Listener Questions – Probiotics, Anxiety, Libido, Protein Powders, SIBO, Reflux

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Listener Questions – Probiotics, Anxiety, Libido, Protein Powders, SIBO, Reflux

Answering your questions about gut symptoms, treatments, and hormone imbalance.

Dr. Michael Ruscio:     Hi everyone, welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio, DC, joined by Erin Ryan as usual for our listener question episode. We’re going to jump in on listener questions in just one second. I did want to share one or two interesting things that I’ve been writing about in our clinician’s newsletter that I think are worth mentioning.

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Management of IBS and Chronic Idiopathic Constipation

Key Takeaways

[Back to Top]

  • Probiotics appeared to be a more efficacious or effective therapy for IBS than Rifaximin
  • If you are doing other things to improve the health of your gut (diet, sleep, lowering stress, antimicrobials, enzymes etc.), then there is a much better chance that you will see resolution with probiotics
  • Rifaximin has a 0% likelihood of adverse events and probiotics have a 3% chance

The first is from the American College of Gastroenterology. It’s a paper from 2014 so it’s a little bit old, but what’s novel about this paper, what’s important about this paper is it provides the most up to date comparison for treatment effect between Rifaximin and probiotics for IBS. Now they compare the effectiveness of these treatments through a measure known as number needed to treat or NNT. It’s important for us to keep in mind that we want to, in a research setting, convert “I’m feeling better” into a numeric score so that we can compare between different studies the amplitude of “I’m feeling better” and that is, in part, what the number needed to treat is attempting to do. Specifically, the number needed to treat is how many patients need to be given a particular therapy before one of them will have a response.

So this paper entitled American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation [1] was published in the American Journal of Gastroenterology in 2014 and they made a few conclusions. The bottom line is the probiotic number needed to treat is seven and the Rifaximin number you get to treat was nine. So what that means is for every seven patients, you’ll have one that responds favorably to probiotics and every nine patients you’ll have one that responds favorably to Rifaximin. Said more simply, probiotics appeared to be a more efficacious or effective therapy for IBS than does Rifaximin.

I share this for, as you can imagine, a number of reasons. One, there are some gastroenterologists that I think have an off the mark non-evidence guided narrative regarding probiotics. Not to say that they’re wrong, but I’d like to see some of the integrative conventional gastroenterologists be a bit better about recommending probiotics. Not to say that they don’t, but it seems that in their practice model, probiotics are kind of an “if you want to do it on your own” kind of thing, thankfully some patients are smart enough to figure that out.

Other patients aren’t and they say, well, you’re the expert, you’re the doctor. Can you give me a little bit of assistance here in terms of how to find a good probiotic, what to use, what dose, what have you, which it also turns out, looking at, in this case, 23 high-quality clinical trials that were used to calculate this number needed to treat, different doses and types of probiotics for used, which establishes another premise that we’ve talked about before, which is there is no ideal, perfect or optimal probiotic for IBS.

Quality, yes, is important, so you wanted to make sure you go through the appropriate quality assurance measures, but there’s no special specific SIBO or IBS probiotic. Rifaximin came in with a number needed to treat of nine. Now if you’re saying to yourself, boy, so that means seven people are treated and only one responds favorably, yes. That’s what the evidence shows. Now does that mean you have a one in seven chance of responding to probiotics? In my opinion, no, but there’s one contextual piece that’s very important to keep in mind, which is if you create a multifaceted care plan for an individual, diet, probiotics, potentially enzymes if they may indicate they need enzymes or hydrochloric acid, potentially herbal antimicrobials, consideration of a trial on an elemental diet, now you have a much higher probability that you’re going to see the response that you’re looking to see. That’s why it’s important not to have a mono therapeutic approach, meaning we only do one thing.

That same applies to Rifaximin. It’s not to assume that you have a only one in nine chance with Rifaximin. Now, if you’re someone who’s drinking soda, smoking, not exercising, and then you go in and the one thing you do is Rifaximin, the data tells us that you have a one in nine chance with Rifaximin and if you’re doing that same thing, one in seven chance with probiotics. However, again, importantly, if you are doing other things and finding multiple inputs to improve the health of your gut, then in my estimation you have a better than a one in two chance. You have a better than a 50-50, in my mind you have about an 80 to 90% chance that you will see a resolution.

I wanted to put this out there just so people have another evidence point in case their doctor’s telling them don’t use probiotics, whether that doctor would be a conventional gastroenterologist or a naturopath or chiropractor or whatever. Also, adverse events, this is one of the things that some of the resistance to probiotics camp will proclaim as their main gripe, the adverse events on probiotics was 16% as compared to placebo, which was 13% so if you subtract probiotics from the placebo, you have about a 3% adverse events. Which is pretty darn great in my opinion, which again, supports that reactions are minimal. Rifaximin actually had no difference in adverse events when compared to placebo. So Rifaximin, we can say, has a 0% likelihood of adverse events and probiotics have a 3% chance. So what that tells me is they both have a pretty darn low incident of adverse events, but you may have some occur with the probiotics. Those were the main couple of findings there that I wanted to share. That will be written up in detail for our Future of Functional Medicine Review clinical newsletter.

Effects of Regulating Intestinal Microbiota on Anxiety Symptoms

Key Takeaways

[Back to Top]

  • Overall microbiota modulating therapies, most namely low-FODMAP and probiotics collectively had an efficacy of 86% for lowering anxiety
  • There doesn’t seem to be a negative to long term probiotic use
  • Probiotics may have a modest impact on lowering blood pressure, on lowering cholesterol, on improving sleep, on potentially reducing joint pain, lowering inflammation, reducing leaky gut, and encouraging balance in the intestinal microbiota.

Also, a quick mention here, a paper published in the Journal of General Psychiatry, 2019, entitled Effects of Regulating Intestinal Microbiota on Anxiety Symptoms: A Systematic Review[2], and they essentially concluded, let me start with their conclusion. I think this is the most moving. Okay, well sorry, let me give you a few select citations. Essentially, they found that 80% of the studies essentially using diet to modulate the intestinal microbiota, namely the low FODMAP diet, 80% of these studies were effective for anxiety and 45% of the studies using probiotics were effective for anxiety. So when they sum this all up through another method of analysis, they concluded overall microbiota modulating therapies, most namely low FODMAP and probiotics collectively had an efficacy of 86% for anxiety.

So this establishes the importance of the gut-brain connection and it also counters something that we had talked about recently, Erin, which is this question about one finding that probiotics may potentiate brain fog, and we discussed a number of reasons why I disagreed with that study. I think it’s interesting research and important research to be done and people should be asking those questions and trying to prove that probiotics are bad because if there is harm that can be done by probiotics, we want to document that. But unfortunately what happens is we have literal systematic reviews. In this case, looking at 21 studies that were high-quality trials and this is being overlooked at the expense of one interesting study in 15 odd patients, or some small sample size of that sort.

So I just present this as an important juxtaposition to the media sound byte that was interesting. Could probiotics be causing your brain fog? It’s possible, it seems to be a very, very low probability and in this case the efficacy of either diet or probiotics for anxiety, which is not brain fog but it’s related to it, was 86%.

So just a couple tidbits there that I wanted to share that I thought were interesting. Again, this is being written up with all the summaries, the quotes, the references and the clinical recommendations in our Future of Functional Medicine Review clinician’s newsletter, but just wanted to kind of kick us off with those few tidbits. Erin, any comments on any of that?

Erin Ryan:  The only thing I’d say is that mirrors pretty perfectly my own experience. The second study that you mentioned about the anxiety is, I mean, you’re experiencing so much anxiety just from feeling sick and then on top of that, this issue is causing me anxiety. So now that I’m out of it, anytime I sort of have some symptoms come back, if I notice that I’m feeling more anxious in life, now that is a red flag for me. Whereas in the past, I kind of blamed that on, oh, I was born with anxiety, I guess. So now it’s not just, oh my gut is bloated or I don’t feel so good, if I’m starting to feel really anxious I look at how much histamine I’m eating because I have histamine issues. Yeah, that’s really kind of incredible, and the first study actually, that that rings true for me too because I took Rifaximin as sort of a first action to the SIBO that I was dealing with and it was really short-lived and probiotics, I have not stopped since you and I have been working together and I feel great.

DrMR:  That’s good, which is another very good and important point. We can keep someone on probiotics for a long time. There doesn’t seem to be any negative to longterm use, at least not that’s been identified, especially when considering that probiotics may have a modest impact on lowering blood pressure, on lowering cholesterol, on improving sleep, on potentially reducing joint pain, lowering inflammation, reducing leaky gut, encouraging balance in the intestinal microbiota. So you know, it’s really my opinion it’s a travesty that there seems to be this resistance to probiotics, in some pockets, there are clearly many people who get it and use probiotics.

I guess I just am trying to over-correct for the fact that a patient will come in having had struggled with gut health for one year, two years because they were told by their naturopath, by their functional medicine, gastro, whoever, you better avoid probiotics cause you had that one SIBO breath test positive from three years ago. We put them on probiotics and in three months they’re seeing improvements they haven’t seen in two to three years. So I’d love for that not to occur. So that’s why I’m trying to, I guess, beat this message really into our audience here. So I apologize if it’s a bit of a dead horse here, but you know, important stuff to mention nonetheless.

ER:   Yeah, I agree.

Sponsored Resources

DrMR: Hi everyone. I am very excited to announce we have two new versions of our Elemental Heal available. Elemental Heal in case you haven’t heard of it, is our great-tasting meal replacement, hypoallergenic gut-healing formula. We now have two new versions: One is low carb and the other is a fully elemental whey free and dairy free formula, and they both taste great. The really nice thing about these is they are the only of their kind available on the market. Including the fact that they don’t require a doctor’s note in order to use them.

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Listener Questions – Probiotics, Anxiety, Libido, Protein Powders, SIBO, Reflux - Elemental Heal LC New M

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Should You Eat Higher Carb While Treating SIBO

Key Takeaways

[Back to Top]

  • If a patient’s symptoms are mild to moderate then it might make sense to use a prebiotic during SIBO treatment but often times adverse events occur with prebiotic use
  • You don’t really gain anything noticeable clinically by using a prebiotic at the same time that you use an antibiotic or herbal antimicrobials

DrMR:  All right, and what do we have for questions?

ER:   All right, so we’ll take our first question from Ryan. He says many functional medicine professionals suggest eating higher carb / FODMAP foods during the treatment phase for SIBO in order to ultimately draw out bacteria, which makes the therapy more effective. Can you speak to this theory?

DrMR:  I think it’s a reasonable theory and it’s one that I think Pimentel has worked on and there have been a couple of studies showing better improvements in SIBO treatment when, most namely, hydrolyzed guar gum was co-administered with Rifaximin. There’s also evidence showing that any type of prebiotic can actually help IBS. The challenge there is there’s also a decent amount of adverse events, so you have to be a little bit careful. It’s not to say never use a prebiotic, but because it appears that the more sensitive and the more reactive a person is, the more likely a prebiotic will flare them, I don’t like using a prebiotic out of the gate. Some do and in some cases, I will, if the patient’s symptoms are mild to moderate, but if they’re more toward the severe end of the spectrum, I will wait.

Now directly to the question. My thinking is you don’t really gain anything noticeable clinically by using a prebiotic at the same time that you use an antibiotic or herbal antimicrobials. Now that’s my clinical sense, I am happy to be proven wrong on that if quality data substantiate that, but right now we have only one or two, I believe, studies even documenting that and what we don’t have is data showing someone’s symptoms get appreciably better if they add in the prebiotics along with the Rifaximin, let’s say, or along with their antibiotic or antimicrobial. Said more simply, two groups of patients, one does, let’s say an antibiotic, plus prebiotics. The other does just the antibiotic. A month later, my assumption is that their symptoms will be about the same. Perhaps there’s a statistically significant reduction in a SIBO breath retest in the group being given the prebiotic, but, this is a key but, it may be mathematically significant, but it may be clinically meaningless.

Just like I’ve discussed with a biofilm study that we’re publishing, we documented that anti-biofilm agents are actually better or they lead to better reductions in SIBO breath testing, but the impact didn’t seem to be clinically meaningful and didn’t seem to be worth the additional expense for the patient. It’s important that we don’t take a seven-point additional drop on someone’s SIBO breath test to mean, and this is a vastly more effective therapeutic offering, especially when we weigh that against the fact that you may increase the risk of flaring a person symptomatically.

So for all those reasons, essentially I question if it’s anything more than a minor impact and it may significantly increase the risk of a reaction, it doesn’t seem to be a tenable recommendation. Now again, there’s a little bit of nuance there where the less reactive the patient is, I think the more they’re able to tolerate and benefit from a prebiotic, so you can make the argument that if you want to be robust and your symptoms are mild, then sure, add in the prebiotic, but I don’t think it has a huge impact really one way or the other, so I don’t think it makes a big difference.

Is HIIT Training Causing My Low Libido?

Key Takeaways

[Back to Top]

  • Going too low carb or fasting while also doing High Intensity Interval Training can affect libido
  • In times of prolonged stress, the body can not meet its optimal hormonal output targets, so it makes a priority decision to produce the stress hormones at the expense of the steroid hormones
  • Gaintaining – eat as much as you can without gaining weight

ER:   Okay. This next question is from Jeff. It’s a question about libido and gut health, which I don’t feel like we hear from a lot of men on this topic and I thought it was a really good one, so it’s a little bit about a longer question. It’s about two minutes, but I think it’s worth it because there’s probably a lot of people that have the same question.

DrMR:  Sure.

Jeff:   Hi, Dr. Ruscio. Thanks for everything you do. I have a question regarding high-intensity interval training in a fasted state and loss of libido. Something you alluded to way back when, and I wondered if you could elaborate on that. I have lost my libido doing high-intensity interval training in a fasted state for a couple of years and wondering if that could be the cause of it. I also have hydrogen dominant SIBO which I haven’t been able to clear for several years as well, so I’m just wondering if SIBO could lead to no libido and or high-intensity interval training in a fasted state.

Some background. I am a 55-year-old white male, very healthy, been exercising my whole life. When I hit 50 things started going south, even though eating fruits and vegetables and paying attention to my health and still haven’t been able to recover, getting rid of the SIBO or getting my libido back. So wondering if you could shed some light on that and just give you a couple of numbers, a little more information. My early morning free T was tested at 5.4 pg/ mL and a sex hormone-binding globulin was tested at 102.5 nmol/L, so these are both serum and it tells you that a very low free T and very high sex hormone-binding globulin. So wondering if you could shed some light on this. Thank you very much.

DrMR:  All right, great question. Said simply, it sounds to me like you’re putting your body under too much stress from the HIIT training in a fasted state and you are likely putting your body into a stress response and forcing your body to prioritize stress hormone production over steroid hormone production. There’s this concept from naturopathic medicine, I believe it was pioneered by Dr. Brian Timmins and it is labeled as Pregnenolone Steal. The first molecule in the steroid hormone synthesis pathway is the conversion of cholesterol into pregnenolone, and then from there, there’s a bit of a fork in the road where that precursor pregnenolone can be diverted.

Either one way toward the production of testosterone and estrogen because yes, men do have some estrogen in their system also, or the other fork in the road, cortisol and some of the other accompanying adrenal hormones like adrenaline and epinephrine and norepinephrine.

The theory is that in times of prolonged stress, the body can not meet its optimal hormonal output targets, so it makes a priority decision to produce the stress hormones at the expense of the steroid hormones. Now that’s the theory and that is the proposed mechanism for why people who are under too much stress seem to have suppression of their libido. The same thing happens with women and in women what you’ll see is they have problems with their cycle or that you can become amenorrheic, where they don’t cycle at all anymore. Now I see this more in women than I do in men, but the same underlying principle applies, which is oftentimes in women, you’re fasting too much, you’re eating too low carb and you might be training too much. Your body, globally, is under too much stress. So we have to start taking these stressors off of you. Even healthy stressors

Even the healthy stressor of being low carb or fasting or exercise, they have the upper limits for which you then start to have a negative response to them. Now I learned this the hard way. We’re really trying to optimize for body composition and growth hormone production, exercising in a fasting state. There’s this funny, I guess it’s a moniker really, for the approach that Ben House and Mike Nelson advocate, who are two exercise-focused PhDs who’ve been on the podcast in the past, they call it gaintaining, right? So eat as much as you can without gaining weight. Now this counters much of what you’re hearing from the fasting camp, which is fast, go low calorie. These both have a time and a place, but performance and longevity may be toward different ends of a spectrum where eating low calorie, fasting, potentially eating low carb, I’m not fully sold on the low carb piece, but those may be better for longevity, but they may not be better for performance.

So you may have positioned your dial too far toward longevity and now your performance is starting to suffer. So as an experiment, try going to the opposite end of the spectrum and see what kind of response you have. I like going to the opposite end of the spectrum because it’ll make the effect more apparent. Reduce your fasting. I’m not sure how often you’re fasting, but if you’re doing this daily then that’s definitely way too much in my opinion. So if you’re doing it daily, try to cut it back to one or two days per week. Up your carbs a bit, up your calories a bit. Well obviously, for fast and last you’ll be upping your calories. Give that a few weeks and see what happens with your libido.

Stress is something that does impact libido, and again, fasting is a stressor, carbohydrate intake is a stressor, and then if you’re also exercising in that fasting state, your body’s already stressed by being in the fasting state, and now you’re doing high-intensity training.

So if you’re also doing low carb with this, this is kind of a perfect storm for crashing your system. So quite simply what is likely happening is your body is under too much healthy LL static load and now it’s having to reprioritize how it’s using its energy substrates or its hormonal substrates for stress hormones at the expense of steroid hormones because you’re not putting enough into the system to allow it to do it all adequately, and the sex hormone-binding globulin is likely a derivative of this same picture. Insulin is anabolic and insulin will lower sex hormone-binding globulin, and for the audience, this essentially gloms onto sex hormones in your bloodstream and does not release them.

So if this sex hormone-binding globulin is too high, you have hormones in your system but they can’t get into the system. It’s like being in a gas station, there’s a bunch of gas, but you can’t get it liberated from the gas pump and into your car where it needs to be used. So having gas but being unable to access it, having hormone, but that hormone is bound to this sex hormone-binding globulin, in a sense deactivates your hormone. So that could be why the free testosterone is low. Too much stress, too low calorie, too low carb. All those are catabolic. Sex hormone-binding globulin goes up and some of these hormones go down. That’s also what’s compounded by the production of the hormones I was talking about via that pregnenolone steal mechanism.

Now if you eat a bit more, if you fast a bit less and you increase your carbs, that will improve things from the top of the fork there at the pregnenolone steal and the sexual hormone-binding globulins to go down plus releasing more of your free hormone into the bloodstream, thus hitting this both from the start of the synthesis cascade and then also essentially at the receptor sites. So this one is not very hard and those things should have a pretty sizable impact.

Regarding the SIBO, just a breath test result in isolation, to me, is very hard to interpret. It sounds like there are not any gastrointestinal symptoms, so if there’s not, I wouldn’t be too concerned about the SIBO. Now that’s not to say that you couldn’t have SIBO that’s only manifesting as other symptoms, but in your case, if the main complaint is libido, then looking at the context here, the most likely thing driving that complaint is the presumed low carb combined with fasting. So a bit low calorie with the high-intensity training. That is the most likely factor driving this. The SIBO might be a bit of a red herring unless you have other symptoms that would not be related to this imbalance. If you were having, let’s say skin rashing, that’s one symptom that’s not driven by being overly stressed.

Symptoms that are driven by being overly stressed, problems with sleeping, potentially muscle pulls and joint pain, problems with cognition or focus or energy during the day are some of the main symptoms you’ll see manifest as a byproduct of your system being under too much stress. So those are some things to think about.

The first thing I would do, change those factors to get yourself out of this presumed chronic stress response. Give that a few weeks, see what happens with your libido and then try to find the optimal balance in terms of, okay, you want to do a little bit more fasting over time, play with it and find your sweet spot. Right now it sounds to me like you have missed the mark, you have overshot and now we have to bring you a bit more back to center.

ER:   Okay, that was a great explanation. I could really see everything going in the body how you were explaining it. I bet that’s probably pretty common, and I bet a lot of men rush to go find pills to try to make that turnaround and it’s probably just a simple lifestyle change.

DrMR:  That’s one of the tough things about health care recommendations is that they can be misapplied, right? I mean, it’s easy for me to say it’s easy, but that’s because I’ve been doing this all day for now about 13 years. So you know, on the first day in practice I didn’t have this figured out. So even for someone who’s trained as a clinician, it can take years of observation and you start to see a certain type of person come in. What’s your complaint? I have brain fog, I have low libido, I don’t sleep that well. What is their diet history look like? I’m doing KETO, I’m doing intermittent fasting. What does their training look like? I’m doing CrossFit.

So you see enough of these and you go, hmm, there seems to be a clear pattern here, and then you start making recommendations. Let’s stop fasting so much, let’s get off KETO, let’s bring down the exercise a little bit, and you see that work a number of times and that reinforces that the observation and the trend that you saw was causal and it’s easy to kind of pick this out. Yeah, I mean it takes a while to figure out how to optimally dial all these things in. So give that a try and let us know how it goes.

How to Find a Protein Powder That Doesn’t Cause Gut Symptoms?

Key Takeaways

[Back to Top]

Find a protein powder that is not putting fillers, agitating sweeteners, and excipients in the product

Protein powders to consider:

  • Anthony Gustin at Perfect Keto
  • Legion Athletics, which is Mike Matthews’ company
  • Try some of their protein powders in addition to the Elemental Heal
  • Our Elemental Heal does not contain lactose, does not contain casein. It’s about as close to being dairy free as possible in terms of the common allergens in dairy.

ER:  Okay, good luck Jeff. Okay, next question is from Robin. Every type of protein powder I’ve ever tried has given me stomach troubles. Any idea what causes that and should I power through to see if my gut gets used to it or give up trying? Also, do you think that it could be an issue with Elemental Heal for people who struggle to digest protein powders?

DrMR:  Great question and I’ve had the same thing with some protein powders myself. What I found and what I would think is true in the majority of the cases, you need to find a protein powder that is not putting fillers and potentially agitating sweeteners in there and also potentially excipients. Although I believe the amount of excipients in powders is minimal, although I could be mistaken in that, but I’m trying to get even more granular in my understanding of exactly how much excipients go into powders. Is it a one powder formula? Is it a multi powder formula? Is it a pill formula? But in any case, the quality in the cleanliness or the purity of the formula is probably the most likely culprit. Second, to that could be the form. You might have an issue with whey, you might have an issue with, let’s say you’re doing a beef protein or an egg protein…

DrMR:  So yes you want to try to find a few different clean sources of protein powders and then try those, kind of in isolation and see where you have tolerance. Likely it’s not very often that you see someone who truly has a problem with whey protein. The number of people who, say, have a problem with dairy and they don’t want to use Elemental Heal because it has whey in it, and then I convinced them to try it and they feel great, is staggering. There’s a difference between whey and dairy. Our Elemental Heal does not contain lactose, does not contain casein. It’s about as close to being dairy-free as possible in terms of the common allergens in dairy.

But there’s a decent amount of whey proteins on the market that aren’t lactose-free. They might also have the casein protein in there as a filler and they may have some kind of other sweetener in there that’s agitating. So that’s why I shake my head sometimes and I was like, ah, not all whey protein are the same.

I’ve personally felt that where I’ve shared on the podcast before, I was saying, why am I getting bloating after every workout? Then I changed my protein powder and the bloating went away. So find a good formula and try it, it’s not a guarantee, but it’s certainly worth trying to see if there are some quality and or filler issues that are causing a reaction. Elemental Heal is definitely something to try. We, depending on when this podcast airs, we’ll have or will soon be releasing both low carb and a whey-free if you wanted to try a formula that was either lower in carb or instead of using whey, use an amino acid powder.

I think you have a pretty good likelihood if you’re using a clean formula that you will not have a reaction. So find some quality formulas our Elemental Heals are a great place to start. I know Anthony Gustin over at Perfect Keto also has a few protein powders and you may want to look at Legion Athletics, which is Mike Matthews company and try some of their protein powders in addition to the Elemental Heal, depending on exactly what you’re looking for because, of course, Elemental Heal has other stuff in it. So if you’re looking for just a pure protein, then you may want to try just a pure protein, do some experimentation, and I think you have a good likelihood that you will find a couple of formulas that are actually tolerant. So give that a shot and let us know how it goes.

ER:  Yeah, and if it’s any consolation I’ve gone through, I think all of them myself and landed on collagen protein. So it’s not as easy because you don’t just scoop that and go, you kind of have to make your shake and then add the collagen protein, but that seemed to work for me, and I had that same issue with pretty much every protein powder out there that I tried.

Can I Take Iberogast Instead of Zantac with a Peptic Ulcer?

Key Takeaways

[Back to Top]

  • There is good evidence that supports Iberogast can help with reflux
  • If you are someone with ulcers it is VERY important to continue treatment of the ulcers while you also work on treating the underlying cause.

How do you treat the underlying cause?

  • Low FODMAP diet is definitely something to consider
  • Elemental Heal can be used along with Iberogast
  • Gut Rebuild Nutrients or any like formula will help to heal the lining of the stomach
  • One study found that the ulceration and damage that can be caused by using things like Advil can actually be countered by using probiotics

ER:  Okay, let’s see. Yeah, we’ve got a question about Iberogast, so here we go.

Speaker 4:  So I have a question about the Iberogast, I was interested in using it because I wanted to stop the Zantac I was using and when I got it, it said that you should consult your health care practitioner before using it if you have a peptic ulcer. So I do have an ulcer and I have the acid reflux and so I’m trying to figure out what to do, and can you also use it if you’re taking the Elemental Diet or you’re starting the fast? Thank you, God bless you.

DrMR:  Oh, thank you. I believe the reason why this is listed on the label, the “consult your doctor before using if you have an ulcer”, is mainly just a liability shield than it is anything else. I’ve read almost every study on Iberogast and I’ve never seen any reason that either Iberogast would cause any problem with ulcers, but, and this an important but, it ties into kind of a med-legal issue. If you have an ulcer and you’re taking Iberogast and Iberogast is helping to prevent the reflux but not treat the ulcer, then that could be a potentially very big oversight because ulcers can lead to tissue dysplasia and then cancer. So certainly you don’t want to leave an ulcer unfettered and that can also lead to chronic bleeding and then therefore anemias.

DrMR:  So it’s important to address the ulcer. It’s not to say, to my knowledge, there’s any reason that Iberogast would be harmful or counterproductive. You just wouldn’t want to stop following through on your ulcer care because you’re trying Iberogast and there’s pretty good evidence for Iberogast helping with reflux. So that’s where I think it has its best evidence and the evidence for acid-lowering medications in the treatment of ulcers is pretty good, 80 to 90% success rate with four to eight weeks of use. So I’m not going to be a purist and tell patients never to use a PPI because your body needs acid. Agreed, that is the correct gripe for a natural doctor to have or any doctor to have against acid-lowering therapy if the acid-lowering therapy is going to be used in perpetuity, but if it’s going to be used as part of a global plan, we’re going to change your diet, we’re going to try to address the underlying cause and we’re going to use a PPI to temporarily, one to two months, lower your stomach acid to facilitate healing of your stomach lining, I have no problem with it at all.

Now to the point of how do you treat the underlying cause, low FODMAP diet, definitely something to consider. Elemental Heal, also another thing to consider and that can be used along with Iberogast. Elemental Heal and Iberogast, fine. Use them at the same time, no problem at all.

Our Gut Rebuild Nutrients or any like formula that will help to heal the lining of the stomach and also probiotics. In fact in one study found that the ulceration and damage that can be caused by using things like Advil can actually be countered by using probiotics.


ER: Oh, wow.

So those things all used together can be quite helpful and ideally what you would do is treat the symptoms, so to speak, with the Zantac or a similar agent while also going to work to address the underlying cause of the ulcer, which is likely a combination of a number of things. Of course, if you’re using chronically things like Advil or Tylenol or ibuprofen, you want to stop doing that. If you have a chronic joint pain issue, then you may want to try to figure out where that’s coming from and address that because I know it’s something that’s easier said than done to stop using a pain medication, but we want to take those steps and then do the work in the gut to try to resolve what’s driving presumably high acid, which is eroding the lining of your stomach, which is causing the ulcer. Now, low FODMAP may be able to reduce histamine levels.

There’s recently been an article written challenging this and the degree to which a low-FODMAP diet lowers histamine, perhaps is debatable, it seems reasonable, and we also know that a low FODMAP diet can help with GERD or reflux. So the clinical endpoint we’re trying to get to, which is a reduction of the syndrome, the reflux, can be achieved by a low FODMAP diet, as can, as we talked about a moment ago, probiotics help to attenuate damage done to the lining of the stomach and the small intestine, and then we can supercharge that with something like glutamine, which has been shown to help with healing and that all can congeal into a really good care plan.

So you’re using some conventional medicine, you’re using some functional medicine and that should be a fairly effective approach for your ulcer. So you know, I think hopefully now you have what you need to get over the hump here and you should be able to do quite well with this approach. I’d recommend if you need feedback, have a good doctor on each side to help steer you, but those are the general items on the board, and by applying those I think you have a very good probability of success. I see lately, actually, a lot of reflux and it responds really well to the exact therapies that we talk about every day here on the podcast.

Episode Wrap-Up

ER:  Great. I think that’s all we have time for this episode, but we’ve got some good questions saved for next time.

DrMR:  Sweet. Well, thank you guys for the questions, as always keep them coming. It’s admittedly easy for me, not really much prep time that’s required but they’re great questions because these are things that, when I’m in the clinic, I’m dealing with on a one on one basis. So it’s always nice to be able to share this with a broader audience to help you find your way through all these different, I’m fasting, I’m doing high-intensity training and my libido’s low, what does that mean? I also have SIBO, is that tying in or I have reflux and I’m using Zantac and should I come off the Zantac? I understand that it’s hard to know how to apply these therapies. Healthy Gut, Healthy You gives you that overarching roadmap, but if we can answer some specific questions here to further enlighten the audience, then I’m always happy to do it. So thank you guys as always. And please keep the questions coming. Erin, did you have anything you want to add here as we sign off?

ER:  Nope, just that, oh, the new website looks amazing.

DrMR:  Oh yeah, if you guys haven’t checked it out, we have a new website. I don’t love it because there’s a big picture of me on the home page.

ER:  It looks great.

DrMR:  Our consultants wanted to do it and I was like, ah, okay I’ll do this. So just for the audience, it was not of my doing or design, but thank you Erin. I’m glad it doesn’t look as goofy as I feel that it looks.

ER:  No, it’s great.

DrMR:  But from a functionality perspective, I think it’s much easier to navigate and get around and we’re working on kind of putting the most helpful content, the questions that we get the most. We’re trying to make sure the content answers those questions is kind of front and center in the navigation menus and also for the store items they make it much easier for you to find what you’re looking for. So thank you Erin, and yeah, we do have a new website up and hopefully, it makes it a little easier for you guys to find what you’re looking for.

ER:  Yeah, yeah. I love the user experience of it. It’s great.

DrMR:  Cool. Thanks everyone. We will talk to you next time.

ER:  All right.

➕ References

[1]  2014 Aug;109 Suppl 1:S2-26; quiz S27. doi: 10.1038/ajg.2014.187.

[2]  2019 May 17;32(2):e100056. doi: 10.1136/gpsych-2019-100056. eCollection 2019.

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