Best Diet for IBS with Dr. Norm Robillard: Rational Wellness Podcast 80
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Dr. Norm Robillard discusses what is the best diet for patients with Irritable Bowel Syndrome with Dr. Ben Weitz.
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Podcast Highlights
6:47 When you look at studies on IBS, there is a wide range as to what percentage of patients are caused by Small Intestinal Bacterial Overgrowth (SIBO), in one meta-analysis from 4 up to 78%. This has made some doctors and researchers to question what relationship SIBO has to IBS. Dr. Robillard explained that there are some issues with test methodology, including whether you use lactulose or glucose as the substrate and glucose is less sensitive since it will miss SIBO in the distal part of the small intestine, since it is absorbed in the proximal portion of the small intestine. Lactulose should be a preferred substrate, since it is not digested by humans. There are some potential issues with the 24 hour test preparation, which requires strictly following essentially an intervention diet and then an overnight fast and if these procedures are not strictly followed, it can affect the test results. Also, this test is only one snapshot in time and there is a constantly changing situation in your gut where if you eat a lot of fermentable carbohydrates, the likelihood of SIBO will go up, while there are a number of mechanisms that work to prevent it from developing, including the Migrating Motor Complex, bile, hydrochloric acid from the stomach, digestive enzymes, and your Gastrointestinal Associated Lymphoid Tissue (GALT), the immune system clustered around your digestive tract. Dr. Robillard thinks the correct number is somewhere in the range of 45-65% of people with IBS who have SIBO.
11:48 Dr. Robillard has coined the term LIBO for large intestinal bacterial overgrowth because he believes that some of the time the gastrointestinal symptoms are coming from an overgrowth of bacteria or archaea in the large intestine. When bacteria ferment carbohydrates they produce short-chain fatty acids, which are acidic. They did a study at John’s Hopkins that looked at 47 patients with IBS and they had them swallow a SmartPill that could detect pH changes. They did not see any pH changes till they got to the large intestine, which they interpreted as bacteria in the large intestine, not the small intestine. Dr. Robillard believes that when you have methane SIBO it is likely caused by archaea not in the small intestine but the large intestine, because the methane gas slows down motility, which causes constipation. This is why you get methane showing an elevated methane even in the zero time point in the breath test. He thinks that the archaea in the large intestine can overgrow and produces so much gas that if forces open the ileocecal valve leading to the gas getting into the small intestine. Evidence has shown that when researchers placed a pressure sensitive instrument in the ileocecal valve it was weaker, which could be because it is being forced open by back pressure from gas being produced in the colon. Dr. Robillard also mentioned that he has written a book about reflux and his theory that reflux is caused by pressure from the gases being produced by the overgrown bacteria pushing up into the stomach pushing the acid up into the throat. He found that a low carb diet made his reflux go away.
25:37 If the archaea are really overgrown in the large intestine instead of the small intestine, this might explain why treating methane SIBO is more difficult and why Rifaximin is not as effective for the archaea, since it acts mainly in the small intestine.
27:18 The causes of SIBO can include the motility of the intestinal tract related to the migrating motor complex and the iliocecal valve. Hypochlorhydria or low stomach acid can also be a factor, since the acid helps to keep the bad bacteria out of the small intestine and from moving up to your throat, lungs and sinuses. Low stomach acid can result from the use of Proton Pump Inhibitors (PPIs). It can also come from H. pylori infection, which is a corkscrew like spirochete bacteria that burrows through the mucosa into the lining of the stomach. If H. pylori grows in lower part of the stomach, the antrum, it can result in increased hydrochloric acid. But if it grows in the upper part of the stomach, the fundus, where the parietal cells are, it can damage these parietal cells and results in decreased hydrochloric acid secretion. Low stomach acid both increases the risk of SIBO and also stomach cancer. Patients with liver problems like cirrhosis will produce less bile and are at increased risk for SIBO. Also patients with pancreatitis, since they may have decreased production of pancreatic enzymes. Kids with cystic fibrosis have a high instance of SIBO and GERD and have to be on digestive enzymes. Pain medications can slow motility and cause SIBO. There’s an increased risk of SIBO with Celiac and Crohn’s disease. Diabetes can lead to nerve damage and predispose to SIBO. Surgery and other adhesions in the intestines can lead to SIBO. Scleroderma is also risk factor for SIBO. Simply eating too many fermentable carbohydrates in your diet, esp. as we age since our digestion may not work quite as well as we get older.
33:18 Dr. Robillard has developed a special diet, the Fast Tract Diet, and the Fermentation Potential (FP) point system to easily keep track of how to eat less fermentable carbs. Dr. Robillard has also found that a super low carb diet like the ketogenic diet works well with GERD and SIBO. The Fast Tract diet limits lactose, fructose (and polymers of fructose), resistant starch fiber, and sugar alcohol. The FP calculation uses the glycemic index, which measures how quickly carbohydrates are broken down and converted into blood sugar. For diabetes you want low glycemic foods, but for gut issues you want higher glycemic foods that digest more easily. After you take the glycemic index you add in fiber and sugar alcohols to do the calculation and Dr. Robillard has developed an app for your phone that does this for you, the Fast Tract Diet Mobile App.
47:50 Wine and light beer are surprisingly low on FP points because foods that are fermented have less carbohydrate in them because the carbs are being converted into alcohol.
50:19 It is common in the Functional Medicine world that after the patient has been placed on a treatment protocol for SIBO that involves a restricted diet, such as a low FODMAP diet, along with herbal antimicrobials or other supplements for a number of months, once the patient feels better, that we try to broaden their diet as much as possible. But Dr. Robillard does not really agree with this concept. He does not feel it is helpful or necessary to add back in a lot of fermentable carbohydrates and fiber. He likes to see people diversify their diet by adding more low FP vegetables, fresh herbs, and small servings of fermentable foods, like pickles, kimchi, sauerkraut, and maybe a little bit of yogurt. If you have an animal-based diet with some fatty fish, plenty of green leafy vegetables, and some nuts, there is no reason to add grains and beans and other fermentable carbohydrates. If you need some fiber, you can use psyllium or cellulose, or something like that’s not very fermentable. Rather than supplement with prebiotics, Norm would rather have someone have an organic garden and compost pile, which will inhance your micobiota. Studies on compost piles show that they are similar to the microbes in your gut. Dr. Robillard is also not a big fan of antibiotics for SIBO, given the harm they cause to our microbiota as well as other side effects.
Dr. Norm Robillard has a PhD in microbiology and he is the founder of the Digestive Health Institute and he is a gut health expert and author. He is the creator of the Fast Tract Diet and the Fermentation Potential (FP) System, the author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. He also consults directly with patients.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Podcast Transcripts
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top expert in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free eBook on my website by going to DrWeitz.com. Let’s get started on your road to better health. Hello Rational Wellness podcasters. Thank you so much for joining me again today. This is Dr. Ben Weitz. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review.
For those of you who’d like to see Dr. Robillard’s face, as well as listen to him, you can always go to our YouTube page and watch the video version of the Rational Wellness Podcast. Anyway, our topic for today is Irritable Bowel Disorder, or syndrome, and small intestinal bacterial overgrowth, and then how to treat it. Irritable Bowel Syndrome is a condition marked by gas in the intestines, bloating, abdominal discomfort, constipation, diarrhea, alternating one and the other, as well as a series of other symptoms. IBS, Irritable Bowel Syndrome, is the most common gastrointestinal disorder and occurs in up to 20% of the U.S. population.
For many years, IBS was considered a stress-related condition with no known cause, and this is partially because IBS was most common in women. Traditional medical treatment has been generally composed of medications for controlling symptoms, such as medication to reduce constipation, another medication to control diarrhea, et cetera, et cetera, but in functional medicine, we don’t wanna just treat symptoms, we’re trying to get to the underlying cause of our health conditions. Dr. Mark Pimentel, from Cedars-Sinai, was really the first one to discover that small intestinal bacterial overgrowth, or SIBO, is the cause of IBS in up to 84% of cases. SIBO consists of bacteria that normally grow in the large intestine or colon that then start to grow into the small intestine, which normally has relatively small amounts of bacteria.
When you eat certain types of carbohydrate foods that contain fermentable fiber, our gut bacteria eat the carbs and they produce various types of gases, like hydrogen and methane. When this occurs in the colon, this is not a problem, since the colon’s very expandable and there’s a valve, the ileocecal valve, to keep this gas from going back up into the rest of the digestive tract, but the small intestine is a relatively narrow tube and it’s not really expandable in a way that the large intestine is. If there are bacteria there that are eating fermentable carbs, they’ll produce gas, and this gas, likely, will cause discomfort, a feeling of gas and bloating, and many of the other symptoms of IBS or SIBO. The gold standard for diagnosing SIBO is finding more than a tiny amount of bacteria upon jejunal aspirate, which means that when putting a scope down into the intestines, you scoop a small amount of the liquid in the proximal jejunum, which is the lower part of the intestine, and then analyze it via culture, or PCR.
Unfortunately, this test is very invasive and it’s not typically done on a regular basis in clinical practice. What we have is a somewhat imperfect but fairly useful test, which is known as lactulose hydrogen-methane prep test to diagnose SIBO. Dr. Pimentel also found that SIBO often results from a bout of food poisoning, where the bacteria that causes food poisoning give off an endotoxin referred to as cytolethal distending toxin. The immune system reacts to this toxin and attacks this cytolethal distending toxin, but then, because the cytolethal distending toxin is similar to some of the structural proteins in the intestinal wall, the immune system cross-reacts and ends up attacking the intestinal wall. By this understanding, SIBO is really an autoimmune condition. This can be diagnosed via a blood test that Dr. Pimentel developed called the IBS check test, and now Cyrex Labs has Array 22, that’s a more sophisticated way of trying to measure these antibodies produced by the immune system in this attack on these toxins, as well as the antibodies to the structural proteins in the intestinal wall, in order to be able to diagnose SIBO. This is all, obviously, a very complicated and confusing condition, and that’s why I’ve asked Dr. Norm Robillard to join us today. Dr. Robillard’s an expert at IBS and SIBO. He has a PhD in microbiology from the University of Massachusets where he studied Bacillus species of bacteria, which are the spore-based bacteria. He’s the founder of the Digestive Health Institute, and he’s also a gut health expert, author, and microbiologist. He’s the creator of the Fast Tract Diet and the Fermentation Potential system. The author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. Thank you for joining us, Dr. Robillard.
Dr. Robillard: Thanks for having me on, Ben.
Dr. Weitz: When you look at the studies on IBS, there’s a big range as to what percentage of patients with IBS are actually positive for SIBO, and so there’s one review paper that says it ranges from as little as 4% all the way up to 78%. This has led some practitioners and doctors and researchers to even wonder if there really is a relationship with SIBO and IBS and what percentage it is. On the other hand, Dr. Pimentel did a study in which he found that 84% of patients with IBS tested positive for SIBO. Why do you think there’s such a wide variation in these results and what percentage of patients with IBS do you think are really caused by SIBO?
Dr. Robillard: Yeah, that’s a good question. Of course, there’s basic test methodologies. I used to run an analytics testing laboratory, and so there’ll always be precision, accuracy, intermediate precision, which is how closely different laboratories get the same result, so it requires a lot of training and a lot of calibration to get these labs on the same page. Of course, the test for SIBO, there are different techniques used. Some people, you mentioned lactulose sugar, which is really, I would think, the preferred method, because lactulose is not digested by humans, so it passes through the intestines until it runs into bacteria that can break it down and produce hydrogen. When you use lactulose, you can detect bacteria all the way through the small intestine. But a lot of labs use glucose, which is quickly absorbed, and so if the bacteria are not up in the proximal or early part of the small intestine, you may not even see them with that test, so it’s less sensitive, however, it’s more specific.
There are some test methodology issues. Before we went live, you and I were just talking about the test preparation, which I think is also important and, potentially, a flaw or an imperfection in this testing, because before people take the breath test, there’s a 24-hour preparation period where you’re, essentially, on an intervention diet, and so you’re avoiding legumes. You can still have some fish and chicken, no fruit juice, and you mentioned they can have some rice, and some rice is worse than others, as we’ll get to in a little bit, but nevertheless, they’re on an intervention diet for 24 hours and then they fast overnight before taking the test.
You, obviously, follow Dr. Pimentel’s work, and those folks down there have really worked a lot on this migrating motor complex, so SIBO is a snapshot in time. If these bacteria move their way up into the small intestine, your body, stomach acid, a lot of these mechanisms we’ll be talking about today, motility, it’s always trying to move these bacteria out, bile, antimicrobial factors, your immune system, and so the more chance you give it to not be either fed more with carbs, things like fasting, the more of a chance you have of being negative. On the other hand, if you feed everybody a lot of fermentable material, you’re going to see the number of people with SIBO go way up. Again, it’s a snapshot in time.
The last point I wanted to make is, and I hope we get a chance to talk about this a little bit today, I had coined the term LIBO in an article I wrote a few years ago on resistant starch, it’s to stand for Large Intestinal Bacterial Overgrowth. In your introduction, you mentioned, well, as long as all this fermentation happens in the large bowel, you can accommodate that all, bacterial growth and a lot of gas, but if you have too much, that could be problematic as well. People would come in with symptoms and test negative for SIBO, and they still have excess bacterial fermentation, that’s what I believe. The second part of your number was what’s a number, right? What should it be–87% or 4%? Again, from being analytics testing all of these years, I do know that if you test something enough, the answer gets closer and closer to the accurate value. Dr. Pimentel had put together a meta-analysis of a whole variety of studies and really validated the finding of SIBO and connecting it to IBS, and I thought that was pretty powerful. When you look at enough data, you’re going to get a better answer. Is it 45% or 65%? I don’t know, but it’s probably somewhere in there, again, fluctuates.
Dr. Weitz: Right. Yeah, that’s interesting, you talk about LIBO, or bacterial overgrowth in the large intestine, I wonder if you could use the SIBO breath test to diagnose that if you just look at the rise in gases after 120 minutes or beyond.
Dr. Robillard: Probably not, because when you go from even somebody with SIBO, they have greater than 100,000 bacteria per mill in the small intestine, which anybody that works with bacteria will tell you, that’s such a tiny, tiny amount, and then you get to the large bowel, and the large intestine contains 100 trillion bacteria, so much more, so basically, this lactulose would be just rapidly consumed and produce a lot of gas, even if somebody didn’t have “LIBO”.
Dr. Weitz: Oh, okay.
Dr. Robillard: However, there was a study done, jumping into this LIBO thing a little bit, by a group that looked at, I think they were out of John’s Hopkins, looked at 47 patients with IBS, and some controlled, so it’s pretty good end for statistical analysis, and they had them swallow a wireless motility capsule, kind of a SmartPill, and this pill could detect pH differences, so it’s going through the stomach, small intestine, and into the large intestine, and it was measuring acidity. What they found was really interesting, they didn’t see any pH change, no increased acidity in the small intestine. Just to back up for a minute, when bacteria ferment carbohydrates, they produce short-chain fatty acids, right? They’re fats and they’re acids, and that’s where the acidity comes from, but they didn’t see any increased acidity in the small bowel of people with IBS, but when the SmartPill got to the large bowel, they did see an increase in acidity, and they indicated that they interpreted that as the bacteria in the large bowel.
For IBS patients who were very active, producing more of these short-chain fatty acids and more of the acid, they were questioning SIBO. While we’re on that topic of questioning SIBO, there was another lab up in Canada that used a radioactive tracer molecule when they gave people, and again, it was a pretty good sized study, I think it was about 40 people with IBS and some controls, when they gave them the lactulose breath test, at the same time, gave them the lactulose, they gave them this radioactive tracer probe. They could literally follow this probe on somebody’s body, and they had mapped out, here’s the end of the small intestine, the ileocecal valve should be right here, and they were literally following this radioactive probe through the small intestine. What they found was that by the time people were registering as hydrogen-positive within 90 minutes indicative of SIBO, that that dye had already reached the ileocecal valve and was entering at the large bowel. Again, they were saying that they think that people that test positive with SIBO, perhaps, have faster motility, and that’s what they’re measuring, not the actual SIBO. I thought about both of these studies and I really think the answer is that both LIBO and SIBO exist. For instance, in this radioactive probe study, yes, as people were recording a positive breath test, some of this dye, for at least 5%, had reached the large bowel, but a lot of the dye was still back in the large intestine, small intestine, and a lot of the lactulose was still back in the small intestine, so I don’t think it debunks SIBO so much as it suggests, both of these studies, that we need to look at LIBO and SIBO. While we’re on that topic, again, with the SmartPill and the acidity, they found that they had no change in acidity in the small intestine, but they did in the large bowel, but again, getting back to the numbers, even if you have 100,000 or 500,000 bacteria in the small intestine, is that enough bacteria to meaningfully change the PH, especially when the small bowel adds bicarbonate and it neutralizes the acidity from the stomach, and all of that? I think SIBO could exist, easily exist, and that it’s not debunked by these methods, but I do think it is a good reason for us to look at it in a different way and think maybe it’s a combination.
Dr. Weitz: Yeah. A thought I also have about that, and then I think maybe I should ask you to explain what the SIBO breath test is for those listeners who are not familiar with it, is some of the real acid-loving bacteria, like the lactobacillus, is they’re typically not part of the SIBO equation, whereas primitive archaea are, and I wonder, if they’re not really as acid producing as some of the bacteria, so that could be a factor as well.
Dr. Robillard: Well, in SIBO, so we’ve been talking about breath testing, but you also mentioned the gold standard, which is taking an endoscope that can sample the small intestine, aseptically as possible, pull these bacteria out and try to culture them. Some of those studies have been done and they’re not perfect studies because, first of all, 80 or 90% of the bacteria in your gut will not grow and culture. They haven’t figured out how to grow them, and that’s why they use the 16S rRNA gene sequencing to look at these strands molecularly. They have done some culture work and they find that SIBO is comprised of an overgrowth of some bacteria that are from the small intestine, so there’s your lactobacillus and some staph and strep, but also, bacteria that are more associated with the large bowel, some Firmicutes, some clostridium species, some bacteroides, like bacteroides fragilis and several other Gram-negative and Gram-positive strains, so bacteria in the large bowel and from the small bowel are overgrowing there, so that-
Dr. Weitz: Also the archaea, right?
Dr. Robillard: Well, okay, some people may have thought that early on, because in some of these breath tests, the people have high levels of methane and they’re like, “Wow, okay, must be the archaea,” they’re not bacteria. These other micros called archaea take the hydrogen and they use it to reduce carbon dioxide to methane. That’s the little molecular food chain there, and so where are these archaea? Because wow, even in the first sample, they have high methane and they just continually have high methane, but remember, with these breath tests, they have you blowing in these tubes, right, so that if any hydrogen’s being produced by bacteria in your gut gets absorbed into your bloodstream, exhaled through your breath and you capture it in this tube.
You blow in that first tube, it’s called times zero, put the cap on, put a label on it. That’s times zero, that’s before you drink the sugar solution, then you set that aside, then you drink the lactulose sugar solution, and then every 15 minutes, 20 minutes, depends on the test, usually about every 15 minutes, you blow in a new tube and put the cap on. With hydrogen, you can see a real kind of time course there if you plot it out. Zero sample is hardly any hydrogen in it, and then all of a sudden, starts to come up, and it may be 40 minutes, and 60 minutes comes up, then it starts to, maybe, go down a little bit, and then it hits the large bowel past 90 or 120 minutes and it goes through the ceiling. You can get a profile like that with hydrogen, but with methane, you almost always just see that it’s high in the zero time point, so that’s telling us that it has no dependence on the lactulose sugar. It’s doing its thing, taking the hydrogen and CO2 and combining that to make methane. There has been some work on it, I’m not sure I can cite any particular studies at the moment, but that shows that these archaea are in the large bowel and that they’re just churning away. Some people may not know this, people with IBS-C, or constipation-predominant IBS, almost always have these really high levels of methane because methane, there’s been good work on this, you can inject methane into the intestines of animals and it slows down the transit. There’s just such a tight corelation with people that are high methane having slow transit and constipation. There is a strong belief that these archaea organisms are doing that in the large bowel.
Dr. Weitz: I thought that they had grown into the small intestine, and that was one of the theories, I talked about Dr. Pimentel’s theory about the autoimmune component, but to follow up on that, what that meant is by damaging the structural proteins in the small intestine, it caused decreased motility, and he describes it as like a stream that stops running quickly and starts backing up and that allows the bacteria from the large intestine to grow into the small intestine, so I thought that’s where the archaea-
Dr. Robillard: Well, right. This whole story, and it’s a great story, by the way, they worked out with Cytolethal Distending Toxin and the autoimmune reaction with Vinculin, which slows down motility, hits the nerves and so forth, causes constipation. Slowing everything down, whether that causes archaea organisms to back up all the way into the small intestine, I’m not sure. I do have my own theory about connections between the LIBO and SIBO. Something we’re not talking about today, but it’s just relevant in this discussion, is when I first got into nutrition and dieting, it was only because I had chronic acid reflux myself, and I had found that a super low carbohydrate diet caused my symptoms to just go away, and so I was so amazed by this. I was playing around with this idea, and I started following the food groups through the digestive process and came up with this new theory that, what was happening, I believed, was that I was consuming too many carbohydrates, too many were getting malabsorbed, feeding blooms of gas-producing bacteria, right? As a microbiologist who grew these bacteria, right? You mentioned I worked in a Bacillus lab for my graduate work, but I also worked as a post-doctorate fellow on bacteroides fragilis, that’s 10% of the gut bacteria, and E. coli. I was actually the first one to be able to move genes between E. coli and this strict anaerobe bacteroides through this conjugative process.
One thing I knew about these bacteria, they produced a lot of gas. They were saccharolytic, they loved carbohydrates, they produced a lot of gas, and I came up with a theory that all this gas produced too many carbs, was pressurizing my stomach, it was translating into my stomach, and they do know people with GERD, acid reflux, have much higher pressure in their stomach, and the theory was it was pushing reflux, opening this valve instead of the original theory that stood for 60 years. We’re saying that this valve was dysfunctional or it was weaker, or it was relaxing spontaneous, and so there’s a lot more evidence for this gas-producing bacteria driving reflux, and so I’ve written a couple of books on that. Now, to this new discussion on SIBO versus LIBO, these guys with the PH SmartPill, they found all this acidity past the ileocecal valve in the early part of the large bowel.
How could that relate? Suppose you had SIBO and LIBO, how’s the SIBO getting there? I have a theory that it might work the same way as my acid reflux theory, that these bacteria are producing a lot of gas in the early part, the ascending colon, just past the ileocecal valve, a lot of growth, a lot of gas, and maybe this same gas pressure is pushing back on the ileocecal valve. It’s interesting, it ties into another study done out of John’s Hopkins as well, I think, where they found that people with SIBO, was it a SIBO population or an IBS population? I think it was SIBO, but one or the other, but probably people with SIBO, they found their ileocecal valve pressure and they measured it like a colonoscopy tube going right up to the valve. They put a pressured, sensitive, like a manometry instrument, position it right in the ileocecal valve, and it was weaker, there was less pressure, people that had SIBO. It could be the same thing, if you have gas pressure from bacteria pushing back on that valve and pushing it open, if you have a pressure-sensitive tube in there, it’s going to look like it’s weaker, but really, it’s being forced open by back pressure. Anyway, something to think about.
Dr. Weitz: That’s interesting. If the archaea are really in the large intestine, that could be one of the reasons why it’s difficult to correct methane SIBO and kill or cut back the archaea if Rifaximin, which is what gastroenterologists often use when they treat this, is basically acts in the small intestine, so it might not be acting in the large intestine where, under your theory, the archaea really are.
Dr. Robillard: Yeah. Well, it probably explains why Rifaximin alone is not efficacious for IBS-C.
Dr. Weitz: Right, that’s why they usually recommend Rifaximin plus Neomycin, or another antibiotic.
Dr. Robillard: Yes, and both are nonabsorbable. If you’ve seen my other work, you know I’m not a big fan of antibiotics, but at least these two are nonabsorbable. You can eliminate some of the systemic problems.
Dr. Weitz: Right.
Dr. Robillard: They use both. The Rifaximin is probably, by their own estimations, not very useful in the large bowel, right? There’s a whole story about, well, it won’t upset your microbiome because it requires bile for its most efficient inhibition, and 95% or more of the bile is reabsorbed at the end of the small intestine, so the Rifaximin is probably not a big factor. It would be, really, what’s the Neomycin doing?
Dr. Weitz: Interesting. We’ve talked about a couple other things that could cause SIBO, we’ve talked about the damage to the motility of the intestinal tract, and you mentioned the migrating motor complex, and you also talked about the ileocecal valve. What are some of the other causes of SIBO?
Dr. Robillard: Yeah. Motility is big, and Pimentel thinks it’s really probably one of the biggest. Low acid is another one, people with hypochlorhydria, achlorhydria. The acid not only is it important for digestion, but it’s important for keeping the bad bacteria out of your gut, keeping the bacteria in your gut from moving up to your throat, lungs, and sinuses, so acid’s important. By the way, on the acid, there is an autoimmune disease that will lead to atrophic gastritis and hypochlorhydria, but it’s quite rare, actually, so unless somebody has a lot of other autoimmune conditions, you might not have to look at that one, but definitely PPIs, that’s what they do, they knock down your stomach acid.
Dr. Robillard: The other big one is a prolonged infection with Helicobacter pylori, bacteria that infects the stomach, it’s a corkscrew shape, like a spirochete, and it burrows down through the mucus and anchors on the stomach lining and it makes these colonies. Depending on where those colonies are in your stomach, that’s where the damage happens and that’s where the gastritis and atrophic gastritis happens. For some people, it effects the hormones that regulate stomach acid and they can have too much stomach acid, and they’re very susceptible to duodenal and stomach ulcers. People that have these bacterial colonies of H. pylori near the parietal cells that produce the acid, those are the ones you have to worry about having low stomach acid, so that’s a big one, too, I think, in a subset of people. Any kind of-
Dr. Weitz: That’s really interesting because most people think of H. pylori as automatically associated with increased acid production, but you’re saying if the H. pylori grows in a certain part of the stomach, it can be associated with decreased hydrochloric acid secretion?
Dr. Robillard: Absolutely. Right. The two doctors down in Australia, one of them gave himself an H. pylori infection and got gastritis.
Dr. Weitz: Yeah, Marshall, right.
Dr. Robillard: Wow, that was a great story, but they were focused on the ulcers, with the cause of ulcers, but they can also cause the opposite.
Dr. Weitz: Interesting.
Dr. Robillard: The people that have low stomach acid, not only will it really mess with your digestion, can still have symptoms, but they also are at higher risk for stomach cancer with the low stomach acid, which caused me to wonder, if they studied PPIs, if they would see there was also a gastric cancer risk with PPIs. No one’s been reported so far, but it also really knocks down your stomach acid. Just to cover a couple more quick ones, any kind of liver issues, we talked about liver and it produces the bile and that’s antimicrobial, people with cirrhosis, any kind of liver problems, they can have SIBO, a lot of problems, anything with your pancreas, pancreatitis, the pancreas produces amylase, protease and lipase, right? If you have any kind of problem with your pancreas, you won’t be digesting food as well, especially if you’re deficient in the amylase.
Even kids with cystic fibrosis, while they don’t have a pancreas problem, per se, they do have a lot of mucus in the ducts where the enzymes are released from, so kids with CF have a very high instance of SIBO and GERD, for that matter, right? There’s another link there, and they have to be on digestive enzymes. Problems with drugs, we talked about PPIs, pain medicines, man, there’s a whole story about MSDS, it’s just unbelievable. Too many pain meds, especially narcotics on the motility front, Pimentel, in one of his interviews, was talking about anybody on morphine has SIBO. You don’t even have to ask, so they really do slow down the motility. We talked about GI infections already, and not just bacterial. Gastroenteritis from food or water-born illnesses, bacteria, yes, but also protozoa, viruses, anything that causes gastroenteritis.
Dr. Weitz: You mean even fungal infections, and you can have what’s called a SIFO, or a Small Intestinal Fungal Overgrowth?
Dr. Robillard: Certainly, sure. We talked about the ileocecal, other genetic-based diseases, celiac and Crohn’s, it’s huge, diabetes, it might be a nerve damage issue going on, surgery and adhesion’s, I’ve heard Pimentel talk about that. I cover all of these in the Fast Tract Digestion books, by the way. I have a whole chapter on this. Speaking of scarring, scleroderma is a big problem for a lot of people with SIBO.
Here’s one that never gets any attention, and I’m not sure why, too many fermentable carbohydrates in your diet. Now, I learned that the hard way myself. When I was in my early 40s, I was having a terrible time eating all these carbs and having all these symptoms, took the carbs out of the equation and no problem, so I really think that some people, maybe as we get a little bit older, a lot of these functional GI issues start in our mid 30s and 40s, our digestion just may not work quite as well. You might not be able to put your finger on exactly what it is, but if you’re not digesting and processing carbohydrates well, digesting these things is a real finely tuned collaboration between our own digestive powers and the ability to use bacteria to help us out. If we overwhelm them and then throw in a couple of these other potential underlying causes, I mean, you’re in real trouble. There’s a handful. I have a whole chapter on this if people want to read more.
Dr. Weitz: Yeah. It’s interesting, I think a lot of us in the functional medicine world, when we are putting patients on treatment protocols, I know myself, we usually use a diet that’s designed to have less fermentable carbohydrates. I typically use the Low-FODMAP Diet. Now, you’ve looked at some of these diets, like the Low-FODMAP Diet, specific carbohydrate diets, some of these other diets that are popular, and you found some problems with those diets and so you came up with your system. Maybe you could tell us about your Fast Tract Diet and your fermentation-potential figure for being able to analyze, quantitatively, which foods to include.
Dr. Robillard: Sure. This story goes back quite a few years, 15 years ago is when I really found that very low carbohydrate helped my GERD symptoms, started looking into this, and so that’s not on your list, right? You mentioned FODMAP and specific carb diet, but just a low carb, even a ketogenic diet, I use ketogenic diet in my own consultation practice as a troubleshooting tool. We’ll get into the Fast Tract Diet in a minute, but it allows some carbohydrates, kind of a flexible approach for people with different dietary preferences. Jasmine rice is better than basmati rice, for instance, for reasons we can talk about, but what happens if, well, even the jasmine rice I’m having IBS symptoms or heartburn symptoms”? Okay, well, there may be a problem for you even digesting the easier to digest starch.
For instance, jasmine rice has amylopectin, an easier to breakdown starch, some people have trouble even with that, so I’ll go to a ketogenic diet just as a troubleshooting method to say, well, let’s take all the starches out and see how you do. Why did I come up with this diet? Well, initially, I had just found low-carb diet works, but when I came up with this theory about the underlying cause of reflux, linking it to bacterial overgrowth, similar to what Pimentel was doing at the same time with IBS, I was doing with acid reflux, when you limit all of the carbs that seem to be okay, so I had written a book on just this mechanism. I just wanted to get out there, it’s a new theory, new way to look at acid reflux.
I was living not too far away from you at the time in Thousand Oaks California, and I was pretty close to Dr. Mike Eades who was living down in Santa Barbara, he and Mary Dan, his wife, also an M.D. who wrote Protein Power, their book was the first time I ever read about any kind of diet ever, and it was to go on this low-carb diet. I noticed, in his book, which he had written in the mid-90s, he said, “Oh, by the way, we have patients that their heartburn improves on a low-carb diet,” and I’m like, “Ah, that guy speaks my language,” so I sent him my book on the mechanism. Well, actually, I didn’t just send it to him, I was going to send it to him, but when I had him on the phone, I said, “Gee, I’m gonna be at the farmer’s market down in Santa Barbara,” we agreed to meet and I gave him a copy. We became friends, drank some wine together, and we’re talking about this stuff, and he was the one that really asked a key question, he said, “Well, low carbs is helping heartburn, we know that, and now we know there’s a mechanism for it,” and he bought in fully into my theory.
He thought it made sense, and there’s a lot of evidence for it, but he said, “You know, which types of carbohydrates are the most problematic?” That one question sent me on my way for another couple of years of research. I wasn’t really aware much of the FODMAP and the specific carb diet. I think I had, at some point, read Elaine Gotschall’s book Breaking the Vicious Cycle, I can’t remember exactly when, so I was aware of that, but I was just thinking about which of these carbs are hard to digest? I didn’t have any specific lenses on except just look at these, so I came up with lactose, fructose, and, of course, polymers of fructose, those are actually dietary fibers, resistant-starch fiber and sugar alcohol, so there’s five.
The next step was to come up with a way to quantitatively measure these in foods because you pick up a pear, how much of these five things are in that pear? Who knows. Give it to the best dietitian in the world, she might not know either, or he. I was thinking about this problem, and by the way, the specific carb diet, it limits disaccharides, it limits grains and starches but not honey. That didn’t cover these five that I was interested in, and the same with the FODMAP diet, which, right, Fermentable Oligo-, Di-, Mono-saccharides and Polyols, so some of the monosaccharides like fructose, polymers are fructose, sugar alcohols, polymers of galactose, for that matter, too, but not fiber or resistant starch. I think the reason not all these diets cover it is because they either just don’t think some of these are very fermentable or they just think they’re so darn healthy for our gut that we need to include them. I came up with the five, I came up with the FP calculation to quantitatively measure them, but many years after I wrote the first Fast Tract Digestion book, I came across this textbook, can you see that?
Dr. Weitz: Yeah.
Dr. Robillard: Textbook of Primary and Acute Care Medicine, it’s fat.
Dr. Weitz: Wow.
Dr. Robillard: A lot of good stuff in there, but this book was published in 2004. It’s used to train doctors, but I think some doctors might have skipped the chapter on intestinal gases because when you go to page 1192 and open it up and read it, there’s those five carbohydrates that the Fast Tract Diet restricts, so it’s not that far out there. It’s aligned with this Textbook of Primary and Acute Care Medicine, that’s why I chose those five and why I developed my own diet that was low-carb keto is a great approach. The other ones, I think they’re missing a couple, and I think that can be challenging for some people if they’re having problems. There’s so many different types of fibers and we know some of those are very fermentable, stachyose, ravinose, various other polymers of sugars. I think you need to limit all five, and then the other thing was I needed to find a way to do it quantitatively, so I could make the diet something people could use. In the books, in the mobile app, the Fast Tract Diet mobile app, there’s all these tables of all these foods with these FP values. The FP calculation, it took me a long time to figure it out because I didn’t know how I was gonna measure the five carbohydrates in a way that you could just look at any food and say is there a lot of fermentable material in this or not?
I struggled with that issue, and for a while, I started thinking about the glycemic index instead of thinking, well, that measures how quickly carbohydrates go into the bloodstream, must be some way to use that. I was just, I don’t know, kind of dense thinking about it at first, but as I thought about it more and more, eventually I realized that it wouldn’t be that hard to modify that equation, flip it around and modify it because instead of measuring carbohydrates going into the bloodstream, I wanted to measure how many carbohydrates were persisting in the small intestine and not being absorbed. I turned the equation around, but because the glycemic index equation does not measure fibers or sugar alcohols, I needed to add those back after, so I flipped the equation around. Then, after that first part of the calculation, you add dietary fiber and any added sugar-alcohols, and so all you need is the glycemic index and the nutritional facts for any food and you can do this calculation. Of course, the app has a calculator for this, but also, it has tons of table sets. We’re releasing a new version in the next month, we’re about 10 months behind releasing this, but it’s going to have over 1,000 foods in it now. It’s got voice recognition on it, so if you just open it up, I have it opened up now, search. Whoops, I pushed on the happy face instead of the other thing. Carrots. You can bring up carrots raw, and you can cook them after, by the way, but it will just tell you what the fermentation points are for any given serving size. And if the points are too high and you still like carrots, just use a few less. Use half the number of carrots, it will cut the servings, it will cut the points in half. That’s how it works, in a nutshell.
Dr. Weitz: Is there a quantitative amount of FP points somebody’s supposed to have in the course of a day or is that related to their total caloric intake, or how does that work?
Dr. Robillard: No, that’s a good question, it does matter a great deal. In fact, we’re listening to our readers on this one. We had initially set a flexible range between 25 and 35 points, and just to put that into perspective, 30 grams of undigested carbohydrates that are fermented by bacteria can allow bacteria to produce 10 liters of gas, so just an ounce of these carbs can drive a whole bunch of gas production, that’s why you do need to limit these. Typical western diet may have 150 or more FP points a day, so that’s 50 liters of gas, that’s a lot. We wanna get that level down, and so we recommend somewhere between 25 and 45, depending on if you have a lot of severe symptoms, you want to go to the lower end, and as you get better and start improving, you can increase up to more than 45, but you’ll probably never really be eating 150 a day again if you’re somebody that suffers with these functional issues.
We have a Facebook group, Fast Tract Diet Official Facebook Group, people should join. There’s about 8500 members on there right now sharing recipes and talking about all this stuff. We have a lot of groups of people with these different conditions, not only IBS and SIBO, acid reflux, we have people with laryngo-pharyngeal reflux, real subtle irritation in the throat and vocal chords, it’s linked to reflux but it’s subtle, but it’s also persistent and it’s hard to get rid of. We’ve had people on the page, many of them, saying, “Well, this irritation’s persistent, subtle, but you know what? If I really was diligent with my points, I had to go less than 20, down to 15, and I had to do it for weeks,” and some people months, and finally their throat symptoms would get better when nothing else worked. They were driving this with us and they were saying, “You know what? You’re not cutting the points enough, you have to cut more,” so we’re learning from them. We’re involved in a clinical study where we’ve actually reduced the points based on what people on our Facebook group are telling us.
Dr. Weitz: Interesting. I wonder if there’s an issue with pre-diabetic or diabetic patients, because your program is actually promoting consumption of foods that have a higher glycemic index, right?
Dr. Robillard: I never thought about it as promoting. It is a flexible eating plan, right?
Dr. Weitz: Right.
Dr. Robillard: Yes, if you were going to have rice, rather than Uncle Ben’s or basmati white rice, because a small bowl of those is going to give you a whole lot of points, maybe 10, 20 points, depending on how big the serving size is.
Dr. Weitz: Partly because those foods are digested slowly, right?
Dr. Robillard: Yeah, yes.
Dr. Weitz: It makes them more preventable.
Dr. Robillard: So far, I’m making your point for you, yeah, versus a jasmine or sushi rice has a higher glycemic index, hence a lower FP. They’re more easily digested, more will go into your bloodstream, less will stay behind, so you’ll have less GI symptoms. Now, what happens, though, your blood sugar increases, and so in the book we’re cautious to warn people about prediabetes metabolic disorders and diabetes, and people have to be responsible for their own blood sugar levels. Somebody that doesn’t have an issue, or they’re an athlete, or they’re carb loading, or they’re a construction worker, so this book, a lot of different people are going to use this book. Other people may have to really watch their carbohydrates, so a low GI, low GI carbs is one way to do it, but it is going to feed the bacteria a lot, so that’s the downside.
If you’ve got functional GI issues, your solution, in the end, will probably be a lower carbohydrate diet. That way you’ll have less blood sugar, you’ll also feel less of the bad guys in your guts, the overgrowing bacteria. We’re not telling people to load up on sugars, even if you look at our tables and the serving sizes. I mean, there’s different categories on this app, so let’s just go down to rices, right? Well, here’s the one we just talked about. I’m gonna click on jasmine rice. Cooked jasmine rice, all right. What’s the total serving size? I don’t know if you can see it there, but it’s a half a cup. People with blood sugar issues, chances are they’re wolfing down a lot more rice than that, so we purposely, even though it’s low in FP points, we purposely tell people that, really, small serving sizes are better, lower carb is better, and eat slowly and chew well, which will also help digest these starches and some of these carbs better.
Dr. Weitz: I was surprised to see wine and beer, or light beer, on your list because these are fermented, but I guess there’s a difference between foods that are fermented and are fermentable, is that the case?
Dr. Robillard: Okay. Yeah, you’re bringing up a couple of points there. Foods that are fermented, right, there’s less carbohydrate in those foods when you consume them because the fermentation happens in a vessel, in a vat or a tank or a mason jar, right? The lactic acid bacteria, in the case of pickles, the yeast in the case of beer and wine, they’re using the sugars and they’re producing alcohol, right? Well, not in the lacto-fermented, they’re producing short-chain fatty acids and so forth, but in the beer and wine, they’re producing alcohol and they’re consuming the carbohydrates, so when you consume those foods, there’s less carbohydrates than there otherwise would be in there. However, when it comes to beer, a light beer has many fewer points. I think it’s somewhere around six or something for a bottle of light beer, four to six maybe. No, I’m sorry, maybe three or four, but when you have a heavier beer, like one of my favorites, IPA, it has a lot more points because there are a lot more carbohydrates in there. Regardless of the fermentation process, you still have to look at, anyway, it’s gonna take me too long to find the drinks and open up the beers, but-
Dr. Weitz: Yeah, I got it.
Dr. Robillard: Yeah. I purposely watch my points on days when I’m going out with my buddies because I want to have a couple of IPAs, but they have more points, and so if I’m also eating french fries, and something like that, and I have a couple of these beers, it’s kind of like death from a thousand cuts. These points add up and then they really get you, and then you need a couple of days, two or three days, to unwind it. You have to pick your poison. Distilled liquors are fine because they have no carbohydrates at all. Dry wines, red or white, are pretty low in points, and light beer is pretty low on points. From there you just have to conserve your points and pick your poison.
Dr. Weitz: Now, it’s common in the Functional Medicine community to put a patient on one of these restricted diets along with using some other protocols to try to get rid of the SIBO, and yet, once we’re done with the treatment period, whether that be one month, two months, six months, whatever that period is, it’s usually recommended that we try to broaden the person’s diet as much as possible. This is to make sure that we are bringing back in some of the fibers that are necessary to have a healthy microbiome and also to make sure we’re getting all of the phytonutrients from having that diverse diet, but you have a little bit different take on using your Fast Tract Diet, don’t you?
Dr. Robillard: Well, I do. I’ve been doing this for 15 years myself, and my own, which was terrible, chronic acid reflux, it was horrible. I was choking in the middle of the night, reflux entering my lungs and all-day heartburn, it was a terrible situation, so I’ve been doing this for 15 years. I don’t worry so much about encouraging people to add back fermentable material. I find that when people get better, and the more you do stay lower FP or you control these fermentable carbs or focus on identifying and addressing all of these underlying conditions, like a lot of people with H. Pylori, they will say, “Well, I’m just not gonna do anything about it. I heard it’s not that big of a deal,” maybe when you’re younger, but in time, gastritis, loss of stomach acid, and you might need some help. We have a consultation program where we really work on this, what are these things and what are the risk factors and what are your symptoms? How do we mostly throw things out, but the things that are remaining, the few things that are remaining, we have to confirm and address those. Of course, I’m a microbiologist, I’m not a doctor, so I give them my notes. I’m a consultant microbiologist to them, they take my notes to their doctor and we work through these things. You have to identify and address potential underlying causes, that’s one thing.
As you reduce the fermentable carbs, work on the underlying causes, you’re going to have less fermentation, less bacteria there that make proteases that damage the enzymes and the tips of your villi, toxins, you may actually damage the microvilli and villi themselves, kind of like a mini version of celiac disease where you get some blunting, does occur with SIBO. As you have less inflammation, control your diet, look at these causes, your digestion will improve. I do like to encourage people I work with to broaden their diet, in terms of three food groups, low FP vegetables, and there’s a lot of those. If you look at the vegetable lists and apps, there’s, I don’t know 180 vegetables, fresh herbs, but low FP, fresh herbs, low FP fresh vegetables with the idea of a diverse diet. They do have some fiber and some fermentable material, just not as much, but diversifying it will diversify your gut microbiota. Fresh vegetables, fresh herbs, and then also some small servings of some fermented foods, lacto-fermented pickles, kimchi, sauerkraut, that kind of thing, maybe a little bit of yogurt, just don’t go overboard. That’s a nice mix, but this thing about immediately feeling like you have to come back with a ton of fiber, I think that’s misguided. I think I might be one of the only ones out there, at this point, arguing against too much fiber. Everybody just seems to think we’re starving our microbiota. I just don’t believe it, especially if you have an animal-based diet with some fatty fish and you still have plenty of green leafy vegetables and you’re consuming some nuts, to me, that is an ancestral diet and a healthy one.
I feel like people, when they get better, they can be the best judge of what they can tolerate. I feel like I don’t have to ram fiber down their throat. On that topic, I was reading a review by, his name’s William Chad, I haven’t met him yet, a gastroenterologist up in Michigan who I hope to meet at this upcoming SIBO conference because he’s a GI guy doing work on diet, it’s just great to see. He wrote a review, co-authored it with, I think, one of the Australian folks that works on these diets, on fiber, and they are on the same page with me. They recognized there’s so many different types of fiber and their fermentability is so different, and so they worked, well, what’s the fermentability of all of these diets? I have a chapter on that in the Fast Tract Digestion books where I do the same thing, and they reach the same conclusion, psyllium, cellulose, something like that’s less fermentable, and if you’re gonna play around with anything, maybe start there, that’s the less invasive of all of these other ones because some of the other ones are very fermentable. There’s papers on using these. People that had GERD, they gave them fructooligosaccharide, right? A polymer fructose, but it’s a mini dietary fiber, and their reflux, they were measuring it with probes. The reflux occurred much more frequently, it was much more severe, and they had terrible symptoms, so that’s a prebiotic. They gave people with GERD a prebiotic and they really almost killed them. I mean, it was terrible symptoms and terrible reflux.
Dr. Weitz: That’s very common in the Functional Medicine world right now, is prebiotic supplements. You even see doctors saying, rather than use probiotics, it’s much more important to use prebiotics, and it’s definitely very popular right now.
Dr. Robillard: Yeah, it is. I’m not against prebiotics in very small amounts or a little bit of experimentation. Some people are worried about taking a probiotic because some of these probiotic contain a prebiotic with the idea that it’ll help get these bacteria going once you swallow them and they get into your intestines, but if you look at the label closely on those, they typically add about 50 milligrams of one of these prebiotics, which is really a tiny amount. It’s less than a 10th of an FP point because an FP point is a gram. One FP is one gram of fermentable material.
Dr. Weitz: Yeah. I think part of this putting the prebiotics in afterwards, also, after your treatment period is part of the 4-R or 5-R program that’s been so prominent in the functional medicine world and pretty much accepted as one of the few biblical versus in the functional medicine world, which is that first you get rid of the bad bacteria and then you replace and repopulate with bacteria and prebiotics with probiotics and prebiotics.
Dr. Robillard: Yeah. I mean, my favorite way to repopulate is just to have an organic garden and a compost pile. That’s what I’ve been doing my entire adult life, flipping the compost and growing my own garden so I get away from the chemicals for a lot of the year. We’re harvesting some squash right now, we’ll put them in a basement, they’ll still be good next spring. If you make some pickles, those will last you another winter. There are ways to eat less chemicals. Also, when you eat some of your vegetables raw, I mean not all of them, cooked vegetables are little bit easier to digest, but at least some of them raw, some grains. We grow a lot of dill and parsley and basil, then you are repopulating your gut with bacteria from your environment. By the way, they’ve done studies on compost piles. There’s a lot of similarities between the microbes in our gut and what’s in a compost pile. A lot of the same groupings of bacteria. That would be my preference, yeah. I’m not a real nut for the prebiotics unless they’re in limited amounts.
Dr. Weitz: Right. I’d like to ask you one more question because I know we need to wrap up soon. From reading some of your articles, you’re generally not recommending a lot of nutritional supplements. You do recommend digestive enzymes and ox bile and probiotics, but you don’t particularly like herbal antimicrobials, and I think these are a common part of many functional medicine protocols for SIBO. I know myself, we typically put the patients on one of these restricted diets and include these antimicrobials, and the thought is first we’re gonna starve the bacteria and then we’re gonna try to kill them using natural agents like berberine and oregano oil, et cetera, et cetera, but you’re not a big fan of these?
Dr. Robillard: Yeah. I mean, I could see why there’s a temptation to do that. I’m not totally against it. I spent 10 years working on and developing antibiotics. I worked on the development of Cipro, I’ve studied a mechanism of action of antibiotics, I’ve studied mechanisms resistance and the genetics of antibiotics, so I’ve worked on them for along time, they can be lifesavers. I mean, they’re very important. I’m against the loose use, I guess, of antibiotics because of resistance and a lot of problems. I really want to see diets continue to be improved and refined, and a lot of people have eating disorders or preferences and it’s hard for them to change their diet, I understand that. “I’m a foody,” I hear that a lot, “I wanna eat what I wanna eat.” I get it, but I have more of an ancestral health perspective and I’ve been reading more and more about this over the years and it just makes so much sense, that the more we can eat like our ancient ancestors, that’s really the way we evolved, but of course, it’s not exactly the same today. The foods not the same.
The Western diet is just not only terrible but also the availability of all of these snack foods, it’s just too easy to eat these things, and so it’s harder to change your diet. Also, our microbiota is changing, especially since the invention of antibiotics and the clinical development of antibiotics in the 40s, that’s only been, what, 60 years, it’s having a huge impact on our gut. Also chemicals and preservatives, so our gut bacteria are not the same, they’re not nearly as diverse. If you go back and look, and Jeff Leech has done some great work living with and eating like and sampling the guts of the Hadza in South Africa. Their guts are much more diverse and much more in touch with the biosphere than we are.
We’ve got this gut microbiome that’s gotten used to eating more processed foods, more easy to digest food, and then, all of a sudden, we’re getting all this advice, well, if you wanna be like the Hadza, you better throw some of this fiber at it, but your gut microbiota and your digestive tract is not handling it well. You can keep fighting it or you can just say, “Well, I have to go with it a little bit, but I still wanna eat healthy, green-leafy veggies,” occasionally maybe a half of a sweet potato or a half a cup of rice, for some people. You also have to consider, you mentioned diabetes, but also, how about cardiovascular risk? It’s huge. I don’t know if you follow the work of Ivor Cummins and Jeffery Gerber, but they just came out with a new book that’s super, and follow their lectures.
Dr. Weitz: What’s the name of the book?
Dr. Robillard: Eat Rich, Live Long, I believe. Yeah. I just started reading it myself, but yeah, you can also google Ivor Cummins lectures, just phenomenal stuff.
Dr. Weitz: Okay.
Dr. Robillard: Really looking at things, starting out from the basics and saying, “What’s important? Is LDL really that important?” Turns out, actually, it correlates very poorly with cardiovascular risk, but you know what all correlates really well? Insulin. It’s just fascinating lectures, I can’t say enough for their work.
Dr. Weitz: I’m not sure if you’re distinguishing between antibiotics, which are prescription medicines, and oregano oil. I totally agree that antibiotics, especially broad spectrum antibiotics, have a negative effect on the microbiota and can have harmful effects, but generally speaking, my understanding and my reading of the research is that these herbal antimicrobials don’t have a negative effect on the microbiota.
Dr. Robillard: Yeah. Okay, so I didn’t cover that, let’s cover that. First of all, when you look at the history of antibiotics, most of them came from other living things, back in the day, anyway, from bacteria, from fungi, and then the Germans started to figure out how to use chemistry and sulfur drug, came up with sulfur drugs and so forth, and then it grew from there. A lot of regular commercial antibiotics come from other organisms, so do these herbal antibiotics, and while I would say you could put them, maybe, on a less invasive scale than some of these more powerful pharmaceutical antibiotics, every antibiotic is going to kill or inhibit, right? Some are cidal, some are bacteria static, are going to kill or inhibit a certain variety of bacterial types, and they’re also going to have a certain potency, right?
What is the concentration of antibiotics you need to get to to kill those particular microorganisms? With herbals, and there is that one study, is that also, I think that was John’s Hopkins as well. It’s funny, all these study’s from John’s Hopkins, talking about using berberine, some other herbals, and they were as good as Rifaximin, so I think that’s interesting and it’s good to look at. Maybe they’re not as bad, but we don’t really know that much about it.
A lot of the work for those has been done on the side, outside of the mainstream, and I do think we need to learn more. By the way, when you say something as good as Rifaximin for treating SIBO, you’re basically saying, if you look at the target studies, that’s 10% better than placebo. I think diet, behaviors, and identifying and addressing underlying issues, those three things should be front and center. If you don’t do that, I think you’re dead in the water. After that, then you can start to look at supplements, digestive enzymes, absolutely. If there could be a stomach acidity issue, betaine, right, some vinegar, work your way down. Somewhere, herbals are in there as something to try, but for me, at least, and for people that I work with, I just don’t know enough about it to really be too gung-ho.
Dr. Weitz: Have you used motility agents like ginger and 5-HTP, things like that?
Dr. Robillard: Yeah. I think, again, there’s a whole thought that motility is slow because something’s wrong, right? That could be, and yes, with the vinculin and then the gastroenteritis, absolutely. There may also be an adaptation too, depending on what you’re consuming, right, because bacteria want to help us get all of those calories out of the food. Our bodies are collaborating with the bacteria, so depending on what you’re eating, your motility could speed up or slow down for a whole variety of reasons, it doesn’t really mean something’s absolutely wrong. Also, you do have to look at the extremes of diet, as well. I was reading a study the other day that, in anorexics, they found that they had a spike or an increase in these archaea organisms, Methanobrevibacter smithiii, that produces the methane, so it makes me wonder, under extreme caloric deprivation, is this a mechanism to make sure you ring every last calorie out of any kind of vegetative matter you consume by these archaea going up and motility slowing down? I first try to look at everything in terms of what could the natural mechanisms be here. Am I smarter than 50 million years of evolution? No. I just have a little more of a cautious approach. I try to really understand before I just jump to try this and try that.
Dr. Weitz: Awesome. Thank you Dr. Robillard. This has been an amazing podcast, gives us a lot to think about. How can listeners get a hold of you and get your books and your programs?
Dr. Robillard: Sure. Well, you can find us at DigestiveHealthInstitute.org, and I would also encourage people to join the Fast Tract Diet Official Facebook Group. I’m on there most days, poking in here and there and answering a few questions, but there’s a lot of people that have become real experts on the diet, and they’re very helpful as well. I think those are the two main places to find us. If you wanna specifically look at the mobile app, you can go to FastTract, T-R-A-C-T, Diet.com. You can find those on iTunes and Android store, as well.
Dr. Weitz: That’s great.
Dr. Robillard: Thanks for having me, Ben. It’s great talking.
Dr. Weitz: Thank you Norm. Yeah, I really enjoyed the conversation.
Dr. Robillard: Me too.
