Lori Esarey: Wellness is a practice, not just a word.
Kelly Engelmann: Welcome to the Synergee Podcast, where myself, Kelly Engelmann, and Lori Esarey shed light on powerful tools and topics, that nourish your body,
Lori Esarey: and most importantly feed your soul.
Kelly Engelmann: Welcome Synergee listeners, Lori and I are back in studio for recording and we are super excited about this topic today. So lean in if you have been struggling with brain fog, low energy, digestive insults, whether you’re having reflux or bloating or constipation, diarrhea, any of, or all of those things lean in because we’re going to talk about a deep topic today called the Gut Microbiome.
Lori Esarey: Exciting stuff. Well, we have Alicia Galvin with us today, a registered dietitian, so happy to have you today. She’s a clinical science liaison with microbiome labs. She has also owned her own private practice since 2014 with a keen interest in gastrointestinal diseases as well as a focus on fertility, autoimmunity, and chronic inflammatory conditions. In addition to owning her own business, she has spent years practicing as an integrative and functional dietitian at a functional medicine clinic, helping patients develop customized solutions that empower them to take control of their health challenges. She is a co founder of SIBO Academy, an online educational training platform that delivers evidence based courses for nutrition professionals in the realm of functional GI disorders. Alicia earned a master’s education and Counseling degree from the University of North Texas and completed her integrative and functional nutrition certified practitioner certification with the Integrative and Functional Nutrition Academy. We are so excited to be here with you today.
Alicia Galvin: Thank you so much for having me I’m really happy to be here.
Lori Esarey: So we get to start out with a discussion of then what in the heck is the gut microbiome? We’ve got to start there.
Alicia Galvin: Yeah. So our gut microbiome is essentially this massive amount of bacteria that are in mostly in our GI tract, now the microbiome is really multiple different places. I mean, we have our skin microbiome, we have an oil microbiome, there’s a vaginal microbiome, but for the most part whenever we talk about the microbiome, we’re usually referring to the largest microbiome, which is in our colon, we have literally trillions of bacteria in there. And it’s also includes other things like certain fungal species, viruses, so there’s lots of different types of microbes it’s not just bacteria, and they all work together in synergy with each other and what’s really interesting about the microbiome is that the more that we learn about our microbiome, the more we realize we don’t know, but also the more we realize how much are functioning as a human relies on a healthy microbiome and really relies on these different microbes to signal and to communicate and to produce these byproducts that we as humans, the human hosts really rely on. For overall good quality health. So, it’s a really fascinating field of research. It’s a very new and emerging field of research, but it also is enlightening us just on the health side of how can we really maximize this microbiome’s health? How can we take care of it? What are the various factors that can damage our microbiome, but it’s a really large collection of microbes.
Lori Esarey: So patients oftentimes when we start talking about having them collect a stool sample so that we can evaluate their gut microbiome, they were like, why do we need to do this? Right? Why do we need to look at just poop? Right. And so as you mentioned, there’s so many different layers to what the gut microbiome has the capacity to do for us, either in a very good way or a very inflammatory way. So what are we looking at in the gut microbiome? Talk a little bit about like the layers of the gut microbiome and what they’re responsible for.
Alicia Galvin: Yeah. So to kind of understand the microbiome, as it relates to the gut, we have to do a little bit of review on some anatomy, just so everyone’s on the same page with this. If you think about your GI tract when you swallow food, it goes down a tube, which is your esophagus, it goes into your stomach, it gets mixed up with a lot of different juices and stomach acid and enzymes, and then it gets spit out into a second tube called your small intestine. And your small intestine leading into your colon, that’s also 1 long tube, and the innermost part of that tube so where all of that food and all those different proteins are coming into contact with each other. That’s what’s called the lumen. That’s what we refer to as the lumen of the gut, so that’s that innermost part. And that’s also where our microbiome is, so that’s where all of our microbes and our bacteria and all of these bacterial byproducts. That’s where they all are residing. And when we think about the different layers of the gut and the microbiome, it’s really important to understand that if foods or microbes or bacterial products are contained in the lumen, they’re still technically outside the body, because if you think about our GI tract, there’s a hole at the beginning and then there’s a hole at the end. And if things pass all the way through, they’ve essentially not gotten into our body. But if we have a breakdown of the different layers of GI tracts, so which we’ll talk about here in a 2nd, but if those things start to break down, then some of these things can trigger immune activation can trigger information, some of these bacterial byproducts that are maybe more inflammatory can actually get through into circulation and that can flare and cause a lot of diseases, so it’s important to understand that. As long as you have a really healthy, intact GI tract and a really healthy microbial composition, things are going to go well for you. You’re keeping things out of the body that should stay out of the body, but then the different mechanisms of digestion allow for nutrients and beneficial things to pass through and actually get into circulation. So that lumen is where the bacteria are. Then we have this layer of mucus that is between the lumen, so where all the bacteria are and a single cell layer that is called the intestinal epithelium. Now it’s just 1 cell layer thick. And if you think about our immune system, there’s 80 percent of our immune system is actually in the gut. And it’s only 1 cell layer, which is teeny tiny that separates everything that’s happening in the lumen with our immune system. And so it’s important to make sure that intestinal epithelium has really nice and intact, what are called tight junctions, which you can think of them as like shoelaces that are keeping all of your cells nice and tight. But this mucus layer that separates that epithelium, that single cell layer from the lumen. That single mucus layer is oftentimes not talked about, we hear about leaky gut a lot, we hear about tight junctions and we hear about that, but not everyone’s always talking about this mucus layer. And what’s interesting about this mucus layer in the colon, is it’s the only part of the entire human body that is sterile. It doesn’t have any microbes there. We once thought that things like blood was 100 percent sterile and urine was sterile and the vaginal tract was sterile and the uterus was sterile. Now we’re finding that no, actually it’s not, there are some microbes in there, but this mucus layer that’s in the colon is completely sterile. And part of that is because it acts as this, no fly zone, or if you want to think of it more as, if you’re on a long road trip, and you have 2 kids in the backseat of your car, you want to make sure there’s a middle seat between the 2 kids because you want to make sure there’s separation and that no one’s encroaching on the other space. And that’s what this mucus layer does is it helps to keep everything that’s happening in the lumen separate from that intestinal epithelial layer so that you’re not, laying directly on top and potentially coming all the way through and activating the immune system if there is any sort of compromise in those intestinal type junctions. So, those different layers and this is very high level. There’s obviously much more complexity to it, but for the purposes of understanding how this relates to overall health, that’s essentially what we’re looking at when we’re thinking about the different layers of the gut.
Kelly Engelmann: So it’s the thing that separates the outside world, what we’re eating or putting in what we’re ingesting from the inside world. It’s that buffering effect that happens.
Alicia Galvin: Exactly.
Lori Esarey: So how does doing a stool test, because I know that this is a question we get a lot, how is a stool test really giving an indication? What are we looking at in a stool test that gives us an indication of the health of the gut microbiome?
Alicia Galvin: So there are different types of stool testing out there. And I just want to go back and explain that a stool test that your doctor maybe does is going to be very different with a very different purpose, then what we call a functional microbial analysis. A functional microbial analysis is typically more along the lines of what you’re going to get from like a functional medicine practitioner, where you’re looking at all these different markers, whereas a stool test that you get from your like, maybe your primary care or just your GI doctor is usually just looking at, is there some people fat or is there a pathogen? So you’re not going to get a true sense of the function and the composition of your microbiome. So, in a functional stool test is looking at is it’s looking at basically who’s there, so what types of microbes are there? There’s different categories, there’s different families and different groups of bacteria that in their research if certain ones are elevated, that tends to be more inflammatory, if certain ones are low, then that’s usually could indicate that you might have more of this degraded mucus layer. There are some keystone species, so keystone species are, they’re kind of like your Instagram influencers. They make a very small percentage of the overall, group the overall total population of your microbes, but they have a disproportionately great influence on the health of your microbiome so there’s a few main ones Akkermansia Muciniphila, Faecalibacterium Prausnitzii, Bifido Longum, Bifido adolescentis. These are some of the main ones that have had the most research around them. There’s many others, but these are the primary ones. And so usually a functional stool test will look for these particular microbes, because if you don’t have them, then that can be linked with various cardiovascular and metabolic issues. It can be linked with low, something called short chain fatty acid production, which is something else we can look at in a test. And we can get into that in a minute if you want, but yeah, you really want to look at the composition. You also want to look for diversity. And that’s something else that stool tests can look at certain ones, not all of them do, but some of them do. We’ll look at diversity because we also know that if you have a whole lot of different types of species in your gut and they’re the right ones that are supposed to be there, then that is exponentially more associated with better health outcomes and better aging potential, so we want to have a lot of different diversity within our gut microbiome. And so a stool test can tell us how diverse is your microbiome. There are certain tests that depending on the technology that they’re using, like, for example, at microbiome labs, we have our buying the effects tests and ours uses what’s called whole genome sequencing, meaning we can map out the microbe from top to toe, we know the full sequence of their genetics, so we know exactly who’s there. But the other thing that it can do is it can help to show us the functions. So we can look at genes of the bacteria to tell us, is there increased histamine production? Is there increased glutathione production? Is there vitamin synthesis from our microbiome is there’s certain things like ammonia production, which can be very tough on the liver, it can be tough on the kidneys. So we can see are there a lot of microbes in there making a lot of ammonia. So we can also come up with and can see the functions of the microbiome of what it’s actually doing in that particular individual and then we can tailor, our recommendations based on that. So there’s quite a bit we can actually glean from a functional microbiome analysis stool test through looking at these various functions and then the composition of the gut.
Kelly Engelmann: Yeah, we’ve come a long way with being able to evaluate the gut microbiome. It used to all be culture based, right? And now we have such better technology to be able to look at that. So let’s back up a minute and talk about how is the gut microbiome established? Right. What happens at birth? Let’s go through that story.
Alicia Galvin: It’s really interesting because it actually starts to be established in utero. So before we’re even born, before we’ve even come into this world, we start to establish and there are certain influences in utero that can actually dictate certain things once we’re actually born and, into this world. So to first start out when we’re in utero. There are these and what’s really fascinating, I think, is it also it’s not only the establishment of our microbiome, but the establishment of our gut brain access also starts in utero, because in the 1st, 1000 days, the 1st, 2 to 3 years of life starting in utero, the way our neurological system develops is intimately connected with our microbiome and our GI tract development. So, if we back up just going back to, when we’re babies and mommy’s tummy, the mom’s microbiome and the health of the mom’s microbiome will influence how this gut brain connection starts to work. There are certain, what are, these are called Peptidoglycan or PGNs. These are certain components in the cell walls of bacteria and what they do is they can actually shed and they can cross through and into the placenta. And what is interesting is that the placenta has these receptors, these PG and receptors, and they also have these sensing molecules. And what happens is when, if the mom has a really good, healthy microbial composition. So she has a lot of these peptidoglycans because there’s more peptidoglycans in our healthy bacteria than in our unhealthy bacteria, so you’re going to have a whole lot more of these PGNs if a mom has a really nice, healthy microbiome. So when they shed, they get into the bloodstream and they pass through and they get to the placenta. The placenta has these receptors and these sensing molecules that then say, Oh, look, here’s some peptidoglycans. Let’s transport them through and let’s bring them into the baby and the baby’s brain actually also has these sensing molecules and these transporters. So what happens is that the more, you know, peptoglycans that are able to get through the placenta and into the baby’s brain, that actually helps with the neurodevelopmental process. So it helps with myelination and it helps with differentiation, it helps with the blood brain barrier formation, which is that protective barrier around our brain that helps to keep the brain separate from the rest of the body. And so it’s actually the mom’s microbiome and her composition that really helps this sort of initial process of the gut brain access to develop. So that’s all happening in utero. And then when we’re born, babies really have very few bacteria in their gut they really only have 2 main types. They have Bifido and then they have enterobacteria. So there’s really just 2 main types. And then as the baby starts to breastfeed, and then eventually starts to add solid foods, then that further facilitates the diversification and helps to increase diversity of the baby’s microbiome. But that all comes from the introduction of food and breast milk. And, and as we go through, starting, from when we’re born through about the age of three, that’s when there’s this real interesting interdependent kind of parallel timeline of our gut microbiome maturation, the different intestinal cells the enteric nervous system, which is the nervous system at the GI tract, all of these GI specific functions are developing and helping to Influence in a bidirectional way, the development of perception and memory, and development of neural circuits and cognitive development. So the gut and the brain are instantly connected from the very, very beginning. And of course, there’s lots of other influences, stress and environment, whether the baby’s born vaginally versus C section. Is going to obviously shift and change some of the microbial composition, whether they’re breastfed versus formula fed. So there’s a lot of different variables that influence and play a role in the development of our microbiomes and how what they start to look like as adults. But it’s really important to understand that you can do a lot just in the prenatal and then the very early stages of life with some of the different food choices and with the state of the mom’s health. Now, that doesn’t mean that if you don’t capture it at the very beginning that, all is lost. It just means that there’s definitely things you can do down the road and later in life that can help to, if you have any sort of microbiome imbalances, you can certainly do many different things with diet and lifestyle and nutrition to help to rebalance things, but just to kind of bring it that if this is, an area that thinking about getting pregnant, or if you are pregnant that just think about your health of your microbiome and that can be you’re just giving them a head start.
Lori Esarey: That’s so good to know, too. As you were talking, 1 of the things that kind of came to mind is, how does a person really know? Like, is everyone who has an unhealthy microbiome or an imbalanced microbiome? Do they have symptoms of that? How would they know that they really need to have a test or see somebody about this?
Alicia Galvin: It’s kind of sort of a spectrum. So when you have an imbalance of the microbiome, it doesn’t mean that you have necessarily GI symptoms. I think that’s something that people sometimes think is like, Oh, I don’t have GI symptoms, so I must not have leaky gut or I must not have an altered microbiome. But the thing of it is again, like I mentioned earlier, the more that we know, the more that we learn about the microbiome, the more that we realize that there’s all of these gut organ axes, so there’s the gut skin axis, there’s the gut mouth axis, there’s the gut reproductive axis, there’s the gut liver axis. So maybe you’re not having GI problems in terms of symptoms. But maybe you’re struggling with eczema, or maybe you’re struggling with an autoimmune condition, or maybe you’re struggling with the metabolic disorder, like diabetes or cardiovascular disease, or maybe you’re struggling with PCOS or endometriosis or some sort of reproductive system challenge, or, maybe you’re having some GI issues maybe you’re having fatigue, or maybe you’re having brain fog. Like, there’s so many systemic because that’s what we’ve now realized is. Everything really health really starts in the gut and what I was mentioning with the different layers of the gut and having a really nice intact intestinal barrier system so that we’re not getting massive inflammation coming through and triggering the immune system, chronically over time, that’s where everything starts and if we start to get more systemic inflammation, well, that can be traced back to just about every chronic disease that we face in our modern day world. So it can be a whole gamut of symptoms, it might just be that you’re more fatigued than usual, and, but you can also do stool tests, prophylactically because there’s sometimes there’s things that we can catch in terms of microbial composition or certain patterns that we see that we can start, you can start to do some things initially prophylactically to then prevent any future further progression to where you are actually having symptoms. So, you can use it in a few different ways.
Lori Esarey: We hear that all the time. I mean, I think Kelly and I can both, the majority of people walk in and say, listen, but I’m I’m not having symptoms. Why are you proceeding with this course of action? And I want to go back to what you said is, we hear all the time, but 70 to 90 percent of your entire immune system is dictated right here. So if you don’t start right here, have a conversation at least about right here, then you may not get very far in your journey or path towards wellness, or you might have a delay in getting there just as quickly.
Alicia Galvin: Yeah, exactly.
Kelly Engelmann: Absolutely. So Alicia, what I heard you say was if you have an inflammatory response going on anywhere in the body, then having a stool analysis or an analysis of the gut microbiome could be appropriate. And then if you’re interested in just overall health improvement and vitality, doing one preemptively, doing one just to see where you are, because the things that we can do to help navigate a healthy gut microbiome can go a long way in prevention. So, I think knowledge is power. We always say test, don’t guess. And, yes, we do look at symptoms, and symptoms are an important indicator, oftentimes, of what’s going on, but it doesn’t always tell the whole story. So, testing and being able to make some recommendations. You mentioned diversity as part of the recommendation earlier. Diversity in the diet, diversity in fiber, and that’s something that we talk a lot about with our patients, because that’s such a profound strategy for improving gut microbiome in general.
Alicia Galvin: Absolutely. Yeah. I’ll think of it just like an ecosystem, you know, an ecosystem that has a lot of different plants and a lot of different animals. That’s usually going to be a much stronger, much, much more robust ecosystem. Then if you have, 2 plants and a couple of animals, like that’s not a very healthy, robust, strong ecosystem. So it’s the same thing in your gut. You want to have lots of different types of plants, lots of different guys, and they’re doing lots of different functions. And so you can achieve that with through diet with fiber diversity as well, the more different types of plant based foods that you can consume, wide variety of different types of vegetables and fruits and nuts and seeds and beans I mean, that’s also going to help to encourage a really nice diverse microbiome.
Lori Esarey: So we hear the term dysbiosis all this time and I typically will explain that to our patients as abnormal growth of living cells. And you’ve said, we’re made up of trillions of bacteria, but are there specific bacteria that we’re finding in the research now that are just pivotal besides, you talked about commensals and you talked about those particular back bacteria that are so important, but aren’t there some that are kind of really the hot topic right now that people might be hearing?
Alicia Galvin: Yeah, like, in terms of, like, lack the orbital strains, those types of things. That’s and what’s really important to understand with when it comes to bacteria is you have to know the strain level, so when we categorize any living organism, you have kingdom, you have filo, you have, all the different group family, you can have all the taxonomy, right? So, if you think about dogs, the way I like to explain it to people is you’re not going to send a Chihuahua out to go to do the job of a sheep dog, because a Chihuahua and a sheep dog are very different. Yes, they’re both dogs. But they have very different functions. They have very different jobs that they do and with bacteria, it’s the same way, and that’s when we have to get down to that strain level because it’s the strain of the bacteria that dictates what it actually does for us in the body. So one thing when like you hear about. If it along them, or plantarum, or, L. Ruteri, that’s a, that’s still actually at a pretty, pretty high level. You’re talking about, like, the dog level, but you’re not getting necessarily down just to, strain level in those particular instances. So just kind of be mindful and always ask the question when you hear about a research study, or if you’re looking at a probiotic, or, you’re looking at like a probiotic food of some sort, you always want to look at the label and also pay attention to the fact that, are they also mentioning the strain? Are they talking about the strain when they’re talking about this research, article that just came out, or are they talking, are they giving you the strain when you see it on the label? Because It’s a granular piece that can sometimes make the world of difference, a total difference in what that bacteria is going to actually do for you. So that’s just really an important piece that I think is important for people to understand.
Kelly Engelmann: So you’re talking specifically about taking probiotics. So taking a supplemental probiotic, looking at those strains in a certain way to know what you’re taking and why you’re taking it and the potential effects it can have on the body because probiotics are not probiotics are not probiotics is what I hear you say. Like, going over the counter, getting probiotics may not be the best option. When you’re looking to change a specific function in the body.
Alicia Galvin: Exactly.
Lori Esarey: Yeah. Some of the most expensive probiotics that I have come across are the ones that don’t work, even if a person only pays a dollar for them. Right. Or they actually cause more harm than good. I know that there’s some commonly commercially available probiotics that people will come in and say, this is what my doctor recommended. And, I look at it and I apologize first and then, take the course of explaining a little bit more, not to the extent that you just did, but I do want to dig into that a little bit more as. How does one choose a probiotic?
Alicia Galvin: Well, the one thing just to your points, probiotics on probiotic. So that’s the first thing is you want to look at, are they listing the strains? Cause if they’re not listing the strains, which is usually some sort of a number at the end. So it’s, SC 2 0 8 or it’s 1714 or 3 5 6 2 4 so it’ll be, for example, like one of the ones we have is Bifido longans 1714 or Bifido longans 3, 5, 6, 2, 4. But if you just see Bifidolongam. You don’t really know what you’re getting. There’s lots of different bifido longans out there, but you don’t know which one you’re actually getting in that particular probiotic so that’s the first thing is you want to see, are there some numbers after the name of the probiotic? Because that’s going to tell you if it’s actually at the strain level. The other thing that is really distinguishes different products out there on the market is if the products, the company itself has finished product research, which means that they haven’t just taken strains that have been studied just in the research and in the research, this probiotic has shown to help. Diarrhea, but then, they might put that along with maybe a couple others in this finished product formulation and then they just assume that it’s going to do the same thing as what it has shown in the research, and that may not always be the case so the other thing that you want to always ask of the product that you’re looking at is, does this company or does this product have actual finished product research? Meaning that that product itself in that finished formulation was studied in clinical trials and did that formulation of that product show certain outcomes and those clinical trials, that’s what really separates the different brands that are out there, because that final step that finished product research it’s not done really at all in the supplement industry. There’s just maybe a couple of, companies out there that have a lot of finished product research behind their probiotics. So there’s really just a handful, if any, that are really doing that. So that’s just like the second thing that you’d want to be mindful of is their final product research.
Kelly Engelmann: That’s awesome. That’s really good information to know. So we talked about how the gut microbiome gets established, in utero, then changes it, birth and as food is introduced, what could go awry with the gut microbiome? What are the things that create an unhealthy gut microbiome? How do we get ourselves into a mess with our gut microbiome? Talk about some of that.
Alicia Galvin: The biggest ones are, diet. So if you’re eating a lot of processed foods, a lot of saturated fats that are unhealthy, a lot of, meats that have had antibiotics added to them, if you are not consuming a wide variety of fibers and vegetables at all, like if you’re not really eating any plants that kind of can starve the microbes, because that’s what bacteria prefer to eat is they prefer to eat fiber, that’s what they rely on to then make these byproducts called short chain fatty acids. Specifically, things like butyrate, which have been shown to be super helpful in reducing brain inflammation and helping with insulin sensitivity and helping with cardiovascular disease and so there’s just a whole host of things that bead rate has also shown, which is a byproduct of fiber fermentation. So if you’re not eating enough fiber and you’re mostly eating a lot of processed foods, high sugar foods, then that’s going to really disrupt the microbiome. The other thing is antibiotics, which I’m not bashing antibiotics, they have saved lives and they are in some cases absolutely necessary to prevent infections from going awry. What I’m talking about is just the overuse or the unnecessary use of antibiotics and not being mindful of when to bring an antibiotic in. Now, if you need to take an antibiotic because you have an infection, you have to take your antibiotic, but what we do know about antibiotics is that they can really disrupt the microbiome because they clear out everything they get the bad along with the good and this what the studies show is that it can take up to about 2 years for the microbiome to really rebound from just 1 7 day course of antibiotics. So, if you have to take them, you have to take them and that’s required for you for your health and for your well being, but it’s the unnecessary or the overuse of antibiotics. So that can really affect the gut. The other thing can be also, excessive alcohol. Excessive alcohol can affect the microbiome negatively. It can also really enhance this where we were talking about earlier with intestinal permeability, alcohol can really damage that intestinal lining. The other thing to that can disrupt the microbiome are, over consumption of emulsifiers so, drinking a bunch of things that have the kerogens and the different emulsifiers and the different gums that are in our different processed foods and beverages that we consume now, those emulsifiers can also disrupt this intestinal homeostasis and it can really start to degrade that mucus barrier, and it can start to erode at system that’s in place to help to keep things separated, so stress. Stress is a huge one. Stress can absolutely disrupt the microbiome. So keeping your stress managed can be helpful, I’ve even seen that in stool tests where, their diet’s pristine, they’re taking all the right supplements, they drink the cleanest water, you look at them and you’re like, Oh my gosh, they’re doing way better than I’m even doing. And yet their microbiome is a mess, but it’s because they are stressed to the hilt and they just are burning a candle at both ends and they just are stressed, stressed, stressed chronically and that can disrupt the microbiome despite all of your best efforts, so stress management is huge with that.
Lori Esarey: That’s a lot right there.
Kelly Engelmann: That’s a lot.
Alicia Galvin: Those are the main ones I think that we come into contact on a regular basis in our society and in our lives that can really affect the microbiome.
Lori Esarey: I want to ask a question specifically about alcohol because we get this question a lot. So how much is excessive? I think that we’ve heard drink in moderation that’s okay. But how much is too much? And then what exactly does it do that really does wreak havoc on the microbiome?
Alicia Galvin: So I’ll give you the technical answer, and then I’ll give you kind of more of the clinical answer. So the technical answer is technical answer is 1 drink per day for women 2 drinks per day for men. And that drink is defined as the 5 ounces of wine, the 1 ounce of liquor, the 12 ounce beer, like your standard drink. That’s technically what’s considered like an acceptable, normal kind of moderate intake of alcohol. Now, clinically, if I have somebody who is, who I know has a lot of these different, they’ve been struggling with health issues, they have a lot of chronic inflammatory conditions. They are having a lot of symptoms or, they have. Like I said, just any of those kind of chronic inflammatory conditions. My stance is we really need to work on trying to heal and work on rebalancing and repairing the GI tract and helping to reclaim this good what’s called you biosis, which is just like more balance of the microbiome and work on that rebuilding that mucous layer, and if you continue to try to put alcohol in at that rate, you’re kind of working against yourself because it’s like you’ve dug a hole and while you might not be shoveling, all the dirt back in, if you’re still putting, fairly good amount of dirt back into that hole, it’s going to be a lot harder for you to climb out of, so let’s try to get you out of the hole before we start back to you having some of that alcohol again. Now, for some people they might be able to do fine with maybe 1 or 2 drinks a week or just have it socially. But, I really try to reduce it if we’re being, trying to be really corrective and really trying to help with healing, but technically, the 1 drink a day is considered acceptable. I also think it depends on the type of alcohol that you’re drinking because things like wine and red wine. There’s I mean, you look at the Mediterranean diet, look at people in Europe and you look at, the historical significance of wine throughout the years. And it does have some health benefits to it. Especially, like, if you’re drinking red wine with the reserve, but, you know, depending on how the wine is made and how the grapes are sourced and are there a bunch of soul fights or there are a bunch of, pesticides and, those types of things I mean, that can also come into the wine as well. So, depending on what type of alcohol you’re drinking could also dictate the level at which, you’re having versus like an organic wine, it maybe doesn’t have all those things doesn’t have sulfites doesn’t have the pesticides. You may not have as much of a negative impact on your GI tract and your microbiome by drinking that versus something that is higher in those things like glyphosate which not and whatnot. So, there’s going to be some variation between people clinically, and so that’s we’re working with your health care provider and really talking with them about what is your best plan for you around alcohol, but those would be some of the parameters that I typically think about when I’m working with clients.
Lori Esarey: We say less is best and none is better.
Alicia Galvin: Yes. Yes, I agree with that. Yes. And that will depend on each individual person.
Kelly Engelmann: Yeah. So Alicia, you mentioned earlier, the patient that’s doing everything right, and they still have challenges with their gut microbiome. I think that goes back to what you were talking about with the Maltesers too. A lot of times they are eating very helpfully and they’re eating, they’re drinking almond milk, coconut milk, those kinds of things, not realizing that some of those formulas have a heavy content on emulsifiers, which may be sabotaging their efforts to repair their gut lining. So looking at those labels carefully so that you are aware and unfortunately those labels have gotten tricky where they’ll have ingredients, almonds, water, sea salt, or salt. And then they’ll have other ingredients listed kind of a paragraph below, which lists all of the emulsifiers that you may, you may not have seen the first time you looked at that label. So I would say look at those labels on those things because you could be doing so many things right and not be seeing the progress that you want to make just for little subtle things that you’re just not aware of.
Alicia Galvin: Yeah. And the good thing is that there’s several companies out there that now make, various almond milks and oat milks and cashew milks that don’t have those in most bars. They really are just the nut salt and water. So that’s the good news is that it might just be as simple as making a switch in the brand that you’re buying. So we’re not saying you can’t have your, almond milk in your smoothie, but just maybe look at what you’re currently buying. And then next time you’re at the grocery store, try to find one that maybe is a more simple ingredient list, and you can still carry on with your smoothies and stuff in the morning, you’re just choosing something different that may actually help shift your progress.
Kelly Engelmann: Perfect. So we alluded to the concept of intestinal permeability, leaky gut that can happen if that gut lining has insults that it can’t repair. So let’s dig in to talk about that a little bit more. What that looks like for patients, what that feels like, how it’s going to show up downstream effect with other disease states, other inflammatory conditions.
Alicia Galvin: So there’s this, it’s called metabolic endotoxemia. I don’t know if this is something you guys have have talked about with your people yet, but metabolic endotoxemia is basically this really big word. That means well, let me back up here. So we have different types of bacteria, right? So we have our, what are called gram negative and gram positive. Every bacteria is classified in 1 of those 2 groups and that’s separate from what I was mentioning earlier with like species and strain. So everybody belongs to either a gram-negative or gram-positive group. And our gram-negative bacteria have what’s called an L P S or a lipopolysaccharide, which basically is just a big word for a fat sugar, so it’s a fat that has a sugar attached to it, and this is part of that bacteria’s cell wall, and when we eat those bacteria, some of them die off and they slough off these LPS is, and that’s just a normal part of being human like that’s a normal part of our microbiome, but what is not normal is if we have an overabundance of these LPS is that we have an overabundance of these dysbiosis, these gram negative species so if we have a whole lot more of these different types of microbes giving off a whole lot more of these LPS is, then that could pose a problem. Now, if you have a really robust intact microbiome or a really nice intact intestinal barrier you have a really robust mucus layer and intestinal epithelium may not be as big of an issue, the problem is, if you have a degraded mucous barrier if you have an intestinal barrier system that’s compromised and these this overabundance of LPSs are able to get through into and pass through that intestinal lining. What happens is that they attached to our immune cells, because remember, we have about 80 like you mentioned, about 70, 80, 90 percent of our immune system is actually just right underneath that single cell layer that’s our intestinal epithelium, so we have a whole bunch of immune cells just sitting right underneath that. So if these LPSs get all the way through, and they attach to these immune cells, then that activates the inflammatory cascade. We get an over activation of a lot of what are called cytokines, which cytokines are just basically signaling proteins that dictate how our immune system responds so some cytokines activate the immune system and some cytokines calm it down. In the case of these LPS is this is like turning on the alarm bells and the fire sirens and like getting the body on a high alert to, oh, my gosh, like, we have these things coming through and it’s really inflammatory let’s sound the alarm and activate the immune system, and what we’re finding in the research which emerging in the research now is that these process of these LPS is attaching to these immune cells and triggering and getting into the bloodstream, is actually being tied back to things like insulin resistance and diabetes even before you start to see the changes in insulin, so there’s been some papers that have been published and some research that’s come out even from the American Diabetes Association that has basically said that these LPS are essentially what triggers the whole cascade of diabetes, so that’s really interesting there’s also been some emerging research around things like Alzheimer’s and cognitive decline that these can get through and they can get into the bloodstream and they can go up to the brain and they can attach to these various receptors in the brain, and when they attach those receptors, it activates more neuroinflammation, depression, mood disorders, anxiety these also have been associated back with these LPS attaching and getting into the various organs and attaching to receptors and triggering inflammation. Infertility, low testosterone, PCOS have also been associated with this. Cardiovascular disease, atherosclerosis those have also been associated. So all of these conditions, all of these symptoms can basically, and we have research emerging now, that’s really showing this and really growing as a body of research that actually the trigger for a lot of them and the perpetuating factor for a lot of these is coming from our gut, it’s coming from this compromised barrier system and from this dysbiosis leading to this imbalance of these certain lipopolysaccharides or these fat sugars that are floating around in circulation and then triggering a lot of these, this inflammatory cascade.
Lori Esarey: That is absolutely exciting research, we spend so much time talking to our patients about blood sugar and its relationship to overall disease and its relationship to inflammation. But I have to be honest, I haven’t heard necessarily about that direct statement about LPS, we look at it all the time, but that direct relationship so that was good stuff. It’s really interesting. So I have a question about probiotics. I want to go back, I want to talk about more there’s so many out there, obviously and spore based probiotics and non spore based probiotics. I want to talk about that because I think spore based probiotics are a hot topic right now, I want to talk about that and then I wanted to to talk about the right way and the wrong way to take a probiotic, and is there a right way in a wrong way?
Alicia Galvin: So spore based probiotics. Yes they have definitely over the last, I’d say 10 years, five, 10 years, have really gained a lot of attention and traction and of course mega score was really the first on the market that really sort of disrupted the whole probiotic space and that’s our original product we’re very proud of our mega score because we have 13 finished product research studies on MegaSpore, so as I was mentioning earlier, making sure you’re thinking about companies that are investing in their research and the clinical trials to ensure that what they say, or what they tout and their claims is actually being backed up by research and that’s what we have. What’s interesting about spores and this is a conversation I have a lot with patients and providers is that spores work very differently from your traditional use of probiotics, so traditionally, I think we’ve all been used to and we’ve been taught. Oh, you rotate your probiotics you have take a multi string lactobifido blend, get as many different species as you can get a high account, 50 billion, 60 billion, 100 billion to try to receive the microbiome, I think that’s the traditional conversation around probiotics. But what spores do is they actually go in and they work to shift and change the garden, so to speak so they’re going into that ecosystem that might be somewhat depleted and they’re actually starting to resuscitate the soil, they’re going in and changing the pH, they’re going in and bringing in new dirt and helping these other microbes to become resuscitated and start to grow again. So spores are not about receding like some of these other bacteria are and these other probiotics are intended because the other issue that happens with taking these lacto bifido blends is that lacto and bifido species they don’t always make it to the colon. They don’t always make it to the site at which you’re wanting them to do their work, and the reason is because we have several digestive checkpoints in our digestive system that are intended to keep things that are coming in from the mouth or from that we’re swallowing or that we’re eating or inhaling, we have stomach acid that’s very acidic, we have digestive enzymes, we have bile acids, which are all geared towards yes, food digestion but the other part is that they have antimicrobial action to them. And so these lactobacillus strains when they’re ingested, they don’t always survive that process and that journey from through the stomach and through the small intestine and finally to the colon so we actually, I really aren’t getting as many of those making it to the end point that you’re trying to make to get to when you’re just taking a lactobifido blend. The other thing that is different is that sometimes in the research, I’m not saying that lactobifido haven’t had really great research on them in general because they have, but the reason why you see some of the benefits from these different strains is they are called what are metabolic response modifiers. And what that means is when they go through, and they get killed off by these various digestive functions, it’s actually these little they’re called outer membrane vesicles, there’s these little secretions in the membranes of the bacteria that interact with our human DNA and genetics and they can affect transcription factors and whatnot. So some of the benefits that we see from these other probiotics are actually not because the bacteria is alive and doing its job, it’s actually because they’ve died and it’s these outer membrane secretions that are doing the shifting and the changing of the symptoms, now the problem with that is you’re not making any changes to that microbiome ecosystem, you’re just literally getting this action from this particular microbe from this outer membrane vesicle after it’s died while you’re taking it, so the minute you stop taking it, you can have a relapse in those symptoms other symptoms can come back. So it’s not changing gut ecology you’re not really shifting or colonizing or establishing most probiotics have shown to only be in the system for maybe 5 to 7, maybe 10 days after you stopped taking it. So, they’re not going to stay around really when you’re ingesting them, whereas spores, they are trying to shift and change the gut ecology they are making a more long lasting change in that microbial ecosystem they’re encouraging these keystone species, like acromansia and bacterium and bifido species, so they’re indirectly working to enhance these other beneficial species and these keystones and these commensals and they’re helping to competitively exclude and to sort of knock back the more problematic or opportunistic bacteria, so spores are in there kind of more as your bouncers in the club, they’re kind of regulating everything and they’re getting everybody situated and organized and then they head out so they’re really only in your just in about 3 weeks, but 3 set of time so we recommend for for about a 3 month period, 2 capsules daily, we always recommend our probiotics with food for the most part there are a couple exceptions to that, but in general, probiotics are best taken with food they’re going to have better action that way and also better survivability going through the GI tract. So we always recommend with the other thing too is with spores, they don’t get killed off by the stomach acid, they don’t get killed off, they are very stable. Spores have been around for millions of years, the oldest spore that they discovered was 250 million years old. I think they found it out in somewhere in New Mexico. And then when they plated it and the conditions were right for it, it germinated and it started to do its thing and that was 250 million years old.
Kelly Engelmann: Wow.
Lori Esarey: Like, how does that happen?
Alicia Galvin: But that’s what spores have what’s called a biphasic lifestyle. So they’re actually dormant as long as they need to be dormant. And then when the conditions are right for them to come out and germinate they do, and the human gut is the right conditions for them to come out and germinate. So, as they start to kind of work their way through the small intestine and getting into the colon, they start to come and they start to germinate. They start to do their job, but they can say dormant for years, and so they’re very stable. They don’t get killed off by stomach acid there’s been repeated studies on that showing their survivability and their stability. So that’s also something else that distinguishes them from some of these other species and types of bacteria and probiotics is that element, as well.
Kelly Engelmann: Yeah. So you talked about probiotics, not making it where they’re intended to go. And so that brings me to the next big topic and that’s SIBO, small intestinal bacterial overgrowth, or even SIFO, small intestinal fungal overgrowth. So I feel like we’re seeing that more and more today related to lack of GI motility, lack of that micromotor complex activity. What would you say to that? Like, what are you seeing clinically? What do you feel like is the underlying root cause of this exacerbation SIBO that we’re seeing clinically?
Alicia Galvin: Yeah, I feel like there’s and again SIBO is another one of those things that I feel has just gained a ton of attention in the last really, I’d say last 5 years for sure, probably last 10 years definitely in terms of research and just awareness around it, because I think for so long doctors would be like, I don’t know, you have like, we can’t figure out what what’s wrong with you, go take some relax and good luck or take some emodium. But I think a big part of it is a lot of what we talked about earlier with these disposes risk factors but, why SIBO develops is well, 1st of all, what is SIBO? It’s an overgrowth of bacteria in the small intestine. So, as I mentioned earlier we, you’re supposed to have a whole lot of microbes in your colon. Trillions of microbes in your colon, your colon is designed to handle that level of microbes and the large intestines function is based off of that large amount of microbes. Your immune system in the colon is geared towards handling that level of microbes. Your small intestine has a pretty good amount of microbes, much more than like in your stomach or your esophagus or the upper part of your digestive tract, but not the level of what you see in the large intestine and the small intestine, the immune system, it’s geared towards food absorption and nutrient absorption so there’s a lot of functions in the small intestine that relies on keeping those microbes at an appropriate level. So, in SIBO the problem comes when you have someone who has an overabundance, their bacteria load has increased above that normal level of bacteria, and so they have an overgrowth, a small intestinal bacterial overgrowth in their small intestine. So, that’s what SIBO is. Now, how do you get SIBO? It’s actually SIBO is considered sometimes like a really complex topic, and there are people who are very complex who deal with SIBO, and it is sometimes difficult to get rid of but when you’re looking at root cause, you can really drill it down to a few things. It’s either going to be an issue with their stomach acid production. So, they’ve lost that barrier protection of that gas of having an appropriate level of gastric acid. So, think about, PPI’s, or H 2 blockers, or if they have an autoimmune condition that they can’t make that much stomach acid. So it’s going to be a compromise in their stomach acid it’s going to be a compromise in their pancreatic output, so maybe they’re not secreting their digestive enzymes from their pancreas as well. So you can think about things like diabetes pancreatic and exocrine insufficiency. So it’s going to be pancreatic issues because again, pancreatic enzymes help with antimicrobial action. It could be an issue with their bile flow. So, think about people who’ve had their gallbladder removed because I want to talk about that for just one second, because I know you hear when you have your gallbladder removed, you hear oh, but your liver makes the bile so it’s fine. But the thing is that liver bile looks very different in its composition compared to gallbladder bile, because when bile goes from the liver to the gallbladder, it gets concentrated. And you have a higher concentration of bile salts in the gallbladder, because that’s where that happens so when you have someone who’s had their gallbladder removed, yes, they’re still making bile but it’s not a concentrated bile, it’s not the composition that happens when they have a gallbladder so I just want to take a sidebar on that.
Kelly Engelmann: Yes, that’s so important for people to understand.
Alicia Galvin: Yeah, If they had issues on their bile flow, if they’ve had hypothyroidism that can affect their bile flow if they have overweight or if they have diabetes or if they’re on different hormone medications that can affect the composition of your bile. So, I was also going to have antimicrobial so, stomach acid, pancreatic enzymes and bile flow or kind of the top, the above the small intestine that if there’s compromise there, it can lead to 2 issues of overgrowth. And then, as you mentioned earlier, the migrating motor complex, which is our motility complex when we are fasting. So I think everybody here is probably familiar with peristalsis. Peristalsis is when we eat, there’s that slow squishing movement of moving food through the GI tract for absorption and digestion. Well, once your body’s done with peristalsis and you’re in a fasted state after about an hour and a half or so, since your last meal your body switches over into the migrating motor complex. And that migrating motor complex is more like a quick propulsive movement, so it’s more like if you’re sweeping at your house and you’re doing this kind of quick, sweet brushing movements, that’s what the migrating motor complex is and that’s its role, it’s to clear out any residual debris or food debris or bacterial debris from the GI tract in preparation for the next meal. So, if there’s a compromise in that MMC so if there’s a motility disorder, or people have had a history of abdominal surgeries so C sections, or if they’ve been in a car accident and they’ve had injury to the abdomen, or if they have things like endometriosis, or Crohn’s, or some of these other things, those can cause adhesions, and those adhesions really inhibit how well that MMC can work through, so there can be some anatomical influences as well. So the MMC is really important. The immune system in the gut is important because, what we’ve been talking about for the last 30 minutes or so, everything we’ve just been discussing about our immune system and our microbiome being really healthy and robust, I mean that has to be there as well. And then the last piece that can happen, but it’s not. I wouldn’t say it’s like the majority is the ilocecal valve, which is the little valve between our colon and our small intestine. And if that valve is not working very well, then you can get back flow from the colon to the small intestine that can lead to an overgrowth. The last thing I would say that actually makes a big impact, it’s actually emerging as 1 of the biggest triggers of SIBO is food poisoning, actually so people who have had a food poisoning episode and they start to develop these IBS type symptoms about six months after that has been recognized as another big reason for why people will develop SIBO.
So those are the real top ones it’s looking at the structure and the function of the GI tract and what are all the different checkpoints in our GI tract that help to keep those microbes in check. And if any of those things go awry, then that’s when we get into trouble.
Lori Esarey: You know, we’ve often heard and I know with our patients when we initiate probiotics in that subgroup of patients with potential SIBO or what we suspect to be SIBO, many of them don’t do very well with probiotics. So how would they be approached? Would a score based probiotic be more appropriate or not? How would you approach them?
Alicia Galvin: I’ll tell you clinically I’ve used score based probiotics in like all my SIBO patients, they’re very well tolerated. There’s actually been some scores that have been studied in SIBO and have shown to be very helpful in SIBO. I find that they do really well with it, I do agree though with you, and you don’t want to just throw any kind of probiotic at somebody because a lot of probiotics will have prebiotics added so that’s not great for people who have SIBO, cause again, we talked about fermentable fibers and wanting to get a lot of different fibers in people and that’s great if you have, if you don’t have SIBO, but if you’ve had SIBO, you’re going to not feel so great, feel very bloated and have a lot of GI issues. And so if these probiotics have a lot of prebiotic fibers added to them like any line or trickery route that can make people feel not well, there’s some strains of probiotics that have been more specifically studied in the research for SIBO. It’s a short list, but I would the spores I have found to be very well taught and that’s what I’ve used clinically for years with patients.
Lori Esarey: What other secrets do you have up your sleeve for SIBO patients? Because they are difficult to treat.
Alicia Galvin: They are. I mean, the biggest thing is making sure that you have them on well, that you’re supporting all of those digestive checkpoints so, and also figuring out what their root causes, what are you struggling with? Have you had a history of food poisoning? Have you had a history of endometriosis? Have you had a history of diabetes or do you currently have diabetes or thyroid hypo function? Or have you had your thyroid evaluated? Because I’ve had people where it’s their thyroid is totally out of whack and it’s missing their entire motility system and their sphincter valve function and all that’s totally black out and that’s really their trigger and their cause. So part of it is Is working with your practitioner and working with them to give them a really good clinical history so that they can be more aware of why the person might have have it in the 1st place, because that’s a really important part. But I’d say, secondly, it’s making sure that you’re really supporting that motility and that migrating motor complex. So, I like to use a lot of natural agents like artichoke and ginger is a natural pro kinetic. We have a product called mega guard, that I really just love because people really notice a difference pretty quickly, some of what we’ve talked about might take a few months to even a year or so to see changes, but with something like mega guard, where it’s working on gastric emptying, and it’s working on small intestinal transit, and it’s working on calming the inflammation, because there’s an ingredient there called gut guard that say it’s an extract from the licorice plant, but it has a very, very high flavonoid content. And it’s really great at helping to just sort of calm overall inflammation, but it also has a little bit of antimicrobial action to it as well, specifically against H. pylori. Which H. pylori is another big reason why people have recurrent SIBO or the really resistant SIBO is they have this H. pylori infection that just hasn’t been addressed yet. That’s suppressing that stomach acid. So making sure that you’re doing something to help with that motility to move things through, and then there’s this whole, there’s a big debate around what do you use to kill to get rid of the SIBO to get rid of the overgrowth and our stance is really don’t go in with just trying to blow everything out of the water at the get go, because natural herbs, natural antimicrobial herbs can have detrimental effects on the microbiome, just like antibiotics can to somewhat of a lesser degree in some cases, but in some cases not and just being mindful of when you bring them in. I mean, I’ve definitely use them. I think there’s absolutely a time and a place to use them and there’s sometimes there’s people who are just really stubborn and you have to go in with bigger guns to try to knock back that overgrowth, but we actually have a product called , which is one of the spores. It’s a, it’s a high dose of one of the spores, the bacillus Septus, HU58, and it secretes its own antimicrobial compounds against bacteria like E. Coli and enterobacter and Klebsiella, which are some of the ones that are most overgrown in SIBO cases. And so that’s what we like to use initially when going through a SIBO regimen to help to try to mitigate that overgrowth and knock back those bacteria and it can be really, really helpful for people and I’ve had people who felt really great on it. And then I’d say working on digestive support making sure they’re on a good broad acting digestive enzyme and score based probiotics, because like I said the scores can really also help with mitigating any of the down trickle effect because if you have SIBO, you probably have large intestinal dysbiosis as well, because that’s just how the GI system works, it works kind of top down, if you have imbalances up above, your gonna have imbalances down below and so those scores can come in and really help to shift and change the gut ecology of that large intestine as well.
Kelly Engelmann: So oftentimes SIBO patients have struggled for a very, very long time. They’ve tried multiple strategies for resolving their symptoms oftentimes, they are told they have just irritable bowel syndrome, and so you mentioned the fibers before we talk about diversity, we talk about getting enough fiber in the diet, but it’s the timing of those things. So we have to resolve for motility first before we can start adding back in that fiber otherwise, it just sits there in ferments in the small intestine, and adds more fuel to the fire of those bacteria, they’re in the wrong place.
Alicia Galvin: Yeah, there’s definitely some dietary strategies that you can use to help to lower that load of overall fermentable fibers, but it’s really intended for very short term and the challenge.
Kelly Engelmann: Yes.
Alicia Galvin: Is to your point of sometimes these people have had SIBO or they’ve been dealing with this for sometimes years and what you don’t want is to have them go on a restricted diet and restrict their fibers for too long.
Kelly Engelmann: Exactly.
Alicia Galvin: There’s different dietary strategies like the low FODMAP diet, I’m sure you guys have used and talked about it’s recommended a lot by GI doctors who to patients who have been diagnosed with IBS and they tell their patient, okay you go on a low FODMAP diet and that’s kind of the end of the conversation and I’ve had patients who have come to me who’ve been on a low FODMAP diet for 2 years. And that’s not good, if that’s not good for maybe it’s managing your symptoms, you’re causing other issues down in the colon with the diversity and the robustness of the microbiome. So there’s that balance between figuring out what kind of dietary strategy works for them versus, not overrestricting. There’s an enzyme that we actually have that helps to kind of serve as a little bit of a bridge for this situation, because it’s an enzyme that is specifically formulated to help to break down some of those 5 maps and, you do 2 capsules, 2, 3 capsules with meals. And it helps for people to kind of keep some of that diversity and that variety into their diet without having all of the negative effects of those symptoms because if you’re able to go in and break apart and kind of help to break down some of those fibers as it’s coming in, and if they’re not able to really be fermented by the bacteria, then you can lower that those symptoms that those people are experiencing. So, fun made is a nice option to help if somebody can’t do any sort of diet modifications or if they’re just, if they’ve been on diet modifications and we’re needing to really try to expand their diet and get more variety into their diet, it’s a nice option to kind of help with that bridge for them as well.
Kelly Engelmann: Awesome.
Lori Esarey: Yeah, this was great. I could probably sit here all afternoon and challenge you with some really fun facts or some questions and also just pick your brain for fun facts about the gut. But I know that in honor of your time and ours, we have to maybe hit the pause button and reconnect at the next time to talk deeper about all of this, but thank you so much for spending the time with us today and talking about a very important topic that is near and dear to our hearts and our practices makes a huge difference when we are able to focus our efforts on the gut microbiome and the health of our patients.
Alicia Galvin: Absolutely. Well, I love talking about this stuff, I could sit and talk with you guys all day. Well I think it’s so fascinating and I think it’s such an area that you can make big, big changes with really minimal interventions by focusing on the gut and gut health and the microbiome, you can really change somebody’s whole health trajectory with pretty simple interventions at a very targeted rate, I think it’s just such a fascinating area.
Lori Esarey: Well, this topic is going to have to be to be continued. What do you think?
Kelly Engelmann: I do agree. I do agree. This has been amazing. We appreciate your time and the richness of the conversation. I can tell this is something you’re extremely passionate and very knowledgeable about. So I can’t wait to get this out to our listeners.
Alicia Galvin: Awesome. Well, thank you guys for having me. I appreciate it. I’d love to come back.
Lori Esarey: Thanks so much for listening to today’s episode. You can find more information about Synergee at Synergy for life. That’s S Y N E R G E E the number for life. com.
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Lori Esarey: The purpose of our Synergy podcast is to educate. It does not constitute medical advice by listening to this podcast. You agree not to use this podcast as medical advice to treat any medical condition in either yourself or others, including, but not limited to patients that you are treating, please consult your own physician for any medical issues you may be having.
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