INTESTINAL PARASITES, BACTERIAL DYSBIOSIS AND LEAKY GUT

EXCERPTS FROM POWER HEALING (RANDOM HOUSE, 1998)
BY LEO GALLAND, M.D.

The human intestine maintains within its inner cavity a complex, crowded environment of food remnants and microbial organisms (called "the intestinal flora") from which the body derives nourishment and against which the body must be protected. The relationship between the human host and her army of microbes is described by the Greek word, symbiosis, which means "living together". When symbiosis benefits both parties, it is called mutualism. When symbiosis becomes harmful, it is called dysbiosis. The first line of protection against dysbiosis and intestinal toxicity is strict control of intestinal permeability, the ability of the gut to allow some substances to pass through its walls while denying access to others. The healthy gut selectively absorbs nutrients and seals out those components of the normal internal milieu which are most likely to cause harm, except for a small sampling which it uses to educate and strengthen its mechanisms of immunity and detoxification.

Bacteria form the largest segment of the intestinal flora. The number of bacteria in the large bowel (about a hundred trillion) exceeds the number of cells in the human body. Intestinal bacteria perform some useful functions, so that our relationship with them is normally one of mutual benefit. They synthesize half a dozen vitamins, supplementing those which are obtained from food. They convert dietary fibre--that part of food which humans cannot digest--into small fatty acids which nourish the cells of the large intestine. They degrade dietary toxins like methyl mercury making them less harmful to the body. They crowd out pathogenic bacteria like Salmonella, decreasing the risk of food poisoning. They stimulate the development of a vigorous immune response. Four-fifths of the body's immune system is located in the lining of the small intestine.

Bacteria are dangerous tenants, however, so that dysbiosis is a common problem. As powerful chemical factories, bacteria not only make vitamins and destroy toxins, but also destroy vitamins and make toxins. Bacterial enzymes can inactivate human digestive enzymes and convert human bile or components of food into chemicals which promote the development of cancer. Some by-products of bacterial enzyme activity, like ammonia, hinder normal brain function. When absorbed into the body, they must be removed by the liver. People whose livers fail this task, because of conditions like cirrhosis, develop progressive neurologic dysfunction resulting in coma and death. For them, the administration of antibiotics which slow the production of nerve toxins by intestinal bacteria can be life saving.

The immune reactions provoked by normal intestinal bacteria may be harmful rather than helpful. Inflammatory diseases of the bowel, including ulcerative colitis and Crohn's disease (ileitis), and several types of arthritis have been linked to aberrant immune responses provoked by intestinal bacteria. Two types of aberrancy have been described. First, intestinal bacteria contain proteins which look to the immune system very much like human proteins; they confuse the immune system and may fool the body into attacking itself. Second, fragments of dead bacteria may leak into the wall of the intestine or into the blood stream due to a breakdown in the mechanisms which regulate intestinal permeability. Circulating through the body, bacterial debris is deposited in tissues such as joints, provoking an attack on those tissues by an immune system trying to remove the foreign material.

Bacterial colonies in the human intestine co-exist with colonies of yeasts, which are no less dangerous, just far fewer in number. Bacterial colonization prevents yeasts from expanding their niche. Frequent or prolonged use of antibiotics decimates bacterial colonies, removing the natural brake on yeast growth. The most obvious effects of yeast overgrowth are local infections, like vaginitis, produced when yeast invade and disrupt cells which line the body's surface. Intestinal yeast infections can cause chronic diarrhea, although most gastroenterologists fail to recognize this. Yeast can also provoke allergic reactions, precipitating asthma, hives, psoriasis or abdominal pain. The occurrence of allergic symptoms or the aggravation of a pre-existing allergy which follows the use of antibiotics should always prompt an investigation into yeast overgrowth as a potential trigger. Neglect of this factor by allergists has left countless patients trapped in a spiral of increasing allergic reactivity, augmented each time antibiotics are prescribed.

In addition to bacteria and yeast, most of the world's four billion people are also colonized by intestinal parasites. Contrary to popular belief, parasitic infection is not unusual in the U.S. population. It is a common ocurrence, even among those who have never left the country.

Unlike bacteria, parasites appear to serve no useful function. The part of the immune system which they stimulate does not strengthen the organism to resist serious infection; instead it contributes to allergic reactions, so that parasitic infection increases allergic tendencies. There are two general groups of parasites. The first consists of worms--tapeworms and roundworms--which attach themselves to the lining of the small intestine, causing internal bleeding and loss of nutrients. People infested with worms may have no symptoms or may slowly become anemic. The second category is the protozoa, one-celled organisms like the amoeba which caused John Gerard's colitis. The first protozoa were discovered over three hundred years ago by Antonie van Leeuwenhoek, the most famous of the early microscopists. When the inquisitive Dutchman set about to examine everything in the world that would fit under the lens of a microscope, he found organisms in his own stool that closely match the description later given to Giardia lamblia.

Giardia is the major cause of day-care diarrhea. Twenty to thirty per cent of workers in day care centers harbor Giardia. Most have no symptoms; they are merely carriers. A study at Johns Hopkins medical school a few years ago demonstrated antibodies against Giardia in twenty per cent of randomly chosen blood samples from patients in the hospital. This means that at least twenty per cent of these patients had been infected with Giardia at some time in their lives and had mounted an immune response against the parasite.

In 1990 I presented a paper before the American College of Gastroenterology which demonstrated Giardia infection in about half of a group of two hundred patients with chronic diarrhea, constipation, abdominal pain and bloating. Most of these patients had been told they had irritable bowel syndrome, which is commonly referred to as "nervous stomach". I reached two conclusions from this study: (1) Parasitic infection is a common event among patients with chronic gastrointestinal symptoms. (2) Many people are given a diagnosis of irritable bowel syndrome without a thorough evaluation. My presentation was reported by numerous magazines and newspapers, including the New York Times. My office was flooded with hundreds of phone calls from people who were suffering with chronic gastrointestinal complaints. Most of them had been given a diagnosis of Irritable Bowel Syndrome (IBS) by their physicians. The standard treatment for this syndrome had not helped them. All they had received was a label. Many had been told there was no cure. In evaluating these patients, I found that the majority had intestinal parasites, food intolerance or a lack of healthy intestinal bacteria. These conditions were not mutually exclusive. Many patients had more than one reason for chronic gastrointestinal problems. Treating these abnormalities as they occurred in various patients produced remarkably good therapeutic results. A year later, researchers in the Department of Family Medicine at Baylor University in Houston reported findings similar to mine.

Giardia contaminates streams and lakes throughout North America and has caused epidemics of diarrheal disease in several small cities by contaminating their drinking water. One epidemic, in Placerville, California, was followed by an epidemic of Chronic Fatigue Syndrome, which swept through the town's residents at the time of the Giardia epidemic. Possibly, this epidemic was due to failure of some people to eradicate the parasite. In 1991, my colleagues and I published a study of 96 patients with chronic fatigue and demonstrated active Giardia infection in 46 per cent.

Sometimes, the intestinal damage produced by giardiasis persists for months after the parasite has been successfully treated. The impairment of digestion and absorption which results from this damage may cause fatigue and other symptoms.

When I first began presenting the results of my clinical research on parasitic infection, in the mid-1980's, my reports were met with considerable skepticism. The present decade has witnessed an increased awareness of parasitic infection as a common public health problem in the United States, thanks largely to Cryptosporidium, which recently achieved notoriety for contaminating Milwaukee's water supply, causing the largest epidemic of diarrhea in U.S. history, infecting 400,000 people and causing over one hundred deaths. Most municipal water supplies in the U.S. today are home to protozoa like Giardia and Cryptosporidium and one in five Americans drinks water that violates federal health standards. Every year, almost a million North Americans become sick from water-borne diseases; about one per cent die. Further epidemics are inevitable. A recent epidemic occurred in Clark County, Nevada, despite state-of-the-art municipal water treatment.

How protozoa make people sick is not clear. Some directly invade the lining of the intestine, others provoke an allergic reaction that causes the damage. It appears certain that humans coexist quite readily with their parasites as long as the barrier formed by the intestinal lining remains fully intact, so that the parasites cannot attach to the wall of the bowel. Millions of people throughout the world are carriers of E. histolytica; the organism can be found in stool samples but it does not seem to make them ill. The variability of pathogenic potential recalls Pasteur's challenge to the French Academy: do the causes of disease lie within the microbe or do they lie within the host? When the attachment of a parasite initiates a series of injuries to the intestinal wall that increase its permeability, it generates a cascade of reactions that can shatter a person's health in many different ways. Excessive permeability permits excess absorption of antigens and microbial fragments from the gut, over-stimulating the immune response, fostering allergy and auto-immunity.

Excess permeability also allows excessive absorption of toxins derived from the chemical activity of intestinal bacteria, stressing the liver. All materials absorbed from the intestine must pass through the liver before entering the body's general circulation. Here, in the cells of the liver, toxic chemicals are destroyed or else prepared for excretion out of the body. The cost of detoxification is high; free radicals are generated and the liver's stores of anti-oxidants are depleted. The liver may be damaged by the products of its own attempts at detoxification. Damage may extend to the pancreas. Free radicals are excreted into bile; this "toxic" bile flows into the small intestine and can ascend into the ducts which carry pancreatic juices, damaging the pancreas, aggravating malnutrition.

The symptoms produced by excessive intestinal permeability may be limited to the abdomen or may involve the entire body. They may include fatigue and malaise, joint and muscle pain, headache and skin eruptions. The clinical disorders associated with increased intestinal permeability include any inflammation of the large or small intestine (colitis and enteritis), chronic arthritis , skin conditions like acne, eczema, hives or psoriasis, migraine headaches, chronic fatigue, deficient pancreatic function and AIDS . In most cases, it is incorrect to think of excessive permeability as the cause of these disorders. Instead, excess permeability occurs as part of the chain of events which causes disease and aggravates existing symptoms or produces new ones.

Just as excessive permeability may have many different effects, it may also have many different causes, each of which may add to the effects of the other. These causes include intestinal infection of any type (viral, bacterial or protozoan), alcohol, and NSAIDs (non-steroidal anti-inflammatory drugs) which increase permeability by decreasing the body's synthesis of beneficial prostaglandins. Allergic reactions to foods also produce an increase in intestinal permeability.

The fate of people treated for chronic arthritis exemplifies the spiral of problems caused by excessive intestinal permeability. Arthritis (inflammation of the joints) is the leading cause of physical disability in industrialized countries.

Some forms of arthritis are preceded by increased intestinal permeability. People with inflammation of the intestine are prone to develop inflammatory arthritis which may continue for many years after the intestinal inflammation is healed. Fragments of intestinal bacteria have been identified in the joints in some cases. In others, antibodies directed against intestinal bacteria may attack the person's own joint tissue, causing an auto-immune reaction.

For most people with chronic arthritis, however, excessive intestinal permeability develops as a result of arthritis and its treatment and may aggravate the arthritis, creating a vicious cycle. People with any type of severe arthritis usually take large doses of NSAIDs on a daily basis to control the pain, stiffness and swelling in their joints; they rapidly develop increased intestinal permeability. Excessive permeability allows bacteria or bacterial antigen to penetrate the wall of the intestine, creating a smoldering inflammation in the intestinal wall (called enteritis), which in turn further increases intestinal permeability. Enteritis develops in seventy per cent of people taking NSAIDs daily for two weeks. The excessive permeability caused by drug-induced enteritis allows fragments of bacteria to enter the circulation, where they cause or aggravate more arthritis.

Much of the research on intestinal permeability and NSAIDs has been conducted with people who suffer from rheumatoid arthritis, an inflammation which affects many joints at the same time and is especially noticeable in the hands. It typically strikes women in their twenties or thirties and lasts for life, crippling thirty per cent of its victims with severe deformities of the affected joints and shortening their life expectancy by ten to fifteen years. Patients with rheumatoid arthritis taking NSAIDs develop antibodies against components of the normal intestinal bacteria. Development of an abnormal or excessive immune response is called sensitization. Sensitization to intestinal bacteria may cause or aggravate arthritis. When patients with rheumatoid arthritis take antibiotics which reduce the numbers of intestinal bacteria, not only does their enteritis clear up, but their arthritis also improves. NSAIDs, the standard treatment for arthritis, by increasing intestinal permeability, create a new problem which aggravates the old one. Increased intestinal permeability explains the beneficial effects of diet for the treatment of rheumatoid arthritis. Fasting and vegetarian diets benefit patients with rheumatoid arthritis. Fasting reduces the excessive intestinal permeability of patients with rheumatoid arthritis while at the same time dramatically improving symptoms. Vegetarian diets alter the bacterial growth in the intestine, acting in a sense like natural, highly selective antibiotics. Those people who respond to vegetarianism with a change in the intestinal bacteria are the ones that benefit. Those people who do not change their intestinal bacteria as a result of changing their diets do not improve their arthritis by becoming vegetarians.

There is a common belief that avoiding specific foods can benefit people with arthritis. One effect of the increased permeability produced by NSAIDs is to increase the absorption of antigens coming from food. People with rheumatoid arthritis frequently become sensitized to food proteins. Their arthritis often improves when they avoid specific foods and then flares up when they consume those foods. I have treated enough patients with rheumatoid arthritis to know that food allergy is not the cause of rheumatoid arthritis. It is part of the cycle of immunologic sensitization, inflammation and increased intestinal permeability that occurs in most patients with severe arthritis. The treatments that are used for chronic arthritis may temporarily relieve pain but they help to maintain the vicious cycle. Perhaps this explains why the long term outlook for patients with rheumatoid arthritis is so bleak and has not been improved by any of the drug therapies developed over the past thirty years. Professor Ann Parke, of the University of Connecticut, voiced an opinion not often heard from rheumatologists, "...maybe NSAIDs have had their day. We should, instead, be striving to maintain the integrity of the gastrointestinal tract in an attempt to prevent the disease at a potential source, rather than treating the complaints and risking perpetuating the disease."

If medicine is to regain its Hippocratic roots, preserving and restoring health, then physicians must learn the science of preserving and restoring normal intestinal permeability. This is not an attempt to "cleanse" the colon with laxatives or enemas or to correct constipation. In the early years of the twentieth century, "auto-intoxication" was a fashionable concept. It was considered to be the cause of chronic fatigue, stomach ulcers, rheumatoid arthritis, high blood pressure, hardening of the arteries, breast cancer and ovarian cysts. The complex regulation of intestinal permeability was not understood and autointoxication was attributed to "intestinal stasis", a fancy term for constipation. In keeping with the spirit of the times, it was treated invasively: enemas for mild cases, colectomy (surgical removal of the large intestine) in severe cases. Even institutions as august as the Mayo Clinic sanctioned colectomies for autointoxication during the first two decades of the twentieth century.

The preservation and restoration of normal intestinal permeability rests on two principles: building resistance and reducing risk. A diet of high nutrient density, described in Chapter...., is the cornerstone for maintenance of intestinal health. The intestinal lining has the fastest growth rate of any tissue in the body. Old cells slough off and a completely new lining is generated every three to six days. The metabolic demands of this normally rapid cell turnover must be met if excess permeability is to be prevented or if healing is to occur. Thorough chewing of food may be important. Saliva contains a substance called epidermal growth factor (EGF) which stimulates growth and repair of tissue. EGF has been used therapeutically to heal the intestine when injured or inflamed.

Essential fatty acids play an important role in maintenance of intestinal integrity. Fish oils limit the intestinal injury caused by toxic drugs and GLA (found in primrose, borage or black currant oils) stimulates production of prostaglandins which help to maintain normal permeability. The principles for EFA supplementation detailed on pages.....should be followed. Merely consuming large quantities of vegetable oils, however, is likely to be harmful to the intestinal lining. High intake of polyunsaturated oils increases the free radical content of bile, producing a toxic bile that may damage intestinal integrity.

In addition to a nutrient dense diet, there are several specific dietary resistance factors which warrant careful attention for their ability to preserve normal intestinal integrity and should be part of any program for intestinal detoxification.

(1) FIBRE

Fibre is the term that describes remnants of plant cells that are resistant to human digestion. The usual sources are vegetables, cereals, bread, nuts, seeds and fruits. Eating a fibre deficient diet increases intestinal permeability. Although medical researchers have been recommending high fibre diets for about twenty years, and sales of metamucil and other bulk laxatives have gone up, there has been no significant increase in fibre consumption from food and the fibre intake of Americans is far below recommended levels. This is unfortunate, because the fibre found in food is far more complex than the purified powders sold in drug stores.

There are many different chemical types of fibre, but the most important distinction is between soluble and insoluble fibre. Soluble fibre dissolves in water, forming a thick gel. Fruit pectin, for example, is a highly solube fibre. Psyllium seed, the commonest source of bulk laxatives, contains fibre that is moderately solube. Wheat bran consists of relatively insoluble fibre that is most readily evident as "roughage". Although all fibre adds bulk to bowel movements, the chemical effects of the different types of fibre can be opposite.

Soluble fibre feeds the intestinal bacteria, which ferment it to produce chemicals called short chain fatty acids (SCFAs). SCFAs have a number of positive effects on the body: they nourish the cells of the large intestine, stimulating healing and reducing the development of cancer. When absorbed from the intestine, they travel to the liver and decrease the liver's production of cholesterol, lowering blood cholesterol levels. Oat bran, for example, contains fibres of moderate solubility; eating oat bran can lower cholesterol levels. Within the intestinal canal, SCFAs inhibit the growth of yeasts and disease-causing bacteria. The effects of soluble fibre are not always beneficial, however. Feeding high levels of soluble fibre supplements like guar gum encourages an overgrowth of the normal intestinal bacteria which deprives the body of vitamin B12 and produces an increase in the concentration of bacterial toxins. Although low fibre diets increase gut permeability, excessive consumption of soluble fibre from supplements can also cause excessive permeability and may create changes in the intestinal milieu that actually enhance the development of stomach or bowel cancer.

Insoluble fibre does not feed bacteria well and is not readily fermented to SCFAs. Eating wheat bran, which is largely insoluble fibre, has no effect on blood cholesterol levels. Insoluble fibre inactivates intestinal toxins, however, and high intake of insoluble fibre is associated with a decreased risk of colon and breast cancer. Supplements of insoluble fibre as wheat bran or pure cellulose appear to decrease the risk of bowel cancer. Insoluble fibres also inhibit the ability of disease-causing bacteria and parasites to attach themselves to the intestinal wall. Insoluble fibre plays an important role in preventing excess intestinal permeability.

It should be obvious that humans need a mixture of soluble and insoluble fibres in the diet and that food, not supplements, is the best source. Eating high fibre foods protects against the development of the major degenerative diseases of the modern world--heart disease and cancer--increases longevity and protects against the development of parasitic infection. The best sources of mixed fibres are unrefined cereal grains (oats, brown rice, whole wheat), peas, beans and squash. Among fruits, one gets the most fibre per serving from apples and berries.

Some high fibre foods contain natural chemicals which help to maintain normal intestinal permeability by unique mechanisms. Carrots, carob, blueberries and raspberries contain complex sugars (oligosaccharides) which interfere with the binding of pathogenic bacteria to the intestinal lining. These have been used in Europe for centuries for the treatment or prevention of diarrhea. Synthetic oligosaccharides are presently being developed as drugs for treating infection. Brown rice is the source of gamma-oryzanol, a group of powerful antioxidants which have been tested extensively in Japan for their ability to heal intestinal and stomach ulcers and alleviate a variety of chronic gastrointestinal complaints. Gamma-oryzanol can be consumed in rice bran or rice bran oil or in pill form. The therapeutic dose is 100 mg three times a day.

If you become constipated when increasing dietary fibre, you may need more fluid. Drink eight glasses of liquid a day, between meals, not with meals.

(2) FRIENDLY FLORA

A large body of research over the past ninety years has demonstrated the preventive value of eating foods fermented with Lactobacilli or their cousins, Bifidobacteria. Eating these friendly bacteria prevents intestinal infection due to viruses or pathogenic bacteria and preserves intestinal permeability in the face of infection or other types of injury, can prevent antibiotic-induced diarrhea and travelers diarrhea and can lower serum cholesterol levels. Lactobacilli and Bifidobacteria also show anti-cancer activity, by two mechanisms: they inhibit the growth or activity of cancer-promoting bacteria and some strains actually produce chemicals which inhibit tumor growth.

There are numerous species of Lactobacilli and many strains for each species. Some, like Lactobacillus acidophilus, are normal inhabitants of the human digestive tract. Others, like L. bulgaricus, which is a common starter for making yogurt, are not. L. bulgaricus disappears from the intestine within two weeks after yogurt consumption is stopped. Sauerkraut is sour because of L. plantarum, a beneficial organism that is normally found in the human intestine and that stays for a long time after being introduced. Commercially available fermented foods are, unfortunately, unreliable as sources of Lactobacilli, because the lactic acid and hydrogen peroxide which Lactobacilli naturally produce may kill the producers themselves if their concentration becomes excessive. A few years ago, the Annals of Internal Medicine published a study which proved what many women have known for years, that eating yogurt daily can prevent vaginal yeast infections. The researchers were lucky. The batch of yogurt they gave their patients was loaded with living Lactobacillus acidophilus. These organisms not only took up residence in the intestines of the women who ate it, but also colonized the vagina, preventing yeast infection. When the scientists attempted to perform the same experiment a year later, they found that the same brand of yogurt contained no living bacteria.

The most reliable way to supplement your diet with Lactobacilli is to make your own yogurt or sauerkraut, or to buy nutritional supplements which have been tested by an independent outside laboratory and which list the concentration of viable bacteria found on culture. Lactobacilli are killed by heat, moisture and sunlight. The making of tablets generates heat which lowers the number of viable organisms. Lactobacilli should be freeze-dried, in powder or capsules, in opaque moisture-proof containers, stored in the refrigerator. They should be consumed with meals. The strains which have been most extensively tested for their viability in the human intestine are L.acidophilus strain NCFM-2 and L.plantarum. L. acidophilus is well-suited to growing in the small intestine, where it is normally one of the dominant bacterial species. L. plantarum has growth characteristics which lead it to grow especially well in the large intestine. The daily dose should be between one billion and ten billion viable bacteria. More may cause gastrointestinal irritation.

"Nutritional yeast" has been used as a dietary supplement for generations, as a source of vitamins and minerals and for treatment of digestive complaints. After treating hundreds of yeast-allergic patients, I was very reluctant to prescribe yeast for anyone, until I discovered a preparation which the French call "Yeast Against Yeast". The yeasts which invade human tissues, causing yeast infection, are mostly members of the genus Candida. The yeast used in baking bread or brewing beer belong to the genus Saccharomyces. Yeast Against Yeast is Saccharomyces boulardii, a microbe which inhabits the surface of many different plants and which was first isolated from lichee nuts in Southeast Asia by French scientists during the 1920's. Saccharomyces boulardii has been used in Europe for decades to treat acute diarrhea and controlled trials have shown it effective in preventing or treating diarrhea brought on by antibiotics. S. boulardii appears to exert its beneficial affects by inactivating bacterial toxins and by stimulating intestinal immune responses. S. boulardii has been available in natural food stores in the United States since 1991. People who are allergic to baker's yeast may also be allergic to S. boulardii, but for most people, including women with chronic Candida infection, Yeast Against Yeast lives up to its name.

(3) SPICE

Before they were used as seasoning, culinary herbs and spices were probably used for food preservation. Many varieties have natural antimicrobial activity and can retard spoilage. They are also used to mask the flavor of spoiled food, so I suggest using them at home, where you know the food they flavor is fresh to begin with.

The world's most extensively studied spice is garlic. Its medicinal use predates recorded history. Garlic is mentioned in the earliest Vedic medical documents, written in India over five thousand years ago. During an epidemic of plague in Marseilles, in 1721, four condemned criminals were enlisted to bury the dead. None of them contracted plague. It seems that they sustained themselves by drinking a cocktail of crushed garlic in cheap wine, which came to be called vinaigre des quatre voleurs (vinegar of the four thieves). In 1858, Louis Pasteur demonstrated garlic's antibiotic activity. The herb was used by Albert Schweitzer for the treatment of amoebic dysentery at his clinic in Africa. Antimicrobial activity of garlic has been repeatedly demonstrated against many species of bacteria, fungi, parasites and viruses. In addition, garlic lowers cholesterol and blood pressure and may protect against cancer. The dose of garlic needed to obtain significant benefit is at least ten grams (about three small cloves) per day.

Onion, garlic's closest edible relative, has also been widely used for medicinal purposes. Although it lacks the potency of garlic, it can be consumed it much larger quantity, so that its antimicrobial benefits may be equal to those of garlic if consumed regularly.

Turmeric, a major ingredient in curry powder, is a natural antibiotic that relieves intestinal gas by lowering the numbers of gas forming bacteria, has antifungal activity and has been traditionally used for relieving inflammation. The effective dose is about one gram per day.

Ginger, which contains over four hundred chemically active ingredients, has long been used for the treatment of digestive complaints. It protects the intestinal lining against ulceration and has a wide range of actions against intestinal parasites. Cinnamon, which I recommend for sweetening the taste of ginger tea, has anti-fungal activity.

Sage and rosemary contain the essential oil, eucalyptol, which kills Candida albicans, bacteria, and worms. Oregano contains over thirty biologically active iingredients of which twelve have antibiotic, anti-viral, anti-parasitic or anti-fungal effects. As mentioned earlier, thyme has anti-parasitic activity.

Meals seasoned with these pungent, aromatic herbs, consumed regularly, help protect against intestinal infection. However, heating at 200 degrees (Fahrenheit) for twenty minutes destroys the antibacterial activity of most of these spices. They should be added to food at the end of cooking, just before being eaten.

NOTE: If high fibre diets, friendly flora, or spicy food give you diarrhea, gas or abdominal bloating, instead of improving digestive function, you may be changing your diet too rapidly, or you may have an allergy to one specific component of the regimen described here. Slow down and try again. Be methodical, making one change at a time. First, cut down on sugar and fat, then switch to whole grains, then add more vegetables. Give yourself a chance to know how each new food you try affects your body. It may take a few days. Then add nutritional supplements, one at a time, allowing yourself three or four days between each change. Experiment with different brands. For some people, one preparation of Lactobacillus will cause diarrhea, but another will not. If you still find that you cannot increase your consumption of fiber or flora without feeling worse, rather than better, you may have an overgrowth of bacteria or yeast in the small intestine which have adapted to using the fibre you are taking to expand their niche, rather than to limit their growth. Bacterial overgrowth of the small intestine is far more common than doctors suspect and most commonly results from a lack of stomach acid or from prior surgery. Yeast overgrowth usually results from taking antibiotics. Resources for dealing with these problems are listed in Appendix III.

RISK REDUCTION

The most common, preventable causes of increased intestinal permeability are drugs and infections. Aspirin and NSAIDs should not be taken on a daily basis. Most people using NSAIDs daily are trying to relieve chronic headache or joint and muscle pain. Alternative strategies for pain relief are often available. The likelihood of benefit depends upon the location of the pain and the presence or absence of inflammation. Pain control strategies and resources are listed in Appendix IV.

After NSAIDs, alcohol is the drug most likely to destroy normal intestinal permeability. More than one glass of wine or beer is likely to be detrimental.

The body's first line of defense against intestinal infection is the acid produced by a healthy stomach. Stomach acid kills most of the bacteria and parasites that are swallowed along with meals. Strong suppression of stomach acid increases the risk of intestinal infection. The widespread use of antacids is, therefore, a reason for concern, and the FDA's recent decision to make the acid-lowering drugs Tagamet and Pepcid available without a doctor's prescription is a terrible disservice to the American people. Most people who take treatments to buffer or reduce stomach acid do not need acid reduction and should avoid it. Tagamet and Pepcid are called H-2 blockers because they block certain effects of histamine in the body. (Conventional "anti-histamines" used for treating symptoms of allergy are called H-1 blockers). They were originally developed for the treatment of ulcers and they made huge profits for the companies which owned them. Doctors soon began using H-2 blockers for relieving stomach pain which was not caused by ulcers (this pain is called "non-ulcer dyspepsia"), even though their efficacy for non-ulcer pain was disputed. The most common cause of non-ulcer dyspepsia, by the way, is taking NSAIDs. If NSAID use were markedly reduced, the frequency of stomach pain and the need for H-2 blockers would also be reduced. Recently, it has become quite clear that most ulcers are triggered by a bacterial infection of the stomach and that antibiotics are superior to H-2 blockers for treating ulcers. As the need for H-2 blockers in the treatment of ulcers just about vanished, the FDA suddenly approved their non-prescription use for the treatment of heartburn. The truth is that H-2 blockers are rarely needed to treat heartburn, because heartburn is not caused by excess stomach acid. It is caused by reflux of normal amounts of stomach acid into the esophagus, which occurs when the valve responsible for preventing acid reflux is not working properly. The usual reason for valvular incompetence is dietary. Coffee, alcohol, chocolate and high fat meals prevent the valve from closing properly. Calcium, in contrast, makes it close more tightly.

Almost all people with frequent heartburn can get relief by eating small, low fat meals, chewing a calcium tablet after each, and not eating for four hours before bedtime. Temporary avoidance of coffee, alcohol, and spicy or irritating foods until the heartburn stops is also a good idea. Were these measures followed, the use of H-2 blockers and antacids could be cut by ninety per cent.

A second line of defense against intestinal infection is the normal intestinal bacteria, especially Lactobacilli residing in the small intestine. Antibiotics decimate Lactobacilli. In so doing, they may increase the risk of subsequent intestinal infection. Although antibiotics, when appropriately used, are the most important therapeutic discovery of modern Western medicine, they are often used inappropriately and the effects can be devastating. Whenever I prescribe an antibiotic, I always consider its possible effect on the beneficial intestinal flora. An antibiotic that is rapidly and completely absorbed in the stomach, reaching high levels in the tissues of the body and low levels in the small or large intestine, is least likely to harm intestinal ecology. I also administer Lactobacilli along with the antibiotics. L. plantarum is the only Lactobacillus not harmed by antibiotics and can be taken simultaneously with them.

A key component of risk reduction is maintaining a safe supply of food and drink. Epidemics of giardiasis and cryptosporidiosis from contaminated water and of food poisoning due to Salmonella in chicken or to toxic strains of E. coli in hamburger serve notice that the U.S. food and water supply is not safe. There are guidelines that I give my patients to help them avoid infection when travelling to Asia and Africa. These same guidelines should be applied in the United States, at home or when dining out, because the food in the U.S. may be no safer than in many non-industrialized nations. Although some of these guidelines may seem burdensome, they significantly reduce the risk of acquiring a food- or water-borne infection:

(1) Always wash your hands carefully with soap and water when returning home from outside and before handling food. Hand- washing is a very effective way to remove pathogens. In day care centers, where Giardia infection can be rampant, the parasite can be found on surfaces, tables and chairs. Handwashing by the staff drastically reduces the frequency of diarrhea. Regular handwashing also protects against catching colds or flu from other people.

(2) Do not drink tap water that has not been properly filtered or kept at a rolling boil for at least five minutes. Chlorination does not kill the cyst forms of Giardia or Cryptosporidium, which are extremely hardy. The most effective way to remove Cryptosporidium from tap water is to use a reverse osmosis system, which can be mounted under the sink or on a countertop. Reverse osmosis also removes many chemical contaminants from water but is slow and wasteful. To remove Cryptosporidium, a water filter must have pores that are no larger than one micrometer. Water filters that effectively remove Cryptosporidium are certified by the National Sanitation Foundation (NSF), an independent non-profit organization, under their Standard 53 for "cyst removal". No water filter practical for home use will remove bacteria. Have the bacterial concentration in your drinking water tested by an independent laboratory. Call the Water Quality Association at (708) 505-0160 or the American Council of Independent Laboratories at (202) 887-5872 for the name of a certified laboratory near your home.

The quality of bottled water is completely unregulated. Some bottled water comes from municipal water supplies. To discover the source of any bottled water, call the bottler and request documentation about the nature and purity of the source. Bottled water that comes from municipal water supplies or lakes should be treated by reverse osmosis before being bottled, if it is to be considered safe.

Avoid using ice unless you feel secure about the purity of the water from which it was made. Remember that automatic icemakers use unfiltered tapwater. Freezing kills most parasites but does not kill bacteria.

Use pure water for brushing your teeth and rinsing your toothbrush.

(3) Peel all fruits and vegetables, unless they are to be thoroughly cooked. Wash your hands afterwards. If you cannot peel

them, soak them for fifteen minutes in a solution made by adding one teaspoon of three per cent hydrogen peroxide to two quarts of water and then rinsing thoroughly with filtered water.

(4) When eating out, only eat food that has been cooked just before it is served to you. In many restaurants and delicatessens, soups, sauces and stews are frequently stored in large containers, often left uncovered on the floor and reheated in a microwave oven. Microwave cooking does not kill Salmonella and other strains of pathogenic bacteria. It is safest to eat food that is fairly plain and to avoid soup, unless you know how food is handled in the restaurant where you are eating.

(5) Avoid salad bars. At first glance, salad bars seem like a good place to get healthy food in a hurry. Look again. Some years ago the Wall Street Journal sent a reporter to investigate the cleanliness of salad bars in different parts of the country. Problems were rampant and they lay not only with the restaurant but with the clientele. People are unsanitary in their use of salad bars. They sometimes sample food and put it back. The handles of the serving utensils frequently fall into the food trays, providing an opportunity for contamination.

(6) Do not eat food that has been prepared by a street vendor.

(7) Avoid restaurants where there are flies. Flies can spread parasitic cysts and pathogenic bacteria.

(8) Remember that uncooked meat, fish or poultry are often contaminated with pathogenic bacteria. When preparing your own meals, always keep raw flesh foods away from other food that will be eaten raw, like salad. Cook meat, fish and poultry well and wash your hands after handling them. Also wash the utensils you use to cut them. People have become ill by handling chicken contaminated with Salmonella (as most American chicken is), and then using a contaminated knife or contaminated fingers to prepare other food that was not to be cooked. To kill Salmonella on utensils, soak them in a solution of chlorox for fifteen minutes, then make sure you rinse the chlorox thoroughly away. Do not use dishrags to wipe off kitchen counters, stoves, sinks and tables. Dishrags actually spread germs around. Use recycled paper towels to mop up the bacteria-laden juices from meat, poultry and fish and either use paper towels or sponges to wipe surfaces. Run the sponges through the dishwasher every day to thoroughly remove bacteria.

Tofu is increasingly popular as a substitute for meat. Tofu that is bought floating in water has high levels of bacterial contamination. Wrapped and sealed tofu is safer. To kill bacteria, tofu should be cooked to an internal temperature of one hundred and sixty degrees.

(9) Have your pets de-wormed regularly. Wash your hands after handling your pets. Do not let your children crawl on ground where pets are free to roam.

For people travelling to places where a safe food supply cannot be assured, despite the implementation of all the precautions listed above, I recommend the use of antimicrobial herbs after each meal. My preference is a combination of berberine (the active ingredient in the herb goldenseal) and artemisinin (the most active ingredient in Artemisia annua). This combination can help to prevent or treat bacterial and parasitic infection. These herbs should not be taken by pregnant women, however. The safety profile of artemisinin is high, but it can induce miscarriage.

There is a novel approach to control of intestinal pathogens, which derives from their need for iron. Virtually all bacteria, except for Lactobacilli and Bifidobacteria, require iron for growth. Animals protect themselves from infection by making chemicals which bind iron, so that the microbes cannot use it. Iron-binding proteins called lactoferrins are concentrated in human milk and are found inside human white blood cells. The high lactoferrin in human milk protects breast-fed infants against intestinal infection. Pure lactoferrin is now available in capsules and has proved to be very useful for the prevention and treatment of intestinal infection, without side effects. It inhibits the growth of pathogenic bacteria and protozoa by starving them for iron, while improving iron absorption by the human host. I recommend that travelers and other people who cannot control the cleanliness of their food supply take one thousand milligrams of lactoferrin at bedtime and the artemisinin-berberine herbal mixture after meals.

Ulcerative colitis is considered to be a distinct disease entity, which must be separated from other disease entities, especially infectious colitis. Intestinal infections with amebic parasites or certain species of bacteria can produce symptoms and signs indistinguishable from those of ulcerative colitis. The main difference is that antibiotics may cure infectious colitis but have a rather inconsistent effect in ulcerative colitis. Actually, the role of infection in ulcerative colitis, although obscure, is not inconsequential. People with a diagnosis of ulcerative colitis have an increased susceptibility to infections of the large intestine, which aggravate their colitis. Many people who develop the disease in adulthood only acquire ulcerative colitis after contracting a parasitic or bacterial infection. Antibodies directed against the cells which line the large intestine occur in patients with ulcerative colitis, and may also be found in people with chronic forms of infectious colitis. One theory holds that ulcerative colitis is an autoimmune disease provoked by an allergic reaction to micro-organisms in the intestinal tract. Another theory holds that ulcerative colitis may result from toxins produced by intestinal bacteria. Both theories make the boundary between infectious colitis and ulcerative colitis very fuzzy. In addition to the possibility of multiple infectious triggers in ulcerative colitis, the condition may be aggravated by allergic reactions to foods or to the very drugs used to treat mild cases of the disease. Twenty per cent of patients with ulcerative colitis improve by eliminating all milk protein from their diets. Low fat diets may be useful in decreasing the risk of colon cancer, because there is a direct correlation between the development of cancer in ulcerative colitis and the secretion of bile from the liver; the liver secretes bile in response to eating fatty foods.

Ulcerative colitis is a complex illness that demands a flexibile therapeutic approach. Like all chronic diseases, it is far more clearly understood through its mediators, triggers and antecedents in individual patients than as an abstract disease entity. Conventional drug therapy of ulcerative colitis has as its goal the suppression of the mediators of inflammation. Little attention has been paid to the divergent triggers of different patients. Over the past twenty years I have found some patients in whom ulcerative colitis was profoundly affected by diet, or the composition of the intestinal bacterial flora, or allergic reactions to intestinal yeast, or emotional distress, or the smoking of cigarettes. Each has responded differently to therapies which included diet change, antibiotics or the administration of friendly bacteria like Lactobacilli, but almost all have responded, sometimes with complete remission of symptoms. There are even some patients who develop colitis when they stop smoking cigarettes and who experience a complete remission of colitis when they resume smoking.