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I'm not sure where I got this recipe, there are lots of great recipes online, but this one is both delicious and nutritious and turns out great every time! Hemp Hearts Tabbouleh 1/2 cup extra virgin olive oil 1/4 cup lemon juice 1/2 tsp sea salt 2 bunches of parsley - chopped (I sometimes add another bunch) 1 1/3 cup Hemp hearts 3 medium tomatoes - diced 8 green onions, finely diced 1 garlic clove - minced optional: 1/4 cup chopped fresh mint Mix olive oil, lemon juice and sea salt - whisk to combine Then add remaining ingredients, toss to coat and serve. It is best fresh. Based on 6 servings: calories:  293 fat: 32.6 carbs: 8.1 g fiber: 5.2 g protein: 13.1 g

By Karen Miller-Lane, ND, LAc “The challenges of studying nutrition and aging are one of the reasons I’ve become more flexible in my beliefs around diet for optimizing health with age. What is clear from reviewing the current evidence is that most people would benefit from increasing their protein intake with age. While there may be some exceptional circumstances, for many people, higher dietary protein would help maintain skeletal muscle, improve immune function, and reduce frailty – all of which translate to an increase in lifespan and healthspan.” Peter Attia, MD a Stanford/Johns Hopkins/NIH-trained physician focusing on the applied science of longevity and well-being How many of us understand what protein does and why it is important, let alone how our needs change as we age? Protein is one of the macronutrients, along with carbohydrates and fats that we hear alot about when it comes to supporting good health. Based on the research over the past 40 years we now understand that increasing protein and resistance training can contribute to thriving as we age and prevent a condition called sarcopenia. Sarcopenia is the loss of muscle mass and strength as we age; it can increase the risk of falls and fractures as well as contribute to frailty. The focus for this article is the importance of protein. I will leave the importance of resistance training for another article. However, protein and resistance training go hand in hand. But, for now, let’s explore what protein is, what it does, why it’s important, how much we may need, and explore examples of how to get enough protein daily. Proteins are essential for building new tissue and repairing old tissue. There are 20 amino acids that go into making a variety of proteins. Protein is made up of 20 amino acids. All of the 20 amino acids contribute to a wide array of cellular activity such as creating enzymes and hormones. We require approximately 300 grams of new protein per day. Of the 20 amino acids that are important for maintaining healthy muscle tissue and maintaining cellular activity, there are 9 essential ones that we need to get from our diet. Animal protein is considered a complete protein because it contains all of the 20 amino acids that we need. Plant based proteins are considered incomplete because they lack one or more of the essential amino acids. Proteins are much more than we realize. For example, insulin and our liver enzymes are made of proteins. Insulin is composed of 51 amino acids and myosin (a protein for muscle contraction) is made up of thousands of amino acids. Liver enzymes are replaced every hour whereas muscle proteins have a half life of 15 days. Amino acids, such as leucine, are also signaling molecules that directly stimulate muscle protein synthesis - building and maintaining muscle. For every new protein that’s getting made in the body about 6 or 7 amino acids are getting recycled. The body replaces every protein in it about four times per year. While we understand that young bodies have particular nutrition requirements, research is revealing that aging bodies have different nutrition and lifestyle requirements. According to Don Layman, a Professor of Food Science and Human Nutrition at the University of Urbana-Champaign, “aging increases the daily turnover of protein, meaning there is a greater need for protein intake simply to replace the tissue you already have.” For the past 40 years, Layman has investigated the role of dietary protein in muscle protein synthesis. He states, “We now know that protein efficiency goes down as we get older. If you give a 16 year old a certain amount of protein they will have a very good response. A 65 year old may have a 10% response or no response at all. As we get older, we can buffer that response with higher quality proteins and resistance exercise.” “Your overall health is determined on keeping the muscle healthy because it keeps everything else healthy.” Don Layman, Ph.D. When we get older, a higher level of certain amino acids such as leucine is required to stimulate maximum muscle stimulation and growth. Aging reduces the ability to breakdown and synthesize protein which reduces our ability to build muscle mass and strength. This is called anabolic resistance. The nutrition that allows you to easily build muscle in your 20s won’t be sufficient to keep building lean mass in your 50s and 60s. With the study of one of the essential amino acids leucine, Don Layman has found that if you give leucine to an older adult you can actually make the adult look just like a 16 year old in terms of muscle stimulation and growth. What we are learning is that while efficiency of synthesizing protein goes down, the capacity to respond does not. Resistance training and protein are a powerful signal for promoting protein synthesis, countering anabolic resistance, and maintaining muscle with age. The good news is it’s never too late to build muscle. We have the capacity to build and maintain muscle in our 60’s, 70’s and beyond. In order to do this we need to pay close attention to both the quantity and quality of our protein and incorporate consistent resistance training. Current thought in the field is that if you have a dietary protein requirement that’s about twice the minimum RDA of 0.8 gm per kg (2 x 0.8 = 1.6 gm per kg), you can get the 65 year old to respond the same as the 20 year old in terms of muscle protein. ” Don Layman, Ph.D. As we age, we have a greater need for protein simply to support cellular activity and the decreased ability to recycle our own protein. By increasing protein and focusing on high quality protein, we can maintain and build muscle and support the increasing need that comes with aging. The Recommended Daily Allowance (RDA) is a low water mark, it’s the minimum required to prevent disease. This may not reflect what is necessary to support optimal health. The difference as we age between 0.8 gms of protein per kg of body weight and 1.6 gms of protein per kg of body weight is the difference between living and thriving. Using the formula above which reflects a dietary protein requirement that’s about twice the minimum RDA, let’s provide an example of a ballpark range of protein requirement. Using 1.6 gms per kg, a 60 year old, 140 pound woman (140 divided by 2.205 = 63.502 kg x 1.6 (gm per kg) would need approximately 101 grams of protein daily. For a 200 pound male that would be around 145 grams of protein daily. A number of leading authorities in the field are suggesting that these may be on the low end depending on exercise and activity level. Some authorities recommend 2 gms per kg. Another consideration is how we look at the macronutrient protein. When we look at the macronutrients, protein, carbohydrate and fat amounts are often reflected in percentages such as ‘fat should be 20% of calories’. Based on current research, the amount of protein we get in a day should be an absolute number such as 100 gms NOT a % of calories such as ‘protein should reflect 30% of overall calories. Our need for protein is an absolute number and shouldn’t go down even if we are lowering overall calories. So if you are trying to lose weight, especially in our 40’s and beyond we need to be maintaining our absolute number of protein in grams. If I determine, for example, that I need to take in 1800 calories to lose weight and I need 101 grams of protein a day, I need to eat 101 grams of protein a day and work my other macronutrient calories of fat and carbohydrates around it. Consuming the necessary or ‘absolute number’ of protein is important because when people are trying to lose weight they don’t think about what they are losing. We don’t realize that we are losing lean muscle along with fat. So not only do we have an increased tendency to lose lean muscle, we exacerbate this when trying to lose weight. Muscle helps us to burn fat and excess calories and it is important for good metabolic health - how we break down and use energy. Research continues to support the fact that building and maintaining muscle mass is critical for remaining active and healthy as we age. As we age, there is a greater need for protein to just replace the tissue we already have. Also with age there is a blunted response to protein and therefore building muscle. Protein is essential to increasing muscle mass and we shouldn’t short change our consumption of protein when on any weight loss plan. This is also why it is important to understand that we need to get an absolute number of protein based on age and activity, not as a percentage of calories. When we look at protein there are two factors that go into a protein quality score: What’s the composition of those 9 essential amino acids? What’s its bioavailability? (how well do we digest it and absorb it) Not all protein is equal, getting 20 grams of protein in a meal doesn’t mean we are digesting and absorbing 20 grams of protein. Animal proteins contain all the 20 amino acids. They are complete proteins. With animal proteins and most isolated proteins such as whey, even soy protein isolates, the digestion and absorption is pretty close to 100%. Digestion and absorption for animal proteins is usually 95% or higher. Digestion and absorption for plant proteins is approximately 60-70% available because we can’t digest the fiber attached to the protein. Plant proteins are incomplete in that they do not have all of the 9 essential amino acids. If you are eating a plant based diet, the three important essential amino acids to make sure you get enough of are leucine, lysine, and methionine because they will be limiting in adults for protein synthesis - the ability to absorb and utilize the protein. Lysine is always limited in grains, methionine is limited in legumes, and methionine is low in all plant products. Protein synthesis is limited by the availability of the 9 essential amino acids. If our 20 grams of protein is limited by methionine or especially leucine, the body will only make protein until the methionine or leucine runs out. Don Layman explains that if you look at wheat protein on a cereal box and, for example, say it was wheat flour; and the cereal box says there’s 4 gms per serving of protein, there’s actually less than 2 grams that you can actually absorb. This is where quantity matters and if you are eating a plant based diet you should be aiming for 100 to 125 gms of protein per day to ensure an adequate amount of bioavailability. In our 50’s, 60’s and beyond, if you are only getting around 50 grams of protein a day, you may not be getting adequate amounts to support maintaining muscle and building new tissue, repairing old tissue, and the wide array of cellular activity that adequate protein provides. You may be asking how I can navigate and apply this information today? In general, determine how much protein you need based on the recommendation of 1.6 grams per kg especially if you are 50 years or older and consider 2 gms per kg if you are an athlete or quite active. Remember, protein quantity and quality become more significant as we age. I always recommend as close to a whole foods diet as you are able. This means the food you are eating and preparing is as close to how it came into the world - for example, an apple vs. an apple pie. Examples of meeting protein needs in a day: Breakfast options: 2 egg white/2 egg (4 egg) scramble (20 gms protein) - adding 1 oz of cheese increases this to 25 to 27 grams of protein. ¾ cup greek yogurt plain (add your own sweetener) with blueberries (17 gms protein) High Protein Overnight oats (approx. 38 gms protein) see recipe below Lunch options: Salmon salad with 1 can of salmon on a bed of greens and veggies (38-40 gms protein) or in a whole grain wrap. Bean and Vegetable Enchilada Casserole (15 gms of protein) see recipe below Mid-Morning or Mid-afternoon snack options: Whey protein isolate or pea protein shake (20 to 25 grams of protein) 1 cup of edamame (17 grams of protein) Dinner options: 4-6 oz of chicken or turkey breast - used in a veggie stir fry (4 oz = 35 gms; 5 Oz = 44 gms; 6 oz = 52 gms) One pot lentils and Quinoa (19 gms protein) see recipe below Examples of protein servings: 4 oz cooked chicken = 35 grams of protein 4 oz cooked turkey breast = 34 grams of protein ¼ pound or 4 oz of hamburger patty = 28 grams of protein 3 oz of shrimp = 18 grams of protein 3 oz of salmon = 17 grams of protein 1 hard boiled egg = 6 grams of protein 1 ½ cups of cooked tofu = 30 grams of protein ½ cup cooked black, pinto, lentils = 7 to 10 grams of protein ½ cup cooked split peas = 8 grams of protein ½ cup quinoa = 4 grams of protein 3.5 oz of wild rice = 4 grams of protein The take home message is that our protein needs increase as we age. As we age, protein and resistance training supports getting stronger, staying active, having a healthy immune system, and improving our quality of life. What do you want to be doing in your 60’s, 70’s and beyond? Whatever it is, ensuring you get enough quality protein is essential to making that happen. Dietary protein: amount needed, ideal timing, quality, and more | Don Layman, Ph.D. [peterattiamd.com podcast #224] Recipes High Protein Overnight Oats: ½ cup milk of your choice (may want to add a bit more if too stiff) ½ cup greek yogurt, 2% Fage plain yogurt, or vegan yogurt ½ cup old fashioned oats 1 tsp maple syrup or other sweetener of your choice (optional) ½ tablespoon chia seeds 1 scoop protein powder - ex. Whey protein isolate or pea protein powder Berries and/or chopped nuts to top Mix all the ingredients except berries in a jar or sealable bowl the night before. Store in the fridge. Add berries and/or nuts before you eat. One Pot Creamy Spinach Lentils with Quinoa Since this one-pot meal has loads of dried herbs, the lentils soaked it all up and brought everything together. Super simple and super delicious! author: Alyssa https://www.simplyquinoa.com/one-pot-lentils-quinoa-with-spinach/ INGREDIENTS 2 tablespoons olive oil 1 large shallot chopped 1 cup chopped carrots 2 cups chopped mushrooms 2 - 3 garlic cloves minced 1/2 teaspoon red pepper flakes 1 teaspoon dried oregano 1/2 teaspoon dried thyme 1/2 teaspoon dried rosemary 2 bay leaves 1 cup green/brown lentils 2 cups vegetable broth 2 1/2 cups water divided 1 teaspoon miso paste optional* 1/2 cup red quinoa or variety of choice, uncooked 4 - 5 cups fresh spinach Salt + pepper to taste Olive oil fresh herbs and grated cashews* to garnish I INSTRUCTIONS Heat the oil over medium heat in a large Dutch oven or cast iron pot. Add shallots and carrots and cook until the carrots have started to soften, about 3 - 4 minutes. Add mushrooms and continue to cook until mushrooms are juicy and tender, another 5 minutes. Add garlic, red pepper flakes and herbs. Stir around until the whole mixture becomes fragrant, about 1 minute. Pour in lentils, broth, 2 cups of water and miso (if using). Bring the mixture to a boil, cover and reduce to simmer for 15 minutes. Remove the lid and add quinoa and remaining water. Stir to combine. Bring the mixture back to a boil, recover and reduce to simmer for another 15 minutes. Remove pot from the heat, uncover and add spinach, stirring gently to combine. Taste (carefully!) and season with salt and pepper. Serve with a drizzle of olive oil, fresh herbs and grated cashews. The miso adds a great umami flavor, but you can just use sea salt if you don't have miso. You can also totally use parmesan if you want! Makes 4 servings. NUTRITION Calories: 374kcal | Carbohydrates: 58g | Protein: 19g | Fat: 13g | Saturated Fat: 1g | Sodium: 457mg | Potassium: 1254mg | Fiber: 21g | Sugar: 6g | Vitamin A: 9205IU | Vitamin C: 15.5mg | Calcium: 100mg | Iron: 6.6mg Bean and Vegetable Enchilada Casserole A delicious vegetarian dish with Mexican flair. INGREDIENTS • 1 medium bell pepper, chopped • 1 large onion, chopped • 2 cloves garlic, minced • 1 Tbsp. olive or avocado oil • 1 can (14 oz.) black beans, drained and rinsed • 1 can (14 oz.) pinto beans, drained and rinsed • 1 package (16 oz.) frozen corn, thawed • 1 can (28 oz.) pureed or crushed tomatoes • 1 Tbsp. chili powder • 1/2 tsp. ground cumin • Dash of hot sauce, to taste • Salt and freshly ground pepper, to taste • 12 corn tortillas • 1 cup grated reduced-fat Jack cheese DIRECTIONS Preheat the oven to 350 degrees. In a large saucepan, heat oil over medium heat and saute bell pepper, onion and garlic for five minutes. Add beans, corn, tomatoes and seasonings, including salt and pepper, if desired. Reduce heat to low and simmer for 15 minutes. Assemble the casserole in a 9 x 13-inch baking dish. Cover bottom with one third of bean mixture. Layer six tortillas on top of beans. Repeat once more, ending with bean mixture on top. Sprinkle cheese on top and bake until hot and bubbly, about 30-40 minutes. Makes 8 servings. Per serving: 320 calories, 7 g total fat (2 g saturated fat), 53 g carbohydrates, 15 g protein, 11 g dietary fiber, 677 mg sodium. Recipe from the American Institute for Cancer Research.

November 7, 2023 There are three attached articles that I wanted to share to add perspective to how we dance with health and our health care system - today specifically bone health. The first two articles are from Teppo Jarvinen, a professor of Orthopaedics and Traumatology at the University of Helsinki and Helsinki University Hospital. The third is a study on how exercise effectively prevents falls and fractures. 1. Is boosting bone mass through pharmacotherapy really the best way to prevent fractures in the elderly? 2. Labelling people as 'High Risk': A tyranny of eminence 3. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

This is a beautiful passage from a generative book by James Hollis, PhD who is 83 years old and is a practicing Jungian analyst and author of numerous books. This passage is from his most recent book A Life of Meaning - Relocating Your Center Of Spiritual Gravity, Sounds True, pages 107-109, 2023. In the seventeenth century, Blaise Pascal, in his book Pensees (Thoughts), said even the king, king though he be, if he thinks of self will grow miserable and frightened. So the court has invented the Jester to distract the king and the court from reflecting on things that matter. Pascal labeled this distraction "divertissement," what we now call "diversion." Think about that in the light of contemporary culture with its twenty-four-hour seven-days-a-week wired-in experience of distraction. So much greater must be our estrangement from our own souls. So much greater must be our fear of that still, quiet voice that speaks within each of us. The ancients know this voice, and they talked about it. They chronicled it. They wrote scripture and mythologies about it. And then we forgot what they learned. The question is, can we return to that? This whole process of stepping into our depths can be intimidating. It can feel isolating, and still, we have to remember, this is our journey. This risk is what brings depth and dignity to our lives. Let's turn once again to a paragraph from Rainer Maria Rilke's fine Letters to a Young Poet. When the young poet is expressing his apprehensions about the difficulties of life and whether he'll be up to it or not, Rilke writes to him, "You must not be frightened if a sadness rises up before you larger than you've ever seen, if a restiveness like light and cloud shadows pass over your hand and over all you do, you must think that something is happening with you. That life has not forgotten you, that it holds you in its hand. It will not let you fall. Why do you want to shut out of your life any uneasiness? Any miseries or any depressions? For, after all, you do not know what work these conditions are doing for you." It's a lovely paragraph because it's a reminder that there's something in us, a life force that supports us, that holds us in its hand... ...Our own psyche keeps showing up, keeps knocking on the door, keeps summoning us back to the high calling of the journey. This is important because the soul also provides each of us the tools with which to navigate and constantly reminds us that we're charged from the beginning with accountability to what may be seeking its expression through us into the world. Our psyche is constantly summoning us, calling us back to the higher calling of that journey. Moreover, it gives us the tools with which to navigate, to find our way---the internal compass. It reminds us from time to time that we are charged from the beginning of the journey to its end with accountability to what is seeking its expression through us into the world, asking us only that we manage to be as courageous as possible, to show up as best we can, and to live that journey with as much integrity as we can muster.

What are the ten most important physical tasks you will want to be able to do for the rest of your life? Dr. Peter Attia, MD calls this the Centenarian decathlon. Here is a list of examples of physical tasks – what might you include? 1. Hike 1.5 miles on a hilly trail. 2. Get up off the floor under your own power, using a maximum of one arm for support. 3. Pick up a young child from the floor. 4. Carry two five-pound bags of groceries for five blocks. 5. Lift a twenty-pound suitcase into the overhead compartment of a plane. 6. Balance on one leg for thirty seconds, eyes open. (Bonus points: eyes closed, fifteen seconds.) 7. Have sex. 8. Climb four flights of stairs in three minutes. 9. Open a jar. 10. Do thirty consecutive jump-rope skips. “Exercise has the greatest power to determine how you will live out the rest of your life. From lengthening our lives by years, delaying the onset of chronic disease across the board, and both improving and extending our healthspan. Did you know that one of our most powerful tools for preventing cognitive decline is exercise? This is nothing new and there is more and more evidence supporting how essential exercise and movement is to our health.”[i] Below I provide some examples from different YouTube channels that show you how you can begin to move more, improve mobility, and build strength. I also highly recommend working with a physical therapist and /or trained fitness specialist to develop exercises and programs to meet your specific needs over time. The key is to begin. Small, simple, gentle movements, built with consistency over time into increased mobility, stability, and strength. Please remember that before you embark on any exercise or training program, especially if you have specific health concerns or issues, first talk with and get evaluated by your doctor. CARS (controlled articular rotations) part of a mobility program - Full explanation 10 min full mobility flow 1 of 5 videos explaining how to create a strength training regimen for beginners or even seasoned practitioners [i] Peter Attia, Outlive: The Science and Art of Longevity.

And once the storm is over you won’t remember how you made it through, how you managed to survive. You won’t even be sure, in fact, whether the storm is really over. But one thing is certain. When you come out of the storm you won’t be the same person who walked in. That’s what this storm’s all about. Haruki Murakami

Our understanding of health is a dynamic expression of pillars such as sleep, nutrition, movement, light, relationship, and the sacred as it dances with the cycles of a day, week, year, and life. Imagine health as an experience of movements over the phases of a life that can support and inform how we inhabit our bodies, ourselves, and our world. Please recognize that when I say there isn’t a problem in this video I am referring to a space where we can include a dynamic understanding of health. This never excludes that when there are health concerns, questions, or issues they are addressed promptly with your physician.

Karen Miller-Lane, ND, L.Ac Join me as we explore in more depth how the physiological sigh can support relaxation and reduce stress. Brief structured respiration practices enhance mood and reduce physiological arousal Balban, Melis Yilmaz et al. Cell Reports Medicine, Volume 4, Issue 1, 100895 https://doi.org/10.1016/j.xcrm.2022.100895

By Karen Miller-Lane, ND, L.Ac In Part One, I provided an overview of small intestinal bacterial overgrowth or SIBO. An important consideration to keep in mind is that SIBO may be an underdiagnosed cause of irritable bowel syndrome (IBS). Then, in Part Two, I reviewed the pathophysiology of SIBO in which the overgrowth of microorganisms in the small intestine can lead to GI symptoms such as bloating, gas, nausea, heartburn, stomach discomfort, diarrhea, and or constipation. Recall that factors such as stress or a GI infection, or when mechanisms that maintain gut health such as gastric acid, and digestive enzymes are impaired, they contribute to microbial overgrowth in the small intestine. These conditions and pre-existing conditions such as hypothyroid or celiac disease can lead to damage and inflammation of the gut mucosal barrier which then sets the stage for additional systemic conditions. [1] Small intestinal bacterial overgrowth: the chicken or the egg? In Part Three, we turn our attention to the consequences of a disrupted small bowel ecology that may affect other systems in the body. For example, when there is low stomach acid or a decrease in digestive enzymes, our natural GI protective mechanisms are compromised. This leads to dysbiosis, a state of microbial imbalance. In addition, changes in gut motility (the muscle contractions that mix and move food along the GI system), mucosal inflammation, decreased absorption of vitamins and minerals and fat-soluble vitamins (such as B12, iron, zinc, Vitamin D, A, and E) and increased intestinal permeability, all affect small bowel ecology. These factors can then set the stage for issues in other systems such as the skin, liver, and vascular systems. Many human and animal studies suggest that the intestinal microbiome’s influence extends beyond the gut and in fact contributes to the function, and dysfunction, of distant organ systems.[2] We discussed in Part Two that bacterial overgrowth in SIBO may be implicated in inflammation, intestinal permeability, and food sensitivities due to changes in the mucosal lining of the small intestine. In cases of disturbed intestinal barriers, intestinal bacteria as well as the metabolites of these microorganisms have been shown to accumulate in the skin and disrupt the balance of the skin.[3] This state of microbial imbalance may be implicated in acne vulgaris, atopic dermatitis or eczema, and psoriasis. Symptoms of SIBO have also been present with a variety of liver diseases perhaps due to intestinal permeability and inflammation. In liver disease there can also be increased intestinal permeability which occurs when the gut barrier is compromised and there is a translocation of bacteria, endotoxin, a toxin present inside a bacterial cell, and other inflammatory agents.[4] The bacterial translocation and inflammation involved in SIBO may contribute to conditions such as non-alcoholic fatty liver disease or NAFLD. Further investigation is needed before we can make any final conclusions. SIBO is also being investigated as a link to subclinical atherosclerosis. There is a protein (matrix Gla) involved in maintaining vascular health. Vitamin K2 is a prerequisite for matrix Gla’s activation and function. Vitamin K is present in two main forms (i) phylloquinone or vitamin K1 and (ii) menaquinone (MK) or vitamin K2. Vitamin K2 is involved in strengthening bone and, via the production of matrix Gla protein, preventing vascular calcification by repairing smooth muscle and endothelium. This means vitamin K2 is involved in preventing plaque formation in our arteries that leads to cardiovascular disease. Early studies show vitamin K2 may also enhance insulin sensitivity thereby supporting healthy blood sugar regulation. Intestinal bacteria are the main source of vitamin K2 in humans and bacterial dysbiosis is associated with altered K2 metabolism and impairing the protein (matrix Gla) required for maintaining vascular health. [5] Humans need gut bacteria in order to fulfill their vitamin K requirements because the dietary intake of vitamin K is often insufficient. SIBO, a condition characterized by gut bacteria imbalance, is also associated with impaired vitamin K metabolism. Therefore, SIBO and/or low vitamin K may hypothetically put someone at increased risk of atherosclerotic disease.[6] We still have a long way to go to understanding what constitutes the normal bacterial population of our gut – our gut microbiome - along with the challenges and limitations of testing. Our concept of SIBO will most likely change over time with further research and understanding. This is a normal part of scientific investigation. It means that, at times, it is appropriate to twist and pivot from what we think we know to be “true” to what is emerging as new insights and interconnections. Our challenge is to make these pivots consciously rather than reactively. At the moment, I believe SIBO is a useful and valid concept for understanding some of the mechanisms behind the varied symptoms of a form of irritable bowel disease. A diagnosis is always a thing in motion. A diagnosis is often a compilation of symptoms as we learn to understand what lies betwixt and between what we see, how we see, what we measure, and how we interpret. The diagnosis continues to be in flux, along with the tools we use and the way we come to know. This shared learning process between humans and our environment is all in service of a deeper integration of our understanding of how bodies and selves interact in the world. So, where does this leave us in the treatment of SIBO? The diagram below reminds us of where we began – exploring the factors that protect or go awry in the development of SIBO. [7] Treatments for SIBO have predominantly included antibiotic therapy. The above diagram points to the many considerations involved when treating SIBO. Some of the factors that I investigate and consider when treating SIBO include: proper digestion, healthy gut motility and healthy gut integrity. Some of the many questions that I ask include: · Is there an infection that needs to be treated? · Is there a pre-existing or underlying condition that is contributing to the disordered physiological processes? · What are the stressors that can be modulated? · Is there a gut imbalance or a predominance of certain gut bacteria that may be generating symptoms such as pronounced gas? · What foods aggravate the condition or is gut integrity the cause of food sensitivities? If so, could we experiment with changes in diet? · How do we calm an inappropriate immune response and inflammation? Are there nutrients that are being compromised and need to be replaced? · Are antibiotics and which antibiotics may be most effective? · Are there herbs or other nutrients that can soothe, and heal the gut, or reduce the bacterial imbalance? These questions and considerations are just some of what is involved in exploring SIBO in relationship with your doctor. The questions are built on a commitment to be curious and to pull back the lens sufficiently to be able to explore the intersection of our bodies, ourselves and our environment that manifest as our health. This process provides a dynamic, ever evolving understanding of how to listen, test, experiment, and treat conditions that are complex and that we are still trying to understand. There are some conditions and treatments that are more straightforward than others. As you can see, with SIBO, there are numerous moving parts as we continue to research and understand all of the factors and physiology involved. This again is why you are in relationship with your doctor to determine how to navigate this together with the best information and understanding possible in the moment. For example, there is research into certain herbs such as the Quebracho Colorado from Argentina. It is from the bark of a tree called the axe breaker and it is used to deal with fungus and the organism archaebacter which produces methane in SIBO. Peppermint leaf may be more appropriate than the oil due to the polyphenol content. M. balsameas a specific type of peppermint may be more useful in calming the stomach and small intestine than other forms of peppermint. There may be certain probiotics that may secrete a range of natural antibiotics that target common pathogenic organisms in SIBO such as Bacillus subtilis HU58 and herbs such as licorice flavonoids that protect gastric mucosa and balance H. Pylori levels. One of the unique challenges we face today is we are inundated with information that is limited and that does not include the full context. How we navigate what ails us is a dynamic process. A dance. Research is ever changing. SIBO is not just one thing - how it is expressed and treated is the art of medicine. Our symptoms may be complex and point in seemingly divergent directions. This is why the relationship between doctor and patient must not be merely transactional, but, rather, relational and grounded in a shared commitment to listen, learn, and explore what health means. [1] Menees S, Chey W. The gut microbiome and irritable bowel syndrome. F1000Res. 2018 Jul 9;7:F1000 Faculty Rev-1029. doi: 10.12688/f1000research.14592.1. PMID: 30026921; PMCID: PMC6039952. [2] Salem I, Ramser A, Isham N, Ghannoum MA. The Gut Microbiome as a Major Regulator of the Gut-Skin Axis. Front Microbiol. 2018 Jul 10;9:1459. doi: 10.3389/fmicb.2018.01459. PMID: 30042740; PMCID: PMC6048199. [3]Ibid. [4] Quigley EM. Gut bacteria in health and disease. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):560-9. PMID: 24729765; PMCID: PMC3983973. [5] Rakel, D. Integrative Medicine. Elsevier Inc, 4th Edition, Chapter 33, 2018. [6] Ponziani FR, Pompili M, Di Stasio E, Zocco MA, Gasbarrini A, Flore R. Subclinical atherosclerosis is linked to small intestinal bacterial overgrowth via vitamin K2-dependent mechanisms. World J Gastroenterol. 2017 Feb 21;23(7):1241-1249. doi: 10.3748/wjg.v23.i7.1241. PMID: 28275304; PMCID: PMC5323449. [7] Bushyhead D, Quigley EMM. Small Intestinal Bacterial Overgrowth-Pathophysiology and Its Implications for Definition and Management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002. Epub 2022 Apr 7. PMID: 35398346.

You cannot enter into any world for which you do not know the language. --LUDWIG WITTGENSTEIN Language entraps us within a view like two mirrors facing each other, each reflecting the other’s image. It provides the entire context of our worldview. We cannot see anything but what the word proclaims because we are looking through the word to see the world. Only by understanding how the word limits perspective will we become quiet enough to listen beyond the word’s definition. When we see the limitation of language, we are already moving beyond it. Rodney Smith, Stepping Out of Self-Deception The Buddha’s Liberating Teaching of No-Self, Shamabala Boston & London, 2011.

Karen Miller-Lane, ND, L.Ac My intent in providing these summaries is to strike a balance between what can be the overwhelming technicality of a research article in a professional medical journal and the oversimplification of important, albeit complex topics, in mainstream news sources. To be clear, there is technical information in these summaries because I believe that when we are able to access meaningful, scientific information, we are better able to make informed health decisions. However, hopefully, you will find these summaries clear enough to be meaningful and helpful. I look forward to having further conversations. As we discussed in Part One, SIBO is a common cause of irritable bowel syndrome or IBS. Symptoms of SIBO often include bloating, abdominal gas, flatulence, belching, heartburn, abdominal pain, constipation, diarrhea, or a mixture of the two. That said, there is often a varied presentation of SIBO. In other words, SIBO may look different depending on the individual's past medical history, underlying conditions, and present health concerns. In this article, we will look at the pathophysiology of SIBO which may shed light on its varied presentation and provide insight into how to approach its treatment. In SIBO, bacteria grow in our small intestine due to an infection, antibiotics, or stress for example. The small intestine should be relatively sterile, whereas the large intestine has a dense and varied microbiome. Along with stressors such as an infection or antibiotics, motility disorders account for a high percentage of SIBO cases. Motility is a term to describe the muscle contractions that mix and move food along the GI system. We have a migrating motor complex (MMC) which acts as a housekeeper in the gut. The MMC creates movements that clear the intestines at regular cycles between meals. It is also responsible for clearing bacteria from the small intestine to the large intestine and inhibiting bacteria from the large intestine entering the small intestine. Anything that impairs MMC function can be a risk factor for SIBO. The MMC is triggered by the fasting state, so MMC can be impaired if you aren’t allowing enough time (three to four hours) between meals. In a vicious cycle, the overgrowth of bacteria in SIBO can also exacerbate impairment of MMC function. Other risk factors for SIBO include decreased stomach acid, decreased digestive enzymes, and ileocecal valve dysfunction (IVD)--a condition that can occur when the valve that separates the small and large intestine ceases to function correctly. What follows describes a story in which factors affecting digestion, absorption, and the movements within the GI system cause imbalances and dysfunctions that create a landscape hospitable for SIBO. Stomach acid eliminates most of the bacteria that enters the body in our food. Digestive enzymes support efficient digestion of food thereby leaving less substrate for bacteria to ferment and the digestive enzymes also play a role in eliminating bacteria not meant for the small intestine. Bile acids break down fatty acids and are necessary in the absorption of fat-soluble vitamins. As detergents, they can alter bacterial membranes, reducing numbers. The ileocecal valve is a sphincter muscle located at the junction of where our small intestine and large intestine meet. If there is a dysfunction in the valve, then materials from the large intestine can back up into the small intestine. A healthy functioning GI system ensures appropriate digestion, absorption, and maintenance of a healthy gut ecology. Also, pre-existing conditions such as hypothyroid, diabetes, celiac disease, fibromyalgia, or lactose intolerance can lead to bacteria populating the small intestine and cause fermentation. The by-products of this fermentation, particularly of carbohydrates, are methane, hydrogen, or hydrogen sulfide, which account for the three types of SIBO. The hydrogen dominant type often causes diarrhea. The methane dominant often causes constipation. And the hydrogen sulfide results in diarrhea or constipation. Besides bacteria, the human microbiome consists of organisms called Archaea which are methanogens, meaning that the microbes belonging to this genus or category of organisms in the gut produce methane. The most prevalent species from this genus is Methanobrevibacter smithii. M. smithii is a methanogen, an organism that soaks up hydrogen and produces methane. Modern day antibiotics will not work on this organism. Methanobrevibacter smithii resides in the large intestine but is found in the small intestine of individuals with SIBO. Methane is relevant, not only because it generates significant gas, but because the methane works as a local paralytic. Methane slows everything down creating gut motility issues. This creates and exacerbates bacterial overgrowth. It’s worth pausing and recognizing that the space within our esophagus, stomach, small and large intestine is, in fact, the outside world. The mucosal barrier of our digestive system determines what enters our body, similar to our lungs and skin. Literally the space in the tube that extends from the mouth to the anus is the outside world. The mucosal barrier that lines our gastrointestinal tract is literally that, a barrier to the outside world. The reason I am pointing this out is because we often presume that everything that is inside us is our own inner world. Yet, our gut, is the space where the inside and outside world dance. The mucosal barrier of the GI system is there to determine which partners we are meant to dance with. Everything we eat and drink is of the “outside” world, yet, what we need to recognize is that the distinction between outside and inside is far more porous than we generally realize. Our GI system is both inside and outside–this relationship is central to our health. The increased bacterial overgrowth leads to inflammation within the lumen or cavity of the intestines. Within the lumen - or central cavity of this tube - are dendritic cells that reach up through the intestinal wall and sample the outside world – they are called B cells. B cells determine friend or foe (our dance partner). When bacterial overgrowth occurs the B cells trigger a larger immune response now comprising T cells, and memory cells. This initiates a further immune response. With SIBO there is an inappropriate immune response. This inappropriate immune response can generate chronic inflammation, intestinal permeability, and food sensitivities. The imbalance of microorganisms and bacteria in the small intestine generates an inappropriate immune response which causes changes to the mucosal lining of the small intestine. Here we find ourselves, once again, at the junction of where our body meets the outside world. When there are imbalances in the ecology of the outside world it affects the ecology of our internal world. This imbalance shows up as inflammation and malabsorption. As a result, inflammatory changes to the lamina propria and villous atrophy often occur in SIBO. The lamina propria is a type of connective tissue found under the thin layer of tissues covering the mucous membrane of the small intestine. Villi are the microscopic, finger-like tentacles that line the wall of your small intestine that absorb nutrients. Chronic inflammation, changes in bowel motility, and overgrowth cause the villi to atrophy and erode, leaving a virtually flat surface of the small intestine which causes malabsorption. This cycle can also cause malnutrition in other ways. The bacteria alter bile, which creates fat malabsorption (steatorrhea, fat-soluble vitamin deficiency). Along with a deficiency of fat-soluble vitamins there are also decreased levels of nutrients such as vitamin B12 and iron. The overgrowth of bacteria affects enzymes that are involved in digestion leading to carbohydrate malabsorption, fermentation, and gas. Thus, SIBO is involved in a cycle that provokes an inappropriate immune response within the mucosal lining of the intestines generating inflammation which can then initiate additional systemic symptoms which we will discuss in Part Three. Below is a diagram, by Dr. Allison Siebecker an advocate and educator in the understanding and treatment of SIBO. It provides an overview of the pathophysiology of SIBO that I have discussed above. The diagram provides a quick snapshot into the symptoms and conditions that can arise due to changes in the gut caused by SIBO. In the third and final article in this series, we will explore the effects that SIBO can have on other systems in the body and as a result other conditions that may be associated with SIBO such as rosacea or nonalcoholic fatty liver disease (NAFLD). In conclusion, we will look at approaches to addressing SIBO. For Further Reading: Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020 Feb;115(2):165-178. doi: 10.14309/ajg.0000000000000501. PMID: 32023228. Quigley EM. Gut bacteria in health and disease. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):560-9. PMID: 24729765; PMCID: PMC3983973. Takakura W, Pimentel M. Frontiers | Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update (frontiersin.org); 2020 July. Volume 11. https://doi.org/10.3389/fpsyt.2020.00664

I’m here to invite you on a journey, an exploration into the meaning and experience of open hearted health. Let's explore together! Karen Miller-Lane, ND, L.Ac.