208. Acid Reflux Isn’t Just an Acid Problem: PPIs, Rebound, and Deprescribing | Badal Shah, DO

0:00 Welcome to Medicine Redefined. I'm Dr. Ultima Sharaja. And I'm Dr. Darsha. Let's put the hell back in healthcare. Today we're joined by Dr. Babel Shah, a board-certified gastroenterologist practicing in the Tampa Bay area. After earning his Doctor of Osteopathic Medicine degree from Nova Southeastern University and completing his Gastroenterology Fellowship at Jefferson Health, New Jersey, Dr. Shah built his career diagnosing and treating digestive disease through endoscopic procedures and evidence-based medical therapies. But over time, he began asking a different question. Why were so many patients still struggling despite receiving the right medications and procedures? That curiosity sparked a deeper interest in lifestyle medicine and the role that nutrition, sleep, stress, movement, and the gut microbiome play in digestive health.

0:49 In this episode, we take a deep dive into acid reflux, proton pump inhibitors, also known as PPIs, the gut microbiome, probiotics, small intestinal bacterial overgrowth, and why digestive health is far more interconnected than most people realize. We separate what the evidence actually supports from where the science is still evolving while exploring how combining conventional gastroenterology with sustainable lifestyle change may be the key to treating the root causes, not just the symptoms of GI disease. Dr. Babel Shah, welcome to Medicine Redefined. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice who are finding health and performance.

1:31 I'm opening a limited number of founding member spots at refininghealthrx.com. All right, let's jump in. Welcome back, everyone. We have colleague, friend, and I'll even include mentor after all our chats, but we got Dr. Boblusha here, gastroenterologist extraordinaire. Welcome, man. Welcome to the show. I appreciate you guys having me, man. Thank you, guys. Yeah. So the audience will know this, and Boblusha, I don't know, but in another parallel universe out there, I'm probably a GI specialist. That was actually my first love when I was going to medical school because of lifestyle medicine, the microbiome, there was so much talk about it. And so... I understood it, right? It was like from hole to hole. It was a tube. It all makes sense. I really enjoyed the pathophysiology about it. It's good to have you on here, man, and talk shop.

2:11 Absolutely, man. Again, thank you guys for having me. I'm excited to talk about whatever you guys want to talk about. Yeah, let's do it. I'm going to take just that little piece right there from hole to hole. We're going to make multiple reels out of that in different formats, quote it, put it on the ground right here. That's how you go viral. That's how you do it, man. Yeah. That one line. So we got a hodgepodge of topics here. Some of the things I'm interested in, the common ailments that you especially see, right, in the inpatient rehab, skilled nursing, what patients or even people just at home even deal with, right, acid reflux, whether it's constipation, diarrhea, IBS, IBD. So we'll get into all those things. But why don't you first tell us a little bit about your journey? How did you end up into gastroenterology? Yeah. So again, throughout medical school and training, there are a few things that really stood out.

2:52 One thing was with internal medicine, I love the aspect of learning all aspects of medicine, right? And I think that's the most important thing is for me, it was to be a doctor. I need to know everything in general, you know, everything, all specific aspects of different organs. And so the GI for me, gastroenterology included multiple organs, right? And you got, of course, the GI tract, but you also had the liver, the pancreas, a lot of pathology there. And then with that, with gastroenterology, you get a lot of procedures. And that's two of the things that I love the most were procedures and then also being able to practice medicine in that way. And so it was a good combination of both. And throughout residency and fellowship, that's kind of what I leaned on. And I thought, you know, just like every South Asian background, the GI tract was the most important thing growing up.

3:33 And so for me, it was stressed upon as well as growing up. It was something that definitely stood out. Yeah, no, for sure. There's obviously a lot of Ayurvedic medicine that deals with the GI tract, and a lot of our natural remedies are also intertwined with the GI tract. So when you graduate from fellowship, you were private practice, you were doing scopes, you were doing procedures. You've now pivoted completely to post-acute care, right? So we know each other from Encompass Health and the inpatient rehab. You're also at multiple skilled nursing facilities. What made you make that change? Because you're not really doing much procedures besides maybe Why do you change? I think I trained in a reactive model. You treat symptoms, you prescribe meds, you do scopes.

4:13 The focus was reflux, that leads to PPIs, and that leads to potential procedures. Irritable bowel syndrome, which medication, antispasmodics, inflammatory bowel disease, steroids, biologics. I think. What I realized that were patients were still sick. The reflux patients were still symptomatic on max PPIs. The IBS patients were still triggered by stress and sleep. Inflammatory bowel were still flared. And I think my goal eventually is I wanted to help these patients heal. I think we were missing out on the more fundamental aspects of what we needed to do from a lifestyle standpoint. I think this new position allowed me to transition from the traditional sense. And I'm still on my journey right now to continue to implement lifestyles to the way I practice medicine now. Yeah. No, I love that. And one of the things that we were talking about right before we get started is that you had an interest in lifestyle medicine.

4:58 And my question for you is, tell me more about what that means to you and when you develop that in the sense in more what we talk about today and how you guys connected. Yeah. You know, I think that what I was seeing in practice was that our focus was on more medication based in terms of treatment. A patient would come to me, they would have acid reflux and we would say, yeah, you know, these are some of the things that you could use. from a lifestyle standpoint, such as dietary changes, to help manage some of these symptoms. But our first go-to was antacid therapy. And I don't think we did a good enough job of actually implementing lifestyle changes. What I mean by that is, from a dietary standpoint, decreasing the amount of ultra-processed foods, increasing the amount of fiber. Sleep, sleep was very important with acid reflux.

5:38 Sleep was something that we weren't getting of stress. Stress is an all-day, everyday thing, and that can increase hypersensitivity to the esophagus and lead to worsening acid reflux. So there's immobility. We know that that's an issue as well. Unfortunately, that's part of our lifestyle is with work and all that. We're not as mobile as we need to be, and that could lead to worsening acid reflux. You know, not implementing these and focusing on these, I wasn't doing a good enough job, and I felt as if patients weren't getting better. Instead, we're maxing out on more of these therapies without really setting a good foundation. You mentioned acid reflux, so let's dive right into that. So I think common knowledge or common thought is acid reflux is a problem of too much acid. However, we both know, like in the functional medicine world, there's now talk about acid reflux is actually a hypo problem that stomach is not producing enough.

6:21 Let's break this up into a framework, I guess. Let's start with the pathophysiology or let's just kind of think about what is actually happening with acid reflux. Yes, and I agree with you. I think that it is a common misconception, right? And so that's why we see a lot of patients on antacid medications. They feel better because we're decreasing the amount of acid in their stomach. But really, it's an issue of lower esophageal sphincter dysfunction. Right. And so what happens is you have transient lower esophageal sphincter relaxation, and that is the main mechanism. That could be due to a lot of mechanisms. I have a lot of reasons. Gastric distension, visceral hypersensitivity, stress can increase symptom perception. Obesity can lead to increase in intra-abdominal pressure. That leads to these transient lower esophageal sphincter relaxations. And that causes acid to go where it's not supposed to go, to the end of the esophagus, and that leads to symptoms.

7:04 And so that's what really triggers acid reflux. As we get older, we actually produce less acid in the stomach. And so what PPIs are treating, and that's why patients feel better, is that you're decreasing the amount of acid production in the stomach. It does a really good job of it. Almost 50% of the acid production decreases it. So that's why you eventually feel better. But we're not really treating what's actually going on. That's why patients end up staying on it longer than they're supposed to. Yeah. So when it comes to PPIs, right, we've learned, I think, in medical school is sure acid reflux, but also GI bleeds, right? Especially upper GI bleeds, you're automatically putting somebody on a proton pump inhibitor, protonics, all those. And that's really to suppress the acid from making any type of like ulcer worse, right, or the bleed worse. If it's not a GI bleed, though, how are these patients getting initiated most of the time from what you've seen in your practice?

7:48 Well, I think it's just, it's symptoms. It's really just refractory to any sort of lifestyle changes, any sort of things that they have done. So they may come into the office, they may say, hey, I've had these acid reflux symptoms. They've been ongoing. I've tried to change my diet. I've tried to eat earlier. I've done all these things, but I still have symptoms. And then they get on the medication and they take it for supposedly two weeks. They feel better. And then what happens is they stop the medications because they feel better. And then they get the rebound reflux again. And then it's an ongoing cycle. A lot of times, adultery patients, they'll be placed in the hospital for stress prophylaxis while they're in the hospital for whatever reason. And sometimes they'll be discharged with the medication and then they'll be on the medication. But we as providers need to do a better job of then describing the medication if they don't need it again. So sometimes these patients will be on these medications for long term.

8:30 And just by initiation in the hospital or a symptom that they may have had, and then it doesn't get described. Gotcha. Tell me about rebound reflux. Because I mean, a lot of people I know, well, they know they're going to have a jalapeno pizza at night and they're going to pop some PPIs or a Pepsit or whatever it is. But you mentioned rebound. Tell me a little bit about that. Yeah. So typically, when you're on anted medications, especially when you're on it for a few months or long term, a lot of patients are on it for years, the acid in your stomach is suppressed for so long. But when you stop that medication, especially if you stop at cold turkey, you're going to get rebound reflux. Because what's happening is now these cells in your body that have been suppressed for symptoms again. And so in reality, when you stop someone, you want to slowly wean them off the medication, especially if you've been on it long term.

9:11 What I typically do is if you have a patient who's on PPI for years and you want to get them off the medication, I'll slowly titrate them off. So I'll do it every other day for two weeks, every two days for two weeks, once a week for two weeks, and then, or I'll transition them to an antihistamine blocker prior to then getting them off completely. And that's when you'll get the best results, I think, because if you try to take them off cold turkey, you're going to get rebound reflux because that acid production is going to I'm interested in regional differences in practices, right? So that happens a lot. So we were talking about how you spent some time in the Northeast, where I am right now, and now you're in the Southeast, right? Are any other points where you ended up practicing? You got a sense of the patient population? Or just did you go from here? No, that's it.

10:14 Have you gotten a sense of what the biggest culprit is from one of those lifestyle factors for patient? Is it more of a obesity related thing? Is it more of a perception on, I guess what I'm trying to ask is, like Darsh has mentioned to me, Tampa has this vie where people are more health forward. as opposed to the Northeast. And so I'm wondering when people come to you, are they more receptive to that conversation that, Hey, we're not going to jump right to Omeprazole and X, Y, and Z. And maybe even they haven't already exhausted those options. Cause like I've been dealing with this for a while and man, like I'm going to GI when I'm ready to get school. Like that's when I'm going to GI. You know what I mean? Cause like all this stuff is available to you. So where do you catch the patient in their like lifetime, if just exposure to acid reflux?

10:55 Yeah, I mean, I think that it's different based off the population. I think the younger patients are definitely trying to find other ways of managing their symptoms besides medications. I do feel that. And a lot of times they do come in with a lot of information, research that they found, et cetera. I also try to tell these patients it's not just one part of lifestyle because it's not just fixing a diet that's going to help all your symptoms, right? It's also, hey, the stress. It's also the job that you have that you don't like and that you're up all night. It's also the five hours of sleep. There's many factors in it. And so that's what makes it very difficult. Because I do believe that there's so many challenges to our society in terms of being healthy. Meaning, right, it's easier to be sick than healthy. And there's so many different factors because of that. So it actually takes work. It takes a lot of effort.

11:36 It's a battle every single day to stay healthy. I mean, there's a thing about all the factors when you go to work. You wake up, you're stressed. You have all these things on your mind. You miss breakfast. You go there, you see donuts. You're like, oh, I got to add something to eat quickly. You grab a donut, you eat that. And then your day goes on. You're working at a desk. You're not moving that much. You go back home. You got to make your kids food. You're eating whatever you can. You stay up late because you deserve to watch your show, binge watch your show, and you don't get enough sleep. And so you have all these factors that play against you. And I think that all of this adds up over time. And so what I try to stress to patients, it's not just one thing, it's multiple things. And I think the younger patients understand it. They're also like, hey, what am I supposed to do about this? Like, you're telling me all these things that I need to fix, but how can I do that? And I tell them it's one step at a time. And I think by able to slowly implementing and making these lifestyle choices, In addition to evidence-based medicine, that's when you're going to see people actually not only just feel better, but actually stay better.

12:26 And I think that's important. I think you see that with the younger patient populations in their 20s and 30s. They want to make that change. I think what we get in trouble with more in the older patients that have been on chronic PPI for many years, they're also on all these other medications and factors that could probably play a role on it. And so... it's a lot harder for them to make those lifestyle changes. In addition, the polypharmacy that we see and make those changes in addition to that, because that's probably playing a factor in some of these patients as well and overall. But you know what? The goal is to get you on the lowest dose or no medication, right? And if that requires you to change from PPI to an H2 blocker or weakest medicine possible, that's our goal because that's what we want. We want you to be able to be on the least amount of medications if possible.

13:06 And that should be our goal for all patients. Dude, I love that. To your point earlier that it's easier to be sick, maybe just modify that a little bit by saying it's probably a lot easier to get sick, but it's really hard and it sucks being sick. I think about this patient I saw earlier today where I hadn't seen her in a while in her 80s and said, hey, long time no see. And she goes, oh yeah, we're around. We're usually at a doctor's office. And if you're sick, that's what you're doing. That's what life it is, right? You're in pain and you don't have the ability to have the quality of life that you want. You can't, if you have a lot of weight, maybe you have excess load going through your joints and things. So it actually is really hard being sick, but it is easy getting there. And it's much harder getting healthy. And once you are healthy, life is just better. You have more options, more freedom, as Darshan and I talked about, right?

13:47 You want to be able to go to, I don't know, whatever those steps were in Spain or wherever you, one of your million journeys that you went to Darshan. Always traveling. But I digress. I think you used an earlier word, deprescribing. I think that's really important to it. We often talk about this in the pediatric realm. I think pediatricians do a good job addressing this, that children maybe will get diagnosed with something like a behavioral issue, ADHD. Let's take that for example. And then over time, it's really important for them not to let that diagnosis define them for the rest of their life and get them off a stimulant if that was appropriate for a short period of time. This is not a conversation that anybody's having about adults, at least not one that I'm hearing. And I think it's important because PPIs is one of those things, right? So this is, at least in the United States, most of these things are available over the counter, right?

14:28 You can go over to CVS or whatever your pharmacy of choice, and you can pick that up. And then it works so well in the beginning that you just keep going back to it, right? Why not? That reward loop is so good because God forbid, I give up the dark chocolate and the caffeine, as I talked about, particularly in medical school, sodas, all those things that it is easier to your point to just be in that. I guess maybe an important point for us to discuss is like, why are we bashing on the PPIs? It's not because we don't necessarily like omeprazole and all those things, but they actually have some serious issues down the road that people can develop. A lot of these in the musculoskeletal realm that we see, what are some of those things, maybe black box warnings that people need to be aware of that, hey, this is not to be taken lightly. This is not something that you should be on for 35 years. Yeah, no, absolutely. And don't get me wrong. I mean, I think PPIs save lives, right?

15:10 I think when you lose it in the right setting, they, peptic ulcer disease, active bleeding, that's what we use to help with that. Baird's esophagus, which is precancerous tissue from acid reflux over time, prevents adenocarcinoma. I mean, these are very good medications. I think what we forget is that, you know, a lot of these patients who are asymptomatic, who have a history of reflux, who've been labeled with acid reflux, have been on these medicines for 10 to 15 years, some even longer than that. And down the line, you do get concerned. And some of the concerns associated with it are one, increase in enteric infections, so increase in C. diff infections. The thought process behind that is that these medications reduce the amount of acid in your stomach. And so that allows... pathogenic strains of enteric infections, such as C. diff to kind of proliferate and cause worsening issues.

15:51 It also increases risk of pneumonias as well. We believe that because of the same reason, if you lower the acid, you have these pathogens that develop in the upper GI tract and you micro aspirate and that causes you to have higher risk of pneumonias. Because of low acid, you decrease the amount of calcium absorption. And that can lead to increased risk of fractures. And that's been shown down the line. These are patients who've been taking it for years, but that's been shown also to be a potential risk factor as well. So, yeah, I mean, I think they're going to tell you to take it for a certain amount of time, but definitely patients are taking it for longer periods of time. And the goal is to try to figure out what's causing your symptoms and to get off the medication if you're able to. And of course, if you have a history of Barrett's or if you're at high risk of a GI bleed, you're over the age of 65 and have a previous history of a bleed on aspirin, then yes, that is a treatment of choice and you should be on one for prevention.

16:38 But our goal should be always to figure out what's causing your symptoms and then try to get you off the medication if possible. Is there any type of test people can do to note that they should know whether they should be on a PPI or not? Or is it really just based off clinical symptoms to see whether they should get off of one or whether they should be on one? No, I think if you have chronic reflux for over five years, and that's one of the risk factors for Barrett's esophagus. And that's why I use that five-year mark is that if you have acid reflux for over five years, that's something that maybe getting an endoscopy to evaluate the end of the esophagus determined if you have a high or hernia, determine all these other factors that could lead to acid reflux. And that would help determine if you need to be on it or not in terms of a long-term or not. Gotcha. Or just a short-term.

17:19 Do you need to be on PPIs? If you have an ulcer that we find on endoscopy, then you'll be on it for a couple months and then we'll repeat the endoscopy to make sure the ulcer is gone and the goal is to wean you off the antacid. That's how I would potentially do it. If you're having short-term symptoms, you could take it for two-week course. You feel better than you know it's likely related to acid, but then slowly weaning yourself off is important. Try to make those lifestyle changes to help. Now, I'm sure a lot of people who follow the functional medicine influencers have probably seen things like apple cider vinegar, licorice root, I believe. I don't know what other supplements are out there, but is there any validity to any supplements that you know of or any natural remedies to help with acid reflux? I don't think any of them stand true in terms of evidence-based. I think that some patients may feel better with that.

18:00 What I would recommend is more of a higher fiber diet. Sometimes I like the low fermentable. I don't get heard of the low FODMAP diet. Have you heard of that? We use it for patients with irritable bowel syndrome or any sort of dysbiosis, but essentially decreasing the amount of fermentable carbs in your diet. So doing almost like an elimination diet. I think that really helps patients because you're essentially removing fermentable carbs that could increase symptoms, upper gastrointestinal symptoms for about four to six weeks. And then you slowly reintroduce these foods into your diet to see which one's causing your symptoms. And I think that really helps because it breaks it down pretty good in terms of how to manage that. I do like that approach. In terms of like supplemental approach, I don't really use any of those. I do recommend sometimes increasing amount of fiber. I think that helps with overall gut motility.

18:43 More so in the stomach, but overall motility in the GI tract. I think that really helps. Keeps you satiated as well. So it prevents you from eating these other hyper palatable foods, ultra processed foods that can increase your risk of acid. Does the type of fiber matter? Well, it's like soluble versus insoluble. What's that? Yeah, no, I think because the type of fiber matters in terms of what it does to the motility of the stomach. Soluble fiber slows emptying and insoluble fiber can speed up emptying. But in terms of overall fiber improves overall motility. So that I think is probably the most important thing. Because it lowers abdominal pressure, stabilizes glucose, it improves microbiome, it replaces reflux triggering food. So that all improves, I think, overall GI health and reflux symptoms, I think. Yeah. Fiber in itself has like a large umbrella thing.

19:25 It's kind of a superfood, right? So actually, I was thinking about, you're actually not a first GI, right? So Dr. Bolzewicz, way back in the archives, right? So came back and I think he had talked about, did he say 20 different plants a week he's going for? Like that's his target. Yeah, all these plant forward diets, like that's how they work, right? And when we look at the outcomes in fiber, they pretty much help with everything that we can think about from a cardiometabolic standpoint. Some of the reasons that you've highlighted, they have really good evidence. And I think probably less than 15% of the US population are getting the recommended daily allowance, which is somewhere around 30 grams for men and maybe 20, is that correct, 24? That's right. Yeah, I know. I think most people get about 10 to 15 grams of fiber, and the goal is 30 to 35 grams of fiber a day. I think that's where we lack a lot, and I agree with you.

20:07 I think it's daunting when you say that 30 grams of fiber seems like a lot, but it really isn't. And I think if you focus on it, it's definitely doable, and I think it would help a lot of patients that have chronic GI symptoms overall. Now, I will say this, and I might know this from personal experience. If you have been on a low fiber diet for a very, very long time, you very rapidly ramp that up. It is not going to go well. No, no, no. It's not going to feel good. You're going to feel a lot of bloated. Yeah, it's going to feel bad. And maybe that has something to do with the microbiome, which we'll touch on in a second. But before we do that, I kind of want to just come back to stay on this acid reflux thing for a sec. So we've talked about the role of stress, something that has been well known for a long time. I'm not sure I understand the mechanism and how increases that acidity in the reflux.

20:51 Can you elaborate on that for me a little bit? Sure. Sure, yeah. So stress lowers the lower esophageal sphincter tone. It increases a transient lower esophageal relaxation. So you have more episodes of relaxation of the lower sphincter. It heightens symptom perception. So you have hypersensitivity. And also the vagus nerve regulates motility as well. And so if you are stressed, that can decrease motility. So then you have more perception. So anxiety itself can make mild reflux feel severe. And so that itself can do it. So that's typically how stress does it. So it does lead to more acid exposure to the esophagus. So that's interesting. So that lower esophageal sphincter you said, right? What receptors are there? Those beta receptors, muscarinic receptors, what receptors are there? Because I'm trying to think about, so primarily, and this might be getting too into the weeds, and like if you're thinking about in high stress rates where you have more adrenaline run through the body, those are primarily going to act on your alpha receptors.

21:41 You do not have any alpha receptors in the GI system that I'm aware of. Is that correct? The way you want to think about it, I think, is more of a rest. And we say parasympathetic rest and digest. That's why we tell patients, hey, before you eat, take some deep breaths, relax. It helps with the digestion. It's true. It helps with motility. I think when we eat in a more stressed chewing, we can get another lecture on chewing, you know, in terms of the lack of chewing that we do when we eat food, because we're just kind of scarfing down food. It doesn't allow us to really break down the food. It doesn't allow for us to really digest, and the motility of it gets affected as well. And so then you're left with less gastric emptying, more chances for distension, and that leads to more of these relaxations at the end of the esophage, the sphincter tone, that allows more acid reflux. Okay, cool. I suppose it's one of those things where I'm missing the forest for the trees.

22:25 I do want to talk more about IBS and IBD. It's another one of those things that particularly IBS can be so challenging, right? The objective things, well, it's supposed to be IBD, and I'll let you define how you use the criteria to put each in these neat buckets for people. But before we do that, we touched on the microbiome a little bit. And I know this could be in its own seminar that people talk about. But the microbiome is one of those topics, buzzwords, that as we say, people are going to want to hopefully click on this and they're going to want to know all about that. And you have some people on this far and they're like, oh, it's all in the gut. It all starts. Literally everything that is wrong with you or right with you is because of your gut. And then you're going to be other people like, we just don't know enough. And we're actually, they'll say, no, that's nonsense.

23:05 We're not quite there. And I find myself to be maybe in that middle camp, maybe a little bit more towards that. I do think this has a pretty significant effect in a lot of things. Where are you in that camp? Number one. And then how do you even define that? Or how do you explain the microbiome to somebody who's never heard of it? Yeah. No, it's obviously a big topic. I think if you ask my dad, he would say that it defines everything. The guy. He's a microbiome. Is he a gastroenterologist too? He thinks he's a doctor, but he's not. There's no medical doctor. Right. Yeah, he's a doctor in the house. In the house. Yeah. Oh, yeah. I got you. Yeah. It's all the WhatsApp lectures that they get. Oh, my gosh. All the forwarding. Yeah. That's 40. He's the apple cider vinegar guy. For sure. No, I mean, so healthy microbiome. So diverse, stable, rich in small chain fatty acid producers like butyrate, low inflammatory species, good barrier integrity, good motility of a healthy microbiome.

23:54 And then you think of the opposite side of that dysbiosis, you know, which is like means your gut bacteria out of balance. Right. So you have reduced diversity. You have loss of beneficial species. You have harmful microbiomes, inflammation, permeability. And that's where some physicians and some in the functional medicine space, they'll say that's what leads to autoimmune disease. They'll say that's the root cause of autoimmune disease is gut permeability. And so, you know, really, I think of a healthy gut as a diverse garden. And you think of dysbiosis as a bunch of weeds taking over. That's kind of how I think about that. And so it's just dysbiosis is what we get concerned about, right? Which is an unhealthy microbiome that fuels the bloating, the inflammation, reflux, the irritable bowel syndromes, the inflammatory bowel disease. When you talk about gut permeability, is that what people say when they're saying leaky?

24:37 Yeah. The appropriate medical term, is that the same as SIBO, like small intestinal bowel? No. Explain SIBO to me. Yeah. So small intestinal bacterial overgrowth is essentially what it sounds like. There's a bacterial overgrowth in the small intestine. And that could be from, there's a lot of factors that could cause that. It could be from chronic PPI. Low acid in the stomach over time can lead to bacteria overgrowth in the small intestine. And so we do see that. A lot of other gastrointestinal conditions like celiac disease or inflammatory bowel disease or even irritable bowel disease have been linked to bacterial overgrowth as well. And that's different from gut permeability because that's essentially what that is. Really, when you have decreased butyrate production, that leads to increase in inflammatory lipopolysaccharides from the bacteria.

25:17 And that can lead to increase in intestinal permeability, and that's what we believe is that leaky gut. So the intestinal permeability, how does that present? What are symptoms? What are some objective findings that people will get a sense of before they go to your office or they come across you? Yeah, a lot of food intolerances, bloating. They feel, some feel fatigue as well as a generalized symptom. Bloating, a lot of it is the general GI symptoms that you'll get from upper GI symptoms. So bloating, reflux, everything makes me feel bad. Anytime I eat anything, it just makes me feel uncomfortable. Gas production. So it's more upper GI stuff. Like you're not going to see a lot of constipation? For the most part, but you can also get changes in bowel habits too. And that's the hard part is to try to differentiate the different symptoms. And I think our goal essentially is the same, whether it's how to implement lifestyle changes to help you get back and restore the gut permeability or even treat some of the irritable bowel symptoms.

26:06 And then what about the other, the SIBO? Like how will that, is it very much the same in terms of? Very much the same in terms of symptoms. We typically do a breath test as an outpatient to help diagnose SIBO. So that will tell you if you have that condition or not and how we manage it. it what are you checking on the breath test is that urea hydrogen like spikes essentially different spikes from a that bacteria produces to see whether or not if it's produced and it spikes during certain levels then you can have a diagnosis what's the test called though like if i were to order it what would i order sebo test yeah you can just order a sebo test sebo breath test i love it ours i think it's sort of what i was in resident we just call breath test yeah there's a breath test for i mean there's a process for h pylori there's a process for sebo there's different companies out there depending on the company you can use it How do we test the microbiome?

26:52 So I know there's in the functional medicine world again, right? If we go there, a lot of people, ultimately to your point about starting with the gut, I think naturopaths actually get taught that. So when I've listened to podcasts and naturopaths, the first thing they get taught is if you can't figure something out, go straight to the gut. I've shadowed functional medicine doctors who would get these stool samples, essentially, and then it off to a company and you can see the diversity or lack thereof. of the bacteria really see that as much in like the traditional health system. So when you were training at things, how would you guys go about understanding whether somebody would have leaky gut or dysbiosis? We didn't really talk about it much in terms of looking into dysbiosis. That term wasn't used at all. who had risk of C. diff for prevention purposes, who had antibiotic-associated diarrhea.

27:34 I think we were using them more so for that, but really in our training, it wasn't taught to us to use these stool tests to determine what their flora looked like, if they had dysbiosis or not, if they had a good gut flora or not. So in reality, that wasn't in our training. Gotcha. To stick on probiotics, my understanding now, if somebody is going to take probiotics, which again, you get over the counter, a good quotation marks, because I still think there's a debate, has to be over, correct me if I'm wrong, 100 billion CFU? It depends. When you look at it, again, this is another topic we can go on for a long time, but when you think of probiotics, there's so many different strains out there. What's right for what person? There's the lactobacillus, there's bifidobacterium, there's saccharomyces, there's bacillus. These are A couple of them are bacteria. One's a fungus, one's a soil-based.

28:15 By getting a diversity like that, and it's really specific to the person on whether it's going to work or not. But typically, it should take about two to three months to even know if it's helping you because it does take quite some time. And I think most people probably give up on that probiotic if it doesn't seem to help them right away. But don't people say your microbiome changes within 24 hours? You could, like, your next meal can change completely? Like, absolutely. Yeah, Bea, you're talking about that. Within two days, you can completely change your microbiome. That's why checking these stool tests and all that for diversity is very tough. I think that you see a big fluctuation in that. That's why I don't typically do it myself is because I think if we're going to implement lifestyle changes, let's see how that works. I think that's probably the most important thing. And you got to think of probiotics as a seed and actual diet as the soil.

28:57 If you're taking probiotics but still have a crappy diet, you're not going to get much of a benefit there. I think you'll see the most benefit if you're on a good diet, in which case you're probably going to have a well diverse microbiome to begin with. I don't think probiotics are a bad idea. I think they could help supplement if you're already doing the right things. I think we get into trouble when you're trying to take a supplement, but still don't have a good foundation. I think we're all taking this for granted. Some people listening already know what probiotics are. So that is just you supplementing your gut bacteria, right? So there's actually strains of bacteria which have, in a lab, been isolated. Different strains that you highlighted, a couple of them. You didn't mention acromantia. That's in the news a lot. That's a big one, yeah. That's Nasir's GLP. You've got to get that one.

29:38 Yeah. People can get these and CFUs, as I was talking about, so colony forming units, if I remember, the dose, if you're looking at it as a medicine. If you were to recommend probiotics for the right person, what would you look for? Yeah. What are some of the things that you look for in a supplement probiotic that might suggest, hey, maybe this is not a bad idea? For me, I would look at diversity. I would look at, and again, the ones that I listed, I would look to see because, again, it is hard to determine what is going to be right for you. So I would definitely include lactobacillus, bifidobacterium as a two bacterial strains in there. I would include saccharomyces, which is the one that we use a lot for patients who are on antibiotic, who have antibiotic-associated diarrhea or C. diff, and we want prevention.

30:20 And then a good soil base is bacillus. So that's what I'm looking for in terms of which strains to have in there. Again, is it going to work right for you? It takes about two to three months to tell if you have bloating symptoms, if it helps with the bloating, if it helps regulate your bowels or not. These are some of the things that I find that is benefit. And sometimes you won't, if you just want a good probiotic because you want to take for prevention purposes. Those are some of the strains that I would have to include. I like to include all those different aspects because I feel like it is otherwise difficult to know what you're lacking. Yeah. I've heard the importance of keeping them refrigerated. I don't know if, like I know with fish oil, with oxidization, like light is really important that it has to be in a dark container and so on and so forth. Is that the case with these probiotics as well? A lot of studies have been done on that and they did show that even you did not refrigerate, you should see some benefit there.

31:05 I don't think it necessarily has. Now there are certain companies that do recommend refrigeration, in which case I'd go with the company from what they recommend. But from what studies show, there still seems to be a benefit, even if not refrigerated. But again, I still think that other factors like life, whether it's diet and all that, play a big role in it too. Yeah, I was going to say, I think the company that's making waves with acromantia is Pendulum. And I think you're supposed to refrigerate their specific one. But it leads me to ask, so I know you're looking for diversity in the supplement. Now, some of these supplements, they just come with one strain. Is there a risk of overpopulating the microbiome with just one strain or is that meh? I haven't really seen that. Obviously, in immunocompromised patients and all that, I think you'd probably want to stay away from probiotics. So if you have patients on immunosuppressant therapies and all that, I probably wouldn't be giving that just because of the risk of something like that.

31:50 But I haven't seen that. I think there's not, to my knowledge, I have seen any sort of risk of overpopulation there. I mean, there have been case reports of bacteremia associated with some of these things, but they've been very few and rare. And I haven't seen too much of that. Is that like where? Linky gut, I guess it. I believe that would be the reason why. Yeah. But again, these patients probably overall don't have, they were probably fairly sick to begin with. And they probably had multiple comorbid issues. And I think putting a patient on a probiotic at that point, unless it's for an anteprevention of C. diff, that's something I would probably avoid. Real quick, just define bacteremia for somebody listening. Who doesn't know? Yeah, so a bloodstream infection with the bacteria. Real bad news. I just want to think out loud here with you, Babel. You mentioned two to three months of needing a probiotic to see if there's any changes.

32:30 Now, in my mind, I'm thinking human body probably has homeostasis. So even when we're told like, hey, the gut microbiome can change after a meal, it'll probably reset to kind of what it's been used to, almost like a set point theory. There are a lot of companies out there now that sell a probiotic based off your genetics. Right. So they'll do a saliva test, I'm guessing, and then or maybe even a stool test and then give you a specific regimen. What are your thoughts about those companies and are they legit? Yeah, I mean, I'm not really quite sure on the research behind that. I think if they can prove that or changes long term, then that's where it's at. I think testing is probably the most important in that realm of able to test and show that, hey, these patients are prior to starting had a unhealthy microbiome. And now after continuing these therapies, they've persistently shown that, hey, they have a more of a healthy microbiome.

33:15 And I think it's worth it. But without testing and without knowledge, I don't know you can make that assumption without that. I think testing is probably the most important thing. And then keeping up with it. I think that's important. So a lot of these companies I know, as long as they're doing the right testing for it and they're staying persistent with that long term, I think that's something that they're definitely looking for. In the conventional medical model, I have seen stool testing done for people who've got this persistent diarrhea. Maybe you're concerned about C. diff. Like you mentioned, that's a big scary one as well. What are the actual stool tests checking? Are they just checking for all these bacteria that we talked about, or are they checking for C. diff and anything else? Yeah, I mean, there's specific stool tests for C. diff. Stool culture will give common bacterial organisms that could increase your risk of whether it's Campylobacter.

33:56 Oh, yeah, Giardia, all that good stuff. Giardia, yeah, and parasites is another one that we check for. So these are stool tests that are checking for infections. But of course, there are other stool tests that test for pancreatic insufficiency. And so we use a fecal elastase stool test to check for that. We use a fecal calprotectin, which is a stool test to check for inflammation in the stool. So like in inflammatory bowel disease, it would be elevated in ulcerative colitis or Crohn's patients. And so different stool tests. I think the functional medicine will be using their own sort of GI profile testing and stool testing for advanced to check for the microbiome and all that, which we don't see much often in traditional GI. Yeah. Last thing here, Babel, in regards to this topic, at least for me. So throughout residency, when probiotics, we started using them.

34:37 What is the verdict with conjunctive use with antibiotic therapy? A lot of my attendees would say don't use it while they're on an antibiotic because they'll kill the probiotic anyways and then use it after. But then some of them have said you might as well just use it with it. Is there anything that's been proven? I do believe that at least from certain strains can cause a more of a disruption in the microbiome if you take it while on antibiotics is the assumption. And there have also been studies that if you take while you have C. diff, for instance, if you take saccharides, that doesn't have that same disruption. And then to continue with the probiotic therapy afterwards to help prevent recurrence from happening. I generally haven't found any issues with doing them together. I think that anyone that's on an antibiotic would benefit from a probiotic, especially if you have a history of C. diff.

35:19 I think you should be on lifelong probiotics after that, I think, for prevention purposes. I do believe that. I think that once you're at risk, you're at a higher risk for recurrent episodes. Taking a probiotic afterwards would be beneficial for you. Yeah. And for those who don't know, C. diff is a highly infectious thing. So it's like somebody in your family is getting it. That's going to be difficult to run away from. I think it's probably worthwhile to spend a couple of minutes talking about prebiotics. So we have probiotics to the other coin of that. How would you explain to the listener what prebiotics are? It's actually food for the bacteria. So food for the probiotics. So inulin and some of these products, artichokes, there's certain foods that can increase good food for the bacteria to help it thrive. And again, that's part of the diet profile where diet is very important for these probiotics to work, for these bacteria in the gut proliferate to essentially be happy.

36:04 I think that's important to fuel it. And so a lot of it's fiber, certain vegetables that can increase your risk, increase these products to help with the bacteria. You mentioned one specific group where probiotics was not a good idea, right? So anybody on any type of immune therapy, immune system is depressed. Is that where postbiotics, I know people are like, we're just different tenses here. Postbiotics, so for those who don't know, so if we didn't specify this, probiotics are live organisms. Yes, and correct me if I'm wrong, by the way. Postbiotics are inactivated, or I guess they're dead organisms, but they're still beneficial, correct? So postbiotics is the byproduct, right? Of probiotics? It going through the GI tract. So you have probiotics. So is that what we're talking about right now?

36:44 Your poop, yeah, your poop. Absolutely, man. Your poop has the butyrate, the small chain fatty acids. That's why people take butyrate supplements. And we don't know for sure if they work because it's not going through that natural process. It's just, here's the end product. Here's what we know is good for you. And that's what you should take is what people think. But you're going to get these small chain fatty acids that are necessary, like butyrate production with a healthy diet. I think that's a diversity plant forward, high fiber diet is what will allow you to reach that goal. Interesting. I love this. Is it worth talking about fecal transplants if we're talking about postbiotics? Just explaining that. And I wonder if there's a lot more research coming out on it, especially because we're talking about longevity and people talk about, what do you call it, like blood transfusions and swapping, Brian Jonathan, giving blood to a younger person.

37:25 What is it called? Hold the hole. Hold the hole. I can't think of the words, but whatever. A younger person giving their blood to somebody older to change their markers. What can you tell the audience about fecal transplants? I mean, for C. diff, right? Recurrence C. diff? Yeah, I mean, it's really effective. I mean, so what fecal transplant is essentially is what it sounds like. It's taking one stool and placing it in another's intestine. Initially, we're doing it. all through colonoscopy. We would test someone's stool, make sure they didn't have any underlying infections or chronic infections, hepatitis. And then we would transplant that stool in the colon. And that was very effective in treating recurrent C. diff. In the 90s, you know, talking about 95% or above 95% effective in treating recurrent C. diff. Now there's better options in terms of that.

38:06 There's something called VALS. There's pill formed where you can take to help prevent recurrent C. diff. Yeah, so that's another therapy out there, but it's very effective. They think not just C. diff, but it's been used in patients with inflammatory bowel disease as well. They even did studies on weight loss. So patients who have a normal BMI and patients who are obese. And if you give... Let's say, for instance, you gave an obese, you take a stool from an obese patient and you give it to a normal BMI that they found that the patient with the normal BMI would start gaining weight. And so they've done studies that show that how much it can alter someone's. And then they're still doing future studies on it. But I think from a C. diff standpoint, very effective. And now they're coming out with oral therapies. And I think it has been a game changer in terms of treatment.

38:46 A lot of hospitals don't do that procedure. Sometimes they have to send them out to Mayo Clinic, etc., to get it done. And certain, even in Tampa, I think there's only a few hospitals that do it here. It's hard to store the stool, etc., to make sure it's viable. It's a process. And so in order for it to happen, there's a lot that has to go through. It's funny that, Darsh, you bring this up because I remember not too long ago, I think Tim Ferriss talked about this on our podcast, where we have studies like, so you take a person, and they did this in mice models first, where you have an obesogenic mouse. You'll take its fecal transplant, so you take its gut microbiome. You transplant it in a small, skinny, normal weight mouse. it's going to turn into obese and vice versa, right? Interesting factoid, because we talked about the vagus nerve well back. So it all comes back for if you cut the vagus nerve before doing that, you do not have those downstream effects of the normal mouse becoming obese after the fact.

39:35 So there is certainly some interplay like you talked about. And this comes back to this thing that people talk about, the whole gut-brain axis. We didn't talk about this a lot today, but I think Dr. Jyoti Patel way back in the archives came back talking about majority of the serotonin in our body, maybe 90% or something like that, is produced in the gut. And we know there's an interplay that when your gut is unhealthy, your brain, your mood, it affects that and vice versa. And actually even vagotomy, they've looked at that and that's just cutting the vagus nerve. That in that transplant, when you have the vagus nerve that's transected or severed, the depression-like symptoms, mood-related symptoms don't tend to happen. So that's something that's really interesting. I know Darsh and I spent some time talking about this on the progress note a while back, but I can see how people can get trapped into it. It's all in the vagus nerve.

40:15 It's all in this. It's all in this. It's all in the gut. And I think that for me, I like to say it's all very interesting. And a lot of this stuff is mechanistic and in mice models. And maybe we can extract some information from that. But I always pause when somebody says it's all in enter blank. Yeah, absolutely. I mean, there's a lot of things I play for sure. Bobo, do you listen to Tim Ferriss, his podcast? No, I don't think I've listened to this one. I'll send it to you, but he did one with Kevin Tracy about the vagus nerve and the importance of the vagus nerve when it comes to mental health, especially. I'll have to go back and listen to it or look at it, but they talk about Pepsid specifically. And I guess some data showing about how Pepsid affected the vagus nerve and actually- Modulated, yeah. Yeah, modulated the vagus nerve to reverse a lot of mental illness. So- Amazing.

40:56 Touching on the gut brain, I'll send it to you and we'll put in the show notes as well for the audience. Very interesting. I'm wondering what's that in it. There are certain foods that are histamine elevated and then that could decrease in the histamine. I mean, that's very interesting. I'd be very interested to listen to that. Yeah, I just came quick Google searching. Here's a 2022 paper. Phamotidine activates the vagus nerve inflammatory reflex to attenuate cytokine storm. Maybe that's not exactly what he's talking about, but... Huh. Interesting. Loss of antenna flow. Okay. We got to look into this. Well, I love it, man. But I think this is a great place to park it. I know we had a list of topics that we wanted to just bounce off of you, and we did not anticipate that it's going to be a conversation. My main takeaway from the conversation is hole-to-hole and then PPI save lives. So I'm going to put those on my license plate.

41:39 I can't decide which one. H2 HPPI. That's right. H2 HPPI. We'll come back for part two, man. We have a lot of interesting things to talk about, but this has been great, man. Thank you. Absolutely, man. I appreciate you guys having me on. I'll definitely be changing my license, please. I think that's a good one. All right, man. Until next time. All right, man. Thank you, guys. Thanks for listening to another episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at MedRedefined. We also want to thank our team for the production of this podcast, specifically Ethan Ju on video, Harita Yapor on social media, Zanab Lugmani on research, and Saira Khan for newsletter.

42:22 Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday, please be sure to sign up for our newsletter. Also, if you enjoy this show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever so important disclaimers. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, nor should be construed as medical advice. No physician-patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.