Small Intestinal Microbial Overgrowth: A Conversation with Dr. Vincent Pedre, MD IFMCP
All microbes, not just bacteria, can contribute to problems in the small intestines. Today more than ever, this idea is essential given the influx of hard-to-treat gut problems in clinic. Dr. Pedre brings his own gut healing journey and strong Functional Medicine background to talk to us about treating patients with SIBO-or as he likes to call it-SIMO, which encompasses microbes beyond bacteria and includes the oft-overlooked fungal piece of the puzzle. Dr. Pedre shares loads of treatment pearls from his gut-centric practice, but reminds us that any protocol must be individualized for the person sitting in front of us.
In this podcast you’ll hear:
- Pearls for clinicians starting their FxMed journey
- Dr. Pedre’s own gut journey and how this helps him help his patients
- Botanicals and pharmaceuticals recommendations
- When to consider biofilm busters, probiotics, and motility agents
- Treating leaky gut
- Laboratory testing: What Dr. Pedre uses
- Dr. Pedre’s opinion on the Elemental Diet for SIBO
- Agents we can use to minimize with die-off during treatment
Bio: Dr. Vincent Pedre, MD IFMCP
Dr. Vincent Pedre is the medical director of Pedre Integrative Health and founder of Pedre Wellness. He is an IFM certified practitioner. He’s the medical adviser to two health tech startups including MBODY360 and Fullscript. He’s in private practice in New York City and has been so since 2004. He’s a clinical instructor in medicine at Mount Sinai School of Medicine. He’s also certified in yoga and medical acupuncture. Dr. Pedre believes the gut is the gateway towards excellent health and for this reason, he wrote the book, Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy and Eliminate Pain, which helps people resolve their gut-related health issues.
Websites:
http://www.pedremd.com
http://www.happygutlife.com
Study on Rosacea and SIBO
Podcast Sponsors
Commitment to nutritional well being through innovative ideas and innovative products; that pretty well says what Biotics Research Corporation is all about.
Dr. Kara F.: Hi, everybody. I’m Dr. Kara Fitzgerald. Welcome to New Frontiers in Functional Medicine. Today, I’m really excited to have a fellow IFM certified practitioner with me today to talk about all things gut. His name is Dr. Vincent Pedre. You’re likely familiar with his book, Happy Gut. Dr. Pedre is the medical director of Pedre Integrative Health and founder of Pedre Wellness.
He’s the medical adviser to two health tech startups including MBODY360 which actually is a great app that we’re using in my practice and Fullscript. He’s in private practice in New York City and has been so since 2004. He’s a clinical instructor in medicine at Mount Sinai School of Medicine. He’s also certified in yoga and medical acupuncture. Dr. Pedre believes the gut is the gateway towards excellent health and for this reason, he wrote the book, Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy and Eliminate Pain, which helps people resolve their gut-related health issues. Dr. Pedre, welcome to New Frontiers.
Dr. Vincent P.: So great to be here. I will also add, for any doctor that has gut patients, my book is a great way to educate them about the types of things that you would talk to them about that are gut related.
Dr. Kara F.: Actually, I would concur with you. I think you really do a nice … It’s an in-depth book. You cover a great deal of complexity but you language it in a really accessible way. I appreciate that. As I was reading it, it’s written obviously from the perspective of being a physicians and you’ve got lots of really great patient stories in there that I think people will find inspiring and just really illustrative but you also have your own story. This book is coming from that place as well. Talk to me about your own digestive health challenges and the years of suffering you went through growing up.
Dr. Vincent P.: Yeah. I think it’s really interesting because I look back at it and I thank it for what it did for me because it’s brought me to this place where I help hundreds of people with their gut issues but when I was a child, to me, it was my normal. I didn’t know that something was wrong. I just thought that I had a digestive system that functions different from other people. No one would have known that I was becoming gluten sensitive or that dairy was an issue for me but those were the top foods in my diet as a child, lots of bread, pizza, ice cream, milkshakes.
I mean I used to get a milkshake after school every day. My mom would drive me … I hate to say it now but she would drive me to Burger King because I loved their vanilla milkshake and at some point, I just started getting sick really often. I had this really weak immune system, ended up on antibiotics and then, it was year after year after year antibiotics once, twice a year, pneumonia, bronchitis, pharyngitis and all of that wiped out my gut microbiome. We know now from studies looking at how long it takes the gut microbiome to recover from a course of Cipro, for example. It takes 12 months …
Dr. Kara F.: It’s so profound.
Dr. Vincent P.: … or Augmentin, six months or a Z-Pak. We think, “Oh, I’ll just give you a Z-Pak. It’s just five days. Not such a big deal.” It takes about three months to recover, for your gut microbiome to recover and it causes a dysbiosis which then can increase the leakiness of the gut. We can talk about that as we talk about things. Something that western medicine did not believe and then naturopathic medicine was talking about leaky gut syndrome for decades.
Now, the science finally caught up and we know that gut permeability is controlled by a protein called zonulin and there are certain things that can stimulate zonulin secretion and that will increase the permeability of the gut like gliadin, the protein in gluten. That is across the board for anyone. It could be a celiac patient, a non-celiac gluten sensitive or even a normal patient. Now, they’re all affected to different degrees so the celiac is the most sensitive, the most affected by gluten but even … What was shocking about this study is that even a normal patient was found to have some degree of effect in change in gut permeability.
Through this journey, I finally … When I went to medical school, I accidentally took dairy out of my diet because it just wasn’t convenient for me to sit down and have milk with cereal in the morning because I always had to just rush out the door. I noticed that I wasn’t getting sick as often. I used to be the type that if I was around someone coughing, I would pick up everything.
Dr. Kara F.: Wow.
Dr. Vincent P.: I just really paid attention to that, that fact because no one had ever told me that. I thought, “Wow. Maybe there’s something here because that’s the only thing that I changed.” I was eating a little healthier. I was incorporating avocados, healthy fats, olive oil and I had mostly cut out dairy except maybe occasional ice cream here or there and I wasn’t getting sick as often. That was like the beginning of my curiosity into what does diet, what role does diet play in our health even though we got very little nutrition training in medical school so I had to do a lot of reading on my own and just self-experimentation.
Dr. Kara F.: Thank God you are observant. That’s really cool. I don’t know that if I didn’t have the background that I would have connected those dots. Geez, I’m not, “What has changed?” That’s pretty cool. Obviously, it kind of catapulted you on your journey.
Dr. Vincent P.: That catapulted me on my journey and also kind of like a strength that I bring into my care of patients because a lot of times, they say the devil is in the details, I think what we do in functional medicine aside from really taking a thorough history is that we really listen to our patients. We’re spending more time with the patients. To me, it’s always I’m listening for that small detail. That is the differentiating factor.
You can’t do that in a Western medicine style 10 to 15-minute encounter where you’re just rushing in and out the door and the first thing on your mind within the first five minutes of the conversation, you’re thinking, “Is there a medication I can prescribe this patient so that I can get through this visit?” It’s such a different way of thinking through medical problems.
Dr. Kara F.: Yes. Yep. It’s like we can exhale, we have time to pay attention. Our journey impacts how we treat and so now, you are really bringing this rich background both as a medical physician but also your history as … to your focus on GI. What are you seeing in your practice?
Dr. Vincent P.: I do see … I mean it might be a little skewed too because I, since I am a gut expert. It does bring me a lot of gut-related patients. They really do seek me out. I see a lot of what falls under IBS, irritable bowel syndrome, which to me is not really a diagnosis. Within that, I see a lot of bloating, a lot of either diarrhea, constipation, alternating between the two or constipation predominance or diarrhea predominance, but I also see a lot of people just come in and say, “I don’t feel well,” very vague symptoms, sometimes not gut-related. Occasionally … That’s a big question because every patient that have a gut issue have gut symptoms and the answer is no.
Dr. Kara F.: Yes.
Dr. Vincent P.: A lot of times, a patient may not even complain to you about anything gut-related. My best example and I’ll never forget this patient, she was an Irish woman and she came in with hives, really bad hives, like embarrassing hives because half her face would swell up. It was completely unpredictable and could happen at work. She had been to five different dermatologists in New York, one of the top dermatologists for hives at Mount Sinai. I don’t know the name. Then, she came to see me. This is in my early days of functional medicine. I’m sitting there thinking to myself, “Oh my God,” like, “She’s been to some of the top doctors. What am I going to do?”
I had the little brief freak out moment. Then, I just sit there and listen. I had done the GI module by then. I was really starting to incorporate a lot of the principles. I thought the privileges and one of the persons who really has mentored me, Dr. Leo Galland, who’s considered one of the fathers of functional medicine, he said, “You know, one of the privileges we have is that if a patient has been to five other doctors, you can learn from what didn’t work.” I’d really learned a lot by seeing what didn’t work for patients. It goes back to, again, being really detail-oriented and spending the time and really listening.
Also, I thought, I’ve always been curious about ancestral diets. In Ireland, wheat was really not a part of their diet. Even though I didn’t have a test at the time, I told her, “You know, let’s do an experiment,” because nothing has worked so far and everybody is treating this as a Band-Aid, prednisone, prednisone creams, all sorts of topicals. I said, “You know, let’s take wheat out of your diet.” She was eating a lot of wheat and gluten.
She’s like, “Oh, I can’t do this,” like, “Look, I’m not telling you to do it for life. Let’s just do the next three to four weeks, you’re going to go gluten-free and we’re going to do all these blood tests and we’re going to look at underlying issues.” I gave her all the resources and I said, “You know, we’ll follow up in a couple of weeks. I don’t want you to eat gluten until … I don’t want you to do … No gluten until we meet again.” She comes in a couple of weeks later. Her hives were like 75% gone at that point. I was like, “Wow.”
Dr. Kara F.: This works. Oh my God.
Dr. Vincent P.: Oh my God. Yeah. I was like, “Oh my gosh.” Not only does it work but sometimes … and I think for somebody in … I know you have a question about this later but for a newbie in functional medicine, you can go to those lectures and you hear like all these amazing interventions and very complex plans but sometimes, it doesn’t have to be that complex. A lot of times, it can’t. It can’t start off complex because you have the patient that’s freaking out like, “Okay, you ask me to go gluten-free. I don’t know how I’m going to do this.”
Dr. Kara F.: Yes.
Dr. Vincent P.: What if when she comes back, I’m going to tell her, “You know what? The gluten is working so well. Let’s add dairy to the picture. You’re going to go dairy-free as well.” You really have to meet the patient where they’re at. This is one of my … One of the remarkable transformations because her … She did have the celiac genetics in the end. We did check for that. She did not test positive for celiac, so she’s in that category non-celiac gluten sensitive but her hives disappeared just by taking gluten out of the diet.
Dr. Kara F.: Listen. I want to just stop you because you’ve just said … I don’t know really about 10 different pearls that I really kind of want to swing back and underscore.
Dr. Vincent P.: Let’s highlight them.
Dr. Kara F.: Yeah, because they are just, they’re incredibly important. First of all, you said a lot of our patients don’t have gut issues, but gut is central. We see that and I just want to underscore that because that’s absolutely true but the flipside, and this was your story, is that you would acclimatize all these gut issues. I think there’s also patients who’ve got profound gut issues but as you said, it’s their normal. There’s this whole continuum. Then, some people of course are incredibly aware of their gut issues and on the great hunt towards fixing them but there’s this all of these important things maybe absolutely asymptomatic as far as gut issues but you know it’s an immune system thing as was the case in this hives patient and that’s where you started.
The other thing that you said that was just really jumped out … Actually, before I get to the clinical pearls for practitioners, you also pointed out that she was on prednisone, kind of ad nauseam because they didn’t know what else to do. First of all, Leo Galland is an amazing person and I absolutely agree. A lot of times, we get patients who’ve been to many different physicians and yes, we can pour over what interventions they’ve already done, what labs they’ve done, what hasn’t worked, hugely important. Thank you for that.
Also too, we know that she’s going to be the damaged process even as the prednisone gives some relief and it’s essential when they don’t know what else to do, you can’t be in total body hives and existing. Prednisone was essential while that was the only tool in the kit that worked. Thank God, for whatever reason, she came to your door. The prednisone piece is also going to kind of further damage the process and God knows what would have happened after a period of time if that’s all she had but she found you. Then, you pull her off of … You just did this very short-term trial of gluten elimination.
That’s the other huge thing that you said. New functional medicine clinicians, yeah, keeping it really simple can be exquisitely powerful and absolutely meeting your patients where you’re at, where they are at, excuse me, not where you’re at, where they’re at.
Dr. Vincent P.: That’s one of the really big pearls, I think, is that I think when we’re learning functional medicine, I think for instructive purposes, they’re teaching you a case in its ideal with we did this and this and this and this and this, but when you go out and you start practicing in reality, you start finding that you can’t tell a patient that’s never done any of that to go out and do 10 different things all at once.
Dr. Kara F.: Yes.
Dr. Vincent P.: That’s why this style of medicine is really … It’s more like you’re taking the patient by the hand and together, you’re walking a journey and you know what the destination needs to be but you have to help them get there.
Dr. Kara F.: Yes. You know, the fact is some patients jump in and they’re full steam with anything but some patients are not. Just as you said, we really need to allow ourselves to be open to where we need to meet them. Otherwise, we’re not going to see them again if we layer on some unattainable complexity so just … and not really fabulous.
Dr. Vincent P.: One really important question I ask patients when I start building a plan for them is, “Do you think you can do this?” just kind of like a check-in like, “Hey, I just gave you this.” Sometimes, they’ll say, “You know what? I can do one and two but I can’t do three.” I’m like, “Okay.” Then, you kind of, that’s where you negotiate because you want the person to be successful. We’re also educating people about what … If a patient comes in with asthma and has no gut issues or has allergies and has no gut issues, then to teach them that this is in fact related to the gut in many ways and if we start there, we can start to fix some of the other issues, that takes a while for people to understand that and even for practitioners to get.
I always thought it was logical especially things in the airway because if you looked at embryology, the same tissue that turns inward to become the digestive system is also what becomes the airway. Embryologically, they are related. They form from the same type of cells. It’s just interesting that for thousands of years in Chinese medicine, the gut and the lungs were interrelated. The same energy, the chi pathways, affect both things. If you want to improve lung health, you’re using pathways that deal with the spleen, the stomach. It’s kind of interesting.
Dr. Kara F.: Yeah. That is interesting. Gosh, that would be another, a whole another cool podcast, another conversation. One other thing I just wanted to say for new clinicians transitioning into functional medicine that you said just to underscore it, is that I think we’re also really blown away when we first start practicing. Even now, it’s just like … when you really, really walk with somebody and they get it and they’re healthy, just seeing the power of this medicine. Your patient comes back after two weeks and her hives are all but resolved. It’s as amazing and gratifying for us, I think, almost perhaps as it is for the patients. New people coming in, just hang in there with it. If it doesn’t seem possible, you will. You will absolutely experience these things.
Just circling back to the gut, you’re seeing a lot of SIBO, you’re seeing a lot of SIFO. I want you to talk about … First of all, talk about how you’re approaching SIBO. Define SIFO. Let’s just have a conversation around those two conditions which I’m sure you’re seeing plenty of.
Dr. Vincent P.: There seems to be or it feels like there’s an epidemic of it. Again, I get a lot of gut patients so my perspective maybe skewed. It may also be that we have better testing now or more awareness around it that it does exist whereas before, we kind of piled it under IBS, somebody has, because SIBO also can masquerade as different things. SIBO, for the people who don’t know, is small intestinal bacterial overgrowth. What that means is small intestine is not completely sterile but it has a very low count of bacteria. It’s about 10 to the third, 10 to the fourth ml whereas when you go into the large intestine, you’re at 10 to the 12th, 13th, so a big change in magnitude.
Our biggest reservoir is in the large intestine. SIBO is basically either an overabundance of the regular bacteria that live in a small bowel. They’ve overpopulated or it’s migration of bacteria from the large intestine into the small bowel. We’re not just talking about bacteria because we also get into an issue with archaea which, to me, I think of it as an ancient form of bacteria. It’s single cellular organism but very fastidious and doesn’t respond easily to the same antimicrobials as a regular SIBO with a hydrogens. You can have … I guess I should define.
Dr. Kara F.: Yeah, define.
Dr. Vincent P.: There’s two types of SIBO. There’s hydrogen predominant and there’s methane predominant. I will add, there’s a third type which is the combo, hydrogen and methane. That’s the toughest one. When I see hydrogen predominant, I am quite happy because I know this one is easier to treat.
Dr. Kara F.: Is it the dominant form that you’re saying hydrogen producers type of SIBO?
Dr. Vincent P.: I seem to see a mix but I do see a lot, I think, more hydrogen than methane but I do also get good amount of methane producers. The methane, again, it comes from archaea. One of the distinguishing factors of the methane-producing type is that methane stuns the migrating motor complex, that nerve complex along the small bowel that triggers peristalsis. A very big characteristic of the methane predominant is constipation. I’ve heard Dr. Pimentel, who’s a gut motility specialist, lecture and say that he even suspects that the methane may still be an issue even if it’s a low detectable on the breath test, that he still suspects that it may be a factor in people with constipation.
I don’t know that you can say that every woman that comes in and is constipated has methane predominant SIBO but you have to suspect it in someone who’s constipated and also really gassy or gets gassy after they eat. This is, again, listening to the details in the story. If someone eats and they immediately feel like their stomach swells up and it’s very high up in the GI system and it happens within 30 minutes of eating, like the first 30 minutes, that could be acid insufficiency. They’re not making enough stomach acid especially with a protein meal or someone who tells you that, “I don’t eat red meat because when I eat it, it sits like a brick in my stomach.” That’s a sign that they’re not making enough stomach acid.
Now, SIBO could come close to that but usually it’s about 15, 30 minutes after you finish eating, then you start to feel bloated and it peaks into an hour as the food is starting to move into the small bowel. Again, it depends on where the SIBO is. When we do a breath test, the thought behind it is you’re checking the breath sample every 15, 20 minutes and the longer you go in, it takes about 120 minutes to reach the ileum, the end of the small bowel but you have to take into account if someone suffers from constipation, it may take 150 minutes to get there. You always have to consider that. It kind of gives you an idea of where the SIBO is. I’m never surprised. If you take a thorough history, you kind of know what the test is going to look like. What you don’t always know is whether there’s methane and hydrogen together.
Dr. Kara F.: Right. Listen. I just wanted to thank you for that. Nice discussion on paying attention and really being able to track clinically what you’re likely to see. Go ahead.
Dr. Vincent P.: The other thing I wanted to say is that we all talk about SIBO but we really should be thinking of it as SIMO, small intestinal microbial overgrowth, because I think the problem is that SIBO then is getting us into the mindset of Western medicine like, “Oh, we’ve got the diagnosis and we do the treatment.” Then, you can miss something if you approach it that way. Your treatment can end up causing another problem and I’ve seen that where patients go to a GI doctor and they get treated with Xifaxan for hydrogen predominant SIBO and three to four weeks after the treatment, their symptoms start to come back.
The question at that point is do they have a recurrence of their SIBO or are they now developing SIFO? Have they developed dysbiosis because of the Xifaxan, Xifaxan being kind of really interesting antibiotic because the brand Xifaxan does not enter circulation. It stays in the gut. I heard one of the leading experts on Xifaxan did a lot of the research. He’s from Italy. Interestingly, Xifaxan acts not just as an antibiotic but also as a probiotic. It makes me feel little less guilty if I write Xifaxan for a patient …
Dr. Kara F.: That’s pretty fascinating. Do you know …
Dr. Vincent P.: … because they don’t know completely why but it promotes the growth of bifido in the large intestine.
Dr. Kara F.: Does it really?
Dr. Vincent P.: Usually, a treatment is 15 days but it actually lingers and stays in the gut for another two weeks. Its effects are four weeks long. It’s having the antimicrobial effect and then it’s having a probiotic effect in the large intestine.
Dr. Kara F.: It’s pretty interesting.
Dr. Vincent P.: Now, that said, I kind of hinted at it. When you’re thinking of someone, you see someone who comes in with bloating … I didn’t mention so I’ve had patients with SIBO, hydrogen predominant SIBO that didn’t present with so much bloating as diarrhea. If you see a patient come in with unexplained sudden onset of chronic diarrhea that just won’t go away, you have to think of SIBO. You should be breath testing them. It’s usually accompanied with malabsorption. Maybe they’re not absorbing iron and they start to feel really fatigued.
I had another patient very similar. For years, she had loose stools, severe fatigue and iron deficiency. You see a woman with iron deficiency and she was a menstruating woman and you think, “Well, this is just normal for a menstruating woman,” but the ferritin was really low. It was maybe like nine. You have to think, is it just that? I think that when you’re not asking yourself that question, what else could it be, that’s when you miss things. If you just go for, “Oh, this is just normal menstruating woman. Let me put her on iron,” she’s not going to get better because you have to fix the … what’s sequestering her iron is the bacterial overgrowth.
After seven years of fatigue, and this is another one of those remarkable stories, we treated her SIBO and she came back at the end of the treatment and said she felt like she was her old self from seven years ago in just a couple of weeks after being, again, to doctor after doctor after doctor trying to figure out what was going on with her. I was hinting at it that you really have to think of it as SIMO because when you’re treating SIBO as a bacterial infection, you have to wonder, is there a fungal overgrowth in the background.
Dr. Kara F.: Yes.
Dr. Vincent P.: If you don’t think that, you’re going to miss it. To me, the way I think of SIBO treatment and why so many people fail it with the Western approach is, “Okay, you have SIBO. Let me treat you with Xifaxan. If you have methane predominant, maybe I’ll give you a combination of Xifaxan with neomycin because we found that the methane predominant doesn’t respond to Xifaxan so you have to treat it with a combo of Xifaxan and neomycin.”
The problem in why I have started to abstain from neomycin is I’m concerned about ototoxicity with neomycin. I get really nervous about that, it’s not completely successful. The way I look at it is like the first part of the treatment may be an intense part with a prescription antimicrobial but for you to have a successful SIBO or SIFO treatment or a combination thereof, you have to have the tail of the treatment. Then, the tail of the treatment which may go on for two to three months afterwards, I’m giving them an herbal antimicrobial. I may be using an herbal combination. I may use a very high-grade garlic extract and allicin. There’s one that I get that comes from the UK that’s really a highly concentrated and they have a pro version that’s like much higher strength than their regular version.
Dr. Kara F.: You can say brands.
Dr. Vincent P.: Okay. One example is Biocidin. That’s one brand. The other one that I’ve been working on seeing what protocol works best … because I had another patient with refractory SIBO and I treated her with Xifaxan. She got a little bit better. This is the interesting thing with these patients is that even after explaining to them that this is a two to three-month process, they come back after the first two or three weeks and they’re like, “Oh, I don’t feel any different.” I’m like, “Well, we’re not there yet. We got to keep going here.” It’s like, “You’re just getting the low-hanging fruit and then you really have to get in there.”
I used a biofilm buster called InterFase. I like to use InterFase Plus and that I’d put into the tail of the treatment with the allicin. This was particularly successful for this refractory case. Even at the two-month mark, she was still, herself, not recognizing all of the benefits but she noticed that she was feeling less bloated. I knew we were on the right track and I had her on a very strict SIBO-specific diet. It’s like the low FODMAP diet. A lot of times, I refer patients to siboinfo.com which is Dr. Siebecker’s website. She has a really great SIBO specific diet with a spectrum of which foods are the worst and which foods are not as bad but still make you feel bad because really, there’s not one diet for every SIBO patient. One patient may get super bloated with avocado and another patient might be fine with avocado.
Dr. Kara F.: Yep, that’s right. I think she’s doing, it’s probably evolved but a FODMAP with a layered specific carbohydrate diet on it as her foundational but you’re exactly right. Yep. It is an individual process.
Dr. Vincent P.: What can make it really tough and difficult is that as the practitioner, you have to engage the patient to really listen to their body and the wisdom of their body because you can’t just prescribe that one diet. You have to say, “Okay, these are the guidelines but I want you to really pay attention and see if there’s still some foods in these guidelines that maybe don’t work for you.”
Dr. Kara F.: Listen. Let me ask you a couple of questions around that. Some people like Dr. Pimintel are all about having folks consume the problem foods so the bugs are not sort of in a kind of hidden or dormant place during the active treatment. I personally, in my clinic have found patients are not keen on doing that because the diet helps for symptom relief pretty quickly.
Dr. Vincent P.: You’re feeling pretty bad.
Dr. Kara F.: Yes. Tell me what you do. It sounds like you’re concurrently implementing a diet.
Dr. Vincent P.: I’m concurrently implementing a diet because if you don’t get people well quickly, they’re not going to come back to you. You work on diet. An interesting thing I started doing and I must have heard this in a lecture, is adding slippery elm bark because inevitably, these patients having leaky gut syndrome. You have to start working on that but sometimes, I find that adding L-glutamine too soon can actually make the bloating worse. I don’t tend to use L-glutamine until a little bit later in the treatment but I heard this in the lecture. The slippery elm bark is gobbled up by the bacteria that are producing hydrogen, for example, and it serves as a shuttle so it helps if you’re treating them with Xifaxan, if you’re prescribing the antibiotic, the slippery elm bark targets it into those bacteria.
Dr. Kara F.: Really?
Dr. Vincent P.: I’ve used it concurrently as part of my treatment and then I continue patients on … I teach them how to make a slippery elm porridge because the slippery elm is so mucinous. It’s really protective for the gut linings as you start to heal the leaky gut. It’s a really good first step as long as the person doesn’t have tree allergies. Some people who have tree allergies might not do well with slippery elm.
Dr. Kara F.: That’s great. That’s a really nice pearl. I know you can buy bulks slippery elm in a powder.
Dr. Vincent P.: Yeah.
Dr. Kara F.: What do you do?
Dr. Vincent P.: NOW, the brand, NOW, produces an organic version.
Dr. Kara F.: What do you have them do? Just give me a recipe really quick because I know clinicians are going to be asking me.
Dr. Vincent P.: You can basically have them take a tablespoon or two and you put it in a cup of water. You cook it like you would an oatmeal. You slow cook it until it starts to thicken. Now, the slippery elm bark porridge is going to taste pretty disgusting so I have them put cinnamon in it. They can put a little bit of vanilla extract if they want and sometimes, I have them take it and then add it to their protein smoothies. Now, they’re having this smoothie with this slippery elm porridge or they can eat the porridge separately. You can also add a nut milk as well so you can make it with like coconut milk or almond milk to get … It seems that it does better actually if you don’t make it with water and you make it with … or you add milk afterwards because the creaminess of the nut milk helps take away some of the grittiness of the slippery elm bark powder.
Dr. Kara F.: Perfect. Thank you for that. We’re talking about how miserable people are and I just appreciate your approach. You’re starting with, it sounds like an antimicrobial, a pharmaceutical protocol.
Dr. Vincent P.: Sometimes. Yeah, most of the time … I was in a lecture recently where they used Biocidin as a treatment and it was anywhere between a two and a three-month treatment but sometimes, I feel that sometimes, the patient is so uncomfortable that you just have to get them to that place where they’re feeling at least enough percent better that they recognize it so then they’ll continue working with you. Not everyone has the patience for the slow recovery but again, I never just treat the beginning … There’s, what I call the tail of the treatment. If you don’t do that, it’s going to come back.
Dr. Kara F.: Are you using a biofilm buster as in the tail in all of your folks?
Dr. Vincent P.: Yeah, like InterFase or Biocidin itself as a biofilm buster or the InterFase Plus.
Dr. Kara F.: Now, what about motility?
Dr. Vincent P.: That’s another thing. Everybody talks about the importance of … Dr. Pimentel really believes that motility is a big issue with why it develops in the first place. There’s Iberogast which helps stimulate the migrating motor complex, the MMC, but you can also use ginger as a pro-motility. I know that people use erythromycin low dose but I honestly don’t like the idea of using an antibiotic as a pro-motility agent just because everybody who has this has dysbiosis, in the recovery phase, you really have to start working on healing leaky gut, so maybe using L-glutamine, DGL … I love bone broth. I basically … A protocol that I use as long as they can … and I’ve been testing this protocol on patients also with hives, allergic conditions, is slippery elm porridge in the morning and bone broth at night …
Dr. Kara F.: Interesting.
Dr. Vincent P.: … both working to really heal the gut lining. Maybe with the bone broth, add some collagen powder in the bone broth. I know there’s questions about that. I’m not completely sure whether the collagen powder really adds added benefit in terms of healing the leaky gut.
Dr. Kara F.: Right. Maybe now, I noticed a couple of labs are … Zonulin is becoming more available and I’m sure that it will be-
Dr. Vincent P.: Cyrex. Cyrex is testing for zonulin antibodies.
Dr. Kara F.: Genova and DSL, Diagnostic Solutions Lab, both have started to offer … just started. I actually haven’t even seen the result and I’ve ordered both of stool tests from both of them. They’ve started to create big … They created fecal zonulin which doesn’t have a lot of …
Dr. Vincent P.: Interesting.
Dr. Kara F.: Isn’t that interesting? I think, Vincent, a lot of us clinicians will be … We will be looking at a lot more zonulins. I know it’s fecal zonulin which doesn’t have the evidences that the serum zonulin does but they’ll be readily accessible on a lot of the stool tests we’re getting.
Dr. Vincent P.: As we’re talking about stool test, the other really important marker that I look at in the stool, a new marker, is calprotectin because that can really be a distinguishing marker whether the person who you’re seeing has IBS, under that umbrella, or if they have IBD, if really what they have is an inflammatory bowel disease, and I’ve caught those borderline people. I have a patient that has collagenous colitis and she’s a young woman. I ended up sending her for colonoscopy because her calprotectin came up high. Then, the biopsy showed she has collagenous colitis. There’s also been a question about the associations between this and SIBO. Here’s another interesting pearl I heard in a lecture that I was listening to, that the research has showed there’s 100% correlation between rosacea and SIBO.
Dr. Kara F.: Wow, 100%.
Dr. Vincent P.: If you see a patient with rosacea who’s not complaining about gut issues or maybe just has kind of not … A lot of times, you really have to dig because people think that it’s their normal. They might not report it to you because they just don’t think it’s so significant but if you see a patient with rosacea, test them for SIBO. Think about SIBO.
Dr. Kara F.: Absolutely. Thank you. 100%, that’s amazing. If you can put your hands on that study and just shoot me a reference, I’ll pop it on this transcript. I just wanted to clarify. You’ve got a really nice, robust protocol. You’ve got the baseline that you talked about and then you have this tail, and you’re doing a diet congruently.
Dr. Vincent P.: The tail is really taking into account that this could be both bacterial and fungal.
Dr. Kara F.: Yes, okay. Yep.
Dr. Vincent P.: In the tail, I’m treating both and I’m being very careful about bringing in probiotics. You don’t want to bring a too broad spectrum probiotic too early on. A lot of times, I’ll start with just a lower strength bifido probiotic. I’ve also been experimenting with using a spore based probiotic. In this refractory case that I have, my tail treatment was a product by Klaire called BioSpora with the biofilm buster, InterFase Plus, and the Allimax and she was an extreme refractory case like she felt … She had mental fog. She had both SIBO and SIFO. She was sick for years and it’s been amazing. Now, she’s three months into the treatment and her family is telling her that she is her old self again after years of not … Her mind is clear. She had … That was another thing I didn’t mention, the gut-brain issues that you get. If you see someone with mental fog, you have to think dysbiosis and you have to think possibly candida or yeast overgrowth as possibly causing this mental fog.
Dr. Kara F.: All right. BioSpora from Klaire and then the Allimax is the allicin. It’s the potent allicin product that you’re talking about. What about … Are you using motility agents or are you finding that you don’t necessarily need them?
Dr. Vincent P.: I know that that’s what they classically teach. Again, it depends on whether the person is having full bowel movements or not. I go with what the patient is telling me because again, you don’t want to overload someone with too many things to take. Typically, they’re already … There’s, how many supplements? That’s four that I already mentioned, so then you’re adding … I use them more with the methane predominant, the ones that I know are having a major motility issue. You have to be careful because if the person is already going frequently, if you add a motility agent, you might cause loose stools. I take it as a case by case basis. I don’t take it as across the board, as something … Again, that’s just an example of really … it’s good to understand the general treatment plan but then you have to really individualize it to each patient.
Dr. Kara F.: Are you using elemental diets at all?
Dr. Vincent P.: I know the elemental diet and I have not used that as a prescription for a patient. Honestly, my New York patients would look at me cross-eyed if I told them but, Integrative Therapeutics came out with a formula. It’s called Physicians’ Elemental Diet. It basically has everything you needed in the elemental diet in the formula. I’ve tried it out with a couple of patients. I think it’s really hard to keep up and it’s really hard for them to feel that they’re getting enough nutrition through the elemental diet. Speaking of, you can make a SIBO patient better if you put them on a, say you put them on a bone broth, liquid fast for a couple of days, just kind of give their gut a rest. That in itself can be really helpful. If you have a patient that’s really, really miserable, you could just have them drink bone broth for two or three days. At least you know they’re getting nutrients and minerals through the bone broth.
Dr. Kara F.: Absolutely. I think that’s a great idea. What about-
Dr. Vincent P.: You could use the Physicians’ Elemental Diet formula and supplement with bone broth so the person doesn’t feel … I don’t think it’s enough nutrition to substitute real eating. It’s hard to deal with it for two weeks.
Dr. Kara F.: It is. It’s hard to … Yeah, it’s a hard sell for the full … for two plus weeks definitely. I’ve used the bone broth as you’re describing and I think it’s really helpful. I also use the elemental diet, the IT Elemental, very short term and it can be helpful to just give a little bit of relief, much the same way as the bone broth.
Dr. Vincent P.: Yeah. The idea behind it is that if the SIBO or the overgrowth is happening at the end of the small bowel which is about 20 feet long and you’re giving them elemental nutrients meaning they’re already in their digested form, they’re amino acids, everything is readily available, it’s going to get absorbed in the upper part of the small intestines so it’s never going to reach where the overgrowth is to feed the bacteria or the archaea.
I didn’t mention another product since we’re here and I know you have more questions but for the methane predominant, I’ve been looking at this product by a gastroenterologist called Atrantil that has peppermint leaf extract which, to me, is a great treatment also. I didn’t mention peppermint, enteric coated peppermint oil or combination of peppermint, menthol and ginger oil. There’s a product by Protocol for Life. I think it’s called GI Guard. That one is really nice just to get help, people with the symptoms, the bloating, the discomfort, the pain. Atrantil has peppermint leaf extract. Then, it has an extract from the konjac tree and another flavonoid. The idea is that it’s able to break through the cell wall of the archaea to kill them.
Dr. Kara F.: That’s great. Yeah, go ahead.
Dr. Vincent P.: The issue I found with it is you have to be really careful with patients because they can get a die-off and they can feel really bad from it. The recommended dose for treating is two capsules three times a day but a lot of times, I’ll start patients on, depending on how … I might start at one, one a day and then one twice a day and then one three times a day and slowly work them up so that you mitigate the amount of die-off that occurs. If you start them at two, three times a day, they might give you a call telling you they feel really miserable and they stopped it.
Dr. Kara F.: Yes. I’ve actually seen that. I will corroborate it. I’ve absolutely seen that in my practice.
Dr. Vincent P.: It tells you it’s a really good formula. It works. You kind of have to work it up with people.
Dr. Kara F.: You just keep bringing up all these different aspects of treating small intestinal microbial overgrowth and I think you’re right. I’m in favor of changing it to SIMO. That makes a total sense.
Dr. Vincent P.: I think it’s better because then, you’re-
Dr. Kara F.: It’s all-encompassing.
Dr. Vincent P.: It’s all-encompassing and it takes you out of pigeonholing it to be just one thing and then you’re not going to miss the other stuff.
Dr. Kara F.: Let me ask you this. You mentioned die-off now and in this case with … What am I saying? Atrantil, it’s kind of a funky name but anyway, it’s-
Dr. Vincent P.: Atrantil. I listened to a podcast.
Dr. Kara F.: You did. Isn’t that funny?
Dr. Vincent P.: How are we going to know how to pronounce … It’s Atrantil. I’m like, “How did you come up with that?”
Dr. Kara F.: Yeah. Why that it almost sounds a little pharma? I wish she-
Dr. Vincent P.: Why not call it a Trantil? I don’t know.
Dr. Kara F.: Yeah, Trantil. That’s right. Listen, talk to me … Die-off happens. It doesn’t happen in everybody but it does happen in some folks and so obviously dropping the protocol, slowing the protocol down is smart and effective. Anything else you’re doing for die-off in SIBO patients or SIMO patients?
Dr. Vincent P.: The other thing is using a binder. You can use activated charcoal. I also like a product by, I think it’s biopharmaceuticals. It’s called G.I. Detox.
Dr. Kara F.: What is that?
Dr. Vincent P.: It’s like a clay. It has a little bit of activated charcoal. You know what, I can look it up quickly because I-
Dr. Kara F.: While you’re looking-
Dr. Vincent P.: It’s like a PyruVite or something, so it’s basically a complex binder. It’s going to help with the die-off. It’s going to help absorb toxin that is released during the die-off.
Dr. Kara F.: Let’s talk a little bit too, and we’ve got a handful of minutes left here, laboratory testing for your gut patients. What are some of the go to tests?
Dr. Vincent P.: Yeah. I think the first thing that’s really important to say about testing is that the most important thing is not the test. It’s the conversation you have with the patient. That’s where you need to start. The lab test is just there to orient you but you can’t take it as the final answer because say, you do a stool study and they’re very limited in finding yeast overgrowth, so you may see it, you may not see it. You probably see it in the sicker patients but if you don’t, then, you really have to go back to the history and, pardon the pun but listen to your gut. Your gut instinct is usually right because if you don’t think it and then, you bank everything on the test, then you may miss it. Stool studies like Genova, there are certain ones, because I’m in New York State, I can’t use.
Dr. Kara F.: Right. That’s right.
Dr. Vincent P.: Sometimes, I’ll find ways around working with practitioners out of state and I’ll send patients there but the GI Effects is a really interesting study. It gives a lot of useful information. There’s the CDSA, the Comprehensive Digestive Analysis, a little less useful but because I can do it in New York State, sometimes I do do it because it still gives me the calprotectin and eosinophilic protein X and butyrate which is so important, so, so important. I think we don’t understand …
Dr. Kara F.: Yes, yes, yes.
Dr. Vincent P.: … how important this, that the short chain fatty acid produced by our colon bacteria or butyrate producing bacteria, how key it is to … It helps with insulin sensitivity. It helps regulate blood sugar. It prevents metabolic syndrome. It keeps the colon healthy and it also has epigenetic effects in the brain so it triggers a release of neurotrophic growth, nerve growth factor. It helps with memory and learning. It’s pretty wild.
Dr. Kara F.: Yep, that’s right. I know. There’s some really interesting work around breast cancer specifically and intervention with a butyrate. It’s actually butyrate with an amino acid residue on it. Actually, it was in drug development. I should look it up and see where it is but the butyrate was able to augment sort of an estrogen expression at the genetic level. I know. You’re absolutely right. It’s fascinating. You’re right.
Dr. Vincent P.: Okay. I found it. It’s pyrophyllite clay.
Dr. Kara F.: Okay.
Dr. Vincent P.: Pyrophyllite clay.
Dr. Kara F.: The name of the product is, again?
Dr. Vincent P.: It’s G.I. Detox by Bio Botanical Research. That’s the company that also produces the Biocidin. They have-
Dr. Kara F.: Okay, sure.
Dr. Vincent P.: They have two types of Biocidin. For the gut, you want to use the regular Biocidin. Then, they have the Biocidin … It’s called LPS or …
Dr. Kara F.: The liposomal Biocidin?
Dr. Vincent P.: LSF. That’s more for internal infections.
Dr. Kara F.: Listen. Let me just ask you. You’ve given a lot of pearls today. Clearly, you’re a real in the trenches-
Dr. Vincent P.: I hope people are taking notes.
Dr. Kara F.: The whole transcript is there. I’ll harvest some of these pearls and pop them up at the top of the transcript. Also, your contact information will be there. What website do you want to direct people to?
Dr. Vincent P.: They can go to happygutlife.com.
Dr. Kara F.: Okay. All right. You guys-
Dr. Vincent P.: I have good recipes there. I have a slippery elm bark porridge recipe. I have a bone broth recipe. For people who are vegetarian, I have a vegetable broth recipe.
Dr. Kara F.: That’s great. We’ll have your website. You actually gave me a couple of them. I’ll put them all up there and your clinic information. I’ve referred a number of New York State, New York people who’ve requested city referrals. I’ve sent them over your way.
Dr. Vincent P.: Yeah. My clinic website is pedremd.com.
Dr. Kara F.: Okay. All right, great. Now, we’re talking to … A lot of clinicians who are transitioning into functional medicine listen to this podcast. Actually, students do as well and in fact, somebody told me recently that this is a popular podcast at Bastyr University so I just want to give a shout out to you guys there but-
Dr. Vincent P.: Awesome.
Dr. Kara F.: I know. I know. It’s really-
Dr. Vincent P.: They’re doing such good work.
Dr. Kara F.: They are. I know. Give me some advice for practitioners who are starting out in the field of functional medicine. You already did at the beginning but anything else, any other pearls, any words of wisdom from your own experience?
Dr. Vincent P.: Absolutely. I started on this road back in 2006 when I attended my first annual conference for the Institute for Functional Medicine. I can tell you, until then, I felt like I was a fish out of water. I was here in New York and I didn’t really know other people. I had an idea of what I wanted to do and when I got there, I felt like I was home, like I felt much pride. I felt like I was finally in the right place after so many years of feeling like I was the odd ball.
One thing that I really would advise and I know I got stuck in the beginning, and I call it like don’t get stuck like a deer caught in the headlights because when you first go, you hear all of these protocols and all of these supplements and it starts to get really confusing, like where are you going to start? That’s my second pearl. Don’t get stuck on the sideline but where do you start? Start small. You don’t have to do a fancy protocol.
Just decide like … Really, for me, it was I was really fascinated with the gut and I just decided, you know what, what I’m going to do is I’m going to start with the gut and I’m just going to start working with patients with the gut. That’s how I ended up where I’m at now because I wasn’t even trying to be a gut specialist. I just thought it was fun. For the first time, I had a language that could translate what, to me, was always really confusing. When people came in, they just all sounded the same to me. I started working with gut patients and at first, I wasn’t doing all the fancy stuff. I just started with diet interventions like, “Hey, let’s take gluten out. Let’s take dairy out. Let’s see how you do. Let’s explore. Why don’t we do a stool study and see what that shows me?”
Get your feet wet. Don’t think that you have to be the best when you first start incorporating functional medicine. You’re never going to get there unless you walk the walk. That was my third pearl, is you learn by going. If you’re standing still, you’re not going to learn. You just have to start walking and trying things and listen to Dr. Fitzgerald’s podcast because seriously …
Dr. Kara F.: It’s true.
Dr. Vincent P.: I learn a lot by listening to podcast like, wow, maybe I can incorporate this. To me, it’s like painting a painting. I would start with maybe the diagram in pencil and then, you start to color it in. Then, you go back and you keep filling in the details and keep filling in more and more details. That, to me, is what this journey has been about, is constantly filling in new details. I refine, refine, refine as I go on. I never think that I have arrived and that’s fine because it keeps it all interesting.
There’s always something new that you can learn. There’s always new scientific literature that’s coming out, new and incredible information, so you can’t get stuck thinking that you have to be the best and do everything and develop a 10-part protocol for every functional medicine patient because then, you might burn out because it might just be too much to do. I’ve seen a lot of people get stuck on the sideline and talk about like, “Hey, are you starting your functional medicine practice yet?” “No, I’m still in emergency medicine.”
I’ve seen that happen to people for years. I think there’s a little bit of resistance in all of us to change. There’s that fear of the unknown but one thing that I’d learned recently in a mastermind group that I’m in, I think when you’re feeling fear, it’s because you’re expanding. You’re like really … You’re going beyond your comfort zone. As long as that fear is not a fear like I’m in danger … because there’s that fear that you’re in danger but there’s that other fear that you know it was just you nervous about doing something new. When you’re in that moment like when you lean into it, that’s when the magic happens. When you’re willing to do that, that’s where you grow.
Dr. Kara F.: I think that that’s a really beautiful place to end. It’s inspiring, empowering and I think it’s really sage advice for the clinicians that are coming into our field. I just appreciate you today and getting to know you a little bit better. I know our paths have crossed in many occasions but just having this chance to talk to you and just mine some of the pearls, because you’ve obviously been doing your work and paying attention, so thanks for joining me today.
Dr. Vincent P.: Such a pleasure. Thank you for having me.