Reflux with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 379

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Dr. Steven Sandberg-Lewis discusses Reflux with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Steven Sandberg-Lewis has been a practicing Naturopathic Physician for 46 years and he continues to teach at the National University of Natural Medicine.  He wrote an awesome medical textbook, Functional Gastroenterology, which is now in its second addition, and his newest book is Let’s Be Real About Reflux: Getting to the Heart of Heartburn.  His websites are FunctionalGastroenterology.com and HiveMindMedicine.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, I’m very excited that we’ll be speaking with Dr. Steven Sandberg Lewis about reflux, which is an extremely common gastrointestinal disorder. 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 percent of most Americans. And in [00:01:00] up to two thirds of those with IBS, which is, I think, the most common GI condition. Heartburn can be caused by a reflux of the intestinal content up into the throat or esophagus, or it can occur without reflux. Other symptoms of reflux include regurgitation, chronic cough, sore throat, vomiting, hoarseness, chronic throat clearing.

Reflux is often used interchangeably with gastroesophageal reflux disorder, GERD, but this is not correct because there are other forms of reflux, including bile reflux. And silent reflux, which is also known as laryngopharyngeal reflux. The NIH website has now introduced a new term, GER which is gastroesophageal reflux, but not disorder.  Anyway, if you’re confused, I’m confused. And we’re going to try to sort this out a little bit with Dr. Steven Sandberg Lewis.

Dr. Sandberg Lewis is one of the smartest integrative physicians I’ve ever spoken to. He’s a practicing naturopathic physician for 46 years. He teaches gastroenterology at the National University of Natural Medicine, lectures around the world.  He has an awesome medical textbook called Functional Gastroenterology, which is now in its second edition. And his newest book is called Let’s Be Real About Reflux, Getting to the Heart of Heartburn. and Dr. Sandberg Lewis Practices in Portland, Oregon at Hive Mind Medicine. Dr. SSL, thank you so much for joining us.

Dr. Sandberg-Lewis: Yeah, my pleasure. Always good to talk with you.

Dr. Weitz: You know, one of the coolest things about your book is the limericks. Every chapter has a limerick.

Dr. Sandberg-Lewis: Yeah, we wanted to be a little lighthearted about it too.

Dr. Weitz: I want to read the limerick for the introduction. If a hammer is all that you see, then now every problem will be.  So reject a poor hammer and think in a manner that allows things to be seen clearly. So let’s see if we can see clearly about reflux.

Dr. Sandberg-Lewis: Yeah, well, you know what you said, Ben, about GER, Gastroesophageal Reflux, without the D on it.

Dr. Weitz: Yeah,

Dr. Sandberg-Lewis: We add the D when there are symptoms or destruction, you know, of tissue.  But GER, just having reflux itself, is considered a normal phenomenon that occurs perhaps about three times after each meal. But it’s so minimal, and if all the protective mechanisms are in place that move it back down before it does any damage or causes any symptoms, then people don’t even know they have it.  And, you know, we talk about this as like, babies actually have regurgitation as a normal thing.  Most babies spit up in the first year of life and that’s not considered a problem unless they have failure to thrive or start to have other kinds of problems or sleep problems or pain or other signs of distress.  Yeah these reversals in flow of the upper GI tract are normal as long as all the protective mechanisms are in place.

Dr. Weitz: So essentially everything in the GI tract is supposed to go from north to south and anything that moves the opposite direction is what we call reflux.

Dr. Sandberg-Lewis: Yeah.

Dr. Weitz: But why should there be a normal amount when you eat if we have all these contraction of these muscles and this motility mechanism that pushes everything down?

Dr. Sandberg-Lewis: Well, again, There’s so many different mechanisms and that’s why I have a chapter in there on all the mechanisms of this. But if you think about probably the simplest one or the most direct one to discuss is transient lower esophageal sphincter relaxations, right? So TLES for lower esophageal sphincter and relaxations.  So this is a normal mechanism that allows gas and pressure to vent from the stomach out as a belch. And it involves [00:06:00] the lower esophageal sphincter opening much longer than a normal swallow. So normally when someone swallows, something the peristaltic wave moves down, muscularly moves the food or liquid down, and then the lower esophageal sphincter just opens just for a couple of seconds to allow the material to move through, and then it closes tight if it’s working properly.  And that’s its normal state is to be closed and contracted. With TLESRs they’re opening the lower esophageal sphincter and then eventually the upper esophageal sphincter to allow gas to vent from the stomach so people don’t have horrible pain. Some people can’t belch properly and they have a lot of pain. I see a lot of those people. So this lower esophageal sphincter relaxation, this transit type, it’s not that transit.  It’s sometimes up to 20 seconds long, and that’s just way longer than it’s supposed to stay open. [00:07:00] So people who eat in a way that creates more gas in their stomach or small intestine and need to vent it, they can have a lot more reflux. That’s thought to be a major mechanism.

Dr. Weitz: Or people have SIBO who have more gas being produced, right?

Dr. Sandberg-Lewis: Right. Small intestine moving up into the stomach and then venting, you know, can vent either way. It could go down or up, but up is closer.

Dr. Weitz: So what’s the difference between, explain more about what exactly is heartburn as compared to reflux?

Dr. Sandberg-Lewis: So heartburn is that, as you said, subjective sensation of burning or pressure usually in the lower sternal area sometimes slightly lower, but usually right around there, substernal, and it’s not necessarily only caused by reflux of [00:08:00] stomach contents into the esophagus. That’s one cause, but it can also be caused by just pressure differentials. So there’s this thing called Functional heartburn, where there’s actually no reflux at all. If you do all the tests to see if there’s actually reflux, there isn’t, but people have the same symptoms and there’s all kinds of creative ways to explain that nobody really has pinned down the exact mechanism of why people have burning pain, substernal, without having any reflux of stomach contents.  But, it’s fun to make up mechanisms, but, yeah, you don’t have to have reflux of stomach contents into the esophagus to have the same symptoms. An interesting thing, I mention a study in the book where they just found that pressure from, say, more [00:09:00] gas or anything that distends the esophagus, pressure in the esophagus can either trigger burning pain or it can trigger chest pain.  People feel like they’re having a heart attack. And that’s why reflux is, sometimes they say it can mimic a heart attack or angina, because it’s a very similar sensation. And it doesn’t have to be from reflux. It could just be from pressure within the esophagus.

Dr. Weitz: Now it’s generally thought in the medical community that reflux has to do with too much hydrochloric acid, which is why medications are often prescribed that reduce acid.  Like PPIs.

Dr. Sandberg-Lewis: Right. But that’s why I wrote the book. Cause that’s not the whole story.

Dr. Weitz: Of course. And in fact more people have low acid than high acid. [00:10:00]

Dr. Sandberg-Lewis: Yeah. So again, just having pressure of fluid in the esophagus can cause heartburn or chest pain. So it doesn’t have to be acid. Also and that’s called either weakly acid reflux or non acid reflux.  And it’s probably 40 percent of cases of people with heartburn that are tested. But also, Remember this. First of all, there are a number of really good studies that purport that the symptoms of reflux are actually due to inflammation and not burning. It’s like, oh, it’s not actually burning the tissue, it’s causing inflammation in the tissue.  So that’s one thing. And of course, chronic inflammation can lead to Barrett’s esophagus and even cancer of the esophagus, so that’s a big deal. But also, if you think about it, what’s the actual cause? enzyme that digests [00:11:00] protein. The first one is pepsin, right? And pepsin is the active hormone that can digest tissue such as the lining of the lower esophagus or the stomach if it’s not protected properly.  But it’s actually secreted as pepsinogen, a zymogen that doesn’t have that ability. And it’s the acid in the stomach. The pH of the stomach cleaves it and turns it into, from pepsinogen into pepsin. So, again, you don’t actually have to have fluid refluxing. You may just have kind of a mist, you know?  You can have, and we think that’s why, reflux can really aggravate asthma because you’re inhaling pepsin and stomach acid and [00:12:00] possibly slightly not completely digested food in little droplets and inhaling that into your lungs. Wow. Irritant. There are other mechanisms for that as well, but just think about it.  You don’t have to have fluid coming up. You don’t have to have food coming up. It could just be a mist of pepsin and or acid. And the pepsin alone is enough to cause a lot of irritation.

Dr. Weitz: How do we know about this mist? Has that been something that’s been confirmed by some sort of testing?

Dr. Sandberg-Lewis: The The standard tests that are used for reflux don’t actually show that, but there is a test where you can check pepsin levels in the saliva.  And you know, if you’ve got significant amounts of pepsin, like 40 units or more in a saliva specimen, you know for sure that what was in the stomach is now in the throat. [00:13:00] And so it’s especially used to help to diagnose LPR, that laryngopharyngeal reflux that you mentioned. Where people don’t necessarily have heartburn symptoms in the lower sternum, but instead have all these voice and throat symptoms that you mentioned, like clearing and coughing and sore throat and changes in their voice and hoarseness, et cetera.

Dr. Weitz: So for physicians listening, right?

Dr. Sandberg-Lewis:  Your patient doesn’t even need you to order the test. They can go to, I think it’s pepsincheck. com, I think is the website. And they can order a pepsin test. They get three vials to take samples of saliva three different times in the day, and they’ll measure it for pepsin, and then they can share those results with you.

Dr. Weitz: Interesting. For the average patient with reflux, since most people don’t have too much [00:14:00] acid, is there a real rationale for using PPIs, proton pump inhibitors?

Dr. Sandberg-Lewis: Well, of course, there’s proton pump inhibitors and there’s histamine blockers.

Dr. Weitz: Okay. And so like Pepin is an H2 histamine blocker. 

Dr. Sandberg-Lewis: Pepcid AC is a brand name for famotidine the generic, which is a H2 receptor antagonist. Yeah. And I like, I just had a new patient who was having severe, severe cutting pain and he, we know based on his upper endoscopy that he has duodenal ulcers, multiple ones, not just a single solitary one. And he was having so much pain and taking a proton pump inhibitor didn’t do anything for his pain. He got some relief from sucralfate, which is, it’s kind of like [00:15:00] a I call it allopathic, DGL ’cause it kind sos it kind of coats the tissue and relieves it.

Dr. Weitz:  What is it called?

Dr. Sandberg-Lewis:  Suc fate. Suc. Suc crawl fate. It’s S-U-C-R-A-L-F-A-T-E. Huh. Anyway, he got some relief from that, but then he started to have side effects, so he’s now taking famotidine and that has. because it’s an H2 receptor blocker has completely taken his pain away so far. Totally different mechanism.  So again, this is a guy, he’s a guy who tends towards asthma and other allergic tendencies, and so it, it makes a lot of sense if he actually wants to block his acid to, to use this kind of histamine mechanism, rather than try to just shut off the whole proton pump, and a lot of people don’t tolerate that.

Also, like you said when I do Heidelberg testing in my [00:16:00] office to actually measure pH, I used to say, about 25 to 30 percent of people actually are hypersecretors of acid and the other probably 50% underproducing and the rest were normal producers of acid. But what I’m seeing now more and more, I’d say it’s about 50:50.  So about maybe 50 or 40 percent of people are hypersecretors of acid. But this is one thing I think is really important and I think what’s happening is people who have been taking a proton pump inhibitor, when they go in for testing, you know, any kind of testing to see if they have reflux, they have them stop the proton pump inhibitor for seven days.  And then they do the test, and I think that clearly, during that time, they are hypersecreting because [00:17:00] their proton pump inhibitor is not there, so all of that histamine and gastrin, we know gastrin levels go sky high in the blood when you’re taking a proton pump inhibitor, because gastrin is the stomach hormone locally produced that’s trying to trigger you to make more acid, but you can’t because you’ve taken the proton pump inhibitor.  You take that drug away and now you’ve got these really high levels of gastrin and now you’re going to produce huge amounts of acid. So people that get tested for reflux after they’ve already been on a trial of proton pump inhibitors, often look like they produce huge amounts of acid. So I don’t blame anybody for being confused about that and thinking, oh, it’s all about too much acid.  Well, it is once you’ve been taking a proton pump inhibitor for three or four weeks or three or four years, or some of my patients 20 years. I think that, unfortunately, those very good tests, [00:18:00] like the Bravo test and the pH impedance test, they’re, unfortunately, they’re measuring, most of their patients are people that were already put on a proton pump inhibitor, took it away for a week, did the test, and they just look like they create huge amounts of acid, even though that might not be where they started.  Interesting. So what is bile reflux? So bile reflux is when you move down one valve and if the pyloric valve instead of the lower esophageal sphincter is not functioning properly and staying closed.

Dr. Weitz: So this is a valve between the stomach and the small intestine?

Dr. Sandberg-Lewis: Right, and when that valve is hypotonic, or not as functional as it should be, that can allow reflux of small intestine contents into [00:19:00] the stomach, and that alone can then cause a lot of irritation because bile, okay, let’s talk about, so what’s coming up through the pyloric valve.  It’s bile, it’s bacteria and fungus, it’s Brush border enzymes that are produced on the small intestine lining. It’s undigested food, you know, not incompletely digested food. And it’s also pancreatic enzymes, which can also digest fat, protein, and carbohydrate. You know, there are proteases in there really strongly.  So, now you’ve got this soup, and then you might mix it with stomach acid in the stomach, and pepsin, and now it’s a much more complex soup. irritant. And then of course if people have reflux into their esophagus, all of that goes up into the esophagus. But some people it just really irritates their [00:20:00] stomach and that’s called bile gastritis or reactive gastritis.  But if it refluxes into the lower esophagus it can cause the worst kind of reflux heartburn. esophageal irritation. And we think actually is a more potent stimulator of Barrett’s esophagus over time than just regular reflux.

Dr. Weitz: Yeah. I spoke with Dr. Rahbar and he said when he does his endoscopies, patients with SIBO have an increased risk of that bile reflux.  And he feels that potentially indicates fungal overgrowth. I forgot why though.

Dr. Sandberg-Lewis: Well, you know, he I liked, I really liked the way he does his upper endoscopies. First of all, when he’s checking for parasites, often he’ll take a sample of the bile, actual bile from one of the ducts, or if it collects in the duodenum, and he’ll test [00:21:00] that instead of just stool for parasites because we know parasites like to live in the gallbladder. But also he and Dr. Satish Rao can also culture the duodenal contents for fungus as well as bacteria and see the exact, what’s actually overgrown instead of just the breath test that doesn’t tell you, just shows you how much gas they produce.  So yeah he’s very progressive. I love what he does.

Dr. Weitz: One of the fears of reflux is that if it burns the esophagus, it can set up the risk of Barrett’s esophagus and eventually esophageal cancer. So, how do we protect against that? Obviously, we have to reverse the reflux, and part of it’s about the protective factors in the esophagus.

Dr. Sandberg-Lewis: Yeah, so first of all I [00:22:00] mean the best thing you can do is to actually diagnose Barrett’s early, and the, it’s kind of a joke in terms of how few people actually get tested for Barrett’s because if you, if you consider the top four risk factors, being Caucasian, being male, being over 50, and then there’s a whole other list.  So basically, all white guys over 50 should be screened because they have the highest risk. If you add type 2 diabetes any smoking history, and then also having a waist circumference that puts you in the visceral adiposity obesity range. Those are all big risk factors. So, you know, there’s just, there’s a lot of people that should be screened.

And that’s why I wish that the ESOGuard test [00:23:00] had been picked up and used by more doctors, because that’s a non, kind of a non invasive way to take a sample, like you would take a pap smear. You take some tissue from the cervix and the vagina and you can check it microscopically. In this case, they take some scrapings brushings from the lower esophagus by putting a tube down through the nose and down into the lower esophagus expanding this little bulb on the bottom, pulling it up through the lower esophagus, and then deflating it again and taking it out. It takes like five minutes. And then they can check it for DNA adducts that are common for Barrett’s esophagus. Or esophageal cancer. So it’s just a great little screening tool.  Unfortunately, it didn’t catch on and I hope that over time it will. I talk about it in the chat. Is that a test that you do? It is. It, you [00:24:00] know, it’s not available everywhere, but we do have it available here in Portland. There’s a hospital that where you can send patients where they do it. ESOGuard test, but anyway in terms of besides early diagnosis once you know that the patient has it.

There’s so many things you can do. So first of all you can use green tea extract, you can use vitamin A and C, excuse me, vitamin C and E, you can use of course diets that are higher in fruits and vegetables, and we often will use a, an extract of berries, like a frozen berry extract, so they can get a real good dose of anthocyanidins and beta carotene through that each day.  And then folic acid, and also riboflavin those B vitamins have been shown to be really protective against further [00:25:00] development. And then you know, like you said, probably the most important thing is actually treat the cause behind the reflux if you can, so they don’t continue to have reflux and don’t have that chronic inflammation.

I mean, the good news is that, Even in men that have a higher risk of this, you know, if you know the patient has Barrett’s esophagus, you can periodically biopsy those areas and make sure there’s no dysplasia occurring, because mild, moderate, and severe dysplasia, just like with a pap smear, you know, looking for dysplasia, those are the precursors to esophageal cancer in this case.  when you check in the lower esophagus. So you can prevent dysplasia and prevent the whole process from going forward to cancer with a lot of these factors. And of course, all the lifestyle factors that help to correct that need for transient lower esophageal sphincter [00:26:00] relaxations and gas and all those things that fuel reflux.  We talk about that in the chapter on lifestyle issues too.

Dr. Weitz: What about using nutrients that would directly affect the esophagus. I’ve had some patients slowly sip on some slippery elm in water to try to soothe the esophagus and produce some healing.

Dr. Sandberg-Lewis: Yeah. Some of the, probably the more healing herbs that we use for that are the DGL, you know, the licorice without the glycyrrhiza, unless your patient’s also hypoadrenal, and then you might want to use some whole licorice as well. Slippery Elm Althea, which is marshmallow root Aloe Vera, all those things can really help allay irritation, chronic inflammation and often heal tissue. But melatonin is another [00:27:00] really important one, and that’s why there’s a whole chapter in the book on melatonin, because it’s It just really impresses me that there’s a study that shows that people with the lowest melatonin levels are people who have duodenal ulcers.  People with the slightly better levels have erosive esophagitis, and people with the best levels of melatonin in their system are people that have NERD, which is non erosive reflux disease. They don’t have any damage. from reflux, even if they have reflux. So in all three cases, you’re talking about people.

Dr. Weitz: And what do we think would be a reasonable dosage of melatonin? Because people are all over the place on how much melatonin they use. When it comes to sleep. [00:28:00] Some people are advocating three. I’ve heard people recommend 3. There’s some herbal melatonin now that Deanna Minich is recommending at super low dosage.  And yet on the cancer front, people are recommending two or three hundred milligrams per day. Yeah, they’re, yeah, I know when I read your book, you were talking about the levels in the gut as being like 400 times the levels in the bloodstream. So I’m wondering, would that lead to a recommendation of a higher dosage of melatonin to take for this purpose?

Dr. Sandberg-Lewis: Yeah, so, typically we use 3-6 mg.

Dr. Weitz: Which is to the sleep recommendation.

Dr. Sandberg-Lewis: Yeah, yeah. And, on the other hand, if you consider one of the risk factors for [00:29:00] Barrett’s esophagus is sleeping less than 6 hours.

Dr. Weitz: Oh, really?

Dr. Sandberg-Lewis: Yeah, it’s on that list with the other things I mentioned.

Dr. Weitz: Oh, okay. So,

Dr. Sandberg-Lewis: again, if you can improve someone’s sleep and if you can balance their melatonin, cortisol, and DHEA, You know, because there’s a big relationship there, right?  When cortisol is highest in the morning and drops down to its lowest at night, that’s what allows melatonin to come up. And then melatonin drops as cortisol’s coming up in the morning. And so they take turns, you know, they’re in phases. And so, if you can improve sleep, if you can balance cortisol and other stress hormones so that people make more of their own melatonin, I think that’s probably the best.  I probably don’t, I don’t have people take melatonin as a pill, as much as I try to really improve their sleep and their stress hormone balance.

Dr. Weitz: How do you help them improve their sleep?

Dr. Sandberg-Lewis: Oh, yeah. Well, first of [00:30:00] all if you find somebody who’s got high cortisol at night, instead of its lowest level, right.  That’s really going to help them sleep. If you can help modulate it with adapted genic herbs especially ashwagandha. Okay.

Dr. Weitz: Phosphatidylserine.

Dr. Sandberg-Lewis: Phosphatidylserine is one that we think works through the ACTH, negative feedback loop. And then sometimes if they also, as well as having a high cortisol, they also have a low DHEA. Bringing up the DHEA will help modulate the cortisol down toward where you want it. So it’s a balancing act there.  And then of course there’s sleep hygiene and, getting people off of their screens late into the night and all that kind of thing. 

Dr. Weitz: Getting away from the blue light, et cetera.

Dr. Sandberg-Lewis: Yeah. Or neurofeedback and other forms of biofeedback that can help. The gut and the nervous system produce better [00:31:00] levels of these sleep hormones and protective, GI protective hormones.  So again, yeah, it’s a, there are lots of ways to approach it, but if you can get their melatonin and its related hormones in balance, that’s probably even better. And, you know, get them sleeping closer to eight hours.

Dr. Weitz: Now there’s a number of categories of drugs that increase your risk of reflux. So we have drugs such as NSAIDs, corticosteroids, alcohol, bisphosphonates, which are the anti resortive drugs for osteoporosis that we know have esophageal issues benzodiazepines, which people often use for sleep or for stress, and calcium channel blockers. [00:32:00]

Dr. Sandberg-Lewis: Yeah, so things that disrupt the muscle function, smooth muscle function anticholinergics can be a problem there too. But you mentioned about the bisphosphonates, I think, so there’s two categories really, there are drugs that irritate the esophagus, and can make reflux worse, the symptoms worse, and bisphosphonates are in that group.  You know, that’s why you have to be able to stand or sit for at least 30 minutes after you take it, so it won’t pool in your esophagus, because it’s so irritating, and NSAIDs are the same way. But then there’s the other group that affect the muscle tone or other factors that actually can cause reflux, and you mentioned those.

Dr. Weitz: And that whole thing about the position you’re in, that’s super important for managing reflux, meaning patients who you’re trying to help relieve their reflux, you want to recommend that they not eat a [00:33:00] meal and then put their feet up or recline that they sit upright. Maybe I often will suggest going for a walk just to push the food down and decrease the likelihood that things will come up.

Dr. Sandberg-Lewis: Yeah and that’s the reason why. finishing food by at least three hours before you lie down to go to sleep is a great idea. And some people do much more than that, more than three hours sometimes. But I think you might want to also consider people that have reflux symptoms that have a hiatal hernia, sliding hiatal hernia.  And then those who don’t, you know, they have reflux, but don’t have a hiatal hernia. Really when you think about it, If you have a sliding hiatal hernia and it’s up, cause it can slide up and down.

Dr. Weitz: Right, so let’s explain to the public what we’re talking about. You’re talking about this opening in the diaphragm [00:34:00] and the stomach slides up through that opening, correct?

Dr. Sandberg-Lewis: Correct.  Yeah, so, of course, the esophagus is in the chest with the heart and the lungs.

Dr. Weitz: Right.

Dr. Sandberg-Lewis: Then there’s the diaphragm muscle, and it separates everything that’s in the chest from what’s in the abdomen. The stomach’s in the abdomen, so it has to meet up with the esophagus, and they’re in two different parts of the body.  So there’s an opening called the hiatus, which means window in Latin the hiatus of the diaphragm. That allows the esophagus to meet up with the stomach that’s underneath the diaphragm. And so a sliding hiatal hernia, let’s say this is the hiatus here in the diaphragm and here’s the stomach hiatal hernia is typically about two centimeters is an average small one.  Two centimeters of the stomach has moved into the chest. Sometimes three centimeters. If they’re [00:35:00] really big, they’re larger than five centimeters. So even having this, basically a less than an inch of the stomach in the chest can cause all kinds of symptoms. And if you think about it, the diaphragm is a muscle.

It’s smooth muscle, just like the lower esophageal sphincter, which is part of the esophagus. The esophagus and the lower esophageal sphincter are running through that hiatus in the diaphragm, which is a muscle and actually has to what are called CRUX, C R U X, and it means like a cross, and these are like little extensions of the muscle of the diaphragm that hug the lower esophageal sphincter.

So the lower esophageal sphincter is a muscle. and it’s surrounded by the diaphragm muscle. You put those together and you have a [00:36:00] really good system. If you move the lower esophageal sphincter, which is right here at the top of the stomach, up two centimeters or three centimeters, now it doesn’t have its big brother around it, hugging it anymore.  it’s going to be way weaker. So those transient lower esophageal sphincter relaxations and regular openings, all of that can be a lot weaker. So having a high sliding hiatal hernia just adds a whole new ball of wax to the whole reflux issue. That’s why it’s really important to deal with it if you can.

Dr. Weitz: What do you think about patients getting that surgery, the Nissen fundoplication?

Dr. Sandberg-Lewis: Yeah, Nissen fundoplication is, often a pretty effective treatment. There are visceral manipulation and exercise treatments that [00:37:00] can correct the smaller ones.

Dr. Weitz: Yeah. I often use the technique I learned from you.

Dr. Sandberg-Lewis: Yeah. But yeah, for persistent ones or the really large ones the ones that are greater than three centimeters that just won’t stay down, or if someone has hypermobility syndrome, like Ehlers Danlos Syndrome, where their tissues just don’t hold things in place as much, those people are really prone to lower esophageal sphincter laxity and hiatal hernia, sliding hiatal hernia, that you can put it back in place, but it won’t stay.  So, there are definitely some good reasons to, to use Nissenfund application if it’s needed as a last resort.

Dr. Weitz: Now we’re talking about medications and we know that anything that alters esophageal or gastric motility, is going to increase the risk of reflux. And we now have this class of medications that is taking the [00:38:00] country by storm, that we’re now seeing millions of people use, and we’re probably going to see Tens of millions on soon.  And these are the GLP 1 agonist drugs like Ozembic, which people are using for weight loss. And now they’re being touted for 20 other health benefits supposedly. And we know that they work partially by slowing gastric motility.

Dr. Sandberg-Lewis: Right, slowing down the absorption of carbohydrates. They, really, GLP and the other incretins that are normally produced in the small intestine, they are amazing.  They’re really important. for treating diabetes and insulin resistance and helping people lose weight and normalize their blood sugar. 

Dr. Weitz: But all these GI disorders that are related [00:39:00] to decreased motility are likely to be exacerbated.

Dr. Sandberg-Lewis: It’s very, yeah it’s a side effect that can definitely be an issue. 

Dr. Weitz:  I asked Dr. Pimentel and he said looking at breath tests and and microbiome of these patients, it’s totally messed up.

Dr. Sandberg-Lewis: Yeah, and I’m, I think that there’s another drug that has the GLP 1, but also has another in Cretin as well Terzapatide. Yeah. And I think that one’s gonna turn out to be a better choice because, again, when they started giving all women going through menopause estrogen back in the 1960s, It was a miracle.  I mean, their hot flashes were better, they slept better, all kinds of things were better. Then they found out a lot of them are getting cancer of the uterus. Because you’re only [00:40:00] using one hormone. And what about the progesterone? They balance each other. They’re… 

Dr. Weitz: Not to mention it was horse estrogen.

Dr. Sandberg-Lewis: Well, yeah, I mean, you can, you could argue about the ratios of E1, E2, and E3. 

Dr. Weitz: Horse estrogen.

Dr. Sandberg-Lewis: The thing is,

Dr. Weitz: we gave women horse estrogen.

Dr. Sandberg-Lewis: The thing is that I think whenever you give a single hormone and you don’t give its sister or brother hormone, the other incretins in this case you’re looking for trouble.  You’re gonna, because every, basically every or most of the endocrine organs in the body have these paired balancing hormones. And if you look, even look at the thyroid, We know that thyroxin demineralizes bone if you have too much of it. Thyrocalcitonin, also produced in the thyroid, builds [00:41:00] bone.  So if you just give one hormone, you can really cause imbalances. You don’t get that fine tuning that we normally have. So that’s why I think we’re going to find that using the incretins as a group, instead of just semaglutide by itself, It’s probably going to be better. But of course, if you can get your patient to make more incretins, just like if you get your patient to make more melatonin, instead of having to give it to them, that’s even better.  And there’s lots of good ways to do that.

Dr. Weitz: Right. But don’t you think we’re likely to see a big increase in reflux?

Dr. Sandberg-Lewis: If you consider that it’s, So common already. You mentioned 30 percent of the population has reflux at least once a week and maybe 20, 20 percent has it on a regular basis.  More often than that, it’s already so common. Yeah, again, you can’t fool mother nature. You can’t mess [00:42:00] around and not use a balanced approach and not expect to do well.

Dr. Weitz:  When you have patients who are taking proton pump inhibitors, how do you handle that? If you have ’em, stop them.  How do you wean ’em off?

Dr. Sandberg-Lewis: So first of all, the newest recommendations from the American College of Gastroenterology for Barrett’s esophagus is for patients to be offered a proton pump inhibitor to take at least once a day. indefinitely. They have found that that does reduce the risk of dysplasia and conversion to esophageal cancer.  So currently, its changed. Three years ago, they didn’t say that. They said it wasn’t beneficial. And now the research shows that it is. I let patients know that. I let them know that unless they have bad side effects or for some other reason, can’t take a proton pump inhibitor, taking one [00:43:00] once a day, if they have Barrett’s is the recommendation.

Dr. Weitz: And what if they don’t have Barrett’s and they’re worried about?

Dr. Sandberg-Lewis: If they don’t have Barrett’s and they just have heartburn and you think it’s reflux or you know, it’s reflux. Right. Certainly if they have erosive esophagitis. You know, there’s LA grade A through D esophagitis, and D is the worst, but if they have grade C or D reflux esophagitis, I recommend that they do take a proton pump inhibitor until it’s healed.  And a lot of those people may need it long term unless you can treat the causes of their reflux. So there’s a place for it. And it really can heal. And it’s just, those are the people that they take a proton pump inhibitor and it’s like a miracle from the first dose. because all that incredible burning pain that they’re having all the time from a raw esophagus that’s eroded [00:44:00] is suddenly gone.  It usually works really well for those people. So you use it until it’s healed and you work on the underlying causes while you’re doing that. If someone’s just taking a proton pump inhibitor because that’s all their doctor knew for their heartburn, a lot of times it’s not even working. 40 percent of the time it doesn’t work, and people still take it because, well, my doctor told me to.

Those are people that, you can definitely wean them off if it’s not helping anyway. And a lot of people that it is helping, you can wean them off too if you can treat the underlying causes. So I have a little step down approach to it where what we often do is we will Let’s say they’re taking a proton pump inhibitor when you first see them.

They’re taking it twice a day, maybe at high potency. We’ll cut it down to the lower potency twice a day. [00:45:00] And then if they’re doing just as well as they were before, then we’ll cut it down to once a day. If they start having reflux, that part of the day where they’re not taking their second dose, We’ll, you know, we’ll use these, either a natural medicine to help that, or we’ll use famotidine, that H2 receptor antagonist, which is, in my experience, a lot less prone to creating this rebound hypersecretion.

We keep doing that, you know, if it’s been, it could be two weeks, it could be a month, they’re realizing, okay, I’m doing fine now. Then, we take the other dose of the proton pump inhibitor out. And if they need it, we might use the famotidine. So they’re taking it once or twice a day on the days they’re not taking the proton pump inhibitor.

And now they’re taking maybe the proton pump inhibitor Monday, Wednesday, Friday, and Saturday. [00:46:00] And they’re just taking the famotidine on the other days. And if they’re doing just fine, we go even further and we have them just take it Monday, Thursday, and Sunday, you know, every third day. And it’s a very slow process.

When someone’s been on a proton pump inhibitor for decades sometimes, even just years, you really have to do it slowly. But if you do it slowly, you can normalize that rebound hypersecretion. There’s one study that states that rebound hypersecretion can, in some cases, can go as long as 8 months. Wow. So, yeah, you know, if someone’s been taking a proton pump inhibitor for a long time, take your time, have them take their time and say, Hey, look, if a year from now, you’re off of this drug that you don’t need, because we’ve assessed you don’t need it what’s the harm?  You’ve been taking it for 5 [00:47:00] years already, right? If you just try to stop it quickly, you will fail. So let’s do it right.

Dr. Weitz: H. pylori infection. Now, the story about H. pylori infection, for people who don’t know, is that this is a bacteria that burrows itself into the wall of the, into the stomach, and that Dr. Marshall proved a number of years ago that this was the cause of ulcers. And he did it by drinking H. pylori solution, gave himself an ulcer, proved that he had it, and then used triple antibiotic therapy, two antibiotics along with the PPI and cured himself of ulcers. And so the thought was that these ulcers derive because the [00:48:00] stomach starts secreting more acid in response to the H. pylori. And a lot of doctors feel that H. pylori infection is one of the causative, possible causative factors of reflux. I know that you definitely disagree with that.

Dr. Sandberg-Lewis: It’s a, it’s just a misconception. All the, virtually all the research shows that H. pylori is protective against reflux, Barrett’s esophagus, and esophageal cancer.  So to me it makes no sense to even test somebody for H. pylori if they already have reflux or Barretts. And then, if they have an upper endoscopy. They’re going to be tested because you, that’s part of an upper endoscopy, and they’re going to get treated if they have it. [00:49:00] Luckily, the research that I looked into says that if you treat the H. pylori once you already have Barrett’s, it doesn’t seem to make it all worse. It doesn’t make the reflux worse, but 100 percent of the world’s population, we think, had H. pylori in their stomachs for at least 60, 000 years until we started killing it in the 1990s. And yeah, it can cause duodenal ulcers, stomach ulcers.  It can cause gastritis, inflammation of the stomach lining, and it can cause a really rare form of lymphoma that occurs in the stomach called maltoma. And there are some other conditions that it can aggravate. It can aggravate psoriasis and a number of other things, chronic hives. There are other things that it could be associated with in adults.

But in children, it’s [00:50:00] very important for maturing the immune system, especially in the gut where most of the immune system is. And so our concern and Dr. Blaser writes about this very eloquently, the concern is we’ve gone from 100 percent of the world’s population having this protective thing in the first few years of your life to mature your immune system to having less than five percent of children in the US have it now when they need it. And, it’s also, it reduces the risk of hay fever, food allergy, respiratory allergy, asthma, Crohn’s disease. Really good meta analysis showing, a bunch of studies that show that it really helps protect against Crohn’s disease.

Dr. Weitz: Is there any way that we know of to increase H. pylori?

Dr. Sandberg-Lewis: Well, yeah Blaser has a great solution. And he says, so he thinks once the FDA understands this process, which might be 30 years from now when babies are born, they will give them a multi strain probiotic of H. pylori, not just one strain, several strains seems to be better than one, and they’ll just give the, to the kids, and then they’ll have that protection.  reduce risk of autoimmune diseases, allergic triad, and reflux and its complications. And then, if when they’re older, they develop ulcers, or they look like they might be at risk for stomach cancer, if there’s a family risk, then they’ll kill it with triple therapy, but they will give it to the newborns that need it.  So, so much.

Dr. Weitz: Yeah. We do the GI map stool test quite a bit, and that includes H. pylori and the virulence factors.

Dr. Sandberg-Lewis: Yeah. Now, you know, I have a bug about that, and that is I have a slide in my lecture on H. pylori and it says, how natural doctors get it wrong. My feeling is if you’re going to do stool panels.  Do a stool panel that doesn’t have H. pylori. I use, can I say names of labs? 

Dr. Weitz: Yeah, sure.

Dr. Sandberg-Lewis: I use Doctor’s Data Origin, sometimes Genova, but mostly Doctor’s Data. They correctly on their panels, they’re checking for parasites and they’re checking for fungus and they’re checking for beneficial bacteria.  They check for pathogens like Clostridium Difficile, but they don’t test for H. pylori unless you do a special order for it, because I don’t want to test my patients. that just have reflux. I [00:53:00] don’t want to test them for H. pylori and then have to kill their H. pylori, which has nothing to do with causing their reflux.

Dr. Weitz: Well, I don’t feel any compulsion to having to kill their H. pylori just because it comes up.

Dr. Sandberg-Lewis: Well, that’s the thing though, is a lot of doctors, when they see that it’s a positive, and for good reason, the dictum in H. pylori The world of H. pylori is test and treat, meaning if you test somebody, you’re supposed to treat them,

Dr. Weitz: right?

Dr. Sandberg-Lewis: So I don’t even want to test them unless I have a good reason to because they have a disease that’s associated with a more virulent form.

Dr. Weitz: Now, I’m pretty sure that you write in your book that if we use like the triple antibiotic therapy, which is the standard for killing H. pylori, that can increase the risk for GERD, right?  Or [00:54:00] reflux?

Dr. Sandberg-Lewis: I think the mechanism there is I’ve seen people develop SIBO and IMO. Okay. Overgrowth after triple therapy, because it’s kind of a perfect way to get Overgrowth, right? You’ve taken two antibiotics that really affect the balance. And then you’re taking a proton pump inhibitor, which has more negative effects on the microbiome probably than the antibiotics, but you put all three together and you’re really, really likely to get overgrowth.  So yeah, you can definitely get reflux when you didn’t have it before. I see that a lot, I don’t want to talk people out of. Treating H. pylori or saying they’re doctors wrong because it’s test and treat. I wonder what the

Dr. Weitz: effects are if we treat it with mastic gum and the other natural treatments.

Dr. Sandberg-Lewis: What you do that and then you retest them and you see if it worked.

Dr. Weitz: Sometimes, sometimes we just base on how they feel.

Dr. Sandberg-Lewis: Yeah, mastic is a wonderful demulsant, it just it can heal [00:55:00] ulcers. We know that it’s used For thousands of years for that purpose and gastritis. It’s really soothing and healing And there are some studies that show a little tendency for it to reduce H pylori But you know no single agent kills H. pylori. That’s why triple therapy and quadruple therapy are what they are, right? Right. So there’s no prescription or natural thing that’s going to work on its own. It’s going to have to be a combination. And really if you’re thinking the H. pylori really needs to be killed, then you need to retest.

And the thing about, one thing I’ll say about the GI map, their test, if I’m correct, when I look at it, their H. pylori test is DNA. It’s PCR DNA. Correct. And that is not a standard test [00:56:00] for H. pylori. It’s their own test that they made up. I think it’s great to be creative, but I’m not going to di I’m not going to diagnose H. pylori based on that because it’s not a standard test. So if it comes back positive, I run a standard test, which would be H. pylori IgG blood antibody, Or even better, H. pylori stool antigen, you know, which is a protein in the stool, or H. pylori breath test. Those are definitive tests, and the breath test, as well as the stool antigen, those are telling you that you have it right now.  The blood antibody, if you got treated, it could still be positive, even if it’s gone. You can’t use that to retest. But the stool antigen or the breath test, they’re going to, they’re going to turn negative. Once you’ve treated it properly. So, I just say, if you’re going to do that and nothing wrong with the [00:57:00] GI map, double check it with a standard test.  If you get a positive.

Dr. Weitz: Let’s go through some of the most important treatments that we want to think about. You’ve mentioned some of them already, but we were trying to find some of the underlying causes. So we want to see if they have. Structural issues like some of the ones you’ve talked about, like hiatal hernia problems with the lower esophageal sphincter whether they have issues with motility we want to see if they have SIBO, because SIBO can lead to gas and affect motility, and then correct those.  We want to rule out food sensitivities, right? Do you regularly rule out food sensitivities or is that something you look at sometimes?

Dr. Sandberg-Lewis: You know, I tend to use diets that initially are restrictive of certain food groups, and [00:58:00] I tend to do that as more of an elimination diet rather than testing, but it’s an important thing.  I know personally from my own health, and I never talk about my own case, but when it comes to reflux, If I want to have reflux, all I have to do is eat white potato. Really? If I eat white potato in any form, more than a couple teaspoons, I’m going to have reflux. Now, of course, I do a lot of things right in terms of my overall diet, but that’s the one thing I know will do it.  And I have other patients that it could be that, it could be sugar, it could be one patient it’s kiwis and other citrus fruit. Some people it’s dairy. They cut out dairy products or lactose containing dairy products and their reflux completely goes away. Some patients, Especially celiac disease and non celiac gluten intolerance patients.  They take the gluten out. They don’t have reflux anymore. So you’re [00:59:00] absolutely right. That’s a big deal. Not everybody’s designed to eat everything you can buy in a supermarket.

Dr. Weitz: Right. So, what are some of the other treatment approaches?

Dr. Sandberg-Lewis: Yeah. So again, the way I did it in my chapter on natural treatments is I did it by mechanism, right?  Which I think is a good way to think about it. So if you know on somebody’s upper endoscopy it, the report says, the lower esophageal sphincter was gaping open. I’m going to do things to help with parasympathetic tone, diaphragmatic breathing exercises, getting good diaphragmatic tone, help to get the big brother to hug the little brother.  You can use vagal toning exercises. You can use what I use a lot.

Dr. Weitz: What do you, what are your favorite vagal toning exercises?

Dr. Sandberg-Lewis: Well, actually my favorite is alternate nasal [01:00:00] breathing together with diaphragmatic breathing.

Dr. Weitz: Alternate nasal breathing. I never, yeah,

Dr. Sandberg-Lewis: it’s called a Pranayama in yoga. Okay. You breathe out of one nostril and I breathe out of the other one.  It’s on my website, I have a description and you can, it’s just Pranayama explains it, but it’s a really good brain balancing, vagal balancing exercise along with toning of the diaphragm. But in addition, we know from the heart math research, right. Feeling a sense of gratefulness before meals can really improve vagal tone.  So using, if people like using some kind of an app, they can use HeartMath. The HeartMath folks and other companies, they make a Biofeedback device that gives you heart rate [01:01:00] variability, biofeedback, and you can learn to improve your heart rate variability, which is a direct result of good vagal tone.  And it’s very enjoyable kind of little games that you can play with your vagus nerve.

Dr. Weitz: What about vagal nerve stimulating devices?

Dr. Sandberg-Lewis: You know, there’s more and more versions of that now that are less scary than the ones they used to have, and I haven’t started using those, but I’m sure we’ll see more and more data about those as time goes on.  It makes sense. It passes through here. One of the ways that I just test for vagus nerve tone is to look at the person’s rise in their palate when they say ah. And I want to see symmetrical rise and a brisk rise. So I do that as part of my physical exam, but yeah, other things that I do for the lower [01:02:00] esophageal sphincter tone is Huperzine A, right?  Huperzine A, which is a anti cholinesterase. It’s a cholinesterase

Dr. Weitz: Often included in brain formulas.

Dr. Sandberg-Lewis: Yeah, because acetylcholine is such an important memory and cognitive brain neurotransmitter, but it’s also the main neurotransmitter. neurotransmitter for the vagus nerve and the lower esophageal sphincter.  So use that. Sometimes we’ll use phosphatidylcholine or other sources of choline as precursors for acetylcholine as long as well as the huperzine. So again, depending on the mechanism, I use different treatments. But I usually have people start out with the lifestyle issues. The Reduce Carbs, Reduce Reflux mnemonic, C A R B S, that has all those things in it.

Dr. Weitz: Is that, [01:03:00] so what kind of diet are you typically putting these patients on?

Dr. Sandberg-Lewis: Again, it depends. If they have SIBO, it’s going to be a low fermentation diet, right? If it’s, and most of the, again, when I came up with that mnemonic, Reduce Carbs, Reduce Reflux. The C A R B S was just a way to remember everything, but it is true that high carbohydrate diets seem to be the most important causes of reflux, and so most of the diets we use are lower fermentable carbohydrates, like FODMAP diet, or even Cedars Sinai diet, or Oh, Dr.

Dr. Weitz: White Rice, White Bread Diet.

Dr. Sandberg-Lewis: Hey, you know, it’s it’s the least restrictive. And so if you have a patient that just says, you’ve had these patients, they come in and say, okay, let me just tell you right at the start here, I’m not changing my diet. I don’t want to change my diet. [01:04:00] Or maybe they have an eating disorder, history of an eating disorder and you can’t really mess with their diet because they already have so many issues with it that they work with their counselor on.  So you want to, sometimes you use that as the least invasive as opposed to the biphasic diet by Dr. Jacobi, which is probably the most restrictive, but it works great and it’s great for vegetarians and vegans and low histamine also.  Right.  I have about five or six different diets I use depending on the situation, but I think the important thing is The meal spacing, going at least four hours between meals and 12 hours at least overnight and not eating at least for three or more hours before they go to bed.  That can be very important.

Dr. Weitz: Do you like adding digestive enzymes or herbal bitters to increase the likelihood that they’ll break [01:05:00] down the food?

Dr. Sandberg-Lewis: I think bitters are great for anybody that responds well to them. Bitter herbs, the bitter receptors are in most of the tissues in the body, even blood vessel walls, I believe.  We call them bitter taste receptors because that’s what we first discovered was they could taste bitters, but they do a whole lot of other really essential things. Yeah, bitters are great. Bitters are great. Digestive enzymes, I got a whole chapter on that because it’s pretty complicated, but certainly we treat people that don’t make enough pancreatic enzymes or don’t make enough brush border enzymes, but also, food based enzymes, raw food, sprouted food.  and the kind of plant enzymes that you can buy, they’re a whole different category, because they’re actually starting to digest food when it’s in the stomach, whereas most pancreatic enzymes that you produce in your own body, or [01:06:00] take as a a medicine that’s made from pork those only work in the small intestine.  So these plant enzymes are like food based enzymes that have a much wider range. Like I say, they start working in the stomach, they work in a very wide pH, instead of very narrow pH.

Dr. Weitz: So you like the plant based enzymes better?

Dr. Sandberg-Lewis: Well, they’re just a whole different animal. They’re not even an animal. They’re just, they’re so different.  Are they good? They can be extremely helpful. Okay. Yeah, even just, even papaya enzyme can be really helpful. protein. Yeah, for some people’s reflux can be really helpful. And it’s a helpful thing also for gastroparesis, which we haven’t talked about, but we nudged up against it when we were talking about ozempic.  But, you know, that’s another big one. If you have delayed gastric emptying, you have to treat that with a number of things that, besides prokinetic [01:07:00] herbs or drugs that help keep things moving through the stomach so they don’t back up into the esophagus.

Dr. Weitz: And delayed gastric emptying can be common in patients with diabetes and certain other conditions.

Dr. Sandberg-Lewis: Diabetes and celiac and other gluten intolerances I find are the biggest, biggest group that have that.

Dr. Weitz: So you use natural prokinetics or you use prescription prokinetics?

Dr. Sandberg-Lewis: Yeah, I’ll just mention too, traumatic brain injury is a major cause. Okay. Of delayed gastric emptying and gastroparesis as well, which is often ignored in medicine.  But yeah, I’ll I often, the simplest is ginger, right? Ginger is just a wonderful prokinetic for the stomach, upper GI, prokinetic. And that’s what, I think one of the reasons why it helps with, Nausea [01:08:00] in many cases. It also is a serotonin receptor modulator, which can help with nausea, but it’s, yeah it’s the simplest and most elegant if people tolerate it well.

Dr. Weitz: I think that’s the questions I had prepared. Any, anything else you want to tell us?

Dr. Sandberg-Lewis: I will tell you that there’s a chapter in the book called Your Brain May Be Sabotaging Your Digestion.

Dr. Weitz: Okay. Here’s the book right here. 

Dr. Sandberg-Lewis: It’s the only chapter I didn’t write.

Dr. Weitz: Oh, really?

Dr. Sandberg-Lewis:  It’s chapter 11.

Dr. Weitz: Okay. Who wrote that?

Dr. Sandberg-Lewis: My brilliant wife.

Dr. Weitz: Oh, okay.

Dr. Sandberg-Lewis: Kayla Sandberg Lewis wrote it. She’s a wife. Oh, okay.  biofeedback and stress management provider. And she, if you don’t read anything else in the book, I think that chapter really helps you get your lifestyle in gear, chewing, breathing,[01:09:00]  your approach to Eating, breathing, drinking liquids that can really provide the strong underpinnings for proper digestion.

Dr. Weitz: Chewing your food, eating slowly,

Dr. Sandberg-Lewis: drinking water away from meals in adequate amounts for hydration, together with breathing by using your diaphragm, like some of the things we alluded to, to get the vagus nerve working properly.  All these things are really important for vagal. function and just getting your body in the right neurologic phase for digestion.

Dr. Weitz: What about that heel drop exercise? I know we mentioned that last time we talked a year or so ago. That seems like a really cool exercise. Do you give that regularly to the patients?

Dr. Sandberg-Lewis: Yeah, I have a handout sheet [01:10:00] that we hiatal hernia too, but I have a little handout sheet when I do the visceral manipulation for hiatal hernia syndrome. I will give him that handout and it talks about avoiding breath holding during exertion and core muscle contraction. I teach people that before they get up off the table, I say, now take a nice full belly breath and breathe out as you sit up, as you contract your abdominal muscles.

So any exercises, core exercises they’re doing, anytime they’re lifting something heavy, or even more so, if they’re constipated, or even if they’re not constipated, if they bear down to have a bowel movement, and push it out, that’s okay, but take a full belly breath first and exhale slowly as you bear down, if you run out of air, stop bearing down, take another breath.

That way you’re reducing that [01:11:00] great increase in intra abdominal pressure that occurs when you hold your breath and do a Valsalva maneuver that greatly increases the intra abdominal pressure intends to push things upward. In addition, the heel drops exercise is just something you can do in the morning after a correction that we do in the office.  Drink at least 12 ounces of water to fill the stomach and weigh it down like a water balloon a little bit, and then go up on the balls of your feet, drop on your heels 11 times, and that, that pendulous stomach pulls down. And it helps to keep that correction that we did in the office in place below the diaphragm.

Dr. Weitz: Great. So everybody pick up Dr. Sandberg Lewis’s book and they can get a hold of you through your website. What’s your [01:12:00] website?

Dr. Sandberg-Lewis: HMM, which is Hive Mind Medicine, PDX, which is the abbreviation for Portland, dot com. HMMPDX. com.

Dr. Weitz: And you have courses available, correct?

Dr. Sandberg-Lewis: I teach courses and we have some online courses that we’ve done through Shivan Sarna and Neurala

Dr. Weitz: Jacoby.

Dr. Sandberg-Lewis: They have those at their websites.

Dr. Weitz: Yeah. I took the course that Neurala has on the physical. Yeah. That’s a good one.

Dr. Sandberg-Lewis: They did a really good job on that. They did a really good job on that.

Dr. Weitz:  Well, thank you so much, Stephen.

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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 Podcasts or Spotify and give us [01:13:00] a five star ratings 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 want to 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.