The Interplay of SIBO, Fungal Overgrowth, Food Allergies, and Mast Cell Activation with Dr. Sam Rahbar: Rational Wellness Podcast 266

Dr. Sam Rahbar discusses The Interplay of SIBO, Fungal Overgrowth, Food Allergies, and Mast Cell Activation with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on June 23, 2022.

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Podcast Highlights

8:04  Dr. Rahbar’s new topic for this talk is “The Interplay of SIBO, fungal overgrowth, food allergies, mast cell activation, and FODMAP intolerance”.  Dr. Rahbar is sharing his presentation notes and references from his Dropbox: Here is the link to Dr. Rahbar’s Dropbox. 

12:31  Dr. Rahbar presented some cases from his practice that can teach us about some of the patterns of GI dysfunction that he has treated successfully.  The first case that he calls the Paradoxical Clinical Outcome, which is a young female with a history of methane SIBO and she previously responded well to Xifaxan and neomycin and at times to fluconazole and nystatin with good results.  This indicates that the microbiome of that patient goes through a dance where at one point bacteria become predominant and at another time, it becomes fungal dominant.  Dr. Rahbar decided to treat with the Elemental Diet and he also treated with fluconazole and nystatin. Three days after starting elemental diet, the patient complained of severe abdominal bloating, which is very unusual for being on the elemental diet.  He speculated that the clinical picture was one of fungal overgrowth and that the fungi had become resistant to nystatin and fluconazole and he changed the treatment to itraconazole and within few days her abdomen became flat and the patient reported that she has never felt this good ever.

19:32  The next case is a young female with high methane level SIBO, which Dr. Rahbar calls a Mega Meth Pattern.  The patient was given Xifaxan and neomycin with good response and then a second course and a breath test that showed 80% improvement. The patient wanted to do a third round and after this the patient felt much worse and then her breath test became terribly abnormal.  Dr. Rahbar checked the patient for tickborne diseases and Babesia duncani came back clearly positive, so he treated the patient with Malarone for 6 weeks and after 2 months the patient was completely symptom free and her breath test was now completely normal.  Retesting for Babesia was now negative. Clearing the Babesia altered the immune system to allow it to reduce the archaea that produce the methane.

22:20  Another case of a patient with a very high hydrogen pattern of SIBO.  This patient’s SIBO kept recurring after successful treatment. He ran an organic acid test that showed high levels of markers for fungal dysbiosis. This patient also had evidence of environmental toxins, BPA and glyphosate, and some mycotoxins. Dr. Rahbar treated her with a variety of binders and antifungal therapy for several months and then went back and treated the SIBO and this time the SIBO cleared and did not recur. In fact, this patient felt better and then pursued pregnancy. There is a drawing of fungal overgrowth that disrupts the mucous layer and the hypae actually grow down between the intestinal enterocytes and disrupt the tight junctions of the intestinal wall. This also can cause aggravation of the mucus layer and aggravation of the mast cells and the release of histamine and other inflammatory chemicals.  Fungus is an underappreciated player in cases of mast cell activation and can be a player in recurrent cases of SIBO, of recurrent urinary tract infections, and also with recurrent sinus infections. And each time you prescribe antibiotics, you promote the fungal overgrowth and this creases a vicious cycle. The mucus layer along the intestines and the rest of the digestive tract and if it is damaged, it creates more opportunity for opportunistic bacteria and fungi to lodge there. The probiotic Akkermansia muciniphilia is important for the health of the mucus layer and if the stool test shows that Akkermansia is depleted, it might be beneficial to incorporate supplements of Akkermansia into the therapeutic protocol.



Dr. Sam Rahbar is an Integrative Gastroenterologist in Los Angeles, California, combining conventional gastroenterology, performing colonoscopies, endoscopies, and Heidelberg pH testing, but incorporating anti-aging and Functional Medicine into his unique treatment approach to digestive disorders. He can be contacted through his website http://www.laintegrativegi.com/ or by calling his office 310.289.8000.

Dr. Ben Weitz is available for Functional 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.

Okay, so welcome to the Functional Medicine Discussion Group Meeting tonight, and the topic is the interplay of SIBO, fungal overgrowth, food allergies, and mast cell activation. That’s a mouthful with Dr. Sam Rahbar. I’m Dr. Ben Weitz, and I’ll make some introductory remarks before introducing our sponsors, and then I’ll introduce our speaker for this evening. And please, that our sponsors for this evening are Integrative Therapeutics and Vibrant America Labs. So I’d like to introduce Dr. Steve Snyder from Integrative Therapeutics to tell us a little bit about some of the integrative products. Steve?

Steve Snyder:                    That’s cool. Thanks. I just got a doctorate. That’s awesome. You guys, if you haven’t seen or heard Dr. Rahbar before you’re in for a treat, we work with him, can I say that? Pretty, pretty extensively for a long time, and he’s great. And this is kind of right up our alley. We have one really, really important product for this that I want to… I see a lot of people who already know this on the attendees, but our Physicians’ Elemental Diet is a medical food for moderate-to-severe gut dysfunction, and it was formulated based on the research that Dr. Mark Pimentel did using the product Vivonex with elemental diets and SIBO. That research is pretty impressive for this treatment. And although if anybody’s ever tasted Vivonex, it’s the most gross thing ever. So they asked us to try and make something that was a little better tasting, that was hypoallergenic, and kind of a more functional medicine appropriate product.  So we have protocols, we have samples, we have discounts for patients that can’t afford the treatment. We have tons of support for this product. And it’s something that we think is really important and really powerful. So we want to make sure people are well armed to get the positive results that this can yield. If anybody has any questions about it or anything, reach out to me. I know several of you know about it. The research continues on it. It’s really the only real elemental diet out there, aside from Vivonex, so there’s a few trying to pretenders out there, but if you really look at the labels on those, it’s not really what it’s supposed to be. So without any further delay, Dr. Rahbar

Dr. Weitz:                            Actually, you know what, Steve? For those of us who might be listening to this recording afterwards, who are not functional medicine practitioners, maybe you could just tell us briefly what is the benefits of elemental diet? Exactly, what is it accomplishing?

Steve Snyder:                    Well, there’s different ways to use it, but in the context of SIBO, the main two things you’re doing are you’re providing complete gut rest, so you’re providing all of the nutrition the person needs in elemental forms, so it’s easily assimilated. There’s no work of digestion necessary, and it’s all absorbed in the upper GI, so it doesn’t get down there to feed the displaced bugs, which is the other reason that it’s good because it’s starving those bugs. In the Pimentel research, it was about 80% negative breath tests after two weeks of the elemental diet and the people who were still positive, they did another week and it ended up being about 85% breath test negative. So the antibiotics and antimicrobials are one way to attack this problem and the elemental diet is a different way. Especially, for people, who’ve had been through a lot of courses of antibiotics and stuff and want to try something different, this is a great option.

Dr. Weitz:                            Essentially, you’re starving the bacteria.

Steve Snyder:                    Correct. And also giving your gut a chance to sort of reboot. In other uses, you don’t have to do a whole two weeks necessarily. You can get pretty good effects with just even a three-day treatment, but the research in SIBO is at two to three weeks.

Dr. Weitz:                            And you guys have a dextrose-free and a dextrose one [inaudible 00:05:04]

Steve Snyder:                    Yeah, the original one was dextrose. We did that because we wanted it to be a little different than Vivonex, which is dextrose-free. It works great, it’s very sweet, so we came out with the dextrose-free one. We jiggered a little bit with the percentages of fats and carbohydrates and protein equivalent, so it’s a little less sweet, and some people prefer that one better. It’s all a matter of taste really, and that’s why we have the samples.

Dr. Weitz:                            Great. Steve. And thanks to Integrative Therapeutics.


Vibrant America Lab


Dr. Weitz:                              The Vibrant is also co-sponsoring this evening. If you’re not aware of Vibrant America, they’re an awesome functional medicine lab testing company, and it’s pretty much a one-stop shop. There’s not much they don’t offer. They have all sorts of great gut testing. They have a great stool test. They offer a great food sensitivity testing. They have hormones, everything that you could possibly want to get. They have great toxin testing. They offer excellent testing for Lyme disease. So it’s a great go-to lab. It doesn’t go through insurance and their prices are very, very awesome for cash prices. So consider Vibrant America and thanks to Vibrant for sponsoring this evening.



Dr. Weitz:                             So our speaker for this evening is Dr. Farshid Sam Rahbar, and he’s the founder and medical director of Los Angeles Gastroenterology and Nutrition in Century City. Dr. Rahbar is one of the few integrative gastroenterologists in the country, and he performs endoscopy, colonoscopy like traditional GI doctors, but he also incorporates anti-aging and functional medicine for a truly integrative, holistic approach to digestive care. Dr. Rahbar, thank you so much for joining us this evening.

Dr. Rahbar:                         Thank you everybody. And thank you, Ben, for inviting me. I must say it was a little bit of a short notice. I know the other speaker did not show up or canceled it. But I was able to put this talk together in a busier schedule. I apologize, I don’t have slides, but I put my thought process and the message delivery on Dropbox paper, which I can send a link to Ben and he can put it on the website. Here is the link to Dr. Rahbar’s Dropbox. If everybody’s ready, I’ll proceed. I did modify the title a little bit. Originally, Ben and I spoke about the interplay of SIBO, fungal overgrowth, food allergies, mast cell activation, and then I added the syndrome of FODMAP intolerance.  We were seeing more and more people becoming intolerant to FODMAPs, and my recollection is that this thing wasn’t there before, why we’re seeing more of this now coming that we are becoming intolerant to the small molecules. And the word interplay, it’s really refers to a dance of these elements in the intestinal lumen of all these elements, they’re part of the microbiome, and kind of a… It appears to me that as practitioners, we try to interfere by trying to optimize this relationship of the microbes in the gut, so our role would be more of a choreographer to see if we can have them play correctly.

Now, my goals for this presentation are appreciation of the connection of the chain of events that lead to immune dysregulation and addressing the transkingdom playground of again, bacteria, fungi, and how do these things communicate with each other. The role of fungi in promoting bacterial persistence by mechanical disruption of the mucosal integrity.  The unappreciated role of fungi in creating an anaerobic environment and promoting methane-producing archaea. The role of fungi in supporting C. difficile infection and appreciation of the mucus barrier in intestinal barrier disruption, so called the leaky gut and the immediate and delayed food allergies and sensitivities. Digging deeper to potential causes of dysbiosis persistence, environmental factors, stealth infections, mold, toxins, and exposure to environmental chemicals, and other interplay of elements.

And then, I put some references here and I encourage you to read these references. This is not something you see in traditional textbooks, and these concepts are probably about 10 years out before standard academic centers will start to incorporate these, in my opinion. Intestinal microbiota in health and disease from a disrupted equilibrium to clinical opportunities, this is from Immunology in 2019, To Be or Not Be a Pathogen, Candida albicans and celiac disease. And we will come back and look at this picture here. This is really out of this world the way this was drawn and we see the significance of that. The role of fungi in C. difficile infection, an underappreciated transkingdom interaction. And again, a reference here, an article Intestinal Mucus Barrier, the Missing Piece of the Puzzle in Food Allergy. And this is in journal of… I guess, I forgot to put the link for this article, but this was published in 2021. It’s really a basic science article, but it’s significantly talks about the role of mucus, which I’m going to touch base on that.

And just a comment about alkaline phosphatase. Intestinal alkaline phosphatase is different than the bone alkaline phosphatase, and the one from liver intestinal alkaline phosphate, which is zinc dependent as a cofactor and their good quality zinc, particularly zinc carnosine, available to support this enzyme, which has antibacterial and antifungal properties to keep the gut clean. And here’s a reference to the talks about immunity and microbes and alkaline phosphatase. Now, before we proceed and to be able to appreciate these concepts and these goals that I’ve created, I thought I present to you in the 30 minutes that I have to do this presentation some case examples, and see if I can stimulate the mindset of the audience to see if we can say, “Okay, let’s go back to the literature.”

One other reference I did not add here. It is my personal experience. We are observers, and at one point we start to appreciate what we observe. We have hundreds of patients who have similar pattern. I don’t believe I always need another article to come out in 10 to 20 years from now, when you have hundreds of a similar pattern coming out. At least, in our practice, which I think is quite unique in the type of patients we encounter, there seems to be, what I call, a pattern recognition. A pattern that is recurrent, and that has prompted us to come back and see what is out there, put these references out there for you, but these references, they support our own personal experience. Okay? Now, in these case examples, I’m going to go with this first one, and this relates to elemental diet that Steve were just pointing out. And if you ever heard my talk from 2019 at the SIBO conference, at that time, I presented the pattern that we see with SIBO, and generally there are about 10 different patterns that we see.  I think, Ben, you were there in that conference and I think that’s one of the classification appear to be appealing just to be able to memorize these type of SIBOs that we see based on the clinical response. This first case, I call it the paradoxical clinical outcome. Young female with history of methane SIBO, previously responded well to Xifaxan and neomycin. And at times to fluconazole and nystatin with good results. This by itself tells us that the microbiome goes through a dance. I call it the dance of the microbiome. Sometimes it becomes more bacterial predominant, and sometimes becomes more fungal predominant. And at times, it’s difficult to know which one is the player. You have to do a therapeutic trial. In this particular instance, when we went back and forth, we got to point that the patient was having some bloating and SIBO symptoms, and a SIBO test showing you hydrogen predominant SIBO. At that time, we decided to treat with elemental diet, but because of fear of fungus associated with the sugar, I incorporated nystatin and fluconazole, both of them concurrently with the elemental diet.

Dr. Weitz:                            Now, why did you decide to include both of those?

Dr. Rahbar:                         Because of the experience I had with the patient and the testing results previously that fungus at times was a player and she had clearly responded to these two previous. I said, “Look, there’s a little bit of a carbohydrate in the elemental diet and I don’t want this thing to take over.” Three days after the elemental diet, patient complained of severe abdominal bloating, what do you do?  Now, it is not usual to hear anybody saying, “I got bloated on elemental diet.” Indeed, in 40 years of practice and 20 years of doing this, I’ve never heard of that scenario before.  But I like you to think about it for a moment, and then we can come back and say, “You know what to do?”  Unfortunately, this is not a completely interactive dialogue with audience, but what do you do?  Patient is already on fluconazole.  Patient is already on high dose nystatin, 3 million units a day compounded and pure, and abdomen is bloated on the elemental diet. What do you do at this time?  So just to make a long story short, what we did, we had to stop everything and-

Dr. Weitz:                            By the way, what kind of testing had you done for this patient?  She had a SIBO breath test?  Had she had other testing?

Dr. Rahbar:                         She had a SIBO breath test showing that the SIBO was there, but it wasn’t very severe. We didn’t know if it’s a fungus or bacteria, but there was still some element. Generally speaking, when people go on elemental diet, there’s usually no bloating because you don’t really have any substance there and people get flat and comfortable. This was very, very unusual to feel bloated. Anyhow, what we did, I stopped-

Dr. Weitz:                            Oh, somebody asked: why compounded nystatin versus conventional?

Dr. Rahbar:                         Well, I don’t like the ingredients of the generic nystatin. If you look at it, the tablet is sugar coated and it cannot guarantee that there’s no wheat or gluten or corn products in it, or somebody who is so sensitive to many things with this type of case complexity, I don’t usually use standard tablets.  Just ask your pharmacy to give you the excipients and other ingredients on the tablet, you will see what you get as a report is quite impressive.  Anyhow, what we did in this case, we stopped everything.  I speculated that the clinical picture is one of fungi, and I also speculated that the fungi was resistant to nystatin and fluconazole because we had used it before.  And what we did, we changed the treatment to itraconazole, and within few days the abdomen became flat and the patient reported that she has never felt this good ever.  We know a previous workup had revealed that there was evidence of mold exposure from maybe a residence that the person might have been in, and that might have been a trigger factor in the background, allowing fungal predominance here.  Now, please stay with the thought, there’s a lot to cover some of these concepts.  Most of us have heard of all of these SIBO, SIFO allergies, but what I’m trying to emphasize here is how these things they interact. In this particular instance, you just notice how the fungus can suddenly become the predominant picture.  It was probably there to begin with for a long time, and then suddenly it took over under the SIBO treatment.

The next case, there was a case of a young female with, I call it the mega gas, mega methane, or mega meth pattern with a peak of methane over 100. Patient was treated with Xifaxan and neomycin with good response, went over for a second course and a breath test that shows improvement by 80%, and patient says, “Well, I want to do a third round,” and this is the classical treatment pattern that it has been done outside. After the third course, the patient felt worse and the breath test was terribly abnormal. It was worse than the first one. So suddenly after two rounds of neomycin and Xifaxan that had given patient’s significant improvement, suddenly she got a very bad methane. We were back to square one. What do you want to do?

Dr. Weitz:                            Sam, how often do you end up prescribing two or three courses of Xifaxan?

Dr. Rahbar:                         Well, I used to do this more often.  This case is from few years ago.

Dr. Weitz:                            Okay.

Dr. Rahbar:                         Nowadays, I do take a little bit more precaution because of my understanding of how fungi might be a player into this, so please allow me to go through this. You will see, I’m trying to make a point from this presentation. In this case, I speculated, this is back about 2019, that the patient had a reason for immune dysregulation, allowing the archaea to produce methane. And when we checked the patient for tickborne diseases, Babesia duncani came back clearly positive. So the patient was treated with Malarone for six weeks, no other antibiotics, six weeks of Malarone. After two months, she walked into the office and said, “I feel good. I just want to repeat my breath test.” We did the breath test. The breath test was completely normal, completely. We did not use any more treatment for SIBO.  It was obvious that the treatment of the underlying problem might have altered the immune system in a way to allow clearance of this type of archaea. So the response was very remarkable. She even came back a few months later, did the same test again, it was consistent. It looks like the problem was addressed. The Babesia test later on turned to be negative. It was done through IGeneX. Another case is, what we call, incongruent pattern. Patient presented with very high hydrogen pattern, recurrent pattern of SIBO. You keep treating, response, but it keeps coming back. Eventually, we did some sort of urine organic acid and the markers for fungal dysbiosis were high. And I speculated that the fungi might be in the background leading to surface disruption and allowing crevices and cracks in the wall for the bacteria to persist in the mucosal layer.

Dr. Rahbar:                         I’m sorry, what is it?

Dr. Weitz:                            I think he just wasn’t muted. Somebody just came into the room. Sorry.

Dr. Rahbar:                         That’s nice. Okay. Yeah. So how do you manage a case like this? In this instance, what we did? We stopped focusing on the SIBO and we focused on the managing the fungi. The question was that why a patient would have persistent fungal scenario, and when we checked it, there was evidence of environmental toxins, BPA and glyphosate, and some mycotoxins. It was hard to say which one is the player. I basically treated the patient with a variety of binders for several months and concurrent antifungal therapy, and eventually we went back and treated the SIBO and the SIBO this time cleared, and it appeared that they stayed under control. The patient felt better and eventually decided to pursue pregnancy. These three cases they could be… I presume, other physicians would see difficult patterns to control, and I think it is good to keep these in mind.  Based on these presentations, I want to come back and show you one of the pictures we clearly refer to is this one here. In this case, if you… This is published in an article, looking at some of the patients with celiac disease, that they may still have symptoms and they’re gluten free, that you may be dealing with a scenario of celiac. However, I use this slide as an example to show that if the mucus layer is disrupted, if the epithelial, the enterocytes are disrupted, you can allow, or one can allow the fungi to change shape from yeast format to hyphae. And these hyphae, they can have arms and leg. This is like an Eiffel tower. This is like a jackhammer, and they can actually crack the wall and affect the tight junctions. This will cause aggravation of the mucus layer and aggravation of the mast cells and release of histamine and other inflammatory chemicals.

This will lead to patients sometimes showing up with allergies, nasal congestion, seasonal allergies, and dermographism, mast cell activation, so the whole chain of events can take place by doing this. However, if you do, you see evidence of mast cell activation. Even by a simple physical exam, looking at dermographism, it suggests that the mast cells are turned on. And in many cases, one must think of this fungal element. I don’t believe we have appreciated the fungal kingdom adequately. These are different than bacteria. Bacteria, they can stick together and could be subtle, and they produce a little biofilm. This thing can actually mechanically disrupt the tissue. By mechanically disrupting the tissue, you can produce crevices and cracks and that will allow bacteria to stay here. And I believe, this is one of the reasons you see SIBO, SIBO, SIBO keep coming back because of the mechanical disruption.  Now, we have seen this in our practice, many women with recurrent urinary tract infections, men or women with recurrent sinus infections. And every time you give antibiotics, you basically feed this creature again and we basically fall into a vicious cycle or, what they call, like a domino effect. This pattern actually has been described with fungi and C. difficile. And once I understood this concept, I said, “Look, is it possible C. difficile, that is recurrent, might be doing the same thing?” And when I searched, the article easily came up. This was published in 2019 and talks about this unappreciated feature, so it’s not just about UTI and sinusitis, C. difficile. In our patients that we treat with treat for C. difficile, I generally incorporate an antifungal program with it, both as far as the dietary and maybe adding nystatin to the regimen.

This is not a standard of care written everywhere, but considering these concepts, if I feel it’s appropriate, I make a clinical judgment and I incorporate antifungal treatments in the treatment of C. difficile in the hopes of preventing that recurrent pattern, spore formation and so forth. Again, my theory behind this would be that’s probably some mechanical disruption of the surface that allows the spores or the bacteria to hang around longer, and then after your first course of treatment, you end up another one. Now you add immune dysregulation, weakness, and clinical picture of malnutrition to some of these cases that even [inaudible 00:29:01] further to recurrent C. difficile. Now, this particular article talks about intestinal mucus barrier, the missing piece in the puzzle of food allergy. Let me see if I have this, actually. You see my screen? Let me just put that here.

Okay. So this is the article that was published and it really nicely goes into the details of this that we need to appreciate further the glycoprotein that it creates the mucus layer of the gut. And there’s a mucus layer in the stomach, small bowel, and colon, and obviously, the stomach has its own version of the mucus layer, small bowel has its own version, and the colon has its own. There are two layers with this that they describe. One is tight and is attached to the very surface, and there’s a looser mucus layer from glycoproteins that is sitting on top of it. What these mucus layers do? They create a smooth and sliding layer. It’s like ice skating. These bacteria can float on them and through the gut movement, they can be pushed out. When the mucus layer is damaged, then you’re going to have a rough surface and that creates for these additional opportunistic bacteria and fungi to further lodge into this.  Now, the relationship of the mucus layer with Akkermansia is very, very important, because as you might know, Akkermansia that recently became available as a probiotic is Akkermansia muciniphilia. And this particular bacteria for most part is supposed to be a good bacteria, because what it does, muciniphilia means it likes mucin, it eats off the mucin. And by doing this, if you have a thick mucin, it makes it… kind of loosens it up. It almost keeps the mucin in good shape. In scenarios of fungus, from what we have seen, and I’m sure many of your patients have shown you rope forms by passing thick mucus layers from rectum means that mucus becomes very thick and abnormal, and that makes it very easy for this thick biofilm to allow many bacteria and fungi to lodge in there.  Presence of Akkermansia is very, very important to be able to keep a healthier and this article, they do talk a little bit about the Akkermansia muciniphilia, a commensal bacterial member of the human and non-human gut microbiota and a mucin-degrading specialist that has been associated in human with both beneficial and harmful effects in multiple disorders. Obviously, if your mucus is thin and abnormal and this thing comes and eats the rest of the mucus, you’re going to have more problems. But in the setting of fungus, in my experience, if the Akkermansia is depleted, and many of your labs will show you if you have adequate Akkermansia or not, it might be beneficial to incorporate Akkermansia as part of your therapeutic protocol [inaudible 00:32:57]. Intestinal mucus layer-

Dr. Weitz:                            For those who don’t know, there is a commercially available Akkermansia muciniphilia product available from Pendulum Therapeutics.

Dr. Rahbar:                         Right. You should invite them the next time to support this program. Okay. Anyhow, stomach produce this mucin 5AC, MUC5 I call it, and then the gut has the MUC2s, and again, each of these are two layers and then they have subclassification. It goes into a lot of biochemistry, and just for you to know that amino acids are commonly used in this mucus production, threonine, serine, and glutamine during necessary for production of this mucus layer. And the glucose is attached to the protein by, what they call, O-glycosylation. It attaches itself to the oxygen molecule and it is a form of a glycated protein, basically that is created here. In addition, the protein [inaudible 00:34:12] mucins O-glycosylation is an important feature that contributes to the viscoelasticity of the mucus, thus promoting activity as a lubricant to help expel particles and parasites.

Now, I gave a new language we don’t hear is mechanical disruption of the surface. Previously, we talked about leaky gut. Leaky gut could be loss of those tight junctions. Leaky gut could be loss of a cell that it dropouts or extrusion. But now we should also think about leaky gut as mucus layer being damaged, either too thick or too thin, and this can happen. Now, this article talks about environmental chemicals, which is fascinating because many of the environmental chemicals, they work as a detergent, like a soap, and they can actually damage the mucus layer. And I believe many of these syndromes that we’re seeing that I call the syndrome of FODMAP intolerance is because of exposure to this environmental chemical that they’re showing up in our food chain and in the urine. As we speak, we are currently working with Vibrant laboratory. We have already started a research project to look at digestive manifestations and other manifestations in patients with abnormal urine outputs having these type of chemicals.

As you might already know, back in 2021, in January, we published digestive and non-digestive manifestations of patients with vector-borne disease that was published in journal of patient-centered reviews by University of Wisconsin and Aurora Health. And that our article is already available online. Our next focus is going to be looking at the correlation or the association of presenting symptoms, whether it’s digestive or non-digestive, with abnormal urine chemicals including toxins of mold, environmental chemicals, that would be 36 of them would be studying, and metals in the urine. We will see what the update would be in the [inaudible 00:36:50]. I’m going to close this article here. Okay. And then going back to… So that reference is also available. I’m sure if you look it up, it’s going to come up easily. It is free online.

Dr. Weitz:                            And Sam, I just put a reference for your article in the chat box. Can I ask you, should we think of the mucus layer as crucial for both the health of the intestine and to allow the healthy bacteria to grow, but at times can’t it also become a biofilm to protect the problematic organisms?

Dr. Rahbar:                         Exactly. And I think that’s where we need more research to understand how do you delineate what is normal and what is abnormal and how much is too much. I can tell you that there was an article published in traditional journal of gastroenterology describing biofilms. If phenomenon that I could never really understand that why when I do colonoscopy in the area of cecum, occasionally we see a layer of biofilm stained green, but it is so sticky that if I use high pressure water, I would still have difficulty getting it off. And then you have another patient that comes for colonoscopy and the colon is completely clean, the mucosa is shiny, and I don’t have such a biofilm. And somebody published this in last couple of years, and then I realized that when I looked back in our patients who have this type of biofilm, the majority of them were patients with Lyme disease and other problem that they had received a variety of antibiotics, that probably created a very dysbiotic flora as a consequence of ongoing antibiotic use.  And now, I hypothesize personally that persistence of this bacteria, it requires a rough surface that most likely it is fed or sustained by this fungal interaction, and that’s what I call, the interplay. And so, when I see recurrent bacterial infections, either sinus, urinary tract, or even gut, then we realize that this may have a fungal component under it, and I think that also has to be addressed. So that’s one of the take home messages I try to emphasize. The other thing is-

Dr. Weitz:                            Sam, let me just stop you for a second. Guy Citrin asked: what products have you seen or utilized that have successfully helped to repair the mucosal barrier?

Dr. Rahbar:                         Well, I use a variety of products for that, but this probably would be better to do it in a Q and A, so I don’t get disrupted in my thought process.

Dr. Weitz:                            Oh, okay. I’m sorry. I’m sorry.

Dr. Rahbar:                         Just hang in there with me. I can tell you what we do and what’s available out there, but-

Dr. Weitz:                            Okay.

Dr. Rahbar:                         … and then, we can go from there. There’s a few take home messages that I like to cover. Another take home message here is the correlation between methane and fungus. Now, for those of you that you treat SIBO, the methane SIBO, it does not have the same character as the hydrogen. Methane generates very low, less than three. They say, if you get to methane level of 10 is abnormal, but I think even that might be too high, but to produce methane, you need archaea. Archaea are bugs that they don’t like oxygen. They don’t survive in an environment that is oxygen. On the other hand, fungi, they like oxygen. That’s why, if you put a piece of fruit outside for a few days, you’re going to see becoming a little moldy outside. You can actually see it sometimes visibly.

Based on this concept, I said, “Let me do a search and see how do they grow archaea or methane producing bugs in the laboratory.” I found a nice article. It is not listed here, but is available online that… This was done by microbiologists, how to grow methanogens in laboratory. So I went to the methodology and they said, “Okay, this is your Petri dish and you put A, B, C, D like a kitchen,” and they were putting a little fungi in it. Wow, why they put fungi into that? And partly because fungi can produce nitrogen just like the way we make beer, and nitrogen is going to replace the hydrogen, so you create an anaerobic environment. I say, “Well, maybe the same phenomena is happening in the gut.” New genome showing a high level of methane, like the case I just presented to you that to have a high methane, it appears to me that you need to have fungi around.

So we started to look at the fungal markers for our patients with high methane. Nearly 90% of patients with high methane. They had markers for fungi positive. Either the stool had fungal growth or the organic acid showed it, or the antibody to fungi were showing up in the blood. There were reasons for us to believe that the fungus might have been a player. Obviously, fungus scenario and fungus dysbiosis, it has no discussion currently in classical textbooks of medicine. Unless it’s invasive, when you’re in the intensive care unit, having with fever and invasion, or you’re dealing with oral thrush, esophageal candidiasis or vaginal yeast, there is no discussion beyond these areas of the role of fungi. And I think it needs to be further research.

If you look at the references I’ve given you, the same language is used by the authors as how unappreciated this scenario could be. And because of its ability to disrupt the microbiome, disrupt the mucus layer, disrupt the enterocyte layer, crack the wall and create a mechanical disruption that produce crevices for the box to grow. This is what I call cracks in the wall, and it may be another concept to keep in mind when we’re trying to deal with this. With that scenario, I can give you a summary what I like to be the take home message, and I’m happy to answer any questions. I put your concepts to consider. Methane SIBO indicates possibility of underlying fungal dysbiosis, recurrent C. diff may be facilitated by fungal dysbiosis. Surface disruption, that’s something I put there as a possibility.

Underlying fungal dysbiosis indicated possibility of immune dysregulation directing in two directions, Th2 dominance and allergies. Food sensitivities and/or immune weakness align fungal persistence, as if you took steroids, you took chemotherapy or antibiotics, so it looks… That’s now, you have a vicious cycle. Fungal persistence may increase the likelihood of bacterial infections, such as recurrent sinusitis, UTIs, and the need for antibiotics; hence, the domino effect. Immune weakness can originate from microbiome disruptors, particularly mold exposure and environmental chemical exposure. Such conditions make coexist with vector-borne diseases. Clinical experience and therapeutics trial are needed to understand as what might be the major player in symptom presentation. A vicious cycle may follow. More emphasis need to be placed on understanding lubricant mucus layer and ecology of fungal kingdom. That’s the take home message. So I’m ready for any questions if you have.

Dr. Weitz:                            Okay. So one of the questions is: what’s the best way to repair the mucus layer?

Dr. Rahbar:                         Well, I mean, one of the first thing we do is we understand if there’s bacterial or fungal scenario, we need to identify that. I don’t always start to mobilize toxins, because if you bring them into the gut and the gut is dysbiotic, you may actually make the dysbiosis worse. If I feel there’s a fungal elements, I usually use antifungals. Then, you need to think about what does the mucus layer need to repair itself. Now, there are some elements that I use routinely is glutamine, for sure, and then there are other amino acids are usually given, array of all amino acids. But again, some of the main ones that are part of glycoprotein, like thionine, threonine, serine, and glutamine. You can find these in a product, for example, such as the MegaMucosa from the Microbiome Lab, I think, it has some of those elements.

Most of the time, what concerns me with these blended products is the excipients that they put in their colors, sugars, stuff that they put. I don’t personally like those things, so when I see those things, then I may start to use the elements individually as opposed to using it as a blended. The more blended the stuff you use, more chance patients may have a reaction and it would be hard to know what’s going on. But amino acid replacement, including glutamine. Omega-3s are very important. Omega-3 actually helps to promote the growth of Akkermansia, which as we said, is helps keeping a healthy mucus layer to the best of our understanding. And I use a variety of high quality multivitamins, including the Bs to make sure that those elements are there.

And if the patient is going on a carbohydrate-limited diet, I use short-chain fatty acids and butyrate as a replacement, so to make sure the enterocytes have adequate amount of energy available to them. I also include zinc carnosine. And then, we go from this replacement phase into attack phase. And if necessary, I add some microbiome disruptors, such as [inaudible 00:48:21] or sometimes lauric acid, Lauricidin, monolaurin, as a measure to help to disrupt the microbiome. NAC is another one I use, but again, sometimes I use a combination, sometimes I use one at a time to make sure the patient can tolerate it, and we go from there.

Dr. Weitz:                            I think one of the issues with fungal overgrowth, Candida, et cetera, is the difficulty in having a definitive test for it. For example, there’s no breath test for fungal overgrowth. What do you find is the best way to test for the presence of fungus?

Dr. Rahbar:                         Well, the honest answer is that I first use my clinical judgment, and in clinical judgment, we look for potential risk factors that allow that. I do remember one case that I told the patient, “Look, I really believe you have a fungal clinical picture, you have taken antibiotics, you have been under stress, your cortisol is high, and you were on birth control pills,” but all the tests I did, came back negative. And I just said, “Please, I want you to take a leap of faith and just do the antifungal treatment.  I’m going to put you on this regimen with nystatin and a dietary change,” and she dramatically improved.  So most of the time, I think clinical judgment is important, but to support it and maybe put the patient’s mind at ease, I use antifungal antibodies. Vibrant has a nice expanded panel of antifungal antibodies, and is more than what you can get from a Quest Lab because they only do Candida albicans antibodies.

The other one is that I heavily rely on is urine organic acids, the microbial organic acids, but we have numerous cases where the tests or organic acid was normal, and I could see fungal growth in the stool. One example was today, a man with history of inflammatory bowel disease, 2 plus Candida glabrata, which is a relatively aggressive fungi in the stool showing up, but urine organic acid was negative. But the antibody test was also positive, so there was still supportive evidence that this patient might be suffering from a clinical picture of yeast, if you will.

Dr. Weitz:                            When it comes to treatment for fungus, number one, when do you use nystatin versus other antifungals? And then, how long do you think it’s safe to treat with nystatin?

Dr. Rahbar:                         Well, I didn’t know the answer until we kind of evolved into this, and I don’t think you’re going to find literature on this one, but I’ve talked to other colleagues as well. We have patients now on antifungal regimen sometimes over a year. If I ask them to come off, they won’t. Okay. I mean, they know that they’re going to have trouble. Now why the immune system has a problem? My theory is the chemicals, especially exposure to mold, toxins. Especially, if somebody has the HLA profile that Dr. Shoemaker had described that they’re multi-susceptible or more susceptible, they hold onto this. It is almost a hundred percent guaranteed I’m going to see this pattern if somebody has persistent scenario, that genetically they’re susceptible to the mold and they may have a slower mechanism in getting rid of the toxins there.  So going back, I think, as for how long? We have used it long. I just monitored the liver, the kidney function and I just look that I have the patients follow up with me periodically to make sure we’re not making a microbiome switch going to bacterial, to fungi, and the liver and kidney functions and blood counts are normal. I mean, in our patient practice, I can tell you, I have not seen a single case of liver enzymes going up with Diflucan.

Now having said that, it may be, I may be too naive or too inexperienced that have not seen it. Maybe, time eventually will show a case. Have not seen any problem with long-term use of nystatin. In one case, the creatinine went up a little bit, but I was not sure if that was nystatin or not. Anyhow, we stopped it and we changed it to something else. If you do use long-term use of these medications, it’s obviously appropriate to monitor the labs. I know one thing for sure, that dealing with the fungus, this is not a strep throat to take a 10-day course of penicillin. And this creature, it has its own behavior. It is capable of penetrating its arms into the mucosa. And that hyphae pattern, it may take it months to years to [inaudible 00:53:42] to clear.

Dr. Weitz:                            What are the most effective natural products for antifungal?

Dr. Rahbar:                         I’m not going to give you one single item, because there’s no research to use say, “Oh, this versus the other one.” You have garlic, from [inaudible 00:54:00] from oil of oregano, from pau d’arco, all these things have been studied. Please bear in mind that when you use an herb, which in my experience, the herbs are not as powerful in dealing with the fungus clinical picture, especially if it’s an advanced form. now, I may be seeing a skewed population in my practice, and many people may just get away by an herbal product. In our patient population, I cannot completely rely on herbs as an antifungal. However, I use them maybe more so for maintenance, maybe an adjunct.

But I want to give you an example of a quick patient where a patient came and I saw evidence of fungi and SIBO, both of them. I said, “Look, I’m not sure which one to treat. Shall I treat your fungus first? Shall I treat…?” And she said, “Well, can you just give something to cover both?” So I came up with a five-herb program. I used five different herbs, okay? Herbal products from Biotech Research, from ADP, Dysbiocide, and [inaudible 00:55:21] and this other one… Anyhow, five of them we put together. And within three days, patients said, “Look, I am more bloated on five different herbal products.” I speculated that the herbs basically lowered the bacterial component more preferentially than the fungal component. I immediately stopped the herbs, put the patient on nystatin alone. Within a week, the bloating and discomfort subsided. So when you use herbs, the herbs are good, but they’re not as specific just for fungi. They’re also for bacteria. And case by case may vary because we don’t know to what preference they may actually suppress that particular kingdom, if you will. Are you with me on this one? It’s very important to understand because-

Dr. Weitz:                            Yeah.

Dr. Rahbar:                         … you can create a microbiome switch with this. And this type of language comes from having encountered patients with this scenario we had to deal with, but it’s not something one would forget.

Dr. Weitz:                            Somebody asked a question about colon hydrotherapy.

Dr. Rahbar:                         And what about it?

Dr. Weitz:                            Is that ever something you might use, say with a patient with chronic constipation or…?

Dr. Rahbar:                         I do. If somebody has constipated. We have [inaudible 00:56:50] recommended coffee enemas and colon hydrotherapy, especially if they’re constipated. It may help to remove some of the thick microbiome and fungal elements, but it’s not going to be adequate because you’re not completely addressing the small bowel. And I usually tell the patients, “If you do it, how do you feel?” People say, “I feel good. I feel refreshed. I feel energized.” I say, “Okay, do it. If it didn’t make any difference, please don’t do it.”

Dr. Weitz:                            So what are the particular dietary factors that you think are most beneficial for patients with fungal problems? Are you putting them on low sugar carb approach, Like an anti-candida diet? Are you avoiding things like mushrooms and other sources of fungus, peanuts, et cetera?

Dr. Rahbar:                         Well, I definitely do not recommend peanuts, especially you get the [inaudible 00:57:55] you don’t know what they crushed in there. Okay. Okay. Look, I’m not the one who does the dietary counseling directly, which I give the principles, but people say, “Why shall I follow an antifungal diet?” I said, “There are three reasons to follow an antifungal diet.” You don’t want to take the sugary stuff either with this juice or fruits or stuff like cookies or chocolate or ice cream that directly feeds the fungus. The second principle is that you want to make sure that the product that you eat doesn’t have ochratoxin or other mycotoxins in it, because if you swallow it, you’re going to add to the problem. And the third scenario is you want to make sure that, that particular product is not actually a fermented product from yeast, such as kimchi or sauerkraut or some of these things that are really more fungal fermented.

We don’t really know what is going to do. I am not in favor completely in using S. boulardii. In this scenario, you got to be very careful. If the patient has immune suppression, S. boulardii can sometimes take over. This is part of their actually… their precaution when you look at the… Like the use of this in patients with chemotherapy, patients who have a line, the beneficial bug can become sometimes a pathogen. Now having said that, I’ve had many patients who say, “Look, I took S. boulardii and I feel my fungal clinical picture is behaving better with me.” I don’t argue with them. If you tried it and it was beneficial, but if you try it, make sure the patient is not immune compromised because it could go other way for you.

Dr. Weitz:                            Now, medicinal mushrooms are commonly used in many functional medicine practices to strengthen immune system, for brain function. Should they be avoided while treating a patient for fungal overgrowth?

Dr. Rahbar:                         Well, are you using a crushed mushroom or you’re using an extract of mushroom? I don’t have a problem with an extract. Okay.

Dr. Weitz:                            Okay.

Dr. Rahbar:                         I don’t have a problem. Like, there are products that we use for that [inaudible 01:00:08] T-cell. They support the T-cell function. And if somebody actually has a Th2 dominance, it may be beneficial to use something like that, but to get mushroom and crush them and eat them that way is a little tricky. You have to look at the clinical outcome. If they said, [inaudible 01:00:29] I got to say, “Look, you got to try and see what happens. It’s not something I’m going to rush into recommending somebody.”

Dr. Weitz:                            What are some of the most common symptoms that alert you to the idea that they might be having a fungal problem?

Dr. Rahbar:                         Generally speaking, first of all, we see it more in female gender. And I just think that… I always say to my patient, “It looks like fungus loves women and they loves estrogen.” And so, anytime there’s hormone replacement, particularly birth control, stress, high cortisol, it give me clues that this could be the problem. Also ask your patients if they have had athlete’s foot or toenail fungus, or they have dandruff, these may be almost tell tales that there may be a fungal clinical picture going on in that scenario.

Dr. Weitz:                            Do you worry about resistance using antifungals for so long and…?

Dr. Rahbar:                         I do. I do. That’s why I just gave you the… My first case was an example of that. We don’t even have a way to check for that. I cannot see what is their sensitive tool, what is their… You got to use a lot of clinical judgment in this. That case probably would’ve puzzled many people with bloating, because I personally had never seen it before. Most people would say “My stomach is flat.” So this was quite unusual. I knew that we were dealing with a major fungal scenario as soon as I heard that.

Dr. Weitz:                            Have you ever had your patients get fecal microbial transplant? Is that a treatment option for some of these cases?

Dr. Rahbar:                         Patients have done it on their own, overall with some good success. We obviously need more data on that. I actually made a trip to Taymount Clinic in UK, Dr. Erdman. We went to city of Letchworth next to close to London. And we looked at how they do. They use actually aggressive colon hydrotherapy to clean up the colon before they do FMT. I think part of it might be because they’re trying to clear some of the thick biofilm that might be there. I think, the FMT has some role. We tried to actually see if we create a protocol, but when we got to the IRB, we got stuck with them. They couldn’t understand what we were doing. And then, right after that, COVID pandemic came in March 2020 and $20,000 worth of trying to do IRB work got wasted.

Dr. Weitz:                            Oh, bummer. Is there an issue using antifungals with patients with Crohn’s or ulcerative colitis?

Dr. Rahbar:                         I don’t know if there’s an issue, you need to monitor, but certainly, in my practice, if I see evidence of that, I use it. I mean, if you look at cases of pouchitis… Many cases of pouchitis, I may treat not only with mesalamine to block hydrogen sulfide, I sometimes use Xifaxan also in addition. But if I see any fungal scenarios, I add nystatin, preferably a compounded version that is pure to that. They may be resistant, but we’ll see. Today… Indeed, as we speak today, we did see one patient who came with history of Crohn’s and history of pouchitis after colon was removed and basically an ileal pouch was made. But the question was that: why there was pouchitis? And pouch inflammation was driven by what? Now, obviously traditional medical model uses TNF-alpha blockers and IL-23 blockers, Stelara, to control this type of inflammation, but I don’t believe it really addresses what drives the fire.

When we looked at these patients, most of these patients have exposure to mold or environmental toxins that has led to fungal overgrowth, and it becomes a vicious cycle. You don’t know what came first. However, to recover is conceivable to me to use antifungals in this scenario. Most of the time, I use nystatin, and so far, I have not had any problem with that. However, you need to use clinical judgment and see if that would be appropriate for your patient.

Dr. Weitz:                            Now, we know Candida can colonize all throughout the GI track and in different parts of the body and other mucus membranes. Do you ever have to treat the nose or other areas?

Dr. Rahbar:                         I mean, for patients who have nose problems or congestion, I usually get a culture and see if it actually show fungus in that area. Many of them, they do have MRCoNs. I personally don’t use the antibiotic regimen for the MRCoNs. I try to use nasal irrigation and sometimes silver, maybe sometimes xylitol to make it uncomfortable for this bacteria or the biofilm to stay there. To get rid of the MRCoNs is very difficult, and if you introduce antibiotics and if the patient has a gut problem with fungus, any of that stuff gets into the gut, you can actually make the fungal dysbiosis worse. So I’m a little bit more conservative when it comes to nose treatments.

Dr. Weitz:                            Do patients who have fungal problems in the gut, do they also tend to have fungus in their nails?

Dr. Rahbar:                         It’s a common question for me to ask. It’s not a common occurrence, but it’s a common question. I would say probably about one or two out of 10 patients will tell you they have toenail fungus. The fascinating part is this that you will not believe it, several of our patients where we only treated them with nystatin, which is nonabsorbable, they reported to me that the toenail fungus was completely clear. I give them nothing but [inaudible 01:07:20]. So it is obvious that when you manage the immune system and you allow it to recover, it takes care of itself.

Dr. Weitz:                            Given the fact that a lot of these patients have compromised immune systems. Besides treating the fungus, what are the most effective ways to treat the immune system?

Dr. Rahbar:                         That’s a broad question. And I’m not sure if I can give you a quick answer to that. Okay. I mean-

Dr. Weitz:                            Well, let’s say you get a stool test and they have a low secretory IgA. What-

Dr. Rahbar:                         That’s not… I mean, we’re not talking about gamma globulin deficiency and other things. I mean, if I see…

Dr. Weitz:                            Right.

Dr. Rahbar:                         Okay. Many of your T-cell… If you have a T-cell function that is low, like a CD57, one of your T-markers are low, you may have used nutritional replacement. Some of this could be malnutrition. And so, by providing the nutrient replacements, many times you can actually support the immune system. If the immunoglobulin is low, then we just use either colostrum, or better the serum-derived bovine immunoglobulin, which is a favorite one. It is part of one of the proteins that we use for the leaky gut, and I think somebody asked that earlier, what you do for that, this is also one of the things we add to it.

Dr. Weitz:                            You’re talking about [inaudible 01:08:47]

Dr. Rahbar:                         Something like that.

Dr. Weitz:                            Something like that. Yeah. Okay. Any other questions? Do you like BPC-157? Do you use peptides?

Dr. Rahbar:                         I do. We frequently use the BPC-157 as part of our leaky gut protocols.

Dr. Weitz:                            And what dosage do you use for that?

Dr. Rahbar:                         Most common dose is the 500 mcg once a day, because it’s also a little bit pricey. Occasionally, at first, especially if somebody has, let’s say, a lot of hives and rashes, I make for maybe two, three months [inaudible 01:09:25] two a day, like one twice a day.

Dr. Weitz:                            Oh. And then, in terms of the compounded nystatin, what is the dosage you’re typically using?

Dr. Rahbar:                         The maximum dose is usually 3 million units a day. In one case, the patient requested for me to go higher because she tried it on her own and said, “Look, I did better on 4 million units.” It was actually a patient with celiac disease, and I showed her the article that how the fungus can interact and she was having symptoms, so we went up to four, but unfortunately she was living in a moldy home and she couldn’t get out. And that I believe continued to allow persistence of a fungal clinical scenario, because the mycotoxins are immune suppressants, like the mycophenolic acid, that’s like CellCept that they use in chemotherapy and in transplant medicine. So many of these are immune suppressants and they allow growth of micellar form of the fungi. So 4 million, I have one case we went. Most of the time three, and I usually start very slow maybe at 500,000 once a day and just ask them to add maybe by one pill every five days to get to the maximum dose.

Dr. Weitz:                            Great. Awesome. Dr. Rahbar, thank you so much for an excellent, excellent presentation on a fascinating complex topic. And for those who want to find out… who want to get a hold of you, to contact you, where should they go?

Dr. Rahbar:                         Well, our website is probably the best place to refer to the laintegrativegi.com and our contact information and email is on the website.

Dr. Weitz:                            Great. Excellent. And thank you everybody for joining us and we’ll see you next month.

Dr. Rahbar:                         Thank you. Have a good night.



Dr. Weitz:                            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.


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