Reducing Fermentation to Heal Your Gut

Episode 61 with Dr. Norman Robillard

Episode Intro

Dr. Michael Ruscio, DC: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am here with Dr. Norm Robillard, who I am excited to chat with. He is, I guess you could say, another digestive health aficionado, as I am myself. Norm, thanks for taking the time out to be in the call today.

Dr. Norm Robillard: Oh, hi, Dr. Ruscio. And thank you very much for having me on the show.

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Dr. Norm Robillard Bio

DrMR: Can you tell our audience a little bit about your background? I know you’ve written a number of books and you’re involved with a research, which I love to see. Can you give people kind of a short orientation to your background and what you’ve been up to?

DrNR: Sure, my own entry into the digestive health area was really because I was affected with chronic acid reflux myself. So even though I was working in the biotech industry, I was doing some unrelated research. But my own acid reflux condition continued to get worse. But one year I tried something different.

One of my sons told me to try a low carbohydrate diet. And I just couldn’t believe it. My acid reflux went away. It was that simple and basic observation that really got me thinking in this direction. To make a long story short, I actually came up with a new theory about the ultimate cause of acid reflux having to do with excessive fermentation by bacteria in the gut feeding on carbohydrates that our body digest fully.

So it had to do with gas pressure bacteria. You make a lot of gas. It builds up pressure. And you get this intragastric pressure that actually forces the LES to open. So it was a completely different way of looking at it.

It just happened that the dovetail and to some of the work that others would do in the area of IBS. And you’re probably very familiar with this as I listen to your podcast and follow your work. And so I know that you’re into the IBS and the SIBO. So you probably know all about Dr. Pimentel’s group and see the amazing work they’ve done.

But also John Hunter’s group at Addenbrooke’s Hospital in UK has also done a lot of work with microbial fermentation, carbohydrates. And both of those guys are giants in the field. And they’ve really pushed forward the SIBO connection with IBS. I’ve been trying to do the same thing with acid reflux.

DrMR: Is acid reflux the primary area that you’re focusing on?

DrNR: Acid reflux gave me a new lens to look through when I was looking at acid reflux. But, of course, you very quickly realize that SIBO is associated with a whole wide range or other – not only functional gastrointestinal disorders, but autoimmune diseases to leaky gut and also other systemic conditions such as rosacea. You know the list, it’s very long, Crohn’s disease, cystic fibrosis, chronic fatigue syndrome.

Acid reflux brings a couple of other conditions into light, as well, like asthma. 80% of kids that have asthma have chronic acid reflux. I’ve written a blog really asking the question how is asthma connected with acid reflux. I have another theory for that.

One thing leads to the other. So really the fast tract diet books, fast tract digestion, IBS and heartburn and more to come. This book series is looking at all of these conditions. But essentially it’s a diet approach to quiet down the gut, limit this fermentation of carbohydrates and control SIBO.

DrMR: Gotcha. And, of course, there’s many important aspects regarding the gastrointestinal bacteria and how they can affect a number of things, as you mentioned: rosacea, GERD, IBS and in other things like problems with insomnia or brain fog. So certainly, there’s far reaching effects of the gut bacteria and how they can affect your gut and how your gut has such a far reaching effect on every other system of your body.

Difference Between Clinical Observations and Research

One of the things that I think our audience is familiar with, but I just think this is a nice time to maybe paint this orientation is the important difference between kind of theoretical, observational information and a clinical information. And where this has the most relevance, I think, is right now with this boom of microbiota studies.

There’s almost this bacterial obsession. We need more bacteria. We need to eat lots of fiber. We’re going to feed these bacteria because of a lot of the research coming out of regions in Africa and other hunter-gatherers predominantly. There are certainly some important information there.

However, a lot of that contradicts what many clinicians are doing, which are almost anti-fermentative, anti-bacterial approaches because many people that are not feeling well almost have a different approach that’s needed where we want to prevent bacteria, rebalance bacteria, and/or decrease the feeding of bacteria.

At least that’s how I’m seeing this generally speaking. Of course, there’s always exceptions to the rule. But would you agree with that general kind of posit?

DrNR: Yeah, it’s a big topic. And I think of course, I’m fond of the Paleolithic studies. I think it’s a great idea to look back and say, “What was that diet?” back there and what were our gut microbes like?” Through some fossilized poop analysis, they’ve started to get a little bit of a handle on that.

The bottom line is the gut microbiota seems to follow the diet. And of course that changes where people arise. And if they are in an area where they’re eating a lot of carbohydrates and resistant starch, their microbiota will reflect that, as will the microbiota of people who eat more animal based foods. So you’ve got some differences there.

Clearly, the gut microbes are adaptable. But also they’re being depleted. That much is very clear. Of course, our diet is changing, more processed foods, more preservatives, more antibiotics. So the diversity is shrinking. And so how will our new gut microbiota that we have currently perform? And I think that clearly, it does pose some limitations on diet, especially as people get a little bit older and they don’t digest carbohydrates quite so well.

I think it’s clear that a lot of these conditions are being brought about by increased carbohydrate malabsorption. On top of that on the western diet, we just have so many of these carbohydrate rich foods in our diet that we have a problem.

When I read about this, it’s complicated. And there’s a lot to remember. But I try to keep a larger picture in my mind. What are the really good bacteria? How do they live? And what are some of the bad ones and how does this whole picture evolve?

So of course you know in the small intestine, you need a lot of these lactic acid bacteria. They’re firmicutes. But at the same time, there’s other firmicutes that are real gas producers from the large intestine. And some of those are involved in SIBO. They produce a lot of gas.

What’s the balance? Same with bifidobacteria. They’re more of a large bacteria organism. But they’re also bacteria that don’t too much gas. You’ve also got the significant roles of some of the key bacteroidetes organisms, such as bacteroides fragilis, thetaiotaomicron, other bacteroidetes that are very good at not only breaking down complex carbs and proteins, but anti-inflammatory mediators, such as b-frag.

A lot of work has been done on the polysaccharide A that B-fragilis produces that really helps keep our gut in order interacting with toll-like receptors and so forth. So there’s all of that, and then of course the new players coming into the field, Faecalibacterium Prausnitzii, another firmicutes, but a very important one, makes a lot of butyrate. But it’s anti-inflammatory.

And then lastly at least on my immediate list is akkermansia muciniphila from the Verrucomicrobia family that’s very anti-inflammatory. And this bacteria lives on the mucous membrane of our gut and survives purely on mucous, which is 80% carbohydrate. But that mucous supplies that organism with everything it needs, both nitrogen and carbon and energy.

So how does all these come together? It’s a puzzle. It’s just unfolding. And you’re either actively researching it or you’re reading about it and trying to make sense of it. And then of course, how does this all impact clinical situations where people come in and they’re sick?

DrMR: Right, it’s a great narrative. To your point, there’s a lot of detail here. There’s a lot of moving parts. And there’s admittedly probably more that we don’t know right now than we do know. And I think that’s really important for people to bear in mind. And I say this because I’m wary of some of the claims that are floating around there on the internet as there always are. There’s always going to be stuff that we have to be wary of.

But I just want to make the point that we should be a bit careful as the healthcare consumer or the doctor about people that are making – if you disagree with this please let me know, but this is definitely my opinion – but it’s formed from looking through the research literature and also my clinical experience. When people have very, very highly specific claims to be able to custom manipulate the microbiota to produce a health outcome, I’m very wary of that because there’s so much about the microbiota that we don’t know.

And taking Faecalibacterium Prausnitzii as an example, half of the studies I have seen show that eating more carbs feeds that bacteria. And half of the studies I’ve seen show that eating less carbs feeds that bacteria. So finding consistency tends to be a rarity in a lot of the research. And this makes me a bit reserved. Some of these run a very detailed microbiota analysis prior to custom manipulating the microbiota because I think it’s more complex than that. But to your later point, Norm, bringing it back to clinical recommendations, what can we do clinically?

Fortunately, the clinical stuff, the clinical interventions, the things that people can do to improve their gut health are a bit more simple. And how exactly they affect some of the hundred somewhat species and the ratios of species I think we’re not clear on yet, at least not in my opinion from the research.

But how that translates to being able to help someone have less GERD, or less IBS, or improve their SIBO, improve their gas that are bloating, we do have some very good clinical information established for that.

Dr. Robillard’s Fast Tract Diet

And so maybe with that as a transition—and this is a big topic I know—but where do you start in terms of someone comes in with any combination of digestive symptoms? Where do you start in terms of their diet to try to rebalance everything in the gut ecosystem and help them with their symptoms and get them moving in a better direction?

DrNR: It is a big topic. By the way, just before we get going on that, you mentioned the Faecalibacterium Prausnitzii again. And you might have read or remember a recent study by Moleen Renly. She’s in Austria, I believe. Her group came out with a – it’s kind of a pilot study. But they found increased gut microbiota diversity and an increased abundance of F. Prausnitzii, as well as akkermansia after fasting.

DrMR: I did see that study, I think, yeah.

DrNR: I really think this idea of less is more is kind of where I start from. So I like to keep things simple. And that goes back to my original observations that my acid reflux went away on a low carb diet, done. Now, the fast tract diet really focuses on just the hard to digest carbohydrates because those are the most likely to not be fully digested and persist in the small intestine feeding blooms of bacteria.

And so that’s what I focus on. You can forget about my research for a minute. Just look at the Textbook for Primary and Acute Care Medicine. I look at that book all the time. And I just happened to run across an interesting quote on page 1,192 about excess intestinal gas and these fermentable carbohydrates. And I’m literally holding it right here.

I’ll just read from here. “Dietary alterations to reduce gas require elimination of most of the foods in table one.” And then you flip over to table one and what are those foods? Sugar, alcohol, fructose, and related oligosaccharides, resistant starch, fiber, and lactose.

Those are the exact five carbohydrates that the fast tract diet targeted. And that went back to a discussion I had with Dr. Mike Eades about protein power. He was giving me some advise on this low carb approach. He had written about heartburn and carbs. He was a co-author of that book with his wife Mary Dan Eades. And he got me started on which carbs are the worst. And it turns out that the list that we came up and targeted in the fast tract diet was the same exact list in this textbook.

So doctors have been exposed to this information. But of course how to turn that into therapy is really the challenge. I think doctors at that time and even in that textbook they mentioned, “People might not really like a diet like this if you take out all these things because they can’t eat as many beans,” and so forth.

But what I did was develop a mathematical formula that used the glycemic index to instead of measuring how quickly carbs go into the bloodstream, it measure how likely they are to persist in the small intestine. And that’s the FP calculation.

With that, the diet is really like a Weight Watcher’s diet. It’s just a point system. And so you don’t have to be a dietician with three PhDs to figure out how many of these hard to digest carbs are in the foods you’re eating. You just need to look at the FP points. And that’s why we came up with a fast tract diet mobile app that does the same thing very easily.

In fact, it’s got voice recognition. You can just be in the supermarket and say, “Lentils” and they’ll come up and you can see how many points they have. And it also tells you the serving size. If you want less gas, less of these points, you just have a smaller serving size. So that’s my approach is to keep it simple.

Let me add just one more thing. So in addition to actually restricting these fermentable carbs a little bit, limiting those, putting our  microbes on a diet, so to speak, the other piece is to modulate behaviors that are pro-digestion. So it means that more of your food will be digested and less of it will persist, again, driving these symptoms. So behaviors, the food.

And then the third piece is probably something you deal with quite a bit. And that’s looking at these, a number of underlying causes that can make SIBO and these symptoms and conditions worse. That’s my approach. I try to keep it simple. Go after those five carbs. Work on the behaviors. And honestly, I find most people that fail on the diet, it’s a compliance issue honestly. It’s hard. You want to eat all the good snack foods. And so you have to be a little disciplined.

DrMR: Sure, I love that FP calculator. And the FP that stands for fermentation potential right?

DrNR: Correct.

DrMR: Yup. I’m actually going to have a look at that because I’m always looking for the easiest way to help a patient understand how to restrict highly fermentable foods. And we typically use a Low FODMAP list and/or a Low FODMAP SCD list, which I’m assuming probably has a lot of similarity. But if someone can just punch in a food and get an answer, that may be a little bit easier. Or maybe something that could be in conjunction with the food list to kind of give someone something they can go to the ask a question. Because sometimes it’s not very clear from the food lis. And that’s where it’s nice to interact like an app, they can help with that.

So I’m definitely going to have a look at that. Is that something you can just go to the app store and search for?

DrNR: Yeah, it’s on Android and Apple. A little bit about these diets. Of course, the elemental one is the most stringent diet, right? It’s just predigested carbohydrates. You get glucose. The proteins are just amino acids. And the fats are fatty acids.

So it’s the most effective. But of course, you can’t stay on that long-term and you probably should be under a doctor’s care because that’s too extreme for your microbiota long term. You really should be on a whole foods diet.

But let me just ask you, if somebody is lactose intolerant, what do you do?

DrMR: Take them off lactose.

DrNR: Simple right? Or they could take a lactase supplement. If somebody is fructose intolerant what do you do?

DrMR: Take them off fructose.

DrNR: Right? And of course there’s no supplement for fructose because it’s a monosaccharide, right? It’s just hard to absorb, so you have to cut back on fructose. Same thing with sugar alcohols, right? Go to the FDA website. And sugar alcohols other than erythritol, the one friendly sugar alcohol…Sugar alcohols are very fermentable. And so when somebody has an intolerance, they have to stop or cut back on these carbohydrates, right?

Fiber and Resistant Starch

But all of a sudden, when you get the fiber and resistant starch, some kind of new type of thinking takes over. And there’s a thought that, “Oh, no. We need more fiber, more resistant starch. We need to feed our gut microbiota.”

When in my eyes, people with these problems…If somebody is healthy and they can eat lots of fiber and resistant starch, that’s great. In fact, Jeff Leach, interesting guy, he’s traveled in Africa. He’s looked at some of these indigenous people eating high fiber diets. And he actually reported how bloated their bellies were.

They are getting a lot of bloating because they were fermenting a lot of carbohydrates. But it was a natural part of their diet at least at that particular time of the year. Maybe the animal killers weren’t as plentiful and so forth. But processing carbohydrates really involves a collaboration with your gut microbes. But I really think that you can overdo it.

That’s why I include, unlike the specific carb diet that doesn’t limit fiber and it limits all starch, I just limit the difficult to digest starch which, is mostly the amylose starch because it contains a lot of amylose, and also fiber. It has many different types of fiber. And they vary in their fermentability but my starting point—and you mentioned keeping it simple—is limit all of these fermentable carbs to somewhere between 15 and 40 grams a day, depending on how severe the symptoms are.

So it’s not an elemental diet. It’s not a no FP or a no carb diet. It does feed the microbiota. But it puts them on a diet. And so just like you would do with lactose, fructose or sugar alcohol intolerance, I do the same thing because I really believe that fiber and resistant starch and tolerance is a real problem, too. And there’s a lot of evidence for that I cover in my books.

DrMR: I completely agree. One of the things that I’ve seen in the clinic is higher fiber intake, high prebiotic intake, high resistant starch intake for many people can really flare them and set them off. And that’s been reflected really pretty well in the literature. I think we see IBS studies and definitely IBD studies that show high dosage of prebiotics can cause flares.

Alyson and I spoke about this a few episodes back. There may be a small subset of people that do better and seem to respond well to carbs and prebiotics and fibers. And that may just be an issue of them having a, I guess, trying to evolve potentially in the more equatorial sort of climate. And so they have a genetic lineage or a microbiota passed down from generation to generation that does better on a higher carb prebiotic diet or what have you.

But that certainly seems to be potentially the minority than it does the majority. I mean I totally agree with you, Norm, where it seems like most people need to cut back in some of these things.

Reintroducing FODMAPs, Fiber and Resistant Starch

There’s a couple of things I wanted to get your expansion on in that regard. I’ve seen this. I’m sure you’re seeing also this has been published with some of the Low FODMAP diet studies where after people initially restrict these things, with time they tend to be able to bring more in and have increase of tolerability with time. So is this something that you’re seeing and what thoughts do you have for how someone can get to a point of expanding their diet?

DrNR: I do agree with that. I agree with everything you said. I’m a little case study in myself because I had acid reflux for a decade or two, a long, long time. And it was terrible. And now I’m completely free of it. But, of course, if I really overdo it around holidays and I consume too many of these fermentable carbohydrates, eventually it does catch up with me.

I’m much more tolerant than I was. And so I think that when you really get things under control, don’t forget Elaine Gottschall and her book, Breaking the Vicious Cycle where she came up with a specific carb diet. She had really the best analogy with this vicious cycle of when you get a lot of bacterial overgrowth. These bacteria are releasing their own digestive enzymes, proteases. And they damage the little enzymes on the tips of our microvilli. And then we can’t fully digest and absorb carbohydrates.

And so, it feeds the bacteria more. More bacteria grow that produce more of these proteases and more of the damage. And it’s a cycle. It’s similar, not quite as dramatic. It’s similar in some ways to the autoimmune dysfunction and celiac disease. But in this case, it’s a cycle of bacteria in the digestive enzymes.

And so, you need to break that cycle. And I think the biggest mistake people make is they feel better and they jump back in the pool too soon and too deep. And so I really think you have to be very diligent with people I work with in our consultation program. I’m the carb police.

But luckily with the fast tract diet, it is a flexible system because when you look this fermentation potential, it’s a new lens. If you add up the FP points like a bowl of Uncle Ben’s Rice, that’s a rice that has a lot of more resistant starch and amylose starch. A five-ounce serving has about 20 grams or more of FP points, resistant starch that can ferment in the gut. And to put that into perspective, 30 grams of fermentable carbs can yield 10 liters of hydrogen gas in the intestines.

So 20 grams is seven liters. So with a bowl of Uncle Ben’s Rice, you can end up with seven liters of gas in your intestines. But if you switch that out for jasmine rice, the FP is zero because it’s all less resistant amylopectin starch. And so, really, it’s much more gut friendly.

If somebody really wants to have some rice, then if they have gut issues and gas problems and reflux and IBS, I would say pick the jasmine rice. Don’t do Uncle Ben’s. Don’t do basmati and a number of these other rice. You basically look it up in the app or the book. And you say, “Here’s the rices I can’t have. Here’s the ones I can have unless I want to significantly cut back the portion” because that’s another way to control the points.

DrMR: Gotcha. I love specificity of that because I think that will really help people. You made a good point which is not all rices are the same. And there has been a way that I try to coach people on this, which is listen to your response to each individual food because we do know that some people will react differently to what looks like the same food but maybe is a slight variant.

I think the app is a nice way of being a little bit more precise in that. So I am really curious to have a look at that app and maybe start having some patients use it and see if it gives them another level of kind of clarity in the process of figuring out what carbs are going to be the best. They kind of bring it back in like a dip their toe back into the carb pool, so to speak.

DrNR: And you bring up a good point. No matter how scientific you make it—and this is very scientific and very quantitative—but you will still get people that say, “Well, I can’t eat tofu.” I’ll say, “Well, the FP is very low.” “I just can’t eat it. It’s got antinutrients and it bothers me.” It’s like, “Okay, let’s work around that.”

So I think at some point you just have to listen to people and say, “Well, this food is a problem and try to work around it.” But I think the other extreme of that is sometimes people, especially if they have been doing a lot of reading about a lot of different diets and they limit some foods from this diet and then limit a few foods from this diet, and because they haven’t…

Maybe they associated food with some problems. Other foods in their diet may have been responsible for those symptoms, especially some of the fibers foods that can cause symptoms 24 hours after you consume them. So you can start having symptoms and say, “Oh, this yogurt did it.” But actually it was something you had the day before.

DrMR: Sure.

DrNR: So what I worry about is with some people, they are limiting so many different foods that they aren’t getting proper nutrition. And so sometimes I think it’s best to just try a diet. Somebody came up with this diet. They wrapped their brain around it. And just try it. Try it. Forget everything else you learned and just see what happens.

Once you’re on, for instance, a fast tract diet, you’ve cut your FP way down. Let’s say with bad symptoms, you went down to 20 grams a day of fermentable carbs. If you still have some issues there, then I think you can put some weight behind that now because you’ve controlled for a lot other thing.

DrMR: Yup. I completely agree. I think it’s one of the most challenging things can be when you give a patient a recommendation and they start doubting it a third of the way through. And then they start changing things. And then when you see them at their follow up, you ask, “How did it go?” and they’ll usually remark, “Well, I’m not doing well.”

And then you ask about, “Okay, well, what have you been doing?” “Well I was doing this for seven days. But I didn’t feel like it was working. So I changed. And then I tried this. But then I read somewhere else that I should maybe do this instead.”

And it’s very, very challenging on the clinician end to be able to sort that out, because like you said, you need to kind of ask and answer a question, “Will this diet help? Yes or no?” and see it through until you’ve answered the question and then move on. So I totally agree.

DrNR: Absolutely, I think some people, they want it all in one session. But that’s why we recommend that people to have at least three sessions because you’re right. You shouldn’t be changing everything willy-nilly.

You need to have a certain approach. And then you need to either change one thing at a time—and that’s painstakingly slow when it comes to diet—or you need a well-organized matrix approach, basically using scientific principles to understand what the heck is going on.

DrMR: Yup, I totally agree. And for any patients listening that might be floundering, I understand if you try your diet and you don’t fell like you’re getting better, I understand how defeating that can be. But if you’re working with a clinician or nutritionist, or someone that you have confidence in – like you’ve probably heard me say before, take the time, or give them the time to work through their process because we’re all trying to get you there as fast as we can.

It’s just sometimes we have to go through what doesn’t work to get to what does work. And that does suck. I get it. But if you change things willy-nilly as Norm said, you make it really hard to eventually get you to that point where we figure what will work for you.

DrNR: Yeah. Of course from our end we have to listen, too. Going in, not only do we have a pretty extensive questionnaire, but then I really spent the first hour working with somebody to just listen and ask a lot of questions because you can get to the point where you say, “Okay, well here’s the diet.” And they’re like, “Oh, that’s great, except I’m a vegetarian.” “Oh.”

DrMR: Right, it is a big mess.

DrNR: I actually worked with a lot of vegetarians. No surprise, right, because they’re on a plant-based diet, and plants are where all of fermentable carbs come from.

DrMR: Not all.

DrNR: Some animal foods do have some fermentable carbohydrates and other products, too. But it’s mostly from plants. It’s not unusual that people on a plant-based diet have a lot of symptoms. And it’s very challenging. But the more you know up front about somebody’s dietary preferences, the better you can tailor the approach to that person.

DrMR: Absolutely. I absolutely agree.

Resistant Starch & SIBO

There’s two more things I’d like to touch on. I guess first, I know that you’ve written about, or at least I believe, you wrote, I believe, there was an article series on resistant starch and how that relates and pertains to SIBO because I know as resistant starch kind of went through its in vogue session and everyone and their mother was on copious doses of resistant starch, there was a lot of press about it. And I think you looked into some of the specifics. And if you have some specifics to share there, I’m sure people would love to hear it.

DrNR: Yeah, it’s an interesting area. And of course, we limit resistant starch in the fast track diet approach as we limit all carbohydrate types to get symptoms under control. But resistant starch is an interesting story. Bnd whenever I bump into a situation like this where some people are claiming, “Wow, there’s all these benefits,” and other people are saying, “I don’t feel good,” I tend to default to a pros and cons approach. And I just want to look at it on both sides.

So I wrote two pretty extensive blog articles. One is called “Resistant Starch: Friend or Foe.” It’s on digestivehealthinstitute.org and then the other one takes it up a notch. It’s called, “Resistant Starch: Friend, Foe, or Lover?” And it was kind of a collaboration with Tim Steele and Mr. Nikoley because they have been very interested in the positive attributes of resistant starch.

And I had been limiting it in my diet and working with some people that seemed a lot better when they get rid of it. And of course the success of a low carb diet, a low starch diet and so forth, it really seems starch is a problem for some people. People can read those two articles, but I go through a lot of different things.

First of all, there’s a lot of claims that are made about fiber and starch. And some of them might be true. And most of them it turns out not to be true, especially in fiber. And larger well-controlled studies have shown that, no, fiber, it isn’t going to protect you against colon cancer and all of these other things. So time will tell with the studies. But in the meantime, there are things you can do.

There’s a concept. So looking at the pros a little bit, there’s a concept that resistant starch may actually help people with SIBO. And some of the research that’s cited is kind of interesting. Resistant starch added to rehydration media for people that had extensive diarrhea and cholera, resistant starch seemed to help.

And there’s even a mechanism or proposed mechanism for that where bacteria that’s overgrowing, in this situation cholera bacteria, attaches to the starch because it wants to eat it. These bacteria, they attach and form little biofilms on the starch particles, but then they keep moving through the digestive tract. And so basically they start flushing these organisms out of the body. And so that’s really interesting.

But of course there’s no evidence that it works with other types of diarrhea, from other pathogens. And then what about with diarrhea associated with IBS? So it’s kind of an open question.

On the other hand, there are a lot of people that report symptoms from consuming a lot of starch and that getting rid of the starch helps. I think you just have to keep looking at both sides. And then you can also look at the types of bacteria that are present in SIBO. So in IBS or SIBO, when you look at then organisms, there haven’t been a lot of studies done on this, but there have been some where they’ve actually recovered these organisms and cultured them. And there’s a lot of firmicutes. There’s some bacteroidetes. And you have to look at each one. There’s clostridia.

When you look at all of these bacteria, I took a look at these and the microbiology behind them and their metabolic pathways. And it turns out that many of these organisms that are present in SIBO in the small intestine comes from the large intestine. And, in fact, they are very, very good at breaking down and fermenting starch.

Now, if you have diarrhea, maybe the same mechanism would take place and would start to flush the starch out. So you could maybe try a little if you had diarrhea. But with constipation, I imagine that the opposite might be true. There’s a starch sitting there and these bacteria are colonizing it, these biofilms. And they’re breaking it down. And then you’re going to get of gas and symptoms.

So I think, keeping an open mind, but also just paying attention… I looked at a lot of feed in Facebook and sites and the comments. And there were people that wanted to experience positive aspects that people were talking about with resistance starch, the raw and modified potato starch for instance, the vivid dreams, and some of the others. They wanted it so bad. But there’s one person with an autoimmune condition, ankylosing spondylitis, who was getting terrible autoimmune symptoms. But he kept going because he just thought maybe he can push through it. But sometimes, the best thing to do is stop and take stock.

DrMR: Totally agree. And I’m so glad you closed that comment with that point because I think that’s really the most important thing that people to takeaway is that if you want to experiment, do so cautiously. But also don’t kid yourself. Don’t fall in love with the dream or something that was true for somebody else and then see that it’s clearly not working for you and just keep beating your head against the wall because nothing wrong, sure, with experimenting. But, again, just listen to your body and trust your own intuition that you’re…

I think we’re all a little bit smarter than we think if we can just kind of get out of our own way and not let stuff that we read bias us to much into blindly following one position or the other.

Other Components to Dr. Robillard’s Treatment for SIBO

Norm, one of the final questions I’d like to ask you is other things that you’re doing for SIBO, we’ve talked about what I think is a terrific dietary approach for helping to starve SIBO. Are there other things that you’re doing for SIBO in terms of using some form of elemental diet, using herbal antimicrobials, using antibiotics, is there anything else that you’re doing in this regard?

DrNR: Well, it’s what I’ve said. It’s a three-part approach, limiting the fermentable carbs and using prodigestion strategies. And those are actually just quite a few. Some are simple. And some are little counterintuitive. For instance, you heard people say, “Chew well.” Why? It’s been around for a long time, but why do that? Well, it turns out to be very, very critical, because our saliva contains amylose-degrading, salivary amylase. And the amount that people have in their saliva, it turns out, due to some recent studies, is quite different, person to person.

Again, it comes from where your peoples came from. And some people actually very few gene copies of salivary amylase, whereas other regions, people have many more copies of salivary amylase genes. And that translates into more. This amalyse enzyme in your saliva, it can be up to 60% of the protein in your saliva. What about somebody with one copy? And then you don’t have much.

And so that’s a big part of how you digest starches even before you swallow it. There’s pancreatic amylase that helps complete the job in the small intestine, but the salivary amylase is critical. So if you’re a person without very much of it and you’re not supplementing, then one ting you can do is chew your food very, very well, 20, 25 chews per bite. That gives this amylase more time to break down the starch before you swallow it.

It’s simple things like that, but there’s a little science wrapped around it to make you understand, “Wow, this is actually important.” And it does take time to get in that habit. Sometimes people might say, “Yeah, yeah, I’m doing that. I do chew my food well.” But sometimes you catch yourself not doing it. Over the years, I’ve gotten very god at it, especially if I eat something that’s high resistant starch, certain types of rice. We have friends that are from India and I eat some Basmati, I’ll know I better chew that pretty well or I’m going to suffer, and the same with pasta.

Things like that, but also choosing fully ripe vegetables and fruits. For instance, the fermentation potential of an unripe banana is about three or four grams higher than a ripe banana. So choosing ripe fruits, sometimes, peel the vegetable – shaves off, so to speak, a little more FP.

Preparing starch is probably, because you want low FP-types of starch to begin with, but also cooking them with plenty of moisture, cooking them in such a way that they’re light and fluffy and consume them fresh. As soon as you refrigerate that rice or potatoes, a lot of resistant starch builds up. And so you want to do things that avoid that.

Those are the types of thing I do. And then of course, it’s very important to really work with people and dig and dig and dig to make sure they don’t other underlying cause that is driving some of those symptoms. If somebody has undiagnosed celiac disease, somebody needs to know about that.

DrMR: Sure, absolutely. Okay, I like it.

DrNR: The list goes on, immunodeficiency. Maybe it’s an infection. Sometimes there are certain drugs people take are constipating. That will make a big effect. Have they been using antibiotics recently? Have they had a gastrointestinal infection? You know the list, low stomach acid, motility problems. But I really think, I really believe, Michael, that carbohydrate malabsorption is at the center of this thing. I really do. And I believe it in my gut. And all the work I’ve done has only reinforced that idea with me.

People even mention, “Well, maybe some prebiotics are good.” Prebiotic does mean a good biotic right? There’s had been a big promotion of oligosaccharide, for instance. But you don’t have to go back too far to see studies on FOS, fructooligosaccharides were actually triggering symptoms. They gave it to people with chronic acid reflux in the ‘90s. And they had more reflux and more symptoms and more acid in their esophagus. It didn’t work.

So it’s one thing to experiment. But at the same time, like you said, I think we have to always be looking deeply into literature and seeing what do they have and what works and what doesn’t work, both in terms of your experience, but also in the scientific literature.

Gut Health and Treatment Approaches

DrMR: Totally agree. And one thing I’m just kind of piggy back on that…And I think we talked about this in an episode recently. But the way I’m starting to look at this very kind of superficial and generic, trying to organize us into different camps, is the healthier someone’s gut, the more they flourish on things like resistant starch, high fiber diets, and prebiotics. If you have a really healthy gut, then these people tend to respond well to these things. And I think, these are the people that, when you are reading on Facebook groups or message boards on the internet, these are the people who aggregate in those camps.

However, when you have people that have underlying problems with their gut, carbohydrate malabsorption, whether that be from SIBO or not having a lot of enzyme production or a motility impairment or they have a low level inflammatory bowel disease or they have frank inflammatory bowel disease, those people with the not super healthy guts in my observation—and I think there’s a good amount of literature as you’re citing a few examples of, Norm, that really support this—that these people will not do well on higher fiber, higher starch, higher resistant starch, higher prebiotic diet. And they have to be a little bit more careful. And it’s really more of an antifermentative approach that these people tend to flourish on.

DrNR: Yeah, I agree with what you’re saying. I’m a little bit more cautious about how we label this if we’re going to put into bucket. If you have somebody who has lactose intolerant, let’s say they come from Greece and they’re lactose intolerant or somebody…90% of Northern Europeans are lactose tolerant.

Does that mean this person from Greece has an unhealthy gut? No. they just don’t have the genes switched on in adulthood for lactase. So it’s a difference. I don’t think it necessarily means one person is healthy and one person isn’t. It’s the same thing with these gene copy numbers for amylase.

If you happen to come from an area where gene copy numbers for amylase are low, maybe mostly animals. And you don’t really need a whole lot of amylase turned on. So it might have been an genetic adaptation that wasn’t a problem. But now we shift people all over the world, and we put them on all these different diets. And things happen.

I think that certainly people with an unhealthy gut are going to have digestive health problem, but I do think there are people with a healthy gut that just don’t tolerate as many – certain carbohydrates as – maybe even as they get older.

We know that the same way athletic prowess declines with age, so does digestive prowess for many people. I think it gets back to the same thing, you need to be cautious and observant and understand that. But I wouldn’t jump to say somebody’s just got an unhealthy gut because they’re intolerant of certain carbohydrates.

DrMR: Sure, I totally understand what you’re driving at with that. And maybe I could restate that. And all I’m trying to do here is give people who are new to this issue or struggling with the question of, “My friend went on a bunch of resistant starch. She feels a lot better. Should I be the same thing?” I’m trying to help give people a general way of maybe organizing this.

Certainly when you try to be general, it’s easy to poke holes in a theory. So I totally get that. But I’m hoping that although this wouldn’t be very technical or something that would stand up to much scientific scrutiny, maybe I could restate that to help people, again, very broadly that the more symptomatic you are, the more likely you’re going to negatively react to a high fiber, high resistant starch, high prebiotic diet, compared to someone who is not symptomatic.

DrNR: You may also just have a temporary imbalance. Eventually your gut will come back. Maybe temporarily your gut is not healthy because, say, you’re on an antibiotic. We know there was just a good study that came out in Nature from a group at Stanford University School of Medicine that actually proposed a mechanism for antibiotic mediated dysbiosis.

And that was all about when people going antibiotics, two things happen. The number of gut bacteria is dramatically reduced, right? Who would argue with that? But what happens when that bacteria that normally ferments all these carbohydrates is reduced or gone? You still have those carbohydrates. So you also have a dramatic increase in the available carbohydrate in the gut.

According to the authors, the proposal is that these extra carbs and fewer friendly bacteria allows bad bacteria to take over, which would perfectly explain why people that take antibiotics are much more at risk for C. difficile infection.

Working with Doctors to Get Patients Off Medications

To get back to, you mentioned, what else do I do? One thing I do really try to do…And of course, I have people talk to their own doctors about this. I’m a microbiologist. I make that clear to people I work with. but I try to, first of all, get them working with their doctors off all of these other meds. PPIs, antidiarrheals, laxatives, pain meds, many of these are not effective. None of them address the root cause. And they all have side effects, many of which are serious or carry serious health risks. And PPI’s have been in the news; every couple of months a new study comes out. They are just horrible.

And then antibiotics are a little bit of a… You have to pause it because if somebody has the more serious symptoms of SIBO or it’s really affecting their health—bruising, night blindness, severe weight loss—you may need to have that in your arsenal, and a doctor may need to prescribe them. But in most cases, I really feel that people want to jump on these too quick, because it’s easy, just popping a pill. And many people are noticing initial improvement, but others don’t. And the question really is, “Is the response durable?”

Even early research out of Pimentel’s lab shows that after two or three months, a lot of these people who revert, some of the strains become resistant or tolerant of the antibiotic. Or they just grow back. And so people get these symptoms again, especially if the underlying cause hasn’t been addressed. And so, yeah, we can do more research into these, but I don’t think it’s going to be a durable response the same way carbohydrate limitation is a durable response. We know that.

Some of these are short term studies for carb limitations, but then again, they’ve done studies on lactose intolerance. And they’ve looked out a whole year or two later. They’re still off lactose. They’re still fine. There is no question. It is durable.

Of course, the antibiotics – I don’t want to go on a rant here, but it’s a shotgun approach. It kills or inhibits bad and good bacteria and depletes protective strains. So I’m not saying antibiotics won’t be needed in some instances, but I think they’re overused. And this is why it’s important to get these clinical studies done on diets that limits fermentable carbs so that a doctor can actually just reach for these diets more easily, instead reaching for an antibiotic.

And antibiotics should be a backup. It shouldn’t be the first thing, but can be a back up.

DrMR: I agree with you that the diet should be looked to first. And this is why we always have patients start off with diet. And for some patients, for many patients, that’s all they’ll need to do. Sometimes in the clinic, we do use something like the elemental diet or an herbal antimicrobial or sometimes, the more SIBO specific antibiotics.

However, I also see a number of patients that have been diagnosed with SIBO from, say, a conventional ganstroenetrologist, have done a round of antibiotics, felt better for a short period of time, and then relapse. And I think the relapse happens because diet, lifestyle and other series of factors like probiotics or potentially some enzymes support, those things have all not been done. And that’s where we’re able to get the results or just a standalone antibiotic was not able to. Soi I’m in a complete agreement with you there.

DrNR: And then, of course, the last thing is something that affects everybody is antibiotic resistance is out of control. I worked on antibiotics. I helped developed Ciprofloxacin when I was at Vale when I used to drive right by your office out there along the creek on my way to Berkley. I worked on the development of Cipro. Saves a lot of lives, but what happens is that when we have all these resistance from overuse of antibiotics and using them on a farm and overusing it for people with conditions where they don’t need it and shouldn’t have it, now we have methicillin-resistant Staph aureus. We have carbapenem-resistant enterobacteriaceae, such as Klebsiella pneumoniae and E. coli.

This affects everyone. Any given year, it might not affect you. But there’s 200, 000 people or more that are infected with these resistant bacteria, resulting in over 20,000 deaths a year. And something has to be done to preserve this antibiotic arsenal for lifesaving situations.

DrMR: I totally agree.

DrNR: I think I was influenced by Stu Levy when I was a post doc at Tufts in the ‘80s. He was right next door to me. And he wrote The Antibiotic Paradox, which is a very good book. Even though it’s written some years ago, it’s still worth a read because I think it just outlines what is actually coming to pass with the overuse of antibiotics. So I feel you can’t use enough caution when it comes to that. And they can make it worse.

DrMR: I agree. And I think it’s important that we, as you said, reserve those things for when they’re truly needed and not – of course there was the common cold when they’re often way over prescribe a viral infection that has no indication of becoming a secondary bacterial infection, but they’re giving antibiotic anyway to see if it might help with something like a head cold. That sort of practice really needs to stop.

And definitely there are some that are really starting to make these criticisms much more vocally and much more in the conventional community. So hopefully this pendulum will continue to swing more in a reasonable direction as we’re hoping for.

DrNR: You’re right. And you see it at the national meetings. In 2013, I presented some data the Digestive Disease Week meeting. Gastroenterologists from all over the country attended that meeting. And they actually had a big symposia there about the over prescribing of proton pump inhibitor.

So here’s all these specialist and doctors saying, “Listen, guys, we can’t give people these proton pump inhibitors in the morning and at night. And you add an H2 blocker. They have no acid. And they’re having all these problems.” So even the doctors and specialists are starting to realize that these medicines are not the answer often, and they need to be limited.

DrMR: Absolutely, especially when the PPI drugs are used in the long term. Really the  best evidence if we’re going to be truly evidence- based is using these things when people have documented ulcers and they’re used for four to eight weeks and then discontinue. They show a very impressive ability to help with ulcer healing. But they’re only used in a four- to eight-week application.

Somehow, we really drifted very far away from what they were studied and shown to be effective to use.

DrNR: When somebody has ulcer, the first thing you need to look at, too, is see if they’ve had a prolonged H. pylori infection.

DrMR: Right, that’s exactly what I was going to say. Of course, there are a whole litany of other underlying causative factors of ulcers that haven’t even been addressed.

DrNR: That’s a good point about short-term usage. It’s appropriate for that.

Episode Wrap-Up

DrMR: Well, Norm, this has been a great call. And hopefully we’ll have you back on at some point in the near future because I love the way your mind works. I feel a lot of kinship with you in that regard. Can you tell people a little bit about where they can track you down or find more information from you if they wanted to?

DrNR: Sure. And by the way, the same with you, Michael. I really enjoy talking to you. I like the fact that you’re open to just discussing a lot of issues and digging deep into what’s driving some of these illnesses and what can we do in a holistic way to help people.

Sure, if people want to get in touch with me or look at our stuff, they can go to digestivehealthinstitute.org. A lot of my blogs and stuff is there. If they want to look into our app, they can go to fasttractdiet.com to look at the mobile app. And we have a free e-book actually at the digestivehealthinstitute.org site if they want to see how the diet works. It’s a pretty extensive write up on the diet, on the first page. They can get that.

And then, please, I’d like your listeners to come join us at the fast tract diet official Facebook group. And there’s always a lively discussion going on there. And I’m jumping out all the time, too. So come over and join us.

DrMR: Great. Well, Norm, thank you again. This was a great call. And I’m sure people will get a lot out of it.

DrNR: Thank you, Michael. I appreciate it. Be well.

DrMR: My pleasure. Take care.

What do you think? I would like to hear your thoughts or experience with this.

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