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Welcome!

This presentation is copyrighted by Purpose Inc. with all rights reserved, available for student reuse strictly subject to the terms outlined in the student program agreement.

Tracy’s health counseling certification is from Columbia University for the Institute of Integrative Nutrition in New York.

She has completed ongoing training and is working on a certification in understanding the root causes of chronic illness with the Institute of Functional Medicine and on an additional Masters degree in Human Nutrition at Bridgeport University.

She holds a Masters degree in Engineering from MIT and a Masters degree in Management from The Sloan School at MIT.

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Take lots of notes! The more often you see these connections, the more readily you will be able to recall them.

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SAFM Deep Dive Clinical Courses2

Disease Begins in the Gut 101Part 2

This presentation is copyrighted by Purpose Inc. with all rights reserved, available for student reuse strictly subject to the terms outlined in the SAFM student program agreement.

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Today’s Agenda

Brief Reminders

The 5Rs of Gut Healing and More Gut Pearls

Stomach Acid: Digestive Hero

What goes Wrong: Stomach Acid Acid Reflux (GERD) Gastritis, Ulcers, & H Pylori Asthma, Allergy

Supporting Low Stomach Acid

Mighty Digestive Enzymes

Looking Toward Part 3

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G E N E S ILL-NESS

ENVIRONMENT:

What we Maximize, Minimize, and

Prioritize

WELL-NESS

InteractiveBiochemistry

Endocrine (Hormones)

Immune (Inflammation)

Nervous (Neurotransmitters)

Digestion(Nutrients)

Metabolism(Energy)

Detoxification(Clearance)

?

Choices

Choices

Functional Medicine: The Big Picture5

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Putting the Puzzle Pieces Together

We are not designed to beStressed, Toxic, Inflamed, Infected, Malnourished, & Unrested

and yet still easilyThrive, Grow, Reproduce, be Thin, feel Well,

Eat Anything we want, enjoy perfect BMs, and have Great Sex.

This combination would be Not Natural.

Why are we struggling?Nutrient-poor Food, Toxins, Stress

Even when aware, we lack Education, Inspiration, and Empowerment support!

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Gut Impact Goes WAY Beyond Digestion

A weird, weird world.

Essentially a tunnel – or the inside of a doughnut - a well-guarded and regulated exchange corridor that is outside of the systemic body.

The entryway for essential nutrition to fuel every cell in the body.

The exit path for most toxins and waste – of exogenous and endogenous origin.

Guarded by a planetary level population and diversity of microbes. Regulated by their behavior and DNA (which can transfer genes to humans)*

Home to more than two-thirds of the immune system,surveilling our intake, outflow, and microbial balance.

Exchange controlled by a very complex, semi-permeable interface that is only one-cell thick.

Housing its own nervous system which generates neurotransmitters used throughout the body.

The gut and brain connect via a highly interactive vagusnerve with 90% of the nerve fibers going

from the gut to the brain (afferent).

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* https://bmcgenomics.biomedcentral.com/articles/10.1186/s12864-017-3649-yhttps://www.the-scientist.com/?articles.view/articleNo/47125/title/Bacteria-and-Humans-Have-Been-Swapping-DNA-for-Millennia/

Dis-ease Often Begins in the Gut

Deficiency-Driven Dysfunctiono e.g. anemia, neuropathy, depression, headache

Gastrointestinal Dis-easeo e.g. IBS, constipation, belching, bloating

GI-origin Inflammationo e.g. osteoarthritis, asthma, migraine, chronic fatigue,

fibromyalgia, eczema, intestinal permeability

Autoimmune Dis-easeo Hashimoto's thyroiditis, lupus, multiple

sclerosis, Crohn's disease, rheumatoid arthritis

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Dis-ease Begins in the Gut: Many Ways….

Dysbiosis? An imbalance in indigenous, human gut bacteria OR species of bacteria in the wrong place in the gut OR potentially pathogenic microbes(e.g. parasite, bacteria, yeast). Perhaps compounded by toxins secreted by the microbes or inflammatory byproducts of the microbes themselves (e.g. LPS).

Food? Low in nutrition or the food itself, especially that which looks a little too much like a toxin, allergen, or foreign invader e.g. processed, refined, homogenized, hybridized, pesticide-laden, GMO.

Toxins and Insults e.g. pesticides, Red #40, birth control pills, NSAIDs, artificial sweeteners, chlorinated tap water, mercury, alcohol, antidepressant drugs.

Malnourishment via maldigestion and/or malabsorption e.g. magnesium for motility, B12 and B6 for nervous system, vitamin D for tight junctions, zinc for immune strength.

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…and Many More. Dis-ease Begins!

Even the healthiest diet in the world is not useful if it cannot be both well digested and then well absorbed. And we need healthy body parts to ensure optimal function!

In the Mouth: Impaired by stress and distraction, poor chewing, low saliva production (e.g. dehydration, some drugs (antihistamines, beta blockers, anticholinergics), very low estrogen, Sjogren’s).

In the Stomach: Impaired by what does (or doesn't) happen upstream in the mouth and also impaired by eating in a stressed or rushed state*, drinking lots of liquids during meals, medications (e.g. proton pump inhibitors, H2 receptor blockers, NSAIDs), gastric infection (e.g. H pylori), allergy/asthma, hypothyroid function.

In the Small intestines: Impaired by what does (or doesn't) happen upstream and also impaired by stress or lack of sleep, microbial imbalance or overgrowth, low digestive enzyme secretion, poor bile consistency or flow or concentration (e.g. liver health, taurine, B6, missing GB), microbial imbalance (e.g. SIBO, pathogens), food sensitivity, medications (e.g. birth control pills, antidepressants, NSAIDs, statins?**), thinning of mucosal lining or villi damage (e.g. celiac disease).

In the Large Intestines (Colon): Impaired by what does (doesn't) happen upstream and also impaired by food grazing (in sensitive folks), low-fiber diets, high dietary sugar or chemical, toxic transport, neuropathy, diarrhea, antibiotic use, diverticulosis, constipation.

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* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC26223/ /* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5550934/

#3 Stress Inhibits All Digestion and Absorption

Sympathetic

o Fight-or-Flight

o Increased focus and alertness

o Increased metabolic activities

o Stops all digestive secretions (e.g. stomach mucus, stomach acid, digestive enzymes)

o Can cause expelling of food (e.g. vomiting, diarrhea)

o Designed to be short-term exceptions for survival

Parasympathetic

o Rest-and-Digest

o Relaxed external muscles.

o Increased digestive activities to store energy for future use

o Designed to be our primary state

Gut Healing Order of Operations: the 5Rs

1. Remove first. (e.g. stress, crap food, constipation, harmful microbes, allergen/sensitivity foods, foods that feed undesired microbes).

2. Replace (e.g. digestive enzymes, stomach acid support, bile acids, herbal remedies to boost immune system insufficiency, adrenal and/or thyroid support)

3. Reinoculate (e.g. probiotics, prebiotics, cultured foods, dietary fiber increase)

4. Repair (e.g. villi regeneration, nurturing mucosal layer, increasing SCFA with larch gum or other fiber additions)

5. Rebalance (e.g. stress relief, long-term diet changes, attitude/mindset/beliefs)

Order of operations is important. You have to peel an onion layer by layer. e.g. Probiotics may make someone with IBS feel worse! Additional digestive fiber (or a probiotic formula that includes prebiotics) will *very* likely do this.

Stages of the 5Rs will nearly always overlap each other. Duration and approach need to be customized for each unique case.

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More Gut Pearls

When in doubt, Start with Eating Hygiene and better Food Choices.

Simple is OFTEN Sufficient. “Doing a stool test” is seldom the most logical 1st step.

And reducing Stress, Going to Bed earlier, becoming an Eating Hygiene expert, and taking some Zinc does not cost $400+

Think upstream. If stress or hypothyroid state or rock-bottom cortisol is at play, no amount of targeted antimicrobials is going to help a person to maintain a peaceful harmonious gut. The same is true of chronic anxiety.

Wait at least six weeks after completion of steroid medication use before relying on any data assessing immune system reaction/strength (e.g. food sensitivity test, WBC data, Globulin, fecal sIgA). Full recovery may take much longer

It may take months for a gut microbial population to be restabilized after a course of antibiotics. Be willing to change your plan when the unexpected happens.

No food sensitivity test is comprehensive. Tell Your Clients This In Advance. Antibody-based testing (e.g. IgG) tests require that the food is being consumed. Remember: an elimination diet or specific elimination is faster, more reliable, & free!?

Food sensitivity or stool test? Assess if their symptoms are persistent. Happen every day? Wake up with them? Again, start with the Basics! Often, symptoms disappear.

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Stomach Acid: Digestive Hero and What Goes

Wrong

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Stomach Acid: Digestive Hero!

Hydrochloric acid (HCl) is produced by parietal cells in the lining of the stomach (pepsin from goblet cells). Required to denature proteins & isolate/prepare nutrients for absorption.

Suboptimal HCl may be caused by many factors e.g. poor eating hygiene, sympathetic nervous system state, hypothyroid state, hypoadrenal state, SIBO or other dysbiosis (antibiotics), chronic use of NSAIDs, H Pylori infection, autoimmune antibodies, and – of course – acid-suppressing medication. *

Acid-suppressing meds are very common e.g. PPIs, H2 receptor blockers, NSAIDs. Taking too many mineral supplements with a meal can create an overly alkaline environment, insufficient for optimal digestion. Excessive bicarbonate intake (e.g. baking soda) can also naturally restrain HCl production.

Suboptimal HCl may create opportunity for microbial overgrowth/pathogens, immune system reaction to maldigested foods (e.g. allergy/sensitivity), or drug malabsorption. **

Internal production decays with age because of simmering H Pylori infection. Study show half of adults in their 60s and 80% of people over age 85 don’t have optimal levels.*

Low stomach acid (hypochlorhydria) can cause

o Slowed gastric emptying (promoting GERD, bloating, etc.) and downstream digestion.o Poor protein digestion and absorption (and thus, potentially, sensitivities/allergies)o Nutrient deficiencies, esp. B12, Minerals (Ca, Fe, Zn, Mg), Folate

Gut Connections! Hypochlorhydria is a key contributor to downstream dis-ease dynamics e.g. Ulcers, Osteoporosis, Low energy, Indigestion, Depression, Anemia, Weak immune system, Dysbiosis, Food Sensitivity, Allergy, Auto-immune disease, Cardiovascular inflammation, Arthritis, Cognitive impairment.

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* http://www.ramauniversityjournal.com/medical/pdf_june/16-26.pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5304992/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546438/#R137 ** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1379419/pdf/gut00574-0143 pdf https://www ncbi nlm nih gov/pmc/articles/PMC3946491/ and https://www ncbi nlm nih gov/pubmed/15679471/

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Stomach Acid Gone Wrong: GERD

In fact, insufficient stomach acid (hypochlorhydria) is often an acid reflux driver (promotes slow gastric emptying).

PPI medications are highly-prescribed, available OTC, & overused.*

Weak sphincter (LES) caused by stress, medications, a diet high in sugar, refined carbohydrates (chips, fries), & chemicals

Common LES irritants: citrus, cooked tomatoes, peppery/spicy foods, fried foods, peppermint, chocolate/tea/coffee, alcohol.

Stomach juices bubble up into the esophagus where there is insufficient mucus protection from acidic juices (it hurts!). Pepsin can erode tissue but also directly causes an inflammatory response.

May just be an issue of eating in a rushed and/or stressed state and drinking too much liquid during a meal, especially a rushed one. WS tip: The combination of insufficient stomach acid paired with insufficient magnesium, poor eating hygiene, and a food sensitivity is often the perfect storm of factors in chronic GERD.

Bacterial overgrowth is often involved in chronic acid reflux. GERD is often coincident with IBS/SIBO. Hiatal hernia may be involved. Complementary therapy may help.

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It’s almost never the case that there is too much stomach acid; instead, acid reflux is Stomach Acid being in the wrong place!

* http://bmjopen.bmj.com/content/7/6/e015735 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707629/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3388523/ and http://onlinelibrary.wiley.com/doi/10.1002/pds.4135/pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987764/

Stomach Acid Gone Wrong: Esophageal Assault

Esophageal Cancer Barium Swallow

showing narrowing of esophagus

Cancer Endoscopy

Photo

Barrett’s EsophagusUnaddressed GERD can lead to

Barrett’s Esophagus or Esophageal Cancer

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An inflamed esophagus can cause a narrowing

of the passageway (think about similar

dynamics in atherosclerosis).

Stomach Acid Gone Wrong: Gastritis & Ulcers

At least 80% of ulcers and atrophic gastritis are caused by an infection (overgrowth) in the stomach lining by Helicobacter Pylori (H Pylori).*

Another 10% of ulcers are caused by NSAID medications (e.g. Aleve, Advil, Aspirin). NSAID therapy is also a relatively common cause (>2%/year) of gastritis/gastric bleeding.**

Primary symptom is stomach pain when eating. Many are undiagnosed.

Stress exacerbates ulcers because it suppresses the immune system which allows the H Pylori to flourish and reduces maintenance of the protective mucosal lining. Urease action frees ammonia in the gut which gives foul breath odor (e.g. similar to urine).

H Pylori weakens protective gastric mucus layer and impairs internal acid regulation. Again, pain is from acid in wrong place! Eventually, H Pylori causes atrophic gastritis.

Make sure you know the type of ulcer! If ulcer is duodenal, H Pylori will typically overstimulate acid production. If it is gastric, there will likely be underproduction of acid.

“Triple antibiotic therapy” is conventional for H Pylori, but recurrence is common. PPIs are usually prescribed but designed to be used only for a short time (2-3 weeks) for healing process. Longer-term use allows H Pylori to flourish and promotes atrophic gastritis.****

H pylori is endemic in the human gut and only pathogenic when overgrown. Antibiotic use and other microbial overgrowth can promote H Pylori surge. It is also highly contagious from oral contact and notoriously antibiotic-resistance. Eradication rate around the world is typically 50-75% even with conventional treatment. ***

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* https://jamanetwork.com/journals/jama/article-abstract/389732 ** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3590424/*** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635158/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635158/#B175 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928162/ **** https://www.ncbi.nlm.nih.gov/pubmed/8598839

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Gastritis and Ulcer Support

Mastic gum has been shown to eradicate H Pylori 60-90% effectively at higher doses. Mastic gum also acts as an anti-inflammatory agent to reduce oxidative damage at the mucosal lining. * E.g. Designs for Health’s “GastroMend”, twice daily on empty stomach, ~30 min. prior

to food and then again at bedtime, for 3 months. Silver nanoparticles (not typical colloidal silver) have demonstrated ability to counter

H Pylori, though further in vivo studies are needed. **** e.g. Designs for Health “Silvercillin” twice daily.

Zinc carnosine, aloe, slippery elm, and other mucilaginous herbs help to replenish the damaged mucosal layer. Zinc carnosine has also been shown to enhance H Pylori eradication rate.** E.g. Thorne’s “GI Encap” three times daily on empty stomach. E.g. Metagenics “Zinlori”, twice daily with food

Taking various lacto/bifido combination probiotics alongside antibiotic therapy sometimes increases eradication and sometimes decreases risk of recurrence. ***

H Pylori infections are implicated in higher risk of cardiovascular disease and stomach cancer. ***

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** https://link.springer.com/article/10.1023/A:1018847324172 , http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.16.s2.12.x/pdfhttps://www.naturalmedicinejournal.com/journal/2013-11/nutrient-profile-zinc-carnosine* https://www.ncbi.nlm.nih.gov/pubmed/19879118 and https://www.ncbi.nlm.nih.gov/pubmed/12888582 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127998/ and https://mafiadoc.com/in-vitro-and-in-vivo-activities-of-chios-mastic-gum-extracts-and-_5a4249511723dd2461a11a56.html **** http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.877.1941&rep=rep1&type=pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158114/ *** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635158/#B175

Stomach Acid Gone Wrong: PPI Withdrawal

Use of a PPI medication for even eight weeks is very likely to promote a strong resurgence of stomach acid upon drug cessation. *

Esophagitis, aggressive acid, and gastritis reflux may result from rapid withdrawal. Small, gradual titration downward is key.

Support the gastric mucosal lining for at least 2-3 weeks before adding in any HCl support to improve stomach acid during meals and before starting withdrawal.

Ensure keen focus on eating hygiene and address all breakthrough acid reflux before starting any medication withdrawal. Avoid all reflux trigger foods during withdrawal.

Do HCl experiment and begin supporting stomach acid during meals to optimize digestion.

Optimal titration timing varies by person. A six-weekplan works such as this for many. If there is any breakthrough reflux along the way, address it fully before moving on. Half-dose for two weeks Quarter-dose for two weeks Every other day for two weeks

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* http://www.gastrojournal.org/article/S0016-5085(09)00522-8/pdf . This is a powerful, lay news article warning of the possible magnitude of withdrawal done quickly: https://www.npr.org/templates/story/story.php?storyId=112564382

Gut Connections: Stomach Acid & Asthma

Nearly 80% of asthmatics also have chronic acid reflux (GERD)*

Hypochlorhydria has been shown to increase IgE allergic reactions by 10X (ten-fold, as in 1000%) ** and is more common in asthmatics than the general population.******

80% of asthmatic children have hypochlorhydria. Avoiding food allergens and supporting with supplemental stomach acid (Hcl) yielded clinical improvement. ****

“It is concluded that in atopic children, gastric hyposecretionand epithelial degeneration may promote the passage of unhandled food allergens into the mucosa, predisposing them to more severe changes.” *** Acid secretion returned to normal for most – but not all – children on the appropriate elimination diet.

* http://www.nature.com/gimo/contents/pt1/full/gimo47.html** http://www.fasebj.org/content/early/2005/03/25/fj.04-3170fje.full.pdf*** http://link.springer.com/article/10.1007/BF00441481#page-1**** Bray GW. The hypochlorhydria of asthma in childhood. Q J Med 1931;24:181–97.****** http://qjmed.oxfordjournals.org/content/4/4/397.abstract

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Frequent use of bronchodilators (weakens the LES) and diaphramatic pressure will predispose those with existing asthma to chronic GERD. *

Clinical tip: magnesium deficiency is often seen in both acid reflux and asthma (think: predisposition to muscle spasms). Use a non-citrate form of magnesium unless constipation is also a symptom.

Allergy can decrease stomach acid production. **

Hypochlorhydria reduces Vitamin B12 absorption which promotes wheezing. Wheezing can then trigger acid reflux through compression of the LES.

* http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714564/** http://www.ncbi.nlm.nih.gov/pubmed/574086

Allergy can promote Low stomach acid.

Low stomach acid can promote GERD.

GERD can promote Asthma.

Low stomach acid can then worsen allergic hypersensitivity,

Creating a vicious cycle.

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Gut Connections: Stomach Acid & Allergy

SupportingLow Stomach Acid

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Lab Considerations for Low Stomach Acid

Heidelberg Capsule test directly measures gastric pH. Smart Pill is similar and more widely used by progressive GI docs.

Look for evidence of downstream nutrient maldigestion e.g. suboptimal amino acids (e.g. Albumin and Total Protein in lower half RR, low iron stores (ferritin <50 ng/mL), low RBC Zinc (in lower half of RR), and low serum Vitamin B12 (serum B12 below 600 and/or MCV >91 fL or methylmalonic acid in upper half of RR) in a carnivore are also a key indicators of maldigestion/malabsorption.

In some comprehensive stool tests, one can measure “products of protein breakdown” which are putrefactive short-chain fatty acids, produced by bacteria when they ferment maldigested protein. Elevated levels (with normal total SCFA) indicate suboptimal protein digestion, often due to low stomach acid.

Gastrin is a hormone that stimulates the stomach lining to produce more acid. If fasting gastrin levels (blood) are elevated, it is a good sign of suboptimal acid production.

Low levels of Vascular endothelial growth factor (VEGF) in saliva correlate well with impaired stomach acid production (but this test can be hard to find).

Remember none of these is going to be an accurate endemic baseline when a person is using PPI or other antacid medications routinely!

Rather than a single data indicator, look for a pattern of multiple symptoms and data points as a clear, collective indicator that stomach acid support trial is merited. Educate your patient/client! Ask them about their intuition regarding this need.

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Look for the Signs! Low Stomach Acid

Frequent daily belching Upper GI bloating, belching, and/or an early sense of satiety during or right after meals Feeling nauseated after taking supplements with food (except zinc which may promote

nausea on its own or except when limited to excessive calcium/magnesium at once) Clearly seeing undigested food in stools Irritable bowel syndrome (IBS) or SIBO or frequent gut infection or microbial imbalance (e.g.

candida, parasite) Feeling particularly fatigued after meals (especially if meal was otherwise consumed slowly) Insufficient levels of Vitamin B12 despite eating a carnivorous diet Hair or nails that break frequently or are thin Chronic allergy or urticaria Multiple mineral deficiencies despite a whole foods diet

(e.g. iron, zinc, magnesium, chromium, copper) Rosacea Osteoporosis or advanced osteopenia Multiple food allergies or sensitivities Chronic asthma, especially if wheezing is also involved Chronic indigestion or GERD

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Support Low Stomach Acid – 1

While you are helping someone to address the true root causes of hypochlorhydria, Stomach Acid Supplementation may make sense.*

HCl supplementation is not safe for those with active gastritis/ulcer or who are using certain drugs e.g. steroids (e.g. prednisone), NSAIDs (e.g. ibuprofen, aspirin, diclofenac).

Consider first if the gastric mucosal lining needs support. Mucilaginous herbs may be needed to build up protection (e.g. Thorne’s GI Encap, slippery elm lozenges). E.g. long-time use of acid-suppressing medications, history of gastritis/ulcer. When in doubt, do this first.

Address eating hygiene and common drivers of acid reflux first. Ideally, a pattern of chronic acid reflux has been fully eradicated before HCl supplementation is explored (noting there are exceptions where low HCl is a main trigger and must be addressed before this can occur).

Can use apple cider vinegar for mild cases. E.g. 1 Tbsp apple cider vinegar (mixed in just 4 oz water) sipped on throughout a meal starting after the first few bites. Can be increased to 2-3 Tbsp as needed. Not appropriate for any yeast allergy/sensitivity or any type of esophageal or mouth dis-ease or inflammation.

Capsules of Hydrochloric (HCl) Betaine with Pepsin allow a more metered experiment. Begin low’n’slow with one ~650mg cap per meal. Try for ~6 meals and increase dose by one cap every ~2 days as long as no negative effect is noted (maximum typically 4-5g/meal). Take in the middle of the meal, each cap followed by a few bites of food.*

Bitter herbs (e.g. gentian) can also work to stimulate greater stomach acid secretion and gastric motility where HCl supplementation is not tolerated or appropriate.

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* There is a course handout on Stomach Acid and hypochlorhydria which gives detailed instructions on this action

Support Low Stomach Acid – 2

Best HCl dosage will vary with food! More for meals with more protein. If there is patient desire to experiment but some fear in trying it, use initially only with meals containing at least 20g protein.

If gastric pain results right away with initial trial, stop and support mucus layer (e.g. aloe, slippery elm, marshmallow, DGL licorice) for at least two full weeks. Do not attempt acid replacement support with those who have existing esophageal erosion (e.g. pre-Barrett’s) unless you are highly experienced with this dynamic and are providing medical care for it. Again, do not use any stomach acid support if there is active gastritis/ulcer.

The supplementation experiment encourages a gradual dose increase until there is evidence of too much and then dropping down to a regular dose at one-cap less. With too much HCl betaine with pepsin, a person will typically experience a warm, uncomfortable feeling in their chest (typically NOT acid reflux) or else loose stools (consider enzyme/bile need). Don’t recommend going over 8 capsules/meal even if no symptoms. If there is indeed acid reflux, stop experiment and return to root causes of reflux first (e.g. insufficient magnesium, stress/anxiety, hiatal hernia, eating hygiene).

Replacement can be done while someone is on PPI or other antacid medications and may help them to be able to reduce their dosage/frequency over time, especially while weaning down from these medications in an attempt to quit.

Optimal intestinal pH requires adequate bile flow. Consider supplementation as needed e.g. bile salts, artichoke, d-limonene.

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* Good client/patient resource for common HCl mistakes/challenges: https://scdlifestyle.com/2013/10/4-common-betaine-hcl-mistakes/

Remember: For most, addressing low stomach acid is just triage. You

still need to address Root Causes!

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Mighty Digestive Enzymes

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Digestion and Enzymes

Be a detective: GI discomfort after eating may be a digestive deficiency OR a food sensitivity OR a microbial issue. Perhaps ask a client to keep a “Food Reaction” diary for several varied meals.

Damage to the mucosal lining and brush border of the intestines is likely to result in digestive enzyme deficiency due to impaired hormonal signaling along the GI tract. Brush border damage may result from insults such as

o pathogenic microbial infection or overgrowth (e.g. Clostridia, Salmonella, parasites),

o microbial dysbiosis especially due to antibiotic use – especially from repeated or lengthy courses (e.g. Candida infection),

o medications (e.g. birth control pills, antidepressants),

o toxins in food or water (e.g. HFCS, chemical colors, too much alcohol, arsenic, lead).

o celiac disease or ANY form of gluten sensitivity

A downward spiral can develop as our poorly digested food then feeds undesirable bacteria and fuels their overgrowth, furthering (1) inflammation, (2) brush border damage, and thus (3) further digestive dysfunction.

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Ask your clients very detailed questions about any GI distress. Generally, they KNOW what specific (or categories of) food causes their discomfort. Their intuition

might be inaccurate, but start with it.

The Mighty Pancreas

Life-critical gland with both digestive and endocrine roles

Digestive: producing digestive enzymes and bicarbonate which help to break down foods in the intestines. 99% of pancreatic cells do this.

Endocrine: producing insulin, glucagon, & other key hormones. ~1% of pancreatic cells do this.

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Mighty Digestive Enzymes

Most digestion in the small intestines occurs in the first portion (12”), the duodenum. Most absorption occurs in the two latter segments, the jejunum and ileum.

Most carbohydrate and fat digestion (and final protein digestion) occur in the small intestines thanks to digestive enzymes.

Enzymes come from both the pancreas and the brush border itself. Bile secreted from the gallbladder (but which is made liver) must emulsify fats to allow full digestion (more on the key roles of Bile in the Part 3 webinar of this course)

* https://www.ncbi.nlm.nih.gov/pubmed/2464656/ , https://www.ncbi.nlm.nih.gov/pubmed/1812045/ , and https://www.ncbi.nlm.nih.gov/pubmed/1721657 ** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5301368/

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Pancreatic digestive enzyme release can be impaired** by multiple factors including • chronic stress, sympathetic nervous system • hypothyroid state, hypoadrenal state• dysbiosis or microbial imbalance• low stomach acid• age* (may be 50% reduction or more!)• gastric bypass and related surgeries• celiac disease• type 2 diabetes• cystic fibrosis, toxicity, pancreatitis/cancer

Pancreatic Insufficiency Clues

Lower-belly bloating, increased fatigue, and/or flatulence specifically ~2+ hours after meals – and for most meals. Wake-up feeling fine (perhaps feels is best of time day for their gut!)

Undigested food in stool is a common symptom of insufficient enzymes (but not always true).

Semi-digested food sitting in the intestines is fermented by bacteria, creating gas & bloating with nearly all meals. SIBO is especially vulnerable to exacerbation from insufficient enzymes.

Lower belly bloating, flatulence, and loose (fatty – floating) stool in response particularly to a higher-fat meal is likely due to fat maldigestion, perhaps due to pancreatic insufficiency and/or insufficient bile flow.

Pancreatic enzyme deficiency is common in Type 2 diabetics (up to 1/3 of them) and also Type 1 diabetics (over 50%)*

Heavy alcohol use lowers digestive enzyme secretion.**

Remember: optimal digestive enzyme release and action require upstream, optimal stomach acid secretion.

* http://www.codhy.com/berlin/Uploads/assets/hall%20c/hall%20c%20sunday/ppthardt.pdf** http://pubs.niaaa.nih.gov/publications/aa22.htm

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Enzyme Supplementation

You can test for digestive enzymes, but a trial of enzyme support is fast and easy!

o Comprehensive stool tests often include Elastase 1 or PE1 (passive enzyme).o Blood levels of pancreatic amylase or lipase can assess poor secretion

Many brands of digestive enzymes are available with many different blends of enzymes to support digestion of specific types of foods or the full spectrum.

Enzymes are either “plant-derived” (which means from yeast fermentation e.g. aspergillus) or animal-derived from pancreatin extracts. Individuals with related allergies or sensitivities may not well tolerate one form or another.

Take digestive enzymes just prior to a meal for dramatic insufficiency or post-injury or –surgery healing. Otherwise, in the middle of the meal to allow body’s natural secretion to fully take place.

Excessive digestive enzyme intake will most commonly result in diarrhea.

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Enzyme Supplementation

Enzymes are available or very targeted intolerance needs or for food sensitivities. Combination digestive enzyme formulas with HCL support and/or bile salt support

are available.

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Looking Toward Part 3

Brief Reminders

The Magic of Bile and the Epidemic of Gallbladder Removal

The Many Faces of Dysbiosis: IBS and SIBO

The Power of Probiotics

Intestinal Permeability and Intro to Food Sensitivities

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Disease Begins in the Gut 101Part 2