SIBO with Dr. Vincent Pedre: Rational Wellness Podcast 198
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Dr. Vincent Pedre discusses Small Intestinal Bacterial Overgrowth with Dr. Ben Weitz.
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4:37 Dr. Pedre had gut problems himself for years that he believes stemmed from taking many rounds of antibiotics–two or three courses of antibiotics per year as a child for various infections, such as a throat infection, bronchitis, or sinusitis. They would also sometimes give him a gamma globulin shot and this would make him feel better for a while. By the time he was 17, Dr. Pedre had taken 21 courses of antibiotics, which took a toll on his microbiome. Dr. Pedre developed dysbiosis that led to leaky gut that led to becoming reactive to foods like gluten and dairy. When Dr. Pedre became a doctor, he wanted to figure out why he felt so sick, which is what led him to focus on gut issues. As he treated patients with gut issues, he came to realize how many other health issues are connected to the gut.
10:30 Taking a thorough history is the most important factor in patient care. The history can then help guide your choice of testing. Should I get a breath test to confirm a suspicion that the patient has SIBO. Should we also order a PCR based stool test because there might also be a parasite or yeast overgrowth. Or should I order an organic acids test to get a broader look at metabolites and better be able to rule out fungal overgrowth. For stool testing, Dr. Pedre switches between both Diagnostic Solutions GI Map and Genova’s GI Effects, which both have their strengths.
23:20 Treatment protocols for SIBO. Dr. Pedre believes in starting with diet first. He used to use the low FODMAP diet, but now he uses Dr. Siebecker’s SIBO Specific Diet, which is a little less restrictive than the strict low FODMAP diet. Intermittent fasting can also be helpful to have periods when the gut can rest. Dr. Pedre will often put SIBO patients on Rifaximin at the same time as the SIBO diet but he will also put them on Slippery elm bark as a prebiotic to make the bacteria easier to kill. This avoids Dr. Pimentel’s concern that placing patients on a low fermentation SIBO diet will starve the bacteria and make them harder to kill. Dr. Pedre has found that patients with SIBO tend to be type A personalities, high achievers, who tend to be anxious, and this tends to affect vagal tone and decrease gut motility. He recommends patients improve vagal tone through things like gargling, humming, and he recommends spore based probiotics.
29:44 Spore based probiotics. Dr. Pedre has found that many of his patients with SIBO do not tolerate typical probiotics, such as acidophilus, esp. at higher dosages, but they tend to do well with spore based -probiotics. One reason that spore based probiotics may help SIBO patients is that many also have fungal overgrowth (SIFO). He believes that this may be why patients who get treated with Xifaxan get better and then a month later, their symptoms come back. Spore based probiotics do quorum sensing to group together, and they produce other active compounds, enzymes that can break down biofilm, called bacteriocins, which are like local antibiotics that inhibit other species from growing.
32:45 Biofilms. If you have a treatment resistant SIBO patients, then you should consider biofilms and you can use things like Serrapeptase to break down the biofilm and use that on an empty stomach.
34:41 If Dr. Pedre does not use Rifaximin, he may use natural anti-microbials like Candicid Forte. But yeah, they include berberine, caprylic acid sometimes mixed in with some artemisinin and black walnut. Kind of broad spectrum herbals, olive leaf extract, all these things. He may also use serum derived, bovine immunoglobulins.
35:40 Prokinetics. Dr. Pedre said he has heard Dr. Pimentel talk about Motegrity as a magic bullet for lack of intestinal motility, but he has not found it to be a magic bullet and he tends not to prescribe it. Dr. Pedre looks at the behaviors in his patients and encourages his patients to do cardiovascular exercise like running and he works on improving parasympathetic tone in his patients.
Dr. Vincent Pedre is the Medical director of Pedre Integrative Health and president of Dr. Pedre Wellness. He is a clinical instructor in medicine at Mount Sinai School of Medicine. He is a board certified internist, as well as the best-selling author of Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy, and Eliminate Pain. His website is PedreMD.com.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Hey, this is Dr. Ben Weitz host of the Rational Wellness Podcast. I talked to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me. And let’s jump into the podcast. Hello, Rational Wellness podcasters. Our topic for today is small intestinal bacterial overgrowth with Dr. Vincent Pedre. Many of you are probably already somewhat familiar with small intestinal bacteria overgrowth, also known as SIBO from previous conversations we’ve had with many in the functional medicine world, including Dr. Pimintel and Dr. Alison T. Becker. But for those of you who have not heard of SIBO. This is the most common cause of IBS or irritable bowel syndrome. And irritable bowel syndrome is the most common gastrointestinal condition marked by a number of symptoms including gas, bloating, abdominal pain, diarrhea, or constipation, or alternating of the two, urgency to defecate and nausea among other symptoms.
And IBS affects approximately 15, maybe as much as 20% of the population. And now we know that IBS is, in many cases, an autoimmune condition resulting from a bout of food poisoning. And we know that the reason why we have a problem with bacterial overgrowth in the small intestines is that, our small intestines are supposed to only have a relatively small amount of bacteria, especially as compared with the large intestine or the colon. Too many bacteria in the small intestine will affect the ability of the small intestines to absorb nutrients and excess bacteria can also produce gas, specifically hydrogen, methane, or hydrogen-sulfide gases. And these gases increase many of these symptoms that I just mentioned above. And so that’s really what we’re talking about with small intestinal bacterial overgrowth.
I’m very happy that today’s podcast episode is being sponsored by Lifestyle Matrix Resource Center, which is a hub of clinical resources, digital patient education materials, and marketing tools to help healthcare practitioners successfully implement lifestyle medicine in their practices. With the resources offered by Lifestyle Matrix Resource Center plus access to their knowledgeable implementation support team, practitioners can quickly become the go-to expert in their communities on a variety of functional medicine topics like GI health, immunity, and stress. Learn more on your website, lifestylematrix.com exclusively for Rational Wellness listeners. Lifestyle Matrix Resource Center is offering a free download on dysbiosis and probiotic supplementation. Head to lifestylematrix.com/rational-wellness-download to claim your copy. That’s lifestylematrix.com/rational-wellness-download and claim this free copy.
And Dr. Vincent Pedre is the medical director of Pedre Integrative Health and president of Dr. Pedre Wellness. And he’s a clinical instructor in medicine at the Mount Sinai School of Medicine. He’s a board certified internist, as well as the best-selling author of Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy, and Eliminate Pain. Dr. Pedre, thank you so much for joining us today.
Dr. Pedre: It’s a pleasure. Thanks for having me.
Dr. Weitz: Good. So why don’t you tell us a little bit about your story and how you became interested in focusing your practice on digestive disorders?
Dr. Pedre: Ooh. Yeah. I mean, I basically grew up with I guess you would call it IBS. And honestly, I can’t say whether it was due to food poisoning of any sort like Dr. Pimentel says, or if it was what I think due to being put on multiple rounds of antibiotics as a child. Probably starting around the age of 10, I was put on so many rounds of antibiotics, probably two or three courses of antibiotics per year for all infections that the child would get, a throat infection, long bronchitis, sinusitis. And sometimes back then, which is scary to think about, my immune system didn’t seem to just wasn’t functioning. And I don’t think they do this anymore, but it was custom back then that if you weren’t responding to the antibiotic, they would give you a gamma globulin shot. So it’s basically pulled immunoglobulins from a bunch of people. And usually when I got a shot of that, I would start to feel better. But no one was really figuring out like, “Hey, why is this child having an immune system that’s not functioning properly and he keeps getting sick over and over and coming back for course after course of antibiotics?” Which by the time I was 17, I had been on probably 21 courses of antibiotics. So you can imagine what that did to my gut and my gut microbiome. And as a result, I had no clue what leaky gut was back then and nor did my family. But I can look back after my training as a doctor and then training as a functional medicine practitioner, that I developed a dysbiosis that led to leaky gut that then led to becoming reactive to foods like gluten and dairy.
And it wasn’t just fructose intolerance, it was actually a sensitivity to the proteins and dairy, and that weekend my immune system. So my selfish endeavor in becoming a doctor was to figure out, “Hey, how do I not get sick?” But as a result of that, it led me to my life’s passion, which is working with people on gut issues and then just realizing that so many things are connected to the gut. That it’s really not just about the gut, it’s your immune system, it’s your brain health, it’s auto-immunity, it’s allergies, asthma, lung health. So many other things are connected to gut health that it just became just something that I did that I really enjoyed. And before I knew it, even though I was a general internist, I had patients referring. They would come in with gut issues and they would get better and other things would get better, not just their gut.
And then they would refer a friend, friends would refer another friend, family members. And before I knew it, I was this accidental gut expert without really planning on it, which I think is the best way to find something that you’re passionate about is just to fall into it. Because a lot of times when we do our training as doctors, before you really understand what you feel passionate about, I mean, maybe some would understand that, you’re already having to decide if you want to be a pulmonologist, cardiologists and you’re just trying to survive to get through your residency. You’re working 80 to a 100 hours per week and now you have to decide what you want to do within that. And I couldn’t decide at the time, but then it just fell on my lap and I’m so happy that it did that way. Because it stemmed from my own childhood problems and even early adulthood with gut issues and then working with patients on their own gut issues.
Dr. Weitz: So when you see a patient complaining of gastrointestinal issues like gas and abdominal pain, constipation, et cetera, how do you work them up and what type of testing do you do?
Dr. Pedre: Oh, I mean, first and foremost, super important to take a thorough history. I think that’s a slowly dying art in our insurance driven medicine where doctors have less and less time with patients.
Dr. Weitz: Well, actually, that’s one of the questions I was going to ask you because I went over to your website and I noticed that you actually take insurance.
Dr. Pedre: I have a bit of a hybrid system. So I have a-
Dr. Weitz: I’m curious how you can spend 90 minutes doing a full, detailed, functional medicine history for HMO insurance. How do you make that work?
Dr. Pedre: For that reason, I only take PPOs and I actually have cut them down over the years. And now I only take about, I don’t know, somewhere between three and five plans. And I also have cash based programs between supplements, concierge program, functional medicine program. That then allows me to still see insurance patients and be able to balance the time and be able to give them the time that they deserve. Because you can’t take a thorough history in 15 minutes.
Dr. Weitz: No. I know.
Dr. Pedre: You just can’t. And the history is primo, it is the most important thing that you start with because the history is then going to guide you on which direction you choose in terms of testing. Especially sometimes and I look at it as a challenge because I do see some patients who have financial limitations, and a lot of this functional medicine tests that are out there are quite expensive. So if a patient can afford it, then you have to start deciding, “Well, which is the most important test for me to do? Should I get a breath test because I suspect that they have SIBO and maybe that’s going to point me in the right direction. At least we can get the ball rolling? Or am I going to get a PCR based stool analysis along with a breath test? Because I think maybe there’s more going on here than just SIBO. There could be a parasite, there could be yeast overgrowth, or maybe I want to do organic acids testing to get a broader look at metabolites and see what else might be going on that could be going into the picture of the patient.”
And I will tell you this, test results can either mislead or they can surprise. And I have had test results that have surprised in patients that had no GI issues and turned up with a parasite and with a yeast overgrowth. So if there is a suspicion, and the reason I did the test even though the person did not complain about any gut health issues, is because there was enough in the history and they had tested positive for multiple autoimmune markers. And because we know there’s a connection between gut health and immune system and auto-immunity, I decided, “Okay, with this patient, even though she answered every question negative on the review of systems on GI, no constipation, no problems.” And yet she was presenting with autoimmune disorder with hives, skin rashes, with achy joints. So I knew, “Okay, got to look at the gut with this person,” even though they’re not coming in with a gut complaint, but they have gut related health issues. So I think, first of all, is the story. You have to understand the person’s story, and then from there you start to put the picture together.
Dr. Weitz: Yeah. Absolutely. What’s your favorite stool tests these days?
Dr. Pedre: I have been using, I switch between the two and they give you different information. But I’ve been using the GI-Map Diagnostic Solutions. But the one thing that doesn’t give you that I really like that the Genova GI Effects Profile does is that, the GI Effects will give you a view of diversity whereas the GI-Map, it doesn’t really give you that. The great thing about it is, it has a really fast turnaround. So you can get a result within three to five business days of them receiving it. But the GI-Map does a lot of similar things as the, I mean, the Genova GI Effects does a lot of similar things but it takes a little bit longer to get the results.
Dr. Weitz: Yeah. We seem to prefer the GI-Map these days. We seem to get more clinical useful information. And when you talk about autoimmune, I liked that section where it has the potential autoimmune markers and it’s one thing to consider.
Dr. Pedre: Yeah, definitely. I see a lot of Prevotella coming up there.
Dr. Weitz: Yeah, yeah. And sometimes it really correlates and we’re still waiting for the research to see if reducing the Prevotella is actually going to have an effect on their autoimmune condition, right?
Dr. Pedre: Yeah. I think it’s always difficult to… Because then we’re trying to bring it down to that one thing which is like Western medicine magic bullet approach, and it really isn’t a magic bullet. And I think even when you get these test results, it’s always really important to put the test result next to the patient. And the story that the patient and the symptoms that the patient is having, and make sure that the two sync up with each other. And if they don’t, you have to wonder like, “Am I going to do an intervention that even though the person doesn’t have symptoms or do I pay attention to the patient and leave this alone?” Because we still don’t understand it completely, and we’re still learning how to manipulate the gut microbiome. And even a test like the GI-Map is not like doing whole genome sequencing. You’re going to get a full picture of what’s in the gut.
Dr. Weitz: And that’s the other type of stool testing which is a whole different thing. And that as much clinical focus on parasites and things like that, but a better overall picture of the whole microbiome.
Dr. Pedre: Yeah. And the thing is, then you get a lot of information and I honestly think we’re still figuring out how to use that information.
Dr. Weitz: Absolutely. And everybody’s focused on which bacteria are low or high. And then of course we know that even if you give supplemental bacteria probiotics, they’re only temporary visitors there, they don’t actually take up permanent residence.
Dr. Pedre: Yeah. We do know that certain bacteria influence the growth of other bacteria. And for example, because there’s cross feeding between strains, so certain bacteria can help promote butyrate producing bacteria. But I know there’s a company out there that does whole genome sequencing and then creates a customized probiotic based on the whole genome sequence. And when I saw patients use the product, I saw that were mixed results. Which tells me that we still don’t know fully what… If you have a genome sequence and you see that something’s low, does giving them more of that, does it actually improve the outcome or is the picture much more complex than that?
Dr. Weitz: Yeah. I think it’s early. I think we definitely do not know the answer to that.
Dr. Pedre: I don’t think so. I mean, the one thing that I do find remarkable and I’m just going to segue just a little side note to FMTs, because I’ve been looking at the research at Memorial Sloan Kettering using autologous FMTs for patients undergoing bone marrow transplant. And so they’ll take their stool, they’ll keep it. And then they’ll give them their own stool back after the bone marrow transplant. And it helps re-institute, because they have to use high doses of chemo and antibiotics because their white blood cells drop. And what they found is that by giving them back their own stool during an autologous FMT, that it recedes the gut with the diversity of the gut microbiome. And it actually helps prevent things like graft versus host disease and improve survival.
Dr. Weitz: Wow. And this is with cancer patients?
Dr. Pedre: This is with bone marrow patients who are undergoing bone marrow transplant at Memorial Sloan Kettering. So I was really happy to see that they’re studying that because they’re realizing, “Okay. We do cause damage as doctors by giving patients antibiotics. And these are the most delicate patients out there, how can we improve their outcome?” And it turns out just take their stool and give it back to them after the bone marrow transplant.
Dr. Weitz: Yeah. Interesting. So there’s actually a whole series of medications that are commonly prescribed to have negative effects on the microbiome, not just antibiotics, but all anti-inflammatories, proton-pump inhibitors.
Dr. Pedre: Definitely. And just to connect it with SIBO, I’ve had a couple of cases of SIBO that were triggered by putting a patient on a proton-pump inhibitor. That basically it changes the environment in the gut. So if you change the environment in the stomach, then what you have to realize is that you’re going to change everything downstream from there. So once you’ve raised the pH in the stomach, you’re affecting the pH in the rest of the gut by using these proton-pump inhibitors. And I’ve seen a few cases where the person very clearly did not have any issues was put on a proton-pump inhibitor, usually for too long, because they’re really only meant to be used for two to four weeks. They’re not really meant to be used for months on end. But the practice unfortunately in medicine that I see is, doctors will place patients on PPIs and then just keep giving them refills with no end point in mind.
Dr. Weitz: Well, the problem is you’re treating a chronic condition like reflux or GERD without any understanding, or even trying to probe what the underlying triggers and causes are, and you’re just treating it symptomatically. So if you don’t try to get to somebody’s underlying root causes, what’s the likelihood that you’ll ever be able to stop taking the drug.
Dr. Pedre: Exactly. And the longer you’re down the trail, the much more difficult it is to wean somebody off that PPI.
Dr. Weitz: Right. Have you started using the new breath test for hydrogen sulfide gas?
Dr. Pedre: In New York, we’re not allowed to use that test yet.
Dr. Weitz: Really?
Dr. Pedre: Yeah. But I am aware of it and I know that patients can go across the bridge to New Jersey and get the tests done. But we can’t run it in New York yet. New York has really weird regulations on which tests can be run and which ones can’t be run because they basically have their own licensing board that reviews all these tests and-
Dr. Weitz: So you can use the existing SIBO breath test but not the new one?
Dr. Pedre: Yeah. Exactly. And I really do think that we’re missing stuff with the old SIBO breath tests that we really need to do the Trio breath test to look at sulfur as well.
Dr. Weitz: Right. Are you presently diagnosing hydrogen sulfide by a flat line?
Dr. Pedre: It’s a good question. That’s where I go back and say, we’ve got to not just look at the test, but look at the test and the patient. And if the test result doesn’t make sense based on what the patient is telling you, then you pay attention to the patient.
Dr. Weitz: Right. So-
Dr. Pedre: I can’t tell you how many times in Western medicine, patients will present with symptoms and then they go have blood work done and the doctor will tell them, “Well, your blood work is fine.” And they’re like, “There’s nothing wrong with you,” but the patient is like, “But I feel this way.” And I think it’s so disempowering to patients and I always think, “The patient is not wrong, it’s the test.” And the test that we did, wasn’t the test that showed exactly what the problem was. It doesn’t mean that there isn’t a problem.
Dr. Weitz: And especially today, as you mentioned, our insurance based system, there’s very strict limits on what tests are going to be approved to be paid for.
Dr. Pedre: Exactly. Yeah.
Dr. Weitz: Lab panels have gotten skinnier and skinnier and skinnier.
Dr. Pedre: Oh yeah. I mean, I’ve had insurance reject a cholesterol panel in a routine wellness visit. Now, this is not common, but I thought, “Well, if it’s a wellness visit, cholesterol is part of that. What’s happening here?”
Dr. Weitz: Yeah. Well, you probably tried to order an Advanced Lipid Profile and they definitely don’t want to pay.
Dr. Pedre: Oh, I’ve been told all sorts of things and had patients receive letters from insurance plans being told that I’m ordering experimental tests.
Dr. Weitz: Yes. We’ve had the same thing of course. So let’s get into some treatment protocols for SIBO. So what are some of your favorite treatment protocols for patients with hydrogen SIBO, methane SIBO, now we call it IMO, and hydrogen sulfide SIBO?
Dr. Pedre: Yeah. These are obviously complicated cases and I think diet is always first and foremost really important-
Dr. Weitz: So you start with diet before?
Dr. Pedre: Diet along with other interventions. If it were-
Dr. Weitz: What’s the best diet for these patients?
Dr. Pedre: I really… So initially I was using FODMAP diet, low-FODMAP. But what I don’t like about the FODMAP diet is that, it’s very black and white in terms of what’s in and what’s out. So I started using Dr. Siebecker SIBO Specific Diet, Because there you have green, orange, red, I think you have three categories. And I think it’s much easier for patients because the FODMAP is so limiting. But if you can eat a quarter of an avocado, but not the whole avocado, then at least you’re making the diet a little more diverse and not feeling so restrictive. So I tended to use more the SIBO Specific Diet to guide patients and intermittent fasting too. I think that’s really important when treating patients with SIBO is having at least a 12 hour overnight fast and letting the gut rest. And then depending on the type of SIBO, so if it’s-
Dr. Weitz: So will you put the patient on recommend dietary changes first, or will you also use other protocols at the same time?
Dr. Pedre: At the same time. Yeah. Because people want… And the thing is, I have to say that most of the time when patients are coming to my practice, they’ve already been to the gastroenterologist. They’ve already been treated with Rifaximin. They’ve at least had one or two rounds of antibiotics of different sorts. So they’re frustrated, their patience is at the very end of the line. Lucky us, we inherit these patients at this point in the treatment. And so you want to try to get results as quickly as possible. And I was trying to figure out, “Do I put them on another round of antibiotics and then really try to work on diet.” Normally when they go to a Western based doctor, they’re not even addressing the diet component. They’re just putting them on the antibiotic and saying, “This is your magic bullet. And you’re going to be better than that.”
Dr. Weitz: Well, Dr. Pimentel actually thinks that going on a low-FODMAP diet at the same time would interfere with the antibiotics’ effectiveness at killing the bacteria, because antibiotics tend to work by breaking down the replicating cell wall of the bacteria. And if you put them on a low-FODMAP diet, you starve them. So they don’t tend to replicate as much.
Dr. Pedre: Yeah. What I started doing is, if I say I used Rifaximin in a patient, I would give it to them with Slippery Elm Bark at the same time. And the Slippery Elm Bark as a prebiotic serving as a shuttle to help get the bacteria to gobble up the Slippery Elm and they also taken the antibiotic with it. So that was my trick. And then I really started thinking, “This is a chronic issue. This is not a quick fix issue with persons.” It’s like what Willie Moseler used to say, “Tell me the patient that has the disease.” It’s really more like the type of patient. And realizing that there’s a psychosocial component to SIBO, these patients tend to be generally very anxious type of people, type A personalities over achievers. So their vagal tone gets effected and that can affect gut motility. So working on stress reducing tactics, working on improving vagal tone through things like gargling, humming. And then I was looking for, “How can I approach this in a way that would really help people get through the hump?” And that’s when I started using spore-based probiotics as part of the treatment protocol, because there’s so many research based benefits to these spore-based probiotics that made a whole lot of sense to me in terms of treating patients with SIBO. And when I started using them-
Dr. Weitz: I just want to let everybody know that there’s been a big controversy, should we be using probiotics when we’re treating patients for bacterial overgrowth? In other words, why would we want to put more bacteria in when they already have too much bacteria?
Dr. Pedre: Exactly. And you certainly don’t want to put a patient on a traditional probiotic like lactobacillus bifidobacterium species combination. I’ve seen that just…
Dr. Weitz: And yet you know there’s a very prominent practitioner who treats a lot of SIBO patients and he has popular podcasts. And that’s his first line of therapeutic intervention, putting patients on several different probiotics. So he uses spore-based, and a Broad Spectrum, or he calls it like Acidophilus Bifido blend and Saccharomyces. And some of the studies have shown benefit from taking probiotics.
Dr. Pedre: Yeah. I mean, what I found in my experiences that the dose matters, and generally what I found patients with SIBO, they don’t tolerate even a 20 billion CFU probiotic. It would have to be really low potency. But when I started using the spore-based as my first line, I found that maybe sometimes they had a period of die off and then they really started to feel better and they tolerated the probiotic really well. And the other thing is that we haven’t really addressed or spoken about is that, everybody’s thinking a SIBO patient is a small intestinal bacterial overgrowth. But the truth is that a lot of the SIBO patients are SIBO and SIFO combined. And what’s confusing, and I think what happens when they go to Western doctors is they get a round of antibiotics. They get better, and then a month later, they’re slowly start to get bloated again and symptoms come back. And you’re wondering, because a lot of times what I’ve seen is, they don’t retest them. They just treat them. And I used to think that Xifaxan could not cause a fungal overgrowth, but I found that it actually can like any other antibiotic. And sometimes what people think of as recurrent SIBO might actually be intermixed with a bit of SIFO. And I mentioned it because these spore-based probiotics, because they do a number of things, including quorum sensing to group together, and they produce other active compounds, enzymes that can break down biofilm, bacteriocins as they call them. They’re like local antibiotics that inhibit other species from growing. It’s almost like you’re giving them a targeted antibiotic that’s not going to destroy their gut, because they found that using these spore-based probiotics actually improve diversity of gut bacteria.
Dr. Weitz: When is the best time to take probiotics? Is it better to take them apart from meals, with meals, time of day? What do you think works best?
Dr. Pedre: It depends on what type of probiotic. So if you’re giving a regular probiotic that has lactobacillus and bifidobacterium in an acid stable capsule, I tend to prefer patients to take that on an empty stomach. So either 30 minutes before a meal or some patients I have them do it 30 minutes before bedtime, so after dinner. But if it’s a spore-based probiotic, you reverse that because the spores need to germinate. So you do it five to 10 minutes after a meal, instead of on an empty stomach.
Dr. Weitz: Interesting. Okay. So what do you think about biofilms? The podcast we have up this week is an interview with Dr. Preet Khangura from Canada. And he finds that biofilms are a big player in SIBO as well as in a lot of other forms of gut dysbiosis infections. And he feels that until you can break up those biofilms, it’s hard to reduce or eradicate the bacteria.
Dr. Pedre: I definitely agree. And I’ve had some really challenging cases. And what I think is important too for the clinician is to think that, if they have a treatment resistant SIBO. So a patient you’re doing everything right, and they’re just not responding in the way that you think they should respond, then the next thing you should be thinking about is biofilm. And then you should be using things like Serrapeptase to break down the biofilm and use that on an empty stomach between meals. And that could be a treatment that goes on for a while because biofilms can be pretty challenging to break down. Whether they’re in the gut or in the sinuses, I’ve had patients with a biofilm in the sinuses.
Dr. Weitz: Dr. Khangura prefers using bismuth dial combinations. He has something compounded with with DMSA or DMPS along with bismuth and alpha-lipoic acid. I guess Dr. Paul Anderson has pioneered that kind of a biofilm disruptor.
Dr. Pedre: Yeah. It makes sense because biofilms can also have heavy metals and other things that need to be removed in order to break up the biofilm.
Dr. Weitz: So as far as natural anti-microbial treatments, if the patient doesn’t want to go on Rifaximin or you don’t think it’s appropriate, what is some of your favorites?
Dr. Pedre: I will use some herbals and it depends again, what I think is going on with the patient. I really like… the name is escaping me now, but I will use sometimes-
Dr. Weitz: Berberine, oregano.
Dr. Pedre: Yeah. I was thinking of products like Candicid Forte. But yeah, they include berberine, caprylic acid sometimes mixed in with some artemisinin, black Walnut in there. Kind of broad spectrum herbals, olive leaf extract, all these things.
Dr. Weitz: Okay. So what about trying to restore the motility with a prokinetic?
Dr. Pedre: Yeah. Good question. Probably I’m going to suspect Dr. Pimentel has more experience with that than I do. I tend to try to not in terms of prescribing prokinetic drugs like Motegrity. It seemed when Motegrity came out and I heard Dr. Pimentel talk about it, that seemed like it could just turn on the migrating motor complex and it was going to be a magic bullet for that. But as all magic bullets, they’re never really a magic bullet.
Dr. Weitz: Yeah. I thought a number of practitioners used to say how tremendous it is. And for some reason, in my practice, I seem to have seen a lot of patients who didn’t get much benefit from it.
Dr. Pedre: Yeah. Or what I’ve found is they get benefit in the early stage, the first couple of weeks. And then the benefit starts to wane down. And you really have to treat the behaviors that lead to the symptom in the first place. A lot of my patients don’t realize how stressed they are. They just don’t realize how stressed they are. And there’s also other herbs that you can use, or roots like ginger, D-limonene to stimulate motility in a more natural way. But really even just getting patients to do cardio exercise, like going for runs, can improve motility, vagal nerve stimulation like I mentioned before. Really important. And working on… I’m going to throw in their heart rate variability, getting them to really create more of a balance between parasympathetic and sympathetics, as most people are just living imbalance. There are too high on the sympathetic and not high enough on the parasympathetic, which wouldn’t improve gut motility.
Dr. Weitz: Yeah. We actually just started using a wearable called the Apollo that uses vibrations to help put you in more of a parasympathetic mode and it’s been shown to improve HRV. So it’s a new tool to use to help [crosstalk 00:38:03] stressed patients.
Dr. Pedre: Interesting. I just ordered, I don’t have it yet. But I wanted to experiment on this, the quorum sensor or… what is it called? What is the name of the company?
Dr. Weitz: I know there’s a lot of new wearable devices.
Dr. Pedre: Sorry, the brand is called Whoop. And it’s a wearable sensor that it’s waterproof, you can wear it into the shower, tracks your sleep. But I more ordered it because I was curious about heart rate variability and the connection to gut health.
Dr. Weitz: So when you’re treating a patient with SIBO, how long do you typically treat them for?
Dr. Pedre: That’s the million dollar question.
Dr. Weitz: So we normally say like if you’re going to use rifaximin, then it’s typically two weeks.
Dr. Pedre: Yeah. Or sometimes, actually some doctors will treat for four weeks with rifaximin depending on the case.
Dr. Weitz: Okay. Or [crosstalk 00:39:07] and repeating it. And then if you use herbals, then…
Dr. Pedre: Then you’re looking at month long treatments, so usually at least a month. But a lot of times it could be two months then incorporating the spore-based probiotics. And I might use a serum derived, bovine immunoglobulins as well in that combination, and there’s reasons for that. And that might go on for three to six months as I’m working on the lifestyle factors of the person diet, stress management, exercise. Because working with patients, especially in New York City, people are busy and getting them to institute those lifestyle changes can actually take six months of work.
Dr. Weitz: Yeah. Now you mentioned SIFO, which is small intestinal fungal overgrowth, and there’s no breath tests for a fungal overgrowth. So now, how do you diagnose the fungal overgrowth if you suspect it? Are particular tests you use to help confirm it, do you use the stool tests? Do you use the organic acids test? And then how do you exactly fungal overgrowth?
Dr. Pedre: I look at a combination of tests. So if I can do the stool test, stool piece TR. It’s very hard to get a yeast culture on the stool. So those most of the time come back negative. I like using the organic acids. At least it gives you another window into whether there might be yeast overgrowth. And then of course, the story that the person tells you. If they have yeast overgrowth symptoms, like craving refined carbs, craving sugar. Just those signs that you look for mental fog, then you can suspect that there’s yeast overgrowth. And I will tend to use things like, again, berberine, oregano oil, as well as caprylic acid. If you use the right dose of caprylic acid, you can get a really strong die off in a person. It can be quite powerful. And then I use combinations supplements as well.
Dr. Weitz: And then do you change the diet for the fungal overgrowth?
Dr. Pedre: Definitely. I mean, but it will be usually three to four weeks where I’m really limiting refined carbs and sugars. Because that diet is very difficult for people to continue on. Before they’re asking you for a lifeline when they’re on that type of diet. Like, “When can I have a carbohydrate, please?”
Dr. Weitz: Sometimes you get these patients who’ve been on the scene at the low-FODMAP diet for so long and you treat them and they finally feel better and now they don’t want to expand their diet. And it’s actually a little bit of a struggle to get them to start eating more diversity of foods.
Dr. Pedre: Yeah. And I can understand that having gone through so many gut issues over the years myself. But what I tell people is, just try little bits at a time and see how that affects you. And if it doesn’t cause symptoms, then you know you can slowly start to expand the diet. The error that people make though is that, I tell them, “If you don’t know what the temperature in the pool is, you’re not going to just jump in, right? You’re going to dip your toe in first to see how cold is this pool before I jump in?” But a lot of people what they do is that they’re like, “Oh, I’m going to have pizza.” And they just jump in and then they call me the next week then telling me, “Oh, my symptoms are back. I feel horrible.” I’m like, “Well, what did you do?” Like, “Well, I eat pizza.” Like, “Well, I told you to dip your toes, not to jump in the pool.”
Dr. Weitz: So which form of SIBO do you find the most challenging?
Dr. Pedre: I’m going to say methane predominant.
Dr. Weitz: So any particular strategies that you find particularly effective for methane?
Dr. Pedre: I’m still looking for the best strategy for that one. That is a really tough one. I still will use spore-based probiotics for that one. Because I do believe that, that’s an important key part of the treatment protocol. And then I’ve tried different things including bioflavonoids seem to play a big role in helping with those patients. There is a product that includes a combination of bioflavonoids that-
Dr. Weitz: Oh, [inaudible 00:44:00]?
Dr. Pedre: Yeah. It can be helpful. And even just peppermint oil for treating the gas, the uncomfortableness of it. But those can be quite challenging because you need to get their bowels moving too. You really need to get their bowels moving.
Dr. Weitz: [crosstalk 00:44:22] do that?
Dr. Pedre: Any means you can. No, I’m just kidding. But usually things like throwing in Cape aloe, making sure that you want them to get fiber, but you don’t want them to get too much fiber. And-
Dr. Weitz: What was the first thing you said? Aloe?
Dr. Pedre: Cape aloe. Yeah.
Dr. Weitz: What’s Cape aloe?
Dr. Pedre: It’s just a different type of aloe that is really good for constipation.
Dr. Weitz: Okay. That comes from the capsule or liquid or?
Dr. Pedre: Capsule.
Dr. Weitz: Okay.
Dr. Pedre: Yeah. And it comes in different strings.
Dr. Weitz: Okay. And use magnesium?
Dr. Pedre: I will use magnesium, but in a patient with methane predominant SIBO, they’re most of the time going to be pretty resistant to magnesium. So I will resort to other things like Cape aloe sometimes gut motility agents as well. But again, these patients, it’s like a patient profile. You see the patients who come in and these are also tend to be very high, strong, stressed out people, and you really need to work on vagal nerve tone. You really do.
Dr. Weitz: So you mentioned gargling and what are some of the other strategies you find helpful for vagal tone? [crosstalk 00:45:49].
Dr. Pedre: Some really great ones. Humming, humming is really good because the vibration here through the vocal cords stimulates the vagus. Or just singing, like singing in the shower at a high voice almost like operatic, that can also stimulate the Vagus. Some people often wear-
Dr. Weitz: Poor to me, that makes everybody around me a lot more painted
Dr. Pedre: That might put other people into sympathetic. It’ll put you into the parasympathetic. There are also tools that can be used, I don’t use them with patients. But there are devices that E-stim devices that can be used to stimulate the vagus nerve. And they’ve used these in studies on treatment resistant depression and found that they can be quite effective.
Dr. Weitz: So do they actually attach wires to… How do they get to the vagus nerve?
Dr. Pedre: I think the easiest access is here.
Dr. Weitz: Right there?
Dr. Pedre: Yeah. Right on the neck.
Dr. Weitz: So they insert wires into it?
Dr. Pedre: No, no. It would be on the surface.
Dr. Weitz: Ooh okay. I see.
Dr. Pedre: No. Not an invasive type of thing.
Dr. Weitz: Yeah. I know some doctors use infrared laser to stimulate the Vagus. I don’t know if any of this stuff is really documented, but I guess if it works, it’s good.
Dr. Pedre: Yeah. I mean, I found at least one study where it did have a significant reversal of treatment resistant depression. So it is possible to stimulate the Vagus. I think it’s easier just to sing in the shower.
Dr. Weitz: Yeah. Do you ever find patients with difficult to treat SIBO and may turn out to have mycotoxins, for example?
Dr. Pedre: Very possible. I think the thing is that the patient doesn’t always tell you exactly what they have. They just come in with a host of problems and you need to figure it out. And that’s why I think my functional medicine training has been really helpful. And just having a roadmap of where to think, just a questionnaire to see, where is it that you need to be thinking that there might be problems where you need to dig deeper and look at other possibilities as well. Patients are complex, right? They never come in with just one singular problem.
Dr. Weitz: Right. Yeah. I know the methane patients, as you mentioned, that seems to be really difficult to treat. Dr. Rahbar, who is an integrative gastroenterologist in LA, I talk to him a lot and he finds a lot of these patients either have fungal overgrowth, as you mentioned. Some of them actually have Lyme disease or parasites. And he’s been doing some actually culturing, going in and doing a scope and pulling out some of the juice in the small intestine and testing it and finding some of these things.
Dr. Pedre: Yeah. I mean, obviously not practical for every patient and it’s invasive. But that’s the gold standard for diagnosing SIBO. But I great to hear that he’s thinking about other things. Because I think that’s where we can hit our heads against the wall is, if you’re just thinking this one thing and the patient’s not getting better and you just keep doing it, that’s where you have to think, “There must be something else going on here. What else could be going?”
Dr. Weitz: Exactly. And often layers, not just one thing but different layers.
Dr. Pedre: Oh, I can tell you I’ve had so many patients come in to my office as, let’s say a SIBO patient, and then once we resolve that, then they realize how the process works. And then they tell me, “Well, I have this other symptom that I’ve had for a really long time,” and then we start working on that. And it’s really funny, it’s like peeling the layers of an onion, you’re finding heavy metals, mold exposure, all sorts of things.
Dr. Weitz: And these things are cumulative. So you don’t necessarily need to have one cause or one trigger, you can have multiple triggers. And so as you peel back those different layers of root causes and triggers, you’ll see the symptoms continue to decrease.
Dr. Pedre: Definitely. Yeah.
Dr. Weitz: So I think that’s all the questions I have. Any final thoughts you want to leave our viewers and listeners and then how to get a hold of you and find out about seeing you and getting your book and your courses.
Dr. Pedre: Best ways, they can check out my website, pedremd.com or really just find me on social media, Facebook, Dr. Vincent Pedre or Instagram @Dr. Padre. And I’m constantly posting gut related information on my social channels. So trying to stay active there.
Dr. Weitz: Right. Good. And in your book, I’m assuming is available wherever books are sold?
Dr. Pedre: Yeah. The big monster called Amazon. Yes. You can get it there.
Dr. Weitz: I go out of my way to try to go to Barnes and Noble.
Dr. Pedre: I don’t think we have any Barnes and Noble opened in New York City now anymore.
Dr. Weitz: Or you can order online and find its available.
Dr. Pedre: Exactly. You can order online. The book is called Happy Gut and yeah, you can get it from… Or you can even-
Dr. Weitz: Oh, and it’s so sad that there’s almost no bookstores left.
Dr. Pedre: Oh, it’s really… I miss going into a bookstore and just browsing.
Dr. Weitz: Yeah. I know I do too. Okay. Thank you, Dr. Pedre.
Dr. Pedre: Thanks for having me.
Dr. Weitz: Well, thank you listeners for making it all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts and give us a five-star ratings and review. That would really help us so more people can find us in their listing of health podcasts. I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at (310) 395-3111. That’s (310) 395-3111. And take one of the few openings we have now for individual consultation for a nutrition with Dr. Ben Weitz. Thank you and see you next week.
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