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Dr. Kathleen O’Neil-Smith discusses The Elemental Diet in IBS and IBD with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on September 22, 2022.

[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

6:40  SIBO, Small Intestinal Bacterial Overgrowth, is often related to immune dysfunction, similar to Lyme disease.  There is a lack of consensus about what SIBO is and it changes.  Patients are often bloated and SIBO is often related to malabsorption syndromes 

11:45  While our DNA is 99.9% identical with the person next to us, but our microbiome may only be 10% similar.  Our microbiome is inherited from our mother through birth, but it is extremely dynamic and changes within each individual over time.  There is an important bidirectional connection between the gut and the brain.

Dr. Kathleen O’Neil-Smith is a magna cum laude graduate of the Boston University School of Medicine.  She did a fellowship in Anti-Aging and Regenerative Medicine and she has an extensive background in nutrition, applied physiology, and sports medicine.  She has been on the faculty at Tufts University School of Medicine and Boston University School of Medicine. Dr. O’Neil-Smith is an international thought leader in the clinical use of peptide therapy.  Her office in Newton, Massachusetts is Treat Wellness and her office phone is  617-630-2882.  Dr. O’Neil-Smith specializes in the primary prevention of illness and disease, as well as the optimization of overall health and wellness.

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. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.

Hello, everybody. Welcome to the Functional Medicine Discussion Group of Santa Monica. Tonight, we’re going to speak about the use of the elemental diet for IBS, SIBO, and inflammatory bowel disease with Dr. Kathleen O’Neil. I’m Dr. Ben Weitz, and I’ll be making some introductory remarks before introducing our sponsor, Integrative Therapeutics. Then I’ll introduce the speaker. I encourage each of you to participate and ask questions by typing your question in the chat box. Then I’ll either call on you or ask Dr. O’Neil-Smith your question when it’s appropriate.  Thanks for joining the Functional Medicine Discussion Group monthly meeting. I hope you consider attending some of our future events. I look forward to meeting in person once the Santa Monica library goes back to their normal hours. Our next meeting is October 27th, and it will be on Males and Females have different immune systems, and why it matters with Dr. Felice Gersh.

Dr. O’Neil-Smith:                Oh, she’s amazing.

Dr. Weitz:                            We’ve had her speak several times.  I even figured out November 17th.  Then if you’re not aware, we have a closed Facebook page of Functional Medicine Discussion Group of Santa Monica that you should join, so we can continue the conversation when this evening is over.  If anybody’s listening to this recording afterwards, I just want to mention that this group is just for practitioners.  I’m recording the event.  I’ll include it in my weekly Rational Wellness Podcast, which you can subscribe to on Apple Podcast, Spotify, or YouTube.  If you listen to the podcast, Rational Wellness, please give me a ratings and review on Apple Podcast.  I’m pleased that the sponsor for this evening is Integrative Therapeutics, and we have Steve Snyder on the line to tell us a little bit about a few of their products. Steve.

Steve Snyder:                    Hello. I don’t want to take too much time. Dr. O’Neil-Smith is going to do most of the stuff for me tonight, but there are some pretty exciting new changes to the Elemental Diet dextrose-free version that I want to just let people know about. We have two. There’s the original formula that uses dextrose as the carbohydrate source, and then the second module is the dextrose-free formula that used a maltodextrin. We had not a whole lot, but some feedback on the maltodextrin dextrose-free version that we took into account, and we made some changes to.

We’ve changed the actual source of the maltodextrin, so we were using a different raw material supplier. Dr. Weitz was asking me a different source. Does that mean Vietnam instead of China or corn instead of malt or whatever?  None of that.  It just means we’re using a different raw material supplier.  We feel like they make a higher quality product, and we feel like it’s going to lead to… So far, it’s bearing out that it leads to a more well-tolerated formula and a better patient experience. While we were doing that, we reduced the total carbohydrates from 23 grams to 15 grams per scoop, and each scoop is 150 calories.  We increased the protein content from seven and a half grams to 10 grams per scoop, and we increased the fat content from four grams to six grams per scoop. None of this has changed the hypoallergenicity, if that’s a word, of the formula. It’s a little more dense. The scoops are going to be a little bit smaller, and it’s not going to be anywhere near as sweet. It’s actually a little more citrusy. Some people have said tart, but the higher amino acid content is where you get that citrus flavor from. We think, so far, people who’ve had both are like, “Don’t send me that old stuff anymore.  That’s a pretty good feedback on that. We have sample packets of it. So anybody who’s interested in trying it just to see what the patients are in for, we’re happy to provide those. We also have samples of the original formula, and lots of resources to go with it for not just the SIBO protocols, but everything else. That’s it on that. Let me know if you have any questions.

Dr. Weitz:                        Thanks, Steve. Dr. Kathleen O’Neil-Smith is a magna cum laude, graduate of the Boston University School of Medicine. She did a fellowship in anti-aging and regenerative medicine, and she has an extensive background in nutrition, applied physiology, functional medicine, and sports medicine. She’s been on faculty at Tufts University School of Medicine and Boston University School of Medicine. For a decade, she competed as a member and later as coach of the US Women’s National Rowing Team. Kathleen, you have the floor.

Dr. O’Neil-Smith:             Oh, great. Thank you. Steve, I wonder why you don’t just get rid of the old version. That’s the question of the elemental diet, but you could answer that maybe later. Let me share my screen. Thank you all for having me. It’s early for y’all. I don’t even know if the sun has set, but we have been long set in Boston, but I wish I were there with you.  Sadly, I’m not.  But at any rate, let’s start.  Can you see my screen?  Can you see the slides?

Dr. Weitz:                        Yep.

Dr. O’Neil-Smith:             SIBO, I think it’s very enigmatic.  I think SIBO is part and parcel of many things.  I think there’s just such an interconnectedness in the body, and we need to be thinking about that and thinking bigger than SIBO.  For me, SIBO is more like a Lyme where when we’re talking about chronic Lyme, we might want to think about the immune system as the problem.  We’re talking about long COVID, it’s the immune system that’s the problem. When we’re talking about SIBO, there’s likely another problem as well. I think that in terms of SIBO, why talk about it even?  Doctors don’t know that much about it. We don’t really understand it, but that’s what’s surprising because the microbiome is still being elucidated.  It’s funny, but it feels to me like the microbiome is a has been.  Meaning it’s been around for a long time, and we still don’t know that much.  I’ve already moved on to the fascia, which is, again, just as complex a system and just as omnipresent. You know that as a chiropractor, Ben.  So, there’s a lack of consensus of even what SIBO is, and everybody has their new name on it, and it changes regularly.  I follow Allison Siebecker, et cetera, and just keep up on that, but there’s really no easy therapeutic algorithm, thank goodness, because I’m not about algorithms, or easy treatment plan because everybody responds to different things.  You’re all familiar with that pain or with the woman who looks pregnant with a SIBO belly. I saw one yesterday.  I saw a woman yesterday who she said, “I have all this fat.”  I said, “Can you just pull up your shirt, and let me have a look, and felt it?”  But it was actually a very bloated belly, and she thought it was fat, so people don’t really know.

We know that historically SIBO has been related to malabsorption syndromes, whether it’s post-surgical blind loop or post-gastric bypass. I had a gentleman today who had a sleeve put in, and said it was the best thing he ever did, because he lost 75 pounds. The interesting thing about what he said that I just love because we take for granted that people really know what we’re talking about… Probably in California, they do more than in Boston. But at any rate, he said he’s from New York. He’s in a country club. He’s a real big wheeler dealer, high net worth person.  He said he was going through the buffet line at the country club recently post his gastric bypass and some…  He has a small plate, and somebody behind him, a woman, had a big plate.  He said to her, “How are you going to eat all that?  How are you pos…” She said, “This was you two years ago, dude.  What are you talking about?”  He said, “No, that couldn’t have been me.” He thought he always ate from a plate. It’s so interesting. I only eat from solid plates.  I don’t eat from a big nine-inch, 12-inch plate, right?  But people don’t… They’re not aware.  My point in that is that people really aren’t aware of their behavior, and helping them become aware is really helpful.

But, SIBO today, I mean, obesity is the number one problem. I talked about that at A4M in the immune system module this weekend in Boston.  Obesity’s a really, really big deal, and we’ve got to address it.  Obesity is probably an infectious disease problem in addition, but not alone.  It’s as complicated as SIBO.  NASH, Nonalcoholic Steatohepatitis, which is fatty liver, systemic sclerosis, you’re bound to have SIBO if you have some of these other issues, including gastroparesis, which is functional from diabetes type two.  Irritable bowel gives you gastroparesis, Crohn’s and Celiac, any of these things.  Not many people have celiac. They might have a non-glutenin celiac-like syndrome, but not many people have celiac.  They’re very sick if they do, and they probably have a GI in their pocket.  Understanding the connection between SIBO and other conditions is really important if you’re going to come up with a treatment.  So probably most of you have heard of Alessio Fasano. I hope so.  He’s here in Boston.  He runs a mucosal immunity center at the Mass General.  But most importantly, he runs a massive lab.  He doesn’t really treat mucosal immunity.  He doesn’t see clin… He doesn’t really see many patients.  I’ve referred patients to him, but he doesn’t know the things that you know and that I know. So, you would do a better job. But obviously, all diseases begin in the gut. We really have to look at the gut, because the gut is our interface with the outside world, and the gut is where we determine whether we’re going to let some… It’s the moat to the castle. Is something going to get in? Is something going to knock it in, and how are we going to keep it out, and what’s going to happen if it does get in, but it really doesn’t belong inside of us?  When things are entering, whether they’re microbes or whether they’re antigens, which often are proteins, or whether they’re foods that we don’t tolerate, we really have to think about what’s going to happen with the immune system. It is going to challenge the immune system.  We have that to think about.  But in addition, we have to think about the small molecules that are the metabolites of the microbes that live in and on us, so it’s pretty complicated in terms of treating the gut.

You know that there’s an extraordinary variation in the microbes that live on and in each of us.  Our human DNA, we’re almost 100%, 99.9%, the same as the person next to you or all of us on this call. But in terms of the gut microbiome, we might only share 10% with any one of us on this call. That’s pretty important. That gives you a sense of the complexity of the microbiome, and that’s why it’s taking so long in order to understand the microbiome. The microbiome is inherited from the mother primarily through birth. It’s extremely dynamic. I mean, the dynamic nature of the microbiome, the dynamic nature of fascia, the dynamic nature of these complex systems that are connecting the dots between various parts of our body is really important.  Dynamic means it’s always changing and hard to understand. It’s complex. There are changes within an individual over a period of time. You can change the biome of your pharynx. You can change the biome of your mouth. You can change the biome of your vagina over time. There’s a lot of changes from one individual to the next individual. The bidirectional communication that happens between the gut and the microbiota, you can see in the microbiota in the lower right, and the brain, which is down on the bottom where it says clinical outcome, we know that these are involved in the development of not only gastrointestinal disorders.

The microbiome, even though it’s in the gut, it can cause disorders of the gastrointestinal tract. It can cause disorders of the central nervous tract. I think of the gut really as the primary brain, because it has to do so much work to protect the central nervous system. But autism, Parkinson’s, and all of these diseases that we label as being central nervous system are all related to the microbiome. We know that when someone has a brain injury, within minutes, you can see a leaky gut. If you have a gut injury within minutes, you might see a leaky brain, because there’s constant communication, very dynamic and very quick and rapid.

In addition, as we mentioned, those small molecule metabolites that are created by the microbiome that lives within you, and that interact with the microbiome, the short chain fatty acids, they all modulate the immune system, and they also modulate the metabolism, so it’s pretty complex. So, the question we have to ask is, “Is SIBO a disease entity, or is SIBO a consequence of some other disorder?” I would say that there’s usually other things that are involved. I love this picture. I show it to my patients all the time in the screen in my office because I say, “What do you think this is?”  They think it’s the mouth. This is actually the single epithelial layer of the GI tract. I think it’s pretty key, because people understand the carries of the mouth, and they understand how they can get breakdown in their teeth and in their gums. Well, they can understand the single epithelial layer of the GI tract as well. When you think about it, and you look at the outside on the upper right, and you think about antigens, whether it’s gluten or any other antigen, it could be whey protein. It could be any part of a food. There’s multiple different antigens within one type of food.

Wheat has multiple antigens, which we know. But all of those, when they cross through the barrier, particularly if it’s leaky as you see on the right side of the screen, they are going to activate the immune system. Once the immune system is activated through the antigen presenting cells, there’s a responsibility of the immune system to determine what’s self and what’s non-self, but regardless, it’s now going to flow throughout the entire body. It’s going to flow to the central nervous system. It’s going to flow to the joints. It’s going to flow through the liver.  It’s going to involve even the GI tract. What’s outside the GI tract, and the lumen is not really the GI tract, it’s just passing by, so irritable bowel and inflammatory bowel disorder is the GI tract that gets affected by the immune system based on non-self antigens, whether they’re food proteins and food antigens or microorganisms or byproducts small molecules of those microorganisms that basically cross through the lamina propria, which is the… It’s like the gum of the GI tract.

Here, we have study that Dr. Fasano is working on. It’s an international study, multi-clinic study, basically where they’re looking at autism disorder and GI.  Basically, what they’re finding is that… Hang on. It’s open label, and it’s multi centered. They’re looking at microbiota transfer therapy on the composition of the microbiome of the gut or the microbiota. Microbiome is genome. I’m used to saying that, but it’s really microbiota. They’re seeing what happens with the GI and the autism spectrum disorder symptoms in children who are diagnosed with autism spectrum disorder. In doing this MTT therapy, the microbiota transfer therapy, they have shown that there’s been about an 80% reduction in the GI symptoms at the end of the treatment, including significant improvements in symptoms of constipation, diarrhea, indigestion, abdominal pain. That’s a pretty big deal.  These improvements have persisted after the treatment stopped for up to eight weeks. Specifically, what they found… I think that this is neither here nor there, but the overall bacterial diversity and the abundance of certain types of microbiota, prevotella, just full of vibrio and other taxa increased with the MTT, and these changes persisted. It could be other things as well, because again, I think that the microbiota are very complex. Basically, this extended duration treatment protocol appears to be a promising approach because we don’t have many other things that can alter the gut microbiome and virome, and help to improve the symptoms in children with ASD, pretty important.

Also, in anorexia, there is evidence that shows a causal role of an altered microbiome. As we know, the psychiatric diseases, especially anxiety and depression, 100%, but also in anorexia, because not only these microbiota can influence neurotransmitters in the production of neurochemicals in the gut, but it can also influence altered energy in how you’re using it, get energy from food. Maybe you get a lot of energy from food, and you store it, or maybe you use the energy right away. You know how different people’s metabolisms work, but it’s certainly related to the microbiota.

Hormonal changes are influenced bidirectionally with the microbiota, increased gut permeability, et cetera. We know that there is a direct influence on brain and behavior, including anorexia, sorry about that, in patients. I just think of the gut. I don’t like to get into diagnoses. Even though I’m physician, I don’t like the DSM. I don’t like the ICD-9 or 10 or wherever we are. I just think of physiology. I think of pathophysiology. I think of a barren physiology. What is going wrong? What is there that doesn’t belong there, and how bad is it?

I hope that when I find something, or when the patient comes in with symptoms, and we begin to look that we find something that’s not that bad. That’s earlier in the progression of a problem, but not significant. I just think of problems with the gut. I pretty much assume that there are some dysbiosis going on, and which is basically just a disturbance in the microbiome. We can call it SIBO, LIBO, LIFO, whatever we want. Small intestinal microbial dysbiosis, I don’t really care for me. For me, it’s like we don’t know what the ideal microbiome is. However, we know that the lactobacillus species and the bifidobacter are very important. So we know a few things, but not everything.

We do know, as we just talked about, that the human gut microbiota influences, I would say, all physiological processes. The fascia influences all physiological processes. We’re not talking about that today, but we’ve got to be thinking there’s a lot we need to learn. The microbiota influences our risk for GI or non-GI diseases, not just SIBO, but any disease. Whether it’s type one diabetes, whether it’s systemic sclerosis, whether it’s lupus, the microbiota are involved for sure. We know that there are strong associations, although not causation at this point, between the presence of certain microbes or the absence of certain microbes and specific clinical conditions.

The microbiome or the gut, it’s one contiguous segment of tissue. We have to think about the mouth. We talk a lot about SIBO, but the mouth and the stomach are big influencers of whether or not we have SIBO, so we don’t even think about the mouth. I ask all of my patients about their gum health, their teeth health, whether they’ve had implants, and whether they floss regularly. That is the most important question if we’re even going to start with the GI tract, because we ignore that. I think oral disease is pretty important for all of the diseases that we suffer with, or all of the symptoms like SIBO that we suffer with.  We know it’s complex. We know that there are distinct microbial niches along the different segments of the GI tract. So just pausing and thinking SIBO, S-I-M-D, which is small intestinal microbial dysbiosis, it doesn’t really matter. There’s a perturbation in the microbiota. There may be a systemic disease that has caused that or that is as a result of it. But no matter what, there will always be a systemic disease connection. So we have to think of what are the other functional problems that are going on so that we can understand and fix as many upstream issues or connected issues as we can. It’s very important, and I know you know that.

So, is there an ideal microbiota? That’s a pretty tough question to answer. We’ve been trying to answer that for decades or more, maybe two decades. I know that they… In Boston, of course, the talk is that they took Tom Brady’s microbiota, and they’re trying to replicate it so that people can be like him, which I find very comical because I really don’t want to be like Tom Brady. But that said, I know that MIT definitely has a sample of his microbiome. I know that everyone’s fascinated by it, except me for sure, but because it’s complex, and really, he is not representative of any other individual. We know that from the beginning of this talk.

Microbes are much more numerous than we thought, and more important than we ever imagined. They play a role in all aspects of our health. We’re made up of 10 trillion human cells, but we’re made up of 100 trillion microbial cells. So really, we are the guest of the microbes. When we think about the ideal small intestinal microbiome, we know that each segment of the GI tract has a various its own pH. The stomach has a very low pH. It’s not the same pH in the small intestine or the esophagus. Each part has variable motility patterns, variable mucosal thickness, enzyme presence. The small intestine has a lot of enzymes.

These factors influence the type and quantities of microbes in each area. The diversity of the stomach is predominantly H.pylori. You know that H.Pylori can be pathogenic, but it’s also essential. Jeff Bland did that work demonstrating that H.pylori probably has an essential role. But obviously when it’s in abundance, when there’s a bacterial overgrowth, then it can be problematic. The small intestine has a low abundance of gram positive aerobic bacteria, very important bacteria that like oxygen. The large intestine has predominantly anaerobic bacteria that are gram negative.

Different sets of species inhabit different parts of the body where they play specialized roles, but they play essential roles in the most fundamental processes of our lives that include digestion, immune responses, immune regulation, which is really, really important. I would argue more important than digestion, but digestion is where we get the building blocks and the nutrients for repairing our body. They also play a role in behavior. Now, we have next-gen sequencing, et cetera, and we can identify these species of microbes that we share a home with.  There’s a massive 200 million or more human microbiome research project that’s helping to expand this knowledge, but it’s pretty formidable. There are many unknown links between obesity, arthritis, autism, depression, and anxiety. You can see the various parts of the skin, your genital tract, the colon, et cetera, and the different microbes that live there. You’re welcome to have and use any of my slides that you want. You can use anything that you hear from me. I’m here to teach you. Whatever you take from it, it’s yours.

Dr. Weitz:                         Of course, now, we also have the mapping of the small bowel by Dr. Pimentel and his group.

Dr. O’Neil-Smith:             Absolutely. Thank you for that. Very important. SIBO, what is SIBO? It’s really just non-specific symptoms. You have a fever. You don’t know what it’s from, because you don’t have symptoms, particularly if you have type one diabetes. I know I have type one diabetes, and I know that when my blood sugar is resistant to the insulin that I’m taking, that something’s going on. It might take two or three days to figure it out, because I may not have symptoms, then they’re nonspecifc, and then we have to figure it out, or maybe it just resolves. So these non-specific symptomatology things are pretty complex.  They’re not really as simple as we want to make them out to be. It doesn’t mean we shouldn’t try to understand them. We certainly should, but we should be thinking we should be… I like to go to 40,000 feet, 400, 4,000 feet, and to four feet as often as I can in and out, zooming in and out, zooming in and out, asking questions, taking the microscope and thinking about it, but really zooming out to have a treatment plan. SIBO can be related to the quantity of microbes. That’s one thing. It can be related to the type of microbe. It can be related to the metabolites or the small molecules that the microbes are secreting, like microbial transglutaminase.

You could have a microbe in your gut that’s making a small molecule. That’s a transglutaminase. That is not measurable by measuring your transglutaminase tissue to see if you’re reacting to gluten or to wheat or one of the antigens in the wheat. That’s pretty interesting. So, we have to think about the metabolites. That’s complex, the metabolic alterations that even occur within the normal microbiota that live within the gut. Sorry, I’m a little bit… I got to be very gentle with my fingers on making this move. It’s a very heterogeneous condition, which is not a bad thing.

I mean, it means that you probably can’t go wrong if you start treating it in any way. There can be many different mechanisms by which people get a shift or a translocation in the bugs, whether it’s from the rectum to the vagina. That’s how they said UTIs always were caused, or whether it’s from the colon back to a translocation into the ileum. There can be many different ways that this happen, or you can just feed these bugs, and they can overgrow, right? It’s important to just be thinking about all of the possibilities. When something’s heterogeneous, it’s not easy to diagnose.

I know that when I look at a low B12, I have to start thinking about the stomach and the small intestine. When I see a patient who has a B12 of 300 in their serum, or a high MMA or a high MCV, methylmalonic acid or MCV in their CBC, then I have to be thinking something’s going on in the gut. There’s either a bacterial problem. There’s an intrinsic factor problem. There’s a hypochlorhydria problem, but there also could be a SIBO problem. So when we see nutrient deficiencies, any of them, iron, I’m sure iron has to do something with the microbiota, D3, B1, B3, but they also have to do with other organ systems.

So it’s not just the microbiome, the microbiota, it’s also to do with other organ systems as well that may be influencing the deficiency. You could do a small intestinal aspirate culture. I’ve had people suggest to do that for my patients, but that’s a little invasive. I don’t think it’s necessary just to enumerate the bacteria, because then what do you do about it, right? Breath testing is basically fermentation activity. That’s why we use glucose and lactulose for our breath testing to see what’s fermented. Obviously, we don’t want to…

We know even our bread when we grow… When we make bread, we put yeast, and we add sugar, and a good environment of moisture and warmth, and the yeast is going to go gangbusters, and it’s going to ferment. So, molecular assessment, I think, is great of the GI microbial ecology. I use lactate levels reg regularly anyway, so there are a lot of diagnostic challenges, and there are a lot of limitations, obviously, in an aspirate, and also in a breath test. The biggest factor influencing how you look at the microbiota is what? Orocecal transit time, number one.

When we do these testing, there’s nothing to account for the differences in orocecal transit time, and that’s pretty important. So, the question that we have to think about is we don’t want to misinterpret a breath test, and it’s pretty easy to misinterpret it unless you have somebody skilled like the gentleman that we know that run the breath testing. I actually am a medical director of a SIBO breath testing company. I’m not pushing any products because they’re all related. But when they see thousands and thousands of them over years, they have a better sense of what’s going on, particularly if they’re able to talk to the clinician, and understand the symptomatology.

I don’t have experience with thousands of breath tests like the owner of the company. Gary does, but I have small exempt, but he’s taught me a lot. But the question we have to ask is, “Should breath test also be combined with some other means of diagnosis, estimating what’s going on with the fermentation, and where is it happening, et cetera?” Here is a typical SIBO test result, and you can see this is a positive test result. Here is what you get when you look at the transit time from the beginning of the GI tract through the GI tract over 180 minutes, but that doesn’t really account for the pace with some.

Some people may digest their food in three days, and some people may digest their food very rapidly in three minutes. You’ve got to be thinking about those aspects when you’re thinking about what’s going on with the bloated, distended abdomen of the “SIBO patient.” The other problem is that when you have methane gas, and that’s what you predominantly might diagnose, you’ve got to be cautious. Because if you have a lot of excess methane gas, you may have hydrogen gas as well, but you might not see that. Depending upon where you think the problem is, if you think it’s in the proximal GI tract like the proximal small intestine, then glucose is a better substrate.

Getting people to follow the protocol is very difficult. If you use lactolose, and you’ve got a really rapid transit time, you may have an early rise in hydrogen gas, and then you’ll have a false positive, so you’ve got to be thinking about these things when you’re using this testing. You guys all know Pimentel [inaudible 00:33:15]. Breath testing, no matter what, it is useful. It is inexpensive. It is simple. It is safe. I mean, so it’s not a bad diagnostic test in the evaluation of these common GI problems. There is the new test that you can do at home that Allison was talking about recently. I forget the name of it, but that’s another option. It’s all about-

Dr. Weitz:                        You mean the trio-smart breath test?

Dr. O’Neil-Smith:             Yeah.

Dr. Weitz:                        Also tests hydrogen sulfide.

Dr. O’Neil-Smith:             Exactly. Exactly. We just talked about that. You can… There’s many ways of doing it, but regardless, for me, I can assume if I see the bloating like I saw in the patient I had yesterday, that there’s something going on there. We can look at any kind of stool or SIBO testing that we want, but we also have to look at where it’s happening in the GI test. When we’re doing breath testing, we just need to recognize that it’s evidence of gas production fermentation of undigested carbs. We know how difficult it is with the FODMAPs, et cetera, and these other diets, so maldigestion which is an enzymatic problem, poor sampling technique.  Did the patient follow the testing, dietary restriction methods, et cetera? That’s important to be thinking about. You all probably know about the Rome versus the North American consensus in terms of SIBO and the diagnosis. There’s no reliable gold standard, but everyone can agree that glucose breath testing and lactulose breath testing are the least invasive way to look for a diagnosis of SIBO or what’s the cause of the symptomatology. You all know about the molecular assessments, and they’re based on genomic and metabolomic methods.

That particular type of testing has demonstrated that all SIBO patients have an elevated strep tigurinus and sporadic overgrowth of a few types of gram-negative species, whether it’s klebsiella, haemophilus, or prevotella, but there can be a massive overgrowth or sporadic overgrowth in a variety of duodenal samplings. That’s pretty important. We know that people with… If we were to see in a pulmonary ICU with an influenza, someone who is a chronic alcoholic, significant alcoholic, we would expect to see klebsiella and haemophilus and different things in their lungs.

We have to look at our patients, and we know that when we see klebsiella and haemophilus and typical other types of e.coli and Citrobacter in the GI tract, that we know that there is definitely some problem going on, likely with digestion, likely with food and antigens, et cetera. So, we also have to think about for a diagnosis of this dysbiosis and this symptoms. What’s going on with the innate defense? You all know about hypochlorhydria and gastric HCL, bile acids. A lot of people have cholecystectomies, and there’s a big need for bile acids.

There’s a lot of webinars online about those, the different types of enzymes, whether it’s gastric, because we know. My patient today had a gastric bypass. He got rid of blood… He got rid of all of his blood sugar meds. He had type two diabetes. He got rid of all of his blood pressure meds. So, think about what that tells you about what’s going on in the mucosa of the stomach. Pretty significant hormones that we don’t even think about like cholecystokinin that we can’t really even measure somatostatin, you name it.

The gastric secretions, the pancreatic secretions, the motility, the transit time, secretory IgA. Does somebody have an IgA deficiency? If they have a high IgA level, then that is likely to be appropriate, but what happens in the mouth versus in the gut, something to really understand, and the competence of the ileocecal valve, how could you know that? You’ve got to ask them, “What’s your past medical history?” Discern the past medical history from listening to their stories and their symptoms. Have they had pancreatitis?

I worked in the morgue at the Mass General as a pathologist for a year, making diagnosis of people who die within 24 hours of admission to the hospital. I can tell you from age 15, 30, 50, 60 years of age and older, I didn’t see anybody who didn’t have diverticula. It’s pretty rampant, even though people get… I have diverticular disease. I would say in my mind, given what I saw at the Mass General, and even very young people who succumbed and died, there was a lot of diverticular in their colons. I had to run the entire colon, cut the entire colon open, flush it, wash it, spread it out, look at it, the entire GI tract. It’s pretty interesting to see how many people have particular disease.

Fistulas can be undiagnosed. I mean, people can have… A fistula could feel like a little paper cut. Someone may not know. It’s very important. PEI, it’s diet on the radio in Boston. I don’t know about there, but they’re basically advertising, “Educate your doctor about pancreatic exocrine insufficiency.” The medical community in Boston is pretty big on diagnosing pancreatic endocrine insufficiency, or maybe not because the A1C can get to the sixes before they tell you have diabetes, but exocrine insufficiency is pretty common, certainly in anyone who has pancreatic endocrine insufficiency, whether it’s type two or type one diabetes. But I would say hand in hand, anyone with type one will likely have an exocrine insufficiency as well.

Autonomic neuropathy, scleroderma or any of the autoimmune conditions, fatty liver, chronic immunodeficiency with low secretory IgA or anything like that. You’ve all seen this before. You’ve all seen this diagram. I mean, it tells you the significance of what’s going on in the lumen. There’s no space. The lumen is a space, an open space that we think of, right? Just a big tube through the body, but there’s no space in the body that doesn’t have a function. If you look at the non-specific barriers, the bacteria, the microbiota, the gastric acid, the mucus, the mucin, the defensin, a variety of enzymes, secretory IgA, the lamina propria, the…

I’m blanking on what these little… The celia, that get brushed away if you have diarrhea, et cetera, but there are so many non-specific barriers. There are so many specific immunological barriers, and then there’s that epithelial layer with those tight junctions that we’ll look at a little bit more. But I mean, we’ve got to look at every aspect of this in order to understand what’s causing dysbiosis of the GI tract. You cannot get away with not looking at every aspect if you want to be thorough, and give your patient the best, most effective treatment. There are predisposing functional diagnosis.

Migrating motor complex, I mean, in motility, if you think about the MMC and how it’s supposed to happen, it’s supposed to occur… This housekeeping process on the next slide occurs in a cyclical pattern. Mostly when we’re not eating at night, when we’re resting, and we’re doing our autophagy and our cleanup, clearing the residue, all the residue from the day of the GI tract. Have you ever asked your patients if they wake up at night and eat? I can tell you, if you ask them, you would be shocked to know how many people think that the gurgling that they feel or hear in their GI tract in the middle of the night means they need to get up and eat.

There are so many people that eat in the middle of the night. It’s amazing, but they’re not going to have a healthy MMC, because when you have food in the GI tract, and you’re attempting to digest it, you’re not going to be able to activate the MMC. It’s the phase three of motility, and it’s a secretary phase in order to move the contents of the lumen of that space, that GI space from the stomach to the duodenum, through the ilium into the colon and yada yadi. There’s a lot of gastric and pancreatic secretions that are going on, probably more than we even realize. The MMC, I don’t know anybody who doesn’t eat late at night and is still doing digestion when their MMC components and phase should be activated.

Hypochlorhydria PPIs, we know how common they are. They’re now over the counter. It’s insane. If you can just take a little PPI, and feel better, you don’t have to pay attention. You can then go and eat whatever you want, and continue to eat. But even without PPIs, hypochlorhydria is a problem in and of itself. PEI, we talked about. Even hypothyroidism is going to affect the motility of the functional gastric gastro motility, whether it’s causing some functional paresis, gastroparesis, et cetera. It’s variable day in and day out.

The MMC, we talked about the circadian rhythm. It is not regulated by one thing. It is regulated by many things. It’s extremely complex. The enteric nervous system, the autonomic nervous system, the vagus nerve, for goodness sake, whose vagus nerve is healthy? All of the GI hormones, those ones in the stomach, somatostatin, cholecystokinin, substance P, you name it, ghrelin, serotonin, pancreatic polypeptide. There is a very complex system that we don’t even talk about these type of hormones ever. We just keep talking about the same hormones over and over.

There’s a lot of variability for the same person in the migrating motor complex and its activation and between people, so it’s hard to understand. If anybody has an autoimmune disorder like lupus and progressive systemic sclerosis or scleroderma or anything like that, Crohn’s, diverticular disease, hypothyroidism, those all affect motility as well as stress. I mean, if you have elevated activation of the HPA access, you can get gastric emptying as well. I mean, reduce gastric emptying, excuse me, gastroparesis as well. The medications that people take, whether they have surgery or radiation.

I have a 50-ish-year-old man who had radiation when he was 20. Actually, he’s probably in his mid 50s now. He’s been my patient from the very first day I opened. He was radiated, so 35 years ago. He’s got so many adhesions and so much lack of function. Honestly right, now he’s gotten his kidney to his chagrin. He has a panhypopit, and his kidney is failing to function, and his gut has been failing to function. It’s not because he has primary gastric GI disease or primary kidney disease. It’s all from the radiation and the influence of the radiation all around the mouth, the neck, the thorax, et cetera.

It’s so sad, but nobody pays attention to it. He’s just like, “Nobody even… Don’t worry about it. We’ll tell you when you need to be on peritoneal dialysis, and then you’re not going to get a kidney transplant at that point.” So, we have to be thinking about these things. But I’m sure for him, these are part of the issue. Any patient who goes in and has an endoscopy, they’re going to have some form of gastritis. It may be chronic atrophic. It may be chronic inflammatory. Every single person is going to have gastritis. Guess what happens. They get put on a PPI even if they don’t have gastritis. It doesn’t matter.

Hypochlorhydria can cause some of the things that are seen on endoscopy that docs aren’t aware of. Fasting can cause hypochlorhydria, so the patients are obviously fasting when they do a lot of their testing. There’s a sevenfold increase. The first conversation to have with your patient is how often did they take a PPI? When was the last time they needed a PPI, et cetera? We’ve got to be thinking about that. Pancreatic exocrine insufficiency, EPI, PEI, however you want to say it, you can put the exocrine first or the pancreatic first.

That’s definitely related to SIBO, because if you’re not breaking down the sugar, the food with all of the different enzymatic chemicals that are secreted from the pancreas from an exocrine perspective, then you’re going to have mal-absorption, and you’re going to leave a lot of food in the space of the gut for bugs to munch on. Hypothyroid is a mal… It was shown actually in a large retrospective, not the best type of study, but cohort that levothroxine itself was shown to be a strong predictor of SIBO, stronger than even having hypothyroidism. That’s pretty wild, and that wasn’t that long ago.

So, what are the strategies for treating SIBO? You have to look at their diet. They have to be low in carbs. We want to be thinking about fibers and things like that. Certainly, we’ve got to be cautious. We don’t want to induce. I think most people would prefer a diarrhea over constipation, but we’ve got a… You’re not absorbing as many nutrients, so we’ve got to be thinking about what the starting point is of the patient. Lactulose can be used as a prebiotic. You can use a 10, 20, 30. You can use a 10 gram of 10 BID gram lactulose as a prebiotic, and it will lower any translocation, improved transit trend, and also act as a barrier.

That can be something to start with in your constipation patients. You certainly want to restore their nutrients, because the GI tract and all of these functions of the epithelial cells will need nutrients in order to function. So depending upon what nutrients they need, and depending upon what their symptoms are, you can determine how you want to get them, but I think the elemental diet is a great way to get nutrients. You all know this SIBO protocol from Norm Robillard. You can start with diet. I always start with diet no matter what I do, because if the patient doesn’t want to help me…

I believe lifestyle is a really important thing. If they don’t want to help me help them, then that’s a hard thing to do. If the diet isn’t helpful by cutting carbs, et cetera, FODMAPs, whatever you want to try, an elemental diet, and a period of rest for the GI tract, not complete rest because they’ll get nutrients through the elemental diet is a wonderful option. You can start with herbal antibiotics, or you can start with antibiotics. I work with my patient. I have patients that come in and say, “No, I took rifaximin, and that helped, and that’s what I want right now.” I bargain with them a little bit, and try to get them to at least pay attention to the food, but they are insistent.

Most patients will insist that it’s not their food, yada, yada, yada. But typically, we will get… Eventually, we’ll get to talking about the food, but maybe I start with rifaximin. Maybe I start with herbs, something that is going to be like a wormwood or something like that, antifungal, whatever I think is an underlying issue depending upon their symptoms, but I’m definitely going to use diet and one of the others along here, one of the other treatments along this. We know that fasting is not good for the mucosa for the single epithelial layer. That’s long understood. I mean, even for hospitalists, et cetera, fasting is not good for the…

You will get atrophy of your mucosal layer, and that’s not the goal. The goal is to have it robust and functioning, so that’s why we don’t really want gut rest. It is better to have something going through the gut in order to continue to restore these layers. So an elemental diet using the Physicians’ Elemental Diet Program, you know it’s a medical food. It’s balanced with nutrients. It contains what I like are the free form of amino acids. I mean, I think antigens are the primary problem when we think about what’s causing a problem in this non-specific barrier, and that’s breaking down the specific immunological barrier.

It’s often antigens that can come from proteins or in wheat. It can come from a carb, or it can come from a protein source. So, there’s a lot of different formulas on the market. You don’t want a lot of sugar. You don’t want a lot of glucose. You don’t want a lot of carb, so bravo to IT for changing the formula a little bit. You don’t want too much fiber. You definitely want some MCTs, but it’s really important to be thinking about what is in it, so [inaudible 00:49:54].

Dr. Weitz:                            I’d just like to point out, there’s a number of products on the market that are essentially meal replacements, typical protein powder with some carbs and some fat, and market it as elemental diet, and they’re not.

Dr. O’Neil-Smith:             That’s amazing. Ben, because I have not even seen those, to be honest with you. I don’t know where I am, but I never think of any protein powder or anything like that being like an elemental diet. Certainly, you can get a sense of whether or not people are absorbing the amino acids, or they’re able to even break down the protein powder, but an elemental diet has a lot of micronutrients in it in addition to the basic foods. So when we eat, we eat fat, carb, and protein. It’s the fat that we should be using aerobically in order to make energy like ATP fuel. It’s the glucose or the carb that we should be using.  Ideally, a carb with fiber like a vegetable or a fruit with fiber, something like that, that we’re using to get the sugar under anaerobic conditions, but we don’t… If we had lactate, we don’t want to have to use lactate because it requires a lot of oxygen for energy, for ATP production, because you’ll never make adequate ATP if you’re relying on lactase. Carbs are not a bad thing. Fat is not a bad thing. Nothing’s a bad thing. We need everything in balance, and we need to understand why we have it. I’m glad to hear that the carbs have been reduced in the Physicians’ Elemental Diet, Steve, thanks so much, and that the proteins have been increased, or the amino acids have been increased.

The micronutrient levels, I mean, there’s no better way than to get these with the amino acids because that’s how you’re going to make the chemicals that you need. Whether they’re neurochemicals, you’re going to join your amino acids together using the B6. If you’ve got glutamine, and you don’t have B6, you’re not going to be making GABA, right? So, it’s very important to just think logically about these things. This is not rocket science. Here, when we’re looking at the epithelial layer, these just single cells, and we’re thinking about the act in filaments, et cetera, on the left, and the occludin, zonulin just being the laces that are holding the two cells together. But really, it’s the actin and talin.  Once the actin, talin begin to unravel, the occludin/zonulin will unravel. You can see there’s a variety of different antigens, whether they’re bacterial, microbial, cytoskeletal, gluten, dairy, whatever they are, these food antigens, these microbial antigens. They can either come through the cell in a paracellular way, or they can come between the cells. But if they’re coming through, they’re definitely going to be coming between, because the occludin/zonulin is going to unravel, and so the laces of the two cells are not going to be held together. Now, I don’t really measure a lot of zonulin in the beginning when we heard about it. What is it? Eight or I don’t even know.  10 years ago, zonulin was sexy, but now, I’m much more interested in understanding the antibodies to the occludin, and the antibodies to the zonulin, the LPS, et cetera. I think it’s much more valuable to know, because you’ll know that there’s something going on. I really like the elemental diet. You can see here, if you’re having a whey protein, you have to digest it on the right. So traditional food proteins, they all require digestive enzymes to break down that food. If you haven’t fixed the enzymatic problem or the HCL problem or the bile problem, whatever the problem is that’s also related with these symptoms, then you’re going to worsen the symptoms.

For me, it’s a no brainer to… It’s better than TPN to give somebody elements or nutrients that are in the elemental form. I really like that. You can use elemental diets any way you want. You can use them just as for… Again, like I told Ben earlier, I treat a lot of very young wounded warriors. I have a young wounded warrior I saw yesterday. He is 25 years old. It’s amazing to me that he is even already been in the army, and he’s already out discharged because while deployed, he had a triple A. He had an abdominal aortic aneurysm dissection. This kid basically died and was brought back to life.

He’s got multiple issues, again, kidney issues that are really significant that no one’s paying attention to, his sugar issues, et cetera. He’s got gut symptoms, so he’s on elemental diet. I just think it’s a great way for these warriors who are so young to get them some basically healthy amino acids in its most elemental form. If you’re using them with someone who has SIBO, I would say there have been patients, not many, that are willing to do elemental diets fully. I have one patient who was willing to do it for three to four weeks, and get her calories through elemental diet because her symptoms were so severe, but that’s very rare.

Normally, I have to replace one meal with the elemental diet, or a snack with an elemental diet. Typically, I’ll do a partial elemental diet. It’s very rare for me to use it just for three days. I may be using it for two weeks. I may be using it for a month. But generally as a partial, we’re talking about the foods that they’re going to eat at the same time as the elemental diet. We’re coming up with a list that is acceptable for that person. It’s very individualized. I don’t have a one-size fits all. I don’t just say FODMAPs. I don’t do that.

I spend a lot of time with the patient understanding a lot of their other symptoms, whether they have histamine issues, whether they respond to histaminergic foods in a negative way, et cetera. The most important thing in my mind with an elemental diet is that when you recommend a patient to have the powder that they drink it slowly, they don’t think about something that they’re going to down in two minutes, and gulp and it’s gone, throw away the container. I don’t mean of the powder, but of the drink. Basically, you want them to drink it slowly. You want them to drink it over a time period, a bare minimum of 30 minutes, but likely an hour, so they can absorb those nutrients over time, and not only absorb them, but assimilate them appropriately.

Nothing needs to have a dumping on it. We don’t need to dump a lot of nutrients in any system, because that as well can create functional gastroparesis, but you know that patients will not feel well, and they’ll have other symptoms if they take it too quickly. So, a 14 to 21-day program for SIBO has been studied, and the normalization of the lactulose breath test is pretty significant compared to normals with respect to using the elemental diet. So, this has been studied, and that’s why there, it’s backed up by evidence. For acute Crohn’s, I’ve used it in acute Crohn’s. Basically, it’s better.

It’s as safe as TPN or anything else, so wonderful. I’ve used it in chronic Crohn’s. I’ve used a half elemental diet. I had a patient that was in the hospital here at Mass General with severe Crohn’s with a PICC line, and was getting food through there. She was eager to get out. She came out. We did a number of peptides, orally and sub-q. We also did elemental diet and shakes, and she healed. That was probably four years ago, and she has not been back to the hospital with an exacerbation, grazie a dio.

Dr. Weitz:                        By the way, what peptides do you find most effective for Crohn’s?

Dr. O’Neil-Smith:             In her acute phase and in the active phase, she was pretty acute still when she got out with the PICC line, et cetera. We used BPC sub-q. She could tolerate food and pills, so we used BPC orally. We also used… That way there, I’m thinking of treating the outside of the body through the GI tract in the space of the lumen. Then I’m thinking of getting it into the body through the subq. We also used thymosins as well for her, so she alternated the thymosins, and took BPC. Honestly, she continues to do that, and it’s been almost five years later with no exacerbation. That’s a beautiful thing.

You know that these are a variety of the mechanisms that the elemental diet will work through. Basically, it will improve the nutrient status, help to reduce antigen exposure because of the nature of the elemental diet, reduce inflammatory mediator cytokines, pro-inflammatory leukotrienes, et cetera, reduce permeability over time, over time, modulate the immune system response, help with mucosal repair, particularly because of the bowel rest. We know that there’s a lot less endotoxemia. Whenever there’s injury, and I talk about this a lot in my peptide lectures, we are going to get deposition of adipose tissue.  Injury will within a month deposit adipose tissue. So having adipose tissue surrounding the gut is not going to fare well for anybody, so we want to treat any inflammatory issues, supply the building blocks and the nutrients and the energy and the essential fatty acids in order to reduce bad outcome in repair. Pardon me, this is another way of looking at mechanisms of the elemental diet. There’s multiple ways of looking at it, and you can read all of these on your own. These are the same things that we just talked about, decreased need for pancreatic enzymes, et cetera. Pardon me, I’m trying to be gentle.

The efficacy of the elemental diet is great, but it’s even better if you understand whether it’s a diarrheal SIBO, whether it’s a secretory SIBO, or if it’s a constipation. There will always be other supportive treatments that are necessary when somebody has a bacterial or SIBO symptoms, always, always, always. I’m not sure if you all, because you’re on the West Coast, are familiar with Gerry Mullin. He is a physician at John’s Hopkins, and he did a head-to-head study looking at comparing the treatment of herbal antibiotics and antibiotics like rifaximin for the treatment of SIBO. He’s a lovely man as well.  Basically, what he found is that herbal therapies are at least as effective as rifaximin per resolution of SIBO by lactulose breath test, and that they appear to be just as effective as triple antibiotic therapy for SIBO rescue therapy for people who didn’t respond to rifaximin. I mean, obviously, this can be repeated. Here, we’re basically looking at different places along the GI tract that we have to be thinking about. We talked about this past medical history and understanding, and then some of the factors that may influence if people have had chronic antibiotics, et cetera, sugar, alcohols, what food they’re eating, bile, et cetera, so pretty self-explanatory.

It’s a great paper actually. Let me try to get to the next slide. Then he looked at all of the different antibiotic regimens, and basically elucidated those that people have tried for SIBO. Then he compared a variety of herbal antimicrobials with the rifaximin, so he used things like Chinese skullcap, berberine, rhizome extract. You’re familiar with all of these things, licorice root, ginger rhizome, rhubarb root, acacia, artemisia, et cetera. Many companies have products with these particular ingredients in them, some thymos parts, et cetera. I think that it’s really important to be thinking about what herbal antimicrobials you might use.  Here are some herbal antimicrobials, the berberine complex, and the para-gard. You want to be thinking about whether or not your patients are likely to have parasites. Are they likely to have yeast? Are they likely to have other bacteria, gram negative or otherwise? So, all of these products will have the proprietary blend of the company of different herbs and extracts that are very helpful. The migrating motor complex, we already talked about that and its role in health and disease. It’s very essential. Motility activator, something with some ginger, artichoke, d-limonene. 5-HTP, we know that that’s made in the gut.

We know that we’ve used Zelnorm and other things when people have irritable bowel, which is 5-HTP, a serotonergic medication. Vitamin C, I use all the time to tolerance, and NAC to tolerance. I use those all the time to tolerance, because there are so many other benefits with NAC and vitamin C. Vitamin C lowers blood sugar. It’s wonderful. Here, d-limonene and safety and clinical applications, terpenes are very effective for the gut as well. So probiotic therapy, to do or not to do. I mean, I don’t think that the data is conclusive in any way, shape, or form. So if you have… Definitely, if someone comes in to me, and they have diarrhea, predominant SIBO or an issue, I will usually try a probiotic with them.

But when they have a constipation, constipation-based SIBO, the first thing I need to do is get their bowels moving. We’ve got to start to clean out the bowel. The research is all over the map, and I don’t think there’s any one way of doing it. I certainly don’t think that I have the right way of doing it, so we’ve got to be thinking about all of the different interactions of the body, and the interrelatedness of the body and understanding how are we going to treat SIBO? It is not an entity in and to itself, just like I don’t think chronic Lyme is. I mean, I think chronic Lyme or chronic COVID, those are immune system disorders, and we’ve got to understand those.

We can do a little case study here. 38-year-old man came to my practice, Let me go back one. He came to my practice in January of 2018, but in the summer of 2017, he began to get ill. I did not see him for six months or more. Basically, he was out of the country. He came back, and he said his gut had never been the same. He went to see his PCP. He was having explosive diarrhea. He was having diarrhea nocturnally. He was exhausted. He was irritable. He was bloating. There was no blood testing done, and really no stool testing done. They put him on a simple carbohydrate diet, FODMAPs-like, and he had no improvement.  Then they gave him Flagyl for 10 days, and he had no improvement. This is all through the course of July, August through December when he finally ultimately made an appointment to come in in January in my practice. He had a typical conventional stool test in December ’17 at his primary care doctor’s office that shows C. diff toxin, and he was treated with Vanco at that time for 10 days. Despite that, he continued to have symptoms, and so his PCP was recommending another course of Vanco. He had a friend. Actually, his friend was a woman with the Crohn’s colitis that I had treated before. She said, “Enough is enough. You’ve got to go see a doctor that can help you.”

He came in, and he said that he had fatty liver. He was taking align as a probiotic. He had diarrhea, bloating, gas, stools, 24 hours a day, fatigue. He also had muscle pain. Obviously, we know that there are many symptoms. Any symptom can go along with it, but I found the interesting thing is when somebody has diarrhea, I have never had a SIBO-like patient who has diarrhea that lost weight. They all seem to gain weight, which is quite interesting. Maybe it’s that adipose tissue deposition as well.  They all gain weight. What I did just while we did some testing was I said, “Hey, let’s go rest your gut. You can have one meal a day. Pick the meal that you’re going to have, but try to rest your gut for the majority of the 24-hour window, and then we’ll give you the elemental diet as a second meal.” Then I did give him probiotics VSL actually. Oops, see.

Dr. Weitz:                        So in that case, did you have him use the elemental diet as many times as he wanted, or just add one meal?

Dr. O’Neil-Smith:             No. One meal. One meal. It was temporary while we waited for labs to come back. Here, we see his B12 at 295. His folate’s not even… It’s not useful because it’s a serum folate. His testosterone is low. He’s only 38. We know there’s a bunch of things going on. His cortisol is six as well, so he’s got some significant stress that’s been going on for some time, right? His AA… We looked at his essential fatty acids and his AA:EPA ratio. This is probably one of the highest AA:EPA ratios, the bottom red mark there at 37, that I’ve ever seen. He has an omega-3 index that’s two, which should be five.  So, he’s very deficient in essential fatty acids, which are basically going to affect the cell membranes of all of his cells. He is markedly inflamed, not absorbing. Definitely, we know that he has fatty liver. We know he probably has something going on in the stomach as well, because of the low B12, stomach and small intestine. He has significant insulin resistance with an insulin score of 37, which is very important. That’s not surprising, because whenever there’s a microbial dysregulation, you’re going to have insulin resistance whether or not you have diabetes, but the point is that we have to correct this.

What is a normal insulin level? I talked with an interactive session in the immune competence module at 4AM this weekend in Boston, and people don’t really even know. A normal insulin level, fasting, obviously should be two. But with a healthy meal, a very healthy meal of… Let’s say it was a dinner of vegetables, some olive oil. What I had tonight, I had roasted kale in a wood oven. I had some broccoli, and I had some Branzino and mostly with olive oil. Then I had a salad with some mint and some lettuces and cucumbers in that with olive of oil. That was my dinner tonight.  My insulin level with a dinner like that that I just described should literally be under 10, single digits, so an insulin level of 37 at any point in time is completely inappropriate. It means that he needs a high insulin in order to get his blood sugar to be normal. So, a glucose on its own is never beneficial, because you have no idea what insulin you needed to get to that level. I know you all know this, but I’m trying to drill home a point that glucose is not very useful. We can see he’s got liver function abnormalities. He’s got an inflammatory process going on in his liver with his AST and his ALT.

He’s got a bilirubin that’s elevated. These are really important numbers to know. We know there’s a lot more going on than just the diarrhea and the bloat, et cetera. Here is this stool test that I did on him in January of 2018 when he was told to take the second course of Vanco. He did not have C. difficile. That’s important to know. I’m glad he didn’t go through that second course of SIBO. We used a glucose substrate, because I thought there was something proximal going on. Definitely, we saw that there was some SIBO, positive SIBO. We looked… I’m so sorry about my… We looked at the antigens, and you’re all familiar with Cyrex, and looked to see what was going on.  But it’s not surprising, anybody with diarrhea for the length of time that he has, he’s basically going to have no brush border. He’s not going to be able to identify or keep anything out of his system. This is meaningful but still relatively meaningless, because when he repairs his lumen, his epithelial cells, and the creeps of those epithelial cells, he should be… Maybe he’ll be okay. But for now, I’m definitely going to recommend that he not go on any box product, no gluten-free product, no buckwheat, sorghum, hemp, no rye, no barley, no wheat at this point in time, because they’re too antigenic, and that’s an issue, eggs, et cetera.

You can see from this testing that anything in the yellow and the red, really, he’s got to really simplify his diet. Let me go here. Here’s where you see the transcellular and the paracellular roots that anything can get in the antigens. The food antigens get in through the paracellular when the zonulin is broken apart, but you can also have the microbes that are coming in transcellularly. We know that within the epithelial cell, every single cell in the body has actin, and actin is responsible for what in the cell regulates the cell across that membrane of an epithelial cell.

Increased levels of actin suggest that there’s damage, because the actin is not together where it needs to be holding to keeping the integrity of the cell. We know that when there’s increased actin levels, that there is a lower barrier function, increased permeability, and that there’s cell damage. Zonulin is the gatekeeper between the cells, so actin within the cells, zonulin between the cells. Basically, it is there for transport of nutrients into the body, but we know that an increased zonulin indicates that there is a compromised lining of the gut, and that there is leaky gut.

Then once we get that paracellular roots of antigen penetration, we know that they’re going directly and activating the immune system, so pretty important to understand. Here, we did another test just looking at a stool sample. Oftentimes, the tests I use depend upon the insurance of the patient, the pocketbook of the patient and what they’re willing to spend, but I try each test to see what I think of them. This is a test again from California that I’ve used. You can see the microbes that are delineated here, and basically looking at the health of the microbiome. We can see what’s high and what’s low, and we can see the level of evidence with associations with either IBD or irritable bowel.

Then the recommendations, you can either follow them or not. Generally, they’re pretty good, but it depends on when you’re going to start them, when you’re going to start the recommendations that they might have or you might want. This patient has lower short-chain fatty acid, so he doesn’t have a lot of good metabolites that are coming from his microbiota. He obviously has leaky gut, as we would know. He has TMAO levels that have probably increased based on the clostridial species and the other species that are elevated here that… I’m not really worried about them affecting his cardiovascular health. I’m just worried about his overall health, but we do know that TMAO can be a precursor to early cardiovascular disease.

Dr. Weitz:                            Kathleen, which stool test is this?

Dr. O’Neil-Smith:             This is vibrant.

Dr. Weitz:                            Okay.

Dr. O’Neil-Smith:             That’s plenty. He’s SIBO positive. We know he has increased intestinal permeability. He has antibodies to actin, antibodies to zonulin. I would expect every food to be as positive as it is. He’s got low diversity in his gut, so we did a half an elemental diet, just one meal a day. He also had another meal a day that he could choose. We talked about… We did… We took away the antigens that we know. Also based on his testing, we gave him some antimicrobial herbs. We gave him B12 subq and folate subq as well, because we have folate here, but the reality is that you don’t need to do everything at once.  I gave him B12 and folate subq, because basically… I didn’t give it to him every day. These I did not give every day. I gave once a week. Vitamin D, you can also inject in order to get good absorption of these things, and not to use the gut for that. Just use the elemental diet for that. So we basically do… I don’t try to win the game in the first minute of the first quarter. The goal is to help this gentleman heal and repair in the last seconds of the last quarter of the game. It is Thursday night football, guys. The bottom line is you can do it at any pace you want, but the pace will depend upon how the patient is doing. What symptoms are they having?

The people I saw today, for example, I did multiple treatments on them for GI, for pain, for other things. I did treatments here, injections here, peptides here. They went home with whatever they went home with. I will check in with them on Sunday to determine what we’re going to do on Monday. It’s one of the natures of my practice. These are the variety of things that I will do, but you can do it any way you want. So, just got restoration with support and supplements like L-glutamines and carnosine, MSM, alo, okra, DGL, NAG, all the things that we talked about previously.  But the most important thing, thinking about this gentleman and thinking about any of the patients that you have, is treat the whole person as opposed to just a disease process. I think about a barren physiology, and what part of the physiology is not functioning, not that it’s pathologic at this point, but why? What’s not functioning well? How can I restore that so I can prevent pathophysiology? That’s what I would encourage you guys to do.

Dr. Weitz:                            That was great. When do you decide to use a partial elemental versus doing a full two weeks just elemental?

Dr. O’Neil-Smith:             Oh, because patients are very unlikely to do it, that’s the main reason. Patients really don’t love to do that. So if you have a patient that’s willing to do… I always start with small things. I’m not, again, speaking of any game. I’m going to go out and get a score. I’m going to try to get three points on the board. I may say, “Let’s just start with three days.” You check in with my staff or me. Let me know how you’re doing. Can you do another three days? I never go big. I always go small and try to win big.

Dr. Weitz:                            Some of the questions have come in. One question is from JoEllen. If the patient has constipation, would it be a good idea to do the elemental diet?  I think she’s probably thinking the fact that there’s no fiber in there.

Dr. O’Neil-Smith:             Well, fiber can be problematic for people with constipation, so we don’t want to start with a lot of fiber. Honestly, I may even start with a bottle of mag citrate. I’m going to start with anything. I may tell them to make a jug with vitamin C in it, and drink that vitamin C along with magnesium. I’m definitely going to clean out the bowel. I want to start fresh. I am cleaning out the bowel before I start with anything. I think you can do an elemental diet if you want to get them nutrients for sure, even if they have constipation. But most important… Because the bugs aren’t going to feed on the elemental diet, it’s not going to happen.

The reality is that you need to help the patient empty the bowel. Even if you get to that point, they’re going to love you because there’s nothing like an empty bowel if you’ve feeling full of shit. Part of my expression, but it’s true. I was on the plane going to California once. This is a long time ago. Literally, this is more than a decade ago. I sat next to this over… I was the middle seat. I know I don’t do the middles anymore, but I was in the middle seat, and this heavy set man is sitting next to me. He knew I was in medicine, in functional medicine.

He said, “You know what my doctor told me?” That’s what he tells me on the plane. He said, “I’m full of 35 pounds of shit.” I’m like, “Oh, your doctor is smart.” I can’t believe the guy knows this. He knows this. He’s sitting next to me. You think I want to sit next to the guy full of 35 pounds of shit? I’m like [inaudible 01:19:16].

Dr. Weitz:                        Did he have orange hair? No, I’m just kidding.

Dr. O’Neil-Smith:             No, but can you believe it?

Dr. Weitz:                        Well, the other thing is if the elemental diet helps to starve our archea that are causing methane, we know the methane gas is what causes the constipation, so it should help with the constipation for that reason. You mentioned SIFO, small intestinal fungal overgrowth, and somebody asked about diagnosing SIFO testing.

Dr. O’Neil-Smith:             I mean, SIFO, I think, is pretty rampant to be honest with you. Everybody has many fungal forms in them, but I do a variety of testing on most of my patients. I really try to pick and choose with the money, but I want to know that there’s consistency, and SIFO’s going to produce gases. You’re going to have gases that are flowing through the system. You’re probably going to have a lot more lactate. You’re probably going to be more anaerobic. Definitely, sugar’s going to be a problem.  You can look on organic acid testing, and see if there’s a propensity towards fungal, mold, aspergillus, you name it. Even just with that testing alone, if patient describes the symptoms, for me, they have it. It doesn’t matter. If they have symptoms, and I see on an organic acid test a propensity to higher yeast forms, no testing’s perfect, but I’m going to treat that.

Dr. Weitz:                            Right. I think a lot of people use organic acid testing for fungal. You mentioned motility activator, and somebody asked, “What’s the best protocol for using it?”

Dr. O’Neil-Smith:             Motility activator alone won’t get somebody with a methane-induced constipation to be active, but the goal is how do we keep them active, right? So once we move all of that stool out, and we reduce that constipation… I know that I’ve had patients in the practice who have had four bowel movements a month, and they’ve gone from that over time, not a month, not three months, but over the course of a year where they might now be having multiple bowel movements a day. So, motility activator will be a part of that, but that will be a late in the restoration program.  It’s not going to be early, because you’ve got to be on a circadian rhythm. You really have to have a very good circadian rhythm, rhythm and bowel movement in order for that to be very effective.

Dr. Weitz:                            Somebody asked, “Could we use the elemental diet periodically every so many months to help with maintenance in a patient whose SIBO is improving?” We know some of these patients… Ideally, we like every patient to be on a protocol for one or two months, and then to resolve 100%, but we know a percentage of patients are going to have lingering symptoms. It’s going to become somewhat chronic.

Dr. O’Neil-Smith:             Yes, of course. Well, of course, you can do any of that, but I do want to note that I know you have such a smart group there, because I’ve been there with you all in the past. I was intimidated to do this thinking, “Oh, they’re so smart. I don’t even think I can help them.” But yes, of course, you can do that. Yes, that’s a great idea. It’s brilliant. Yes, of course.

Dr. Weitz:                        Oh, another question about motility activator. What is the best time of day? I think typically, I know I recommend taking it after lunch and dinner.

Dr. O’Neil-Smith:             I think that’s best.

Dr. Weitz:                        I like to use it as part of the protocol during active treatment with the antimicrobials and [inaudible 01:22:52].

Dr. O’Neil-Smith:             Use it earlier.

Dr. Weitz:                        I want to get that MMC going.

Dr. O’Neil-Smith:             It really gets damaged, and it’s a very complex system. We don’t really keep very good biorhythms. Look at me. I’m here at 11. I feel wide awake. I probably won’t sleep till 2:00 at this point tonight, but I mean, the biorhythms are really a big part of it.

Dr. Weitz:                        Dr. Homa Bakhtar said, “Is it possible to have the nights?” Doc, what did you mean?

Dr. Bakhtar:                     Notes.

Dr. Weitz:                        Oh, the notes, the slides.

Dr. O’Neil-Smith:             No, of course. Yes, they’re yours.

Dr. Weitz:                        Could you email them to me, and I’ll-

Dr. O’Neil-Smith:             100%.

Dr. Weitz:                        Okay, great.

Dr. O’Neil-Smith:             Of course, use any of them. I have permission from Alessio, whatever I’ve used of him or even Johnny. I’ve asked permission to use all these, so they don’t care. They want us to teach each other. It’s no problem.

Dr. Weitz:                         Good.

Dr. O’Neil-Smith:             Of course.

Dr. Weitz:                         Great. Awesome. Thank you so much, doc. That was awesome presentation.

Dr. O’Neil-Smith:             Well, don’t intimidate me next time. I’m teasing.

Dr. Weitz:                         Thank you, everybody. See you all next time.

Dr. O’Neil-Smith:             Thank you, guys. Have a great evening. Thank you for coming.

Dr. Weitz:                         Thank you.

Dr. O’Neil-Smith:              Ciao. Ciao.

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 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. 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.