Bile, Digestive Support and the Microbiome: A Conversation with Dr. Laura Brown

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is your host, Lindsey Parsons, and today I'll be speaking with Dr. Laura M. Brown, a registered naturopathic doctor with a functional medicine approach. She's the owner of South End Natural Medicine in Ontario, Canada, a bestselling author of Beyond Digestion, a HeartMath certified practitioner, a Level 2 Certified Gluten-Free Practitioner, and holds the designation of ADAPT Trained Practitioner from Kresser Institute. But before our conversation, if you haven't yet followed or subscribed to the show, be sure to do so. And if you wanna get transcripts of the podcast, pop over to my website, HighDesertHealthCoaching.com, and sign up for my newsletter. You'll also get my free ebooklet, Finding Your Root Cause Through Stool and Organic Acids Testing, when you sign up. And if you haven't yet done my quiz on which stool test would help you get to your root cause, you can find a link in the show notes and take that. Now onto the show.

Welcome to the podcast, Dr. Brown.

Thank you very much, Lindsey. It's a pleasure to be here.

Yeah, it's a pleasure to have you.

So today we discussed that we would talk about bile. So I don't think we've really had anybody on the podcast to talk about that topic. So let's start out with what is bile and why do we need it?

Really good question. I mean, I did a little bit of like more recent research. It's been a while since I had dipped into this topic myself. I mean, we always take it for granted. I mean, bile is there, but bile is something that our liver makes, our gallbladder stores, and then upon a trigger that is, that is coming from an enzyme in the small intestine, the gallbladder will release that bile in order for us to help digest fats is the main thing. But there's so much more behind it, as we're going to talk about today. And if somebody has their gallbladder removed, the liver still makes the bile. It just releases it as it's needed to. It doesn't have that chance to store it and concentrate it in the gallbladder. So the body has some wonderful mechanisms and backup plans, like Plan B, in order to help us continue to digest our foods or our fats that we use bile for. But we're finding out so much more about bile acids. So That's what we're gonna also talk about today.

Great. So isn't the base of bile dead red blood cells?

There is dead red blood cells in there as well. Yep. There's cholesterol, obviously it's made from cholesterol. And I mean, there's other components in there too.

Yeah.

So, but, and we're learning more and more about what's in there and, you know, what is it used for? So yeah. So I think our interest was more like on the gastrointestinal tract and what are these things doing, right? What are bile acids doing? Because bile acids are a big component of, you know, you were talking about TUDCA when we had first touched base together. And this is a secondary bile acid that is created through the processing with the gut microbiome and kind of the recirculation of the bile. Because as we know, bile is released, but it's also brought back into circulation. We only excrete about 5% of it through our stool, and then 95% of it comes back up to be reused. And when it's, as it's going through these processes, it's going through a number of different chemical reactions. And it gets pretty detailed because there's about 4 different kinds of primary bile acids are those ones that are initially released from the liver, and then they get turned into secondary bile acids by the gut microbiome when they, you know, when they start to reach, you know, that 5% that actually reaches the large intestine, those get changed and as they recirculate, they have different purposes and the TUDCA is one of them that they're doing a lot of studies in mice right now, starting to do more in humans. On a lot of the neurodegenerative diseases like Alzheimer's or ALS or Huntington's, Parkinson's, and they're seeing some positive results or influences with it acting as like an antioxidant or promoting or preventing, I should say, preventing that misguided protein folding that we see so often in Alzheimer's. So it's really early in those types of research. As I said, lots of mice studies, starting the human trials. So I think before, you know, we stopped the presses on some of the other drugs that they're doing, but to continue the research on the synthetic TUDCA that they're doing, and the TUDCA just stands for torodeoxycolic acid. So it's a bit of a mouthful, so they called it TUDCA.

Yeah, T-U-D-C-A.

Yeah, yeah, exactly.

So what can go wrong with the bile and the organs that produce and store it?

I mean, there's, there's lots, right? If you have issues with your liver, right? If your liver's, if something's up with the liver and it's not making proper bile, right? Then we have an issue. So we have to address liver health when it comes to that. And the liver makes the bile in one area of the liver and receives the recirculated bile acids in another area of the liver. So there's that part of it. There can be issues with the gallbladder and the storage. And this is where I do a lot of digging, or I see a lot in clinic with patients coming in. And I'm always so sad when somebody says, oh, I had to have my gallbladder removed. I'm like, oh, did you really have to? Because we see this a lot in celiac and non-celiac wheat-sensitive patients. And I'm like, what's going on? So what's going on is the wheat is affecting. Now, we don't— none of us have the digestive enzymes to break down wheat, right? This is, you know, a fiber that goes through our digestive processes and gets fermented in our large intestine. And that's why they've always promoted whole grain products or whole wheat products to help feed the microbiome. And it's a good fiber, helps you go to the bathroom, all this. So yeah, maybe, but then for some people, I would say for everybody, or most, let's just start back up the bus. For most people, they will have damage in the small intestine from eating wheat or gluten. Some people think of it as gluten, but wheat has over 100 different proteins, gluten being one of them. So the wheat damage happens in everybody. For most, within 20 minutes, that's healed up. But for those who are celiac or non-celiac wheat sensitive, the damage can last for up to 5 hours. And then typically it's time for the next, and usually there's gluten in it again, right? Like if they're not knowing, right? Undiagnosed. And this repeated damage prevents that enzyme we mentioned before called the cholecystokinin or CCK from, from releasing and then when that doesn't release, then the bile isn't getting triggered to be released. And then if the bile sits around, because the liver makes the bile, sends it to the gallbladder, the gallbladder condenses it. And if it sits there condensed and not being used, then it's gonna get sludgy and it's gonna start to make gallstones. And then the sludginess and then the gallstones, you have to think these gallstones are like, prickly little, little, little things, right? And they can be centimeters. I had somebody walk in yesterday, 2 centimeters. Could you imagine like this 2-centimeter stone sitting in this tiny little organ? And it's gonna be bumping up against the sides of the walls, right? And as it's bumping and rolling around in there, it's gonna create scar tissue. Sometimes that scar tissue can cause inflammation in the gallbladder, right? So now we have cholangitis, right? So we have inflammation of the gallbladder or inflammation of the, the ducts. So you've got these little stones or the sludge kind of sitting around too long or bumping against the walls and causing damage. And now we have those nice little ducts getting damaged. And we also see it kind of blocking up the ducts too, gets sludgy and blocks it up. And then that can backflow and block up the duct that comes down kind of in the same neck, the same wire. Kind of an intersecting highway where the pancreas sends down its enzymes. Okay? So then we get backed up of the enzymes from the pancreas with all this, this blocked duct stuff going on. And this is all because bile isn't moving freely, right? It's not flowing. And this can cause issues with the gallbladder, inflammation with the gallbladder, gallstones, the, the duct blockage. And this all can happen from a trigger. And it's not the only trigger, but the wheat, right? It's not the only thing that can cause all this, but that's one thing that I often think about. And when we do a wheat-free, sugar-free, an anti-inflammatory diet, essentially, you know, no alcohol, no wheat, no sugar, low dairy, and then just lots of vegetables. It seems to, seems to, to help the cause, of course. Everybody's individual and we're not giving medical advice today. We're just kind of talking and educating about kind of what can happen here.

Yeah.

Well, that's interesting. I didn't know that there was any relationship between wheat and gallbladder issues. So yeah, it's great to know that. And then if you do have thick bile, what kind of foods can help you thin it and get rid of that sludge?

Yeah, so we want, we want like bitter foods will help trigger bile release, right? Even, and it's stimulating all of our bitter foods will stimulate all of our digestive juices. And it's not just bile that starts. So I always like the example of, okay, so I want you to picture a nice, bright, juicy lemon. Okay. And then I want you to picture taking a knife. Cutting that lemon in half and now taking that half a lemon and then just like squeezing it into your mouth. And I bet that you've already got digestive juices flowing in your mouth.

I do.

Even the thought or the imagery of a bitter food gets that going and you're flowing in your mouth, but not just getting the salivary juices flowing. You're now stimulating the whole digestive tract, including the bile, really stick to kind of get things moving, get things ready for digestion. So having like a hot cup of lemon water in the morning, I think most people have kind of heard like, oh, what do we do that for? So that can help stimulate a nice bitter green salad, you know, the endives, the radicchio, that kind of thing.

Arugula.

Arugula. That can help stimulate.

Yep.

Dandelion. Those bitter teas. And then sometimes we, you know, in naturopathic medicine, we use tinctures of like gentian or bupleurum or things like that that are really bitter that help stimulate the digestive tract. Even like a cup of chamomile tea or dandelion root tea are nice and bitter. They can stimulate as well. So those things—

Bitter aperitifs are for as well, right?

You got it. You got it.

Yeah.

Yeah, so these things can help stimulate the bile to keep it flowing and the digestive juices to keep them flowing because anything that becomes stagnant obviously doesn't flow so well.

Right. Okay, and so what are the symptoms of gallstones?

Oh yes, so lots of sharp, like intense pain. Usually, you know, it can be under the right breast. You can kind of feel it there. I mean, your liver, if you were to take your palm of your hand and kind of nestle it up under your right breast. That's kind of where your liver sits, is kind of there. So some, and then your gallbladder, the, the, the, uh, the ducts and stuff come off of kind of where your index finger would be kind of in that area. So sometimes you get pain right there, but unusually you can get pain in your right shoulder and have pain in the right shoulder. So that can be part of it as well. Nausea, vomiting, that can be issues. If it's extreme and you have blockage, you can end up with jaundice, yellowish of the whites of the eyes, yellowish skin. Sometimes you can end up with diarrhea. Okay, so some issues there. So those are some of the, some of the nausea, not feeling well, pain, diarrhea that you can think, oh, well, what's going on here? Oh, that might be, that may be a gallstone kind of kicking around.

So are there some early signs on any of the functional medicine tests that you do with patients that tell you that there may be a bile issue?

That's a good question. I mean, some people say, oh, maybe you'd look at, you know, small intestinal bacterial overgrowth to see if something's going on there. We see different things in stool tests. We know those with inflammatory bowel diseases have imbalances of Firmicutes and Proteobacteria, which affects how we shift bile acids. So that can, and then that affects the recirculation. So that's something to watch for. I mean, you can look at liver enzymes and things like that, but you know, often you have to have like severe inflammation or something really, strong going on before the liver enzymes rear their head. Often it's caught inconsequently, maybe on an ultrasound image, if somebody's having it done for something else. They, it could be that indigestion. Sometimes people will complain of the indigestion or that little bit of pain. So watching for those kinds of complaints, family medical history of what's going on, food sensitivities, understanding what's happening there. So just picking up on different things. As far as screening tests and trying to— I mean, you'd look at bilirubin and things like that. But again, you'd have to be pretty far down the road before those things would be red flagging.

And where would you find the bilirubin test? That's part of a CMP, or?

You can do that through blood. You can do that through looking at the urine, seeing— the urine is more measuring how the kidneys are functioning. So kind of looking at the blood tests. Yeah.

And what about the markers for fat in stool? Are those indicative of, of bile insufficiency?

Sometimes. Like a floating stool, you could think, oh, is, are we not, are we not releasing the bile? So if we're not digesting our fats, our stool might float.

Excuse this brief interruption, but I wanted to remind you that if you've been struggling with IBS, IBD, reflux, gastritis, SIBO, dysbiosis, candida, diarrhea, constipation, and all that gut health stuff.

That's my specialty.

So I work with clients not just here in Tucson, Arizona, where I live, but also virtually on video chat. And I offer single appointments as well as a 5-session gut health program for people with tougher gut health issues or mental health or autoimmune challenges that go along with that, who likely require testing and longer-term follow-up. As well as 12-week programs for weight loss. If you think that a 5-session or longer course of health coaching might help you meet your health goals, you can set up a free 30-minute breakthrough session with me to talk about what you've been going through, and I'll listen and hear if it sounds like I have something in my toolkit that you haven't already tried and let you know if I think that health coaching would be appropriate for you. You can find a link for that in the show notes, and I hope to hear from you. I don't think that is.

I think I'm talking about on the test though, like, uh, like steatocrit is on the GI-MAP, for example.

Yeah, you can use, you can use that as a clue. I don't think you can diagnose from that. I would put together other symptoms and other things going on. It's, that's just one way the body's talking to us when you're looking at it that way. It's like, oh, okay, you know, let's look at the bile. What's going on there?

What's happening?

Yeah.

So what does total bilirubin on a blood test mean?

Bilirubin is your breakdown product of your red blood cell, and it is a part of bile. So you'd be looking at how much is there and do you have enough? Is it too much? Is there not enough sitting there? Usually you're more concerned if, if it's not releasing, right? If there's blockage. Depends on what's going on, right? If there's blockage, your stool might even look whitish or grayish, right? If your bile ducts are blocked because you're not getting any of you're not getting that red blood cell breakdown product or bilirubin into the stool, which, you know, is typically kind of what makes it look kind of brown.

Right.

So if you've got a clay-colored stool and it floats, yeah, let's think about that, right? Let's think about, you know, is the bile being blocked? And then why is it being blocked? Is it because the liver's not making enough? Or is it because something's clogged there? Or are we trying to pass a stone? So there's different things that could be going on. So you just, you know, I'm always taking things as clues.

Right, right. So what are the different supplements that one uses to deal with bile issues and what types of situations might warrant their use?

So the different types of supplements that I look at, vitamin C seems to be helpful, vitamin D seems to be helpful. Then I look at malic acid. I found this, it was very interesting. So malic acid, which is in crabapples. There's a great gemmotherapy that, which, and a gemmotherapy is where you take the, the, the twig in the springtime of the plant that has like the new fresh buds on it. And then you crush the buds of the, the leaves, which would have all of the genetic material to help it grow and, and do its thing. And you would crush that down and soak it in alcohol, glycerol, and water. And then it's, with that, it's extracting the components that would be dissolvable in alcohol and water and glycerol. And then so you, you make a kind of like a tincture or syrup out of that. And when you do that with the crabapple or the mayapple, you're able to create a medicine that helps dissolve the gallstones. So that can be helpful.

That's called malic acid?

Malic. Malic. M-A-L-I-C. Yeah, M-A-L-I-C acid. So that's found to dissolve. Berberine, which is found in Oregon grape root, Hydrastis canadensis. Berberine is really great for the health of the liver. It's good for blood sugar control. It's good for the gut. It's antimicrobial. It, in its physical form or in a homeopathic form, I've used for addressing gallstones and bile. If you want to just stimulate bile itself, as we mentioned, bitter-tasting foods, bitter-tasting tinctures can stimulate what's going on there. If you're trying to look at the health of the liver, we know, you know, St. Mary's thistle or milk thistle is always great to help the health of the liver. So that would maybe indirectly help the production of bile. And then if we, if we want to, you know, stimulate new bile, we take bile acid sequestrants, which would be fiber essentially, maybe some psyllium or something to help pull that out of the system so that we have less recirculating. So it forces us to make fresh, to make more. So that's sometimes helpful to help reset the system a little bit there. So there's lots of different things that I think about it. It's kind of like where, where are we at? What seems to be, what seems to be the issue? Because we want, we wanna balance, we don't wanna like overproduce this stuff. We know when we eat too many fatty foods, then we end up with too much bile acid being released. And this can be an issue as well. It's acid. And when it's a primary bile acid or when it's initially released, it's, it's an acid. So it's accurate. It's going to it can actually cause damage. And that's why the body quickly throws, you know, hydroxylizes it or does, you know, adds some kind of chemical component on it to kind of buffer it a little bit so it's not so damaging. And that's what's a secondary bile acid. But if we end up with too many secondary bile acids, this can be damaging as well. So we want a balance, right? The balance is key. So it's not just more is better or less is better. It's the balance between the primary and the secondary. And that means having a good balance of the right gut health. So having a good balance of the Firmicutes and the Proteobacteria so that we're actually changing the primary bile acids into the secondary bile acids. Those with inflammatory bowel disease have this issue. They have low levels of Firmicutes and Proteobacteria. So they're not transforming as much of the primary bile acids into the secondary bile acids. So then this is causing inflammation or this is contributing to the inflammatory picture. It wouldn't necessarily be the only cause.

So that's interesting. I had never heard that about IBD. And so do they tend to have high Bacteroidetes then?

That would be separate, right? And you would look at the different families within that. So, because you break down all of the different components of, of the Firmicutes, it's just a family, right? So is the bacteriota— is that what you remember offhand?

Phyla.

Yeah, those are the phyla.

So you're looking— yeah, you're looking at what's in there. So sometimes that's where you see when you get your results back from the GI Map or the GI 360 test, you're getting that breakdown of the 6 or 7 families that are common. You kind of get the breakdown within them and you can see what's high, what's low. But we're looking at those greater families and you could have less or more of different phyla within the families.

Yeah, no, I wish the GI Map would list proteobacteria, but it doesn't list proteobacteria. So you kind of have to extrapolate from the overgrowth of individual bacteria, whether that's an issue.

Look at the GI 360 and see if that solves, um, what you're looking for.

Yeah.

That might, might be something of interest.

I like the GI-MAP because it's got H. pylori on it, and it's an issue for a lot of people.

Yeah, you can, I think you can add that to the GI 360. In Canada, or at least in Ontario, we're not allowed to add that in, but I think it is an option. You may be able to. But these, these harmful effects of the primary bile acids, as I mentioned, in inflammatory bowel disease, we also see an abundance of them in other gastrointestinal diseases, in obesity, in type 2 diabetes, in liver diseases, in cardiovascular diseases, and neurological diseases. So this is, it gets down to some pretty nitty-gritty details of what's going on in there, especially when you have 4 different ways that a primary bile acid could be chemically modified. And then how the secondary bile acids, how they get how they work and what they go into. So it branches out and then branches out. It's like they told 2 friends and then they told 2 friends. It's a lot of branching out of what can happen, a big domino effect. Comes back to often diet and often our standard American diet, which is high in processed foods, high in processed sugar and processed fats.

And certainly high in wheat. Yeah.

Yeah. You got it.

Yeah. No, I don't, I don't eat gluten or dairy. And sometimes if you, well, if you're in the situation where you have to eat a meal in public, like an airline meal or a cocktail party, it's just shocking how dominant gluten and dairy is in that setting.

Incredibly. And you know, it's something, you've probably had to learn to navigate. I know I did.

Yeah.

To navigate all of that because it can be challenging and you want to, I mean, I just kind of boil it down. Okay. I always say, you know, like just focus on the people, not the food. Listen before I go. Right. And then just smile and say, you know, no thanks.

Well, you know, or eat some more carrot sticks and hummus.

Yeah. And hope for the best. Yeah, exactly. Exactly. Okay.

So when is actual supplementation with bile acids like Ox bile recommended or not? 'Cause I know there's some types of SIBO for which it's contraindicated. Yeah.

So tell, tell me what you know about that, the SIBO and the contraindications with the Ox bile. What is it, where is it that you're thinking on that?

It may be the hydrogen sulfide SIBO where it's contraindicated. Actually, I think that's what it is.

And, and would that be because there's a hot high levels of hydrogen in there that could be Interacting with the bile?

I'm not sure. Let me, let me dig up this piece of information. Okay. No. So bile is good for methane SIBO, not good for hydrogen sulfide SIBO. That's right. Okay.

So that's what you're saying.

That's what you're saying.

Yeah.

That's what I heard.

Do they say why?

I'm not sure.

Okay. Okay. It's not something I have on the tip of my tongue, to be honest. Okay. So I'd have to, I'd have to look that up as well. I use digestive enzymes sparingly. I'll use them. I'll use the Ox Bile with the gallstones and, and help with that, help with the digestion. I'll often start with, instead of using bile right away, like second, to, to use like bile as a supplement, if I'm stimulating things, I'll use the bitters. I'll use the apple cider vinegar, like 2 tablespoons of apple cider vinegar with a bigger meal. To help the stomach, you know, make that hydrochloric acid so that it can be more acidic, so that it can stimulate what's going on, so that we can— so just to help the body. Because as you know, when you're introducing, I'd like to find ways to remove the obstacles and then to support the body in what it naturally does. So when we're putting the ox bile down there, yes, it could be helpful in some situations, but I like to see the, you know, the body kind of do what it does naturally because it does it better than we can. Right. And so supplements short term.

What about if someone doesn't have a gallbladder?

If they don't have a gallbladder, then you may be looking at higher fat meal. Yes, use, you use it, use your digestive enzymes with, with the Ox bile in it, but also teach them how to have smaller, smaller meals or meals that are less fatty. So they're not always taking an enzyme every time they eat. Okay, the liver is still producing bile, so it can handle amounts of it. And you'll see this, you may see the issue with people with short bowel syndrome. I saw that as well. So if somebody has issues with the short bowel syndrome, they're not reabsorbing their secondary bile acids as much, and they're probably having issues absorbing in what small intestine they do have. So it's helping them out with that. So yes, so there are some situations where you would. Supplement. And then we're looking at what we talked about before, the Tutka, or the secondary bile acid that is being used in some of the research to help with the barrier function, to help with cognitive degeneration. That's something that I'm going to follow that research and see where that leads. It's not something that I'm going to pull out of my pocket right now and say to my patient that I would trust in this not giving you Alzheimer's. No, but it's something I'm going to follow because it's very interesting. We've been using bile supplementation since like thousands of years. The Chinese medicine repertory uses it in many different, like for thousands of years they used bear, they used the bile from bears in order to help with digestive disorders. So it's not new. It's just picking and knowing some of these more detailed researches. Research studies that are coming out to be able to understand what we might use it for. Other than just kind of, okay, we don't have a gallbladder, we're eating a fatty meal, we're giving it. We've got a gallstone. We know that Ox bile can help dissolve cholesterol-based gallstones. We're having issues digesting, so maybe we take a little bit, but maybe we try that apple cider vinegar first, see how that helps get the gut under control, and then reduce the wheat, the dairy, the sugar. The alcohol, right? Those types of things get the obstacles out of the way instead of throwing Band-Aids at stuff.

Yeah. So I'm wondering, since bile is so important in digesting fat, how much fat is too much in the diet? Like I know people, and I think it kind of happened to me that when they tried a ketogenic diet, they started having sharp abdominal pains and I'm thinking maybe they were gallbladder pains.

Yeah, likely what they were, 'cause some people can't handle it, especially those with their gallbladders removed, right? They can't handle that bolus of fat.

Oh yeah, for sure. If they'd have it removed. Yeah.

Right. So it's, it's, it's spreading that out throughout the day. Sorry, the question again, you're dropping it.

It was how much fat is too much in the diet? 'Cause like a, a ketogenic diet is supposed to be 70% fat. Yeah.

I mean, it's individual, right? I mean, there's no one right diet for anyone and no one diet for any of us for life. So it's, it's finding out what works and what doesn't work. And yeah, you might find that the keto diet is not for you. So, you know, maybe you just modify it a little bit and then you're okay. But just be, yeah, be watchful for those symptoms like the sharp pains or the nausea or the, the gray and floating stools or the pain in the shoulder. Maybe it's the right shoulder that you're getting that pain in, or you're just not feeling well when you're eating that level of fat. It's not for everyone.

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Yeah. Yeah. No, I discovered it definitely wasn't for me because I love carbs too much, but it also wasn't for me because of the pain. So how do, uh, constipation or diarrhea relate to bile? Is there one more than the other that might point to an issue related to bile if other causes are ruled out?

I mean, there's bile acid diarrhea, right? That's something that we know is part of like the IBSD. It could be bile acid diarrhea. And that is essentially you're, you're not, you don't have the bile to, to break down the fat. So you're getting that, that immediate kick. And this sometimes happens with people with undiagnosed celiac disease is if the problem is, is just that, that they're not digesting the fats and it's just like quickly getting exited because the body's going in, we can't digest this, out of here, right? So it's fast exit. So that could be part of what's going on.

So in that case, it'd probably be like, there would be fat in the stool and there would be diarrhea.

And you got it. Yeah.

Yeah.

Okay.

And what does the research say about the impact of saturated fat on the microbiome?

Well, I mean, different people handle saturated fats in different ways. We know too much fat is inflammatory and there's some saturated fat that we can handle little bits of, other people not so much. We know saturated fat in some people. Especially with the familial hypercholesterolemia. So high cholesterol runs in the family. These people tend to absorb more saturated fats from their diet easier, and then they end up driving up their cholesterol. It affects them. For others, the saturated fats doesn't affect their cholesterol so bad. So in moderation, they're okay. But we know too many fats of any kind can— especially the saturated or the hydrogenated or the industrial seed oils are inflammatory. They promote the arachidonic acid cycle, which is inflammatory. So this is affecting the gut barrier. And sorry, my brain's just kind of going into different things because the bile acids hit vitamin D receptors. And there's a lot more there to unpack that I'm just kind of getting into now. So there's different ways that that high fat affecting more primary bile acids being released. If we have more primary bile acids being released, then we end up with more secondary bile acids. Some secondary bile acids are helpful. Too much are now inflammatory and not helpful. So that, that can cause issues as well. So it's a lot about balance, right? Starting with what we put on our plate and what we put in our mouth.

And I guess the best thing a person can do is sort of experiment with what feels good, right? Like, I, I mean, I, I know personally that if I eat, say, pork belly, that I'm not gonna feel good. Like, that's a guarantee. I better take some digestive enzymes. I better do something because it's just gonna be too much.

Right. So you've learned.

I've learned. Yeah. But I mean, I can handle a couple slices of bacon. It's not gonna, it's not gonna make me feel bad. So. So I think our bodies give us clues as to what works.

I always say the body sends us lots of messages, like thousands of messages. And if we're quiet enough, we can hear the whispers. Sometimes it even screams, right? Sometimes the body even screams at us. And we just have to, we just have to know what the body's telling us and, and, or at least relay what the body is telling us. So people come in my office and they're, They're trying to find words for what's going on. I'm like, just give me the motions. Just, just like, because the body doesn't speak in words, the body speaks in, in messages, right? Or hand gestures, things like that. So I just try to get people just to explain it. Doesn't have to be a real word because this is often how the body speaks, is in gibberish, because it just can't get it out. That is such a great clue to what's happening and what's going on. And then we, we keep pulling on the loose strings to figure out the puzzle.

So are there dangers of following a super low-fat diet following a gallbladder removal?

That's a good question. I think you have to introduce the fat slowly to help train the liver, right? So I wouldn't go out and eat a bacon and avocado sandwich with cheese, right? That would be really high fat. Meal immediately after having gallbladder removed, you would slowly reintroduce the amount of fat so that your body would acclimatize to its new reality.

I just know that I hear, I hear people who said, oh, I had my gallbladder removed, so I just can't eat fat anymore. And so they literally are avoiding it very purposefully. No added fat to cooking, just really. And I imagine that you could end up deficient in some of your fat-soluble vitamins if you went super low.

Well, exactly. And you want, you want to trigger some of that bile to come out because you need it in order to help dissolve the fat-soluble vitamins, or else, as you said, you're not going to absorb them. And if you're, and if you're missing out on even like your essential fatty acids, what's your body going to be making your, your cells out of? Every cell in the body has a phospholipid bilayer, which means it's made of fats. And if, if it doesn't have healthy essential fats like omega-3s from fish, fatty fish, or walnuts or flaxseeds or things like that, then it's going to make it out of whatever it can. And when it's not making it out of the, the more fluid fats, it's going to make it out of other stuff. And typically that membrane ends up being a little more rigid. And if it's more rigid, it's not going to let the toxins out or the nutrients in as easily as if it were more fluid. So you still need some fat. It's not a no-fat diet, it's a low-fat or kind of a trickle fat, but you know, it's adjusting and acclimatizing and just retraining the liver to deliver it just in time, right? You want that bile to be delivered just in time. But yeah, you're right. Your vitamins A, D, E, and K are all your fat-soluble vitamins. And you need to have them with some fat and you need the bile to be able to, to go in and emulsify or break it apart, just like the dish detergent does in the sink, takes those little, those bigger fat droplets and kind of breaks them all into little smaller ones so that that can be absorbed in the small intestine. And if we're not absorbing those things, they're not getting the fat or getting the bile to help digest that, we're going to miss out on those key, key nutrients, which is important. But you have to think lots of foods that we might not think have a lot of fat, sometimes just a little bit of fat can be enough for somebody. So nuts and seeds, for example, sometimes people don't think of having a lot of fat, but they are, they're pretty high in fat.

Right.

So it's, it's sometimes thinking that, oh, I didn't realize that that had fat in it. They're just thinking the overt pouring oil on something.

Right, right. And of course, meat and fish and yeah, those have fat too.

So absolutely. Like salmon, right? You know, fatty fishes with your essential fatty acids.

Those are key.

Yeah. Yeah.

So you'll be getting some of it. So the body learns, the body's very resourceful, right? Very resourceful.

I know you can take out any number of pieces of our body and it still manages to function, perhaps not optimally, but it functions.

Exactly. It'll Yeah, exactly.

Yeah. So we've been focusing very on bile, but what else is involved in fat digestion?

So we're looking at those enzymes, we're looking at that fat coming in. I'm not sure what you're getting at, 'cause we've talked about those things as well. What do you think? What are you thinking there?

Oh, I, I was just thinking, you know, the other digestive enzymes like lipase and such that are involved in fat digestion in that process.

Right. And the lipase coming from the pancreatic area. And those types of things are often included in like a digestive enzyme as well. It's not just Ox bile, that type of thing. So if we're having issues digesting, those would come with it. Yeah. So there's, I mean, the digestive enzymes are coming from, yes, this for starches starts in the mouth and then stomach is meant to kind of break and break things down chemically. And also with the acid, but then we're, we're needing the bile and the digestive enzymes from the pancreas to do that first breakdown. And then obviously the microbiome, as we talked about before, to change those primary bile acids into the secondary bile acids. So that's part of our digestion for fats too, in order to help do things that way. But most of the fats are being absorbed ideally absorbed in the small intestine, the first part of the digestive tract. Okay.

And so earlier you mentioned you use digestive enzymes sparingly. So I'm wondering why so sparingly and whether, and what kind of situations you, you use them in?

Well, I say sparingly cuz I don't like to use anything unnecessarily, and I believe everything has a, a time and a place for it. There's some people that have issues with their pancreas, sometimes Advanced celiac disease patients need a digestive enzyme with every meal. We know that there's different types of digestive enzymes, not just Ox bile. There's Papain, there's Bromelin, there's other types of ones that help break things down. There's ones that, um, cystic fibrosis patients might use to break down mucus and those types of things. So you would use those in those cases. If you're using something to act systemically, not to digest food, you would take it away from food, right? So that might be— that's a different use of a digestive enzyme. And you might call it more of an enzyme, not just digestive, because it's an enzyme. An enzyme is, is really something that helps a chemical reaction occur without consuming itself. So that is what an enzyme is. So it helps a chemical reaction occur. And we have lots of different chemical reactions happening in our body all the time. So the digestive enzymes taken away from food can help break down mucus, can help break down inflammation. Oh, there's— can help with like inflammation in joints, arthritic conditions, gout conditions. So those are, you know, that's one area to use digestive enzymes between meals or away from food. On an ongoing basis to help with that type of thing? If you're using it to help digest food, is there some kind of physical roadblock to our own digestive enzymes? Is the pancreas damaged? Is the gallbladder removed? Is the liver damaged? Can, can we heal the liver? You know, if the gallbladder is just sludgy, can we clean it out first, right? Or while we're cleaning it out, take the enzymes, but then when we're done, we don't need them anymore. There was some thought with the secondary bile acids, some of them might help heal some of the pancreatic cells. So there were some ideas there that I saw in some of the research. So you might use them to help the healing, but then when you get the healing done, or when you're using them in the meantime while you're doing healing with other things, then when you're done, you're done, right? So using, as I said, using it sparingly, there's a dose, there's a time, and there's a duration. Not, it's not in all circumstances that once you start it, you have to be on them forever.

Do you think they're useful in SIBO? Because I, I, I have, I have post-infectious IBS, so I, I'm always getting bloated after a time. I mean, I can take antimicrobials and then, then it starts over again. So, so I, I thought, I mean, my, my thinking was I take a digestive enzyme with each meal just because I wanna make sure everything's getting digested and everything's not hovering for the bacteria to grow.

So then, you know, I'd look at what, what's the, what's the mechanism of the recurrent SIBO and what's going on there and what can we do to prevent that? And is there something that we can do to halt the presses on that? Often I see food sensitivities that impact the ileocecal valve, which is the valve between the large intestine and the small intestine. And it gets a little grumpy when it gets constantly irritated by foods it doesn't like. So then it gets lazy and lets the bacteria that's supposed to stay in the large intestine up to the small intestine. This is small intestinal bacterial overgrowth. And then it's meant to ferment. The bacteria in our large intestine are designed to ferment foods. And if it's sitting up in the small intestine, it starts to ferment and it goes crazy because this is where you get more of the sugars and things like that. So it starts to ferment and that's the bloating, the gas, you know, the uncomfortableness. But so it's looking at food sensitivities and what's going on there. But we also know there's things like levothyroxine can promote small intestinal bacterial overgrowth. So if it's something you need to be on because you have hypothyroidism, then maybe every once in a while we're doing, or maybe once a year we're doing kind of a gut cleanup and, and doing some antimicrobials just to help prevent that from happening. There's a nice little move that I do in the clinic to help shut the IC valve, and that can happen. So I'll do that for some people. I had the one lady walk in one time just off the street. She was like, "Oh, Sally Stein, I've been having this pain for 2 years. Can you do something about it?" And I'm like, "Okay, you're just telling me about it." And I'm like, "Okay, lay on the table." And then I'm just kind of poking around. You know, just to the right of the belly button and over a couple inches, depends on the person. So I'm feeling around there. You could tell that there was some irritation there. So I just kind of did the move that helps close the IC valve. And I'm like, okay, her appointment was over. I said, let me know how you feel. And I never hear from her. So some time goes by and I reached out to her and I'm like, I thought maybe I offended her or she didn't like that or it felt weird or hurt her or whatever. And I said, is everything okay after your last appointment? And she goes, yeah. She goes, I walked out of there with no pain. She goes, the pain I had for 2 years is gone and it's never come back.

Oh, that's wonderful.

So yeah, I mean, that doesn't happen every day in practice, but I mean, it was like, hey, this is great. So bad for business, but great for the patient.

Yeah.

So, so I mean, things like that can be helpful to watch out for, but this, but But then it's looking at, you know, looking at the diet, looking at the food sensitivities, looking at why do we have this recurrent SIBO going on. And that's individual for the patient to dig into that so that we can get, you know, moving forward. And sometimes it is food restriction. Sometimes it is antimicrobials on a rotating basis. Sometimes it's fasting just to give that whole digestive engine a break, right? A digestive rest. Sometimes that's good as anything. And it's finding what works for you as an individual, what works for you to help reset. You know, I kind of find my little arsenal of stuff and don't know what works. Like, I love bitters. I know if things get slow for me, I've got a lovely bitter formula that I put together and it's Chinese bitters. And I mean, I'm lucky that I don't have a strong bitter receptor. Some people do, so I can get it past my mouth and it's not an issue. But I find that can be really helpful for me and it's, it doubles as an antimicrobial. But if I think, find things are kind of slow to digest, I feel like food's kind of sitting there too long. Cause you get that sensation, right? It just feels like the things aren't moving through, bit sluggish. So I find for me, bitters are really awesome that way to get things flowing and going.

Yeah. Yeah. No, in my case, I have elevated vinculin antibodies, so I, so I'm, I know I'm going to be getting SIBO over and over again. So it's just a matter of, yeah, continuing to to chip away at it. So prokinetics. Yeah. And trying not to eat constantly. I'm not a big fan of fasting though.

And it's finding, and there's no one right way to fast. You could just extend, you know, maybe it's a 12-hour fast, maybe it's a 14-hour fast.

Yeah. That's, I, I shoot for, I shoot for 12 hours at night. Shoot for.

Yeah.

I'm not sure I always hit it, but I shoot for it.

You know, and then maybe every once in a while it's, you know, you make a bunch of bone broth or, You just have something that's a little more simple to digest, or you have like a, I'm going to eat vegetables all day today, right? That kind of thing. Just to give the body a break from heavier stuff, digesting heavier things.

Interesting.

Yeah. Yeah. So you give it a break from the fat and the protein and the heavy carbs. You just go like on a, you just eat vegetables all day. Nothing wrong with that, right? You can do it for a day or a morning, right? Maybe you don't want to do it all day.

Yeah.

So yeah, just give a little digestive break. I can, I can tell my brain that I'm doing a digestive break, but if I say I'm not going to eat, the first thing I want to do is eat. So, but a digestive break, that's fine because it's a whole engine, right? We started, you know, we talked about things start when we think about it. We thought about that lemon and boom, what happened? We didn't even eat a lemon and we were just thinking about it and everything started to flow.

Yeah, right. It's amazing, the power of the mind.

Our, our experience with food starts when we think about it. It's intensified when we see it and smell it. And that is the beginning of our digestive process. Then we eat it, right? Then it starts to go down that through that whole process. So sometimes we do need to give it all a bit of a break. Okay.

So we may have sort of covered this In a roundabout way, but just, just concretely, if somebody is staring at a suggested gallbladder removal, what would you tell them to do to try and avoid that?

Well, it depends on how far along we are, how much damage has been done. Is the gallbladder, you know, intensely inflamed? Are we in a lot of pain? Are we able to eat? So we kind of take those things into consideration. If I have somebody that has some gallstones and the doctor said, well, let's just remove it. It's really kind of, it's bothered them. Yeah, they've been to emerg a couple of times, but we've kind of figured out that it's when they eat pizza and a lot of biscuits or something. It's like, okay, hey, let's, let's change up the diet. All right, let's get the gluten and the processed foods out of there and the sugar. Let's get that out of there. Let's. That's, you know, let's hold up the alcohol. And, you know, these sometimes are stepping stones or can be roadblocks for some people. So it's, it's helping them understand how to do that. And then getting more vegetables, lots of cabbage-based family vegetables, getting some bitters in there, getting some of the, some of the, you know, maybe that hot lemon water or the chamomile tea or the dandelion root tea, like just getting some of these things into the diet. And then, and then seeing maybe using some of that malic acid tincture from the— that I talked about, or some of the homeopathics, or maybe we're using some Ox bile, or some combinations of these things. And then we're giving it a month or so to see how we're feeling. Are we feeling better? Do we have less pain? Are we— we're not doubling over anymore? We're able to eat and feel fine. And then usually they'll go back for like an ultrasound or something to see if there's where the inflammation and where the gallstones are at. So we can see, oh, do we have this under control?

Okay.

Sounds like a good plan. Well, that was all the questions I had about bile.

Anything you would care to add?

Just that there is ongoing research in what the secondary bile acids do for us. The secondary bile acids are a byproduct of the gut microbiome in the large intestine. 3 different things. It makes things made from, like, the short-chain fatty acids, and it makes the secondary bile acids. And then there was one other thing, I think it was some, uh, a taurine-based byproduct that it also makes. And it's taking a look at what these things are responsible for in the gut and just understanding and appreciating the complex interaction of the gut microbiome its byproducts and our human immune system, our gut lining, and not only the gut lining, but the blood-brain barrier and just how those things go together. And just appreciating the health of the gut and how it affects the rest of the body. I mean, this is why I wrote a book on it. Book I wrote is called Beyond Digestion. And it just, I found so many things started in the gut. And just appreciating that if we take care of our gut, it's gonna take care of us. Our microbiome is, is huge. 99% of the genes that we carry around with us aren't us. They're our microbiome. And if we take care of it, we're gonna be much healthier. And we're learning this more and more and more. And it comes first and foremost with diet, what we're putting on our plate, and then how we're treating ourselves. Stress is huge. So finding ways that way. But there's many different things that affect the health of the gut. It's been great talking about bile. It was interesting doing a deep dive on some of the more recent research. So I appreciate that stimulation, Lindsey, to bring that to light and just know that this, some of these things like the TUDCA is of great interest for the neurodegenerative diseases and just to keep following up on that if you have family members with Alzheimer's or Parkinson's or Huntington's or ALS, this might be something that would be really helpful in the future where we have little to offer otherwise, but everything comes back to the gut and, and, and food is medicine. Yeah.

Okay. Awesome. Well, thank you so much for, for doing that deep dive on bile.

Excellent. My pleasure. Anytime.

It was great having you.

Well, I'm sure that's way more than you ever wanted to know about bile, but actually that was really good information if you're having gallbladder or fat digestion issues or mystery pains. I'll put links in the show notes for some of the articles she mentioned and for some of the bile-related supplements like Swedish bitters, ox bile, tudca, and malic acid. If you'd like to connect with me online, you can follow my High Desert Health Facebook page, join my gut healing Facebook group, or join my newsletter list at highdeserthealthcoaching.com. As well as follow me on Twitter, Instagram, and Pinterest, and links for those are in the show notes. And if you're a longtime listener or getting a lot of useful information from the podcast, please consider becoming a regular supporter on Patreon. And thanks for joining me today, and here's wishing you all the perfect stool.