Dr Steven Sandberg-Lewis - Redefining Reflux Part 2

Nirala Jacobi:

Welcome back to part two of the SIBO Doctor Podcast, and let's jump right back into it. Can you talk to us more about H. pylori? You did a great podcast on the SIBO Doctor called H. pylori, what's the story? And really myth-busted a lot of misconceptions around H. pylori for us. Can you summarize that chapter in your book?

Steven Sandberg-Lewis:

Yeah, so most people have learned, and most doctors have learned about the negative effects of H. pylori because it can definitely cause peptic ulcers, stomach or duodenum, very much associated with that. It can cause a type of lymphoma that occurs in the stomach called maltoma, and it can cause stomach cancer. These are factors that, there's a lot of detail to it that I won't get into, but these are risks. On the other hand, 100% of the world's population had H. pylori until about the mid 20th century. And once it was discovered that H. pylori was associated with ulcers, they developed and once it was accepted, after it was initially ridiculed, they decided that the way to approach this was test and treat. That means if you test some of them for H. pylori, you have to treat them if it's positive. Now the problem is, until we started using antibiotics in large amounts and changing a lot of other things in our lifestyle back in the 1920s with the first antibiotics, 100% of the world's population had H. pylori as the major bacteria in their gastro biome, meaning the microbiome of the stomach.

And H. pylori is very important for maturing the immune system in children. So it's really most important for children maybe up to age nine or 10, and especially newborns and recent young infants. So it helps mature the immune system within the gut, which is the major part of the immune system, which greatly reduces the risk of food allergy, hay fever, eczema, asthma, Crohn's disease, laryngeal cancer. I mean the list goes on and on. It's very, very important.

And when it comes to reflux, it protects against reflux and its complications, including Barrett's esophagus and cancer of the esophagus. So having H. pylori in your stomach, I like to call it nature's proton pump inhibitor because it actually helps to normalize acid and protect against... Normalize the immune system in the gut to protect itself from acid. So now that in the US, I don't know what it is in Australia, but in the US, less than 10% of adults now have H. pylori in their stomach, and less than 5% of children. To me and to others that have studied this and researched it, we are opening ourselves up to a whole generation of people with extensive autoimmune tendencies and allergic, hyperallergic tendencies, and increasing esophageal reflux and its complications like we never had before. And it's because, there's a book called Missing Microbes we talked about before by... Sorry, I forgot his name.

Nirala Jacobi:

Martin something, right? What was his-

Steven Sandberg-Lewis:

Martin Blaser. Thank you. Martin Blaser at New York University. Missing Microbes is all about this. I think everybody should read that book. It really explains some very important things about H. pylori. So I don't test everyone for H. pylori. I don't do those kinds of stool tests that have H. pylori on them. I add it on if I want it for a patient, but I don't screen people for it because that's, I think, a bad idea since it's a commensal, normal, beneficial bacteria.

Nirala Jacobi:

I've had a couple of cases, well, I've had more than a couple of cases of H. pylori that were really, really symptomatic. I find that H. pylori, when it's symptomatic, is actually, in my experience, quite difficult to get on top of with natural substances. Have you found that as well?

Steven Sandberg-Lewis:

Yeah, I certainly have seen some people who mastic gum works like a miracle or some other natural treatment, but in general, and again, I'm not saying you should never treat H. pylori, it's a real thing, and especially as people get older it can cause diseases. But my concern is that the overtreatment of commensal H. pylori and people who really shouldn't have been tested in the first place and treated, that's making less H. pylori available in the population to give to the newborns. They're supposed to get it from their family and their parents so that they can mature their immune system. In terms of natural treatments, there's also a matula tea that occasionally people have had really good results with, but it's not easily killed. And again, make sure you have a reason to test for it and treat.

I just get very frustrated when people go to the doctor for reflux or they have Barrett's esophagus and they test them for H. pylori. Well, it's protective against Barrett's, well, you already have Barrett's in this case, but why take away something that is protective if there's no reason? And it generally does not help reflux, sometimes makes it worse because it's more of a protective factor.

So H. pylori, because of the extensive treatment that has been done for it, is getting more and more resistant to standard treatment, especially clarithromycin, the most common antibiotic used. So now there are a bunch of new treatments that are being used that are more aggressive, and there's even a new type of acid suppressive drug that's being used and is FDA approved in the US for treating H. pylori along with antibiotics. They're called PCABs, and they're a potassium... I haven't looked at this in a couple of months, but it's a potassium channel blocker that is even more profound at suppressing acid than proton pump inhibitors. And I'm really worried about what kind of side effects we're going to see from that. But that's a new gun in the armamentarium against H. pylori.

Nirala Jacobi:

Yeah, there's a lot of medications out there to give people symptom relief for something that what we think of is, it's such a totally different paradigm I find in the conventional medical model and the naturopathic model of how digestion works, and how we're actually wanting to support different processes in the digestive tract rather than just suppressing something that seems so vital or is so vital for digestion.

Steven Sandberg-Lewis:

Can I mention something that I learned from you?

Nirala Jacobi:

Yes, please.

Steven Sandberg-Lewis:

So your question about what can you do to improve the efficacy of H. pylori treatments if the person needs it? First of all, using a probiotic along with antibiotics and proton pump inhibitors in that 14 or 10 day treatment has been shown to increase the efficacy. Using a biofilm disruptor such as an acetylcysteine has been found to increase the efficacy. And some docs disagree with that, say, "That wasn't good research." And then also using lactoferrin, which is present in colostrum during that 10 to 14-day treatment as well, has been shown to increase the efficacy. And what I learned from you was about nickel sensitivity mucositis. And it turns out that in order for H. pylori to function well, it needs a nickel containing enzyme. So if you follow a nickel free diet during the weeks that you're treating, it also can increase the efficacy of the treatment.

Nirala Jacobi:

Wow, that's new to me. That's awesome. Great. So nickel mucositis, for the listener, you can go back in the archives of the SIBO Doctor Podcast and find that episode. It was a really interesting one. I want to also mention before we go into some of the treatments and some of the first line approaches that you find helpful for reflux in general, for people listening, I want to talk about the hiatal hernia, because this is something that's just, I think, so important for people to also realize that structural issues can increase reflux and other symptoms in the upper gut. And want to also remind practitioners that are listening that Dr. Sandberg-Lewis, when he was here in 2018, we recorded a whole course on the functional gastrointestinal exam, including how to release a hiatal hernia and ileocecal valve maneuver. And I just watched it again the other day and it's just such a great course, especially that segment on the hiatal hernia. And I want to make sure that people understand the connection between reflux and hiatal hernia, if you could elaborate on that a little bit.

Steven Sandberg-Lewis:

Yeah, it's another one that I put a whole chapter in the book about because it's so important. And I'm glad you brought it up because it has a lot to do with the lower esophageal sphincter. So the diaphragm is a big thin but broad muscle that separates everything in the chest from everything in the abdomen and has several holes in it. One of them, the hiatus, that allows the esophagus to come down from above and meet up with the stomach. And the stomach, hanging down like a half moon here, the lower esophageal sphincter, the top of the stomach, is supposed to be right at that hiatus. So the lower esophageal sphincter at the bottom of the esophagus, the top of the stomach, is a muscle, the diaphragm is a muscle and it hugs the lower esophagus. It's hugging the lower esophagus.

There's actually two ligaments called the crus or legs of the diaphragm, and they wrap around the lower esophageal sphincter like that. They wrap around. And so you can think of the diaphragm as the outer half of the lower esophageal sphincter. It gives it almost twice as much muscle tone. If you move, if you have a hiatal hernia that slides up two or three centimeters, even one centimeter, you now have your lower esophageal sphincter up here, one to three centimeters above the diaphragm. So you don't have that hugging outer muscle to support the lower esophageal sphincter. It's out there in the cold with only half of its musculature. That's going to make a big difference in tone.

So having a doctor or physical therapist or massage therapist that knows how to bring the stomach back down in concert, so the LES and the diaphragm are in the same place, is really important. In addition, if you can do toning exercises to strengthen the diaphragm, to tone the diaphragm muscle, because if you don't use the diaphragm, it'll lose tone and gets less strong, if you tone the diaphragm, that can also really be helpful for reducing reflux and strengthening the LES.

Nirala Jacobi:

Great. And again, practitioners, you can check out this course on the SIBO Doctor website because it is just chock-a-block full of incredible helpful maneuvers and assessments in office that are really so helpful as a practitioner.

Moving into, what are some of the sort of dietary approaches that you recommend for managing reflux symptoms?

Steven Sandberg-Lewis:

Well, in my mnemonic, which is-

Nirala Jacobi:

You're the king of mnemonics. You're absolutely the king od mnemonics.

Steven Sandberg-Lewis:

Reduce carbs, reduce reflux, carbs being C-A-R-B-S as the mnemonic. In the A of carbs, A in part is for acid. Some people are sensitive to acids, and I think these are often especially people that have erosive esophagitis, and a real irritation of the lining of the esophagus. But acids for other people can actually reduce reflux because maybe they don't produce enough acid. And so acid foods can actually be stimulating and help them. Your question, so I don't lose it though, is how does diet affect it? So I think there's a thing called the acid lovers diet. For some people where acids really a major factor, a diet like that could be helpful. But in general, reduced carbs really does go for low fermentation diets, carbohydrates, whether they're refined or even whole, unrefined carbohydrates are a major factor.

And I talk about a number of studies in the lifestyle chapter that show that a lower carbohydrate diet can dramatically reduce or clear reflux, and it's pretty dramatic, and much more important and effective in the research than low or high fat diets making a difference, although you hear about that too.

I think fat is especially important because fat tends to keep food in the stomach longer, it delays gastric emptying. And so if someone eats too much and their stomach's distended and then they put a lot of fat in there too, they're much more likely to have reflux up and out because it can't go down as fast. Or if they have gastroparesis, the same problem. But the reflux aggravation from carbohydrates really seems to be a major factor. And maybe that's in part because carbohydrates aren't digested in the stomach, only protein is really digested in the stomach. So the carbohydrates sitting there in the stomach for four to five hours or longer, if someone has delayed emptying, and can ferment, and especially the higher fermentation carbohydrates cause a lot of gas, which then triggers TLESRs to vent the gas.

Nirala Jacobi:

Because I'm thinking also about gastritis, I have a lot of patients that have gastritis symptoms, not necessarily reflux, but just more of a gastritis pain. Do you vary your diet approaches with gastritis versus reflux or do you have pretty much a standard diet for it. Just not in terms of diet, but other treatments as well. Because we think of demulcents, we think of all these kinds of soothing substances for the actual treatment of reflux and gastritis, but in terms of diet, I actually, in my experience, especially with atrophic gastritis, I'm always very careful with a high protein diet because they just can't handle it.

Steven Sandberg-Lewis:

Well, with atrophic gastritis, you have reduced parietal cells because of the atrophy of the lining, and those are the cells that make not just intrinsic factor for B12 absorption, but gastric acid. So you're not going to have enough, you're probably going to have hypochlorhydria, most cases do. Some actually have achlorhydria and don't make any stomach acid. That's kind of rare, but I think it depends on the cause of the gastritis. So autoimmune gastritis, which is probably the least common, but pretty important, there, you have antibodies attacking the stomach lining and causing atrophy and inflammation, that's going to be treated a little different than what we call reactive gastritis, which is a general term for gastritis that's due to irritation in reaction to something that's in the stomach. That could be alcohol, it could be non-steroidal antiinflammatory drugs, it could be foods that you're allergic to, or have a sensitivity to.

And the third type would be what you talked about, atrophic gastritis from H. pylori. Gastritis from H. pylori is more of a bacterial gastritis. So depending on which type of gastritis you have, you might have a slightly different treatment, but it's often some combination of demulcents that help assuage the inflammation, things like turmeric that help, or resveratrol, foods that are high in resveratrol and anthocyanidins that help balance the inflammatory response. And then just the basics of a lower fermentation diet, like the Bi-Phasic diet that you often use, or Dr. C. Becker's Food Guide, or the specific carbohydrate diet, something like that. And aloe vera is a great one in the demulcents, that can help regenerate mucosa. Berberine containing herbs like hydrastis can really help regenerate mucosa. So there are a lot of good options.

Nirala Jacobi:

And looking into the treatments of reflux, so first of all, I want to say everybody that has reflux should just go out and get your book, because obviously that's where all of the resources are. But can you throw us a couple of nuggets of what your favorite treatments are for, let's say, just general reflux and then maybe bile reflux, if that's how you're structuring it?

Steven Sandberg-Lewis:

Yeah. First I'll say that I can't promise the book will be available at major book sellers' websites until the beginning of February. We're still getting it all put together, it's written, but we're working on the details. But it will be available at Amazon and Barnes & Noble and all major bookseller-

Nirala Jacobi:

Great.

Steven Sandberg-Lewis:

... websites at that time. But the way that I organized the chapter on natural treatments for reflux, I did it by mechanism. So I talked, like we did before, about LES laxity and how to approach that with natural treatment. I talked about issues with excessive acid or too little acid in a different part. So it depends on which mechanism it is, but as a general mechanism, I'd say probably the most important things are in the lifestyle chapter, which have to do with chewing thoroughly and taking your time so you can activate the parasympathetic nervous system, and so you can tell when you're full, so you tend not to overeat.

Most people don't want to spend 90 minutes eating, if they're chewing their food until it's liquid, you can't just shovel it in. It'll take too long, and within 20 minutes, you'll actually start to feel that you're full. So that's one of the advantages of slow eating. So that kind of eating and then eating a lower fermentable carbohydrate diet, many, many examples, and there's a chapter on that, on diet, as well as using the cephalic phase of digestion. So even before you eat, smelling the food, if you just grab something out of refrigerator and scarf it down, you don't really smell it or think about it or taste it or salivate. But if you're preparing food, and you're smelling a food, and you're thinking about the food, and looking at the food, that's a big part of the digestive process, the cephalic phase or the head phase, and it can provide at least 20% of the enzymes that are needed for digestion. So that I think is really important.

And we know that heart rate variability is important for improving parasympathetic, rest and digest tone, and one of the real easy ways to do that is to feel grateful. So that's what grace is all about. It's not just a religious thing, it's actually a parasympathetic toning thing. So if you can think of at least one or two things that you're really grateful for before you eat, take a minute and take a few diaphragmatic breaths, that really improves parasympathetic tone. So I think those are really important.

In addition, if you don't make enough stomach acid, then bitter herbs or one or two teaspoons of vinegar in water before you eat, or even taking betaine hydrochloride capsules, if that's needed, can be dramatic, dramatically change the whole picture. If you make too much acid, that's not going to help you. In that case, you probably need things like alkaline water, drinking water that has a pH of 7.8, 8.2. There are studies that show that reduces reflux, and they think part of the mechanism is that, by slightly reducing the pH in the stomach, it raises gastrin levels, which are produced in the stomach as a response to low acid, and that actually strengthens the tone of the lower esophageal sphincter. That's one way that proton pump inhibitors might help reflux too is because they lower the acid, raise the pH and stimulate more gastrin, which may tone the lower esophageal sphincter.

Also, certainly if people have pancreatic insufficiency, that in itself can cause reflux, and a bunch of different mechanisms that can do that. But remember that plant enzymes, meaning the kinds of enzymes that are in sprouted food, or raw food, or naturally fermented foods, pre fermented foods like sauerkraut, those substances are unique in that they fortify our own pancreatic enzyme function, which takes place in the small intestine, but they start working in the stomach. So food, natural food actually has enzymes in it that help us digest it, as well as having bacteria, probiotics that help us digest it. So can't say enough about natural enzymes and their presence in foods, and some people benefit from taking extra supplements of those things as well.

Nirala Jacobi:

I'm so glad you mentioned pancreatic insufficiency. I almost forgot to ask you about that. And it's something I have been really looking into over the last couple of years because I have a lot of patients that have symptoms of low stomach acid and improve with either hydrochloric acid or bitters. I'm a big proponent of bitters for those people. But on a test, on a stool test, they have a low elastase, and I know you and I have had a conversation about this before, and there isn't a whole lot of research about supporting how... Well, we know secretin causes this release of digestive enzymes, which is triggered by hydrochloric acid, but do we know hypochlorhydria actually causing a low elastase, is something I'm still sort of searching the answer for.

Steven Sandberg-Lewis:

I would love somebody to do a steady looking at that because it makes sense physiologically, and the physiological books talk about it, but does that actually cause a low elastase? I don't know.

Nirala Jacobi:

And for the listeners, low stool elastase is an indicator of pancreatic exocrine insufficiency, which is basically low enzyme output. And sometimes the symptoms of that are very similar to hypochlorhydria or low stomach acid. But I did not know that pancreatic insufficiency can actually cause reflux, I guess because of the fermentation of undigested foods leading back to the pressure and the issues that we talked about, is that one of the mechanisms?

Steven Sandberg-Lewis:

Yeah, exactly. Because pancreatic can cause every symptom of SIBO, and increased pressure, because it is a cause of SIBO. Pancreatic enzymes and hydrochloric acid and bile are a major group of factors that protect against upper small intestine bacterial overgrowth.

Nirala Jacobi:

Wow. I feel like we're just getting into it now. There's always so much more, so many more questions. I'm always learning so much from you, Steven. Great. Well, we do have to wrap it up. It's been over an hour, so thank you so much for your time with me again. And also, you've mentioned that your book will be available very soon in all major outlets, and on Amazon and everywhere else, somebody can buy a book. We'll put the link into the show notes, but also I think you're going to have to let me know where you are practicing so people can find you and all of that.

Steven Sandberg-Lewis:

Okay.

Nirala Jacobi:

Because you're in the process of moving, right?

Steven Sandberg-Lewis:

Yeah, but the thing is that I see people in my office here in Portland, I'll just have a different office in Portland, but I also do a lot of national and international work, mostly national. I'm licensed in Oregon and California, but I see clients, not patients, in other states as well.

Nirala Jacobi:

Thank you so much, and good luck with the launch of your book. I'll be promoting the heck out of it because I love what you offer at the public. It sounds like such a unique and different approach, and really very helpful for people that are also trying to get off of PPIs and get off the merry-go-round of that whole story. So thank you so much for all you do.

Steven Sandberg-Lewis:

You're welcome. It's been great talking to you.

Speaker 3:

To access the Bi-Phasic Diet and the SIBO success plan, or if you're a practitioner and would like to become an affiliate, go to thesibodoctor.com.

Thank you for listening to the SIBO Doctor Podcast. We hope you find the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, Sibotest.com, a breath testing service with easy online ordering. Thanks again for listening.