How To Alleviate Constipation And Heal Your Gut

Coming up on this episode of the Doctor's Pharmacy.

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Week'S episode of the Doctor's Pharmacy. Hi, this is Lauren Fein, one of the producers of the Doctor's Pharmacy podcast. Nearly 50 million Americans suffer from IBS, and one of their main symptoms is constipation. Constipation is often a sign of an underlying gut imbalance that over time can lead to more serious problems. in today's episode, we feature four conversations from the doctor's pharmacy about the factors that lead to constipation and what steps you can take to resolve it. Dr. Hyman speaks with Drew Prode about a case study showing how magnesium deficiency can lead to constipation, with Dr. Mark Pimentel about SIBO or small intestinal bacterial overgrowth, and with Dr. George Papam: about conditions like Candida that could be causing constipation, as well as the connection between IBS and constipation. Let's jump in.

And the first question that we have here from our audience is, I struggle with chronic constipation. What are some things that I could be keeping in mind to alleviate my symptoms? Well, constipation is very common and it's often, you know, we call it Irritable Bowel Syndrome C or constipation. There's Irritable Bowel Syndrome D, which is diarrhea. But constipation is very common and it can be many reasons for it. that are not food related. Hydration is a big one, people not drinking enough water. Magnesium deficiency is a huge one. Now, magnesium deficiency is sort of food related, but not necessarily. It's really because one, our diet is so deficient magnesium, which comes from greens and beans and nuts, which we eat very little of. And two, we do a lot of things that cause us to lose magnesium. Caffeine, sugar, alcohol, stress all cause you to leak magnesium. so getting enough magnesium is important and magnesium citrate can be very, very helpful. And then there's other factors that can cause constipation that are based on dysbiosis, like yeast overgrowth is a big cause of constipation. Dairy is a big cause of constipation, even though for some people it can cause lactose intolerance and diarrhea, it can cause constipation for many people. In fact, it's the number one cause of constipation in little kids. And it's also the number one cause of anemia, which is kind of striking. Why? Because it's an irritating protein in a set of proteins in dairy that irritate the gut and cause bleeding in the intestines of little kids. Wow. Now think about that. I'm not making this stuff up. This is in National Library of Medicine, PubMed, major journals. So constipation is really common. and it can be also caused by parasites or other issues. So in one case I had was really fascinating. She had a tick infection, Babesia, which caused a nerve paralysis in her gut, which is really unusual. So there's unusual causes, but usually constipation is really easy to fix by upping the fiber, upping magnesium, upping vitamin C, upping hydration, and for most people, you know, that'll work. I had a patient once who was a, a, a radiation oncologist. She was a resident actually at the time, and she had severe headaches, migraines, and she had been treated, she was a resident at the Mayo Clinic, right? She was a doctor at the Mayo Clinic, which is where everybody goes to figure out problems that no one can fix. And she saw everybody and no one could fix her. And she was taking all the preventive drugs and all these different drugs. and it was just stuck. She was on narcotics and Zofran and chemo drug, like chemotherapy, anti-nausea drugs that would be used for chemotherapy. I mean, it wasn't working. And she came to me and said, okay, she had migraines, but what else do you have? Let's talk. And so we went through a list and she had constipation that was severe. She had palpitations. She had anxiety. She had insomnia. She had muscle cramps. These were all magnesium deficiency symptoms. I said to her, so how often do you go to the bathroom? She says, well, I'm pretty regular. I said, well, how often do you go? She's like, I go every week. I'm like, that's not regular. Well, she says, regular for me, I go every week. I'm like, you should go every day or twice a day. She's like, really? It's amazing people don't even know what's normal. And so I gave her enormous doses of magnesium because it was what it took to get her to go to the bathroom and her headaches went away, her muscle cramps went away, her constipation went away. palpitations went away, all this insomnia went away. And so really she had a magnesium deficiency problem. And how would you look for the symptoms that give you clue that they might have a fungal issue?

It's, you know, I look at Canada as a sort of comes along for the ride, right? And sometimes it's gonna be, it's gonna hijack the ship and become the main player. And sometimes it's gonna be lurking there in the background and you're not gonna realize creating a problem until you fix some other things or you can't fix those other things. So I suspect that most all the time I'm dealing with gut issues.

Yeah.

The kind of gut issues that we see when people come in with long standing constipation, long standing eczema, long standing yeast infections, recurrent vaginal yeast infections, recurrent UTIs, athlete's foot that's recurrent, allergy, you know, as I said, allergies. I, I start to suspect there's inflammation going on, and then we know there's inflammation. We know we're going to find something in the gut. And can't, you know, candida needs to be on that list.

Yeah. You know, and I, and I, and I think, you know, I go through, like, when I think about it, I go through what, what are their risks? Right. Have they been on antibiotics that will cause fungal issues? Have they been on hormones like the birth control pill? have they taken steroid drugs? Have they eaten a diet that's tons of sugar?

Those are the four big players.

Yeah, sugar and starch. Are they drinking a lot of wine and alcohol and beer? These are all things which promote the growth of the fungus. It's like feeding the bad guys. And then, so if they're at risk for that, then I go, wait a minute, what are their symptoms? And like you mentioned, a lot of them, but they can be really common things that people just kind of think, oh, it's not a big deal. I got a fungal toe growth. or I have an athlete's foot, or I have vaginal itching and yeast issues, I have anal itching, I might have some eczema, I might have some psoriasis.

I might have dandruff on my head. I crave carbohydrates.

I crave carbohydrates. I can't lose weight. I can't lose weight. I'm constipated, like you said. So we begin to sort of create this whole thing. And I remember I had this one patient, she was like a walking mushroom. She had like dandruff and eczema and anal itching and vaginal itching and, She had athlete's foot. I mean, she pretty much had everything. And she had these like tinea patches, which is another kind of skin, which is a well-known fungal infection called tinea versicolor, which is common. And so she had all these issues and she was also feeling like crap. And people can get other issues from it. They can get depression, they can get fatigue, they can get brain fog, they can get inflammation, they can get joint issues, they can get all these weird symptoms. So I'm always on the alert. and, and that's not to say that everybody who comes in has a fungal issue with these issues, but you, you have to make sure you don't overlook it. And that's really what we focus on in functional medicine.

Yeah. Yeah.

And we, and, and so when somebody comes in that sick and that's, and that's how we, we see them. They, they do come in that sick and they come in, you know, almost despairing sometimes because they've been fighting these symptoms for years and they're being treated with antihistamines and they're being given topical steroids for their rash and they're given PPIs for their heart and their acid blockers, acid blockers for their heartburn or the regurgitation, and they're taking some over-the-counter Senna for their constipation. So they come in with these long lists of pills to combat every symptom that was put in its own silo, and nobody stopped to put together the fact that maybe these all belong together as one problem.

So we see this a lot and we treat it usually in the context of everything else. It's not only often just the yeast, but it's their overall gut flora and their imbalances. But you had a patient, Julia, who had all these issues and she had a big yeast issue. Tell us about her and what you found and what you did and how you helped her.

Yeah, so Julia, sort of, she represents the symptoms that I was just talking about. She came in with fatigue, brain fog, recurrent vaginal yeast infections, anxiety, carb craving, inability to lose weight. She, let me make sure I got it all. Oh, she had migraines as well. She was also under an enormous amount of stress. And I think it's important, and we're going to talk about that in the role stress plays with Candida. But she had enormous amount of stress, which I came to find out came from some childhood trauma that was significant. Her recent stress was a divorce. that had just drawn out over four years. It was really difficult. There was custody battle. And it was during this period of time that all these symptoms really worsened and she was not getting any relief from the multiple doctors she's been seeing. And so she arrived here. Her symptoms were really at this point like anxiety and bloating and constipation. Secondarily, she was talking about, I also have had this longstanding rash. It comes and it goes. and I get migraines. So, of course I do a gut microbiome test. And I'm already, because of her symptoms, I was already thinking that, yeah, this is definitely a gut issue, but the yeast vaginitis, the recurrent rash, the bloating, I was definitely think she had dysbiosis or imbalance. But I did suspect that she might have Candida because of the carb craving and the bloating and the rectal itch. so it was there. So I did some of it. I did additional tests. I did Candida antibodies. So I, Candida can be hard to find.

Yeah.

And I really like to have something to hold onto when I make the diagnosis, something that is real. So here are the places I look. I did the Candida antibodies. The complete diagnostic stool test that I did is going to measure, is going to actually look for Candida using PCR testing. and it's. Then the other place I look.

These are tests you just don't get at your regular. You not. So what we do at the Ultra Wellness Center, so we look at things like antibodies to different foods, antibodies to.

Yeast, we look at stool tests. And then I, I also, you can also look at what we talked about earlier was the Organix acid test. The Organix acid test can actually look for metabolites of gut bacteria in your urine.

Or fungus.

Or fungus. Or fungus. And one of those metabolites that candida makes and makes alone is D arabinose. And so I checked for D arabinose on our organics acid test, and that was enormously elevated off the chart. And so that was the, that's all I needed to know, understand that she had Candida.

So what you're saying is basically there's, there's tests that you can do where you can see if it's growing in the stool, whether there's the genetics of it in the stool, whether there's actually indicators in your blood from antibodies, but also you can look in your urine to see that these, these metabolites of fungus or even bacteria. can be absorbed from your gut and then they end up in your urine. So they're not human metabolites. So if you see this thing in your urine, it's not coming from you. It's coming from that critter in your gut. And that can be an issue. So we use basically the history, which is really important. All the symptoms we talked about, we have thrush or you have a white.

Coated tongue or all these things. I just have to emphasize one thing. Everybody gets a really, really, really deep history and a physical exam.

Right?

And I, you know what? And it's out of that that I cognate and I begin to put the pieces together. The narrative comes together and it can't come together unless you do those two things.

Yeah, that's really the story. And the tests confirm it.

And then the tests confirm where I was going and, you know, what I was thinking. And in this case, if the test didn't come back positive, right, then I wouldn't have, you know, maybe she didn't have Candida. But I will say the final thing is that, on how do you make that final decision to have Candida- Or yeast, your first- Or yeast, Candida fungus is an umbrella term.

I think it's not just Candida.

It's the most common, but we can use the term yeast or fungus. I may say, you know what, I know the test came back negative. I know how hard it is to find, but clinically I think this person has fungus. I'm going to treat it.

Absolutely. Some of them walk in mushroom, they have a white coating on their tongue and vaginal yeast infections and itching in their anus and they have eczema and they have blepharitis, which is crusting around the eyes, they have itchy ear. I mean, like there's a million symptoms that are from overgrowth of fungus or yeast. And even if their tests are normal, you still have to treat them.

Yeah.

And what's amazing is these people really get better.

They do get better.

It's like one of those miracle things in functional medicine.

When you get it right, it is, you know, and that's why it's really important because it's maybe 10% of the people that come in have a fungal origin for their symptoms. And I will tell you most of the time it's just not that. It's usually just not that. It's usually gut dysbiosis or imbalances of bacteria to begin with. It's the fact that the nutrition's been really poor and they have multiple nutritional deficiencies. They live that really stressed out life. And that stress changes the gut microflora in such a way that makes you more susceptible to to to candy. Absolutely.

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What do you do? Yeah, so those are the things I look at. so again, I look at the general lifestyle and I start to think about, you know, where, what's going to work. And I, it's going to be all the lifestyle issues. So it's going to be nutrition, it's going to be sleep, it's going to be exercise, it's going to be stress reduction. Those are, those are key for anybody. Key for anybody. So nutrition becomes a key place. So when I think about candida, I think about changing their diet. I think about treating it.

What do you do to the diet?

So the diet. So the diet, we want to take out, you know, sugars, processed carbohydrates. We want to take out. Because those are the things that feed your Candida. So there's some specific. Stop feeding them.

Yeah.

Yeah.

Stop feeding them. So we're getting rid of, like, all the processed foods, all the sugar. We're going to limit alcohol and reduce stress.

Those are my top four things I do.

Yeah.

Okay. You don't have to go on this super extreme anti-candida diets that everybody talks about. Well, they're dangerous. I mean, they're not that they're dangerous, but. if you think about the anti-Candida diet, it restricts too many sugars, right? And the same thing with the, there's a diet called the GAPS diet. There's a diet called the SCD diet and the anti-Candida diet. One thing they have all in common is they're very restrictive of carbohydrates, almost to a fault, to the point where you might go into ketoacidosis or ketosis.

You wouldn't go into ketoacidosis.

Well, you go to, I'm sorry, I'm sorry. I mean ketosis. I mean ketosis. you may go on an experiment.

Which isn't necessarily a bad thing.

It's not. However, there are some studies that have shown that the antifungals we use, both the pharmaceuticals and the herbs that we use, do not work as well in a fasted state.

Interesting.

And also, neutrophils don't function as well, and neutrophils are very important in fighting the the candida and keep it from adhering to the the back the intestinal wall. Those are your white blood cells. Right. And so so those diets, you know, that's one of the, you know, there's some research that points to them doing that. So I'm a little cautious about wanting to use such strict.

Yeah, just getting rid of the sugar, the starch and processed carbs.

That's what we do.

So we do basically here is we and you probably don't want to eat.

Any blue cheese, right? So we do those things. We get rid of the processed carbohydrates. We get we get rid of the starchy carbohydrates. We get rid of the sugars. We limit the alcohol. reduces stress. And, you know, there's, so we do something a little bit like a low FODMAP diet. So we reduce those, those foods that are easily fermentable. It's like onions and gar, onions and asparagus and wheat would be examples of some of those foods you want to restrict. So now that's a great place to start because good nutrition is good for everything. But generally, I find in my patients that it's usually not enough. Candida is hard to treat and we need to then treat it. And typically we'll see- you- need a weed killer. You need a weed killer. Yeah, you really do.

And what do you use?

So, I'll typically start with herbals. So, there's caprylic acid, there's undecylic acid, there is lauric acid.

Which is in breast milk and coconut, right?

Yeah, breast milk and coconuts. And then two spices that are very potent and I think you need to be careful when you use them are oregano and thyme.

Yes.

And they can be very, very helpful.

Oregano is a great anti- Berberine.

Berberine can also be effective and berberine also is an antibacterial so it can be used to treat a bacterial overgrowth as well as a fungal overgrowth. so I will generally start there. I'll also add in some biofilm busters because these Candida, like other bacteria, they will congregate together, they will form a little town, they'll put up their umbrellas and be invisible to the immune system. So what is a biofilm buster?

So what is a biofilm? What is biofilm?

So biofilm is that, it's when they gather in a, it's like a big village of these Candida, they throw up their umbrellas.

It was like a protective tent over them.

Tent over them. So they are invisible to your immune system. and they're, they're protect themselves against the antibacterial that you're gonna use or the antifungal that you're gonna use. So, so biofilms, when I have a patient, it's not getting any better, I'm gonna pull out the bio, I'm gonna pull out the biofilm busters. And those are gonna be things like, serpeptidase, nattokinase, and, there's one more that I use, that's slipping my mind right now. That's okay. So we've got, we've got the antifungal.

Herbs, we've got biofilm busters, and when do you decide to use medication and what do you use?

So when we, when that's not working, then we oftentimes do have to go to medication. So I'll use Diflucan, Nystatin. Nystatin is sort of like the Zifaxin. If people have heard of SIBO, Zifaxin is an antibiotic. It's not systemically absorbed. It just stays in the gut.

Okay, you give Nystatin to babies.

Yeah, yeah. And yeah, pregnant women, babies can use Nystatin. And so Nystatin is a good choice if you're concerned about patient's sensitivity to medications. So nystatin might be one of my starting points. The most effective treatment I use is Diflucan.

Yeah. Now, Diflucan is one of those drugs that we hear is bad and bad for your liver. Doctors freak out about it. They don't want to take it for more than a day. But, you know, the old fungal drugs were dangerous. We used to learn about this in medical school. It was a drug called amphotericin. We called it amphoterrable because it had all these side effects. But these newer drugs don't, especially if you're not taking a lot of other medications or there's drug interactions. and I prescribed probably more diflucan than any other drug I've ever prescribed in my entire medical career. And knock wood, I really had no problems with it. People do get die off where they can feel like the yeast gets killed and then they'll get an immune response to that and they can feel kind of like flu-y for a little bit. But that you can kind of cut out with getting charcoal afterwards a few hours later. And I think that this is really in a very effective treatment for people who really need it. And I think I wouldn't be afraid of using it. And it's used for more than just a day.

We use it for a few weeks.

Or sometimes even a month.

Yeah, this, look, you know, Candida is one of those controversial areas in conventional medicine. But in functional medicine, you're going to come across people who have fungal infection, they have yeast infection, and it's having an enormous impact on their life. And you've got to be really cognizant of that. You need to test for it, and then you need to treat it appropriately. It is not that easy to get rid of it. It can recur.

Yeah.

And so, we have to be really diligent in helping our patients not just get rid of the Candida, but rebalance their nutrition, rebalance all of their lives because it's those things that led to the Candida infection in the first place.

Right. What is the root cause of bugs growing where they shouldn't be in your gut? In other words, like most of the bacteria should be in your large intestines, but then it migrates up to the small bowel where it's not supposed to be, and then you get all these symptoms. Why does that happen? It's not clear. It's not like a human, 74% of people have a defective gene or some bad human design that God designed us poorly. Something's going on with our modern diet, lifestyle, something that's causing this epidemic of GI symptoms.

That's a lot to unpack, but we have a lot of answers. We don't have all the answers, but we have a lot of answers. We now believe that, and you sort of brought this up as part of the introductions, is that we now believe that food poisoning starts the whole process. so you.

And.

And eating is part of it. You know, back in the day, meaning like 40, 50 years ago, when we were in kindergarten, we would sit in a sandbox and eat the sand. Now we eat salad out of a bag until we go to Club Med. And for the first time in our life, we see salmonella or, you know, we go somewhere and we. We get Travelers diarrhea. or we get food poisoning or whatever, we start to explore the world of food. But food poisoning triggers this. And we now have identified the toxin in food poisoning, the CDTB toxin, that trips off some antibodies in the human body that then cause your nerves of the gut to fail or to be impaired. And so when the flow of the gut is slowed by this impairment, bacteria build up. and there's two bacteria that just flourish when it's a little more swampy. So I used to watch Survivor shows on TV on Discovery Channel. You probably watch those. And they always say, I like the loss.

I used to watch loss, which is kind of like Survivor.

It's a little bit different. There's a little more raunchiness. With Survivor, you're just kind of trying to make it to a road somewhere. But the point was that he always, this guy on the Survivor show would always say, if the water's not moving, don't drink it. If the water's flowing fast, drink it because it's cleaner. And the same thing with the small bowel. If the small bowel stagnates, it becomes swampy and bacteria grow in it. And, and the same thing is happening in the human small intestine. And, and so it's a sequence. So food poisoning, the antibodies, and then you develop the bacterial buildup.

So you're almost saying it's like an autoimmune disease of the nerves of the.

Gut that develops that kind of sluggish.

So, this is a kind of a radical idea that irritable bowel is an autoimmune disease, isn't it? I mean, this is kind of not what most doctors typically think of when they think of IBS. They think of IBD or inflammatory bowel.

Disease, but they don't think of irritable bowel being autoimmune disease. Dr. The interesting thing about contrasting IBD to IBS, so the antibody that we discovered is an autoantibody that is directly related to the pathology. So, the higher that antibody is, the sicker you are. The antibodies in IBD are markers of IBD. They're not directly implicated in the pathophysiology. The antibody to vinculin that we discovered is directly related to the pathophysiology. We can make rats have IBS just by giving them this toxin. And so that's very cool because it allows us to study new drugs and new therapies coming in.

Not so cool for the rats though. Wow. So this is fascinating. So you were saying there are different kinds of bacteria. Can you explain, you know, what are the kinds of bacteria? And then, and then what type of food poisoning is it any, like if you get Giardia or if you get Salmonella, Shigella, Campylobacter or Entamoeba or like, you know, what, what are, are the kinds that typically cause the problem?

Well, the four horsemen of the apocalypse of IBS are Campylobacter, Salmonella, Shigella and some E. Coli, food poisoning type of E. Coli, pathogenic E. Coli. Giardia can do it too. It turns out it has vinculin in its structure and so maybe that's how you get the antibodies from Giardia. The viruses are less likely to precipitate IBS. So the four horsemen, Campylobacter, Salmonella, Shigella, and E. Coli. So that's and it occurs about starts to occur about three months after you get sick. Patients will remember. Some don't remember and they'll say, well, you know, they have a couple of days of diarrhea and they don't pay much attention to it, but they remember going on a trip to Hawaii and they end up in the hospital with bloody diarrhea.

And then ever since then, nothing's been the same. I have heard that story so many times. You know, I went to Thailand or.

India or, you know, Jamaica and like, and sort of tripped the whole thing going.

Yeah.

Or the taco truck in Venice.

Yeah. So, a lot of possibilities. Wow. So, so this explains like sort of 60%, you say, but. not all of it, right? What are the other things that may be driving irritable bowel syndrome? And are they also related to SIBO or is it all something else?

Well, so based on culturing the bowel, we've been able to isolate that 60% of IBS is SIBO. The other 40% is a mixed bag. So, for example, and you probably talk about this now, Ehlers-Danlos syndrome, POTS syndrome, we're starting to recognize those illnesses as characteristically GI centric, at least in their early presentations as well. So some of the leftover 40% have Ehlers-Danlos syndrome or POTS or some of them are celiac that we've missed. Some of them are food sensitivities, some of them are histamine sensitivities, some of them, so it's a mixed bag of a number of other disorders. And some of them are fungal overgrowth. so we see that in about 6 to 10% of that 100 pie. So there's still more to unpack. We're not ignoring the other 40. We're trying to figure the rest out, but it's a little bit harder to unravel.

So let's pause there for a minute because you just said something that I think might slip by, which is this whole idea of fungal overgrowth or what often is referred to as C-FO, small intestinal fungal overgrowth. And in my coming of age as a functional medicine doctor, basically people would laugh when we talked about yeast overgrowth or anything like that and candidiasis, and it was just like a quacky alternative concept. But it seems to be now understood as potentially playing a role in some of these cases. Can you talk about the current understanding of this and actually some of the treatment? And then I'll sort of loop back to the how do we start to treat and think about IBS differently?

Yeah, I mean Satish Rao, Dr. Satish Rao in Georgia has done a lot of the seminal work in this. but more recently we've done shotgun sequencing of the small intestine and we've been seeing this fungal overgrowth.

That doesn't mean you shoot somebody in the gut with a shotgun.

Shotgun sequencing means we sequence every single piece of DNA we can find and then characterize it and see what organisms it represents.

Yeah.

And it represents fungus about 10% of the time and that when the fungus is higher, you're the patients are experiencing more abdominal pain and more diarrhea. So there is a subclass of these patients that it is fungal, but it's smaller than some would like to believe, but larger than those who are naysayers, as you've probably heard. And so it is there, it's real, but it's a little more challenging to identify. There's no breath test for it. You got to go in and chase it. And that's the challenge.

Chase it by doing stool cultures or- well, chase it.

It could be by stool, but if you want to find small intestinal fungal overgrowth, you've got to get into the small intestine and that's really sample that. Yeah, you have endoscopy and all that. That's how Dr. Rao identifies it. Yeah.

And, any particular species of fungus or is it sort of a broad array?

So, what we found in this, quote, shotgun sequencing is Candida albicans is a big part and a little bit of Candida glabrata. And, there's a few other Malassezia and all these other organisms that are very minor, but they generally aren't at a high number that we think are as consequential as the first two I mentioned.

Yeah, no, I definitely have seen that on cultures. And, you know, in my experience, maybe it's not Universal, but it tends to lead to more constipation. And so people tend to have more constipation. And also, I can tell because they might have other fungal symptoms. They might, you know, eat tons of sugar and starch. They might actually have fungal rashes on their skin or dandruff or other. kind of clues that they have kind of a yeasty kind of situation going on. But I, I think it's important that it's been identified. And going back to kind of the treatment of that, how, how would that normally be treated? Well, yeah.

Generally, in, in allopathic medicine, we try an antifungal. There are natural antifungals as well, and I, I'm, you're probably better versed in those than I am. But we, we do use fluconazole. We do use Nystatin. Occasionally we use more radical, more advanced antifungals, but those are the typical first two choices.

Yeah. Sometimes you can take what we used to call Amphotericin B, which is a horrible first generation antifungal, but it's not absorbed. So, if you take it orally, it's not absorbed and that can turn into... Exactly.

Yeah.

Oh, yeah. And then in terms of the bacterial stuff, you talk about these three different bacteria, right? You've got methane producing, hydrogen producing, sulfide producing, and they all are a little bit different. And, you know, said the methane producers are not really bacteria. They're Archa. But, you know, for, you know, Simplicity's sake, let's call bacteria. And, and I don't, I don't think most people know what Arka is. It's Arcane. Right. So, yeah. So what, what is your approach to starting to kind of differentiate these and then how do you determine what the right treatment is for a patient and can kind of, kind of guide us through what to do both in terms of lifestyle, diet, and any kind of supplements that might be helpful and medication.

Yeah. So, first of all, we helped develop the first three gas breath tests. So, just full disclosure. But it's changed my practice because there are patients who fell through the cracks without knowing hydrogen sulfide. So, unpacking each, the hydrogen positive breath test patients are generally, we actually just published this paper, it came out literally yesterday, there are two bugs. That's it. That caused the hydrogen overgrowth. It's Escherichia Coli, the non-pathogenic one, and Klebsiella pneumoniae. Those two characters, when they come into town, everybody leaves because they're so opportunistic and bullies. And we think they produce even toxins to the other bacteria around them to try and get rid of the. The have inhabitants. So it's like you've got a gang that comes into the small town and everybody leaves. so it's a disrupter of the microbiome and then they rise very high in number. So that's the hydrogen one. The second category is the methane or methanogens and those characters live both in the colon and the small bowel and we have a paper coming out showing exactly where they're living and it's pretty universal in a lot of these patients. So hence we call it intestinal methanogen overgrowth and not SIBO methane because It's not just the small bowel, it's colon also. And when they produce methane, it gives you a lot of constipation, a lot of gas, and you can't pass the gas. And it's these people are quite miserable. And then the third is the hydrogen sulfide, which is the new kid on the block, which has changed my practice because some of those patients, we didn't know breath test is normal, everything looks fine, and then the hydrogen sulfide's positive. We get rid of it, and all of a sudden they feel better than they have in their life. and for some reason, when you get rid of hydrogen sulfide, it doesn't come back so quickly, which is beautiful. I have patients who've gone a year just one treatment and they're done. And so, I'm really excited about that. I could talk about the treatments if you like now or-- yeah, yeah, yeah.

Go through the treatments because I think they're real different. This is important to understand for people because just because you have a real bowel, it's not like a one-size-fits-all approach. You've got to differentiate what type it is and these tests that Dr. Pimenta developed the tests for anti-CdTB and anti-Viculin antibodies are really important. And then, the breath test that allows you to look at hydrazine, methane, and sulfur. So, can you talk about what are the different treatments for each of these? Yeah. So, I mean, if I have an.

IBS patient with diarrhea or a patient with diarrhea and bloating, my practice now I do the antibodies because I want to be able to say was it food poisoning or not? And, if the antibodies are really high, it makes it harder to treat. But also, you travel, you better take prophylaxis because you could get into further trouble with these antibodies going higher. So, I universally do that.

Like prophylaxis like what? Like Zifaxin?

I give Zifaxin prophylaxis. That's what I do in my practice and a lot of the GIs now do that because if the antibody goes higher, the damage to the nerves of the gut is more intense or the effect on the gut is more intense and at least that's what we're seeing in our clinic. so we're very careful with those patients who have the antibodies positive. When it comes to then we do the 3-gas breath tests in all of our patients. And if it's hydrogen, and we all know Rifaximin got FDA approved for IBS with diarrhea on the basis that IBS was in part a microbiome disease and now we understand that microbiome condition is SIBO. So I give Rifaximin for that. If it's methane, we have one double blind study that we can lean on and it's rifaximin plus either neomycin, which is what the double blind study covered, or rifaximin and metronidazole. And then the third category is hydrogen sulfide. And we give rifaximin, but we give it with bismuth because bismuth is an anti, it blocks some of the synthetic functions of hydrogen sulfide in the sulfate reducing bacteria. Point is, the hydrogen sulfide goes down, the bacteria are reduced, and therefore the patient's normal bacteria take over and things get better more permanently in that group it looks like.

And that's basically Pepto-Bismol. Yeah, yeah. Interesting. So in terms of diet, is there a different approach to each of these in terms of what you would recommend from a food perspective?

We haven't sorted out and or had time to sort out the different diet approaches. But I envision smarter people in me and diet will come up with a way. What we do now is what we call low fermentation eating. So we don't use low FODMAP in our practice because you can't do it indefinitely. But low FODMAP will reduce the amount of calories you're providing to bacteria, and therefore they'll ferment less and, and that might help. But long-term low FODMAP hurts your microbiome and can cause nutritional deficiencies. So you can't stay on the full low FODMAP indefinitely.

And FODMAP is like fermentable oligo saccharides.

That- yeah, fermentable oligo saccharides, monosaccharides, et cetera. And basically it's too restrictive. But you've probably, most people have probably read about FODMAP diet, it's very popular in the last few years. but we use what's called low fermentation eating, not as restrictive. And the philosophy of that was with a low fermentation diet, you can go to any restaurant in the country and you'd find a meal. So it's, you know, you don't want to be the person at the table just because you have IBS that spends 10 minutes with the, with the, you know, trying to explain your dietary restrictions on a low FODMAP diet. So, you know, that that's. part of the reason. We want our IBS patients to feel as normal and as socially non-isolated as possible, and that's part of it.

What is a low fermentation diet?

So, it's basically restricting non-digestible carbohydrates, so low fiber, no dairy, and then none of the artificial sweeteners because, of course, they're easily fermentable. and then spacing your meals so you don't eat for five hours between meals because the damage of the nerves, we talked about that earlier, the damage to the nerves causes a reduction in cleaning waves of the gut. So the cleaning waves only occur when you're not eating. So your gut is sort of like got two computer programs, eating mode, cleaning mode. If all you do all day is spend time in the break room taking a bite of a bagel that's in the break room, you never go into cleaning mode. So in addition to the construct of what to eat, we tell you when to eat and to try and space your meals up.

So anyway, the typical dietary recommendation when I was in medical school for IBS was more fiber, like Metamucil, basically. What you're saying is that you want to restrict soluble fibers that are digestible. And low fiber diets seem to be you know, it seems like a contrary notion when you want to create a healthy microbiome because good bugs also live on fiber. So how do you, how can you navigate that?

Well, you know, I may be punished for saying something like this, but everything has fiber in it now. Even Cheerios, they put fiber in it because it prevents colon cancer and it's colon health and all this stuff for 20 years. How many, how much have we heard about colon health and fiber?

A lot.

And what have we, what have we got now? we've got colon cancer happening in the 40s and we're doing screening colonoscopy at 45 now. I'm not saying it's fiber causing that, but all the fiber we've been pounding and the cardboard we've been eating hasn't really done as much as we thought it might. So I'm. I'm a little unclear about fiber, but from the point of view of bacteria, you put more fiber, you're going to have more of the bacteria. If you had bad bacteria to begin with, there's going to be more of them. and for a healthy person whose microbiome is healthy, no problem. But not for these patients with these microbial conditions.

Now, if you've gotten these antibiotic treatments, you've gotten diagnosed, you've gone through the testing, you've gotten the personalized treatment, you do the course of antibiotics. What prevents the bacteria from coming back? And in my experience, it often does. So how do we manage the sort of recurrence that occurs? Because you don't want to keep giving people antibiotics because intuitively people go, Wait a minute. Antibiotics are bad for the gut.

So why are we giving antibiotics to someone who's got a gut problem? It seems counterintuitive. Well, I can answer in two or three ways, but I'll try to touch on a little bit of each. We looked at rifaximin before and after treatment, the small bowel, and when you get rid of the bullies in the town, all the inhabitants of the town come back. So it goes opposite of what people think. We're not, you know, being cataclysmic. It's getting rid of the E. Coli and the Klebsiella in SIBO that allows the regular bacteria to re-flourish, repopulate, and take over again. for a period of time. But remember, the problem is those cleaning waves are not working. So it is possibly going to come back. It depends how badly damaged. And that's where that antibody comes in. Because if the anti vinculin, which is that auto antibody for the autoimmune disease of IBS, is very high, the neuropathy is more high or more intense, and you're going to relapse or reoccur more frequently. So that's where we were able to have some further strategy. But first of all, take the antibiotics. They actually repopulate the town counter to what you think. We've never seen antibiotic resistance to rifaximin so far. Knock on wood. It's a very unique chemical drug. And then we get them on the low fermentation eating diet. That's what we do. And for those where the antibody is high or those who relapse, we do put them on a prokinetic. So so they space their meals, everything's going right, but we want to stimulate those cleaning waves at nighttime because that's the longest time you're not eating and make you clean up as much as possible at night so that the bacteria don't have a chance to come back. So we don't do all three things for everybody. It depends on, you know, if somebody relapses in two years, we don't need to put them on a drug every day to prevent, but if they relapse every three months, then we can stretch it out to a year by adding the prokinetic doing more aggressive diet strategies.

So, this is something that's a chronic condition that has to be kind of continually retreated in some ways, is that what you're saying?

That's right. It's sort of that way for now, but that's the point of the antibody. The antibody is causative. Get rid of the antibody, get rid of the disease. So, the focus of our lab right now is get rid of that antibody.

And how do you do that?

Well, I can't tell you, first of all, because we haven't worked it all out. But there are ways to do these kinds of things. And we're exploring multiple ways or avenues to do this because the ultimate goal is to cure this and not just go, you know, what I'm telling you today, hopefully, if everything goes according to plan 10 years from now, we won't be doing what I'm telling you today. we'll be doing something much more permanent.

Now, is it a pharmacological solution or is it something else? Yeah, it would have to be. It would have to be something and.

It might even be a biologic agent to try and drag that antibody out of the bloodstream. But then, it's cured and you don't have to worry about anything. You can go do whatever you want, go wherever you want.

Interesting. I was just thinking about from my perspective as a functional medicine doctor, I think of things like how do we deal with autoimmune neuropathy, right? right? One, we look for the cause. Well, if it was some infection, we try to get rid of that. But it could be, you know, other things like nutritional deficiencies or toxins or other things, and, and even certain things might be helpful, like lipoic acid. Just kind of theorizing that there's any evidence about this, but lipoic acid is great for diabetic neuropathy. Could it help the gut? Plasmapheresis is often used for, you know, chronic neuropathies, peripheral neuropathies or things like Guillain-Barre.

Could that be helpful?

You know, so I'm just sort of.

Wondering, are there other kind of novel things that we haven't thought about that might be helpful? So, so.

Just anecdotally.

And so I don't like doing anecdotal medicine. We like to do our, you know, publish our papers and do good randomized control trials as, as you know.

But, but, by the way, all, all feces of medicine come from anecdotes. So I start with, like, an observation.

I'm gonna. No, I, what I'm saying is I, I'm going to tell you things that we do that have been very, very successful. So I, I'm, that wasn't meant to be critical, more critical of what I'm going to just. to now tell you, because I don't want people to go out there and start doing plasmapheresis in IBS patients. But we have in five patients, and for one month, their IBS is gone.

Wow.

Until the antibodies repopulate. So, you know what you're saying is actually absolutely the list of things that should be tried. And so you're spot on is what I'm saying.

But I just made that up. I just was guessing because based on the theory of how he would normally think about these things.

As I know, I've known you for 20 years, you generally don't riff. And, and that riff is based on a lot of scientific knowledge.

Yeah.

Yeah. And, and you riff off at least two things that we've tried that have worked very, very successfully. But we need to do something even more advanced than that because, you know, you can't put a catheter in the neck and do dialysis like plasmapheresis on an IBS patient, 70 million people in the U.S. as you start.

No, no, no.

So it's not an answer, but it's. it proves the hypothesis, right? As you mentioned.

Amazing. Now, one question I have is, do you worry about giving the antibiotics and then seeing fungal overgrowth? Because, right, it's all about like the weeds, right? If you kill, you know, one plant, then other plants grow. So, if there's, is there any kind of necessity to deal with, you know, kind of cleaning up after the antibiotics with herbal or natural or non-absorbed antifungals.

Or even like nystatin or even things like Diflucan, is that ever needed? Yeah. So, I mean, as you probably are aware, I've treated thousands of patients with Rifaximin, and it's not zero, but it's extremely rare that we see people get worse. We did a study where we looked at the number of people who got worse with Rifaximin had to stop the drug from taking it, and you have to treat 8, 000 plus patients for one person to feel bad enough to stop Rifaximin. that's how safe it is. However, but in the old traditional thinking, yeast should get more if you give antibiotics. But as we're dissecting the microbiome, they're almost mutually exclusive, so they don't always happen together. And so maybe the ones that don't, rifaximin doesn't work, it's not making it worse, but you need to go to the antifungal. and that's what we're trying to sort out is, you know, odds are you have overgrowth of bacteria because it's 60%. Start with that. And maybe the ones who fail start to think about fungal if the symptoms continue to be typical of an overgrowth of some kind.

Yeah.

Interesting.

You know, the other thing, you know, I think about is probiotics, because typically people think, oh, I have tummy problems. I'm going to take probiotics, but they.

Can make IBS worth and they can make SIBO worse.

Right.

Yeah, yeah, a couple things with probiotics that you love to hear. Probiotics do make IBS worse because you already have an overabundance of bacteria. Fun fact, and this goes back to the beginning of the program, you were talking about the microbiome. But the beginning of the microbiome was only looking at stool. Nobody looked in the small bowel, the darkest area of the gut, and that's when we started looking. So lactobacillus, very nice to have in your stool. You know who gets a lot of Lactobacillus? People who age very badly. They have a ton of Lactobacillus in their small bowel. So when we just published our aging paper, Lactobacillus in the small bowel was a sign of unhealthy older people. And so different regions of the gut, different benefits or harms to different whatever you're taking as a probiotic. So so I'm not so big a fan of lactobacillus. We didn't see that for Bifidobacterium or some of the other probiotics, but lactobacillus, I'm not sure.

Maybe it's a, it's not so great to take if you're older. But interesting, if you, you know, if you think often, I'll, you know, empirically just kind of try to reset the gut after a treatment with rifaximin or antibiotics. And, and, and I don't give probiotics before, but I'll give them after and I'll, you know, and I'll give things to help sort of support gut health, like, you know, fish oil or vitamin A or GLA, other nutrients that are important for helping the digestion kind of repair. So that's my sort of hope that it wouldn't come back. There's not a lot of great evidence about that, but it's sort of a framework we have in functional medicine of just putting like the whole package together of restoring the gut ecosystem.

It's a really common problem. About 80 million people per, you know, the prevalence is very high. So 80 million people are going to suffer with constipation, And it gets worse as you get older. And it's an $800 million business, and that's an underestimate because it doesn't include the over-the-counter meds. So it's only $800 million that's being spent to have a nice bowel movement.

Well, you mean from with doctors. You're not talking about like the stuff you get over the counter like Ex-Lax and Senokot.

That's what doctors and I said it's an underestimate because it doesn't include the OTC meds.

The over-the-counter meds you get in the grocery store, which is probably way more than that, right? So tell us what are the complications of constipation and why is it bad to not go regularly? Why is constipation bad?

Yeah, so first off, what is not regular and what do people consider constipation? Why is it such a, you know, why is it something that people are, you know, we see people with gut issues and constipation almost one out of every three patients of mine, no matter what they're coming for, has a gut issue. So, gut issues in general are just prevalent throughout the world, quite honestly, because we get people from all over the world in the center. I'm always dealing with gut issues, particularly constipation. Constipation leads to bloating and distension, and then people identify foods that cause their constipation. Then there's food fear and anxiety, and it just begins to really take a toll on people's lives. It is a really big deal. What's a normal number of bowel movements? I was taught anywhere from three bowel movements a day to one bowel movement every three to five days. That's what I was taught a long time ago. The most recent study using the most respected tool for studying this, called the Rome III, identified constipation is less than three bowel movements a week. so in conventional medicine, that's what is defined as less than three bowel movements a week for more than three months. You know, I would know.

So. Well, why? Why?

So.

So.

But when you get constipated, it causes other health issues. So why is it bad to be constipated? Okay, why? So I go three times a week. I go. It's pretty regularly. Why? Why do I care?

Okay. I think there's two ways to look at that. One is, is that. not like once I'm constipated with the problems, but what got me to being constipated in the first place. And that goes back to what we always talk about is how you live. It goes back to lifestyle, it goes back to nutrition, it goes back to stress, it goes back to exercise, and just to name three of the the lifestyles that are most impactful. If you're not getting good exercise, you're not getting good sleep, you're not eating nutritious, you're going to be in a position to end up with gut issues, including constipation. How you got there is really important because if you've got constipation, that's just the beginning of the problems. Once you have the constipation, the problem is that you need to be able to evacuate your toxins, your metabolic waste. And the more that stool sits there, there are biochemical changes that happen in that stool that allow for the toxins and the compounds that your body didn't want anymore to leak back into your system. And when that happens, then you begin to impact your immune system, you begin to increase inflammation. and as we always talk about, that inflammation begins to have an impact on every organ system in your body.

Okay, so bringing it down, there's really two main issues. One is just the direct harm from being constipated, which includes hemorrhoids, anal fissures, anal prolapse, pain, and also just feeling like crap because you're full of crap. You're full of crap. and you're literally reabsorbing a lot of the toxins that get excreted by your liver right into your intestinal tract. You're reabsorbing them. You're also affecting your hormonal metabolism and you're producing all these products in there that are getting absorbed. And what's true about your gut is it's a whole ecosystem of bugs in there that has to be healthy. It's like a garden. And if the garden isn't healthy, you're not healthy, your immune system's disrupted. You're toxic. It creates brain inflammation. It creates systemic disease, heart disease, cancer, diabetes, Parkinson's. I mean, Parkinson's disease. You're 400% more likely to have Parkinson's disease if you're constipated. And we know that Parkinson's disease is related to environmental toxins. So, not only are you having this sort of anal and physical issues of being constipated, not only do you feel like crap, but it has long-term risk for many, many chronic diseases. so it's really important to go and go often and go every day or two or three times a day. And once you understand how to regulate your gut and fix the causes of constipation, then you won't be constipated. And most doctors just give you laxatives or tell you to have more Metamucil or fiber, and that can be helpful or drink a lot of water, but there's so much more to it. So tell us what is the conventional medicine approach to constipation. And then let's talk about what the functional medicine approach is to constipation.

And, you know, conventional medicine again, it is the name it, blame it, symptom, and, you know, treat it. And so, and, in it, you know, so they treat the constipation. And so over the counter, you can get all types of different products that will be either there'll be bulking agents, you can have laxatives that bring more water into your stool. You can have lubricating agents. All these are available. All they do is get the poop out. That's it. And make you feel more comfortable, but it doesn't solve the underlying problem. Then for people with what's called chronic idiopathic constipation, which is the most common idiopathic means, by the way, I don't know.

Right?

So I don't know why you have it, but I'm going to give you a really expensive drug to make your bowels move. And so there are really expensive drugs on the market that stimulate the receptors in the bowel to get them to move so you can have a bowel movement. So that's the conventional approach. Let's get it out and let's, you know, make the bowels move faster so that it will come out. But we're not going to look at the underlying root causes of why the person is constipated. Nor are we going to think about the downstream effects of that constipation, not only of the constipation itself, but to get to that constipation, again, it goes back to the fact that it's this long-term inadequacy of your diet, the long-term impact of stress that results in constipation. the patient, but what you can't see is the impact it's having on your brain, the impact it's having on the blood vessels of your heart, the impact it's having on your immune system. On the functional medicine side, that's what we do. We begin to focus on nutrition, stress, lifestyle, exercise. We begin to change people's lives so that they're living healthier, and therefore the constipation can resolve on its own. Yeah.

Well, before you jump into that, I want to talk a little bit about the problems with traditional treatments because, yes, it's fine to take extra fiber and so forth. All times that have weird artificial sweeteners in it and stuff, that's weird. You can take mineral oil, which is fine, but that's kind of gross. you can take various laxatives and suppositories. A lot of the treatments can be very dangerous, like Ex-Lax or Senokot or Cascara. Things are even considered natural because they create a lazy bowel. So people who have been constipated a long time, they take these drugs which work for their body and I even smooth move tea, which is fine for an occasional issue, but these things become habit forming and they cause a lazy bowel and people can something called megacolon where they literally cannot eliminate without these things or people get reliant on enemas or they get reliant on colonics. And the truth is unless you dig down into the root causes of constipation with a functional medicine lens, all these things are just like Band-Aids and they often are harmful, not helpful. Let's look down into, you know, from a functional medicine perspective, how do you identify what's causing a person's constipation? what are the tests you do? How do you think about it? You know, what are the, what are the main causes of constipation in our patient population? Yeah.

So, so the main causes of constipation are going to be one, I'd say there's food sensitivities. So not being aware of food sensitivities and that can create inflammation and alter the function of your gut. There's going to be nutritional issues like you're just not getting enough fiber. I know you talked about using exogenous fiber to treat the constipation, but you don't get into that situation if you're eating foods that aren't processed. All the processed foods that we eat don't have any of the indigestible fiber that's required for the stool to form correctly and also to maintain a healthy gut microbiome. Again, it goes down to some nutritions involved. What else would be some causes?

I think there's a lot of causes. Let's just go through them. So you've got things that are often missed like thyroid, right? You've got low thyroid function as a big cause. Lack of magnesium, which is a huge issue for people. I think 40% of the population is low in magnesium and that can drive constipation. People often have yeast issues from taking lots of antibiotics, which can be a big factor in constipation that causes a dysbiosis. Dairy is the number one cause of constipation in kids and not only constipation, but anemia because the dairy irritates the guts of these kids and causes blood loss in the stool. So constipation from dairy is a huge factor. So we've got a lot of things we think about. It can be also things like heavy metals, which are factors that can impair gut function or even weird things like tick infections, oh yeah. cause a neurologic problem in the gut that help damage the neurological pathways that cause peristalsis and that leads to constipation from tick infections. So from a functional medicine perspective, we really dive deep into figuring out what's going on. And the treatment is often so easy and so effective. And we really start with the foundational things, right? We start with diet and then we go on to the use of specific supplements and other things that can help fix it. So take us through this patient you had and then let's dive deep into the story of what are the real treatments that we find so successful in rebuilding someone's gut so they have healthy bowel movements and have health as a consequence.

So the patient that I had, she was a 19 year old nursing student who came to see me, and she had had prolonged, she had constipation after prolonged use of antibiotics for recurrent urinary tract infections. So interestingly enough, she was, you know, at the end of her first year of nursing school, lots of enormous stress test she had to pass, be able to continue the nursing program. She was in a new relationship and her diet was really not very good. She was under a lot of stress. She was eating poorly. So when she came to see me, she had significant constipation. And we do some tests that really help us get down to the root problem. And we do that complete diagnostic stool analysis that allows us to look at the microbiome. so we're able to see if you have a balance of your good and bad bacteria. We're able to see if you picked up any bad guys along the way like parasites and worms that can impact your gut function. And we look to see if you have all of the markers for healthy digestion, which is really key. So we're able to see if you're making enough of the pancreatic enzymes you need. Is your gut detoxification working correctly? Is your immune system working correctly? or markers of inflammation high, that gives us a complete picture of what's going on in your gut. We also look for something called leaky gut, that when you have enough inflammation, you have enough destruction of the mucosal membrane, you'll end up breaking down those gates that are responsible for keeping the bad guys out, letting the good guys in, they're called tight junctions. And when those aren't operating, then bacteria and compounds toxins can get into your system and trigger lots of inflammation and disease. We do those tests. We look for food sensitivities. The most common ones that we look for are going to be gluten, gluten cross-reactive foods that will include egg and dairy and soy and rice because they will act like gluten in your gut when you're sensitive to them. will be produced when you have leaky gut. So I did all those tests on her. And did I do any other tests on her? I just have to remind myself that was the, those are the tests that I did. And so what we look for, you.

Know, spectral overgrowth, you look at, you know, stool, food sensitivity testing, right?

Yeah, yeah, we did all that testing. And so what I found, what I found with her is that she did significant leaky gut, and she had something that's called SIBO. She had the bacteria that lives in your large intestine, it's just, she just lived there, had migrated up into her small intestine, and now it's where we don't want it to be. All that digestion and fermentation should happen in the large intestine, that very thick walls, and now It can maintain all that fermentation without you experiencing discomfort. But when you're doing fermentation in a small intestine that has thin walls, that fermentation starts to happen, the gases build up, you get bloated and extended. If the bacteria that's causing that overgrowth happens to be a Methanobacterium and produces methane, those organisms will slow down gut transit. And that will lead to constipation. And oftentimes those people get labeled irritable bowel syndrome with constipation. And in conventional medicine, we'll be put on medications like lunschtes, which will get the bowels to move but not solve the problem, which is bacteria in the small intestine. So in her case, we treated her small intestine bacterial overgrowth. with herbal antibacterials. We treated her leaky gut by using something called L-glutamine, which supplies nutrients for the gut to heal. I use quercetin as well because quercetin can actually impact and regulate the tight junctions we talked about and begin to heal the leaky gut. So, you know, we took care of a leaky gut. We reestablished a good gut microbiome. And then we helped her understand the importance of her nutrition. So then I talked to her about getting more of the high fiber food that she needs to get into her diet. Nuts, seeds, beans, chickpeas, chicory, dandelion root, onions, garlic, which she can't get right away. We had to increase her fiber after her SIBO was treated because some of those foods will actually exacerbate her symptoms. But once we treated her SIBO, once we took care of the dysbiosis, and then we talked to her about the lifestyle changes that she could make, which included higher fiber with the foods I just mentioned, which included making sure you did drink enough water because water is important. You need that water in the stool to make it fluffy and move quickly and easily through the gut and finally out through the rectum. Because if you have hard stools, they're really uncomfortable. And lots of times people call constipation hard stools. I just have hard stools. I have them every day, but they're hard. And that is constipation to some degree, and it's a uncomfortable and painful, but that is because they're just not drinking enough fluid, they're not getting enough fiber. Now, going back to Neanderthal man, his poops are really big because he's getting 150 grams of fiber a day. Today, less than 5% of the American public gets the amount of fiber they should, which is anywhere from 20 to 40 grams of fiber. Most people are getting about 8 to 10 grams of fiber per day. and that it has a lot to do with why we're having gut problems, dysbiosis, because that fiber also, when it's broken down, produces a lot of nutrients that are good for the colonocytes and good for the healthy bacteria so that they can maintain a good, robust population. So, we fixed those things in her, and her constipation was gone within six weeks.

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