Evolution of Gastroenterology

In anticipation of this month’s Functional Forum: Reversing Digestive Disorders, we bring you this special Podcast: Evolution of Gastroenterology, featuring integrative gastroenterology expert Dr. Ronald Hoffman

This presentation was given in 2014 at the Evolution of Medicine Summit, and is chock-full of digestive health and root-cause resolution clinical tips and tools for today’s functional medicine practitioner.

Tune in now to learn from one of functional medicine’s celebrated digestive health pioneers, including:

  • The connection between the GI tract, the GU tract, the urinary tract, sexual organs (specifically in women), the neurological system, the brain, mouth, nose and throat
  • An incredible story of a woman who was diagnosed with Parkinson’s Disease, only to find out gluten was the real culprit behind her symptoms
  • Key clinical clues into gut-related ailments and skin issues
  • What types of tests Dr. Hoffman uses to check for gut issues
  • The importance of developing “local environmental resistance” to create optimal gut ecology
  • Clinical insights on causal factors behind IBS, IBD, ulcerative colitis, leaky gut syndrome, SIBO, and more

And for more on the latest in functional gastroenterology, be sure to join us for this month’s Functional Forum: Reversing Digestive Disorders, LIVE from Washington, DC.

Will you be in the DC area Monday, October 1? Click here to get 2 free tickets to the LIVE show using the coupon code “Dutch”, courtesy of our sponsor: Precision Analytical.

Resources mentioned in this podcast:

Functional Forum: Reversing Digestive Disorders

 

James: So today we’re talking about the evolution of gastroenterology. Now, some people, particularly any gastroenterologists that are listening, might be a little bit surprised to know that you’re not actually a gastroenterologist. Why do you feel like in terms of the evolution of medicine that it’s relevant for a non-gastroenterologist to be speaking on this topic?

Dr. Hoffman: Well, I think the analogy might be is it appropriate for a member of one particular political party to speak on the political scene in America. I think that if you are a gastroenterologist, you may have a little bit of tunnel vision about the potential for gastroenterology to influence all systems of the body, and also a little bit of a tendency to be invested in some of the tried and true therapies of that field such as prescribing lots of acid-blocking medication, for example.

James: Okay. And so would you say that your perspective on the gut is more in terms of its influence on the other systems? I mean, how do you feel that, if I say the evolution of gastroenterology, what do you see looking forward from what you’ve seen in your twenty-five years?

Dr. Hoffman: Well, I’m the consummate generalist. I’m trained in internal medicine. I do medical nutrition, but I see the gut as being very central to just virtually everything that’s going on in the body. A lot of what happens in the brain, a lot of what happens in the joints, in the skin has its origin in the gut. So we can’t really compartmentalize. Unfortunately, in medicine we see the gastroenterologist and we see the dermatologist and we may see the neurologist and it’s that kind of fragmentation that sometimes leads to problems.

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James: And so if we look at the major things that are going on with the gut, I mean, it seems like digestive diseases are probably the core focus of the gastroenterologists. What do you see as sort of the causes of those diseases? If we’re looking at evolution, we really want to look at these causes. What do you see as the causes of the majority of these digestive and gastrointestinal diseases?

Dr. Hoffman: Well, the gut that we have is not designed for the environment that we live in from a variety of standpoints. It’s a gut that was designed for certain types of foods that the vast majority of us don’t consume anymore. It’s also a gut that is designed for microbes that we do our best to eradicate. Literally, from cradle to grave we’re fighting against microbes. And that’s good because in some ways we would succumb to many infectious diseases. But the trade off is that we’ve dramatically altered the composition of the gut. And we’re coming to recognize the key word, microbiome. The microbiome is so influential in so many aspects of our health.

James: So, if you were a gastroenterologist in school let’s say ten, twenty years ago, what would you have missed if you obviously probably wouldn’t be learning that much about microbes at that point. This is a new science, is that right?

Dr. Hoffman: Well, it’s new. But it’s also very old because I believe it was in the early 1900s that Eli Mechnikov won a Nobel Prize for talking about the microbiome. He was a big proponent of natural cultures, of yogurts, to replenish that GI tract. And that concept got a little bit lost because we kind of got enamored of high tech medicine, of the new powerful drugs that were at our disposal, and lost our way a little bit, I think, in our global understanding of what’s right for the body.

James: Has the gastrointestinal tract become even sort of simplified and split up itself? It seems like you have specialists for the top of the tract and the bottom of the tract. It’s really one pipe, right?

Dr. Hoffman: Well, absolutely. And problems higher up affect lower down. And also there’s an intimate relationship between the GI tract and tissue that’s very close. The GU tract, the urinary tract, the sexual organs particularly in women. There’s also a relationship with the mouth, the throat. And ENT doctors. It’s getting so that ENT doctors when patients come in and say, “I’m hoarse. I have a little congestion or tightness in the throat.” They’ll say, “Take an acid-blocking medication because that’s gastro reflux.” So they recognize that there’s a close interplay.

James: So can you maybe just give an example from your time as a clinician where you’ve had an issue that’s come up in a completely disparate part of the body from the

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gut and worked on the gut and then there’s been a full resolvement of that case without need for medication or ongoing medication?

Dr. Hoffman: I have a very interesting case of a woman who came in with a bizarre neurological condition. She literally came staggering into my office. She was actually a very, very celebrated yoga teacher here in New York with a fantastic clientele until she developed this debilitating neurological disease that caused her to stagger. And she was initially diagnosed with Parkinson’s disease. But she was rather young for that in her early fifties. And then they said, “Well, it seems like you have Parkinson’s disease. But this is atypical Parkinson’s disease.” Long story short, they began treating her to Parkinson’s disease with very little benefit.

James: What does that look like, treating for Parkinson’s? Because from listening to someone like David Perlmutter, the treatment for Parkinson’s disease is really just anti- medication to stop the symptoms.

Dr. Hoffman: To stop the shakes, yes. Yeah, various types of medications that may slow the progression or relieve symptoms. But ultimately don’t change the course of the disease. So we evaluated her. And one of the things that I look for—and I look to Dr. Perlmutter as an important mentor—is gluten sensitivity. And, in fact, she didn’t just have minor gluten sensitivity, she had full blown celiac disease. And upon elimination of the gluten, her symptoms got about fifty percent better.

Now, you may say, “Well, your proposition was have you seen total resolution with some sort of crucial GI intervention?” And the problem is once you’ve had a neurological condition that has developed over the course of perhaps decades, it’s very hard to reverse some of the damage that’s been done. Literally your nervous system may have been poisoned by some of the immune factors that are generated by celiac disease that traverse the gut wall and go into the systemic circulation and then ultimately hit the brain and the nerves.

James: So once you do damage to the brain and the nerves, it’s very difficult to sort of rehabilitate that.

Dr. Hoffman: Some of it is irrevocable, but, however, remarkable improvement. And she was very grateful for the insight that every day she was literally poisoning her nervous system.

James: So, that’s one way of interacting with the brain. I know you’re also quite bit – I’ve been following your intelligent medicine podcast and so forth. You’ve been very

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interested in psychobiotics, which is effecting the function of mental health or the brain through interventions in the gut. That, to me, just screams the evolution of medicine because there’s no way that a neurologist is thinking about the gut or that these types of specialists are communicating.

But it seems obvious that given that the body is almost a perfect example of wholism, of different systems working together, it seems that the evolution of medicine will have a big focus on now these disparate specialties working together and thinking together.

Dr. Hoffman: If you have a toxic gut, that toxicity may manifest early as a general sense of malaise or even what might be described as depression. And so it may be true that altering your GI microbe composition may make you happy or at least alleviate something that’s pulling downward on your mood.

James: That’s so interesting. And so beyond the brain, you mentioned skin earlier. I was just actually speaking with a doctor recently whose husband is a dermatologist. And the tough cases that he gets, he sends to her. And then they clean up the diet and things sort of mysteriously disappear. The skin seems to be another big axis with the gut. How is that interaction happening biologically?

Dr. Hoffman: Yeah. The most classic example of that is in celiac disease—which we recognize as a gastro problem where there’s inflammation of the gut characteristically due to gluten—one of the cardinal manifestations of that, a key sign, is a condition called dermatitis herpetiformis. Now, if you are familiar with Latin or Greek—I don’t even know where the root comes from—but herpes, herpetiformis…In other words it, has a little form of herpes on your skin.

There’s little sort of herpes-like bubbles that appear on your skin due to gluten consumption. And the theory is that various types of immunological factors get generated because of the clash between the gluten and your own immune system. They circulate through your bloodstream. They’re deposited in the skin. And, lo and behold, you’ve got skin problems.

Look, that’s a dramatic example, a classic example, one that’s recognized by medicine. But there’s so many other examples. For example, acne or eczema. Too often the gut- skin connection is ignored. Or the food-allergy-skin connection is ignored. Food allergies can effect the gut. Foods that are improperly digested pass through what is called a leaky gut. This is a very important concept now in medicine is that the permeability of the gut, normally it keeps bad things out like microbes and allergens, but it absorbs good things. So you want actually the proper balance between good absorption and

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keeping the bad things out.

With a leaky gut, it’s almost like there’s this onrush of toxic elements and allergenic elements into your systemic circulation. And then the possibilities are endless for various types of symptomatic problems. Head to toe, organ system to organ system, you could have problems.

James: I think that is the most important thing that we will discuss in all of this is that if we’re only looking at medicine in terms of symptoms, how would we know whether these disparate versions of symptoms are all coming as a result of this one cause which is just this break in the mucosal lining, this break in the gut lining and yet the symptoms could be anywhere.

If we’re only waiting for symptoms to occur and dealing with their symptoms, we’re never going to get back track there. It seems like starting with the gut is really the only starting point when you’re getting these chronic symptoms coming up. Is that typical of your strategy and practice to start working on the gut as sort of a primary measure?

Dr. Hoffman: Well, very much so. So we’ll check patients for leaky gut. There are tests that can tell us whether that’s present. We’ll also look for food intolerances that can trigger inflammation in the gut. We may check the status of the bacteria in the gut to see if there’s a normal balance. If there are good bacteria or, conversely, if there are harmful bacteria there.

And this goes back to the 1980s, we recognized a condition called candida or the yeast connection, which I think was sort of a foresight about how things would develop now in the 21st century. Twenty or thirty years ago people were talking about candida or a yeast problem. I think a more sophisticated way to look at it is that yeast and other harmful microorganisms create a toxic brew in your intestinal tract, creating various forms of problems.

James: Would you say that the future of gastroenterology, it seems like you need to be more like an ecologist rather than a specific gastroenterologist. It’s really an ecology down there. It’s an ongoing development like habitat.

Dr. Hoffman: Well, yeah, it kind of goes to the way that we do agriculture or the way that we do warfare in America. If you think back to the Vietnam era, the strategy to defeat the North Vietnamese was to defoliate the country. And in so doing, we destroyed the country. We created a lot of ecological devastation. But we didn’t win the war and left a terrible legacy. Similarly, we take the strategy, find a bug, use a drug. We try to

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eradicate harmful bacteria. If there’s gastrointestinal symptoms that we attribute to acid, we block the acidity.

But, to your point, we really need to pay attention to the integrity of the ecology or the ecosystem that keeps healthy because if we take care of one aspect of it, but we damage the ecosystem then the health goes downhill. And unfortunately, I see a lot of talk about this. And I see a lot of research.

But there’s such a lag time in the adoption of these strategies by most doctors. Most doctors are very harried. They have to treat symptoms. They have to give patients immediate relief. And also many patients don’t want to make lifestyle changes. So, unfortunately, we’re not seeing this type of medicine become mainstream. It’s certainly a lot of people demand it, look for it. My patients do. But the major medical paradigm in America I’m concerned is moving in the wrong direction.

James: Well, I hope with this summit, and the other things that we have going on, Dr. Hoffman, is that more and more people will understand this is really a rational framework for dealing with a chronic set of symptoms. And so I definitely applaud your leadership in this and sort of being ahead of the curve. But I hope that the adoption is improving.But what I do see is that more and more people are starting to realize that they can actually affect their own health with their lifestyle choices which is encouraging.

So if we just go back to sort of the biochemistry and the physiology, what is an ideal environment for optimal health? If we go from mouth to colon, what would be an ideal environment that means that the gut is doing what it’s meant to be doing, which is obviously right digestion, immunity, metabolism? What’s happening through that and what will you see as an ideal environment?

Dr. Hoffman: Well, one suggestion that I’ve made—a little bit tongue in cheek—was be born in a manger. That doesn’t necessarily mean that you’re the Son of God. It means that you’re born in an environment where you’re exposed to certain pathogens. And literally you’re exposed to barnyard animals as humans were over centuries and millenia of evolution because we interact healthfully with many of these microbes.

You know, the human immune system, it’s a little bit like when you get a new computer or when you get a new iPad. It’s get a lot of potentiality. But if it had every single program that you could possibly have already on it, it would be the size of an eighteen- wheeler. So that’s why it’s got a lot of potentiality. That’s like the human immune system because otherwise we’d have to be born with a huge amount of extra tissue to program resistance.

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So what we do is develop resistance to what’s in our local environment. And so, if you’re born in Mexico City, it’s one thing. If you’re born in New York City, it’s another. If you’re born in Mumbai, it’s another. So, this eliminates redundancy. But, in order to program your immune system, you have to be exposed to certain things. Also you have to not instantaneously eradicate every infection that a child has. The tendency now to reach for the antibiotics at first instigation. Pediatricians are getting better about this. But still parents demand it. It’s a lot of anxiety. Kids get a lot more meds than they need. We destroy their helpful bacteria.

James: So a solid sort of a deep combination of microbes all the way down through the gut is important. How about the permeability of the gut itself? Like, what stuff should be getting through and what stuff shouldn’t?

Dr. Hoffman: Well, one big mistake—here’s another big mistake that we make—if you want to screw up your intestinal permeability, take a lot of pain killers, particularly aspirin and non-steroidal anti-inflammatory drugs, things like Advil and Motrin, because those drugs are known the cause ulcers. But even if they don’t cause an ulcer, they may cause little microscopic fissures in your gastrointestinal tract, literally giving you leaky gut.

Now, I recently saw a kid who’s a very promising young college football player who’s developed ulcerative colitis. And I took the history and then I said, “Well, what are some of the things that happened right before?” Well, he was taking a lot of antibiotics because he’d had some sinus infections. And, oh, by the way, he plays football. He’s had some injuries. So virtually every day during practice he would pop a few Advils because the coach said, “Hey, you want to get loose? You want to feel okay when you’re hitting the tackling dummy? Go ahead and take some Advil.” So literally he created a leaky gut situation.

I’m not saying that we can always go back in time and trace the origin of the disease. But that’s the perfect storm for developing problems. Add a little stress, freshman year away from home playing in a big college football team, and you’ve got a perfect storm to create ulcerative colitis.

James: Yeah, that’s such an important story for me, hearing that because one of my best friends from school, I think same exact thing, rugby.

Dr. Hoffman: I knew you were going to say rugby because you being from—

James: Yeah, so he played rugby. He was a great player. And I think there was a few

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things that maybe contributed to it. But he was certainly in a rugby position where you’re getting hurt all the time. And I would say that he basically had exactly the same thing as this guy except instead of walking into Dr. Hoffman’s office, he’s walking into a regular NHS hospital and two days later is having three feet of his colon removed.

Dr. Hoffman: Yes.

James: If that guy had walked into another hospital, is that the plan that most people would have done with ulcerative colitis? Is that the plan?

Dr. Hoffman: Well, that’s the end stage. You wage war strategically against ulcerative colitis starting with mild medications and then steroids and then powerful immune suppressive drugs. As a very last resort they say, “Well, the colon. You can survive without it. We’ll just remove it and things will be fine.” The problem is that I see a lot of people after they’ve had their colon removed, and their problems are not over. So, it’s not like—

James: Right. You’re just starting new problems. What is the net long-term effect of not having that part of your colon I mean in terms of absorbability of nutrients and so forth? It seems like there’s obviously a reason why that’s there, and you’re taking it out.

Dr. Hoffman: Clearly. It’s like, “If thine colon offend thee, pluck it out.” And there’s another condition that I think really needs recognition. It’s called SIBO, which is small intestine bacterial overgrowth. First there’s the esophagus, the stomach, then the small intestine, which is really not so small. It’s about ten or twelve feet. And then there’s the large intestine, which in colitis is affected and can removed, so they say, without consequences.

But the small intestine should not have any bacteria. And when bacteria migrate from your large intestine where they belong into your small intestine then you start getting symptoms. You get gas, bloating, cramps, and this is a condition that afflicts tens of millions of Americans. We make it worse with acid-blocking medication. I can’t tell you how much damage these medications do. And so many doctors when patients ask, “Well, how long do I need to be on this?” And the doctor says, “Mmm, for the rest of your life. It’s fine. No problem.” Well, there are a lot of problems associated with disrupting your digestion via total destruction of your acid environment.

James: So there’s that many people using it. Could you just explain for everyone out there, what is the perceived or intention of the mechanism that’s being used when they take an acid blocker and what does it do? Like why do millions of people trust it? And

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then what are the long-term consequences that are happening from doing that?

Dr. Hoffman: Well, if I were to grab your hand and say, “Here, I’ve got some potent hydrochloric acid here. And I’m going to drop this on your palm,” after a few drips and drabs of that, your palm might start to sizzle. So the notion is that simply if you have gastrointestinal burning, pain, irritation, or even an ulcer, that by eliminating the acid, there’s sort of a neutral environment there. And there won’t be any additional damage and that healing will occur. That is the case occasionally. And I do prescribe these medications.

The problem with this is these medications are the ideal drugs for the pharmaceutical industry because once you’re on them, you get hooked. And I’m not talking about you get high hooked. But you become dependent on them because once you remove these medications, your acid doesn’t just go back to normal. It surges to unprecedented levels. And so a lot of people going off them, trying to go off them, they have terrible distress. And they say, “Well, I guess I really need to be on this medication.” They don’t really need to be on the medication. It’s just that they’ve had acid rebound. And so this is a very, very insidious problem.

James: Acid rebound. Is that a technical term or is that one of yours?

Dr. Hoffman: No, indeed it is a term because you suppress your acid. And correspondingly, your body says, “Well, gee, there’s no acid. We’ve got to make some acid. We’ve got to make some acid.” When you take away the medication, it’s almost like you’ve let go of a rubber band and snap! You’re going to get a reaction and a hyper acidity situation, which convinces you or your doctor that you really need to be on these medications for life.

James: Yeah. That’s very worrying. And I see that across quite a few drug categories, actually.

Dr. Hoffman: Indeed. Headache medications characteristically. Many drugs.

James: Panic, you said?

Dr. Hoffman: Headache medications.

James: Oh, headache, ok.

Dr. Hoffman: And certainly psychiatric medications, very much so. Yeah.

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James: It’s a great business model.

Dr. Hoffman: Recently there was a guy named Kevin Trudeau who was convicted of fraud. And then because he didn’t pay this huge settlement that he owed the government, they’ve now thrown him in prison. And his analysis of the situation—which was repeated endlessly on infomercials and late night TV—was that drug companies are trying to deprive us of natural remedies intentionally so they can sell us more drugs.

And I have to say that that may be the subtext or the unintended consequence of their business model. I don’t really believe that the drug companies are out to deliberately undermine the health of Americans so that they can profit more. I’m not a conspiracy theorist along those lines. But the net effect is that using drugs that people become dependent on is not ultimately in their interest and is a great business model because the use of drugs is self-perpetuating.

And I don’t think that some diabolical plan has been developed. I just believe that that’s the consequence of how we’ve evolved. Look, it’s a profit-oriented system. And the media is very, very prey to the commercial influences of the pharmaceutical industry. Same thing with medical school. In medical school, our learning was basically underwritten by the pharmaceutical industry.

James: When were you in medical school?

Dr. Hoffman: In the 1980s. So it’s even worse now. So doctors should be trained to be critical consumers of what’s out there. They should say, “Okay, look. Here’s the nutrition. Here’s the natural therapies. Here’s the pharmaceuticals. We’ll utilize them as appropriate for our patients.” But, often the orientation is here’s the disease, here’s how you treat it. Boom, boom, boom. This is the protocol. Follow the protocol. If you deviate from the protocol, it’s bad practice, malpractice.

James: Not evidence based.

Dr. Hoffman: No tevidence based and so on. And then you get ostracized from or even sued or lose your license. This is the way it is.

James: What we actually see probably across all of these things, it’s like short-term gain versus medium- to long-term loss. That’s really what we’re talking about with these kind of things, right? Because there obviously has to be a short-term gain in order to become evidence-based.

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Dr. Hoffman: Yeah. However, even the system by which we base evidence is subject to a lot of concerning features because much of the research is drug company sponsored. Much of the research that shows inefficacy of drugs is buried. Studies that show that this drug doesn’t work, well, let’s not publish that study. Let’s deep six it. And sometimes the data is not even accessible to people who want to find out, “Well, what went wrong with that drug?” “Well, sorry. That’s proprietary.”

James: That’s a real mess. So we’ve started sort of at the top, and we’ve looked at acid and stomach and so forth. If we go a bit further down the GI tract towards the large intestines when we mention SIBO, what are some of the other things that millions and millions of Americans and people in all industrial economies are dealing with further down the gut?

Dr. Hoffman: Well, you travel further down, you get irritable bowel syndrome, IBS. You get diverticulitis or diverticulosis. Colin Burkitt illustrated it very nicely in the 1960s…He was a British surgeon who kind of got tired of slicing and dicing people. And he kept saying, “Gee, maybe there’s a way that we can avert all this surgery.” It got pretty routine to take out people’s intestines. So he said, “Let’s do some further research.” He traveled down to Africa. And he discovered that the diseases that were rampant in England were virtually unknown in Africa because, well in those days, many decades ago, they had not yet suffered the ravages of the Westernized diet. More and more Africans are beginning to suffer from degenerative diseases.

James: Yeah, well, they’ve got McDonald’s in Cape Town now.

Dr. Hoffman: Well, big time. But also in the so-called developing countries, their diets have really deteriorated. They’re not indigenous diets anymore. And so, for example, if you were a med student in Rwanda, you would be reading a textbook that probably was published in London. And you’d be reading about diseases like ulcerative colitis and colon cancer and diverticulitis.

But you would remark, “Gee, I’ve never really seen a case of that” if you were a doctor in Rwanda. But, actually, Colin Burkitt remarked that when he was down there in one of these underdeveloped countries, the only person who ever suffered colon cancer that he ever encountered was himself a doctor, a doctor who was of that country who was affluent enough to consume a Western diet and develop colon cancer.

James: Yeah. That makes a lot of sense. One of the things I think is a huge, huge part, with my sort of quasi-medical education—if you’d call it that—has really become through understanding the body as a flow system. That was Hans Heinrich Reckeweg talked

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about the body is a flow system. And if you just go back to all of it, it seems like the real flow, the major flow is this GI flow from mouth to colon. And his thoughts were that a lot of these stagnation diseases were just being caused by essentially a blockage in the main part of the flow, essentially constipation. And I see that. You know, it’s funny as a Brit growing up because fart jokes and feces jokes and whatever is, you know, the classic British—

Dr. Hoffman: I thought that was a German thing.

James: Well, a lot of people find it funny, but the British particularly. But I think the British, it’s also this like embarrassment and fear and shame and guilt and those kind of things. And it seems to be all interwoven with GI stuff. How important is a good flow at that end of bowel movements? And what are the causes that you see being the symptoms as a reflection of that flow being suboptimal?

Dr. Hoffman: This goes back to medical school. Already in medical school I had an interest in natural medicine. I already knew I wanted to be a nutritionally-oriented—in those days—the word holistic physician. I learned pretty quickly that one way to the key to success in medical school was to learn this stuff and not necessarily to attend every lecture because not all lecturers were good. And you could learn this stuff, pass your test.

But I saw a lecture on the schedule entitled diarrhea and constipation. And I thought, “Wow, that’s actually something very tangible. That’s something that I could really learn from.” So, I went to the lecture. I showed up. And the lecture began by polling the audience, medical students, “How many of you have three or four bowel movements per day?” A few people raised their hands. “How many of you have one bowel movement per day?” People raised their hands. “How many of you have a bowel movement every other day?” A few people raised their hands.

“How many of you have like two bowel movements per week?” And people raised their hands. And he said—and I’ll never forget this—he said, “You are all normal.” And I just shook my head vociferously. And I said, “That’s not right!” Because there is such a thing as optimal intestinal transit because those who might be having two bowel movements per week were courting the risk of intestinal toxicity. They had slowed down transit. And that’s not good. And that may be a sign of a very low fiber diet or a destroyed microbiome in their intestinal tract. So, you know, optimal elimination. I mean, this is the way that we eliminate toxins from our body. It’s a very, very important part of optimal health.

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James: Yeah, it’s amazing. You know, it’s funny you say the word toxins because I think as holistic doctors or people in this, people say, “Oh, what are these toxins? These mystery toxins.” But we’re talking about metals and chemicals. There’s a lot of toxins out there.

And I was at a lecture last year at the IHS on microbiome. And they were saying that between fifty, but more like ninety percent of all of the toxic metals that come out of our body come out through the feces. That’s the way that the body does it. That’s the microbes working in tandem. This seems like a hugely important way for toxicity to move out. And if you don’t have that there, that’s the first time that now toxicity is touching tissue essentially, right, if it’s not moving consistently?

Dr. Hoffman: Right. I mean it’s clearly an elimination pathway for the body, but it’s also your gut is like a chemical toxic factory potentially.

Let me give you an example. A guy was found to be drunk, uncoordinated, and inebriated periodically. And his wife was a nurse. For some reason he was staying at home. And his wife was going to work. And she would come home and he’d act disoriented. And she said, “You’ve been drinking again.” And he said, “No, I’ve given up drinking. I’m not drinking.” She says, “I can tell you’ve been drinking and to prove it, I’m going to give you the alcohol breath test.”

She had a device that she borrowed from the hospital, brought it home. And he blew very, very high DUI levels of alcohol from his breath. She says, “Look, there’s no sense in hiding it from me. Where are the bottles?” He said, “Look, I’m not drinking.” So, look, she says, “We’re going to go to the hospital. And I’m going to consult with an expert in the hospital. And we’re going to get to the bottom of this.” And so they told the story.

The guy said, “Look, there’s only one way to resolve this. We’ll put this guy in a metabolic ward where he’s absolutely locked down. He will have no access to alcohol. Then we’ll test him.” And after three days, they tested him. And he was blowing phenomenal levels of alcohol. And the conclusion was that it was from his gastrointestinal tract. He was literally autointoxicated.

And this was written up in a major medical journal as a short brief communication. So what was the treatment? They gave him antifungal medication because we know that if you want to make wine, beer, any kind of alcohol, you just need some yeast and some kind of fermentable carbohydrate and boom! You’ve got alcohol, ethanol.

James: Do you think that would stand up in a court of law for myself or anyone who I

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know in the future who happens to get a DUI?

Dr. Hoffman: That’s a good idea. I’ll have to think about that. You know, I have a couple of patients who are should we say law enforcement officials. And they give me their cards, their sort of get out of jail cards. And they say, “If you have any trouble when you’re in Long Island, give me a call.”

James: But, yeah, I like that defense. So what that’s essentially saying is that this ecology down there in the gut is capable of producing a lot of chemicals. There’s a lot of things that could happen.

Dr. Hoffman: Right. Not just that but a myriad of chemicals. That’s just one very obvious chemical that we can measure. But aldehydes and various putrescant byproducts of abnormal digestion.

James: Putrescent is a great word. And it’s quite onomatopoetic in the way of sort of understanding a smell that may come. Would you say that a smell of the bowels is sort of like a lead indicator of overall health?

Dr. Hoffman: Well, you know, Tibetan medicine is largely based on smelling stuff and tasting stuff. Hopefully not tasting stool. But I had the opportunity to shadow an eminent Tibetan doctor, the doctor to the Dalai Lama—his name is Yeshi Dhonden— many years ago. And when he saw patients, he would ask them to produce a urine sample. And he would smell it. And then he would, to my utter horror, taste it, dip his finger in and put it on his tongue.

And the smell of the skin, he would smell the patient. “Open your mouth, bad breath and all. Let me have it.” And this was one of the ways where in that system of medicine, very ancient system of medicine, they were able to come up with diagnoses. But now they’re coming up with this new idea that they will have devices that will actually be able to smell diseases. You know, dogs can smell cancer. Dogs can be trained to recognize certain cancers. They’re saying, “Well, let’s use an electronic device that has an ultra- sophisticated nose that can detect the smell of, say, diabetes or the smell of certain cancers.”

James: That is amazing. And that is amazing particularly in the context of this evolution of medicine where, in some ways, you know, can you just talk from your experience a little bit here and GI focused or otherwise, you said you’ve been with Tibetan medicine and there’s Chinese medicine. There’s all of these other systems of medicine that sort of it seems as though western medicine sort of poo pooed and laughed at because it wasn’t

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sophisticated. But it seems like pieces of this are sort of coming back into medicine. And one of the things I sort of think about is like we have no idea how long these medical systems were around for. And it seems like if one thing they had going for them is that they were sustainable. And so in the same way that an acid-blocker might be good in the short-term, but poor in the long- and medium-term, it seems like western medicine if you take a step back is good in the short-term and maybe not so good in the short- term and the longer-term and medium-term.

And that’s the reason why, hey, perhaps for the first time ever in America, certain segments of the population are not living as long. We thought we’d be living until 150 or 200 twenty years ago. And we can map the genome and all this stuff. And it’s just not happening. What do you think that medicine as it evolves can learn from these other systems of medicine that we’ve probably sort of maybe a bit arrogantly looked at without too much respect? What can we learn from them?

Dr. Hoffman: Well, an admission here: when I was in college, I had absolutely no idea that I wanted to go to medical school. It was the farthest thing from my mind. I was studying cultural anthropology. And one of the tenets of cultural anthropology is that you go into the field with an inquisitive and open mind. And you look at the practices of the individuals, as absurd as they might seem to the Western eye, and you try to understand their functionality and their usefulness or lack thereof because not everything that people do makes sense.

But from that perspective, I derived a great deal of respect for ancient practices, alternative practices, natural health systems that weren’t science-based, but were empirically-based that kept people sustained for the vast majority of our existence as homo sapiens. You know, we look at the tip of the iceberg. The scientific revolution has been going on for what? Maybe 200 years. In medicine perhaps 150 years. And the practices that we use are science-based, but they’re very novel. And we have sort of a cultural or scientific hubris that makes us believe that somehow they are superior to ancient or unscientific practices that really deserve more attention.

James: Yeah, and integration. I think I’ve heard already a number of people say, Andrew Weil always says you’ve got to do Western medicine well. You’ve got to do this medicine well. And just deliver good medicine. And it seems like that’s sort of the evolution that we’re moving towards is taking the best of things and combining them together. So if we were to look at from that perspective of gastrointestinal, what do you see as sort of like the optimal gastrointestinal health or relationship with a doctor or strategies for the myriad of the types of diseases that we see today?

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Dr. Hoffman: I think there will always be a place for gastroenterologists who utilize high-tech methods to detect disease. They can scope people six ways to Sunday and find out where the problem is. And there’s a need for medications for people who are super sick because I say to some patients who come in very sick with GI problems, they want a natural cure. And I say, “Look, if your house is one fire, we’re not going to have you talk about fire prevention. We’re going to go in with high pressure hoses and axes, chop down the door, flood your home. But we’re going to put the fire out. And that’s so you can survive.” So there’s a place for that.

On the other hand, I think there is in gastroenterology in particular, but I think this is something that all integrative physicians can use. And no question that chiropractors, naturopaths, nutritionists, are all very turned on to this, not just holistic MDs and DOs. The importance of diet, the primacy of sustaining the microbiome, being a little bit of a what I sometimes I feel like I’m a little bit of an arbiter between conventional medicine and the patient in the sense that the patient comes in and says, “Well, look, they say I need to take this.” And I go, “Well, you know, if you just took this natural therapy, you might be fine. You don’t really need it.” Or in some cases, like, “Look, don’t delude yourself. You really do need to take medication.” So I think there’s a place for gatekeepers to protect people from the excesses of medicine to come up with lower-tech or more natural approaches.

James: Yeah. There’s a couple of things that I’d like to get into because I really would like to get into the microbiome stuff at some point. But I know that just on that what you’ve just spoken about, one of the books that I’ve read that you wrote is called How to Talk to Your Doctor. And I know although there’s probably a lot of people on this line today who are listening who are thinking, “I know that I can change my diet and improve my health, but my doctor doesn’t necessarily feel like that way.” And they sort of maybe hide things from their doctor, or they do that.

What would you say, what are some of the basic strategies in that book by which people can have a more open and honest dialogue about the kind of things that we’re speaking about today? Because I know that there are people that are addicted to acid blockers. I know there are people addicted to laxatives. And these are not sustainable strategies. But the doctor says you’ve got to be on them. You’ve only got seven minutes to communicate to them. Like how do we go about having a more open, honest, and mutually-respectful relationship with our doctors to help the doctors move along this course, as well?

Dr. Hoffman: Well, I think you have to establish some ground rules for how you’re going to interact with your doctor. Always be respectful, and always be not

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confrontational. But say, look, you’re interested where possible in natural approaches, in low-tech approaches, in preventive approaches. And where necessary you’re willing to listen. And then assess your doctor’s reaction. If your doctor says, “Look, my way or the highway. That stuff is all bunk. It’s garbage. It’s fraud,” then you have to vote with your fee. You really do. I don’t expect all doctors that you’ll encounter to say, “Hey, that’s great. I’m all for these natural therapies.” That’s a little bit too much to hope for.

Some might. But the vast majority will say what you’re aiming for is a doctor who will say, “Look, I don’t know that much about these natural therapies. But if you bring me the information and you keep me apprised of what you’re doing, I’ll be happy to supervise your use of these approaches. However—” and the doctor will tell you this, “— if I think you’re going down the wrong path, I will speak up and inform you.” I mean that’s more of a balanced approach to this.

James: That does sound balanced. And you bring up something that I think is so important is voting with your feet, generally. And it’s almost voting with your feet, but it’s also voting with your dollars. You know, people are frustrated by the paradigm of what they see out there of the foods that are available in certain areas. We’re in New York. It’s very lucky. You can get basically anything you want at any time of the day.

But, in most places, I used to live in Georgia. And I know that it was difficult to get the right kind of healthy food choices. You had to be very proactive about it. So this idea of voting with your feet and voting with your dollars, what do you think is the most empowering way for patients to start to change some of these habits?

Dr. Hoffman: Well, you know, I think you have to look at diet, exercise patterns. I think it’s important to inform yourself from reliable sources. Some of the sources aren’t reliable. I think a good place is to start out with information that comes from well-vetted sources. I would consider you a good curator of information. I’m guilty of self- promotion. Forgive me, but the Intelligent Medicine podcasts are, I hope, a source of useful information. You can get them at DrHoffman.com.

And a lot of people I think empower themselves. And this is sort of a grassroots movement to some extent. You know, a lot of the stuff that we do that’s good for us is not government sanctioned. It’s not sanctioned by corporate America. It’s not sanctioned by establishment figures in our lives. But things that we do maybe locally in our community to help friends, families, others who are less fortunate, many of the best efforts are grassroots efforts that aren’t necessarily coming from some centralized bureaucracy with edicts.

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James: Well, one of the things that’s encouraging in a certain way, and this is not the way that we all like it to happen, but so many people are starting to, one, get these symptoms that their doctor can’t help and, two, make these changes by themselves, use the Internet, get different information in, see improvement. It’s almost like we now have a sort of fertile place for people to be able to make these kind of changes. Because just think back thirty years ago, there’s no way that all this information you could get it. Where were you going to get it? The library? I mean this is not—

Dr. Hoffman: Remarkable changes have occurred.

James: So easy.

Dr. Hoffman: Yeah.

James: So, yeah, DrHoffman.com/podcast is the Intelligent Medicine podcast. There’s a lot of great information on there. I think those are some great starting points.

Let’s just go through these different areas that we’ve spoken about and talk about some of the natural ways that you’ve seen to be effective. So let’s start at the top. Like the combination of GI and ear, nose, and throat things, acid blockers, the stuff that’s going on there. What are the kinds of things that you’re using in the practice to work with those kind of issues?

Dr. Hoffman: Well, if you’re on acid blockers, don’t go off them very quickly. You need to taper slowly. So I think many people and sometimes doctors make the mistake of saying, “Okay. You can go off now.” So taper slowly. Utilize products like DGL, which is deglycyrrhizinated licorice. It’s important that the licorice be deglycyrrhizinated because too much licorice will raise your blood pressure. You don’t need that component to soothe the esophagus and the stomach. And you can take these little lozenges and chew on them all day long. You can have eight or ten or twelve a day. And it’s very soothing.

You can use aloe vera gel, not the juice, aloe vera gel taken away from meals. That’s very healing. A product that I like to use, and it’s unfortunately not available retail. It’s available through doctors. It’s called Endefen. And it’s a mixture of plantain and other mucilaginous substances that’s very soothing to the esophagus. We heal a lot of GERD, reflux, and gastritis symptoms with that product.

And then probiotics, of course. But, the key is diet change. And, you know, even people who are on a “healthy” diet. You know, they’re eating like granola, skim milk, and lots of fruits and vegetables and juices, they may have a lot of gurgling and reflux. They might

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find that they do better when they reduce their carbs and have more in the way of animal protein, I find.

James: Yeah. Well, we’re going to have a lot of discussion about diet. And I know that you have your own views on that. And other people think very differently.

Dr. Hoffman: Huge controversy.

James: Yeah, it’s a controversial area. But I think the one thing that you would probably agree with is that people are different. People are going to work out different ways. And they need to be in a relationship with a doctor, a functional medicine doctor or someone like that, who can help them to go through and try out different things until they find something that’s sustainable for them.

Dr. Hoffman: Exactly. A lot of it is trial and error and different strokes for different folks.

James: Okay. So, we’ve got just about ten minutes left here. And I want to get into a little bit of this microbiome because it’s so valuable to think a little bit about this because let’s just give the example of gut infection. So we’re talking about GI diseases. The moment that I saw that fecal transplants were the cure, this amazing cure, for these chronic infections like C-difficile, which were antibiotic resistant, I knew that the game was up as far as like our regular understanding of the germ theory and how germs are sort of causing disease. Can you just give a quick overview for people at home about what these new types of treatments are? Because it’s really a super probiotic, isn’t it? Feces in the gut.

Dr. Hoffman: Right. Okay, caveat: this is not yet ready for primetime. It’s being done in very strict research protocols. And my general advice is don’t try this at home. The yuck factor is very high here. But the point is that when people have very, very disrupted microbiomes, there’s probably as many different types of species of bacteria in your gastrointestinal tract as there are stars in the sky. So taking one probiotic or taking even a combination of probiotics—eight, ten, twelve different things—it’s still not going to replete you and restore you to normalcy. So that’s the principle behind fecal transfer or transplants.

It’s been helpful in very, very serious diarrhea problems like C-difficile. Some studies have been done in ulcerative colitis and Crohn’s disease. And that’s hopeful. The problem is how are you going to commercialize this? I really fear for the lack of impotence to get this on stream because all the money, all the commercial emphasis

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and our current paradigm is to find a very niched drug which can be patented and that we’ll miraculously block this or that or the other pathway and change the immune system. So how are you going to monetize donating feces? I’m not sure.

James: Well, the gift economy is certainly starting to arise. So I’ll be generous with mine. I’m not sure if I’m exactly…I think we need to find the healthiest people.

Dr. Hoffman: Oh, you must have great flora! I think your flora’s probably—

James: I’ve not had that much antibiotics. I think that’s probably a good starting point. Yeah, you bring on to an interesting topic there which is sort of this what’s cheap versus what works and the future of medicine as far as the proliferation of things that don’t make money. I know this is another topic that you speak about a lot, just sort of like the war on natural medicine and so forth. What are your sort of hopes and fears for the next five years in American medicine? What do you fear will happen and what do you sort of hope will happen?

Dr. Hoffman: Well, I see real problems occurring. Especially, Obamacare, whichever political party you adhere to. It just happens to be that the current administration is holding the ball of on the demise of American medicine that’s been occurring for a really long time. And there’s going to be a point of reckoning where it’s going to undermine the health of Americans, destroy our productivity, and also just destroy our economy the way we’re allocating money with expensive solutions for problems that might be more amenable to lower-tech, cheaper solutions and prevention.

But what’s going to happen, I think, just like physical fitness, Americans are getting fatter. However, the physical fitness movement is burgeoning in America. More and more Americans are getting healthy. I think it’s going to be maybe an enlightened minority of Americans who opt for healthier styles of health management that will lead the charge that hopefully…I mean, I’m very uncertain about the way things are going to go. I think there may be a real crash and burn that’s required. You know, it’s like in addiction theory, you got to hit bottom before you can begin your twelve-step program.

James: Yeah. Well, I think that’s definitely the direction that we’re headed, unfortunately. But if you’re on the more hopeful side, what signs do you see that we’re moving towards a more sustainable medical system that the evolution of medicine is occurring?

Dr. Hoffman: Well, there’s just an explosion in the number of practitioners offering this type of medicine who are well-trained, well-informed. I see that coming from my field –

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medicine, MDs. But, naturopaths are really a very important force in this country providing this type of information. They’re well-trained, very scientifically-based. Chiropractors have a lot of this information at their disposal. So, there is a phalanx of health practitioners, nutritionists who are not just pushing Jell-O in hospitals and Ensure and Boost. But nutritionists who have functional medicine understanding are really making a difference. Particularly, here, we’re talking New York, San Francisco, Denver, Boston, points of light in kind of a dismal American scene.

James: Yeah. Well, it’s definitely proliferating. And that’s one of the reasons I started Revive Primary Care is I just felt, look, there are enough of these practitioners around. If you have the right person to find these people, it’s a great starting point. And having one of these practitioners, however they’re credentialed, alongside your current medical care seems to be synergistic.

Dr. Hoffman: That’s the way to go. That’s the way to go.

James: Yeah. And other things that we’re trying to do in this Summit is really start to talk about how doctors can work with coaches, how doctors can work with nutritionists, how to get communication in medical structures because I think that this is really what it’s going to take for everyone to work together.

And I think what you’ve outlined today is a great vision for the future of gastroenterology. And if the future of gastroenterology looks like this, I think the knock on effects to the rest of the body will be huge. In the same way that a toxic gut leads to all kinds of other symptoms, a healthy gut or a revitalized gut will certainly lead to improvement in lots of other areas. And I see this coming all the way through.

So, yeah, thanks so much for your time and being here today, Dr. Hoffman. You can find Dr. Hoffman’s podcast is the Intelligent Medicine podcast. It’s at DrHoffman.com/podcast. Great guests all the time and actually just an unlimited or just a history of all of the podcasts that you’ve been doing for a long time with great people on there. And I’ll look forward to coming on again soon. Thank you so much for being here today.

This has been The Evolution of Medicine Summit, a great session on the Evolution of Gastroenterology. And I’ve had Dr. Ronald Hoffman here. Thanks so much again, doc.

Dr. Hoffman: My pleasure!

If that guy had walked into another hospital, is that the plan that most people would have done with ulcerative colitis? Is that the plan?

Dr. Hoffman: Well, that’s the end stage. You wage war strategically against ulcerative colitis starting with mild medications and then steroids and then powerful immune suppressive drugs. As a very last resort they say, “Well, the colon. You can survive without it. We’ll just remove it and things will be fine.” The problem is that I see a lot of people after they’ve had their colon removed, and their problems are not over. So, it’s not like—

James: Right. You’re just starting new problems. What is the net long-term effect of not having that part of your colon I mean in terms of absorbability of nutrients and so forth? It seems like there’s obviously a reason why that’s there, and you’re taking it out.

Dr. Hoffman: Clearly. It’s like, “If thine colon offend thee, pluck it out.” And there’s another condition that I think really needs recognition. It’s called SIBO, which is small intestine bacterial overgrowth. First there’s the esophagus, the stomach, then the small intestine, which is really not so small. It’s about ten or twelve feet. And then there’s the large intestine, which in colitis is affected and can removed, so they say, without consequences.

But the small intestine should not have any bacteria. And when bacteria migrate from your large intestine where they belong into your small intestine then you start getting symptoms. You get gas, bloating, cramps, and this is a condition that afflicts tens of millions of Americans. We make it worse with acid-blocking medication. I can’t tell you how much damage these medications do. And so many doctors when patients ask, “Well, how long do I need to be on this?” And the doctor says, “Mmm, for the rest of your life. It’s fine. No problem.” Well, there are a lot of problems associated with disrupting your digestion via total destruction of your acid environment.

James: So there’s that many people using it. Could you just explain for everyone out there, what is the perceived or intention of the mechanism that’s being used when they take an acid blocker and what does it do? Like why do millions of people trust it? And

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then what are the long-term consequences that are happening from doing that?

Dr. Hoffman: Well, if I were to grab your hand and say, “Here, I’ve got some potent hydrochloric acid here. And I’m going to drop this on your palm,” after a few drips and drabs of that, your palm might start to sizzle. So the notion is that simply if you have gastrointestinal burning, pain, irritation, or even an ulcer, that by eliminating the acid, there’s sort of a neutral environment there. And there won’t be any additional damage and that healing will occur. That is the case occasionally. And I do prescribe these medications.

The problem with this is these medications are the ideal drugs for the pharmaceutical industry because once you’re on them, you get hooked. And I’m not talking about you get high hooked. But you become dependent on them because once you remove these medications, your acid doesn’t just go back to normal. It surges to unprecedented levels. And so a lot of people going off them, trying to go off them, they have terrible distress. And they say, “Well, I guess I really need to be on this medication.” They don’t really need to be on the medication. It’s just that they’ve had acid rebound. And so this is a very, very insidious problem.

James: Acid rebound. Is that a technical term or is that one of yours?

Dr. Hoffman: No, indeed it is a term because you suppress your acid. And correspondingly, your body says, “Well, gee, there’s no acid. We’ve got to make some acid. We’ve got to make some acid.” When you take away the medication, it’s almost like you’ve let go of a rubber band and snap! You’re going to get a reaction and a hyper acidity situation, which convinces you or your doctor that you really need to be on these medications for life.

James: Yeah. That’s very worrying. And I see that across quite a few drug categories, actually.

Dr. Hoffman: Indeed. Headache medications characteristically. Many drugs.

James: Panic, you said?

Dr. Hoffman: Headache medications.

James: Oh, headache, ok.

Dr. Hoffman: And certainly psychiatric medications, very much so. Yeah.

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James: It’s a great business model.

Dr. Hoffman: Recently there was a guy named Kevin Trudeau who was convicted of fraud. And then because he didn’t pay this huge settlement that he owed the government, they’ve now thrown him in prison. And his analysis of the situation—which was repeated endlessly on infomercials and late night TV—was that drug companies are trying to deprive us of natural remedies intentionally so they can sell us more drugs.

And I have to say that that may be the subtext or the unintended consequence of their business model. I don’t really believe that the drug companies are out to deliberately undermine the health of Americans so that they can profit more. I’m not a conspiracy theorist along those lines. But the net effect is that using drugs that people become dependent on is not ultimately in their interest and is a great business model because the use of drugs is self-perpetuating.

And I don’t think that some diabolical plan has been developed. I just believe that that’s the consequence of how we’ve evolved. Look, it’s a profit-oriented system. And the media is very, very prey to the commercial influences of the pharmaceutical industry. Same thing with medical school. In medical school, our learning was basically underwritten by the pharmaceutical industry.

James: When were you in medical school?

Dr. Hoffman: In the 1980s. So it’s even worse now. So doctors should be trained to be critical consumers of what’s out there. They should say, “Okay, look. Here’s the nutrition. Here’s the natural therapies. Here’s the pharmaceuticals. We’ll utilize them as appropriate for our patients.” But, often the orientation is here’s the disease, here’s how you treat it. Boom, boom, boom. This is the protocol. Follow the protocol. If you deviate from the protocol, it’s bad practice, malpractice.

James: Not evidence based.

Dr. Hoffman: No tevidence based and so on. And then you get ostracized from or even sued or lose your license. This is the way it is.

James: What we actually see probably across all of these things, it’s like short-term gain versus medium- to long-term loss. That’s really what we’re talking about with these kind of things, right? Because there obviously has to be a short-term gain in order to become evidence-based.

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Dr. Hoffman: Yeah. However, even the system by which we base evidence is subject to a lot of concerning features because much of the research is drug company sponsored. Much of the research that shows inefficacy of drugs is buried. Studies that show that this drug doesn’t work, well, let’s not publish that study. Let’s deep six it. And sometimes the data is not even accessible to people who want to find out, “Well, what went wrong with that drug?” “Well, sorry. That’s proprietary.”

James: That’s a real mess. So we’ve started sort of at the top, and we’ve looked at acid and stomach and so forth. If we go a bit further down the GI tract towards the large intestines when we mention SIBO, what are some of the other things that millions and millions of Americans and people in all industrial economies are dealing with further down the gut?

Dr. Hoffman: Well, you travel further down, you get irritable bowel syndrome, IBS. You get diverticulitis or diverticulosis. Colin Burkitt illustrated it very nicely in the 1960s…He was a British surgeon who kind of got tired of slicing and dicing people. And he kept saying, “Gee, maybe there’s a way that we can avert all this surgery.” It got pretty routine to take out people’s intestines. So he said, “Let’s do some further research.” He traveled down to Africa. And he discovered that the diseases that were rampant in England were virtually unknown in Africa because, well in those days, many decades ago, they had not yet suffered the ravages of the Westernized diet. More and more Africans are beginning to suffer from degenerative diseases.

James: Yeah, well, they’ve got McDonald’s in Cape Town now.

Dr. Hoffman: Well, big time. But also in the so-called developing countries, their diets have really deteriorated. They’re not indigenous diets anymore. And so, for example, if you were a med student in Rwanda, you would be reading a textbook that probably was published in London. And you’d be reading about diseases like ulcerative colitis and colon cancer and diverticulitis.

But you would remark, “Gee, I’ve never really seen a case of that” if you were a doctor in Rwanda. But, actually, Colin Burkitt remarked that when he was down there in one of these underdeveloped countries, the only person who ever suffered colon cancer that he ever encountered was himself a doctor, a doctor who was of that country who was affluent enough to consume a Western diet and develop colon cancer.

James: Yeah. That makes a lot of sense. One of the things I think is a huge, huge part, with my sort of quasi-medical education—if you’d call it that—has really become through understanding the body as a flow system. That was Hans Heinrich Reckeweg talked

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about the body is a flow system. And if you just go back to all of it, it seems like the real flow, the major flow is this GI flow from mouth to colon. And his thoughts were that a lot of these stagnation diseases were just being caused by essentially a blockage in the main part of the flow, essentially constipation. And I see that. You know, it’s funny as a Brit growing up because fart jokes and feces jokes and whatever is, you know, the classic British—

Dr. Hoffman: I thought that was a German thing.

James: Well, a lot of people find it funny, but the British particularly. But I think the British, it’s also this like embarrassment and fear and shame and guilt and those kind of things. And it seems to be all interwoven with GI stuff. How important is a good flow at that end of bowel movements? And what are the causes that you see being the symptoms as a reflection of that flow being suboptimal?

Dr. Hoffman: This goes back to medical school. Already in medical school I had an interest in natural medicine. I already knew I wanted to be a nutritionally-oriented—in those days—the word holistic physician. I learned pretty quickly that one way to the key to success in medical school was to learn this stuff and not necessarily to attend every lecture because not all lecturers were good. And you could learn this stuff, pass your test.

But I saw a lecture on the schedule entitled diarrhea and constipation. And I thought, “Wow, that’s actually something very tangible. That’s something that I could really learn from.” So, I went to the lecture. I showed up. And the lecture began by polling the audience, medical students, “How many of you have three or four bowel movements per day?” A few people raised their hands. “How many of you have one bowel movement per day?” People raised their hands. “How many of you have a bowel movement every other day?” A few people raised their hands.

“How many of you have like two bowel movements per week?” And people raised their hands. And he said—and I’ll never forget this—he said, “You are all normal.” And I just shook my head vociferously. And I said, “That’s not right!” Because there is such a thing as optimal intestinal transit because those who might be having two bowel movements per week were courting the risk of intestinal toxicity. They had slowed down transit. And that’s not good. And that may be a sign of a very low fiber diet or a destroyed microbiome in their intestinal tract. So, you know, optimal elimination. I mean, this is the way that we eliminate toxins from our body. It’s a very, very important part of optimal health.

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James: Yeah, it’s amazing. You know, it’s funny you say the word toxins because I think as holistic doctors or people in this, people say, “Oh, what are these toxins? These mystery toxins.” But we’re talking about metals and chemicals. There’s a lot of toxins out there.

And I was at a lecture last year at the IHS on microbiome. And they were saying that between fifty, but more like ninety percent of all of the toxic metals that come out of our body come out through the feces. That’s the way that the body does it. That’s the microbes working in tandem. This seems like a hugely important way for toxicity to move out. And if you don’t have that there, that’s the first time that now toxicity is touching tissue essentially, right, if it’s not moving consistently?

Dr. Hoffman: Right. I mean it’s clearly an elimination pathway for the body, but it’s also your gut is like a chemical toxic factory potentially.

Let me give you an example. A guy was found to be drunk, uncoordinated, and inebriated periodically. And his wife was a nurse. For some reason he was staying at home. And his wife was going to work. And she would come home and he’d act disoriented. And she said, “You’ve been drinking again.” And he said, “No, I’ve given up drinking. I’m not drinking.” She says, “I can tell you’ve been drinking and to prove it, I’m going to give you the alcohol breath test.”

She had a device that she borrowed from the hospital, brought it home. And he blew very, very high DUI levels of alcohol from his breath. She says, “Look, there’s no sense in hiding it from me. Where are the bottles?” He said, “Look, I’m not drinking.” So, look, she says, “We’re going to go to the hospital. And I’m going to consult with an expert in the hospital. And we’re going to get to the bottom of this.” And so they told the story.

The guy said, “Look, there’s only one way to resolve this. We’ll put this guy in a metabolic ward where he’s absolutely locked down. He will have no access to alcohol. Then we’ll test him.” And after three days, they tested him. And he was blowing phenomenal levels of alcohol. And the conclusion was that it was from his gastrointestinal tract. He was literally autointoxicated.

And this was written up in a major medical journal as a short brief communication. So what was the treatment? They gave him antifungal medication because we know that if you want to make wine, beer, any kind of alcohol, you just need some yeast and some kind of fermentable carbohydrate and boom! You’ve got alcohol, ethanol.

James: Do you think that would stand up in a court of law for myself or anyone who I

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know in the future who happens to get a DUI?

Dr. Hoffman: That’s a good idea. I’ll have to think about that. You know, I have a couple of patients who are should we say law enforcement officials. And they give me their cards, their sort of get out of jail cards. And they say, “If you have any trouble when you’re in Long Island, give me a call.”

James: But, yeah, I like that defense. So what that’s essentially saying is that this ecology down there in the gut is capable of producing a lot of chemicals. There’s a lot of things that could happen.

Dr. Hoffman: Right. Not just that but a myriad of chemicals. That’s just one very obvious chemical that we can measure. But aldehydes and various putrescant byproducts of abnormal digestion.

James: Putrescent is a great word. And it’s quite onomatopoetic in the way of sort of understanding a smell that may come. Would you say that a smell of the bowels is sort of like a lead indicator of overall health?

Dr. Hoffman: Well, you know, Tibetan medicine is largely based on smelling stuff and tasting stuff. Hopefully not tasting stool. But I had the opportunity to shadow an eminent Tibetan doctor, the doctor to the Dalai Lama—his name is Yeshi Dhonden— many years ago. And when he saw patients, he would ask them to produce a urine sample. And he would smell it. And then he would, to my utter horror, taste it, dip his finger in and put it on his tongue.

And the smell of the skin, he would smell the patient. “Open your mouth, bad breath and all. Let me have it.” And this was one of the ways where in that system of medicine, very ancient system of medicine, they were able to come up with diagnoses. But now they’re coming up with this new idea that they will have devices that will actually be able to smell diseases. You know, dogs can smell cancer. Dogs can be trained to recognize certain cancers. They’re saying, “Well, let’s use an electronic device that has an ultra- sophisticated nose that can detect the smell of, say, diabetes or the smell of certain cancers.”

James: That is amazing. And that is amazing particularly in the context of this evolution of medicine where, in some ways, you know, can you just talk from your experience a little bit here and GI focused or otherwise, you said you’ve been with Tibetan medicine and there’s Chinese medicine. There’s all of these other systems of medicine that sort of it seems as though western medicine sort of poo pooed and laughed at because it wasn’t

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sophisticated. But it seems like pieces of this are sort of coming back into medicine. And one of the things I sort of think about is like we have no idea how long these medical systems were around for. And it seems like if one thing they had going for them is that they were sustainable. And so in the same way that an acid-blocker might be good in the short-term, but poor in the long- and medium-term, it seems like western medicine if you take a step back is good in the short-term and maybe not so good in the short- term and the longer-term and medium-term.

And that’s the reason why, hey, perhaps for the first time ever in America, certain segments of the population are not living as long. We thought we’d be living until 150 or 200 twenty years ago. And we can map the genome and all this stuff. And it’s just not happening. What do you think that medicine as it evolves can learn from these other systems of medicine that we’ve probably sort of maybe a bit arrogantly looked at without too much respect? What can we learn from them?

Dr. Hoffman: Well, an admission here: when I was in college, I had absolutely no idea that I wanted to go to medical school. It was the farthest thing from my mind. I was studying cultural anthropology. And one of the tenets of cultural anthropology is that you go into the field with an inquisitive and open mind. And you look at the practices of the individuals, as absurd as they might seem to the Western eye, and you try to understand their functionality and their usefulness or lack thereof because not everything that people do makes sense.

But from that perspective, I derived a great deal of respect for ancient practices, alternative practices, natural health systems that weren’t science-based, but were empirically-based that kept people sustained for the vast majority of our existence as homo sapiens. You know, we look at the tip of the iceberg. The scientific revolution has been going on for what? Maybe 200 years. In medicine perhaps 150 years. And the practices that we use are science-based, but they’re very novel. And we have sort of a cultural or scientific hubris that makes us believe that somehow they are superior to ancient or unscientific practices that really deserve more attention.

James: Yeah, and integration. I think I’ve heard already a number of people say, Andrew Weil always says you’ve got to do Western medicine well. You’ve got to do this medicine well. And just deliver good medicine. And it seems like that’s sort of the evolution that we’re moving towards is taking the best of things and combining them together. So if we were to look at from that perspective of gastrointestinal, what do you see as sort of like the optimal gastrointestinal health or relationship with a doctor or strategies for the myriad of the types of diseases that we see today?

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Dr. Hoffman: I think there will always be a place for gastroenterologists who utilize high-tech methods to detect disease. They can scope people six ways to Sunday and find out where the problem is. And there’s a need for medications for people who are super sick because I say to some patients who come in very sick with GI problems, they want a natural cure. And I say, “Look, if your house is one fire, we’re not going to have you talk about fire prevention. We’re going to go in with high pressure hoses and axes, chop down the door, flood your home. But we’re going to put the fire out. And that’s so you can survive.” So there’s a place for that.

On the other hand, I think there is in gastroenterology in particular, but I think this is something that all integrative physicians can use. And no question that chiropractors, naturopaths, nutritionists, are all very turned on to this, not just holistic MDs and DOs. The importance of diet, the primacy of sustaining the microbiome, being a little bit of a what I sometimes I feel like I’m a little bit of an arbiter between conventional medicine and the patient in the sense that the patient comes in and says, “Well, look, they say I need to take this.” And I go, “Well, you know, if you just took this natural therapy, you might be fine. You don’t really need it.” Or in some cases, like, “Look, don’t delude yourself. You really do need to take medication.” So I think there’s a place for gatekeepers to protect people from the excesses of medicine to come up with lower-tech or more natural approaches.

James: Yeah. There’s a couple of things that I’d like to get into because I really would like to get into the microbiome stuff at some point. But I know that just on that what you’ve just spoken about, one of the books that I’ve read that you wrote is called How to Talk to Your Doctor. And I know although there’s probably a lot of people on this line today who are listening who are thinking, “I know that I can change my diet and improve my health, but my doctor doesn’t necessarily feel like that way.” And they sort of maybe hide things from their doctor, or they do that.

What would you say, what are some of the basic strategies in that book by which people can have a more open and honest dialogue about the kind of things that we’re speaking about today? Because I know that there are people that are addicted to acid blockers. I know there are people addicted to laxatives. And these are not sustainable strategies. But the doctor says you’ve got to be on them. You’ve only got seven minutes to communicate to them. Like how do we go about having a more open, honest, and mutually-respectful relationship with our doctors to help the doctors move along this course, as well?

Dr. Hoffman: Well, I think you have to establish some ground rules for how you’re going to interact with your doctor. Always be respectful, and always be not

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confrontational. But say, look, you’re interested where possible in natural approaches, in low-tech approaches, in preventive approaches. And where necessary you’re willing to listen. And then assess your doctor’s reaction. If your doctor says, “Look, my way or the highway. That stuff is all bunk. It’s garbage. It’s fraud,” then you have to vote with your fee. You really do. I don’t expect all doctors that you’ll encounter to say, “Hey, that’s great. I’m all for these natural therapies.” That’s a little bit too much to hope for.

Some might. But the vast majority will say what you’re aiming for is a doctor who will say, “Look, I don’t know that much about these natural therapies. But if you bring me the information and you keep me apprised of what you’re doing, I’ll be happy to supervise your use of these approaches. However—” and the doctor will tell you this, “— if I think you’re going down the wrong path, I will speak up and inform you.” I mean that’s more of a balanced approach to this.

James: That does sound balanced. And you bring up something that I think is so important is voting with your feet, generally. And it’s almost voting with your feet, but it’s also voting with your dollars. You know, people are frustrated by the paradigm of what they see out there of the foods that are available in certain areas. We’re in New York. It’s very lucky. You can get basically anything you want at any time of the day.

But, in most places, I used to live in Georgia. And I know that it was difficult to get the right kind of healthy food choices. You had to be very proactive about it. So this idea of voting with your feet and voting with your dollars, what do you think is the most empowering way for patients to start to change some of these habits?

Dr. Hoffman: Well, you know, I think you have to look at diet, exercise patterns. I think it’s important to inform yourself from reliable sources. Some of the sources aren’t reliable. I think a good place is to start out with information that comes from well-vetted sources. I would consider you a good curator of information. I’m guilty of self- promotion. Forgive me, but the Intelligent Medicine podcasts are, I hope, a source of useful information. You can get them at DrHoffman.com.

And a lot of people I think empower themselves. And this is sort of a grassroots movement to some extent. You know, a lot of the stuff that we do that’s good for us is not government sanctioned. It’s not sanctioned by corporate America. It’s not sanctioned by establishment figures in our lives. But things that we do maybe locally in our community to help friends, families, others who are less fortunate, many of the best efforts are grassroots efforts that aren’t necessarily coming from some centralized bureaucracy with edicts.

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James: Well, one of the things that’s encouraging in a certain way, and this is not the way that we all like it to happen, but so many people are starting to, one, get these symptoms that their doctor can’t help and, two, make these changes by themselves, use the Internet, get different information in, see improvement. It’s almost like we now have a sort of fertile place for people to be able to make these kind of changes. Because just think back thirty years ago, there’s no way that all this information you could get it. Where were you going to get it? The library? I mean this is not—

Dr. Hoffman: Remarkable changes have occurred.

James: So easy.

Dr. Hoffman: Yeah.

James: So, yeah, DrHoffman.com/podcast is the Intelligent Medicine podcast. There’s a lot of great information on there. I think those are some great starting points.

Let’s just go through these different areas that we’ve spoken about and talk about some of the natural ways that you’ve seen to be effective. So let’s start at the top. Like the combination of GI and ear, nose, and throat things, acid blockers, the stuff that’s going on there. What are the kinds of things that you’re using in the practice to work with those kind of issues?

Dr. Hoffman: Well, if you’re on acid blockers, don’t go off them very quickly. You need to taper slowly. So I think many people and sometimes doctors make the mistake of saying, “Okay. You can go off now.” So taper slowly. Utilize products like DGL, which is deglycyrrhizinated licorice. It’s important that the licorice be deglycyrrhizinated because too much licorice will raise your blood pressure. You don’t need that component to soothe the esophagus and the stomach. And you can take these little lozenges and chew on them all day long. You can have eight or ten or twelve a day. And it’s very soothing.

You can use aloe vera gel, not the juice, aloe vera gel taken away from meals. That’s very healing. A product that I like to use, and it’s unfortunately not available retail. It’s available through doctors. It’s called Endefen. And it’s a mixture of plantain and other mucilaginous substances that’s very soothing to the esophagus. We heal a lot of GERD, reflux, and gastritis symptoms with that product.

And then probiotics, of course. But, the key is diet change. And, you know, even people who are on a “healthy” diet. You know, they’re eating like granola, skim milk, and lots of fruits and vegetables and juices, they may have a lot of gurgling and reflux. They might

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find that they do better when they reduce their carbs and have more in the way of animal protein, I find.

James: Yeah. Well, we’re going to have a lot of discussion about diet. And I know that you have your own views on that. And other people think very differently.

Dr. Hoffman: Huge controversy.

James: Yeah, it’s a controversial area. But I think the one thing that you would probably agree with is that people are different. People are going to work out different ways. And they need to be in a relationship with a doctor, a functional medicine doctor or someone like that, who can help them to go through and try out different things until they find something that’s sustainable for them.

Dr. Hoffman: Exactly. A lot of it is trial and error and different strokes for different folks.

James: Okay. So, we’ve got just about ten minutes left here. And I want to get into a little bit of this microbiome because it’s so valuable to think a little bit about this because let’s just give the example of gut infection. So we’re talking about GI diseases. The moment that I saw that fecal transplants were the cure, this amazing cure, for these chronic infections like C-difficile, which were antibiotic resistant, I knew that the game was up as far as like our regular understanding of the germ theory and how germs are sort of causing disease. Can you just give a quick overview for people at home about what these new types of treatments are? Because it’s really a super probiotic, isn’t it? Feces in the gut.

Dr. Hoffman: Right. Okay, caveat: this is not yet ready for primetime. It’s being done in very strict research protocols. And my general advice is don’t try this at home. The yuck factor is very high here. But the point is that when people have very, very disrupted microbiomes, there’s probably as many different types of species of bacteria in your gastrointestinal tract as there are stars in the sky. So taking one probiotic or taking even a combination of probiotics—eight, ten, twelve different things—it’s still not going to replete you and restore you to normalcy. So that’s the principle behind fecal transfer or transplants.

It’s been helpful in very, very serious diarrhea problems like C-difficile. Some studies have been done in ulcerative colitis and Crohn’s disease. And that’s hopeful. The problem is how are you going to commercialize this? I really fear for the lack of impotence to get this on stream because all the money, all the commercial emphasis

and our current paradigm is to find a very niched drug which can be patented and that we’ll miraculously block this or that or the other pathway and change the immune system. So how are you going to monetize donating feces? I’m not sure.

James: Well, the gift economy is certainly starting to arise. So I’ll be generous with mine. I’m not sure if I’m exactly…I think we need to find the healthiest people.

Dr. Hoffman: Oh, you must have great flora! I think your flora’s probably—

James: I’ve not had that much antibiotics. I think that’s probably a good starting point. Yeah, you bring on to an interesting topic there which is sort of this what’s cheap versus what works and the future of medicine as far as the proliferation of things that don’t make money. I know this is another topic that you speak about a lot, just sort of like the war on natural medicine and so forth. What are your sort of hopes and fears for the next five years in American medicine? What do you fear will happen and what do you sort of hope will happen?

Dr. Hoffman: Well, I see real problems occurring. Especially, Obamacare, whichever political party you adhere to. It just happens to be that the current administration is holding the ball of on the demise of American medicine that’s been occurring for a really long time. And there’s going to be a point of reckoning where it’s going to undermine the health of Americans, destroy our productivity, and also just destroy our economy the way we’re allocating money with expensive solutions for problems that might be more amenable to lower-tech, cheaper solutions and prevention.

But what’s going to happen, I think, just like physical fitness, Americans are getting fatter. However, the physical fitness movement is burgeoning in America. More and more Americans are getting healthy. I think it’s going to be maybe an enlightened minority of Americans who opt for healthier styles of health management that will lead the charge that hopefully…I mean, I’m very uncertain about the way things are going to go. I think there may be a real crash and burn that’s required. You know, it’s like in addiction theory, you got to hit bottom before you can begin your twelve-step program.

James: Yeah. Well, I think that’s definitely the direction that we’re headed, unfortunately. But if you’re on the more hopeful side, what signs do you see that we’re moving towards a more sustainable medical system that the evolution of medicine is occurring?

Dr. Hoffman: Well, there’s just an explosion in the number of practitioners offering this type of medicine who are well-trained, well-informed. I see that coming from my field –

medicine, MDs. But, naturopaths are really a very important force in this country providing this type of information. They’re well-trained, very scientifically-based. Chiropractors have a lot of this information at their disposal. So, there is a phalanx of health practitioners, nutritionists who are not just pushing Jell-O in hospitals and Ensure and Boost. But nutritionists who have functional medicine understanding are really making a difference. Particularly, here, we’re talking New York, San Francisco, Denver, Boston, points of light in kind of a dismal American scene.

James: Yeah. Well, it’s definitely proliferating. And that’s one of the reasons I started Revive Primary Care is I just felt, look, there are enough of these practitioners around. If you have the right person to find these people, it’s a great starting point. And having one of these practitioners, however they’re credentialed, alongside your current medical care seems to be synergistic.

Dr. Hoffman: That’s the way to go. That’s the way to go.

James: Yeah. And other things that we’re trying to do in this Summit is really start to talk about how doctors can work with coaches, how doctors can work with nutritionists, how to get communication in medical structures because I think that this is really what it’s going to take for everyone to work together.

And I think what you’ve outlined today is a great vision for the future of gastroenterology. And if the future of gastroenterology looks like this, I think the knock on effects to the rest of the body will be huge. In the same way that a toxic gut leads to all kinds of other symptoms, a healthy gut or a revitalized gut will certainly lead to improvement in lots of other areas. And I see this coming all the way through.

So, yeah, thanks so much for your time and being here today, Dr. Hoffman. You can find Dr. Hoffman’s podcast is the Intelligent Medicine podcast. It’s at DrHoffman.com/podcast. Great guests all the time and actually just an unlimited or just a history of all of the podcasts that you’ve been doing for a long time with great people on there. And I’ll look forward to coming on again soon. Thank you so much for being here today.

This has been The Evolution of Medicine Summit, a great session on the Evolution of Gastroenterology. And I’ve had Dr. Ronald Hoffman here. Thanks so much again, doc.

Dr. Hoffman: My pleasure!

James: Hello! And welcome to The Evolution of Medicine World Summit. We are here today with a very special guest. I have Dr. Ronald Hoffman in the house. Dr. Hoffman is a veteran researcher and physician, has been in practice in New York for over twenty- five years, has been on the radio for twenty-five years. So I’m sure that this is a medium that you’re going to be very comfortable in, Dr. Hoffman.

Dr. Hoffman: Indeed

James: So today we’re talking about the evolution of gastroenterology. Now, some people, particularly any gastroenterologists that are listening, might be a little bit surprised to know that you’re not actually a gastroenterologist. Why do you feel like in terms of the evolution of medicine that it’s relevant for a non-gastroenterologist to be speaking on this topic?

Dr. Hoffman: Well, I think the analogy might be is it appropriate for a member of one particular political party to speak on the political scene in America. I think that if you are a gastroenterologist, you may have a little bit of tunnel vision about the potential for gastroenterology to influence all systems of the body, and also a little bit of a tendency to be invested in some of the tried and true therapies of that field such as prescribing lots of acid-blocking medication, for example.

James: Okay. And so would you say that your perspective on the gut is more in terms of its influence on the other systems? I mean, how do you feel that, if I say the evolution of gastroenterology, what do you see looking forward from what you’ve seen in your twenty-five years?

Dr. Hoffman: Well, I’m the consummate generalist. I’m trained in internal medicine. I do medical nutrition, but I see the gut as being very central to just virtually everything that’s going on in the body. A lot of what happens in the brain, a lot of what happens in the joints, in the skin has its origin in the gut. So we can’t really compartmentalize. Unfortunately, in medicine we see the gastroenterologist and we see the dermatologist and we may see the neurologist and it’s that kind of fragmentation that sometimes leads to problems.

 

James: And so if we look at the major things that are going on with the gut, I mean, it seems like digestive diseases are probably the core focus of the gastroenterologists. What do you see as sort of the causes of those diseases? If we’re looking at evolution, we really want to look at these causes. What do you see as the causes of the majority of these digestive and gastrointestinal diseases?

Dr. Hoffman: Well, the gut that we have is not designed for the environment that we live in from a variety of standpoints. It’s a gut that was designed for certain types of foods that the vast majority of us don’t consume anymore. It’s also a gut that is designed for microbes that we do our best to eradicate. Literally, from cradle to grave we’re fighting against microbes. And that’s good because in some ways we would succumb to many infectious diseases. But the trade off is that we’ve dramatically altered the composition of the gut. And we’re coming to recognize the key word, microbiome. The microbiome is so influential in so many aspects of our health.

James: So, if you were a gastroenterologist in school let’s say ten, twenty years ago, what would you have missed if you obviously probably wouldn’t be learning that much about microbes at that point. This is a new science, is that right?

Dr. Hoffman: Well, it’s new. But it’s also very old because I believe it was in the early 1900s that Eli Mechnikov won a Nobel Prize for talking about the microbiome. He was a big proponent of natural cultures, of yogurts, to replenish that GI tract. And that concept got a little bit lost because we kind of got enamored of high tech medicine, of the new powerful drugs that were at our disposal, and lost our way a little bit, I think, in our global understanding of what’s right for the body.

James: Has the gastrointestinal tract become even sort of simplified and split up itself? It seems like you have specialists for the top of the tract and the bottom of the tract. It’s really one pipe, right?

Dr. Hoffman: Well, absolutely. And problems higher up affect lower down. And also there’s an intimate relationship between the GI tract and tissue that’s very close. The GU tract, the urinary tract, the sexual organs particularly in women. There’s also a relationship with the mouth, the throat. And ENT doctors. It’s getting so that ENT doctors when patients come in and say, “I’m hoarse. I have a little congestion or tightness in the throat.” They’ll say, “Take an acid-blocking medication because that’s gastro reflux.” So they recognize that there’s a close interplay.

James: So can you maybe just give an example from your time as a clinician where you’ve had an issue that’s come up in a completely disparate part of the body from the gut and worked on the gut and then there’s been a full resolvement of that case without need for medication or ongoing medication?

Dr. Hoffman: I have a very interesting case of a woman who came in with a bizarre neurological condition. She literally came staggering into my office. She was actually a very, very celebrated yoga teacher here in New York with a fantastic clientele until she developed this debilitating neurological disease that caused her to stagger. And she was initially diagnosed with Parkinson’s disease. But she was rather young for that in her early fifties. And then they said, “Well, it seems like you have Parkinson’s disease. But this is atypical Parkinson’s disease.” Long story short, they began treating her to Parkinson’s disease with very little benefit.

James: What does that look like, treating for Parkinson’s? Because from listening to someone like David Perlmutter, the treatment for Parkinson’s disease is really just anti- medication to stop the symptoms.

Dr. Hoffman: To stop the shakes, yes. Yeah, various types of medications that may slow the progression or relieve symptoms. But ultimately don’t change the course of the disease. So we evaluated her. And one of the things that I look for—and I look to Dr. Perlmutter as an important mentor—is gluten sensitivity. And, in fact, she didn’t just have minor gluten sensitivity, she had full blown celiac disease. And upon elimination of the gluten, her symptoms got about fifty percent better.

Now, you may say, “Well, your proposition was have you seen total resolution with some sort of crucial GI intervention?” And the problem is once you’ve had a neurological condition that has developed over the course of perhaps decades, it’s very hard to reverse some of the damage that’s been done. Literally your nervous system may have been poisoned by some of the immune factors that are generated by celiac disease that traverse the gut wall and go into the systemic circulation and then ultimately hit the brain and the nerves.

James: So once you do damage to the brain and the nerves, it’s very difficult to sort of rehabilitate that.

Dr. Hoffman: Some of it is irrevocable, but, however, remarkable improvement. And she was very grateful for the insight that every day she was literally poisoning her nervous system.

James: So, that’s one way of interacting with the brain. I know you’re also quite bit – I’ve been following your intelligent medicine podcast and so forth. You’ve been very interested in psychobiotics, which is effecting the function of mental health or the brain through interventions in the gut. That, to me, just screams the evolution of medicine because there’s no way that a neurologist is thinking about the gut or that these types of specialists are communicating.

But it seems obvious that given that the body is almost a perfect example of wholism, of different systems working together, it seems that the evolution of medicine will have a big focus on now these disparate specialties working together and thinking together.

Dr. Hoffman: If you have a toxic gut, that toxicity may manifest early as a general sense of malaise or even what might be described as depression. And so it may be true that altering your GI microbe composition may make you happy or at least alleviate something that’s pulling downward on your mood.

James: That’s so interesting. And so beyond the brain, you mentioned skin earlier. I was just actually speaking with a doctor recently whose husband is a dermatologist. And the tough cases that he gets, he sends to her. And then they clean up the diet and things sort of mysteriously disappear. The skin seems to be another big axis with the gut. How is that interaction happening biologically?

Dr. Hoffman: Yeah. The most classic example of that is in celiac disease—which we recognize as a gastro problem where there’s inflammation of the gut characteristically due to gluten—one of the cardinal manifestations of that, a key sign, is a condition called dermatitis herpetiformis. Now, if you are familiar with Latin or Greek—I don’t even know where the root comes from—but herpes, herpetiformis…In other words it, has a little form of herpes on your skin.

There’s little sort of herpes-like bubbles that appear on your skin due to gluten consumption. And the theory is that various types of immunological factors get generated because of the clash between the gluten and your own immune system. They circulate through your bloodstream. They’re deposited in the skin. And, lo and behold, you’ve got skin problems.

Look, that’s a dramatic example, a classic example, one that’s recognized by medicine. But there’s so many other examples. For example, acne or eczema. Too often the gut- skin connection is ignored. Or the food-allergy-skin connection is ignored. Food allergies can effect the gut. Foods that are improperly digested pass through what is called a leaky gut. This is a very important concept now in medicine is that the permeability of the gut, normally it keeps bad things out like microbes and allergens, but it absorbs good things. So you want actually the proper balance between good absorption and keeping the bad things out.

With a leaky gut, it’s almost like there’s this onrush of toxic elements and allergenic elements into your systemic circulation. And then the possibilities are endless for various types of symptomatic problems. Head to toe, organ system to organ system, you could have problems.

James: I think that is the most important thing that we will discuss in all of this is that if we’re only looking at medicine in terms of symptoms, how would we know whether these disparate versions of symptoms are all coming as a result of this one cause which is just this break in the mucosal lining, this break in the gut lining and yet the symptoms could be anywhere.

If we’re only waiting for symptoms to occur and dealing with their symptoms, we’re never going to get back track there. It seems like starting with the gut is really the only starting point when you’re getting these chronic symptoms coming up. Is that typical of your strategy and practice to start working on the gut as sort of a primary measure?

Dr. Hoffman: Well, very much so. So we’ll check patients for leaky gut. There are tests that can tell us whether that’s present. We’ll also look for food intolerances that can trigger inflammation in the gut. We may check the status of the bacteria in the gut to see if there’s a normal balance. If there are good bacteria or, conversely, if there are harmful bacteria there.

And this goes back to the 1980s, we recognized a condition called candida or the yeast connection, which I think was sort of a foresight about how things would develop now in the 21st century. Twenty or thirty years ago people were talking about candida or a yeast problem. I think a more sophisticated way to look at it is that yeast and other harmful microorganisms create a toxic brew in your intestinal tract, creating various forms of problems.

James: Would you say that the future of gastroenterology, it seems like you need to be more like an ecologist rather than a specific gastroenterologist. It’s really an ecology down there. It’s an ongoing development like habitat.

Dr. Hoffman: Well, yeah, it kind of goes to the way that we do agriculture or the way that we do warfare in America. If you think back to the Vietnam era, the strategy to defeat the North Vietnamese was to defoliate the country. And in so doing, we destroyed the country. We created a lot of ecological devastation. But we didn’t win the war and left a terrible legacy. Similarly, we take the strategy, find a bug, use a drug. We try to eradicate harmful bacteria. If there’s gastrointestinal symptoms that we attribute to acid, we block the acidity.

But, to your point, we really need to pay attention to the integrity of the ecology or the ecosystem that keeps healthy because if we take care of one aspect of it, but we damage the ecosystem then the health goes downhill. And unfortunately, I see a lot of talk about this. And I see a lot of research.

But there’s such a lag time in the adoption of these strategies by most doctors. Most doctors are very harried. They have to treat symptoms. They have to give patients immediate relief. And also many patients don’t want to make lifestyle changes. So, unfortunately, we’re not seeing this type of medicine become mainstream. It’s certainly a lot of people demand it, look for it. My patients do. But the major medical paradigm in America I’m concerned is moving in the wrong direction.

James: Well, I hope with this summit, and the other things that we have going on, Dr. Hoffman, is that more and more people will understand this is really a rational framework for dealing with a chronic set of symptoms. And so I definitely applaud your leadership in this and sort of being ahead of the curve. But I hope that the adoption is improving.But what I do see is that more and more people are starting to realize that they can actually affect their own health with their lifestyle choices which is encouraging.

So if we just go back to sort of the biochemistry and the physiology, what is an ideal environment for optimal health? If we go from mouth to colon, what would be an ideal environment that means that the gut is doing what it’s meant to be doing, which is obviously right digestion, immunity, metabolism? What’s happening through that and what will you see as an ideal environment?

Dr. Hoffman: Well, one suggestion that I’ve made—a little bit tongue in cheek—was be born in a manger. That doesn’t necessarily mean that you’re the Son of God. It means that you’re born in an environment where you’re exposed to certain pathogens. And literally you’re exposed to barnyard animals as humans were over centuries and millenia of evolution because we interact healthfully with many of these microbes.

You know, the human immune system, it’s a little bit like when you get a new computer or when you get a new iPad. It’s get a lot of potentiality. But if it had every single program that you could possibly have already on it, it would be the size of an eighteen- wheeler. So that’s why it’s got a lot of potentiality. That’s like the human immune system because otherwise we’d have to be born with a huge amount of extra tissue to program resistance.

So what we do is develop resistance to what’s in our local environment. And so, if you’re born in Mexico City, it’s one thing. If you’re born in New York City, it’s another. If you’re born in Mumbai, it’s another. So, this eliminates redundancy. But, in order to program your immune system, you have to be exposed to certain things. Also you have to not instantaneously eradicate every infection that a child has. The tendency now to reach for the antibiotics at first instigation. Pediatricians are getting better about this. But still parents demand it. It’s a lot of anxiety. Kids get a lot more meds than they need. We destroy their helpful bacteria.

James: So a solid sort of a deep combination of microbes all the way down through the gut is important. How about the permeability of the gut itself? Like, what stuff should be getting through and what stuff shouldn’t?

Dr. Hoffman: Well, one big mistake—here’s another big mistake that we make—if you want to screw up your intestinal permeability, take a lot of pain killers, particularly aspirin and non-steroidal anti-inflammatory drugs, things like Advil and Motrin, because those drugs are known the cause ulcers. But even if they don’t cause an ulcer, they may cause little microscopic fissures in your gastrointestinal tract, literally giving you leaky gut.

Now, I recently saw a kid who’s a very promising young college football player who’s developed ulcerative colitis. And I took the history and then I said, “Well, what are some of the things that happened right before?” Well, he was taking a lot of antibiotics because he’d had some sinus infections. And, oh, by the way, he plays football. He’s had some injuries. So virtually every day during practice he would pop a few Advils because the coach said, “Hey, you want to get loose? You want to feel okay when you’re hitting the tackling dummy? Go ahead and take some Advil.” So literally he created a leaky gut situation.

I’m not saying that we can always go back in time and trace the origin of the disease. But that’s the perfect storm for developing problems. Add a little stress, freshman year away from home playing in a big college football team, and you’ve got a perfect storm to create ulcerative colitis.

James: Yeah, that’s such an important story for me, hearing that because one of my best friends from school, I think same exact thing, rugby.

Dr. Hoffman: I knew you were going to say rugby because you being from—

James: Yeah, so he played rugby. He was a great player. And I think there was a few things that maybe contributed to it. But he was certainly in a rugby position where you’re getting hurt all the time. And I would say that he basically had exactly the same thing as this guy except instead of walking into Dr. Hoffman’s office, he’s walking into a regular NHS hospital and two days later is having three feet of his colon removed.

Dr. Hoffman: Yes.

James: If that guy had walked into another hospital, is that the plan that most people would have done with ulcerative colitis? Is that the plan?

Dr. Hoffman: Well, that’s the end stage. You wage war strategically against ulcerative colitis starting with mild medications and then steroids and then powerful immune suppressive drugs. As a very last resort they say, “Well, the colon. You can survive without it. We’ll just remove it and things will be fine.” The problem is that I see a lot of people after they’ve had their colon removed, and their problems are not over. So, it’s not like—

James: Right. You’re just starting new problems. What is the net long-term effect of not having that part of your colon I mean in terms of absorbability of nutrients and so forth? It seems like there’s obviously a reason why that’s there, and you’re taking it out.

Dr. Hoffman: Clearly. It’s like, “If thine colon offend thee, pluck it out.” And there’s another condition that I think really needs recognition. It’s called SIBO, which is small intestine bacterial overgrowth. First there’s the esophagus, the stomach, then the small intestine, which is really not so small. It’s about ten or twelve feet. And then there’s the large intestine, which in colitis is affected and can removed, so they say, without consequences.

But the small intestine should not have any bacteria. And when bacteria migrate from your large intestine where they belong into your small intestine then you start getting symptoms. You get gas, bloating, cramps, and this is a condition that afflicts tens of millions of Americans. We make it worse with acid-blocking medication. I can’t tell you how much damage these medications do. And so many doctors when patients ask, “Well, how long do I need to be on this?” And the doctor says, “Mmm, for the rest of your life. It’s fine. No problem.” Well, there are a lot of problems associated with disrupting your digestion via total destruction of your acid environment.

James: So there’s that many people using it. Could you just explain for everyone out there, what is the perceived or intention of the mechanism that’s being used when they take an acid blocker and what does it do? Like why do millions of people trust it? And then what are the long-term consequences that are happening from doing that?

Dr. Hoffman: Well, if I were to grab your hand and say, “Here, I’ve got some potent hydrochloric acid here. And I’m going to drop this on your palm,” after a few drips and drabs of that, your palm might start to sizzle. So the notion is that simply if you have gastrointestinal burning, pain, irritation, or even an ulcer, that by eliminating the acid, there’s sort of a neutral environment there. And there won’t be any additional damage and that healing will occur. That is the case occasionally. And I do prescribe these medications.

The problem with this is these medications are the ideal drugs for the pharmaceutical industry because once you’re on them, you get hooked. And I’m not talking about you get high hooked. But you become dependent on them because once you remove these medications, your acid doesn’t just go back to normal. It surges to unprecedented levels. And so a lot of people going off them, trying to go off them, they have terrible distress. And they say, “Well, I guess I really need to be on this medication.” They don’t really need to be on the medication. It’s just that they’ve had acid rebound. And so this is a very, very insidious problem.

James: Acid rebound. Is that a technical term or is that one of yours?

Dr. Hoffman: No, indeed it is a term because you suppress your acid. And correspondingly, your body says, “Well, gee, there’s no acid. We’ve got to make some acid. We’ve got to make some acid.” When you take away the medication, it’s almost like you’ve let go of a rubber band and snap! You’re going to get a reaction and a hyper acidity situation, which convinces you or your doctor that you really need to be on these medications for life.

James: Yeah. That’s very worrying. And I see that across quite a few drug categories, actually.

Dr. Hoffman: Indeed. Headache medications characteristically. Many drugs.

James: Panic, you said?

Dr. Hoffman: Headache medications.

James: Oh, headache, ok.

Dr. Hoffman: And certainly psychiatric medications, very much so. Yeah.

James: It’s a great business model.

Dr. Hoffman: Recently there was a guy named Kevin Trudeau who was convicted of fraud. And then because he didn’t pay this huge settlement that he owed the government, they’ve now thrown him in prison. And his analysis of the situation—which was repeated endlessly on infomercials and late night TV—was that drug companies are trying to deprive us of natural remedies intentionally so they can sell us more drugs.

And I have to say that that may be the subtext or the unintended consequence of their business model. I don’t really believe that the drug companies are out to deliberately undermine the health of Americans so that they can profit more. I’m not a conspiracy theorist along those lines. But the net effect is that using drugs that people become dependent on is not ultimately in their interest and is a great business model because the use of drugs is self-perpetuating.

And I don’t think that some diabolical plan has been developed. I just believe that that’s the consequence of how we’ve evolved. Look, it’s a profit-oriented system. And the media is very, very prey to the commercial influences of the pharmaceutical industry. Same thing with medical school. In medical school, our learning was basically underwritten by the pharmaceutical industry.

James: When were you in medical school?

Dr. Hoffman: In the 1980s. So it’s even worse now. So doctors should be trained to be critical consumers of what’s out there. They should say, “Okay, look. Here’s the nutrition. Here’s the natural therapies. Here’s the pharmaceuticals. We’ll utilize them as appropriate for our patients.” But, often the orientation is here’s the disease, here’s how you treat it. Boom, boom, boom. This is the protocol. Follow the protocol. If you deviate from the protocol, it’s bad practice, malpractice.

James: Not evidence based.

Dr. Hoffman: No tevidence based and so on. And then you get ostracized from or even sued or lose your license. This is the way it is.

James: What we actually see probably across all of these things, it’s like short-term gain versus medium- to long-term loss. That’s really what we’re talking about with these kind of things, right? Because there obviously has to be a short-term gain in order to become evidence-based.

Dr. Hoffman: Yeah. However, even the system by which we base evidence is subject to a lot of concerning features because much of the research is drug company sponsored. Much of the research that shows inefficacy of drugs is buried. Studies that show that this drug doesn’t work, well, let’s not publish that study. Let’s deep six it. And sometimes the data is not even accessible to people who want to find out, “Well, what went wrong with that drug?” “Well, sorry. That’s proprietary.”

James: That’s a real mess. So we’ve started sort of at the top, and we’ve looked at acid and stomach and so forth. If we go a bit further down the GI tract towards the large intestines when we mention SIBO, what are some of the other things that millions and millions of Americans and people in all industrial economies are dealing with further down the gut?

Dr. Hoffman: Well, you travel further down, you get irritable bowel syndrome, IBS. You get diverticulitis or diverticulosis. Colin Burkitt illustrated it very nicely in the 1960s…He was a British surgeon who kind of got tired of slicing and dicing people. And he kept saying, “Gee, maybe there’s a way that we can avert all this surgery.” It got pretty routine to take out people’s intestines. So he said, “Let’s do some further research.” He traveled down to Africa. And he discovered that the diseases that were rampant in England were virtually unknown in Africa because, well in those days, many decades ago, they had not yet suffered the ravages of the Westernized diet. More and more Africans are beginning to suffer from degenerative diseases.

James: Yeah, well, they’ve got McDonald’s in Cape Town now.

Dr. Hoffman: Well, big time. But also in the so-called developing countries, their diets have really deteriorated. They’re not indigenous diets anymore. And so, for example, if you were a med student in Rwanda, you would be reading a textbook that probably was published in London. And you’d be reading about diseases like ulcerative colitis and colon cancer and diverticulitis.

But you would remark, “Gee, I’ve never really seen a case of that” if you were a doctor in Rwanda. But, actually, Colin Burkitt remarked that when he was down there in one of these underdeveloped countries, the only person who ever suffered colon cancer that he ever encountered was himself a doctor, a doctor who was of that country who was affluent enough to consume a Western diet and develop colon cancer.

James: Yeah. That makes a lot of sense. One of the things I think is a huge, huge part, with my sort of quasi-medical education—if you’d call it that—has really become through understanding the body as a flow system. That was Hans Heinrich Reckeweg talked about the body is a flow system. And if you just go back to all of it, it seems like the real flow, the major flow is this GI flow from mouth to colon. And his thoughts were that a lot of these stagnation diseases were just being caused by essentially a blockage in the main part of the flow, essentially constipation. And I see that. You know, it’s funny as a Brit growing up because fart jokes and feces jokes and whatever is, you know, the classic British—

Dr. Hoffman: I thought that was a German thing.

James: Well, a lot of people find it funny, but the British particularly. But I think the British, it’s also this like embarrassment and fear and shame and guilt and those kind of things. And it seems to be all interwoven with GI stuff. How important is a good flow at that end of bowel movements? And what are the causes that you see being the symptoms as a reflection of that flow being suboptimal?

Dr. Hoffman: This goes back to medical school. Already in medical school I had an interest in natural medicine. I already knew I wanted to be a nutritionally-oriented—in those days—the word holistic physician. I learned pretty quickly that one way to the key to success in medical school was to learn this stuff and not necessarily to attend every lecture because not all lecturers were good. And you could learn this stuff, pass your test.

But I saw a lecture on the schedule entitled diarrhea and constipation. And I thought, “Wow, that’s actually something very tangible. That’s something that I could really learn from.” So, I went to the lecture. I showed up. And the lecture began by polling the audience, medical students, “How many of you have three or four bowel movements per day?” A few people raised their hands. “How many of you have one bowel movement per day?” People raised their hands. “How many of you have a bowel movement every other day?” A few people raised their hands.

“How many of you have like two bowel movements per week?” And people raised their hands. And he said—and I’ll never forget this—he said, “You are all normal.” And I just shook my head vociferously. And I said, “That’s not right!” Because there is such a thing as optimal intestinal transit because those who might be having two bowel movements per week were courting the risk of intestinal toxicity. They had slowed down transit. And that’s not good. And that may be a sign of a very low fiber diet or a destroyed microbiome in their intestinal tract. So, you know, optimal elimination. I mean, this is the way that we eliminate toxins from our body. It’s a very, very important part of optimal health.

James: Yeah, it’s amazing. You know, it’s funny you say the word toxins because I think as holistic doctors or people in this, people say, “Oh, what are these toxins? These mystery toxins.” But we’re talking about metals and chemicals. There’s a lot of toxins out there.

And I was at a lecture last year at the IHS on microbiome. And they were saying that between fifty, but more like ninety percent of all of the toxic metals that come out of our body come out through the feces. That’s the way that the body does it. That’s the microbes working in tandem. This seems like a hugely important way for toxicity to move out. And if you don’t have that there, that’s the first time that now toxicity is touching tissue essentially, right, if it’s not moving consistently?

Dr. Hoffman: Right. I mean it’s clearly an elimination pathway for the body, but it’s also your gut is like a chemical toxic factory potentially.

Let me give you an example. A guy was found to be drunk, uncoordinated, and inebriated periodically. And his wife was a nurse. For some reason he was staying at home. And his wife was going to work. And she would come home and he’d act disoriented. And she said, “You’ve been drinking again.” And he said, “No, I’ve given up drinking. I’m not drinking.” She says, “I can tell you’ve been drinking and to prove it, I’m going to give you the alcohol breath test.”

She had a device that she borrowed from the hospital, brought it home. And he blew very, very high DUI levels of alcohol from his breath. She says, “Look, there’s no sense in hiding it from me. Where are the bottles?” He said, “Look, I’m not drinking.” So, look, she says, “We’re going to go to the hospital. And I’m going to consult with an expert in the hospital. And we’re going to get to the bottom of this.” And so they told the story.

The guy said, “Look, there’s only one way to resolve this. We’ll put this guy in a metabolic ward where he’s absolutely locked down. He will have no access to alcohol. Then we’ll test him.” And after three days, they tested him. And he was blowing phenomenal levels of alcohol. And the conclusion was that it was from his gastrointestinal tract. He was literally autointoxicated.

And this was written up in a major medical journal as a short brief communication. So what was the treatment? They gave him antifungal medication because we know that if you want to make wine, beer, any kind of alcohol, you just need some yeast and some kind of fermentable carbohydrate and boom! You’ve got alcohol, ethanol.

James: Do you think that would stand up in a court of law for myself or anyone who I know in the future who happens to get a DUI?

Dr. Hoffman: That’s a good idea. I’ll have to think about that. You know, I have a couple of patients who are should we say law enforcement officials. And they give me their cards, their sort of get out of jail cards. And they say, “If you have any trouble when you’re in Long Island, give me a call.”

James: But, yeah, I like that defense. So what that’s essentially saying is that this ecology down there in the gut is capable of producing a lot of chemicals. There’s a lot of things that could happen.

Dr. Hoffman: Right. Not just that but a myriad of chemicals. That’s just one very obvious chemical that we can measure. But aldehydes and various putrescant byproducts of abnormal digestion.

James: Putrescent is a great word. And it’s quite onomatopoetic in the way of sort of understanding a smell that may come. Would you say that a smell of the bowels is sort of like a lead indicator of overall health?

Dr. Hoffman: Well, you know, Tibetan medicine is largely based on smelling stuff and tasting stuff. Hopefully not tasting stool. But I had the opportunity to shadow an eminent Tibetan doctor, the doctor to the Dalai Lama—his name is Yeshi Dhonden— many years ago. And when he saw patients, he would ask them to produce a urine sample. And he would smell it. And then he would, to my utter horror, taste it, dip his finger in and put it on his tongue.

And the smell of the skin, he would smell the patient. “Open your mouth, bad breath and all. Let me have it.” And this was one of the ways where in that system of medicine, very ancient system of medicine, they were able to come up with diagnoses. But now they’re coming up with this new idea that they will have devices that will actually be able to smell diseases. You know, dogs can smell cancer. Dogs can be trained to recognize certain cancers. They’re saying, “Well, let’s use an electronic device that has an ultra- sophisticated nose that can detect the smell of, say, diabetes or the smell of certain cancers.”

James: That is amazing. And that is amazing particularly in the context of this evolution of medicine where, in some ways, you know, can you just talk from your experience a little bit here and GI focused or otherwise, you said you’ve been with Tibetan medicine and there’s Chinese medicine. There’s all of these other systems of medicine that sort of it seems as though western medicine sort of poo pooed and laughed at because it wasn’t sophisticated. But it seems like pieces of this are sort of coming back into medicine. And one of the things I sort of think about is like we have no idea how long these medical systems were around for. And it seems like if one thing they had going for them is that they were sustainable. And so in the same way that an acid-blocker might be good in the short-term, but poor in the long- and medium-term, it seems like western medicine if you take a step back is good in the short-term and maybe not so good in the short- term and the longer-term and medium-term.

And that’s the reason why, hey, perhaps for the first time ever in America, certain segments of the population are not living as long. We thought we’d be living until 150 or 200 twenty years ago. And we can map the genome and all this stuff. And it’s just not happening. What do you think that medicine as it evolves can learn from these other systems of medicine that we’ve probably sort of maybe a bit arrogantly looked at without too much respect? What can we learn from them?

Dr. Hoffman: Well, an admission here: when I was in college, I had absolutely no idea that I wanted to go to medical school. It was the farthest thing from my mind. I was studying cultural anthropology. And one of the tenets of cultural anthropology is that you go into the field with an inquisitive and open mind. And you look at the practices of the individuals, as absurd as they might seem to the Western eye, and you try to understand their functionality and their usefulness or lack thereof because not everything that people do makes sense.

But from that perspective, I derived a great deal of respect for ancient practices, alternative practices, natural health systems that weren’t science-based, but were empirically-based that kept people sustained for the vast majority of our existence as homo sapiens. You know, we look at the tip of the iceberg. The scientific revolution has been going on for what? Maybe 200 years. In medicine perhaps 150 years. And the practices that we use are science-based, but they’re very novel. And we have sort of a cultural or scientific hubris that makes us believe that somehow they are superior to ancient or unscientific practices that really deserve more attention.

James: Yeah, and integration. I think I’ve heard already a number of people say, Andrew Weil always says you’ve got to do Western medicine well. You’ve got to do this medicine well. And just deliver good medicine. And it seems like that’s sort of the evolution that we’re moving towards is taking the best of things and combining them together. So if we were to look at from that perspective of gastrointestinal, what do you see as sort of like the optimal gastrointestinal health or relationship with a doctor or strategies for the myriad of the types of diseases that we see today?

Dr. Hoffman: I think there will always be a place for gastroenterologists who utilize high-tech methods to detect disease. They can scope people six ways to Sunday and find out where the problem is. And there’s a need for medications for people who are super sick because I say to some patients who come in very sick with GI problems, they want a natural cure. And I say, “Look, if your house is one fire, we’re not going to have you talk about fire prevention. We’re going to go in with high pressure hoses and axes, chop down the door, flood your home. But we’re going to put the fire out. And that’s so you can survive.” So there’s a place for that.

On the other hand, I think there is in gastroenterology in particular, but I think this is something that all integrative physicians can use. And no question that chiropractors, naturopaths, nutritionists, are all very turned on to this, not just holistic MDs and DOs. The importance of diet, the primacy of sustaining the microbiome, being a little bit of a what I sometimes I feel like I’m a little bit of an arbiter between conventional medicine and the patient in the sense that the patient comes in and says, “Well, look, they say I need to take this.” And I go, “Well, you know, if you just took this natural therapy, you might be fine. You don’t really need it.” Or in some cases, like, “Look, don’t delude yourself. You really do need to take medication.” So I think there’s a place for gatekeepers to protect people from the excesses of medicine to come up with lower-tech or more natural approaches.

James: Yeah. There’s a couple of things that I’d like to get into because I really would like to get into the microbiome stuff at some point. But I know that just on that what you’ve just spoken about, one of the books that I’ve read that you wrote is called How to Talk to Your Doctor. And I know although there’s probably a lot of people on this line today who are listening who are thinking, “I know that I can change my diet and improve my health, but my doctor doesn’t necessarily feel like that way.” And they sort of maybe hide things from their doctor, or they do that.

What would you say, what are some of the basic strategies in that book by which people can have a more open and honest dialogue about the kind of things that we’re speaking about today? Because I know that there are people that are addicted to acid blockers. I know there are people addicted to laxatives. And these are not sustainable strategies. But the doctor says you’ve got to be on them. You’ve only got seven minutes to communicate to them. Like how do we go about having a more open, honest, and mutually-respectful relationship with our doctors to help the doctors move along this course, as well?

Dr. Hoffman: Well, I think you have to establish some ground rules for how you’re going to interact with your doctor. Always be respectful, and always be not

confrontational. But say, look, you’re interested where possible in natural approaches, in low-tech approaches, in preventive approaches. And where necessary you’re willing to listen. And then assess your doctor’s reaction. If your doctor says, “Look, my way or the highway. That stuff is all bunk. It’s garbage. It’s fraud,” then you have to vote with your fee. You really do. I don’t expect all doctors that you’ll encounter to say, “Hey, that’s great. I’m all for these natural therapies.” That’s a little bit too much to hope for.

Some might. But the vast majority will say what you’re aiming for is a doctor who will say, “Look, I don’t know that much about these natural therapies. But if you bring me the information and you keep me apprised of what you’re doing, I’ll be happy to supervise your use of these approaches. However—” and the doctor will tell you this, “— if I think you’re going down the wrong path, I will speak up and inform you.” I mean that’s more of a balanced approach to this.

James: That does sound balanced. And you bring up something that I think is so important is voting with your feet, generally. And it’s almost voting with your feet, but it’s also voting with your dollars. You know, people are frustrated by the paradigm of what they see out there of the foods that are available in certain areas. We’re in New York. It’s very lucky. You can get basically anything you want at any time of the day.

But, in most places, I used to live in Georgia. And I know that it was difficult to get the right kind of healthy food choices. You had to be very proactive about it. So this idea of voting with your feet and voting with your dollars, what do you think is the most empowering way for patients to start to change some of these habits?

Dr. Hoffman: Well, you know, I think you have to look at diet, exercise patterns. I think it’s important to inform yourself from reliable sources. Some of the sources aren’t reliable. I think a good place is to start out with information that comes from well-vetted sources. I would consider you a good curator of information. I’m guilty of self- promotion. Forgive me, but the Intelligent Medicine podcasts are, I hope, a source of useful information. You can get them at DrHoffman.com.

And a lot of people I think empower themselves. And this is sort of a grassroots movement to some extent. You know, a lot of the stuff that we do that’s good for us is not government sanctioned. It’s not sanctioned by corporate America. It’s not sanctioned by establishment figures in our lives. But things that we do maybe locally in our community to help friends, families, others who are less fortunate, many of the best efforts are grassroots efforts that aren’t necessarily coming from some centralized bureaucracy with edicts.

James: Well, one of the things that’s encouraging in a certain way, and this is not the way that we all like it to happen, but so many people are starting to, one, get these symptoms that their doctor can’t help and, two, make these changes by themselves, use the Internet, get different information in, see improvement. It’s almost like we now have a sort of fertile place for people to be able to make these kind of changes. Because just think back thirty years ago, there’s no way that all this information you could get it. Where were you going to get it? The library? I mean this is not—

Dr. Hoffman: Remarkable changes have occurred.

James: So easy.

Dr. Hoffman: Yeah.

James: So, yeah, DrHoffman.com/podcast is the Intelligent Medicine podcast. There’s a lot of great information on there. I think those are some great starting points.

Let’s just go through these different areas that we’ve spoken about and talk about some of the natural ways that you’ve seen to be effective. So let’s start at the top. Like the combination of GI and ear, nose, and throat things, acid blockers, the stuff that’s going on there. What are the kinds of things that you’re using in the practice to work with those kind of issues?

Dr. Hoffman: Well, if you’re on acid blockers, don’t go off them very quickly. You need to taper slowly. So I think many people and sometimes doctors make the mistake of saying, “Okay. You can go off now.” So taper slowly. Utilize products like DGL, which is deglycyrrhizinated licorice. It’s important that the licorice be deglycyrrhizinated because too much licorice will raise your blood pressure. You don’t need that component to soothe the esophagus and the stomach. And you can take these little lozenges and chew on them all day long. You can have eight or ten or twelve a day. And it’s very soothing.

You can use aloe vera gel, not the juice, aloe vera gel taken away from meals. That’s very healing. A product that I like to use, and it’s unfortunately not available retail. It’s available through doctors. It’s called Endefen. And it’s a mixture of plantain and other mucilaginous substances that’s very soothing to the esophagus. We heal a lot of GERD, reflux, and gastritis symptoms with that product.

And then probiotics, of course. But, the key is diet change. And, you know, even people who are on a “healthy” diet. You know, they’re eating like granola, skim milk, and lots of fruits and vegetables and juices, they may have a lot of gurgling and reflux. They might find that they do better when they reduce their carbs and have more in the way of animal protein, I find.

James: Yeah. Well, we’re going to have a lot of discussion about diet. And I know that you have your own views on that. And other people think very differently.

Dr. Hoffman: Huge controversy.

James: Yeah, it’s a controversial area. But I think the one thing that you would probably agree with is that people are different. People are going to work out different ways. And they need to be in a relationship with a doctor, a functional medicine doctor or someone like that, who can help them to go through and try out different things until they find something that’s sustainable for them.

Dr. Hoffman: Exactly. A lot of it is trial and error and different strokes for different folks.

James: Okay. So, we’ve got just about ten minutes left here. And I want to get into a little bit of this microbiome because it’s so valuable to think a little bit about this because let’s just give the example of gut infection. So we’re talking about GI diseases. The moment that I saw that fecal transplants were the cure, this amazing cure, for these chronic infections like C-difficile, which were antibiotic resistant, I knew that the game was up as far as like our regular understanding of the germ theory and how germs are sort of causing disease. Can you just give a quick overview for people at home about what these new types of treatments are? Because it’s really a super probiotic, isn’t it? Feces in the gut.

Dr. Hoffman: Right. Okay, caveat: this is not yet ready for primetime. It’s being done in very strict research protocols. And my general advice is don’t try this at home. The yuck factor is very high here. But the point is that when people have very, very disrupted microbiomes, there’s probably as many different types of species of bacteria in your gastrointestinal tract as there are stars in the sky. So taking one probiotic or taking even a combination of probiotics—eight, ten, twelve different things—it’s still not going to replete you and restore you to normalcy. So that’s the principle behind fecal transfer or transplants.

It’s been helpful in very, very serious diarrhea problems like C-difficile. Some studies have been done in ulcerative colitis and Crohn’s disease. And that’s hopeful. The problem is how are you going to commercialize this? I really fear for the lack of impotence to get this on stream because all the money, all the commercial emphasis and our current paradigm is to find a very niched drug which can be patented and that we’ll miraculously block this or that or the other pathway and change the immune system. So how are you going to monetize donating feces? I’m not sure.

James: Well, the gift economy is certainly starting to arise. So I’ll be generous with mine. I’m not sure if I’m exactly…I think we need to find the healthiest people.

Dr. Hoffman: Oh, you must have great flora! I think your flora’s probably—

James: I’ve not had that much antibiotics. I think that’s probably a good starting point. Yeah, you bring on to an interesting topic there which is sort of this what’s cheap versus what works and the future of medicine as far as the proliferation of things that don’t make money. I know this is another topic that you speak about a lot, just sort of like the war on natural medicine and so forth. What are your sort of hopes and fears for the next five years in American medicine? What do you fear will happen and what do you sort of hope will happen?

Dr. Hoffman: Well, I see real problems occurring. Especially, Obamacare, whichever political party you adhere to. It just happens to be that the current administration is holding the ball of on the demise of American medicine that’s been occurring for a really long time. And there’s going to be a point of reckoning where it’s going to undermine the health of Americans, destroy our productivity, and also just destroy our economy the way we’re allocating money with expensive solutions for problems that might be more amenable to lower-tech, cheaper solutions and prevention.

But what’s going to happen, I think, just like physical fitness, Americans are getting fatter. However, the physical fitness movement is burgeoning in America. More and more Americans are getting healthy. I think it’s going to be maybe an enlightened minority of Americans who opt for healthier styles of health management that will lead the charge that hopefully…I mean, I’m very uncertain about the way things are going to go. I think there may be a real crash and burn that’s required. You know, it’s like in addiction theory, you got to hit bottom before you can begin your twelve-step program.

James: Yeah. Well, I think that’s definitely the direction that we’re headed, unfortunately. But if you’re on the more hopeful side, what signs do you see that we’re moving towards a more sustainable medical system that the evolution of medicine is occurring?

Dr. Hoffman: Well, there’s just an explosion in the number of practitioners offering this type of medicine who are well-trained, well-informed. I see that coming from my field –medicine, MDs. But, naturopaths are really a very important force in this country providing this type of information. They’re well-trained, very scientifically-based. Chiropractors have a lot of this information at their disposal. So, there is a phalanx of health practitioners, nutritionists who are not just pushing Jell-O in hospitals and Ensure and Boost. But nutritionists who have functional medicine understanding are really making a difference. Particularly, here, we’re talking New York, San Francisco, Denver, Boston, points of light in kind of a dismal American scene.

James: Yeah. Well, it’s definitely proliferating. And that’s one of the reasons I started Revive Primary Care is I just felt, look, there are enough of these practitioners around. If you have the right person to find these people, it’s a great starting point. And having one of these practitioners, however they’re credentialed, alongside your current medical care seems to be synergistic.

Dr. Hoffman: That’s the way to go. That’s the way to go.

James: Yeah. And other things that we’re trying to do in this Summit is really start to talk about how doctors can work with coaches, how doctors can work with nutritionists, how to get communication in medical structures because I think that this is really what it’s going to take for everyone to work together.

And I think what you’ve outlined today is a great vision for the future of gastroenterology. And if the future of gastroenterology looks like this, I think the knock on effects to the rest of the body will be huge. In the same way that a toxic gut leads to all kinds of other symptoms, a healthy gut or a revitalized gut will certainly lead to improvement in lots of other areas. And I see this coming all the way through.

So, yeah, thanks so much for your time and being here today, Dr. Hoffman. You can find Dr. Hoffman’s podcast is the Intelligent Medicine podcast. It’s at DrHoffman.com/podcast. Great guests all the time and actually just an unlimited or just a history of all of the podcasts that you’ve been doing for a long time with great people on there. And I’ll look forward to coming on again soon. Thank you so much for being here today.

This has been The Evolution of Medicine Summit, a great session on the Evolution of Gastroenterology. And I’ve had Dr. Ronald Hoffman here. Thanks so much again, doc.

Dr. Hoffman: My pleasure!

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