 Hi everyone, so today we'll be talking about gut immune function how to balance our ancestral genome with our modern-day environment for optimum gut and immune health and I think when you look at this issue from the perspective of the immune system You start to see why I've made some recommendations that have been counter to What you may hear in other places and this is because I think one of the things that's been left out of the picture Is looking at how our immune systems are formed? and how our immune systems are not hunter-gatherer immune systems So therefore creating a hunter-gatherer gut may not be a great idea because the immune system and the gut may not get along And i'm going to expand on that posit here throughout the body of the talk today So here's the outline we'll go through Replicating ancestral dietary and lifestyle practices can clearly be helpful claims suggesting otherwise are clearly not taking into account all the data two Some ancestral practices are mismatched with our genome or i'm sorry mismatch with our immune systems and can make people ill Creating a gut environment suitable for the immune system may involve a reduction of some seemingly healthy foods Point four imbalances in the microbiota are sometimes adaptations to protect the host Attempting to force change to these imbalances can be damaging Five Overtesting is one of the most damaging practices in natural functional or complementary and alternative medicine And a sound process can be used to optimize one's gut and immune system health. So let's jump in The point one let's Expand on this slightly All diets that reduce process foods and focus on whole fresh foods can improve health It's important that we're clear on this Any diet that's a shift from a process food laden standard american type diet Shows health benefit in clinical trials. It doesn't matter if it's vegetarian Mediterranean akins paleo They all tend to work Now comparative trials have found many of them have found that paleo or low carb diets often have a slight edge But the effect size Is minimal significant but minimal meaning taking weight as one parameter Low-carb diets produce more weight loss But oftentimes the effect size in terms of the difference between a vegetarian diet for weight loss and a low-carb diet may only be three pounds So they do work better But they all work and this is important to keep this in mind. So we don't have dietary dog mind, right? And we are a little bit open-minded And some other things that have been helpful outside of a a ancestral type diet, which would be a paleo-waste type of diet Fasting we could argue that's something that falls in the ancestral paradigm Sleep and I mean sleep according to Sarcadian rhythm and also good sleep hygiene a dark room and I just see dan party sitting down So he's the godfather of that um Also time in nature As shown to have health benefit for example Observational trials have clearly shown that people that live in blue zones or green zones Oceanic or forest type environments have a lower all-cause mortality And walking has been shown to be arguably the foundation of fitness making sure we get enough steps And this may be because it's more important to have a large amount of low-level activity Rather than a short Punctuated burst of high-level activity, right? So this fits back to the ancestral paradigm, right? So all this supports that many ancestral practices are health promoting So that's an easy point to substantiate. Let's move on to point two And this is what where we get a little bit more controversial Some ancestral practices are mismatched with our immune systems and can make some people ill So let's develop this Now the foundation that's important to understand here is that much of the immune system is programmed in early life They have done studies where they've shown That the earlier antibiotics are administered 12 months 9 months 6 months 3 months the earlier they are administered the more damaging they are Conversely the same thing holds true with probiotics The earlier they are administered the more beneficial they tend to be And this can even mean for when someone is a teenager or In adulthood the effects of early life programming are are somewhat locked in for the perpetuity of your life C-section and breastfeeding has either a negative Positive impact depending on if your natural bird then your breast feed that's protective if your cesarean bird and your bottle fed That's a detriment And also living on a farm Has also been shown to be health promoting Now The challenge can be if a non hunter-gatherer immune system is presented with a hunter-gatherer type environment that can be Detrimental and a quick side point. I'm using the term hunter-gatherer diet diet loosely And the context here is There there's been some excitement with the Research in the microbiota and I spoke about this at the last ancestral health symposium Much of this research is coming out of areas that eat a relatively higher carbohydrate fiber and prebiotic diet And so an erroneous assumption is being made That a paleo diet needs to be a higher fiber prebiotic and carbohydrate diet So i'm saying i'm using this term Hunter-gatherer diet a little bit loosely because you could argue against that as I did in my presentation last year And we'll expand on that more in just a moment But I want to bring you down to where it says examples Of non hunter-gatherer immune systems not doing well with a hunter-gatherer like diet or gut Interestingly if a child grows up on a farm, it's protective against many Allergic or inflammatory disorders But if they visit a farm that can actually cause a flaring of inflammatory conditions like allergies atopic dermatitis So this is this was a big observation for me that opened my eyes to the fact that If you have a non hunter-gatherer immune system, and then you try to force yourself into a hunter-gatherer environment that may not jive Continuing a low fob map diet which reduces foods that feed bacteria Actually shows impressive clinical benefit for many people Also a low histamine diet has shown some impressive clinical benefit for people with various health ailments Now although fob map diet reduces foods that feed bacteria, although histamine diet reduces many fermented foods That we harp on as being so health promoting and they can be health promoting, but they may not be for all people So this supports The statement I made a moment ago essentially this is a paper by cordane where they surveyed hunter-gatherer diets worldwide and to quote Most 73 of worldwide hunter-gatherer societies derived over 50 of their energy from animal foods Whereas only 14 of these societies derived over 50 from plant foods Okay High reliance on animal-based foods coupled with relatively low carbohydrate content of wild plant foods so This is supporting the my contention which is Not everyone needs to be on a higher prebiotic higher carbohydrate diet It's not saying everyone should be on a ketogenic diet All right, don't don't take a counterpoint me meaning that we have to swing all the way to the other extreme But clearly there's evolutionary evidence showing that being on a high carb high prebiotic diets is not going to be helpful for many people Now I want to just show this study really quick because you may hear that and think Oh, so does this mean everyone should be on a low carb diet? No, this study essentially showed better weight loss when going on a high carb diet for Asian women So again, we need to get away from this model of thinking About one thing being the best all the time This is the only way to do it because that doesn't really help people It confuses people because then you hear one camp saying to do this another camp saying no do that People read all this stuff. They don't know what to do and they feel paralyzed right So let's continue developing my main contention Creating a gut environment suitable for the immune system may involve a reduction of seemingly healthy foods Again, so much of much of creating a suitable environment for one's health does involve Recommendations that we're all probably accustomed to paleo diet sleep time and nature walking However, it can require also the reduction of seemingly healthy foods I made the example of low FODMAP and low histamine. So let's develop these In this study entitled dietary guidance normalizes large intestine endocrine cell density in patients with irritable bowel syndrome They took I'll just I'll read it here for you The study included 13 patients with IBS and 13 controls the patients received three sessions of individualized dietary guidance on the low FODMAP diet Both the control subjects and the participants were scheduled for colonoscopies at baseline and again At three to nine months after dietary guidance Biopsies were taken from the colon and rectum and were immunostain for all types of large intestinal endocrine cells The daily total consumption of fruits and vegetables rich in FODMAPs decrease significantly from 16 grams before dietary guidance to nine grams after conclusion The density of large intestine endocrine cells tend to normalize Following dietary guidance in this case a low FODMAP diet and may have contributed to the improvements of the patients with IBS symptoms And this is some of their data here They're essentially showing the main change here was an increase in serotonin cells in the colon so we get so Obsessed with the fact that a low FODMAP diet may cause a decrease of bacteria in the gut and freak out because We've heard that bacteria are so important, but it may not all be about the bacteria We may be causing an improvement in the endocrine cells in the intestines that are responsible for serotonin release And serotonin is important for not only nociception, but also for motility And this may be why the low FODMAP diet works well But you get confused when you try to make the recommendation based upon mechanism the mechanism is Bacteria are good So a low FODMAP diet must be bad because the low FODMAP diet decreases bacteria This is why I've repeatedly said you should not make clinical recommendations based upon mechanism You should look at clinical data when you look at clinical data The low FODMAP diet is very effective for IBS and IBD, right? So outcome always trumps mechanism Does that make sense? Yeah, okay So you may be saying to yourself, but what about the small intestine? Maybe you've heard me talk about how important the small intestine is And how the small intestine is oftentimes left out of this conversation Another study has been done changes in duodenal. So small intestine Enteroendocrine cells in patients with irritable bowel syndrome following dietary guidance The densities of enteroendocrine cells are abnormal in patients with IBS However, they tend to change toward normal levels in the stomach, ilium and colon following dietary advice The aim was to identify types of duodenal and enteroendocrine cells affected after receiving dietary guidance, again low FODMAP, in this group of patients In conclusion, the densities of several duodenal and enteroendocrine cells in IBS change toward the values measured in control subjects following dietary guidance The changes in serotonin and somatostatin cell density may have contributed to the improvements in IBS and particularly pain in diarrhea So now we're showing, not only in the colon, but also in the small intestine you can have improvement in cells that secrete things like serotonin So while, yes, the low FODMAP diet may decrease bacteria, that may not be a bad thing because we may see an accompanying improvement in some of the wiring and some of the hormones in some of the cells in the intestines in patients who go on a low FODMAP diet But wait, there's more A low FODMAP diet has also shown the ability to decrease leaky gut as assessed by LPS, lipopal saccharide And another study showing, and this I think is very key Metabolic profiling of urine showed groups of patients with IBS differed significantly after the diet And this is a low FODMAP diet again, as you see there With three metabolites, histamine, p-hydroxybenzoic acid and azelaic acid being the primarily responsible for discrimination between these two groups Histamine, a measure of immune activation, was reduced eight-fold on the low FODMAP diet Again, I don't want to paint myself as a low FODMAP fanatic, right? But it's important, I feel like I'm one of the few people saying Hey, maybe not everyone needs to try to feed their bacteria And you see this, if you work with patients and you're objective And you're not married to a particular philosophy, you clearly see that bacterial reducing approaches Work far superior for many patients with IBS, with IBD, and other food sensitivities, health ailments, gut involvement, what have you Again, it's not to say that low FODMAP is the diet that every patient in my office gets in a dogmatic way But it's important that we're familiar with some of this information Because I don't think it's getting the attention that it deserves It's coercing us into this thinking that everyone needs to be feeding their gut bugs when I don't think that's really supported Oh, and one more So in this study, concomitant prevalence of low serum, diamine, oxidase activity, and carbohydrate malabsorption 20% of patients showed histamine intolerance, making it as common as lactose intolerance in this group Abdominal pain, bloating, and diarrhea are some of the leading symptoms associated with histamine intolerance Histamine is a signaling molecule in the gut, not only in the gut, but it's involved in the immune response Now, when people have overly zealous immune systems, especially in their gut, they will have a predilection toward high levels of histamine Although FODMAP diet can lower histamine by eight-fold So what does that tell you? It tells you that somehow, by decreasing bacterial load in the gut, you are calming down the immune system Does that make sense? Low FODMAP and low histamine diets, though, call on one to restrict foods that we often times associate being the beacon of healthy diets So it's important that we understand this because by understanding this, we can get people to recommendations that will be more beneficial for them In this study? So this study essentially took patients that had been non-responsive to other IBS therapies and they assessed them for things like fructose intolerance, lactose, malabsorption, histamine intolerance, and they essentially found about just under a third of patients had histamine intolerance, making about as common as lactose intolerance All right, so it's important that we understand this So yes, these are IBS-type symptoms, abdominal pain, bloating, and diarrhea being very abdominal pain and altered bowel function being the two most predominant symptoms associated with IBS So let's review Normalization of intestinal and enteroendocrine cells can occur on a low FODMAP diet and these cells are responsible for the release of serotonin and somatostatin We also see with a low FODMAP diet a normalization of immune activation via reduction of a leaky gut and reduction of histamine Are we all on the same page? You guys with me on this? Yeah, okay Now, I do have a clinical newsletter For anyone in the audience or listening to this who is a clinician who wants to get more into this because I do think it's important that clinicians are aware of this information We've done a number of case study write-ups in our clinical newsletter So, and this is one of them I'm not going to go through this case study but if you go to that URL there Dr. Ushua.com slash review You can access case studies where we go through What does histamine intolerance look like? How does it present clinically? And how do people respond? I'll tell you one of the most common flags is when someone says the healthier I eat the worse I feel That's a that's oftentimes a flag for histamine intolerance because they what are they eating? They're having lots of soups and bone broth or they're having lots of fermented foods Right and these things can be very problematic for people that are histamine sensitive So they keep trying to eat these foods because the community keeps harping on how healthy they are and they can be healthy for many people but for people who have this immune dysregulation in the gut that can actually make this subset of people worse As I said earlier antimicrobial therapy is oftentimes more effective than promicrobial therapy and this is very important for us to understand Low FODMAP, low carb, low histamine, herbal antimicrobials or antibiotics if you look at all of the literature I'm not saying that there's one cherry-picked study but if you look at the evidence at large and you weigh it those therapies are generally more effective than higher FODMAP diet, higher carbs, prebiotic supplementation and fiber Again, for some not for all right so this is not an absolute but you do see a trend in the data when you look at the clinical trials there tends to be more benefit for antimicrobial strategies than promicrobial strategies The more symptomatic someone is the the iller you are the more important this is the more likely you are in my observation to do better with antimicrobial approaches rather than pro-microbial approaches Now what about probiotics? Probiotics are more likely to be net antimicrobial amongst other things than they are pro-microbial They most probiotics do not colonize you They've been shown to reduce SIBO combat Candida and fungus and assist in the clearance of H. pylori and various protozoa So we oftentimes don't realize that by taking a probiotic we may actually be taking a pseudo-antimicrobial Doesn't colonize you and kill stuff in the gut right? Elemental diets can also be very helpful As you continue down the spectrum of people who are progressively more ill or more more challenged with their diet or their gut health Elemental diets which are essentially hypoallergenic liquid diets that have essentially zero fiber and probiotics in them can be very helpful for these highly sensitive patient subgroups And ironically at least one study showed the ability of an elemental diet to somehow increase microbial diversity in the small intestine Now why might that be? How could something that starves bacteria increase diversity of bacteria? Because what's probably happening is by starving bacteria you're calming down the immune system and it's the immune system attacking the bacteria in the gut that's causing the low diversity to begin with When you calm down the immune system you reduce the insult on the microbiota and allow the microbiota to then flourish Does that make sense? Now this is maybe a slightly off topic but I think it's worth mentioning When all else fails and we can't create the right environment in a gut for the microbiota we can replace the microbiota so if you can't fix it you can replace it and this is where FMT can come in and I just want to touch on this briefly This is a retrospective analysis of 406 patients who underwent FMT and they've listed here or I've listed here for you from the study the cure rates and the improvement rate So RCDI recurring clostridium difficile infection 85 percent versus 95 percent you know cure rate and improvement rate Now that probably doesn't apply to many people here but constipation may 40 percent cure rate 67 percent improvement rate ulcerative colitis 34 percent 68 percent IVS 47 percent 73 percent and Crohn's So we see some hopeful benefit here for people that fail out of all other therapies but I want to be clear in saying this is something that should be reserved for people who fail out of all other therapies not I read two books on gut health and now I'm going to do a FMT you should definitely get yourself to a highly skilled gut doctor like myself or someone else who knows what they're doing and have them help you before you think about doing an FMT Also here I'm cautious with this regarding IBS because IBS is extraordinarily prone to placebo effect So this is a systematic review with meta-analysis showing again benefit of about 45 percent for IBD I think the next FDA approved condition that FMT will be sanctioned for will be for inflammatory bowel disease because the data is there But this is why I caution adverse events do occur a systematic review of adverse events in contrast the incidence of serious adverse events were 2 percent and 6 percent for upper and lower gastrointestinal administration routes A total of 44 kinds of serious adverse events occurred in 9 percent of patients including death in 3 and a half percent infection in 2 and a half percent relapse of inflammatory bowel disease in 0.6 percent in clostridium difficile infection So it's not to say this therapy is not without its risks and this is why I get admittedly irritated when I hear people talking about this being the next weight loss cure and oh my cousin's skinny can I just do an FMT with her poop and lose weight I mean come on Okay so review Anthemicrobial therapy often more effective than pro-microbial therapy If no therapies work we can replace the microbiota 4 imbalances in the microbiota are sometimes adaptations to protect the host attempting to force changes to these imbalances can be damaging Just a few things here I hope you can yeah you can see that Okay all right So treatment of diabetes improves the microbiota They did nothing but gave type 1 diabetics insulin and the microbiota improved Is that possible? Yes it's possible because the health of the host is the environment for which the microbiota lives and if you improve the environment you improve what lives inside of you Type 2 diabetics going on a low carb diet saw an improvement of their microbiota as their blood sugar became more normal Exercise has been shown to correlate with the healthy microbiota in fact cardio respiratory fitness in one study predicted microbial diversity and another study tracked changes from sedentary to active and showed that as you exercise and improves the health of your microbiota So this this thinking that the microbiota is the cause of all disease and treating the microbiota is is the next miracle is really ill founded and you're taking this from a gut geek if anybody wants it to be true it's me right but it's not it's not true certainly improving your gut health can be a miraculously helpful intervention but trying to custom manipulate your microbiota to do what you think it should do doesn't really pan out Vacuuming using a sponge So one study showed children that grow up in households that use a sponge have a lower incidence of allergic diseases compared children growing up in houses that use dishwasher probably because of the residual bacteria in the sponge So another thing in your environment that can affect your microbiota The frequency of vacuuming has also been shown to affect your microbiota So we need to get away from these things thinking that if we if we show a change the microbiota we're going to be able to do so much it's a little silly and even a calorie reduction improves the microbiota in obese subjects probably because the calorie restriction diet improved metabolism in these subjects Another study showed a reduction of carbohydrate improved thyroid autoimmunity and what's more important here is that 80% of these patients express signs of carbohydrate malabsorption So again coming back to this thinking that feeding the gut with carbs and prebiotics may not always be the best thing to do Anti-inflammatory drugs also increase the diversity in the gut microbiota and I would speculate the same thing would occur with anti-inflammatory herbs Now why is that? It's likely because the anti-inflammatory drugs are toning down an overzealous immune system that's attacking the microbiota So the diversity may not be the cause of the disease it may be a result of the disease the disease being an imbalanced immune system And now developing this further prebiotics caused inflammation and a doubling of symptoms but a healthier microbiota So let's pick into this Effective varying dietary content on fermentable short-chain carbohydrates on symptoms, fecal microenvironment and cytokine profiles in patients with IBS Study of purpose to evaluate the effect of a low FODMAP diet compared to a diet high in prebiotics on IBS symptoms and related co-morbidities They tracked IBS symptoms, general health symptoms GI microbiota, short-chain fatty acids and cytokines So essentially here the intervention they took a bunch of patients they put them on a low FODMAP diet Then they kept them on a low FODMAP diet one group took a placebo the other group took a prebiotic and then they switched groups Here's what they found There was a significant improvement in all IBS symptoms after three weeks on a low FODMAP diet and overall patient satisfaction of 85% Those on a low FODMAP diet also expressed a significant improvement in belching, passing gas, nausea, vomiting and fatigue Here's the key piece When transitioning to either placebo or FOS fructillary saccharides, a prebiotic 80% of those on the placebo maintained their improvement whereas only 30% of those who started taking a prebiotic maintained their improvement Went on a prebiotic patients experienced a worsening of nausea, vomiting, headache, belching and passage of gas Additionally cytokines a reduction in inflammatory cytokines was noted in those on a low FODMAP diet but not for those on the prebiotic Now the microbiota paradoxically became slightly more dysbiotic what we think is dysbiotic I think we still don't really know what a dysbiotic microbiota truly looks like and the short chain fatty acids decreased So we see some things that may be considered bad but my argument would be that we don't know how to truly label a dysbiotic microbiota yet so I totally discount that and short chain fatty acids decreasing is not always a bad thing because you do see elevated short chain fatty acids in some subgroups patients with IBS may have elevated short chain fatty acids patients who are obese may have elevated short chain fatty acids So if you go back to the erroneous thinking via mechanism short chain fatty acids good therefore if I increase short chain fatty acids people become healthier do you see how quickly that can get you into trouble we should look to clinical data to make decisions not speculate based upon mechanism There's also the bifidobacterium paradox another reason why we should not make decisions based upon mechanism the low FODMAP saw a decrease in bifidobacterium but people felt a lot better Ironically though, bifidobacterium is one of the most beneficial supplemental probiotics in the IBS literature So again, it's why we shouldn't be speculating for mechanism Okay, so to improve the health of the host or by improving the health of the host we can improve the microbiota treating diabetes, exercise, stress hormone support these can all reduce inflammation or I'm sorry and reducing inflammation can all improve the microbiota a dye that discourages bacterial growth can benefit the host it can reduce inflammation and reduce symptoms this may occur while becoming quote unquote dysbiotic and maybe accompanied by less short chain fatty acids neither one of these may be a bad thing and I'll be brief here because I'm a little over time over testing is one of the most damaging practices in natural functional complementary and alternative medicine the state of functional medicine excessive and expensive there's a belief that more testing equals better results this is simply not true there's a belief that more treatment equals better results this is simply not true and information has become a form of marketing you can take a mechanism and you can find a mechanism to support whatever it is you're trying to sell lab tests supplement whatever it is but you can't do that with clinical data which is why I always come back to the evidence-based pyramid where we should be making our decisions based upon high-quality clinical outcome data when it's available and in gastroenterology we have a wealth of data available empiric medicine has been forgotten we've been sold a bill of goods that this fancy functional medicine testing holds the key to becoming healthier and it preys upon the desperation of sick patients and the fear of doctors not being able to help their patients and it's really wrong and it does a lot more harm than it does good what's needed is a return of practical and cost-effective care which is progressive but also conservative I'm growing increasingly concerned that's what's happening at least two times a month I have a patient come in from another clinic where they were required to do $3,000 worth of testing or more on day one and this doesn't even include the consultation visit or what have you again, more testing does not equal better results and a few examples not needed at all in my opinion adrenal testing, food allergy testing microbiota mapping many functional GI markers like certain enzymes, fecal fat, shortening fatty acids, obscure inflammatory markers and most gene testing often not needed initially expanded thyroid panels, Lyme, metals, mold, and female hormone assays this is a big difference between or this is a difference between, for example, $4,500 worth of testing out of the gate and $800 to $1,200 of testing out of the gate now if you have insurance these totals will all be a little bit less but these things make a big difference but I know someone who did a microbiota mapping assessment and felt better on fiber and prebiotic supplementation great but you didn't need the test to do that right so the flawed assumption the gut is important so perform microbiota mapping then use specially tailored diets, prebiotics and fiber and probiotics and this is simply not true it wastes time and money and I think worsens care if we are treating markers that are meaningless what are we doing? we're wasting time we're wasting money and we're potentially harming someone and just as a quick aside I was lecturing at the international symposium on natural medicine in Australia a few months ago I was there with Professor Rob Knight and we were both on a question and answer panel and he's sitting right next to me and someone asks Dr. Russo do you use microbiota mapping like American gut and new biome in your clinic sitting next to the guy pretty much invented this testing and I said I really don't because it's just not clinically relevant and I was so pleased to see Professor Knight the guy when it comes to this nodding his head in agreement as I'm saying this and essentially being completely in agreement so take it don't take it from me if you want to take it from the guy who has pioneered this work the microbiota mapping is not ready for clinical practice it's just not so if you're doing that test I would ask you kindly to stop and just to realize that hey sometimes you think something's going to help when we learn more we realize I guess that wasn't really helpful so we can just change doesn't doesn't mean anything bad or foul play but if you're trying to treat something that does not have meaning you are making the clinical process harder because you've introduced a meaningless variable into a already variable rich process does that make sense and I've seen patients I'd say there's a small contingent of patients that I see who've gone to doctors and the doctors have treated their microbiota mapping test results instead of treating the condition or treating the patient and what happens oftentimes to put it simply someone with IBS or IBD goes to see a doctor they poop in a cup they have low diversity ensuing of bacteria so they're given a bunch of fiber prebiotics and probiotics and guess what the clinical literature shows people who take prebiotics and fiber have the the highest adverse event that's reported is a flaring of gastrointestinal symptoms so what do you think happens to these patients they get worse and the doctor goes huh that's weird you know your diversity was low I'm trying to feed your diversity you were low on this bacteria so I gave you this bacteria they're not getting that there's there's not clinical data substantiating that has any effect and that's why they're not getting any better okay so last slide or last couple of slides a sound process can be used to optimize one's gut health and immune system this will be outlined in my coming book healthy gut healthy you it'll publish in February but here's a brief overview start with the ancestral paleo type diet and lifestyle those who are mostly improved from this are good candidates for prebiotics and fiber they may obtain additional benefit from this those who do not will most likely need to visit reduction strategies autoimmune paleo low carb low FODMAP low histamine probiotics robolenthalmicrobials potentially even pharmaceutical antibiotics then later reintroduced to see how much they can tolerate and how much benefit they obtain from feeding strategies this group B may need occasional trimming of the shrubs guys some conditions have a natural ebb and flow a natural remit relapse remit relapse and it doesn't mean that the world is ending all right if you've had a musculoskeletal injury like a knee injury you may notice every once in a while it flares up a little bit right you have to take it easy do your stretches do your rehab whatever and then it gets better same thing happens in IBS and an IBD and in SIBO all right and it's unfortunate people read on the internet that you can never get rid of SIBO and it always and that guys it's not really how this works the analogy I like to use is think about the shrubs the bushes outside of your house they grow and then something just trim them and then they grow and you trim them again it doesn't mean that you need to rip out your shrubs right so there are some people that I think don't have good ability to keep the the the shrubs trimmed because their immune system may not be highly attuned at doing that or they may have certain genetic polymorphisms and so they need to occasionally visit something like a couple of days on an exclusive elemental diet or a short low dose gentle course of antimicrobials or a low FODMAP or low histamine diet right to kind of keep that proper environment in the gut and there's nothing wrong with that and we should stop painting that as SIBO is this chronic condition you can never clear because of auto immunity in the gut it's it's just way it's too much okay so getting off my soap box improvement gut health is not a cure all but it's a great place to start why GI problems can manifest solely as non-GI symptoms fatigue pain depression skin lesions and so you may be chasing down what you think is hypothyroid and it's actually not it's actually a problem in the gut more in-depth testing and treatment has a time and a place but we've become way too exotic with our approach more does not equal better the resources for you the link from my book was published in February the link for the training newsletter which is active and the website there with podcast articles videos and I'll open it now for questions and thank you guys for your time and your attention