Beyond the Microbiome: 3 Levels of Digestive Health
An extraordinary gastroenterologist has a new approach to gut health.
Posted Mar 03, 2020
We can think of our digestive health on three levels: the microbiome on a microscopic level inside our intestines, macrobiome that includes our whole brain-body, and megabiome that includes the context of the larger picture in which we are living with others. Think of the megabiome as our collective gut, so to speak.
To help us understand the dynamic relationship among these three levels of the gut, I spoke with Dr. Latifat Alli-Akintade, a gastroenterologist for Kaiser Permanente with whom I collaborated several years ago to start a Crohn’s and Colitis program along with Registered Dietician, Monica Randel. Dr. Alli-Akintade has treated thousands of patients for digestive diseases and sees many people with irritable bowel syndrome every single, busy, workday.
“The micro-level includes those bacteria inside the small and large intestines and the millions upon millions of nerves in GI (gastrointestinal) tract,” she says. “The communication among these nerves are as important as the nerves in our brain.”
What is the #1 thing we can do to affect our guts on this micro-level?
“The way we eat is the most important way to impact our guts on the micro-level. What we feed these bacteria determines our health to a large degree.”
On this level, we have a moderate amount of control regarding how we grow the microbiomes we have been given. We understand some of it, not all of it, but we know it is related to health in many ways, including dementia.
What are the broad strokes as far as eating for gut health?
“Gut flora are changed by processed foods, and not for the better. Eat less processed foods and more fiber, overall a plant-focused diet,” Dr. Alli-Akintade says without hesitation. “Eat food that is good for you. It won’t be the same around the world, but mostly plants.”
She goes on, “Take the long view of food, not searching for this food causing that symptom.” Note the obvious upsetting foods, but stop looking for cause-effect with everything you eat. “Do the hard thing, eat well now to save yourself from a life of heartache and medications.”
She gave several examples of successful patients. One woman with a family line of severe obesity, now presenting with a fatty liver and cirrhosis. “Our family genetic history is one thing, but our family behavior history is even more powerful (referring to epigenetics, changes in gene expression rather than the genetic code itself). Our genes are affected by our behavior for generations.”
Her patient was determined to break the family curse of obesity, lost 30lbs herself and each child lost 50lbs. “This inspires me. I told my patient that you are changing your family for generations and their life expectancy. It is a gift for your family.” Adding a reality check, “I told her she may have a setback and gain some weight back. Then you cry about it and get back in there. Fight for your life and your family’s life.”
Beyond diet, she says reducing over-use of antibiotics (for viruses, not bacterial infections when it is needed) improves the health of the microbiome. “You might think that antibiotics help the virus you have, but you forget that time passes and that is why you feel better.”
The macro-level or macrobiome is our entire brain-body where Dr. Alli-Akintade says we have the most control – over our habits and choices: how and when we sleep, eat, move, practice intentional relaxation, breathe, and slow down for self-care. “And you must sleep, close to seven hours is best.”
As a physician, wife, sister, and mother of three young children, I am wondering how she does this. “Get off my phone, no TV in the bedroom, take a shower, lower the lights, white noise, soft music, breathe in and out enough you will fall asleep.” Later she added, “I still my mind and guard my heart,” she says referring to the megabiome, or social level of health. “Trying to fix the world is overwhelming and burnout is real. I guard my brain, filter what and how much I take in in one day.”
I asked her for an example. “Issues of poverty overwhelm me, hunger overwhelms me. It can cripple me. I have to stop myself, create a door that limits the flow of information going in. Our family feeds the homeless and directs funds to support these causes, but moment to moment, I keep my mind clear about what I can do.”
Dr. Alli-Akintade integrates this mega-level into her medical practice on a regular basis. “Forty percent of GI symptoms are related to 3 areas listed above. I cannot change this for others, but being present and having empathy is key. A fix is not always necessary, but caring matters.”
“I also ask patients what gives you joy? Dream, let your heart speak without fear of logistics. Pray, swim, whatever it is, and create a group around it.” If you see Dr. Alli-Akintade, an example of a treatment plan may include these three things in this specific order:
- Find your mosque, church, temple, synagogue, or holy place and go there regularly. If you do something regularly at home, take it outside. Join a group.
- Laugh more.
- Get a colonoscopy, if recommended. “I will do that colonoscopy to rule things out, but honestly this may be the least important as far as getting better long-term for many gut symptoms.”
She could just simply talk to the patient about #3 and call it a day, “but I would doing a disservice if I didn’t tell her #1 or #2. Try it for three months and see what happens.”
Another thing, she believes that increased maternity and paternity leave would benefit our collective guts and collective health on all levels. “We push for unwell and then wonder why we aren’t well,” then added, “Netflix, Facebook, and Google have increased maternity and paternity leave time,” so hopefully the tide is changing on this.
Other macro-level care we have some control over include simplifying our lives and enjoying more with less. “This means something different to everyone. Find contentment. Don’t chase.”
This would mean not comparing ourselves to others and limiting social media. I asked her why she thinks that we buy into ideas of finding joy in more social status and consumption. “It depends what evidence you are listening to. This happens if we listen to commercials and not to science.” Or to our deeper inner voice that is in touch with what we truly value. We must be counter-cultural in many ways to be well. I don’t believe anyone’s deepest values are to be rich and famous, but that we want to be valued and seen.
“It’s complicated. We can make it simple. Stop. And be well.”
I had one more question for her for the many people who worry that something else going on with their guts. They have palpable fear that the doctor is missing something. Their symptoms are so severe sometimes it feels like there must be something horribly wrong.
“Pain and Google doctor can increase anxiety quickly; pinky pain means pinky cancer. Fear of cancer is real.”
How do you know someone's symptoms aren't cancer?
“My training has me assessing each person with all of my senses involved to see the whole picture of how this person presents. I know you are someone’s loved one: sister, brother, spouse, child. I want to be thorough and will ask the red flag questions about weight loss, bowel movement out of control in the middle of night, family history. I also remember to do no harm, and more tests can lead to more invasive procedures that can cause real harm. You could die from chasing down an incidental finding. I have seen that happen. It can be worse than rare cancer you are chasing.”
Her final thoughts for wellness? “Kindness,” she says. “Don’t Be Nice, Be Kind.” She is not known as a nice person, but people trust her because she is kind, with honesty coming from a good place.
“And forgiveness – we could all practice more forgiveness.”
We agree it is easy to be self-righteous when someone else messes up.
“Grace transcends religion. I read the Bible and it is the people who transform and change, who come from a dark place to see the light of love who make the biggest impact.” She is suggesting as a society we let people who have made mistakes own them authentically, be sorry, and then be held up to a new standard. And be forgiven. “Allow people to transform. When I look at the life they lead I can see who they really are.” There is always room for forgiveness and sincerity.
“I know when I don’t want to, I still have to work toward forgiveness,” she said shaking her head. I raised my eyebrows after she shared a recent private issue about a family member. “I know, it’s annoying to have to forgive that, but I must. Forgiveness transforms me.”