Keys To Better Gut Health with Dr. Edison De Mello: Rational Wellness Podcast 229
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Dr. Edison De Mello speaks about the Keys to Better Gut Health with Dr. Ben Weitz.
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1:27 Gut problems, including stomach pain, bloating, gas, diarrhea, and constipation, are extremely common today. Gut problems exist because of our toxic environment, because of stress, and because most of us haven’t asked ourselves what our relationship with that food is.
7:05 Bloating. Bloating needs to be distinguished from swelling and from fat. With bloating it comes and goes from one day to the next, whereas when you get fat, it continues to increase and doesn’t come and go.
8:57 Once we rule out the most severe pathological conditions, the most common cause of bloating is gut dysbiosis, which means an imbalance of the microbes in the microbiome. There are various reasons why there is gut dysbiosis, including eating foods that inflame our gut, taking antibiotics for sinusitis that also kill the good bacteria, by eating on the go, by having your hormones imbalanced, or there may be overgrowth of bacteria or fungus. There may be small intestinal bacterial overgrowth (SIBO) or there may be overgrowth of other bacteria in the colon like strep or prevotella. There might be parasites or H. pylori or overgrowth of candida. We can do a breath test for H. pylori. We can do the SIBO breath test. Dr. De Mello orders his SIBO breath tests through Dr. Sam Rahbar, who is an integrative Gastroenterologist in Los Angeles and who assists in the interpretation. He also likes to order the 3 day stool test from Genova.
18:52 If the tests come back and the patient has multiple issues that might be contributing to gut dysbiosis, such as a positive SIBO breath test for methane and overgrowth of certain bacteria or fungus on the stool test, then Dr. De Mello will focus on the condition that he feels is the priority. But he makes sure his patient is ready to be committed to changing his diet and lifestyle and he wants to make sure that he is not overwhelming his patient. He will ask his patient to make a list of the changes that he or she is willing to make, such as changing their diet, taking their supplements, sweating a lot, exercising to get these toxins out, etc.
22:32 Dr. De Mello feels that taking some specific herbal supplements is a crucial part of the treatment. He tends to use the herbal products–either FC Cidal and Dysbiocide from Biotics or Candibactin AR and Candibactin BR from Metagenics that were shown to be equally effective to Rifaximin or to triple antibiotic therapy (Clindamycin, Flagyl, and neomycin) in the John’s Hopkins study: Herbal Therapy is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth. He may either recommend a low FODMAP diet or do food sensitivity testing with Cyrex Labs to see which foods should be avoided. Or he may use the low FODMAP diet and also eliminate certain foods and then test them back over time.
28:58 Dr. De Mello may also place the patient on low dose erythromycin 50 mg as a prokinetic to restore their intestinal motility, esp. if they have elimination problems. He will typically treat SIBO patients for 90 days and then he will pulse it one week on, one week off. When treating for SIBO he may also treat for candida with an herbal blend for candida. If that doesn’t work, he will treat with nystatin for up to 3 mths as long as the liver enzymes are fine.
33:33 Dr. De Mello may order an Organic Acids test, esp. if there are no clear signs of what the cause of their gut symptoms are caused by. The other thing he finds may impact gut health are hormones. For hormones, he prefers to test with blood and he asks women if they are still menstruating to run it between days 17 and 22 during the luteal phase, though he will sometimes use the dried urine DUTCH test.
Dr. Edison De Mello is a licensed psychotherapist and a board certified Integrative Physician. Dr. Demello is the founder and medical director of the Akasha Center in Santa Monica. His PhD dissertation was entitled “Gut Feelings – A Psychosocial Approach to Gastrointestinal Illness,” and he is committed to integrating the mind and a person’s emotional and spiritual health and body into his approach to health. Dr. Demello has recently published his first book, Bloated: How to Reclaim Your Gut Health and Eat Without Pain.
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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk 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. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.
Hello, Rational Wellness podcasters. I’m very excited to be interviewing Dr. Edison De Mello today, who’s our special guest. Dr. De Mello is a licensed psychotherapist and a board certified integrative physician. Dr. De Mello is the founder and medical director of the Akasha Center in Santa Monica. Dr. De Mello’s PhD dissertation was entitled Gut Feelings-A Psychosocial Approach to Gastrointestinal Health. He’s committed to integrating the mind and a person’s emotional and spiritual health into his approach to treating patients with digestive disorders. Dr. De Mello has recently published his first book, Bloated? How to Reclaim Your Gut Health and Eat Without Pain. We certainly need to know about that. Dr. De Mello, thank you for joining us today.
Dr. De Mello: Thank you for having me here, Ben, and thank you everybody out there for listening to us this morning.
Dr. Weitz: Absolutely. Dr. De Mello, why do people have so many gut problems these days, including stomach pain, bloating, gas, diarrhea, constipation, et cetera?
Dr. De Mello: Well, that’s the million dollar question, right? I know we’re dealing with a horrific epidemic right now, and I don’t mean to diminish, certainly, all the suffering, and all the death, and all the desperation of this epidemic, because I’m one of the physicians out there in the front lines, but there’s another epidemic happening.
Dr. Weitz: The epidemic within the epidemic, as I’ve heard Dr. Bland say recently.
Dr. De Mello: Exactly, exactly. As we know, health starts in the gut and we’ve heard this throughout our lives in medicine, that the gut is the carburetor of our health, basically. Without the gut, we wouldn’t be able to function. We wouldn’t be able to correctly metabolize our hormones. Because of lifestyle and because of the toxicity of the environment, because of stress, and because most of us have not really sat down and asked ourselves, “What is my relationship with food? How does my body receive this nutrient that it needs that is heavily necessary for our wellbeing?” If it’s not done correctly it can work against the very thing that we want to do, which is to be healthy.
Why do we have this epidemic? Again, I can go through a list of things with you, Ben, today, but I will start by saying we need to step back and ask ourselves, “Is what I’m doing in my life, is what I’m doing with my eating working? Am I processing my food correctly? Am I eliminating correctly? Am I able to dedicate time to really allow my body to digest this food?” That’s where I start with my patients when they come in. Certainly, the complaint that I hear most often, because of my double degree and the type of focus that I apply in my practice, the complaint is, “I don’t feel well. I don’t feel comfortable. I’m embarrassed.” If it’s a woman, “I look like I’m pregnant.” If it’s a man, “I have a beer belly, even though I don’t drink that much,” and so the question is, what is your body telling you? What is the message that the body has to tell you that something is off?
The first thing is, look at our lifestyles. Look at how we relate to the very nutrient that we need. The second thing is the ability to listen to the message that the body has for us. We are all about communication, and the body’s no different. The language of communication in the body to relate to us is called symptoms. Our job, as the host of this body, is to stop and listen and say, “Hmm. I keep hearing the same message. I eat and I don’t feel well. I eat and I cannot eliminate.” Or, “I feel bloated.” Or, “I don’t feel healthy.” What’s going on? When you pose that question, I think you have walked halfway into a possible answer.
Dr. Weitz: It’s amazing that we get all these signals and yet, most people are totally oblivious to those signals, partially because of all the noise, and all the things going on, and the messaging about eating unhealthy foods that just happen to be profitable. What I have found is a lot of people are not at all attuned to those messages.
Dr. De Mello: No. First of all, I think when we have symptoms or disease, we usually think of it as the enemy and we want to fight it off. When we do that, we spend so much energy on the symptoms, trying to fight it off, rather than stopping and saying, “What is the message?” Actually, as obvious as it may sound, as a result, okay, so this body, like I said before, is trying to tell me something. Let me take notice of it. The first thing that I do, Ben, when a patient comes in is try to figure out who this person is. Who is this person who happens to have a condition? Because when we connect with a person and we find out what his or her views of disease are, what the lifestyle is, what the relationship is with food, why now? Why bloating now? When we stop and meet the patient, before we meet their diseases, again, I think there’s a great deal of information that we can get from those patients. As you know, being in that space of functional medicine yourself, that’s the cornerstone of integrative medicine, of functional medicine, is to meet the patient, is to let the patient be part of this incredible journey that we’re doing in discovering the message that the body’s trying to tell us.
Dr. Weitz: Your book’s about bloating. What do we mean by bloating? What is bloating? How is this different from gas? What’s the significance of bloating?
Dr. De Mello: Okay. Excellent question. In the book, I try to explain the difference between bloating and swelling, right? So-
Dr. Weitz: And bloating and fat, and bloating and a lot of things, right?
Dr. De Mello: Exactly. Bloating and fat, as you said. Bloating’s a condition where it’s gas, basically. It’s a lot of gas in your body, and there’s no rhyme or reason when it’s going to happen. Sometimes you eat, and soon after you eat, your belly extends where you feel like you have a watermelon sitting there. Other times, it takes a couple of hours. It can even take a day, which is a delayed hypersensitivity reaction to whatever you’re eating.
Bloating is completely separate from fat. You know fat takes a little while for you to build in your body when you we don’t eat healthy, when our hormones are not metabolized. It progressively increases and it gets worse and worse. With bloating, you have it one day, the next day you find a way to diminish. The next day, the day after that it gets worse. It’s this kind of ongoing battle, where there are days that you can close your jeans, there are days that you can’t. You ask yourselves, “I didn’t do anything differently.” Here’s a question that I hear the most, Ben, “But Dr. De Mello, I hardly ate anything yesterday. Why am I bloated today?” I say, “Well, let’s have a little talk with your gastrointestinal bacteria. Let’s talk to your microbiome and see what’s happening there.”
Dr. Weitz: Once we’ve ruled out some of the most severe pathological conditions, which we don’t see too often, like fluid from liver or kidney disease or congestive heart failure, what are some of the most common reasons for bloating?
Dr. De Mello: Yeah, so thank you for qualifying that for our great listeners out there. We have to, before we move into the bloating wagon, we need to rule out any potential medical reasons, physiological reasons for that. As you said, it could be anything from a liver condition, where you’re retaining water. It can be your kidney as well. It can be congestive heart failure. It can be a multitude of things that we healthcare professionals will focus on eliminating, starting with perhaps a simple imaging exam or imaging test such as an ultrasound and also looking, of course, at labs. Once that is ruled out, the most common reason for people to have this bloating disorder, bloating condition is a dysbiotic gut, meaning your gut is out of balance. Here’s the interesting thing about bacteria that we all know. Bacteria is incredible, helpful, to our lives, from making our incredible wine, to making cheese, to helping with our gardening, to helping even clean our environment. Bacteria is, can be incredibly helpful to a very, very good lifestyle, but as I wrote in a paper once, called Bacteria: Friend or Foe? bacteria can also kill you. When you go into the hospital, you can have several reasons or several possibilities why bacteria has overgrown, from a simple cut that was not well taken care of, to a surgical condition that became a problem, to a multitude of other things that could lead to bacteria overgrowth.
The question is, “How do I look at this bacteria overgrowth? How do I balance my microbiome?” The first question, again is, “What am I eating? Is there a connection between what I’m eating and this bloating that happens?” Not only, “What am I eating?” but, “What have I been fed?” as well. For instance, we often say, “We are what we eat,” and I add a little bit more. I say, “And what we’ve been fed.” Because as kids, we don’t have a choice and sometimes, as patients, we don’t have a choice. We’re fed antibiotics, and for good reasons, a lot of the times, to saves our lives. When we’re fed the bad foods, the bad antibiotics, the multitude of medical intervention meant to help us stay alive, in most cases, it does the job of helping us stay alive but also diminishes the overall function of our immune system because, as I said, health starts in your gut. Your gut is the seat of your immune system. The idea is to say, “Okay. If I need to take this antibiotic, or if I need to take this medication, how can I help my body break it down?” One of the most important things out there is probiotics. How many times do we hear in traditional medicine, when a patient come in to say, “My doctor put me on antibiotics for a sinusitis or for pneumonia,” and we say, “Did she or he tell you to eat a bit differently when you’re on antibiotic? Did he tell you to take probiotics, to exercise to sweat this thing out of your body? How about drink water?” The idea is to really be able to support the body to be able to process those things out of your body, out of the body including some foods, including antibiotics, including even our vitamin and supplements. The idea is to allow the body to digest it better. How do you do that? You do that by, first of all, stopping to ask yourself, “Can I dedicate a specific amount of time to my eating, or am I eating on the go?” Then secondly, will say to yourself, “I’ve noticed that when I eat these foods, I don’t feel good. Can I do a process of elimination, and do elimination diet?” Third, you can say, “I wonder if my hormones have been checked, so let me talk to my practitioner about that.” Because if your hormones are off, so is your metabolism. You can go through a list of things that can help you get to this idea of, “Why am I bloated?”
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Dr. Weitz: Let’s say, and this question, let’s answer it both from the perspective of an educated patient as well as a practitioner. A patient has bloating. How do we go about the process of figuring out what some of the causes are? You mentioned dysbiosis. Of course, dysbiosis is somewhat of a diagnosis, but it’s kind of a general one. It means that there’s some imbalance in the gut bacteria. Within that general sort of larger diagnosis, we have small intestinal bacterial overgrowth. We have overgrowth of candida and fungus. We have other bacteria that could be overgrown like strep or Prevotella. We have parasites, we have food sensitivities, we have H. pylori. How do we now drill down, what sort of tests and procedures do we want to do to figure out exactly what is the cause of bloating in this patient?
Dr. De Mello: Yeah, so again, excellent question. I start with the big ones. I want to do a breath test for H. pylori.
Dr. Weitz: Okay.
Dr. De Mello: There’s a great deal of patients out there who have H. pylori and they don’t even know it. They have GERD or acid reflux. They have bloated, they don’t feel good. They feel the energy is much decreased than it used to be, so I do the breath test for H. pylori. Depending on the history, if the history is also the history where bloating just suddenly come, then I will also do a SIBO test. The SIBO test, as you mentioned, is small intestinal bacterial overgrowth. The SIBO test, it’s a breath test, and then we usually do it in the office or we teach our patients how to do it at home. Depending, of course, on the patient’s financial ability and insurance protocol, I will also order a stool test. I personally love the Genova’s three-day stool test.
Dr. Weitz: Okay.
Dr. De Mello: That is because I’m looking for not only an assessment of your microbiome, the patient’s microbiome, but I’m also looking for other microorganisms growth that is in there. I’m looking for digestive enzymes. I’m looking for the metabolites coming out of the patient. The three-days really yields a lot of more information, so those are the three big ones.
Dr. Weitz: This is the Genova GI Effects stool test, the three-day one.
Dr. De Mello: Yeah.
Dr. Weitz: Which SIBO breath test do you do?
Dr. De Mello: I work with Sam Rahbar, who’s a gastroenterologist.
Dr. Weitz: Yeah, yeah. He’s a good friend of mine. He’s been on the podcast a number of times. Yeah, yeah, yeah.
Dr. De Mello: I use his test that he-
Dr. Weitz: Oh, okay.
Dr. De Mello: The reason I do that is because I can call Sam when I get the results and I say, “Wait, wait, wait. Can you explain this to me here? The patients have this and this symptoms, but it’s not correlating with the results.” Sam being who Sam is, he gets right to it and say, “Okay, here’s why,” and so I’ve been doing that with him, using his lab for SIBO for a number of years.
Dr. Weitz: Okay, that’s great. Then, so let’s say you get some positive results. Let’s say the SIBO breath test comes back positive for methane SIBO, and the stool test shows some overgrowth of certain bacteria, or maybe candida, and maybe some issues with a lack of digestive enzymes. Where do you start? Do you treat multiple things at the same time? Do you try to prioritize? What’s your approach to treating gut issues?
Dr. De Mello: Yeah, I focus. I try to stay really laser-focused on what is this, what condition or symptom is disturbing the patient the most? Because, of course, when we are bloated there could be an N number of possibilities and a million things that we can do to get to the bottom of it. That alone can overwhelm anybody. It can overwhelm me when I’m looking at a patient and go, “There’s so many steps for him to take.” The first thing that I do, and it’s going to sound repetitious, but I meet the patient and I want to know, “Is this the right time for you? Are you ready to do this?” Because here’s what happens, as we know, and this is the psychologist hat that I’m wearing here right now, Ben. As we know, we can set up our patients for failure without knowing it. Of course, we don’t mean that. We want to help the patient, but if we don’t know what his lifestyle is like, if we don’t know what his emotional life is like, the demands on him is like, and we say, “Okay. You have to do this, this, and this,” and he’s going to be looking at you because he respects you as a practitioner. After all, he came to see you. He’s going to say, “Yes, yes, yes,” and he’s going to go home and start pulling his hair out. Literally pull, not his hair but his head or his neck because there’s so much going [inaudible 00:20:51], and so I want to make sure that I’m not overwhelming the patient.
I love that saying, “You cannot feed a starving child a piece of steak,” because the child doesn’t have the metabolism for it, just been starving. If a patient is that full of symptoms and that overwhelmed in life, I want to know. I want to know, what is it that I can do? So I’m going ask him. First, I said, “Okay, so here’s the diagnosis. You have SIBO and it’s curable, but it will require your attention. It require that you really spend time deciding what you’re going to eat. We’re going to give you a protocol. Taking your supplements, sweating a lot, exercising to get these toxins out of your body. Tell me about your lifestyle right now. Is there something that you can do?” Then I will list the things to them, and so they will look at me and say, “Well, I think so.” I say, “Okay. Let’s make a list of the things that you can do.”
Dr. Weitz: “I don’t have time for all that. I don’t want to change my diet. Just give me something to take.”
Dr. De Mello: Exactly, exactly. I’ll say to them, “It won’t work. It’s only going to frustrate you. It won’t work,” and so I try … Then given their lifestyle, let’s say somebody who’s a single mom, and working during the epidemic and trying to keep the kids at home. I cannot tell her to go exercise every day, or to go into an infrared sauna and have the luxury of sweating out some of the toxins, but I can say to her, “Okay, so given those things on the list that you can do, pick three that you can do right now.” Of course, one of them has to be a set of supplements and herbs that I can help the patient with. Once we determine the lifestyle and the question of, is the patient ready to do this? Then I will present the patient with the plan. The plan, usually, if let’s say if it’s SIBO, will involve what I refer to as the Johns Hopkins protocol. It’s the paper that came out about seven years ago that revolutionized the field. I know you’re familiar with it.
Dr. Weitz: Yes, of course. Yeah.
Dr. De Mello: Yeah. Where it showed that Rifaximin, Neomycin and Flagyl together was very helpful, but a set of specific herbs that they studied called FC Cidal, Dysbiocide and Candibactin from Metagenics was actually equally effective.
Dr. Weitz: Right.
Dr. De Mello: I put them on that protocol to start with. Three supplements in the morning, two of it, and then that makes six pills, plus at dinnertime. Then, of course, I will look at other physiological needs of the patient, including hormonal therapy.
Dr. Weitz: Let’s drill down for a minute on your specific protocols for SIBO. The patient, we’ve identified SIBO is their primary issue, so you’re going to put them on some of these antimicrobial herbs. Are you going to put them on, what type of diet? Are you going to put them on a low FODMAP diet?
Dr. De Mello: Yeah, depending on, again, the lifestyle of the patient. Let’s say it’s somebody who can do, who can follow the protocol. A FODMAP diet is the first diet that I start with, and I let the patient … I give them the guidelines, and I say, “Let’s see which food on this list you can, indeed, consume without having some of the bloating that you may have experienced in the past.” I’ll ask the patient if some of those foods have caused bloating. If financial means is not a problem, then I’ll also do a food sensitivity. I usually, I really like Metagenics … Excuse me. Cyrex.
Dr. Weitz: Cyrex.
Dr. De Mello: Yeah, using the food sensitivity, the leaky gut sensitivity. Because the worst thing for those patients is that we say to them, “Here’s the FODMAP list of foods,” only to later on find out that they have sensitivity to some of those foods. If they can do the test or afford the test, I’ll do the test. In some situations, they can’t. Then I do an elimination diet. I go through the list of foods that they know they have experienced a relationship to bloating, cause and effect, and I will remove those foods from the FODMAP list.
Dr. Weitz: Okay, so you’ll combine a low FODMAP and elimination diet to start with?
Dr. De Mello: Yes, yes. Again, because I want to empower the patient.
Dr. Weitz: Right.
Dr. De Mello: Right?
Dr. Weitz: Now, the low FODMAP diet already eliminates a number of foods that people would typically take out. It eliminates dairy, and gluten, and beans. What is some of the other foods you’ll eliminate in the elimination aspect of the diet?
Dr. De Mello: Well, I want to know if the patient, for instance, if the patient can tolerate oat, for example. I tell them oatmeal is a good source of complex carbohydrate.
Dr. Weitz: Well, let’s say they don’t know.
Dr. De Mello: Then I’d say to them, “Well, let’s, before we start you on this diet here, why don’t you eat this food for three to five days, and let’s see how you’ll feel once you’re at the end of three days.” I want to make sure that some of the foods that I’m going to give it to them, if they haven’t done the sensitivity test, that they know whether or not it’s one of those trigger foods for them. Right?
Dr. Weitz: Okay.
Dr. De Mello: I will involve them in their own elimination diet before I will give them the FODMAP, if they don’t have the food sensitivity test onboard.
Dr. Weitz: Right, okay. What are some of the other common foods, besides oats, that you see are problematic?
Dr. De Mello: Well, a lot of patients, believe it or not, even though they can have some fruit in the FODMAP, even some of the berries that we recommend, they have a hard time breaking down some of those fruit, including berries, for example, that I’ve seen. Again, I tell them, “What do you put in the berry? How do you eat the berry?” Because sometimes they think it’s the berry, only to find out that it’s the coconut milk that they put in the berry, but it was not the coconut milk. It was they added things to their coconut milk. You can take this so far, so long down the road of trying to find out, through elimination diet, what the patient’s actually sensitive to. We know it’s not a food allergy because they would know, but food sensitivity’s so hard to detect, as you know.
Dr. Weitz: Right. And probably changes over time, depending upon leaky gut, and how often they’re eating it, and things like that.
Dr. De Mello: It does. It does, and that’s why I also think that it’s really great for patients to be able to design their own diet. It gives them power. I give them the FODMAP, for instance, the FODMAP guidelines. Within FODMAP, I want them to tell me which diet, number one, they can stick to and which diet they think, it’s going to work for them. In that regard, I become a consultant to the patient who is receiving the information from her or his body, and I’m only consulting with him or her based on what they’re saying. I think that empowering patient, especially with SIBO and bloating disorders, is essential for the success of the treatment.
Dr. Weitz: Now, some of the other strategies that some of the doctors in the SIBO world employ include addressing potential motility issues, because we know that there’s this potential autoimmune origin of SIBO, where you have this damage to the migrating motor complex, so some practitioners will use either prescription or natural prokinetic agents. Do you ever use those?
Dr. De Mello: Yes, yes. If the patient has elimination problem. If the patient has an elimination problem or it’s irregular, then I’ve tried a couple of natural ones out there, but the one that I really like right now that is bringing a lot of benefits to my patients is actually erythromycin, 50 milligrams. I found that it’s-
Dr. Weitz: Low-dose erythromycin.
Dr. De Mello: Low-dose, yeah. I have it formulated. Again, I feel that for most of my patients, they’re really able to respond well to that. To the point where, before I stop the erythromycin, usually, I’ll give them a break after 90 days because that’s how I treat SIBO, for 90 days, and then I try to scale back. Then I may even do erythromycin every other day. Including also the SIBO protocol, the so-called Johns Hopkins protocol the way I referred to it. If the patient is doing well after 90 days, I will not stop it, I will pulse it. I would do one week on, one week off, just to see how the patient does to try to get to the big question of bacterial seeding. It seeds there, it stays there, and so instead of stopping altogether, I like pulsing the medication.
Another thing that I think is important with these patients is even though they may test negative for candidiasis, I often assume that there’s candidiasis in there, even as you know, it’s one of the most difficult microorganisms to detect. Depending on the severity of the symptom, part of my protocol will include putting the patient on either a natural anti-candida protocol using oregano oil, using, really, a blend that I love, it’s called [gamma 00:31:35] oil, which it has olive oil, has a lot of turmeric, it has garlic, it has basil. It’s like this incredible combination of herbs. Really, herbs that have been studied for many, many decades out there in integrative medicine. I like using that. When it doesn’t work, then I will go to nystatin and start them on nystatin. Again, sometimes for three months, depending on the liver enzymes are good and everything points to that being a good thing for them, I’ll start them on nystatin and then scale back and put them on the natural ones.
Dr. Weitz: Now would that be concurrent with the antimicrobial SIBO treatment, or before or after?
Dr. De Mello: No, I usually do concurrently. I’ve spoken with a number of colleagues in the field, and people do it differently. Some people do it as part of the protocol. Some people do it after the protocol. I do it based on the symptoms of the patient. If the patient has symptoms that clearly indicate there is a candida element, some women with a lot of discharge, the coating on their tongues. I can also look at any rashes that they have that can become really beefy-red all of a sudden. There is the whole picture of candida that we can tell. Also, a lot of people who may have negative test for methane, which gives the foul smelling to our gas, even though they may have test negative for methane, there’s a lot of odor to their elimination, I will think of candida and I’ll say, “Let’s try to see if we can mediate that with a little bit of an approach to candida.”
Dr. Weitz: Some practitioners do an organic acids test. They feel that that’s a more accurate way to pick up candida overgrowth.
Dr. De Mello: Yeah, the OAT Test. We use the OAT test a lot, especially because of the pandemic, but I use that when I’m not really clear, there’s no signs, Ben, and I’m kind of like on the fence about it, the patient can afford. As you know, it’s an expensive test insurance doesn’t cover. Sometimes I ask myself, “Will the OAT test change my approach? If the answer is yes, then I will do the OAT test. In most cases, it’s no, it’s not. The patient clearly has a symptom, and maybe a lab will show but maybe not so, “Let me try this kind of litmus test,” even for 30 days, and see how the patient respond.
The thing that I also think it’s missing in our field out there is trying to, once the patient starts feeling better, is really looking at the person’s hormone metabolism and see, how are their hormones working for them? Is it time for us to think about hormonal replacement therapy? Because sometimes, fatigue and not really feeling, not being able to digest the food, a lot of the symptoms of SIBO, as we know, become enhanced or gets worse when our hormones metabolism in addition to SIBO, of course, is not balanced.
Dr. Weitz: How do you prefer to test for hormones?
Dr. De Mello: Well, we blood test. It’s our go-to approach. For women, if they’re still menstruating, we try to do it between day 17 to 22 during the luteal phase. For men, we do it whenever he has the time to come in. I think a blood test is the best way to go. Sometimes we’ll also use the DUTCH test for, to see if there’s anything else going on with that. We may even do a urine test to test through urine as well. I think, especially with COVID, there’s so much going on in terms of really being able to get to a treatment that works for patients to patients as soon as possible, that I think the blood test offers the best and quickest approach to assessing hormone metabolism.
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Dr. Weitz: One more question on SIBO. Does your approach differ if the patient has hydrogen, versus methane, versus hydrogen sulfide SIBO?
Dr. De Mello: You know what? That’s a question that I was asked about a week ago also by another- [crosstalk 00:37:56]
Dr. Weitz: Oh, really?
Dr. De Mello: Yeah. For me, it really doesn’t because I have found that, in the years that I’ve been doing this, that the most people will have a hybrid of those two gases together. One may be more dominant than the other, and I equate this to looking at people’s hormone. A woman may be estrogen-dominant versus not, but the approach to treating their hormone balance will change, but not drastically. We’ll just have to pay attention to that other part. When it comes to SIBO, because it is so difficult to pinpoint a precise diagnosis, I will focus on what the lab is saying, methane-dominant, hydrogen-dominant, but I will actually, when I develop a treatment, I will treat both.
Dr. Weitz: Okay. Since your background in psychology makes you, in many ways, a unique practitioner, if you determine that in a given patient with bloating and other gut symptoms that mental and emotional issues are playing a significant role, and this question is probably more for functional medicine practitioners, what sorts of tools or strategies, other than simply referring a patient to a counselor, can functional medicine practitioners do when they’re treating a patient for gastrointestinal symptoms that have a significant mental or emotional component?
Dr. De Mello: Excellent question. I know how busy most of us are, especially with the pandemic, but the number one thing that I would suggest that we do is to listen, to listen to the patient, to listen to our own judgment that we may have. We all have it. The question is, how much? Is it a judgment? Is it a discernment? I think, listening to our patients, relating to the patient. Taking a step back and say, “How would my life be affected if I were that patient right now with SIBO, with not feeling good, having to take care of the kids, not feeling sexy. Feeling that, ‘No matter what I do, I failed”? Because a lot of patients come in with a multitude of steps they’ve taken before that either worked for a little bit and stopped or never worked. The first thing that I check, and I do a self-assessment is, “Can I leave my judgment out the door, and can I be here with this patient, no matter what he looks like, what she looks like, what my feelings might be? Let me listen,” so listening to the patient and putting yourself in their shoes, I think, is the best step, the first step. The second step, and a very excellent question, Ben, is to say, “What is the purpose of this condition right now in this person’s life?” Not to say that I believe that people can sit down and basically muscle themselves into a condition, all the time. That is possible. It’s not common. What’s common is that people come in with a condition that relates to a particular incident in their lives or particular situation. My job is to try to connect the dots with them, without depowering them, by not saying, by not letting them for one second think that I’m implying that it’s all in their heads. It’s not. Even when I don’t know why and it doesn’t meet my scientific evidence, I still want to let the patient know that I believe what she’s saying or that what he’s saying. The second step, for me, is to try to see what the connecting dots is.
About three weeks ago, I had a female patient who came in, very, very bloated. She had been to some of LA’s great doctors, some of whom are really good friends of mine and have actually become people that I look up to when I have questions. She felt very deflated. She felt that nobody was listening. She felt that everybody, the main question that people are asking her is, “Are you pregnant?” The book talks about a case, to use the book, it talks about a case like that. It became very interesting, quickly after that. She’s a single woman. Her clock is ticking and she’s not pregnant. The question is, I had to be very careful in navigating is, “Would you like to have a baby?” The answer was, “Yes,” and so there’s this really discomfort in her psyche, this duality of her feeling really upset that people are assuming that she’s pregnant, but actually there’s a part of her that goes, “Oh, this is what I would look like if I were pregnant,” so we had to talk about that. We had to talk about this discord. If she is feeling upset about it, there’s a part of her that actually likes when she looks in the mirror and she sees her belly protruding out. Really helping her understand that those two things are not jiving in her psyche, that we need to go in and make peace with it, so that’s one case.
As we know, disease can have secondary gains. For her, the secondary gain was that she really wanted to get better, but she actually was dubious about the fact that, or was curious about the fact that she looked pregnant. Sometimes it’s like the feeling, so what is the secondary gain? A guy who is not happy at home, who doesn’t feel connected with his wife, who has a protruding belly. Is this an excuse for him not to be intimate? Is that another excuse? Let’s talk about that. We talk about SIBO. We do everything in the protocol, but let’s talk about what else is under the hood. This is if the patient wants to or is ready to talk about that. I think exploring who the patient is, connecting with the patient, asking questions. “If bloating had a message for you,” I ask them … “This is going to sound weird,” I tell them. “It’s going to sound really weird, but if bloating had a message for you, what would the message be?” They kind of go, “What?” I say, “Sometimes, disease can have a message for us. If bloating could whisper something to you about why it’s there, what would it whisper?” Right?
Dr. Weitz: Right.
Dr. De Mello: Really looking at those pieces, I think it’s important. I understand that a lot of us don’t have the time to do that, so there were times that I didn’t have the time during the pandemic, the height of the epidemic in California that I had to see people for shorter amount of time, but I would pose those questions via email to them and say, “Okay. Here are the questions. Here’s what we found out. Here’s your treatment. Here’s the questions that I’d like for you to answer,” and so I would pose those questions. Some people, the posed questioning, writing was more comfortable than being asked right in the session.
Dr. Weitz: Right. Interesting.
Dr. De Mello: Did that answer your question?
Dr. Weitz: Yeah, absolutely. You’re an excellent writer and one of the things that makes your book very readable is the stories that you weave in-between, and really makes your book very human and not just like a medical textbook.
Dr. De Mello: Yes. Thank you, Ben. I had to really think about, how do I want to write it? What do I do to write a book about a topic that is so uncomfortable? Who talks about poop? We have a culture where that is a taboo. We don’t talk about it. When I ask my patients, “What does your poop look like? What is the texture?” I have to make a joke before we do that because otherwise, people feel a little embarrassed or a little funny, so I wanted-
Dr. Weitz: I noticed you put in the first chapter that research shows that humans fart 14 times a day.
Dr. De Mello: They do. It’s normal. They’re not the silent killers that we hear on an airplane, or that when we sit next to somebody on the airplane, we want to dash out the door. It happens. What I wanted to do, I wanted to make people with this condition understand that they’re not alone, and understand that it’s something that happens more often than they know, and that it’s just a matter of it exists in a spectrum. There are people who are really, really bloated beyond explanation, that we haven’t been able to move the dial, and those are people with severe gastrointestinal dysbiosis, SIBO, and there are people who have bloating occasionally. They eat something, they don’t feel good. They notice that, again, the jeans are not closing, but bloating is a condition that is an equal opportunity condition. It doesn’t discriminate. Whatever your socioeconomic background is, your ethnic background, your age, bloating is there. I see kids who are bloated. I see elderly who are bloated, so the two spectrums of the population.
What I think the book brought, where the book was successful is that it told people stories. Why do we go to the movies? We want to hear stories. Why do we read novels? We want to hear stories. Why we watch TV shows, especially during the pandemic? Why is Netflix now a multi-billion company? Because we want to hear stories that we can relate to, and that was my goal in the book. It was to create a sort of a manual, where people could go through. Basic to a lot of people who have already done this, but really important to people who have no idea where to start. I wanted to offer them some of those guidelines, while also telling them, “Look, let me tell you some stories that you may relate to,” and I had some good laughs during it, so …
Dr. Weitz: Do you know what? I just want to throw in one more question. I know we only have about three minutes left, and it might not be enough time to answer this, but we didn’t bring up probiotics. I’m sure that’s a question a lot of people would want to know. Some practitioners I’ve spoken to don’t believe in using probiotics because if there’s bacterial overgrowth, “Let’s not throw more in.” Some practitioners feel that probiotics are actually the first thing you should do, the primary intervention. Other practitioners do like to use certain probiotics along the way because as we’re killing the bad bacteria, we want to replace them with the good bacteria. What’s your feeling about the use of probiotics while treating patients for conditions like SIBO?
Dr. De Mello: Yeah, all of the above. Very simple.
Dr. Weitz: Spoken like a true politician.
Dr. De Mello: Yeah, I know, I know. Again, Ben, who is the patient and what is the symptom? Where does the symptom fall within the spectrum? What I will usually do with probiotics, I will get a history of whether or not probiotics have helped them. Most of the patients will have taken probiotics because their friends told them to, or another doctor told them to, so get a history. Has probiotic made it worse, made it better, or no difference? If, certainly, has made it worse, I’m not going to use it.
Dr. Weitz: Of course.
Dr. De Mello: If it has made it better, I will say, “Let’s do this. Let’s do one week, two weeks with the probiotics and two weeks without and see where you stand, where your body stand.” If it’s neutral, then I will do the same thing. I will start two weeks on and then stop for two weeks and see what happens. I think where I’ve made mistakes before, and I think some of my colleagues out there can relate, is when we try to put everybody on the same protocol like a pigeonhole. The way I explain this when I speak is that, look, there’s eight billion of us on the planet and there’s eight billion fingerprints, so we cannot be treated the same. We have to be treated as unique individuals. That’s what I try to do, so that’s why I said, “All of the above,” because it depends on who the patient is, and I think probiotic is one of the most important approaches that we can use in trying to optimize the microbiome.
Dr. Weitz: That’s great, Dr. De Mello. Thank you so much for joining us. How can listeners and viewers find out about getting your book, and find about seeing you, or coming to your clinic, or doing consults with you or your colleagues?
Dr. De Mello: Thank you. The website is akashacenter.com. It’s A-K-A-S-H-A, akashacenter.com. You’re going to have a list of services and programs that we offer. The book, there’s its own landing page. It’s called bloatedbook.com. Just bloatedbook.com. You can also go to Amazon. It’s on Amazon, it’s on Barnes & Noble and Apple. On Amazon, you can just say, “Bloated by Dr. Edison De Mello” and it gives you an option of what kind of format you want, Kindle or paperback.
Dr. Weitz: Excellent.
Dr. De Mello: Yeah.
Dr. Weitz: Thank you so much, Dr. De Mello.
Dr. De Mello: Thank you for having me, Ben. I appreciate this hour with you.
Dr. Weitz: It’s been a pleasure.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple Podcasts and give us a five-star ratings and review. That way, more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition clinic. If you’re interested, please call my office, 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you, and see you next week.
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