There are many autoimmune diseases that are considered risk factors for SIBO. And yet, many of the downstream effects of SIBO (like leaky gut) also put you at risk for developing an autoimmune disease. This week, I’m joined by Dr. Susan Blum for a primer on the immune system, how it functions within our gut’s ecosystem, and why things can go awry and lead to the development of an autoimmune condition.
Dr. Blum is the author of the iconic book The Immune System Recovery Plan and more recently, Healing Arthritis, which gets more into the specifics on how gut health and autoimmune conditions are linked.
A quick taste of what we’ll cover:
- How the immune system works within the ecosystem of your gut
- What causes your immune system to malfunction and trigger an autoimmune disease
- The relationship between autoimmune diseases and SIBO – which comes first?
- What root causes need to be alleviated to cure an autoimmune condition
- Why SIBO can cause local inflammation in the gut and also systemic inflammation throughout your body
- How to heal a leaky gut and whether a low lectin diet is a good approach
- Why SIBO usually also means dysbiosis in the large intestine and how to structure your treatment plan to tackle both
- Epstein Barr Virus’ role in autoimmune disease and whether or not that celery juice is actually the answer
- And so much more…
Resources, Mentions and Notes:
- Dr. Blum’s website
- Dr. Blum’s books: The Immune System Recovery Plan and Healing Arthritis
- The Wellness Project book
- Dr. Blum’s self-assessment worksheets
- Gerrard Mullin’s study on herbs versus rifaximin
- Biociden for SIBO maintenance – 5 drops 3 times a day
- Metagenics Detox Program for Heavy Metals
- Blum’s online classes
- Join the SIBO Made Simple Facebook Community Page
- Subscribe to receive a free download of the episode transcript
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FUNCTIONAL MEDICINE APPROACH TO AUTOIMMUNE DISEASE
PHOEBE: Okay, Dr. Blum, thank you so much for taking the time to come on the podcast. I was very excited to meet you at a conference recently and maybe attacked you slightly after your talk. I don’t know, hopefully not too aggressive.
BLUM: No, you’re fine. I remember meeting you. I remember our meeting, and I appreciate as I do now your enthusiasm for bringing information to people. It’s a wonderful thing.
PHOEBE: Thank you for facilitating that today and taking the time to chat. I’d love to start for those out there who aren’t familiar with your work, who haven’t read you entire book like I have, how did you become interested in focusing in on the immune system and telling people how it dictates our general health?
BLUM: Just, in a way, similar to you and I think similar to so many integrative medicine warriors out there doing this work, I came to it because of my own health issue. I was diagnosed with Hashimoto’s about I want to say 18 years ago or so, and it was around the same time that I was just exploring functional medicine. I did the first training in functional medicine, AFMCP, in 2001 so about 17 years ago. I was recently diagnosed with Hashimoto’s, and like all great functional medicine, or integrative people, or clinicians, I put on my detective hat. I want to know why. Maybe I was that way as a kid. I don’t know. I’d have to ask my parents, but just walking around like why? What’s going on here? Why did this happen? Why did this happen?
I want answers, and functional medicine I discovered at that time and it’s true to this day offers us a roadmap for answering the why question. There’s really no other place to go that offers a structure for asking those questions. It gave me those tools to start my own exploration about why and how I got Hashimoto’s, worked on treating those root causes, and what I discovered about my own – and I cured the antibody. I cured the autoimmune issue for my thyroid, so I cured the Hashimoto’s. I started working that way with all my patients, and it was just an unbelievable story that I felt was so important to get out there because most people back then and even certainly still now are basically not given any information. They’re not given any hope or thought that they could actually cure this or that there is something to be done about the autoimmune part of Hashimoto’s, as well as the autoimmune diseases. They’re just given medicine to treat the symptoms. That’s how I got here. It’s my own Hashimoto’s and my own discovery of how to treat it that I wanted to get the word out, give hope to people that there is something they could do to treat themselves.
PHOEBE: Now, of course, I want to know all about your own root causes. You just hid them.
BLUM: It’ funny because I think I probably had all of them. When you go through the checklist, the funny saying we have with – not the funny saying but we have a favorite saying in functional medicine that, if you’re sitting on a tack, the goal is to find the tack and remove it, and that’s how you get better. Not just take aspirin or pain killers for the tack. When it comes to autoimmunity or any problem with the immune system, there are multiple tacks, and you actually have to methodically find each one and remove it in order to really heal and repair the immune system. The most common tacks for the immune system or for immune dysfunction are food, stress, and hormones, the whole HPA axis and stress system, gut health, gut microbiome, imbalances in the gut, which we’ll dig into today for sure, toxins, and all kinds of toxins. Not just the few we’re familiar with but toxin load as well as individual toxins like mercury. There’s toxins, and then final one are infections. That’s everything from Epstein-Barr to mold to Lyme. Infections often give off toxins as part of the infections.
All of that you can think of as environmental. The food you’re eating you’re bringing in from the outside world, so that’s a lifestyle, environmental exposure. It’s an exposure to the food. You’re being exposed to – well, if you’re having a stress response, there’s stressors in your world, so there’s the environment that you’re bathing yourself in and your stress system. Gut health is often a manifestation. I mean, your gut microbiome and the health of your microbiome is secondary to other factors. Everything you can go deeper and say, well, how did you get SIBO, or how did you get dysbiosis? The gut health is driven by stress and the food you’re eating and other factors and the environmental toxins and infections. These are all things that interact with our own ecosystem, our genetics, and who we are, and then all these environmental things happen to us. How we manage them and how they come in and trigger disease is where – that’s where the rubber hits the road.
For me, my triggers I think were – I was a gut person my whole life. Sometimes you can actually look at it, and sometimes most people have multiple triggers. Sometimes there’s one that stands out more than others when you do a history and when you do your own history. Actually, in the book, I go through the four parts of the book. It’s food, stress, gut, and detox, and in each one, there’s really good self-assessments. You can see if you think you have a high toxin load, or if you’re a “gut person,” or where you think your primary issue might be, but for me, I had really high mercury levels. My gut microbiome was in really bad shape, and I had to do a lot of work with both of those. I had to clean up my food and eat anti-inflammatory diet in multiple ways. We could talk about that. Of course, certainly make sure my stress system wasn’t undermining all my efforts.
You work your way through all of that. You have to balance it all in order to make sure your immune system is healthy. That was a very long answer to your question. I’m sorry.
PHOEBE: No, it was a good answer. Actually, for whatever reason, I haven’t heard the specific tack analogy. I have been told one that’s like over the years you keep putting tinder into a box, and eventually, one thing is going to light the whole thing on fire.
BLUM: Last straw kind of thing.
BLUM: Yeah, I think that’s probably another one that works very well. That’s a good way to think about it as well. That speaks to how you get here. How did this happen?
PHOEBE: What is actually happening in the body? What is the switch that’s flipped for people who aren’t intimately acquainted with the whole concept of autoimmunity?
BLUM: Yeah, and so what happens in the body is that your immune system is your friend. Every day you have – its job is to protect you from outside invaders, and so I like to think of the immune system almost like – think of it like your military. There’s the Army and the Navy and the Air Force, and you have different divisions. There are soldiers in each of them, and they all have different functions. A healthy immune system is an immune system – and these soldiers, they’re hanging out in army bases, which you can think of as your lymph nodes. Most people know they have those lymph nodes in there neck when they have sore throat, but we have lymphoid tissue throughout the body. In fact, along the intestinal lining, there’s an enormous amount of lymphoid tissue we call it, which are army bases for all these soldiers. It’s called the GALT, which is the gut-associated lymphoid tissue, and estimates are that about 70% of all of your lymphoid tissue is in your intestinal lining. It’s right below the surface.
Why did Mother Nature put all the lymphoid tissue there? It’s because you bring the outside world into your mouth every day. Your immune system, your army is waiting and lying in wait to react and protect you from foreign invaders. Going back to the analogy of this lymphoid tissue, in this tissue, think of them like army bases. Whenever there’s an invader that comes into the body in any way, the sentinel soldiers come back to the base and say, oh, alert, alert. There’s an invader. You start making a lot of soldiers, and then the soldiers multiply and multiply and get sent out throughout the body. That’s things like lymphocytes and different – lymphocytes are the ones that generally respond to invaders that are toxins or viruses, those cells that are called neutrophils that more respond to bacterial infections, and so you have different army soldiers that do different things.
What happens is in a normal and a healthy immune system, an invader comes. The immune system turns on. They go do the good fight. The invader is put out. They take care of business, and then everything quiets down again. A healthy immune system knows when to turn on when it’s supposed to and turn off when it’s done, when the jobs done. The other thing that a healthy immune system is supposed to know is what’s an invader, and what’s your own self? It knows that, hey, that’s normal thyroid. That’s my thyroid. I’m not going to attack that. That’s normal.
Just pick anything. That’s my joint. That’s my cartilage. I’m not going to attack that. That’s normal. That’s me. The healthy immune system knows the difference between its own tissue and what’s a foreign invader. Self and not self we call it. We call that the ability to be really – to not attack your own tissue. It’s called tolerance. The word, you could think about it like I can tolerate myself.
PHOEBE: Some of us can. I don’t know.
BLUM: Some of us can, and so it’s called tolerance. A healthy immune system has the right amount of tolerance for itself, and it knows the difference between self and not self. What can happen in autoimmunity is that, for some reason and we’ll talk about that in a second, the immune system loses its ability to know the difference between self and not self. It starts reacting against your own tissues, and so the soldiers do multiple things. They can fire bullets, which are like antibodies. We can think of the immune system. People might be aware of their autoimmune condition, and they measure antibody levels. Antibodies are just guided missiles towards the tissue that’s being attacked. There’s a certain kind of B cell lymphocytes that fire the missiles. They make antibodies, so you can have that kind of attack, or you can have – I call them the hand-to-hand combat, T cells that can attack your tissues.
You can have different kinds of immune reactions against your own tissue, but the bottom line is that the immune system’s confused. It’s not that it’s overactive. It’s that it just got confused. It just is misguided, and so the goal then of treating autoimmunity is to figure out why the immune system got misguided to begin with and help bring that balance into play. When we go back to our triggers, the things that – the tacksor the wood in the fire, those things that piled up that got the immune system this way, the common kind of things – the way we think about it are let’s say there’s a chronic infection. Something like Epstein-Barr virus is good example. A chronic infection, you can have an invader of your own tissues where a virus is living inside your cells, and your immune system is trying to get at it. In order to get at it, it actually damages your own cells, and so you can end up with a lot of collateral damage in your own cells because the infection is hiding in your own tissues. You can get that with Lyme disease. You can get that with Epstein-Barr. You can get it with other viruses as well, and so that’s one common mechanism that a virus can be one of those pieces of wood in the fire.
The other thing when we think about toxins is that the immune system is so – it just has this ongoing activity in a long-term chronic, annoying way. That the immune system is just so active for so long trying to cope with a chronic exposure that you have for so long that it just loses its way. It becomes just a renegade activity because it’s so chronically stimulated for such a long period of time. Toxins can also damage the tissues themselves. Then the immune system sees these tissues and says, boy, your thyroid – that thyroid looks really not like my thyroid anymore because there are toxins in there, or there’s an infection in there. Toxins can cause abnormal looking tissue, which can cause the immune system to react. Do you see where we’re going with all this?
PHOEBE: Oh, yes.
BLUM: Yeah, and so the last one and then I want to give you a chance to talk because I’m doing all the talking, but just to complete this thought is that the last really important piece – because this is where the gut comes in. I know we want to talk about the gut today. The really important part about the gut is that, when you have – since 70% of your immune system lives in the gut, one of the big ways that autoimmunity can develop is something called – the loss of tolerance can be from central problems, meaning the immune system itself has become not working right. There’s something called T regulator cells, which are – they’re the balancing cells. One of the things that can happen is the immune system can turn on, and it can’t turn itself off. There’s just a way that the body helps turn itself off, which are these T regulators they’re called. They really develop and stay healthy with a healthy microbiome. When the microbiome, which is all the bugs in the gut, when there’s bad bacteria, or yeast, or parasites, or SIBO, or other imbalance in the gut and the leaky gut, you can get loss of tolerance and impaired function of the T regulators, so the whole autoimmunity develops in a central kind of way. Not from the damage to the tissues but from just the functioning of the immune system as a core issue.
PHOEBE: We’re going to get to SIBO eventually because I do think it is all interrelated on some level. You did mention when you were talking about your story about curing your Hashimoto’s, and I’m just curious. Going from point A of how do you get an autoimmune disease all the way to the end game which is the big question is can you actually cure completely an autoimmune disease, and does it have to do with where the dysfunction is coming from, the toxins, the gut, or virus as you mentioned?
BLUM: Yes, and so what I will say from my 17 years of experience treating autoimmunity as well as my own – what I would say is that the best chance of a cure – and yes, it’s possible to cure it. The best chance of a cure is at the beginning, so closer towards when you were first diagnosed. It doesn’t mean you can’t cure it later on. It’s just a lot easier and quicker the earlier you are in the process, so that’s the first thing I will say. What I suggest to people listening who might have an autoimmune condition, the way I did it myself is you methodically go through all of these places where the immune – where you might have your trigger. You have to think about it as you want to make sure your immune system is functioning optionally. How do you do that? For the central stuff, you have to make sure you have good gut health, and that means removing or trying to remove anything bad that might be in there.
I use the analogy for the gut as an inner garden. If we think of – it’s simple analogy. It’s a little simplistic, but it works. Think about your whole gut microbe population as an inner garden, and you want to have these really nice flowers and many different colors. Diversity is really important. Like any beautiful garden, there’s always weeds in the garden, and weeds are normal. In a healthy gut ecosystem, the weeds are really kept really at bay, and they don’t take over and do anything bad in the garden.
Under conditions such as taking antacids, eating food that’s damaging to the gut, too much sugar, for example, and processed food will feed the weeds instead of the healthy microbes. Under certain conditions, the weeds can overgrow, too many antibiotics, certain medication, taking – I think I said [00:16:15]antacids. Different things can allow the weeds to overgrow, and that’s a condition called dysbiosis, and a kind of dysbiosis is SIBO, small intestinal bacterial overgrowth. When you have that, the immune system really struggles. It’s really damaging to the immune system. You can end up with a lot of inflammation in the body as the beginning thing, but eventually, the actual functioning of the immune system can be damaged. You always begin by making sure the gut is healthy.
For myself, I started – first of all, I sent out tests so did my stool test. Found I had dysbiosis. I had a little yeast in there, candida. I started treating myself with a lot of herbs to treat that. The second thing I did was I tested myself for metals. I had a lot of mercury fillings as a kid, and I was eating a lot of fish. My mercury was very high, and so I embarked on a whole journey to – it’s not enough just to do a “detox” for 21 days. It’s really embarking on a journey of exploring your environment, where you’re living and your whole toxin load and cleaning up your cosmetics and your personal care product. I mean, the parabens and the plastics that you’re using in your – that might be affecting your water in your drink and testing your water. It’s all of that and eating organic as much as I could, and really trying to figure out where all my toxins might be coming in.
If you have a lot of toxin exposure from all those things, I really like to help people understand that it’s a concept of a toxin load. It’s like what’s the total exposure? Your liver and your kidneys have to manage all of it. If you had a lot of incoming, you have just a lot of exposure, the mercury won’t – you can’t clear the mercury out because the liver’s busy trying to clear everything else out. Then it can accumulate in the tissues and end up causing damage. I had a lot of mercury, and I had a lot of toxins. I actually stayed on a whole detox program probably for the good part of a year, and all that meant was I stayed on an elimination diet, which was no gluten, dairy, soy, corn, and eggs. In those days, it was 2001. Metagenics was really the main company that was around doing this stuff, and I stayed on, basically, their detox protocol for the supplements for about a year. I got all my mercury out. At the same time, I was working on my gut health, and I was eating an anti-inflammatory diet.
About 18 months after my first diagnosis, my antibodies were gone, and so for me, that was great. I just realized that this is a process, and it’s been 17 years. My gut, I have on and off. I have to keep re-treating my gut sometimes because I have stress like other people do too. This is an important part of the conversation when it comes to even talking about SIBO is that there’s no such thing as quick fix. It’s long-term habits that you have to put into place, so my gut is pretty good. I mean, I haven’t had it treated in a while, but I do periodically need to treat it again, yeah.
PHEOBE: What happens when you go through periods of stress and you feel it in your gut? Does it show up in your labs as antibodies, or is the Hashimoto’s just long gone in the rearview mirror?
BLUM: The Hashimoto’s is long gone in the rearview mirror. My gut stuff, when it shows up, I just become a little symptomatic. I’ll get a little bit of reflux, and I’ll think, oh, that’s not good. There’s something going on. I’ll just do a stool test, and I’ll see that. I tend towards a little bit of SIBO myself, a little methane SIBO, and I’ll just see that it will have acted up, meaning my numbers. I’ll see a high abundance pattern, and sometimes I’ll do a SIBO breath test as well. I’ll see it’s just positive again, and so then I’ll just do a round of treatment. I just do it based upon a little bit of symptoms.
My symptoms tend to be – I generally tend to have no symptoms whatsoever, so I’m very sensitive to knowing when I do. A little bit of symptoms and my radar goes up. I go right ahead, and I take care of it. I never get to the point where my immune system’s in jeopardy again. I’m so clean. At his point, look, I’m so many year into it. I’m very sensitive to knowing when things are out of balance in my body.
PHOEBE: I was going to say that’s the goal.
BLUM: Right, and the cleaner you are, the more sensitive you’ll be to being exposed to toxins and smells.
PHOEBE: Yes, it’s a double-edged sword, for sure, but that awareness is certainly something to cultivate and strive for.
BLUM: Right, I mean, we do the best we can. I was pumping gas today. I was out of gas, and I went to a gas station that I’m not – the one I always try to go to is the one where you set it. Then you get back in your car, and you don’t have to hold it. The fumes, I mean, those are just things that – if you stand and pump your gas and you’re smelling the fumes, that’s something your liver has to deal with. Your body has to deal with that exposure you just had. Multiply that by 1,000 for what sometimes people are doing every day, and it’s a lot.
PHOEBE: Yeah, the city analogy is the Uber drivers with the horrible air fresheners in the car.
BLUM: Right, oh, I hate those air fresheners.
PHOEBE: It’s really a struggle not to have a confrontation.
BLUM: Right, this is what I’m talking about. We become a health advocate for ourselves. Those things that we know that – it’s just you flip the coin. Instead of thinking about it that I’m treating myself all the time, which I’m really not, but instead, what I’m doing is I’m living – what I call just living a detox lifestyle. I’m living a gut supportive lifestyle. I’m living an anti-inflammatory food plan lifestyle. I meditate every morning. I’m just living a lifestyle that I know that I’m getting my nutrients, and I’m getting my antioxidants. I’m a vegetarian, so I eat plants all day long.
I know that the way I’m living is supporting my immune health because I’m supporting my gut health. I’m keeping my toxins low. I am making sure my stress system is not getting out of whack. I had acupuncture this morning. It’s one of my favorite ways to just bring balance. That’s one of my – everyone needs their team of what their – who’s on your team, and what does it look like to support your health and keep you in balance? I think that the struggle to stay in balance and make sure that we’re always supporting those foundations in a positive way, that’s the long-term game plan.
PHOEBE: Exactly, well, to switch gears to focus a little bit more on the specific topic at hand, SIBO, so you mentioned before that, of course, one part of healing an autoimmune disease is to clear up some sort of whatever dysbiosis is affecting you, SIBO being among them. Then, of course, when we talk about SIBO and I’ve had a lot of conversations where we talk about how certain autoimmune diseases are part of the risk factor, so it’s just a confusing chicken or the egg situation in my mind. I’m curious about the relationships as you see them in your practice, whether one comes before the other more often, and then in terms of how the immune system is wrapped up in the correlation, I would love you to go into that a little bit.
BLUM: Okay, so how does dysbiosis or the bacteria trigger autoimmunity? It’s via this mechanism of the weeds in the garden or the overgrowth of bacteria, certain bacteria. The bacteria damaged the tight junctions, the gates. They actually damage the gates and open them. Parts of the bacterial cell walls slip through the gates and get into the body and trigger an immune reaction and trigger inflammation. This ongoing triggering of an exposure of the immune system to these pieces of bacteria from your gut are actually one of the – that’s one of the mechanisms that we know that drives something, for example, like rheumatoid arthritis. Arthritis with this very well worked out mechanism for this. It’s very cool. I know. We know a lot more than people realize about how this happens.
Going back to SIBO, so I see SIBO as just on that – when it comes to just the autoimmune part, I see the SIBO as a spectrum of that. In terms of chicken and an egg, were you asking about the chicken egg versus – does the SIBO come – or the dysbiosis, gut microbiome stuff come before the autoimmunity thing? Are we talking about the…
PHOEBE: Yeah, does SIBO lead to certain autoimmune diseases? We know just from correlation that certain autoimmune diseases are big risk factors for SIBO.
BLUM:Yes, what I would say is that I think it – I don’t know that we know the answer to that. What I would say is that the most evidence for the relationship of the gut and gut microbiome issues as a predisposing cause of autoimmunity would be when it comes to autoimmune inflammatory arthritis, like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis. That grouping of autoimmune diseases have a definite – we know that the gut – in all likelihood, the gut comes first. That being said, I don’t know that we have the definitive answer on that. We know that in mice we can make rheumatoid arthritis happen by altering the gut microbiome, so we know that in mice we see that that’s definitely true. We can say yes. Actually, in mice, there’s a lot of – there’s other health conditions as well, like MS, for example, where there’s MS mice that they have been – you can manipulate the gut microbiome, and then see that they develop autoimmunity.
Now, what I would say about SIBO particularly, there’s no really good research looking at SIBO as its own separate entity, separate from microbial dysbiosis. I haven’t seen research particularly on SIBO. Maybe there’s one article just associating SIBO also with autoimmunity just like other dysbiosis, but as soon as you have any kind of alterations in microbiome that cause a leaky gut of which SIBO does, then you have the risk of all the autoimmunity happening. I think from a – my opinion and perspective on it is that, yes, the gut issues likely comes first. There’s a lot of research that’s pointing at that, and certainly, in mice, we know that. We could do it. You can actually do it as opposed to manipulating that in humans is hard to get that – to really look at the order of things. You have to actually give – alter the gut microbiome, and then see what happens and follow it in order to really prove the timeline, the causation that way. In mice, it definitely looks like the gut comes first.
PHOEBE: Dysbiosis definitely we know leads to autoimmune disease. We’re not quite sure if the SIBO piece of it does, but we do know that SIBO causes leaky gut. That is the key issue.
BLUM: I think that there is all reason to believe in the studies that are looking now at SIBO, at least in the SIBO – that SIBO does in fact cause leaky gut. At first, we didn’t even know if that was the case. SIBO can be an overgrowth of your own bacteria, not even the worst – not really even weeds. There could be too many flowers for some people. The thought was is it a – is that a problem? It turns out that SIBO is most of the time overgrowth of weeds as well as the flowers and that SIBO is associated with leaky gut. I think that was – that’s the first step in the research to really confirm that. Now that we confirm that SIBO does in fact cause a leaky gut, I think we can look at it as an associated issue for autoimmunity.
PHOEBE: Why does it cause leaky gut? Is it just because the bacteria are not supposed to be in the small intestine in that quantity and, therefore, can feed on the intestinal lining?
BLUM: When you look at the gut lining and the whole – what’s there? You have villi, and you have these – the lining of the intestine has epithelial cells, which are the cells, and in between the cells are these junctions, which are gates in between the cells. On top of the cell, on top of all these cells is a mucous layer, and the mucous layer is filled with polysaccharides. It’s like this really thick – it’s supposed to be – depending on where you are, it’s this thick layer that separates – it’s actually a separation between the bacteria and the actual – and yourself, the intestinal lining. The bacteria are not supposed to touch your own cells. There’s this separation via this mucous.
In the small intestine, the mucous layer is really, really thin. In the large intestine, it’s very thick because that’s where most of the bacteria are supposed to be. Because the mucous layer is so thin in the small intestine, the idea is that there’s – if the bacteria are in such abundance that they overgrow, the bacteria actually become – have contact with the epithelial cells. The bacteria actually have contact with the immune system that’s always – it’s almost like probing. There’s always immune cells that are probing into the lumen, that are sticking out to check out what’s going on in the gut. The immune system actually gets a lot of exposure then to bacteria that it wouldn’t normally have, and so that’s one of the problems. The other thing is that, the bacteria, they release compounds that digest the tight junctions. Normally, the mucous layer in the large intestine is really thick and protects – it’s like a barrier to keep the bacteria on one side and your cells and your immune system on the other. If everything’s piled up in the small intestine, the body gets a really big exposure to bacteria that it shouldn’t have.
PHOEBE: It makes sense to me why an autoimmune disease may happen, yeah.
AUTOIMMUNE DISEASE AND SIBO
BLUM: Yeah, nature did not expect there to be so much – so many bacteria there. I mean, what happens in the small intestine? In the small intestine, you’re supposed to be digesting and absorbing all your nutrients. That’s why there’s so many villi, those fingerlike projections. We say the villi is like shag carpeting. You have all the shags running through the small intestine, and there’s not too much of a mucous layer because you wanted all the nutrients that you’re digesting and absorbing to be absorbed into the body. There’s a very thin veneer between your body and the lumen, and that’s to enhance your digestion.
The problem is, if you have so many bacteria there, it mucks up your digestion and absorption, and you run the risk of having all this exposure, like I said, of the bacteria to the immune system and the body. Nature didn’t expect that – didn’t mean for that to happen. That’s why there’s such a thick, thick, thick barrier. I think the barrier is about 10% of the size in the small intestine as comparted to the large intestine, the mucous, so it’s just not that thick.
PHOEBE: What happens when the immune cells meet the bacteria?
BLUM: When the immune cells meet the bacteria, they register them as foreign. This is again this idea of tolerance. The bacteria are not ourself. We have tolerance for our own tissues, but we don’t have tolerance really for the microbes that live in the gut. What that means is – which is why nature gave us this barrier. We want to keep these two fighting people separate from each other. We want to keep the immune cells and the bacteria that are foreign away from each other, but if they end up having exposure, the immune system has a reaction. The way the immune system reacts, these cells in your immune system, is they release what we call cytokines and inflammatory compounds. It’s like fireworks. The immune system shoots out free radicals and fireworks to try to damage and harm the bacteria.
What happens is two things. You end up with local inflammation. That’s where you can have a little local inflammation in your gut, abdominal pain, discomfort, so that’s the first thing that can happen is you can have local inflammation. The problem is that you – that’s how you can also have systemic inflammation. If the bacteria are exposed to the immune system, they’re also – it depends on whether it’s just still a local effect, or they can slip through into the bloodstream or pieces of them can. When the immune cells are sending out this fireworks and bullets and they’re trying to kill the bacteria, they break it into pieces sometimes, and pieces of the bacteria end up floating around in the bloodstream, which causes inflammation at distant sites. There are studies that have shown that bacterial cell wall proteins are in the joints of people with rheumatoid arthritis. The pieces of the bacteria end up all over the body because they float through the immune – they float through the blood, and so it’s not just a local effect. I think that’s one of the really interesting things to remember is that it becomes a system-wide problem, so there’s inflammatory reactions.
The other really important thing that happens and this is one of the things I was talking about, about how a person can develop autoimmunity, is if you think about this happening day in, day out, day in, day out for months, the immune system just becomes – can run the risk of becoming broken because it just is a chronic, ongoing irritation over a long period of time. It just starts not working properly, and so the cells themselves can’t regenerate. The cells always have to be regenerated, this army that we’re talking about. The army needs constant resupply. You need more troops coming, and you need to recycle yourself, and you need antioxidants to reload your weapons. There’s all sorts of ways to keep the immune system going in the face of this chronic, chronic exposure. Eventually, the immune system can become dysfunctional. That’s when I was talking about the T regulator cells stop working properly, and you can develop a loss of tolerance to your own tissues. The immune system gets damaged by this chronic exposure to the bacteria, and that’s how things can happen.
PHOEBE: In the case of SIBO, when the immune cells meet the bacteria and they start going nuts, firing off the fireworks and what have you, I would assume that most of the time they’re not successful at actually eradicating it. My question is, I guess, when it becomes more of a systemic level of inflammation, does that also affect the balance of good bacteria in the large intestine if it’s teaching your immune cells to see the bacteria period as a bad guy?
BLUM: It’s good you brought up the large intestine because that’s an important player as well. I think you just have parallel things happening at some point, potentially in the large intestine, which is where we see the classic dysbiosis, which is the weeds overgrowing, overtaking the garden. I think that problem happens directly because of the SIBO. Not indirectly via what’s happening systemically. Again, another analogy that I really like is to think of your whole digestive tract as a river. You’re starting in your mouth, and it’s supposed to flow one way, through your mouth, through your stomach, through the small intestine into your large intestine. This actually speaks to the causes of SIBO as well. What happens? Why is everything piling up?
PHOEBE: Beavers dam up the river.
BLUM: It also speaks to then what’s happening upstream affects what’s happening downstream, and so if you don’t have enough acid in your stomach, for example, like hypochlorhydria, low stomach acid, you can end up with SIBO. The acid that comes out of your stomach helps prune the garden downstream. You could end up with SIBO, but you can also end with dysbiosis in the large intestine at the same time. Somebody with SIBO I think is at a very high risk of also having dysbiosis in the large intestine. I actually think it’s likely that both are going on potentially at the same time. For some people, though, there are symptoms. I think SIBO is notorious for being extraordinarily symptomatic. I had a patient that couldn’t leave the house because her gas and bloating and need to run to the bathroom was so bad in the mornings, and her gas was so embarrassing. She was almost homebound. Some people can be really symptomatic, and some people could be not really at all, barely symptomatic, and just have a little bloating after they eat, or a little reflux, or just chronic constipation. It runs the whole gamut of symptoms.
People with dysbiosis, it’s common for people with autoimmunity to have no symptoms in the gut at all. When you do a stool test, you find all sorts of dysbiosis, which is more large intestine related. I think the most – the people who are really symptomatic, the people with IBS that have been diagnosed with IBS all these years, I think that they’re more likely to have a SIBO kind of a – I mean, I’m generalizing a little bit, but I’m just pointing out that SIBO is usually not quiet. Dysbiosis in the large intestine in my experience can be quiet, and people don’t know that they have it.
PHOEBE: Does that mean that it’s not as dire to fix, or we still must fix it?
PHOEBE: Asking for a friend, just kidding.
BLUM: They still must fix it. This is why it’s so interesting. That people with autoimmunity, generally speaking, you can assume you have a leaky gut and even if you have no digestive symptoms. That’s because you can definitely have overgrowth. There’s certain Gram-negative bacteria that tend to overgrow in the large intestine like klebsiella, pseudomonas, prevotella, citrobacter. These are these Gram – these kinds of bacteria. These are weeds that’ll often overgrow in the large intestine, and people don’t often have symptoms if they really – that bring their attention, or bring them to the doctor, or have them seek help. They might be like, yeah, I might be a little constipated or that kind of thing. They just have accepted their mild things not working right, but they don’t really go seeking help. Sometimes people with SIBO are just really uncomfortable and really concerned.
Dysbiosis of this kind in the large intestine is definitely, definitely a very important trigger for autoimmunity, and in fact, in all these years, until SIBO has become – the past three, I guess, years, three to four years, SIBO has become notorious as a big issue in the forefront of being diagnosed and treated even in conventional gastroenterology. For the first 10 years of my – 10, 12, 15 years of my life as a functional medicine practitioner, I’ve just been treating dysbiosis for autoimmunity, so I don’t even talk much about SIBO in the book because I wrote it in 2012. SIBO I think has become an entity that we can measure and follow and treat. As in the beginning of our conversation when you asked about the research, I think there will be more and more research about the systemic, body-wide effects of having SIBO. It’s more in its earlier stages of understanding, whereas the understanding about dysbiosis and leaky gut in general has been around for a long time. I think it is important to know that if you have SIBO, you are likely because the underlying factor that gave you your SIBO probably have also have given you some dysbiosis in your large intestine as well.
PHOEBE: In terms of healing, I know you have a lot of information about how to heal leaky gut, how to take on a more anti-inflammatory diet in your book. You mentioned them both earlier. I still want to hear what both those two things are. Then I also want to hear about how the SIBO treatment factors into all of that, and what order you do all these things in.
BLUM: Okay, let’s work backwards. This is a couple of really important points. They’re the things I talked about ten years ago, and then there’s the things I focus on now as a person who’s treating and retreating and retreating people, or just treating people long-term. Couple of points – let’s see. The first point is that I always like to – what do you start with? I believe you always start with the gut, food and the gut. You always want to treat gut microbiome before you move on to detox, and that’s why in my book, I have it in order. Step three is the gut, and then step four is detox. I think if you have no gut symptoms at all – for some autoimmune people, toxins –if you do your own self-assessment, and you see that you have a huge exposure, you had some, and I guide you through things to ask yourself. Even on my website, which I know you’re putting up, and there’s my book page on the immune system recovery plan.
There are free downloads where you can assess, do self-assessment to see how high is my toxin load. Sometimes I’ll go to detox before the gut. If you have digestive symptoms, you know you have SIBO or you have a lot of – if you have digestive symptoms that you know, abdominal pain, reflux, gas and bloating, diarrhea, constipation, then you want to fix that before you move onto detox. The reason is because if you have microbial overgrowth or weeds in your garden, those are giving off toxins that are going straight to your liver. Your liver is busy dealing with those toxins. All the veins from your intestinal system go and feed the liver before they go anywhere else in the body because the liver’s your first line of defense for checking out what you just ate. If you have a lot of toxins coming out of your gut because you have SIBO or because you have dysbiosis, then you want to get rid of those toxins before you start detoxing because you might feel sick.
I don’t know if you have friends or you know people who went and did these detoxes, and they felt really sick when they started doing them. I think one of the ways you prepare the body to be successful with detox is by treating the gut first. That’s just my experience over all these years. I believe in gut comes first. The second thing to answer your question is that I’m really passionate now about the long-term ecosystem of the gut and understanding how to heal yourself, how to really have deep healing that stands the test of time. We can all do these – there’s a lot of push in our world of ten-day this and two-week this. Do a 30-day cleanse and you’ll be all better. It’s really important to do therapeutic interventions and do these therapeutic programs for short periods of time. They’re intensive for the first 30 days, but the question is, then where do you go from there? How do you finish what you started?
The gut, gut health, and treating SIBO especially – SIBO’s famous for needing treatment and retreatment and retreatment because it doesn’t just get fixed with the first round of treatment, as you probably know. There are two reasons why, and two things that you need to do. You need to look at the underlying reasons why somebody’s getting SIBO in the first place. I want to hit on that before we finish our talk today, but I think it’s important for people to understand, expectation-wise, that this is a whole ecosystem. You don’t just have a magic bullet that fixes it. You have to work towards balance in your life, your food, and what you’re eating. The way I treat SIBO is with we’ll call quote unquote weed killers. I tend to use herbs, antimicrobial herbs, to really clean out and prune the garden. I love weed killers like berberine and uva ursi. I use artemisinin, black walnut, oregano, and thyme oil, different blends of herbs that treat dysbiosis.
Years ago, Jerry Mullen, who’s a great functional medicine gastroenterologist – he did all these studies comparing, looking at herbal protocols for treating SIBO. They found them as effective as and sometimes more effective than using Xifaxan or one of the other prescriptions that people use. I tend to use herbal protocols. In my experience, I usually start with two months of herbs, and it’s a long time. A two-month treatment program is the first round, and that really does the trick in most people. What will happen in four to six months, unless you’re really working on the underlying issues, it’ll come back or you’ll get symptomatic again. It might not come back in as roaring – the symptoms might not be as bad, and it won’t come back as bad, but you probably have to think you’re going to do the herbal – treat yourself with herbs every six months for a month to keep working in the direction of getting it really, finally, fully under control.
I like to think that for SIBO, it famously recurs. I think anyone – you probably know that already. Retreatment is really expected, and not to feel like you failed or anything. I think that’s just the normal course. Over time, you’ll need to retreat less often. I think that’s the first really important point. This really is an ecosystem that you’re trying to shift, and that’s not going to happen in just one treatment.
PHOEBE: We’ve talked a bit about the more general root causes on other episodes of the podcast, but are there specific ones for certain autoimmune diseases? We actually did do a whole episode that revolved around the thyroid and how the impaired motility for Hashi people can lead to SIBO. Is there any other correlation for some other autoimmune diseases that need to be dealt with?
BLUM: Yeah, I don’t know that it’s any different for – I think everybody’s going to be different. All Hashi people don’t have that as the main thing. There’s not one thing that’s the same for everybody, which is why you can’t even say that motility is the main reason a Hashi person has SIBO. Certainly, hypothyroid people are going to have lower motility, so it can predispose them to having SIBO because poor motility is a cause, one of the reasons somebody could develop SIBO. There’s a lot of reasons people could have poor motility. Stress is one of them. Stress causes a tremendous alteration in the whole functioning of your digestive system. You end up with low stomach acid. You end up with poor digestion. The food sits in your stomach. You end up reducing your digestive power in your enzymes, and you freeze. You do not – sympathetic nervous system, parasympathetic nervous system, which is relaxation system – that’s the one that increases motility.
When you meditate, for those of you who are listening who are meditators, you might find that after your morning mediation, you need to go to the bathroom because relaxation is going to help with motility. There’s a whole issue there. Autonomic nervous system dysfunction, nervous system issues, Lyme disease people – some people with infections that affect the autonomic nervous system can cause motility from just the nerves directly. The nerve endings aren’t working like they should. In my opinion, the most common cause is just a direct stress issue, which is one of the reasons – that’s one of the really important pieces to SIBO that I don’t think people spend enough time on. I think that rather than just making some linear connection between SIBO and any particular autoimmune disease, what I would say is that if you have an autoimmune disease, you absolutely need to make sure you don’t have SIBO. If you have SIBO, you’re at an increased risk for all autoimmune diseases.
PHOEBE: It’s a vicious cycle.
Dr. BLUM: It’s a vicious cycle. It’s a chicken, egg thing on one hand, which is really why we come back to the rule of tacks or the rule of the logs in the fire. There are many logs in the fire. There are many tacks. Each person, I really, really – and that’s the way I approach it in the book – everybody needs to go through every step if you have autoimmunity. You need to fix your food. You need to make sure you’re practicing, you’re addressing your stress system, and how stress is coming into your body and affecting your gut, affecting your nervous system, affecting your hormones. You need to make sure your gut is really helping your microbiome. You need to treat your SIBO. You need to treat your dysbiosis. You need to make sure your toxin load is low. It’s by cleaning up your world. It’s by definitely doing a detox program once or twice a year, probably until you make sure your toxin load is low.
These are just all things you have to do to make sure your immune system is free and clear, and to function its best. The other thing, when it comes to infections that I always like to say is that – certainly, if you have Lyme or something like that, you need to make sure you get treatment. Chronic viruses like Epstein-Barr – the reason why it’s chronic is because your immune system is not working right. Doing those four those things, with the food, the stress, the gut, the detox, and the toxins, will help your immune system work better and help you with your chronic Epstein-Barr virus. Those things, those four places are always where to start, and everybody has to do all four.
PHOEBE: I’m so tempted; I must ask. Are you a believer of the celery juice with Epstein-Barr that is now flooding Instagram, the green juice?
BLUM: I don’t know. I haven’t tried that. I don’t think – honestly, I don’t know that there’s any one thing that’s a really quick fix, but you know what? I work so hard with my patients that have chronic, active Epstein-Barr virus that I love to hear that there’s a magic bullet. Look, celery juice is actually really good for hypertension. I think that there’s all sorts of interesting phytonutrients out there. I’m always saying that could be until you prove me that it’s not. I think that in general, there’s usually no magic bullets out there. If you’re doing the celery juice, that’s good because it’s good for your immune system. It’s an antioxidant. It’s assisting microbiome. It’s doing good things, so go for it.
PHOEBE: Totally – not going to solve all your problems forever.
BLUM: It’s not going to solve. One thing is not going to solve all your – if you’re busy, stressed out, eating a modern American diet, and you have really high toxins, you have candida overgrowth and all that, celery juice is not going to solve your problem.
PHOEBE: Some people find it stressful to keep that much celery in their refrigerator and to juice it every morning, just saying.
BLUM: Yeah, exactly. It’s actually that saying of, hurry up and relax. I’m stressed out getting de-stressed. I’ll make one pitch then here for health coaches. There’s a whole movement now of health coaches. I think that people can get really stressed trying to do the best they can for themselves in terms of being healthy, making all these decisions, and figuring all this out. Do the best you can to put a team together to support you. Try and write. It’s really important not to get too overwhelmed and too stressed while you’re busy trying to help yourself with your health condition.
PHOEBE: Totally – well, before I let you go, I just would love some concrete advice to give people in terms of specific diet things that they can do to tackle the leaky gut and the dysbiosis. I’m just curious since a lot of the prevailing diet recommendations for quote, unquote good gut health are the opposite of the low-FODMAP diet that a lot of people are using to health SIBO. I think that’s a big point of confusion for people. That’s why I was asking before about what order do you do things.
BLUM: Oh, I see. Okay, here’s my read on FODMAP also, which we use all the time, the low-FOMAP diet. I know what it is, and I understand it. Low-FODMAP diet is great for helping you feel better. It’s going to help control your symptoms because you’re going to be reducing the activity of those organisms that are busy eating those foods. I don’t find low-FODMAP to be curative of anything. There are studies that are suggesting that when you’re doing the herbal program – I put people on this two-month herbal program – that you don’t actually need to follow low-FODMAP diet while you’re on the program. You want the bacteria to be active. I find that rather than putting somebody on a long-term low-FODMAP diet, the best approach is to even do long-term – to take some herbs even for months. There’s a product called Biocytin that I really like that you can get online. It’s a nice little liquid herbal blend. It’s five drops, three times a day, and some water.
It prunes the garden. I prefer to really work that way and not have people – because what’ll happen is, that will be working to actually treat the SIBO, as opposed to low-FODMAP diet is just controlling symptoms. Let’s just make – I just want to make that point. The second thing is that I want to differentiate. This is actually really good. I’m glad that you triggered me to want to remember to say this. I love therapeutic food plans. I think they’re really important, and we need them when we need them. If you need a low-FODMAP diet, I consider that a therapeutic food plan. I don’t consider it a plan that you’re going to eat for the rest of your life, just like a ketogenic diet or even a no-grain, autoimmune, paleo, no lectin diet. People that go on – these are therapeutic plans. They’re really good for when you are really struggling, when you’re still really symptomatic, and when you are at the beginning of your journey and you really need to be three, six months even, when I’m talking about autoimmune, paleo.
I try to do even shorter than that, like three months. Three months, you’re doing this intensive, therapeutic food plan, but the goal – that’s not a long-term to way to eat for your gut microbiome. Ultimately, no matter what therapeutic food plan you’re going to start with, the goal is always to move towards a healthy eating plan that’s more like a Mediterranean diet. The studies are very clear on what kind of food plan you need to eat for your gut microbiome, and what kind of food plan you need to eat to support detoxification processes, which is rich in antioxidants, phytonutrients, greens, and all of that stuff. You need to be feeding your liver’s detox system at the same time, you’re feeding your microbes. The goal, my goal is always to work our way towards being able to eat like that. Whatever food plan that people need to eat at the beginning is fine.
Low-FODMAP is fine, but long-term, in order to heal your gut ecosystem and to end up in a really great, balanced ecosystem that you can live with for the rest of your life that’ll support a healthy immune system, will support good digestion and absorption of nutrients, that will help you keep inflammation low, and keep your antioxidant levels high, it’s all about eating plants. You have to get there somehow, and that’s where we do our work. That’s why I do a lot of herbal treatment and retreatment because I don’t want somebody to be left with having to eat low-FODMAPs for the rest of their lives.
PHOEBE: Right, I totally agree. I guess the one piece that I still would love clarity on is just the leaky gut section because people talk about going grain-free and legume-free as part of the healing course for that. Some people even say that, in-tandem, when you’re on a low-FODMAP diet, that helps heal the leaky gut. I’m curious what your take is on the strategy there.
BLUM: Right, for somebody with a really bad leaky gut, a lot of times, it is helpful to do a lectin- free diet for three to six months, perhaps, for healing the gut. What’s causing the leaky gut? The leaky is caused by the dysbiosis, the bad bacteria that are there, so we’re treating that. Then the damaged tight junctions are caused by – there’s a list of things that do that. Advil does that, Prednisone does that, and bacteria do that. Damaging compounds in foods can do that if you’re eating a large, great quantity. If you think about it, the modern American diet is filled with lectins because people overeat grains. I think that for a person with a really severe autoimmunity – and this is how I talk about it. I teach live online programs. I teach live classes online. I get on and I teach the class. I always am answering this question about lectin-free or not lectin free. I think that I don’t think everybody needs to – I don’t think everybody needs to be lectin-free.
I think it depends upon how bad the damage is to your gut and what was causing it. It’s a personalized thing, the no lectins. I think that there’s definitely a subgroup of people who have very severe autoimmunity, severe arthritis, or severe gut, digestive issues, and they’re going to feel much better and heal more quickly on the low-lectin diet. I like to do low-lectin as opposed to the no-lectin. I think I’m fine with that, but I still put that in the category of the therapeutic food plans. You stay on that to heal your leaky gut. Maybe you stay on it for six months. If your leaky gut’s really bad, maybe you’ll stay on a no-lectin diet for three months to six months, and then you’ll move to a low-lectin where you eat – you can reduce the lectins and legumes. Nature gave us legumes. I just don’t believe that they were meant to be dangerous for us to eat. I think you can – I eat lentils, mung beans, and adzuki beans, which are the lowest lectin, easiest to digest legumes.
I practically live on them. You soak them really well. You boil them. You have to just cook them. In the summer, I sprout them. You get a lot of the lectins out. You can help the foods become lower in lectins. Sprouting helps, and the way you prepare them. I think that there’s just ways to move yourself towards a low-lectin food plan that doesn’t mean you can’t eat legumes. I think there’s a way to reintroduce them and stay low-lectin as you come out of it. The long-term goal is, again, getting back to eating a Mediterranean diet. There’s legumes in there. I just want to differentiate a therapeutic food plan, which some people might need, and I consider a lectin-free, the [59:14]stuff, the [59:15]paradox. I consider – that’s a therapeutic food plan. I don’t think that people should accept that that’s the way they’re going to need to eat the rest of their lives because once you’re healed and we do all the work that we talked about today, I think you should be able to eat them again.
It’s also a matter of quantity and how they’re prepared, how those foods are prepared. You might have to just be careful about not overdoing it. Just as bad as the lectins are things like wheat germ or glutenins, in terms of the gluten in wheat that damage the gut. There’s glyphosate from Roundup that damages the gut on pesticides. Those directly damage the tight junctions. I’m not sure if it’s all about the lectins when people eat grains or it’s the glyphosate that’s coming in from the herbicides that’s damaging the gut. When you get rid of all the grains, you’re actually reducing the amount of exposure you’re having to Roundup. There’s a lot of other things at play here that I think we blame the lectins for. There’s other sneaky things in the food that might be damaging the gut as well. I just always like to go to back to the basics of what nature tells us, and also, around the world, the kind of food that cultures have been eating forever. I think some of these things just are not the food’s fault.
I think our gut is just in bad shape. I think stress, overwork, what we’ve done to ourselves with processing food, the modern American diet, the medications we take, the overuse of antibiotics. There’s just so many things that our gut – it just can’t handle nature’s food, and we’ve also changed our food. If you can find a way to make sure your food is clean, the way it was made in nature, prepare it properly. Make sure you’re tending to your gut ecosystem the way we’ve talked about today. My goal is always to help people get off that therapeutic food plan that they need to control everything into a long-term gut ecosystem-balancing food plan. That should always be everybody’s goal, not being stuck in that therapeutic food plan forever.
PHOEBE: I think that’s amazing advice. I also completely agree when I hear people doing any sort of restrictive diet. Depending on where they’re starting from, I think such a large part of it is, it forces you to cook. It forces you to eat more vegetables across the board. Yeah, it just takes you into cleaner territory, no matter what particular evil you’re attempting to restrict at any given time. Thank you so much, Dr. Blum. I will definitely link to your free downloads that you mentioned. If you send me a link to any upcoming classes, I’ll also put those in the show notes. We’ll let everyone know where to find you and continue following your work. I can’t recommend your book more. Even though it is five years old, it still really holds true to so many of these bigger picture things to consider.
BLUM: Exactly, it’s unbelievable how the book is still great. I will say that my second book, which came out a year ago, is called Healing Arthritis. That book is all about the gut. I dug into all the research on gut health. I talk more about SIBO in there. It’s really a gut treatment book because arthritis is so connected to the gut. Anybody who wants to learn more about inflammation and the role of the gut, Healing Arthritis takes – it brought in all the newer research on the gut microbiome, which is really why I wrote it, and that whole connection with inflammation and the gut.
PHOEBE: Amazing, I’ll definitely link to that as well, and I will also pick it up. I need to read it. Thanks so much. Have a wonderful day.
BLUM: Thank you so much.
Disclaimer: The information in this podcast does not provide medical advice, professional diagnosis, opinion, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.
I have severe SIBO constipation. Do you know anything about Macrogol? Does it increase SIBO symptoms?
رعاية مسنين بالمنزل says
i found this article very interesting and good for me about SIBO Connection and How to Heal, thanks for sharing this valuable info