Gastroesophageal Reflux with Dr. Dipti Sagar: Rational Wellness Podcast 427

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Dr. Dipti Sagar discusses Gastroesophageal Reflux with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Dipti Sagar is an Integrative Gastroenterologist who practices in Century City as an associate of Dr. Farshid Rahbar and reflux is one of the many GI conditions that she treats regularly in patients. Her website is LAIntegrativeGI.com.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

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Podcast Transcript

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

Hello, Rational Wellness podcasters. Today we’ll be speaking with Dr. Dipti Sagar about gastroesophageal reflux disorder, which is a very common gastrointestinal condition. Heartburn is the main symptom in reflux and is often described as a discomfort or a burning pain felt in the chest or throat.  It occurs at least once a week in about 30% of Americans, and up to two [00:01:00] thirds of those with irritable bowel syndrome. Heartburn can be caused by a reflux of the gastrointestinal contents up into the throat or esophagus, or it can occur without reflux. Gastro. Esophageal reflux means that the stomach contents have moved up.  Into the esophagus, and this can damage the esophageal lining, especially if there is acid or bile, and this eventually can increase the risk of esophageal cancer. Other symptoms of reflux besides heartburn include regurgitation, chronic cough, sore throat, vomiting, hoarseness, chronic throat clearing. Dr.  Dipti Sagar is an integrative gastroenterologist and I would say one of the few in the country who practices in [00:02:00] Century City as an associate of Dr. Sam
Rahbar and reflux is one of the many conditions that she treats regularly. So Dr. Sagar, so thank you so much for joining us.

Dr. Sagar: It’s been a pleasure.  Thank you so much for having me and for the lovely introduction. I would say you made my presentation very easy because you summarized it so well.

Dr. Weitz: So, maybe we can start by defining some terms. Sure. So what is reflux? What is GERD or gastroesophageal reflux? And what is heartburn? And sometimes they’re used interchangeably.  Let’s make sure we know what we’re talking about.

Dr. Sagar: Yeah, that’s great because a lot of times we use GERD for acid reflux and reflux for heartburn, right? So let’s make it very simple. Reflux is simply the fact that the stomach contents are moving up into your esophagus. That’s simply reflux, right?  Heartburn is the symptom that happens because of this. It could be a burning sensation in the chest or in the throat. GERD, which is gastroesophageal reflux disease and is when that reflux happens frequently or causes complications like esophagitis or stricture or Barrett’s esophagus.

Dr. Weitz: Okay. Isn’t a small amount of reflux normal and usually this doesn’t even create symptoms, right?

Dr. Sagar: Absolutely. It’s very normal to have sm occasional small reflux episodes and they’re asymptomatic. The reason why we don’t have symptoms is because our esophagus have protective mechanism. For example, the saliva that we produce, so we produce like 1.2 liters of saliva every day. And what stimulates saliva production is reflux.  So every time there is acid in the lower esophageal in the lower part of the esophagus, which is like 20 centimeters. The, it stimulates production of saliva, so that protects you. The second is the bicarb, which is again a protective [00:04:00] mechanism and the clearance mechanism of the esophagus, which is the peristalsis.  That itself helps to neutralize the small amount of assets that comes up into the esophagus. It becomes good when the balance tips towards injury or towards symptoms. So you’re right, a small amount is normal, but we have in our ability to clear it by ourselves.

Dr. Weitz: Right. And essentially it’s when the lower esophageal sphincter opens, which happens every time you eat and once it’s open, a little bit of the contents moving up is part of the normal balance, right?

Dr. Sagar: Right, so I’m glad that you brought this. So whenever we are swallowing there, it’s always associated with peristalsis. So as you mentioned, when we are eating the lower ral sphincter relaxes, it opens, but remember it’s always followed by peristalsis, so that clears the acid. But there is something called transient relaxation of the lower feal sphincter, which [00:05:00] is different from the regular swallow induced, relaxation because that one, first of all is longer. It’s more than 10 seconds. It’s not followed by peristalsis. So that’s different. And in people who have reflux disease, the transient relaxation of the lower is vi, sphincter and motility is probably what causes it.

Dr. Weitz: Right? So essentially it’s a motility disorder, but yeah.  Correct. The main treatment is using acid blocking medications like Prilosec, for example, which is a proton pump inhibitor, also known as omeprazole. That decreases the hydrochloric acid, but this is not treating the cause. It’s not affecting motility.

Dr. Sagar: That is exactly correct, and the irony is like, you won’t hear this from a gastroenterologist, but I have to say it out loud, that most acid drift flu patients who have good, they usually have normal acid.  And this is something that I see in my practice like every day because I do, but I do an endoscopy. What I do is I collect the gastric juice and check the pH for all patients. And this is not regularly done by a gastroenterologist when they’re doing the endoscopy. I have seen so many times patients with acid reflux and they are on omeprazole and they say, I have heard heart bone, and I’m, I just have so much of acid reflux.  I just did a endoscopy yesterday on this patient for acid reflux, and when I did the pH testing, it was actually two, so the normal pH of our stomach of the gastric juice is zero to one. So if it’s two. That’s like hypochlorhydria, right? Like it’s not too much acid. So the main issue is the dysfunction, as you mentioned about the lower esophageal sphincter and impaired motility, what PPI does, it reduces the acid so it can relieve some of the symptoms, but they don’t fix the underlying mortality disorder.  And the reason why they’re the main first line of treatment is because they’re [00:07:00] effective for short-term relief, but they do not address the underlying cause. The underlying issue of it, and that’s why I’m completely, I’m not in a favor of like giving PPIs to patient. Now, in the short term, when you have esophagitis or complications from acid reflux, yes, you can give it for like eight weeks, but long-term use really don’t have any benefit.

Dr. Weitz: In fact, couldn’t it harm because it’s gonna decrease the ability of us to break down our food. We need that hydrochloric acid to break down our proteins and other components in the food. And so if the patient has normal or even decreased hydrochloric acid secretion and now we’re decreasing it even more and if you’re not properly digesting your food.  Unfortunately, this is fairly common in our society. Partially ’cause everybody’s eating so quickly, they’re eating on a run. They’re eating foods that they can hold in their hand, in the [00:08:00] car while they’re at their computer at work, et cetera, et cetera. And people often don’t chew enough. They’re not getting enough hydrochloric acid, digestive enzymes to break down the food.  So now decreasing that hydrochloric acid may actually make the situation worse.

Dr. Sagar: Absolutely, and I actually can talk on this topic for odds and that’s why I didn’t bring it up. But the thing is, we need acid, right? Like there is a reason why there is acid in our stomach, right? So first of all, it helps with the absorption of food.  As you said. If you don’t have enough acid, there will be malabsorption. Second of all, acid is important for absorption of minerals and vitamins like vitamin B12, zinc, magnesium, vitamin D, calcium. So if you are, if you don’t have enough acid, you will be deficient in all this micronutrients. Other important thing is the acid in your stomach is actually protecting you from the bad bacteria in the gut.

So [00:09:00] if you have low acid, some of those bacteria will escape because there is not enough acid to kill them, and that changes your gut microbiome as well. And as you know, like the more we learn about the gut microbiome, we know that every. All disease actually arises from the microbiome. So just by decreasing the acid in your stomach, you’re setting yourself up for malabsorption, disease, inflammation, and chronic conditions.

Dr. Weitz: Including small intestinal bacterial overgrowth which is something that can lead to gerd.

Dr. Sagar: Exactly. So that is a big thing that people miss. We talk about motility. So the motility, I’m not just talking about the lower residual sphincter, but there are two other concepts with motility. First is delayed gastric empty, which is delay in the passing of the food and contents of the stomach into the deum.  So if you have delayed gastric ending again, which is a mortality problem, can cause acid reflux. The other one, which I’m passionate about, I wanna bring more awareness. It’s the al [00:10:00] gastric reflux, which is basically the stomach. The contents move from your stomach to your small bowel, so that’s the direction of flow.  But when you have dysbiosis in your small intestine, like just you mentioned small intestinal bacterial overgrowth or fungal overgrowth or any kind of dysbiosis, even parasites, it causes increased intraabdominal pressure. So now there is backflow of contents or bile. From the Odum into the stomach.

So it’s like opposite. And this is a very important concept because as I mentioned, this person I did an endoscopy on yesterday. They had a gastric pH of two. But you know what was more interesting? Like as soon as I went into the stomach. As a gastroenterologist, you’re supposed to see clear gastric juice because the gastric juice is clear.  There is no color to it, but what I saw was just yellow bile in the stomach. So there is no reason for you to have bile in your stomach. So why is bile coming in your stomach? It’s, it should be going down, [00:11:00] right? Like it’s a downward flow. That is a clear indication that it’s a. Dear neuro gastric reflux, that means bile is coming into your small bowel.  And when that happens, remember there is dilution. So the gastric acid, which has a pH of zero to one, is now diluted with bile, and probably that’s why the pH is now two. So again, this causes malabsorption. And I would say this happens because of what is in simple language is a dirty gut involvement. So whenever there is dysbiosis in your small bowel because of parasites or fungus or bacteria, this is what causes the backflow of bile.

So, yeah.

Dr. Weitz: So, instead of prescribing PPIs, do you ever actually recommend hydrochloric acid and or digestive enzymes and or herbal bitters to improve digestion?

Dr. Sagar: Very good question. So everything should be evidence-based. So in patients you have already confirmed that they have a hypochlorhydria, like when I do the pH testing, like this guy who had a pH of [00:12:00] two, then yes, you could gently support them with hand et c.

Dr. Weitz: So when you do your endoscopy, you take a sample of the juice from the stomach, and then you measure the pH in it.

Dr. Sagar: Yes.

Dr. Weitz: That’s

Dr. Sagar: exactly it.

Dr. Weitz: Now there’s another test that I understand is not being done that I think that you were doing previously, the Heidelberg test. Yes. What’s the status on that?  I understand they might be bringing it back in a different form or.

Dr. Sagar: Yeah, unfortunately the, we don’t have those pills anymore. I think we just have like two of them left. They stopped making and they can measure the acid, but it’s not available unfortunately.

Dr. Weitz: So yeah, I think they’re gonna bring it back in, in a slightly different form.

Dr. Sagar: Yeah. So, but we don’t have that available now.

Dr. Weitz: Right. Okay.

Dr. Sagar: Coming. So in the meantime, we could do the pH impedance testing or any patients who are undergoing endoscopy. It’s very easy where you just suction the juice and the pH testing strip is available on Amazon. [00:13:00] You know, so like anybody can get it.

Like, I mean, last week they ran out of it. So I bought it from Amazon for only like $10 and it just, so this

Dr. Weitz: is one of the reasons why doing a upper endoscopy is an important part of a workup for patients with reflux.

Dr. Sagar: That’s one part. So checking the pH, but also important to see if there is any mucus cell damage.

Right, because then treatment is different. So when I do endoscopy for acid reflux and I see esophagitis and Barretts, then the treatment is different because then I know that they would respond to an acid medicine like PBI. However, majority of the patients,

Dr. Weitz: by by the way, for those who don’t know, Barrett’s esophagus means there’s a certain amount of damage to the esophageal mucosal cells.

Dr. Sagar: Yeah, so it’s intestinal metaplasia, which is it shouldn’t be in the esophagus. So the mucosa in the esophagus changes to that of the stomach, which is abnormal. So that’s what Barr’s esophagus is, right? So, yeah, to answer your question here, to look at the mucosal [00:14:00] damage, to look at if there is no muc cell damage, is there bile in the stomach, if there is gastritis, all of that information is helpful in.

Deciding how you will manage this patients. So yes, definitely. And in our practice we do something very special called Al Aspiration, which is not done in any other endoscopy center. So what is that? Basically when I go in, when like in this patient, when I see there’s a problem with the bile, we go in the small bowel and we just suction the.

Which is in the small bowel, and then brush the mucosa of the small bowel and send that for pathology, just like GI Map or culture, that gives us information as to what kind of dysbiosis is this. Because if there is a proximal dysbiosis, a lot of time that’s not picked up in the breath test, and you’ll be surprised that the breath test is normal.  But the patient is having all these symptoms, which is very specific for sibo. So it picks up proximal dysbiosis. Like from CAPA or strep? Pneumo. Pseudomonas. So if you see [00:15:00] all that in the bile, then you would know that this is proximal dysbiosis. Also, candida is a big issue

Dr. Weitz: And by the way, one of the advantages of this is then you can treat the SIBO or you can treat the candida and then that will help to I improve the underlying cause of the reflux.

Dr. Sagar: Exactly. Rather than having them on PPI for life. That’s correct.

Dr. Weitz: You know, PPIs, if you look at the description inside the containers say that they should only be used for short periods of time. And yet, as you said, some patients are on ’em for years and for life. So when you get a patient who’s on PPIs and you decide that it it’s not helping them it’s difficult to get ’em off. Correct. How do you get ’em off?

Dr. Sagar: Very good question. So first you can give them instructions, but I think that here’s where motivational interviewing comes into picture, and we as physicians have this role to kind of talk to our patients exactly.  As you mentioned, it’s so much easier to [00:16:00] buy a fast food burger and eat it while you’re driving and then just go home and take a PPI that does not involve, that does not require any change from your side. Right? It’s so, so much easier. So if you now tell the patients that you have to sit with your food and chew your food, it takes a lot of effort on their end.

So instead of saying like, you have to do this, we as physicians should be very efficient and motivational interviewing. And that’s where we have to kind of like really tell them. Lifestyle is important. Like when we are eating the food, we have to chew the food at least 15 times, you know, like from the front of the mouth because we are producing saliva, and saliva has important enzymes like amylase, which is so important for digestion of protein.

Okay. And also. When you’re eating a chew food and chewing it swa slowly you are increasing your mind gut brain connection, right? The mind body connection, and you’re like really being present with the food that really helps. Not drinking cold water, you know, when you’re eating [00:17:00] your food is also important because when you drink cold water, you’re shutting down the blood circulation because cold water.

It’s gonna do vasoconstriction, so there will be decreased blood circulation in your stomach and that’s not very helpful for digestion of your food. You need more blood. So drinking warm bottle really helps. And obviously at nighttime don’t eat or drink two to four hours before bedtime. And many times people say that, oh, half my dinner at six and I go to bed at 10 and I don’t eat anything.

But in between that period, between six to 10, they’re drinking tea, they’re drinking this, they’re drinking that. So. We also have to let them know that even a sip of water can stimulate the acid. So no eating or drinking even water for at least two to three hours before bedtime. Those are some important or lifestyle changes that you know, we have to incorporate.

And as of course, as you know, a lot of food will relax the lower oph, which sphincter, so we have to avoid those food items and some food items like,

Dr. Weitz: and let me just point out also that [00:18:00] one of the reasons why. People tend to drink a lot of water when they eat is ’cause they’re not chewing properly. So the food won’t go down.

If it’s properly chewed and it’s broken down into, you know, the proper consistency, then you don’t need water to swallow it. But when you’re trying to swallow the food whole, because you’ve only chewed it once or twice then you need a lot more water.

Dr. Sagar: I think you’re making a great point there because a lot of time, you know, when we do as a gastroenterologist, we do the endoscopy and people come with like stuck steak in their throat.

Like, how did that steak get in your throat? Like, it’s because we don’t chew, you know? Right. So I always say, Hey, chew your food. We are meant to chew your food and like really not swallow it. So you made an excellent point. And in terms of like decreasing, how do I taper them off the PPI. So I don’t take it off immediately.

And this is something that we all need to understand if you are on PPI. And if you just stop it, it means that you are going to [00:19:00] have a rebound hyperemia because. All of a sudden you’re taking away the medication that has stopped the acid production, so your heartburn and acid reflux will worsen. So what are usually the doing ‘

Dr. Weitz: cause because when you decrease the hydrochloric acid secretion, the body secretes more gastro.  That tells the stomach to make more hydrochloric acid. So then when you stop the PPI, you’ve got all this gastrin and you get this big increase in acid production.

Dr. Sagar: Yeah, and then the patient will be like, oh my gosh, I feel so worse, and I’m going back on the PPI. Right? Right.

Dr. Weitz: So

Dr. Sagar: that’s why we have to taper it very slowly.  So for example, if you’re on 40, you would go back on 20 and then to 10 and then every other day. So I taper it over the course of like two to four weeks rather than just topping it all of a sudden.

Dr. Weitz: Right. I’ve also heard doctors use a different acid medication on an interim basis.

Dr. Sagar: Yes.

Dr. Weitz: A non PPI say,

Dr. Sagar: yeah.

So [00:20:00] we can use something like H two blockers in the interim, right. Along with the lifestyle changes, I talked about stress management, right? We can also combine some hopes, which is helpful for acid for help for acid reflux, which is DGL or alora or marshmallow, and you can kind of bridge that until you know you are completely off the acid medicine.

Dr. Weitz: What do you think are the most effective herbs? I know some people have talked about using slippery elm. I’ve actually had some of the patients make kind of a paste at a slippery elm and use it to sort of coat their throat. Yeah.

Dr. Sagar: Slippery elm is great. My favorite is DGL. Okay. Slippery m sometimes I use in combination DGL and Slippery m Avera is another one, but be careful with Avera because it’s a little, a bit of a irritant so it can give you diarrhea, so you don’t want to have like diarrhea instead of acid flux.  So we have to be careful with that. [00:21:00] And then I also like marshmallow and zinc carnosine because they have kind of a very anti-inflammatory effect, especially the zinc carnosine for the gut. So that helps. 

Dr. Weitz:  What do you think about melatonin?  I’ve seen some papers on melatonin having a beneficial effect.

Dr. Sagar: Yeah, I definitely use that too. Especially if there is with issues with sleep and usually in combination therapy in a very low dose, like three milligram, that helps as well.

Dr. Weitz: Yeah. Okay. So, let’s see. There, there’s certain foods that we need to consider them not eating that can increase reflux.  And that’s because they can say, decrease the pressure on the lower esophageal sphincter, or because they decrease motility.

Dr. Sagar: Yes. So anything that decreases your lower fial sphincter pressure will increase the reflux. This include chocolate, you know, peppermint or fatty food, alcohol, carbonated beverages, even medications, [00:22:00] which are commonly used for high blood pressure, like calcium channel blockers.  A lot of patients are on benzodiazepine. NSAIDs, SSRIs. So knowing these will allow our patients to have to make targeted lifestyle changes. Remember peppermint is used a lot of times for IDS, but it also, yeah, is the enteric

Dr. Weitz: coated peppermint oil.

Dr. Sagar: Yeah, but be careful because a lot of times that will relax the lower esophageal sphincter and now you are dealing with the acid reflux problem, so remove that.

The first thing. So important to look at the herbs too, like what the patients are taking. If you’re taking a lot of peppermint, we have to stop that

Dr. Weitz: now in terms of motility. We talk a lot of times in the, when we’re talking about gut problems, about the motility of the intestines and the migrating motor complex.

And and then we have motil pro kinetic agents that we know work to improve that motility. But the motility of the [00:23:00] esophics esophagus is different. What do we know about? Promoting motility of the esophagus.

Dr. Sagar: Good question. So, as I said, every time that there is acid in your stomach, there is persis. So there’s there’s motility.

But what you could also help with, which I didn’t mention before, how we can use saliva for this, like for removing the acid, because that’s like a normal alkaline solution, right? So. After your meals, what I recommend is chewing some kind of gum, and that doesn’t have to be like a sugarcoated gum, because as you know, a sugar will have its own issue.

So we could use like a xylitol based gum. And when you chew that for 10 minutes after your meals, what’s happening? So after your meal, the stomach is full of acid. Some of it might be coming up if the immortality of the esophagus is not very good, or if there is some problem with dysfunction. So when you choose a gum, it’s producing the saliva and the pH of [00:24:00] that saliva is between 6.8 to 7.4.

And when you swallow that saliva, it neutralizes the acid in your stomach, so it’s your body’s natural anti-acid. Without the use of PPI. So Heidi, if you have a motility problem where you’re there is a delayed gastric emptying or esophagus is not clearing very well, chewing the gum after every meal, like breakfast, lunch, and dinner, does so much good.

Like you, it’s like your own natural anti acid, as I said.

Dr. Weitz: Now, do we know if any of the. Say pro kinetic either drugs like procal pride or nutritional supplements, like we use ginger and artichoke and five HTP and things like that. Do we and then we have strategies like trying to stimulate the vagal nerve.

Do we know if those strategies work for esophagus motility?

Dr. Sagar: Absolutely it does. Because the stress management is [00:25:00] important. So remember, there are for the antireflux, the body’s natural way to prevent reflux is three three layers to it. First is the pre epithelial factors, and that is like saliva, mucus bico.

And then the epithelial factors, which is your, the tissue resistance, you know, the epithelial cells resistance. And then there is the post epithelial factors, which is improved blood flow. Now that improved blood flow is de is decreased when you have inflammation. And that inflammation could be from stress.

So whenever we work through stress management, decreasing the cortisol, that in turn will decrease inflammation. That in turn will improve blood circulation. So it definitely works.

Dr. Weitz: Okay.

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Dr. Weitz:  H pylori is a bacteria that grows in the stomach and this can sometimes be a player in gerd.  What should we think about h pylori? Should we test for h pylori regularly? Should we eradicate it? I think conventional gastroenterology my understanding is if you see h pylori, you definitely need to get rid of it no matter what. Yet there’s some controversy over what tests are even accurate for h pylori, whether stool testing that shows DNA of h Pylori or whether there’s stool antigen or a breath test.  And then there’s an argument that h pylori is actually protective. 

Dr. Sagar:  It seems to be.

Dr. Weitz:   Potentially correlated with decreased esophageal cancer. There’s an argument to be made that this is a microbe that is important and we shouldn’t get rid of it even though most of us don’t have it anymore.  What should we think about h pylori?

Dr. Sagar: Very good. That’s a very important topic to discuss because it’s a little complicated. So just to make it simpler in terms ofmy and the physiology of how Hval works, is that, so Hval could be in your antrum, which is the distal part of your stomach, or it could be like in the fundus, which is the upper part of your stomach.  So when you have h Bori, which is an predominant. You re it’s gonna actually, and you remove it, then it’s going to improve the acid reflux. But a lot of time the h pylori has migrated to the fundus and the proximal side. And if you actually, and that is actually protective against esophageal cancer.

And if you try to remove it. It’s actually going to make the [00:29:00] acid reflux even worse. So the best way to kind of do this is when you’re doing the endoscopy, I take different biopsies, one in the antrum and then one in the fundus. So if there is an anally predominant h pylori, I know that the acid reflux will improve after this.

But if it’s more fundus. Then I do tell the patient that, hey, we can treat it, but it can bring back acid reflux. Now if you don’t have acid reflux, then you can go ahead and treat it, but we have to educate the patients that, you know, it can make your acid reflux worse. Now, in terms of treatment, and I understand what you’re saying, so I take a very individualized approach.

If by the way,

Dr. Weitz: What do you tend to use for diagnosis? What testing do you think is most helpful?

Dr. Sagar: Good question. Accurate if they’re doing an endoscopy biopsy is great, but if not, then either the stool antigen testing or the ure breath test, both of them checks for the antigen. There are some problems with that, like, you know, if they have been on antibiotics or PPI or you know, like, red meat, that all of [00:30:00] that can affect the way the hval.

Will show up. The antibody testing is not a very sensitive testing because it’s a blood test. If you have ever had an HP, even if it’s not active, it will come back positive. The most sensitive is the biopsy because it’s not affected with all of these. And you can also know like where in the stomach the HP.

Well

Dr. Weitz: what about the stool? DNA testing.

Dr. Sagar: Yeah. Good. Very good. So the, that one, like especially if you do the integrative labs, you know, the stool testing like GI Map or you know, through Vibrant, the problem is those it has to benefit and disadvantage. The benefit is it’ll tell you the virulence factor.

Which is very helpful and the problem is that the titer is not very sensitive because it’s going to pick up another other type species of helicobacter, which are not h pylori. So if I see that the titers are very high, but the Vance factor is negative, and patient is young and has no family history of gastric [00:31:00] cancer and have no symptoms, which is specific for H ery, I tend not to treat it.

Because I think the treatment has more harm than any benefits, you know, giving them antibiotics. It’s not very good.

Dr. Weitz: What about using the natural treatment, say like masum?

Dr. Sagar: Yeah, I was coming to that a lot of time. The esophageal cancer that we are concerned about, and sorry, the stomach cancer is because of the viral, the bacterial load.

That means the more the bacteria there is the higher chance of having the cancer. So antibiotic will completely eradicate it, but it has its own complication. But natural therapies like master gum, they reduce the bacterial RO load without total eradication. That really helps with preventing the complication as well as help with symptoms.

But as I said, the decision has to be very individualized based on family history patient preference, patients cofactors, all of that.

Dr. Weitz: Right. That’s interesting. Now it’s been my thought. I, that’s the number of [00:32:00] gastroenterologists and they’ve all said, oh no, the natural treatments don’t work.  You have to use the. Quadruple. And now it’s a quadruple antibiotic therapy. So we and those of us who study the microbiome know that using broad spectrum antibiotics, especially multiple ones, is caught putting the microbiome at risk and would rather not do that.

Dr. Sagar: Yeah, that’s, so if you treat a patient with quadruple antibiotics, how many of them come back again after a month or so, or maybe six months with, again, H pari positive, right.  Right. Yeah. So that’s the problem. And I agree that it the natural therapies are not very good with eradication, but they’re very good in decreasing your bacterial load and that’s all you need.

Dr. Weitz: Yeah. And I’ve seen that consistently in a number of my patients, so that’s why I was kind of skeptical about.

[00:33:00] Hearing that they, they don’t do anything because I think you’re right. They’re looking at, you haven’t completely eradicated it, so you haven’t done anything. But it’s more a question of the balance, which it is for so many things.

Dr. Sagar: Right. And as you know, how does Hval transmit it’s fecal oral route, right?  So if somebody has hval in the house, right, and you’d give them antibiotics, I’m sure the people who are sharing the plate sharing bathroom, you know, living in the same household, it’s cross contamination. And that’s why a lot of times it’s difficult to eradicate, you know, especially in endemic areas because everybody in the family has it.

So you have to give antibiotics at the same time for everyone, and may work for somebody may not work for someone else. So it’s tricky. So we have to find that balance, as you’re saying the most the least side effect and the most effective. And I think natural therapy is the way to go.

Dr. Weitz: Now, one category of patients that I’ve run into several times is patients who have hypermobility syndrome, [00:34:00] like LERs Danlos syndrome, and these patients often have other gut problems like SIBO and because of this hypermobility, meaning their ligaments are kind of loose. These are people who are like hyper flexible, their arm hyper stands et cetera. So, which means that some of the connections in their gut, like the valves tend not to be as tight. And same thing with the lower esophageal sphincter, as well as some of the other valves.

Have you run across these patients? I’m sure you have. And are there some strategies that can help?

Dr. Sagar: Absolutely. So the simple answer is, the way it works in patients with EDS or AL Syndrome is that the mu everything is hypermobile, right? So there is a weakened lower phial sphincter tone. So we have to understand the physiopathology first, then we don’t, we do the treatment.

So they have the tone of the lower phial [00:35:00] sphincter is weakened and that’s why they have this issue. So I would do the same things that I talked about, how to clear the acid from the esophagus. If you have a lower, so it’s all about lifestyle. Chewing your food, you know, saliva production after eating, not drinking water avoiding the food or medication that’s going to lower this FTA tone even more.

A combination of all this natural supplements like DGL. So it has, it’s more like a teamwork, working with the patient to see what works, what not. But that’s what I do usually in these cases.

Dr. Weitz: Oh, you know what? Now it occurs to me melatonin, one of its benefits not related to sleep is it seems to increase the protective factors in the mucosa,

Dr. Sagar: right?

So, yes, that is correct. The other hers that you could use, which helps with that, it is sodium alginate. Right. That also helps protective thing, melatonin. And then I am also a big fan of artichoke and [00:36:00] ginger because they’re like pro motility. So those are some of the things that we can use in combination.

Dr. Weitz: Okay. Now, one category of drugs that really tends to sometimes damage the esophagus are the osteoporosis drugs that bisphosphonates like Fosamax. Can you talk about these and what can we do about this?

Dr. Sagar: So they work differently. The bisphosphonate, they cause direct mucus cell damage. So it’s not about the motility, it’s just that they go and stick with the mucosa.

They create ulcers and damage so that, because again, if you understand the pathology, you would understand the treatment. So the treatment is simple. Do not let them stick to the esophagus. That means whenever you are drinking or having a pill, which is bisphosphonate, drink a lot of water, like a whole glass of water so that it goes into your stomach, and then you have to stay upright for like 30 to 60 minutes.

Because if you lie down again, it might come back in esophagus. So understanding pathology [00:37:00] helps with treatment. So it’s a direct MCO cell injury, and you prevent it by not causing direct contact with the mucosa by drinking a lot of water.

Dr. Weitz: Have you ever had the patient do the heel drop thing? You haven’t drank all this water, and then they drop down and the idea is it kind of pulls the stomach down.

Dr. Sagar: Yeah. So don’t do that together all. So he drop very well. I really recommend, but you have to do it correctly. So you have to kind of lift up and then drop certainly, and

Dr. Weitz: right.

Dr. Sagar: People do it just one or two times, but no, you have to do it like 10 times. Right. And obviously at least two to three times in the day.

Dr. Weitz: Right?

Dr. Sagar: Yeah.

Dr. Weitz: And right now in this country, the. Most popular new drugs are the weight loss drugs, the GLP one agonist drugs. And these drugs work by slowing down GI motility. Are you starting to see an increase in patients with [00:38:00] reflux because of these medications?

Dr. Sagar: Yes, and I’m glad you asked this question because I

Dr. Weitz: by the way these are drugs that we’ve all heard about that everybody’s taken for weight loss that started out as diabetes drugs.

Dr. Sagar: That is correct and a lot of people are using it. It’s funny you say that because I launched my online platform and I do like live sessions in it, like every couple of weeks and this last Friday I had this gentleman who took GLP one for type T and now they’re dealing with acid reflux and constipation.  You know, so I talk about natural ways to kind of lose weight and these things in my platform. So we had like a two hour discussion on this. So this is, I’m passionate about this. So first of all, we have to understand that losing weight is not the same as being healthy. You can lose weight by just drinking water or eating like a little bit of chicken throughout the day.

But does that mean that you’re healthy? The answer is no, because it has a lot of biochemicals that comes into play [00:39:00] with the GLP one. How does they help you lose weight? They decrease your mortality, right? So you’re not feeling that hungry, but that in turn also changes your gut microbiome, so we have to understand that concept as well.

So to answer your question, yes, a lot of patients with GLP one will have acid reflux. The problem happens that we don’t take those things into consideration before starting. So I think it’s important to have that dialogue with our patients that, hey, this is going to decrease your mortality so it can worse in your acid reflux it worse in your constipation.  And also it is not a magic pill because once you come off it, you are going to gain all that weight back.

Dr. Weitz: Right.

Dr. Sagar: Are you willing to. Be dependent on a chemical for all your life, because ultimately you have to change your lifestyle, right. In the weight loss, you know? Right. So that and

Dr. Weitz: these drugs, like Ozempic is one of the most popular ones.

You’re right. People tend to gain the weight back. Not only that, but there’s a tendency when people lose weight to [00:40:00] lose muscle, which means your metabolic rate is slowed and it’s gonna be even harder to keep the weight off.

Dr. Sagar: Yes. And remember, once you are overweight. The chemicals in our body alters in such a way that your mind and body will try to maintain that weight.  So you have to remember this because that’s why it’s easy to lose weight, but maintain it is difficult because now you’re kind of fighting against all these chemicals. So training, how to kind of reduce that, you know, that fight. And then setting a new baseline. For chemicals for your system is more important and that’s the way to sustain the weight loss rather than through the help of these chemicals.

Dr. Weitz: You’ve talked about some specific foods like coffee and Mint to avoid, but is there a sort of general diet that’s beneficial?

Dr. Sagar: Very good question. Nutrition, I love that because I think food is medicine for acid reflux. I would say that a [00:41:00] whole food-based anti-inflammatory diet with emphasis on mindful eating, as we mentioned, chewing the food thoroughly.  Having smaller portions throughout the day and avoiding those trigger is key. There has been some benefit of low FODMAP diet or low acid approaches. And if somebody is interested, they could look into that, but I believe it adding more food items rather than removing. So eating everything but more like whole foods non-processed that’s the way to go.

Dr. Weitz: What about food allergies?

Dr. Sagar: Good question. So yes, food sensitivities or

Dr. Weitz: food sensitivities, yeah.

Dr. Sagar: Yeah. So the food sensitivities can trigger inflammation and motility changes, and that can worsen your acid reflux. So, if you have been tested for food allergies and if you are allergic or sensitive to something, you could start with a elimination diet.  But as I said in my practice, I have seen that it’s never the food, which is the problem. ’cause if somebody, if you [00:42:00] do the food allergy testing on ports on a person who has a lot of GI issues, they will come back positive for like 50 different food items. But it’s usually not the food. It’s because there is something going on in your gut, like there is a dysbiosis or there’s a leaky gut which is causing all this allergies.

So that needs to be addressed,

Dr. Weitz: right? Some patients with gut problems have histamine intolerance. Or elevated histamine levels. Can this also be a factor?

Dr. Sagar: Absolutely. So high histamine levels from diet or from mast cell activation or poor breakdown of histamine can increase the the acid secretion and it can also worse in the reflux.  So you have to support the histamine metabolism and reduce the food items that has histamine. And I also feel like it’s kind of a vicious cycle because if you have dysbiosis, gut issues, then the histamine is produced every time you eat the food. So rather than just suppressing the histamine, addressing the root causes of why you have [00:43:00] elevated histamine is also important.

Dr. Weitz: Okay. I think I, those are the main questions that I had. Any other things you want to tell us about?

Dr. Sagar: Yeah, I think the, in patients with acid reflux, a lot of time we just think about the digestive track, right? The esophagus. But you have to understand that if the a traditional approaches have not worked out, then we have to have a more multidisciplinary approach.

And what we, I’m really talking about. Sometimes acid reflux can give you atypical symptoms like bad dreams or headaches or sinusitis. And when you have a patient who has not improved with conventional treatment, we have to look beyond the digestive track and things like oral cavity. So if you have infection in your mouth because of root canal or poor dental hygiene, remember the microbiome in your oral cavity is not separate from that in the gut, right?

It’s all connected. Swallow that. So you have to look in [00:44:00] your MI oral cavity and probably refer them to a holistic dentist who can actually clear up the infection in the mouth so that they can have a better microbiome and symptoms. Sometimes that helps with acid reflux.

Dr. Weitz: Right? I understand. If you have, say, an increase in p gingivalis in the oral cavity, that’ll lead to a more acidic pH in the mouth.

Dr. Sagar: Yes, exactly. That’s that’s absolutely true. The other thing that we missed is I had a patient actually who had very refractory acid reflux and, you know, she was losing weight and then she had IBS and we did all these endoscopies and different testing. Ultimately I referred her to an ENT specialist and what she really had was a deviated nasal septum, and she went under the surgery to kind of correct the septum and her acid reflux improved.  So looking at the sinuses to see if there is infection there because they’re all interconnected. So just to keep in the back of the mind that sometimes [00:45:00] it’s really not the stomach or esophagus, but it could be the sinuses, it could be your oral cavity. So we have to have like, like this whole person approach to this.

Dr. Weitz: Yeah, that’s a really good point. I think it, the oral cavity can play a role in almost any GI can condition, including, it could be a factor in IBS, SIBO and dysbiosis and we often don’t really pay much attention to it and we really need to.

Dr. Sagar: Yes, we do. And I think we don’t ask this question to our patients, but we should ask them like at night, do you breathe from your nose or from your mouth?  Right. This is important question that we miss as you know, physicians, primary care doctors, because if they’re breathing from their mouth, then it’s kind of like just changing your microbiome, not just in the mouth, but also in the gut. And really the answer is very simple. You just tape your mouth so that you breathe from your nose.  Obviously, your nos, your nostril need to be clear. But this is from habit. Some people breathe from their mouth and that can affect your gut health [00:46:00] also. So please ask, start asking this question to your patients going forward.

Dr. Weitz: And address your oral hygiene with flossing. Do you like things like oil pulling?

Dr. Sagar: Well, I feel like if you, your sinuses and nostrils need to be open. Okay. And whatever helps with that. I’m a big believer in breath work and meditation. Okay. I teach a lot of that in my platform as well. So there is something called alone below, which is kind of a breath work where you close one of your nostril.

And you breathe in from this one, and then you close this one and breathe out from the other one. That’s, if you do that practice every day, it’ll help to open up your sinuses and nostrils. So, simple things. You don’t really have to go to ENT if you can just do this and open up your nervous nostrils.

That, that would be very helpful. That’s

Dr. Weitz: great. So how can listeners and viewers find out more about you, get in contact with you, your website, et cetera?

Dr. Sagar: [00:47:00] So that’s the QR code. Okay. You just like to do this and it’ll take you directly to my online platform. And yeah, once you join, you’ll have access to self-paced modules gut health, root cause all of that.

I do live q and a sessions. We did one session with how to remove subconscious blocks for healing and the during the live q and a sessions. It’s so much fun. It’s a sense of community, a lot. Patients are there and they kind of, we support each other for healing. Now

Dr. Weitz: not everybody is gonna be looking at this.

If you’re listening on your phone, you can go to my White’s Chiro YouTube page and you can pull this up. And this’ll be towards the end. Or if they just want to type in your your URL code to go to your website where would they go? Would they use this code here?

Dr. Sagar: Yes, you can use your phone to kind of scan this, if not the u U RL is on the top, so you, we can just like, put that,

Dr. Weitz: You wanna read it out real quick?

Yes. So, yeah,

Dr. Sagar: sure. [00:48:00] So it’s www.school SKOO l.com. And then there is like a

Slash and guta, so G-U-T-V-A-N-A slash about A-B-O-U-T. And also, if you guys follow me on Instagram, I have the link on the Instagram. So that’s another way to kind of get the link.

Dr. Weitz: What’s your Instagram handle?

Dr. Sagar: It’s Dr.

Dipti. That’s it.

Dr. Weitz: That’s great.

Dr. Sagar: Yeah, it’s all together. There are no dashes. All smalls. Yeah.

Dr. Weitz: Thank you Dr. Segar.

Dr. Sagar: Thank you so much Dr. Wise. It was such a pleasure.

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Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcast or Spotify and give us a five star readings and review.  As you may know, I continue to accept a limited number of new patients per month for functional medicine if you would like help. Overcoming a gut or other chronic health condition and want to prevent chronic problems and wanna promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we can set you up for a consultation for functional medicine and I will talk to everybody next week.