Manage episode 282163424 series 1333691
Dr. Marvin Singh speaks about Gut Health and Autoimmune Diseases with Dr. Ben Weitz.
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5:38 Dr. Singh has both an integrative and a conventional Gastroenterological practice and in his conventional practice he still offers lifestyle modifications and natural treatments if patients prefer that approach.
7:28 The gut and the immune system are intimately connected and 70% of our immune system is located in our gut, which is how gut health plays an important role in autoimmunity. The gut immune connection centers on the microbiome, which is this ecosystem of micro-organisms that live inside of our digestive tract. The microbiome runs our metabolism, makes vitamins for us, releases chemical metabolites and hormones and neurotransmitters, which is how these microbes regulate our immune system.
9:05 Leaky gut or increased intestinal permeability means that the tight junctions in our one layer thick lining of our digestive tract is damaged in some way that allows bacteria or food particles or toxins to get into our bloodstream, where the immune cells may launch an attack on them. Once you have this immune reaction to what gets into our system through the leaky gut, either it will resolve or it won’t resolve and cause a chronic problem and there may be chronic inflammation.
14:34 Dysbiosis is a medical term for an imbalance in our microbiome. Unfortunately, there is still a lot that we don’t know about what the ideal microbiome looks like, but there has been a tremendous amount of research on this in the last few years. And we are getting a lot closer to understanding what creates such imbalances in our guts and how to fix it.
16:32 There is a section on the GI Map stool test that lists bacteria that if overgrown are potential autoimmune triggers. Dr. Singh believes that we don’t need to respond to one microbe or another. Let’s say there is elevated Klebsiella, which can be an autoimmune trigger for ankylosing spondylitis, but you don’t necessarily want to try to treat the Klebsiella. There may be 10 excellent microbes who are beating up the Klebsiella every day and the Klebsiella may not be doing a lot. Another classic example is Claustridium Difficile (aka, C. Diff.), which shows up on many stool and microbiome tests but many of these don’t have an infection and they don’t need Flagyl or Vancomycin. In this case, the C. Diff is a commensal and when we see bad bacteria, we don’t have to go around killing them all the time if they are not causing a problem. We need eventually to focus not just on the microbes but at the metabolites that they produce or release. So if you have Klebsiella in there producing a lot of bad metabolites, this can drive inflammation and inflammatory processes and they can call other bad microbes to the table so they do their bad stuff as well.
19:26 If a patient has C. diff and they have diarrhea and a fever, then you know you have an acute infection that needs to be treated with antibiotics and this can be a very serious, even life threatening infection. On the other hand, if there is no fever and chronic diarrhea or even constipation, this may be IBS or SIBO and they may just happen to have C. diff as a commensal. Dr. Singh recommends testing for C. diff toxin via PCR and if that is present, then you should treat. And if antibiotics don’t work, then the treatment is a fecal transplant, which a ginormous probiotic enema. Sometimes you can have a patient with a C. diff infection and severe diarrhea, fever, and classic symptoms and you teat them with Vancomycin or Flagyl and their symptoms go away and they are fine. Then a year later they do a GI-Map to look at their gut health and C. diff is still sitting there. What does that mean? What did we do when we treated the C. diff? Are we just shutting down the genetic mechanisms that make the toxin? Are we just impacting the functions of the organism? The other thing to consider is that you can have C. diff, get treated and be fine and 6 months you could end up with ulcerative colitis that was triggered by the C. diff. and this happens not just from C. diff but from any infection of bacterial, viral, or fungal origin.
23.54 From an Integrative perspective, in addition to reducing the level of the pathogenic bacteria that shouldn’t be there, or at least not at that level, we also want to restore gut health and the microbiome with proper diet, exercise, and supplements like probiotics, serum-derived immunoglobulin, colostrum, L-glutamine, etc.
26:55 While supplements like colostrum and serum derived immunoglobulins can support the immune system, they don’t really rev it up or put it into overdrive, which you might no want to do with a patient with an autoimmune disease. In fact, there are published case reports where bovine immunoglobulins have been helpful with C. diff and in inflammatory bowel disease, which is autoimmune in nature. On the other hand, some of the immune stimulating herbs like ashwaganda should be used with caution because they could in certain situations and in certain patients could overstimulate the immune system, so they should be used at the right time.
33:04 Gluten from wheat and glyphosate, which is the main ingredient in the herbicide RoundUp, which is often sprayed on GMO wheat, can cause leaky gut and play a role in the development of autoimmune diseases. This is especially the case if you eat wheat frequently or every day, then you may get chronic leaky gut, which loosens the tight junctions, which allows toxins and chemicals and pathogens to get into your bloodstream and can trigger autoimmune diseases. Antibiotics can save your life in certain situations, such as if you get bacterial pneumonia, but if you take a Z-pak every time you get a runny nose, you are messing up your gut and creating leakiness of your gut barrier by doing that. And glyphosate is designed to kill weeds and when we ingest it, it can kill the bacteria that make up your microbiome. If we eat wheat we directly ingesting glyphosate and we may be exposed to it inhalationally and traces of it are found in common foods like sugar, corn, and soy as well. And now we have seen cases of folks, like a groundskeeper at a school who got cancer from spraying RoundUp. Dr. Singh said that he will either put patients on an elimination diet and take them off wheat, eggs, soy, dairy, shell fish, tree nuts, and corn, etc. or he may order food sensitivity testing from Cyrex Labs, who he feels have the highest quality testing. If they don’t want to do the testing, then he will take patients off these foods for 4-6 weeks to let things calm down and then reintroduce them in 2 week intervals. The problem is that there can be some negative effects of eating some of these foods, like damage to the microbiome, that may not be felt right away. Dr. Singh always recommends eating non-GMO, organic whenever possible.
40:54 TMAO is a marker developed by Cleveland Heart Lab that is a marker for increased risk of heart attack and stroke, but it is very controversial and it has a lot to do with diet and microbiome. But fish contain a lot of TMAO and we know that fish reduces the risk for heart disease, so this TMAO concept is controversial. TMAO is a metabolite that can be produced by certain microbes in the microbiome, which make TMA (Trimethylamine), which can then be converted into TMAO in the liver. TMAO also comes from foods that contain choline or L-carnitine like eggs, dairy, and red meat, which has been used by those advocating a vegan or vegetarian diet to demonstrate another reason why eating animal foods promote heart disease. But Dr. Singh regards this as a marker for the health of the microbiome more than a marker for an unhealthy diet.
Dr. Marvin Singh is an Integrative Gastroenterologist in San Diego, California, and a Diplomate of the American Board of Integrative Medicine. He is also board certified in Internal Medicine and Gastroenterology/Hepatology. Dr. Singh is currently the Director of Integrative Gastroenterology at the Susan Samueli Integrative Health Institute at UC Irvine. He is also an Assistant Clinical Professor at UCSD in the Department of Family Medicine and Public Health. Dr. Singh is one of the editors of the Textbook of Integrative Gastroenterology, 2nd edition and he has written several book chapters and articles. His website is DrMarvinSingh.com. Dr. Singh’s Precisione Clinic website is Precisioneclinic.com.
Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness podcast for a weekly updates. And to learn more, check out my website, DrWeitz.com. Thanks for joining me, and let’s jump into the podcast. Hello, Rational Wellness podcasters.
Today, our topic is gut health and autoimmune diseases with integrative gastroenterologist Dr. Marvin Singh. Autoimmune diseases are becomingly increasingly common causes of sickness and death in the U.S. Autoimmune diseases have been on the rise for at least the last four decades. Our immune system is designed to protect us from bacteria and viruses and parasites, and to repair our tissues from damage. Autoimmune diseases are diseases where the immune system attacks our own cells and organs instead of fighting these outside pathogens. Our immune system, therefore, is out of balance. And there are over a hundred different autoimmune diseases, and at least 40 others diseases are suspected as having an autoimmune basis. Autoimmune diseases are one of the leading causes of death in the United States, and to just name a few of the more common autoimmune diseases, we have Alzheimer’s disease, Parkinson’s, rheumatoid arthritis, psoriasis, alopecia, which is hair loss, Crohn’s disease, Hashimoto’s, hyperthyroid, M.S., type-1 diabetes.
One of the first researchers to explain one of the mechanisms by which the gut is related to the autoimmune disease was Harvard researcher Dr. Alessio Fasano, who, in his 2009 Scientific American article, laid out how leaky gut is an important contributor to autoimmune disease in combination with certain generic tendencies, along with gluten sensitivity. Dr. Aristo Vojdani, Dr. David Brady are two of the more prominent functional medicine practitioners who’ve explained how, I should say, functional medicine researchers and doctors who’ve explained how immune reactions to various infections, including gut infections, food sensitivities, and toxins can lead to an autoimmune disease through the mechanism of cross-reactivity. And 75% of our immune system is centered around our digestive tract, so it certainly makes sense that our gut would play an essential role in regulating that immune system.
Dr. Marvin Singh is an integrative gastroenterologist in San Diego, California, and a diplomat of the American Board of the Integrative Medicine. He’s also board-certified in internal medicine and gastroenterology-slash-hepatology. Dr. Singh is currently the director of integrative gastroenterology at the Susan Samueli Integrative Health Institute at UC Irvine, he’s also currently a voluntary assistant clinical professor at UCSD in the department of family medicine and public health. And Dr. Singh is one of the editors of the Textbook of the Integrative Gastroenterology. Dr. Singh, thank you so much for joining me today.
Dr. Singh: Thanks for having me, appreciate it.
Dr. Weitz: Good, good, good. So I’ve been looking forward to this discussion, there are precious few integrative gastroenterologists in the entire country, actually. In fact, Dr. Rahbar in L.A. is the only one I know in the L.A. area, and so you are a rare breed, Marvin.
Dr. Singh: I am, thank you.
Dr. Weitz: Not everybody is aware … actually, why don’t we touch on that for a second? It’s actually quite challenging to be a integrative gastroenterologist, because to embrace all the conventional gastroenterology strategies and thinking and also combine it with an integrative functional medicine approach is quite challenging. How did you come to meld those two?
Dr. Singh: Well, it is definitely challenging. As you were reading my bio, you can kind of see all the different things that I’m doing. I guess it just ended up that I ended up doing a lot of different things, I have three jobs, basically. I still like doing endoscopy and colonoscopy and taking care of sick people in the hospital and things like that, so I have a conventional GI practice where I do all that stuff. I have my integrative GI practice, specifically it’s a university one at the UC Irvine, where I’m the director of integrative GI over there. And then within this whole field, I really became passionate about precision medicine, and so I created another practice called Precisione Clinic, which is where I have a lot of fun doing these very deep, integrative and functional medicine evaluations and developing personalized protocols for people. So I guess I work all the time, that’s how I figured it out.
Dr. Weitz: You know, I wonder how, when you’re doing your conventional gastroenterology and you’re doing these scopes, and maybe you’re seeing in the patients who have limited income on insurance, how do you … it must be difficult sometimes to just give them, when it comes to treatment, the cookbook, conventional medical strategies when you have all this integrative stuff in your head, but you know that to really go into would require a lot of time delving into a deep history and everything else that you don’t really have time for in a conventional office visit that’s covered by health insurance.
Dr. Singh: Mm-hmm (affirmative), yeah. So that’s the thing, I can’t necessarily shut my head off whether the practice is different or not. So sometimes, oftentimes I’ll feel the person out, I’ll talk about, let’s just pick heartburn as a general topic, because it’s pretty common. And we’ll talk about heartburn, we’ll talk about lifestyle things, which is most people would do, lifestyle modifications, and then I’ll say, “Well, you know, I can give you some treatments that are more natural that are not prescription medications, they’re more like herbs or supplements, would you prefer that or would you just prefer to take a medication?” I don’t force it on anybody if they’re not really into it or tuned into it, but I offer it. I would say nine times out of 10, they’ll just say, oh, I want the natural treatment, because most people don’t want to take medication.
Dr. Weitz: Right.
Dr. Singh: And then that opens up the discussion, because I always will offer integrative approach to a common GI problem. Even in my general GI practice, I am handing out a lot of herbs and stuff instead of medications.
Dr. Weitz: Cool. So let’s get into the topic here: not everybody’s aware why the gut plays an important role in the immune system. Can you explain some of this important connection?
Dr. Singh: Yeah, well, it comes down to the microbiome. So the microbiome is really this ecosystem of microbes, there are micro-organisms that live inside of our digestive tract, or that’s what we call the gut. And these are predominantly bacteria, but we also want to remember and acknowledge that there are other members of the community, like viruses and fungi. So there are more than just bacteria there-
Dr. Weitz: Protozoans and sometimes worms and primitive archaea.
Dr. Singh: Hopefully not too many worms, I think. So 70% or so of our immune system is located in the gut, and it’s not just the digestive tract itself, the elementary digestive tract, it’s the microbiome and its role that it plays in the gut. So oftentimes, when we say gut health, we’re really referring to the microbiome and its interactions with everything else in the digestive tract, which is the gut. This digestive tract runs our metabolism, makes vitamins for us, they release chemicals called metabolites and hormones and neurotransmitters and all kinds of stuff that communicates with all the other cells in our body, so this is why the gut or the digestive tract is so important. It’s because of the functions that these microbes play in regulating our immune system.
Dr. Weitz: Now, what is leaky gut and why is it important?
Dr. Singh: So leaky gut, otherwise known as intestinal permeability, is basically exactly what it sounds like. To explain to people, our gut or our digestive tract is not, like, 10 cell layers thick. It’s not like a big fortress that you have to penetrate in order to create an injury. It’s only one cell layer thick. So if you imagine just a bunch of rectangles kind of standing up next to each other, boom-boom-boom across the straight line, and then in between these rectangles there’s a little drawbridge or a little connection. These connections are called tight junctions, and they kind of regulate what can pass through that gut barrier and into the bloodstream. Leaky gut means when there’s an injury or a problem with this tight junction, which are just protein complexes. So it’s nothing too crazy, they’re just complexes of protein. And when there’s an injury to this tight junction, then stuff that shouldn’t be coming through the digestive tract into bloodstream can get into the bloodstream. These could be particles of bacteria, they could be food particles, they could be toxins. So then when that happens, these things get into the bloodstream, and now the immune system, the immune cells in the blood are like, what is all this stuff going on? So they launch an immune response. And when they launch an immune response, you know inflammatory chemicals are released, macrophages, neutrophils, all these immune cells are kind of being called into play because they think there’s an enemy in your system and they want to clean it up. And they go through this whole process of clearing out the problem or reacting to the problem, and depending on what the actual problem is, it’ll either resolve or it won’t resolve. If it’s food, for example, like a carrot or something, your immune system now may be cued in to reacting to carrots because it saw it in that manner. The problem with leaky gut is that chronically, we do things that we may not know are creating this leakiness of the gut, and then chronically the immune system is revved up against it. And then we have chronic inflammation as a result of that.
Dr. Weitz: Now, leaky gut is a concept, or increased intestinal permeability is a concept that’s been around in the functional medicine world for quite a while, and I know for a significant period of time it wasn’t really accepted as a real thing by the conventional medical world. Where are we in terms of that?
Dr. Singh: You know what’s funny, though, if you look back in the literature, the scientists who are doing the research, they’ve been talking about intestinal permeability for a long time.
Dr. Weitz: Right.
Dr. Singh: So I don’t really [crosstalk 00:12:14]-
Dr. Weitz: But you know on the average it takes 17 years for a new concept that’s actually been proven in the literature to get into conventional practice.
Dr. Singh: Yeah, and even … actually, it was a few years ago, I was reading Dr. Bland’s book, and he was talking about the stethoscope. I think he said in his book that it took 50 years for the stethoscope to be accepted as an actual tool that a physician could use in examining a patient.
Dr. Weitz: Wow.
Dr. Singh: Now what happens? If a doctor walks in the room without his stethoscope around his neck, you think, what is this guy? Doesn’t even have a stethoscope. So I still think the conventional group of docs are still a little slow coming around to this intestinal permeability concept. There are some that are seemingly trying to be more tuned in and, I think, as different studies come out suggesting this kind of concept, that they’re more accepting. But I wouldn’t say it’s widespread still at this point; even some of my GI colleagues will still just kind of poo-poo it, no pun intended, and just blow it off.
Dr. Weitz: Right. Plus, there’s no drug on the market to cure your leaky gut.
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Dr. Weitz: So let’s talk about the gut microbiome and autoimmune disease. What is dysbiosis?
Dr. Singh: Great question. Dysbiosis is just really a medical term for imbalance, so you can just kind of think of it as an imbalance of the microbes in the gut. And some of the key concepts, now there’s a lot of stuff about the microbiome we don’t yet know. This is a very, very active part of science and research. Actually, interestingly enough, if you got to Pub Med and you type in just gut microbiome, I think I did this recently, I think it’s like, 25,000-some hits you get, just by typing in that. But they default to a 20-year time span. If you narrow that down to three years, 2018 to 2020, it’s 15 or 16,000. So you can see that a majority of the research has been done in the last few years, actually. So this is very growing area of science and research. And so we’re learning more and more about what happens when the gut gets imbalanced or when there’s this dysbiosis. We know some common things that can actually cause the imbalances, and I’m sure we’ll talk about some of that. And we know that there are a lot of diseases associated with it. Exactly what mechanisms or what actually happens or what the reasons are and how to get the therapeutics to intervene in that manner, this is an ever-growing field of medicine and science. I’m super-excited about this kind of stuff, so this is going to be cool when we figure out that, oh, you have too much of this bacteria and too little of this bacteria, so in order to fix this problem, we’re going to have to do this. And voila, your Parkinson’s tremor is better now, you know? That’s going to be cool. I’m sure we’re going to get there, but we’re not there yet.
Dr. Weitz: Have you run the GI-MAP stool test and you see that section, that list of potential autoimmune triggers? There has been a certain amount of literature showing that various bacteria are related to specific autoimmune disease, for example, Klebsiella. I recently had a patient I’m treating who has ankylosing spondylitis, we did a GI stool test, bam, he’s got all this Klebsiella. And that can be a potential trigger for ankylosing spondylitis. But then the question is, if we treat that Klebsiella, how does that impact the ankylosing spondylitis?
Dr. Singh: There you go, yeah. So I am a big believer, and this is my philosophy, in that we don’t necessarily need to respond to one microbe or the other, because there are trillions of microbes in there, and everybody is so different. So it’s not like a blueprint, you’re not going to be able to open up the textbook of the gut microbiome and see exactly what to do for a Klebsiella, and it’s going to be the same for everybody. Because for all you know, there could be 10 excellent microbes in there who are beating up the Klebsiella every day, and the Klebsiella’s actually not doing a whole lot. Or the Klebsiella, in proportion, relative proportions to the other microbes, is very small, it may be there.
I mean, another classic example is C. diff, Clostridioides difficile. Oh man, I see that in so many people’s microbiome tests these days, but they don’t have an infection, they don’t need Flagyl or Vancomycin or any kind of treatment for it. It’s a commensal. Another way of looking at it is that we have criminals, right? We have jails, we have prisons, and those criminals are in jail. Just because there are present doesn’t mean we have to go around trying to figure out a way to kill them. I mean, they’re fine. They’re being rehabilitated. Just because the bad guys are there doesn’t mean that it’s actually something bad is happening.
So what we’re going to see happening, as the years go by, is perhaps shifting our view from just looking at the microbiome itself and trying to focus on the metabolites, because the metabolites are the things that the microbes make or produce or release. And these are the things that really make the things happen, so if you have Klebsiella in there producing a lot of bad metabolites and that’s driving inflammation and inflammatory processes, and it’s calling other bad microbes to the table so they can do their bad stuff as well, then we have a problem. So yes, the Klebsiella may be where the problem came from, but the real problem is what the Klebsiella is doing, what it’s making, and how that’s impacting you.
Dr. Weitz: Well, then, how do you address that? Let’s say you see somebody with C. diff infection, and the levels of C. diff are elevated over whatever is supposedly the normal, which is a very small amount, right?
Dr. Singh: Mm-hmm (affirmative). We can use C. diff as the example, since we’re talking about it. So you do-
Dr. Weitz: Let’s say you have one case where it seems to directly correlate with their symptoms, and this can be a very serious, even life-threatening condition where they have severe diarrhea. I had a patient in the office a couple of days ago who I’m working with, and she’s got severe constipation and it doesn’t really seem to relate to her symptoms.
Dr. Singh: Mm-hmm (affirmative). So we want to know whether somebody clinically has signs of infection, and then we want to usually confirm, if we have a suspicion, that oh, there was a GI-MAP or some other test that C. diff is showing up on, and this person has diarrhea. I mean, if they have diarrhea and a fever, then I think you pretty much have your answer there. But if they just have chronic diarrhea, you don’t know, is this really C. diff, or is this just IBS? Because they could have that, or is this SIBO and they just happen to have C. diff as a commensal? I would always confirm by doing a test of toxin PCR, see whether or not there is detection of C. diff toxin in the stool. And if you do see that, then I would go ahead and treat, because it is a contagious infection that can really make people sick, especially immune-compromised people. People could even lose their colon if the infection gets out of control. But interestingly, if you look at, you’re starting from the conventional standpoint, looking at this kind of infection, it’s like, okay, I give the antibiotic. Okay, give the antibiotic. And then if the antibiotics don’t work, then what’s the solution? Fecal transplant, which is not an antibiotic, it’s basically a ginormous probiotic enema.
Dr. Weitz: Right.
Dr. Singh: So what you’re doing is reconstituting the microbiome, and if you use my example before, what we may be doing is just basically hiring a bunch more police officers and throwing them into the mix so we can regulate it, and this fecal transplant stuff works really well. I mean, within a day.
Dr. Weitz: So what you’re saying is that the good bacteria are keeping the bad bacteria in check.
Dr. Singh: Exactly, and we see that people … so let’s just make up a scenario, person comes in, severe diarrhea, fever, classic symptoms. You do a C. diff test, C. diff is positive. They get Vancomycin or Flagyl, symptoms go away and they’re fine. And then a year later, they do a GI-MAP because they want to look at their gut health, and C. diff is sitting there. Then what? What does that mean? That means that you didn’t kill the C. diff in that it’s, like, executed and entirely gone from your system, you just shut it down. So I don’t think we really talk about this in the literature much, and I would love for us, some of these scientists to do studies about this particular topic, because it definitely has implications for the general public health, but what are we doing when we treat C. diff? Are we just shutting down the genetic mechanisms that make the toxin, is that what we’re doing? Are we just impacting the functions of the organism? Perhaps we’re doing that by dramatically decreasing the population of that organism in your gut. That’s why we say, oh, well, you have C. diff as a commensal, you should be cautious about using excessive or unnecessary antibiotics, because then what happens? Well, maybe we’re killing the good guys that are controlling the C. diff and some of the other bad guys, and when those populations of the good ones go down, then C. diff has the opportunity to grow. And when it has the opportunity to grow, they like making toxin. That’s why we call them a bad guy. Then you get sick again. So really looking at, what are we actually talking about? What is actually happening? That’s really the important part. We’re not really fully around there in having every discussion over every medication and every situation around that, but I think, in the future, that’s where we need to go, because that’s the real deal there. That’s what we’re talking about.
Dr. Weitz: Right. And from an integrative or functional medicine perspective, if we treat that patient for C. diff, in addition to trying to reduce the levels of C. diff bacteria, if we, at the same time … let’s say, assuming they’re not getting a fecal microbial transplant, with a functional approach, we’re not just giving the antibiotic and that’s it, we’re also trying to restore the gut with probiotics-
Dr. Singh: Exactly.
Dr. Weitz: -and nutrients that can help to restore gut health and a proper diet and exercise and lifestyle factors that are going to improve the overall balance [crosstalk 00:24:35]-
Dr. Singh: That’s the difference between us and conventional doctors, because it’s not so simple as, oh, take these antibiotics for two weeks, you’ll be fine, see you later, follow up with my never type of thing. Okay, we’re going to treat this thing, now we have to rebuild the gut. We’re going to talk about probiotics, we may talk about a serum-derived bovine immunoglobulin, colostrum, other things are good for gut health.
Dr. Weitz: L-glutamine.
Dr. Singh: L-glutamine. So we know that this happened, we want to try to not only fix the causative agent, but we also want to repair the underlying things that that causative agent could do, because then, if you look further and we focus on IBD, which I know is one of the things we want to talk about anyways today, how does IBD happen sometimes? I could get C. diff and be treated and be fine. You could get C. diff and get treated and be fine, and then six months later you start have rectal bleeding, and then it doesn’t go away. And now you have pain and diarrhea, and then they think, well, maybe you got, C. diff came back again, you got C. diff colitis. And they check C. diff and it’s negative. And then time passes, time passes, and then you eventually get a colonoscopy and they say, oh, Ben, you have ulcerative colitis. So how does that happen? This is a classic scenario, actually. It’s not just a make-believe scenario, there’s a classic scenario where somebody gets an infection, it doesn’t have to be C. diff, it could be salmonella, it could be E. coli, it could be anything like that.
And what happens is that your immune system may clear it out, or your immune system may not really, fully shut down after this infection is gone. And that may have to do with various different things, whether it’s genetic factors get triggered or environmental factors start coming into play when there’s leakiness of the gut, meaning that something wasn’t causing you a problem, but now you had a flood in your basement and other things are causing a problem where they being controlled before. And then your immune system just says, oh my God, this is some bad stuff going on, we got to keep knocking it out, even though that C. diff or salmonella is gone. And now your colon gets inflamed. This is the basis of kind of this discussion of autoimmunity, where we started this conversation in the first place.
Dr. Weitz: Yeah. I’m going to get a little off-topic, I tend to do that, but you just mentioned colostrum and serum-derived immunoglobulins. The thought came up recently in a discussion: when you have a patient with autoimmune disease, there’s generally this thought that the immune system is overactive, so is it really a good idea to recommend things like colostrum or immunoglobulins that help to strengthen the immune system?
Dr. Singh: Well, I think you got to look at each thing on a case-by-case basis. These things I’m less worried about compared to various different kind of herbs. The concern is that if your body is revved up and you give something to further rev up the immune system and that you want to make the immune system work to your advantage, that you might actual, paradoxically, do the wrong thing and actually exacerbate the underlying process. I think you got to kind of look at what’s realistic for that person. I was just actually looking up for somebody else, a patient a couple days ago, ashwagandha. Ashwagandha is a great adaptogenic herb, and it’s good for stress reduction, it actually has immune modulating effects. But sometimes we talk about, oh, well, if somebody has Hashimoto’s, you really shouldn’t give them ashwagandha because it might make their thyroid worse, because it’s autoimmune. And I was looking up, I mean, one of the things that’s cited is a case report of somebody who got thyrotoxicosis.
This is not like we got thousands of cases that say that ashwagandha equals thyroid disfunction. In that person, on that case report, or maybe in people that are similar to that, there could be a problem. But as we go back to our discussion on metabolites and things like that, that’s where the mystery really lies. We don’t really know who is going to be a problem with ashwagandha and who is not if they have Hashimoto’s. You maybe want to look at what are some of the other factors: they have a lot of autoimmune issues, are there thyroid antibodies just a little bit or is it a lot? Because it may be kind of a case-by-case, and then be aware, if you see that the numbers are going in the wrong direction, then pull back.
I’m cautious in these types of situations, I think things like colostrum and serum-derived bovine immunoglobulin, I think they operate a little bit differently in that they’re really kind of working at the microbiome level in the gut. They’re primarily not systemic agents, like if you take an herb, you may get some of the stuff systemically. They’re really, majority of the stuff stays in the gut, and it’s towards that end that they work. And there’s literature on C. diff in bovine immunoglobulin, in H. pylori, in all kinds of different kinds of bacterial infections and situations. There are even case report studies in inflammatory bowel disease where there are patients who were not responsive to much else, and then they got high doses of serum-derived bovine immunoglobulin and voila, the inflammation receded.
Dr. Weitz: Yeah, and I really also think it’s probably a mis-thinking to characterize somebody with autoimmune disease as an immune system that’s on overdrive. I don’t think that’s really what’s happening. It’s not like, instead of going 60 miles an hour, now they’re going 90. What it really means is they went down the wrong road, their system’s out of balance, really.
Dr. Singh: We want to try to find that balance back, it’s that dysbiosis concept. We want to trying to bring balance back to the system, because … I started this thought, but I don’t think I finished it. Some of the things that we universally agree on, knowing that everybody’s microbiome is different and different things are happening in different people, what we universally agree on is that diversity in the microbiome is a sign of strength or resiliency. And that’s one of the main goals that we’re looking for. And the concept is simple if you kind of think of it … I’m a king of analogies, so I often give analogies to make people understand.
It’s like if you’re starting a business, you’re a CEO and you got to hire 100 people, and you need 100 different employees. When you’re looking at them, you could say, okay, well, I want everybody to be from NYU with an MBA and this background, and they should all have been born in Virginia and have parents who are together for 50 years and be of this age group. They may all be smart people, but they may all have the same skillset and background, philosophies and beliefs. So if you’re thinking that you want to be entrepreneurial and do something good and new and different, it would make sense to get smart people, get people with a good background, get people that have different beliefs, ideas, philosophies, who can come to the table with new ideas and concepts so that you can actually innovate and create and do good things.
So you want a diverse workforce, that’s a very kep concept to being successful. You don’t want a bunch of robots in your business, you want a diverse workforce, because that’s a sign of resiliency within your workforce itself. And it’s the same thing. That microbiome is your workforce. So we want a diverse, resilient microbiome, and in order to do there, there are a lot of things we have to do: we want to try to … we can get into the conversation over lifestyle measures, but diet, a varied diet, a lot of plant foods and different kinds of things on an ongoing basis are part of that whole process as well so that we can grow that diversity and resiliency.
Dr. Weitz: What role can gluten or glyphosate play in the development of autoimmune diseases?
Dr. Singh: Yeah, Dr. Tom O’Bryan is the king of gluten; he often talks about the study by Harvard, which I often refer to as well, scientists at Harvard where they suggested that everybody, it was a big study, it was thousands of patients, I think, everybody develops some leakiness or some permeability of the gut when they’re exposed to gluten.
Dr. Weitz: Right.
Dr. Singh: Now, if you don’t usually eat a lot of gluten and you go to Paris and you want to have a baguette because you’re in Paris and that’s the cool thing to do, that’s fine, right? As long as you don’t have an allergy to gluten or whatever. But if you’re eating bread all the time, every day, then you may develop this leakiness of the gut on a chronic basis. Remember, the whole key concept is chronicity. And when that happens, it itself may not be the actual problem per se, but it may open the door; those tight junctions are now open so that problems can occur. So it’s just like, if you get pneumonia, I’m not going to say, no, Ben, antibiotics are bad, you’re just going to have to suck it up, and you might die. Nobody’s going to say that. They’re going to say, take the antibiotics. We’re in 2020, we’re a civilized group of people, we have science and technology behind us. Medications are not all bad, they can save your life. But if you say, every time I get a runny nose I take a Z-Pak, I’m going to say, no, Ben, that is not the right thing to do. You are messing up your gut. You’re creating leakiness of your gut barrier by doing that.
So it’s the same kind of concept. These things, our body is not so weak that you’re exposed to a non-organic apple one day and you get a little glyphosate, oh my God, I’m going to die. That’s not what’s going to happen. Your body is stronger than that. But if you’re doing this on an ongoing basis, you’re literally just giving small punches to your gut every day all day, and then you have a problem. And it’s not just glyphosate, it’s not just gluten. Stress can do this too. Not sleeping well can do this too, not exercising and being sedentary can also do this too. This is actually how I got really excited about lifestyle modifications and how that can influence the microbiome, because believe or not, there is literature on all of these topics as well, that you get imbalances in the microbiome when proper lifestyle choices are not followed.
Dr. Weitz: By the way, for those who don’t know, glyphosate is the main active ingredient in Round-Up, which is a herbicide that’s commonly sprayed on wheat and corn and other crops, especially to ones that are genetically modified to be resistant to Round-Up.
Dr. Singh: Yeah, and we’re directly ingesting it, we may be exposed to it inhalationally. Traces are found in common things like sugar, corn, soy, wheat. These stuff disrupts our detoxification capacity, it may directly disrupt the microbiome and its ability to have various different kinds of functions. It’s almost like the reason why I think I went to antibiotics is like, it’s not an antibiotic, but it’s kind of like the same concept of an antibiotic, because it’s supposed to kill stuff, basically. So that’s what it’s doing. Maybe the purpose is to kill the bugs so it doesn’t ruin the plants, but when you eat that stuff, it’s killing what the bugs that are inside your gut do, and you don’t want that. That’s not the point. And there are some associates that they have felt to be from glyphosate related to diabetes, obesity, depression, Alzheimer’s, cancer. Even in the news probably a year or two ago now, there was a big lawsuit against the company that makes this stuff, because what was he … a groundskeeper at a school and he was spraying Round-Up everywhere, and he got cancer as a result.
Dr. Weitz: Yeah. There have been a series of others after that.
Dr. Singh: Yeah.
Dr. Weitz: So when you have a patient who sees you for some gut health issues and also has some autoimmune disease, setting aside IBD right now, do you place them on a gluten-free diet, do you put them on a gluten-free, dairy-free, do you take them off of corn, soy, peanuts? Do you have a certain protocol you use?
Dr. Singh: I often do, especially if we’re going to do an empiric kind of food elimination and we’re thinking about how we can modify the diet. People are often resistant to eliminating too many things, so the conversation that I have is, we can do some tests to see if we can kind of direct it a little bit, but-
Dr. Weitz: What kind of food sensitivity testing do you like to do?
Dr. Singh: Well, I guess the caveat to this is I always tell people that these are not like you’re getting the commandments from Heaven, coming down and telling you that if this is a positive test, that 100% certainty, that carrots are bad for you, you’re going to go get sick. So they can be very helpful. In some cases, we hit the home run. And in some cases, they’re not so helpful. So everything has a risk and benefit, so the risk in this is that you gave some blood or you did a finger prick and you paid some money for it. It’s not like we’re talking about experimental chemo or anything, it’s just food we’re talking about here. As far as that, the risk is low. I use a lot of Cyrex for the food stuff.
Dr. Weitz: Okay.
Dr. Singh: Huh?
Dr. Weitz: Yeah, I think they’re among the most accurate.
Dr. Singh: Yeah. Dr. Vojdani is a friend of mine, both of them, father and son, and I talk to them often, and I think the methodology and the way that they make the test is pretty sound and they’re very well-intentioned, so I use a lot of Cyrex for the food stuff. But even in the conventional literature, if you look at food elimination, what are they talking about? The top things, it’s like the big six things is gluten, soy, dairy, shellfish, tree nuts … I missed one.
Dr. Weitz: Eggs.
Dr. Singh: Eggs. And then I throw in the number seven as corn. And so when people are like, I don’t want to do any tests, I just want to kind of … what can I do? Then you tell them all those things, they’re like, whoa-whoa-whoa, that’s a lot of stuff. So what am I supposed to eat, then? So I say, well, let’s just do this for a set period of time. If it was four weeks, six weeks, something like that, we want to do it for a reasonable amount of time so that if something is actually causing an immune reaction, that we have a chance for that reaction to calm down. And then, one by one, we can try to reintroduce them in two-week intervals, so we can see if you notice anything symptomatically in your body and health as far as something happening as a result of that reintroduction. The problem is that often, at the microbiome level, you may not really feel like, it may be something that you see and you feel it in a different. So you have to kind of be astute to that, maybe follow other things like your microbiome evaluation and things like that over time, and I always try to hit home the idea of non-GMO organic, because if you’re going to reintroduce something, at least try to make it a clean product so that we’re not being confused by contaminants as driving the problem.
Dr. Weitz: I wanted to talk a little bit about the TMAO concept. I saw it in your slide presentation that you sent me. TMAO, as maybe not a lot of people know, is a marker that was developed by Cleveland Labs that is a marker for increased risk of heart attack, stroke and … it’s very controversial. One of the reasons why it’s controversial is that TMAO is found in high amounts in fish, and there’s just tons of research showing that eating fish lowers your risk of heart disease. It’s also stimulated by eating choline or L-carnitine, and L-carnitine is found in meat and a whole lot of other foods that are often considered part of the healthy diet as well. And in choline, of course, is found in a whole series of different things that we eat, and we’ve always found choline actually be super-beneficial for brain health. So I’ve always had a tough time believing that we should really stop eating all these things because some test shows an elevated TMAO level.
Dr. Singh: Yeah. I presented this, these slides that you’re referring to, at a conference to specifically point out the controversial viewpoint on TMAO.
Dr. Weitz: Right.
Dr. Singh: Because this is what we like to do in science: we find something, we find association, and then we just go gangbusters in a kind of tunnel vision about it. TMAO bad, equals heart disease. TMAO bad, equals heart disease. Well, I mean, fish are made up of a lot of TMAO. When you do a test and you’re checking for TMAO, you’re actually supposed to stop your fish oil and don’t eat fish for 24 hours before because it can falsely create an elevation. And I actually had a specific patient whose TMAO came back at, like, 120. This guy was like, what in the world is going on? I’m a healthy guy, I’m exercising all the time, I’m eating majority plant foods, the only meat I eat is fish.
And I said, “Well, did you eat fish right before you did this test?” He said, “Uh, well, I think I might have.” So we repeated it, and it was normal. So fish need TMAO, it’s what helps make them float. I don’t think fish are croaking over with heart attacks in the ocean every five minutes. So we have to really look at what’s the big picture, what is TMAO, what are we actually talking about? TMAO is a metabolite that’s produced by microbes.
Actually, TMA is the metabolite that’s produced by microbes, so TMA is called trimethylamine, and trimethylamine is produced by, there’s a whole host of microbes, I could tell you the names of some of them, but it probably wouldn’t make sense to anybody just listening to these names, you know? But there’s maybe eight or so of these microbes that make TMA. And when TMA is produced, it goes to the liver. The liver converts TMA to TMAO, trimethylamine-N-oxide, and the Cleveland Clinic discovered this, and that’s why it’s available through Cleveland Labs, because they’re associated with each other.
It was felt that high levels of TMAO were associated directly with risk of heart disease. And then when they looked back at, well, where does TMAO come from, what are the kinds of foods? Like you mentioned, eggs, dairy, red meat and things like that. So therefore, the inference was that red meat equals TMAO, which equals heart attack. And maybe there is some truth to some of that, but I don’t know that that’s really the full picture. I think there’s really, again, it’s in individualized type of situation, because I guarantee you, you get a couple carnivores on your show, they’re going to have a problem with that statement.
Dr. Weitz: Absolutely.
Dr. Singh: Not that I promote the carnivore diet at all-
Dr. Weitz: When the TMAO stuff came out, right away that became a new weapon for vegans to tell everybody why they shouldn’t eat meat.
Dr. Singh: I have seen people that don’t really eat a lot of meat that have elevated of TMAO, too. I don’t deny that their elevated TMAO is related to increased risk of cardiovascular events, MI, stroke, cardiovascular death. I mean, they have literature suggesting that. But going one step behind that one step behind that, is where is this risk coming from? TMAO directly, or other factors and they happen to have high levels of TMAO? I don’t know that we know all that stuff, you know? This is a bacterial metabolite-generated issue, then looking at the microbiome level is where probably better answers are going to come from.
Dr. Weitz: Right, so what you’re saying is somebody with a certain microbiome with certain microbes could eat some of these foods and they would not produce a lot of TMAO-
Dr. Singh: Maybe.
Dr. Weitz: Somebody else with a different microbiome might, or is more likely to, and so therefore the thing to focus on is somebody with a dysbiotic microbiome and fix that, and you don’t have to worry about the TMAO.
Dr. Singh: Yeah. So one of the slides I had in this presentation is actually, there’s literature on this stuff, but people don’t talk about it as much because I guess it’s not as beneficial for whatever argument you’re making. It’s not like you eat red meat, you have a high TMAO level, now you’re going to have a heart attack. It doesn’t work like that. TMAO levels are determined by other factors also: your host genetics. TMA and TMAO are distributed throughout the body; it can accumulate, so that may depend on what you’re eating regularly on an ongoing basis and what other factors are going in your body.
Half of the TMAO is excreted unchanged in the urine, through sweat, your breath and urine. So you may be excreting half of this, if you want to call it a toxin or bad substance, out of your body anyways, as it is. Then the other half may be turned into TMA, back to the original metabolite, by a bacterial TMAO reductase in the gut. So then it may become nothing again. That’s not going to be harmful. So what makes it harmful in somebody versus not? Well, maybe it has to do with TMAO reductase in the gut, how much of that is being produced? Maybe that has to do with dysbiosis, maybe that has to do with all the gluten you’re eating, not the red meat. I don’t know.
So these things need to really be teased out, so understanding this on a case-by-case basis, because TMAO is an osmolyte, it stabilizes protein structures against destabilizing forces, that sounds like a good thing to me, right? Maintains the volume of interstitial cells under osmotic and hydrostatic stresses. So these are some of the other things that I’ve talked about as well, and they sound like good effects. So really, this whole discussion on metabolites, which TMAO is, is really going to become a very personalized thing.
It’s the same concept, you know, not that I’m promoting meat here, because I actually promote a very plant-heavy, focused diet, but I’m not afraid of meat, I’m not an anti-meat person, because I think diet is such a personalized thing. When they do these studies about red meat, they’ll often say red meat and processed meat, and they lump it together in the same phrase. Well, red meat and processed meat are different things, you know? I mean, lunch meat is not the same thing as an organic, grass-fed four-ounce filet mignon.
Dr. Weitz: And the average person’s not getting a grass-fed organic filet mignon, they’re getting a less-quality meat that’s sort of produced at a factory farm.
Dr. Singh: Exactly. So I just encourage people, when you’re looking at these things, these stories and these literature articles that come out or people talk about these things, dial it back and see what are they actually talking about and what are they citing? I think a lot of people notice, they’re eating lunch meat all day long and it’s not … lunch meat comes in different varieties, too, you know? If they’re eating the lowest-level salami all day long, okay, I could see how you’re going to have a problem. That’s not healthy for you.
Dr. Weitz: Right.
Dr. Singh: But if you’re eating clean foods that are free of toxins and that were taken care of throughout the life of that animal, the nutrient profile and what happens when you ingest it is going to be different than when you’re eating something that’s not. It’s a good idea to have a varied diet, remember, because the microbes want resiliency and diversity in their system. So it’s good to have a lot of plants, because plants do that in your diet as well, they help diversify the microbiome. So it’s important not to just be uni-focused in how you’re eating as well. We want to have a varied diet, and I’m not allergic to the concept of people having meat, but I do suggest that you kind of look at what you’re doing, make a personal choice for who you are, what works for you, and if your numbers are good and your microbiome is happy, do what you like, because that’s you. That’s the whole concept of Precisione Clinic that I started, because you can’t just say everybody should eat this and that’s what’s going to make you healthy. That’s not how it works. So in Precisione Clinic, we look at everybody on a very personalized level and we say, this is what I think you should eat, based on da-da-da-da, all these things that we kind of determined.
Dr. Weitz: Yeah, absolutely. I’m with you on that. I know we started talking about autoimmune diseases and we thought that we would go into it later, but I’m pretty much out of time. So …
Dr. Singh: We could talk for hours, probably.
Dr. Weitz: We definitely could. Unfortunately, today’s patient day in my office, so let’s wrap this discussion and then hopefully we can have one in the future about some of the other topics.
Dr. Singh: Sounds good.
Dr. Weitz: So how can our listeners and viewers get a hold of you, Marvin?
Dr. Singh: I’m pretty active on social media, it’s @DrMarvinSingh, my website is PrecisioneClinic.com, Precisione with an E, so P-R-E-C-I-S-O-N-E Clinic.com. Email address is there, the contact information is there, so I’m pretty readily accessible.
Dr. Weitz: Any final thought you want to leave with everybody?
Dr. Singh: I guess the final thoughts is just to summarize the key concept of when you’re talking about gut health and microbiome, it’s not necessarily one microbe and that’s your solution or your problem. We want to look at what’s happening in the entire ecosystem. Look at it from a global perspective, because when we’re talking about even environmental pollution and things like that in politics, it’s not just necessarily one thing that we have to go after that’s going to really solve global warming or something.
There’s a lot of different things. We want to attack all of these things, just like if I say, well, your diet needs to be healthy, and you say, okay, I eat a perfect diet, but I sleep two hours a day, I don’t exercise at all, I’m stressed out and I yell at everybody all the time. You’re not going to be healthy, man. It doesn’t matter what you’re eating. So you got to look at, just as we look at our lifestyle factors in that perspective, we have to look at the microbiome in that perspective, too. It matters what’s happening in the ecosystem, what’s the ecosystem generating? What’s it doing and how healthy is it, how balanced is it? Because therein is where the inflammation and chronic problems are going to come out of.
Dr. Weitz: Great, awesome. Thank you, Marvin, and thank you for spending this time with us.
Dr. Singh: No problem, it was my pleasure.