How To Recover From IBD Without Surgery & Medication
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Hey everyone, it's Dr. Mark here. Inflammatory bowel disease, or IBD, has increased dramatically over the last 20 years. Millions of Americans are suffering from gastrointestinal inflammatory disease, such as Crohn's or ulcerative colitis, that make it really hard to function in the day-to-day life. They're in pain, they run into the bathroom incessantly, often not able to eat, especially during the flare-ups.

In today's episode, we feature three conversations from the doctor's pharmacy about why the functional medicine approach to healing gut pain starts in the gut with addressing the microbiome of the individual, along with low-level systemic inflammation and stress. I talk with Dr. George Papanikolaou about dietary and lifestyle changes to help reduce symptoms, and with Dr. Miguel Ruggiero about the benefits of certain probiotics to heal and protect the gut.

and curcumin to reduce inflammation. And finally, with Dr. Shilpa Ravella about how to test for inflammation and address the root cause of it. So let's jump right in.

The microbiome is the gateway to the immune system. And we know that there is a strong immune component to inflammatory bowel disease. So the autoimmune paleo diet basically is going to eliminate foods from your diet that can trigger your immune system to have that autoimmune response and to create that inflammatory response. And it's going to allow the gut lining to heal.

And so there are foods that are thought to really be- What do they take out? What is an autoimmune paleo diet? What do they take out of the diet? They're going to take out grains, legumes, nuts, seeds, nightshades, eggs, and dairy. All of these have inflammatory components to them. Wow.

And so then, you know, yeah, so that's the main things. So like grains and beans and nuts and seeds and they're just supposed to be healthy, right? They are, but they have inflammatory components to them. Once your system begins to break down,

then those foods can tend to have, you know, trigger the immune system to have that, you know, an increased autoimmune response. Because what happens with some of those foods is that you develop the mucosa breaks down, so it can't do its job. Number one, it can't break foods down, so you're not going to get the nutrients that you need. Number two, that mucosa now, this very –

finely designed gait system is broken and these foods when they're not broken down into the smallest peptides possible can actually they don't have to be because the gates are broken so now you have these larger peptide forms in these particular foods their proteins are inflammatory to the immune system when they're larger and the immune system can't recognize them so the immune system that

It begins to create the autoimmune response and the inflammatory response. So that's why these particular foods are taken out. And it includes alcohol, coffee. It includes processed oils, corn oil, canola, cottonseed. You want to not have those oils in your diet as well.

Absolutely. And so you're getting rid of all that stuff. And what are the kind of results you're seeing with those patients? Well, with the AIP diet, we see very good results. Because a lot of folks, when they've come to us,

They've never been told that you can eat a certain way to improve your symptoms. So when we take these foods away for, you know, six to eight to 12 weeks, it gives the intestine and the immune system opportunity to rest.

And now you can get healing of the gut because you are still eating very nutritious foods that are healing to the gut. We're able to, once the symptoms begin to, you know, to be vanquished, they're able to tolerate more foods. We can get more fiber in, we can get more probiotics in, and then the healing process really begins. And, you know, by 12 weeks, we're seeing, you know, people with,

you know, all symptoms are gone and they feel great. And that's even in the AIP with probiotics. That's incredible. I mean, really, when you think about the fact that this is such a debilitating disease, that it's such a difficult challenge for patients, that the drugs are so potentially toxic and harmful, that...

You know, so many millions of people suffer from this. And what you're saying, George, is that in functional medicine, we have a map to figure out why. We have an approach to improve the microbiome, to treat them with an anti-inflammatory diet, and to reset the gut microbiome through microbiome.

a whole host of interventions that we call the 5R program in functional medicine. We've talked about that on the podcast before. And we also tend to look for other things that people don't look for, like heavy metals or infections or other issues. And it's amazing what you'll find and what you see

And it's so gratifying. I mean, of all the conditions, I love it when I get a patient with Crohn's or colitis because it's such a slam dunk. And for me, I had one of those cases that just was not getting better. And so I always get the cases, whatever it is, and then I have to figure it out. And I figured it out. And I think, you know, there's other treatments that can be helpful. And I used ozone, I used exosomes, there's a lot of different things. But

It's quite amazing when you see the potential for this. Yeah. And I want people to know that, you know, it's, there are, look, you're really sick. You're not feeling well and you're having bloody mucousy schools and you're having them 11 times a day and you're having pain and you can't eat. You're desperate. And, you know, and then you're going to be told, well, guess what? We're going to put you, we're going to eliminate all the foods that you like. Well, you know what? Sometimes, unfortunately,

We don't even, we don't even, you have to, you can't even start an AIP diet. You know, because people, when they come, can be so debilitated that they can't even, they can't tolerate food. So to really give their gut a rest, I'll use something called an elemental diet. You know, an elemental diet is basically medical food that has all the nutrients that you need, but doesn't require your body, your broken mucosa,

to break down the proteins and the complex carbohydrates. And so we're able to use the elemental diet to really rest.

and really get all the symptoms calmed down, then move on to AIP to then add in our probiotics. And then we have other things that we can do for long-term maintenance of a healthy state. And that is some things that can boost the immune system, modulate the immune system. I commonly will use things like low-dose naltrexone, which modulates the autoimmune response.

And I'll use CBD with THC blends that, again, can have a modulatory effect on the immune system, decrease inflammation in the gut, increase appetite. And so there are a lot of things that we can do in functional medicine, just as you just pointed out. And those are some of them in a little bit more detail. Wow. Thanks, George. Well, listen, we're going to get right into it. So inflammatory bowel disease, how common is it? What is it?

What symptoms do people get? And tell us about what we know about the disease in terms of a traditional approach from traditional conventional medicine. What's the approach to this? Because it just seems like a vexing problem, and we just seem to have made some advances, but still, it's not great.

Yeah. So, you know, it's very common. There's about 3 million people have it per year in the United States of America. That is actually up from 2 million in 2000. So there's a very steep increase over the last several decades. And the projections are that it's going to increase at an even more rapid rate over the next 20 years. So ulcerative colitis, Crohn's disease, which both are the two major inflammatory bowel diseases, are...

are frequent and common and are very, very disruptive to the people that have it. They can really just completely upend their lives. You know,

Depending on how quickly you want to get into this, I can get right into it. I'm just thinking of all my patients and their suffering. I can tell you that when it's uncontrolled, there is a lot of pain. There's a lot of diarrhea. There's an inability to eat. There's fatigue and weakness that keeps people from being able to do their jobs. Weight loss. Weight loss. All of those symptoms. Malnutrition can be included in there. So there's a lot of people that have it.

it, it's a growing problem. And when you have it, it's very disruptive. And even when you are well, you have to work hard at staying well. Yeah, it's a huge problem. And, you know, it's basically an autoimmune disease of the gut. What's amazing to me is in traditional gastroenterology, I've talked to gastroenterologists and they're like, oh, you know, what you eat doesn't really impact it.

I'm like, wait a minute. You're putting pounds of some foreign substance in your mouth every day that's going through your gut. How could that not affect it, right? It's just so striking to me that there's just this complete

almost ignoring of the role of nutrition and food in what's going on with gut disorders that's just kind of a meta a meta comment because it's such a big obvious like dot of me yeah but to make it to retort with another meta comment i would say that in our food yes but in that food are toxins and in our environment and we have medications and we have you know we have xeno we have a

endocrine-disrupting hormones, all of which end up in our gut, in our gut microbiome, and are very disruptive. And if a person has a genetic predisposition to ulcerative colitis or Crohn's, inflammatory bowel disease in general,

then they're going to be at high risk for triggering that gene and developing that disease they have predisposition for. It's our diet. It's our environment. It's the stress. All of those can trigger genetic predispositions.

Absolutely. Absolutely.

agriculture and food production in our country and how it is toxic and why it's toxic. We don't have healthy soil and that's where it begins because if we don't have healthy soil, we're not going to get the nutrients in our gut soil to grow good bacteria and have a healthy microbiome so that our intestines can stay healthy and do their job for us.

Yeah, it's such a big deal. And, you know, from a conventional perspective, the treatments are really to shut down your immune system, right? Oh, yeah. Prednisone, steroids, chemo drugs.

TNF alpha blockers, things that increase risk of cancer and infection. They're pretty extreme drugs and they can be very helpful and they can be lifesaving and they can work for people. But the question is, is there an alternative? And do we have to deal with this the same old way we've been doing with it? And then of course, for a lot of patients who have it, sometimes they need surgery. They need total colectomies for ulcerative colitis where they remove your entire colon or resect whole sections of your bowel with Crohn's disease, which doesn't really cure the problem.

It's just a rough, rough disease. It is rough. And I think you and I can bring people some really good news today that using functional medicine and what we understand about the gut microbiome, what we understand that food is medicine, you can get better and stay better without having to use

the kind of drugs you just mentioned that can lead to cancers down the road. People on immunosuppressive drugs, you know, followed for 20 years, or, you know, they're already at very high risk. They're already at increased risk with inflammatory bowel disease for, you know, colon cancer. And then if you put them on an immunosuppressive drug and follow them for 20 years, you know, they have an increased rate of skin cancers by about 40%.

And so, you know, and during that period of time, they have increased rates of infection. They have side effects to the medications. They have to come on and off them. They have to try new medications. And by and large, you know, they're moderately effective and sometimes not effective at all for some people.

People suffer a lot from this and they can manage the disease, but it often doesn't go away or it's not curable. But from a functional medicine perspective, it can be really curable. And I can tell you so many patients that I've had. I mean, I just actually how I got the job and probably how I got the job at Cleveland Clinic was because I met someone to the CEO who whose niece had severe colitis, was tried all the medications, wasn't working.

was about to have her total entire corner moved at 32 years old. And I said, look, just have her come to me. No promises, but no, it's worth trying before she rips out her entire colon, which is irreversible. Right. And I think she was skeptical. She was from new Orleans and probably wasn't the healthiest, you know, lifestyle down there. And she,

She agreed to do what I told her, but she was quite skeptical. But I changed her diet. I reset her gut microbiome. You know, simple things, simple things. And six weeks I talked to her. She said, I'm perfect. I'm fine. I'm on no medication. And I'm like, what? Literally six weeks and they were going to take her colon out and she's symptom free and off her medication. And I can tell you story after story like another young kid was 25 years old. Same thing about take his colon out. Just some simple dietary lifestyle changes.

And getting the gut microbiome straight and resetting the gut with the functional medicine for our five-hour program is so key. So I think it's... We had talked earlier as we were preparing for this, and one of the first things that happened, and you can correct me if I'm wrong, but you met with Dr. Ruggiero, who's a GI doc through the clinic, and you guys developed a collaborative to work with functional medicine and traditional and conventional forms to treat cancer.

ulcerative colitis inflammatory bowel diseases and that that sounds like a phenomenal um partnership absolutely it really is and i think there's a real openness to understanding there's there's really room for this including with everything it's not either or yes how do we how do we create the best conditions for a patient to get to health and i think you know just in terms of causes let's sort of dive into that because from a functional medicine perspective

We really look at root causes. Today, I was going through my medical research that I do every day and just looking at what's new. I was shocked to see this. Well, not really shocked. I actually kind of expected it, but I was shocked to see it published so prominently in a medical journal, really discussing the way in which food additives and ultra-processed food will drive changes in

in people's um gut so when you look at this data it was quite interesting they looked at uh mice and people and they basically show that high sugar processed food diet affects the gut in a harmful way we also know that there's a lot of emulsifiers and additives in food like that they're thickeners even things like microbial transglutaminase which is a like a gluten product that's put

on purpose in food to make it stick together because gluten makes it blue, makes it stick together. And so we have to sort of think about when we take care of these patients what the causes are. And I've seen all sorts of cases of Crohn's and colitis. And I'll just share another story of a guy who I saw years ago

who had severe colitis, was really losing weight, struggling. I tried all the normal functional medicine stuff. Reset his gut microbiome, 5R, elimination diet, tried everything, the right supplements, and he just wasn't getting better. And so I went back to the principles, first principles that I learned from Sid Baker, which is what could be bugging this person that needs to be gotten rid of? Is there something else that I'm missing? And what am I missing? Is there something I'm missing? Yeah. So I went back to the drawing board as my medical detective had on and

got up this guy had really high levels of mercury and it wasn't until i chelate his mercury that he was able to correct his colitis and it's now symptom free um i personally had a different cause you know i was i was somebody who mostly had a healthy gut most of my life and then i developed mercury poisoning and that messed up my gut i didn't get colitis but i had really bad irritable bowel and bacterial overgrowth and all sorts of issues that i cured but then a few years ago about five years ago i got

a confluence of events where I ended up having to take an antibiotic for a bad tooth and a root canal and it was clindamycin and this antibiotic is known to cause C. difficile which is a really common

intestinal infection that causes death in about 30,000 people a year. And all of a sudden I started getting not just, you know, diarrhea and this and that from it. I started getting really severe pain, nausea. I'm going to the bathroom 20 times a day, bloody bowel movements. It was just, it was miserable. I literally was in bed five months running back and forth to the bathroom. And it turned out I had developed colitis from the C. difficile and then continued even after we cured the infection to

the colitis continued. And so I had to really go back to the drawing board and think about what do I do? Because I also had mold exposures and I had all these imbalances, I had low ecromancia. So I learned a lot about, on a personal level, which I really didn't want to learn that way, but I learned about what the symptoms are, what it does, and how to actually start to think about fixing it differently.

And for me, I did a number of things. I used a cocktail of, I call it gut food, which is a cocktail of components that are, I think, not really been put together too often, including prebiotics, probiotics, polyphenols, and immunoglobulins, and things that really help the body to reset the gut. And I also dealt with the mold that I had in my house. And I also used ozone to help boost my immune system and kill infections. And it was really amazing. Within a very short time, I was able to really recover.

And I think a lot of us sort of struggle without really knowing what to do. And even sometimes when you do an elimination diet, if you have colitis, you don't necessarily always get cured because there may be something else going on. Maybe like what I had, maybe there was...

you know, C. diff or maybe there was mercury or maybe, you know, there was something else going on. But you can really help these patients so much. Crohn's is often a little more challenging, but we do a lot of different approaches. So traditional medicine is pretty cut and dried. So what are the kind of things we find that work the best? And talk about from a dietary approach and then sort of drill down into the other aspects of our treatment for colitis and Crohn's disease. Right. So the, you know,

Neck and neck, it's diet and gut microbiome. It's really neck and neck. I will say with the gut microbiome, it's very intriguing because there's more and more research being done

into the differences between a healthy gut microbiome and a gut microbiome of a person that has inflammatory bowel disease and there are significant differences. And in a person that has inflammatory bowel disease, one of the key factors

bacteria, as you mentioned earlier, is acromantia. Acromantia plays a role in keeping the mucosa, the gut lining, the goblet cells really healthy. It breaks down the mucin

And then when it breaks that down, it turns it into short chain fatty acids. And we know that short chain fatty acids are the, you know, that's the honey of the, you know, the colonocyte. It just loves, you know, it's short chain fatty acids and that keeps it really healthy.

People who have inflammatory bowel disease tend to have really low levels of acromantia. And it's not uncommon for me to find that they're not even detected when I do the complete diagnostic stool analysis on a patient. So replacing acromantia has been shown to have an important role in helping the gut mucosa heal. There is a study that I had done.

come across in preparing for this. It was in the European Journal of Inflammation 2020. And it basically, in this study, they took bifidobacteria, another, another strain of, of,

bacteria that is found to be really low in patients with inflammatory bowel disease and they took a specific strain by food of bacterium lactis and they combined it with xyloglucan which is a

non-digestible fiber stores. So they had a prebiotic and a probiotic together in a patient with ulcerative colitis. And they followed, you know, all of the patients in the study and control groups. And they found that there was at six weeks, the study group had significantly more healing and resolution of their symptom, more healing of the gut mucosa and healing of

and resolution of symptoms. And this is just, they had no other therapy. This is just a prebiotic and a probiotic and that they use. And so using probiotics, you know, to control and to, um,

resolve an exacerbation can be really critical. I think we're learning more and more about how they work. There are other probiotics or other bacterial species that are missing or are in low concentration in patients with inflammatory bowel disease, including lactobacillus GG, sarcomyces boulardii. And when you replace these, you find huge benefits.

So I use probiotics pretty quickly in a patient. I also will use, there's a probiotic called VSL number three. A lot of people know about that because it's frequently used and it's really powerful. It has all the strains of lactobacillus and bifidobacterium that are

are low and also very helpful in healing that gut lining, that gut mucosa. And just by using that, I've been able to help people start to feel better and see the symptoms resolve. So as you can tell, the gut microbiome, using probiotics, are really a big part of how I'll treat my patients. But there has to be balance about what you can tolerate

and where they are in their disease because the diet then becomes really important. Sometimes I can't give probiotics right away. Sometimes I've got to get this person eating. I've got to get them feeling better before they can actually tolerate the addition of the probiotics.

Inflammatory bowel disease, depending on the estimates you see, are about 2 million Americans have inflammatory bowel disease. And the estimate may actually be higher, but it's about 2 million Americans. A lot of people. Yeah. And a lot of toilet paper. A lot of bathrooms and everything that goes with it. There are other therapies that people are exploring that are out there, like probiotics and various supplements and curcumin. And we had a speaker come, Josh Korsnick, from...

Harvard, who came to talk about some of the work he's doing, looking at sulfide production in the gut, that you get these sulfide-producing bacteria. You can change them by giving butyrate, which is a nutrient, or vitamin B12 and using probiotics. And tell us more about where the research is around that.

Yeah, so again, I think it's emerging. And as long as this has been out there, I think we're still learning from this. So two things I wanted to pick up on, the probiotics and extra curcumin as well, based on the IBD studies. So curcumin, which is, as you know, turmeric, or it's been an Indian spice. Curry, exactly. The yellow in a lot of the Indian foods, not the hot spices, I tell my patients. But there was a study where actually curcumin

Adding curcumin to misalamine, which is an anti-inflammatory for ulcerative colitis versus misalamine alone actually showed that the curcumin group did better in terms of inflammation. The other is probiotics and probiotics, especially in people who've had surgery already. And there's a lot of bacteria pooling in this pouch that they have after surgery.

probiotics have been a primary treatment for a lot of those patients and a specific one called BSL number three. So there's clearly probiotics. And then we use it in probably even more commonly in patients who may have a lot of gas and bloating. We think there's bacterial changes. And, you know, quite honestly, we're learning there are a lot of probiotics that don't work. So I think we need to understand more. But there's there is definitely something there. And it's a big interest. I mean, we're really at the infancy of

Of our understanding of probiotics and the microbiome. Now, there's so many probiotics out there and they all promise different things. Very few of them have been studied rigorously. They might be small trials or some scientific studies. The question is what happens when it gets to the shelf? How long is it stable? Does it work? What's in there? It's challenging. And I think we're getting much more specific and thinking different strains and what they do.

It's pretty extraordinary. We actually are probably going to be involved in a study. I was talking to the European researchers who we may collaborate with and people who have had Crohn's and had surgery, and they get an intestinal resection then connected back together so that it's not an ostomy. And we know the recurrence rate is high in people who have Crohn's who have surgery and get connected back.

And this research group is looking at the microbiome specifically as the recurrence when people have Crohn's that comes back. And we're looking at it's not really going to be a probiotic, but it's going to be a different agent that alters the microbiome. And it's interesting. These are probably the approaches that we're going to see in the next decade that are going to completely change what we do. It's really true because, you know, in medical school, we never learned, well, how do you create a healthy gut?

We know how to treat symptoms. We know how to treat diseases. And sometimes the drugs we use, for example, to treat GI symptoms like the acid blockers cause secondary problems like diarrhea or bloating or bacterial overgrowth or other things. And you end up with like, you know, you might not have reflux, but you got irritable bowel now.

And so we never learn about the science of actually creating a healthy inner garden or creating a healthy gut or what we should eat. And yet that seems to be where the future, where the research is going and how do we combine that with traditional therapies to actually help people really recover.

Well, again, so it's kind of going back to the future, right? So when we think about 40, 50 years ago, lower incidence of inflammatory diseases, more of these whole-based diets, whole food diets, less of the artificial processed foods, lower sugar, lower fat, people weren't getting these diseases. So obviously there's something there. Fascinating. Yeah. In functional medicine, we talk about, we call the 5R program, which is a strategy, a method for helping to restore the gut function.

And it works for so many diseases. We've been doing this for 35 years. And, you know, it's regardless of what's going on, if you don't even know that much about what's actually happening, you just try this, it works. And it's not just for inflammatory bowel disease, other digestive issues, autoimmune issues. And it's basically removing the things that may be irritants, whether it's foods, like you said, processed foods, it could be gluten and dairy, whether there's bugs growing in there that shouldn't be growing in there, like bacterial overgrowth, or maybe there's parasites.

replacing things that might be needed in the gut if there's pancreatic insufficiency or if there's need for prebiotics and replacing, re-inoculating with probiotics when we can. And then using things to help repair the gut lining. I use curcumin or fish oil or zinc or other things that the gut, glutamine that the gut needs to heal. I mean, and then we use Restore, which is to help deal with the stress response. So it's sort of a very specific methodology that can be applied to help

the gut function and it's sort of a foundation of our practice in functional medicine and it really helps. Now, it doesn't get everybody better all the time, but it's a really interesting model and it's sort of a, almost it would be amazing to actually think about how do we start to integrate studying that as a foundation and then you have treatment failures, you add on other things. Like you said, the diet,

plus the medication works better, like your patient or their curcumin plus the medication works better. So how do we begin to sort of integrate these? Well, and I think it begins with a partnership. And I think that

The thing I like about this relationship is that it's not either or. And I think for so long on the traditional side, it's been it only is the traditional way. We don't have any outside the box thinking or partnership. So the thing I like, too, is that you're saying and constantly to the patients we send to functional medicine is.

Work together collaboratively with your IBD team and functional medicine. And I think that's where we're going to see success. So it's a complementation, if you will, if that's a word, working together. Well, I mean, there's a certain humility that comes with practicing for a while on either side. Like if you're alternative, don't ever take medication. And you go, wait a minute. I'm like, these people aren't getting better. And you might need to, you know.

And then the other side is, well, yeah, maybe everything we're doing isn't working 100%. So what else can we learn? And I think that's just a wonderful collaboration attitude that you have here. And Cleveland Clinic is really one of the few places where I've really seen that dynamic where there's real openness and curiosity and willing to collaborate and asking questions. And it's really pretty exciting. Yeah. So one of the main reasons I came to Cleveland Clinic is obviously my interest in

gastroenterology, but looking at population health and specialty health, but also in the field of IBD, the interdisciplinary approach to treating these patients as a whole person and conducting not only studies, but clinical programs where we're not so uni-focused on one approach. It's looking at multiple disciplines. And it really has been something I've enjoyed about the Cleveland Clinic.

It's great. And, you know, we've been talking together about creating, for example, shared medical appointments where people come in a group, they get nutrition coaching, they get life coaching, they get support from the doctor and various kinds of healthcare providers and a team that helps them change their behavior. Because, you know, it's easy to take a pill or get a shot every few months.

But to actually start to shift what you're eating and how you're taking care of yourself and dealing with stress, those are the big levers that we don't tend to use. Right. And so I think the secret sauce in any medical home, if you will, is really looking at the psychosocial stressors that patients often have and the diet patterns.

that's impacted. And so when I look at the subsets of patients that I think benefit the most from this kind of this shared model, there are clearly a number of patients there and clearly we see results. Yeah. And you've also pioneered a really amazing thing, which is this idea of a patient-centered medical home for specialty care around inflammatory bowel disease, which has dramatically reduced costs and improved outcomes. So I'm

almost sort of recommending the same thing as you would as a one-on-one visit, but it's done in a different delivery model. And that's really what's happening in medicine. We're realizing, wait a minute, the one-on-one doctor visit, Norman Rockwell kind of style of medicine just ain't flying in today's world, which is complex where chronic disease is

prevalent, where it's influenced by our social determinants of health and all these other factors that are squishy and not part of your medical care. But you're like, no, wait a minute, we have to do this. So tell us about that. Yeah, so it came about for a couple of different reasons. And again, this was where I used to work for and we used to see patients come in all the time with unmet needs beyond what we were delivering. So we knew we could get them better to a point.

But then the secret sauce again was realizing that the psychosocial part, the diet part, but then looking at how we can integrate with payers, the insurance companies, how we can look at cost, how we can look at the whole person. So these specialty medical homes, in my opinion, would be principal providers being a specialist. Doesn't mean not working with primary care. Actually, at the Cleveland Clinic, we're working on a medical neighborhood, which will really deploy our primary care physicians in these care models.

But really where the principal provider for Crohn's and ulcerative colitis often that's their only disease. They're young and otherwise healthy. So the medical home is principal provision by a gastroenterologist with a team. And I think what you said a minute ago is important. Team is a key element to this. It's not just one person. So they come in and they see somebody about

The diet. I mean, it's what you do in functional medicine. The diet, the psychosocial part. They may work on health maintenance issues in terms of how can we prevent diseases. And then, yes, they might need to see the gastroenterologist and the surgeon and then other people as well. So it's a one-stop shop.

whole person care, where we also try to keep the people back in their communities. So at school, at home, at work, really trying to avoid coming back and forth by also leveraging digital technology. It's incredible because what you're finding is that even though that sounds like an expensive enterprise, you've got all these extra providers and nutritionists and coaches and behavioral therapists and

pharmacists and blah, blah, blah. And yet you found that not only was it cheaper, but that people did far better and the outcomes were better. So it's quite a striking sort of thing to think about because we are so afraid in medicine to think differently about how to deliver care, but we have to. Well, I think, and also a lot of times what we are talking to our patients about when the past, when they get stuck, what do they do? They go to the emergency room.

So by decreasing these unplanned care visits, ER visits, hospitalizations, going back and forth, getting testing after testing, and really saying, how can we flip this paradigm on its head? So I agree, it is a bit outside the box. I wouldn't say it's the primary care physicians started these medical homes years ago, but now we're seeing different specialty areas that have chronic diseases really deploy these teams around whole person care.

Inflammation is actually an ancestral force that evolved to protect us from things like pathogens and poisons and traumas, all of these ancient killers. So it's actually a good thing in our bodies to have inflammation when we need it. But the problem is that because we've evolved these strong, robust immune responses, we also tend to pay a price for it. And this is called the biological price of having inflammation.

of having strong immune system. And we can see that with autoimmune diseases, for example, like rheumatoid arthritis or inflammatory bowel disease,

But now what we're seeing is that we've also transformed our modern environments from the food we eat to the air we breathe, to how we move, how we interact with others in terms of social connections. So our immune systems are constantly triggered at a low level. And this leads to chronic silent inflammation in the bodies. And we know today that this type of inflammation can actually be an independent cause of disease. And it is tied to

a variety of modern chronic diseases. The majority of our top killers is tied to heart disease, cancer, diabetes, neurodegenerative disorders, some psychiatric issues, obesity. So what we're seeing today is that the majority of us in the modern world are inflamed. Yeah. Most people don't walk around going, oh, I'm inflamed. Like if you, if you got a rash or you have a sore throat, you know, I'm inflamed, right? We have a

arthritis in your knee and it's swollen up, you're going, I got a problem. But most people who are overweight or have heart disease or high blood pressure or diabetes or depression, they're not walking around thinking, oh, I'm inflamed. I better deal with that, right? Right. Absolutely. So explain how inflammation plays a role there because we think of inflammation typically as being something that is there to fight infection or immune system that gets activated to fight cancer.

And then it can get dysregulated with autoimmunity and allergy. But we don't think of it in terms of sort of this general state of being kind of low-grade inflammation, which we're all suffering. Right. And I think that's a great point, is that we don't tend to think of inflammation as being so broad. For example, when we think of inflammation, we think of autoimmune disorders, typical autoimmune disorders, or as you said, when we have a cold or a flu. But now what we're seeing is that...

low-level inflammation can actually cause some of these disorders, or it is tied to nearly all of these modern chronic disorders. And you're right that if you go into your doctor's office, your typical Western physician's office, you're unlikely to be offered a test for inflammation. So the question is, how exactly do you know that you're inflamed? And I think there are a lot of things that are coming up these days. For example, in cardiology clinics, people

Doctors might test you for something called C-reactive protein, high sensitivity C-reactive protein. And that's a marker of inflammation in the body. It's made in the liver in response to areas of inflammation. And there are a variety of other markers as well. But some of the problems with these tests is that they may not be that specific. So if you have elevated C-reactive protein, you may have that elevation from the

cold you have and you cannot be sure where it's coming from in your body, how long it's been there for. But, you know, there are new markers being developed. There are inflammatory signatures, for example. There was a Stanford study a couple of years ago on aging and an inflammatory signature

comprised of several markers that can help to predict healthy aging. And, you know, there are so many different things that are in the works, I think, from tests like CAT scans and MRIs that can pick up inflammation around blood vessels, for example, and predict which plaques are most likely to rupture.

So, those are some of the things. And one of the proxies for being inflamed that we can all look at when we go to our primary care physician's office is just things like high blood sugar or diabetes. If you have prediabetes or diabetes, you are most likely to have some amount of inflammation in the body because high blood sugar does tend to create inflammation.

And if you have that belly fat, for example, then you also know that you most likely have some level of inflammation in the body because we know that the belly fat is a marker for the fat that wraps around your internal abdominal organs. Yeah. I mean, by the way, that fat, right, is a source of a lot of inflammation, right?

because it's not just, you know, the belly fat is not just holding up your pants. It's actually a very active immune hormonal organ that's spewing out all kinds of inflammatory signals if you get this excess belly fat. And I think most people don't realize that. If you have a big belly, you've got a smoldering fire inside of you. And that is really important to understand. And the reason we get the big belly is because of what we're eating. So, you know, let's talk about, you know, the...

some of the things you were talking about, like how do we know, right? So we can do a CRP, but it's not very specific. It doesn't tell us why. There are other markers. You mentioned Stanford research. I think that was David Furman's work on the 1,000 Immunomes Project where he looked at cytokines or inflammatory markers in 1,000 people from little kids to old people. And he found there were like things that we probably never heard about in medical school, these cytokines that are

we don't test for in a normal lab result, but that actually are probably more predictive and more correlated with various age-related diseases than other markers that we actually do measure, right? So we're sort of learning about how to test for this. And you mentioned high-resolution scans, imaging tests. Now, for example, with Alzheimer's, we know that...

is an inflammation in the brain, we can see through various MRI and high technology scans, we can see inflammation in the brain. We can see, for example, a new AI-driven heart scans. We can see inflamed plaque orthostatic.

Or rather than just looking at an angiogram or even calcium score, which gives you a rough idea of the calcified plaque, it doesn't tell you how inflamed your plaque is. So we're getting more and more sophisticated. But are there tests that we should all be doing to check for inflammation? And are there tests that help us figure out the why? Like what is the why behind why we're so inflamed?

I think that's certainly a tough question for sure. And I think it's also very specialty dependent. For example, in my own practice, I tend to see inflammation all throughout the intestinal tract. And so depending on what sorts of symptoms a patient's

come in with. I may do endoscopic testing. I may do an upper endoscopy and a colonoscopy, and I may catch microscopic inflammation in the intestines as well through that way. And there are also stool tests that we do in our practice to measure inflammation, like lactoferrin, which is one of the stool tests. And these are very situation dependent. And again, if you go to your physician in general, you're unlikely to be told, hey,

let's just check you for inflammation and then let's try to treat it. And we're not quite there yet, but I think we're getting there. And I think one of the interesting things too with testing is that, you know, perhaps we should be measuring inflammatory responses to challenges rather than just like a baseline snapshot of inflammation. I think that's something that could be very interesting as well, because we want to know that the immune system is doing its job when it should be and not overreacting as

as well. So I think there are a lot of great things that will come up in the future regarding testing and hopefully we'll see more and more specific markers and we'll see more trials in this space. But I think when we go to our physician's office,

in the modern age, we have some proxies that can tell us if we're inflamed and we have specialty specific diagnostic tools that we can use as well. Interesting. So you mentioned sort of a challenging in the immune system. Can you talk more about that? Because we know, for example, if you want to check for diabetes, you do a glucose tolerance test where you give people a bunch of sugar and see what happens to their blood sugar. Or if you want to check someone's heart, you don't just check an EKG, you put them on a stress test or do a stress echo to stress their system. So tell

Tell us what you're talking about. I think this is a really interesting concept of how do we test our immune system's function? Are we overreacting or underreacting?

Yeah, I think it can be as simple as injecting a molecule like lipopolysaccharide and trying to figure out what the immune system's response is. Is the immune system, one, responding appropriately? And two, is it overreacting? Are we having too much inflammation to a stressor? And I think that could tell us more than perhaps just a snapshot of the blood markers that we have currently.

And this is something that I think maybe that we will see in the future. Yeah. Now we've all heard about the cytokine storm from COVID and cytokines are basically the messenger molecules of your immune system. And a lot of the work by David Furman, things we're measuring like CRP, TNF-alpha, IL-6, cytokines, they're just the symptoms of inflammation. They're not the cause. They're the body's response to something that's

irritating, right? So my question is, you know, is, is, you know, why always, why is the immune system pissed off in the first place, right? It's easy to measure, look at, you know, you can look at scans, you can look at a colonoscopy, you can look at CRP, you can look at all these other biomarkers, but it's not going to tell you the why. And so, you know, my joke always is that a functional medicine doctor is really an inflammologist. Like I'm an inflammologist. I like made it my life's work to understand inflammation, to understand what causes it,

how to actually remove the causes and how to get the body's own immune system to calm down and to reduce the inflammation naturally. So can you talk a little bit about, from your perspective, what do you see as the main drivers of this epidemic of inflammation and inflammation, which we talk a lot about? I think, first of all, that this idea that all of these disorders share a deep biological link from heart disease and cancer to some cases of depression and neurodegenerative disorders,

that lengthening inflammation, it forces us to look at all of these things and really try to figure out what these root causes are. And it forces us also to look at patients and to treat patients not only from specialty perspectives, but also holistically in some ways as well. And a

a lot of what is causing this low level chronic silent inflammation today is our environment, our dietary habits, our lifestyle. And we know that chronic inflammatory disorders, and when I talk about chronic inflammatory disorders, I'm talking, you know, not just about rheumatoid arthritis and inflammatory bowel disease, but all of these different modern diseases, because these are inflammatory disorders. And so we know that our lifestyle factors play a very, very important part

So talk more about specifically, what is it about our diet that's driving the inflammation? And then I want to get into potentially exploring other causes that may not be immediately obvious to people that are driving inflammation. Sure. Your book is really Silent Fire, talks about diet as a big driver of inflammation. So exactly what are we talking about here? There are so many different factors. And I think one of the biggest ones is the weightlessness.

Western diet. And this type of diet is loaded with an excess amount of sugar, salt, inappropriate fats, processed foods, processed meats, refined carbohydrates. And the problem with this Western diet is that our immune system actually tends to respond to it as it would a germ. Your immune system

tries and tries to kind of fix things in your body. And it's realizing that keeps getting these hits, you know, maybe three times a day or six times a day, however many times a day you'll have a meal. And when we are eating this Western type of diet, we're also starving our gut microbes of their most beneficial nutrient, which is fiber. And fiber can manipulate all arms of the immune system from the innate immune system to the adaptive immune system. And it's an incredibly powerful

powerful, powerful nutrient that we need to be eating more of. But 95% of Americans today do not meet the recommended daily allowances of

fiber. It's 28 grams for females and 38, I think, for males. So we are really starving that microbiome. Then the microbes change their behaviors, causing inflammation. They'll inch closer to the mucosa. They will create more inflammatory molecules like lipopolysaccharide. Those molecules will go out into the bloodstream, causing body-wide inflammation. So it's changing the

you know, who the microbes are, the species in your gut, and also what their behaviors are. So the Western diet, one of the biggest losses is also the fact that we are depriving our bodies and our guts and our gut microbes of their most essential nutrient. So diet is certainly a very big component of creating this low-grade inflammation. And I would also say that the other main- Not just a lack of fiber though, right? It's probably other things in our diet. Right, plenty.

Plenty of other things. And, you know, the other thing too, I would say is that we, we tend to think of foods as dampening or creating inflammation, but there's also a reversal going on. This whole process by which inflammation tends to die down in the body is not a passive process. It's an active process and immune cells like macrophages and neutrophils will secrete new mediators.

And we need to feed that process. And so we need to eat healthy fats like omega-3s. And I think that's something that we don't do enough of, nearly enough of. So that potential to resolve inflammation in our bodies, we need to really

be able to create those molecules. And that also comes from diet because the precursors of these lipid signaling molecules are actually omega-3s, which we find in a variety of foods. Yeah. I mean, these are called the eicosanoids, right? This is what we learned in medical school, these pathways of regulating cytokines, inflammation, and they're highly regulated by the fats in our body, particularly the omega-3 fats. I want to loop back to what you earlier talked about because I think it's really important. I don't want to skip over it, which is the role of the microbiome

And as a gastroenterologist, I think this is your area, which is the microbiome plays a huge role in regulating our immune system. And most people don't know that 70% of our immune system or 60% of any you're talking to is in our gut. And it's because it's the first place where we interact with the outside world, right? We put all these pounds of foreign stuff in our mouth every day and it goes down there and has to be sorted through. And then you've got all this bacteria and bugs and poop in there. And, you know, you have to lay down the right stuff, but keep out all the bad stuff.

And when we get a problem with the microbiome, we tend to get damage to the gut and more inflammation. So can you kind of walk us through that whole story of what we're doing to damage our microbiome besides just not eating fiber and what changes happen in our microbiome and how that starts to up-ramp the inflammation cycle in our body? Right. So when you look at the microbiome,

When you see, for example, a mouse who grows in a sterile bubble with no microbiome, no germs on that mouse whatsoever,

You find that this mouse actually tends to develop all kinds of abnormalities, like a deformed heart and lungs and a shrunken brain. So microbes actually train our immune system. They help our immune systems to develop. Our microbes are having conversations with our immune cells at all hours of the day. And this is a process that begins even before we're born. And once we're born, of course, and all throughout life.

So we need to be having those essential conversations. And how do we foster those conversations? And again, it comes down to lifestyle. What kinds of foods are we eating? I have mentioned fiber, but there's so many other foods that are great for the gut microbiome because we know also that a lot of the fats that we eat can make their way, some of them can make their way down into the colon. And we have that proportion of fats, for example, being metabolized. And we know that there are

spices and herbs and all of these wonderful foods with polyphenols, which are amazing compounds for the gut microbiome, because again, some of those make their way down and are metabolized by the microbiome. So it's not just about the fiber, but all of these amazing nutrients that we find in foods. And what we know today too, is that a dysbiotic microbiome or a microbiome that is an imbalance is very often an inflammatory one.

So when you have microbial dysbiosis, when you're eating a poor diet and not exercising, stressed out and not getting enough sleep or social connections, and you have a dysbiotic microbiome, we do know that you most likely have low-level chronic inflammation coursing through the body in those states. So our microbiome is incredibly important for the inflammation picture as a whole. And our immune system shapes the microbiome as well.

We know that microbes do so much in the body, from digesting nutrients we cannot digest to changing gene expression to modulating the inflammatory response. Thanks for listening today. If you love this podcast, please share it with your friends and family. Leave a comment on your own best practices on how you upgrade your health and subscribe wherever you get your podcasts. And follow me on all social media channels at DrMarkHyman. And we'll see you next time on The Doctor's Pharmacy.

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