Dr. Nirala Jacobi:

Welcome back to part two of the SIBO Doctor Podcast, and let's jump right back into it.

Dr. Will Bulsiewicz:

Now, histamine intolerance.

Dr. Nirala Jacobi:

Oh, hang on. I just wanted to say something, and I want to loop back to histamine intolerance. But one of the things that I do a lot often, that you also mentioned in your book of course, is prebiotics, and prebiotic fibers. And I think that that may be the rehab you mentioned, is that you start really low and you start with extremely digestible fibers, rather than long strands of amylose, and cellulose, and starches that a really compromised microbiome may not have the ability to break down. But if you start with something that's maybe more immediately digestible, like galactooligosaccharides, or partially hydrolyzed guar gum, I find that that is often a good starting point for people that have a really, really low diversity. We do, a lot of practitioners that I talk to, and that do my trainings, we are familiar with some of the stool tests that are being offered. And you can see success when you actually start with prebiotics, and then move on to more complex carbohydrates, that require a little bit more microbiome muscle to break down. Is that what you mean when you talk about rehab?

Dr. Will Bulsiewicz:

Yeah, it is. And I love that, thank you. Because I actually practice this. See, it's so interesting that you're on the other side of the world and we've found the exact same thing in our clinic. That's exactly what I do. And I've been doing that for years now. It has been probably in the last five years of my practice, that virtually a hundred percent of my patients... Because bear in mind, I am convinced that almost every single person that walks through the doors of my clinic has dysbiosis.

Dr. Nirala Jacobi:

Well, it is selection bias, right? Because you are a gastroenterologist.

Dr. Will Bulsiewicz:

No, it's a hundred percent selection bias. I'm not convinced that every American has dysbiosis, but I'm a hundred percent convinced that the people who come to see me because of their digestive issues... And almost a hundred percent of them, I have a physician assistant who works with me, and it's almost comical, because she just knows that part of the plan every time is a prebiotic fiber supplement. And it's always start low, and introduce slowly over time and ramp up. And there's some actually interesting studies that back up what you just said, that I found more recently, even though I've been achieving such great success with these prebiotic fiber supplements for years. And it's kind of interesting when the research comes second, and it rounds out your clinical experience that you've been having.

Dr. Will Bulsiewicz:

So looking at lactose and lactose intolerance, as your listeners I'm sure know, lactose of course, the sugar found in dairy, is a FODMAP. And lactose is, we have attributed the digestion of lactose to the brush border of our intestine, which does certainly play a major role in the digestion of lactose. But so does the microbiome, the microbiome is deeply involved in the processing and digestion of our lactose. And going back to this idea of train the gut, make it stronger. They did a study where they took people who are lactose intolerant, and what they showed, is that they could make them lactose tolerant. And the way that they did this, was applying this idea that I'm describing, which is that they started to give them milk. And they started super low, and they ramped it up over time.

Dr. Will Bulsiewicz:

And what was fascinating is that the body needed an opportunity to adapt to what you were doing, but then once the body was given an opportunity to adapt, they found that there was tremendous efficiency in terms of the ability of the body to process and digest the lactose. Meaning that you could take on way more dairy and produce even less gas, because it became so good. But there's a second study that I make reference to in my book, that I love, which is that they did a different study, and rather than feeding people lactose, they instead gave them a fiber supplement. And after basically treating the microbiome with a fiber supplement, they were able to reintroduce lactose. And they found that these people did so much better. And the reason why, is because when you heal the gut, you will improve its capacity to process and digest other things, more than just the fiber that you fed it. When you heal the gut, you're basically rising the tide.

Dr. Nirala Jacobi:

So, how do you, and I'll come back to histamine, I promise for you listeners. But I'm just, of course I want to ask you about SIBO in your practice. And let's say you have patients that have motility, you have functional dyspepsia, you have people with SIBO that have an obvious dysmotility in the upper gut. How do you propose this concept to them?

Dr. Will Bulsiewicz:

So SIBO, I find to be a challenge for me to talk about on a podcast, I'll be honest with you. And the reason why, is because I think that the definition of CBO needs to be very clean for the purposes of the conversation. And what I find to be difficult about it, is that many of the patients who come to me with a diagnosis, or a conception that they have SIBO, I find that they do not. And the challenge is, that I worry about ensuring when we have the conversation of SIBO, that we're on a level playing field where this is truly in fact, a case of SIBO. From my perspective, if we're talking about a person where we have ruled out alternative explanations, it's not chronic constipation that they have, that this is a person who does in fact have SIBO and they have a test to support that, basically confirming your suspicion, for example, a breath test.

Dr. Will Bulsiewicz:

In that particular setting, I'll say this: I have treated some patients with antibiotics. I have treated some patients with Xifaxan, Rifaximin, but I tend to do that second or third line. And the reason why, is because I'm worried, I understand the studies that have shown benefit. But the problem, and I think we would all agree, and we see this in our own clinic, is that when you treat with an antibiotic, the SIBO comes back in a huge percentage of the patients. And what I worry about, is that we know that patients that have SIBO, they are to me, by definition, they have dysbiosis. And when we treat with an antibiotic, are we making it worse? Are we perhaps accepting short term gain where they have symptomatic improvement, because of the manipulation of the microbiome, where we are altering the microbiome on a temporary basis, are we making it worse in the long run because we were not able to reestablish a healthy microbiome post antibiotics?

Dr. Will Bulsiewicz:

And that's the challenge, and I will admit, I'll be the first to admit, I am very different than my peers when it comes to the approach to SIBO. Conventional treatment in gastroenterology is to do first line antibiotics immediately. Even on suspicion of SIBO, many of my peers will actually administer antibiotics, even without a test to confirm the presence of SIBO. Whereas for me, I am concerned about longterm outcomes with the administration of antibiotics in a patient that has underlying dysbiosis. And so, my approach is what we're talking about, it is individualized.

Dr. Will Bulsiewicz:

It's a little bit hard for me to speak painting with broad strokes, because it's always individualized to the needs of my patient. But it typically does involve ultimately trying to restore a healthy microbiome, initiating prebiotic fiber supplements, and then working in conjunction with a dietician that I have, to try to bring back dietary diversity over the course of time. Recognizing that there may be some gas and bloating, recognizing that there may be a need for a low FODMAP diet, not on a permanent basis, but more so as a tool to identify where those weaknesses are within the microbiome. And then once we know where the FODMAP weaknesses are, then we can be much more cautious in terms of where we choose to moderate our diet, as opposed to where we have the freedom to be much more wide open.

Dr. Nirala Jacobi:

I really love that. I actually think there's a lot of synchronicity in how we approach it. Because A, I also think that there's a lot of overdiagnosis and overtreatment of SIBO, and that there are different categories of causes. I always aim to understand why somebody has SIBO, so that you can really get to the underlying cause, and not everyone has a motility issue or a damaged migrating motor complex, not everyone has that. And so I do think that we agree, that there is an element of dysbiosis from the get go, that there is a problem with also small intestinal microbiome.

Dr. Nirala Jacobi:

And what's really fascinating to me is that it's actually only just now that we're starting to understand that the distribution of the different phyla, of the different bacteria in the small intestine, as opposed to the large intestine, the large intestine, as we all know, is really where most of your microbiome actually lives, and that the small intestine from the duodenum all the way to the ileocecal valve has sort of increasing amounts of bacteria that all do different functions, and are, as you just mentioned, really involved also in the digestive process. So, the more antibiotics or even herbal medicines that you use longterm, especially things like oregano oil and grapefruit seed extract, also will alter the microbiome when used longterm. So I've been definitely, I agree with you there, that there is too much killing and not enough regrowing in some sense. But having said that, some people do feel tremendously better once their SIBO's resolved, and then moving on from there, I think should be the goal, is to regrow what was lost.

Dr. Will Bulsiewicz:

Yeah, I agree with you. I think that there's a place, I guess to frame it a little more clearly, I tend to not reach for antibiotics early. But I wholeheartedly agree with you, that I think that there's a place for a sort of reset, followed by reintroduction. In the sense that you would treat the SIBO with antibiotics, effectively looking to knock back the pathogenic microbes that are being disruptive. So you knock them back, and then you chase that with the dietary implementation, with the goal of growing the good guys.

Dr. Will Bulsiewicz:

Because I'm of the belief, we have this instinct in healthcare to kill, kill the bad guy, get rid of it. And even in real life, you will get politics around the globe, and the way that we deal with problematic countries and stuff like that. We tend to not win when we just try to kill the bad guys, we tend to win when we empower the good people and allow them to develop a healthy economy, and infrastructure and all of those things. And it's the same thing in our gut ecosystem. When you empower the good guys, the good guys tend to take care of these issues for us.

Dr. Nirala Jacobi:

I love that. I think that's so true, that we can extrapolate to the macrocosm there from the microbiome. And the more diverse, that's the other thing, is the more diverse a culture is, the more healthy, and the more diverse a gene pool is, the more healthy, and the more diverse an ecosystem is, the more healthy it is. So I think there's a lot to be learned from the microbiome. And I think we're all sort of on the same page, it's just that we, as practitioners that are really at the coalface on some level with this tsunami of microbiome decimation, how do we do this? How do we regrow something that has been through so much trauma on some level, and really missing species?

Dr. Nirala Jacobi:

I had somebody yesterday in my practice, that had zero short chain fatty acids, zero akkermansias. Even for me, somebody who sees a lot of stool tests, and I know that there is some controversy in especially conventional medicine, it's still at the beginning to understand our microbiome. But I don't see that level of decimation that often. How do we, short of fecal microbiota transplants, how do we actually regrow their own species? I think that's really what people want to know, is how do I actually do this without becoming extremely symptomatic?

Dr. Will Bulsiewicz:

Yeah. And then I think that the future is going to be enhanced through stool testing, we just need the studies to help us to guide that path. So I do think that there will be personalized recommendations that we'll be able to implement. I'll be honest with you, what I worry about right now with the stool testing, is that the stool testing, which is very similar to food sensitivity testing, that's done, whether it's skin prick or antibody based, what I worry about with it is that it's encouraging people to restrict. And that's the reaction, that's not necessarily a scientifically supported approach. That's just our interpretation of the results that is in front of us. And I believe that instead, what this is, is this is helping us to identify the strengths and weaknesses. And rather than restrict, I think that the rule should be when we identify weaknesses, we moderate, and then we build, and we get stronger.

Dr. Nirala Jacobi:

All right, looping back to histamine. We have about 10, 15 minutes left. Definitely want to address that, because a lot of patients are sensitive to histamines, what's your approach to that?

Dr. Will Bulsiewicz:

Yeah. So I think that the big thing from my perspective is, let me say this, number one: this is such a ripe opportunity for research. And I can't wait, I hope that there is someone with a research interest in the microbiome listening to us right now, who hears this and says, "Gosh, I could be the one. I could be the one to define the disease state," because that's what we need right now. And the study of all major health issues involves great scientists who advance the work, advance the knowledge, and get us to a place where the knowledge that we receive allows us to really understand how to navigate these processes.

Dr. Will Bulsiewicz:

But I don't think it comes as any surprise that I don't think histamine... I think histamine intolerance is indicative of a damaged gut microbiome. I don't think that that comes as any surprise. And the key from my perspective, is to heal the underlying gut. And so, that may require number one, because the manifestation of symptoms in histamine intolerance can be more severe than a routine food sensitivity, such as manifesting hives, I believe that in that setting, we need to be increasingly willing to significantly restrict, even potentially eliminate on a temporary basis, the foods that are triggering symptoms of that intensity. So, you know this, but let me just tell your audience real quick, that in my book I wrote an entire chapter about the value of fermented foods. And I believe that for most people, fermented foods are an important part of adding more diversity to our diet. And I believe that they're good for our microbiome.

Dr. Will Bulsiewicz:

But the person who has histamine intolerance or histamine sensitivities, is going to struggle with fermented foods. They're sort of the classic food that triggers these symptoms. And I just don't think that it's necessary for a person who, for example, does the protocol in my book, it's a four week protocol. I don't think it's necessary for them to make themselves miserable forcing fermented foods down, when in fact what I would encourage in that setting is restrict, even potentially eliminate the fermented foods, focus on the foods that you are capable of eating, bring as much diversity into your diet as you can, have your prebiotic fiber supplement. Let's heal the gut, let's optimize the gut as much as possible, and in healing and optimizing the gut, the hope is that in the future you're able to reintroduce these foods, and bring them back into your diet.

Dr. Nirala Jacobi:

And I think that that was well outlined in your book, so people who want to get more information, definitely check out Fiber Fueled. But maybe in closing, we haven't really even dove in to all the wonderful substances the microbiome does, but I just felt like what people really want... They're all on board, I know that most people understand that are listening, that our microbiome is incredibly important for not just our gut health, but for systemic health, gut brain access, et cetera, you name it. Motility, everything. So what people really want to know is if they start and they get symptoms, should they persist? Should they back off? I always advocate for working with a professional as well, but there are many people that are listening that do not have access to people that are adequately trained, in microbiome restoration, I would say.

Dr. Nirala Jacobi:

And working with a dietician, you know that a lot of dietitians, no offense, but they follow those guidelines that are still, I think, not inclusive enough of this concept of microbiome restoration. I don't know what your thoughts are on that, but really, should people persist if they're symptomatic, or should they... What's the guidance you give people when they come back to you and say, "Well, I tried it and I'm just totally symptomatic with this diet"?

Dr. Will Bulsiewicz:

So, I think where I start is this: if a person comes into my clinic, and they're there to see me for food sensitivities, and it's very common, I'm sure you can appreciate this, that I often see people who have been to five or six doctors. I have patients who have been to some of the top medical centers in the United States, and then they come to see me. And when that person is with me, the first visit, I'm not just, hey, how am I going to manipulate their diet? For me it always starts with, what am I treating? I need to know what I'm treating, because you can't implement a proper dietary approach, or a proper treatment approach, period, if you don't even know what you're up against. So from my perspective, it always starts with the idea of make sure that you know what you're treating.

Dr. Will Bulsiewicz:

And two things that I've discussed in the book, because I find these to be extremely helpful in my clinic, are number one: if you suffer with constipation, that needs to be dealt with. Don't do the diet with the intention of fixing the constipation, fix the constipation, then do the diet to heal your microbiome. I find the people who suffer with constipation, they have tons of gas and bloating, virtually a hundred percent of them have gas and bloating as one of their symptoms, and they are sensitive to honestly, almost everything. They just can't tolerate fiber, they can't tolerate FODMAP's.

Dr. Will Bulsiewicz:

But in that setting, what's kind of fascinating and powerful is that if you can get them pooping, those food sensitivities may potentially go away entirely. And then they're able to reintroduce these foods, and really start to ramp up their fiber and their FODMAP's, and heal their gut. So you have to make sure the constipation is not there, and in the interest of time, I'm not going to get into too much detail on that. But suffice it to say that it's extremely common. There are people who poop every day, who have constipation because they're not completely evacuating. And there are people with diarrhea, who have overflow diarrhea because they're severely constipated.

Dr. Will Bulsiewicz:

And then the other thing that I would mention, is that celiac disease is hugely on the rise of these days. And it can manifest in a number of different ways, it's not just the classic diarrhea. There are many different ways that celiac can manifest. And so, it's important in many of my patients who are suffering with digestive issues, to make sure that I've properly ruled out celiac disease. And although many people believe that blood testing such as an antibody test is adequate for celiac disease, I'll be the first to tell you that that's not true.

Dr. Will Bulsiewicz:

There's really two ways that you can rule out celiac. The gold standard test is to do an upper endoscopy and get biopsies from the small intestine, because there are forms of celiac, mild forms that will not show up in the antibody tests, but you will find them when you do endoscopy with biopsies. The other option is to do celiac genetic testing. If a person does not have the gene for celiac, then they will not have celiac disease. So that's a noninvasive way that could be done first, if you needed to, do that first. If you don't have the gene, good, taken care of. But if you do have the gene, then it becomes necessary to actually do the endoscopy and get the biopsies to see if celiac is present.

Dr. Nirala Jacobi:

And that's HLA-DQ two and eight?

Dr. Will Bulsiewicz:

That's right? DQ2 and DQ8.

Dr. Nirala Jacobi:

Great. I know that there is a million more questions to ask you, but it's been an hour, so we do have to sadly wrap it up without even touching on short chain fatty acids. But there's nothing that prevents us from having another podcast, another time. I have mentioned some of these products of the microbiome on previous podcasts, so I really hope that listeners are encouraged by that it can be done, that you can regrow your microbiome, and that it is of utmost importance for immunity. And in times like these, not just immunity, but overall health. So it's definitely an important topic, and I want to thank you so much, Dr. B, for coming on the podcast. And for those of you interested, the book name and all that is going to be in the show notes. Is there anything else, I know people are going to want to know where to find you, and want to come and see you as a gastroenterologist, and where can they find you?

Dr. Will Bulsiewicz:

There's some really good and exciting news, which is that in the coming weeks, I will be launching an online course. And so, you will find information about that if you come to my website, theplantfedgut.com. If you go to theplantfedgut.com, you will find information about my course. You will also find my email list where I do breakdowns of studies for people, like when there's breaking news, a new study just came out, I will break it down and email you about it. I have a COVID-19 guide, I have a clinical research guide for people who want to understand the fundamentals of clinical research. All that's free on my website.

Dr. Will Bulsiewicz:

You will learn about my course, which is going to be launching in probably the second half of August. And the beauty of the course is that you can go beyond the book and take a deeper dive with me, even if you live in Australia. And so that's the beautiful thing about all that. And then my book is called Fiber Fueled, it is American spelling, so I apologize for that. F-I-B-E-R, and then there's only one L in fueled. So, somehow I managed to title a book that has a different spelling in every country in the world except for the United States.

Dr. Nirala Jacobi:

That's right. It gets autocorrected in the weirdest way, when you write it, I can tell you that. That's fantastic. You're still in clinic, and you see patients, and all that?

Dr. Will Bulsiewicz:

Yeah, I'm a practicing gastroenterologist, that's what I do full time. And then you can also find me on Instagram as The Gut Health MD. That's the other place that people can find me.

Dr. Nirala Jacobi:

Fantastic. Well, any last minute parting words of wisdom?

Dr. Will Bulsiewicz:

I think just to reinforce everything that we've said from today, the take home is this: that you, speaking to your listeners, you are not born with your medical issues for the most part. That we believe that 80% of health versus disease during our lifetime, is made up by diet and lifestyle, diet and lifestyle really is what's molding and shaping your microbiome. And the beautiful thing is this: that your microbiome is actually surprisingly forgiving, and it can be strengthened, it can be healed, it can be molded. You can make it what you want it to be. You are not stuck with your lot, you are not stuck with whatever your issues are, that we can fix those issues, we just need to have the proper approach. And as we spoke about during this episode, to me, the proper approach is when we allow the science to guide us, and to give us the fundamental understanding that we need to really know how to go about doing that.

Dr. Nirala Jacobi:

That's wonderful. Thank you so much for your time.

Dr. Will Bulsiewicz:

Thanks for having me on.