Podcast Episode #185: (Best of) Chris Kresser – All About Digestion

Diane Sanfilippo Digestion, Featured, Podcast Episodes 3 Comments


1.  What’s new for you from Diane [1:59] 2. Digestive function – normal and abnormal, signs and symptoms [8:15] 3. Stress response and stomach acid production [32:21] 4. Small intestinal bacterial overgrowth (SIBO)[44:22] 5. FODMAPs [1:03:10] 6. Gut pathogens [1:08:16] 7. Weight loss resistant pathogens [1:13:58] 8. The best nutritional approaches for gut healing [1:20:18]

[smart_track_player url=”http://www.blogtalkradio.com/balancedbites/2015/04/02/185-best-of-chris-kresser–all-about-digestion.mp3″ color=”00aeef” title=”#185: (Best of) Chris Kresser – All About Digestion” artist=”Diane Sanfilippo & Liz Wolfe” ]


Notes: Digestive Wellness for Children by Elizabeth Lipski

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Diane Sanfilippo:
Hey everyone! Welcome to episode 185 of the Balanced Bites podcast. Today we’re going to do something a little bit different. As you may be able to hear from the sound of my voice, I’ve been a bit under the weather lately, and Liz is out on maternity leave, so I wasn’t able to get my voice rallied to do a full episode this week on my own or with a guest. So I wanted to bring back an amazing episode from the archives, and I think this will be really fun for those of you who are new to the show and maybe didn’t listen to the old episodes, and hopefully it will encourage you to go back and listen to the ones in the archive, because they’re actually fantastic episodes. We cover lots of Q&A that I think a lot of newer listeners may still be very interested in and we had a lot of amazing guests.

One of our favorite guests was Chris Kresser, and we talked all about digestion in this episode. So I think you’ll really love it. I think its pretty fun to listen to the archived ones where Liz and I had a little bit different of a back and forth. She referred to herself as my sidekick, and I think that’s pretty funny, because obviously as you guys know now if you’re current listeners, we’re definitely partners in crime on this podcast. But in the very beginning, I had to drag her into doing it with me, so it’s pretty funny to listen to.

1. What’s new for you from Diane [1:59]

Before we get into the episode, I wanted to give you guys just a couple of quick updates. Number one, this Monday April 6th, if you’re tuning in live, it’s going to be the kick off of the April 21-Day Sugar Detox. I know tons of people have jumped in this month. It’s a great time to do it before the summer. We also start a new group the first Monday of every month, so if this Monday isn’t right for you, no big deal. But you can always jump onto 21DSD.com and check out the getting started guide, and kind of figure out how to jump in if you want to do that at some point. I think before the summer is a great time.

April 24-26th, I will be in Austin at PaleoFx. If you’ve been on the fence about it, just in a few more weeks, definitely join us there. I believe that I have talks a couple of times on Sunday, and perhaps other times through the weekend, some workshops and book signings and things like that. But definitely, if you’re coming to the event be sure you stay all the way through Sunday, because I know I have my last panel later in the day on Sunday. Hopefully folks aren’t leaving too early, because it’s an expensive trip to make, and hopefully y’all will be able to stick around and hang out with me. So that will be a really fun time.

The one other update I want to give you guys, which I’m super excited about, we have a brand new sponsor joining us this month and that is Tin Star Foods Ghee. As any of you who have been following me on social media know, I’m a huge fan of the product. I don’t generally talk a lot about products that I’m not a big fan of, so I wanted to invite Tin Star to come on and be a sponsor. And I’m really excited to introduce those of you who haven’t heard of it yet to this ghee.

For those of you who aren’t sure what ghee is, it’s a clarified butter. So if you’re sensitive to dairy proteins, it’s a really good option. For people who are highly, highly allergic, maybe it’s for you, maybe it’s not. I know that Tin Star Ghee is certified as casein free as well as lactose free, but there are some folks who will always be sensitive. But if you’re a little bit borderline and feel like you can handle a tiny bit, which that’s where I am. I definitely don’t do as well with butter, it gives me a little bit of acne. But the ghee has been clarified, so those dairy proteins are gone, and I have no problems with it whatsoever.

It tastes amazing, and it’s a really healthy cooking fat. So if you’re looking for an alternative to something like coconut oil or other animal fats that have a different type of flavor, the ghee is a fantastic choice. I used it just this morning to scramble my eggs, so it’s one that I highly recommend. The flavor and texture of Tin Star Foods ghee is fantastic. I absolutely love Hima, the owner of the company, who is just working really hard to get the company off the ground. She’s really excited to join us as a sponsor, so I’m excited to introduce them.

You can save 15% off any ghee in your order from primalfoodpantry.com, that’s the website. So anything that you add to the cart that is a ghee product. She’s got, also, I don’t know how to pronounce it, it’s like a brown ghee, which tastes amazing. You can get 15% off any of the ghee products that you put into your cart. And you can go ahead and shop for anything else you want while you’re there. I know she’s got some other fun paleo/primal foods there, as well. So visit http://www.primalfoodpantry.com/ and use code BALANCEDBITES to get 15% off any ghee in your order.

Liz Wolfe: Hey everyone, I’m Liz Wolfe, sidekick to Diane Sanfilippo of Balanced Bites, and welcome to a very special episode of the Balanced Bites podcast. Hey Diane, are you there?

Diane Sanfilippo: Yes, I’m here. You’re funny. [laughs]

Liz Wolfe: [laughs] I try.

Diane Sanfilippo: Yeah.

Liz Wolfe: So what’s going on?

Diane Sanfilippo: Oh, well, we’re really excited. I’m really excited, at least.

Liz Wolfe:I’m super excited.

Diane Sanfilippo:This podcast is semi-self-indulgent here, I think, on both of our parts. That we just wanted to bring our friend, Chris Kresser, on to talk about digestion. I just have my, you know, tons of questions of my own, just kind of little nagging things that I want to get a little more information on, and just wanted to help people give people a different perspective on digestion from what I normally teach at my seminars, clients, or whatever. So for those of you who don’t know who Chris is- which, if you don’t know who Chris is, I don’t even know how you found this podcast, so-{laughs}

Liz Wolfe: {laughs} Yeah, you must be new around here.

Diane Sanfilippo: Exactly. Chris is a licensed acupuncturist, and integrative medicine practitioner. He has an office in Berkeley, California, and he also works with patients in person as well as nationally and internationally, via phone and Skype. Chris, are you there?

Chris Kresser:Hey, Diane and Liz, it’s a pleasure to be here.

Diane Sanfilippo:Awesome.

Liz Wolfe: Thanks for being here.

Diane Sanfilippo: It’s uh-we’re all in different time zones, so I’m a little more chipper at noon. I think we’re like spread across the country today, but…

Liz Wolfe:Yeah.

Chris Kresser: Yeah.

Diane Sanfilippo: So yeah, I just wanted to get into some things on digestion, like I said. You know, I’ve got my own kind of selfish indulgence in mind here, but we’ve got tons of questions readers posted on Chris’s blog, some posted on mine. What I’ve tried to do is collaborate a bunch of those questions into more general, like let’s talk about these topics, and then, I think actually Chris mentioned you might do another podcast more on digestion, too, so maybe some more of the specific questions will come in then. But I think we’re going to cover a lot of what people are asking about just in talking about how this whole thing works, so maybe we can kind of just jump right in and then, I’m not going to-Chris, I don’t know if you get carried away, but I’m not going to give your whole background because I feel like…

Chris Kresser:No, that’s not necessary.

Diane Sanfilippo:Yeah, they either know or they can kind of hop on your website: ChrisKresser.com is his website, and we’ll link up to anything that we reference, any output sources that we reference to, we’ll just link to in our notes. So yeah, I shot Chris an email, and I said, hey, want to talk about digestion, here are some things that I want to talk about, and he said, awesome. So….

Chris Kresser:My favorite topic.

Diane Sanfilippo:Yeah, I guess..what?

Chris Kresser:My favorite topic.

2. Digestive function – normal and abnormal, signs and symptoms [8:15]

Diane Sanfilippo: Is it? I think it’s my favorite topic, too. So this is all about digestion. What, you know, happens when it doesn’t work properly. So, can you just give us a brief overview of when our digestive system is working properly, what’s supposed to happen from when we eat to when we eliminate?

Chris Kresser:Sure.

Diane Sanfilippo: And you know, just stuff that I describe for people all the time, but I’d love to hear it from you. What should be happening?

Chris Kresser: Yeah, so I think one of the most important things to understand about the digestive tract is that it’s one of the three barrier systems in the body. We have three barrier systems: one being the digestive tract, the others being the respiratory tract, and the third being the blood-brain barrier. And the job of the barrier system is essentially to determine what gets in the body and what stays out. And in the case of the digestive tract, of course we want nutrients to nourish our body and fuel cellular processes to get in, and we want toxins and waste to stay out. And that’s really the primary job of the digestive tract. To make that discernment, number one, and then to carry out the job of filtering the good stuff that we ingest and getting it into the bloodstream where it can be moved around the body to the various different places that it needs to go.

And then making sure that the other stuff gets excreted in a timely fashion, because if it doesn’t, if the transit time is too long, then those toxins can stick around and be exposed to the lining of the intestinal tract for longer than they should be, and then they can damage the intestinal tract and make the gut permeable, which I’m sure a lot of your listeners have heard of. It’s called intestinal permeability in the medical community and the research literature, but it’s referred to as “leaky gut” by most people. And then once the gut becomes leaky like that, that’s when all the problems start because that ability to discern and keep the wrong stuff out and let the right stuff in, it’s lost and then you get things crossing the gut barrier into the bloodstream that shouldn’t have ever been there in the first place. Then the immune system mounts a response to those things as if they were foreign invaders, which they are, and you get things like autoimmune disease and inflammation.

Diane Sanfilippo: I’m hearing a little bit of feedback. I don’t know if that was mine. Okay. Cool, well, I talk about transit time a bunch in my seminars and with my clients, and that’s definitely an important factor. Just kind of keeping everything moving through. As far as what should really be happening, I guess I’ll take this quickly from a top-down approach. We’re going to talk a bunch about gut bacteria and all those kind of things, but maybe we should start with just chewing and stomach acid….

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And what kind of happens and when the breakdowns occur when those things are not kind of working properly. Whether somebody lacks certain enzymes, just from the get-go, off in their mouth and in their saliva, or what’s happening in the situation of low stomach acid or other issues that are happening just before we even get to the small intestine.

Chris Kresser:Sure.

Diane Sanfilippo:Do you want to talk a little bit about that?

Chris Kresser:Sure. The digestion starts in the mouth, as you implied, and we have enzymes like amylase that are produced in saliva. Amylase is the enzyme that’s required to break down starch, and so, just inhaling food without chewing is a really good way to have indigestion, as most people probably have experienced themselves, and that’s because the act of chewing and masticating food is what starts the secretion of digestive enzymes in the mouth, and then it also primes the pump further down in the digestive tract to get the digestive juices flowing.

One of the things I really emphasize with my patients is that digestion, as you said, is a top-down process, and if things don’t happen right at the top, then they’re not going to happen right further down, so…In other words, if stomach acid, which we’ll talk about in a second, is not being secreted properly or there is some issue with it, then you know, no matter how well things are working further down in the digestive tract, your digestion is going to be impaired.

So stomach acid, which is hydrochloric acid, it plays several roles, but in the context of digestion, one of the most, the main important role is that it’s primarily responsible for breaking down proteins, and then for turning solid food that we eat into a substance called chyme, which is solid food mixed with stomach acid, and it becomes basically the texture of, I don’t know, like mud {laughs} or sludge, or something like that.

Diane Sanfilippo: Mmmm! {laughs}

Chris Kresser: Yeah, very appetizing. But it’s required, you know, you need to break down the solid food into that consistency before it can pass into the small intestine. Another really important thing to understand is that if the stomach acid is sufficient, and the pH, or the acidity of the chyme is adequate, that’s the signal, once that chyme that is properly acidified passes into the upper part of the small intestine, that’s the signal for pancreatic enzymes to be produced.

Diane Sanfilippo: Mm-hmm.

Chris Kresser: So one of the things that happens with low stomach acid is that the chyme is not sufficiently acidified, and then when it passes into the small intestine, because it’s not acidified, it doesn’t send the signal to the pancreas to produce pancreatic enzymes. So that’s one of the reasons why I’m a bigger fan of when people are having digestive issues that are related to low stomach acid, this would be things like burping after meals, you know, within a relatively short time after meals, a feeling of distention or bloating in the upper part of the digestive tract, like right underneath the sternum and above the umbilicus; of people having symptoms like that, I prefer to use relatively higher doses of hydrochloric acid and skip the digestive enzymes in most cases because if you get the acid right in the stomach, the enzymes, you know, the pancreas will do its job and secrete enzymes in most cases.

Diane Sanfilippo: That’s very interesting. {laughs}

Chris Kresser: Yeah.

Diane Sanfilippo: Yeah.

Chris Kresser: Yeah, it’s a little known thing….

Diane Sanfilippo: Yeah.

Chris Kresser: Because I think in most cases, the problem is not with the pancreas’ ability to secrete enzymes, the problem is with the acid, the pH of the chyme.

Diane Sanfilippo: Mm-hmm. Right.

Chris Kresser: And if you get that right, then the pancreas will work. There are certain cases where yes, the pancreatic output of digestive enzymes might be lower than optimal, and I think digestive enzymes can be helpful in that case. But I prefer to try to fix the problem at the root and then let the body take care of the rest.

Diane Sanfilippo: Yeah, so I think one of the reasons I think this stuff is really interesting to me is that for some people who have been probably following my work or just kind of see what I’m up to. This past winter my dad had his gallbladder out. Which, I don’t have that specifically as a topic we’re going to cover today, but I’ve been really interested in it, and it’s something that I’ve tied back to his sort of health history. Just, you know, parents don’t tell you what’s wrong, but just kind of watching over the years the meds that they would take or self-medicating with antacids. I’m recognizing that he’s probably had this issue with stomach acid for pretty much forever, recognizing that that, like what you’re kind of saying now, kind of led to an attack of pancreatitis for him. And he had all these other issues going on with the gallbladder and whatnot, but just recognizing the whole upstream effect of not having food properly broken down to send all of the right signals, and I think that that’s really interesting that that bolus of food having the right pH is what sends the right signals.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: I love that. That to me is a nice little light bulb moment. Like okay, so what are the pieces? What is the upstream effect? And then the downstream effect of when that isn’t working properly, so I think that was really interesting.

Chris Kresser: Yeah, we should probably talk a little bit about why people’s stomach acid would be low in the first place….

Diane Sanfilippo: Yeah.

Chris Kresser: Because it’s a pretty ubiquitous problem. I would say, just as a back of the napkin estimate, I would say probably 60% of my patients have low stomach acid when they come to me. And it’s really all ages across the board. I mean, I even see it; I work a lot, of course, with kids, and even infants through my work with The Healthy Baby Code, and I think that that’s even a problem in infants, and it’s one of the main causes of reflux in infants. But in general, we could break down the causes of low stomach acid into insufficient production and suppression.

Diane Sanfilippo: Mm-hmm.

Chris Kresser: And suppression would be caused by things like acid-suppressing medications, you know like the over the counter stuff and then the PPIs that are kind of handed out like candy these days. And you know…

Liz Wolfe: PPIs being Proton Pump Inhibitors.

Chris Kresser: Proton Pump Inhibitors, yeah, sorry. So they’re like Zantac-actually, Zantac is an H2 agonist, but Prilosec is probably the most prescribed PPI. They’re among the most popular drug class today, you know, billions of dollars a year for the pharmaceutical industry. They’re so effective that they suppress stomach acid production almost to zero in some cases.

Diane Sanfilippo: Mmmm. Wow.

Chris Kresser: So that’s why-

Diane Sanfilippo: Yeah, they gave my dad one of those after his gallbladder surgery.

Chris Kresser: Right.

Diane Sanfilippo: Awesome. Yeah. I mean, the stuff, yeah, it’s horrible.

Chris Kresser: And originally, when they were first developed, and actually if you look on the labels, they’re not supposed to be prescribed for long term. They’re only supposed to be like a 10 to 14-day period, you know?

Diane Sanfilippo: Yeah.

Chris Kresser: So now they’re prescribed, and I’ve had patients who have been on them for 20 or 25 years. You know? I mean….

Liz Wolfe: Wow.

Diane Sanfilippo: Yeah. I know someone in their 30s, who was prescribed it and said, “you’ll be on this for your whole life.” I was like, that does not sound like a good idea at all.

Chris Kresser: In my opinion it’s bordering on malpractice, you know? Because….

Diane Sanfilippo: Yeah.

Chris Kresser: When you really understand the importance of stomach acid-we’ve only touched on the basic functions, you know. Stomach acid, in addition to breaking down proteins, is also required to digest minerals, like iron and vitamins like B12. So if you don’t have stomach acid, you’re on the road to vitamin and mineral deficiency, which can cause serious problems. And then it’s also required to protect us from pathogens like parasites, bacteria, yeast, and mold. So if you’ve got almost no stomach acid, you’re far more likely to have intestinal infections.

So anyways, it’s a big deal, and getting back to the things that cause low stomach acid; we have medications like PPIs, but other medications like antibiotics, which can profoundly alter the function of the digestive tract can do it, and we have probably the biggest cause of low stomach acid, especially in the elderly is H. pylori infection, which is the bacterium that causes ulcers. And one of the nifty survival strategies of H. pylori is that it suppresses stomach acid. Cause as I just said, stomach acid is what protects us from pathogens as pathogens can’t survive in an acidic environment. But H. pylori is pretty smart, it’s been around for a long time, so one of the ways that it survives in the stomach is that it suppresses stomach acid. {laughs} Good for it, not for very good for us.

Liz Wolfe: Man {laughs}.

Diane Sanfilippo: Smart little bugger.

Chris Kresser: Yeah, exactly. And we know that like once people reach their fifties or sixties, their odds of having H. pylori overgrowth are, you know, in some studies, 1 in 2.

Diane Sanfilippo: Hmmm.

Chris Kresser: And that produces atrophic gastritis, which is a condition where stomach acid production is really impaired. And then the third, I think, major cause of decreased stomach acid production chronically is stress.

Diane Sanfilippo: Mm-hmm.

Chris Kresser: So in the acute situation, like acute stress, you’ll actually see an increase in stomach acid production, which is, you know, a lot of people might have experienced if they’re going to speak publically or something, and they notice some burning in their stomach or an increase in stomach acid production. But over the long term, it decreases stomach acid production. So stress, the use of PPIs, and an H. pylori infection are the 3 biggest, and they’re very, very common.

Liz Wolfe: So, I have a quick question, if I could jump in.

Diane Sanfilippo: Go for it.

Liz Wolfe: Because I think this is appropriate. I think a lot of us that follow you, you know, your Facebook page and at ChrisKresser.com, know that you just had a little one of your own.

Chris Kresser: Yeah, They were in the background just now.

Liz Wolfe: And I can hear her sweet voice in the background, but you mentioned that one of the things that you see in the little ones, even, is suppressed stomach acid and stuff like that. And just as far as the digestive tracts of the little ones and feeling that gut, can you just speak to that real quick, about what you’re working with children and stuff like that?

Chris Kresser: Yeah. I think in a lot of cases what happens there is an infant’s development of their digestive function is largely dependent on the gut flora of their mother. So if mom has a messed up gut, it’s pretty likely that baby will have a messed up gut. And that’s unfortunate because a lot of people have messed up guts. And, everyone’s doing the best they can to resolve that problem, but it’s not always possible. You know, people aren’t always able to resolve it before they get pregnant and give birth.

Liz Wolfe: Mm-hmm.

Chris Kresser: And then you’ve got, you know, in the case of a c-section, the first exposure to bacteria and the colonization of the infant digestive tract happens in the birth canal, which only obviously happens with a vaginal birth. It doesn’t happen with a c-section. With a c-section, the first exposure of the baby’s gut to bacteria is the hospital environment, which contains a lot of bacteria that you don’t necessarily want to be exposed to. And the baby’s gut in utero is completely sterile; there’s no bacteria in it at all. So the first bacteria that they’re exposed to really sets the tone for how their gut flora is going to be for the rest of their life, which is pretty serious. The studies have shown those initial first few days actually can predict things like rates of obesity when kids are 7 or 8 years old, and their predisposition for autoimmunity and asthma and allergies, and things like that.

So in infants, if there’s anything like a c-section or mom has a messed up gut, or autoimmunity or something like that, then I think that changes the gut flora, that changes the way that stomach acid is produced, and then that can lead to reflux, and unfortunately one of the main, you know, even infants now are being prescribed PPIs….

Diane Sanfilippo: Mm-hmm. Mm-hmm.

Chris Kresser: Because reflux is, it does have consequences. The acid going up into the esophagus can damage the esophagus and cause problems, and so people are understandably concerned about that, but the really sad thing about the way that it’s treated is if you give an infant PPIs, as we just discussed, they’re never going to be able to digest their food well, and that’s going to actually worsen the reflux because it will produce gas that presses up against the lower esophageal sphincter, and then whatever acid still is in the stomach will get up through that opening and still get into the esophagus. Not to mention that these babies will be way, way more vulnerable to infection. In fact, I just had a consult with a mother a couple of days ago on her baby. We did a stool test on her two-year-old and the two-year-old had two different parasites, 3 different types of opportunistic bacteria….

Diane Sanfilippo: Wow.

Chris Kresser: And a yeast infection.

Liz Wolfe: Oh my gosh.

Chris Kresser: And this is a two year old. You know? And she had been on PPIs since infancy. And I think that’s exactly why this happened.

Diane Sanfilippo: Do you think for people who’ve kind of already been past the, well, I’ve already had a c-section, you know…I guess two sort of follow up questions is one, is there something that people who, if there could be an emergency situation, you kind of planned all the right things, and then you still ended up having the c-section, even if you were planning an at-home, natural birth, something could kind of go wrong. Is there sort of a backup plan of like, hey, here’s what to do right away to help inoculate that infant?

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And then secondarily, the people who are dealing with; okay, I had my baby a year ago by c-section, I haven’t thought about any of this, is there something that they can be doing now? Because those are the people, you know, I feel like people who are listening to everything that we’re educating on, are very well aware of a lot of these things that we’ve discussed already, and I feel the most compassion for those who feel like, oh my God, I didn’t do that. So now what? You know?

Chris Kresser: Yeah.

Diane Sanfilippo: Now what can I do to give my kid the best shot possible? Because even sitting here, I’m pretty darn sure I was not breastfed.

Chris Kresser: Yeah.

Diane Sanfilippo: I mean, we were like this whole generation of…

Liz Wolfe: Mm-hmm. Same here.

Diane Sanfilippo: formula and then possibly even soy formula, and it was like, well {laughs}. We’re all kind of on an uphill battle. So what is it that people can kind of do, either right away, you know if you have a backup plan, you get a c-section and some way inoculating and then potentially, you know, within that first couple of years or even if someone’s dealing with a child.

Chris Kresser: Yeah. Yeah, so I’m glad you brought that up because it’s true. I mean, c-sections can be a life-saving procedure and we’re lucky to have that ability when it comes to that. And a lot of women, you know, like you said, do all the right things and they have a natural childbirth plan and then they end up having to have a c-section for whatever reason. In those situations, I do recommend that right after birth they start with a multi-species probiotic. The one I use in my practice is called Ther-Biotic Infant, which is from Klaire Labs, and it’s really, really important not to administer the dose that they recommend on the bottle, which is a quarter teaspoon, because that could cause fulminant diarrhea and severe digestive distress. It’s really, really potent. I don’t know why they recommend that dose. I’ve written a letter to them and talked to them about it, but it’s just crazy.

What you want to do is lightly dust the nipple, presuming breastfeeding, which is also another really important thing, I’ll come back to that. But you would lightly dust the nipple maybe twice a day before a feeding with this, because it’s a powder. And then the baby gets the probiotic that way. There are a number of strains that have been shown to be beneficial, particularly for infants, like bifidobacterium infantis in this formula, and it can help colonize the digestive tract with good, healthy bacteria.

Another important thing that I just alluded to is breastfeeding. Breast milk has bacteria, probiotic bacteria in it, and is also a really important way of colonizing the digestive tract with good flora. And then, you know, mom just making sure she’s doing the things to support her own health and bacterial balance, like following a Paleo type of diet, Primal/Paleo type of diet, and avoiding food toxins and taking probiotics herself is another important step. I think in general, mothers who’ve had c-sections just have to be that much more careful about their own health and their babies, you know, what they feed their babies as their babies grow because there may just be a little bit increased sensitivity, you know, because of the c-section.

Liz Wolfe: Mm-hmm.

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3. Stress response and stomach acid production [32:21]

Diane Sanfilippo: Cool. One of the books that I’ve kind of grabbed and been studying over the last several years is Digestive Wellness for Children, and I don’t think it’s an all encompassing, every answer kind of book, but I do think it’s a nice handy sort of reference guide that’s accessible for parents. I don’t know, have you seen this book? By Lipski?

Chris Kresser: By Lipski?

Diane Sanfilippo: Yeah.

Chris Kresser: I know Lipski’s main book, you know, Digestive Wellness, but I haven’t seen that one.

Diane Sanfilippo: Yeah, so you know, she doesn’t follow all the same things that we do necessarily about every group of foods to either include or not include, but I think that her approach is very accessible, so if people, you know, are kind of beyond where they haven’t checked out. If they’ve already had a baby and they haven’t gone through Healthy Baby Code and learned more about that, if they’re kind of…Like actually Digestive Wellness for Children is a book I’ve given to a handful of my friends when they’ve had a baby, and they’re like, [sarcasm] wow, thanks, great [laughs]. You know, like…

Liz Wolfe: Worst shower gift ever.

Diane Sanfilippo: Right? I’m like The Giving Tree and Digestive Wellness for Children. And you’ll thank me later, you’ll look through your bookshelf when your kid’s got an infection and a rash.

Chris Kresser: Yeah.

Diane Sanfilippo: And realize that probiotics or maybe prebiotics, I don’t know if there’s much to that too, but just getting that kid sort of inoculated with these bacteria that are beneficial is so, so critical. I mean, I feel like most kids who weren’t born in a perfect situation are probably at some disadvantage already.

Chris Kresser: All of us, like you pointed out.

Diane Sanfilippo: Oh, exactly. So ok, we’ve kind of veered off track a little bit because we can very easily get into a million tangents and we’re excited about all these topics, but I’m just quickly going to come back to stomach acid, and then I want to move on to some questions around gut flora. And a lot of this is, we talk about these things, like ah, low stomach acid, but I like kind of delving into the whys and the what to do about it. But one thing about the stress response that you were mentioning, like a stressful situation or chronic stress, even acute stress causing that low stomach acid…

Chris Kresser: Mm-hmm.

Diane Sanfilippo: Or suppressed stomach acid, would that be essentially just the body’s own response, of like the fight or flight mode, where, I know we talked about people training, and you’re like, well, I tell people try not to eat too close to when you’re training because your body moves from parasympathetic to sympathetic mode, where essentially you go from rest and digest to fight or flight…

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And so it is it kind of what’s happening where people are in this moderate, chronic level of fight or flight, even if it’s not to that level 10, they’re sitting at this like level 4 or 5 of stress all the time, and that’s kind of what’s suppressing it, where they’re almost in fight or flight like all the time?

Chris Kresser: Yeah, that’s the way I explain it to my patients. I mean, on a mechanistic level, it has to do with cortisol disregulation, but in the simplest way of explaining it is that we only have two nervous system states: it’s sympathetic and parasympathetic, and only one can be activated.

Diane Sanfilippo: Right.

Chris Kresser: So if you’re in a chronic state of low level stress, you’re in a chronic sympathetic arousal state, and that means that your body will be prioritizing everything required only for immediate survival, which is basically marshalling the resources you need to fight or flee…

Diane Sanfilippo: Mm-hmm.

Chris Kresser: So like sending blood to your lungs, you know, pumping more blood to your skeletal muscles, increasing your blood pressure, doing all of the things that will help you to survive a threat. But at that same time, it’s diverting resources away from things that you need for long term survival, like reproductive function, digestive function, tissue regeneration and repair. So, stomach acid production and peristalsis and gut health aren’t necessary when you’re running away from a lion or…

Diane Sanfilippo: {laughs} right.

Chris Kresser: You know, in a fight to the death. So your body doesn’t really care if you’re digesting the food that’s in your gut at that point, because it makes no difference to your survival in that moment.

Diane Sanfilippo: Yup.

Chris Kresser: So I mean, that makes sense when you’re actually running from a lion, but if you’re sitting in traffic, you know, and that same response is going on, your life’s not really in danger, but your body doesn’t know that and it reacts in the same way.

Diane Sanfilippo: Mm-hmm.

Chris Kresser: Because there hasn’t been enough time from an evolutionary perspective to evolve a different response.

Diane Sanfilippo: Yeah, so this is one of the things that one of my teachers back in school used to always talk about. Her name is Laura Knoff, and she was really, really big on the whole, sit down and eat, kind of chill out, come home, decompress, do what you need to do. Which is actually one of the interesting things I think about, the concept of cooking versus just reheating something and within two minutes you’re eating and you may not even had time to shift modes.

Chris Kresser: Right.

Diane Sanfilippo: I think that the process of cooking and then sitting down to eat a meal, and hopefully with someone else to slow that down even further, is even farther upstream from chewing. It’s just this whole process.

Chris Kresser: Yup.

Diane Sanfilippo: You know, and, what’s the word, anyway just the whole eating process to make it a way to reducing stress.

Chris Kresser: Your relationship with food.

Liz Wolfe: Mm-hmm.

Diane Sanfilippo: Yeah, and sort of your food hygiene in a sense, and I don’t mean that in a cleanliness way, but just your rituals and how you kind of approach eating.

Chris Kresser: Yeah.

Diane Sanfilippo: So many people are walking and eating, and on the go, and it’s like Step 1, calm down.

Chris Kresser: Or driving and texting and eating at the same time.

Liz Wolfe: {laughs}

Diane Sanfilippo: {laughs} That’s like a danger from all directions.

Chris Kresser: {laughs} Yeah.

Chris Kresser: Yeah, natural selection will take care of those people. [laughs]

Liz Wolfe: {laughs}

Diane Sanfilippo: Well, you know, a cool thing you mentioned, too, is that our brain hasn’t necessarily caught up to the fact that this stress is not like, we are not in danger of death potentially when we have these stressors.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And I think a really cool sort of; you know, I haven’t studied much about meditation, yet, it’s kind of on my list. But even just something that I’ve noticed that I’ve tried to teach myself in the last couple of years was, if I’m sitting in traffic, just chill out. Put the radio on. There’s nothing you can do about it.

Chris Kresser: Yeah.

Diane Sanfilippo: And just try and actually feel the difference in your body’s sort of level of…I call it like a vibration, you know when somebody comes towards me, who, their energy level is just super high, I feel like they’re buzzing. You know?

Chris Kresser: Mm-hmm.

Diane Sanfilippo: Chris is like the opposite of somebody who’s buzzing. {laughs}

Chris Kresser: {laughs}

Diane Sanfilippo: Like you go near him, and I was calm next to somebody else, I’m like wow, I feel like a bumblebee next to Chris. {laughs}

Chris Kresser: {laughs}

Diane Sanfilippo: Because wow, that guy is so chilled out.

Chris Kresser: Yeah.

Diane Sanfilippo: Not to mention, the first time we met I was kind of nervous, I’m like; this guy is really smart, I don’t know what to say. No. But yeah, I think part of it is really just that self-awareness of when we’re having a heightened reactivity to sort of nothing, like people have these conversations and they’re, sometimes the tone in their voices is all stressed out, and you’re like, why are you stressed out? You’re not even talking about something stressful. {laughs}

Chris Kresser: Yeah.

Diane Sanfilippo: I feel like those are all, you know, they seem to not be important, but then when you look at who’s kind of experiencing these problems, you notice that the people who are generally less stressed out all the time or seem to be managing that better, don’t sweat the small stuff, they don’t have as many of these problems. It’s not a coincidence.

Chris Kresser: Oh, it’s not at all. I mean, I completely agree with you 100%. And I know, I’m always’ I feel like a broken record, and I’m always kind of harping on this, but I see it every day in my practice. The number one reason that people have trouble healing is that they’re not managing their stress. And it’s not because they don’t have their diet perfectly dialed in, it’s not because they’re not exercising the right. I mean, of course all those things are important, but I’m just saying, like in most cases, presuming you’re doing, you know, most of the people listening to this show are already somewhat aware what they should be doing, with diet and their exercise plan is probably already pretty good, and they’ve got those basics down. But my guess is that a lot of people aren’t really doing anything at all for stress management. Because it’s hard….

Diane Sanfilippo: Yeah.

Chris Kresser: It’s easy comparatively to take a new supplement…

Diane Sanfilippo: Yup.

Chris Kresser: Or even to change your diet because it doesn’t really require you to completely change your relationship to life.

Diane Sanfilippo: Yup.

Chris Kresser: Whereas, stress management, like slowing down, and sitting down and eating and chewing and maybe not watching TV or reading something while you’re eating, and just focusing on your food and how it tastes and feels in your mouth. That requires a big change and it requires facing whatever feelings you’re experiencing at that time, which you’re maybe trying to avoid by reading or watching TV while you’re eating, and you know, it’s hard. It’s really difficult to do. And so, I think a lot of people tend to just have a blind spot there, and they tend to ignore it, and I see huge, huge changes, just in my personal experience, when I started to pay a lot more attention to that stuff, and I see it with my patients, too, when they make that commitment.

Diane Sanfilippo: Yeah, and I think, credit to all of our readers and listeners that when they give us questions, they’re extremely detailed. But I feel like there’s a sense that you can get either from just that question or sometimes even from your first initial consult with a person or your first meeting with them, the way that they sort of unload the problem….

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And like, they’re just so at their wits end and giving you every detail of every stress, and that’s great because we need that to help figure out the problem, but right there that tells you what is that person’s relationship with their stress even. You know? We could get into a million things on this, but I feel like also, people are more willing to add something than to take something away. You know, like this whole do less or less is more, and what can you remove from your life or stop doing versus like what you said, you know, adding a pill and they’re quick to do that. But asking them to stop working 14 hours a day, or to get a different job or to remove something from their life is usually a lot more challenging.

Chris Kresser: Absolutely.

Diane Sanfilippo: We’re really good at cramming it all in.

Chris Kresser: Yeah, and I mean, I still struggle with it myself, especially having a 12-week old baby and, having a full time practice, and a blog, and a podcast, and a couple of online programs that I’m doing. It’s a lot to fit in and it’s a daily practice for me.

Diane Sanfilippo: Yeah.

Chris Kresser: It’s a moving target, it’s a constant readjustment and shifting of my relationship to those things and a constant reminder to myself, that I won’t even be able to do all those things if I don’t take care of my body and leave some time to just decompress and connect with myself and with the people that matter to me, and to leave some time for enjoying life.

4. Small intestinal bacterial overgrowth (SIBO)[44:22]

Diane Sanfilippo: Yeah, absolutely. So that was kind of our full-blown approach at stomach acid. I think that’s really important for people to hear, and to hear too that these are things that we take seriously, you know, in dealing with our own lives and with our clients and patients. But let’s kind of keep moving on sort of this whole process. You know, we talked about the upstream and the stomach acid. Let’s get into some topics around healthy gut flora and even before we hit that, if we’re kind of continuing on the track that we go from the stomach to the small intestine, kind of what’s happening as the food passes from there, and maybe a little bit of process, and then a little bit of problems, and I think, Small Intestinal Bacterial Overgrowth or SIBO, I don’t know how you pronounce that as an acronym, just kind of some issues that can arise with that.

Chris Kresser: Mm-hmm. Okay. So the small intestine; this is, if the stomach is where the food gets mechanically broken down and mixed with acid to form chyme, the small intestine is where, in Chinese medicine, they say it’s where the pure is separated from the impure. And I actually like that description because it’s….

Diane Sanfilippo: Yeah, that’s very cool.

Chris Kresser: Easy to understand for most people and that’s exactly what’s going on. So it’s a process of breaking down longer-chain carbohydrates, for example, like starch, which is a chain of several glucose molecules. That needs to be broken down into disaccharides and monosaccharides, which are two glucose molecules in the case of the disaccharide, or one glucose molecule in the case of a monosaccharide. In order for a nutrient to be absorbed, like a carbohydrate to be absorbed into the bloodstream and to fuel cellular processes, it has to be broken down into a single molecule. And that’s what happens in the small intestine. And the brush border enzymes, which are these enzymes that are present on the villi, which are these little hair-like projections on the lumen of the intestine, the surface of the small intestine, those enzymes do that heavy lifting for us and then we can absorb the sugar from the carbohydrate and take it into our body.

One of the things that; I mean, there’s a lot that can go wrong in the small intestine. You know, one of the main things is, just from a general perspective, that that breakdown doesn’t occur properly, and so you get, instead of those longer chain molecules being broken down into the single molecule components, they stay in the longer form, and they kind of hang around in the small intestine for a lot longer than they should. And then they become food for pathogenic gut bacteria that are already in your gut. So we have over five hundred species of bacteria in our gut, and some of them are beneficial, and some of them are not. And just like in any ecological system, it’s all about the balance. You know, there’s always going to be some good and some bad, and as long as the good outweighs the bad, then you don’t really have a problem.

But what can happen is if those food particles aren’t broken down completely, they start to selectively feed the bad bacteria in the gut, and then the bad bacteria can become overgrown. And that’s what you see in SIBO, which is Small Intestinal Bacterial Overgrowth. Normally, we shouldn’t really have that much bacteria in the small intestine except for at the very end of it, in the terminal ileum. The vast majority of the bacteria is in the colon. But in Small Intestine Bacterial Overgrowth, you get an increase in bacteria in the small intestine, and those bacteria can produce gas when they ferment the food in the small intestine, and then you get gas and bloating, and changes in stool frequency and consistency that are characteristic of SIBO.

So the small intestine is really where most of the action takes place in the digestive tract when it comes to absorbing nutrients from food, and it’s where a lot of the problems occur. A lot of the parasites that infect us are in the small intestine, because they’re trying to siphon away the nutrients that we would otherwise be digesting at that point.

Diane Sanfilippo: Right. So is this, what’s happening with SIBO, is this sort of a parallel problem to leaky gut? Because leaky gut is more of an issue of what’s getting through.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And what’s getting through undigested and sort of then hitting that immune layer and causing a response from our body. But if this is sort of just a low enzyme situation, or, what is it that sort of, I guess causing…I guess it’s more of that upstream issue of if the pancreatic enzymes aren’t secreting properly then what you’ve got happening in your small intestine would be an even further passing of that, okay, we still don’t have enough enzymes, and so now a lot of this food isn’t going to be continuing on its way properly….

Chris Kresser: That’s right.

Diane Sanfilippo: Does that kind of make sense?

Chris Kresser: Yeah.

Diane Sanfilippo: I’m always trying to put the pieces together, forwards or backwards, for, what does that mean for why it’s happening and what can people do? Besides; okay, they’re doing everything in the upstream, is this the point at which we’re concerned about more gut pathogens and getting stool testing done to see what’s happening there, and potentially killing off some of what’s there even though we don’t want to be taking antibiotics as an overly preventative, precautionary hyper-reactive approach, but is this where we do to look at doing that kind of testing and then potentially launching an attack on some pathogens to then reinoculate with beneficial bacteria. Or I guess we’re not dealing with bacteria at this point, as much, at the end of it…

Chris Kresser: Yeah, well…

Diane Sanfilippo: I’m asking you a million questions. {laughs}

Chris Kresser: Yeah, I’ll try to go through all of those. First of all, in the gut, and I think this is true for health in general, the more I work with people, the more I understand, the less I am looking for a linear chain of causality, because I think in most cases, it’s much more cyclical than it is linear.

Diane Sanfilippo: Yeah.

Chris Kresser: So an example of how that might play out in the gut is, let’s say your stomach acid is low. So you’re not digesting your food well in the stomach, and then the pancreatic enzymes don’t get produced, so you’re not breaking down the food in the small intestine well, and then it sticks around and it gets fermented by bad bacteria and produces gas and distress. Then that distress causes an inflammation, which will also predispose you to being more susceptible to bacterial infection or a gut infection. And then you get a gut infection, and then that gut infection makes you break down foods even more poorly, which then causes further inflammation and makes your gut permeable, which then causes an autoimmune response that continues to provoke chronic low-grade inflammation in your gut that makes it even worse at digesting. You know what I’m saying? Just like….

Diane Sanfilippo: Yes. No, I get what you’re saying. It’s not a linear process and I’m with you, like its self-feeding and self-fulfilling once one chain of events sort of starts. It’s all systemic from there, but I guess it becomes, well, how do you sort of unwind that? Or how do people unwind it, at least in what they can do themselves? And then at what point is it, look, this really is beyond you can handle on your own. A lot of the questions on your blog were really, really detailed; people have been doing everything they can, and I almost want to give people that out. Like, look, you’ve done everything you can at home. You need to get some testing done or you need to see a practitioner about this because you will continue to just spin your wheels. So that’s as linear as people can be. Then they have to hit a point where they’re like, ok, well, I don’t know where this came from. You know?

Chris Kresser: Yeah. Right. So SIBO, one of the things that you can, I mean, there’s a couple different ways to treat it once it’s already present. I mean, first of all, the sort of standard test for SIBO is the lactulose mannitol test, where you basically drink sugar, a form of sugar, and then you blow into a bag, and they measure the gases in that bag. And if you have a certain percentage of certain gases, then that tells them that you’ve got an overgrowth of bacteria in your small intestine. So if you establish that you have that through that testing, then the options are to either kill the bacteria with some kind of antimicrobial agent, either an antibiotic or botanical medicine, which I prefer to use in my practice. Or, you starve them, and that’s the premise of the GAPS diet.

The GAPS diet; you know, earlier I said with SIBO is that those longer chains of sugar molecules don’t get broken down properly and they become food for pathogenic bacteria, and those bacteria get overgrown and that’s SIBO. So the GAPS approach is to remove those longer chain molecules. So, the GAPS diet doesn’t include any polysaccharides or disaccharides. So no starch, no starchy tubers, which are a part of the Paleo diet of course, like sweet potatoes, or yams, or taro, or plantains, or yucca; those are not permitted on the GAPS diet because they’re starch, which are long chain sugars. And then disaccharides like lactose, you know, that’s found in milk and other disaccharides are also not included. So essentially, the GAPS diet is trying to remove the food source for the bacteria in the small intestine. And in that way, starve them so that they die and the bacterial overgrowth is resolved.

What I can say from my experience is that, you know, refaximin, which is the drug often used to treat SIBO, does tend to be effective for most people; but for a lot of people, it’s only effective for a short period of time. In other words, they take it, they feel better, but then 2, 3, 4 weeks later, they’re back to where they started. And in general, I think that’s one of the problems with the pharmaceutical approach is that, you know, it kills the bacteria, but it doesn’t necessarily do anything to restore a healthy balance of bacteria, and if there aren’t corresponding dietary changes, then the effect is usually not permanent.

Diane Sanfilippo: Yeah, well, that makes sense that if you’re trying to sort starve the bacteria and potentially kill them at the same time, that one positive side of things would be if they all had a prescription that included the antibiotic and the second course was a probiotic, you know.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: And is that something that, if we’re not going to escape this medical model, if there was a way, not that I want them to really have full control over what’s happening with probiotics and not have them available just kind of mass market, you know, that could be one way, but people can do that on their own, if they do even go through that route of dealing with antibiotics. And natural sort of botanical antibiotic agents, things that I tend to use sometimes if I feel like I might be getting a nasty bug and just make sure I always kind of follow it up with more probiotic content, things like oil of oregano, is that something that you use sometimes or…

Chris Kresser: I’m cautious with that….

Diane Sanfilippo:Yeah. It can be a little too much.

Chris Kresser: I do sometimes use it, but yeah, I just want to emphasize that the aromatic oils like that, like thyme oil and oregano oil, they’re actually used in the food industry to kill pathogens over antibiotics because they’re stronger; they have a stronger effect.

Liz Wolfe: Wow.

Chris Kresser: They’re very effective, but I actually feel nervous about recommending them often to people without supervision because they can actually, I think, have an even more profound effect on the gut flora. Because often when people take antibiotics, they just take them for a week or something, right? Or ten days.

Diane Sanfilippo: Yeah.

Chris Kresser: But a lot of people when they take these spice oil blends, they’re taking them for weeks or even months because they figure, hey, these are natural.

Diane Sanfilippo: Yeah.

Chris Kresser: They must be safe.

Diane Sanfilippo: Yeah, if I have ever used it, it’s for a day or two, a couple of drops in some water and that’s really it. I mean, I personally find that to be effective, but I wouldn’t want someone to go crazy with it, but literally, like drops, not spoonfuls of it.

Chris Kresser: Yeah. I think that’s an appropriate use of it, for that dose and that amount of time is an appropriate use of that.

Diane Sanfilippo: Yeah.

Chris Kresser: But I would avoid using it for weeks or months.

Diane Sanfilippo: Yeah, I hate the taste of oregano anyway, {laughs}

Chris Kresser: Yeah, that’s really intense.

Diane Sanfilippo: You smell like you ate an entire pizza, so. But yeah, I do because you know, I’m always looking for more natural remedies, and when you kind of have something that you think might be a little gnarly, especially traveling so much, but anyway. People do pick things up this way and, not that I ever want to send people off with a hey, here’s a protocol that works for everyone but I feel that before people jump to go running to get drugs, knowing that a simple, very limited dose of something that’s natural could be more beneficial and kind of thwart something before it becomes a big problem versus ongoing use and, yeah, dose and duration is always critical. {laughs}

Chris Kresser: Yeah, and there’s the diet part, too, which we meant; so if you do the anti-microbials, you do the probiotics, and then you add removing the foods that feed the bacteria by doing something like the GAPS diet, you know the Intro part of the GAPS diet for a period of time, then that’s the sort of triple whammy approach.

Diane Sanfilippo: Right.

Chris Kresser: Interestingly enough, some of the earlier studies on SIBO looked at the Elemental diet as a possible treatment and it worked very, very well. And I don’t suggest that people do the Elemental diet because it’s basically powders, schwaggy powders mixed with water. {laughs}

Diane Sanfilippo: {laughs} Yeah.

Chris Kresser: But the premise of it explains why the GAPS Intro can work, because an Elemental diet, it just has amino acids and simple sugars that are already broken down into single, monosaccharides, so it’s all absorbed directly in the upper part of the small intestine, so it never reaches the part of the small intestine where the bacteria are. So people, even just after a week of doing an Elemental diet, all of the SIBO is gone.

Diane Sanfilippo: Mm-hmm.

Chris Kresser: So that’s the premise that the GAPS diet is based on, and I have mixed feelings about the GAPS diet, and maybe I’ll have time to get into that or maybe I’ll cover that on my show. I use it in my practice, it’s effective in certain conditions, but I think as you could see from some of the questions that were left on my blog and maybe on yours, too, it’s not appropriate in all circumstances.

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5. FODMAPs [1:03:10]

Diane Sanfilippo: Let’s kind of move through a couple of other questions and then we can kind of loop back if we need to, as I just have a couple of other things that I think are pretty related to kind of cover. The issue of FODMAPs digestion.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: It sounds like this is very, very similar to the SIBO situation. We’ve got monosaccharides, disaccharides, ogliosaccharides that are not-polyols that are not being digested properly, and I’ve seen a bunch of clients recently who feel a lot of relief from removing all of the foods that are in that group, and it sounds like probably GAPS diet is most of that same protocol. I haven’t kind of cross-referenced them. But you know, these people are having trouble digesting a whole host of foods, I mean its so many different kinds of foods, different plant foods. So we’ve kind of already talked about why that might be happening, right, it sounds like this is some of the root cause of that, but I’m just wondering if there are other causes of this same sort of lack of digestive process or if it’s really all kind of one, and those foods just happen to be the triggers.

Chris Kresser: Yeah, I think there is a similar cause. I don’t know that there are any specific issues that cause problems with FODMAPs that aren’t also involved in the other mechanisms that we’ve talked about. But I think that it’s partly like when people get sick, they tend to get sick in their own unique way. We all have our kind of weak areas, or parts of our body that are more likely to get injured or we have repeating injuries, and I think that the way that digestive problems manifest has something to do with that, you know, just what our genetic predispositions are and our unique history, and life circumstances, exposure to foods and environmental toxins, etc. so yeah, I don’t think that the causes are really different.

What I would say about FODMAPs intolerance is that I have also, like you, seen a lot of success in people removing those foods, and I think that my goal over the long term is to address the underlying mechanisms that are causing that intolerance in the first place in the hopes that they’ll be able to tolerate those foods at some point. I mean, some of the foods are not part of what I consider to be a healthy diet anyway, right?

Diane Sanfilippo: Right.

Chris Kresser: Wheat is a FODMAP.

Diane Sanfilippo: Right {laughs}.

Chris Kresser: So I’m never suggesting that people go back to eating wheat, but onions and garlic; you know, onions are a FODMAP.

Diane Sanfilippo: Onions and garlic are the biggest issues for people because they can’t dine almost anywhere and be that safe from those.

Chris Kresser: It’s very hard. Onions and garlic are absolutely the hardest part of the FODMAP diet because yeah, you can’t dine out or if you go to friends for dinner, you get any kind of prepared food, it almost always has some onions or garlic in it. So yeah, that’s exactly an example of why I would seek to deal with the SIBO, deal with the hidden parasitic infection or opportunistic bacterial infection that hasn’t been detected, deal with the leaky gut, deal with the stress that’s oversensitizing the gut, deal with whatever underlying mechanisms are present in the hopes that eventually you can start adding some of the FODMAPs back in that are part of a healthy diet. The other thing I’d say about that is that, in most cases, people are not equally sensitive to all of the FODMAPs. You know?

Diane Sanfilippo: Yeah, I’ve seen that.

Chris Kresser: Some people might be particularly sensitive to fructans and fructose, excess fructose. So fruits or any foods that have a higher percentage of fructose and glucose, like the stone fruits, or pineapples, some of the tropical fruits. But they might do fine with onions or garlic. Or maybe somebody’s really particularly sensitive to the polyols, the sugar alcohols, but they do okay with lactose in milk products. So the best thing to do is to remove all of them for 30 days, and then to try adding them back in, class by class, and see if you can narrow it down to which class do you have a problem with, so that it’s not unnecessarily restrictive.

6. Gut pathogens [1:08:16]

Diane Sanfilippo: Mm-hmm. So it definitely sounds like the same approach that we’ve been talking about with addressing all of these issues sort of collectively of, just getting our digestion working properly. When people do all of that; they’re checking it off, they’ve really worked on reducing stress, they’re sleeping better, they’re avoiding these foods, they’re doing it, right? They’ve kind of moved along, and they reintroduce some foods, and still are experiencing issues. Is this where, really doing that deeper testing. Sort of like, at this point you’ve done everything, like I was saying before, is this the point at which we say, okay, get some testing done, see if there’s something in there that is perpetuating this problem for you that you can’t just fix by changing diet and lifestyle when it’s gone beyond.

Chris Kresser: Yeah, I think so.

Diane Sanfilippo: Like gut pathogens…

Chris Kresser: Yeah.

Diane Sanfilippo: Can we talk about gut pathogens a little bit because I think we talk about it just as an out there, it’s an idea, it could be a problem. I’ve had some friends recently who have been dealing with some weight loss resistance where they’re like, I do everything right, you know? I eat a healthy diet, I’m not overtraining, I eat the right foods, and you know, come to discover they’ve got two to three different kinds of bacteria going on that need to be killed.

Chris Kresser: Yeah.

Diane Sanfilippo: Because they’re just feeding on whatever possible little bits of carbohydrate matter coming in. Yeah, so a little bit about how common it is, and maybe how people pick them up, whether or not that’s even super relevant, because I’m not sure we can totally avoid it. And then symptoms that people would have that would tell you, besides what we’ve talked about here that would tell you, this could be your issue.

Chris Kresser: Yeah, it’s pretty common. The approach that I use in my practice is, I put people on a gut healing protocol for 30 days, and if they don’t respond in the way that I think they should, then that’s a red flag for me to start looking for one of two problems. One would be gut infections, and the other would be a gut-brain axis issue, which you know, we probably don’t have time to go into today.

In terms of infections, we’re looking at different possibilities. We’re looking at opportunistic bacteria; so those are bacteria that are normal residents of the digestive tract and aren’t really problematic as long as they’re balanced by enough good bacteria, but can become overgrown when levels of good bacteria are low. And then we have pathogenic bacteria, which don’t really belong in the gut at all, and those can get into the body by food or liquid. And then we have parasites, and there’s some debate over certain parasites like Blastocystis hominis and Endolimax nana. Some doctors feel like they’re normal residents of the digestive tract and they don’t cause problems. Other doctors say, no, they definitely cause problems.

I think it’s a question, again, of the internal ecosystem. So you take somebody who has really healthy gut, really good, strong, beneficial gut flora, and if they have Blastocystis hominis and no symptoms at all, then it’s not necessarily a problem. And those people are out there. But if you take somebody who’s got poor gut flora, and they’re under stress, and their gut is not a good environment, then Blastocystis hominis can absolutely cause symptoms, and there are a lot of studies that support that.

And then you have fungal overgrowth; yeast and mold. And we have yeast as a normal part of the digestive tract, things like Candida, which I’m sure everybody’s heard of at this point. But, again, the beneficial bacteria keep the yeast in check, so when there’s insufficient good bacteria, the yeast can get overgrown. And then we can also get exposure to mold in buildings and just in the environment at large. So those are the main culprits, and if any of those are present, they’re kind of like deal breakers.

Because no matter what you do, no matter what diet you’re following, no matter what supplements you’re taking, what else you’re doing, if you have a gut infection, you’re not going to be at the top of your game and things aren’t going to work right because of these pathogens, for example, with bacteria, when they die, when the immune system kills them, which is always happening to some degree, they release lipopolysaccharide, which is an endotoxin, and lipopolysaccharide has been shown to damage the gut lining and make it permeable and cause inflammation, so you’d be in a chronic low-grade state of inflammation with a leaky gut. And even if you’re doing the GAPS diet and taking probiotics, and doing everything else right, it’s not really going to; I mean, it’ll help, but it’s not going to resolve the problem.

7. Weight loss resistant pathogens [1:13:58]

Diane Sanfilippo: Yeah. That’s kind of exactly what I was seeing in this one person that I’m thinking of actually, who just really doing everything right and just has been kind of dealing with that cycle. So we’ve got a little bit of time. We’ve got twenty minutes left that we can kind of chat for. But I wanted to ask about, obviously some ways that people can deal with healing some of these things, which we’ve talked about along the way, and also just in terms of the whole weight loss resistance and we’ve talked a lot about digestion and digestive discomfort. We know that that’s the first sign that people are having an issue with their digestion is any digestive discomfort, but a lot of times it shows up more as sort of this weight loss resistance, where they’re just actually resistant to losing weight in a way that seems natural and healthy. And I think, what you talked about, putting someone on certain protocol, the diet for a month, and if you’re not seeing issues become resolved at least somewhat, that’s the sign. I mean, that is the first step for people, that’s why we all kind of take this similar approach with diet. I like to tell people, it sort of levels the playing field. It gives us an even horizon to start with. At least we know it’s not because you’re eating 4 pounds of sugar a day. You know? {laughs}

Chris Kresser: Yeah.

Diane Sanfilippo: At least we know that stuff is out of the way. We’re getting rid of that stuff, so I can rule that out. But yeah, what kind of issues have you seen around how this connects to weight loss resistance or just that chronic state that people are like argh, I don’t know what else to do. And then what can they do further, if there’s anything else that you can kind of think of that we haven’t already talked about?

Chris Kresser: Mm-hmm. Well, weight loss resistance is definitely one symptom, and I’ll come back to that. I realize I didn’t answer your other question about what other symptoms..

Diane Sanfilippo: Oh yeah.

Chris Kresser: People experience with gut infections; there are quite a few. I mean, they pretty much run the gamut because any time there’s inflammation in the gut, there’s going to be inflammation elsewhere in the body, and that can manifest in; one of the most common problems is skin issues, like psoriasis and eczema, which are autoimmune in origin, and they’re really connected to a leaky gut. In fact, 30-40% of people with leaky gut don’t have any digestive symptoms at all, which is a little known thing, and it’s important to get that. Because some patients come, and they’ve got really bad skin issues and allergies and things like that. And I tell them they have a leaky gut, and they’re like, “what are you talking about? My digestion is perfect.” You know?

Diane Sanfilippo: Yeah. Yup.

Chris Kresser: But when we treat them for a leaky gut, they get better. So depression, I think, actually a lot of the recent scientific literature on depression suggests that it’s an inflammatory disorder. For example, inflammation in the gut releases inflammatory cytokines in the bloodstream, they travel up to the brain and cross the blood-brain barrier, and then they suppress activity in the frontal cortex, which is depression. So, I mean, it can really run the gamut.

In terms of weight loss, the main mechanism there is probably mediated by cortisol, so when you have a gut infection that causes chronic inflammation in the gut, and that activates the stress response, basically, and it throws your body out of homeostasis, which is that internal balance. And then, of course, inflammation itself is linked to weight gain and obesity and metabolic problems that are seen in the metabolic syndrome, like insulin resistance, and leptin resistance. There are studies that have shown that inflammation in the gut or inflammatory cytokines can suppress activity in the hypothalamus and the hypothalamus plays a really key role in regulating weight, so if the hypothalamus becomes leptin resistant, then that disregulates the whole body fat thermostat, you know. There’s been a lot of discussion about this on the Internet, in the blogosphere lately about the body fat setpoint. And that’s one way that a gut infection could contribute to your body thinking it should be heavier than it should be, basically.

In terms of what to do about it, the first thing is to identify what you’re dealing with. And the lab that I use in my practice for that is Metametrix. I use them because they use DNA PCR technology, which I think is more accurate than stool microscopy. Stool microscopy is where they put your stool under a microscope and hunt around for stuff. And as you can imagine, it’s kind of like trying to find a needle in the haystack.

Diane Sanfilippo: Needle in the haystack, yeah that’s exactly what I was thinking. Yeah, I use Metametrix, too.

Chris Kresser: laughs] Yeah. Yeah, and at Metametrix, all they need to do is find a little fragment of the organism, and they can then sequence the DNA to find out what it is. So I’ve had a lot of patients who have tested negative on a conventional stool microscopy lab tests, and then when we do the Metametrix test, we find something, we treat them for that, and they get better.

So the first step is to always identify what it is, and then the treatment really depends on what it is. The treatment for parasites will be different than the treatment for bacteria, which in turn will be different for the treatment of yeast. And if you’ve got multiple infections going at the same time, that dramatically complicates the situation. And that’s definitely one case where I would recommend picking up the phone and getting some help because self-treating in that situation can be downright dangerous.

8. The best nutritional approaches for gut healing [1:20:18]

Diane Sanfilippo: Right. So, how long do you think people should be dealing with working on their own issues, and I’m sure this is a huge array of answers, depending on the person. But, for the person who is like, Okay, I’ve been reading all this stuff, I’ve been listening, I’m kind of following this protocol or I’m trying GAPS, or I’m doing all these things, about how long? Do you think 30 days is enough time for that person to really try and approach this before they say, okay, what I’m doing isn’t enough, I should get some extra help. I guess that’s what people want to know. At what point is what is in their capacity already extinguished in a sense, like okay, you’ve been working on this, yes, you’ve been doing everything I would have told you to do for the last month, three months, whatever, now it’s time. We need to give people that power to do something, but then I just want to make sure that people who are listening kind of know that there is a point at which, all right, you can’t handle this on your own anymore. So what are some ideas about that?

Chris Kresser: Yeah, I would say if you do a 30-day gut healing protocol and at the end of that 30 days, you’ve experienced no change whatsoever, then that would be enough for me to suggest that they get some testing and take the next step. If you do a 30-day protocol and you feel some significant improvement, you’re not back to where you would like to be but you’re improving significantly, then I would say go ahead and keep going for another 30 days or another 60 days, and kind of reevaluate at the end of each month in the same way. Like if you’ve reached a point where you’ve plateaued, and you’re still not at where you want to be, and you’ve been strict with the protocol, then it’s time to seek some help.

If the problems are just related to diet, then they should resolve pretty quickly because the cells in the gut regenerate every three days, so the thing about the gut is that it can heal very quickly if the conditions are right for it. But the other thing about it is that if the conditions are wrong, it can never heal, so there’s some middle ground there.

Diane Sanfilippo: Right. So in terms of a protocol besides what we always talk about with food, and there can be a couple of different approaches for protocol on this depending on what people are feeling or experiencing, but pretty severe elimination diets are the first and foremost that we approach with a protocol for healing this.

Chris Kresser: Mm-hmm.

Diane Sanfilippo: Kind of beyond that, the idea of maybe getting in some more probiotic content, and I know some people are really into taking probiotic supplements. I’ve heard some people talk about them not being as effective because we may not even break them down at the right time in our system. What else would you say is involved in the at-home version of a protocol that people can approach easily? And then in terms of probiotics, pills versus things like raw sauerkraut and kimchi that we talk a lot about.

Chris Kresser: Yeah.

Diane Sanfilippo: Which may or may not work if you have an issue FODMAPs and you can’t digest cabbage properly. {laughs}

Chris Kresser: Right. That wouldn’t work. It’s complicated.

Diane Sanfilippo: But just kind of a general at-home, you know, what is that protocol and what might people need to add that they’re not thinking about?

Chris Kresser: By the way, I will say quickly that a lot of people that can’t tolerate raw or cooked, unfermented cabbage can tolerate fermented cabbage, even that are FODMAP intolerant.

Diane Sanfilippo: Cool.

Chris Kresser: Because I think the fermentation changes it in a way that’s more digestible.

Diane Sanfilippo: Breaks down that sugar, yeah.

Chris Kresser: So for me, a gut-healing protocol could be, you could do a Whole30 type of thing, or you could do a GAPS approach, but bone broth has to be in there somewhere. Whether you’re doing an elimination Paleo diet where you remove eggs and nightshades and dairy in addition to the standard Paleo approach, but you would definitely include glycine rich foods like bone broth and fattier cuts of meat because 40% of collagen is glycine, and collagen is a crucial nutrient for repairing the gut lining.

So bone broth, and then you could include a probiotic, either fermented foods, if you tolerate them well, like sauerkraut, or kimchi, or salrubin; beet kvass is another good one. The thing with fermented foods and probiotics, though, is you’ve got to start with a relatively low dose and increase slowly over time, because if you move too quickly, you can actually cause more problems than you solve. Any time you introduce a huge amount of bacteria in the gut, even if its good bacteria, it can cause discomfort.

And then, as we’ve talked about, I think stress management has to be part of that protocol as well, and it’s not really complete unless you’re doing that. I like mindfulness based stress reduction. Go to Mindfulnesstapes.com, and order series #1, it’s a good series, it’s got the Body Scan, which is a progressive relaxation, and a guided yoga meditation. And then there’s a Rest Assured program. It’s under Sleep.com that I like as well. Those are the basic elements, and at the end of that 30 days, if you’re really not making progress, then it’s probably time to dig a little bit deeper.

Diane Sanfilippo: Mm-hmm. Cool. Well, you know, those are things that people can kind of contact you for. People like myself, nutrition consultants, who have different certifications who can order stool testing. Those are things that we all have access to, so you know if people are experiencing trouble with that, we might be able to help out or at least get the testing done and be able to refer them if they need to see an MD or an ND and kind of address it further.

But yeah, so we just have a couple of minutes left, and I just wanted to quickly talk about some other projects. I think we’ve pretty well exhausted at least topics of digestion for today, though I’m sure we could really talk about this for weeks on end.

Chris Kresser: Yeah, I’m getting a-

Diane Sanfilippo: Is there anything else you want to talk about from your side?

Chris Kresser: I don’t think so. I did get a lot of great questions on my blog, so you’ve inspired me to do a digestive podcast as well. Maybe I’ll go into some of the more detailed mechanistic things because I’m a dorky nerd type of guy. {laughs}

Diane Sanfilippo: Yeah.

Chris Kresser: I’m getting a message from my wife that she’s ready to eat breakfast, so I should probably get going soon.

Diane Sanfilippo: Ok, that sounds good.

Chris Kresser: We’ve got to do the handoff where I get to be daddy now and take off my healthcare practitioner hat and put on my gaga daddy hat.

Diane Sanfilippo: {laughs} That sounds good.

Chris Kresser: Which is not a hat.

Diane Sanfilippo: That’s awesome.

Chris Kresser: Yeah, I love it.

Diane Sanfilippo: Is it big and have diapers on it, cloth diapers on it? I don’t know.

Chris Kresser: I love being a dad.

Diane Sanfilippo: I’m sure.

Liz Wolfe: That’s awesome.

Diane Sanfilippo: It sounds awesome. Yeah, totally. So yeah, if anyone else is still looking to find Chris, or you haven’t checked out ChrisKresser.com, absolutely check that out. Healthy Baby Code, you can get to from BalancedBites.com, you can also find that through Chris’s website. And yeah, this is a big topic, and I’m sure at some point in the not-too-distant future, we’ll probably ask you to come back and talk about something else just for our potentially self-indulgent reasons of picking your brain.

Chris Kresser: I’d be happy to.

Diane Sanfilippo: Ok, cool. I know a lot of people had very specific questions and I just felt like a lot of them were sort of the same question in different ways, and I wanted to give people a really good overview of, here’s everything, and sometimes what people think they want isn’t what they need, so I like to shift things around sometimes, and rather than just answer 5 or 6 people’s very specific questions, trying to answer this overarching, what’s happening with digestion and why is it going wrong in so many people in this more broad sweeping way, so that people can really listen, and hopefully re-listen and try and find what they identify with along the way of what we’ve been talking about that they can relate back to some of their questions and sort of address it from there. Yeah, hopefully we’ve done that.

Liz Wolfe: Thank you so much, Chris, for coming on.

Chris Kresser: You’re welcome. It was my pleasure. And thank you for having me on.

Diane Sanfilippo: Thank you.

Chris Kresser: Take care.

Diane Sanfilippo: All right.

Liz Wolfe: All righty.

Chris Kresser: Bye.

Diane Sanfilippo: We’ll talk to you soon. Take care.

Liz Wolfe: Paleo Nerd-a-Thon.

Comments 3

  1. Just listened to your Build a Bad Ass Business (latest post) and it was fantastic! Loved hearing how your hard work and determination paid off with no BS about how you came to where you are today. I’m in the research phase of my own true purpose. Your talk was both motivating and comforting. Thanks so much and keep up the fantastic work! (Jersey girl HAAAAYYY)

  2. Pingback: 9 Primal/Paleo Podcasts You Should Be Listening To | Mark's Daily Apple

  3. I’m trying to figure out if I can drink decaf coffee and still work towards healing leaky gut. I’ve cut out caffeine but really miss the taste of coffee.

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