weitz:                          Okay. Let’s talk about your research mapping the microbiome of the small intestine. This is the first time this has ever been done. What are some of the implications that we’re getting out of this data to help us understanding and treating SIBO?

Dr. Pimentel:                     Yeah. This is super cool because there’s a lot of things we’re learning that would be very important for you to understand today. But about 10 years ago, maybe 13 years ago, the Human Microbiome Project was published in the journal Nature. This was a huge thing because the microbiome was mapped for the first time. What they said was, “We mapped the gut microbiome.” The answer is, no, you didn’t. Because you mapped the stool and you said because you mapped the stool, you mapped the whole gut. What we learned is that, the small bowel in the study that you’re referring to that was just published, is completely different from colon. It’s literally like the sun and the moon. It’s completely different organisms, the different structure of the types of bacteria and so forth and so on. Now, the other thing that is a bit of a fallacy, and this will be easier to understand is, they think because the stool has a size and that it contains a ton of bacteria, oh, that’s really important.   The problem is, the stool is like this and the bacteria is sitting in the center, it’s not doing anything to you. It can’t reach you because it’s got all these other characters in the way. Even though there’s a lot of bugs in there, it’s not a lot of bugs compared … Now think about the small intestine. The small intestine has the surface area of a tennis court. Imagine if you smeared a thin layer of peanut butter across our whole tennis court, how much peanut butter you’d need. We think the small bowel might actually have more microbes than the colon if you consider surface area.

Dr. Weitz:                          Oh wow.

Dr. Pimentel:                     Okay. Then when you add to that, that the small bowel absorbs but the colon doesn’t, it just absorbs water, imagine the chemicals, the bugs in that surface area of a tennis court are giving to you on a daily basis helping, hurting or neutral. We don’t know. And what impact that could have. The Reimagine Study is trying to figure out what bugs and what disease.  Because look, the 13 years since the Human Microbiome Project, zero.  One bug, one disease. Look at C. diff. C. diff was discovered in the 1980s using old school microbiology. But 13 years of microbiome research hasn’t found one bug, one disease. We’re already finding one bug, one association in the small bowel. I can’t talk about that yet because we haven’t published it yet. But it’s fantastic what’s going on in the small bowel in terms of maybe helping diseases.

Dr. Weitz:                          Now we’ve had controversy over where the bugs that cause SIBO come from. Are they overgrowing up from the large intestine or are they in the small intestine and just overgrowing? Has your study helped to answer that question?

Dr. Pimentel:                     My thinking used to be, colon coming up.  My thinking has changed now. It’s, they’re there. You probably all live in LA or I imagine most of you live in LA somewhere-

Dr. Weitz:                          I think most of us, yeah.

Dr. Pimentel:                     We had the drought last year and just before the rains came about two years ago, actually. Burton Boulevard has this beautiful central boulevard of grass, and the grass is Beverly Hills pristine. Then they stopped mowing the lawn just because they wanted to save water. There wasn’t a lick of grass. There was tall weeds, about three feet deep. Not mowing the lawn, the grass couldn’t compete, the weeds worked. Without the cleaning wave, the weeds grow. The weeds are there, they’re just … It’s E. Coli and Klebsiella. That’s what’s causing bacterial overgrowth. Once they get a foothold, it’s hard to flip them out and get the weeds gone. That’s what we think is overgrowth based on the Reimagine Study. It’s E. Coli and Klebsiella, those two characters and a little bit of Aeromonas.

Dr. Weitz:                          Is there such thing as region specific SIBO? Is there duodenal SIBO versus jejunal SIBO?

Dr. Pimentel:                     Yeah. In this study, we mapped the whole small bowel and ironically, it was remarkable that there wasn’t as much of an increase as you get closer to the colon as we had expected based on people just talking. I mean, people talk and they say, “Oh, it must get higher and higher as you get to the colon.” That wasn’t what we found. It wasn’t dramatic like that. As we now get truth, the truth is telling us what the answers are and it’s not quite like that. I don’t think that there’s actually as much regional SIBO as we used to think, but we’re continuing to collect data and I may correct myself in a year if our data suggests otherwise.

Dr. Weitz:                          In your study, I didn’t see methanogens on the list of organisms you found. My question is, did you find methanogens in the small intestine and what about fungus and parasites like protozoa that are normal to the colon?

Dr. Pimentel:                     Yeah. The sequencing we did was for bacteria initially, not for archaea and not for fungus or parasites. But we have all the DNA of all of that and we’re looking through that. In fact, right now my lab had just come back finally, and they’ve been marching through the methanogens in the small bowel, the colon and everywhere, because that’s really important. We’ll have data to share on that hopefully in the next few months.

Dr. Weitz:                          What’s the significance of this reclassification of methane SIBO?

Dr. Pimentel:                     Yeah. The term is SIBO, small intestinal bacterial overgrowth. First of all, it’s small intestine. It has to be in the small intestine, which we agree SIBO is. And then it’s bacterial overgrowth. Methanogens are not bacteria they’re archaea, so you can’t call them bacterial overgrowth. We used to call it methane SIBO, but that’s a wrong terminology. The second part is that methanogens grow in the colon too much as well in these patients, not just the small bowel. We couldn’t say small bowel because it’s both the colon and the small bowel in the case of methanogens. We had to reclassify the term. It’s an overgrowth if it’s a bloom and it’s excessive number of methanogens, but not just in the small intestine.

Dr. Weitz:                          Conceivably, methane SIBO could be primarily in the colon?

Dr. Pimentel:                     It could be. We’re mapping the bowel now and then comparing that to … Again, I’ll be able to tell you more with more granularity that in a few months, but-

Dr. Weitz:                          But of course, if it comes up positive on the SIBO breath test, then that means especially if it occurs in the first 90 minutes, then we know that that’s got to be the small intestine?

Dr. Pimentel:                     Well, methane is different because methane is either there or not. On the breath test, often a methane producer normally hydrogen starts at five and then works its way up over 20, and that’s positive. In methane, it starts at 30 and stays 30. You’re either methane presence or not. It doesn’t really go up that much with lactulose. It’s a different characteristic of the breath test.

Dr. Weitz:                          What should be the cutoff for the breath test for methane? Should it be 10? I’ve heard you mention that perhaps it should be lower.

Dr. Pimentel:                     Yeah. The North American Consensus and the recent SIBO guidelines from the American College of Gastroenterology are saying, for methane, any number over 10 within the first 90 minutes. Then for hydrogen, it’s a rise of 20 within 90 minutes. If you start at five, it’s got to go to 25, and then that’s considered positive.

Dr. Weitz:                          I’ve heard you say perhaps maybe methane at three should be significant.

Dr. Pimentel:                     Okay. This is the problem with consensus. Is that I have my opinion and there’s 20 other people in the room and we have to go along with consensus. The group felt that 10 was a better marker. But let me explain why 10 might be a better marker. When you do research on methane, Dr. Rezaie and I looked at all the breath tests, 12,000, 15,000 breath tests at Cedars over a decade. We looked at, if somebody had three, 90% of the time they went over 10 at some point during the test. Even if we used three, almost all those patients would be over 10 anyway at some point and meet that criteria. It wasn’t so big a deal. But the second part is, if you’re going to give a drug to lower methane, it’s better that it’s 10 so you can see it go down than three, where there’s nowhere to go. We sort of like the 10 now because if we’re going to develop drugs as we’re doing now to reduce methane, at least you have somewhere to go from 10. You don’t have more to go from three. That makes sense?

Dr. Weitz:                          Sure, yeah. Why do you think methane is so difficult to treat?

Dr. Pimentel:                     Yeah. There’s a couple of things about methanogens. Number one, they tend to be closer to the surface of the mucosa or the surface of the human cells. There’s a thick mucus layer where rifaximin and a lot of drugs can’t penetrate, not as well anyways. That’s part of it. The other thing is, they’re not bacteria. We developed antibiotics for bacteria and not archaea. It’s sort of like trying to use antibiotics for yeast and it’s not developed that way, they’re different. That’s why we’re trying to take different approaches. We’re using, as you mentioned in your introduction, sort of a variety or a version of lovastatin which goes into the bug and stops methane production. Then the energy of the bug can’t be produced and the methane is not produced so the constipation gets better. We’re just in the middle of the trial of that drug. We’re super excited to get that done soon.

Dr. Weitz:                            I was just talking to Dr. Rahbar a couple of days ago. He was saying that he sees in cases of methane, he often sees a fungal overgrowth. He said that lovastatin actually has antifungal properties and that could perhaps be one of the reasons why it helps.

Dr. Pimentel:                     Remember, lovastatin comes from Aspergillus, which is a fungus. Aspergillus, didn’t make the lovastatin for human cholesterol. It’s making it to affect things around it. It could be to prevent other fungus from growing there and getting in its way. Certainly in swamps and other places where Aspergillus is prominent, there’s a lot of methane and methanogens which may be intoxicating to the Aspergillus and it wants to block that. Obviously lovastatin has a chemical property that does something to the microbiome which we think is beneficial, but we’ll see. We’ll get some results later this year.

Dr. Weitz:                            Since the methanogens are found in the mucus and it’s one of the reasons why they’re hard to get at, I wonder, would it makes sense to use agents? We have certain nutritional agents that are known to break up biofilms like bismuth, we use certain enzymes, NAC is a mucolytic agent. I wonder if something like that would make sense to break up some of that mucus layer to get at the methanogens.

Dr. Pimentel:                     Yeah. I mean, but the challenge with these things are half-life of the products and how much surface area you have to cover. Because again, we’re talking about a tennis court size area. Yes, we’re looking at all of that actually, but we have to work it in a way that actually is effective in such a large surface area. Stay tuned, I’ll have more things to report in that context. This is all again, coming from the Reimagine Study. Because the Reimagine Study, and I can’t talk about all of this data, but we’re looking at the bugs in the center of the bowel, the bugs in the mucus and the bugs right at the surface. They’re different. As we study the layers, even in the small bowel, it’s pretty remarkable the different bugs. I’ll tell you where the SIBO is, is in the mucus. That’s why it’s hard to get rid of it because it’s in the mucus and that’s where E. Coli and Klebsiella love to live. That may be why we need to get better treatments and they’re coming, we’re working on something right now. It’ll be interesting to see how that evolves.

Dr. Weitz:                          What does your Reimagine Study tell us about hydrogen sulfide SIBO? Right now, our only way to try to diagnose is if we see a flat line of hydrogen all the way through the third hour. Do you think we’re picking up a substantial percentage of patients with hydrogen sulfide SIBO?

Dr. Pimentel:                     Yeah. Well, a new breath test is emerging soon that will be able to test hydrogen sulfide. But we think hydrogen sulfide is causing diarrhea. Methane causing constipation, hydrogen sulfide, diarrhea, and hydrogen is just the fuel source for either direction. Of course the methane bugs don’t like the hydrogen sulfide bugs because they’re eating the same rabbits, which is hydrogen. You either have foxes or you have wolves in the neighborhood because the rabbits are the hydrogen.

Dr. Weitz:                          Right now, what are your current treatment protocols for hydrogen SIBO, methane SIBO and hydrogen sulfide SIBO?

Dr. Pimentel:                     Well, the effective therapies that we use are usually antibiotic therapies. But again, what we’re trying to do is to use as little antibiotics as possible. Because that’s why when we treat … Okay. Let me go through it. For hydrogen, we use rifaximin as first line. There are other things we do if you want to get into it if they don’t respond including peppermint and other natural products that you’ve covered partly in your introduction as well. Then with methane, we use rifaximin and neomycin because there was a double blind study that shows that. Although we can’t wait for the lovastatin data. We’re hopeful that that will show something good. It may not work. If it doesn’t, then we regroup. Hydrogen sulfide, we don’t know what to do with that yet because we don’t have the breath test widely available. Once we get that, we’ll know within months what’s going to be effective there. I’m very sort of excited about that. But once you get control … This is why we do the ibs-smart test.  Because if they are vinculin positive, they got to go on a prokinetic more likely because they really have a motility issue. We’re more likely to give a prokinetic, at least in my practice. Then we try to use diet to try to ward off the overgrowth and prevented it from coming back. That’s also really important. There’re a variety of diets. Low FODMAP, we tend to use low fermentation because it’s better quality of life.

Dr. Weitz:                          When do you kick in a low fermentation diet? Do you do it while treating or do you do when you’re done with treating?

Dr. Pimentel:                     Well, I basically … The reason, and people know this of me, that I don’t do it while treating because of the old mantra of antibiotics back in the ’70s. Which is, starving bacteria, hibernate or form spores, or try to protect themselves by walling off because they’re stressed. Stressed bacteria are not susceptible to antibiotics. I don’t like using the starvation of low fermentation or low FODMAP because it might make it harder to treat. Other people have taken my words and said, “Well, let’s give guar gum, really juice up the bacteria, and then give antibiotics.” I don’t do that, but people have suggested that I said that and I haven’t. But I understand the rationale and maybe it’s helpful, but I haven’t tested it personally. But the bacteria that are fed are going to be more susceptible to the rifaximin or the rifaximin and neomycin. Better not starve before you do the antibiotics.

Dr. Weitz:                          It’s interesting you mentioned guar gum. Because my understanding is, hydrolyzed guar gum is the one fiber that does not really irritate SIBO.

Dr. Pimentel:                     Yeah, I understand that. I don’t know where that came from, but it’s out there and somebody said, I’ve said it, but it wasn’t me.

Dr. Weitz:                          Yeah. I know Allison Siebecker said that she and Dr. Sanford-Lewis normally treat with rifaximin or natural antimicrobials and a low FODMAP type of diet at the same time and find that they get quicker symptom resolution by including the diet at the same time. The concept is, is you’re trying to kill the bacteria and you’re starving them at the same time. You’ve got two different strategies at the same time.

Dr. Pimentel:                     Yeah, that’s true. I do use some other naturals, berberine does help in some patients.  Allicin is quite good for methane sometimes. Again, everything works sometimes and you just got to find the right thing for the right patient.

Dr. Weitz:                          Have you used a different diet when it’s hydrogen sulfide?

Dr. Pimentel:                     Yeah. The opportunity for diets is going to be interesting because a low sulfide diet will actually reduce hydrogen sulfide. But because I don’t have hydrogen sulfide to measure yet, I don’t know how well it works. Once we have this breath test up and running, I think we’re going to get some interesting results as to whether certain diets with low sulfate, for example, could be helpful in that instance. I think it might be, so we may have some tailored diets depending upon the gas profile.

Dr. Weitz:                          When do you think that new breath test will be available?

Dr. Pimentel:                     To be honest, a lot of breath tests are shut down because of COVID. Everything has gotten a bit delayed. I don’t have a timeline for you, but hopefully very shortly.

Dr. Weitz:                          Right. Promotility agents, prokinetics, should these be employed at the same time that we’re treating the SIBO or afterwards?

Dr. Pimentel:                     My routine is after, because that’s sort of how I’ve done it for years. I don’t object to the concept of giving it with the treatment, but here’s the rationale of why I don’t. Is because, back in the early days people were saying, “Mark, are you really giving a prokinetic to a diarrhea patient?” I said, “No, I treat them first. Now they don’t have diarrhea. Then I give the prokinetic.” The patient could suffer with diarrhea if they already have diarrhea and you’re giving them a prokinetic before the overgrowth has gone with the antibiotic. That’s my rationale there. For the constipators with methane, you could argue, you could give them a prokinetic at the same time. Although I sort of do it one after the other, it saves a little money too.

Dr. Weitz:                          What’s your favorite prokinetic these days?

Dr. Pimentel:                     I’ve got to say I love Prucalopride, Rezole or Motegrity it’s called in the US. It’s the most powerful prokinetic I’ve seen on the planet. Now, powerful doesn’t mean isn’t always good. But what I mean is, I start at usually a very low dose, like half a milligram at bedtime to get those cleaning waves going and people don’t have problems with that. It’s not powerful at that dose. You don’t want to start right at the two milligram dose in these patients, because if it’s too strong, they won’t like you for it. Start low and move up as you need to. That’s how I do it.

Dr. Weitz:                          Have you tested LDN or any of the natural prokinetics?

Dr. Pimentel:                     Yeah. I mean, occasionally LDN, and Dr. Rezaie uses LDN a little more than I do. There are prokinetic actions of LDN and anti-inflammatory also properties of that. I think there’s merit in that. You just got to choose what the patient’s going to respond to. I go for the big gun now, the Motegrity, because I think it’s just so superior to everything else. But if I can get away with LDN or low dose erythromycin, it’s cheaper especially for low dose erythromycin.

Dr. Weitz:                          Okay. Why is rifaximin so expensive in the US and are generic versions as high a quality?

Dr. Pimentel:                     Yeah. Well, it’s a complicated answer. Rifaximin is a weird molecule where there’s an alpha beta, gamma and delta form. There’s sort of four … If you make the chemical in your basement, you’re going to get a mixture of four different sort of shaped molecules that are the same molecule, but they bend in a different way. You have to use rifaximin-alpha. The rifaximin from brand name is alpha. The problem with some of the generics, they don’t describe how much alpha versus gamma, beta, delta, and that’s confusing. You might be paying a quarter the price, but you might be getting a quarter of the drug. I don’t know. I think the ones that are branded generic and are available here in the US might have the FDA breathing down their neck if it’s not alpha. But some of the ones from overseas or from other sources may not contain exactly … I mean it’s not toxic, but it may not contain things that you hope and be less effective as a result.

Dr. Weitz:                            What percentage of patients with SIBO do you think end up having recurrences and what’s the best strategy for trying to help when they’re coming back for the second round or the third round?

Dr. Pimentel:                     Yeah. When we did the TARGET 3 Study, which was the rifaximin three treatment trial, about a third of people who got treated and it worked with rifaximin never needed treatment again. That’s amazing. We’re studying that because there’s a term that one of our collaborators from Caltech uses and he publishes on, it’s called hysteresis. Where it’s like a teeter-totter. You’ve got the overgrowth here that’s weighing down, sort of the weeds, but if you get enough of the weeds gone, the totter flips and it’s hard to go back. You see what I’m saying? If the grass is able to grow hardy enough and you’ve got the weeds down far enough, the grass won’t let the weeds come back up. I think that’s true for a third of cases, we can get them to flip and they stay flipped. For some others, the weeds go down and then come up and down and up and we’ve got to keep treating about every three to six months. That’s sometimes frustrating for patients. That’s why we’re trying to look for even better therapies now to try and keep the teeter-totter flipped and growing grass, not weeds.

Dr. Weitz:                            Now, one way we think of it especially in a functional medicine community is, if we want that grass to grow, we give it more grass seed i.e probiotics.

Dr. Pimentel:                     Right. Well, yes. I guess what I’m getting … I don’t disagree with probiotics and I don’t dislike probiotics. I think now that we have Reimagine data and now we understand the small bowel data better and we understand who are the weeds and who are not the weeds … Because we didn’t. We were just giving probiotics. But as you pointed out, this is the first mapping of the small bowel. We were kind of shooting in the dark. Now maybe, there may be an opportunity now knowing what the grass is to give more grass. You’re right, I think that’s the evolution of this over time and maybe there will be something. I’m very optimistic, but we’re learning more every day.

Dr. Weitz:                          Right. Great. I think those are the questions I had. Did anybody have questions? I haven’t seen any typed out. I’m not sure if my screen is even showing them or not, but I don’t even know where they would be.

Dr. Pimentel:                     If you look at the chat bubble at the bottom, I think they’d come up.

Dr. Weitz:                          Okay, there we go. Let me look at some of these questions. Yeah, there’s a bunch of them. Sorry, everybody.

Dr. Pimentel:                     I’ve been doing a lot of Zoom in the last few weeks, I’ve become a Zoom super user.

Dr. Weitz:                          Somebody wanted to talk more about lovastatin for SIBO. Is it currently considered an acceptable treatment or not?

Dr. Pimentel:                     The problem with lovastatin that you would get right now, whose one of the brand names is Mevacor, is that it’s designed to be absorbed into your blood to reduce cholesterol. I want it the other way. I want it not absorbed. I don’t really care about cholesterol. I want it to be sort of slowly moving or released in a different pattern through the gut. The product that we’re testing now is sort of a dual release lovastatin that will release in the gut and won’t get absorbed. That’s what we’re testing because it will have a better effect. The other thing is, what we see in our practice, is to get methane down, we almost have to go to really high doses of lovastatin. Which start to give you body aches and side effects that are typical of that drug. It’s tricky. We do it sometimes and we do get some benefits, but it has to be done in a very particular way. It’s just not like what we’re testing in the big clinical trial right now.

Dr. Weitz:                            I see. One of the questions is, is certain bacterial strains produce methane, some produce sulfate and ammonia. Wouldn’t it be important to keep these bacterial strains in balance?

Dr. Pimentel:                     Yeah. There’s things we know about methane and we’re learning more and more about. Okay. When methane is here, I don’t want to get rid of methanogens because I think there should be a balance. But if your methane is here and normal is here, we just want to get it to here and to keep things in harmony. We’re going to have some data coming out that says, if we can get it here, the microbes start to make the balance come back and it stays here. It’s like that teeter-totter thing again I talked about. Yeah, the goal is not to … That’s why the lovastatin thing is so awesome. Because if it works, we’re basically getting into one organism, taming it a little so that everything grows normally again, instead of this bashing everything with a sledgehammer like in an antibiotic approach. Which is a little more coarse and not fine-tuned. I like where we’re going with more of a finesse touch rather than this sledgehammer approach.

Dr. Weitz:                            Some patients with SIBO get a brain fog and neural symptoms. What do you think is causing that?

Dr. Pimentel:                     There’s a couple of things. You could have what’s called D-lactic acidosis. It’s very uncommon. Satish Rao has published that a few … We’ve checked it a number of times and we find it very rarely. But that’s an extraordinary and sort of encephalopathy or sort of a confusion state that people can get from that. But more commonly, methane, for example, think of methane like halothane and fluorane, isoflurane. Those are gases that they use in the operating room to put you to sleep. Methane is a hydrocarbon like them. We see when the methane is super high in patients, people are more brain fog, more fatigue, more of that. Methane really, I think has an important role. Methane can do all sorts of things. Methane bugs are associated with obesity, they’re associated with higher blood sugar, they’re associated with higher cholesterol. Methane is a weird character. We don’t want it here. We want it nice and normal, and that’s what we’re shooting for.

Dr. Weitz:                            Here’s a question from Dr. Felice Gersh. Felice. I unmuted you, would you like to ask your question?

Dr. Gersh:                            Sure. Where am I? Hang on.

Dr. Weitz:                            I just-

Dr. Gersh:                            Can you hear me?

Dr. Weitz:                            I guess you’re not visual, huh?

Dr. Gersh:                            I can be. Do I need to be for me to …

Dr. Weitz:                            Felice is an expert on female hormones. There she is.

Dr. Gersh:                            Hello. Hi there. Hi there, everybody.

Dr. Weitz:                            Hi there. Go ahead with your question.

Dr. Gersh:             Well, yeah, I’m always bringing in what’s going on with the females and their hormones, because that’s a huge component that’s often left out. As you know, females make up a very high percentage of patients who are diagnosed with IBS. Women are very different in terms of how their estrogen affects their enteric nervous system, the gut microbiome. But the question I have is, about 90% of females these days spend a good bulk of their reproductive lives on either oral contraceptives or what I call similars, progestin agents. What is that doing to their gut microbiome? What’s it doing to their enteric nervous system? How is that impacting all of this? Because there is data published that shows that the microbiome is quite different in women who are on these products. Then of course, the universal event of menopause has many impacts on the gut. I just wanted your comments on the female side.

Dr. Pimentel:                     Thank you. I mean, that’s amazing. Ben mentioned in the beginning this hysterical woman comment, but I think he took it [crosstalk 01:01:55]-

Dr. Weitz:                            I was just kidding.

Dr. Pimentel:                     No, but you took it from one of my … You weren’t kidding because what I’ll tell you is, and this came out in one of my tweets. One of our fellows went to a conference where they were learning how to write the exam, the board exams. One of the senior gastroenterologists said, in 2017, “IBS is a disease of hysterical women.” [inaudible 01:02:18] in the 1980s and ’90s, this is the stupid way this disease was thought of. When Ben said, “Yeah, that’s how it used to be thought of.” It’s literally verbatim of what happened. It’s so wrong because you can’t blame a disease on women. Secondly, it’s not a female disease because men get it also. Those two things, it’s like saying pregnancy is a disease. It’s not a disease, it’s a natural phenomenon. Or these are the crazy things that went on. But let me get to your question. That is, the biomarker, the ibs-smart test measuring vinculin and CdtB.  If you’re a woman and you get food poisoning, you are almost twice as likely to get IBS as men. Women have a tendency to get more autoimmune disease.

                                                There’s more rheumatoid arthritis, lupus, other autoimmune diseases in women. That may be why there’s more IBS in women. It’s super important we figure that out, why is that happening. But it’s very interesting at the same time. But it’s not because of some psychological alteration that women have that they get this. That one I just want to settle that because that’s very frustrating to me that I’ve had to hear that as recently as 2017. The second part of your question is all these hormones. We know estrogens are growth factors for some bacteria. Yeah, I mean, it’s possible that you change the microbiome in the small bowel. Certainly there are studies in the colon, stool, but we’re really interested in seeing what’s going on in the small bowel with estrogen. You’re right, I don’t have the answer yet, but we’re looking at it. We have all the medications of all these patients that are undergoing scope. The only problem with our study, the Reimagine Study, is, they have to have be coming in for a scope for a reason.

                                                More often than not, it’s older folks that come in for scopes rather than younger people who might be on birth control or estrogen replacement. But yeah, and menopausal women, they’re on estrogen replacement. We’re going to address that and I think that’s a very, very, very important question. I have some answers, but not all the answers to your question.

Dr. Weitz:                            Somebody asked a question about bacillus probiotic spores. There’s a study on patients with IBS and apparently this study found that spore based probiotics perform better than rifaximin and a low FODMAP diet.

Dr. Pimentel:                     Yeah. I’m very excited about some of the probiotic studies that are coming out, and this is sort of another example. I’m not cuckooing probiotics studies and I’m not cuckooing this one, I’m excited about it. What I’m saying is that … I’ll give you an example with peppermint. The peppermint studies show peppermint is effective. There’s a double blind study of about 80 patients. But the weird thing about peppermint, when they did a 20 patient study or a smaller study, the p-value was amazing. It was like it was really working. Then they did a bigger study and the p-value is smaller, and a bigger study and the p-value is even smaller. If they did a 500 patient study, would it be statistically significant? This is the challenges that small studies that are positive get published. I’d love to see a probiotic company just step on the gas, put some money down and do a 800 patient study. If it works, wow, they will be … Well, first of all, they all make a lot of money. Which is good for them, I suppose, and that’s the whole incentive for them.  But it’ll help a lot of people if we can get some clarity around this. I love all of it. I want to see it happen and I’m happy to participate in these kinds of trials because I think there’s something there. We just need to do the big trial, the good trial and get a good answer.

Dr. Weitz:                            Somebody asked about, if you have a patient with SIBO and they also have H. pylori how would you treat it? Would you treat the H. pylori first? Would you treat the SIBO first? I’d also like to add in there, to what extent can SIBO be a cause of reflux?

Dr. Pimentel:                     Yeah. SIBO as a cause of reflux is possible. Especially we see that in methane because there’s sort of a double hit with methane. They get gas build up and the colon is slower and the bowel is slower. Everything is sort of building up and then you’re getting more pressure, which means more reflux. Reflux is a combination of two things. It’s this valve at the top holding the acid down, and how much pressure is below your chest and your abdomen that’s pushing acid up. When you have SIBO, that definitely … Now, I forgot the first part of your question.

Dr. Weitz:                          Yeah. If you had a patient who has H. pylori and SIBO.

Dr. Pimentel:                     Yeah, H. Pylori. I would treat the H. pylori first because it’s a larger cocktail of antibiotics and there’s a pretty good chance you could hit two birds with one stone. You might want, in that case, do a breath test after just to see that you kind of got them both.

Dr. Weitz:                          Okay. Interesting. Could there be other gut pathogens that stimulate the autoimmune response besides I guess cytolethal? I guess, could there be things other than bacteria that could be stimulating this autoimmune SIBO response?

Dr. Pimentel:                     Yeah. We’re exploring a lot of different things because there is a Helicobacter, it’s not pylori, that has CdtB. I think its Helicobacter hepaticus. I haven’t looked at this in a while. But Giardia has vinculin in it. If you kill Giardia and it releases all this vinculin, could you form vinculin antibodies? We don’t know. There’s stuff like that that is really ripe for exploration. But your question is right on, we need to look at these other organisms. We have already found some patients and I’m not going to get into the details … Again, it hasn’t been published yet. That do harbor bacteria that makes CdtB. That’s weird, they shouldn’t be there. We’re looking at that and what role that has and how bad their disease is. Or maybe they’re spreaders or they have a tendency to keep these bad bacteria in their gut in a different way.

Dr. Weitz:                          There was a question about anatomical differences. Certainly we know that if there’s obstructions or adhesions that could play a role in SIBO, right?

Dr. Pimentel:                     Yeah.

Dr. Weitz:                          Let’s see. What about your thoughts on a continuous low dose of Xifaxan or natural antimicrobial to prevent relapses? I’d just like to give my input real quick for a second. Is, we sometimes have patients who recover, we do several rounds. Sometimes I have found that a lower dose of one of the antimicrobials that resonates with them, like just a little bit of berberine or oregano that they just take every day, it seems to help manage the symptoms. What about your experience with that?

Dr. Pimentel:                     Yeah, for sure, I have patients who do that or I’ve prescribed that to. The only caution I have, and I’m sure you do this as well, Ben, is that, if they don’t respond like they are magically better and they at least stay better for a few weeks, or if they require this chronicity, I just want to make sure that it’s not an obstruction in the bowel or it’s not something else. Sometimes it’s a cancer or something that’s causing a blockage. I’m a little more aggressive with workup and maybe CT scans and other things just to see that I’m not missing anything. As long as I’m comfortable I’m not missing anything, then I proceed down that road. I think that’s just a point of caution.

Dr. Weitz:                            Yeah, good medicine. It’s always good to be cautious. Why the low fermentation diet? I think we know that. Probiotics, if you’re on birth control and you can’t absorb vitamin B, is vitamin B deficiency common in SIBO? Okay. I’m not sure. Are there vitamin … I guess that’s the question. Do we see vitamin deficiencies in SIBO?  We know the small intestine is how you’re absorbing nutrients from your food. If there’s too many bacteria lining the small intestine, it could potentially interfere with absorption of nutrients.

Dr. Pimentel:                     Yeah. A couple of things there. First of all, let’s start with folate because that’s an interesting one. The folate you get from you comes from bacteria. For example, in dogs, in veterinary world, they can diagnose SIBO by measuring folate. If folate is high in the blood, they think the dog has overgrowth and they treat the dog with antibiotics because he can’t do a breath test on a dog. But in humans, we see a high folate in SIBO quite often. That’s very common. It used to be thought that B12 deficiency could happen in SIBO. I still think we see that, but it’s not as common. That would be one of the B vitamins you’re talking about. What’s interesting is vitamin D, because we actually did a study, this was years ago … We never published it because it was just so profoundly negative. We didn’t see a deficiency in vitamin D and we also did bone scans. We didn’t see any osteoporosis in overgrowth patients, which I was a little surprised with. But this was about a 300 patient study, so quite large.

Dr. Weitz:                          What about if there’s fungal overgrowth at the same time as SIBO? What would you treat first?

Dr. Pimentel:                     Yeah. Generally, I mean, I’ve treated a lot of SIBO with antibiotics and I almost never have patients get worse with rifaximin. I’m not saying it doesn’t happen, I’m just saying it almost never happens. I generally give the rifaximin first. Then if I really think it’s fungal, then I will give the Fluconazole or something of that type for the patient as a backup. But yes, Dr. Rao actually cultures these patients more often but we haven’t been happy or confident with how we would culture yeast at our center yet. As I said, we have the Reimagine data and we’re looking at yeast in the coming months. We’ll be able to have a really clear picture of how many people who have yeast at a microscopic, a molecular level, not culturing. Which is more accurate.

Dr. Weitz:                          I mean, if we see fungal overgrowth on a stool sample, let’s say we have a patient, difficult to treat SIBO patient, not responding, and we see elevated fungal overgrowth on a stool sample. Is that a reason to think, Hey, this might be a case of SIFO?

Dr. Pimentel:                     Yeah, it could be. I mean, it could well be. If they respond to the antifungal, then I think you have your answer. It’s a little indirect because you’re measuring stool and not small bowel, but it may be an indirect way. Then again, as I said, if the patient responds dramatically, which I’ve had cases that respond dramatically, then I think you’ve got your answer. That’s a good thing for the patient.

Dr. Weitz:                          What about the use of elemental diet for patients who don’t do as well with the initial treatment?

Dr. Pimentel:                     Yeah. I used to do a lot more elemental diet when we didn’t have rifaximin and we didn’t have all the more modern approaches which are more effective. Because we’ve done about 3000 patients with elemental diet over the years. I use it a lot less these days, but it’s very effective for hydrogen. For methane, it’s about 50-50. People going into this, I sort of tell them that, “You will hate me the first three days. You will be fine for about seven or eight days. The last three days you’ll hate me more because you wish you were done.” Because it’s hard to do liquid only for 14 full days. But it’s about 80% effective in hydrogen. So very effective.

Dr. Weitz:                          Have you used metronidazole?

Dr. Pimentel:                     Metronidazole, I used … For methane, I use rifaximin and neomycin and sometimes I swap out with metronidazole. I see a question there with nitazoxanide, and that could also be a sub in for neomycin for methane. There are some people who are just using a linear or nitazoxanide. By itself, I don’t do that that often. Sort of because I think rifaximin adds something to that, we give both for methane.

Dr. Weitz:                          We have a question about glyphosate and I guess pesticides as a factor.

Dr. Pimentel:                     Yeah. I mean, all of that stuff is really … The big challenge we have is to understand our food system and our processes that go into producing food in the United States. I can’t tell you how many times I’ve had in my practice people who can’t eat pasta, they go to Italy, and they feel absolutely nothing. They feel perfect and they’re eating pasta every day. If there’s something we’re doing wrong, these are some of the things we’re doing wrong, polysorbate 80 or other agents that are food preservatives, sodium benzoate. I don’t know what we’re doing with all this stuff. There’s something different about the natural food you get in Italy and Europe as compared to here. It’s a quagmire, but I think there’s something wrong.

Dr. Weitz:                          Yeah. Our food system leaves a lot to be desired. We sometimes run some of these food sensitivity panels. One of the things they test is meat glue. Because apparently they glue the meat together. I mean, we really process our foods in all kinds of disgusting ways. Somebody asked about treatment for adhesions.

Dr. Pimentel:                     Yeah. I mean, there’s multiple ways to treat adhesions. I know there’s Clear Passages and other places that do manipulation of the bowel for adhesions, and I’ve sent patients there for that as well. Especially if it’s a single very pinpoint adhesion, that really is quite effective. The problem with surgery is, and for the complex adhesions, it often comes back. Will give it one try, a second try maybe, but after that, it’s futile and they just keep coming back. I hate adhesions and I think it’s one of the worst things I see in my patients.

Dr. Weitz:                          What do you do with it?

Dr. Pimentel:                     Well, again, Clear Passages is one option, so I will refer them there. But in the meantime, if they’re really bad and they’re almost obstructed, they have to go to surgery. I’ve had a couple of patients just in the last two months that struggled with that.

Dr. Weitz:                          Yeah. Okay. Thank you everybody for their questions and joining us. Thank you so much for being generous with your time Dr. Pimentel, we really learned a lot.

Dr. Pimentel:                     Well, I can tell your audience knows a lot because they’re asking some of the amazing questions and some of the tougher questions that I get. Thank you all for knowing so much and asking the right questions tonight because they were very good. Thank you.

Dr. Weitz:                            Great. Thank you. Talk to you soon.