The Dr. Hyman Show - Diverticulitis: A Functional Medicine Approach with Dr. George Papanicolaou

Episode Date: October 11, 2021

Diverticulitis: A Functional Medicine Approach | This episode is brought to you by Rupa Health and Athletic Greens Over 200,000 people per year are treated for diverticulitis, a painful condition in which small pouches in the colon, called diverticula, become infected. Symptoms of diverticulitis include nausea, fever, chills, loss of appetite, and constipation. While conventional medicine treatments for diverticulitis usually consist of antibiotics and surgery, Functional Medicine looks at a wide variety of things like microbiome diversity, dietary fiber consumption, gut health, inflammation, and more, to both prevent and treat this condition.  In this episode, Dr. Hyman discusses diverticulitis with Dr. George Papanicolaou. They talk about how lifestyle habits, such as a low fiber diet and elevated stress, can contribute to diverticulitis. They also share certain foods and supplements that are supportive and healing to the body. George Papanicolaou is a graduate of the Philadelphia College of Osteopathic Medicine and is Board Certified in Family Medicine from Abington Memorial Hospital. He is also an Institute for Functional Medicine Practitioner. Upon graduation from his residency, he joined the Indian Health Service. He worked on the Navajo reservation for 4 years at the Chinle Comprehensive Medical Facility where he served as the Outpatient Department Coordinator. In 2000, he founded Cornerstone Family Practice in Rowley, MA. He practiced with a philosophy centered on personal relationships and treating the whole person, not just not the disease. He called that philosophy “Whole Life Wellness.” Over time as the healthcare system made it harder for patients to receive this kind of personal care Dr. Papanicolaou decided a change was needed. He began training in Functional Medicine through the Institute of Functional Medicine. In 2015, he established Cornerstone Personal Health—a practice dedicated entirely to Functional Medicine. Dr. Papanicolaou joined The UltraWellness Center in 2017. This episode is brought to you by Rupa Health and Athletic Greens. Rupa Health is a place for Functional Medicine practitioners to access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, Great Plains, and more. You can check out a free live demo with a Q&A or create an account at RupaHealth.com.  Right now, Athletic Greens is offering my listeners 10 free travel packs of AG1 when you make your first purchase. Just go to athleticgreens.com/hyman to take advantage of this great offer. In this conversation, Dr. Hyman and Dr. Papanicolaou discuss: How overall fiber consumption has reduced over time What diverticula are and how they can progress to diverticulitis The symptoms of diverticulitis Risk factors for developing diverticulitis The difference between conventional medicine and Functional Medicine treatments for diverticulitis Using bone broth and clove tea to heal a flare up Why it’s a myth that you shouldn’t eat nuts and seeds if you have diverticulitis Suggestions for how to add fiber to your diet Supplements to support the body Case study of a 50-year-old woman with diverticulitis

Coming up on this episode of The Doctor's Pharmacy. And we do this before people develop diverticulitis. We help them arrange their diet and their lifestyle because stress plays a big role in diverticulitis. Hey everyone, it's Dr. Mark. I know a lot of you out there are practitioners like me helping patients heal using real food and functional medicine as your framework for getting to the root cause. What's critical to understanding

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but it affects about most people at some point in their life, which is diverticulosis and its companion problem, diverticulitis. Now, my mother had it, my grandfather had it. It's pretty common. It's not the most exciting, sexy topic, but we're going to make it fun and sexy. That's another than my colleague and friend, Dr. George Papanikolaou from the Ultra Wellness Center. George is a great physician. He's graduated Philadelphia College of Osteopathic Medicine. He's board certified in family medicine.

He's an IFM certified doctor, and he's done a lot of work on the Native American reservations and has really developed his own system. And he's just a wonderful human being. Welcome, George. Mark, it's a pleasure. Thank you for having me today. So on this special episode of House Call, The Doctor's Pharmacy, we're going to dive into a topic that is not on everybody's radar, but it should be, because we are living in a world where we torture our guts and the gut is so important to our overall health. And for many reasons, obviously the microbiome, we've been talking about a lot, but you know, one of the things that I remember from medical school,

you probably remember this, was a guy named Dennis Burkett, who was a physician from England who went to Africa and he studied the difference between the populations that were hunter-gatherers and the same genetic crew that had moved to the city and were living in urban African cities. And he found that the average stool weight for the hunter-gatherers was two pounds a day because they ate so much fiber. And the average stool weight for the city dweller was four ounces. So four ounces versus 32 ounces. Okay. And he found that it correlated with all these chronic Western ailments, things like cancer and heart disease and diabetes. But he also noted that the hunter-gatherers had no diverticulitis or diverticulosis,

which was fascinating. So this is an entirely Western disease and is a really reflection of the lack of our quality diet, the lack of fiber. I mean, we had about 8% of our diet now is fiber. It used to be 100, sorry, 8 grams of fiber a day. If we're lucky, maybe 15 if we are on the high end of the American population. And in hunter-gatherer times,

it used to be 100 or 150 grams a day, which seems like a lot but it's actually what our guts and bugs like and that's led to this problem of diverticula so george take us through what are diverticula how do they form and why are they a problem and who gets it well yeah before i get to that i just want to say say that the Dennis Burkett story is a great one. And, you know, he was a phenomenal doctor. And nothing's changed because they did recent research that compared Ugandan population to the United Kingdom. They looked at 1,200 people, Ugandan versus 1,200 in the U.K.

And they looked at gastric transit time and stool weight. And the gastric transit time for Ugandan is 34 hours. For somebody in the UK, a Western population, it was 80 hours. Okay. 80 hours. Oh my God. Something to pass through your gut. And the stool weight was again that phenomenal numbers

that you just talked about 110 grams of stool weight for the average uk population and for the ugandan it was 400 grams four times heavier wow so so nothing's changed since dr burke made his first observations um it's still the same and our diets have just gotten worse so so yeah to just start this conversation just a couple definitions like what are diver what is you know where does this has all start so diverticula are little pouchings in your. So your colon is this long tube, and it's wrapped with mucosa on the inside. And on the outside layers, it's multiple layers of muscle, and then another final layer.

And so it's like, you know, you've heard of hernias. Hernias are, again, outpouching of your internal organs through the fat and the muscle layers until it's sticking out in your abdomen. Most people are aware of those. Well, the same thing happens inside the colon. You have the inner lining starts to push through and form a sac and that sac is a diverticula. Now, you're actually born with diverticula. So you're going to have maybe one or two diverticula when you're born. But as you get older, you begin to have more. And so research has said that at least 35% of people that are under age 50 have multiple diverticula and have diverticulosis. And then

above the age of 60, you're looking at closer to 70 to 80% of people have diverticulosis. And then 5% of people, adults, will go on to have diverticulitis. And what's diverticulitis? That's when those diverticula become infected. And so you get bacteria that gets in there and you have now an infection and that can spread the multiple diverticula and it usually happens on the left side of your abdomen where your colon your large intestine is descending and then it goes to the sigmoid colon and then the rectum and that's where the stool comes out. It's that lower third of the descending

colon and sigmoid that are typically affected. And if you've ever had it, and unfortunately, I've had it, and it is extraordinarily painful. They call it the appendicitis on the left side. So left-sided appendicitis, it's that painful and you can get nauseous and you can get fevers and you can get chills and you lose your appetite and get constipated. And it's just really, really fun. Oh, it sounds like fun. Yeah, it's not. And so, yeah, I'm not a very fun patient. So I don't think anybody in my house is having fun when I had it. I certainly wasn't. So it's an issue.

Now, I'm not the only person that gets it. About 200,000 people per year get it. And many of them end up in the hospital. Although now we do a lot more treatment outpatient. So what are some of the risk factors? So if you're over 40 and you're male and you're heavy, overweight or obese, if you eat a low fiber diet, we've already talked about that. If you eat a diet that's high in inflammatory fats, you're going to have a problem. If you

don't exercise and if you take non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, which is Motrin or Advil, or you use steroids or opioids or you smoke, those are some of the major risk factors for going on and developing diverticulitis. Amazing. So, George, we really figured out that this is a common problem that's preventable, mostly from lack of fiber and a healthy gut. The traditional treatments are basically surgery and antibiotics. Then it just keeps coming back. So from a conventional perspective, what can we do to prevent it? And what do we do to treat it differently? So take us through what that would look like.

Well, I think you mean from a functional medicine perspective, what do we do to prevent it? Yeah, from a functional medicine perspective. Yeah, from a functional medicine perspective. Yeah, because conventional medicine doesn't prevent it. And that's the big difference. You know, conventional medicine does what it does best. It treats disease and it does that really well if it's acute disease. And so you have these diverticula floating around. You know you're going to have tons of them by the time somebody turns 60.

And you know that at least 5% of those people are going to end up with diverticulitis. But we'll just let it happen. And we'll treat with antibiotics. And if there's a complication, like an abscess, or an obstruction or a fistula forms, you know, you have a track that goes from your intestine to your bladder or intestine to your uterus because we let that infection fester and get out of hand, then you're going to need surgery. And so that's how conventional medicine deals with it. Functional medicine, now we don't think of it as just a fiber issue. There are more things going on. We start to think about the gut microbiome and balancing the gut microbiome and how that can lead to leaky gut and inflammation. And that whole process

can be avoided. We think about gastric motility. Yes, fiber can improve gastric motility, but there are other things that play a role in gastric motility. And some people, once they hit that point where they have irritable bowel syndrome with constipation, their gastric motility is oftentimes beyond improvement with fiber. And we have to be addressing that. And so we look at motility. We look at the gut microbiome balance. We look at the gut permeability. We look at the possibility for inflammation. So we look for, you know, stealth infections. And we do this before people develop diverticulitis. We help them

arrange their diet and their lifestyle because stress plays a big role in diverticulitis. I know the time I had it, I was under enormous amount of stress. And of course, my diet wasn't as good as it should have been at the same time, but stress plays a big role because we know that cortisol produced by the adrenal glands can impact the makeup of the gut microbiome. You can have less favorable bacteria that can cause inflammation, that can push out the good bacteria that can protect us. And so when that happens, we can also, cortisol can also trigger leaky gut. And when that begins to happen, when that process happens, now you're starting that cascade towards inflammation that will lead to the infection that results in diverticulitis. So that's how we approach it. We look at it much

deeply, much more deeper, and we're attempting to prevent and to maximize and optimize gut function, prevent disease and maximize and optimize gut function, prevent disease and maximize and optimize gut function. That's really amazing. And so what are the kinds of things you would do diagnostic-wise to look at things differently? And can you maybe share, you know, some case story of patients? Yeah, so, you know, once the diverticulitis happens, I can tell you, I've seen it enough that in an outpatient setting, just a clinical presentation is usually enough. Because most people have had, you know, by the time they have their diverticulitis, I'd say three quarters of my patients have at least had a

colonoscopy, and they know they have diverticula. So I get the call, Hey, my gut's killing me. What size left? How old are you? I know, I know their age. I'm usually looking at their chart and I, you know, I can pretty much know that. Yeah. And did you have a colonoscopy? Yeah. I had one two years ago. Did you have diverticula? Yeah. I remember he told me that it's a left-sided pain. It's a really painful. They're really struggling. I mean, it can be as simple as just using your powers of observation, your experience, and then the art of medicine that you've developed as your years as a doctor to make that diagnosis. It can be done as simple as that. If I need further confirmation, I can get a blood count to look

for elevated white blood cells. If I think there might be the possibility of something else, maybe a bladder infection, I might get a UA urinalysis. Ultimately, if I need to confirm what's going on, you get a CAT scan. That's the definitive way to diagnose it. And then on the CAT scan, you'll see swelling and inflammation of that lower third of the colon and maybe sigmoid. And that's how the diagnosis of diverticulitis is, you know, finally made. And then the treatment is typically going to be, you know, antibiotics. There are a host of different pharmaceutical agents that would be used and they can be done orally and you can stay at home. Or if you're really that sick, um, you'll get IV antibiotics in the hospital. And then hopefully you don't have any of the complications like development of an abscess

or obstruction, uh, or, uh, possibly even a bursting of your abscess. So now you have all this pus and bacteria flooding into your abdominal cavity. That's bad. And if any of those complications happen, you might be getting surgery done. That surgery can be either laparoscopic, where they enter in with tubes, and you're able to take out a piece of your colon, or it might be open surgery to clear out the abscess or clear out your abdomen if the abscess is burst. So that's sort of the horizon, the playing field of treating diverticulitis. And that's the acute diverticulitis. Now, if you have a mild case, like I had my really bad episode, but I had, you know, after that, I had another episode where I just knew it was coming on. I could just feel it starting to happen.

And so if you're getting there, you don't have to wait. There are things that you can start to do. So I did. And I ended up getting better within like five days, didn't move on to becoming an all out problem. And what I did was, is I use bone broth. You know, bone broth has enormous amount of nutrients as you know, antibacterial capabilities. So, you know, I stopped eating a solid diet, and I made a big batch of bone broth. You get water, you get an antibiotic, hormone-free chicken, you dump it in, you chop up some root vegetables, you put in some great herbs, thyme or rosemary, you put in garlic and onion, you put in carrots and celery, and you just let that boil and simmer it for 24 hours, adding water. And then you have, you know,

a lot of bone broth. And so then I would just drink it like it was coffee or tea throughout the day. And I also did drink clove tea. Clove tea. Clove tea. Really high in polyphenols. It's one of the botanicals. Peppermint tea, peppermint and clove have some of the highest levels of polyphenols. Why are polyphenols important? They are really good at restoring your gut microbiome. Polyphenols are really important to the health of

your bacteria. And so I was doing clove tea, my bone broth, and I was juicing. I was just using some fresh juice, taking the pulp out. And I did that for about 48 hours, about 72 hours, you know, I really felt like the pain was starting to diminish. And the clothes too, you just put clothes in water and boil them up? Yep. That's exactly what I did. I have a little tea basket and I just crushed up the clothes, put it in a tea basket, put it in the hot water and there you go. It's really good. Amazing. Amazing. Yeah. And so, and then you can slowly begin to add in, you know, some vegetables, raw vegetables, some quinoa and refined grains, fermented black rice, fermented grains like barley spelt. So I added those things in slowly. And then by day four, I was feeling really good.

I started adding in more fiber. Now, two things I want to mention. In the conventional world, you hear, hey, if you have diverticulite, don't eat seeds. Right? Well, a lot of research has been done. And recently, nuts and seeds are not the cause of diverticulitis. In fact, because- What is with that advice?

Because we're all told, oh, I can't eat fruit. I can't eat raspberries. I can't eat seeds. Is that really true? No, it's not true. The research shows, and it's already, you can pretty much now, if you read anything on diverticulitis, you'll be told you can eat seeds. I think it was more of a mechanical issue that these things get stuck, that even the

smallest seeds from berries can accumulate inside the diverticuli, then block bacteria in there, and then you get the diverticulitis that's been debunked you can eat seeds in fact because of the high levels in nuts and seeds of um uh linoleic alpha linoleic acid that becomes omega-3s they actually have an anti-inflammatory effect and it's shown to have a benefit for helping you avoid diverticulitis. And also as you're getting better from it, it can help the healing process. So nuts and seeds. And the other one is fiber.

So fiber is, you know, it has been said, don't eat fiber because during your acute diverticulitis, because it's going to build bulk and it can potentially stretch the colon. You might get a rupture. And so. Or the seeds will get caught in the, in the diverticuli and cause problems. Seeds and diverticuli. And then you're, you know, during your episode, you should avoid all fiber. Well, you know, when I started feeling a bit better, I didn't want to have fiber because I wanted to start moving stool through. I was constipated, and I knew that to get better, I needed to get those toxins out of my bowels.

So then I started adding in fiber, and I added in both the soluble kind of fiber, like the oat bran and nuts and seeds and beans and lentils, because that absorbs lots of water. It gets, it gets like, I'm sorry, it gets gel-like in its quality. It actually slows things down, but it allows all the nutrients from those, those, those, um, uh, fiber foods to be absorbed by the gut because those, those nutrients are very healing. So you get a super high saturation of good um uh compounds and nutrients from those types of soluble fibers and then insoluble fiber you know i add in because that's going to absorb water and move bulk through and allow me to detox and clean out so about that third or fourth day when you're feeling better, it's only a

mild episode, you can start adding in insoluble fiber and then also soluble fiber because they do two different things. And the insoluble fiber is going to be more of like your grains, your cruciferous vegetables. You can even find it in avocados, in some fruits. You'll find certain levels of the insoluble fiber that will bulk up your stool, make it nice and soft and pass through. And that's what you should be eating all the time because you want those nice, full bowel movements. That's why fiber is so important. So that's a way that, you know, you can treat a mild early diverticulitis if you want to really try and keep it from getting worse to the point that you're going to end up in the doctor's office, the emergency room,

and they're going to start doing all types of bad things to you. Yeah. You know, and there are some targeted supplements that you can use that can help the gut heal. Glutamine, some of the other things I use, marshmallow root. Those are some of the targeted supplements that you can use that are healthy for the gut um i'm just having a little bit of a mind blank on some of the other ones uh there's slippery elm marshmallow root glutamine um so you can apply those two um as well when you're starting out with your mild early diverticulitis that's great so basically we're getting people on a gut health program, right? And we're looking at things that help.

So talk us through that patient you had, the 52-year-old with arthritis. Yeah, so this is a really interesting patient. What you found and how you treated her and helped her. So this is a 50-year-old female who had arthritis in her right hip that was planning on a hip replacement. She had longstanding constipation. She had recurrent diverticulitis. I think it was over like a three, maybe four year period.

She had at least one episode a year. It may have been, you know, less than four years, maybe three. But so that occurred prior to seeing me. And she was coming to me primarily because of those recurrent diverticulitis episodes and the fact that she'd been constipated for most of her life. So interesting case. The things that were running through my mind were like, why would this woman have so many episodes of diverticulitis? And so I asked her, you know, of course, about her hip.

And the pain had really gotten a lot worse. She, as I said, was planning to have hip replacement, but she was eating Advil all day. Oh, wow. And so Advil is one of those triggers for inflammation in the colonic tissue. And she had diverticula. And so now with the constant use of the NSAIDs that had increased over the last three, four, five years, she was triggering diverticulitis. And on top of that, she'd been constipated most of her life.

So the test that I ran, I ran a stool test. So the stool test is, again, always looking at the gut microbiome, giving us the balance between good and bad bacteria. It's giving us information about how well you're digesting. Do you have everything you need to digest well? It's letting us know if you have any stealth infections that you picked up along the way, parasites, viruses, protozoas that may be impacting your health. And that test also has an inflammatory marker called calprotectin. So calprotectin can tell us if you have this chronic ongoing inflammation, which is not not uncommon in the diets we have today it's not uncommon to have this you know stealth inflammation that you just don't know about so i checked her calprotectin because she had irritable bowel constipation 50 to 60 percent

of those patients have small intestinal bacterial overgrowth. And that overgrowth can lead to constipation, can lead to slower gut motility. And then that becomes that setup as you get older. One of the pieces to the puzzle that might give you diverticulitis. So I tested her for that. And I did some gluten and food sensitivity testing. So what we found on her was that her calprotectin was indeed elevated. So she had marked inflammation. She did have SIBO. And it was methane producing bacteria. Methane-producing bacteria have a significant impact on gut motility, particularly on something called migrating motor complex. So I want to mention that because I think it's really fascinating, and it's part of what we try and do with our diet. But when you eat, you know you get that rumbling in your stomach, your intestines start to move. That's peristalsis. That's taking your food. It's being broken stomach, your intestines start to move. That's peristalsis.

That's taking your food. It's being broken down, moving it through your system, having it broken down, getting it digested. And then finally, it's going to leave your body. That's the peristalsis engaged when you eat. But when you stop eating, about 90 to 120 minutes later, there's a signal that happens that triggers something called the migrating motor complex. There's no food in your stomach or traveling through your intestine, but your brain tells your intestines to start moving. And so you might notice that you get this like growling in your stomach or you notice that your intestines are moving and you haven't eaten. That's the migrating motor complex. And it's the street sweeping effect. It's doing that secondary cleanup in your gut of any food that hasn't left. It's really important, particularly in the small intestine, because if food particles

stay there, they become a nidus for bacterial overgrowth. And so, and that bacterial overgrowth leads to SIBO. SIBO leads to either diarrhea or constipation. It leads to inflammation. It leads to nutritional deficiencies, malabsorption. It can actually have an upstream effect where it will cause less gastric acid in your stomach. It might impact the ability of your pancreas to appropriately discharge pancreatic enzymes to break down fats and carbs. So it's an important thing to understand. And why do I say that? Because if you have problems with constipation and even diarrhea, you're probably Babau is not a good idea. You want to give yourself at least three to four hours between meals so that you can get this migrating motor complex to do that secondary peristaltic sweep up.

So that's why I wanted to mention that. So if any of our listeners might have that issue, that's a key fact. Because gut motility when you're dealing with either IBS constipation or diarrhea is a big deal and a lot of people don't know about that migrating motor complex and the need for it to be triggered and do its work so so what did I do with this this this um young woman I basically found out that she had the SIBO I I treated her SIBO. I used botanical antibacterials. I gave her some gut motility activators. I used 5-HTP. I used ginger and artichoke to get her motility to work. I told her to stop snacking between meals. And we were able to clear up her placebo. For her inflammation,

I just had to clean up her diet. Really, a lot of inflammation was coming from her diet and her NSAIDs. So there are two things I did. One is I started to give her really high doses of fish oil. And then I used something called SPM. Those are special pro resolvins that are, I call them super concentrated fish oil. It's derived from fish oil, have a very potent inflammatory and inflammatory modulating effect. So SPMs, high dose fish oil, I put her on four to six grams a

day. I put her on some curcumin that was really high end curcumin that's readily absorbed. And I had her using that instead of NSAIDs for her pain. I also added in some CBD oil. And between those things, she was able to stop using her Advil, reduce her inflammation as we treated her SIBO. And those are the major things that turned her around. And so she's gone on, it's been almost two and a half years and she hasn't had her diverticulitis return. So basically if you, if you don't have it and you want to prevent it, it's really focusing on all the things you mentioned, your diet, stress, motility, and dealing with those things before they become a problem. And then if you have it, if you have diverticulosis, which you'll find out on a colonoscopy, you want to make sure you're really up in the fiber and the food program that you mentioned,

things like the increased fiber-rich foods of nuts and seeds and lots of fruits and veggies. And don't worry about all the seed thing. It's fine. And then if you get it, there's things you can do to actually deal with it acutely, like bone broth and eating fruits and veggies and different grains and fibers and protein and so forth. So it's a very different perspective about how we address the problem of diverticulosis, which is really common.

Like you said, it affects most people as they're older. Oh, yeah. So this has been great, George. This is hopefully helpful to those people who are suffering from this. If you've listened to it and you have struggled with diverticulosis or diverticulitis, you should follow these guidelines. If you want to come see us, we're happy to see you at the Ultra Wellness Center. We see people from all over. We have a bit of a waiting list now, but we're hoping to try to get you in.

And we've got a great team of five doctors and five nutritionists. And if you've struggled with diverticulosis and you know what's worked for you, share with us. We'd love to hear your experiences and comments. We'd love to hear from you and subscribe wherever you get your podcasts. And we'll see you next week on The Doctor's Pharmacy. Hey, everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love

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