Richard Jacobs: Hello. This is Richard Jacobs from the future tech and future tech health podcast and I have Dr. Samantha Nazareth. She’s double board-certified in internal medicine and gastroenterology/hepatology. She practices in New York City. Well, she’s a noted researcher, writer, and speaker on nutrition, wellness, and the microbiome. She’s has had research published in the New York Times and she started by media as an authoritative source on a wide range of topics that include eating wellness things at home. She’s been featured on CNN, Washington Post, US news & world report, Women’s Health so that’s excellent. Thank you for coming Samantha. How are you doing?

Dr. Samantha Nazareth: Great. That’s excellent. And thank you for the lovely intro.

Richard Jacobs: Yeah. Once I told the guests that they had been featured on Opera thirty four more times than I had, but I have been never featured in Opera

Dr. Samantha Nazareth: I would love to put that in my bio at some point.

Richard Jacobs: Yeah. So tell me about your work. What attracts you to learn about the microbiome and gastroenterology and all the work that you do?

Dr. Samantha Nazareth: Oh yeah. I guess I’ll start with gastroenterology or as it’s known in some circles, GI, gastro, all of the above. I had a love for the insides of people at a very, very young age. Sounds very creepy, but I, I definitely was the little person always-on, um, you know, using that operation game and even like unschooled trips going to like museums and whatnot. I was in gift shops, buying skeletons that you can create and build and put Oregon’s inside. And also like even eating breakfast on top of the place, placemats with Oregon’s all over the place. So it wasn’t, needless to say, I think nobody in my family was as that surprised when I went into medicine. But even before that, as I did, it was like a summer program in high school and I had a really cool opportunity to even do like anatomy physiology at a medical school level. So I was able to start dissecting on human cadavers at like 15, 16 years of age. And I was always like the first person to say, give me the scalpel. As I want, I do write in. I just, I was never afraid. I was always curious about understanding what was not seen, you know, typically cause that that was like the most interesting thing. It’s like what, what’s happening inside the sickness, enigma of our bodies. And you know, I entered medical school with the thought that I would become a surgeon, which, you know, made a lot of sense given all of those interests that I had. And during medical school. Yeah, right. You know, operation, that’s like real-life operation. And while I was in medical school, my mom, she got diagnosed with colon cancer. So you know, with that, and that was pretty early on in my education. I learned so much about GI just because of the care that she was getting. And I really wanted to be well informed of what was happening. And I realized, Oh, GI also, you know, I could work with my hands, I can see inside and I love the guts. So it was, it was kind of a nice marriage of all of that and it fell into place. And, um, sort of that timeline. And to answer your second question about the microbiome, I really learned about it also when I was doing my GI fellowship in New York City at Columbia. The fellowship program requires all of us to do research and identify a research mentor and I mean there are amazing, amazing people at Columbia. And one of them that I worked with was Dr. Peter Green and he’s very, very well known in the CELIAC disease space. And so he was my research mentor and then we started doing some research on probiotics and feel Yak disease patients. And that led me to really, I had to really learn about probiotics. And that’s really how I think the general public has become interested in the microbiome is because of the entrance of probiotics. And now everybody knows what a probiotic is. Back when I was doing this research, it was like, yeah, it was getting popular, but it wasn’t as mainstream as it is now. Like, I mean I see it everywhere. Like even in food and cosmetics, it was only a supplement back then. Now it’s just completely mainstream.

Richard Jacobs: So what is your research turned to? What are you working on lately?

Dr. Samantha Nazareth: No, I’m more clinical now. I used to do a lot more back then, but now it’s straight. I’m just like, you know, the doctor that you see in the office, seeing patients and doing procedures and clinical care at this point.

Richard Jacobs: Okay. So what’s the focus of your clinical work? Do you see people with gastrointestinal distress? Uh, you know, what kind of issues you commonly getting in clinic then?

Dr. Samantha Nazareth: I see just about everything you could imagine with GI and bread and butter and that usually, I would say like the top things that I see are bloating, gas, constipation. I put that in like one category, a lot of acid reflux or heartburn and then also just bleeding, like anything related to hemorrhoids, bleeding, pain, anything down there, essentially. Those are probably the top three things that I would see on a majority, on the day to day basis.

Richard Jacobs: Yeah. One thing interesting I’ve seen with bloating and you know, gas and all that. Um, you know, a lot of people seem to be prescribed proton pump inhibitors and it seems to be the opposite of what actually works. I had one nutritionist that recommended I take tablets of Hcl, you know, it was literally like not pure hydrochloric acid as soon as you would increase the stomach acid. And he told me that a lot of the Proton pump inhibitors and you know Maalox and things like that, they decrease stomach acid, which makes it even harder to digest things. So it’s going in the wrong way. I noticed like for instance, when I would take it shows habits that it would help much, much more. You know, when I had stomach distress mean obviously changing the Diet would be far better, but it does at the time. It was just one interesting thing that I saw. So I don’t know, but I guess I’m just telling you, but what are some of the things that you’ve run into?

Dr. Samantha Nazareth: But even along with that, because I get this question a lot with specifically acid reflux, is this too much acid, too little acid, and you’re referring to Betaine with pepsin, which is something that you basically are giving acid back in a setting where maybe your symptoms are from, you know, lower acid. And I always caution anybody who’s taking that, you definitely have to be ruled out for ulcers. Like you cannot just throw in, you know, HCl or Betaine with pepsin without knowing, you know, do I have ulcers or not because it’s on the flip side. Yes, Proton pump inhibitors definitely have and then all the studies keep coming out more and more of long-term usage and all the side effects associated with them. But in the setting of a bleeding ulcer, this thing works and it works really fast if someone comes into the hospital and they’re bleeding from an ulcer. This drug has given ivy, and I’ve seen this because I’ve literally have done an endoscopy at the beginning of this course of hospitalization and I’ve seen what the ultra looks like and then I’ve seen it a couple of days after they’ve been giving this IB, you know, pro complement number and it, it heals it, I mean very, very quickly. Not completely I would say, but it does in that it’s again like you have to be very, um, personalized when given any drug or any supplement. It doesn’t, it’s not a blanket recommendation like, hey, if you have this, this equals that. But I’ve seen, especially in bleeding ulcers, that drug, it works. And what I think, what I think has happened over the course of, you know, several years is that you, you know, there’s, there’s a subset of patients that end up in the hospital and then basically after they stay on the Proton pump inhibitor, because you know, they’ve had ulcers, but now we’re understanding with all the research has been now that this is not just a benign drug, even though it is over the counter and people have access to it, but it’s not completely benign that people actually have to come off the drug if it’s not indicated. Or if you know, a certain time period has passed. And that’s definitely, definitely true. Especially given the rise of like c difficile and things that it’s been linked to that, you know, is definitely concerning. So my job is usually to say, okay, ulcers or not because that’s a whole other set of the treatment plan. Then if it’s not, you know, you don’t have stomach ulcers and then we have to explore. Yeah. What is your lifestyle like? And I’m the biggest things are like eating late at night that I’ve seen is a huge thing and um, specific foods that can trigger it. But yes, that is a common thing that I do see.

Richard Jacobs: What are some of the causes, for instance, possible causes of acid reflux, bloating or abdominal pain after eating big? In general what are the possible reasons that you think?

Dr. Samantha Nazareth: Yeah, I, you know, I always try to rule out like the big scary thing. So having an ulcer obviously is not great and a big scary thing. So that’s one thing. Secondly, you know, even infectious things that pop up like h Pylori, even small intestinal bacterial overgrowth, which is not a true pathogen. CBOs is called, um, for small intestinal bacterial overgrowth. It’s really just almost like translocation or movement of the bugs that live in the colon to a different place. And so the small intestine that they’re not supposed to be there, but it kind of falls under that, like bugs are where they shouldn’t be or act up. Those things have to be ruled out as well. And then, you know, all of that is ruled out then. Yeah. Lifestyle factors, like I’m eating late at night, even certain foods that just take a long time to digest. Usually, it’s like fried fatty foods that just hang out in the stomach for a long time. And this I’ve always seen even doing really early morning procedures. When I do an endoscopy, I obviously, you know, we tell people that they have to be without food for eight hours, but in some people, even eight hours, I can tell that they had pizza from going inside yet. Yeah, It’s like and obviously doesn’t look like you know, a slice of pizza inside, but I imagine right, my surprise like Oh I know what’s up you had last night.

Richard Jacobs: What’s if you say that’s from Delmonico’s on 12th Street?

Dr. Samantha Nazareth: Exactly right. That would be completely creepy and the patient may be running away from me immediately, but every time I’ve seen something like that, it’s always something fatty, greasy people like that they ate the night before even despite clearing, you know, having the eight-hour window of not eating.

Richard Jacobs: So why do you think that happens? You know, those fatty, greasy fried foods do that. Why is the stomach emptying so slowly and what’s going on? You know, by a lot cause that?

Dr. Samantha Nazareth: Some people, it’s um, you know, just generally it is harder for not harder, but it is slower for that specific food category to pass through the stomach generally. But then if you add another layer of what makes it even more delayed or what makes the transit, that’s like a fancy way of saying it. The transit time or the movement time of the intestine smaller. Biggest things. I would say one is diabetes, that the sugar is not controlled that heavily, heavily affects transit time or the movements of the stomach and even, you know, further down in the colon. And you can imagine like the sugar diabetics have nerve issues, right? Like if you have tingling in the bottom of your feet, what’s called neuropathy, it could affect your gut. It makes sense because the gut has lots and lots of nerve endings and it’s basically under controlled from these nerve endings to move. So just like sugar, high sugar can affect the nerves on the bottom of the feet, they can definitely affect the nerves up and down the intestinal lining. So there’s that. And then a big one that I see is medication.

Richard Jacobs: Well, quick question. So if you have people observed clinically that um, people with diabetes tend to have in general, slower gastric emptying and slower transit time, the digestive symptoms for any kind of food.

Dr. Samantha Nazareth: Not all diabetics, but there is, yes and then that diagnosis is usually called gastro-paresis. So, and that’s something that is well known within the medical community. Yes.

Richard Jacobs: So maybe what happens is, you know, when food enters the stomach is that you said there’s a lot of nerves there. Maybe there’s signaling going on. Yeah. Their stomach is, I don’t know what’s in it, signaling ahead, uh, to the small intestine and the rest of the digestive tract and saying, you know, we’re not going to send you anything for while we’ve got to eat away at this dog. Yeah. Do you think that that’s going on?

Dr. Samantha Nazareth: The minute that you know the left food is coming. There’s a whole coordinated system of eating from salivation to basically preparing for the entrance of food. So you have that. And then you also have the taste of food. Um, obviously you even know, like if someone’s sugar is low, you give them some candy and that just hits their tongue and that immediately affects their sugar. So even the pace of food, your body is knowing, okay, what’s gonna come down? And it really signals it as basically the macronutrients, which is carbs, fats, and protein. So your body is already aware of what comes down. Now those stomachs ability to stretch is also a signal to the brain. So if you think about it, like the stomach is kind of like the size of a fist sitting, but it does, it allows a stretch from that point, like from that little cyst, you can stretch it like a balloon if you just sent me. You could see like those people that do all those, um, those eating contests, I mean, they can, they can eat a lot because their stomach is allowed to stretch a lot. But there are signals that go from that stretch to your brain for say, okay, stop. This is uncomfortable and painful and even signals going down like I’m still hungry. So there’s this constant communication from the minute that food is even presented or the thoughts that you’re going to eat all the way down to as it enters down. And then even as things are in the stomach, there’s kind of a final sweep to call the MMC, the migrating motor complex. And it’s like, I always think of this as, you know, the Roomba, those little cleaning things that you can set that free in your apartment. Kind of like that. And like it’s like the final sweet like it’s going to go around and like clean up the things that maybe you didn’t see or just get everything down where it should be. It’s like that. It’s a file sleep of the digested, you know the stomach, they move things, sweep them along and in the small intestine. So you could see like all of that is so coordinated with nerves, pathways to the brain. And that is so coordinated in that sense that, you know, and we don’t think how hard it is to eat, but our bodies know how to do all this thing in a process.

Richard Jacobs: What do you think would happen if I ate a hello, a standard meal and then I looked at a piece of pizza and I thought to myself, I’m going to eat that. I am gonna eat that. You think that just by doing that my body may speed up the processing of the existing food in my stomach because the things that there are other foods coming up, I’m going to take a while to digest and take a lot of effort. I mean, what do you think that would do to me? You know, in terms of how fast I digest?

Dr. Samantha Nazareth: I don’t think it would affect it. I’m just thinking like you could override your signals clearly if you’re, you know, few things and your body’s like I’m full, you could obviously override it cause a lot of people to make room for desserts, but I don’t think the body would clear it faster knowing that extra food is coming. I, you know, that’s, that would be really hard to study, but I don’t think that it would do that.

Richard Jacobs: Yeah. You just wonder, because you know, again, you’re, you’re getting visual signals and like, you know, people will salivate before they eat or did they think about food? As you said, it starts a whole chain of reaction. So there’s the gut-brain communication here that’s happening. So I wonder if you eat a meal, you eat dessert first, what that would do to you versus eating the, you know, the proteins and the carbs and all that stuff first. I just wonder with having this in the presence of that, having that in the presence of this or not in the presence of them. I would think all those things would inform how you digest and maybe changing, but that’s just speculation.

Dr. Samantha Nazareth: Yeah, I mean we know this from the absorption of sugar really like you were saying the dessert first like if you do dessert first with nothing in your stomach, the sugar does get absorbed faster than if you have something sitting in your stomach and then you have dessert. But in terms of digestion, there’s really no, like there’s not like a quicker way to actually move things along. I’ll let you know there are medications that could do that, but just from like a mind-brain type trick, there’s really none that can do that to make things move faster as you’re eating. The other thing too is most people are rushing, not really in that mind frame of I’m gonna sit down and eat. That kind of speaks to the sympathetic and the parasympathetic nervous system. And even with that, like the sympathetic is basically the, I gotta do a lot of things. I got to, you know, check my iPhone, I got to do all these like tasks and you read emails and everything that’s sympathetic. Before that, it was like I’m going to be chased by like a tiger out of the cave. And then the parasympathetic is okay its rest and digest time. It’s time to eat. And, and I have to admit to, I mean I’m probably not in a parasympathetic state every time I’m eating just because of, well one, I’m in New York City, so it was really hard to do that. But you understand what I mean in that sense. And that also affects digestion because you’re not, you’re that power center, static sort of mind frame is helpful for digestion and the normal processes of digestion, which is different than sympathetic kind of mind frame, which is not meant to rest and digest. It’s meant for you to like kind of be on adrenaline.

Richard Jacobs: Well, so I mean, here we go. So now we are saying that, uh, your mindset does affect, you know, your uni experience. Have you seen any studies that show, uh, eating with a certain mindset in a relaxed state and the stress stayed? You know, I mean, I’ve experienced this myself. I’m thinking there’s gotta be a correlation. You know, if I’m stressed, I may not want to eat or I may want to eat. If I, you know, eating makes you feel better. Again, I may not want to eat when I’m stressed or if I’m stressed and I eat something, I may get indigestion when I normally wouldn’t. So it definitely does seem like, you know, the condition of your nervous system and your thoughts and, and all that affects, you know, the digestion problem.

Dr. Samantha Nazareth: In that essence. Yes. If you’ve already in then you’re trying to trick your body into eating more. Oh, that’s a little bit harder to do because once you’re kind of in the mode of eating like a little bit difficult, but yeah, before you eat, getting into that mind frame and even while you eat. And that’s sort of something that we’ve kind of straight so far from like eating in a group setting and taking the time, more than a half-hour, even lunches longer than that. Like that. That’s so rare now.

Richard Jacobs: Well what about physically what you’re eating? So what happens if I eat? you know, a slow-digesting, they just need needs. Then you need like a steak for lunch. That’s it. Another no versus a steak with like a big side of vegetables, you know, the vegetable legend has a digest a lot faster and move things through the digestive system faster than meat. So what happens when you have just meat or meat and vegetables? What does the combination of vegetables make the meat move do faster and therefore it’s less digested than otherwise would have been? Have you seen any studies that looked at this?

Dr. Samantha Nazareth: No, the only thing is really the feeling of fullness. Obviously, with the veggies, you’re going to feel fuller a little bit faster than if you just had the meat even though meat is on itself as full. That’s pretty cool. But in terms of movement, it’s really shown, it’s specifically for vegetables because that really highlights fiber then yes, if you have fiber in your diet, then your transit time more so than, kind of the downstairs portion, like the colon, is faster just because it helps move things along. But in terms of like affecting absorption, no, but it will help move things along if you have fiber added.

Richard Jacobs: Well, all right. So why would it help things along if you have fiber added or if I’m going to take a probiotic, should I take it before my meal, after my meal, during my meal? And why would one of those ways you better than the other?

Dr. Samantha Nazareth: So yeah, probiotics. It’s interesting because one, there’s been some studies that show that even the probiotics that you take don’t even stick around. So it’s one of those things of, you know, does it make a difference of when you eat it or when you take the supplements perhaps, you know, and then some people would say, well then you should take it as the last thing before you go to bed because then you’re not really bombarding your probiotic that’s there with food. I always just tell people, just read the label and just follow it because there are so many different kinds out there. And at this point, I don’t know what’s gonna stick around in your gut. There’s the mechanism that probiotics are thoughts work is perhaps in a small subset, they do, you know, stick around and then another they kind of pass-through and interact with the microbiome that currently exists and then exits at, you know, as you flush the toilet. So you know, does it matter then what time of the day with food, without food, I would say just follow what’s labeled on the, on the bottle because it depends on how they’ve manufactured it to be delivered inside of the body And now that there are so many different forms of probiotics, I can’t even just say the pill form. I mean there are powders and there are liquids, there’s everything. So it’s even harder to kind of say that in a broader sense.

Richard Jacobs: Correct. Well, what are some of the big questions that you want to have answered, you know, in your clinical work, but what are some of the frustrations you wished they were an answer to or more insight into?

Dr. Samantha Nazareth: I really would because I know how hard it is to study the microbiome and itself. And this research is really, really new and early. The question I get a lot, and of course I’m thinking about it, is there really will we ever get to the point where we can say what a normal microbiome really is? And also are we really sampling the right part to really get a, like a snapshot of a patient or even in an individual other than microbiome. Because right now it’s basically the last half of the colon because that’s what we pope out and that’s what’s really accessible. But is this the microbiome that’s really the most important or is it more like a deeper one, you know, in the mucus layer or even where, let me close a layer which would require a biopsy. Where? Because in different parts of even the colon, there are different bugs that live in different areas in which area for which disease is really most important. How are we able to follow that over time? Because anything can change that microbiome. Perfect examples, antibiotics. So if you have antibiotics, what was shown before the antibiotic is going to be completely different after. And you know, things like that. I think we have to get to a point where, um, the data from the microbiome can become useful in a way that we can personalize medicine. Especially for me for GI medicine to say, okay, your microbiome is like this. And if we manipulate it in a certain way to affect change, it’s going to be like this and these are the results you’re going to get. I mean that’s, that would be really cool for me because then we’re really moving away from pharmaceuticals and highly, highly personalized in some circles called precision medicine, but very individualized, personalized care based on basically just your bugs, the bugs that have been living with you.

Richard Jacobs: You know, of any research that you’re waiting to hear the results of that shared by them, some things you’re interested in?

Dr. Samantha Nazareth: I love, I really like the whole fecal transplant space and there’s a lot of clinical trials that are being done outside of C difficile. So at this point, the only FDA approved indication for fecal transplant. That’s literally just transferring poop from one person to another is for C difficile. That hasn’t really responded to any antibiotics. But of course, you know, now that microbiome is all over the news, it’s really linked to everything else too outside of the GI tract. I mean, it’s been linked to mental, mental illnesses also cardiovascular disease, metabolic diseases, so much more beyond that, that you have to wonder, well, if the obvious question is if you just transfer a healthy person’s poop into someone who wants to change one of these things, what would happen over the long term? And even beyond that is how do we affect people when they’re firstborn? Because that’s when we know that the microbiome is changing like heavily, heavily, heavily and becomes more stable later on in life. So it’s like two-fold. It’s can we do something if someone is an adult and manipulate that and is fecal transplant the way to go? And if fell, then, you know, we have to wait for the studies from the clinical trials to come out to say that one, this does affect something and it’s safe. I mean those are the biggest things that it’s efficacious and it’s safe. And then also, you know, what population can this be applied to? That’s really, it’s really necessary to get that kind of data as how many people, you know, how many participants were in a study like that. And can this be applied to everyone or is this supposed to be applied to just certain people? And it’s so new math sense, but that’s something that I’m looking forward to, to see the clinical trials that are doing fecal transplants outside of that indication of C difficile.

Richard Jacobs: Hmm. Yeah. No, that would be interesting. I mean, inside there’s a lot to figure out.

Dr. Samantha Nazareth: Yeah. And I think it’s just, it’s a really beautiful story of the microbiome that we have. If you think about it, these both have been on this planet for way longer than human race entered a sort of the existence of earth and how, you know, our species has evolved with these organisms that have been here before. They’re way more adaptable than we are. They change, they cross like they share DNA with each other. It’s quite incredible how crafty the microbes are, but that we don’t, we’re not, it’s not just us that we evolved with them and they’re sort of this entity that now has become Insulite of, oh wait, maybe, maybe we shouldn’t just kill like bugs are all evil and that all of them have to be eradicated but that we have to foster this other, these organisms that we are all hosts to and a good way because, one, it affects our health. And two, it affects even generations beyond that. And everybody around us too, because I mean, we share bugs with each other, especially like can imagine with spouses and partners. So it’s this idea that we’re not, we’re not just a species that a species alone, but we also have evolved with all of these other organisms in a very beautiful way in order to survive. And mate, I mean, that’s really, that’s the goal of the microbes too as survival and propagating the DNA to the next generation.

Richard Jacobs: Very good. So what’s the best way for people to, you know, I guess if they’re local to you, they can come to see you, but how can they find out more? Yeah gastrointestinal problem or if they want to learn more about the, yeah, the microbiome or gut health and your recommendation in general.

Dr. Samantha Nazareth: I, you know, The American gut project is spearheaded by a broad night and some other great researchers like Jack Gilbert too. I even just started there, I became a citizen scientist. I submitted my poop that way and started learning. And I like that it’s led researcher-led and its open source and it’s really kind of forwarding the science of microbiome. So that’s kind of like one thing. It’s like as kind of a regular person, what can I do to forward this research? And then I have a website, it’s drsamnazareth.com that’s where you can find like information on some articles that I’ve written and contact for my practice. But just generally the microbiome space, there’s so much out there, but even contributing to science by the data cause that’s where really what we need is more data and how that fits into the bigger scheme of things. It’s really, really important.

Richard Jacobs: Very good. Well, Sam thanks for coming on the podcast. I appreciate it.

Dr. Samantha Nazareth: Thank you. Thank you for having me.