SRQ: What are some contributing factors that cause an imbalance in the gut system? Paulette Weber, RD, LD/N, CLT (Registered Florida Licensed Dietitian/Nutritionist, Enlightened RD): What people are eating is going to make a big difference. A really important thing is the microbiome and the good bacteria, whether there’s enough good bacteria in the gut is an important factor along with whether or not there is yeast, and if they have structural problems or functional problems. But what people eat has the most important impact on their microbiome. Dr. Ravi Kondapalli, MD (Gastroenterologist, Florida Digestive Health Specialists: Venice Gastroenterology): This microbiome—this genetic predisposition—people can have a genetic predisposition to Crohn’s disease or Celiac or Diverticulosis and other diseases. But food plays a big part, and other agents like an antibiotic, or anti-inflammatories, or depression or stress can play a big part in the expression of the disease. Dr. Lee S. Mitchel, MD (Gastroenterologist, Florida Digestive Health Specialists): The best example currently is with the Celiac group. We have experienced things like Monsanto and we are seeing companies changing the food source. You and I have all been exposed to that. They changed the seeds and we’re now seeing an incredible surge of gluten enteropathy (or Celiac disease)—they’re gluten hyper-sensitive. I’m seeing 15 to 20 cases a week—that’s when you say, “Holy moly, something is going on here.” You are constantly hearing Monsanto saying, “It’s not us, it’s not our seeds.” But something is wrong in the food source. Rebecca Henson MPT, MN, RD (Licensed Dietitian, Doctors Hospital of Sarasota): Food sensitivities in general seem to be an up-and-coming topic in GI. It seems like Celiac is more accepted, we know dairy is an issue for a lot of people, and then there is the most common food allergies but there also seems to be a lot more sensitivity testing. I’ve had good luck with food sensitivity testing really helping peoples’ symptoms, kind of narrowing down what, other than gluten and dairy and eggs, is affecting their system. A lot of times the goal will be to get rid of the irritants, temporarily get rid of the inflammation and then they can work back into a normal diet once everything is uninflamed and better situated. Mitchel: We’re seeing Eosinophilic esophagitis in the esophagus, there’s something in the environment that triggers these people. Allergists will change their diet or treat them with a steroid called budesonide. We take a little honey and mix it with the budesonide and it sticks to the esophagus. I did another stool transplant today. Its unbelievable, we’re fixing people with poop. Healthy people’s poop is curing people. I did my 50th one and there’s probably 150 to 200 done in Sarasota. So you’re regenerating the biome, and healthy bacteria rebuilds. 

There has been a huge upsurge in the population of functional disorders like IBS and SIBO. Why do you think all of a sudden this is happening? Jennifer Bielowicz CAP, LMT (Creator and Founder of Ocean Love Ayurveda): From an Ayurvedic perspective, stress shuts down our digestive system because the vagus nerve is connected to our gut and turns on the parasympathetic nervous system, which is the part of our nervous system that helps us relax. When you are stressed out your digestive system shuts down, preparing you for a fight, flight or freeze reaction. Your gut feels like it doesn’t need to digest food right now, it needs to react. Ayurveda also says that food is huge and food today is made from GMOs and it’s processed and we’re eating a lot of frozen food, fast food—we’re on-the-go. It also has to do with how are we eating our food—are we standing? Are we driving? Are we even paying attention while we eat? Are we eating right for our type? Ayurveda believes in balancing the digestive fire to create efficient and proper digestion, which is considered to be the foundation of true health. Kondapalli: Also it’s cleanliness—we’re doing too much of it nowadays. All the moms are trying to keep their kids from getting dirty. We’ve moved from farms to city life, so kids aren’t exposed to many bacteria or antigens or viruses, which is actually not helping our immune system because they are not seeing these bacteria and pathogens in the first two years of life. Many kids now have these allergies: Celiac, Eosinophilic esophagitis. Same thing with Crohn’s, same with ulcerative colitis, because they’re just not being exposed to those pathogens early enough. This may be one of the factors other than the GMOs and genetic predispositions, because we’re not exposed to those bacteria. Another issue is antibiotics. Every time a kid gets sick the mother is upset and the kid pops an antibiotic. Especially when given to a young child, it kills some of the normal bacteria they’re supposed to have so they’re not exposed to all the bacteria, so now when you get exposed to new bacteria, the body is looking at it like it’s an antigen and is reacting as an allergen. Weber: I think proton pump inhibitors (PPIs) probably have an impact too. They’re supposed to be used for eight weeks or 12 weeks but then people are on them for eight years or 12 years. The pH in their stomach then is just not able to digest food. They get B12-deficient, then they get iron-deficient, then they get protein-deficient, they start losing their hair. And one of the long-term side effects is small intestine bacterial overgrowth (SIBO). I’m a big fighter to get people off those medications. When people have GERD or reflux, a lot of them have these because they have food sensitivity so they have candida overgrowth. If you treat the food sensitivity and get them off the medication, then they wouldn’t have the downstream effects over time. Mitchel: [Weber] has brought up a $16-billon question. A few months ago someone on NBC gave a report from the Journal of the American Medical Association, which said there was an association between use of proton pump inhibitors and (possibly) heart disease, kidney disease, protein deficiency, vitamin deficiency, et cetera. It was not a controlled study, it was a retrospective review. This was blurted out on TV, and now I get 10 calls a day about this. And now they’re doing a forward-looking study to see whether there actually is a cause and effect relationship. The generalization has scared our community—maybe for the better because now we’re getting people off the PPIs. Kondapalli: If anything our associations don’t really go over the data. I think they’re kind of circumspect about it. It needs to be a randomized, double-blind prospective study, but the problem is that nobody is going to want to pay for those studies so it won’t happen unless the PPI companies take it upon themselves to prove it. But they help some people. What I tell my patients is that if you have symptoms that are affecting your lifestyle and quality of life—you have to choose your patients but if they really need it, they need it, as long as they know that there’s a downside to it. Henson: There are holistic ways that you might be able to handle it but you have to pay for them, they cost money. A lot of people just want a pill, it’s easier. It does boil down to people being stressed out and busy and not taking time to take care of themselves. Bielowicz: Ayurveda recognizes that each of us is a certain constitution; like increases like and opposites balance. We also look around your environment, internally and externally. For example, we live in a very hot place, bringing out a lot of fire elements—a lot of Pitta types—if we have inflammation going on in our bodies and if we have a lot of those fire elements already, like spicy food, that’s going to increase things and throw things off in the body. It’s about understanding our nature—just because one thing works for one person doesn’t mean it’s going to work for another.

What would the response be from a holistic approach if you were trying to get someone off a PPI? What would be the next step? Weber: I would test for food sensitivities. I would also want to know what their medical history is, what other medications they are on, what are they eating and get a really good history and diet recall. If we identify that they have food sensitivities, I have a protocol that I go through, and then at the point where they are feeling better, they would start reducing their dose of PPI with the blessing of their doctor or their gastroenterologist. I use different supplements to help supplement them through and eventually they can get off the medication by weaning themselves off. If they just stop the medication they might have a gastric surge, they have more intense symptoms for a while. So we remove the cause, the trigger, and then slowly reduce the medication alongside supplements. Henson: It’s quite successful. Kondapalli: What is the success when someone is slightly obese and doesn’t have a great diet? What is your success with weaning them off the PPI? Weber: If they are motivated then I can give them the tools. You can give someone the perfect plan and help them to create it for themselves. Kondapalli: They are motivated to begin with. Henson: By the time they see us, yes. Because they have to pay money to see us. Insurance doesn’t usually cover our services for GI. Mitchel: Which is a bad thing for society. I could hire a dietitian to come to my office and keep them busy with 20 patients a week at least. But for the most part there’s no payment. Diabetics get it paid for, weight loss and bariatric patients as well, but for everyone else, dietitians work in a hospital or a private practice. That’s a shame. Henson: We have great success rates because the people that do pay are very motivated, they’ll do everything we say, they get the blood test—it’s a very graphic result of what foods they’re sensitive to so they see it very green, yellow or red: here is what you can’t eat. And then they work with us, checking in on a regular basis and they know they’re going to answer to us. In that case when they actually do what we say it works quite often. Mitchel: Society errs by not allowing dietitians to be part of our team. When you go to the Cleveland Clinic or the Mayo Clinic what is it they do? They form a team of doctors. Why are these clinics so good? Because they take an approach, they make a team: the dietitian, the doctor. You organize together and sit at a conference table and say, “We can fix Mrs. Jones: she needs to fix her diet, she needs to come to you, she needs to lose weight, make sure her heart and lungs are okay.” You need a team approach. It costs money, that’s the problem.

Do your disciplines ever join forces, GI doctors employing a more holistic approach, and vice versa? How are these practices interconnected? Kondapalli: In the future that’s going to be the push from the Obama administration. Forming a team. The initiative is to have these kinds of interactions. Like for diabetes they would need a neurologist and an endocrinologist and a nutritionist and a cardiologist. The goal will be to compensate people who can collaborate, and make it more effective in their care. It is going to be outcome-based. This is a good idea, it’s just so difficult to implement. Bielowicz: Because it comes down to money. It’s not the quality it’s the quantity. Kondapalli: Right. Things are trying to change but it’ll take some time to get there and right now we have an allopathic approach, an Ayurvedic approach and the nutritionist approach. From all points of view, you should stay away from carbonated drinks, acidic juices, coffee, chocolate and give yourself three hours between dinner and bedtime and losing weight. We tell them that but we don’t normally refer to a nutritionist. It’s not part of our practice. Mitchel: People will not pay any money outside of their copay for a doctor’s office to get going straight and that’s a huge problem. I sat down with an exercise trainer, a dietitian, a psychologist, we actually tried to form a team. It failed for a number of reasons, one was the cost. The money is not available and it should be, because overall it saves money. What is the overall cost of cigarettes and alcohol in this country? Over $750 billion a year. If you stop people from smoking and drinking you would have almost a trillion dollars of available money. Henson: And it’s getting better. When we form a relationship with doctors and the doctors are seeing great results, you hand out ten cards, two of them come to us and they do really well. We develop these relationships. The doctors that work with Doctors Hospital are starting more and more to figure out that we’re there and send people. I think [Weber] and I have more time than most doctors. We sit down with someone for an hour to an hour and a half and then we can really hear what’s happening and we can be the gateway to this person starting to feel better but we can see other holistic practitioners that might be useful as well, if this person is really stressed out and they need a psychologist, we can kind of be a gateway. We can be a form of communication so the doctors know what’s going on. Kondapalli: In terms of gut health, it’s not just gut-related. There are going to be more and more studies in the future about the gut biome having an effect on obesity management, depression—things that we don’t really associate with the gut microbiome, so in the future it’s going to be a lot of different outcomes for managing the gut microbiome. Think of the stool transplants. In the future it’s going to be possible to treat patients better on top of medication by just changing the bacteria in the gut. Understanding biomes is one of the hardest things in the gastroenterology field. Mitchel: An example of that is ulcerative colitis may be preventable by exposing people to parasites or worms. Kids aren’t playing in sewer pits like in third world countries. We are in rural America and are not exposed to these things. The gut biome—the exposure to parasites may protect it, which can be very useful. Getting back to the point about the psyche—the psychiatric side effects of being bloated, having decreased motility et cetera are people getting depressed and overweight, so it’s all connected and hooks us all together.

Do you find that diets like the specific carbohydrate diet or low FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) diet are actually producing outcomes that are viable, from both the dietitian side and the GI doctor side? Weber: They definitely work. The specific carbohydrate diet works for people who have Crohn’s and ulcerative colitis—it’s just very difficult to follow. But when you do it, I’ve had a lot of people that were successful. With the low FODMAPs diet, it’s not meant to be something that you’re on for life, it’s meant to be something that you’re on temporarily because you’re really eliminating a lot of very nutrient-dense foods, so it can reduce symptoms but it’s not meant to be something you follow forever. You really want to find out what is the root cause of the problem. The low FODMAPs diet can make you feel better but if you don’t really find out what the root cause of the problem is you’re going to have to continue on that very limited diet for a long time. Hensen: It’s definitely a challenging field, there are so many potential issues that could be interconnecting, causing IBS and general irritations, so there are a lot of things that everyone on the team needs to check to see what is this individual’s deal. I completely agree that it’s usually more than one factor. Someone might have a genetic predisposition and a whole lot of stress and they’re just on a terrible diet because they’re stressed and just all in combination there is inflammation or ulcers or acids and we need to do temporary medications or diet to get the symptoms to die down while we’re all working together to figure out what the problem is and then solve the problem. 

How does diet factor into GI diseases like Crohn’s or gastroparesis versus a functional disorder like IBS or SIBO? Kondaplli: We try and manage sugars, because if they get too high these patients, especially those with gastroparesis, can become hypoglycemic. Weber: There are definitely things that they can do to help them manage it. It’s what a lot of us are dealing with but I am very much an optimist and in a lot of cases there can be more investigation and people can figure out what the cause of that is. I mean there are a lot of things that affect your stomach and even things like thyroid hormone, estrogen, SIBO, medications, anti depressants. People who have gastroparesis can really look at all possible reasons as to why they have it and keep going from there. Getting a good blender is key: make some great shakes and smoothies because people do well if their last meal is liquid. But there is definitely hope—hopefully people don’t feel like they are stuck with the disease for life. Bielowicz: What we put in our body, no matter what disease you have, is important all around, even more so for people that have these diseases, because it makes us more in balance but also prevents things. Preventative medicine is what we need to look at today, we’re looking at the aftermath of things and not looking at what’s getting us there. Kondapalli: One of the reasons we still have problems with functional disorders is because we haven’t figured them out yet. We’re not really very good at it yet and most of our good treatments are only 30-percent or 40-percent effective. In terms of IBS patients, if you get all the gut microbiomes figured out, we can figure out what kind of food is good for each genetic type or background. We’re not as good at finding what the cause is yet; that’s why we have so many different mechanisms. We found a simple test for Celiac and within six months you’re back to normal. We don’t have tests like that yet for functional disorders. There are literally trillions of bacteria and we are checking for two antibodies. Because we’re doing so many things that means we don’t have an answer yet, which is why everyone is working together. But 20 years from now we might be treating IBS like Celiac, we just don’t have the knowledge yet. Bielowicz: With Ayurveda, we look to see if there’s dampness in your body, if there’s fire in your body, using the elemental forces that are internally with us and externally outside of us. One of the basic tenants is that like increases like and opposites balance—are you going to feed more fire to a fire if you want to bring that down? No. So that’s kind of how they approach diseases differently than Western medicine. I wish that both ends would come together—I think it’s happening and I’m seeing it more. Henson: Actually a lot of Ayurveda matches what the doctor would tell you. If you’re inflamed with reflux you’re not going to go eat a bunch of hot spicy foods. Bielowicz: In that case we’ll advise towards eating cooling foods such as cilantro and coconut. Henson: Someone whose Ayurvedic body type leans towards slow digestion and being overweight is led to a plant-based, high-fiber diet, which tends to help you lose weight and helps things move through for a healthy GI tract. It all works together. Bielowicz: Kapha, which is water and earth, people usually have heavier bodies, have trouble losing weight, they gain weight easily and their digestion is sluggish. Pitta people have a really strong digestion while Vata people have a weak one, they have trouble eating. For the Kapha person, dairy is heavy. We don’t want to feed more Kapha to a Kapha. You look at these qualities of foods, of the persons symptoms.

What are the key ways to keep your gut working properly? Henson: In the diet world we would make sure you have a nice and high-varied fiber diet and I put a lot of people on various probiotics. Weber: Definitely a lot of prebiotic-rich food along with the probiotics, a high-fiber diet for people who don’t have gastroparesis or some other complication there. This is very unpopular but try and avoid alcohol, it’s a gut irritant, sorry. Stay away from antibiotics, avoid medications that can damage your gut by being proactive and by making lifestyle changes. Mitchel: We need an owners manual for the human body. Foods are like medicines—we’re hearing from the entire group here that you need the balance. If you’re too stressed out your hormones go out of whack and then they’re more stressed out, they begin to suffer from distension, bloating, they wake up in the morning and eat their bar while driving to work—stress compounds stress, they eat poorly and now you have a person who feels terrible. We have to start with the basics. We have to figure out what to do by achieving some sort of balance that’s going to take money, input and energy to make happen. Kondapalli: I think we all pretty much know what’s not good for us, we just can’t stop doing it. Observational medicines like Ayurveda and Chinese medicines have seen for thousands of years how people react, in each situation and that’s how they have this knowledge base that came from centuries. We have a side effect for allopathic medicine where we need evidence for everything, the problem is that we don’t have the tools to prove that everything is effective. Once the tools to prove the evidence matches what is instinctively known in Ayurveda, I think there might be somewhere in between where both will make sense in the future. We don’t have the technology and Chinese medicine and Ayurveda don’t have prospective and randomized trials. That’s the problem we’re having.

About Our Participants

Dr. Ravi Kondapalli, MD is a board-certified gastroenterologist specializing in Advanced Endoscopic Interventional medicine, Biliary Tract Disease and Pancreas Disease. He received his medical degree from Kakatiya Medical College NTR and has been in practice for more than 20 years. He completed his internship and residency in Internal Medicine at the Albert Einstein College of Medicine at Jacobi Medical Center and fellowships at the University of Connecticut and the Indiana University School of Medicine.

Paulette Weber, RD, LD/N, CLT is a registered dietitian, licensed dietitian/nutritionist and certified lifestyle eating and performance therapist. Coursework for a master of science degree in Clinical Nutrition was completed at Texas Woman’s University in Houston. Weber is a certified LEAP Therapist, which included over 30 hours of continuing education specific to food sensitivities. She completed the Institute for Functional Medicine’s programs in Applying Functional Medicine in Clinical Practice and Applying Functional Nutrition for Chronic Disease Prevention and Management as well as all three levels of Next Level Functional Nutrition training.

Dr. Lee S. Mitchel, MD is board certified in gastroenterology and internal medicine, graduating with a medical degree from University of Tennessee Center for Health Sciences. He completed his residency at University of Miami-Jackson Memorial Hospital and his fellowship at the University of California, Irvine and Veterans Administration Hospital. His specialties include: Esophagogastroduodenoscopy, Colonoscopy, polypectomy, injection, cautery and laser control of bleeding, endoclip for marking of lesions and control of bleeding, esophageal sclerotherapy and variceal band legation.

Rebecca Henson MPT, MN, RD is a licensed dietitian and physical therapist. Henson is the lead dietitian for a local Medical Nutrition Therapy Program, a Sarasota Cardiac Rehabilitation Program and a dietitian for Doctors Hospital of Sarasota. She has been published in many media outlets including Healthy Living in Sarasota, Karna Quarterly, Longboat Key Club Reflections, Play Golf, Pharmacological Research and Bellisima.

Jennifer Bielowicz CAP, LMT is a certified Ayurvedic practioner, FL State licensed massage therapist, yoga instructor and licensed esthetician. She is also a member of the Associated Bodywork and Massage Professionals, Thai Healing Alliance and the National Ayurvedic Medical Association. She completed a 200-hour yoga teacher training at the Lotus Pond, studied at the Florida Academy of Ayurveda and has received certification in Level II Reiki.