Niraj Naik speaks about Breathwork for Longevity with Dr. Ben Weitz.

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Podcast Highlights

 



Niraj Naik is known as the Renegade Pharmacist and he is a certified UK pharmacist turned wellness and breathwork expert. He is one of the world’s most sought-after spiritual ceremony facilitators and leads breathwork workshops around the world. His journey started in the midst of a “burnout” in his corporate career, when he found himself bedridden with chronic illness for more than a year. Healing himself using breathwork techniques and dietary adjustments, Niraj felt motivated to share his knowledge with others. Today, Niraj runs a global breathwork community and trains hundreds of breathwork experts through his SOMA Breath framework, and if you use the discount coupon Manifestation55 you will get a 55% discount. Also, if you would like to order some awesome colostrum that Niraj formulated, if you go to Shop.somabreath.com and use the Promo code RW20 you will get a 20% discount.

Dr. Ben Weitz is available for nutrition consultations 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



 

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. I’m very excited today to be interviewing Niraj Naik. Naik, is that how we pronounce it?

Niraj:                     Perfect. That will do.

Dr. Weitz:            The renegade pharmacist and breathwork expert, Niraj Naik is a certified U.K. pharmacist turned holistic wellness and breathwork expert. He’s one of the world’s most sought after spiritual ceremony facilitators, and he leads breathwork workshops around the world. His journey started in the midst of a burnout in his corporate career, when he found himself bedridden with chronic illness.  Healing himself using breathwork techniques and dietary adjustments, Niraj felt motivated to share his knowledge with others. Today, Niraj runs Global Breathwork Community and trains hundreds of breathwork experts through SOMA Breath framework, which is also taught at numerous wellness centers in the U.S., Europe, and around the world. Niraj, thank you so much for joining us today.

Niraj:                   Absolute pleasure to be here, [Beitz 00:01:37], [inaudible 00:01:37]. How do I pronounce your name, Beitz?

Dr. Weitz:            Weitz.

Niraj:                   Weitz.

Dr. Weitz:            Right.

Niraj:                   Ah, so it’s a silent B. Got it. Cool.

Dr. Weitz:            Yeah, so Niraj, perhaps you can tell us how you overcame your health crisis, and how you … Tell us about the health crisis that you had and how you overcame it.

Niraj:                   Yeah, so I actually got a autoimmune disease years ago called ulcerative colitis, and this was after a run of a lot of stress, work-related stress. I got the symptoms of … Basically with ulcerative colitis, you get ulcers in your colon. You start bleeding from the bowels, and literally, you’re going to the toilet 40, 50 times a day. It’s horrific.  A few months into it, I had lost a third of my body weight. I tried all the conventional treatments. Nothing was working. I was faced with two options, either have my colon removed, or I go on a trial for an experimental drug that hasn’t even been used before. So, these are my options, and I was like, “Screw that.”  I was told also by a consultant who offered me these options that there’s no evidence that diet has any impact, and stress doesn’t have any impact. Basically, “Shut up. Take pills. That’s all we can do for you.” So, I was obviously very disappointed with that news, especially when, if you get ulcerative colitis, one of the prospects is you have to wear a bag, a colostomy bag, right?

Dr. Weitz:            Yeah. That’s not a fun prospect. I know for a fact that treating quite a number of patients with digestive disorders, that ulcerative colitis can be a very, very difficult condition to treat …

Niraj:                   Horrible.

Dr. Weitz:            … and can be life-threatening.

Niraj:                   So, I’ll summarize what I did then. Luckily, I had met an amazing yoga teacher, Swami Akhandananda, who said to me, “You’ve got a great gift here. If you can change your perception around this disease and look at it as an opportunity, as a gift, if you can fix this using …” So, she taught me some basic pranayama techniques, yoga, meditation, Ayurveda, “… you’d be an amazing role model for other people, and you can help inspire other people.” So, that changed my perception, because she gave me a bit more hope.

I also previously discovered Tony Robbins, at that time, and he always have his mantra of model success. So, the first thing I did [inaudible 00:04:38] was obviously is you do what most people do, they go in the forums, and they just see all this doom and gloom really horrific stories of people suffering with no hope. They’re on all kinds of meds. They’ve had their colons removed, blah, blah, blah. I decided to stop that and start looking at actually people who have healed themselves from this disease, and to model what they did.

I found there were some similarities. Through the Ayurvedic approach which I learned, you can actually find out a lot about yourself, and there’s no one size fits all, because we all have a unique energy blueprint, basically. Through this energy type that we all have, that’s different and individual, which you can find out through a series of special questions, I realized actually the diets that I was trying to use to solve this, which was raw vegan, because that was a big thing blasted all over the media at that time, was actually the worst thing for my health and made me much worse. Also, fruit-based stuff, as well, like fruitarian-type stuff.

Dr. Weitz:            So, were you following a raw vegan diet before you got ulcerative colitis, or you [crosstalk 00:05:46]-

Niraj:                     I had already made that transition to very vegetarian, very heavy on grains and things like that. That’s usually what happens when you go down that path. Not everybody does that, but when you’re first getting into this, get some carbs in there, you start doing that.

But then, I tried to use that same approach for healing, and I went really heavy on things like raw vegan diet, and lots of smoothies, and fruits, and things like that. None of that was working, and actually made me much worse. I checked in the Ayurvedic system that actually, people with ulcerative colitis, as my constitution, should have more grounding, warm, nourishing foods, and actually things like meats can actually be very beneficial. Actually, it was going to a completely paleo diet that solved the problem … well, a big part of the problem.

Also, I just started colostrum, which is an amazing medicine actually from … This is also an Ayurvedic treatment that’s been forgotten. It’s now becoming more popular these days. But colostrum is basically the first milk you consume when you’re born. It gives you your immune system, and it helps you create the gut lining that allows you to digest normal food.

So, if you’re deprived of colostrum as a baby, or if you go through a lot of wear and tear, like through life basically, drinking alcohol, and eating loads of processed foods, and taking prescription meds even, you destroy this gut lining. Children who don’t have enough colostrum get more often childhood diseases, and adults who destroy their gut lining, that means that all the toxins start seeping back through into the bowels, and they start getting leaky gut syndrome and things like that, which was what was happening to me, which then leads to autoimmune and all these other issues.

So, colostrum is an amazing substance, because actually, we can take bovine colostrum, which is a thousand times more potent than human colostrum, and it is actually, the cow produces four times the amount that the calf needs. So, the excess is used for human production, not … There’s no deprivation to the cow, to the calf, at all. Only the excess is used for humans. So, it means it’s done in an ethic way, which I knew that I wouldn’t go down that road if it wasn’t.

Actually, I started to test this out when I realized actually, this is actually one of the reasons why cows are considered holy in India. The Indian holy sweets were made from colostrum. So, in the monasteries and stuff, they would use colostrum quite often to make the sweets, which they give at the end of ceremonies and things.

So, I saw all of this amazing history behind it, which has all been [inaudible 00:08:55] about, and I started to use it. I’m not joking. Within a couple of weeks, the bleeding had stopped. But what was the real catalyst to getting really back to normal was that plus the breathing techniques. Pranayama is like a pharmacy of different breathing techniques, and there’s certain breathing techniques in there which just switch off stress like that, also helps you to change your conscious state so you can actually speak directly to the unconscious mind and change your operating system, which is our mind, which gets corrupted over time by life. So, it’s the first [inaudible 00:09:37] a lot of programming happens, and this can lean to an over-exaggerated sense of fear and hostility from the environment.

I was working in an environment that was already stressful, and there was a lot of fear and negativity in my environment, which is the pharmacy. Then, I ended up working in a corporation where you’re in kind of a room full of sharks, basically. Everyone’s gunning for your job, right? Everyone sees you as a threat. They’re so competitive in the environment. So, I had to deal with all of that, and what you have to do with autoimmune issues is, in my opinion, re-pattern, reframe fear and how we deal with fear.

So, a big part of the plan that I went through was basically rewiring, re-patterning the unconscious mind, and then restoring balance in those system, and using then colostrum as the foundation for healing the gut. So that, plus a few other things, which I created a system for with our SOMA Breath training, is what got me back to normal within a few months, but it has now been tried and tested through our community for many years now. We have so many success stories, countless amounts of success stories. People have had much worse cases than me who have recovered since, so it’s really … That was my driving motivational reason for doing this.

But actually, before that, I always wanted to be a music producer, a DJ. That was my thing, and I ran these big events and all this, so I always thought I was going to do that, go down that line. But strangely, it’s all gone full circle, because during that process of self-healing, I went back into making music, getting creative again, and I found that with music, you can actually make the whole breathing practices a lot more fun, but also effective, altering the brainwave states and getting into these deep physiological states. So, I started to make this therapeutic music, and that therapeutic music became my first online business. So, it became location-independent.

 I’ll tell you what. For most people, the reason why they’re sick is their environment that they live in. It could be that they’re in a relationship where they’re being bullied all the time, and that’s that relationship, that negativity, hostility that’s making them sick, or there’s this frustration that they’re not being true to themselves. It could be they’re in a career where they’re being treated badly, and then, they hate going to work. When you lose that enthusiasm for life basically, your soul wants to escape your body. It’s like, “I want to move into another place, a happier place.”

I think that’s where disease creeps in. Literally, that’s what is the Ayurvedic approach, which is most diseases, chronic diseases are spiritual disturbances. The problem with pharma is that it can never address a spiritual disturbance, something that is … drugs ain’t going to fix your environment. It’s not going to fix your relationship. It’s not going to fix your career.

Dr. Weitz:            Well, they try that with these drugs that increase serotonin production, or try to manipulate brain chemistry, except they’re, generally speaking, long-term, not super effective and very hard to get off of. I think brain chemistry is much more complicated than just increasing …

Niraj:                     It is.

Dr. Weitz:            … one or two neurotransmitters.

Niraj:                     They follow a reductionist scientific model which humans are not. We are completely irrational and un-linear, and therefore … We’re more complicated. Therefore, we need one-on-one customized solutions. Whereas pharma tries to make everybody the same, average, and they try and bring everybody to an average and normal, which not everybody fits into that same average bracket. If you go and get your blood pressure checked, they’re going to say that, if you’re above 120 over 80, or below it, you’re not normal, and therefore, you need some treatment to fix it.  But if you were take everybody’s blood pressure on the planet, you’ll find it’s like a bell shaped curve, right? It’s like this. You’ll have people who have very high blood pressure on one end and very low on the other end. 25% of people are going to have what’s called abnormal blood pressure, but for them, it’s perfectly normal. If I was to ask you, what was Gandhi’s blood pressure his whole life until he got shot with a bullet in his head, and he was like 80 plus years old. Do you know what it was?

Dr. Weitz:            What?

Niraj:                     It was 200 over 100 his whole life.

Dr. Weitz:            Wow. Wow.

Niraj:                   So, he had abnormally high blood pressure, but when they did the postmortem on his body, he had perfect health. None of his organs were affected. So, some people can live with very high blood pressure. Some people can live with very low blood pressure. That’s their normal, right?  But if you check that graph, 25% on each side is going to be a false positive when they go to the doctor for a checkup, because they’re going to be like, “Oh, you’re not 120 over 80.” So, they’re going to give you a medication, and then what’s going to happen is that they’re going to bring you to the normal of what they consider normal. The problem with that is, then you’re gong to get side effects. You’re going to get all these issues with your health, and that’s why we have so many side effects with medications. They use linear reductionist science, and it doesn’t fit the human being. We’re social people. We’re emotional. We are irrational. We don’t fit into a box like that. So, as a chiropractor, you know very well, you can’t just do that.

Dr. Weitz:            I think I should change the name of my podcast to Irrational Wellness.

Niraj:                   Yes. You got it. You got it.

Dr. Weitz:            At some point in your career, you created this infographic that become one of the most viral infographics of all time. I looked at it. It’s pretty cool. It’s called What Happens To Your Body One Hour After You Drink a Can of Coke. I wondered if you could talk about that for a couple of minutes.

Niraj:                   Yeah, yeah. That happened by accident, actually. One of the reasons why I got kind of sick in the first place actually was because I fought really hard to change my career. I wanted to get out of the pharmacy world. The way I started to do that, to make my job a bit more fulfilling, was I figured out a way to give people dietary advice through shopping lists, which I found … it came up through a Tony Robbins event, actually, where it was the first time I ever heard anyone talk about diet, nutrition, breathing, and things like that for health. In pharmacy, you don’t get taught any of this.

Dr. Weitz:            Yeah. He even talks about chiropractic adjustments as a [crosstalk 00:17:13].

Niraj:                   Yeah, he’s great. So actually, I was like, “Well, I’m gong to put Tony Robbins to the test. If he’s full of shit, I’ll find out pretty quick, because in my pharmacy, I’ve got loads of people coming in who are sick.” So, what I did was, I started to just change their diet to a, what I call, the simplest thing was a no factory diet. You’d be surprised that the majority of people consume mostly processed foods in the U.K. I don’t know how it is elsewhere. I’m sure in America, it’s everybody.

Dr. Weitz:            Oh, much, much worse in America.

Niraj:                   Yeah. So, what I started to do, I know there’s a huge correlation between processed food consumption and the amount of meds people are on. So, I started to just make a switch to the no factory diet, which would literally teach people how to make their own food, and just gave them a shopping list and directions to recipes.  Those who took my advice actually started to get better, and I got doctors calling me up going, “What are you doing? This is amazing. Keep going.” I even had lots of patients’ children, because they were older patients, going, “Oh my God, it’s amazing. My dad, he’s able to play again, and I see a smile on his face. I was really getting more job satisfaction, because I didn’t feel like I was doing anyone any favors as a pharmacist.

But then, basically, I got promoted. I had an office at one of the biggest corporations at the U.K., and that’s where I really saw … because I was going to do this healthy shopping service on a big scale. I really saw the level of consumption of fizzy drinks, in particular. You could just see, it was clear as night and day, that sugary drink consumption goes hand in hand with diabetes and metabolic syndrome, and all these issues.  I had amazing results in just the pharmacy getting people off diabetic medications just swapping their fizzy drinks with something else. Basically, some people would drink 10, 15 cups of coffee a day with three spoons of sugar in it, and they were on a whole list of meds. It was unbelievable. The doctor had never asked them, “What do you eat or drink?” It’s fascinating. So basically, when I healed myself and got [crosstalk 00:19:41], I had a lot of people-

Dr. Weitz:            I would say it verges on malpractice, to take somebody with diabetes, hand them a medication, and not do something significant to get them to change their diet and lifestyle.

Niraj:                   It’s unbelievable, yeah, that they don’t do it. So I then actually, when I got out of pharmacy, I had a lot of people asking me, when I healed myself, “How did you do what you do?” So, I made this website, The Renegade Pharmacist. I just put all my information on what I did for free on there. I put loads of advice on food, nutrition, all that.  I just put up … I saw this really cool timeline somebody had written about what happens when you drink a can of coke. I didn’t actually create that bit of content. I did the infographic based on that content, but I did my interpretation of it from my experience in the pharmacy as the article. I just put it up there to illustrate how bad fizzy drinks could be, and my experience with getting people off fizzy drinks.

 So, I just forgot about it, and then a few months later, somebody who had been following my site asked me to share it, and he shared it on a very popular website. Then, suddenly, I was waking up in the morning, and it was like Daily Mail, Huffington Post, Telegraph, Guardian, all these newspapers on my case asking me for permission for them to share it. Suddenly, it’s all over the world. Fox News made a whole show on it. It was just wild. I had several million hits to my website in like a week.

Dr. Weitz:            Wow.

Niraj:                   It was crazy. It blew us up. It made us quite popular. Yeah.



Dr. Weitz:            Interesting. I’ve really been enjoying this discussion, but I’d like to take a minute to tell you about a new product that I’m very excited about. I’d like to tell you about a new wearable called the Apollo. This is a device that can be worn on the wrist or the ankle, and it uses vibrations to stimulate your parasympathetic nervous system. This device has amazing benefits in terms of getting you out of that stressed out sympathetic nervous system and stimulating the parasympathetic nervous system. It has a number of different functions, especially helping you to relax, to focus, to concentrate, get into a deeper meditative state, even to help you sleep, and there’s even a mode to help you wake up. This all occurs through the scientific use of subtle vibrations.

                                For those of you who might be interested in getting the Apollo for yourself to help you reset your nervous system, go to apolloneuro.com and use the affiliate code, Weitz10. That’s my last name, WEITZ10. Now, back to the discussion.

 



 

Niraj:                     SOMA Breath is based on pranayama. Pranayama is the ancient Indian school of energy exercises, breathing, energy movement, and just things that manipulate the energy body. Pranayama actually means energy control. It’s revolves a lot around breathing because breathing is how you produce energy in the body, through respiration. Because that’s what I was taught, was pranayama from my Swami, I went down that rabbit hole, and I started to do as much research as I could to really gain as much knowledge about this as possible.

On my travels, I actually also, indirectly through the infographic, met Wim Hof and became good friends with Wim Hof, the Ice Man, who most people have heard of these days. I ended up making the soundtracks of the Wim Hof Method. He really inspired me. he was one of the few people that really put some science behind this stuff, and we shared some similar techniques and ideas. Then, I started to, when I went and found my home in Thailand, Koh Phangan, there’s a big spiritual community there, and breathwork was quite popular, like rebirthing, holotropic, and things like that.

So, what I decided to do was to start doing breath workshops, use these pranayama techniques, but I found with music, you can make the whole process really powerful and dynamic. But in pranayama, there’s this one method called Savitri pranayama, which is all about breathing in a rhythm. With music, you can time the breath perfectly to the beat. So, when you breathe in, you can breathe in for a certain number of beats, out for a certain number of beats, and you can create a perfect harmony with your breath.

If you’ve heard of [inaudible 00:25:03], they did a lot of studies on harmonic breathing, and rhythmic breathing, and coherence. So, what I started to do was this rhythmic breathing practices with music, and using breath retention, which is the stuff that my Swami taught me, it’s the stuff that Wim Hof is all about, to make these powerful experiences where it takes you into powerful, altered states of consciousness.

So, I found this amazing sequence that I put together with music, that became really popular in Koh Phangan and these workshops. We started with four or five people. Then, it turned into 40 people. Then, 150 people, and then eventually, I was going around the world doing these big workshops. People kept coming up to me, asking me, “[inaudible 00:25:56] do what you do?” Because I’m taking people into incredible peak states, like all these profound states of consciousness. People were having these crazy realizations and moments of inspiration, just … I mean, some people were getting healed of issues like chronic pain and inflammation, and things like that. So, I-

Dr. Weitz:            I don’t think most people realize that breathing strategies, techniques, exercises, can take you to an altered state of consciousness.

Niraj:                     No, exactly. It’s fascinating. Holotropic Breathwork by Stanislav Grof was actually one of the first ones to really go down that way, because he needed an alternative to LSD to treat … He was one of the first psychotherapists to use LSD in … He was a psychiatrist, actually.

Dr. Weitz:            What’s his name?

Niraj:                     Stanislav Grof. He found the hyperventilating-style breathwork with music was a way to create altered states of consciousness. Then, he created holotropic breathwork, which was kind of popular many years ago. Now, it’s revived a lot more popularity in recent times. Leonard Orr [inaudible 00:27:15] rebirthing, which is a similar profound breathing practice, circular connected breathing, which is a similar things.

But these are ancient yogic rituals and practices, as well. These techniques can take you into altered states of consciousness where you can actually release a lot of trapped emotions, unresolved emotions, and also have some self-realization moments. You get into these high gamma, peak gamma brainwave frequencies where you can connect to something higher than yourself, and it’s amazing.

I was doing variations of this but with another technique from pranayama called Kumbhaka, which is a breath retention. With breath retention, you can actually really alter your state of consciousness even deeper by lowering the oxygen for brief periods. When you hold your breath for a long enough period of time, you can get into very deep, very awakening, expansive states of mind where actually, your mind gets very still.

A stillness happens because thought is actually stimulated by breathing, all right? When you breathe in, you inspire. You get inspired. Inspiration actually comes from that word, of breathing in. Actually, expire is the last thing you do when you die, and it’s what you do when you breathe out, right? Inspire is the first thing you do when you’re born. You inspire. That’s when the first thought comes into your mind.

So, the yogis understood, there’s a direct connection between thought and breath. When you hold your breath after the exhalation, as you expire and hold your breath, you pause life for a moment. When you pause life for a moment, and long enough, what happens is, you actually can trick your brain almost into thinking that you’re dead, right? In doing so, it’s like a defrag for your whole nervous system, and it can actually clear all that noise out of your brain and in your mind, and actually clean the operating system.

But you could also use it as a way to actually still the mind so much that you can actually use visualization. If you’re a therapist, for example, you can actually use these techniques while somebody’s holding their breath in the same way to reprogram their operating system. You can also do it consciously with visualization yourself.

So, these are the therapies I started to develop, which was getting people into very deep meditative states using the breath retention, the pause, and through that, helping people to re-pattern their unconscious mind, which is the source of everything, your bad habits, your good habits, your immune system’s function, whether you have autoimmune or not, just your sense of wellbeing. A lot of it comes from … our sense of self comes from this unconscious mind.

So, if we can have a tool that can allow us to go in there and reprogram it, that’s like basically hypnosis on absolute steroids, man. That’s what we have developed now, and that’s what I train our therapists to do. Using these different techniques, you can actually alter brainwave states and help people to re-pattern the mind, the source of all things. Also, another benefit of all of this is that actually, when you hold your breath for a long enough period of time, you create this state called intermittent hypoxia, a lower than normal oxygen level for a brief period.

I met a yogi doctor in the Himalayas called Prakash Malshe, who’s one of my many mentors and teachers. He’s an advisor to our company. He wrote a book called the Medical Understanding of Yoga, and he really, the first time, gave me absolute clarity on the profound deep science of yoga and its medical applications. He really explains the benefits of intermittent hypoxia and why yoga itself, if you do traditional yoga, how it’s supposed to be done, not the stuff that you see in the mainstream yoga now, but traditional yoga where you’re holding each pose for long periods of time, doing breath retention, training yourself to be able to expand your breath retention times. What it does is it makes you very efficient adapted to oxygen. There’s a reason why we do that. The more efficient we are at using oxygen, the less we need to breathe.

 



Dr. Weitz:                            I’d like to interrupt this fascinating discussion we’re having for another few minutes to tell you about another really exciting product that has changed my life and the life of my family, especially as it pertains to getting good quality sleep. It’s something called the chiliPAD, C-H-I-L-I-P-A-D. It can be found at the website chilisleep.com, which is C-H-I-L-I-S-L-E-E-P dot com.

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If you go to chilisleep.com and you use the affiliate code, Weitz20, that’s my last name, W-E-I-T-Z, 20. You’ll get 20% off a chiliPAD. So, check it out and let’s get back to this discussion.



 

Niraj:                   You bet.

Dr. Weitz:            I mean, we certainly have heard of people checking their oxygen saturation. Oh my God, your oxygen saturation’s going lower. You’re going to need oxygen. You can die if your oxygen saturation gets too low at night. You’re going to need a CPAP machine. It seems like we don’t need technique to increase carbon dioxide. You can simply just walk along a freeway, or smoke a cigarette, or do any of these other things in modern life that increase hydrogen, carbon dioxide, and decrease oxygen. So, explain why we need to intermittently decrease our oxygen.

Niraj:                     Okay, so basically, I have a device here. If you have a pulse oximeter, you’ll find that most people’s oxygen levels … I don’t know if it’ll show up, is around 99% at all times. [inaudible 00:34:49]. So, you’ll find that even just with a sip, like that, is enough to oxygenate the blood fully. If you see this, it’s just calibrating. I don’t know if you can see it.

Dr. Weitz:            It’s stopping right there. Yeah. It says 97%.

Niraj:                   It’s at 98%. That’s completely normal. 97, 98, 99 is perfectly normal. You just need a little sip, a little sip of air, and the oxygen levels go right up, okay? Now, that’s the measurement of all the cells. It measures your blood oxygen saturation, so this is your bloodstream. This is not to be confused with body tissue oxygenation, okay?

So, when you breathe in, you inhale, the oxygen binds to your red blood cells, and your blood cells drop off oxygen to the areas of your body that need the oxygen. So, every single organ in your body, every cell in your body is respiring, is breathing. It breathes in oxygen, breathes out carbon dioxide. Now, the most active areas of your body, like let’s say you do some weights, so you’re doing your dumbbells or whatever, these cells here …

Dr. Weitz:            [crosstalk 00:36:08].

Niraj:                     … are going to respire the fastest, okay? So, they’re going to be producing more carbon dioxide, and that carbon dioxide is the signal for telling your blood where to drop oxygen off. Otherwise, it will never know where to drop it off, and it will be a very inefficient method of transportation of oxygen. So, the carbon dioxide level signals your blood to drop off oxygen. The higher the carbon dioxide is, that’s where the oxygen is going to go, right? So, we’ve got this very clever system.

Now, what happens is, when it comes to oxygen efficiency and oxygenation, now the problem is, when you’re stressed [inaudible 00:36:54], we breathe at a faster rate than we need to. If you’re also eating the food that’s not good for you, if you’re not digesting food efficiently, you’re eating process foods, if you’re on loads of chemical medications and stuff, you hyperventilate and actually breathe at a faster rate than you need to, right? So, the faster you breathe, the more carbon dioxide you’re expelling, which means there’s less of that signal in your system telling the oxygen … your blood cells where to drop off oxygen.

So, the oxygen stays bound to your red blood cells, and what this causes, and Harvard have done the studies, is rusting internally. If you are not getting oxygen into your cells efficiently, you can create this internal rusting effect, which will lead to plaque formation, and then heart disease and things like that. But also, if you’re not getting the oxygen from your red blood cells into your tissue cells, the problem there is that your tissue cells needs the oxygen, so they start to get diseased.

Oxygen is also a constrictor. It constricts. It makes your blood vessels narrower. Carbon dioxide is a dilator, and it works with another key ingredient gas called nitric oxide, which is only produced by nasal breathing. So, when we don’t breathe through our nose, which a lot of people … you’d be surprised how bad that issue is actually, we have an epidemic of mouth-breathers, right? If you don’t breathe through your nose and just breathe through your mouth, you over-breathe. The mouth means you have too much volume of air going in and out. You’re not producing nitric oxide, you’re getting rid of too much carbon dioxide, and that then leads to phasic constriction, high blood pressure, but also leads to poor oxygenation of tissue cells. Eventually then, that leads to chronic disease, fatigue, all these issues.

So, when you learn to be able to raise your carbon dioxide totals, because carbon dioxide also is what tells your brain that you need to breathe again, to inhale. Now, if you have very weak carbon dioxide tolerance, if you can’t handle a decent amount of carbon dioxide in your system, you’re going to also chronically hyperventilate, meaning you will breathe faster than you need to. That chronic hyperventilation then again leads to the over-breathing problem. But if you can increase your carbon dioxide tolerance, which is very, very easy to do, it’s just a simple practice, you’ll be able to handle higher volumes of carbon dioxide, keep a good ratio between carbon dioxide and oxygen, meaning you get optimum oxygenation of your body tissue cells.

 This is what Buteyko discovered, but it’s been forgotten. Recently, it’s becoming more known like people like Patrick McKeown, Oxygen Advantage. He talks a lot about this stuff. But it’s still kind of shrouded in a lot of mystery, and doctors and all these people, most of them have no clue about respiration and breathing, and its link to inflammation and things like that. So, we’re doing a lot of reeducation. We have a lot of doctors coming to us to actually train again in respirational science, because they haven’t been taught the right stuff. It’s very simple.

This is what I was talking about. This is the big ah-ha moment for you, because yoga as a system was developed by studying animals in nature. Animals that actually live a very long time are elephants and turtles. They breathe very slow, right? Whales, for example, live over 200 years. They have a breathing rate of less than one breath per minute, and they can hold their breath for two hours at a time. You can only hold your breath for two hours at a time if you have very, very good carbon dioxide tolerance, right, and oxygen efficiency.

The other end of the spectrum, animals that don’t live a long time are rats and mice. They have very fast breathing rates, 150, 300 breaths a minute, right? But there’s a weird anomaly to this rule, and that is the naked mole rat. The naked mole rat basically lives primarily underground in a hypoxic environment. It can hold its breath for over 18 minutes, and it lives 30 years pretty much free of disease, and is really hard to give it diseases in the lab even. It’s a very robust animal.

So, there is a correlation in the animal kingdom between breathing rates, breath retention, and longevity, right? The father of oxidative stress and [inaudible 00:41:45] is Helmut Sies. He did the best studies on this stuff, and he says, although it’s very difficult to live without oxygen, it’s also very difficult to live with oxygen because of the problem of oxidative stress. That’s why we need antioxidants in our diet and stuff like that.

So, yoga as a system, if you do it properly, traditional yoga, the yoga asanas where you hold each pose for maximum effort, holding your breath in poses, is all designed to train your body to become very efficient at using very little oxygen, to adapt to a low oxygen environment. There’s a reason why yogis go and live at the top of the Himalayas, where the oxygen levels are very low, and yogis are famed for longevity, right?

So, I went back to those roots and decided to go through all of this. I made that system of yoga and pranayama a little more accessible, easier to use. The music all helps this. Add in the new, modern sciences coming in to then create a system that’s designed to improve oxygen efficiency in people, and that’s the metric.

If you can improve your breath retention time, like there’s a measurement you can do every morning, the morning BHT. This is what we [inaudible 00:43:05]. Do the morning BHT within the first 10 minutes. Breathe in through your nose. Breathe out through your nose. Hold your nose, and hold your breath. You don’t do any breathing techniques beforehand, just do this. Hold your nose and hold your breath until you get that first strong urge to breathe where you’re not gasping for air at the end of it. You’ve gone too long, if you’re gasping for air, but you inhale release as normal afterwards.

That’s your BHT, breath hold time. If you can bring that to 30 seconds and above, then you’re in good health. If you can go to 60 seconds and above, you’re like super yogi. But if you’re less than 15 seconds, less than 10 seconds, you’ve actually got probably some disease you’re trying to fight. Actually, if you’re five seconds and less, then there’s actually some real issues with your health that I you need to look into. So, that’s one of the measurements we do.

Dr. Weitz:            That’s sweet.

Niraj:                   Yeah.

Dr. Weitz:            Breath hold time, right?

Niraj:                   Yeah.

Dr. Weitz:            Interesting. I mean, we can use that as an exam technique for patients.

Niraj:                   Yes. That’s what Buteyko used to do. He would use that as a test for … Actually, a lot of doctors used to use this test. They would also use the forced hyperventilation test, where you hyperventilate for like a minute, and it would make sick patients more sick. Through that, he would be able to tell which organs are the ones that are sick through the symptoms that would get exaggerated. So, forced hyperventilation makes people more sick. You see, I’m talking a lot right now, and I’m actually hyperventilating. It makes me a little bit lightheaded.

But a lot of people who are working all day long, they’re sat down in a chair talking all the time on the phone, or to their colleagues or whatever, hyperventilating. Then, they’re eating processed foods. That’s make you breathe even faster than you need to. Then, you’re not doing any exercise. Exercise makes more efficient use of oxygen and all of this.

That builds up to then a problem with this gaseous exchange where they get poor tissue oxygenation. Then, that’s what makes people inflamed. It makes people have chronic pain, because the constriction leads to poor blood flow to your body, and to your tissues and organs. Then, that poor blood flow leads to chronic pain.

So, imagine, just by changing the way you breathe, your relationship with your breathe, learning to extend your breath retention time, slowing your breathing down, training yourself oxygen efficiency, which [inaudible 00:45:45] is probably the one that’s really good for you. What it will do is, it will help you with so many other areas of your life.

Then, once you’ve got that bit sorted, you can then go into the [inaudible 00:46:02] rituals, which are where you actually use hyperventilation as a way to get into profound altered states of consciousness. It’s controlled hyperventilation, which is what we do. We have instructors we’ve trained as facilitators. You can take people into these powerful psychedelic-like journeys where you have this connection with the Divine, and get rid of all these emotional traumas and baggage that’s built up from the past.

So, we have a system of doing this in a safe, effective way. One of the problems we see with breathwork today is that there’s too many people jumping straight to the hyperventilation because it gets you high, right? The problem with that, and if you get confused with that-

Dr. Weitz:            Is that what happens like in Wim Hof technique, is they tend to focus on that more?

Niraj:                   No. See, the Wim Hof technique is all about the breath retention. It should be, because it’s 20 breaths in an hour, fast breaths followed by holding your breath. Actually, that is the best method for getting into holding your breath for long periods, because what you’re doing is, you’re hyperventilating for a bit. That brings all the carbon dioxide out. Carbon dioxide is what tells your brain you need to breathe again. So, if you have less carbon dioxide in your system, you’re going to hold your breath for much longer than you normally can. What that does is, it lowers the oxygen levels for a brief period, and that creates this intermittent hypoxia.

We use a slightly different method. We use rhythmic breathing to the beats, so the breath retention’s slower, rhythmical. We use different breathing patterns. So, you have a four eight, four beats in, eight out, or two in, four out.

When you double your exhalation time, it does something else. It actually switches on the parasympathetic nervous system, because when you breathe in, you stimulate sympathetic. When you breathe out, you stimulate parasympathetic. Actually, when you breathe in a rhythm, when you’re breathing in and out at the same time, you balance the nervous system. With you breathe with a double the exhalation time, you turn on parasympathetic.

So, when we’re doing these psychedelic journeys, when you do that, actually people go into very deep parasympathetic, low theta brainwave states, which is very, very therapeutic and healing. It could be, for some people, the first time in their whole life that they’ve activated their parasympathetic for that long. So, people have these powerful healing experiences.

Dr. Weitz:            So, a longer exhalation period is better for stimulating parasympathetic?

Niraj:                   Yeah, and another way you can do that is just by humming. If you om, when you hum, you do a couple of things. You extend your exhalation. That sound, the vibration actually stimulates the vagus nerve, so that calms parasympathetic. It exercises parasympathetic.  But then, also the humming, when you hum and vibrate this area here between your nasal cavities, it’s called the paranasal cavity, the paranasal sinus cavities, what happens is you stimulate nitric oxide 15 times normal than if you were to just breathe normally. Om, this is the science of om, if you do om properly, like I just told you where you put the hum on the hum, you produce all this amazing nitric oxide. Nitric oxide is antiviral, antibacterial, nasal dilator, bronchodilator, also works with carbon dioxide to get that oxygen to your cells. So om, chanting om is one of the best things you can actually do for your health [crosstalk 00:49:55].

Dr. Weitz:            Fascinating.

Niraj:                   Yeah, man.

Dr. Weitz:            Amazing stuff, it really is.

Niraj:                   Cool.

Dr. Weitz:            Really, in the functional medicine world, we should really be incorporating breathwork more regularly into our patients’ treatment plans.

Niraj:                   Oh, 100%. It goes hand in hand with chiropractic. I actually have a few chiropractors where I’m in, in Spain right now, who are doing all our courses, and I’m hoping to work with more chiropractors. I think it just works so well with what you do, as well. It’s all about the energy in the body. [crosstalk 00:50:30].

Dr. Weitz:            So now, we, or our patients, can access your training programs online?

Niraj:                   Yeah. We have a website, Somabreath.com. I’ll give you a link as well, so you can give a discount to your listeners, if they want to take any of our courses. We have the SOMA BreathFit course, which I think is invaluable for people to build healthy breathing habits which will protect them from disease, prevent disease. I’m not going to say it’s going to cure things or prevent everything, but it’s definitely going to give you more energy, and a better experience and quality of life if you learn this stuff. What it is, is the best essence of Buteyko but made much more easy to do and follow.

Then, we have the 21 day course, which is a real deep dive into altered states using breath. It’s done as a group with an instructor online through Zoom and things like that. It’s really transformative, very helpful. We recommend people do both courses back to back.

 Then, we have the instructor training, which is great for professionals like yourself, like chiropractors, to be able to bring breathing techniques and powerful experiences to clients for transformation. Because with breathing, it can also be very fun. Actually, you can get into very good states of being, wellbeing, just with the breath, which creates great foundations for healing, right? So, that’s the different options.

We also have a YouTube channel, SOMA Breath, Facebook group, SOMA Breath, which is an amazing, buzzing community. I love the community we’ve created. It’s super high vibe. Everyone is helping each other out. I feel the community is the thing that’s really going to cure this world’s problems that we’re going through right now. [crosstalk 00:52:26]-

Dr. Weitz:            The website is S-O-M-A-B-R-E-A-T-H .com?

Niraj:                   Correct. That’s it. Yeah.

Dr. Weitz:            Awesome. Hey, great podcast. I really appreciate you spending some time with us and providing some great information.

Niraj:                   Yeah. Sorry if I’ve been talking a thousand miles per hour, because I’m trying to get as much info to you as possible.

Dr. Weitz:            I appreciate it. Yeah. That’s the way my mind works, too.

Niraj:                   Great.

Dr. Weitz:            When people talk slow, I have to speed it up when I’m listening to their podcast.

Niraj:                   Me, too. Me, too. Me, too. We’re very much on the same page.

Dr. Weitz:            Okay. Thank you so much.

Niraj:                   Cool.

Dr. Weitz:            I’ll send you a link when we post it.

Niraj:                   Perfecto. Much love, man.



Dr. Weitz:            Same here. Thank you for making it all the way through this episode of The Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple Podcasts and give us a five star ratings and review. That way, more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts.  I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition Clinic. So, if you’re interested, please call my office, 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.

 

Dr. Edison De Mello speaks about the Keys to Better Gut Health 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 my WeitzChiro YouTube page.] 

 

Podcast Highlights

1:27  Gut problems, including stomach pain, bloating, gas, diarrhea, and constipation, are extremely common today.  Gut problems exist because of our toxic environment, because of stress, and because most of us haven’t asked ourselves what our relationship with that food is. 

7:05  Bloating.  Bloating needs to be distinguished from swelling and from fat.  With bloating it comes and goes from one day to the next, whereas when you get fat, it continues to increase and doesn’t come and go.

8:57  Once we rule out the most severe pathological conditions, the most common cause of bloating is gut dysbiosis, which means an imbalance of the microbes in the microbiome.  There are various reasons why there is gut dysbiosis, including eating foods that inflame our gut, taking antibiotics for sinusitis that also kill the good bacteria, by eating on the go, by having your hormones imbalanced, or there may be overgrowth of bacteria or fungus.  There may be small intestinal bacterial overgrowth (SIBO) or there may be overgrowth of other bacteria in the colon like strep or prevotella.  There might be parasites or H. pylori or overgrowth of candida. We can do a breath test for H. pylori.  We can do the SIBO breath test.  Dr. De Mello orders his SIBO breath tests through Dr. Sam Rahbar, who is an integrative Gastroenterologist in Los Angeles and who assists in the interpretation. He also likes to order the 3 day stool test from Genova.

18:52  If the tests come back and the patient has multiple issues that might be contributing to gut dysbiosis, such as a positive SIBO breath test for methane and overgrowth of certain bacteria or fungus on the stool test, then Dr. De Mello will focus on the condition that he feels is the priority.  But he makes sure his patient is ready to be committed to changing his diet and lifestyle and he wants to make sure that he is not overwhelming his patient. He will ask his patient to make a list of the changes that he or she is willing to make, such as changing their diet, taking their supplements, sweating a lot, exercising to get these toxins out, etc.

22:32  Dr. De Mello feels that taking some specific herbal supplements is a crucial part of the treatment. He tends to use the herbal products–either FC Cidal and Dysbiocide from Biotics or Candibactin AR and Candibactin BR from Metagenics that were shown to be equally effective to Rifaximin or to triple antibiotic therapy (Clindamycin, Flagyl, and neomycin) in the John’s Hopkins study: Herbal Therapy is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth.  He may either recommend a low FODMAP diet or do food sensitivity testing with Cyrex Labs to see which foods should be avoided.  Or he may use the low FODMAP diet and also eliminate certain foods and then test them back over time. 

28:58  Dr. De Mello may also place the patient on low dose erythromycin 50 mg as a prokinetic to restore their intestinal motility, esp. if they have elimination problems.  He will typically treat SIBO patients for 90 days and then he will pulse it one week on, one week off.  When treating for SIBO he may also treat for candida with an herbal blend for candida.  If that doesn’t work, he will treat with nystatin for up to 3 mths as long as the liver enzymes are fine.

33:33  Dr. De Mello may order an Organic Acids test, esp. if there are no clear signs of what the cause of their gut symptoms are caused by. The other thing he finds may impact gut health are hormones.  For hormones, he prefers to test with blood and he asks women if they are still menstruating to run it between days 17 and 22 during the luteal phase, though he will sometimes use the dried urine DUTCH test.

 



Dr. Edison De Mello is a licensed psychotherapist and a board certified Integrative Physician.  Dr. Demello is the founder and medical director of the Akasha Center in Santa Monica.  His PhD dissertation was entitled “Gut Feelings – A Psychosocial Approach to Gastrointestinal Illness,” and he is committed to integrating the mind and a person’s emotional and spiritual health and body into his approach to health. Dr. Demello has recently published his first book, Bloated: How to Reclaim Your Gut Health and Eat Without Pain.  

Dr. Ben Weitz is available for nutrition consultations 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



 

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. I’m very excited to be interviewing Dr. Edison De Mello today, who’s our special guest. Dr. De Mello is a licensed psychotherapist and a board certified integrative physician. Dr. De Mello is the founder and medical director of the Akasha Center in Santa Monica. Dr. De Mello’s PhD dissertation was entitled Gut Feelings-A Psychosocial Approach to Gastrointestinal Health. He’s committed to integrating the mind and a person’s emotional and spiritual health into his approach to treating patients with digestive disorders. Dr. De Mello has recently published his first book, Bloated? How to Reclaim Your Gut Health and Eat Without Pain. We certainly need to know about that. Dr. De Mello, thank you for joining us today.

Dr. De Mello:                     Thank you for having me here, Ben, and thank you everybody out there for listening to us this morning.

Dr. Weitz:                          Absolutely. Dr. De Mello, why do people have so many gut problems these days, including stomach pain, bloating, gas, diarrhea, constipation, et cetera?

Dr. De Mello:                     Well, that’s the million dollar question, right? I know we’re dealing with a horrific epidemic right now, and I don’t mean to diminish, certainly, all the suffering, and all the death, and all the desperation of this epidemic, because I’m one of the physicians out there in the front lines, but there’s another epidemic happening.

Dr. Weitz:                          The epidemic within the epidemic, as I’ve heard Dr. Bland say recently.

Dr. De Mello:                     Exactly, exactly. As we know, health starts in the gut and we’ve heard this throughout our lives in medicine, that the gut is the carburetor of our health, basically. Without the gut, we wouldn’t be able to function. We wouldn’t be able to correctly metabolize our hormones. Because of lifestyle and because of the toxicity of the environment, because of stress, and because most of us have not really sat down and asked ourselves, “What is my relationship with food? How does my body receive this nutrient that it needs that is heavily necessary for our wellbeing?” If it’s not done correctly it can work against the very thing that we want to do, which is to be healthy.

Why do we have this epidemic? Again, I can go through a list of things with you, Ben, today, but I will start by saying we need to step back and ask ourselves, “Is what I’m doing in my life, is what I’m doing with my eating working?  Am I processing my food correctly?  Am I eliminating correctly?  Am I able to dedicate time to really allow my body to digest this food?” That’s where I start with my patients when they come in.  Certainly, the complaint that I hear most often, because of my double degree and the type of focus that I apply in my practice, the complaint is, “I don’t feel well.  I don’t feel comfortable. I’m embarrassed.” If it’s a woman, “I look like I’m pregnant.” If it’s a man, “I have a beer belly, even though I don’t drink that much,” and so the question is, what is your body telling you?  What is the message that the body has to tell you that something is off?

The first thing is, look at our lifestyles. Look at how we relate to the very nutrient that we need. The second thing is the ability to listen to the message that the body has for us. We are all about communication, and the body’s no different. The language of communication in the body to relate to us is called symptoms. Our job, as the host of this body, is to stop and listen and say, “Hmm. I keep hearing the same message. I eat and I don’t feel well. I eat and I cannot eliminate.” Or, “I feel bloated.” Or, “I don’t feel healthy.” What’s going on? When you pose that question, I think you have walked halfway into a possible answer.

Dr. Weitz:                          It’s amazing that we get all these signals and yet, most people are totally oblivious to those signals, partially because of all the noise, and all the things going on, and the messaging about eating unhealthy foods that just happen to be profitable. What I have found is a lot of people are not at all attuned to those messages.

Dr. De Mello:                     No. First of all, I think when we have symptoms or disease, we usually think of it as the enemy and we want to fight it off. When we do that, we spend so much energy on the symptoms, trying to fight it off, rather than stopping and saying, “What is the message?” Actually, as obvious as it may sound, as a result, okay, so this body, like I said before, is trying to tell me something. Let me take notice of it. The first thing that I do, Ben, when a patient comes in is try to figure out who this person is. Who is this person who happens to have a condition? Because when we connect with a person and we find out what his or her views of disease are, what the lifestyle is, what the relationship is with food, why now? Why bloating now?  When we stop and meet the patient, before we meet their diseases, again, I think there’s a great deal of information that we can get from those patients. As you know, being in that space of functional medicine yourself, that’s the cornerstone of integrative medicine, of functional medicine, is to meet the patient, is to let the patient be part of this incredible journey that we’re doing in discovering the message that the body’s trying to tell us.

Dr. Weitz:                          Your book’s about bloating. What do we mean by bloating? What is bloating? How is this different from gas? What’s the significance of bloating?

Dr. De Mello:                     Okay. Excellent question. In the book, I try to explain the difference between bloating and swelling, right? So-

Dr. Weitz:                          And bloating and fat, and bloating and a lot of things, right?

Dr. De Mello:                     Exactly. Bloating and fat, as you said. Bloating’s a condition where it’s gas, basically. It’s a lot of gas in your body, and there’s no rhyme or reason when it’s going to happen. Sometimes you eat, and soon after you eat, your belly extends where you feel like you have a watermelon sitting there. Other times, it takes a couple of hours. It can even take a day, which is a delayed hypersensitivity reaction to whatever you’re eating.

Bloating is completely separate from fat. You know fat takes a little while for you to build in your body when you we don’t eat healthy, when our hormones are not metabolized. It progressively increases and it gets worse and worse. With bloating, you have it one day, the next day you find a way to diminish. The next day, the day after that it gets worse. It’s this kind of ongoing battle, where there are days that you can close your jeans, there are days that you can’t. You ask yourselves, “I didn’t do anything differently.” Here’s a question that I hear the most, Ben, “But Dr. De Mello, I hardly ate anything yesterday. Why am I bloated today?” I say, “Well, let’s have a little talk with your gastrointestinal bacteria. Let’s talk to your microbiome and see what’s happening there.”

Dr. Weitz:                          Once we’ve ruled out some of the most severe pathological conditions, which we don’t see too often, like fluid from liver or kidney disease or congestive heart failure, what are some of the most common reasons for bloating?

Dr. De Mello:                     Yeah, so thank you for qualifying that for our great listeners out there. We have to, before we move into the bloating wagon, we need to rule out any potential medical reasons, physiological reasons for that. As you said, it could be anything from a liver condition, where you’re retaining water. It can be your kidney as well. It can be congestive heart failure. It can be a multitude of things that we healthcare professionals will focus on eliminating, starting with perhaps a simple imaging exam or imaging test such as an ultrasound and also looking, of course, at labs.  Once that is ruled out, the most common reason for people to have this bloating disorder, bloating condition is a dysbiotic gut, meaning your gut is out of balance. Here’s the interesting thing about bacteria that we all know. Bacteria is incredible, helpful, to our lives, from making our incredible wine, to making cheese, to helping with our gardening, to helping even clean our environment. Bacteria is, can be incredibly helpful to a very, very good lifestyle, but as I wrote in a paper once, called Bacteria: Friend or Foe? bacteria can also kill you. When you go into the hospital, you can have several reasons or several possibilities why bacteria has overgrown, from a simple cut that was not well taken care of, to a surgical condition that became a problem, to a multitude of other things that could lead to bacteria overgrowth.

The question is, “How do I look at this bacteria overgrowth? How do I balance my microbiome?” The first question, again is, “What am I eating? Is there a connection between what I’m eating and this bloating that happens?” Not only, “What am I eating?” but, “What have I been fed?” as well. For instance, we often say, “We are what we eat,” and I add a little bit more. I say, “And what we’ve been fed.” Because as kids, we don’t have a choice and sometimes, as patients, we don’t have a choice. We’re fed antibiotics, and for good reasons, a lot of the times, to saves our lives.  When we’re fed the bad foods, the bad antibiotics, the multitude of medical intervention meant to help us stay alive, in most cases, it does the job of helping us stay alive but also diminishes the overall function of our immune system because, as I said, health starts in your gut. Your gut is the seat of your immune system. The idea is to say, “Okay. If I need to take this antibiotic, or if I need to take this medication, how can I help my body break it down?” One of the most important things out there is probiotics. How many times do we hear in traditional medicine, when a patient come in to say, “My doctor put me on antibiotics for a sinusitis or for pneumonia,” and we say, “Did she or he tell you to eat a bit differently when you’re on antibiotic? Did he tell you to take probiotics, to exercise to sweat this thing out of your body? How about drink water?”  The idea is to really be able to support the body to be able to process those things out of your body, out of the body including some foods, including antibiotics, including even our vitamin and supplements. The idea is to allow the body to digest it better. How do you do that? You do that by, first of all, stopping to ask yourself, “Can I dedicate a specific amount of time to my eating, or am I eating on the go?” Then secondly, will say to yourself, “I’ve noticed that when I eat these foods, I don’t feel good. Can I do a process of elimination, and do elimination diet?” Third, you can say, “I wonder if my hormones have been checked, so let me talk to my practitioner about that.” Because if your hormones are off, so is your metabolism. You can go through a list of things that can help you get to this idea of, “Why am I bloated?”

 



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Dr. Weitz:                          Let’s say, and this question, let’s answer it both from the perspective of an educated patient as well as a practitioner. A patient has bloating. How do we go about the process of figuring out what some of the causes are? You mentioned dysbiosis. Of course, dysbiosis is somewhat of a diagnosis, but it’s kind of a general one. It means that there’s some imbalance in the gut bacteria. Within that general sort of larger diagnosis, we have small intestinal bacterial overgrowth. We have overgrowth of candida and fungus. We have other bacteria that could be overgrown like strep or Prevotella. We have parasites, we have food sensitivities, we have H. pylori. How do we now drill down, what sort of tests and procedures do we want to do to figure out exactly what is the cause of bloating in this patient?

Dr. De Mello:                     Yeah, so again, excellent question. I start with the big ones. I want to do a breath test for H. pylori.

Dr. Weitz:                          Okay.

Dr. De Mello:                     There’s a great deal of patients out there who have H. pylori and they don’t even know it. They have GERD or acid reflux. They have bloated, they don’t feel good. They feel the energy is much decreased than it used to be, so I do the breath test for H. pylori. Depending on the history, if the history is also the history where bloating just suddenly come, then I will also do a SIBO test. The SIBO test, as you mentioned, is small intestinal bacterial overgrowth. The SIBO test, it’s a breath test, and then we usually do it in the office or we teach our patients how to do it at home. Depending, of course, on the patient’s financial ability and insurance protocol, I will also order a stool test. I personally love the Genova’s three-day stool test.

Dr. Weitz:                          Okay.

Dr. De Mello:                     That is because I’m looking for not only an assessment of your microbiome, the patient’s microbiome, but I’m also looking for other microorganisms growth that is in there. I’m looking for digestive enzymes. I’m looking for the metabolites coming out of the patient. The three-days really yields a lot of more information, so those are the three big ones.

Dr. Weitz:                          This is the Genova GI Effects stool test, the three-day one.

Dr. De Mello:                     Yeah.

Dr. Weitz:                          Which SIBO breath test do you do?

Dr. De Mello:                     I work with Sam Rahbar, who’s a gastroenterologist.

Dr. Weitz:                          Yeah, yeah. He’s a good friend of mine. He’s been on the podcast a number of times. Yeah, yeah, yeah.

Dr. De Mello:                     I use his test that he-

Dr. Weitz:                          Oh, okay.

Dr. De Mello:                     The reason I do that is because I can call Sam when I get the results and I say, “Wait, wait, wait. Can you explain this to me here? The patients have this and this symptoms, but it’s not correlating with the results.” Sam being who Sam is, he gets right to it and say, “Okay, here’s why,” and so I’ve been doing that with him, using his lab for SIBO for a number of years.

Dr. Weitz:                          Okay, that’s great. Then, so let’s say you get some positive results. Let’s say the SIBO breath test comes back positive for methane SIBO, and the stool test shows some overgrowth of certain bacteria, or maybe candida, and maybe some issues with a lack of digestive enzymes. Where do you start? Do you treat multiple things at the same time? Do you try to prioritize? What’s your approach to treating gut issues?

Dr. De Mello:                     Yeah, I focus. I try to stay really laser-focused on what is this, what condition or symptom is disturbing the patient the most? Because, of course, when we are bloated there could be an N number of possibilities and a million things that we can do to get to the bottom of it. That alone can overwhelm anybody. It can overwhelm me when I’m looking at a patient and go, “There’s so many steps for him to take.” The first thing that I do, and it’s going to sound repetitious, but I meet the patient and I want to know, “Is this the right time for you? Are you ready to do this?” Because here’s what happens, as we know, and this is the psychologist hat that I’m wearing here right now, Ben.  As we know, we can set up our patients for failure without knowing it. Of course, we don’t mean that. We want to help the patient, but if we don’t know what his lifestyle is like, if we don’t know what his emotional life is like, the demands on him is like, and we say, “Okay. You have to do this, this, and this,” and he’s going to be looking at you because he respects you as a practitioner. After all, he came to see you. He’s going to say, “Yes, yes, yes,” and he’s going to go home and start pulling his hair out. Literally pull, not his hair but his head or his neck because there’s so much going [inaudible 00:20:51], and so I want to make sure that I’m not overwhelming the patient.

I love that saying, “You cannot feed a starving child a piece of steak,” because the child doesn’t have the metabolism for it, just been starving. If a patient is that full of symptoms and that overwhelmed in life, I want to know. I want to know, what is it that I can do? So I’m going ask him. First, I said, “Okay, so here’s the diagnosis. You have SIBO and it’s curable, but it will require your attention. It require that you really spend time deciding what you’re going to eat. We’re going to give you a protocol. Taking your supplements, sweating a lot, exercising to get these toxins out of your body. Tell me about your lifestyle right now. Is there something that you can do?” Then I will list the things to them, and so they will look at me and say, “Well, I think so.” I say, “Okay. Let’s make a list of the things that you can do.”

Dr. Weitz:                          “I don’t have time for all that. I don’t want to change my diet. Just give me something to take.”

Dr. De Mello:                     Exactly, exactly. I’ll say to them, “It won’t work. It’s only going to frustrate you. It won’t work,” and so I try … Then given their lifestyle, let’s say somebody who’s a single mom, and working during the epidemic and trying to keep the kids at home. I cannot tell her to go exercise every day, or to go into an infrared sauna and have the luxury of sweating out some of the toxins, but I can say to her, “Okay, so given those things on the list that you can do, pick three that you can do right now.”  Of course, one of them has to be a set of supplements and herbs that I can help the patient with. Once we determine the lifestyle and the question of, is the patient ready to do this? Then I will present the patient with the plan. The plan, usually, if let’s say if it’s SIBO, will involve what I refer to as the Johns Hopkins protocol. It’s the paper that came out about seven years ago that revolutionized the field. I know you’re familiar with it.

Dr. Weitz:                          Yes, of course. Yeah.

Dr. De Mello:                     Yeah. Where it showed that Rifaximin, Neomycin and Flagyl together was very helpful, but a set of specific herbs that they studied called FC Cidal, Dysbiocide and Candibactin from Metagenics was actually equally effective.

Dr. Weitz:                          Right.

Dr. De Mello:                     I put them on that protocol to start with. Three supplements in the morning, two of it, and then that makes six pills, plus at dinnertime. Then, of course, I will look at other physiological needs of the patient, including hormonal therapy.

Dr. Weitz:                          Let’s drill down for a minute on your specific protocols for SIBO. The patient, we’ve identified SIBO is their primary issue, so you’re going to put them on some of these antimicrobial herbs. Are you going to put them on, what type of diet? Are you going to put them on a low FODMAP diet?

Dr. De Mello:                     Yeah, depending on, again, the lifestyle of the patient. Let’s say it’s somebody who can do, who can follow the protocol. A FODMAP diet is the first diet that I start with, and I let the patient … I give them the guidelines, and I say, “Let’s see which food on this list you can, indeed, consume without having some of the bloating that you may have experienced in the past.” I’ll ask the patient if some of those foods have caused bloating. If financial means is not a problem, then I’ll also do a food sensitivity. I usually, I really like Metagenics … Excuse me. Cyrex.

Dr. Weitz:                          Cyrex.

Dr. De Mello:                     Yeah, using the food sensitivity, the leaky gut sensitivity. Because the worst thing for those patients is that we say to them, “Here’s the FODMAP list of foods,” only to later on find out that they have sensitivity to some of those foods. If they can do the test or afford the test, I’ll do the test. In some situations, they can’t. Then I do an elimination diet. I go through the list of foods that they know they have experienced a relationship to bloating, cause and effect, and I will remove those foods from the FODMAP list.

Dr. Weitz:                          Okay, so you’ll combine a low FODMAP and elimination diet to start with?

Dr. De Mello:                     Yes, yes. Again, because I want to empower the patient.

Dr. Weitz:                          Right.

Dr. De Mello:                     Right?

Dr. Weitz:                          Now, the low FODMAP diet already eliminates a number of foods that people would typically take out. It eliminates dairy, and gluten, and beans. What is some of the other foods you’ll eliminate in the elimination aspect of the diet?

Dr. De Mello:                     Well, I want to know if the patient, for instance, if the patient can tolerate oat, for example. I tell them oatmeal is a good source of complex carbohydrate.

Dr. Weitz:                          Well, let’s say they don’t know.

Dr. De Mello:                     Then I’d say to them, “Well, let’s, before we start you on this diet here, why don’t you eat this food for three to five days, and let’s see how you’ll feel once you’re at the end of three days.” I want to make sure that some of the foods that I’m going to give it to them, if they haven’t done the sensitivity test, that they know whether or not it’s one of those trigger foods for them. Right?

Dr. Weitz:                          Okay.

Dr. De Mello:                     I will involve them in their own elimination diet before I will give them the FODMAP, if they don’t have the food sensitivity test onboard.

Dr. Weitz:                          Right, okay. What are some of the other common foods, besides oats, that you see are problematic?

Dr. De Mello:                     Well, a lot of patients, believe it or not, even though they can have some fruit in the FODMAP, even some of the berries that we recommend, they have a hard time breaking down some of those fruit, including berries, for example, that I’ve seen. Again, I tell them, “What do you put in the berry? How do you eat the berry?” Because sometimes they think it’s the berry, only to find out that it’s the coconut milk that they put in the berry, but it was not the coconut milk. It was they added things to their coconut milk.  You can take this so far, so long down the road of trying to find out, through elimination diet, what the patient’s actually sensitive to. We know it’s not a food allergy because they would know, but food sensitivity’s so hard to detect, as you know.

Dr. Weitz:                          Right. And probably changes over time, depending upon leaky gut, and how often they’re eating it, and things like that.

Dr. De Mello:                     It does. It does, and that’s why I also think that it’s really great for patients to be able to design their own diet. It gives them power. I give them the FODMAP, for instance, the FODMAP guidelines. Within FODMAP, I want them to tell me which diet, number one, they can stick to and which diet they think, it’s going to work for them. In that regard, I become a consultant to the patient who is receiving the information from her or his body, and I’m only consulting with him or her based on what they’re saying. I think that empowering patient, especially with SIBO and bloating disorders, is essential for the success of the treatment.

Dr. Weitz:                          Now, some of the other strategies that some of the doctors in the SIBO world employ include addressing potential motility issues, because we know that there’s this potential autoimmune origin of SIBO, where you have this damage to the migrating motor complex, so some practitioners will use either prescription or natural prokinetic agents. Do you ever use those?

Dr. De Mello:                     Yes, yes. If the patient has elimination problem. If the patient has an elimination problem or it’s irregular, then I’ve tried a couple of natural ones out there, but the one that I really like right now that is bringing a lot of benefits to my patients is actually erythromycin, 50 milligrams. I found that it’s-

Dr. Weitz:                          Low-dose erythromycin.

Dr. De Mello:                     Low-dose, yeah. I have it formulated. Again, I feel that for most of my patients, they’re really able to respond well to that. To the point where, before I stop the erythromycin, usually, I’ll give them a break after 90 days because that’s how I treat SIBO, for 90 days, and then I try to scale back. Then I may even do erythromycin every other day. Including also the SIBO protocol, the so-called Johns Hopkins protocol the way I referred to it. If the patient is doing well after 90 days, I will not stop it, I will pulse it. I would do one week on, one week off, just to see how the patient does to try to get to the big question of bacterial seeding. It seeds there, it stays there, and so instead of stopping altogether, I like pulsing the medication.

Another thing that I think is important with these patients is even though they may test negative for candidiasis, I often assume that there’s candidiasis in there, even as you know, it’s one of the most difficult microorganisms to detect. Depending on the severity of the symptom, part of my protocol will include putting the patient on either a natural anti-candida protocol using oregano oil, using, really, a blend that I love, it’s called [gamma 00:31:35] oil, which it has olive oil, has a lot of turmeric, it has garlic, it has basil. It’s like this incredible combination of herbs. Really, herbs that have been studied for many, many decades out there in integrative medicine. I like using that. When it doesn’t work, then I will go to nystatin and start them on nystatin. Again, sometimes for three months, depending on the liver enzymes are good and everything points to that being a good thing for them, I’ll start them on nystatin and then scale back and put them on the natural ones.

Dr. Weitz:                          Now would that be concurrent with the antimicrobial SIBO treatment, or before or after?

Dr. De Mello:                     No, I usually do concurrently. I’ve spoken with a number of colleagues in the field, and people do it differently. Some people do it as part of the protocol. Some people do it after the protocol. I do it based on the symptoms of the patient. If the patient has symptoms that clearly indicate there is a candida element, some women with a lot of discharge, the coating on their tongues. I can also look at any rashes that they have that can become really beefy-red all of a sudden. There is the whole picture of candida that we can tell.  Also, a lot of people who may have negative test for methane, which gives the foul smelling to our gas, even though they may have test negative for methane, there’s a lot of odor to their elimination, I will think of candida and I’ll say, “Let’s try to see if we can mediate that with a little bit of an approach to candida.”

Dr. Weitz:                          Some practitioners do an organic acids test. They feel that that’s a more accurate way to pick up candida overgrowth.

Dr. De Mello:                     Yeah, the OAT Test. We use the OAT test a lot, especially because of the pandemic, but I use that when I’m not really clear, there’s no signs, Ben, and I’m kind of like on the fence about it, the patient can afford. As you know, it’s an expensive test insurance doesn’t cover. Sometimes I ask myself, “Will the OAT test change my approach? If the answer is yes, then I will do the OAT test. In most cases, it’s no, it’s not. The patient clearly has a symptom, and maybe a lab will show but maybe not so, “Let me try this kind of litmus test,” even for 30 days, and see how the patient respond.

The thing that I also think it’s missing in our field out there is trying to, once the patient starts feeling better, is really looking at the person’s hormone metabolism and see, how are their hormones working for them? Is it time for us to think about hormonal replacement therapy? Because sometimes, fatigue and not really feeling, not being able to digest the food, a lot of the symptoms of SIBO, as we know, become enhanced or gets worse when our hormones metabolism in addition to SIBO, of course, is not balanced.

Dr. Weitz:                          How do you prefer to test for hormones?

Dr. De Mello:                     Well, we blood test. It’s our go-to approach. For women, if they’re still menstruating, we try to do it between day 17 to 22 during the luteal phase. For men, we do it whenever he has the time to come in. I think a blood test is the best way to go. Sometimes we’ll also use the DUTCH test for, to see if there’s anything else going on with that. We may even do a urine test to test through urine as well. I think, especially with COVID, there’s so much going on in terms of really being able to get to a treatment that works for patients to patients as soon as possible, that I think the blood test offers the best and quickest approach to assessing hormone metabolism.



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Dr. Weitz:                          One more question on SIBO. Does your approach differ if the patient has hydrogen, versus methane, versus hydrogen sulfide SIBO?

Dr. De Mello:                     You know what? That’s a question that I was asked about a week ago also by another- [crosstalk 00:37:56]

Dr. Weitz:                          Oh, really?

Dr. De Mello:                     Yeah. For me, it really doesn’t because I have found that, in the years that I’ve been doing this, that the most people will have a hybrid of those two gases together. One may be more dominant than the other, and I equate this to looking at people’s hormone. A woman may be estrogen-dominant versus not, but the approach to treating their hormone balance will change, but not drastically. We’ll just have to pay attention to that other part. When it comes to SIBO, because it is so difficult to pinpoint a precise diagnosis, I will focus on what the lab is saying, methane-dominant, hydrogen-dominant, but I will actually, when I develop a treatment, I will treat both.

Dr. Weitz:                          Okay. Since your background in psychology makes you, in many ways, a unique practitioner, if you determine that in a given patient with bloating and other gut symptoms that mental and emotional issues are playing a significant role, and this question is probably more for functional medicine practitioners, what sorts of tools or strategies, other than simply referring a patient to a counselor, can functional medicine practitioners do when they’re treating a patient for gastrointestinal symptoms that have a significant mental or emotional component?

Dr. De Mello:                     Excellent question. I know how busy most of us are, especially with the pandemic, but the number one thing that I would suggest that we do is to listen, to listen to the patient, to listen to our own judgment that we may have. We all have it. The question is, how much? Is it a judgment? Is it a discernment? I think, listening to our patients, relating to the patient. Taking a step back and say, “How would my life be affected if I were that patient right now with SIBO, with not feeling good, having to take care of the kids, not feeling sexy. Feeling that, ‘No matter what I do, I failed”? Because a lot of patients come in with a multitude of steps they’ve taken before that either worked for a little bit and stopped or never worked.  The first thing that I check, and I do a self-assessment is, “Can I leave my judgment out the door, and can I be here with this patient, no matter what he looks like, what she looks like, what my feelings might be? Let me listen,” so listening to the patient and putting yourself in their shoes, I think, is the best step, the first step. The second step, and a very excellent question, Ben, is to say, “What is the purpose of this condition right now in this person’s life?” Not to say that I believe that people can sit down and basically muscle themselves into a condition, all the time. That is possible. It’s not common.  What’s common is that people come in with a condition that relates to a particular incident in their lives or particular situation. My job is to try to connect the dots with them, without depowering them, by not saying, by not letting them for one second think that I’m implying that it’s all in their heads. It’s not. Even when I don’t know why and it doesn’t meet my scientific evidence, I still want to let the patient know that I believe what she’s saying or that what he’s saying. The second step, for me, is to try to see what the connecting dots is.

About three weeks ago, I had a female patient who came in, very, very bloated. She had been to some of LA’s great doctors, some of whom are really good friends of mine and have actually become people that I look up to when I have questions. She felt very deflated. She felt that nobody was listening. She felt that everybody, the main question that people are asking her is, “Are you pregnant?” The book talks about a case, to use the book, it talks about a case like that. It became very interesting, quickly after that.  She’s a single woman. Her clock is ticking and she’s not pregnant. The question is, I had to be very careful in navigating is, “Would you like to have a baby?” The answer was, “Yes,” and so there’s this really discomfort in her psyche, this duality of her feeling really upset that people are assuming that she’s pregnant, but actually there’s a part of her that goes, “Oh, this is what I would look like if I were pregnant,” so we had to talk about that. We had to talk about this discord. If she is feeling upset about it, there’s a part of her that actually likes when she looks in the mirror and she sees her belly protruding out. Really helping her understand that those two things are not jiving in her psyche, that we need to go in and make peace with it, so that’s one case.

As we know, disease can have secondary gains. For her, the secondary gain was that she really wanted to get better, but she actually was dubious about the fact that, or was curious about the fact that she looked pregnant. Sometimes it’s like the feeling, so what is the secondary gain? A guy who is not happy at home, who doesn’t feel connected with his wife, who has a protruding belly. Is this an excuse for him not to be intimate? Is that another excuse? Let’s talk about that. We talk about SIBO. We do everything in the protocol, but let’s talk about what else is under the hood. This is if the patient wants to or is ready to talk about that.  I think exploring who the patient is, connecting with the patient, asking questions. “If bloating had a message for you,” I ask them … “This is going to sound weird,” I tell them. “It’s going to sound really weird, but if bloating had a message for you, what would the message be?” They kind of go, “What?” I say, “Sometimes, disease can have a message for us. If bloating could whisper something to you about why it’s there, what would it whisper?” Right?

Dr. Weitz:                          Right.

Dr. De Mello:                     Really looking at those pieces, I think it’s important. I understand that a lot of us don’t have the time to do that, so there were times that I didn’t have the time during the pandemic, the height of the epidemic in California that I had to see people for shorter amount of time, but I would pose those questions via email to them and say, “Okay. Here are the questions. Here’s what we found out. Here’s your treatment. Here’s the questions that I’d like for you to answer,” and so I would pose those questions. Some people, the posed questioning, writing was more comfortable than being asked right in the session.

Dr. Weitz:                          Right. Interesting.

Dr. De Mello:                     Did that answer your question?

Dr. Weitz:                          Yeah, absolutely. You’re an excellent writer and one of the things that makes your book very readable is the stories that you weave in-between, and really makes your book very human and not just like a medical textbook.

Dr. De Mello:                     Yes. Thank you, Ben. I had to really think about, how do I want to write it? What do I do to write a book about a topic that is so uncomfortable? Who talks about poop? We have a culture where that is a taboo. We don’t talk about it. When I ask my patients, “What does your poop look like? What is the texture?” I have to make a joke before we do that because otherwise, people feel a little embarrassed or a little funny, so I wanted-

Dr. Weitz:                          I noticed you put in the first chapter that research shows that humans fart 14 times a day.

Dr. De Mello:                     They do. It’s normal. They’re not the silent killers that we hear on an airplane, or that when we sit next to somebody on the airplane, we want to dash out the door. It happens. What I wanted to do, I wanted to make people with this condition understand that they’re not alone, and understand that it’s something that happens more often than they know, and that it’s just a matter of it exists in a spectrum. There are people who are really, really bloated beyond explanation, that we haven’t been able to move the dial, and those are people with severe gastrointestinal dysbiosis, SIBO, and there are people who have bloating occasionally. They eat something, they don’t feel good. They notice that, again, the jeans are not closing, but bloating is a condition that is an equal opportunity condition. It doesn’t discriminate. Whatever your socioeconomic background is, your ethnic background, your age, bloating is there. I see kids who are bloated. I see elderly who are bloated, so the two spectrums of the population.

What I think the book brought, where the book was successful is that it told people stories. Why do we go to the movies? We want to hear stories. Why do we read novels? We want to hear stories. Why we watch TV shows, especially during the pandemic? Why is Netflix now a multi-billion company? Because we want to hear stories that we can relate to, and that was my goal in the book. It was to create a sort of a manual, where people could go through. Basic to a lot of people who have already done this, but really important to people who have no idea where to start. I wanted to offer them some of those guidelines, while also telling them, “Look, let me tell you some stories that you may relate to,” and I had some good laughs during it, so …

Dr. Weitz:                          Do you know what? I just want to throw in one more question. I know we only have about three minutes left, and it might not be enough time to answer this, but we didn’t bring up probiotics. I’m sure that’s a question a lot of people would want to know. Some practitioners I’ve spoken to don’t believe in using probiotics because if there’s bacterial overgrowth, “Let’s not throw more in.” Some practitioners feel that probiotics are actually the first thing you should do, the primary intervention. Other practitioners do like to use certain probiotics along the way because as we’re killing the bad bacteria, we want to replace them with the good bacteria. What’s your feeling about the use of probiotics while treating patients for conditions like SIBO?

Dr. De Mello:                     Yeah, all of the above. Very simple.

Dr. Weitz:                          Spoken like a true politician.

Dr. De Mello:                     Yeah, I know, I know. Again, Ben, who is the patient and what is the symptom? Where does the symptom fall within the spectrum? What I will usually do with probiotics, I will get a history of whether or not probiotics have helped them. Most of the patients will have taken probiotics because their friends told them to, or another doctor told them to, so get a history. Has probiotic made it worse, made it better, or no difference? If, certainly, has made it worse, I’m not going to use it.

Dr. Weitz:                          Of course.

Dr. De Mello:                     If it has made it better, I will say, “Let’s do this. Let’s do one week, two weeks with the probiotics and two weeks without and see where you stand, where your body stand.” If it’s neutral, then I will do the same thing. I will start two weeks on and then stop for two weeks and see what happens. I think where I’ve made mistakes before, and I think some of my colleagues out there can relate, is when we try to put everybody on the same protocol like a pigeonhole.  The way I explain this when I speak is that, look, there’s eight billion of us on the planet and there’s eight billion fingerprints, so we cannot be treated the same. We have to be treated as unique individuals. That’s what I try to do, so that’s why I said, “All of the above,” because it depends on who the patient is, and I think probiotic is one of the most important approaches that we can use in trying to optimize the microbiome.

Dr. Weitz:                          That’s great, Dr. De Mello. Thank you so much for joining us. How can listeners and viewers find out about getting your book, and find about seeing you, or coming to your clinic, or doing consults with you or your colleagues?

Dr. De Mello:                     Thank you. The website is akashacenter.com. It’s A-K-A-S-H-A, akashacenter.com. You’re going to have a list of services and programs that we offer. The book, there’s its own landing page. It’s called bloatedbook.com. Just bloatedbook.com. You can also go to Amazon. It’s on Amazon, it’s on Barnes & Noble and Apple. On Amazon, you can just say, “Bloated by Dr. Edison De Mello” and it gives you an option of what kind of format you want, Kindle or paperback.

Dr. Weitz:                          Excellent.

Dr. De Mello:                     Yeah.

Dr. Weitz:                          Thank you so much, Dr. De Mello.

Dr. De Mello:                     Thank you for having me, Ben. I appreciate this hour with you.

Dr. Weitz:                          It’s been a pleasure.

 


 

Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple Podcasts and give us a five-star ratings and review. That way, more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition clinic. If you’re interested, please call my office, 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you, and see you next week.

 

 

Dr. Colleen Cutcliffe speaks about a new Probiotic that helps to manage Diabetes 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 my WeitzChiro YouTube page.] 

 

Podcast Highlights

0:30  Akkermansia mucinophila is a new probiotic on the market. Because it is an anaerobic bacteria, it is very difficult to manufacture it, since it needs to be produced in an oxygen free condition. If even a single molecule of oxygen is present in the manufacturing process, the whole batch of Akkermansia dies.  Pendulum Therapeutics managed to solve this problem by creating an oxygen-free manufacturing process.  They are offering a product that contains Akkermansia and several other probiotics and a prebiotic in a product called Pendulum Glucose Control, which has been shown to reduce blood sugar spikes and hemoglobin A1C in a clinical trial.  Improvements to postprandial glucose control in subjects with type 2 diabetes: a multicenter, double blind, randomized placebo-controlled trial of a novel probiotic formulation

8:57  Akkermancia has been well studied and has been shown to be beneficial for helping with inflammation, immune response, obesity, metabolic syndrome all the way through type-2 diabetes, and leaky gut.  It lives in the mucin layer in your gut and it helps to regulate that mucin layer and make sure it’s the right thickness so that all the small molecules being generated in your gut are staying where they’re supposed to be and that they can get access to the receptors that they need to bind to in the gut lining for the downstream signaling pathways to be operating properly. The challenge is to grow Akkermansia in an oxygen free process but make sure that you provide all the ingredients needed for this strain or probiotic to grow and thrive while not being attached to a mucin layer.  And you have to create a product that’s stable at room temperature so that you can sell the product and it needs to be functional in your gut as well.

16:50  Pendulum Glucose Control includes strains of probiotics that produce butyrate, including Akkermancia, as well as a prebiotic. It was reasoned that if you could increase butyrate production, you could help people improve their LGLP-1 response and their insulin/glucose control.  A placebo-controlled double-blinded randomized trial found that people who were taking Pendulum Glucose Control versus placebo had a Hemoglobin A1C lowering of 0.6% and a lowering of blood glucose spikes by 34%.

18:16  GLP agonists are drugs prescribed for diabetes patients and they are being looked at as potential longevity promoters. Butyrate production is upstream of GLP-1, so stimulating butyrate production can promote the release of GLP-1 agonists.

21:42  Non-alcoholic Fatty Liver (NAFLD) is a major health problem today and it is related to dysregulated glucose control and their study did show that Pendulum Glucose Control reduced the ALT and AST enzymes that indicate improved liver health.

22:14  The effect of Akkermansia probiotics on the gut. Nine out of ten people who took their product reported improved gut symptoms, though there has been no trial specifically on that.  Akkermansia may improve the health of the gut by improving the mucin layer, which is the gut lining.

 

 



Colleen Cutcliffe, PhD is a CoFounder and the CEO of Pendulum Therapeutics, which developed Pendulum Glucose Control, which is the first and only probiotic that lowers blood sugar spikes and hemoglobin A1C in a clinical trial.  Pendulum Glucose Control is a probiotic and prebiotic product that contains Akkermansia Mucinophila along with several other strains and inulin from chicory. You can get more information about Pendulum Glucose Control by going to PendulumLife.com and if you use the code WEITZ20 you will receive 20% off your first order.

Dr. Ben Weitz is available for nutrition consultations 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



 

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. Today, our topic is about a new probiotic on the market for the first time known as Akkermansia muciniphila. Thanks to Pendulum Therapeutics. And we will be having a discussion with Colleen Cutcliffe, PhD and co-founder and CEO of Pendulum Therapeutics. Akkermansia muciniphila has been discussed as one of the more important bacteria that exists in the microbiome of the gut. But it has so far not been available to the public.

Akkermansia muciniphila is a bacteria that grows primarily in the mucous lining of the large intestine. And it plays a critical role in maintaining this mucous layer and in supporting a healthy gut lining and preventing leaky gut. Akkermansia reduces gut inflammation. And patients with Crohn’s and ulcerative colitis tend to have lower levels. Akkermansia is also one of the primary butyrate producers. And this strain of bacteria improves insulin sensitivity and may reduce diabetes risk. It may play a role in reducing obesity. And it may also improve the response of patients with lung or kidney cancer who receive immunotherapy.  The reason Akkermansia has not been available on the market so far is that it is an anaerobic bacteria. So, it can only live and be produced in conditions where there is no oxygen. This makes it very complicated and expensive to manufacture. If even a single molecule of oxygen is present in the manufacturing process, the whole batch of Akkermansia dies.  Pendulum Therapeutics managed to solve this problem by creating an oxygen-free manufacturing process.

Colleen Cutcliffe, PhD, is co-founder and CEO of Pendulum Therapeutics which developed Pendulum Glucose Control which is the first and only probiotic that lowers blood sugar spikes and hemoglobin A1C in a clinical trial. Pendulum Glucose Control is a probiotic and prebiotic product that contains Akkermansia muciniphila along with several other strains and inulin from chicory Colleen, thank you so much for joining us today.

Colleen:               Thanks so much for having me, Dr. Weitz. I feel like that whole intro, that’s it. You got the whole story. I don’t know if I can shed any new insights here.

Dr. Weitz:            The only scary thing is every time I say Akkermansia muciniphila, if you say muciniphilia, it sounds like some deviant sexual thing.

Colleen:               I’ll tell you the trick in our company. We just call it A [muke 00:03:19] just to solve all that.

Dr. Weitz:            There you go. Perhaps, you can tell us a bit about your professional journey and how you came to start Pendulum Therapeutics.

Colleen:               Sure. My background is in pretty hardcore science research. So, I have a PhD in biochemistry and molecular biology from Johns Hopkins. I did a postdoc at Northwestern’s Children’s Hospital. And then, I moved out to the Bay Area where I worked for a pharmaceutical company. We were developing drugs for Parkinson’s disease. And then, I moved to a company called Pacific Biosciences which was building a DNA sequencing instrument. And it was an early stage startup company, went through rapid growth and went public.  And on the other side of that IPO, I started Pendulum with two co-founders. All three of us worked at Pac Bio together. We’re all three very technical. I’m a biochemist. Jim is a biostatistician. John is a biophysicist. And, really, the three of us, what we saw in the technology space was that even though things like probiotics and yogurts have been on the shelves for decades, it’s been the same kind of set of ingredients that have been mixed and matched in all these different products.  There hasn’t really been any new invention until the microbiome science has really started to emerge over the last decade. And the reason that the microbiome can even be a science is because DNA sequencing technologies have enabled us to really understand what are the microbes, what are their functions, what are they doing.

And so, we were coming from a DNA sequencing instrument company and realized that we had all the tools and technologies to be able to take microbiome samples and to develop kind of these microbiome maps of people, and think of it like a systems biology problem where you have all these different pathways in your microbiome. How are they connected to each other? How are they connected to our body? And then, I’ll just share that not only was there sort of a technical expertise. But as I started to learn more about the microbiome, I realized there was sort of a personal connection for me which was around my older daughter.  So, my daughter was born almost two months premature. And when you have a baby that’s born that early, you kind of get to hold them for a few seconds. And then, she was taken away to intensive care where she spent the first month of her life actually hooked up to all these machines and monitors and receiving multiple doses of antibiotics.

And there happened to be a study that came out right when we were thinking about this company where they looked at 12,000 children and found that babies under six months of age were systematically on antibiotics were also systematically more prone to obesity and type-2 diabetes as they grew older and became teenagers. And so, I realized, “Oh, my gosh. We could create novel products that could help millions of people including my own daughter,” and that the microbiome is this really unique opportunity where if you develop products with the scientific and clinical method, you can create products that have the efficacy of a drug but the safety of a probiotic. And that was sort of the origin story and mission of the company.

Dr. Weitz:            Yeah. I think it’s interesting. There’s kind of been these two trends in some of the research that we’ve been discussing on the microbiome and probiotics. And one sort of argument is that probiotics, in general, have a beneficial effect. There’s certain categories. And it really doesn’t matter which strain you have. And the other the other way of looking at things is that each strain is very different, can have specific properties. And it’s very important that we stop just looking at research on probiotics.  In fact, I recall talking to Dr. Pimentel when we were talking about research on SIBO. And he kept saying, “Look, you can’t tell me that this is a valid scientific argument to say that probiotics are beneficial. You’ve got these studies. They’re all using different probiotics, different strains. And you’re blending it all together. Imagine if we took a bunch of different drugs and said drugs are beneficial. It doesn’t work that way. You’ve got to get more specific about this.”  And so, I think that some of the research that you’re doing and that’s being done on some of these species like Akkermansia are super important because I think we are starting to see that particular strains have particular properties and these are not just captured by taking broad spectrum probiotics.

Colleen:               You’re absolutely right. And I think we’re just starting to get a more sophisticated understanding of these different strains and their functions, and what impact they have. So, I’m sure you get asked a lot from patients, “What vitamins should I take? And what’s going to be helpful for me?” And you don’t say, “Just take vitamins.” You know specific vitamins for specific issues. And I think we’re just starting to get there with probiotics.

Dr. Weitz:            Right. Now, you mentioned the fact that we’re having stool tests that use DNA. And one of the important things is that a bacteria like Akkermansia would not be picked up by stool tests that cultured bacteria.

Colleen:               Absolutely right because if your stool test is culturing based, then, it requires you to be able to grow these trains. And that’s been a fundamental problem in why the field hasn’t been able to make as much progress as we would like. It turns out that where all the business is happening in the large intestines there, it’s anaerobic. There’s no oxygen there. So, they don’t grow in the presence of oxygen.  So, if you kind of try to culture them in a non-anaerobic environment, you’re going to lose kind of all the meaty guys. They’re not going to be able to grow there. So, it’s got to be a sequencing-based approach or a metabolic-based approach in order to be able to capture these key strains.

Dr. Weitz:            So, let’s talk a little bit about Akkermansia and exactly what it takes to manufacture it.

Colleen:               Oh, man. It’s a diva. So, Akkermansia has been quite well studied internationally and has emerged as important for many of the things that you mentioned, inflammation, immune response, obesity, metabolic syndrome all the way through type-2 diabetes, and this leaky gut concept where it’s just really important that you have the right gut lining. It’s even been implicated in gut brain issues.  And the finding has been that in all of these different disease states, people appear to be low or missing Akkermansia whereas healthy people have a vast abundance of it. And the underlying mechanism is that it is actually living in your mucin layer and helping to regulate that mucin layer so that it’s just the right thickness, so that all the small molecules being generated in your gut are staying where they’re supposed to be and that they can get access to the receptors that they need to bind to in the gut lining for the downstream signaling pathways to be operating properly.  So, to grow Akkermansia, you kind of have to take all those conditions into consideration because that’s its home. That’s where it likes to live and thrive. And then, we live and thrive out here where there’s oxygen. And we’re not attached to a mucin layer, and we’re trying to grow at scale.

And so, really the challenge has been how do you create an end-to-end anaerobic process where you don’t let any oxygen in. How do you give the ingredients needed for this strain to be able to grow and thrive even though you’re not putting it right up in a mucin layer? And then, also, there’s a temperature sensitivity to it. And so, how do you try to get it to be room temperature stable so that you can actually sell the product?  And the most important thing is it’s got to have viability at the end of this entire process. And so, we actually have three different assays that we use to measure viability. Not just is the strain alive, but is it able to produce butyrate? Is it functional at the end of all of this manhandling? And that’s really key because Pendulum Glucose Control is delivering on a promise of reducing A1C and blood glucose spikes. And so, it’s not just the strains are in there. It’s not just a CFU count. It’s are they going to function in your gut?

Dr. Weitz:            Now, there has been a paradox in all the data related to probiotics. And the paradox is the following, is that we can test the microbiome. We can see which species are low and high or absent, et cetera. We can take specific species. But pretty much, all the data has shown that none of the probiotics we take become permanent residents. They’re just temporary visitors. But yet we know they have these beneficial effects.

Colleen:               Yes, absolutely. Actually, it’s sort of interesting because in our study that was published in BMJ, we did a washout period where people didn’t take the formulation. And then, we looked at whether the strains were still there. And this has been reported for other probiotics. For the vast majority of people, they were gone. But a small percentage around 15 to 20% of people, they still had the strains in their microbiome. And so, of course, the million-dollar question is why? What is it about them that enable them to keep the strains?  And the hypothesis that we’re testing and many others are testing is that there’s something about your microbiome ecosystem. And it is an ecosystem. So, you have to know that there’s a bunch of other things in there that have to grow alongside it. Everybody’s microbiome ecosystem is either going to enable new strains to colonize or not. So, I like to think of it like a garden. You’ve already got a garden that’s got all these plants and flowers growing it. And you’re trying to introduce a new plant.  Some gardens are not going to allow that plant to flourish. And some gardens are. So, what are the kind of things that you can do to your garden to help these new strains flourish? You can change your diet and provide the prebiotics that are really going to help these strains grow. So, higher fiber diets tend to really enable Akkermansia to grow, high polyphenols and things like that.  But, generally speaking, it’s kind of hard to account for all the factors that lead you to have the microbiome that you have. Your microbiome gets depleted over time through things like just aging, stress, circadian rhythm. Every time you go to a place where you have to change your days and nights, for women, menstrual cycles and menopause, these all cause you to become depleted. Well, you can’t really do anything about those things. So, you’re-

Dr. Weitz:            Not to mention all the antibiotics and pesticides sprayed on food, and herbicides, and all these things that kill bacteria in our gut.

Colleen:               Absolutely. So, then to ask this plant to thrive in a garden that you’re constantly spraying with things that are going to kill it, it’s pretty hard to do.

 



Dr. Weitz:            We’ve been having a great discussion. But I’d like to interrupt this discussion for just a minute to tell you about a new nutrition product that is very exciting. We all know that there’s a lot more to health than just healthy eating. And there’s a lot more to nutrition than just calories. Having a healthy microbiome is also a key to better overall health. And diet can significantly impact our microbiome. Over time, people with type-2 diabetes tend to lose some of the gut bacteria that helps digest fiber and manage our blood glucose levels.  A new probiotic, Pendulum Glucose Control is the first probiotic that can help rebuild your microbiome and help you to manage your blood glucose and your A1C levels. Take control of your glucose levels today. Visit pendulumlife.com. That’s P-E-N-D-U-L-U-M-L-I-F-E.com to find out more. And use the promo code Weitz 20. That’s my last name, W-E-I-T-Z 20, for 20% off your first order. Once again, that’s P-E-N-D-U-L-U-M-L-I-F-E..com. Promo code Weitz 20. And now, back to the discussion.



 

Dr. Weitz:            Let me ask you a quick clinical question. I don’t know if you know any answer for this. But as we were talking about the mucin layer, and we’ll get right back to Akkermansia. Besides Akkermansia, do you know of nutritional products that can help enhance the mucous layer of the gut?

Colleen:               I don’t know that there have been really kind of validated clinical trials around that.  And I would say also that the gut lining is a hard thing to measure without actually taking a biopsy of somebody’s gut lining.  But I think that some of the studies have really pointed to anything that really helps is actually pretty much tied to Akkermansia.  Anything that helps Akkermansia grow does tend to have these clinical outcomes of improved GI, improved digestion, and things like that.  And so, on that front, things with polyphenols, so, grapes, cranberries, things like that, they tend to help boost the Akkermansia growth in the lining as well as things that feed the butyrate producers, so, inulin, anything with inulin and Jerusalem artichokes. You can actually buy inulin by itself. Those things also help.

Dr. Weitz:            Well, that’s good. What about mucilaginous herbs and or L-glutamine?  Can they be beneficial?

Colleen:               Oh, man. Now, you’re getting into territory that I don’t know.

Dr. Weitz:            Okay. No, I know. That’s clinical stuff. But I know since you’ve been digging into all this stuff. Okay. So, let’s move on. So, let’s talk about some of the therapeutic benefits of Akkermansia and, in particular, your Pendulum Glucose Control product which contains more than just Akkermansia.

Colleen:               Yes. So, our hypothesis around the consortia that’s in Pendulum Glucose Control is that if you could increase butyrate production, the metabolism of fiber into butyrate, and you could increase this mucin regulation, that you would help people improve their GLP-1 response, and then ultimately their insulin glucose response. And that was based on mostly correlative studies where we found that people with diabetes and pre-diabetes and obesity were lower in these particular functions.  And so, we basically identified strains that could produce butyrate. It’s a multi-step biochemical reaction to metabolize fiber to butyrate. So, we have all of those strains in there that do the two steps of that reaction, plus Akkermansia. And, really, what we found in our clinical data was that you did need this entire consortia. We had an arm where we only had a subset of them. So, you needed the entire consortium to get statistically significant data. And so, in a placebo-controlled double-blinded randomized trial, we found that people who were on product versus placebo had an A1C lowering of 0.6% and a lowering of blood glucose spikes by 34%.  And that’s a really meaningful product for somebody with type-2 diabetes as you know. But it’s all natural. It’s all these naturally occurring strains and a prebiotic in there.

Dr. Weitz:            Since GLP agonists now are being looked at as longevity molecules or potential longevity molecules, perhaps Akkermansia could be part of that mix.

Colleen:               Well, in fact, I think this theory that this whole thing is operating upstream of GLP-1 is that you get these butyrate producers when they combine to the right GPCRs, they then stimulate GLP-1 release. And we actually have in vitro data showing that we can do that. But our chief medical officer once we had this theory about how the product worked, we went and we grabbed Dr. Orville Kolterman who was previously the CMO at Amylin Pharmaceuticals that put out multiple GLP-1 agonists. That company got acquired for something like $7 billion from BMS. He was retired actually. And I met with him and I said, “If you want to really get in on the next frontier of diabetes therapeutics, it’s the microbiome.”  And he went up and did his own research and came back and said “All right. I’m in.” And he’s really guided all of our pre-clinical and clinical development. And you’re right these GLP-1 agonists are really showing up. I think at the core of it is that your ability to manage your blood glucose and to metabolize glucose properly is actually at the core of a lot of health issues that we previously didn’t know were related to each other. I don’t know if you have theories about how these systems are related to glucose control.

Dr. Weitz:            You mean how the gut is related to glucose control?

Colleen:               Well, if you have mismanaged glucose control, it can show up in a variety of ways beyond just type-2 diabetes. I don’t know if you have people talking about fatigue or-

Dr. Weitz:            Sure. But the only thing we really know about that I’ve heard people talk about is the way in which glucose molecules glom onto proteins in the body, glycogen storage stuff.

Colleen:               Yeah. Absolutely. And I think this is what happens is when you can’t manage your glucose response properly, we know this. You have these free sugars kind of floating around binding to red blood cells and all these proteins and…

Dr. Weitz:            Right. Like hemoglobin A1C is sugar molecules binding to red blood cells. And then, these sugar molecules bind to all these other proteins. And that accounts for a lot of the damage that occurs with diabetes.

Colleen:               Exactly.

Dr. Weitz:            So, anything we can do to reverse that is good. And especially for people in the natural world who are looking for ways to hack longevity and who are not that thrilled with the idea of taking medicines like GLP-1 agonists, some natural way of doing it is very, very appealing.

Colleen:               Yeah. And I’ll tell you this. I don’t have diabetes or pre-diabetes. But I take the pills because I actually feel that I have more energy throughout the day when I take them. And I actually wore a continuous glucose monitor on myself and saw that when I was on product versus placebo, of course, I’m a scientist so I had to run the experiment on myself, that actually it helped me with my sugar spikes and crashes. It helped just to minimize those. And for me, that shows up as sustained energy throughout the day, better workouts, and things like that. And so, I’m on it. My mom is on it. My kids are on it. My husband’s on it because it’s a natural product and being able to manage blood glucose is important for everybody.

Dr. Weitz:            Another thing you might look into is could this play a role in non-alcoholic fatty liver, which has to do with sugar storage in the liver.

Colleen:               Oh, you’re right on.  So, actually in the trial that we published, we did see that people’s ALT and AST numbers were improved, so, their liver enzymes.

Dr. Weitz:            Oh, interesting.

Colleen:               Yes. It wasn’t one of the primary outcomes. So, it’s kind of buried in the paper.  But, yeah, you’re right.  That’s something super interesting to look into.

Dr. Weitz:            Cool.  So, what about the effect of Akkermansia on the gut and gut conditions, say like, IBS?

Colleen:               Yeah.  Just to be clear, we haven’t done a clinical trial in IBS.  But what we found that’s interesting is that our customers who are taking the product, we have nine out of 10 people saying they’re getting lowered blood sugar spikes and lowered A1Cs.  But we also have nine out of 10 people saying they have improved GI symptoms.  And so, this isn’t something that we studied in our clinical trial.  But it’s something that we’re definitely hearing from people.  And, certainly, as you’re saying, there’s a lot of research to imply that Akkermansia might be doing that.  And so, you’re stepping into what we’re looking at next which is really IBS and things like that.

Dr. Weitz:            You’d have to pivot really quickly. But it would be interesting to see patients with long COVID symptoms that are GI related if this could be beneficial for them, because there’s a huge amount of inflammation in the gut that happens with some patients who get COVID.

Colleen:               Yeah. And I think understanding the role of Akkermansia in these inflammatory responses and these inflammatory miss-responses, I think, is going to be a really important part of discovery.

Dr. Weitz:            So, how does Akkermansia reduce inflammation in the gut?

Colleen:               Well, the idea is again that you have a mucin layer inside of your gut. And the thickness of that layer is relevant. And so, I think about it like a fence in your backyard. So, I have a wooden fence in my backyard. When we first moved in, oh, it’s beautiful. The planks were perfectly polished. What was supposed to be inside was inside. What’s supposed to be outside was outside. But what happens to these over time where you get sun and snow and just weather in years and times is that those-

Dr. Weitz:            And termites.

Colleen:               And termites, exactly. Those planks can start to deteriorate. And, sometimes, you might lose a plank or two. And then, all of a sudden now, all the outside things can come in. And the inside things are leaking out. And so, your gut lining is just like that fence. And the mucin layer is really like your planks that you’re trying to keep together to keep that solid gut lining. And so, when you lose that, the reason the inflammatory process gets stimulated is because now small molecules are not where they’re supposed to be, and your body responds to that. And that’s really kind of the underlying issue with not having the right gut lining.

Dr. Weitz:            Now, I was looking at some of the research. I was reading one of the studies. And there seemed to be some evidence that Akkermansia plays some role in the way that metformin works, that metformin is for most of you listening if you’re not familiar, is the most commonly prescribed drug for patients with type-2 diabetes. And yet, there’s been some controversy over exactly the mechanism by which it works.  And so, some of the evidence seems to indicate it has to do with its effect on the microbiome, and that Akkermansia may play some positive role in the way that metformin works. Can you talk about that?

Colleen:               Yeah. I think your use of the word controversial is spot on because basically there have been studies showing that I do believe that metformin is impacting the microbiome. I think that seems quite consistent. The way in which it’s impacting the microbiome is unclear. And you have publication saying it increases certain strains. And then, you’ll have publications saying it decreases the same strains. And so, I think it’s not clear. And, to be honest, there’s probably a little bit of a personalized component to this of what metformin is doing based on your microbiome and your ecosystem there. And so, I don’t think there’s any clarity on exactly what metformin is doing to the microbiome and what benefits, therefore, it could be conferring.

Dr. Weitz:            So, how can your product be used for type-2 diabetics? Is it better for patients with pre-diabetes with the beginning stages of type-2 diabetes? Does it matter. And then, how should it be administered and in what dosage?

Colleen:               So, the trial that we did was really in people with type-2 diabetes. And most of them were on metformin. And so, the efficacy is on top of metformin. It’s a bottle of pills that you store in your refrigerator. And you take two pills a day. And that really gets your microbes. And to your point earlier, it’s sort of an ongoing thing unless you’re one of those very special people that’s able to colonize it. You really do keep taking. And people can take microbiome tests to know whether things are colonizing or not.  And we really encourage people to do that. We give people free A1C testing because we want you to see the results. We’re not here to scam anybody. Actually, we have a money-back guarantee that if the product doesn’t work for you, we’ll give you your money back. We really believe in it. And we really want to help people.

So, the work is really done into type-2 diabetes. But as you know, metabolic syndrome is a sort of ongoing continuum from type-2 diabetes to pre-diabetes to obesity. And underlying all of that is the continued inability to metabolize glucose. And GLP-1 has been shown to be effective across those different states. And so, even though we didn’t do our trial and anybody other than people with type-2 diabetes, we certainly have a lot of customers who have pre-diabetes or obesity and are really using the product and seeing benefit. And so, that’s been that’s one of the benefits, I think, of the consumer route as opposed to the drug route.

Dr. Weitz:            And when should they take the two capsules? Should they split them up? Is it better to take it with the meal, without a meal, in the morning, in the evening?

Colleen:               Well, this is a kind of a big unknown. So, I’ll start with that. We don’t exactly know. But here’s what we do know, is that in trial work, we have people take one in the morning and one in the evening because we don’t know what people eat during the day. And we don’t really know what their schedules are like. And so, we were just trying to hedge to say, “If you eat breakfast that has fiber in it, this is great. If you eat a dinner that has fiber in it, we’ll catch you on either end.”  But the truth is actually we have a lot of customers including myself that can’t really remember to do something twice a day, we’re lucky if I remember something once a day. So, I take both my pills in the morning and call it a day. But the trial was really one in the morning and one in the evening to try to capture the effect of your diet on the microbiome.

Dr. Weitz:            And do you think it’s better with the meal or apart from the meal? It sounds like you’re saying it’s better with the meal.

Colleen:               Yeah. We’ve recommended people take it with a meal. The capsules are actually enteric coated so that they can get through the stomach acid and where they need to get to. But as you know, your stomach has a really low pH. And so, when you eat a meal, it does help to raise that pH. And so, the idea is that it will help those enteric-coated capsules not be dissolved in the stomach. So, although I’ll also admit this is terrible that I take my two in the morning with a cup of coffee. And I oftentimes skip breakfast. But what we do recommend people take it with a meal.

Dr. Weitz:            Well, you’re doing intermittent fasting.

Colleen:               Yes. Exactly. Exactly. I don’t want to mess up that part of my routine. So, you can’t take them on an empty stomach.

Dr. Weitz:            Right. Now, I did notice in your study that even though it lowered hemoglobin A1C that there was no change in fasting glucose. Why do you think that is? And did you also look at fasting insulin?

Colleen:               Yeah. That was a little bit of an anomaly. I think one of the things that’s been more interesting to us is actually the use of continuous glucose monitor technologies. It’s really hard with these fasting glucose numbers especially when you’re doing them in clinic because people don’t always fast before they come in and give you their fasting glucose numbers.  And so, wearing continuous glucose monitor enables people to kind of freely live their life the way that they want. And you can get that fasting glucose number before a meal is consumed which you can clearly see through a spike. We definitely have customers who have seen improvements in their continuous glucose monitor data and in their fasting glucose. So, we don’t really actually understand that phenomenon.

Dr. Weitz:            I think maybe in one of your future studies, you should consider measuring the level of butyrate that’s produced if that’s one of the mechanisms.

Colleen:               Oh, now, you’re really getting an all my secret bag of tricks. So, we just presented at the ADA conference data showing that in fact people who were on formulation had increased butyrate levels in their plasma. And so, that is data that has not been published yet.

Dr. Weitz:            All right. So, do you plan to come out with a separate Akkermansia outside of this formula? By the way, the other ingredients, the other probiotics in your formula, talk about those for a few minutes.

Colleen:               Sure. So, the other strains include anaerobacterium [inaudible 00:31:13], Clostridium butyricum, Bifidobacterium infantis and Clostridium beijerinckii. Now, you’re testing my ability to pronounce all of these strains. And so, again, these are really in that pathway of metabolizing fiber into butyrate. These are strains which we found to be kind of in vitro to have a lot of activity on that butyrate production.

And I would say that we’re not quite done yet because the product doesn’t work for everybody. And I think there’s an underlying belief that not all these strains are going to be able to have their functions in your microbiome versus my microbiome. And so, I think that the key thing is these functions and that there’s potentially new strains that we can develop that will help people that have different microbiome issues. And so, all of those strains really do function together along with we have inulin in the pill too. They really all function together to demonstrate efficacy.

Dr. Weitz:            What do we know about Akkermansia as a percentage of the microbiome in younger people versus older people, women versus men, people live in the United States as opposed to Africa or Europe or Asia? Do we know anything about that?

Colleen:               Yeah. I think that there’s still a lot of data being collected. So, it’s still emerging and trying to understand what are the trends with Akkermansia is certainly really an exciting place where there’s been a lot of discovery. So, I think one of the biggest trends that we’ve seen with Akkermansia is that healthy people tend to have a ton of it. It’s one of the most prevalent strains in the stool of people that are healthy.  But as you go down the line and you look at these different disease states from type-2 diabetes to Crohn’s disease to IBS to even autism and some neurological diseases, you see that there’s a depletion of Akkermansia. And so, it doesn’t appear to isolate to men versus women. But there does appear to be an aging component to it. So, as we age, unfortunately, I think many of us remember a time where we could eat and drink whatever we wanted to. We didn’t have to worry about anything.  And part of what happens over aging is you lose some of these key microbes including Akkermansia. And so, the question is if you give them back to your longevity question, if you give them that, will you now have a better functioning engine inside your body.

Dr. Weitz:            Are there similar benefits to taking supplements of butyrate? Do you know?

Colleen:               Interestingly, the butyrate supplements have really strong pre-clinical evidence in them. But there’s been a real struggle to show that butyrate delivery in humans actually has the same impact. And the theory is that because butyrate is used by all of the colon cells and we were discussing this earlier, but your colon cells are the only cells in your body that use butyrate instead of glucose for their sugar, for their energy source.

And so, every colon cell wants butyrate. And so, I sort of think of it like if I were going to give you, Dr. Weitz, a million dollars, would you rather me bring it to your door in a suitcase and hand it to you or would you rather me call you and say, “I let it go all over 101, the freeway. And you can go pick it up there.” The problem with giving butyrate is that you’re just like releasing this on the 101. And every car is going to stop, and people are going to grab this money before it ever gets to your house.

And so, this is why the strains that colonize in the right location in the microbiome produce the butyrate right next to the receptor where it needs to bind to is far more effective than just delivering the butyrate molecule to your colon.

Dr. Weitz:            What about the other short-chain fatty acids like propionate?

Colleen:               Yeah. Propionate and acetate are two other short-chain fatty acids that also are quite abundant. And I think there’s good emerging evidence that they’re also important. And in our hypotheses around butyrate production and having the different enzymes or the different bacteria that perform these enzymatic functions, now, you’re seeing my biochemist kind of bias emerging here. They’re strains, not enzymes. We do actually also produce acetate and propionate because as you know they can be upstream of butyrate. And then, one more modification turns acetate into butyrate. And so, I think trying to understand the role of those other short-chain fatty acids is still emerging. But butyrate has the most, I think, evidence behind it.

Dr. Weitz:            Are you looking into producing… There’s another keystone species that’s anaerobic called fecal bacterium [inaudible 00:35:48] that’s also not available on the market. Are you looking into possibly producing that?

Colleen:               Well, I can’t tell you what’s in our freezer that we’re working on producing. It’s definitely a strain of interest to many people.

Dr. Weitz:            Right. Okay. Great. I think those are my questions that I had. Any other thoughts that you’d like to leave our listeners with?

Colleen:               I think I would just say that as people are out there trying to do the right thing for their bodies and trying to be more healthy and standing in front of these shells filled with probiotics and prebiotics and whatever other marketing gimmicks are being thrown our way and trying to figure out what works or doesn’t work, that it’s really important that they talk to their healthcare professionals.

So, people like you, anybody that they’re seeking advice from to sort of really approach the microbiome more as a science about what are the functions and what are the strains that make sense for me. What is the problem I’m trying to solve? And I think it’s really important that you and the rest of the healthcare professional community starts to become at the leading edge of being educated and being able to guide people on not just probiotics, but what probiotics and what functions are their patients really trying to solve for and being that guiding light because you’re the only ones who can understand the clinical trial data. You’re the only ones who kind of know the problems people are coming at you. And being able to connect those is really in your arena. So, I encourage people to really go talk to their HCPs.

Dr. Weitz:            Now, can practitioners and we have a fair amount of practitioners that list listen, can we get a professional account with your company and sell these to our patients or how do we get these to our patients?

Colleen:               Absolutely. And, actually, this is something we’ve just started with different physician groups and naturopath groups, people who really kind of do understand the microbiome and understand what these trains are doing. And we are absolutely thrilled to get to work with healthcare professionals. And so, anybody can contact us. You go to our website, pendulumlife.com. We can get discount codes specifically for you and your patients. And we have programming set up to also educate you as well as things that you can handle your patients on what to expect. And so, we’re really excited to get to work with healthcare professionals to bring this product to life.

Dr. Weitz:            So, can we buy this product at wholesale and store it in our office and sell it to our patients or not?

Colleen:               If you contact us, we will sell it to you wholesale, and any of your colleagues that’s excited about that. Yeah. I mean we’re an early stage startup company. So, we’re just starting to delve into this.

Dr. Weitz:            Okay. I see.

Colleen:               But we are selling it wholesale to a few partners. And I think that that’s a really big opportunity. I mean you’re seeing patients and you have the ability to really influence them on what they should be doing. So, we want to enable you. And so, the answer is yes. Just reach out to us.

Dr. Weitz:            Sounds good. So, we go to the website or can we call? What’s the best way for us to contact you?

Colleen:               Yeah. If you go to the website and just put something a note into the contact us, it’ll immediately get shunted to our marketing and BD teams that can help set that up immediately. And so, we’re very excited about that. And you had asked earlier if we had thought about selling an Akkermansia-only product. And so, I will tell you that we literally just launched this product a couple of days ago. And so, yeah, You should come work for us because you got all the ideas and the next things to do.  And so, if people are doing these microbiome tests and they’re finding that they’re low in Akkermansia and they just want Akkermansia, we now sell that. And so, we can also distribute that wholesale to physicians as well.

Dr. Weitz:            And so, the website, one more time, is what?

Colleen:               It’s pendulumlife.com.

Dr. Weitz:            Excellent. Thank you, Colleen.

Colleen:               Yup. Thank you so much. And one more thing is that all your listeners get a discount code Weitz 20 for them to try product. And that’ll apply to also the Akkermansia-only product.

 


 

Dr. Weitz:            Oh, that’s great. Thank you. Thank you. Thank you for making it all the way through this episode of the Rational Wellness Podcast. And if you enjoyed this podcast, please go to Apple podcast and give us a five-star ratings and review. That way, more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts.  And I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition Clinic. So, if you’re interested, please call my office, 310-395-3111, and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.

 

Dr. Mark Pimentel provides an Update on SIBO and IBS with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on September 23, 2021.

[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 my WeitzChiro YouTube page.] 

 

Podcast Highlights

6:52   The REIMAGINE study is the project in which Dr. Pimentel and colleagues mapped out the microbiome of the small intestine.  The Human Microbiome project was published in 2007 and they declared that they had mapped out the microbiome of the gut, but it was based on stool studies, so it did really only represented the microbiome of the colon.  [Here is the first paper published by Dr. Pimentel and others on this REIMAGINE study:  Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison with Stool: A REIMAGINE Study.]  This study required a lot of work and resources to be able to collect accurate samples and sequence the microbiome of the small intestine.  It is difficult the sequence the small intestine for a number of reasons, including that the mucous is so thick that they had to add mucolytics to liberate the bacteria and they had to develop special tools and validate them before conducting the trial, so it took years to prepare and then to conduct it.  And they discovered that the microbiome of the small intestine is quite different from the colon.  They also discovered that the small bowel is fairly uniform from the duodenum till the end of the ileum, whereas it was thought previously that you had more and more bacteria as you get closer to the colon.

9:28   Now we know that the bacteria in the small intestine have not overgrown from the colon up into the small intestine through an incompetent iliocecal valve, as was previously believed by some SIBO researchers. The small bowel contains more proteobacteria and much less bacteroidetes than the colon.  What happens in SIBO is that because of damage to the motility of the intestine, E. coli and Klebsiella grow like weeds and crowd out many of the other commensal bacteria.

12:13  Ehler’s Danlos Syndrome (EDS).  There was a thought that patients with EDS who have ligamentous laxity have hyperlaxity of the ileocecal valve leading to an increased risk of SIBO.  Dr. Pimentel explained that what happens with patients with EDS is that they have visceroptosis, which means that their gut sags into their pelvis, which creates bends and twists in their small bowel, creating obstruction, leading to SIBO.

13:48  Dr. Pimentel’s group published data from the REIMAGINE trial that shows that PPIs (proton pump inhibitors like Prilosec) don’t cause SIBO, though they are a risk factor for C. diff colitis.  They also published a paper showing that in postmenopausal women, their microbiome gets shifted in a very bad way, but if they’re on hormone replacement therapy, their microbiome in their small intestine looks like they’re premenopausal.

15:24  This data that PPIs don’t cause SIBO means that taking PPIs will not likely affect the results of the SIBO breath test.  On the other hand, PPIs by reducing stomach acid will reduce methane production, since methanogens feed on hydrogen that is contributed by hydrochloric acid.  You should stop probiotics for about a week before taking the test.  Patients should not take laxatives within 24 hours of taking the SIBO breath test. This also goes for herbal laxatives and magnesium. Patients should also stop antibiotics and antimicrobial herbs prior to taking the test.  On the other hand, if the patient is still bloated with whatever they are taking, then we can conclude that it’s not working and likely will not affect the test result.

23:00  About 25% of those who have a flat line on a two breath test, which we previously diagnosed as being positive for hydrogen sulfide SIBO, are positive for hydrogen sulfide on the three breath test.

23:50  The organisms that cause hydrogen sulfide SIBO is more complicated than those that cause methane SIBO.  With methane SIBO we have Methanobrevibacter smithii, Methanobrevibacter stadmenii and then a couple of other minor methanogens, and we’ve actually shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  Dr. Pimentel said they have shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  In the case of hydrogen sulfide, though, there’s multiple organisms that can produce hydrogen sulfide, including pseudomonas, Fusobacterium, Desulfovibrio, and Bilophila.

26:16  Dr. Steven Sandberg-Lewis, who spoke at our meeting a couple of months ago, he said that he’s been finding a number of patients with hydrogen sulfide SIBO positive with constipation.  Any time you have a patient that does not fit the pattern, such as a patient who is positive for hydrogen sulfide SIBO who has constipation, Dr. Pimentel recommended that you work them up with a colonoscopy or a CT scan to see if they have a tumor or a blockage in their colon.

27:49  Treatment for hydrogen sulfide SIBO often includes bismuth, which dates to a study from 1998 from a gastroenterologist, Michael Levitt, who wrote an article in the New England Journal of Medicine about flatus and how bismuth inhibits sulfate reduction pathways, thus reducing gas production.

29:24  Biofilms.  Some of the microorganisms that cause SIBO, like Methanobrevibacter, reside in the mucous layer, which is essentially a biofilm, so busting this mucous layer a bit may be helpful in erradicating them and maybe bismuth is helping with this.

30:54  Hydrogen SIBO.  The organisms that cause hydrogen SIBO are mainly E. coli and Klebsiella and sometimes Aeromonas. 

32:10  Methane SIBO.  Dr. Pimentel explained that they will be publishing how many methanogens are found along the small intestine in different sections, as well as in the stool. In terms of treatment, he recommends rifaximin and neomycin based on the double blind study, rifaximin with metronidazole as a substitute. He also finds Allicin to work well and he also still likes lovastatin, and the veterinary literature is strong, but the problem is that it gets absorbed, so he is still working on a formulation that will not get absorbed.

33:23  While the type of E. coli that causes hydrogen SIBO is not the pathogenic, E. coli that has the gene for CdtB endotoxin, there are still lipopolysacharides (LPS) that other chemicals that may be getting released that can cause inflammation and pain.

37:02  Dr. Sam Rahbar is an integrative gastroenterologist in LA and he’s recently published on some patients who have tick-borne illness such as Lyme disease and it often seems to be correlated with patients with methane SIBO or IMO.  Dr. Pimentel said that they have not analyzed the genetic material that they found to look for spirochetes or other parasites yet.  Dr. Pimentel also said that he agrees that sometimes fungal overgrowth (SIFO) is a factor in IBS, but it is not as common as bacterial SIBO and he refers to Dr. Satish Rao, who is part of his research group, who has done more work on fungal overgrowth. 

39:48  Are elevated levels of Methanobrevibacter on a stool test indicative of IMO?   Yes, as long as the levels are above 10 to the 4 and they are associated with constipation. 

41:06  Lovastatin has been used successfully by some doctors off label for IMO at a dosage of 30 mg at bedtime.

42:24  Some doctors have suggested using 120 minutes as the cutoff time for evaluating a breath test instead of 90 minutes for patients with slow motility, such as those with constipation, but the problem is that if the patient has gastroparesis or is a narcotic user, you don’t know what their transit time is and even 120 minutes may not be enough.

43:26  Mycotoxins. 

45:26  The relationship between IBS and IBD, (Inflammatory Bowel Disorder like Crohn’s and Ulcerative Colitis).  Dr. Pimentel thought at one time that IBS was a possible precursor to IBD, but he doesn’t think that anymore.  Food poisoning causes IBS but they’re not associated with IBD.  Patients with IBD may have SIBO but they rarely have IMO and if they do, it is because of strictures and other structural blockages.

 

 



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 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.

Welcome, everyone, and thank you for joining our functional medicine discussion group meeting tonight, and we’re very excited to have Dr. Mark Pimentel joining us for a discussion on the latest updates on small intestinal bacterial overgrowth and irritable bowel syndrome.  I’m Dr. Ben Weitz. If you have any questions, please type them into the chat box and I’ll either call on you or ask Dr. Pimentel when it’s appropriate. If you’re not aware, we have a close Facebook page, The Functional Medicine Discussion Group of Santa Monica. I’m recording this event, and I’ll post it on my YouTube page, and I’ll also include it in my weekly Rational Wellness Podcast.  If you’ve not listened to it, please check out the Rational Wellness Podcast, subscribe on Apple Podcast or wherever you listen to podcasts. If you joined, please go to Apple Podcast and give us a ratings and review.

We have two sponsors for this evening, Integrative Therapeutics and Vibrant America Testing. I know that the representative from Vibrant is here. So go ahead and tell us a little bit about Vibrant America Testing.



Margot:                                Hi. My name is Margot. I work at Vibrant America in Los Angeles. We work with Dr. Ben Weitz. So Vibrant is a CAP and CLIA-certified full service lab in Northern California with everything from basic blood panels to autoimmune diagnostics. So today, I wanted to bring up one of our most popular panels. It’s the Total Tox-Burden. It includes 31 mycotoxins, 20 heavy metals plus 39 environmental toxins all for under $400. So if you guys are interested in learning more, please email me at margot.h@vibrant-america.com or you can check out our website at www.vibrant-america.com.



Dr. Weitz:                            Okay. Thank you. It looks like Steve Snyder is not here. So let me tell you something about Integrative Therapeutics. They’re one of the few professional manufacturers of high quality nutritional supplements that we carry in our office. They’re sold through practitioners. They have some great products for SIBO. They have the leading brand of the elemental diet, and they have it in the dextrose and non-dextrose version. That’s one of the treatments for SIBO. If you’re not aware of the elemental diet, you should definitely find out more about it. You can talk to Steve Snyder from Integrative Therapeutics.  They also have a great natural pro-kinetic motility activator, which is a really excellent product and we use that all the time. So I want to thank Integrative Therapeutics and Vibrant America very much for helping sponsor tonight’s podcast, tonight’s functional medicine meeting.



Now, I want to introduce Dr. Mark Pimentel, who’s head of the Pimentel Lab, an executive director of the Medically Associated Science and Technology Program at Cedars-Sinai. Dr. Pimentel really needs no introduction, but he is a prolific researcher having published over 150 scientific papers. His lab researches the microbiome and the irritable bowel syndrome. As most of us know, irritable bowel syndrome is probably the most common gastrointestinal condition affecting between 10% and 15% of people in the United States and around the world.  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 conditions that could be diagnosed with a stool sample or looking through a scope, you are then left with IBS. IBS was and still is seen by an unfortunate number of gastroenterologists as a condition of either unknown cause or caused by stress or anxiety. In fact, antidepressants were once one of the most popular medications to treat IBS.  Dr. Pimentel is the first researcher to demonstrate that small intestinal bacterial overgrowth is a cause of IBS in the majority of cases, and that SIBO could be diagnosed with a lactulose breath test. Dr. Pimentel also pioneered the use of rifaximin, a non-absorbed antibiotic as a treatment for IBS. He’s developed an autoimmune model of IBS being caused by an episode of acute gastroenteritis. He’s developed a blood test looking at antibodies vinculin and cytolethal distending toxin to diagnose this autoimmune cause of IBS.  He’s discovered that the methane-producing organism, Methanobrevibacter, causes constipation. Dr. Pimentel and 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, which is a monumental achievement.  Most importantly, Dr. Pimentel has given hope to millions of patients with IBS that they might be able to feel better and stay better. So thank you, Dr. Pimentel, and thank you for joining us tonight.

Dr. Pimentel:                     It’s my pleasure. Thank you for inviting me.

Dr. Weitz:                          Absolutely. So how do you want to start?

Dr. Pimentel:                     Well, you tell me. You usually do an interview? Is that what you’re hoping to do tonight?

Dr. Weitz:                          Sure. Absolutely. That’s just fine.

Dr. Pimentel:                     I got to tell you, you always ask the best questions. So I love this podcast for that reason. You’re always well-prepared.

Dr. Weitz:                          Exactly. Well, thank you, thank you. So let’s start off with your mapping out the microbiome of the small intestine. Why don’t you tell us about how you were able to do that and what’s some of the latest information that you’ve gotten out of that?

Dr. Pimentel:                     Well, the human small intestine, what I’d like to say is that the Human Microbiome Project was published in 2007. One of their declarations was, “Well, we published the Human Microbiome and this is what the gut represents based on stool studies.” I was always shocked by that because I felt like, well, stool is stool, but what about the small intestine? What about other parts of the gut? Maybe it’s different. It took us a decade to start to get our act together in terms of getting the REIMAGINE study off the ground because we needed a lot of resources and some of the sequencing equipment. Now, we’ve got everything here at the MAST program.  The problem with the small intestine is it’s not easy to sequence. The mucous is too think. So we realized you couldn’t do what you do with stool. You couldn’t process the stool the same way or the small bowel the same way as stool, and we have to add mucolytics and other things to liberate the bacteria before you get their DNA, but we did all that. We’ve published validations of how you’re supposed to handle the small intestinal microbiome.

While we found a ton of stuff since starting, we found bacteria that produce all sorts of things that humans produce manipulating the human body, and you’re going to see some of that. There’s a paper, again, September, sorry. Ben, I can’t tell you things, but next week there’s a paper coming out. I feel like I’m teasing you too much, but there’s a paper coming out that is the next iteration.  Your point was last year we published and made the cover of the journal what the small bowel looks like. The small bowel is completely different than the colon. A couple of pearls. It’s interesting. The duodenum, jejunum, the ileum, they look identical. We used to think, “Oh, the closer you get to the colon, the more dirty it is, the more colonic it looks like.” It wasn’t what we saw. It was, literally, duodenum, jejunum, ileum looked the same. Then it’s like a cliff. The microbiome completely changes once you hit the colon. I think that’s really so poignant. We have other pearls like people don’t-

Dr. Weitz:                          Can’t I ask you a question about that fact?

Dr. Pimentel:                     I’ll do it for that one.

Dr. Weitz:                          So I want to get right back to it, but does the fact that the level of bacteria you’ve seen throughout the small intestine, does that tell us anything about whether the bacterial overgrowth comes from below up or from above down? In other words, we originally were thinking that the bacteria from the colon were overgrowing into the small intestine. Does the fact that there’s not more bacteria at the distal part of the ileum, does that indicate that that’s not the case?

Dr. Pimentel:                     So all of this notion, believe me I’m guilty of saying the same thing, all of this notion that overgrowth is the colon bacteria coming up into the small intestine is from older data that says, “Well, if the ileocecal valve is incompetent then the stool is reflexing into the small bowel and that contaminates the small bowel,” but as the REIMAGINE study is telling us, that’s not exactly how it happens.  What happens is the small bowel contains generally more proteobacteria than the colon. The small bowel contains no bacteroidetes, hardly at all, but that’s half of what’s the colon. So it’s the composition that’s different, but what we find with SIBO, in sequencing I mean, is that there’s weeds that develop, E. coli and Klebsiella. When they start growing because the flow of the small bowel is not correct, then you get SIBO. E. coli and Klebsiella are just rampant. They run up like weeds and then they crush everything else around them. So it’s not really that the colon bacteria are coming up. It’s that E. coli and Klebsiella are taking the opportunity to become those weeds that they want to be.

Dr. Weitz:                          Is this largely because of decreased motility? We still think that’s one of the main factors?

Dr. Pimentel:                     Yeah, decreased motility. One of the slides I finally added to my new slide deck is there’s a paper that came up because people were saying, “Well, you say, Dr. Pimentel, that adhesions slow motility and maybe you get SIBO from adhesions, but where is the paper that’s published that shows this?”  Well, a paper just came out with sequencing the small bowel, again, in patients with partial bowel obstructions, and sure enough, it’s E. coli, it’s proteobacteria, and so SIBO in that. The point of that paper is anything that slows the gut down, we are correct, it does generate SIBO and allows these E. coli and Klebsiella to take the opportunity to be the weeds.

Dr. Weitz:                            So along the same lines, we sometimes see patients with Ehlers-Danlos syndrome and they have a higher incidence of SIBO, and we would think now it was because of laxity, maybe, in the ileocecal valve. I wonder why patients with that condition looking at hyperlaxity would have an increased risk of SIBO if it’s not coming up from below.

Dr. Pimentel:                     Yeah. So I mean we published one paper on EDS where we’re looking at visceroptosis. So I don’t know if you know the term visceroptosis, but it means that the gut is sagging into the pelvis, and by doing so, it creates all sorts of bends and twists in the small bowel. So I think physically, it creates impairment like your hose bent in the garden and the water doesn’t flow through it. I think that’s what’s going on is just everything is crushed on top of each other down on the pelvis.  That’s a characteristic sign. So the way you do a visceroptosis is you give the barium, you get them to stand up and take a picture front and all the bowel should be nice all over the place, but in the Ehlers-Danlos, it’s all flat down on the pelvis. It’s sad to see it because it’s not a pleasant thing to have for the future for that patient.

Dr. Weitz:                            Okay. If you want to continue on your telling us about some of the findings from the REIMAGINE study.

Dr. Pimentel:                     This is what I get excited about every day. Well, what I was going to tell you is that one of the other things we published, so not everything is in September and I can’t talk about it, but we did publish that PPIs, proton-pump inhibitors, don’t cause SIBO. The sequencing data does not support that, but PPIs do do something really interesting. They reduce clostridial species in the gut. You probably know this, Ben, but PPI is a risk factor for C. diff colitis.  So it’s like you have this neighborhood that’s supposed to be full of clostridium but for some reason, PPIs make those clostridia go away, but that gives an opportunity for some houses to be support another type of clostridia that isn’t good and that might be C. diff. So anytime you leave an opening, other organisms take the opportunity to come in there and take over. So maybe that’s why C. diff grabs hold in these PPI-treated patients. So there’s that paper.

We showed in another study presented at DDW that women who are postmenopausal, if you look at their small bowel, postmenopausal women, their microbiome gets shifted in a very bad way, but if they’re on hormone replacement therapy, their microbiome in the small bowel looks just like they’re premenopausal.  So it’s stuff like that that we’re finding. Again, another paper next week that will get some press, I think, that’s going to be another impactful paper on just getting the knots and bolts of what’s going on in the microbiome.

Dr. Weitz:                            So you mentioned PPIs don’t affect SIBO. That brings up, I’ll jump to a question, which I wanted to ask you about. How important are the pretest procedures before somebody gets a breath test and what are the recommendations? Does that patient stop taking PPIs? Does that mean that’s no longer important?

Dr. Pimentel:                     Well, this paper suggests you shouldn’t have to worry about it. So now, there’s a caveat to that. Patients with methane, for example, when you reduce acid in the stomach, you’ll reduce methane production. We showed that in another paper. We don’t see a lot of methanogens in the upper duodenum. So we can’t actually see that methanogens are being affected by PPI in that PPI study. So there’s reasons for not being on PPI, but to be honest with you, I don’t think PPIs do much to the breath. That consensus was three years ago, so we didn’t have the luxury of that data at the time.

Dr. Weitz:                           Interesting. So does that mean possibly for functional medicine practitioners supplementing with hydrochloric acid for patients with methane SIBO or IMO might be beneficial?

Dr. Pimentel:                     The opposite because methanogens can use hydrogen of any sorts.

Dr. Weitz:                           Okay. Okay. Okay. Okay.

Dr. Pimentel:                     Yeah. So it’s possible that you could be making or putting more gas on the fire with acid.

Dr. Weitz:                           Okay. Yeah, yeah, yeah. So since I asked the question about pretest procedures, what other pretest procedures do you think are most important to get an accurate result and what things need to be stopped over what period of time? How about probiotics?

Dr. Pimentel:                     Yeah. I think most probiotics that you take don’t produce hydrogen, but we generally recommend not beyond those for about a week before the test. Where we get into trouble, and this is a question I got earlier today on another call is, “What about my constipated patient taking laxatives, “Are you telling me I can’t take a laxative for a week before the breath test? I’ll die,” because it’s really hard for these patients.  The North American consensus is meant to be a rule of thumb. It’s not meant to be a gospel, but it is true that I have patients where they come in, I was sure they had SIBO, they do the breath test, it’s negative, and then I talk to them and they say, “Yeah, I had a massive diarrhea the morning of the breath test just before I came to the office to do the breath test because I took all my laxatives last night.”  So if you flush the gut, you’re going to have a negative breath test and that screws up the test, obviously. So you just got to be careful in some of these patients with constipation that they didn’t just take a monster amount of laxatives the night before because they were worried about how bloated they get with the breath test.

Dr. Weitz:                          Okay. So they’re supposed to stop laxatives.  What about herbal laxatives?  What about magnesium and vitamin C? Is that the same thing?

Dr. Pimentel:                     Vitamin C, not as much, but, yeah, herbal laxatives, I mean, anything that’s going to cause you to be purging within 24 hours of the test can have an influence, for sure.

Dr. Weitz:                          Including magnesium citrate.

Dr. Pimentel:                     Yes. Yes. Absolutely.

Dr. Weitz:                          What about herbal antimicrobials?

Dr. Pimentel:                     Yeah. Well, any herbal antimicrobials are antimicrobials, but the way I deal with that is, for example, if a patient says, “I’m still bloated with whatever I’m taking,” then they’re still bloated with whatever they’re taking.  A, it’s not working and B, they must have SIBO.  So it shouldn’t affect. Then the other thing is a lot of times patients will do a breath test after antibiotics to make sure it’s gone.  So I have no problem.  You don’t have to wait a month to do a second breath test.

Dr. Weitz:                          Now, has the new Trio breath test, which measures all three gases, has that recently been recalibrated so that fewer patients would test positive?

Dr. Pimentel:                     So the new breath test is the sensors are supposed to be more accurate down to 0.1 or 0.2 parts per million. If you look at the readings and how it’s reported, you don’t just get 49, you get 49 point something because the sensors are certified to be sensitive to that level, not that you need that extra sensitivity, but the bag system is designed to retain all the gases very well and it’s validated that those bags filled with your air, your lung air, can last a week and hold hydrogen sulfide, methane, and hydrogen correctly as it was on day zero.  So that’s all certified by the CLIA Lab. So in that sense, you’re getting a more accurate result.  Also, the CO2 tends to be higher than other testing because of the way the system works.  So it’s a closer to true alveolar gas and, therefore, you could say you don’t have to adjust the gas.  The biggest problem with breath testing is when you get a bad sample and you get a low CO2 and you have to … So what you do is you correct the CO2 up to 5.5. If you have to correct it from one to 5.5, then you got to multiply every number by five and a half. The more you correct, the more error you impose on the breath test. So it’s important that you get good samples.

Dr. Weitz:                          Has the test been changed? In other words, were they getting too many positives and did they have to change the calibration of the test?

Dr. Pimentel:                     I don’t know.  For hydrogen, methane, hydrogen sulfide?

Dr. Weitz:                          No, for hydrogen sulfide, yeah.

Dr. Pimentel:                     Well, no.  So hydrogen sulfide, okay.  So I understand your question now. I’m sorry.

Dr. Weitz:                          Yes.

Dr. Pimentel:                     So hydrogen sulfide, so when we did our first validation of hydrogen sulfide, we selected functional chronic diarrhea patients. The functional chronic diarrhea patients were finding that their hydrogen sulfide was over five parts per million compared to constipation, compared to healthy.  Just recently, and this has not been published, but it’s been used for validation of the test. We completed a group of D-IBS patients. So you have D-IBS and then the diarrhea patients who are functional diarrhea. So they’re more severe. They’re having diarrhea every single day. Whereas DIBS is on again off again diarrhea. The DIBS is almost often over three parts per million. So now that we have that data, it drives a change in what we think is positive, so anything over three now because constipation is almost always less than three. So as data come in, the science dictates how you interpret the test. It’s the same thing as … Sorry. Was somebody asking?

Dr. Weitz:                          No. I just didn’t mute them as they were coming in.

Dr. Pimentel:                     Okay.

Dr. Weitz:                          Okay. Let’s see. What was the question? Have you gone back and seen if patients who got a flat line on the two breath tests, does that correlate with a positive result for hydrogen sulfide on the three breath test?

Dr. Pimentel:                     Yes. We’ve shown that up to a quarter of patients. Up to a quarter of patients are testing positive for hydrogen sulfide in general, and we’ve seen that, but what I mean is up to a quarter of patients with flat line are testing for hydrogen sulfide. There are still some flat liners that could be unexplained as either poor transit, gastroparesis, maybe even bowel. There’s many reasons why you could have a flat line besides hydrogen sulfide, but, yeah, about a quarter of patients are hydrogen sulfide.

Dr. Weitz:                            Can you talk about the organism Fusobacterium varium that you have found to be … This is a question that Alison asked me to ask you. That appears to be linked with causing hydrogen sulfide SIBO.

Dr. Pimentel:                     Yeah. Thanks, Allison for that question.  So the methane story is simpler.  The methane story is you have a couple of methanogens, Methanobrevibacter smithii, Methanobrevibacter stadmenii and then a couple of other minor methanogens, but we’ve actually shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  In the case of hydrogen sulfide, though, there’s multiple organisms that can produce hydrogen sulfide. For example, pseudomonas can produce hydrogen sulfide.  Fusobacteria can produce hydrogen sulfide.  Desulfovibrio can produce hydrogen sulfide, and there’s Bilophila can produce hydrogen sulfide.  So there’s a little bit of a laundry list of hydrogen sulfide producers.  I think Allison is referring to a study we did where we took Fusobacterium and we gavaged or inserted it into the bowel of rats in a rat study.  The purpose for this study was to show putting a bacteria that makes a lot of hydrogen sulfide, will in the animal create the animal to produce hydrogen sulfide and we can detect it.  So we were able to detect an increase in the animal’s production of hydrogen sulfide in their body.  The second part of it is as they grew this Fuso in their body and produced hydrogen sulfide, the animal started to have diarrhea, but then the animal, because this organism wasn’t natural to them, eventually cleared the organism.  The hydrogen sulfide resolved. The diarrhea resolved.  So it’s essentially trying to fulfill Koch’s postulates of cause and effect.  An organism that produces hydrogen sulfide, you put it in, it produces hydrogen sulfide, you get the diarrhea, the organism goes away, the hydrogen sulfide goes down, the diarrhea goes away.  So we’re just trying to prove the point that hydrogen sulfide production causes diarrhea.

Dr. Weitz:                          Now, Dr. Steven Sandberg-Lewis, who spoke at our meeting a couple of months ago, he said that he’s been finding a number of patients with hydrogen sulfide SIBO positive with constipation.

Dr. Pimentel:                     So anything we do has an overlap. There’s no black and whites in medicine. So if you were to look at our graph with a dot plot, you have patients who are constipated, for example, that have, and I could show a graph, but there are occasional constipation patients where their hydrogen sulfide is high and we don’t understand why, but just remember this that if I put a blockage in my colon, let’s say I had a tumor in my colon, and the bowel is obstructed. I would be constipated, and then bacteria in the colon would build up. If you happen to have sulfate-reducing bacteria and they build up, you’d get hydrogen sulfide, but you’re constipated because you have a tumor in your colon.  So anytime in my practice when I see something that doesn’t fit, outliers like that, I go to further workup to be honest, something doesn’t fit, because 90% of people with hydrogen sulfide don’t have constipation. So if I see a constipator, I’m going to work them up further, maybe a colonoscopy, maybe other things.  So these are all clues to something else possibly affecting them.

Dr. Weitz:                          So what do we know about, since we’ve been talking about hydrogen sulfide SIBO, what do we know about treatment for hydrogen sulfide SIBO? I noticed that you tend to use bismuth as part of your protocol and I’ve talked to a number of functional medicine practitioners who also use some form of bismuth. Why do you think bismuth might be helpful?

Dr. Pimentel:                     Well, it was a study from 1998 from a guy, Michael Levitt. I don’t know if you’re familiar with him, but he was a gastroenterologist in the ’70s, ’80s, and ’90s, and he has a New England Journal of Medicine article on flatus. If you can imagine a bunch of flatus article on New England Journal now unless COVID causes flatus, then you’ll get that published.

Dr. Weitz:                            … or if vitamin D causes flatus then that would get published, too.

Dr. Pimentel:                     Yeah, but to be honest, what he was studying was intestinal gas production and it was seminal work at its time. He actually described what he thought was the mechanism is that it inhibits sulfate reduction pathways within the organism and then that reduces their energy and they can die from that. So it was paper of 1998 that I use in my presentation that describes that, but, yeah. I mean, this is all we got to go on at the moment, but stay tuned for more studies that are coming.

Dr. Weitz:                          So here’s some speculation. I think that there’s some data to show that bismuth may be helpful in breaking up biofilms. Have you, in looking at the bacteria in the small intestine and SIBO, have you seen biofilms present and do you think that might be a factor when we treat SIBO?

Dr. Pimentel:                     Yeah. So I mean, the difficulty with biofilms is the way we see it in the REIMAGINE study is you’ve got a layer of thin liquid right on top, then you’ve got mucous, and then when you biopsy the mucosa in between the villi, there’s another layer of mucous. So there’s various biofilms, and each of those layers has a different microbial composition, but we see some of those organisms in the deeper layer.  So, for example, Methanobrevibacter loves the mucosa. So we don’t see a lot of the Methanobrevibacter up in those higher layers of the liquid layers, but busting the biofilm or the mucous can help you in treating some of these patients. So maybe bismuth is working by busting up the mucous and helping you get at these organisms, but we haven’t layered out H2S yet. So I can’t give you an honest answer as to where H2S organisms are residing most commonly.

Dr. Weitz:                          So let’s go to hydrogen SIBO. Which organisms are primarily involved with hydrogen SIBO?

Dr. Pimentel:                     Oh, this we know a lot about. So the REIMAGINE study, we did publish last year a very important paper and we’ve had these debates on these calls as well previously, but E. coli and Klebsiella, those are the two weeds in the garden, but we also showed that the breath test correlated with all the sequencing, and that the hydrogen production pathways are increased in the small intestine of patients with hydrogen SIBO because of the E. coli and Klebsiella.  The reason that’s important is because there are people who said, “Oh, the hydrogen is coming from the colon. It’s coming from colon bacteria and lactulose getting to the colon.” What that paper showed was that that’s not the case. This is happening in the small intestine, and it’s E. coli and Klebsiella. You remember those two, and a little bit of Aeromonas, which I’ll sprinkle in there because we do see a little Aeromonas going up as well.

Dr. Weitz:                            What was I just going to say? I can’t remember what I was just going to say. So I had a thought there. So when it comes to methane SIBO or now it’s called IMO, what’s the latest? What have we learned from the REIMAGINE study on that?

Dr. Pimentel:                     Yeah. So the one thing we’re going to be presenting or submitting to DDW in December is now what we’re doing is we’re mapping intestinal methanogens along the entire intestine. So we’ll show you how much is in the duodenum, the jejunum, the ileum, and then subsequently in stool, and we’ll be able to map it out. In terms of treating IMO, things haven’t changed all that much. We still give rifaximin and neomycin based on the double blind study, rifaximin with metronidazole as a substitute.  Obviously, there’s no FDA-approved drug for IMO because it doesn’t work that way, but that’s what the data and the literature supports at the moment. There are other treatments. Allicin is another product from garlic that seems to work well with reducing methane. We still like lovastatin. Lovastatin, the data in the veterinary literature is very good, but it’s tricky with lovastatin because it gets absorbed.

Dr. Weitz:                            Oh, I know what my question was now with the hydrogen. So do you think that E. coli can produce endotoxins? We know endotoxins are produced by Campylobacter with food poisoning that can often be the cause of SIBO to start with. Do you think that endotoxins secreted by the bacteria that cause hydrogen SIBO or the other forms of SIBO are playing a role in some of the pain and symptoms patients are experiencing?

Dr. Pimentel:                     Yeah. So okay, first of all, hydrogen is something we’ve looked at for years. Hydrogen, no matter how high it is, doesn’t predict the severity of the symptom, whereas hydrogen sulfide does. So the higher it is, the more diarrhea you have, the more pain you have and the more urgency you have, but in terms of the toxin, I think you’re referring to the CdtB toxin.

Dr. Weitz:                          Yeah.

Dr. Pimentel:                     E. coli, pathogenic E. coli has that gene for CdtB, but native E. coli to the gut, which is what’s producing the SIBO, it generally doesn’t. It’s not a pathogen. It’s more of a colonizer, and now it’s blooming, and that’s what’s causing the SIBO, but Campylobacter definitely has CdtB and that’s what triggers your antibody production, CdtB antibody, and then the anti-vinculin antibody, which is the blood test for IBS.

Dr. Weitz:                          Okay. So we don’t think that endotoxins is playing a role other than the endotoxins from Campylobacter that leads to the autoimmune reaction.

Dr. Pimentel:                     I wouldn’t say it that way. I mean, I think I know where you’re going with this, but, for example, E. coli has lipopolysaccharides and other things, other wall chemicals that don’t make you very happy. So having all that E. coli and Klebsiella around does create a bit of an inflammatory response, we think, and in addition to the hydrogen and all these gas dynamics that we’ve been talking about for the last little while.  What lipopolysaccharides or these endotoxins are doing exactly is unclear. Again, we have a study that we just finished. It’s a very large animal study and we see a lot of effect of these endotoxins on the cytokines in this animal, but, again, I can’t really talk about it at the moment, but you’ll see some of that data in a few months.

Dr. Weitz:                            Somebody asked a question about the biofilms. So in the functional medicine world, there are various compounds, nutritional compounds that we’ll use to try to break up biofilms, and some of them are enzymes. There are some products that use a combination of bismuth with some other substances. If we were to use agents that we think might help break up biofilms, would that be something that we would do prior to using antimicrobials or at the same time or what would you think would be the timing of the use of that protocol?

Dr. Pimentel:                     I think some of the data we have that’s published on E. coli is that a lot of these E. coli and Klebsiella are swimming through the mucous. So breaking up the mucous is something we’re very interested in in terms of trying to improve our treatments.

Dr. Weitz:                            Okay. Okay. Good. So let’s go back to IMO. So Dr. Sam Rahbar is an integrative gastroenterologist in LA and he’s recently published on some patients who have tick-borne illness such as Lyme disease and it often seems to be correlated with patients with methane SIBO or IMO. I wonder in your research, have you seen any evidence of spirochetes or other parasites in the small bowel?

Dr. Pimentel:                     So the REIMAGINE study, we have the genetic material from the small bowel. We haven’t actually done this. You have to take the sequences and throw it in a database that looks at parasites or fungi or other things. So we haven’t don’t the parasites yet, but, I mean, there’s data from Sweden and other countries in Europe on the role of spirochetes, for example, in IBS specifically, and they’re finding increased spirochetes in the colon, but the connection to IMO, I don’t have any data for that yet. I’d be curious to see exactly what the data looks like from Dr. Rahbar.

Dr. Weitz:                          Okay. A lot of us have found that the methane SIBO or the IMO is more difficult than hydrogen SIBO, and a lot of times when the patients don’t resolve, we try using different antimicrobials. We look for other possibilities. I think Dr. Rahbar has also spoken at the fact that sometimes he’ll see fungal overgrowth. So the question for you is in your data, did you see candida or other fungus in the small bowel related to IMO?

Dr. Pimentel:                     I think Satish Rao is the ultimate expert on this from Georgia. He’s published a lot of the work on this, but we do see fungal overgrowth occasionally, maybe a handful of times a year in my practice. Dr. Rezaie sees it in some of his refractory patients also. So where he thinks it’s overgrowth or bloating, he treats them, they’re not getting better, and then uses an antifungal and it seems to be effective. He’s also cultured candida in some of these patients as either part of the REIMAGINE study or through the clinical lab and then treated them. So it’s definitely there. It’s definitely present in some of these patients, but I would say it’s not as common as the bacterial SIBO, for sure.

Dr. Weitz:                          Okay. Since IMO occurs throughout the entire digestive tract not just in the small intestine, right?

Dr. Pimentel:                     Right.

Dr. Weitz:                          So would elevated levels of Methanobrevibacter on a stool test could just possibly be indicative of IMO?

Dr. Pimentel:                     So Methanobrevibacter smithii in a stool test, if you go back to a paper we’ve published now a number of years ago, 10 to the four, up to 10 to the four or 10,000 smithii per milliliter is considered physiologic, meaning you don’t have any symptoms, you don’t have constipation, but anybody over 10 to the four was constipated. Anybody over 10 to the six then you start to see it in the breath.  So, yeah, there is some merit to doing stool M. smithii, but you have to use that trial, but we’re getting better at evaluating M. smithii in the stool using QPCR and some of the new refinements are going to have some surprising results, but the point I’m trying to make is, if you see M. smithii in the stool, often that’s normal as long as it’s very low in number.  So you just have to be careful how you interpret those stool tests.

Dr. Weitz:                          Okay. Somebody asked a question about using lovastatin. It sounds like she’s considering possibly using lovastatin.

Dr. Pimentel:                     Yeah. I mean, the dose we use for lovastatin, again, it’s an off label use, is 30 mg at bedtime, and we do see methane reduction, but it’s a little bit, it’s challenging because if you just use plain old lovastatin, there’s always a risk of muscle aches and other side effects of lovastatin.

Dr. Weitz:                          I’m not sure where that echo is coming from. Have you looked into the use of red yeast rice as a possible alternative?

Dr. Pimentel:                     I haven’t personally used it, but I know some people who have and have gotten some decent responses from it because red rice yeast does have lovastatin, natural lovastatin in it.  So that could be effective.

Dr. Weitz:                          Yeah. There’s actually products on the market that we tend to use that make sure that there’s no lovastatin, but they seem to have the same effect, and we see much lower side effects of muscle problems using it versus statins.  So for patients with slow motility such as those with constipation, should we consider a cutoff of 120 minutes instead of 90 minutes for interpreting a positive test?

Dr. Pimentel:                     Yeah. The problem is you don’t know who and what they have. So, for example, there are patients who might have diabetes for a few years and for all intents and purposes they just have bloating. You do the test and they have gastroparesis and you see a flat line because the lactulose or glucose never left the stomach. So it’s those things that create trouble because you don’t know they have gastroparesis and then you get a flat line test, but waiting 120 minutes, waiting three hours, you don’t know how long to wait for each of those individuals because you don’t know what their transit is. Narcotic users have the same issue.

Dr. Weitz:                          Okay. A number of us in the functional medicine world who have difficult to treat IBS slash SIBO patients sometimes will look at the possibility of mycotoxins or exposure to mold and we have found a certain amount of benefit from this pursuit and have had, I know personally have had a number of patients with difficult to treat SIBO who got better after we looked at the possibility of mycotoxins, found that they had some exposure to mold. Do you think that there might be in some way that SIBO might make patients more likely to experience either be more sensitive or to experience symptoms with exposure of mycotoxins?

Dr. Pimentel:                     Yeah. So I mean, my understanding of the literature of mycotoxins is very limited, so I’m going to have a very muted response to that because I don’t know enough about it, but what we are seeing and Mike Camilleri from the Mayo Clinic just is publishing a paper now where there is increased intestinal permeability in some of these patients and in IBS patients.  So the worry is that you have some increased permeability to whether it’s food, food allergies, food antigens. There’s another nature paper that came out of Europe saying that patients with IBS, for example, are more susceptible to allergens maybe because the tight junctions are more open.  So as we start to see maybe the anti-vinculin antibody is allowing these tight junctions to be more open, all of that work needs to still be done, but the pieces are coming in to place. We just don’t have all the answers yet.

Dr. Weitz:                          What about the relationship between IBS and IBD, inflammatory bowel disorder?  I know I’ve seen patients with IBD who also had IBS, and when we treated the IBS, their IBD improved.  What do you think might be the relationship?

Dr. Pimentel:                     I’ve had an on and off relationship with IBD in the sense that there was a period of time where I thought IBS may be a precursor to IBD or maybe even SIBO was a precursor to IBD, but I actually don’t think so anymore. I think IBD and IBS are completely separate entities. I’ll give you the evidence, I think, and things change with time, but from what I understand currently, food poisoning causes IBS. Anti-vinculin, anti-CdtB antibodies are associated with irritable bowel syndrome, but they’re not associated with IBD. So understanding the pathophysiology of that host infectious IBS tells me, “Well, that develops IBS and SIBO,” but we’re not seeing that in IBD at all, not like that.

The other thing is I would challenge you to find me an IBD patient with IMO. They don’t happen almost ever. We did a study where we looked at breath test in IBD patients and out of a huge list of IBD patients, only three had IMO and all three of them when you called them, they were constipated. They weren’t having diarrhea. They weren’t having IBD-like symptoms.  So I don’t know, but what we do see with IBD is that if they have strictures, they’ll have stasis, and if they have stasis, they’ll have SIBO, and if you treat the SIBO, they will get better, but the reason for the SIBO is not IBS. The reason for the SIBO is a mechanical issue due to the strictures and the narrowings and other things that the IBD produce. So that’s how I see it currently.

Dr. Weitz:                          Many of us will use a low-FODMAP diet for SIBO and I know you have the low-fiber diet from Cedars-Sinai. Do you think that there should be a different diet for patients with hydrogen versus methane versus hydrogen sulfide?  A number of practitioners will use a lower sulfur version of the low-FODMAP diet for patients with hydrogen sulfide, for example.

Dr. Pimentel:                     Yeah. I’m getting this question a lot, and I’d like to enthusiastically say that the future is we might have three different diets, but I don’t think we worked out what those diets are yet. I have encouraged some of my hydrogen sulfide patients to go on a low-sulfur diet, but I’m not sure that’s the whole story for them in terms of making them better because I’m giving them antibiotics as well.  So we need more data, more time to unravel that, but what is clear is that from studies done in the past is that people with hydrogen sulfide in their gut that low-sulfur diet does reduce that. That’s been published. So I would imagine that that would, but I don’t have any objective data since the breath test has become available to be able to say, “Aha! This is your diet that you should be on.”

Dr. Weitz:                          Have you seen fasting to be a benefit for patients with SIBO?

Dr. Pimentel:                     I love fasting for my SIBO patients. That’s for sure. I mean, the longer they’re fasted, the more opportunity they have for cleaning waves. The more likely they can naturally clear their bacteria out and so to keep things going. So yeah, I mean, skipping breakfast is something that some of these patients do on their own, but the longer they fast between meals is also part of the low-fermentation diet we developed because it’s not just a diet.  It’s trying to make sure you don’t eat between meals constantly keeping your gut with food and bathing the bacteria with food. It’s not how we used to eat. I mean, thousand years ago, we kill the buffalo, ate the buffalo before it rotted on the field. We didn’t have a refrigerator. We didn’t have potato chips or 7-Eleven. So you eat and then you don’t eat for three days. That’s how life was. Anyway, it’s just-

Dr. Weitz:                          Have you ever recommended patients do an extended fast, maybe a couple of two, three days of water only or something along those lines to calm it down?

Dr. Pimentel:                     I’ve seen patients do that on their own, and that sometimes does work for them, but I don’t generally ask patients to do that because it’s pretty tough.

Dr. Weitz:                          What about the use of the elemental diet? Are you still using that on some patients?

Dr. Pimentel:                     Oh, absolutely. I mean, I’m the one who published that fist trial on elemental diet showing it’s more effective even than antibiotics. So I really like the elemental diet. I think the challenge of the elemental diet is that it is hard for patients to do, but look, we’ve done thousands of patients on the elemental diet, literally. So if we would hit a wall and we want to get rid of the overgrowth, the elemental diet has been quite effective for us.

Dr. Weitz:                          Do you typically do it for two weeks?

Dr. Pimentel:                     So in the study, we have in the past done one, two, and three weeks. So by two weeks, you get your maximum effect and you gain a few percent if you do an extra week, a third week, but I can tell you that there’s two time points in the elemental diet treatment that patients hate me, the first two days and the last three days because in the last three days, they’re like, “I can’t wait till this damn thing is done,” and the first two days, they can’t believe they’re doing this. So the dartboard with my face on it is at the beginning and the end.   You know at the end, what we see is a dramatic response, and then patients, I mean, I have patients who do this three times a year and they just love it. They have the fortitude to do it and it makes them feel better than antibiotics. So it’s not all negative. I don’t mind being the face of the dartboard if it makes the patient feel better.

Dr. Weitz:                          Do you ever see patients who started out maybe as hydrogen SIBO and end up as hydrogen sulfide SIBO or switch from one form to the other?

Dr. Pimentel:                     So we’re still early in the hydrogen sulfide part of things, but I have almost never seen somebody switch from hydrogen to methane, but I have seen if we get rid of methane all of a sudden the hydrogen goes way up because it was always there. It had to be there to make the methane. So I have seen the flip side, but never going from hydrogen as their baseline after treatment to methane, almost never. Maybe one in 10 years that I saw that happen.

Dr. Weitz:                          We got a couple of questions about the elemental diet.  Are you using the integrative product or what product are you using for the elemental diet?

Dr. Pimentel:                     Yes, I’ve used sometimes the integrative diet.  Sometimes I use Vivonex.  So those are mainly the two products.  Peptamen because it’s almost elemental, it may be more palatable for some patients, but those are the two products I mainly stick with.

Dr. Weitz:                          With the elemental, they have a version with dextrose and one without dextrose.

Dr. Pimentel:                     I don’t think it matters to me the dextrose because I think it gets absorbed so quickly it doesn’t really affect the situation. I do have patients who ask me about whether they could have coffee while they’re on it. I always answer, “Well, the study was done with no coffee. If you do coffee and you don’t get better after, don’t blame me,” because I don’t know. I mean, it’s neutral. It’s calorie neutral, but they always ask me all sorts of questions.

Dr. Weitz:                          When I put patients on the elemental diet, I usually give them herbal antifungals because of the possibility that they’re eating a high-sugar diet that can fuel the growth of candida or other fungal organisms.

Dr. Pimentel:                     Yeah. Well, I for sure see candida especially thrush in their mouth on the Vivonex and elemental diets. So, yeah, that’s not an unwise thing.

Dr. Weitz:                          Okay. So I’ve seen where you had a chart of what the microbiome looks like in patients with SIBO and there’s real limitation of a lot of the healthy organisms and you end up with overgrowth of proteobacteria and Firmicutes in particular seem to be really suppressed in patients with SIBO.

Dr. Pimentel:                     Yeah. That’s correct. That’s exactly what we see in the small bowel.

Dr. Weitz:                          So does it make sense to use certain types of probiotics to take up that space that’s been vacated so that we make it more difficult for the proteobacter to continue to occupy the small intestine?

Dr. Pimentel:                     I would love for that to be developed, but I don’t have any evidence to suggest that that would work at this point. The evidence suggests it could work, but I have no evidence to suggest that it does work. One of the things that we’re seeing in another paper is that lactobacillus is a disruptor of the small bowel. It’s doing things like E. coli is doing. So you look at lactobacillus, “Oh, it’s good for your colon. It’s good for your colon.” It’s not good for your small bowel I can tell you that now and you’ll see some data coming out shortly on that. We’ve already talked about that previously. Lots of new things coming in and I’ll be adding that to my slide shortly.

Dr. Weitz:                          Yeah. There’s some new probiotics on the market. There’s now an Akkermansia muciniphila, which is one of the important Firmicutes, which had to be produced in a non-oxygen environment, very difficult, and they finally brought it to market. I wonder if that would be something that would make sense to try to regrow the Firmicutes.

Dr. Pimentel:                     Well, if I know Akkermansia well, it also makes a lot more mucous. So are you making more environment for proteobacteria to hide or I don’t know. I’m not criticizing. I think we have to do more work. I think it’s interesting. I think having it gives us the opportunity to look at those kinds of questions, but, yeah, I’m still not clear yet.

Dr. Weitz:                            Yeah, because I mean, even if we kill the E. coli or the other organisms, we still want to regrow the healthy bacteria in the small intestine. So I wonder if maybe prebiotics would be beneficial.

Dr. Pimentel:                     Yeah. I mean, all of that is on the table. So, again, Ben, I’m not pushing back. I just won’t know what the cocktail will be, but what I think I show and I think the slide you’re referring to or the depictions you’re referring to is the network analysis that we did.  The network is not one organism. It’s not three organisms or five organisms. It’s 100. So what I would love to do is to see the 100 come back and not in a fecal transplant because feces are not the composition of small bowel, but we should do a small bowel to small bowel transplantation, and then we might be talking this stuff. I wish we have that because I think that might be the trick, but single organisms, I don’t know. I have to see.

Dr. Weitz:                          Yeah. Is that something you’re working on?

Dr. Pimentel:                     Not small bowel transplant, not yet. No.

Dr. Weitz:                          Okay. So what’s the best way to reset the motility of the gut?

Dr. Pimentel:                     I really like using prucalopride Motegrity to push motility when it’s down. You can also use low-dose erythromycin. That’s what we old school did. Low-dose naltrexone does some of that, too. I know some people use that, but I like Motegrity now. I’ve had a lot of good success with it in the last couple of years.

Dr. Weitz:                          What do we know about patients who have histamine intolerance and SIBO?

Dr. Pimentel:                     Well, I mean, there are histamine-producing bacteria in the gut. So we have to find those characters and characterize them. Histamine is a really difficult thing. The histamine chemical has a very short half life, hard to measure. So we’re trying to track those characters, but we’re not having a good success with that yet. Stay tuned. We are trying to get at them, though.

Dr. Weitz:                            Okay. I think that’s pretty much all the questions I have. Let me just look through the questions that people have asked here. FODMAP diet, let’s see. Somebody asked, “If you were to use rifaximin plus allicin, would you only do it for two weeks?” which is the way you typically use rifaximin versus when we use herbs, we typically use them for four to six or eight weeks.

Dr. Pimentel:                     So I do use allicin in the form of Allimed is what I generally use. Usually, by itself, and I get some good success with methane. The problem with the allicin is over time the methane returns. Sometimes I keep them on it indefinitely to try and keep it down, but then methane still breaks through. It only goes down for a while.

Dr. Weitz:                          Have you used Atrantil?

Dr. Pimentel:                     I have a few patients on Atrantil and some success there. I don’t use it routinely, but, yeah, I have a few patients who benefit from it.

Dr. Weitz:                          Okay. I think that’s all the questions. Thank you so much for your time, Dr. Pimentel. Any final thoughts you want to leave us with?

Dr. Pimentel:                     No, Ben. You always challenge my brain with the most difficult questions, but I love it because there’s still a lot to learn, obviously, and I can only tell you what I know and I hope that in three months I’ll be able to tell you a lot more of what we’re finding this month and next month and just keep you guys informed, but thank you for all you guys do. I think it’s a challenge to treat these patients, and I know we’re all working together to try and find better treatments.

Dr. Weitz:                          Absolutely. Thank you everybody for joining and we’ll see you next month. Thank you so much, Dr. Pimentel.

Dr. Pimentel:                     All right, Ben. Thanks again. Take care.

 


 

Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple Podcasts and give us a five-star ratings and review, that way more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition Clinic. So if you’re interested, please call my office 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.