208. Acid Reflux Isn’t Just an Acid Problem: PPIs, Rebound, and Deprescribing | Badal Shah, DO

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Welcome to Medicine Redefined.

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I'm Dr. Ultima Sharaja.

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And I'm Dr. Darsha.

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Let's put the hell back in healthcare.

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Today we're joined by Dr. Babel Shah, a board-certified gastroenterologist practicing in the Tampa Bay area.

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After earning his Doctor of Osteopathic Medicine degree from Nova Southeastern University and completing his Gastroenterology Fellowship at Jefferson Health, New Jersey, Dr. Shah built his career diagnosing and treating digestive disease through endoscopic procedures and evidence-based medical therapies.

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But over time, he began asking a different question.

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Why were so many patients still struggling despite receiving the right medications and procedures?

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That curiosity sparked a deeper interest in lifestyle medicine and the role that nutrition, sleep, stress, movement, and the gut microbiome play in digestive health.

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In this episode, we take a deep dive into acid reflux, proton pump inhibitors, also known as PPIs, the gut microbiome, probiotics, small intestinal bacterial overgrowth, and why digestive health is far more interconnected than most people realize.

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We separate what the evidence actually supports from where the science is still evolving while exploring how combining conventional gastroenterology with sustainable lifestyle change may be the key to treating the root causes, not just the symptoms of GI disease.

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Dr. Babel Shah, welcome to Medicine Redefined.

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If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice who are finding health and performance.

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I'm opening a limited number of founding member spots at refininghealthrx.com.

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All right, let's jump in.

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Welcome back, everyone.

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We have colleague, friend, and I'll even include mentor after all our chats, but we got Dr. Boblusha here, gastroenterologist extraordinaire.

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Welcome, man.

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Welcome to the show.

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I appreciate you guys having me, man.

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Thank you, guys.

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Yeah.

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So the audience will know this, and Boblusha, I don't know, but in another parallel universe out there, I'm probably a GI specialist.

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That was actually my first love when I was going to medical school because of lifestyle medicine, the microbiome, there was so much talk about it.

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And so...

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I understood it, right?

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It was like from hole to hole.

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It was a tube.

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It all makes sense.

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I really enjoyed the pathophysiology about it.

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It's good to have you on here, man, and talk shop.

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Absolutely, man.

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Again, thank you guys for having me.

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I'm excited to talk about whatever you guys want to talk about.

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Yeah, let's do it.

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I'm going to take just that little piece right there from hole to hole.

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We're going to make multiple reels out of that in different formats, quote it, put it on the ground right here.

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That's how you go viral.

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That's how you do it, man.

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Yeah.

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That one line.

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So we got a hodgepodge of topics here.

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Some of the things I'm interested in, the common ailments that you especially see, right, in the inpatient rehab, skilled nursing, what patients or even people just at home even deal with, right, acid reflux, whether it's constipation, diarrhea, IBS, IBD.

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So we'll get into all those things.

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But why don't you first tell us a little bit about your journey?

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How did you end up into gastroenterology?

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Yeah.

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So again, throughout medical school and training, there are a few things that really stood out.

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One thing was with internal medicine, I love the aspect of learning all aspects of medicine, right?

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And I think that's the most important thing is for me, it was to be a doctor.

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I need to know everything in general, you know, everything, all specific aspects of different organs.

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And so the GI for me, gastroenterology included multiple organs, right?

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And you got, of course, the GI tract, but you also had the liver, the pancreas, a lot of pathology there.

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And then with that, with gastroenterology, you get a lot of procedures.

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And that's two of the things that I love the most were procedures and then also being able to practice medicine in that way.

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And so it was a good combination of both.

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And throughout residency and fellowship, that's kind of what I leaned on.

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And I thought, you know, just like every South Asian background, the GI tract was the most important thing growing up.

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And so for me, it was stressed upon as well as growing up.

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It was something that definitely stood out.

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Yeah, no, for sure.

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There's obviously a lot of Ayurvedic medicine that deals with the GI tract, and a lot of our natural remedies are also intertwined with the GI tract.

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So when you graduate from fellowship, you were private practice, you were doing scopes, you were doing procedures.

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You've now pivoted completely to post-acute care, right?

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So we know each other from Encompass Health and the inpatient rehab.

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You're also at multiple skilled nursing facilities.

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What made you make that change?

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Because you're not really doing much procedures besides maybe

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Why do you change?

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I think I trained in a reactive model.

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You treat symptoms, you prescribe meds, you do scopes.

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The focus was reflux, that leads to PPIs, and that leads to potential procedures.

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Irritable bowel syndrome, which medication, antispasmodics, inflammatory bowel disease, steroids, biologics.

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I think.

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What I realized that were patients were still sick.

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The reflux patients were still symptomatic on max PPIs.

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The IBS patients were still triggered by stress and sleep.

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Inflammatory bowel were still flared.

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And I think my goal eventually is I wanted to help these patients heal.

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I think we were missing out on the more fundamental aspects of what we needed to do from a lifestyle standpoint.

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I think this new position allowed me to transition from the traditional sense.

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And I'm still on my journey right now to continue to implement lifestyles to the way I practice medicine now.

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Yeah.

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No, I love that.

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And one of the things that we were talking about right before we get started is that you had an interest in lifestyle medicine.

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And my question for you is, tell me more about what that means to you and when you develop that in the sense in more what we talk about today and how you guys connected.

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Yeah.

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You know, I think that what I was seeing in practice was that our focus was on more medication based in terms of treatment.

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A patient would come to me, they would have acid reflux and we would say, yeah, you know, these are some of the things that you could use.

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from a lifestyle standpoint, such as dietary changes, to help manage some of these symptoms.

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But our first go-to was antacid therapy.

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And I don't think we did a good enough job of actually implementing lifestyle changes.

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What I mean by that is, from a dietary standpoint, decreasing the amount of ultra-processed foods, increasing the amount of fiber.

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Sleep, sleep was very important with acid reflux.

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Sleep was something that we weren't getting of stress.

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Stress is an all-day, everyday thing, and that can increase hypersensitivity to the esophagus and lead to worsening acid reflux.

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So there's immobility.

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We know that that's an issue as well.

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Unfortunately, that's part of our lifestyle is with work and all that.

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We're not as mobile as we need to be, and that could lead to worsening acid reflux.

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You know, not implementing these and focusing on these, I wasn't doing a good enough job, and I felt as if patients weren't getting better.

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Instead, we're maxing out on more of these therapies without really setting a good foundation.

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You mentioned acid reflux, so let's dive right into that.

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So I think common knowledge or common thought is acid reflux is a problem of too much acid.

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However, we both know, like in the functional medicine world, there's now talk about acid reflux is actually a hypo problem that stomach is not producing enough.

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Let's break this up into a framework, I guess.

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Let's start with the pathophysiology or let's just kind of think about what is actually happening with acid reflux.

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Yes, and I agree with you.

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I think that it is a common misconception, right?

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And so that's why we see a lot of patients on antacid medications.

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They feel better because we're decreasing the amount of acid in their stomach.

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But really, it's an issue of lower esophageal sphincter dysfunction.

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Right.

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And so what happens is you have transient lower esophageal sphincter relaxation, and that is the main mechanism.

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That could be due to a lot of mechanisms.

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I have a lot of reasons.

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Gastric distension, visceral hypersensitivity, stress can increase symptom perception.

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Obesity can lead to increase in intra-abdominal pressure.

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That leads to these transient lower esophageal sphincter relaxations.

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And that causes acid to go where it's not supposed to go, to the end of the esophagus, and that leads to symptoms.

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And so that's what really triggers acid reflux.

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As we get older, we actually produce less acid in the stomach.

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And so what PPIs are treating, and that's why patients feel better, is that you're decreasing the amount of acid production in the stomach.

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It does a really good job of it.

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Almost 50% of the acid production decreases it.

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So that's why you eventually feel better.

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But we're not really treating what's actually going on.

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That's why patients end up staying on it longer than they're supposed to.

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Yeah.

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So when it comes to PPIs, right, we've learned, I think, in medical school is sure acid reflux, but also GI bleeds, right?

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Especially upper GI bleeds, you're automatically putting somebody on a proton pump inhibitor, protonics, all those.

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And that's really to suppress the acid from making any type of like ulcer worse, right, or the bleed worse.

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If it's not a GI bleed, though, how are these patients getting initiated most of the time from what you've seen in your practice?

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Well, I think it's just, it's symptoms.

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It's really just refractory to any sort of lifestyle changes, any sort of things that they have done.

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So they may come into the office, they may say, hey, I've had these acid reflux symptoms.

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They've been ongoing.

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I've tried to change my diet.

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I've tried to eat earlier.

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I've done all these things, but I still have symptoms.

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And then they get on the medication and they take it for supposedly two weeks.

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They feel better.

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And then what happens is they stop the medications because they feel better.

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And then they get the rebound reflux again.

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And then it's an ongoing cycle.

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A lot of times, adultery patients, they'll be placed in the hospital for stress prophylaxis while they're in the hospital for whatever reason.

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And sometimes they'll be discharged with the medication and then they'll be on the medication.

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But we as providers need to do a better job of then describing the medication if they don't need it again.

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So sometimes these patients will be on these medications for long term.

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And just by initiation in the hospital or a symptom that they may have had, and then it doesn't get described.

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Gotcha.

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Tell me about rebound reflux.

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Because I mean, a lot of people I know, well, they know they're going to have a jalapeno pizza at night and they're going to pop some PPIs or a Pepsit or whatever it is.

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But you mentioned rebound.

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Tell me a little bit about that.

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Yeah.

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So typically, when you're on anted medications, especially when you're on it for a few months or long term, a lot of patients are on it for years, the acid in your stomach is suppressed for so long.

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But when you stop that medication, especially if you stop at cold turkey, you're going to get rebound reflux.

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Because what's happening is now these cells in your body that have been suppressed for

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symptoms again.

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And so in reality, when you stop someone, you want to slowly wean them off the medication, especially if you've been on it long term.

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What I typically do is if you have a patient who's on PPI for years and you want to get them off the medication, I'll slowly titrate them off.

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So I'll do it every other day for two weeks, every two days for two weeks, once a week for two weeks, and then, or I'll transition them to an antihistamine blocker prior to then getting them off completely.

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And that's when you'll get the best results, I think, because if you try to take them off cold turkey, you're going to get rebound reflux because that acid production is going to

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I'm interested in regional differences in practices, right?

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So that happens a lot.

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So we were talking about how you spent some time in the Northeast, where I am right now, and now you're in the Southeast, right?

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Are any other points where you ended up practicing?

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You got a sense of the patient population?

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Or just did you go from here?

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No, that's it.

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Have you gotten a sense of what the biggest culprit is from one of those lifestyle factors for patient?

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Is it more of a obesity related thing?

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Is it more of a perception on, I guess what I'm trying to ask is, like Darsh has mentioned to me, Tampa has this vie where people are more health forward.

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as opposed to the Northeast.

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And so I'm wondering when people come to you, are they more receptive to that conversation that, Hey, we're not going to jump right to Omeprazole and X, Y, and Z.

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And maybe even they haven't already exhausted those options.

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Cause like I've been dealing with this for a while and man, like I'm going to GI when I'm ready to get school.

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Like that's when I'm going to GI.

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You know what I mean?

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Cause like all this stuff is available to you.

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So where do you catch the patient in their like lifetime, if just exposure to acid reflux?

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Yeah, I mean, I think that it's different based off the population.

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I think the younger patients are definitely trying to find other ways of managing their symptoms besides medications.

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I do feel that.

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And a lot of times they do come in with a lot of information, research that they found, et cetera.

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I also try to tell these patients it's not just one part of lifestyle because it's not just fixing a diet that's going to help all your symptoms, right?

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It's also, hey, the stress.

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It's also the job that you have that you don't like and that you're up all night.

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It's also the five hours of sleep.

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There's many factors in it.

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And so that's what makes it very difficult.

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Because I do believe that there's so many challenges to our society in terms of being healthy.

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Meaning, right, it's easier to be sick than healthy.

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And there's so many different factors because of that.

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So it actually takes work.

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It takes a lot of effort.

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It's a battle every single day to stay healthy.

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I mean, there's a thing about all the factors when you go to work.

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You wake up, you're stressed.

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You have all these things on your mind.

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You miss breakfast.

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You go there, you see donuts.

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You're like, oh, I got to add something to eat quickly.

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You grab a donut, you eat that.

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And then your day goes on.

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You're working at a desk.

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You're not moving that much.

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You go back home.

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You got to make your kids food.

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You're eating whatever you can.

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You stay up late because you deserve to watch your show, binge watch your show, and you don't get enough sleep.

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And so you have all these factors that play against you.

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And I think that all of this adds up over time.

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And so what I try to stress to patients, it's not just one thing, it's multiple things.

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And I think the younger patients understand it.

217
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They're also like, hey, what am I supposed to do about this?

218
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Like, you're telling me all these things that I need to fix, but how can I do that?

219
00:12:14.690 --> 00:12:15.951
And I tell them it's one step at a time.

220
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And I think by able to slowly implementing and making these lifestyle choices,

221
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In addition to evidence-based medicine, that's when you're going to see people actually not only just feel better, but actually stay better.

222
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And I think that's important.

223
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I think you see that with the younger patient populations in their 20s and 30s.

224
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They want to make that change.

225
00:12:33.683 --> 00:12:42.571
I think what we get in trouble with more in the older patients that have been on chronic PPI for many years, they're also on all these other medications and factors that could probably play a role on it.

226
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And so...

227
00:12:43.111 --> 00:12:45.793
it's a lot harder for them to make those lifestyle changes.

228
00:12:46.053 --> 00:12:52.916
In addition, the polypharmacy that we see and make those changes in addition to that, because that's probably playing a factor in some of these patients as well and overall.

229
00:12:52.936 --> 00:12:53.557
But you know what?

230
00:12:53.697 --> 00:12:57.099
The goal is to get you on the lowest dose or no medication, right?

231
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And if that requires you to change from PPI to an H2 blocker or weakest medicine possible, that's our goal because that's what we want.

232
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We want you to be able to be on the least amount of medications if possible.

233
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And that should be our goal for all patients.

234
00:13:08.525 --> 00:13:09.046
Dude, I love that.

235
00:13:09.146 --> 00:13:17.735
To your point earlier that it's easier to be sick, maybe just modify that a little bit by saying it's probably a lot easier to get sick, but it's really hard and it sucks being sick.

236
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I think about this patient I saw earlier today where I hadn't seen her in a while in her 80s and said, hey, long time no see.

237
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And she goes, oh yeah, we're around.

238
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We're usually at a doctor's office.

239
00:13:26.023 --> 00:13:27.464
And if you're sick, that's what you're doing.

240
00:13:27.625 --> 00:13:28.685
That's what life it is, right?

241
00:13:28.705 --> 00:13:33.189
You're in pain and you don't have the ability to have the quality of life that you want.

242
00:13:33.329 --> 00:13:38.053
You can't, if you have a lot of weight, maybe you have excess load going through your joints and things.

243
00:13:38.193 --> 00:13:41.556
So it actually is really hard being sick, but it is easy getting there.

244
00:13:41.956 --> 00:13:43.177
And it's much harder getting healthy.

245
00:13:43.217 --> 00:13:44.899
And once you are healthy, life is just better.

246
00:13:44.919 --> 00:13:47.921
You have more options, more freedom, as Darshan and I talked about, right?

247
00:13:47.941 --> 00:13:52.925
You want to be able to go to, I don't know, whatever those steps were in Spain or wherever you, one of your million journeys that you went to Darshan.

248
00:13:53.165 --> 00:13:53.766
Always traveling.

249
00:13:54.006 --> 00:13:54.547
But I digress.

250
00:13:54.747 --> 00:13:57.229
I think you used an earlier word, deprescribing.

251
00:13:57.249 --> 00:13:58.370
I think that's really important to it.

252
00:13:58.450 --> 00:14:00.912
We often talk about this in the pediatric realm.

253
00:14:00.932 --> 00:14:07.497
I think pediatricians do a good job addressing this, that children maybe will get diagnosed with something like a behavioral issue, ADHD.

254
00:14:07.597 --> 00:14:08.498
Let's take that for example.

255
00:14:08.518 --> 00:14:16.945
And then over time, it's really important for them not to let that diagnosis define them for the rest of their life and get them off a stimulant if that was appropriate for a short period of time.

256
00:14:17.145 --> 00:14:21.289
This is not a conversation that anybody's having about adults, at least not one that I'm hearing.

257
00:14:21.609 --> 00:14:24.210
And I think it's important because PPIs is one of those things, right?

258
00:14:24.230 --> 00:14:28.691
So this is, at least in the United States, most of these things are available over the counter, right?

259
00:14:28.731 --> 00:14:32.592
You can go over to CVS or whatever your pharmacy of choice, and you can pick that up.

260
00:14:32.752 --> 00:14:36.533
And then it works so well in the beginning that you just keep going back to it, right?

261
00:14:36.713 --> 00:14:37.113
Why not?

262
00:14:37.253 --> 00:14:46.375
That reward loop is so good because God forbid, I give up the dark chocolate and the caffeine, as I talked about, particularly in medical school, sodas, all those things that it is easier to your point to just be in that.

263
00:14:46.515 --> 00:14:50.637
I guess maybe an important point for us to discuss is like, why are we bashing on the PPIs?

264
00:14:50.657 --> 00:14:57.200
It's not because we don't necessarily like omeprazole and all those things, but they actually have some serious issues down the road that people can develop.

265
00:14:57.340 --> 00:15:04.384
A lot of these in the musculoskeletal realm that we see, what are some of those things, maybe black box warnings that people need to be aware of that, hey, this is not to be taken lightly.

266
00:15:04.404 --> 00:15:05.865
This is not something that you should be on for 35 years.

267
00:15:06.633 --> 00:15:07.534
Yeah, no, absolutely.

268
00:15:07.634 --> 00:15:08.234
And don't get me wrong.

269
00:15:08.254 --> 00:15:10.316
I mean, I think PPIs save lives, right?

270
00:15:10.336 --> 00:15:16.381
I think when you lose it in the right setting, they, peptic ulcer disease, active bleeding, that's what we use to help with that.

271
00:15:16.461 --> 00:15:21.626
Baird's esophagus, which is precancerous tissue from acid reflux over time, prevents adenocarcinoma.

272
00:15:21.726 --> 00:15:23.207
I mean, these are very good medications.

273
00:15:23.407 --> 00:15:33.294
I think what we forget is that, you know, a lot of these patients who are asymptomatic, who have a history of reflux, who've been labeled with acid reflux, have been on these medicines for 10 to 15 years, some even longer than that.

274
00:15:33.434 --> 00:15:35.095
And down the line, you do get concerned.

275
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And some of the concerns associated with it are one, increase in enteric infections, so increase in C. diff infections.

276
00:15:40.859 --> 00:15:45.322
The thought process behind that is that these medications reduce the amount of acid in your stomach.

277
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And so that allows...

278
00:15:46.643 --> 00:15:51.808
pathogenic strains of enteric infections, such as C. diff to kind of proliferate and cause worsening issues.

279
00:15:51.848 --> 00:15:54.311
It also increases risk of pneumonias as well.

280
00:15:54.511 --> 00:16:04.701
We believe that because of the same reason, if you lower the acid, you have these pathogens that develop in the upper GI tract and you micro aspirate and that causes you to have higher risk of pneumonias.

281
00:16:04.841 --> 00:16:07.764
Because of low acid, you decrease the amount of calcium absorption.

282
00:16:08.004 --> 00:16:10.545
And that can lead to increased risk of fractures.

283
00:16:10.785 --> 00:16:12.046
And that's been shown down the line.

284
00:16:12.086 --> 00:16:16.988
These are patients who've been taking it for years, but that's been shown also to be a potential risk factor as well.

285
00:16:17.028 --> 00:16:22.350
So, yeah, I mean, I think they're going to tell you to take it for a certain amount of time, but definitely patients are taking it for longer periods of time.

286
00:16:22.410 --> 00:16:27.452
And the goal is to try to figure out what's causing your symptoms and to get off the medication if you're able to.

287
00:16:27.672 --> 00:16:38.905
And of course, if you have a history of Barrett's or if you're at high risk of a GI bleed, you're over the age of 65 and have a previous history of a bleed on aspirin, then yes, that is a treatment of choice and you should be on one for prevention.

288
00:16:38.945 --> 00:16:44.331
But our goal should be always to figure out what's causing your symptoms and then try to get you off the medication if possible.

289
00:16:44.511 --> 00:16:50.996
Is there any type of test people can do to note that they should know whether they should be on a PPI or not?

290
00:16:51.036 --> 00:16:55.219
Or is it really just based off clinical symptoms to see whether they should get off of one or whether they should be on one?

291
00:16:55.259 --> 00:17:01.544
No, I think if you have chronic reflux for over five years, and that's one of the risk factors for Barrett's esophagus.

292
00:17:01.624 --> 00:17:10.791
And that's why I use that five-year mark is that if you have acid reflux for over five years, that's something that maybe getting an endoscopy to evaluate the end of the esophagus determined if you have a high or

293
00:17:10.911 --> 00:17:13.893
hernia, determine all these other factors that could lead to acid reflux.

294
00:17:14.033 --> 00:17:18.056
And that would help determine if you need to be on it or not in terms of a long-term or not.

295
00:17:18.197 --> 00:17:18.557
Gotcha.

296
00:17:18.697 --> 00:17:19.518
Or just a short-term.

297
00:17:19.538 --> 00:17:20.678
Do you need to be on PPIs?

298
00:17:20.798 --> 00:17:28.384
If you have an ulcer that we find on endoscopy, then you'll be on it for a couple months and then we'll repeat the endoscopy to make sure the ulcer is gone and the goal is to wean you off the antacid.

299
00:17:28.504 --> 00:17:29.825
That's how I would potentially do it.

300
00:17:29.925 --> 00:17:32.667
If you're having short-term symptoms, you could take it for two-week course.

301
00:17:32.888 --> 00:17:37.111
You feel better than you know it's likely related to acid, but then slowly weaning yourself off is important.

302
00:17:37.171 --> 00:17:38.652
Try to make those lifestyle changes to help.

303
00:17:38.772 --> 00:17:46.159
Now, I'm sure a lot of people who follow the functional medicine influencers have probably seen things like apple cider vinegar, licorice root, I believe.

304
00:17:46.419 --> 00:17:54.507
I don't know what other supplements are out there, but is there any validity to any supplements that you know of or any natural remedies to help with acid reflux?

305
00:17:54.607 --> 00:17:58.048
I don't think any of them stand true in terms of evidence-based.

306
00:17:58.128 --> 00:18:00.508
I think that some patients may feel better with that.

307
00:18:00.688 --> 00:18:03.649
What I would recommend is more of a higher fiber diet.

308
00:18:03.749 --> 00:18:05.990
Sometimes I like the low fermentable.

309
00:18:06.010 --> 00:18:07.610
I don't get heard of the low FODMAP diet.

310
00:18:07.630 --> 00:18:08.170
Have you heard of that?

311
00:18:08.370 --> 00:18:14.852
We use it for patients with irritable bowel syndrome or any sort of dysbiosis, but essentially decreasing the amount of fermentable carbs in your diet.

312
00:18:14.952 --> 00:18:16.792
So doing almost like an elimination diet.

313
00:18:16.992 --> 00:18:25.215
I think that really helps patients because you're essentially removing fermentable carbs that could increase symptoms, upper gastrointestinal symptoms for about four to six weeks.

314
00:18:25.395 --> 00:18:29.377
And then you slowly reintroduce these foods into your diet to see which one's causing your symptoms.

315
00:18:29.397 --> 00:18:33.518
And I think that really helps because it breaks it down pretty good in terms of how to manage that.

316
00:18:33.598 --> 00:18:34.539
I do like that approach.

317
00:18:34.799 --> 00:18:37.780
In terms of like supplemental approach, I don't really use any of those.

318
00:18:38.000 --> 00:18:40.521
I do recommend sometimes increasing amount of fiber.

319
00:18:40.681 --> 00:18:42.942
I think that helps with overall gut motility.

320
00:18:43.202 --> 00:18:46.064
More so in the stomach, but overall motility in the GI tract.

321
00:18:46.104 --> 00:18:46.885
I think that really helps.

322
00:18:47.145 --> 00:18:48.386
Keeps you satiated as well.

323
00:18:48.406 --> 00:18:53.589
So it prevents you from eating these other hyper palatable foods, ultra processed foods that can increase your risk of acid.

324
00:18:53.690 --> 00:18:54.910
Does the type of fiber matter?

325
00:18:55.010 --> 00:18:57.032
Well, it's like soluble versus insoluble.

326
00:18:57.052 --> 00:18:57.312
What's that?

327
00:18:57.492 --> 00:19:02.436
Yeah, no, I think because the type of fiber matters in terms of what it does to the motility of the stomach.

328
00:19:02.516 --> 00:19:05.818
Soluble fiber slows emptying and insoluble fiber can speed up emptying.

329
00:19:06.118 --> 00:19:09.020
But in terms of overall fiber improves overall motility.

330
00:19:09.040 --> 00:19:11.222
So that I think is probably the most important thing.

331
00:19:11.362 --> 00:19:17.183
Because it lowers abdominal pressure, stabilizes glucose, it improves microbiome, it replaces reflux triggering food.

332
00:19:17.223 --> 00:19:21.544
So that all improves, I think, overall GI health and reflux symptoms, I think.

333
00:19:21.664 --> 00:19:22.025
Yeah.

334
00:19:22.085 --> 00:19:24.985
Fiber in itself has like a large umbrella thing.

335
00:19:25.005 --> 00:19:26.166
It's kind of a superfood, right?

336
00:19:26.186 --> 00:19:28.406
So actually, I was thinking about, you're actually not a first GI, right?

337
00:19:28.426 --> 00:19:31.027
So Dr. Bolzewicz, way back in the archives, right?

338
00:19:31.047 --> 00:19:35.548
So came back and I think he had talked about, did he say 20 different plants a week he's going for?

339
00:19:35.568 --> 00:19:36.328
Like that's his target.

340
00:19:36.588 --> 00:19:39.129
Yeah, all these plant forward diets, like that's how they work, right?

341
00:19:39.149 --> 00:19:44.771
And when we look at the outcomes in fiber, they pretty much help with everything that we can think about from a cardiometabolic standpoint.

342
00:19:44.791 --> 00:19:47.693
Some of the reasons that you've highlighted, they have really good evidence.

343
00:19:47.733 --> 00:19:58.357
And I think probably less than 15% of the US population are getting the recommended daily allowance, which is somewhere around 30 grams for men and maybe 20, is that correct, 24?

344
00:19:58.477 --> 00:19:58.817
That's right.

345
00:19:58.837 --> 00:19:59.197
Yeah, I know.

346
00:19:59.218 --> 00:20:04.801
I think most people get about 10 to 15 grams of fiber, and the goal is 30 to 35 grams of fiber a day.

347
00:20:04.961 --> 00:20:07.043
I think that's where we lack a lot, and I agree with you.

348
00:20:07.063 --> 00:20:10.765
I think it's daunting when you say that 30 grams of fiber seems like a lot, but it really isn't.

349
00:20:10.926 --> 00:20:18.751
And I think if you focus on it, it's definitely doable, and I think it would help a lot of patients that have chronic GI symptoms overall.

350
00:20:18.891 --> 00:20:21.973
Now, I will say this, and I might know this from personal experience.

351
00:20:22.273 --> 00:20:28.577
If you have been on a low fiber diet for a very, very long time, you very rapidly ramp that up.

352
00:20:28.957 --> 00:20:30.118
It is not going to go well.

353
00:20:30.358 --> 00:20:30.698
No, no, no.

354
00:20:30.718 --> 00:20:31.458
It's not going to feel good.

355
00:20:31.478 --> 00:20:32.659
You're going to feel a lot of bloated.

356
00:20:33.059 --> 00:20:34.280
Yeah, it's going to feel bad.

357
00:20:34.540 --> 00:20:37.202
And maybe that has something to do with the microbiome, which we'll touch on in a second.

358
00:20:37.242 --> 00:20:41.246
But before we do that, I kind of want to just come back to stay on this acid reflux thing for a sec.

359
00:20:41.426 --> 00:20:45.889
So we've talked about the role of stress, something that has been well known for a long time.

360
00:20:46.129 --> 00:20:51.194
I'm not sure I understand the mechanism and how increases that acidity in the reflux.

361
00:20:51.234 --> 00:20:52.775
Can you elaborate on that for me a little bit?

362
00:20:52.795 --> 00:20:52.895
Sure.

363
00:20:52.915 --> 00:20:53.355
Sure, yeah.

364
00:20:53.375 --> 00:20:56.417
So stress lowers the lower esophageal sphincter tone.

365
00:20:56.657 --> 00:20:59.578
It increases a transient lower esophageal relaxation.

366
00:20:59.638 --> 00:21:02.720
So you have more episodes of relaxation of the lower sphincter.

367
00:21:02.960 --> 00:21:04.821
It heightens symptom perception.

368
00:21:04.901 --> 00:21:06.121
So you have hypersensitivity.

369
00:21:06.362 --> 00:21:08.563
And also the vagus nerve regulates motility as well.

370
00:21:08.603 --> 00:21:11.184
And so if you are stressed, that can decrease motility.

371
00:21:11.404 --> 00:21:12.585
So then you have more perception.

372
00:21:12.625 --> 00:21:15.786
So anxiety itself can make mild reflux feel severe.

373
00:21:16.026 --> 00:21:17.467
And so that itself can do it.

374
00:21:17.527 --> 00:21:19.228
So that's typically how stress does it.

375
00:21:19.248 --> 00:21:21.409
So it does lead to more acid exposure to the esophagus.

376
00:21:21.663 --> 00:21:22.464
So that's interesting.

377
00:21:22.764 --> 00:21:25.767
So that lower esophageal sphincter you said, right?

378
00:21:26.107 --> 00:21:27.529
What receptors are there?

379
00:21:27.669 --> 00:21:30.812
Those beta receptors, muscarinic receptors, what receptors are there?

380
00:21:30.832 --> 00:21:41.802
Because I'm trying to think about, so primarily, and this might be getting too into the weeds, and like if you're thinking about in high stress rates where you have more adrenaline run through the body, those are primarily going to act on your alpha receptors.

381
00:21:41.982 --> 00:21:45.305
You do not have any alpha receptors in the GI system that I'm aware of.

382
00:21:45.345 --> 00:21:45.766
Is that correct?

383
00:21:45.946 --> 00:21:48.508
The way you want to think about it, I think, is more of a rest.

384
00:21:48.588 --> 00:21:50.710
And we say parasympathetic rest and digest.

385
00:21:50.730 --> 00:21:54.292
That's why we tell patients, hey, before you eat, take some deep breaths, relax.

386
00:21:54.553 --> 00:21:55.794
It helps with the digestion.

387
00:21:55.834 --> 00:21:56.154
It's true.

388
00:21:56.174 --> 00:21:57.095
It helps with motility.

389
00:21:57.155 --> 00:22:05.341
I think when we eat in a more stressed chewing, we can get another lecture on chewing, you know, in terms of the lack of chewing that we do when we eat food, because we're just kind of scarfing down food.

390
00:22:05.461 --> 00:22:07.922
It doesn't allow us to really break down the food.

391
00:22:07.942 --> 00:22:11.863
It doesn't allow for us to really digest, and the motility of it gets affected as well.

392
00:22:11.963 --> 00:22:21.067
And so then you're left with less gastric emptying, more chances for distension, and that leads to more of these relaxations at the end of the esophage, the sphincter tone, that allows more acid reflux.

393
00:22:21.147 --> 00:22:21.728
Okay, cool.

394
00:22:21.948 --> 00:22:24.870
I suppose it's one of those things where I'm missing the forest for the trees.

395
00:22:25.190 --> 00:22:26.772
I do want to talk more about IBS and IBD.

396
00:22:26.912 --> 00:22:30.134
It's another one of those things that particularly IBS can be so challenging, right?

397
00:22:30.234 --> 00:22:37.160
The objective things, well, it's supposed to be IBD, and I'll let you define how you use the criteria to put each in these neat buckets for people.

398
00:22:37.200 --> 00:22:39.682
But before we do that, we touched on the microbiome a little bit.

399
00:22:40.122 --> 00:22:43.285
And I know this could be in its own seminar that people talk about.

400
00:22:43.385 --> 00:22:50.413
But the microbiome is one of those topics, buzzwords, that as we say, people are going to want to hopefully click on this and they're going to want to know all about that.

401
00:22:50.774 --> 00:22:54.678
And you have some people on this far and they're like, oh, it's all in the gut.

402
00:22:54.939 --> 00:22:55.720
It all starts.

403
00:22:55.780 --> 00:23:00.205
Literally everything that is wrong with you or right with you is because of your gut.

404
00:23:00.365 --> 00:23:02.726
And then you're going to be other people like, we just don't know enough.

405
00:23:03.147 --> 00:23:05.568
And we're actually, they'll say, no, that's nonsense.

406
00:23:05.708 --> 00:23:06.849
We're not quite there.

407
00:23:06.889 --> 00:23:11.591
And I find myself to be maybe in that middle camp, maybe a little bit more towards that.

408
00:23:11.671 --> 00:23:14.273
I do think this has a pretty significant effect in a lot of things.

409
00:23:14.633 --> 00:23:15.994
Where are you in that camp?

410
00:23:16.254 --> 00:23:16.714
Number one.

411
00:23:16.834 --> 00:23:18.915
And then how do you even define that?

412
00:23:19.215 --> 00:23:22.317
Or how do you explain the microbiome to somebody who's never heard of it?

413
00:23:22.477 --> 00:23:22.778
Yeah.

414
00:23:22.998 --> 00:23:24.420
No, it's obviously a big topic.

415
00:23:24.460 --> 00:23:27.023
I think if you ask my dad, he would say that it defines everything.

416
00:23:27.203 --> 00:23:27.484
The guy.

417
00:23:27.584 --> 00:23:28.105
He's a microbiome.

418
00:23:28.185 --> 00:23:29.086
Is he a gastroenterologist too?

419
00:23:29.406 --> 00:23:30.548
He thinks he's a doctor, but he's not.

420
00:23:30.568 --> 00:23:31.729
There's no medical doctor.

421
00:23:31.749 --> 00:23:31.870
Right.

422
00:23:31.890 --> 00:23:33.011
Yeah, he's a doctor in the house.

423
00:23:33.352 --> 00:23:33.752
In the house.

424
00:23:33.772 --> 00:23:33.932
Yeah.

425
00:23:33.952 --> 00:23:34.253
Oh, yeah.

426
00:23:34.273 --> 00:23:34.974
I got you.

427
00:23:34.994 --> 00:23:35.194
Yeah.

428
00:23:35.214 --> 00:23:36.736
It's all the WhatsApp lectures that they get.

429
00:23:36.836 --> 00:23:37.457
Oh, my gosh.

430
00:23:37.797 --> 00:23:38.438
All the forwarding.

431
00:23:38.458 --> 00:23:38.679
Yeah.

432
00:23:39.099 --> 00:23:40.301
That's 40.

433
00:23:40.841 --> 00:23:42.043
He's the apple cider vinegar guy.

434
00:23:42.203 --> 00:23:42.523
For sure.

435
00:23:42.644 --> 00:23:44.266
No, I mean, so healthy microbiome.

436
00:23:44.306 --> 00:23:53.818
So diverse, stable, rich in small chain fatty acid producers like butyrate, low inflammatory species, good barrier integrity, good motility of a healthy microbiome.

437
00:23:54.018 --> 00:23:58.923
And then you think of the opposite side of that dysbiosis, you know, which is like means your gut bacteria out of balance.

438
00:23:58.983 --> 00:23:59.143
Right.

439
00:23:59.183 --> 00:24:00.764
So you have reduced diversity.

440
00:24:01.005 --> 00:24:02.526
You have loss of beneficial species.

441
00:24:02.546 --> 00:24:05.929
You have harmful microbiomes, inflammation, permeability.

442
00:24:06.109 --> 00:24:11.415
And that's where some physicians and some in the functional medicine space, they'll say that's what leads to autoimmune disease.

443
00:24:11.455 --> 00:24:14.938
They'll say that's the root cause of autoimmune disease is gut permeability.

444
00:24:15.158 --> 00:24:18.481
And so, you know, really, I think of a healthy gut as a diverse garden.

445
00:24:18.521 --> 00:24:20.662
And you think of dysbiosis as a bunch of weeds taking over.

446
00:24:20.722 --> 00:24:22.224
That's kind of how I think about that.

447
00:24:22.284 --> 00:24:25.706
And so it's just dysbiosis is what we get concerned about, right?

448
00:24:25.766 --> 00:24:33.332
Which is an unhealthy microbiome that fuels the bloating, the inflammation, reflux, the irritable bowel syndromes, the inflammatory bowel disease.

449
00:24:33.533 --> 00:24:36.875
When you talk about gut permeability, is that what people say when they're saying leaky?

450
00:24:37.075 --> 00:24:37.295
Yeah.

451
00:24:37.696 --> 00:24:41.179
The appropriate medical term, is that the same as SIBO, like small intestinal bowel?

452
00:24:41.479 --> 00:24:41.739
No.

453
00:24:42.199 --> 00:24:42.940
Explain SIBO to me.

454
00:24:43.140 --> 00:24:43.340
Yeah.

455
00:24:43.360 --> 00:24:45.963
So small intestinal bacterial overgrowth is essentially what it sounds like.

456
00:24:45.983 --> 00:24:47.544
There's a bacterial overgrowth in the small intestine.

457
00:24:47.724 --> 00:24:50.467
And that could be from, there's a lot of factors that could cause that.

458
00:24:50.507 --> 00:24:52.048
It could be from chronic PPI.

459
00:24:52.268 --> 00:24:56.692
Low acid in the stomach over time can lead to bacteria overgrowth in the small intestine.

460
00:24:56.832 --> 00:24:57.753
And so we do see that.

461
00:24:57.913 --> 00:25:06.721
A lot of other gastrointestinal conditions like celiac disease or inflammatory bowel disease or even irritable bowel disease have been linked to bacterial overgrowth as well.

462
00:25:06.921 --> 00:25:10.602
And that's different from gut permeability because that's essentially what that is.

463
00:25:10.782 --> 00:25:17.724
Really, when you have decreased butyrate production, that leads to increase in inflammatory lipopolysaccharides from the bacteria.

464
00:25:17.864 --> 00:25:22.165
And that can lead to increase in intestinal permeability, and that's what we believe is that leaky gut.

465
00:25:22.445 --> 00:25:25.746
So the intestinal permeability, how does that present?

466
00:25:26.066 --> 00:25:26.806
What are symptoms?

467
00:25:26.926 --> 00:25:32.768
What are some objective findings that people will get a sense of before they go to your office or they come across you?

468
00:25:32.928 --> 00:25:34.950
Yeah, a lot of food intolerances, bloating.

469
00:25:35.130 --> 00:25:38.172
They feel, some feel fatigue as well as a generalized symptom.

470
00:25:38.533 --> 00:25:42.136
Bloating, a lot of it is the general GI symptoms that you'll get from upper GI symptoms.

471
00:25:42.156 --> 00:25:44.658
So bloating, reflux, everything makes me feel bad.

472
00:25:44.798 --> 00:25:47.660
Anytime I eat anything, it just makes me feel uncomfortable.

473
00:25:47.940 --> 00:25:48.341
Gas production.

474
00:25:48.361 --> 00:25:49.321
So it's more upper GI stuff.

475
00:25:49.442 --> 00:25:50.983
Like you're not going to see a lot of constipation?

476
00:25:51.003 --> 00:25:53.485
For the most part, but you can also get changes in bowel habits too.

477
00:25:53.685 --> 00:25:56.926
And that's the hard part is to try to differentiate the different symptoms.

478
00:25:57.046 --> 00:26:06.168
And I think our goal essentially is the same, whether it's how to implement lifestyle changes to help you get back and restore the gut permeability or even treat some of the irritable bowel symptoms.

479
00:26:06.368 --> 00:26:08.488
And then what about the other, the SIBO?

480
00:26:08.588 --> 00:26:11.289
Like how will that, is it very much the same in terms of?

481
00:26:11.349 --> 00:26:12.809
Very much the same in terms of symptoms.

482
00:26:13.010 --> 00:26:16.810
We typically do a breath test as an outpatient to help diagnose SIBO.

483
00:26:16.830 --> 00:26:19.631
So that will tell you if you have that condition or not and how we manage it.

484
00:26:23.652 --> 00:26:50.944
it what are you checking on the breath test is that urea hydrogen like spikes essentially different spikes from a that bacteria produces to see whether or not if it's produced and it spikes during certain levels then you can have a diagnosis what's the test called though like if i were to order it what would i order sebo test yeah you can just order a sebo test sebo breath test i love it ours i think it's sort of what i was in resident we just call breath test yeah there's a breath test for i mean there's a process for h pylori there's a process for sebo there's different companies out there depending on the company you can use it

485
00:26:51.224 --> 00:26:52.645
How do we test the microbiome?

486
00:26:52.665 --> 00:26:54.507
So I know there's in the functional medicine world again, right?

487
00:26:54.527 --> 00:26:59.571
If we go there, a lot of people, ultimately to your point about starting with the gut, I think naturopaths actually get taught that.

488
00:26:59.811 --> 00:27:04.655
So when I've listened to podcasts and naturopaths, the first thing they get taught is if you can't figure something out, go straight to the gut.

489
00:27:04.795 --> 00:27:11.961
I've shadowed functional medicine doctors who would get these stool samples, essentially, and then it off to a company and you can see the diversity or lack thereof.

490
00:27:12.281 --> 00:27:16.145
of the bacteria really see that as much in like the traditional health system.

491
00:27:16.285 --> 00:27:23.713
So when you were training at things, how would you guys go about understanding whether somebody would have leaky gut or dysbiosis?

492
00:27:23.913 --> 00:27:28.158
We didn't really talk about it much in terms of looking into dysbiosis.

493
00:27:28.218 --> 00:27:29.479
That term wasn't used at all.

494
00:27:29.579 --> 00:27:34.185
who had risk of C. diff for prevention purposes, who had antibiotic-associated diarrhea.

495
00:27:34.225 --> 00:27:45.999
I think we were using them more so for that, but really in our training, it wasn't taught to us to use these stool tests to determine what their flora looked like, if they had dysbiosis or not, if they had a good gut flora or not.

496
00:27:46.219 --> 00:27:48.342
So in reality, that wasn't in our training.

497
00:27:48.502 --> 00:27:48.782
Gotcha.

498
00:27:48.882 --> 00:27:59.212
To stick on probiotics, my understanding now, if somebody is going to take probiotics, which again, you get over the counter, a good quotation marks, because I still think there's a debate, has to be over, correct me if I'm wrong, 100 billion CFU?

499
00:27:59.392 --> 00:27:59.812
It depends.

500
00:27:59.893 --> 00:28:05.518
When you look at it, again, this is another topic we can go on for a long time, but when you think of probiotics, there's so many different strains out there.

501
00:28:05.618 --> 00:28:06.899
What's right for what person?

502
00:28:07.059 --> 00:28:10.843
There's the lactobacillus, there's bifidobacterium, there's saccharomyces, there's bacillus.

503
00:28:10.863 --> 00:28:11.243
These are

504
00:28:11.263 --> 00:28:12.724
A couple of them are bacteria.

505
00:28:13.064 --> 00:28:14.965
One's a fungus, one's a soil-based.

506
00:28:15.145 --> 00:28:19.668
By getting a diversity like that, and it's really specific to the person on whether it's going to work or not.

507
00:28:19.828 --> 00:28:24.952
But typically, it should take about two to three months to even know if it's helping you because it does take quite some time.

508
00:28:24.972 --> 00:28:29.174
And I think most people probably give up on that probiotic if it doesn't seem to help them right away.

509
00:28:29.455 --> 00:28:32.156
But don't people say your microbiome changes within 24 hours?

510
00:28:32.196 --> 00:28:35.138
You could, like, your next meal can change completely?

511
00:28:35.158 --> 00:28:36.019
Like, absolutely.

512
00:28:36.239 --> 00:28:37.460
Yeah, Bea, you're talking about that.

513
00:28:37.480 --> 00:28:39.601
Within two days, you can completely change your microbiome.

514
00:28:39.701 --> 00:28:42.962
That's why checking these stool tests and all that for diversity is very tough.

515
00:28:43.222 --> 00:28:45.583
I think that you see a big fluctuation in that.

516
00:28:45.804 --> 00:28:51.186
That's why I don't typically do it myself is because I think if we're going to implement lifestyle changes, let's see how that works.

517
00:28:51.266 --> 00:28:53.026
I think that's probably the most important thing.

518
00:28:53.066 --> 00:28:57.468
And you got to think of probiotics as a seed and actual diet as the soil.

519
00:28:57.588 --> 00:29:01.990
If you're taking probiotics but still have a crappy diet, you're not going to get much of a benefit there.

520
00:29:02.030 --> 00:29:08.893
I think you'll see the most benefit if you're on a good diet, in which case you're probably going to have a well diverse microbiome to begin with.

521
00:29:09.013 --> 00:29:10.654
I don't think probiotics are a bad idea.

522
00:29:10.714 --> 00:29:13.935
I think they could help supplement if you're already doing the right things.

523
00:29:14.235 --> 00:29:18.617
I think we get into trouble when you're trying to take a supplement, but still don't have a good foundation.

524
00:29:18.797 --> 00:29:20.038
I think we're all taking this for granted.

525
00:29:20.078 --> 00:29:22.159
Some people listening already know what probiotics are.

526
00:29:22.419 --> 00:29:25.681
So that is just you supplementing your gut bacteria, right?

527
00:29:25.701 --> 00:29:30.403
So there's actually strains of bacteria which have, in a lab, been isolated.

528
00:29:30.583 --> 00:29:32.464
Different strains that you highlighted, a couple of them.

529
00:29:32.704 --> 00:29:33.864
You didn't mention acromantia.

530
00:29:33.884 --> 00:29:34.785
That's in the news a lot.

531
00:29:34.905 --> 00:29:35.905
That's a big one, yeah.

532
00:29:35.925 --> 00:29:36.946
That's Nasir's GLP.

533
00:29:36.966 --> 00:29:37.766
You've got to get that one.

534
00:29:38.046 --> 00:29:38.366
Yeah.

535
00:29:38.406 --> 00:29:46.073
People can get these and CFUs, as I was talking about, so colony forming units, if I remember, the dose, if you're looking at it as a medicine.

536
00:29:46.353 --> 00:29:51.458
If you were to recommend probiotics for the right person, what would you look for?

537
00:29:51.778 --> 00:29:51.918
Yeah.

538
00:29:51.958 --> 00:29:57.183
What are some of the things that you look for in a supplement probiotic that might suggest, hey, maybe this is not a bad idea?

539
00:29:57.343 --> 00:29:58.744
For me, I would look at diversity.

540
00:29:58.884 --> 00:30:05.407
I would look at, and again, the ones that I listed, I would look to see because, again, it is hard to determine what is going to be right for you.

541
00:30:05.547 --> 00:30:11.010
So I would definitely include lactobacillus, bifidobacterium as a two bacterial strains in there.

542
00:30:11.250 --> 00:30:19.815
I would include saccharomyces, which is the one that we use a lot for patients who are on antibiotic, who have antibiotic-associated diarrhea or C. diff, and we want prevention.

543
00:30:20.075 --> 00:30:21.976
And then a good soil base is bacillus.

544
00:30:21.996 --> 00:30:25.136
So that's what I'm looking for in terms of which strains to have in there.

545
00:30:25.296 --> 00:30:26.697
Again, is it going to work right for you?

546
00:30:26.757 --> 00:30:32.498
It takes about two to three months to tell if you have bloating symptoms, if it helps with the bloating, if it helps regulate your bowels or not.

547
00:30:32.638 --> 00:30:34.659
These are some of the things that I find that is benefit.

548
00:30:34.679 --> 00:30:38.920
And sometimes you won't, if you just want a good probiotic because you want to take for prevention purposes.

549
00:30:39.100 --> 00:30:41.201
Those are some of the strains that I would have to include.

550
00:30:41.281 --> 00:30:46.242
I like to include all those different aspects because I feel like it is otherwise difficult to know what you're lacking.

551
00:30:46.402 --> 00:30:46.642
Yeah.

552
00:30:46.682 --> 00:30:49.625
I've heard the importance of keeping them refrigerated.

553
00:30:49.645 --> 00:30:57.010
I don't know if, like I know with fish oil, with oxidization, like light is really important that it has to be in a dark container and so on and so forth.

554
00:30:57.210 --> 00:30:59.192
Is that the case with these probiotics as well?

555
00:30:59.292 --> 00:31:05.637
A lot of studies have been done on that and they did show that even you did not refrigerate, you should see some benefit there.

556
00:31:05.757 --> 00:31:06.658
I don't think it necessarily has.

557
00:31:06.678 --> 00:31:11.742
Now there are certain companies that do recommend refrigeration, in which case I'd go with the company from what they recommend.

558
00:31:11.782 --> 00:31:15.705
But from what studies show, there still seems to be a benefit, even if not refrigerated.

559
00:31:15.865 --> 00:31:20.688
But again, I still think that other factors like life, whether it's diet and all that, play a big role in it too.

560
00:31:20.828 --> 00:31:24.051
Yeah, I was going to say, I think the company that's making waves with acromantia is Pendulum.

561
00:31:24.311 --> 00:31:27.553
And I think you're supposed to refrigerate their specific one.

562
00:31:27.593 --> 00:31:30.875
But it leads me to ask, so I know you're looking for diversity in the supplement.

563
00:31:31.036 --> 00:31:32.957
Now, some of these supplements, they just come with one strain.

564
00:31:33.217 --> 00:31:38.821
Is there a risk of overpopulating the microbiome with just one strain or is that meh?

565
00:31:39.041 --> 00:31:40.222
I haven't really seen that.

566
00:31:40.282 --> 00:31:44.623
Obviously, in immunocompromised patients and all that, I think you'd probably want to stay away from probiotics.

567
00:31:44.643 --> 00:31:50.446
So if you have patients on immunosuppressant therapies and all that, I probably wouldn't be giving that just because of the risk of something like that.

568
00:31:50.506 --> 00:31:51.306
But I haven't seen that.

569
00:31:51.366 --> 00:31:55.328
I think there's not, to my knowledge, I have seen any sort of risk of overpopulation there.

570
00:31:55.468 --> 00:32:00.352
I mean, there have been case reports of bacteremia associated with some of these things, but they've been very few and rare.

571
00:32:00.432 --> 00:32:01.793
And I haven't seen too much of that.

572
00:32:01.813 --> 00:32:02.454
Is that like where?

573
00:32:02.674 --> 00:32:03.574
Linky gut, I guess it.

574
00:32:03.835 --> 00:32:05.656
I believe that would be the reason why.

575
00:32:05.856 --> 00:32:06.116
Yeah.

576
00:32:06.237 --> 00:32:10.860
But again, these patients probably overall don't have, they were probably fairly sick to begin with.

577
00:32:10.940 --> 00:32:12.582
And they probably had multiple comorbid issues.

578
00:32:12.622 --> 00:32:18.146
And I think putting a patient on a probiotic at that point, unless it's for an anteprevention of C. diff, that's something I would probably avoid.

579
00:32:18.353 --> 00:32:20.434
Real quick, just define bacteremia for somebody listening.

580
00:32:20.694 --> 00:32:21.214
Who doesn't know?

581
00:32:21.294 --> 00:32:24.014
Yeah, so a bloodstream infection with the bacteria.

582
00:32:24.254 --> 00:32:24.795
Real bad news.

583
00:32:25.055 --> 00:32:26.815
I just want to think out loud here with you, Babel.

584
00:32:27.115 --> 00:32:30.816
You mentioned two to three months of needing a probiotic to see if there's any changes.

585
00:32:30.876 --> 00:32:34.137
Now, in my mind, I'm thinking human body probably has homeostasis.

586
00:32:34.197 --> 00:32:41.759
So even when we're told like, hey, the gut microbiome can change after a meal, it'll probably reset to kind of what it's been used to, almost like a set point theory.

587
00:32:41.779 --> 00:32:46.460
There are a lot of companies out there now that sell a probiotic based off your genetics.

588
00:32:46.720 --> 00:32:46.900
Right.

589
00:32:46.920 --> 00:32:52.141
So they'll do a saliva test, I'm guessing, and then or maybe even a stool test and then give you a specific regimen.

590
00:32:52.382 --> 00:32:55.122
What are your thoughts about those companies and are they legit?

591
00:32:55.342 --> 00:32:58.363
Yeah, I mean, I'm not really quite sure on the research behind that.

592
00:32:58.423 --> 00:33:02.324
I think if they can prove that or changes long term, then that's where it's at.

593
00:33:02.344 --> 00:33:09.446
I think testing is probably the most important in that realm of able to test and show that, hey, these patients are prior to starting had a unhealthy microbiome.

594
00:33:09.606 --> 00:33:15.468
And now after continuing these therapies, they've persistently shown that, hey, they have a more of a healthy microbiome.

595
00:33:15.488 --> 00:33:16.348
And I think it's worth it.

596
00:33:16.428 --> 00:33:19.731
But without testing and without knowledge, I don't know you can make that assumption without that.

597
00:33:19.851 --> 00:33:21.332
I think testing is probably the most important thing.

598
00:33:21.512 --> 00:33:22.473
And then keeping up with it.

599
00:33:22.573 --> 00:33:23.514
I think that's important.

600
00:33:23.534 --> 00:33:30.821
So a lot of these companies I know, as long as they're doing the right testing for it and they're staying persistent with that long term, I think that's something that they're definitely looking for.

601
00:33:30.841 --> 00:33:36.886
In the conventional medical model, I have seen stool testing done for people who've got this persistent diarrhea.

602
00:33:36.946 --> 00:33:39.488
Maybe you're concerned about C. diff.

603
00:33:39.588 --> 00:33:41.530
Like you mentioned, that's a big scary one as well.

604
00:33:41.730 --> 00:33:43.892
What are the actual stool tests checking?

605
00:33:44.092 --> 00:33:48.233
Are they just checking for all these bacteria that we talked about, or are they checking for C. diff and anything else?

606
00:33:48.353 --> 00:33:51.374
Yeah, I mean, there's specific stool tests for C. diff.

607
00:33:51.414 --> 00:33:56.756
Stool culture will give common bacterial organisms that could increase your risk of whether it's Campylobacter.

608
00:33:56.976 --> 00:33:58.596
Oh, yeah, Giardia, all that good stuff.

609
00:33:58.616 --> 00:34:01.217
Giardia, yeah, and parasites is another one that we check for.

610
00:34:01.237 --> 00:34:04.198
So these are stool tests that are checking for infections.

611
00:34:04.578 --> 00:34:07.520
But of course, there are other stool tests that test for pancreatic insufficiency.

612
00:34:07.640 --> 00:34:10.761
And so we use a fecal elastase stool test to check for that.

613
00:34:10.961 --> 00:34:14.463
We use a fecal calprotectin, which is a stool test to check for inflammation in the stool.

614
00:34:14.703 --> 00:34:18.866
So like in inflammatory bowel disease, it would be elevated in ulcerative colitis or Crohn's patients.

615
00:34:19.186 --> 00:34:20.767
And so different stool tests.

616
00:34:20.807 --> 00:34:30.932
I think the functional medicine will be using their own sort of GI profile testing and stool testing for advanced to check for the microbiome and all that, which we don't see much often in traditional GI.

617
00:34:31.092 --> 00:34:31.292
Yeah.

618
00:34:31.492 --> 00:34:33.833
Last thing here, Babel, in regards to this topic, at least for me.

619
00:34:34.054 --> 00:34:36.935
So throughout residency, when probiotics, we started using them.

620
00:34:37.095 --> 00:34:40.557
What is the verdict with conjunctive use with antibiotic therapy?

621
00:34:40.757 --> 00:34:46.220
A lot of my attendees would say don't use it while they're on an antibiotic because they'll kill the probiotic anyways and then use it after.

622
00:34:46.240 --> 00:34:49.302
But then some of them have said you might as well just use it with it.

623
00:34:49.322 --> 00:34:50.562
Is there anything that's been proven?

624
00:34:50.762 --> 00:34:59.307
I do believe that at least from certain strains can cause a more of a disruption in the microbiome if you take it while on antibiotics is the assumption.

625
00:34:59.647 --> 00:35:05.790
And there have also been studies that if you take while you have C. diff, for instance, if you take saccharides, that doesn't have that same disruption.

626
00:35:06.010 --> 00:35:10.532
And then to continue with the probiotic therapy afterwards to help prevent recurrence from happening.

627
00:35:10.772 --> 00:35:13.353
I generally haven't found any issues with doing them together.

628
00:35:13.554 --> 00:35:19.116
I think that anyone that's on an antibiotic would benefit from a probiotic, especially if you have a history of C. diff.

629
00:35:19.156 --> 00:35:22.838
I think you should be on lifelong probiotics after that, I think, for prevention purposes.

630
00:35:23.132 --> 00:35:23.812
I do believe that.

631
00:35:23.872 --> 00:35:26.753
I think that once you're at risk, you're at a higher risk for recurrent episodes.

632
00:35:26.854 --> 00:35:29.435
Taking a probiotic afterwards would be beneficial for you.

633
00:35:29.595 --> 00:35:29.695
Yeah.

634
00:35:29.715 --> 00:35:32.996
And for those who don't know, C. diff is a highly infectious thing.

635
00:35:33.016 --> 00:35:34.557
So it's like somebody in your family is getting it.

636
00:35:34.637 --> 00:35:36.017
That's going to be difficult to run away from.

637
00:35:36.237 --> 00:35:39.759
I think it's probably worthwhile to spend a couple of minutes talking about prebiotics.

638
00:35:39.999 --> 00:35:42.440
So we have probiotics to the other coin of that.

639
00:35:42.660 --> 00:35:45.021
How would you explain to the listener what prebiotics are?

640
00:35:45.252 --> 00:35:47.673
It's actually food for the bacteria.

641
00:35:47.693 --> 00:35:49.014
So food for the probiotics.

642
00:35:49.034 --> 00:35:56.437
So inulin and some of these products, artichokes, there's certain foods that can increase good food for the bacteria to help it thrive.

643
00:35:56.457 --> 00:36:04.620
And again, that's part of the diet profile where diet is very important for these probiotics to work, for these bacteria in the gut proliferate to essentially be happy.

644
00:36:04.680 --> 00:36:06.300
I think that's important to fuel it.

645
00:36:06.320 --> 00:36:12.523
And so a lot of it's fiber, certain vegetables that can increase your risk, increase these products to help with the bacteria.

646
00:36:12.623 --> 00:36:17.467
You mentioned one specific group where probiotics was not a good idea, right?

647
00:36:17.487 --> 00:36:20.910
So anybody on any type of immune therapy, immune system is depressed.

648
00:36:21.110 --> 00:36:24.854
Is that where postbiotics, I know people are like, we're just different tenses here.

649
00:36:25.014 --> 00:36:30.378
Postbiotics, so for those who don't know, so if we didn't specify this, probiotics are live organisms.

650
00:36:30.659 --> 00:36:32.200
Yes, and correct me if I'm wrong, by the way.

651
00:36:32.220 --> 00:36:36.924
Postbiotics are inactivated, or I guess they're dead organisms, but they're still beneficial, correct?

652
00:36:37.124 --> 00:36:39.306
So postbiotics is the byproduct, right?

653
00:36:39.506 --> 00:36:40.107
Of probiotics?

654
00:36:40.367 --> 00:36:41.608
It going through the GI tract.

655
00:36:41.668 --> 00:36:42.768
So you have probiotics.

656
00:36:43.028 --> 00:36:44.769
So is that what we're talking about right now?

657
00:36:44.829 --> 00:36:45.909
Your poop, yeah, your poop.

658
00:36:45.929 --> 00:36:46.450
Absolutely, man.

659
00:36:46.470 --> 00:36:49.071
Your poop has the butyrate, the small chain fatty acids.

660
00:36:49.111 --> 00:36:51.012
That's why people take butyrate supplements.

661
00:36:51.132 --> 00:36:54.033
And we don't know for sure if they work because it's not going through that natural process.

662
00:36:54.113 --> 00:36:55.334
It's just, here's the end product.

663
00:36:55.534 --> 00:36:56.634
Here's what we know is good for you.

664
00:36:56.854 --> 00:36:59.195
And that's what you should take is what people think.

665
00:36:59.235 --> 00:37:04.498
But you're going to get these small chain fatty acids that are necessary, like butyrate production with a healthy diet.

666
00:37:04.578 --> 00:37:10.060
I think that's a diversity plant forward, high fiber diet is what will allow you to reach that goal.

667
00:37:10.200 --> 00:37:10.660
Interesting.

668
00:37:10.681 --> 00:37:11.001
I love this.

669
00:37:11.321 --> 00:37:14.685
Is it worth talking about fecal transplants if we're talking about postbiotics?

670
00:37:14.705 --> 00:37:15.465
Just explaining that.

671
00:37:15.525 --> 00:37:25.575
And I wonder if there's a lot more research coming out on it, especially because we're talking about longevity and people talk about, what do you call it, like blood transfusions and swapping, Brian Jonathan, giving blood to a younger person.

672
00:37:25.736 --> 00:37:26.396
What is it called?

673
00:37:26.416 --> 00:37:26.857
Hold the hole.

674
00:37:27.037 --> 00:37:27.537
Hold the hole.

675
00:37:28.278 --> 00:37:29.519
I can't think of the words, but whatever.

676
00:37:29.539 --> 00:37:33.242
A younger person giving their blood to somebody older to change their markers.

677
00:37:33.522 --> 00:37:35.724
What can you tell the audience about fecal transplants?

678
00:37:35.784 --> 00:37:37.205
I mean, for C. diff, right?

679
00:37:37.285 --> 00:37:37.925
Recurrence C. diff?

680
00:37:38.045 --> 00:37:39.667
Yeah, I mean, it's really effective.

681
00:37:39.707 --> 00:37:42.749
I mean, so what fecal transplant is essentially is what it sounds like.

682
00:37:42.809 --> 00:37:45.951
It's taking one stool and placing it in another's intestine.

683
00:37:45.971 --> 00:37:46.912
Initially, we're doing it.

684
00:37:47.192 --> 00:37:48.213
all through colonoscopy.

685
00:37:48.293 --> 00:37:53.198
We would test someone's stool, make sure they didn't have any underlying infections or chronic infections, hepatitis.

686
00:37:53.479 --> 00:37:56.422
And then we would transplant that stool in the colon.

687
00:37:56.622 --> 00:37:59.205
And that was very effective in treating recurrent C. diff.

688
00:37:59.405 --> 00:38:04.270
In the 90s, you know, talking about 95% or above 95% effective in treating recurrent C. diff.

689
00:38:04.610 --> 00:38:06.392
Now there's better options in terms of that.

690
00:38:06.412 --> 00:38:07.453
There's something called VALS.

691
00:38:07.473 --> 00:38:10.797
There's pill formed where you can take to help prevent recurrent C. diff.

692
00:38:11.097 --> 00:38:13.780
Yeah, so that's another therapy out there, but it's very effective.

693
00:38:13.840 --> 00:38:18.625
They think not just C. diff, but it's been used in patients with inflammatory bowel disease as well.

694
00:38:18.865 --> 00:38:20.707
They even did studies on weight loss.

695
00:38:20.767 --> 00:38:23.730
So patients who have a normal BMI and patients who are obese.

696
00:38:23.910 --> 00:38:24.611
And if you give...

697
00:38:24.851 --> 00:38:33.576
Let's say, for instance, you gave an obese, you take a stool from an obese patient and you give it to a normal BMI that they found that the patient with the normal BMI would start gaining weight.

698
00:38:33.716 --> 00:38:36.398
And so they've done studies that show that how much it can alter someone's.

699
00:38:36.498 --> 00:38:38.839
And then they're still doing future studies on it.

700
00:38:38.899 --> 00:38:41.941
But I think from a C. diff standpoint, very effective.

701
00:38:42.041 --> 00:38:43.622
And now they're coming out with oral therapies.

702
00:38:44.163 --> 00:38:46.504
And I think it has been a game changer in terms of treatment.

703
00:38:46.704 --> 00:38:48.627
A lot of hospitals don't do that procedure.

704
00:38:48.647 --> 00:38:51.131
Sometimes they have to send them out to Mayo Clinic, etc., to get it done.

705
00:38:51.231 --> 00:38:54.896
And certain, even in Tampa, I think there's only a few hospitals that do it here.

706
00:38:55.137 --> 00:38:57.700
It's hard to store the stool, etc., to make sure it's viable.

707
00:38:58.041 --> 00:38:58.742
It's a process.

708
00:38:58.922 --> 00:39:01.486
And so in order for it to happen, there's a lot that has to go through.

709
00:39:01.686 --> 00:39:14.680
It's funny that, Darsh, you bring this up because I remember not too long ago, I think Tim Ferriss talked about this on our podcast, where we have studies like, so you take a person, and they did this in mice models first, where you have an obesogenic mouse.

710
00:39:14.880 --> 00:39:18.363
You'll take its fecal transplant, so you take its gut microbiome.

711
00:39:18.544 --> 00:39:21.827
You transplant it in a small, skinny, normal weight mouse.

712
00:39:22.007 --> 00:39:23.928
it's going to turn into obese and vice versa, right?

713
00:39:24.168 --> 00:39:26.549
Interesting factoid, because we talked about the vagus nerve well back.

714
00:39:26.569 --> 00:39:35.193
So it all comes back for if you cut the vagus nerve before doing that, you do not have those downstream effects of the normal mouse becoming obese after the fact.

715
00:39:35.233 --> 00:39:37.233
So there is certainly some interplay like you talked about.

716
00:39:37.434 --> 00:39:40.575
And this comes back to this thing that people talk about, the whole gut-brain axis.

717
00:39:40.675 --> 00:39:50.299
We didn't talk about this a lot today, but I think Dr. Jyoti Patel way back in the archives came back talking about majority of the serotonin in our body, maybe 90% or something like that, is produced in the gut.

718
00:39:50.519 --> 00:39:55.864
And we know there's an interplay that when your gut is unhealthy, your brain, your mood, it affects that and vice versa.

719
00:39:55.925 --> 00:39:59.408
And actually even vagotomy, they've looked at that and that's just cutting the vagus nerve.

720
00:39:59.608 --> 00:40:07.076
That in that transplant, when you have the vagus nerve that's transected or severed, the depression-like symptoms, mood-related symptoms don't tend to happen.

721
00:40:07.296 --> 00:40:09.197
So that's something that's really interesting.

722
00:40:09.438 --> 00:40:14.922
I know Darsh and I spent some time talking about this on the progress note a while back, but I can see how people can get trapped into it.

723
00:40:14.982 --> 00:40:15.802
It's all in the vagus nerve.

724
00:40:15.842 --> 00:40:16.503
It's all in this.

725
00:40:16.543 --> 00:40:17.163
It's all in this.

726
00:40:17.364 --> 00:40:18.024
It's all in the gut.

727
00:40:18.164 --> 00:40:20.846
And I think that for me, I like to say it's all very interesting.

728
00:40:20.926 --> 00:40:23.248
And a lot of this stuff is mechanistic and in mice models.

729
00:40:23.448 --> 00:40:25.750
And maybe we can extract some information from that.

730
00:40:25.810 --> 00:40:29.212
But I always pause when somebody says it's all in enter blank.

731
00:40:29.392 --> 00:40:30.273
Yeah, absolutely.

732
00:40:30.613 --> 00:40:32.094
I mean, there's a lot of things I play for sure.

733
00:40:32.295 --> 00:40:34.476
Bobo, do you listen to Tim Ferriss, his podcast?

734
00:40:34.536 --> 00:40:35.577
No, I don't think I've listened to this one.

735
00:40:35.637 --> 00:40:42.263
I'll send it to you, but he did one with Kevin Tracy about the vagus nerve and the importance of the vagus nerve when it comes to mental health, especially.

736
00:40:42.363 --> 00:40:46.226
I'll have to go back and listen to it or look at it, but they talk about Pepsid specifically.

737
00:40:46.527 --> 00:40:52.051
And I guess some data showing about how Pepsid affected the vagus nerve and actually- Modulated, yeah.

738
00:40:52.071 --> 00:40:55.534
Yeah, modulated the vagus nerve to reverse a lot of mental illness.

739
00:40:55.595 --> 00:40:56.455
So- Amazing.

740
00:40:56.515 --> 00:41:00.479
Touching on the gut brain, I'll send it to you and we'll put in the show notes as well for the audience.

741
00:41:00.719 --> 00:41:01.260
Very interesting.

742
00:41:01.280 --> 00:41:02.341
I'm wondering what's that in it.

743
00:41:02.481 --> 00:41:06.505
There are certain foods that are histamine elevated and then that could decrease in the histamine.

744
00:41:06.565 --> 00:41:07.446
I mean, that's very interesting.

745
00:41:07.646 --> 00:41:08.927
I'd be very interested to listen to that.

746
00:41:09.007 --> 00:41:10.669
Yeah, I just came quick Google searching.

747
00:41:10.769 --> 00:41:11.970
Here's a 2022 paper.

748
00:41:12.010 --> 00:41:16.335
Phamotidine activates the vagus nerve inflammatory reflex to attenuate cytokine storm.

749
00:41:16.795 --> 00:41:18.477
Maybe that's not exactly what he's talking about, but...

750
00:41:18.697 --> 00:41:18.857
Huh.

751
00:41:19.097 --> 00:41:19.457
Interesting.

752
00:41:19.638 --> 00:41:20.398
Loss of antenna flow.

753
00:41:20.418 --> 00:41:20.558
Okay.

754
00:41:20.718 --> 00:41:21.338
We got to look into this.

755
00:41:21.518 --> 00:41:22.099
Well, I love it, man.

756
00:41:22.319 --> 00:41:24.320
But I think this is a great place to park it.

757
00:41:24.360 --> 00:41:31.583
I know we had a list of topics that we wanted to just bounce off of you, and we did not anticipate that it's going to be a conversation.

758
00:41:31.743 --> 00:41:36.166
My main takeaway from the conversation is hole-to-hole and then PPI save lives.

759
00:41:36.386 --> 00:41:38.947
So I'm going to put those on my license plate.

760
00:41:39.267 --> 00:41:40.207
I can't decide which one.

761
00:41:41.848 --> 00:41:42.789
H2 HPPI.

762
00:41:43.009 --> 00:41:43.569
That's right.

763
00:41:43.629 --> 00:41:44.590
H2 HPPI.

764
00:41:44.710 --> 00:41:46.011
We'll come back for part two, man.

765
00:41:46.051 --> 00:41:48.372
We have a lot of interesting things to talk about, but this has been great, man.

766
00:41:48.392 --> 00:41:48.672
Thank you.

767
00:41:48.892 --> 00:41:49.333
Absolutely, man.

768
00:41:49.353 --> 00:41:50.473
I appreciate you guys having me on.

769
00:41:50.654 --> 00:41:51.994
I'll definitely be changing my license, please.

770
00:41:52.034 --> 00:41:53.155
I think that's a good one.

771
00:41:53.315 --> 00:41:53.755
All right, man.

772
00:41:53.895 --> 00:41:54.496
Until next time.

773
00:41:54.556 --> 00:41:55.236
All right, man.

774
00:41:55.276 --> 00:41:55.697
Thank you, guys.

775
00:41:55.877 --> 00:41:58.178
Thanks for listening to another episode of Medicine Redefined.

776
00:41:58.778 --> 00:42:02.561
If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes.

777
00:42:03.261 --> 00:42:07.584
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778
00:42:08.204 --> 00:42:12.387
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779
00:42:13.225 --> 00:42:22.212
We also want to thank our team for the production of this podcast, specifically Ethan Ju on video, Harita Yapor on social media, Zanab Lugmani on research, and Saira Khan for newsletter.

780
00:42:22.732 --> 00:42:28.977
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781
00:42:29.777 --> 00:42:35.522
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782
00:42:36.505 --> 00:42:39.466
Now, time for the ever so important disclaimers.

783
00:42:40.327 --> 00:42:44.308
This podcast is intended for general public use and is for educational purposes only.

784
00:42:45.009 --> 00:42:48.330
It does not constitute the practice of medicine, nor should be construed as medical advice.

785
00:42:48.890 --> 00:42:54.313
No physician-patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers.

786
00:42:54.913 --> 00:42:59.755
We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.