How To Address Constipation Or Diarrhea

Dr. Miles Nichols

Hi, everyone. I am really passionate about work on the gut and autoimmune both those two are specialties in my clinic and I work with those issues all the time. That goes back to personal experience. I struggled with chronic fatigue and it took me a while to figure out that thyroid was a part and autoimmunity was a part of that. And I became fascinated. I had one autoimmune issue and I started testing a bunch of things and I realized there were two. And I see that so much now in the clinic where when I test someone with autoimmune use, there are multiple and gut issues at play as well. So I didn’t have gut symptoms, but I actually knew the connection with gotten autoimmune and found H pylori in myself treated that had parietal cell antibodies which are cells in the stomach that my immune system was attacking those cells in the stomach. In addition to my thyroid issue, it all started with fatigue and the thyroid issue. It led me on a journey to become very passionate about autoimmunity because that was a big part of what was at play for me personally, and the gut is deeply tied to that.

Terry Wahls, MD

Okay. Well, one of the things we’re talk about are some of my favorite topics, which is the gut bowels and our ability to poop for everyone. With M.S., constipation often precedes the diagnosis of M.S. and that’s true for other neuro immune conditions as well. Why is that? You talk to why it’s so prevalent?

Dr. Miles Nichols

Well, the nervous system is a big part of the gut. And how the gut regulates motility, what we call motility, which is the function, the peristaltic function that moves food through the gut and the something called the migrating motor complex is this it’s governed by this smooth tissue. And the smooth tissue is part of the entire nervous system. And we’re we see a lot of nervous system dysregulation plus inflammation causing motility dysfunction and causing the intestines to either do a hyper motility or a hypo motility, meaning fast or too slow. And usually that manifests into fast hyper motility as diarrhea and into slow as constipation with hypo motility. So we see this a lot with any condition that is dysregulated the nervous system and sometimes with inflammatory conditions as well.

Terry Wahls, MD

So a very difficult problem to treat that can occur with M.S. and with neuro immune is gastroparesis in that people have huge difficulty eating. Is that part of this as well?

Dr. Miles Nichols

It is, yeah. That gastroparesis and the difficulty eating and with appetite, regulation and and even gastritis and other inflammatory gut issues are significant. And I see a lot of secondary issues. So there is the issue that the is primary. So for example, multiple sclerosis can dysregulated the nervous system that can cause the motility issue. It can also cause infection. And we can see diverticulitis, we can see gastroparesis, we can see gastritis. Many different manifestations of that. And there are many times other elements at play as well. We can see stomach acid affected, we can see bile flow affected, we can see pancreatic enzyme secretion affected, and we can sometimes see other infections and dysbiosis at play. We can see a dysregulated gut microbiome home where we’re seeing overgrowth of certain bacteria in the small intestine or overgrowth of archaea that can produce methane gas, that can contribute to slowed transit time. So oftentimes what I see are multiple mechanisms at play and sometimes it’s an infection plus an autoimmune issue plus potentially dietary issues that are all pulling together to create this picture in the gut.

Terry Wahls, MD

So how do you tease that out?

Dr. Miles Nichols

Well, so one of the things that is important to address first thing is diet. Of course, that’s just a baseline thing to address. And if people haven’t started on something like your dietary approach, like the Wahls protocol, the that that diet, if I’m not mistaken, there’s actual research showing that it’s helpful with constipation and IBS. Is that correct?

Terry Wahls, MD

That is correct, yeah.

Dr. Miles Nichols

So to do something on the dietary front first, I mean, if someone’s on a standard American diet, if they’re not getting it, if they’re not getting nutrients and fibers and things like that, that’s a place one to start. And so first is diet, basic lifestyle, sleep. These things are incredibly important. Some movement. And once people have that foundation and there’s still an issue, you know, then we go into the next layer. In the next layer might be that we’re looking at do we if we add extra fiber, does it make it better or worse? Because interestingly, constipation, while the conventional approach is fiber, makes it better, it sometimes makes it worse, especially if there’s an overgrowth of archaea that produce methane gas. And then we see fiber actually makes people worse and they feel more bloated and they feel more clogged up, even though, in theory it’s bulking the stool and it’s helping to move. From one perspective, it may be worsening another perspective and that actually can give us some clues if that helps or hurts the situation. If it hurts the situation, then we can investigate small intestinal bacterial overgrowth, we can investigate. Are there excessive archaea producing methane gas? And that might tune us in on that angle that we’re really wanting to look at a SIBO breath test and possibly look at a some antibodies against the smooth tissue in the intestine called insulin as well.

Terry Wahls, MD

And what kind of fibers do you use?

Dr. Miles Nichols

A lot of people like insoluble fibers, like psyllium husk. I’m not as big a fan of psyllium as I am of some other fibers. I typically, for ease and simplicity, often will have people start with chia seeds or maybe flax seeds. She is my favorite and to take a tablespoon to two tablespoons once or twice a day of chia seeds is a soaked in water for at least 10 minutes is a really nice, easy, simple way to start and see if that’s going to be helpful or not.

Terry Wahls, MD

And we do you use that like make it put in out of it. Do you add it to a smoothie? So what’s it like.

Dr. Miles Nichols

Yeah, for some people just soak it in water and drink it down, kind of drink and chew it. But it can be the whole seeds. You don’t have to really chew it fully. And the that’s easy, simple can be done the night before stored in the fridge for other people. Making a pudding is amazing and they can get some good, healthy fats. They can do some full that coconut milk, they can do some you know, of course, the sweetener is important if if people are making it sweet to to not just regulate the blood sugar or cause inflammation due to a conventional sweetener, it’s great to look at some alternative sweeteners when making the do you putting cheap but it can be a great way to do it.

Terry Wahls, MD

Yeah you know I like blended with some healthy fats some fast choline and then add cocoa, my favorite spices and then whatever berries that are in season. So it ends up being either a very lovely smoothie or a very lovely putting on berries.

Dr. Miles Nichols

You get the sweetness, plus you get the phytonutrients and you get the antioxidants. And that’s really incredible to add those healthy fats and get sweetness from something that’s going to provide something else as well. So I love that.

Terry Wahls, MD

You know, and I like mixing in things like ginger tumor, like cinnamon.

Dr. Miles Nichols

Yeah.

Terry Wahls, MD

So sometimes I put in the seed spices, like allspice or cloves and ginger.

Dr. Miles Nichols

Actually has some, some motility research behind it. So ginger is used sometimes with the lower esophageal sphincter and if the lower esophageal sphincter is spasming. So if there’s sometimes when when we’re dealing with motility issues, there’s the stomach emptying and then there’s the small intestinal motility, and then there’s the full intestinal motility. And sometimes I’ll use ginger as part of a pro kinetic protocol which is broken. That means we’re trying to restore the motility function in the migrating motor complex. And so ginger, it has anti-inflammatory properties, it has motility properties, and it’s warming from the perspective of Chinese medicine and certain other ancient medical traditions. They’re they they talk about how warming substances can really help with the digestive fire in getting the digestive fire going. So for a lot of reasons, I really like Ginger.

Terry Wahls, MD

And what about licorice? What are your thoughts on licorice?

Dr. Miles Nichols

Licorice is amazing. And of course, there’s the concern with licorice around blood pressure rise for those who have elevated blood pressure already, if it’s a form of licorice that includes the glycyrrhizin, there are forms of licorice that are deemed westernized and those are okay with blood pressure even elevated and can still be anti-inflammatory and helpful on the stomach. But the most interesting research on that is on collaborating and collaborating as a constituent in a certain flavonoid x extract of licorice that is called gut guard. And gut guard has been shown to clear H pylori infections. Helicobacter pylori in 50% of people in one research trial in two months, which is usually H. Pylori. 

For those who don’t know H. Pylori, Helicobacter pylori, the bacteria that can live in the stomach and this bacteria that can live in the stomach is at the doctor’s thought. No bacteria can live in the stomach. It’s too acidic. And so it took someone, a researcher, who was laughed off the stage at multiple conferences to drink a petri dish full of this bacteria, give himself gastritis, and then take an antibiotic and make it go away for him to get any research attention. But and he won the Nobel Prize later, which I’m glad he did, but 25 years. Yeah, yeah, yeah, a long time. So H. Pylori Usually the conventional treatment for h pylori is three antibiotics at the same time, triple antibiotics therapy. So the fact that a licorice extract has shown 50% clearance rate in 60 days is phenomenal. And I think it just calms stomach and inflammatory response quite nicely. And a lot of people who even don’t have each pylori, I see it to be helpful anyway.

Terry Wahls, MD

Sometimes it is. It’s common in people with neuro immune issues.

Dr. Miles Nichols

Yeah, I do see it. And interestingly, we see some H. Pylori research with autoimmunity. Now I don’t see a specific li with multiple sclerosis, so you have to tell me if that’s there specifically with them. But I do there are multiple autoimmune conditions that have been research based association with Helicobacter pylori that includes thyroid autoimmunity like Hashimoto’s, that includes type one diabetes and includes a couple of other autoimmune conditions. So we know for example, that research shows that if you treat H pylori, if it is present that you see a decrease in autoantibodies to the thyroid, for example. So I think there is a likelihood that some of the mechanism of H. Pylori is dis regulatory to the immune system and that it may be playing a role in more of the autoimmune conditions than have been presently researched. I think it’s a big player.

Terry Wahls, MD

Okay. Now for the people who are listening, who will start if diarrhea is an issue, what take on lessons do we have for them?

Dr. Miles Nichols

Yeah. So diarrhea is an issue then. Many, many times there’s a hydrogen overgrowth, there’s an overgrowth of bacteria producing excessive hydrogen gas, contributing to diarrhea. Now, there’s the effect on the nervous system directly. But I see. I don’t know how many times I see SIBO present in cases of diarrhea, even if there’s another cause. Also, I think it’s important to rule out small intestinal bacterial overgrowth because irritable bowel syndrome is a diagnosis which is IBS, irritable bowel syndrome, diarrhea type, regardless of of of multiple sclerosis or or other issues, very high percentage test, positive intellectualize, breath test for SIBO. And so it’s very important, I think, to test for small intestinal bacterial overgrowth and treat it if present. And sometimes that will solve it and sometimes it won’t. 

If that does not solve it, then I think it’s important to also do a comprehensive stool analysis and look for some of the infections in the stool that can also contribute to an issue there. And then as a starting point, if someone’s not ready to do testing, I really like Saccharomyces Gulati as a probiotic. That’s a it’s a helpful yeast that crowds out pathogenic yeast. And it’s just I’ve seen it work a lot for diarrhea. So it’s a for an easy simple at home starting point taking maybe 10 billion of Saccharomyces Gulati could be a simple starting point for someone struggling with diarrhea.

Terry Wahls, MD

Okay, now we’ll go to the other end. Constipation, which, of course, really is much more prevalent for people with multiple sclerosis and with other neuro immune problems. What are we to do for them?

Dr. Miles Nichols

Yeah. So with constipation, it’s I’ll just say it’s a little trickier than diarrhea in terms of diarrhea tends to resolve quite simply, even I’ve seen people 20 years plus diarrhea and we do a SIBO test and treat it and it’s it’s gone in not every case but some cases and it’s just amazing. And they’re there. They were on the you know, they couldn’t go drive more than an hour. And now they can live their life again. They can travel. It’s phenomenal seeing that over and over again, the constipation, it is trickier. It does take a little longer typically to identify the root causes and there are often multiple root causes involved. So the neuro immune aspect definitely is a role. The nervous system aspect is a role. I do also like to do a SIBO breath test because the methane gas and methane producing archaea can worsen. 

Anything else that might be causing constipation and medication. Side effects can also be a cause of constipation depending on the medications someone’s on. It may be worth reviewing the side effects of the medications that you’re taking in order and discuss with your prescriber about constipation. If it’s in that list for a medication. And then also to look at, of course, we already talked about the fundamental dietary approach and then add fiber on see if it gets better or worse after screening for small intestinal bacterial overgrowth. In treating that sometimes constipation persist, sometimes SIBO requires multiple treatments in it. It it is still archaea that are playing a role. I do like to test antibody is for a site or lethal to sending toxin be in vacuum with constipation because that’s an immune system attack against directly the smooth tissue in the intestines that regulate motility. 

And if that’s the case then pro motility agents pro kinetic agents are really important in that treatment process. And then there are also some aspects of stool infections, parasitic infections, fungal overgrowth. And then if all of that, if we do a SIBO breath test and we do a comprehensive stool analysis, not just a regular through regular lab stool analysis may miss some things, usually through specialty lab as doing a more comprehensive stool analysis. So see bar breath, test, stool analysis, we’ll find some things the antibodies against Franklin and cite a lethal descending toxin. B we’ll find one aspect of why that’s happening. 

I also like to evaluate have there been surgeries that might there be scar tissue in the intestines? Might there be? I like abdominal massage and in breaking apart scar tissue and doing some visceral manipulation there. And I think that can be helpful for some people. And then I think that there can be sometimes systemic infections when we’ve ruled all those based things out, then I guess this is anecdotal. I have no research to, to, to point to here, but I see systemic infections like Lyme disease and others be playing a role when all the base level stuff has been resolved. But there’s still this chronic and persistent issue. I see toxins and infections playing a big role in those cases.

Terry Wahls, MD

Now for the people who are listening to us and they’re think like, okay, I want to get a check on my for small bile overgrowth and I want a complete stool analysis. Can I just go to my primary care doc and say, could I have those things? How easy or hard is it to access this kind of investigation.

Dr. Miles Nichols

Or right at the beginning of SIBO breath testing becoming accepted by progressive gastro in Kerala. Just so it’s right at the beginning, it may or may not. I mean still less common that a gastroenterologist is going to go to a SIBO breath test right away. But more and more the evidence is in and now it’s just a matter of getting that out to people to understand the primary care physicians and the gastroenterologists, to be willing, ready and able to order that test. So I would say SIBO breath testing the best of it is I like lactose breath testing 3 hours hydrogen plus methane. There’s a newer test that includes hydrogen sulfide as well. And so that three gas test is available now as well. But a minimally a two hour two gas test. I prefer three hour and sometimes.

Terry Wahls, MD

From a primary care doc. If I go out and ask them maybe.

Dr. Miles Nichols

Sometimes, but rarely.

Terry Wahls, MD

Sometimes, but rarely. So I may have to go find a functional medicine trained person and then the poop test.

Dr. Miles Nichols

Yeah. So for stool testing, that’s also you can definitely ask for a stool test, but usually it’ll be a stool to run through one of the big labs like LabCorp or, or Quest. And those tests aren’t very they aren’t great that they’re good as a starting point. So I wouldn’t say don’t do that, but I wouldn’t say think that nothing is going on based on that because more comprehensive specialty stool testing is important and that almost always comes from a functional medicine provider and not from a primary care provider in most cases.

Terry Wahls, MD

Yeah, I would say that the LabCorp and Quest stool tests, they’re not nearly as good at looking for pathogens or parasites, and you’ll get some very basic assessment of that. It’s a much more basic test.

Dr. Miles Nichols

It is, yeah. Yeah. And that’s unfortunate. I wish it was more advanced at this point, but luckily there are good, very advanced stool tests available that are very sensitive to infections.

Terry Wahls, MD

And can a member of the public access any of these functional medicine type tests in any way you as a direct to consumer? Is anyone offering that yet?

Dr. Miles Nichols

There are some like intermediaries that people can go to like a I’m not knowing the name offhand because I don’t use them, but there are these patient direct companies that will be an intermediary and allow patients to order directly certain stool tests. So I believe that there are ways for people to get it on their own. Of course. Then how do you interpret it and what do you do about it? I mean, best to have come on board. Yeah, but I do think we get them.

Terry Wahls, MD

So for a basic start, I’m constipated. We I think we’ve I want to be sure that I’m summarizing this accurately is get rid of sugar in the processed foods eat more like walls diet so more vegetables when it come down on fermented foods helpful so that be part of the solution here.

Dr. Miles Nichols

Yeah. Yeah. So definitely there are research papers that are looking at microbiome diversity in fermented foods and it’s not just all about fiber. Fermented foods are important as well. And there are some people who are sensitive to histamine. In those cases, it may make people worse, but in the majority of cases, when people are not sensitive to if you’re eating fermented foods and you’re noticing worsening symptoms, don’t push through it. You may have a histamine issue, but if you don’t have a reaction that’s adverse, then fermented foods are amazing and can really make a big difference in the biodiversity, in the gut.

Terry Wahls, MD

In fiber. We talked about flaxseed chia seeds. You can make it into a smoothie, you can make it into a pudding. I love my Chia pudding. So, you know, I’ll have to make a mental note here to perhaps suggest some recipes for everyone and then other fibers. You have any thoughts about inulin or large any other fibers that people could be adding?

Dr. Miles Nichols

Yeah. So there are what are called prebiotics, which are soluble fibers like inulin pairs for dog attack. Right. And then there are things that have xylitol was after I collect oligosaccharides as well. These acaricides are hit or miss. If someone has SIBO that can make it much worse. So some people will get quite bloated and worse with some of those soluble fibers like Inulin and xylitol goes out neglect oligosaccharides. Other people will get better, so it’s worth a try. And again, don’t push if you’re reacting negatively, you can start with a small dose and work up slowly. But if it seems to be making you worse, I encourage looking and looking at and screening for small intestinal bacterial overgrowth because until that’s cleared, it may become it may increase bloating, increase some of the digestive symptoms. So I like those fibers when they’re tolerated and they’re foods that are high in fiber, too, like a lot of people don’t know it, but avocado is quite high in fiber, even though it’s a and it’s a soluble fiber, readily digestible. And again, some people with histamine can have issues with avocado, but avocado is generally well tolerated for a lot of people and is a good source of fiber. And so it’s hard to get the amount of fiber that our ancestors got. And so in the world today, you kind of have to try to get fiber. You have to know magnesium.

Terry Wahls, MD

Magnesium is something is.

Dr. Miles Nichols

Very, very important. And that can I mean, so many people are deficient in magnesium. It’s just incredible. And it’s hard to get enough from just food. The soils are a little bit low in magnesium today. And and you can you can really try and get a decent amount in your diet. But when you’re dealing with especially chronic disease and stress in the world today, I encourage almost everyone to be supplemental with magnesium as well. Magnesium has a bunch of different forms and some of those forms are more osmotic and can be drawing more water into the intestines, which can be helpful in cases of constipation, magnesium oxide. 

You won’t get much magnesium out of it, but it will draw a lot of water into the intestines. Magnesium citrate. You’ll get more magnesium out of it, but it will still draw some water into the intestines. Magnesium glycine. You’ll get a lot of magnesium out of it, but it won’t drama water into the intestine. So if you have diarrhea, magnesium, glycine, it is a great magnesium option. Magnesium L three innate for neuro immune issues is nice because it can cross the blood brain barrier and I like magnesium, all three innate for that purpose and it’s not so osmotic. 

So if there’s constipation then potentially even taking a couple of forms of magnesium, including oxide or citrate, can be helpful in drawing some extra water into the intestines. So magnesium has its multiple like for the magnesium itself. Getting that absorbed and then for drawing water into the intestines are two different distinct purposes. Absorbing magnesium itself can be helpful on the smooth muscle and can be helpful on relaxing the smooth muscle in the intestines. So I do like magnesium in cases of constipation.

Terry Wahls, MD

Okay. Then one final question. How about vitamin C? Does Vitamin C have any role in managing constipation?

Dr. Miles Nichols

It does. It can be used as also a it in high doses can help move stool. Now you have to go pretty high for most people might have to get at least into the on the low end three grams, maybe even 5 to 10 grams in order to get a bowel effect from vitamin C. It is certainly one that I think it’s reasonable, it’s safe, it’s good. It I don’t see a lot of problem in trying high dose vitamin C for bowels. I don’t generally use it as a first go to because I am trying to figure out the root cause and not just have a ball effect from a high dose vitamin C, but it’s a good tool to have in the tool bag. And in there are a couple of words like Triphala that’s used frequently that can be nice for bowel regulation as well. So I like tools like vitamin C, triple A, magnesium oxide, having those in the in the tool belt. But I encourage people to make sure that you’re not you’re not ending your investigation for why this might be needed all the time, if it’s needed all the time and even center and smooth move teas and laxatives again, they have their place. They can be used. But if you’re relying on it all the time, then I encourage people keep looking for the underlying cause or causes and resolve as many of them as possible to rely as little as possible on those kinds of interventions, even though they’re effective and can be helpful.

Terry Wahls, MD

Well, Miles, this has been fabulous. Pooping is a vital sign that we should all be asking our patients about. I’m sure you are asking your people about pooping a lot, you know, and I ask you, poop and rocks, bugs that are dry and prickly or smooth logs or snakes or pudding or tea. If the snakes are getting into your pants, that’s a problem. But otherwise, snakes are ideal.

Dr. Miles Nichols

And I love the Bristol stool scale for that as well. And, and to help people to understand that there are also some things that they can do for stool regulation. It’s so important for detoxification, for the connection with the immune system and for autoimmune issues to resolve. These issues, I think is really important and a little at home transit time can be eat a cup of beets and see how long it takes for your stool to turn red. It’s another interesting one for people to do as well.

Terry Wahls, MD

Okay, now this has been invaluable information. I know Miles is going to have a really great gift for you. Everyone’s got to have a happy set of bowels if you’re going to recover from your M.S and neuro immune condition. Now, Miles, where do people find you if they want to come learn more about you or come to you? Well, can you tell us your website?

Dr. Miles Nichols

Yeah, my clinic name is Medicine with heart and medicine with hearts. Tor.com is the website. There’s a blog that has lots of free information available on that website. And there’s also a way to book a call with staff in the clinic to learn more about how to get started working in the clinic. That’s medicine with heart dot com.

Terry Wahls, MD

Okay, this has been wonderful. Thank you so much. Thank you so much, Miles.

Dr. Miles Nichols

Thank you. It’s been a pleasure.