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Is it possible that the most potent medicine in your bathroom is what’s getting flushed down the toilet every day?

Fecal Microbiota Transplantation (FMT) – taking stool from a healthy person and using it to recolonize the colon of someone with a dysbiotic microbiome – has been one of the most exciting areas of medical research in the last five years.

The simple power of poop has been found to be 92 percent effective in treating the opportunistic and antibiotic resistant bacteria C. difficile, with patients reporting dramatic recoveries within 12 hours.

Though these “ick factor” therapies remain experimental, having not yet received full FDA backing, hundreds of trials are underway across the country to determine their future in treating IBD, SIBO autism, obesity and other inflammatory conditions. And plenty more people have taken matters into their own hands to try their luck with fecal transplants at home.

Today on the podcast, we talk about all things stool transplants: how they work, who might benefit most, and what we still don’t understand about their efficacy within the whole microbial ecosystem in all its complexity. Joining me is Dr. Andrea McBeth of Flora Medicine, who is one of the leading experts in the field.

Make sure to listen to the end of the episode as she also addresses the recent controversy over the FDA halting several trials using fecal transplants and what the future might hold for Big Pharma and every day sufferers.

A quick taste of what we’ll cover:
  • How FMT works and the best mechanisms for delivery for various gut issues
  • Why all the other matter in your poop is equally if not more important than the bacteria when recolonizing your microbiome
  • SIBO, IBD, autism, obesity and other inflammatory conditions that are being explored right now with FMT treatment
  • Methods for doing a DIY fecal transplant or fecal therapy
  • How to choose and properly screen a donor
  • The difference between a therapeutic dose for shifting an ecosystem and what you might need to eradicate a pathogen
  • Risk factors and why we still need more safety precautions
  • Why FMT could help certain SIBO cases
  • What lifestyle and diet strategies you need in order for the FMT to work long-term
  • And so much more…
Resources, mentions and notes:

This episode is brought to you by Epicured, a low FODMAP meal delivery service that understands that food is medicine. Each menu is created by Michelin star chefs and honed by doctors and dieticians at mount sinaii to restore digestive health for those with IBS, SIBO, Celiac and IBD. Everything they serve is 100 percent low FODMAP and gluten-free, with no cooking required! My favorite part about their dishes is the healthy spin on takeout gems like shrimp laksa and PAD THAI! Their version had a great balance of fresh veggies mixed in with the noodles that left me feeling both satisfied and completely free of my usual carb coma. Listeners to this podcast can get 20% off their order by using code SIBOMADESIMPLE. Just click here to learn more. 

Disclaimer: The information shared in this podcast is not meant to provide medical advice, professional diagnosis, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.

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Sometimes I put off watching great food TV because it feels like work.

Such was the case with Salt Fat Acid Heat. Believe it or not, I arrived only recently to that party, thanks to an afternoon appointment at Shape House, where you get to watch television while you bake in their sauna sleeping bags, and where I felt just a little too guilty mid-workday watching Younger reruns.

So instead, I opted for Samin and am so glad I did.

The show makes her book come alive in the most sensual way. I wanted to taste everything she tasted. And go everywhere she went. Instead, I tried to make everything she made, starting with this Chicken Escabèche recipe.

This Yucatan-style sweet and sour chicken is traditionally made with a specific type of tart oranges from the area. Naturally, it was something that Samin included in the Acid episode, which centered around Mexican cuisine from this region. It’s also the dish and episode that my close friends might have guessed that I liked the least, since I have a bit of an orange phobia.

But after watching, when left to my own devices, I had an idea to use either limes or Meyer lemons to create a similar acid base for my version of Chicken Escabèche. And since there were so few other ingredients besides hot peppers and onions, I decided to omit the latter and make the dish a low FODMAP taco filling.

In this version, the shredded chicken comes together quickly in the oven, where it braises with a mixture of carrots, jalapeno, lime and a little sugar for sweetness. A handful of fresh mint for garnish really compliments the spice. I also love topping the tacos with crunchy radishes and cabbage, but you can add avocados or any other accouterment you like if you’re not following the low FODMAP diet.

And speaking of that…those who subscribe to my newsletter got the good word yesterday that I’ve finally created a low FODMAP version of my Summer Reset Elimination Diet Meal Plan! You can find out more about it here.

There’s a version of this Chicken Escabèche in the book minus the tacos, since in addition to removing high FODMAP foods, the recipes are also gluten, dairy, soy, corn and refined-sugar free so you can layer a traditional elimination diet on top of your low FODMAP elimination. There’s instructions on how to do this of course, and it’s a really rare thing to find a plan that will help you dual path, so I hope it’s very helpful!

For launch week I’m giving you $25 off with the code TAKE25, so get on it! It expires on the 24th.

In the meantime, you can get a little taste with this Chicken Escabèche recipe!

With health and hedonism,


Chicken Escabèche Tacos (Low FODMAP)

These chicken tacos are made escabeche-style with the perfect balance of sweet and sour from the Yucatan. Instead of orange, I use lime juice with a little sugar. But if you like orange you can add some fresh juice to this recipe. Meyer lemon would also be great. Though there are normally onions, this recipe has been adapted to be low FODMAP.

  • 2 tablespoons olive oil
  • 4 garlic cloves (smashed)
  • 2 pounds boneless skinless chicken thighs
  • 1 teaspoon ground cumin
  • 1 teaspoon ground coriander
  • 1/4 teaspoon ground allspice
  • Sea salt
  • 2 medium carrots (thinly sliced)
  • 1/4 cup sherry vinegar or red wine vinegar
  • 1/4 cup lime juice
  • 2 teaspoons organic cane sugar or clover honey
  • 1 bay leaf
  • 1 jalapeno (thinly sliced)
  • 1/4 cup roughly chopped mint leaves
For the tacos:
  • 12 corn tortillas (warmed in the oven or charred stovetop directly on the flame)
  • 1 cup shredded cabbage (for garnish)
  • 1/2 cup mint or cilantro leaves (for garnish)
  • 6 sliced radishes (for garnish)
  • 4 lime wedges (for garnish)
  1. Preheat the oven to 400 degrees F.
  2. In a large oven-proof skillet or saucepan, heat the oil over medium heat. Add the garlic and cook, turning occasionally, until golden brown on all sides and very fragrant, about 3 minutes. Remove the cloves and discard.
  3. Meanwhile, season the chicken generously with salt and sprinkle the cumin, coriander and allspice over the meat.
  4. Raise the heat to medium-high and add the chicken in a single layer, spice-side down. Cook until nicely browned on one side, about 4 minutes. Remove to a plate.
  5. Add the carrot and vinegar to the pan, scraping up any brown bits that may have formed on the bottom, followed immediately by the lime juice, honey, bay leaf, 1/2 cup water and 1/2 teaspoon salt. Bring to a simmer and reduce for 2 minutes.
  6. Remove from the heat and return the chicken to the pan, seared-side up. Scatter the jalapeno over the top.
  7. Transfer the pan to the oven and bake, uncovered, until chicken is fork tender, about 15 minutes. Let rest 10 minutes, then roughly chop or shred with a fork, top with mint, and serve alongside the tortillas, cabbage, mint or cilantro, radishes and lime wedges.

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Research shows that so much of what sets us up for good gut health later in life happens during early childhood. And yet, it’s often when we take our biggest missteps. In today’s episode, we go beyond SIBO to talk about the rules of greater gut health, why our detachment from the earth is making sick, and how by simply getting dirtier we can correct some of the microbiome mistakes from our youth.

I’m joined by Dr. Maya Shetreat, who is a pediatric neurologist, herbalist, urban farmer, and bestselling author of The Dirt Cure: Healthy Food, Healthy Gut, Happy Child. In our chat, we discuss what’s happening in a developing gut and how some of the popular ills of childhood – like ear infections, fever, rashes, colic, hyperactivity – relate to food sensitivities and a damaged microbiome. More importantly, Dr. Maya gives us some concrete advice on natural alternatives to conventional over-the-counter drugs that might be damaging your kid’s microbiome further.

If you’re someone who is still putting together all the pieces of your health puzzle (or a child’s) this conversation will bring a lot of aha moments, and offer plenty of suggestions for moving forward. 

A quick taste of what we’ll cover:
  • How the genetic vulnerabilities we’re born with play out via our lifestyle and environmental triggers
  • What being out in nature does for our nervous system and biodiversity
  • How the microbiome interacts with the microvirome – our body’s ecosystem of viruses
  • Why childhood fevers are so important for immune development
  • How gut health impacts the nervous system and why certain children present with neurological issues like ADHD or Autism, and others will get an ear infection
  • Why early childhood emotional or physical trauma can affect gut health later in life
  • Cranial-Sacral Therapy, reiki, chiropractic adjustments and how you can expand your child’s wellness toolkit
  • How to approach an elimination diet for children
  • Natural tools for your medicine cabinet to fight common childhood ailments like fever, rashes, etc.
  • What dietary culprits could be behind chronic ear infections in children
  • How we can apply the rules of greater gut health in adult life, even after imperfect childhoods
Resources, mentions and notes:

This episode is brought to you by Epicured, a low FODMAP meal delivery service that understands that food is medicine. Each menu is created by Michelin star chefs and honed by doctors and dieticians at mount sinaii to restore digestive health for those with IBS, SIBO, Celiac and IBD. Everything they serve is 100 percent low FODMAP and gluten-free, with no cooking required! My favorite part about their dishes is the healthy spin on takeout gems like shrimp laksa and PAD THAI! Their version had a great balance of fresh veggies mixed in with the noodles that left me feeling both satisfied and completely free of my usual carb coma. Listeners to this podcast can get 20% off their order by using code SIBOMADESIMPLE. Just click here to learn more. 


PHOEBE: Dr. Maya Shetreat, it’s so nice to have you on. I’m going to call you Dr. Maya like the kiddos, even though we’ve met in person. Maybe I could just say Maya? I don’t know. Actually, I should tell people how we met.

I had emailed you probably five days prior to podcast guest, Jolene Brighten, being in town, and we were supposed to have tea. She texted me the day of and said, hey, I don’t know if you mind, but my friend Maya is going to come, and I was like, oh, my God. I guess fan girling a little bit since I had just reached out to you. We ended up meeting. Discovering that we are not only both Scorpios but have the exact same birthday, and yeah, here we are now. Thanks for coming on the show.

MAYA: Definitely a fated meeting.

PHOEBE: A fated meeting. All right, so for those who aren’t as familiar with your work, tell us a little bit about your story. You’re a pediatric neurologist. Why neurology? Why children? Go.

MAYA: When I was deciding what to do, I – actually, I like the idea of solving puzzles. That was really what I think got me really into neurology. It’s very logical and also, at the same time, very intuitive. In the nervous system, you localize everything based on the symptoms someone’s having. I like problem solving, puzzle solving, like detective work, and I decided I wanted to work with kids because – well, two reasons. One is because children’s brains are so plastic, so there’s just so much capacity for recovery, or at least that’s what I thought at the time. Now I know that, really, everyone’s brain is plastic and that our bodies are also. I’ve seen amazing recoveries that I never could’ve imagined back then with the work that I do, but at the time, that’s what I thought.

The other reason was that I had a mentor who gave a lecture in my second year of med school about autism, and I was so compelled by this mystery of autism. I decided to do research with her and really got connected with a lot of families and worked with the kids. It became a passion of mine, so that was how I got into my initial field of pediatric neurology way back when.

PHOEBE: Awesome, and then your part two, your next chapter was how you came to write TheDirt Cure, which stem from something that happened with your son. Will you tell us about that?

MAYA: Throughout my training, I got married, and I had three children. I had my daughter in med school, my son in pediatrics residency, and my second son in my neurology fellowship. My second son, my youngest, when he was about a year old, he started to have asthma symptoms and, also, a neurologic plateau or even regression where he’d been an early speaker. He stopped gaining words. He got clumsier. He started falling more, but he wasn’t catching himself, which is a normal reflex. He would hit his face into the ground, and he was just agitated a lot of the time. Coinciding with that, he had all these breathing issues, which looked like asthma. He went in this cycle of being on antibiotics and steroids and inhalers.

I took him to different doctors because I was like why did this happen all of a sudden? Nobody was that bothered. They were like, well – I took him to allergists and pulmonary doctors and neurologists. It was like, well, he’s a reactive kid. He’s going to be fine, this kind of thing. After ten months of him being – literally, every other week being sick and being on nonstop meds, I finally got to the bottom of it myself by looking in the scientific literature and ending up connecting with not the most well-known doctor in the world for food allergies or that kind of thing but, actually, a local allergist.

We discovered he was allergic to soy, which probably happened due to a mold exposure, which is a deeper story. He was allergic to soy, and when he stopped eating soy and, in his case, drinking soy because he was having soy milk – which at the time, I thought he was reacting to dairy. I thought, well, soy milk is a great option. We stopped that, and he stopped having asthma after ten straight months. Then we saw him really improve in his neurologic symptoms over time, but what took a long time was actually to recover his gut and his disruptive microbiome. That from all the medications was pretty much a mess.

PHOEBE: Yeah, I mean, one of the many reasons why I really liked your book is that I found that it wasn’t just a great read for parents because I’m not a parent but, really, anyone who is in adult life and suffering from unexplained symptoms. I think back to all the puzzle pieces from, I mean, certainly my own childhood health history, and I know people listening at home probably are people who have been through the ringer with mysterious symptoms for a long time. First off, what’s happening, really, in the early stages of development with children’s guts? How do some of the popular ills of childhood – like your son’s asthma, ear infections, rashes, colic, hyperactivity, how do these all tie in?

MAYA: It used to be – I’m going to start with birth, really. This I will tell you actually applies to everybody. I wrote my book for families, and that includes kids and adults. I’ve had a lot of adults read the book who are not parents. Even going back all the way to birth, it sounds crazy. What happens in the womb and at birth, our own birth meaning, and through childhood actually does affect our lifelong health, so it’s relevant. Really, we imagine that in the womb we’re completely in a sterile environment. This is what we were told for a long time.

It turns out even the womb and the amniotic sac has its own microbiome with its own unique set of bacteria that maintain that environment or help to maintain that environment. Then, when we’re born – so there are all these factors that impact. When we’re born, generally, we’re intended to go through the vaginal canal. This makes people squeamish, but if we’re talking about SIBO, we’re talking about poop I know, so at least we get to talk about all the different places in the body. Basically, part of how we seed – the baby seeds its microbiome, it’s swallowing vaginal fluids. Actually, even around the perineum right as it’s coming out, it’s getting this exposure to the vaginal microbes. That is what actually is like the initial probiotic of life that basically creates a beautiful diverse microbiome, hopefully, for the baby.

What we know, for example, is that if a baby is born by C-section, they don’t have predominantly vaginal flora, but what they have is actually predominantly skin flora. That changes the makeup of the microbiome. This doesn’t mean if a baby’s born vaginally that all their problems – that there are going to be no problems, or that if they’re born by C-section, they’re running into problems. Probability-wise, statistically speaking, they’re more vulnerable being born by C-section. Now, I will say I had my son vaginally, and he was a home birth for that matter. He still ran into some of these problems, so it’s not foolproof. We’re talking, again, about these different things of having healthy flora. Also, if a mom is given antibiotics around birth or before birth, or she’s gotten lots and lots of antibiotics in her life, her flora’s going to be different. The baby’s flora is going to be different and even getting antibiotics around birth or right after birth, so these are some of the issues that can come up.

Now we know that there’s not just a microbiome that contains bacteria but actually a micro-virome where there are actually viruses that maintain the tasks, let’s say, of the flora in the gut. For example, there was a study done, and it was published in Naturea few years ago. It was really like seminal study that showed that when they did these experiments with germ-free mice – and germ-free means that they wipe out all the flora of the mice using antibiotics. They actually gave a controlled group – they got nothing, and then another group got a certain relatively benign virus. The ones that had the benign virus, were given that, were ingesting that, those viruses totally took over for the bacteria. Literally, everything went without a hitch whereas, normally, in a germ-free mouse, there’s gut breakdown. There is all kinds of disruption that goes on physiologically because our – we are dependent on a healthy microbiome.

Things like steroids and Tylenol and vaccines and all these different kinds of exposures that we have that are normal in our lives, they change up the microbiome and the micro-virome in ways that we really don’t totally understand and can’t anticipate the kind of impact it has. When someone has a disrupted microbiome for any number of reasons and there are many possible reasons, what we know happens is that there could be gut symptoms, and moreover, there’s actually immune symptoms very commonly because the immune system and the microbiome are in close communication and then, in addition, neurologic symptoms.  We can actually see all kinds of issues relating to, let’s say, migraines, or seizures, or ADHD, or focus, or mood, or all kinds of neurologic symptoms that basically come from a disrupted microbiome.

PHOEBE: Yeah, I mean, it’s fascinating, and I think it’s something that a lot of people don’t understand is why maybe you could even not be experiencing any digestive symptoms but be someone who gets the ear infections, the rashes, and what have you. Why does that happen? Why does it get expressed in different ways, and specifically, with the gut-brain connections, how does that work?

MAYA: For one thing, we all have different vulnerabilities, genetic vulnerabilities. We all come to the table with genetic vulnerabilities. This is when you say, oh, this runs in the family. My dad has it. My grandfather has it, that kind of thing, so therefore, I have it. That’s not a given. It’s very rarely a given that just because other people in your family had something that you have to express symptoms. You may have that vulnerability for eczema, or you may have that vulnerability for seasonal allergies, or food allergies, or migraines, or whatever, whatever it may be. What it comes down to is what are the circumstances? What are the environmental exposures? What are the triggers going to be that are either going to reveal that vulnerability, which means you’re going to have symptoms, and you’re going to express it, or that are going to keep you resilient?

Having a really biodiverse microbiome, meaning lots of different kinds of bacteria – and not too much of any particular kind but lots and lots of different kinds, so we call that microbial diversity. If you have increased microbial diversity, that’s protective, and that actually protects you in a lot of ways. One of the ways is simply by – that’s what your immune system wants. Your immune system wants to see lots and lots of different flora, lots of different microbes. Actually, it becomes more comfortable with lots of different things like different kinds of foods, different kinds of flora, all different kinds of compounds. Things you might find in nature, right? Nature is so biodiverse with lots of different compounds that your immune system becomes more comfortable with all different kind of things, and then it’s less likely to freak out when it sees something strange, which might like a certain kind of cat, or it might be a peanut, or it might be something else. It’s not to say that that’s foolproof, again, but this is the kind of thing that all this diversity is what our body’s evolved with in nature.

Now we’re in a much more sterile way of living in houses where we scrub it down all the time with bleach. We wash ourselves with soap. Not all of us. Some people though or a lot of people. Yeah, I think being clean and being sterile and being hygienic is what we aspire to. Actually, it doesn’t mean we all have to walk around like pig pen but really getting dirty and being exposed – like coming home with – going outside, getting dirt on our clothes, and sitting down in the grass and being in nature and having even a pet. We hear these scary stories, oh, like sponges that you wash your dishes with. They’re filled with bacteria, but the irony here is that you’re less likely to develop allergies if you use a sponge because you’re getting that microbial diversity whereas with a dishwasher you’re not getting that microbial diversity.

Same using bleach, there’s all this data that when kids are in schools or homes where bleach is used really regularly, they’re more likely to have chronic respiratory infections and bronchitis than if they don’t have bleach exposure, so it’s interesting, right? I mean, it could be the bleach, the chemical, all that, but I think it’s also very likely that it’s related to, again, the microbial diversity that we need that. That’s part of what keeps us healthy. These things that we aspire to do and felt like, wow, I want to be clean; I want everything to look just so, it’s actually being a little dirty, or a little messy, or having the pet, okay. Again, pets also increase your microbial diversity because you’re sharing the microbiome of your pet.


PHOEBE: I have a question about this. As someone who lives in New York City with a pet, who already has a compromised immune system – I have Hashimoto’s. I always wonder. I could, of course, walk to the park and, of course, lay down in the grass and roll around and what have you, but I just worry about the fine line between dirt in a city like ours and toxins. What advice would you give to someone who lives in a sterile apartment without a backyard, who has a dog who is often times walking around on pavement that’s not filthy in a good kind of way? How does someone like me get more comfortable with the idea of getting dirty?

MAYA: I think that, if you’re in an area where you think there could be massive heavy metals or something in the soil, that’s the kind of thing that you can just sample soil, and that’s actually not expensive to do. The city generally will come and remediate if there is a significant heavy metal problem, and of course, there could all kinds of toxins. It’s true, even pesticides and other things, but to me, in general, they don’t outweigh getting outside. That could be as simple as going and taking a walk outside. No one says you have to literally coat yourself in the dirt of the city, although I do recommend on a weekend taking your dog and renting the car or hopping on the train and getting out of the city. I do think that that’s something that people can prioritize, or there’s all kinds of clubs you can join or different things where you can go on little hikes, not far. It’s an incredibly healing thing just to get out of the city first of all, period. I think that it’s really regulating to our nervous systems and our immune systems and all of those things, so I think it’s worth doing that regularly.

Then the studies that look at soil microbes – because it’s interesting. There are different soil microbes that have been studied and have been shown to enhance mood, increase focus, improve cognition, so they make you smarter. You feel less anxiety when you’re exposed to these. One of the ones I’m thinking of is called mycobacterium vaccae. There’s a lot of data on that particular one. It’s a soil microbe. Basically, in the studies that were done, what they said was there’s basically – they called it a superhero effect from when you get exposed to that, and you’re exposed to it though light gardening, or being in the dirt, or in through cuts in your hands, or you inhale it, or you eat a little bit because you’re touching the ground and touching your mouth. I mean it doesn’t have to be very much, but the benefits last for three weeks.

We don’t have to live in a rural area or go off the grid in order to get that benefit, but we do have to show up. We have to go connect with nature. Personally, in the city, I mean, go to Central Park. Go hug a tree. Go have a picnic. You can sit on, literally, a blanket. Again, nobody is saying roll around if that’s not your jam. I do think it’s like – in one teaspoon of soil are as many organisms as there are people on the entire planet.

This is like here we are worrying about microbial diversity and how many billions of CFUs are in a particularly probiotic and stuff like that, but there’s a lot of CFUs in soil and just traces of it. I mean, go to the farmers market and get your food there when you can so that it’s not all power washed vegetables. You’re going to get, again, little traces of soil. You don’t have to eat mouthfuls.

PHOEBE: I’m totally onboard with all that. To go back to the fearmongering side of my brain/society’s brain, what you’re saying is that we shouldn’t worry as much about the idea of city grime equaling toxins per se. Real toxins like the mold, the heavy metals of the world are found in other areas of the city, sometimes your home, but not necessarily you’re going to be affected by those from petting your dog and letting him sleep on your pillow.

MAYA: Yeah, I mean, look, these are the things that can happen, and I think we have to have awareness around it. Honestly, I mean, I think two things. One is whatever traces you might be exposed to, in most cases, they’re not going to impact you in that dramatic of a way. Sometimes they will. I also think by showing up and being out in nature and thinking of nature as us being in relationship with the natural world, that means also that, if they’re going to spray New York City parks just for example, we’re going to show up and say don’t spray my park. I want the microbes that are here, and I don’t care if there’s some wild plant growing that isn’t as nice or might cause an issue. Let’s think of another way to deal with it, which there are other ways to deal with it. Stop spraying poison in my park. One other thing I’ll say about toxins in soil is that, actually, there is some research that shows that the more microbial diverse the soil is, the more the microbes themselves sequester toxins like heavy metals. That means that, if you have really beautiful soil that’s biodiverse and composted and we’re not spraying pesticides on it, it’s less likely if there are toxins in that soil that you’ll even be exposed to them because the microbes deal with them.

PHOEBE: Hmm, that’s really interesting. All right, so going back to the whole category of symptoms , I really loved how you talked about this in the book. Just about how so many kids go through the revolving door of doctors’ offices and just become overmedicated to treat the symptoms and become even more overmedicated to treat the symptoms of the first medication. I’m curious, though. In a lot of your examples, the various symptoms, be it ADHD, autism, rashes, what have you, were a result of a food sensitivity, and a food sensitivity is usually caused by some sort of either toxic burden like maybe in your son’s case with the mold or a gut imbalance. Are those the two main root causes of this plethora of different symptoms? Is that safe..

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SIBO breath testing has been the subject of some pushback in the wider medical community. Today’s episode discusses some of the controversy around the effectiveness of breath testing, when it’s worth doing, how to make sure your results are accurate, and what other tests might be better at getting to the bottom of your gut issues.

Joining me is Dr. Patrick Fratellone, a functional cardiologist and herbalist who used to practice with the late Dr. Robert C. Atkins. He takes us through how he does his gut detective work as a functional medicine doctor, including what comprehensive tests on genetics, vitamin levels and intestinal permeability can tell you about your bigger gut picture.

If you’re someone who’s been debating whether or not to get a breath test for SIBO, this episode might help you weigh that decision.

A quick taste of what we’ll cover:
  • Whether doing a SIBO breath test is worth your time, money and energy
  • What other tests are necessary to determine how your small intestine is functioning
  • Why vitamin D levels are great indicators of your gut health
  • How Dr. Fratellone goes through his process of elimination (hint: SIBO is not the first condition to rule out)
  • MTHFR genes and what they tell you about your health picture, including SIBO
  • Genetic origins of IBS and how to test for them
  • Candida versus SIBO: how to tell the difference
  • Testing for leaky gut / intestinal permeability and why it’s important
  • How to prepare properly for a SIBO breath test so your results are accurate
  • IGG reactivity testing and what it actually tells you
Resources, mentions and notes:

This episode is brought to you by Epicured, a low FODMAP meal delivery service that understands that food is medicine. Each menu is created by Michelin star chefs and honed by doctors and dieticians at mount sinaii to restore digestive health for those with IBS, SIBO, Celiac and IBD. Everything they serve is 100 percent low FODMAP and gluten-free, with no cooking required! My favorite part about their dishes is the healthy spin on takeout gems like shrimp laksa and PAD THAI! Their version had a great balance of fresh veggies mixed in with the noodles that left me feeling both satisfied and completely free of my usual carb coma. Listeners to this podcast can get 20% off their order by using code SIBOMADESIMPLE. Just click here to learn more. 


PHOEBE: Thank you so much for coming on the show, Dr. Fratellone. To get people acquainted with your work and your practice, I know you’re a cardiologist by training but also practise internal medicine. Just tell us a little bit about how you got into more the integrative side, and how you’d describe your approach today?

DR. FRATELLONE: It really dates back to when I was a kid because I was born with a heart defect and I was a blue baby, and how my parents, in the late ’50s surgery wasn’t that great, my grandmother and my mother gave me a lot of herbs since I was a kid. I’ve been using herbs, unknown to me, from a young age. I always wanted to be a doctor, and I actually wanted to be in infectious disease, so I sought out to do an internal medicine – after medical school, internal medicine. I went to medical school in England, which I think advanced my knowledge of that they take a better care of the patients because they actually talk to the patients. I went to school there, came back to the United States, did internal medicine, infectious disease, cardiology.

My first medical partner was the late Robert Atkins of the Atkins Diet. We worked together for a number of years, and even though people know him as a diet doctor, he was the one who told me, or taught me about supplements. We wrote a couple of books together. He had a book called the Vita-Nutrient Solution. We had a radio show, so doing this kind of podcast, it’s not new to me because I’ve been doing radio with Dr. Atkins all those years we were on WOR.

He introduced me to a doctor on one of the shows named Andrew Weil. When Dr. Atkins passed away and I inherited his practice, I then went to do a fellowship with Dr. Weil, the first fellowship of integrative medicine. I stayed in Arizona, I met him, and just like I did a fellowship in cardiology, I now did a fellowship in integrative medicine. I learned more about the topics we’re going to talk about, but I also met someone there who change my life, Tieraona Low Dog. Do you know here?

PHOEBE: I do. Not personally, but I know her work. She’s amazing.

DR. FRATELLONE: She’s great. She was one of my – she was the professor of botanical medicine and a socio professor at the school, and she convinced me when I finished this fellowship that I would be great being an herbologist. I then did a lot of herb courses, and through her and through another herbalist named 7Song in Ithaca, I applied to The American Herbal Guild professional member to get a registered herbalist degree. Not only am I fellow of cardiology, a fellow of integrative medicine, I actually am more proud to say that I’m a herbalist.

From that I did other courses, but I would say I use a different approach, including SIBO and heart disease, using herbs more than medicines. That was how I started.

PHOEBE: Yeah, you’re not alone there, certainly for SIBO. Today we are going to focus on the topic of testing. I know some of your patients. I know you do a very thorough job of testing! I wanted to first of all just answer the question that I get asked from a lot of people, which is why is it even important to test for SIBO in the first place? Some of these people are getting practitioners who think it’s better to just skip immediately to treatment. I want to just talk about what the testing options are later, but first, what is the argument to even start with a test?

DR. FRATELLONE: I’ll take a step back. You start with the test, but you really have to find out – since the gut is the gateway of all disease, you have to find out how the gut is working. When I say gut, I’m talking about the small intestines. You have to do some preliminary blood work before you test for SIBO to see if the gut is leaky, leaky gut, or malabsorbing. Though there’s many diseases, such as sprue, celiac, irritable bowl, Crohn’s, ulcerative colitis, you still have to get the basic physiology. I think physicians miss that they have to find out if the basic physiology of the small intestines is working.
When a patient comes here, and although they think they have SIBO, I want to find out is the gut inflamed, and what is the insult to the gut? The first thing I do is simple blood tests, examination of the patient, good history, and blood tests. The first blood test that gives you a clue is the vitamin D level. Once you get a low vitamin D you know that the three functions of the gut are compromised. One function of the gut is absorption, second is vitamin D, making vitamin D3, and the third function of the gut, which is [04:48] SIBO, is neurotransmitters.
We know that 90% of neurotransmitters are made in the gut and travel to the brain, so this is the gut–brain connection. I think you have to know that before you start treating SIBO because they’ve now found out that certain bacteria are prime – you need certain bacteria to make these neurotransmitters, so I do that first.


PHOEBE: Could the vitamin D be low for any other reason than a damaged gut?

DR. FRATELLONE: Yeah, well, low, when I mean low – everyone thinks that vitamin – we all have a low vitamin D in the northeast where I live, and that’s about 35 to 40, but there’s not many reasons where vitamin D is in the 9s, 10s and 12s. That means there’s an insult to the gut. My job, if you get a D that low, before thinking of SIBO, which I’m going to think of anyway, I want to heal the gut from any insults first.

Now, if all those things that are insulting the gut are negative, that’s when you think of SIBO. I think we go – I don’t go to SIBO right away because I want to go to heavy metals, I want to go to autoimmune, I want to go to EBV, which is in the news a lot today, I want to go to Lyme disease. If I get all negative results for that, then I’m saying, oh my God, this is a SIBO problem that we have small intestinal bacterial overgrowth, maybe because the patient’s been taking the same probiotic for 20 years and not rotating it.

PHOEBE: In terms of testing for all of the things that you just listed, is that just a very comprehensive blood test, it’s all done through blood?

DR. FRATELLONE: Yes, they do a comprehensive blood test looking at vitamin D, B12, folic acid, but the other test that should be part of every workup is to check if the person has a methylation problem. I do methylation blood testing because if the person has a methylation problem of MTHFR, whether it’s the 677 gene of the 1298, that means the person cannot detox. That means definitely something is toxic in the small intestines causing the low vitamin D that could be SIBO, but then also I want to rule out other things.

I always get a methylation initial test on patients, all the time, because it is present in 40% of the population. I don’t think a lot of doctors think of all that. I think they go – some doctors, the GI – well, now the GI – the gastroenterologists are now trying to get on the bandwagon, where me as a functional medicine person have been doing this for a long time. My patients are educating their own doctors to treat SIBO.

PHOEBE: If SIBO could cause some of these issues, like not detoxing properly, why not start there? Why look into all of these reasons that could be downstream damager effects?

DR. FRATELLONE: SIBO could cause all this, but what happens if we treat for the SIBO and the person doesn’t get better? I rather do a comprehensive approach from the beginning, include all the stuff and SIBO, just not go directly to SIBO because people, if they have methylation problems, that means they have heavy metals. If they have a methylation problem they never got rid of their Epstein-Barr. All of this plays a role in SIBO.

I know you’re trying to differentiate it, but to me it’s all the – my job is to find out why the gut is insulted, and repair and restore the gut. Mine is a more comprehensive approach that will include SIBO testing although it’s not that good.

PHOEBE: Great, we’re skipping to the controversial questions that I had written down as well!


DR. FRATELLONE: Well, no, but we know – look, I think only recently due to some – testing in medicine, whether I talk about SIBO testing or Lyme testing, we’re missing some things, but let’s get to the basic thing. If I told you the gut is the gateway of all inflammation, we should really be comprehensive. I think every physician who treats any disease should start in the gut first.

PHOEBE: Besides the blood test, what are some of your favorite other tests for getting a good idea of other types of dysbiosis? Do you like some sort of stool test? I’m curious.

DR. FRATELLONE: Yes, I do, and I don’t just pick a stool test from a lab. I’ll pick Genova Diagnostics because it’s a comprehensive stool test. I will pick – I’ll do an H. pylori breath test or a stool analysis. If I don’t find – I do parasitologist analysis. If I don’t find a parasite but the person has all the symptoms of parasite, I will send the person to get a rectal swab for parasites and actually look at the stool under the microscope.

PHOEBE: Do you ever use a GI-MAPs test, something that can – I don’t know how that stacks up to other tests?

DR. FRATELLONE: No, I don’t use that because the thing is I think that makes it too cook-book.
PHOEBE: What does that mean?

DR. FRATELLONE: I think you have to do different kinds of tests, so right now Genova’s a good one, but there’s other stool analysis tests by Metagenics that are good. There’s one coming out by Thorne Research which is called [One Genetics]. It’s a better analysis right now for SIBO than what we already have out there.

PHOEBE: Is that one you have to get through a doctor or is it one of these at-home kits?

DR. FRATELLONE: No, you have to get it through a doctor. It’s looking at genes, microbes, metagenes, and the pathology of irritable bowel by doing one stool sample versus three from Genova. It is costly. It’s about $395 dollars. The thing I don’t like about it, it takes six weeks to get the result back, so that’s the only thing, but I think it’s a really good assessment.

PHOEBE: I think this is really interesting. I think a lot of people, I wouldn’t say get misled, but run into issues down the line because they’ve been diagnosed with SIBO and then no one even thinks to investigate further into what the root causes are. I think it’s great that you’re starting with what all the possible root causes could be, and then eventually, once you have the full picture, getting to SIBO.

DR. FRATELLONE: I include SIBO, but I don’t want to be one of these doctors, and there are some GI people out there, that when they can’t figure it out because they didn’t feel like doing the work, automatically they go on treatment. Our functional medicine model is the triggers of foods. When you think about it, is there genetics associated with all this? What has been their diet? What food allergens do they have? What toxins do they have? What are biological mediators, like [cytokinin]. This test gets everything.

PHOEBE: How does that tell you about SIBO? How do the genetics –

DR. FRATELLONE: These are the triggers, so when you think about IBS as a functional medicine model, you first look at genetics, then you look at the triggers, and then when you look at the biological mediators, whether you’re looking at cytokines, neurotransmitters, free radical, all of this is the cause of irritable bowel. The basic lab work we get. You could do the fecal occult blood, you could do a breath test, you could do lactulose, but to do gut microbiome by DNA sequencing, that tells us what’s going on in the system. That’s what this test is all about.

PHOEBE: Would you go as far as to say is that the breath tests are a waste of time for people for those who maybe can’t afford to have a functional medicine doctor doing as in-depth testing as you are? What can people take away from just a simple SIBO breath test?

DR. FRATELLONE: I think a simple SIBO breath test could help us make the diagnosis, but what it’s not telling you is that there are 60 or more genes that are involved in IBS which is affecting SIBO, such as serotonin, [12:32], so it’s only giving you a little picture. I think the breath test just gives us a diagnosis and a little picture, it’s not expanding the whole role of the gut. I think it’s good for the person, you’re right, if you can’t afford going to see a functional medicine doctor, we have to start somewhere. You start with the blood test, you start with a simple breath test, and maybe you’ll do some stool testing, but that does not give you the full answer of what’s going on with the gut.

PHOEBE: You’re number one recommendation right now is the Thorne Onegevity test for the one-stop shop, but if you can’t get that, for sure the blood work and the breath test?

DR. FRATELLONE: Blood work and testing, there we have it. You know what, everyone does not have the ability to get this kind of test, and gastroenterologists are not going to use this because they don’t have time to do gene work and looking at what bacteria produces what neurotransmitter, so they will get the basic testing. That’s good enough, that’s good enough. I think we’ve missed SIBO over these years because no one thought about it.

PHOEBE: That’s actually getting back to the controversial side of things. There are some people who think that the breath test isn’t actually measuring SIBO and it’s creating a precedent for this fad that may not actually exist.

DR. FRATELLONE: I agree with that because I think that’s… You’re giving a disease to people based on a test that is not specific for SIBO.

PHOEBE: So what is being measured? How does it work?


DR. FRATELLONE: You’re making a diagnosis of overgrowth, but you’re really not getting into what bacteria, and you’re not getting into the basic pathophysiology of SIBO. You’re just saying, okay, you have SIBO, we’re going to treat you. I feel it’s like a cookie-cutter thing, the test is cookie-cutter. It gives you a diagnosis and you treat. I know people who have gone to gastroenterologists, got the lactulose test, got treated for SIBO, did rounds of antibiotics, and three months later they feel just as worse as they did after they finished a whole round of treatment.

PHOEBE: I think that’s very common. What’s happening in that case?

DR. FRATELLONE: The test is just treating it, it’s not looking at the gut microbiome. It’s not looking at the metabolic variables and the clinical phenotypes of all the bacteria. I think it’s just treating. It’s sort of like, you have thyroid disease; treat with Synthroid – which is not what I do, but I’m trying to make an analogy. You have heart disease; let’s treat the cholesterol. You’re not looking at the whole picture.

PHOEBE: In terms of getting the breath – the argument of getting the breath test to figure out if you’re hydrogen or methane dominant, do you think that’s a worthwhile thing to do as a step one?

DR. FRATELLONE: I think that’s a basic test to start because it gives you an idea. I’m just thinking, since this test has come out – and I really didn’t mean to talk about it, I forgot the topic was on SIBO, but when you think about it, that is the beginning, but if you have something else, then we should use something else. Because that we know the hypothesis is that an imbalance in the gut leads to dysbiosis. We know that. That leads to activation of the gut immune system and low-grade inflammation. I think we know that, but right away we rather give a treatment, or let’s say oh, it’s due to whether you’re producing methane or not, and this is SIBO.

I think the gut is more complicated than that. Let’s face it, we’re talking about 50 billion bacteria here, so how are we going to blame it on one thing? I think it’s multifactorial. There’s a lot of data to suggest that even fungi play a greater role in SIBO than the actual intestinal pathogens.

PHOEBE: I’m glad you brought that up because I’ve talked about it on other episodes with other physicians about how do you distinguish between SIBO and SIFO or Candida.

DR. FRATELLONE: This is why I think this test should be done because this will tell you – without doing five different tests. The problem with testing is that certain states do not allow it. For instance, Onegevity is not licensed in the state of New York and New Jersey. It’s only licensed in Connecticut. Well, I have a Connecticut license and I just opened a practice in Connecticut, so I’m bringing the Onegevity kits into New York and I’m going to get it done, but I have to mail them from Connecticut.

PHOEBE: You’re already citing so many hurdles that people have to jump through just to obviously get the ideal comprehensive testing, which is why I do think I do want to get back to just the simple SIBO breath test for a second!

DR. FRATELLONE: Look, I think in all fairness, the simple breath test is a place to start. Give the doctor a clue that there is a possibility of small intestinal bacterial overgrowth, it’s commonly accepted by insurance, it’s covered, and you start there. I agree with that 100%.

PHOEBE: Let’s dive in further for maybe someone who’s trying to DIY at home, which is obviously never recommended but is a reality. Do you have a position on whether to use lactulose or to do other substrates as well, or is lactulose you think the best starting point?

DR. FRATELLONE: I think lactulose is the most commonly used and it’s the one that we – there’s more studies with it, but you could do a lactulose or glucose, and decide if you’re going to [do it for] hydrogen or methane SIBO production, but that’s that. I think you need to do the lactulose:mannitol test for testing of permeability.

PHOEBE: That’s the test for leaky gut?

DR. FRATELLONE: Yeah. I think you not only need to do a breath test – say we do lactulose, it’s very common, it’s covered, do it, but then you have to do an intestinal permeability test.

PHOEBE: What additional does that tell you, since I know a lot of people’s thinking is if you have SIBO you probably have leaky gut, you’re going to want to fix that anyway?

DR. FRATELLONE: You do, but I want to know to what degree. Listen, I’m a cardiologist doing this! I know more about gastrointestinal disease now than I did in medical school. The thing is, yes, you’re right, people will say well, why are you going to do another test? I want to find how bad your dysbiosis or leaky gut is. And leaky gut is thrown around too much, that term. By me doing the lactulose:mannitol test, I’m finding out the degree of intestinal permeability and how bad this so-called leaky gut..

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My recipe output has been at an all-time high recently. But it’s been at an all-time low on the site. Last week, you found out why. It was a good excuse, right??

I’ve taken my book creativity suck as an excuse to mine some of my friends’ recipe gems for the blog, which has been a much needed helping hand, and conversely also something that’s stoked my creative fires when they are starting to dwindle.

A few weeks ago, I got my hands on my friend Hetty’s new cookbook, Family. Not only was I blown away by the photography, which literally made me want to lick the pages, but her recipes are always such a refreshing take on vegetarian main courses, something I am always trying to offer you guys more of here.

The book offers very special glimpses into the family life, lineage, and cooking outputs of a variety of different families, including Hetty’s own. I could have flagged half the recipes to try, but instead dug into the Asian Roots section, which has a bundle of healthy takes on traditional dishes like this vegetarian Japchae recipe with braised eggs.

For those who are unfamiliar, Japchae is like the pad Thai of Korean cooking. It’s a staple noodle dish and one that can be easily adapted to be gluten-free thanks to the base being made from gelatinous, starchy sweet potato.

If you can’t find authentic Japchae sweet potato noodles at a local Asian grocer, you can easily find rice vermicelli or glass noodles in the Asian aisle of Whole Foods. You can also make them completely paleo by using coconut aminos instead of tamari or soy sauce. Kelp noodles–which actually have a quite similar weight, thickness, and opacity—or spaghetti squash, which is a little thinner, are also great paleo options if you can’t find sweet potato noodles.

My favorite element of this recipe has nothing to do with noodles though. The soy sauce braised eggs make the japchae recipe feel like more of a complete meal, and it’s a technique I have always wanted to try but weirdly never had. There’s nothing like a salty savoury outside to kick your hard boiled eggs up a notch.

Read on for the Korean japchae recipe and for more delicious vegetarian dishes, definitely check out Hetty’s fantastic book, Family!

With health and hedonism,


Vegetarian Japchae with Braised Eggs (Korean Sweet Potato Noodles)

This Japchae recipe is adapted with permission from Hetty McKinnon's Family. These Korean sweet potato noodles are sweet and savoury, a simple and traditional dish often served over a bed of rice to create a more substantial main meal. The texture of sweet potato noodles is elastic, bouncy and surprisingly light. These japchae noodles are given heartiness with braised eggs, which are also slightly sweet and intensely satisfying. If you can’t find Korean sweet potato glass noodles, rice vermicelli works too!

  • 11 ounces (300 sweet potato cellophane noodles
  • sunflower or vegetable oil
  • 1 small brown onion (finely sliced)
  • 2 garlic cloves (very finely chopped)
  • 1 carrot (peeled and cut into thin matchsticks)
  • 4 shiitake mushrooms (finely sliced)
  • 5 ½ ounces (150 English spinach (trimmed and roughly chopped)
  • 1 tablespoon sesame oil
  • 2 shallots (finely sliced)
  • 1 tablespoon sesame seeds (white, black or both, toasted)
  • salt and white pepper
Braised eggs
  • 7 tablespoons (100 mtamari or soy sauce
  • 2 tablespoons brown sugar
  • 125 ml (1/2 cuwater
  • 2 tablespoons mirin
  • 1 scallion
  • 4 –6 hard-boiled eggs (peeled)
  1. To make the braised eggs, in a small pan that will snugly fit your eggs, add the tamari, sugar, water, mirin and chopped scallion, along with ½ cup of water. Bring to the boil, then reduce the heat to medium, add the hard-boiled eggs and simmer for 15 minutes, giving the pan a gentle roll around every few minutes to coat the eggs. Turn off the heat and scoop out the braising sauce – you will keep this for the noodles. Allow the eggs to cool.
  2. Bring a large pot of salted water to the boil and add the sweet potato noodles. Cook according to the packet instructions for 2–3 minutes, until the noodles are just cooked. Drain and refresh under cold running water and, using kitchen scissors, cut the noodles so the strands are shorter and easier to eat. Set aside.
  3. Place a wok or large frying pan over a high heat and add a big drizzle of oil. Add the onion, garlic and carrot to the wok, season with a pinch of sea salt and toss for 2 minutes. Add the mushrooms and cook for another 60 seconds. Next, toss in the noodles, spinach, sesame oil and about ½ cup of the reserved egg braising sauce and cook for 1–2 minutes, until the spinach is just wilted and everything is well coated in the sauce. Remove from the heat and add the shallots. Season with salt and pepper.
  4. To serve, divide the japchae among plates and serve with the braised eggs on the side either halved or sliced up. Scatter over the sesame seeds.

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If you tuned into the podcast yesterday, then the beans have already been spilled: SIBO Made Simple is going to be a BOOK!

Even though I’ve been secretly plugging away at the new manuscript since March, it’s still incredibly surreal to me that I’ll soon have a third book out in the world. Although, book years are more on par with dog years, so “soon” is relative. You’ll likely not see the low FODMAP fruits of my labor on shelves until early 2021.

BUT I wanted to tell you all sooner rather than later for two reasons. First, I’ll be shooting the photography for the first series of recipes in a matter of weeks. Which means, I’ve spent the last two months working at break-neck pace to get all the recipes tested and ready. This might explain why there haven’t been as many new recipes around here lately. It’s for a good cause, I swear!

Second, I would love for you to get involved. More on that below. But first, I’d love to tell you a little about how the book will take shape.

What you can expect from the SIBO Made Simple Book

Since I started writing about SIBO last year (in 2018), the response has been overwhelming. My SIBO posts have become the most trafficked areas of my site. They are also the subject of dozens of emails that I receive from you weekly.

Your craving for more information led me to start the podcast. And when I did, I knew I also wanted another medium to repackage and digest the takeaways. So I began working on a proposal last fall, which went out to publishers earlier this year. By end of February, I had signed with De Capo Lifelong, who is a dream partner for this project.

The book itself will be a hybrid—one part patient expert’s guide to overcoming SIBO, one part cookbook with over 80 recipes. The informational chunk will distill and dive deeper into some of the topics we’ve discussed on the podcast. Like The Wellness Project, there will be plenty of Healthy Hedonist Tips to pick and choose from to design the SIBO recovery adventure that is right for you.

It will truly be a one-of-a-kind toolkit that sufferers will be using as a resource for years to come.

As for the recipes, they will be 100 percent low FODMAP, but also be labeled by various other SIBO diets like the bi-phasic, GAPS or SIBO Specific Food Guide. Unlike many low FODMAP books out there, I’ll also be creating recipes that fit within my idea of an anti-inflammatory diet, with the goal being overall gut healing rather than just kill-level restriction.

Lastly, each recipe will have additional notes on ways you can use them going forward after you’ve reintroduced some higher FODMAP ingredients back into your life, with the ultimate goal being to get you eating as diverse a diet as possible in the long term with small incremental steps.

So far I’ve been having a BLAST creating and testing these recipes. I’ve also seen first-hand how much better I feel while eating them. Since returning from Scotland, Charlie and I have been sharing most of our meals at home in the form of these recipes and both of our guts have never felt better.

How you can get involved

Before handing in the final manuscript in November, I will be taking on a small group of SIBO Made Simple Ambassadors / Amigos. As part of the group, your only responsibility will be to test at least 3 recipes from the book at some point this summer.

It’s not a requirement that you have SIBO, though a general interest in gut health and the subject of the book is preferable, as there will also be a Facebook group for people to compare notes and allow me to pick your brain on book subjects.

If you’re interested in becoming part of the SIBO Made Simple team, you can fill out a quick application here. I will be keeping the group small, so apologies in advance if you’re not chosen. It will be nothing personal, I promise! Just a matter of assembling as diverse a group as possible.

As always, I’m tremendously grateful for all of your invaluable feedback and support over the last year. More so than any other past project, I’m really making this one for YOU. So please feel free to write in below with any requests or topics you’re most in need of resources for. At the very least, I’ll try to cover it in a future podcast episode so you have something to chew on before 2021!

With health and hedonism,

Your SIBO Amigo, Phoebe

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We’ve all experienced some telling signs that our gut is connected to our mood. Think butterflies in your stomach before a big presentation, that last minute urge to pee before going on stage. And if you’re someone with SIBO or other digestive issues, you might be dealing with some of the other downwind symptoms that occur when we let our anxiety get out of control.

On today’s episode, I’m joined by Dr. Megan Riehl, a GI psychologist (yes, it’s a thing) who specializes in tactical approaches to relieving visceral hypersensitivity, food fears, and anxiety related to our gut. We talk about how anxiety around your meals or symptoms can become a self-fulfilling IBS prophecy, and explore a really powerful data-backed approach: hypnosis for anxiety, IBS, and other digestive issues.

If you’re someone who’s prone to both anxiety and gut issues, this conversation is a must-listen.

Also, I have a BIG announcement about a secret project I’ve been working on all spring and ways for you to get involved. Don’t miss it.

A quick taste of what we’ll cover:
  • Cognitive Behavioral Therapy and how it helps with anxiety and gut issues
  • Breathing exercises to dial down our body tension
  • Gut-directed hypnotherapy for IBS, IBD, GERD and other issues
  • Why people get visceral hypersensitivity from nerve endings
  • Why you should see a GI doctor in addition to a therapist, and vice versa
  • Cognitive restructuring around food fear and anxiety
  • How to tell the difference between SIBO-induced food fear and disordered eating
  • Strategies for approaching a meal when you have food anxiety
Resources, mentions and notes:

This episode is brought to you by Epicured, a low FODMAP meal delivery service that understands that food is medicine. Each menu is created by Michelin star chefs and honed by doctors and dieticians at mount sinaii to restore digestive health for those with IBS, SIBO, Celiac and IBD. Everything they serve is 100 percent low FODMAP and gluten-free, with no cooking required! My favorite part about their dishes is the healthy spin on takeout gems like shrimp laksa and PAD THAI! Their version had a great balance of fresh veggies mixed in with the noodles that left me feeling both satisfied and completely free of my usual carb coma. Listeners to this podcast can get 20% off their order by using code SIBOMADESIMPLE. Just click here to learn more. 


PHOEBE: Megan Riehl, thank you so much for joining us on the podcast today for a topic that has been highly requested by our listeners.

MEGAN: Thank you.  I’m very excited to be speaking with you.

PHOEBE: You are a GI psychologist; something that I didn’t even know existed prior to learning about your work through another podcast guest of ours, Kate Scarlata.  Can you explain what that title means?  I think I know what it is from what it sounds like, but go ahead and tell us a little bit about your work.

MEGAN: Sure.  Don’t feel bad, a lot of people have never heard of a GI psychologist. Whether I’m with family or socializing when people inevitably ask what do you do and I say GI psychologist, there’s always a little bit of a look.  I’m a clinical psychologist by training and got my doctorate degree and decided to do GI health specialized fellowship post-doc.  I spent two years at Northwestern University in their GI behavioral health program, training with Drs. Laurie Keefer and Sarah Kensinger. Really, during that time I got to hone my clinical psychology skills with a blend of really becoming expert in gastrointestinal issues.  Because of the strong brain-gut connection, the application of behavioral interventions and psychological therapies really have a natural fit.  As a GI psychologist, I’m a clinical psychologist with expertise in gastroenterology.

PHOEBE: That’s amazing.  I feel like very psychologist and every GI doctor should have both of these qualifications or training because they really do go hand in hand.  I think by now most of our listeners are vaguely familiar with the gut-brain connection. The idea that the gut can dictate our mood and, conversely, that our stress and anxiety levels can affect our gut health.  Which comes first in your opinion, and how can you tell where your problems are stemming from, if they’re actually stemming from your mid-section or your head?

MEGAN: Well that’s a very complex question.  I guess I look at it as it’s a bidirectional pathway. The gut is constantly sending signals up to the brain and the brain is constantly sending signals down to the gut. In patients and people that don’t have GI problems, this dialog isn’t very loud.  We don’t pay attention to it. We really aren’t bothered by it, with the exception of what most normal, healthy, high-functioning people have felt, that occasional butterflies in the stomach. That’s a reminder of that brain-gut connection.  If you’re somebody that occasionally has to give a talk at work or at school, you might feel that urge to run to the bathroom right before going on stage or giving the presentation.  You might go once and feel better and get up on the stage and everything is fine.

We all have that brain-gut connection, but in patients that develop bowel dysfunction and these GI conditions that communication between the brain and the gut becomes dysregulated.  The brain starts to have a hard time down-regulated pain signals and different sensations from the gut and that’s when it begins to feel a lot more like a problem.

PHOEBE: What are some of the root causes of that dysregulation usually?

MEGAN: Sometimes we can pinpoint it.  Sometimes people have traveled and picked up a bug and come back and are having very frequent diarrhea and abdominal pain that they did not have before.  It can alter the microbiome in the gut in a way that might lead to a diagnosis of post-infectious irritable bowel syndrome.  In those cases, we can tie it back to something.  Other times, people can endure prolonged periods of stress, where their body holds out and it gets them through what they need to get through, and eventually, the body just gets to this threshold where you begin having symptoms. It might not be one particular event where we’re able to say because of this, you’re having this.  That can be a big frustration with some of the patients that I see, they’re looking for a root cause.  I always point to, we’re going to waste more time and energy trying to find that needle in the haystack, but right now, we’re confident that you do have a bowel issue.  You either have been diagnosed with IBS or SIBO and so now, we need to address it from a present-focused perspective and get you going on some of these brain-gut therapies that are very effective.

PHOEBE: I assume you probably don’t have data on this, but what rough percentage would you say of people who have serious stress or anxiety end up developing some sort of GI issue?

MEGAN: Well I think the reality of the prevalence of irritable bowel syndrome for example is between 1 in 5 and 1 in 10 people.  It’s a very prevalent diagnosis and we all have stress.  It’s just a matter of how stress and how lifestyle and different behavioral manifestations of how we exercise, how we eat, how we sleep is going to contribute to people being more susceptible to these types of diagnoses.  There’s also literature about patients with a history of trauma are more susceptible to bowel issues.  I think that really the prevalence of IBS is indicative of the level of stress that we as Americans are under and the importance of managing that stress to mitigate the role that it has on our health.

PHOEBE: What is the definitional difference between anxiety and stress?  I think people sometimes have a hard time parsing through their own experiences to put it in one camp or the other.

MEGAN: Yeah, I think a way to look at that is we all have different stress.  How we manage it is going to make a big difference on how both our mental and physical health is impacted.  If you can identify your stressors and recognize that in a given week I like to exercise a couple of times a week; I like to engage socially with some of my friends or family; I like to take time for self-care and that helps me to manage my stress then that becomes a way that you adaptively manage the stressors that are usually present in a person’s life.

Anxiety is a bit more pervasive in that, again, we all can have anxieties, and oftentimes, mild level of anxiety can be quite adaptive. It can help us to prepare for things, to get jobs done, think ahead, so a baseline level of anxiety is not a bad thing. When it becomes more problematic and you find yourself unable to manage the worries, or you recognize that you’re catastrophizing or constantly worrying about things, you’re changing your day-to-day life based on worries or fears of the unknown or things that you can’t control, then we’re leaning more toward that moderate to severe level of anxiety that may fall into more of a classic anxiety disorder that would require mental health care.

PHOEBE: How do your patients find you?  What stage of their journey are they on?  Are they the people who are diagnosed with a GI issue and just can’t figure out some of those techniques and lifestyle interventions to improve their mental health?  Tell me a little bit more about the various scenarios you see.

MEGAN: I’m in a bit of a unique role as I’m a fully integrated faculty member at the University of Michigan in our GI department. Our patients get into my office after they have been working with the gastroenterologist, and together the gastroenterologist and patient decide that they’d like to incorporate these GI behavioral health principles, so a referral is placed.  A lot of my patients already have some insight into some of the strategies that I might be working on with them.  They’re folks that maybe have not responded well to traditional medical treatments.  More recently, we’ve had patients presenting to Michigan Medicine to say to a gastroenterologist, I really want the referral to GI behavioral health because medication isn’t working for them.  People can be very early in their journey, where a gastroenterologist is informing them that these types of therapies can be very helpful or they’ve been suffering for years and come across an article or research about brain-gut therapies and are really seeking out that specific type of treatment.


PHOEBE: What are some of these techniques that you use and work with people on?

MEGAN: There are two that are very common and there’s a lot of evidence and research around using these types of brain-cut psychotherapies for GI disorders.  The first is cognitive behavioral therapy.  I’m sure that most of your listeners have heard of this.  It’s, again, an evidence-based type of psychological therapy that’s commonly used in medical settings.  It really helps patients to learn new, more adaptive ways of thinking about their health, thinking about their symptoms.  Thinking about the way in which their behaviors impact how they feel and behave.  It helps people to look at their maladaptive or unhelpful thought processes and come up with different ways of thinking differently.

Also, it provides patients with more psychoeducation around that brain-cut connection and the importance of other self-care, relaxation-based interventions to help calm down the mind and the body.  There’s CBT and we incorporate into CBT, like I said, these relaxation interventions.  I teach everybody that I work with diaphragmatic breathing and that’s an excellent tool that people love to just – they recognize they can keep it in their back pocket because it’s always with them.  Any time we’re able to slow the breathing down, it can activate our body’s peri-sympathetic system, which is our relaxation response and can help with the digestive process so we can actually feel a physiological change in our body tension and urgency.  Also even having more complete bowel movements by using diaphragmatic breathing.

PHOEBE: When does someone use this and for how long? Is it basically just breathing deep into your abdomen?

MEGAN: It’s belly breathing and I like to talk about it as it’s a great tool for anybody that has stress.  If you’ve ever been driving and maybe you’re running a little late and you can feel your heart rate start to increase and you can feel the mind starting to race, am I going to be able to make it my appointment and I hate being late.  If you’re somebody with GI problems, you feel that in your gut.  You might have that sense of oh great, now I need to use the bathroom!  Immediately starting to slow y our breathe down as you recognize you’re in a stressful situation, breathing in through your nose about four seconds, feeling the belly rise and exhaling out through your mouth for about six seconds, feeling the belly fall.

The amazing thing about this type of breathing is that as you’re diaphragm is activated, it starts to internally massage your intestines and your colon and your stomach in a way that we don’t get from normal chest breathing.  In fact, the chest breathing that we do when we’re stressed is counterproductive. It’s clenching and tensing other muscles in your body, which is just going to further exacerbate digestive problems. When people feel like they have a tool that they can reach for and immediately know that it’s helping to calm their body down, it’s very empowering.  That goes along with learning other relaxation strategies, like body relaxation or muscle relaxation, such as progressive or passive relaxations.  Then even further than that takes us into the idea of gut-directed hypnotherapy, which is another way of relearning how to relax the body but a little bit more sophisticated in terms of working at that brain-gut level.

PHOEBE:Yeah, I’m so excited to hear more about this.  First, I love what you just said about the breathing.  I think it sounds so simple to people sometimes that this could be a real game changer.   I remember, I saw a talk at a conference, I can’t remember what the topic was, but one of the things that I’ll never forget is that the speaker was talking about how when we inhale for a shorter amount of time than we exhale, basically when we focus on the exhale that’s what’s going to wind us down.  If we want to ramp up our energy, then we’re going to breathe in these big breaths and just exhale for a shorter amount of time.  I don’t know if that works definitively but I thought it was really interesting to think about, and actually, it’s something that’s always stuck with me.  When I’m feeling overwhelmed, I’m, like, okay, just box breathing but exhale for longer.

MEGAN: Yeah, the good old box breathing or four-square breathing.  It’s remarkable, I always tell people, I don’t do rocket science.  It’s not the hardest work in the world but this is really hard stuff to implement when behaviorally we’ve been conditioned to respond to stress in certain ways or maladaptive ways over the course of our life. Even though diaphragmatic breathing shouldn’t necessarily rock your world, it really can because you’re relearning how to do something that we were innately born doing.  We were born as diaphragmatic breathers

If you watch an infant sleeping, they’re little bellies so peacefully rise and fall when they’re sleeping.  It’s really once they become toddlers and we start to move and run and be in the upright position that we shift our breathing to this more chest breathing. When we return back to that more relaxed state, it’s the one technique that my patients over and over and over say is really life changing and empowers them to feel like they have a little bit of control when things are starting to become uncomfortable for them.

PHOEBE: I love that.  Hypnotherapy, I think a lot of people out there may think this sounds very woo-woo but I know that there’s actually a lot of great evidence and data for it, for IBS.  Can you explain what it is exactly, what it entails and then why it works?

MEGAN: If you would have told me, again, before I got into GI that I would spend a lot of my week doing hypnosis with people, I would have probably told you that you were nuts.  It’s a really beautiful intervention and it’s extremely effective for our GI patients because it targets a concept called visceral hypersensitivity.  In our digestive tract, we all have these nerve endings that are helping to send those signals to our brain.  In patients that have IBS, we know that those nerves are a lot more sensitive than those that do not have IBS.  Our medical work-ups, though, do not account for that.  You can have very sensitive nerve endings that are causing a lot of pain and urgency or constipation, but you can go through your complete medical workup and be told that everything is fine.  This is really frustrating for our patients because in their life, things are not fine.

Hypnosis really gets at decreasing the brain’s awareness of that visceral hypersensitivity in the gut and the motility disturbances that people have.  There’s also, in addition to the hypersensitivity from the nerve endings, we have this phenomenon of hypervigilance to also either the anticipation of having symptoms or maybe feeling a little bit of gas in the system and wondering, oh, I felt that, now whites going to happen.  The more we think about it, the more it rubs up our system. Hypnosis really helps through teaching patients how to more deeply relax your body and also then very tailored, targeted suggestions to help correct the way in which the brain is interpreting the sensations from the body.

There are two very well-known protocols that have been highly research: there’s the North Carolina protocol, that’s a 7-session protocol, and then the 12-session Manchester protocol.  By way of research, they both have been proven very effective for patients with refractory IBS, meaning that these are patients that have failed everything else.  They’re really struggling.  Where I practice is using the North Carolina protocol.  Typically, patients will come for an initial consultation with me. We’ll talk about their treatment plan. We’ll talk about their symptoms. Based on the patient being interested in the hypnotherapy, being open to it, being willing to do the home practice that’s required, and also them just meeting criteria of IBS and strong hypervigilance and awareness of the visceral hypersensitivity, we’ll schedule the follow ups for the protocol.

The actual hypnosis intervention takes about 30 minutes in session with me.  In between our sessions, we usually book those one time every other week.  They have audio recordings that they will use at home to continue to learn and practice the process of hypnosis.  Each week, the imagery is a little bit different, and we incorporate a lot of really peaceful nature imagery with the suggestions of improving functioning in the gut.  By the mid-way period, patients are typically reporting improvements in symptoms.   I always set people up that this is a brand new skill that they’re learning so it may take longer to really observe improvements. Sometimes, people experience improvements after one session, but ultimately, we aim to complete the seven sessions of the scripted protocol, and people really find it enjoyable.  Any staged hypnosis or any of the wonkiness that you’re describing that might make people go, I don’t know about hypnosis, we really frame it as a medically based intervention that’s highly validated for these GI disorders.

PHOEBE: What makes it hypnosis versus a guided meditation?

MEGAN: There’s some really interesting articles out there answering that question.  The idea is that it’s a deeply facilitated level of relaxation, following the structures of hypnosis.  Our goal is try and facilitate a hypnotic trance and that’s done through a focusing of the eyes initially and then the eyes close.  Then walking the patient through a muscle relaxation and deepening that state of relaxation by, again, some [panting] and imagery.  Then facilitating that description of a peaceful image with the tailored suggestions about the functioning of the gut. Sometimes, patient will say this is a lot like guided imagery, and I don’t disagree with that, but those tailored, targeted suggestions at that stage of the relaxation practice, I think are what differentiate it as more of a hypnotic intervention.


PHOEBE: Do you have to do it in person or are there programs that are online hypnosis or taped hypnosis?

MEGAN: There are some home-based programs that are being validated.  The problem so far with some of that is that insurance coverage has been difficult and also, you want to be careful where you’re getting those home-based services from. Certainly, I would love to see this as an area of growth in our field because it would offer patients – or I guess it would offer a lot more patients access to this really helpful intervention. Right now, it’s something that’s unfolding in literature and in availability for patients.  It’s in the pipeline, it’s happening, it’s just not as accessible as we would like it, so far.

PHOEBE:  Well someone’s got to change that!  We’ll talk offline, Megan.

MEGAN:  Something to be done, yes.  Well, some of my colleagues are really working hard on that and really, it’s just about making sure that the providers that are delivering, even the home-based services, that they’re experts in GI and they’re very familiar with this.  We also have to be very careful about who we deliver this to.  I had a friend who had bowel problems and as she’s describing, “Oh, my psychologist has started to do hypnosis with me for my IBS.”  I said that’s great.  That’s an evidence-based intervention and that’s what I do.  I said are you working with a gastroenterologist as well.  She said, “Well, no.”  I said, well with the symptoms that you’re having, I really would recommend that we just make sure you have the proper medical..

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Like all those cooks out there who’ve had the chutzpah to admit their failures (and, presumably, those annoying beacons of perfection who have not), I’ve made my fair share of mistakes in the kitchen. Luckily, these gluten-free chicken meatballs are not one of them.

In reflecting on my errors this past week, I’d say that most fall into one of two categories. The first is careless negligence, which includes things like forgetting the brussels sprouts in the oven until they resemble something that Khaleesi’s dragons might have sneezed on. A historical favorite is the time I poured cold stock from the fridge into a straight-from-the-oven Pyrex dish, causing it to shatter/explode dramatically and my neighbors to stop by to make sure everything was okay.

Then there’s the type of mistake that’s just pure technical ignorance. Since I didn’t go to cooking school, I’m particularly prone to this genre of fails. But because I prefer to drink uncurdled eggnog and to not have to throw away 6 ramekins of sunken, nasty soufflés, I tend to stick to recipes that are well within my comfort zone. But this approach to protecting my kitchen confidence proved problematic a few years ago when I had to attend a potluck at Dana Cowin’s apartment, in honor of her book Mastering My Mistakes in the Kitchen.

The evening gathered together some of my all time favorite women in the food community, including many who inspired me to start writing about my small kitchen triumphs and failures in the first place (cough cough, Deb). For the meal, we each had to bring a dish that we’d previously failed at and had since mastered.

I had many fails to choose from…obviously. The tortilla espagnola that covered my kitchen with raw egg when I tried to invert it, and the Canal House biscuits that came out as dense as cookies were among the front-runners. But sadly, I hadn’t yet found courage to right my wrongs, and trying to do so in time to impress my idols seemed like yet another recipe for disaster.

So I decided to go a different route, one that was perhaps a loose interpretation of the word “failure” but would at least semi- protect me from inflicting the full meaning of the word on Dana Cowin’s dining room table. My contribution: baked gluten-free chicken meatballs.

Finding a creative gluten-free solution to my old baked meatball recipe hasn’t exactly brought me to my knees in the same way as that lumpy eggnog. But it did light a fire under my butt to create something that doesn’t use gluten-free breadcrumbs (cheating!) and yet doesn’t feel like you’re cutting into the culinary equivalent of a lacrosse ball.

My jumping off point was to omit the crumbs all together, like The Meatball Shop does with their gluten-free chicken ball. But the result was too dense for my liking. At restaurants, sometimes my experience can be colored by gratitude when I discover a gluten-free alternative on the menu to something I ordinarily wouldn’t be able to eat. Beggars can’t be choosers, and it’s a cross that we dietarily challenged folk have to bear. But at home, I have much higher standards.

The fix came to me by way of my friend Sophie, who told me years ago that she liked to make her meatloaf healthier by using oats instead of breadcrumbs. At the time, I couldn’t fathom such a dense grain melting away like dried breadcrumbs do. But my frequent gluten-free baking failures have made me a lot more risqué over the years, so I decided to get ballsy with my meatballs.

The gluten-free oats definitely created a lighter ball, but there was still something a little texturally off. Eventually I found the winning combination by pulsing the oats a few times in a food processor so that they were coarsely ground—not as fine as flour or dried breadcrumbs, but a nice happy medium.

Since I’m a masochist, I had to leave a little margin for error the night of the potluck and tried the gluten-free meatballs out with a pork and beef mixture instead of chicken. Luckily, this worked out even better, since the added fat in the pork made them all the more moist and delicious (simply substitute ½ pound pork and 1/2 pound beef for the chicken and omit the olive oil, which I found necessary when using a leaner protein).

The potluck was such an inspiring evening of conversation and food. I was relieved to hear that Amanda and Merrill both suffer from mistakes in my “fail category one,” mostly in the form of burnt toast. And that even though she went to cooking school, Serena is just as lazy as I am when it comes to mastering techniques. Kitchen misery loves company, and our tales of fails made me even more confident that perfection is over rated. It also might have been just the fire under my ass I needed to master some of my own shortcomings.

So stay tuned for updated and improved eggnog, tortilla espangola, and soufflé. In the meantime, you can learn from some of Dana’s mistakes, which are hilariously captured and beautifully improved upon in her book, along with advice from some of the best chefs in the world.

Oh, and for extra credit for your gluten-free game, make these meatballs!

With health and hedonism,


Italian Baked Gluten-Free Chicken Meatballs

This healthy gluten-free version of baked chicken meatballs uses oats instead of breadcrumbs. It’s a great easy spin on a classic Italian meatball recipe.

  • 1 1/4 pound ground dark meat chicken or turkey
  • 1 extra large egg, beaten
  • 2 tablespoons tomato paste
  • 2 tablespoons extra virgin olive oil
  • ¼ cup finely chopped parsley
  • 2 garlic cloves, minced
  • 1 large shallot, minced
  • 1 teaspoon sea salt
  • ½ teaspoon smoked paprika
  • ½ teaspoon red chili flakes
  • 1/3 cup grated aged parmesan cheese
  • ½ cup gluten-free oats
  • 2 cups tomato sauce (preferably homemade)
  1. Preheat the oven to 400 degrees F.
  2. In a large bowl, combine the ground chicken or turkey, egg, tomato paste, olive oil, parsley, garlic, shallot, salt, paprika, chili flakes, and Parmesan.
  3. In a small food processor, pulse the oats until coarsely ground. Add to the bowl. With clean hands, mix the chicken with the other ingredients until loosely combined. You don’t want to overly break up the meat. Form the chicken into 2-inch balls (an ice cream scoop works well for portioning) and roll in your hands until round and smooth. Arrange the balls on a parchment-lined baking sheet and bake in the oven until cooked through and beginning to brown on the bottom, about 20-25 minutes.
  4. Toss the meatballs with your favorite tomato sauce and serve immediately.

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Have you found that fermented foods, bone broth and wine make you feel sick? Do you sometimes feel edgy, anxious or are unable to sleep? Does your nose stay stuffy year-round to boot? You might be dealing with a histamine intolerance.

In today’s episode, integrative nutritionist Heidi Turner explains how histamine works to support various systems in the body, and the inflammatory effect on those systems when we have too much of it. Heidi specializes in complex health issues including SIBO, autoimmune conditions, histamine intolerance, mast cell activation and food chemical sensitivities, and has counseled thousands of patients on ways to reduce inflammation through dietary change and manipulation of the microbiome.

This chat took me by surprise: I learned so much about the connection between seasonal allergies, sleep, stress and SIBO. And we discuss a tangible path to reversing histamine dis-regulation in just a week. If you’ve been suffering from food sensitivities, even on a low FODMAP diet, this episode is a must listen.

A Quick Taste of What We’ll Cover:
  • What is histamine and how does it work in the body?
  • How over the counter medications work to relieve some histamine symptoms
  • Why certain types of excess histamine presents as a runny nose and others affect your gut
  • How SIBO can spark the development of histamine intolerance
  • Examples of histamine producing foods versus histamine liberating foods
  • Testing for histamine intolerance and how to tell if you have it
  • The biggest rules of thumb for limiting histamine and how to cook around them
  • Long-term approaches to histamine issues and how sleep can be affected
  • Supplements you can use for when you have a histamine flare up
  • Stress management strategies to help with histamine issues
Resources, mentions and notes:

This episode is brought to you by Epicured, a low FODMAP meal delivery service that understands that food is medicine. Each menu is created by Michelin star chefs and honed by doctors and dieticians at mount sinaii to restore digestive health for those with IBS, SIBO, Celiac and IBD. Everything they serve is 100 percent low FODMAP and gluten-free, with no cooking required! My favorite part about their dishes is the healthy spin on takeout gems like shrimp laksa and PAD THAI! Their version had a great balance of fresh veggies mixed in with the noodles that left me feeling both satisfied and completely free of my usual carb coma. Listeners to this podcast can get 20% off their order by using code SIBOMADESIMPLE. Just click here to learn more. 


PHOEBE:  Heidi Turner, thank you so much for joining us today to talk about all things histamine.

HEIDI:  Sure, thanks for having me.

PHOEBE:  Great. Why don’t we jump right in, because I think there’s a lot of misconception around histamine. I mean, we usually hear the term just on television, in terms of various prescription drugs that help with allergies and such. Can you tell us what it actually is?

HEIDI:  Yeah, sure. Yeah, I agree. I mean, our primary connection to histamine is from that perspective. It is, right? Histamine basically is produced as a result of an allergen entering our body and triggering a mass cell that then triggers a histamine release, and then histamine calls on the immune system to get in there and do something about the offender coming through. That’s one of the ways that our body and one of the reasons our body, produces histamine, and it’s probably the one we’re the most familiar with. Then we take that magic anti-histamine – Claritin or Zyrtec or whatever – and it kind of helps to block that response, and then we feel better, and we feel less congested and sneezy and itchy and things like that. That is one of the reasons our body might produce histamine. It’s involved in an inflammatory immune response. It’s there to protect, okay?

We’re always producing histamine. It’s not just that immune response. I mean, histamine is involved in about ten different systems. It regulates about ten different systems in our bodies, so we use it as a neurotransmitter and it’s part of our central nervous system. We use it to help us build stomach acid and help us digest food, in terms of our digestive system. We use it to help build estrogen, to help regulate our hormonal system. We use it to increase mucous within our respiratory track. We use it for a lot of different reasons, and so it’s this really majorly important chemical within our body.

Our body has this wonderful ability to produce histamine to do what it needs to do, and then we have this great enzymatic system that helps to break down the histamine, so that we don’t build up too much histamine in the body. There’s this really great regulatory process – we build a histamine, we break it down, we build it, we break it down – so there’s always this sort of give and take, give and take kind of thing going on, and in a perfect body, in a perfect world, that’s how it works. Histamine is a really critical part of our total health. It is not always the enemy. We kind of think of histamines as these bad things that we’re always trying to block, but actually they’re very beneficial as far as our total health picture.

PHOEBE:  Got it. Yeah, no, that’s so interesting, all the various functions that it’s involved in. Before we get into histamine intolerance and obviously its connection to SIBO, I’m just curious, what do these over-the-counter drugs actually do? Do they work?


HEIDI:  Yeah, sure, depending upon how much histamine you’re building. We have like four different histamine receptors within our body. There’s an H1 receptor, an H2 receptor, an H3 receptor, and an H4 receptor, and the over-the-counter histamines basically cover the H1 receptors or the H2 receptors. The H1 receptors are going to be more involved in that common allergy stuff that’s going to impact our runny eyes and snotty noses, and congestion, and all of that kind of stuff. Basically what those medications do is they block that receptor so that when we produce the histamine, it can’t connect to that receptor. In order for histamine to do what it needs to do, it has to connect to the receptor in order for that whole biochemical response to happen. What the H1 and the H2 blockers do is they kind of get in the way of that histamine being able to do its job, so we don’t get the response that we would normally get.

PHOEBE:  But it’s still floating around the body.

HEIDI:  Still there, yeah, exactly. We’re still producing it, and the more that we produce, the more we’re locking in, we’re going to have more of those symptoms associated with it. In the H1 realm, we’re going to get more of the snotty/sneezy kind of stuff, and in the H2 realm, we’re going to get more of that gastrointestinal stomach acidy kind of stuff going on. When we take those, they block that and all it’s really doing is just helping to manage symptoms. It’s not necessarily stopping the reaction necessarily from happening, it’s just making us more comfortable.

PHOEBE:  So you could still be having a lot of downwind effects or symptoms from ingesting something that’s an allergen and having that reaction to it, but you just might now know it because you’re popping Benadryl.

HEIDI:  Sure. Yeah. Basically. The reaction doesn’t really stop. It’s just that we’re stopping our sensation of it, basically.

PHOEBE:  Is there any risk with these medications, other than the fact that as we just described, they’re kind of a band-aid?

HEIDI:  I think there’s some pros and cons to it. I think the benefits are that you can function. Some people just can’t function who have severe allergies, right, who just cannot – I mean, if you’ve ever had a severe allergic response, it’s pretty significant, can really get in the way of your quality of life. For those people, yes, it’s a band-aid, but if we can’t really get to the source of what’s going on and why we have all these allergies, then sometimes that’s what we have to do.

Certainly, we can use other things – Quercetin or Vitamin Cs or things like that – but for some, we really do need that. For others, it is blocking all of these receptors. Remember, histamines are a really important part of our physiological makeup, so if we’re always blocking those receptors on a pretty consistent basis, potentially we’re going to start to impact other systems in the body, and we’re going to see a certain level of deficiency in terms of our ability to regulate circulation and regulate estrogen, and regulate digestion, and regulate those things. There’s definitely pros and cons to taking those medications, absolutely.

PHOEBE:  Yeah, it’s really interesting. I mean, personally, my dad and I both have terrible insomnia, and he used to always give me Benadryl in [06:32] and he used to take Benadryl, like we weaned himself off of the hard stuff, and then uses Benadryl again, like kind of in a pinch. I was just curious, like what’s happening?


HEIDI:  Histamine’s a major part of our sleep cycle, and so for those who have allergies or do produce an excessive amount of histamine, it’s very neuroexcitatory, and so it just sort of like can keep us more anxious or we might notice in the middle of the night those histamine levels rising, like between two and four in the morning. We might, as part of our own circadian rhythm, start to see that start to elevate. Benadryl’s just like a really strong anti-histamine that just takes everything down. The Benadryl works, but at the same time it is a band-aid. At the same time, we have to function in our world, and for some people that’s what they need to do.

PHOEBE:  Is it making you sleepy because it’s taking the histamine functionality down too far?

HEIDI:  Yeah, it’s just really blocking it down, basically.

PHOEBE:  Whoa.

HEIDI:  Yeah, it’s a pretty intense drug, and a lot of people use it for sleep. It’s incredibly effective for sleep.

PHOEBE:  Okay, so kind of the chicken or the egg question I feel like comes with a lot of these immune reactions. Tell us a little bit about what histamine intolerance is. Is it having too much histamine at one time? What are the downstream effects of that? Is it insomnia? What happens?

HEIDI:  Okay, so there’s – I don’t know, I kind of look at histamine intolerance a little bit different than histamine dysregulation. When I first started doing this 15 years ago, histamine intolerance was basically noted as you could not tolerate the histamines coming through the diet, like they were triggering more of that histamine response – and I’ll get a little bit more into that – whenever we’ve taken too many foods that were exceptionally high in histamine, and we just didn’t have the enzymes available to break all of those histamines that came in through our food now, and it would kind of trigger a larger histamine response within the body.

PHOEBE:  Why is it happening mostly through – well we’ll talk about symptoms a little bit later on, but is it happening mostly through gastro symptoms versus the H1 type symptoms you described before with the eyes and the nose?

HEIDI:  Not necessarily. This is where we get into – remember I talked about that perfect situation, where we build histamine, we break down histamine, we build histamine, we break down histamine, and that’s where that lovely regulation – the body is not becoming too full of histamine, basically, right? Because we have those wonderful – there’s two enzymes. One is called diamine oxidase, also known as DAO; the other one is called HNMT, histamine N-methyltransferase. These are the two enzymes that our body builds in order to help us break those histamines down, and that’s in all of these systems that we’re working with.

When the body is producing too much of this histamine, when that whole regulation starts to break down, the body is building more histamine, and the enzymes that we have to break it down can’t keep up. That means we’re now going to have higher levels of circulating histamine. What we might see in that situation is all of those systems that that histamine is impacting could  – potentially, we could start to see those ramp up. Let’s say the histamine that regulates neurotransmitters, we can’t break those histamines down fast enough, we’re going to build more of that neurotransmitter, and that is a very neuroexcitatory neurotransmitter – it gives us a little bit more anxiety, kind of turns things on a little bit, might not be able to sleep very well – all of the areas where that histamine is actually creating all of a sudden starts to become more so, and we’re just going to see this increase of the symptom and intensification of the system, basically. Does that make sense?

PHOEBE:  Yeah, totally. It’s just funny because I feel like when you hear about people with anxiety and sleep problems – I say this from personal experience – it’s never come up for me, like any question about histamines. I feel like people obviously look to the gut – and we can talk about root causes in a second – and some sort of dysbiosis, but I don’t know, it’s just interesting that histamines don’t come up in casual conversation as much.

HEIDI:  They don’t, and I think we’re really just kind of figuring it out. I think there’s much more research. I mean, 15 years ago when I started this, the research was super limited and histamine intolerance was not considered much of a thing outside of Australia and Britain. We didn’t hear about it at all. If you look at the literature now, you see much more in relation to histamine intolerance, you know, histamine, production of bacteria and mass cell issues. We’re really starting to get a greater sense of how potent this particular chemical is within the body. I think it’s a relatively – even within the research world, it’s there but it’s still limited. Certainly, the understanding within the medical world, I think, is fairly limited, and I think that bit by bit we’re starting to see practitioners sign on to it or understand it or consider it a little bit more.

Really, it’s more online. Going to the webiverse, you’re going to find much more there, I would say, but you have to be aware of it and you have to be looking for it. It’s not necessarily a common thing in conversation, so it doesn’t surprise me that it hasn’t been brought up more. When I look at whoa, you’re not sleeping very well, it’s the first thing I think of now. I’m like, okay, let’s look at all the other symptoms you might be having, right? Let’s think about not just the sleep. Are we also seeing you more congested? Do you have any hives? Is your skin itching? Are you getting more reactivity during menstruation? Do you have asthma? Do you have heartburn? Do you have diarrhea? Then I’m going to start looking at all these other systems where histamine is involved, where histamine is regulating, that would indicate – it’s like oh, yeah, I’m also all of a sudden really congested all the time, I have terrible allergies, and oh, yeah, everything is much worse right before my period, and oh, yeah – like then you kind of start to put together – oh, and my gut is just – this heartburn is terrible. Then you kind of start to put together – you have to look at the whole thing, not just the sleep. You have to look at all the pieces and create a narrative around it.

PHOEBE:  Obviously it’s not common to discuss it, but how common is it actually in terms of who’s being affected?


HEIDI:  I don’t know. I wish I knew that. In my world, every day! Let me step back from that. That’s a great question because I don’t know. I don’t have a research study to say this is how many people are being affected by this, but I feel like in the 15 years that I have been doing this, I have noticed a substantial increase in terms of – and maybe that’s just because I’m specializing in this more and more people are coming to me for that, and I worked in an autoimmune clinic, so I’m much more exposed to it. It’s definitely – I get this sense of an increase that is occurring. When I think about when I’m assessing for histamine dysregulation – and then we’ll start talking about histamine intolerance. When I’m assessing for histamine dysregulation in the patient that comes to me, what I’m applying are – I’m assessing different triggers. What are the systems that could potentially trigger histamine dysregulation that could apply to this particular person?

The first thing that I look at is the amount of stress that the person has been under, and I would say it is always the common element when working with any kind of histamine dysregulation. We know that stress impacts histamine production significantly. That can be emotional stress, physiological stress – surgeries or motor vehicle accidents, or any kind of traumatic stress to the body. Honestly, I see our exposure to the screens and such stressing the nervous system out as well. I kind of look at all the different stressors within someone’s life, and we’re all stressed to an extent. We live in a fairly stressful world, and I believe that that is really increasing as well and our exposure to information is pretty significant, so I look at it like nervous system activity. I believe that’s increased substantially in the last five to ten years. I can kind of look at that piece, and we’re all a certain level of stress. When we start to really address the stress piece, we will see that histamine dysregulation start to improve in every case. That’s a pretty major piece.

I look at the hormonal piece. Do we have any sort of issues related to hormones? I look at environmental piece. I think our environment has changed pretty significantly as well over the last 10 to 15 years, as far as what we’re exposed to, but significant levels of environmental exposure. Also, I see much more allergy coming through the door. Then I look at the dysbiosis, which is SIBO and overgrowth and imbalance of bacteria within the gut, which we can get more into, and then I also look at their diets. Are we working with foods that are triggering histamine response? Are we looking at a histamine intolerance, which is where the body just can’t tolerate the histamines that are coming through the foods? What’s going on from that perspective?

I look at all of these and apply that when I’m trying to determine whether the patient has histamine dysregulation. In most cases, we can see. I’m always looking for the sources. What can we do? Not just give them the H1, H2 blockers, but what can we do to identify all the places where histamine is getting created in the body. Why are you producing so much histamine? Why is this dysregulation occurring? How can we start to address each of those pieces so that we can reduce the amount of histamine that the body is producing and get you out of this fog that you’re in, or reduce the symptoms, or help with the SIBO, or help with all of these other pieces?

PHOEBE:  Gosh, it’s all so complicated and all so connected. It’s interesting. I mean, the whole list that you just laid out is very similar to the list of causes of any sort of autoimmune condition. First of all, let’s get to the histamine intolerance versus disruption. What happens?


HEIDI:  In histamine intolerance, let’s look at the diet. There are foods that contain histamine. The foods that contain the most amount of histamines are fermented foods. These are foods that are aged, have a certain level of age on them or fermentation on them. They build histamine through bacterial fermentation – a bacteria takes in amino acids and it converts it into histamine. If we have an aged cheese or an aged meat, or we have wine, or we have sauerkraut, or kombucha, or anything that gives us that wonderful depth of flavor, that food is going to be – anything that has a level of age on it from that fermentation is going to be loaded with histamines. Then we have certain foods that contain a natural amount of histamines, like tomatoes, avocados, egg plant and spinach. Those are ones that actually contain a certain [18:24] amount of histamine. Then we have something called histamine liberating foods. These are foods that can trigger a histamine response within the body. They don’t necessarily contain histamine, but they can trigger a histamine response. We have all of these histamines in foods.

When we typically will ingest those things, we have a ton of diamine oxidase – that’s that DAO. That’s one of those enzymes that helps us to break down all the histamines within our system. We have a ton of this DAO that the intestinal cells build, so when we take in dietary histamine, that DAO gets released and it helps to break down the histamines that are in our food so that they don’t adversely impact us. We’re not taking in liquid histamine that’s triggering this immune response. We have all of this DAO that helps us to break it down. That’s in a well-functioning, regulated gut. When we move into that dysregulation, where we’re not producing as much DAO, when we take in those dietary histamines, it’s like drinking liquid histamine. It can trigger this immune response because we don’t have the ability to take that histamine down into something that is less reactive and less inflammatory to our gut, and then we start to see more of this histamine mediated symptoms. We can start to see stomach pain or abdominal pain. We can start to see severe stomach acid, reflux. We might start to see diarrhea.


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Feed Me Phoebe by Phoebe Lapine - 1M ago

I developed this creamy black bean recipe many moons ago for Food & Wine magazine, and it’s since become my favorite party alternative to the usual hummus.

Since I don’t eat tons of legumes anymore, I find that it’s usually safest to do so in the context of condiments. Things that I will scoop or dab instead of inhale by the fork or spoonful.

Of course, on weekends away, especially in the summertime, I’m usually one to forget all about my food rules and just inhale anything that’s on the table.

Ever since we forgot to celebrate Cinco de Mayo I’ve been craving an unrestrained grazing session to the tune of tortilla chips and tacos. And that’s hopefully what I’ll be doing on Memorial Day, making up for lost time.

If you too are looking for an easy dip to accompany your maiden grill voyage, I highly recommend giving this jazzed up bean dip a try. You can use sour cream like my original unhealthy version, or Greek yogurt for a slightly lighter more lactose / gut friendly option. Either way, it takes just a few pantry staples and 5 minutes to whip up.

What are your favorite party dips and where are you planning on making them this weekend? Tell me in the comments!

With health and hedonism,


Creamy Black Bean Dip

This black bean dip recipe is the perfect appetizer for any party. Sour cream makes it creamy, but Greek yogurt can be substituted for a healthy version.

Originally published on Food & Wine.

  • 1 clove garlic
  • 1/4 teaspoon ground cumin
  • One 15-ounce can black beans (rinsed and drained)
  • 1/4 cup sour cream (plus more for garnish)
  • 1/4 cup tightly packed cilantro leaves
  • 2 tablespoons lime juice
  • 1 teaspoon salt
  • Corn tortilla chips (for serving)
  1. Combine the garlic, cumin, beans, sour cream, cilantro, lime juice and salt in a small food processor. Add 1/4 cup warm water and puree until smooth. Taste for seasoning.
  2. Transfer the dip to a bowl and garnish with a dollop of sour cream. Serve alongside corn tortilla chips.

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