ASH13 Norm Robillard — Did Cavemen Get Heartburn?


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A new theory suggests that acid reflux is caused by carbohydrate malabsorption, small intestinal bacterial overgrowth (SIBO) and microbe-induced gas pressure. The pressure drives acid reflux much like dropping a Mentos in a bottle of coke. Difficult-to-digest Carbohydrates lactose, fructose, resistant starch, fiber and sugar alcohols are most likely to cause malabsorption and symptoms of SIBO-related conditions such as GERD and IBS. A novel calculation called fermentation potential (FP) can measure the gut symptom potential of any food. The low FP approach was successfully tested in a small clinical study in the Boston area.

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  • Good afternoon. Thanks to the organizers for inviting me and you for coming to my talkTwo part question: What is the underlying cause of heartburn? And if it’s diet, what did cavemen eat and what was their situation?But the real question I want to end on is what modern day foods will give you heartburn and which ones won’t? They might not be what you would expect.A lot of what I am going to say today relates to Irritable Bowel Syndrome as well.
  • *GERD is essentially chronic acid reflux often times accompanied by longer term damage (long term health risks)Main symptom heartburn (burning pain behind the breast bone)
  • People take these meds because it helps control symptoms, but don’t’ work for half the people who take them.There’s a downsideNeutralize stomach acidInhibitsthe absorption of vitamins, minerals and nutrients.No surprise, these drugs are linked to a number of health risks.Do we really need these? Let’s take a look at the underlying cause.
  • Relaxation of LES (TLESRs) was has been the prevailing view of why reflux happens for over 50 years.Didn’t seem to make senseI had horrible GERD myself for many years. Went low carb, no more heartburn.Came up with this alternative explanation. – Read the slideForces the LES open (same result by manometry!)Can this process really create enough (gas) pressure to cause acid reflux? Yes!Think I’m right about this and there’s evidence (elaborated in my book Fast Tract Digestion HB)
  • This is a fundamental change in the way we understand GERD, with critical implications for treatment The scientific evidence for this connection has been building over the past decade. My research has uncovered five distinct points of evidence which convinced me that poor carbohydrate absorption (or malabsorption) coupled with SIBO may be the ultimate cause of acid reflux.Restricting the growth of intestinal bacteria, whether by limiting carbohydrate intake or treating with antibiotics, reduces the symptoms of GERD, including reflux and gas pressure.Carbohydrate malabsorption and GERD can be created experimentally – FOS and increasedTransient Lower Esophageal Sphincter Relaxations (TLESRs). GERD is associated with increased gas pressure in the stomach - People with GERD have been shown to have increased gas pressure in their stomach and belch more frequently. Also, fundoplication surgery is linked to new symptoms in a significant number of GERD patients.Health conditions associated with malabsorption and SIBO are linked to GERD Cystic fibrosis, Asthma, IBS, Obesity.SIBO has been detected in GERD patients .
  • Let’s take it up a notch, which carbs are the worst offenders.The most difficult-to-digest carbohydrates will be most easily malabsorbed, potentially feeding SIBOAvoid these Difficult-to-digest carbohydrates you will experience dramatic symptoms improvement.Only for questions:Lots of evidence that fructose, lactose, fiber and sugar alcohols linked to SIBO / dysbiosis, but less direct evidence that amylose starch is involved.But like fiber, resistant starch is not absorbed and is fermentable by the bacteria present in SIBO. Extra content: Resistant starch is fermentable by the types of bacteria identified in SIBO. The connection between CF and Reflux – it’s a starch issue. Also, starch blocking meds that inhibit amylase enzyme cause diarrhea a halmark of SIBO.Enzyme inhibitors that block starch digestion have side effects resembling SIBO (flatulence and diarrhear).But how to you limit these five carbs if you don’t know how much of each is in each food you eat?
  • Avoiding five difficult to digest carbohydrates is the key to symptom relief but doing it can be complex.New Idea: The Fermentation Potential (FP) measures the amount of hard to digest carbohydrates (SIBO fuel) in any food.In other words, symptom potential.FP is based on the glycemic index which measures efficiency of carbohydrate absorption.FP is a new lens to compare symptom potential of different foods.
  • Typical day on SAD registers an FP of approximately 150 g – translates to 50 liters of gas.In the Fast Tract Digestion book series for heartburn and IBS, I recommend people with GERD or IBS symptoms start by keeping their FP to about 30 grams per day. Still enough fermentation to produce 10 liters of hydrogen (10 better than 50 on SAD)
  • We know cave people ate fiber and resistant starch that’s why we evolved this relationship with 11 trillion bacteria – to help us get energy from foods we can’t digest.
  • As a GERD canary in the coal mine, I know which rices I would choose. (the night at Mark’s house)Note that jasmine and glutinous rice are 100% amylopectin – the others are high in amylose starch.
  • Stachyose,rafinose, stachyose – why beans give you gas.
  • We tested the Fast tract diet in a small clinical pilot study with 19 people and had some encouraging results
  • ASH13 Norm Robillard — Did Cavemen Get Heartburn?

    1. 1. Did Cavemen Get Heartburn? Norm Robillard Ph.D. Founder, Digestive Health Institute
    2. 2. What is heartburn & GERD? GERD: Chronic acid reflux. Acid Reflux: When stomach contents escape past the LES – causes irritation. Reflux Symptoms: Heartburn, cough, sour/bitter taste, sore throat, hoarseness, sinus irritation, gas, bloating, nausea, LPR. Long Term Health Risks: Esophagitis, Barrett's esophagus, esophageal cancer.
    3. 3. PPIs and H2 blockers Block the production of stomach acid • Inhibit the absorption of vitamins, minerals and nutrients • Lead to weakened bones and fractures of hip, wrist and spine – osteoporosis, calcium absorption hindered in the absence of acid • Linked to pneumonia • Linked to C diff (Clostridium difficile) • Cause and perpetuate SIBO • Cause dangerously low magnesium blood levels (hypomagnesaemia) - FDA warning • Don’t address the underlying cause.
    4. 4. Underlying cause of Acid Reflux Conventional • Relaxation of LES from alcohol, trigger foods (TLESRs) New concept • Carbohydrate malabsorption promotes small intestinal bacterial overgrowth (SIBO - >106 bacteria per mL) • Bacteria produce gas (Hydrogen, Carbon Dioxide, Methane) and intragastric pressure • Drives reflux – like Mentos in Coke bottle • LES is “forced” open.
    5. 5. Evidence SIBO causes Reflux  Restricting the growth of intestinal bacteria reduces the symptoms of reflux1,2,3  Reflux can be created experimentally with FOS (Gas, TLESRs, Symptoms)4  Reflux is associated with increased gas pressure in the stomach (and fundo side effects)5,6  Health conditions associated with malabsorption and SIBO are linked to Reflux7,8,9  SIBO has been detected in GERD patients10
    6. 6. Worst offenders for SIBO  Fructose  Lactose  Fiber  Sugar alcohols  Amylose starch (resistant starch)
    7. 7. Fermentation Potential (FP) Formula GI = Glycemic Index NC = Net Carbs (g) DF = Dietary Fiber (g) SA = Sugar Alcohols (g)
    8. 8. FP Recommendations  FP recommendation for single meal ◦ 0 to 7 grams - low ◦ 8 to 15 grams - moderate ◦ > 15 grams - high  FP recommendation for single day ◦ 20 to 30 grams – low ◦ 30 to 45 grams – moderate ◦ > 45 grams - High
    9. 9. Did Cavemen get Heartburn?  Occasionally ◦ Lots of plants - some high in fructose, fiber and RS ◦ Periodic food poisoning likely  Protective ◦ Adapted to diet – unlike the “everything all the time” (SAD diet), balanced microbiome ◦ No antibiotics or preservatives (more diverse microbiome) ◦ Periodic fasting - gut healthy, prevents SIBO ◦ Seasonal diet
    10. 10. How about modern Foods?
    11. 11. Comparing Rices for FP Food (GI) Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Jasmine Rice 5 0 Low Glutinous Rice 5 3 Low Basmati Rice 5 17 High Brown Rice 5 19 High Uncle Bens Rice 5 20 High
    12. 12. Comparing Fruits for FP Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Watermelon 4 2 Low Cantaloupe 4 4 Low Grapes 4 11 Moderate Banana, ripe 4 15 High Banana, green 4 18 High Dates 2 4 Low Apricots 2 23 High
    13. 13. Comparing Tubers for FP Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Pontiac Potato 5 4 Low Parsnip 5 5 Low Taro 5 6 Low Russet Potato 5 7 Low Ontario Potato 5 13 Moderate Sweet Potato 5 21 High
    14. 14. Comparing Dairy for FP Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Mozz cheese 2 1 Low Plain Yogurt 8 7 Low Sweet Yogurt 8 23 High Cream 8 2 Low Whole milk 8 8 Moderate Chocolate milk 8 18 High
    15. 15. Comparing vegies for FP Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Spinach 3 2 Low Tomatoes 3 3 Low Broccoli 3 4 Low Avocado 3 6 Low Squash 3 6 Low Corn 3 9 Moderate Plantain 3 16 High
    16. 16. FP values for Grains / Legumes Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Pasta (rice) 6 5 Low Pasta (wheat) 6 28 High French baguette 1 1 Low 7 grain bread 1 9 Moderate Course Rye 1 14 Moderate Soy beans 5 11 Moderate Kidney beans 5 31 High
    17. 17. Comparing drinks for FP Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Coconut milk 9 0 Low Rum, whiskey, vodka, gin, etc. 1 0 Low Lite beer, dry wine 12, 7 2 Low Non lite beer 12 6 Low Orange juice 9 14 Moderate Apple juice 9 18 High
    18. 18. FP values for meats, fats and seafood Food Serving Size (Oz) Ferm. Potent. (G) Symptom Potential Beef, pork, chicken, etc. 6 0 Low Fish, shellfish 6 0 Low Lard, talow, ghee, butter, oils 3 0 Low
    19. 19. Clinical study of Fast Tract Diet heartburn symptoms
    20. 20. Clinical study of Fast Tract Diet gas related symptoms
    21. 21. References 1. Yancy WS Jr, Provenzale D, Westman EC. Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief cased reports. Altern Ther health med. 2001. Nov-Dec; 7(6):120,116-119. Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006 Aug;51(8):1307-12. 2. Pennathur A, Tran A, Cioppi M, Fayad J, Sieren GL, Little AG. Erythromycin strengthens the defective lower esophageal sphincter in patients with gastroesophageal reflux disease. Am J Surg. 1994 Jan;167(1):169-173. Pehl C, Pfeiffer A, Wendl B, Stellwag B, Kaess H. Effect of erythromycin on postprandial gastroesophageal reflux in reflux esophagitis. Dis Esophagus. 1997 Jan;10(1):34-37. 3. Mertens V, Blondeau K, Pauwels A, Farre R, Vanaudenaerde B, Vos R, Verleden G, Van Raemdonck DE, Dupont LJ, Sifrim D. Azithromycin reduces gastroesophageal reflux and aspiration in lung transplant recipients. Dig Dis Sci. 2009 May;54(5):972-9. 4. Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, Cuber JC, Galmiche JP. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease. Gastroenterology. 2003 Apr;124(4):894-902. 5. Dodds WJ, Dent J, Hogan WK, Helm JF, Hauser R, Patel GK, Egide MS, Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N. Engl J Med. 1982. Dec 16;307(25):1547-52. Lin M, Triadafilopoulos G. Belching: dyspepsia or gastroesophageal reflux disease? Am J Gastroenterol. 2003 Oct;98(10):2139-45.
    22. 22. References 6. Vakil N, Shaw M, Kirby R. Clinical effectiveness of laparoscopic fundoplication in a US community. Am J Med. 2003 Jan;114(1):1-5. Klaus A, Hinder RA, DeVault KR, Achem SR. Bowel dysfunction after laparoscopic anti reflux surgery: incidence, severity, and clinical course. Am J Med. 2003 Jan;114(1):6-9. Beldi G, Gláttli A. Long-term gastrointestinal symptoms after laparoscopic Nissen fundoplication. Surg Laparosc Endosc Percutan Tech. 2002 Oct;12(5):316-9. 7. Ledson MJ, Tran J, Walshaw MJ. Prevalence and mechanisms of gastro-oesophageal reflux in adult cystic fibrosis patients. J R Soc Med. 1998 Jan;91(1):7-9. Vic P, Tassin E, Turck D, Gottrand F, Launay V, Farriaux JP. Frequency of gastroesophageal reflux in infants and in young children with cystic fibrosis. Arch Pediatr. 1995 Aug;2(8):742-6. Fridge JL, Conrad C, Gerson L, Castillo RO, Cox K. Risk factors for small bowel bacterial overgrowth in cystic fibrosis. J Pediatr Gastroenterol Nutr. 2007 Feb;44(2):212-8. 8. Lisowska A, Wójtowicz J, Walkowiak J. Small intestine bacterial overgrowth is frequent in cystic fibrosis: combined hydrogen and methane measurements are required for its detection. Acta Biochim Pol. 2009;56(4):631-4. 9. Nastaskin I, Mehdikhani E, Conklin J, Park S, Pimentel M. Studying the overlap between IBS and GERD: a systematic review of the literature. Dig Dis Sci. 2006. Dec;51(12):2113- 20. 10. Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clin Gastroenterol Hepatol. 2010 Jun;8(6):504-8
    23. 23. “No Disease That Can Be Treated By Diet Should Be Treated With any Other Means.” -Maimonides