The Fast Tract Diet™: A New Approach to SIBO, GERD and Related Digestive Disorders

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is Lindsey Parsons, your host, and today I'm going to be talking with Dr. Norm Robillard. Dr. Norm received his PhD in microbiology from the University of Massachusetts Amherst, studying Bacillus anthracis. And other Bacillus species. Then during his 20-year career in pharma and biotech, he studied the mechanisms of antibiotic action and the genetics of antibiotic resistance. Then he turned his own suffering from GERD, or reflux, and IBS into a mission to create the drug and antibiotic-free Fast-Tract Diet for functional gastrointestinal disorders and founded the Digestive Health Institute. The Fast-Tract Diet was presented at Digestive Disease Week a few years ago to give gastroenterologists another option for treatment of acid reflux, LPR, or laryngopharyngeal reflux, SIBO, and IBS. If you haven't yet subscribed to the show, be sure to press subscribe so you don't miss an episode, and please share it with a friend who you know has gut health issues, or in your favorite gut health Facebook group if you haven't seen it mentioned there. Now on to the show.

Welcome, Dr. Norm. Thanks for coming on the podcast.

Thanks for having me, Lindsey Parsons.

So I, I'm very interested in your work and your bio and all the peer-reviewed papers that you've published. And because you published on the Bacillus species, I have to go a little off track of our main topic and ask you what you think of spore-based probiotics that are Bacillus probiotics.

Yeah.

Interesting. Well, you know, my, my doctoral thesis was on Bacillus anthracis. So there's, there's one you can check off the list that wouldn't be a very good probiotic.

That, that's anthrax, right? Anthrax, right.

And there's some other bacillus species that wouldn't necessarily be good, you know, Bacillus cereus is linked to foodborne illness and so forth, but there are many other species that are very well studied that are in natural food products. For instance, Bacillus subtilis in natto, and that's been used for, you know, hundreds if not thousands of years in Japan. The good thing about the spore-based— a couple of good things about them, I guess. They, they won't be killed by stomach acid, so you don't need a lot of fancy encapsulations that if, if you give people the spores, of course they have to germinate and grow in the gut to impart their benefit. They do as, as a group produce a lot of antimicrobial agents of their own, natural antibiotics, bacteriocins, things that kind of modulate other bacteria, you know, competitors. So there could be some benefit there.

Mm-hmm.

Yeah, so in terms of probiotics in general, I think there's been so many studies on them and the results weren't quite as positive as I think a lot, a lot of people, especially people that produce and sell them, were hoping. And there might be, you know, many reasons for that. But even a full complement of a new microbiome from a healthy person in fecal microbiota transplantation, for instance, hasn't really proven to be very good so far in IBS studies. And I think that there's been maybe, maybe there was 1 or 2 on constipation where there might have been some benefit, which is, that's a great thing if there was. But it's been a little bit challenging to really find the benefits. Some certain specific studies for some strains for certain indications, you know, perhaps. And so I recommend some of those as well. But I really, I personally think if you don't really fix the diet and other factors, you know, if you have any number of other underlying causes that might throw you into any number of forms of dysbiosis, that a probiotic is not going to be a magic bullet. And of course, the only probiotics that are available for the most part are aerobes that are easy to grow and lyophilize and put in capsules. So we don't have probiotics for the anaerobes, which are probably the more important type of organism to look into.

Yeah. One of the things that strikes me with the research on probiotics, in particular thinking about, about that recent study that basically said it takes longer to recover your natural microbiome if you use probiotics following antibiotics, is that they're looking at people who maybe were starting with a healthy microbiome to begin with. But the people that I'm working with are not starting with a healthy microbiome, and they don't want to return to that microbiome. So typically we're using antimicrobials and then following with probiotics because we want to set a new microbiome that's healthier. So in that context, I feel like those studies don't really apply.

Right, and they don't. And if you looked at a comprehensive stool test and you looked at which organisms were really kind of off, chances are almost 100% of the time, it's not going to be a quick fix with probiotics. A lot of people are deficient in lactic acid bacteria, but does that mean they have a deficiency in the large bowel where the fecal material is forming? It's not going to really say much about the small intestine. So, and what if you have, let's say you have no detectable levels of Akkermansia muciniphila, right? An anaerobe that lives on the gut surface and feeds exclusively on mucus and cross-feeds other organisms and has been linked to leanness and perhaps turnover of mucus in a good way. There is no supplement for that. So, right. Again, I think you're back to what are the things that create kind of an anti-inflammatory inflammatory environment and that give your microbes the opportunity. I personally think— and I know some people think sometimes my requirements are a little bit restrictive— but I do think that less is more in terms of kind of resetting the gut. Marlene Riemli, excellent biologist in Austria, did a study. It was a short-term study on fasting. But she found that some of these gut lining microbes, and those are the ones that are probably more, even more important, and that there was some stabilization of Faecalibacterium prausnitzii and some of the other gut lining microbes with fasting. And so if you fast a little bit, if you cut back on your calories and specifically carbohydrates, I do think that there is a little bit it's less of a population for your immune system and your motility and stomach acid and your bile and your digestive enzymes to manage. So these control mechanisms, I think, could have an easier time for it if you took some steps that quieted things down. And I think that's why the Elemental Diet, for instance, has some, you know, has shown to be pretty effective for some forms of dysbiosis.

Do you want to talk a little bit more about what an Elemental Diet is, just because I don't know that I've had anybody discuss that much on the podcast.

Sure, you know, I have a proposal for a better one too. An elemental diet is essentially a diet, and it can be given orally— you can drink the solution— it can be given through a tube for people that can't take foods orally, and it can be given IV. But in every case, it's fully digested nutrients. So there's 3 food groups, right? Proteins, fats, and carbohydrates.. And so instead of fats, you'd have fatty acids. Instead of proteins, you'd have amino acids. And instead of carbohydrates, most of these formulations just include either dextrose, you know, powdered glucose, or a starch-type molecule that's very quickly— like maltodextrin— very quickly broken down to glucose. So essentially glucose. And the idea is those nutrients are very quickly and efficiently absorbed, and so they won't feed the gut microbes very much at all because it gets— the nutrients get absorbed into your bloodstream. So for people with a weight loss issue, you're going to have a better chance to absorb more of the nutrients yourself. And for people with various types of overgrowth, you're going to be able to kind of quiet down, rest the gut, so to speak. However, I'm a little surprised that there aren't more efforts to make formulations that have more fat because most of these elemental diet formulations have very little fat.

Just enough. Yeah, like you're just supposed to add fat at the end or add fat. Like, I think it's just a little impractical maybe to ship things that are in a powder form with lots of fat in it. It makes it probably quite heavy.

And like my friend Mike Ruscio out there in Walnut Creek, right, right, he's got some formulations. He had— was working on one that was low carb. I don't see it in the store lately, but I think that would be—

yeah, I think it probably was.

And he does, right, wrapped up because I I've recommended that to clients. Yeah, and it's semi-elemental, but he cites some data that semi-elemental means the proteins are not fully broken down into amino acids and peptides. He cites some data that those might be absorbed just fine, if not better. So, you know, he's looked into this, and, and I do think for a lot of people, an elemental diet with, with more fat and few fewer carbs. And even in some cases, carbohydrates are not a required food source. I mean, we, we don't need them to survive. So I think for a lot of people, less would be more, just in terms of kind of metabolic health, even if it's glucose, it's rapidly absorbed. But beyond that, some of this glucose could feed bacteria if you had an advanced case of SIBO, say.

Right, right. Yeah, I know I had a client who was diabetic and I can't remember, maybe his low-carb option wasn't available at the time, and then the Elemental Diet just completely spiked her diabetes. Not, not type 2, type 1. Right.

Good.

No, good point. And so they would benefit from some— in other places, I think there are some formularies that would, would do that kind of thing. But the other thing is it could feed SIBO, right? And the reason we know that is because many hospitals use glucose for hydrogen breath tests, and they do find some people that are positive for SIBO, which means that glucose is feeding some of those bacteria.

Right, of course. Okay, that was just a little bit of diversion. Let's get to that. Let's get to the main topic, which is tell me a bit more about your own reflux and how that led you to develop the Fast-Tract Diet.

Sure, yeah, that's— and that's going back a ways now. I'm happy to be free of that, except occasionally a tiny bit around holidays where I go off the rails. Yeah, it was 15, 16 years ago. I had chronic acid reflux for many, many years, and it was really, um, impactful on my, my life in general, work and play, and even at night sleeping. I was getting aspiration reflux and wake up with my lungs on fire wondering what the heck is going on. And I wouldn't have done anything with it except what most people were doing, trying to take some proton pump inhibitors or swallow a lot of Tums. And I just happened to go on a low carbohydrate diet for other reasons, just to lose a few pounds. But when I realized the dramatic improvement in my reflux, essentially it went away. Away on a very low carbohydrate diet. I was just amazed and started doing a little research and try to understand why, why would, why would cutting out carbohydrates have that effect? Because it seemed to go against all of the current research and theories on what was causing acid reflux. And, you know, without making that story too long, it turns out, and this is why I've written 3 books on Well, 2 on reflux and 1 on IBS, because it turns out there's a lot of evidence for why carbohydrates actually drive acid reflux. And so it does have to do with carbohydrate malabsorption, excessive fermentation of gut microbes, and whether that's in the small intestine— we're looking at that now in a study of 90 patients— or whether it's an overgrowth in the early part of the large bowel. But there's no question in my mind that too many carbohydrates for people that aren't digesting and absorbing them well will create blooms of gas-producing bacteria, and that gas pressure builds up and is driving the acid reflux, which is a completely new way of looking at that. So we're still pursuing it in, in the clinic to really, you know, find the proof or not for this theory, but I, I'm pretty sure we're, we're right on this. Whether it will be SIBO or, or LIBO or another form of dysbiosis still remains to be LIBO meaning large intestine bacterial overgrowth. It's kind of a loose term. You won't find any— don't go on PubMed, you won't find it.

I didn't want to confuse anybody.

There is a lot of evidence that LIBO is a real thing. I call it that for lack of a better word, large intestinal bacterial overgrowth. But yeah, there's a couple of studies with pH capsules showing significant increases in the acidity of the early large intestine for populations of people with IBS. And the only reason that could be happening is because bacteria are fermenting more carbohydrates, making more short-chain fatty acids, and that's driving the pH down.

Okay, so why are people not digesting their carbohydrates well from the stomach on down?

Yeah, so the million-dollar question. It could— in many cases, I'm sure, in many cases we know it is for specific reasons. Pancreatitis, pancreatic insufficiency, right? So if the pancreas is not producing or releasing an adequate supply of digestive enzymes, and of course there's protease, lipase, amylase, there's some other ones, elastase, which they measure in a stool test, but those 3 major ones, and but especially the amylase, that could be one reason. Right? There's brush border enzymes, so sucrase and maltase and other enzymes that break down disaccharides. And those are really important not only for breaking down simple disaccharides, which is the name implies, but also the final breakdown of starches. Because don't forget, amylase enzyme, whether you're talking about amylose starch or amylopectin, the two types of starches, you do get these final breakdown products, and those are finished off with the brush border enzymes. And so most research has focused on genetic deficiencies in these brush border enzymes, but I wish they would have— and there's a company up in New Hampshire that tests for this, but I contacted them and right now they're only doing that testing for research studies. But I wish it would be more widespread because I think a lot of people might benefit. It might not— it might be beyond a genetic deficiency. A lot of people have brush border enzyme issues, and you can imagine why they might. For instance, with SIBO, all bacteria are releasing proteases that scavenge for nitrogen sources, right? And they, they need nitrogen, so they'll go after proteins, break them down, and absorb them. And if they happen to be up in where these villi and microvilli are releasing these brush border enzymes right at the tips of the microvilli, they could break down our disaccharidases in addition just to the inflammatory damage on these delicate villi and microvilli. So there's a couple of reasons. I wonder to myself, right, since so many people like myself get these functional GI issues a little bit later in life— 30s, 40s especially, and older— and I wonder if they could just be kind of a general your digestion is not working quite as well as it did when you were 18.

Yeah. Or maybe just too many years of stuffing in too much like bread and pizza and pasta and pastries.

Or excesses. I mean, I'm a fan of moderate alcohol, but some people really go overboard and damage. So there are a lot of things. I think for a lot of people, you won't necessarily be able to put your finger on it, but you can come to a reasonable conclusion that they're not breaking down carbohydrates as well as they did when they were younger.

Right, right. And so for some people, maybe just digestive enzymes would be sufficient, you know, if you get a good enzyme that has both the brush border and the pancreatic enzymes, right?

Sure. And by the way, we didn't really have a chance to talk about the other source of carbohydrate degrading enzyme, the amylase in our saliva. And there's been a number of studies in the last 5 or 6 years showing that there's a gene copy number issue. Some people have many gene copy numbers for salivary amylase, and up, up to 60% of the protein in the saliva is amylase. So they're able to really get started digesting starches just by chewing before they swallow. And other people may have very few copy numbers, and they may not digest starches as well. And it is an evolutionary thing because people with these high copy numbers that that are able to break down starch well by chewing, they also seem to be better adapted or equipped to control blood sugar in the bloodstream.

Interesting. Of course, that's assuming they chew, unlike my son who swallows his food whole.

Oh, I know. And you know what? He's young. He can.

Yeah, he can afford to.

Right.

But I keep telling him, it'll hit you when you're in your mid-20s.

Right.

Good point. Chewing really well, eating really slowly, it's probably the best thing you can do. And just assume that you may be— if you have trouble with starches, you may be one of those people that doesn't have a real high number of amylase gene copy numbers.

Yeah, no, it seems like there's some people that do, do really well, like on a keto diet. They feel great, they have energy. I tried that for about a month and it was a disaster for me. I was just beaten down. I'm just one of those people that has to have some starches in my diet.

Even if— and I'm not pushing it, but I'm just kind of curious— even if— do you consume more fats when you're on a keto diet?

Well, yeah. I mean, I was definitely trying to pound the avocados as much as I could. So you got to fill in the calories with something.

So there you go, though. Hold on. Right. You're getting a lot of fats with the avocados, but you're also getting a lot of fiber with those.

Yeah.

And so there's a lot of fermentable material in avocados. I personally, and most people I consult with, I probably wouldn't ever have more than a third of an avocado and maybe less in a day because of the fiber. It's a superfood and the fats are great, but has a good bit of fiber in it.

Yeah, I probably was having one a day, I would guess.

Are you, are you a vegetarian? I'm just curious.

No, no. I'm more— I just— no gluten, no dairy. So that's, that's pretty much what I do right now. Omnipore. Okay.

Excuse this brief interruption, but I wanted to remind you that if you've been struggling with reflux or another gut health issue, that's my specialty. I work with clients not just here in Tucson, Arizona, where I live, but virtually on video chat. I offer single appointments as well as a 5-session gut health program for people with tougher issues who will likely require testing and longer-term follow-up. As well as 12-week programs for weight loss or reversing autoimmune disease. If you think that a 5-session or longer course of gut 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 hear what health coaching with me involves. I'll put a link for that right in the show notes.

Okay, well, let me, uh, let me dig a little bit more then into the Fast Track Diet. So what is— what does it consist of?

Yeah, when I first had that experience and did a little research and wrote my first book, was basically just go on a low-carb diet. That's the answer, and that's still a great answer today. And it just so happens that while that diet might not be, you know, a great fit like a keto diet for you, for a lot of people it is. And it turns out, you know, in study after study, it's making great headway in randomly controlled trials for controlling you know, blood sugar and reducing cardiovascular risk and inflammation. So this is a huge amount of positive research on the general health aspects of low-carb diets. So, and I just lucked out with that because for me, made my reflux go away, so that was all I needed to know. But long term, I'm happy to say I really think the research for metabolic disorders, diabetes, and on and on, weight loss, is pretty good for a low-carb and ketogenic diet. So I could have stopped there, but I did want to figure out what was the most important part of diet for these functional GI issues, for controlling this, what I'm calling malabsorptive disorders. And so I was talking to a guy named Mike Eades. He and his wife Mary Denise wrote Protein Power. One day, we lived not far from each other in Southern Cal, And he asked me a really important question. He says, "Well, I read your book. I believe you're right." He had heartburn himself that low-carb really helped. He says, "Which carbs do you think are really the problem?" I'm like, "Oh, okay, that's a good question." So I ended up with a list of 5: fructose, lactose, resistant starch, fiber, and sugar alcohols. And I know that's a lot, but don't forget my final approach. You don't have to eliminate them. You just need to limit them. To the point where you can control your symptoms. So those were the 5. The real challenge, and what took me actually a number of years to work out, was how do you control those if you can hold up any piece of food and say, I don't— I have no idea how much of these things are in this food, right? Like avocado, there's more fiber. In fruits, there may be more of some starch in bananas, but also certain disaccharides in other fruits. And And then starches, right? We talked about they have two different types of starches, amylose, which is hard to digest, and amylopectin, which is easy to digest. So how do you know how much of these five types of carbs are in all of these different foods? It was really a perplexing problem, but I felt I couldn't come out with a diet book unless I understood a way for people to get at this question. Because otherwise, it was a research problem for every food. Kind of like the FODMAP diet. There's a lot of research papers on how much of these FODMAPs are in all of these different foods. It's a huge effort, and I wanted people to be able to circumvent that. So I did finally come up with an approach that was based on the glycemic index and the nutritional facts, because we know the glycemic index is a measure of how quickly carbohydrates from any food enters the bloodstream relative to glucose, which goes in the quickest, right? And so when you have the nutritional facts— total carbs, sugar alcohols if they're added to that food, so forth— you have the serving size and you have the glycemic index, or a good estimate of the glycemic index, say based on a very similar food, then you can calculate this value that I call the fermentation potential, FP. So you hear a lot of people on my different forums and so forth saying, well, how many FP points are in this? And that is really a measure in grams per serving of how many in total of these types of carbohydrates are in that food. So it's— a lot of people treat it as kind of symptom potential, be another way to look at it.

So how do you, how do you calculate it?

Yeah, so it's a, it's a manipulation of the glycemic index formula. So, and it's— so it's kind of flipped around and then you, you do have to add— well, let me just kind of say what the formula is. Fp equals the glycemic index minus 100 divided by 100 plus— and then separately, all that in brackets— plus dietary fiber, right? Because that's not subject to the glycemic index, right? It's not digested at all. And sugar alcohols.

Okay, and so then that number you get is your FP points?

And that number is the FP points, right.

Okay, and you want it to have fewer FP points, not more FP points?

Well, right, you know, more would be more, like more prebiotic, right? And so less, if you have a lot of symptoms that are from bacterial overgrowth, a lot of bloating and gas and these functional GI issues, chances are you're consuming too many.

Okay, so I'm really curious, an apple, how many FP points?

Yeah, so an apple, well, let me see. So I, in addition to writing the Fast-Tracked Digestion books, one on heartburn and one on IBS, I also came out with the Fast-Tracked Diet mobile app. And so I have it with me right here. So in the search Apple.

I ask because when I eat apples, I've realized that I can't or shouldn't be eating an entire apple, that that's just like too much whatever for me.

Maybe it's the fiber. It's funny you should say that. In fact, in this mobile app, we put in serving sizes that are a little bit smaller than some people might be used to, but it's just our way of saying, you know, less is more.— if you're having these problems. So for instance, for an apple, I list an apple and the serving size is 1/2 of a medium fruit, right? And that's 91 grams of apple, a half apple. The glycemic index is only 40, right? So you've got this low glycemic index. So that's great for diabetes. It's bad for if you're trying to limit— if you're trying to put your microbes on a diet, it's not so good. And then it has a total Total carbohydrates are 13 grams, not too outrageous, right? But with a glycemic index of 40, and then add on 2 grams of fiber— there's no, no unnatural sugar alcohols— you come up with an FP, or a fermentation potential, of 9 grams. So eating half of an apple is going to give you 9 grams of fermentable material. That's a lot microbes will have to deal with. Well, it is a It is a lot, right? It's the, it's the weight of 9 paper clips or whatever, but it's a lot in terms— if you think in terms of how few grams of carbohydrates it takes bacteria to produce gas, right?

Yeah.

So for 30 grams of unabsorbed carbohydrates, bacteria can produce 10 liters of hydrogen.

Wow.

The beginning of the molecular food chain there. 30 grams equals 9 liters— equals, I'm sorry, 10 liters of hydrogen gas. So for your situation with that half of an apple, that would be a little over 3 liters of gas. So, and your body is dealing with that, right? Some of that gas may be converted to hydrogen sulfide, be converted to methane, and that reaction reduces the volume. Some of it will be absorbed into your bloodstream and exhaled through your breath. So your body's always trying to manage and deal with it. You might belch, you might have a little flatulence. All of these ways your body's trying to manage that gas, but if you've got too much to manage, you know, maybe a couple apple slices might be better than half of an apple.

Yeah, so how many points do you recommend people restrict themselves to? Is it more just a matter of figuring out, well, I felt bad at 30 points, so maybe I need to make sure my meals are no more than 15?

Yeah, well, if you, right, had the tool and were doing it, and then that would be Great. It would be an empirical determination based on your symptoms. I guess at the beginning, right, people have no idea, so it's good to have some basic ideas of what to do. First of all, for a very small person, they would have even less than a very large person. Everything's scalable, right?

Right.

But generally, I was in— when I first wrote, we're on probably a 5th printing on the Fast-Track Digestion books now. But when I initially wrote that book, I was saying, oh, 25 to 45, or even more if you're feeling great, even more points. And that's where it was. Now, people, our readers, and people that have joined us on the Fast-Tracked Diet official Facebook group, and I'd recommend your listeners, if they want to know more, they can just join this Facebook group. There's over 11,000 members now, and everybody's chatting it up and helping each other out, and there's recipes and all this stuff. But they, they are telling us, hey, hey, hey, when, when I have, uh, LPR is a particularly challenging condition, right? Laryngopharyngeal reflux. Very subtle, but a persistent irritation of the throat, the vocal cords. You can have respiratory aspects of it. You can have plugged eustachian tubes. It's very challenging to get rid of this, right? So they started telling us, you know what, for this, your 25 grams is out the window. I really needed to go under 20. And some people said, I went 15. Somebody else says, I went 12. So we started listening to the experience of readers, and when we were working out the details for a protocol for this collaborative study we're doing on, uh, 90 people with chronic acid reflux going off PPIs, we went in and reprinted the manual reducing these points a little bit based on what people were telling us. So let's make a long story short. I'd say maybe 25 is a place to stop, but if you're really having problematic symptoms, maybe going lower.

Right. And that's per meal, right?

I'm sorry, that's per day.

Per day?

Yeah.

Wow.

So you're talking about 7 or 8 per meal. Don't— you were the one that pointed out how many grams of fermentable material that is.—

So is that basically putting people on a keto diet?

Well, no, but keep in mind, right? Hold that thought. Keto and other means, fasting, there's a whole lot of different troubleshooting things you can do. So some people that are really in the throes of this thing, there's some troubleshooting sections in the book and in the mobile app. There's a bunch of mini chapters in the mobile app that have some troubleshooting techniques, and one of them is just in general a low-carb diet or a ketogenic diet or some fasting. But because even when you're low in points, there are some higher-carb foods that are very low in points, and that's because they have a very high glycemic index. So, so in other words, you can eat white bread, right? White bread is Right, it's relatively low, you know, unless you have celiac disease or sensitive to gluten. Jasmine rice and Asian sticky rice or sushi rice, they're very low in points because they have a very high glycemic index. So don't eat too much if you have blood sugar issues, but they are lower in points. Now here's kind of where the troubleshooting section can come into play. The FP calculation, it's a very good way to compare one food to another. In terms of which one would be easier to digest and how many carbs and how many points. However, what we don't know right now is how well people with digestive health issues— what would the glycemic index be if we tested them in those people? Because right now, the glycemic index, to get one of these GI values, a single food is tested in 10 healthy people. Where they give them glucose first and then they measure all the blood levels of glucose, and then they, they give them the test food, and then they measure their blood sugar levels over time, and then they compare the area under the curve of the test food to the, to the glucose to get a glycemic index. But, but if it was a person with IBS, SIBO, a Libo, SIFO, dysbiosis, pancreatitis, cystic fibrosis— they also have trouble releasing enzymes from the pancreas— the glycemic index might be lower for those people. So that's why in the book and in the app we, we do— we're cautious. And that's why we say half a cup of rice. Try a half a cup of rice. Make sure it's fresh. Make sure it's moist and fluffy. That's the best chance you have. And make sure it's either jasmine or sushi or one of the lower FP rices. Eat really slowly and chew really well. And see if you have symptoms because you may not be ready for it if you have some issue with, say, one of the things we talked about, brush border, pancreatic enzymes, salivary amylase, et cetera.

Okay, I wanted you to tell me again the 5 sugars that you're supposed to be wary of.

Yes, they are lactose, and of course, some people are lactose tolerant, right? They've got the gene for lactose.

Not me.

Stuck in the on position, not me either. But well over half the world's population is lactose intolerant. Intolerant as adults. So lactose, fructose, and fructose malabsorption is well, well documented. Again, many, many people around on the planet are fructose intolerant. Lactose, fructose, resistant starch, which there's several types of starches and some types are resistant, and the amylose type we talked about is one of the more resistant types. It behaves like a fiber. So resistant starch Fiber, and there's many, many different forms of fiber, as I know from listening to some of your podcasts, you know all about, and with many different qualities and properties. So fiber is just a general concept. All fiber initially, right, to get symptoms under control is included, as well as sugar alcohols.

Okay.

And sugar alcohol is also well documented just go to the FDA website, you can read about those, how many problematic digestive—

oh yeah, I know all about it, but I put up with it anyway.

But there's one exception. Erythritol is a sugar alcohol, but it's not metabolized by bacteria. There's been some good studies looking at that, and so most of it is excreted unchanged from the body. So sugar alcohols is an exception, and natural sugar alcohols You know, we do recommend those as one of the low-FP sweeteners you could use, that and monk fruit and stevia, things like that, but erythritol is a good one. Now, not everybody agrees with everything I said. We had a reader just the other day write to me and say, "How could you have erythritol in your diet? I just can't believe it. It's terrible." And so I wrote back and I said, "Well, here's a link to a paper. It talks about how bacteria don't ferment it, so forth. And she came back with another paper and she said, but do you— you do know this paper shows that it impacts and reduces how well fructose is absorbed? So it's interesting, we continue to learn from our readers. Fructose, at least according to this one study that she sent me a reference on, fructose is absorbed twice as slow in the presence of erythritol. So So yes, we're reading, we're learning from our readers, but I still think erythritol is a great choice as long as you're not consuming a lot of fructose.

Now it's funny because I feel like I don't really do well on erythritol. Like it kind of makes me feel nauseous, but I do better on xylitol. Not in huge quantities though.

Lindsey, that's really interesting because in studies that looked at erythritol with other sugar alcohols, the other sugar alcohols were just way worse in terms of gas and diarrhea and bloating. Erythritol had none of that, but I do happen to remember that some people in that study with erythritol did feel a little nausea. So that may be, that may be something.

Yeah. Yeah.

I, for some reason, don't have any problem with it, but that's interesting you said that because I do remember that in the study.

Yeah. And if you, if you have to choose your poison, I'll take a little bit of a soft stool over nausea.

Yeah, nausea is a real uncomfortable feeling.

Yeah, and it kind of makes you not want to eat your dessert that you've carefully crafted again. Okay, so I wanted to dig a little bit more into LPR because I think that that is what I had. Now, 30 years ago, I saw a doctor and, you know, had a constant cough and no acid reflux feeling. You know, I never felt acidity in my throat, but I did eventually start to have like my voice felt like it was changing and that kind of thing. I want, you know, I was on PPIs for 15 or 20 years straight.

But I didn't know that.

Wow.

Yeah, at the very beginning, you know, they were giving me like asthma inhalers and that kind of stuff because of the cough and looking for causes of the cough. And then finally somebody said this may be acid reflux. But is the— is LPR a new diagnosis? Because back then nobody had a name for that.

It's been around for some time. Jamie Kaufman, doctor in New York City, she's also done some research, published at least a couple of papers on it. She has a different diet approach. It's, it's a low acid diet to deal with this idea that when people reflux, some of them, the pepsin from the stomach, an enzyme that breaks down protein, will stick to the tissue in the throat and can become kind of even intracellular. And then when you eat very acidic foods, you could kind of turn it on. It's only active at acidic pHs. So she recommends a low acid diet, and this Acid Watchers diet is the same idea. So yeah, it has been known. Maybe it hasn't been as popularized as acid reflux, but it is quite common. Um, of course, the Fast-Track Diet is, is a different approach, right? It's saying, yeah, go ahead and sip some alkaline water if you want to take advantage of those ideas with the pepsin. But really, you want to eventually stop the reflux so that you won't get pepsin and other things up into your throat and your lungs and your airways and your Eustachian tubes and so forth.

Yeah.

Thanks for pointing out some of those symptoms, right? Yes. Cough, sore throat, feeling like there's a lump in your throat that drives you crazy, even though the E.T. will look down there and say, there's nothing there.

That was me with any kind of lactose.

Yeah, and by the way, these respiratory issues— asthma, COPD— also strongly linked with acid reflux. So no surprise there.

Interesting.

So I'm sorry, so let me—

I was just going to ask you about— so I assume on the Fast-Track Diet there is a period of time in which you're kind of going super low FP so that you can get some of those bacteria to die down, and then you maybe ease back up. Is that Is that sort of how it goes?

Yeah, so people, practitioners and so forth that worry about people being on a low carbohydrate diet, they're a little more quick to say, okay, you've been on this 2 weeks, you need to really expand your diet, you need more carbs, you need more of this and that. I don't have that kind of fear because I do think just from my 15, 16 years in this area of study, being close to kind of the low carb keto community, I really do believe low-carb and keto is, is a safe and healthy diet. So I don't worry that much about people rushing to get— to add more carbohydrates. I do recommend a good variety of lower-carb, low-FP plants and fresh herbs. And if you were to look at the— the Fast Track Diet mobile app has all of these different categories for foods, right? And if you looked at— just clicked on the vegetable table They're all— they're listed by FP points, and you would see that there's probably about 50 that are under 3 or 4 points. So there is a huge diversity of vegetables that are low FP, and then they gradually do start going up, and then you get to the more starchy ones and more fibrous ones, and you get to plantains. You know, they do get to be higher and higher. So I do still recommend people do eat a lot of plants. But lower carb, green leafy, lower FODMAP. And there is a great number to choose from. Also, by the way, if you're into legumes, sprouted legumes are also very low.

Okay. So—

but I let people ramp up on their own, you know, when their symptoms allow it. Once I just want them to trust this method to control the symptoms. And once they get that down, I really feel like they can they can manage, you know, then say, all right, well, I feel better, I'm gonna— and then they try all these things and go out for a weekend and eat french fries and this and that, and I'm home and they'll be like, oh man, that was wrong. But they're able to, I think, do it on their own. When I consult with people, I give— I provide extensive written recommendations. So the first session, people might get 6 to 8 or 9 pages of notes. Usually, and I'll consult with somebody at least maybe 2 or 3 sessions, give them notes for everyone so they'll always be able to go back to those notes no matter what happened or were they on holiday or seeing the family. They can just always kind of regroup and say, all right, I need to really kind of go back to the basics here.

Yeah, so I wanted to ask about low stomach acid because that is, you know, in the functional medicine community, one of the causes that is often cited for acid reflux as opposed to high stomach acid. Do you think that that has validity or Do you think that it's just a misdirection?

I do. In fact, one of the first things that I do when I work with people is I do an assessment. You know, of course, if every drugstore had a Heidelberg acid test and you could just bring it home and take it, and I just say, okay, just do that. But as you likely know, there's not a lot of practices that do this, unfortunately, because I do think it's a hugely important test where they dangle the pH capsule on a string. You swallow the capsule, but it's still dangled in your stomach, but it's being held there by a string so it doesn't move, right? And that capsule is radioing out pH activity in, in your stomach to a receiver and a laptop on the practitioner's desk, right? And so it's— for most people, it's going to say your pH is 1 or 2. It's very, very acidic. And then they give you 3 or more bicarb challenges.

Right?

We drink this solution of bicarbonate, and then you can see the pH. You just watch it on the laptop. Now the pH goes from 2, goes flying back up to 7 or 8. And then the question is, how long is it going to stay high like that? That's what they want to know. If you re-acidify quickly, and you can do that several times, you don't have low stomach acid, right? If you're very slow to re-acidify, or you, or you have a not a very acidic stomach to begin with, or it takes too long to re-acidify, then you will almost certainly be diagnosed with hypochlorhydria or even achlorhydria. So that's, that's what you want to know. But how to get at it when a lot of people don't have easy access to practitioners that have that test? So what I do is a risk assessment, and I look at what are the potential causes for low stomach acid, right? And from listening to your stuff, I think you're aware of these too, right? But here, these are the questions I ask because a lot of people will know the answer to most of the questions, and if not, they can be they could be tested. So first of all, do you have any autoimmune conditions, right? So a lot of people may have Hashimoto's or this or that, but autoimmune conditions don't tend to occur in isolation. And so if somebody has an autoimmune condition, then I might suspect pernicious anemia, right? Autoimmune atrophic gastritis, where your own immune system is attacking the parietal cells that produce this acid. And those same cells produce intrinsic factor for absorbing vitamin B12. So if somebody had a, a significant autoimmune reaction, it would make me wonder about that. And there's a quick blood test you can get for that, by the way. It's not as hard as the Heidelberg.

Pernicious anemia, you mean?

B12 levels. But you can have, um, pernicious— no, you wouldn't call that— you could have versions of autoimmune atrophic gastritis where for one reason or another your B12 levels were okay, and some people are supplementing and all of this. But you want to know whether your parietal cells are being impacted. And so there is an anti-parietal cell antibody assay. It's a blood test. So it's available. So that's one. Next one is, of course, H. pylori, right? Because most people won't know if they have— if they're infected with this bacterium, but it burrows through the mucus in your stomach. It attaches to the lining, and there it sits in these little colonies. So it's not a diffuse infection. It makes little colonies. Where those colonies are, over time your stomach lining gets damaged. So if they happen to be in the area of your stomach where these parietal cells are, chances are you will get atrophic gastritis eventually, if not an outright ulcer, and the inability to produce adequate stomach acid. So for so many reasons beyond just stomach acid, I do always recommend if people are H. pylori H. pylori positive to go ahead and suck it up and take that antibiotic treatment to get rid of it because you just don't— especially older people, I'm putting myself in that bucket— we don't want to have that bacteria as we're getting older. We want to get rid of it. That's the second one.

Cancer.

The third one is, are you taking a lot of NSAIDs, nonsteroidal anti-inflammatories, because they will irritate the stomach They can lead to gastritis. For that matter, they can also lead to NSAID enteropathy, make tears and damages small intestine as well. But in terms of the low stomach acid, yeah, people that are abu— that are abusive with these NSAIDs, they may want to be checked again with something further like a Heidelberg acid test. The other one is alcohol, and I'm not talking about moderate alcohol, but people that have really done a lot of binge drinking or alcoholics, that can certainly have an impact And then things that most people won't have, any kind of bypass or stomach surgery or stomach cancer. But that's usually where I, where I start, and I just want to know if they're at risk for it or not before wasting time pursuing that further.

Now, the NSAID piece surprises me a little, only because I know that when I, because of my sciatica, had to take NSAIDs there was nothing else I could do. I was in too much pain and was taking like 6 a day against all my best knowledge and wisdom, but I was taking about 6 a day and ultimately started feeling pain in the same place in my stomach every time I took them, and I knew I had to stop because I was on my way to an ulcer, if not already there. And, and then the recommendation at that point is to go on acid-reducing drugs to try and just heal up your stomach lining.

Right, right.

I know that's been explored, right?

Yeah.

And unfortunately, so many things wrong with long-term use of acid reducers too.

But that's right, right. And I didn't use them long-term in this case. I used them until the pain went away, basically, and then, and then some cultural probiotics.

No, there's another interesting area of research. And by the way, with NSAIDs, you know, the other thing people can do if they just must take them is just make sure you always have plenty of food in your stomach when you take them.

Yeah, which isn't possible when you're trying to take one right before bed and you got like a schedule 3 times a day, right?

Exactly.

And they only last 8 hours, if the longest.

Another area of research that's very interesting, and, you know, like a lot of people, I've been looking over the last few years, looking more into what's this hydrogen sulfide all about. People seem, you know, paranoid about it. And my bacteria, these sulfate-reducing bacteria, they're making all this hydrogen sulfide gas. Gee, my farts stink, I must have it, and oh, I've heard, you know, it's going to give you chronic diarrhea and all of these problems with it. And so most people and practitioners have this big concern about hydrogen sulfide, but there is another side to this molecule. First of all, bacteria make it in our gut, and not just the sulfate-reducing bacteria. Some proteobacteria make it, some Bacteroidetes Organisms produce it. So a lot of, a lot of organisms have the pathway to use this trick to take hydrogen as fuel. Instead of making methane, they make hydrogen sulfide. But aside from this worry about, do I have pathological levels of hydrogen sulfide, there's a whole other side to hydrogen sulfide in terms of its ability to help heal wounds as a regulatory molecule in the body. There's a lot of research going on to see that they might be able to come up with hydrogen sulfide releasing or promoting supplements that would help people when they have to take NSAIDs, prevent the, the bad side of them. So that I think is really— it's still just an area of research, but I think it's one that's really great to follow. What's the positive side of hydrogen sulfide? By the way, when hydrogen sulfide gets out of the gut it's very, very quickly changed into something else other than hydrogen sulfide because it is a toxic molecule at high levels. But the body has mechanisms for dealing with that, quite effective.

Yeah. Okay. So, you know, I'm always struggling back with the whole stomach acid issue though, like with the idea that you may, you may have someone who has, who's absolutely convinced that they have high stomach acid, that the doctors have told them, they put them on the PPIs, they feel burning in the chest, Barrett's esophagus, this kind of stuff. And then to then say to them, I think you may have low stomach acid, take more stomach acid, it's a tough sell.

Yeah, yeah.

And I'm glad you— you're a good interviewer because you pull things back to LPR. I tend to drift, so you got us back on topic there. Yeah, let's talk about PPIs and stomach acid in terms of LPR, because the most common prescription for LPR is a PPI.

Yeah.

And you will find a person here or there that says, well, does seem to help, helps my LPR to be on a PPI. But most people will say no, it's not helping. And in fact, when you look at the studies, and if people go to digestivehealthinstitute.org I wrote a couple blogs on LPR, but one of them in particular is talking about PPIs and their ineffectiveness for LPR. So this question's been studied very well. PPIs for LPR are no better than placebo. Been studied, there's studies on it, there's meta-analyses of studies on it. It is no— they're no better than placebo. And so why is that? And it may be the same reason PPI drugs, acid-reducing drugs, are also no help for asthma. Asthma is another reflux-linked condition in a way, a lot like LPR. There was one study in kids that showed 80% of children with asthma have chronic acid reflux. So with LPR and COPD and asthma, we know there's a strong connection with reflux, right? But There was a study done called the SARA study. 1,000 kids were in the study with asthma, centers all over the US, and they put them all on Nexium. And they had to come out at the end and say, hey, everybody listen up. There was something like 120 authors on this paper. Hey, got to tell you all, didn't work at all for asthma, right? And so— this— you can read this paper on the SARAH study, it's crazy. In the final conclusion was Nexium did not help asthma, so acid reflux must not be the cause of asthma, which I thought was just such a bogus conclusion, right?

Or Nexium doesn't help acid reflux.

Some double the Nexium now. But here's the thing, all they had to do was look at some other studies on, for instance, fundoplication operations. Will you tighten the LES. And it's invasive, I'm not recommending it, but it's a proof of principle.

Okay, wait, before you go on, I just— could you define a little bit more what that means?

Yeah, so there are various ways to tighten the muscles, the group of muscles right at the top of the stomach called the lower esophageal sphincter muscle. So at the bottom of your esophagus, before food goes into your stomach, it has to go through these— this group of muscles called the LES. And they relax when you swallow. They relax and let the food go through, and then they tighten up again. Okay, but some people, there's a thought that, well, maybe it gets looser and so forth. Well, I have a different theory for that, that it's being driven by gas pressure, as I told you about. But people that do have reflux, and in this case asthmatics with reflux, when they did fundoplication operations that tighten up these muscles and don't allow you to reflux much, they did better and they could reduce their medicines. So there is— that proves there's a connection with reflux. And so I think what the study did prove is that acid might not be the most important thing in the refluxate, either for LPR or for asthma, that it's something else. And what are those other characters that— what are those suspects And I think that you can look at bacteria, bacterial end products, digestive enzymes, things from, from our own gut, but I think one of the chief suspects in my mind is bile. And bile wasn't focused on that extensively in reflux by a lot of people, and possibly because it's released in the duodenum past the stomach and thought, well, why would that much bile even be in the reflux? But when they look, they find it. And of course, with my theory of reflux that is basically saying it's from carbohydrate malabsorption, gas building up in your intestines, that, that theory basically entails reflux starting at a much lower point in your intestines. And so you would expect bile and other things from your digestive tract to be in the refluxate, and it is.

Yeah.

And so people that weren't— first of all, I, I think they should get off the PPIs and try the Fast-Track Diet. That's my first advice. Or work with myself or somebody to really go look at these 25 or 30 potential underlying or contributing causes of reflux and other functional GI disorders. But just a quick tip based on that idea is you and your doctor maybe just bring up the topic of bile acid sequestrants. If you think you have a bile issue, there are drugs you can take— the prescription, so I couldn't prescribe them, but a doctor could— that tie up some of this extra bile. Maybe that would help. But I think in the end, the long term, what you do is really want to get control of reflux.

Yeah, now I, I can attest to the fact that when I had that reflux and I coughed up, like, my sputum in the morning was brownish like bile. So I don't know if that's what that was, but anyway, I remember that. It's been so long since I had that, and really for me, going off dairy was the main contributing factor to it going away and that allowed me to go off the PPIs.

And you know, with dairy, it's not just the lactose. No, right? We know all about these oligosaccharides in milk.

Yeah, yeah. No, I had issues with all sorts of things in dairy.

Yeah, right. Well, there's lactose, there's oligosaccharides, and then there's intolerances to the proteins themselves, which is less common, but maybe you did have that.

Yeah. Well, you know, we have gone a bit over time, so I probably should not take any more of your time.

Really? Wow, man. I like talking to you. Time flies. I can't—

I know.

This has been a pleasure for me.

Thank you.

Yeah. Well, so obviously I see you sell your books and your app and your programs, and you see individual clients like I do for gut health issues.

Lindsey Parsons.

So anything you want to— we'll link to all that stuff in the show notes. Anything else you want to mention before we go?

No, I think you did a great job. I'm open to, you know, there's so many great studies and I'm open to talking about all of them to see if we can really as a community increase our understanding. And like I said, we learn a lot of people, a lot of things from people on our Facebook group, from readers, from feedback, from working with people one-on-one. So I really feel lucky to be able to do this with my career at this point.

Yeah.

Plus, it got me out of the corporate realm.

Indeed.

People, I again, just remind people they can join us at the Fast-Tract official— Fast-Tract Diet official Facebook group, 11,000 members. So a lot of good stuff going on there. And they can find all of our information or links to it on digestivehealthinstitute.org.

Okay, great. We'll link to all that in the show notes. Well, thank you so much. I appreciate you coming on the show.

My pleasure, Lindsey.

Wow.

I really love talking to scientists like Dr. Norm who really understand the physiological mechanisms underneath all of these health issues that we have. I'm gonna have to listen to that one a couple more times to absorb all that information. I also want to remind you that I love getting listener questions, so feel free to write me at Lindsey@HighDesertHealthCoaching.com with questions. I'll use your first name on the air unless you ask me not to. And if you appreciate the free info I'm giving you, there are some painless ways to support the show. First, you can buy high-quality vetted supplements in my online Fullscript or Wellivate dispensaries, and there's a link in the show notes if you want to sign up for an account there. Do compare prices if you find the same supplements elsewhere. I also have an affiliate account at iHerb, so if you buy from there and press on the link on my recommended supplements page or the link in the show notes, I'll get a percentage. And you can also support me with a monthly $2 or $5 donation on Patreon or a one-time donation on PayPal. And if you wanna stay in touch and get articles based on each of my shows as well as webinar announcements, you can join my newsletter list at highdeserthealthcoaching.com on the newsletter page. And you can also connect with me by joining my Gut Healing Facebook group. If you wanna ask a question about gut health or suggest a topic or a guest for the show, and you can also follow me, um, my High Desert Health page on Facebook or find me on Instagram, Twitter, Pinterest. And all those links are in the show notes. So thanks for listening, and here's wishing you all the perfect stool.