January 11, 2020

https://bengreenfieldfitness.com/podcast/digestion-podcasts/mycobiome/

[00:00:00] Introduction

[00:01:18] Podcast Sponsors

[00:05:14] About this Podcast

[00:07:37] Coining the Term “Mycobiome”

[00:10:03] Why the human body benefits from having fungus inside it

[00:14:17] What good and bad fungi are

[00:18:31] Signs and Symptoms of a Fungal Overgrowth

[00:21:25] How Biofilms Protect the Gut

[00:29:01] How People Get Fungal Infections

[00:31:00] Podcast Sponsors

[00:33:55] cont. How People Get Fungal Infections

[00:35:40] SIFO and SIBO

[00:38:53] How popular diets may contribute to fungal overgrowth

[00:46:10] What Life Looks Like on The Mycobiome Diet

[01:05:06] How to find a physician who is knowledgeable in treating SIFO

[01:06:06] Closing the Podcast

[01:07:41] End of Podcast

Ben:  On this episode of the Ben Greenfield Fitness Podcast.

Mahmoud:  My name is Dr. Ghannoum. I am the scientist who named the Mycobiome in 2010. The Mycobiome is an ecosystem of trillions of organisms. My interest in the study of fungi came about in the '70s when I noticed people use antibiotic. Both these communities, bacteria and fungi, live in our body. Good bacteria is only half of the story because in our body, we have both good bacteria and good fungus together. We also have to study fungi because when you disrupt this balance, you are causing other problems. So, in probiotic, you need to introduce good bacteria and good fungi because what they do is they will address the digestive plaque, which is made of bad bacteria and bad fungi. And BIOHM is the only probiotic that can keep it in balance.

Ben:  Alright, if any of you all are interested in fungus, this is an episode for you, if you think you might have SIBO or even small intestine fungal overgrowth, Candida issues. My guest on today's show is a fungus ninja. This podcast, before you listen in, you should know, is very much supported by your support of some of the works that I do, and I just launched my new book “Boundless.” So, not only are we having a bunch of book parties this month, if you go to BenGreenfieldFitness.com/calendar, you can get in to the New York City book launch party or the L.A. book launch party. New York City is going to be January 16^th. I'll be in New York City from the 13^th through the 17^th doing a bunch of book tour stuff. That's going to be in New York City. And then 29^th, 30^th, and 31^st, book launch parties in L.A. So, if you go to BenGreenfieldFitness.com/calendar, you can get it in on the Boundless book launch parties. And if you just want to get the book, you go to boundlessbook.com, and that's where you can pre-order the book, too.

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Alright. Well, as you know, the gut is a topic that I talk about a lot on this show. Part of it might be because if I personally have one weak link I guess in my body, I think is my gut stemming from years and years of bodybuilding, and Ironman triathlons, and all the strange things I consumed. And also, the strange critters and parasites, and possibly even fungi as is the topic of today's show that I've been exposed to over the years has certainly made me pretty interested in the gut. And one thing that I see coming up over and over again these days is this idea of SIBO, small intestinal bacterial overgrowth, and all these companies popping up to test the microbiome or to control the growth of something like intestine bacteria in the case of SIBO.

But what isn't talked about a lot of the time is not the microbiome, but the mycobiome, and that's the fungus that lives inside your body. As a matter of fact, there's something called SIFO, small intestinal fungal overgrowth that in many cases can mirror some of the things that you guys might see with SIBO, but the approach to it is completely different. Now, there's this brand new book that I finished last month about the mycobiome. It's called “Total Gut Balance.” The author is the guy who actually coined the term mycobiome and has done a ton of research on fostering healthy fungi and knocking out issues like Candida, et cetera. His name is Dr. Mahmoud Ghannoum, and he's actually professor at the Center for Medical Mycology at Case Western Reserve University. And he's pretty much spent his entire career studying fungi and microbial biofilms.

So, if you guys are interested in intestinal health, and also in things that could be contributing to elements like bloating, gas, brain fog, bathroom issues, and even immune system issues, this is going to be a really, really interesting discussion for you. And so the book was fantastic and I'm just stoked to be able to interview Dr. Ghannoum today.

So, Dr. Ghannoum, welcome to the show, man.

Mahmoud:  Thank you very much for having me. It's great pleasure to be with you.

Ben:  Yeah, yeah. And that's a pretty big claim you make, I think, early in the book about the fact that I think you said you actually coined the term mycobiome. So, I want to hear a little bit about that, like, if you really coined that term, and if so, how that came to be.

Mahmoud:  Yes, certainly, I did coin that term. And really when you think about it, mycology is the study of fungi, since everybody talks about bacteria. So, basically, in the gut, we call it bacterium. So, to me, it made sense to call it mycobiome to refer to the fungal community in our gut, as well as on our skin and different parts of our body. So, for years, I realized that really in our body, we have not only bacteria, but also we have fungus, we have viruses, and so on so forth.

So, around 2008, and just before that, I used to go to all this meeting and everybody talking about the microbiome really basically saying about bacteria. So, to me, as somebody who first did his doctorate in how, if we take a person, let's say a lady that takes tetracycline, the antibiotic tetracycline, you really are killing the bacteria. And guess what happens. She will develop thrush. So, to me, it made sense that we should look at both bacteria and fungi because if you disturb one of them–in this case, we are killing the bacteria, good and bad one, in our gut, we have overgrowth of Candida. And that's why I started writing articles around that time saying, “We really need to look at both bacteria and fungi.” I first wrote an article in the microbiome, which is an American Society for Microbiology, a newsletter. But of course, nobody listened to it, so I did research and I showed in healthy people, we found 101 different fungal species in our mouth. So, you can imagine that really encouraged me to come out with the term mycobiome. And that's how it started.

Ben:  Now, when it comes to the bacteria versus the fungi, can you get into what exactly the reason is that we would have fungus? As you say in the book, fungus among us rather than just bacteria. Like, what exactly are fungal species doing in the gut? Why would the human species actually benefit from having fungus inside us?

Mahmoud:  Really, this is a very good question because a lot of people, when they think about fungus, they think that it causes problems. But in fact, science now is starting to show that we also need fungi in our gut because the good fungi, even Candida, when it is present at low doses, what it does, it helps our body in a number of ways. Number one, it helps you in breaking down food, food fermentation. You have a complex carb, for example. It can be broken down by Candida, which helps beneficial bacteria to use the byproduct and grow. Also, studies are showing that Candida at that level, or fungi at the lower level colonizer, we should call them, they train our immune system. So, as long as they are at low level, they really work with the bacteria to help our body.

Ben:  Okay. So, even Candida would be something that would be beneficial on small levels?

Mahmoud:  Oh, yes. Oh, definitely. That's why when we do our test through BIOHM Healthcare, we look at both bacteria and fungi, and we see fungi in nearly 50% of people, but they are present at low, let's say 1% with respect to 1% of the total fungal load in our gut is Candida. That's no problem. Where you start having problem when it goes up to 10% or more, then we have a lot of that organism. So, having Candida at low dose is not harmful at all.

Ben:  And what's that test that you're running to test for fungus?

Mahmoud:  We do that gut report where we take fecal samples, stool samples, and we extract the DNA from the stools and we look at both bacteria and fungi using 16S, which is a next-generation sequencing 16S RNA, and also IDS, which is the primer or the probe that can detect the fungus. So, we are able to look at most bacteria and fungi in that sample. And then we look at what is the–we compare it to normal, what you may call normal. And in this case, you see whether a person has imbalance or not. If there is imbalance, then we have nutritionists that can guide you how to eat better, and also how to really have a better lifestyle.

Ben:  Now, would that be a different test than a lot of people are doing the Viome or the Onegevity to do their full genes in the biome, or what do they call it, the–I guess they just call it the microbiome analysis, or would it be different than something like a three-day stool panel from–a lot of people will run like a Genova Diagnostics stool panel? Is what you're doing any different than that when it comes to fungal identification?

Mahmoud:  What we do is that when we do–they look usually at bacteria only. We look at both bacteria and fungi. And also, with our background in the field of mycology, we are able to see what is the biological significance of these organisms.

Ben:  Okay. Alright, got it.

Mahmoud:  Which is not done by the other group.

Ben:  What's the website that people could go to if they wanted to get a fungus test? Or is that something you'd order through your doctor?

Mahmoud:  Yeah. No. I think you can do it. Go to the website, biohmhealth.com, B-I-O-H-Mhealth.com and you will see how to do the test.

Ben:  Okay. Alright, got it. So, when you're doing this identification, I would imagine you're coming up with a wide range of fungal species. What would be an example of a good fungal species that you'd see, and what would be examples of bad? Or is it simply the level of all of them that would determine whether they're good or the bad?

Mahmoud:  This is very good question. I think for Candida, the pathogen, I think the level is good and bad. But if you have Saccharomyces, for example, Saccharomyces cerevisiae, it's the yeast that we use to make bread, brew, or beer and this sort of thing. This is a good organism, Saccharomyces cerevisiae. And if you have another organism, which is called Pichia, P-I-C-H-I-A, or some people call it Pichia, which is a good yeast as well. In fact, we did a study in HIV infected patients and published in 2014 where we found people who have Pichia in their mouth did not have Candida. And remember, HIV infected patients, they used to develop oral thrush. So, anyway, the presence of this good yeast, Pichia, was able to control the bad one, which is Candida overgrowth and have thrush in the mouth.

Ben:  Okay.

Mahmoud:  So, this is a couple of examples of good guys.

Ben:  Okay. So, in addition to Candida, what would be examples of a few of the ones that you would be pretty concerned to see in the gut?

Mahmoud:  I like to see, in addition to Candida–I mean, there are different species of Candida, like for example, FIC, Candida albicans, Candida glabrata, or Candida tropicalis, I am concerned. But in addition, there are other things which we look at, like for example, Aspergillus. Okay. Aspergillus is another fungi, but it is a mold; it's not a yeast, anyway, as long as the level is low because we can have it through eating some food, okay? Or Penicillium, for example. We eat [00:16:26] ______ cheese with the fungus in them. So, these are transient and they will be washed out.

So, to me, I look when we have the test, as you say, we come out with large number of organisms, we focus on few of them. Do you have Candida? If yes, what level and what species it is, like glabrata, tropicalis, and this one? Do you have Pichia? Because I like to have Pichia. I also like to have Saccharomyces. If you don't have them, then I like you to take, like for example, probiotic, which is again for the sake of transparency, we in the same biohmhealth.com, we have a probiotic that have a good bacteria and good yeast, which is Saccharomyces boulardii. So, we like you to have that. Also, you can have it by eating food, for example, yoga, or kimchi. Other fermented food would be good as well.

Ben:  No, no, no. Just to interrupt real quick. What I understand from the book is that, and as you kind of alluded to earlier, certain bacterial species can help to control the level of certain fungal species as well. So, do you cross-reference? Do you look at, “Okay, well, this person may have high levels of Candida or moderate levels of Candida, but because their bifidobacteria levels or their lactobacillus levels are elevated or in really good count that Candida must be kept under control?”

Mahmoud:  Absolutely. You raised really a very important point because in a diet, we want to restrict or limit the growth of Candida, but we want to encourage the growth of Bifidobacterium of lactobacillus because these are the good guys. That's why when we look at bacterial and fungal profile, one of the organisms or some of the organisms we look into is Bifidobacterium or lactobacillus as bacteria because we would like to have more of that. So, you are absolutely right.

Ben:  Okay. Got it. Now, when it comes to what happens when the fungus actually gets out of control, I'm sure a lot of people, perhaps they haven't tested but they're curious what it feels like to actually have a fungal overgrowth. What exactly are some of the most common signs and symptoms somebody would experience if they have a fungal overgrowth?

Mahmoud:  I think one of the things is like diarrhea, for example. There are the studies that have been shown that people with a lot of Candida overgrowth do have diarrhea, and some studies in the children showed that as well. You may have allergy, for example. Some studies have shown that allergy could be also contributed to Candida. You have some pain, GI pain, for example. These are the most prominent really symptoms of having too much Candida.

Ben:  And what is it exactly that Candida is doing in the GI tract, like from a cellular standpoint, that would cause that to occur? What exactly is a fungus doing?

Mahmoud:  What happens if Candida overgrow? We showed in our paper, published paper on Crohn's disease patients, for example. This is a good way to really look at how it can hurt us. Candida comes and cooperates with E. coli, and as well as another bacteria, Serratia Marcescens, which are pathogens, both of them, as you know. They work with Candida. They make what we call a biofilm. Okay? This biofilm, the best example of it is the plaque in our teeth. Every morning, we brush our teeth because we have all these organisms form a biofilm. In our gut, we have similar situation. So, what happens when they form this biofilm, these bad organisms get protected because biofilm, a hallmark of it is a–it is resistant to antimicrobials, as well as it's resistant to the immune system, our cellular immune cell, fungicides, for example. Okay?

So, they come together, they start to work together, and then they change. In particular, Candida change its form. Usually, it's a yeast. It's like [00:20:58] _____, oval shape. When it becomes in our gut, inside this biofilm, it starts to form thread-like or filament, what we call filament. And these filaments can start causing damage to our gut lining. And that's where you have damage, and then you have implemented response, and of course, that where we have problem with having Candia in our gut.

Ben:  Yeah. In the book, you talked about how it makes like these enzymes that break down the cell membrane lipids. I think there's another enzyme that actually weakens the host cells to make those little filaments able to attach to the gut wall even more. And then you also talked about this concept that I've heard thrown around before, but I would love for you to explain a little bit more detail, the ability to form these protective plaques, these biofilms.

Mahmoud:  Yes. It's very interesting. For years, I was funded by the National Institute of Health to study biofilms, but it was not related to the gut. What happens when a person goes to a hospital, we put all these catheters in them so that we can give them nutrition, we can give them drugs. When you are in hospital, this is a good way to access the bloodstream and give you, as you say, for example, TBN for kids, nutritional food for kids through the catheter. But what happens, if Candida or bacteria, both of them can do biofilms, stick to the catheter, they become, again they form biofilm, which–let me just give you like visualization. It's like having Jell-O. Inside this Jell-O, you have raisins, for example, or M&M's. The M&M's are the organism, and the Jell-O which covers it is called a matrix, which means it's carbohydrates secreted by this organism, they form a shield around these organisms, the raisins. Okay? So, it's very difficult to get rid of them.

So, that's where I started studying biofilm, and we were able to develop a lock solution. In other words, a solution which you can put it in the catheter, which will be able to prevent and lead these biofilms on the catheters so that you don't have to pull it out. And that was maybe 12 years I was funded from the National Institute of Health to study that. But recently in 2016, the first paper, when we published in Crohn's disease patients, I start looking at biofilms in the gut. And it turns out that in our gut, these organisms, they are not free-floating. In other words, they are not in suspension. They come and they stick to our gut lining. Once they stick to our gut lining, they start secreting these–we call that matrix, and it's basically complex polysaccharides, and forms around it as if you have a tent, and they are living inside the tent. And of course they are protected, as I mentioned, from drugs, as well as our host immune cells. And that's where the damage is.

Ben:  And these things, these biofilms, from what I understand, they can–and I'll ask you later on about how one would get rid of fungus, but whether it's a fungal overgrowth or a bacterial overgrowth, what I understand is the biofilms that make it such a hard condition to get rid of because they're so resistant to being broken down, to being dissolved.

Mahmoud:  Absolutely. And that's where the problem–I tell you, we did a number of studies because I was working for many years in this area, and we showed that very few antibacterial, if you have bacterial biofilm, or antifungal, if you have fungal biofilm, that works. We were lucky we did this study, I forgot now, maybe 2004, 2005, it's been a long time, where we screen all the antifungal agents to see which ones are good to get rid of this biofilm. And we identified a couple of them, which was great because usually, you think, like Diflucan. Everybody knows about Diflucan, or fluconazole. If you use Diflucan, it does not work against biofilms. But we found that there's a new class of antifungal at that time. It's called Echinocandins. They are fantastic against biofilms. And that's now really what people use to treat these infections.

Ben:  What did you call it again?

Mahmoud:  Echinocandins. There are a number of them. One of them called Caspofungin, another one called Micafungin, and the third is Anidulafungin. They are from the same class. What they do with these, they can break the cell wall. They really inhibit the synthesis of the fungal cell wall. And when the fungi does not have a cell wall, it becomes weak and easy to kill.

Ben:  And are these pharmaceuticals, or over the counters, or supplements, or how exactly does one get them?

Mahmoud:  These are pharmaceuticals because remember, when we were developing that, we were targeting people in hospitals.

Ben:  Okay. Got it. And who manufactures those?

Mahmoud:  Oh, different companies like Astellas, for example, Astellas Pharmaceutical, Pfizer, and Merck. And now, what's exciting is we have at least three different investigational antifungals. I helped doing clinical trials for them. We did like in vitro, in vivo, and now we are doing clinical trials, which really also promise. So, I am very happy that we have some really tools to try to get rid of the biofilm in hospitalized patients, cancer patients, immunocompromised patients, and that sort of thing.

Ben:  Are there any probiotic strains that would have an impact on biofilms?

Mahmoud:  In April of 2019, we published this paper where we had the probiotic, which has lactobacillus, Bifidobacterium, as well as the yeast, Saccharomyces boulardii, and we showed that it is able to break the digestive plaque or the biofilms in our gut. And this is published in a journal called mBio, M-B-I-O.

Ben:  Okay. So, there might be a way to actually go after the biofilm with probiotics, but would you think that the best way to do it would be like one of these pharmaceutical formulations that you talked about in the book, like the Caspofungin, or the Anidulafungin, or the Micafungin combined with something like a probiotic?

Mahmoud:  I think this is a good idea. The problem with these antifungals, which we have, are mainly IV. You have to give them by injection. And they don't absorb–they are not very effective when you take them orally. So, there are some drugs which come in the way where they are effective orally, but what is in the market at the moment is by injection. To me, if I want to get a biofilm, I think your idea is a really good idea, but at the moment, what I would do, I will use the probiotic. Also, I'll use certain food ingredients such as apple cider vinegar, garlic, coconut oil have been shown to show good activity against biofilms.

Ben:  Okay. I want to ask you a little bit more about the dietary component because I know you have a whole mycobiome-based diet as well. But before we do, let's back up a second. How would somebody actually get a fungal infection? Is this typically something that comes from food exposure, from some type of parasite exposure, lifestyle, environment? Like, what are the common reason someone actually gets a fungal infection in the first place?

Mahmoud:  Very good question. When you are in hospital, first of all, remember, a lot of these immunocompromised patients, they have a lot of antibiotics. So, you are killing all the bacteria, which we talked about that are useful, like lactobacillus, Bifidobacterium, and this sort of thing. And also, Candida can grow. So, one of the ways for Candida to cause serious infections is it will go through the GI tract, the gastrointestinal tract, and invade in the blood. That's one way. Another way, remember, we talked about the catheters?

Ben:  Mm-hmm.

Mahmoud:  We did a study many years ago where we found that Candida could be in the hands of the healthcare workers, like nurses, for example, or doctors for that matter. Okay? We found 40% of healthcare workers can have Candida in their hand. So, when they are manipulating the catheter, when you are in hospital and the nurse come to take care of your catheter, if she does not have gloves, if she did not wash, that is not good news because 40% of these people had this fungus. It could go through the catheter and cause an infection. So, these are some of the routes for a fungal infection. Also, if you have surgery, like abdominal surgery, for example, in your tummy, that also could be another way where you are doing the surgery. So, you're giving access of the organisms in your gut that can spill into the blood and cause an infection. So, there are a number of factors and number of ways for these organisms to cause infection.

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And then once you are exposed, what type of things–obviously, sugar is a biggie. I know most people know that sugar would feed fungus, which is why oftentimes things like kombucha, and beer, and wine, and processed sugars especially are something that can really help to control Candida. But are there other things that once somebody has been exposed would actually make that Candida or that fungus infection even worse, like any type of drugs, supplements, things along those lines?

Mahmoud:  Sure, sure. I mean, we talked about antibiotic of course. Also, another drug like corticosteroids, steroids, for example, for anti-inflammatory. Again, when I was a young man many years ago, there was a paper where you have a rabbit, which is treated with steroids, and guess what, it became susceptible to Candida infection. In fact, you will laugh at this, my Ph.D. thesis was on the effect of steroids on Candida. So, that's one thing. Now, of course, there are other medications, as well as over-the-counter, some of them, like for pump inhibitors, for GERD, acid reflux pumps, these are not very, very, very good. Sometimes, for example, contraceptives. They can also predispose you. So, there are a number of risk factors. Some of them which you can control, others you can't, okay? And these are a couple of the things which I mentioned.

Ben:  Okay. Now, when it comes to this idea of SIBO, small intestinal bacterial overgrowth, a lot of people think they have SIBO or have been diagnosed with SIBO. And from what I understand, this idea of having a fungal overgrowth, which I think you called CFO, small intestinal fungal overgrowth, it's got to be similar to SIBO. So, can you compare and contrast CFO and SIBO and whether the approach to one would be different than the approach to the other when it comes to actually getting rid of the issue? Also, I'd be interested in whether the two can coexist at the same time.

Mahmoud:  Sure. So, as you defined them, SIBO, small intestinal bacterial overgrowth, and SIFO is the same, small intestine fungal overgrowth. When you look at the published work, you'll find that they have similar symptoms. For example, bloating, indigestion, nausea, abdominal pain, gas, and belching sometimes. Also, another study compared the two since they have similar ones, and what they found out is that nausea is more prevalent and severe in SIFO people. While abdominal pain and gas are more common on SIBO. So, there is some differentiation between them.

Now, what they found again, whether they coexist together or not, they found all individual with SIFO, they grow Candida. While subject with SIBO, they have more aerobic bacteria, bacteria that lives in the air, basically, like Enterococcus, Streptococcus, and the few that had anaerobic flora, which means those that don't like to have oxygen, like Bacteroides, for example. Now, they found about 19% could have both as well. So, you can have SIFO alone, SIBO alone, and some of the people may have both together.

Ben:  Okay. Got it. And how common is that to someone with both SIBO and SIFO? Is that something that the BIOHM test that you run can diagnose, or is two different tests?

Mahmoud:  I think with SIFO, I think it's two different tests. What the BIOHM test can tell you is if you have an increase in Candida. So, definitely, if you have an increase in Candida, we know it has SIFO. I mean, this is a good question. When we look at the bacterial component of the analysis of the mycobiome, we also look at E. coli, C. diff, for example. And if they are high, then you know they are a problem. So, we could detect it, but usually, we don't call it a test for it to know whether you have SIFO or SIBO. However, the data contains that information and we will tell people about it. You have too much of this pathogen, you have too little of that, and the sort of thing.

Ben:  Okay. Got it. Now, one thing also in terms of contributing to a fungal overgrowth could potentially, of course, be not just the consumption of a lot of like fermented beverages, for example, or sugars that could feed the fungus, but then also certain diets as a whole you seem to actually think may have an impact possibly deleteriously on a pre-existing state of a fungal overgrowth. Like, one you talked about is the Mediterranean diet. That shocked me when you said that one study hadn't shown an increased prevalence and abundance of Candida in people who ate Mediterranean diet. And then, of course, our other popular diets like a paleo diet or a vegetarian diet. Are there certain diets that you would say would actually be conducive to a fungal overgrowth that people might think are actually healthy diets?

Mahmoud:  You know, it's really very, very good question. And also, to me, first of all, I am from the Mediterranean region, so I love Mediterranean food, and I think it's very, very healthy. However, there are certain components like the Mediterranean diet has a huge amount of grains also complex called a lot of dependence on pasta, which could encourage the growth of Candida. That's why in the book, we mentioned you can follow the Mediterranean diet provided you avoid, for example, taking too much alcohol because when you are in Italy or in Spain, you sit down and you enjoy yourself and people–or France, for that matter, you enjoy a lot of wine and the sort of thing. And these definitely have effect on our microbiome, which could encourage the growth of Candida as well.

Ben:  Now, just to interrupt you real quick. Is that something specific about the alcohol, or is it the sugars that are in these alcoholic beverages?

Mahmoud:  I think it's the sugar, as well as, as I said, the tendency to have too much cup.

Ben:  Okay. Alright. So, arguably, the same could be said for fruit juices as can be said for alcohol. It's not the ethanol, it's the actual sugar delivery mechanism?

Mahmoud:  Yes. You are absolutely right with [00:41:06] ______ alcohol. Studies have shown that if you drink too much, you are going to have a problem with your gut microbiome.

Ben:  Yeah. Well, yeah. I would suspect to be an indirect effect, like somebody could say, “Well, okay. Well, I'm just going to drink vodka if I have a Candida infection because it's low in sugar.” But then you're looking at potentially the impact that vodka might have on the bacteria because we know that ethanol can produce some toxicity to bacteria, which would then indirectly allow something like a fungal infection to get out of control.

Mahmoud:  I agree with you, absolutely. I mean, to me, when I talked about the Mediterranean diet, more to encourage Candida is really the core aspect, which is too much of that. So, to me, if you take a little bit of corn at different times of the day, it's fine as long as you don't have this huge pasta bowl and this sort of thing, and that's not a good way to go.

Ben:  What about something like a paleo diet?

Mahmoud:  I mean, the paleo diet again, what the interest in that is really, what about what they have? They have some good stuff, as you know, but there are a lot of grains, for example. They don't like, if I remember correctly–this is what I think I will not comment.

Ben:  Okay. Yeah. Well, I believe, if I recall what you said in the book, was that it might have too little prebiotic content because of the lack of whole grains and legumes. And the only thing I would think when it comes to perhaps that not providing enough fuel for the bacteria in the gut would be the idea that we do know that short-chain fatty acids and ketones, particularly beta-hydroxybutyrate to a certain extent can actually simulate a lot of what fiber does in terms of being able to facilitate natural bacterial count. And so perhaps if one were consuming short-chain fatty acids or using butyrates, or even in a relative state of ketosis much of the time, they might be able to get away with something like a paleo diet even if it was low in prebiotic content.

Mahmoud:  I really agree with you. That's why we say our diet, total gut balanced diet or the mycobiome diet is really customizable, and you can change it, you can stick to your diet provided you can add exactly like what you said, if you have the short-chain fatty acid, the butyrate, and whatever. This could substitute for that. So, you can modify it to address the sort of the drawback of that particular diet.

Ben:  Now, does the impact of something like a non-digestible starch versus the digestible starch have any effect? Like, if I'm looking at something like fiber or resistant starch, would that actually feed a fungal infection in a different way than a digestible starch, like processed sugar, or pasta, or something like that? Like, is there going to be a difference in terms of the fungal impact?

Mahmoud:  Yes, definitely. And the simple sugar, as you mentioned before, and the refined sugar definitely, that is a negative impact. However, the resistant starch or indigestible carbs are quite good because what happens, we don't break them down in our intestine. They go down to the large intestine where they are broken down by beneficial bacteria. And by being broken down by beneficial bacteria, we are producing the short-chain fatty acids and the other good metabolites which can help us. So, definitely, I will air into the resistant starch or indigestible carb much more than the simple one or refined sugars because of the fact that–in the one hand, these last ones, the refined sugar and simple sugar are going to increase Candida, whereas the others, we are going to feed the good guys, which keep Candida under control.

Ben:  Right, right. And just to clarify for folks listening in, the indigestible starches would be things that you might get from vegetables, or to a certain extent, whole grains or legumes or fruits, which you're going to be careful with due to the sugar content. But then you've also got your resistant starch foods like sweet potatoes or plantains or squash. And if you are going to have–let's say you're an athlete, you're concerned about fungal infection, you still need carbs to support performance, you definitely want to go over that stuff versus like isolated fructose, maltodextrin, or some kind of processed sugar source, which is going to feed the fungus much more readily than a resistant starch or something like a higher fiber food.

Mahmoud:  Absolutely. I think you said it so beautifully and clearly because of your exercise and bodybuilding maybe experienced before you know this. This is absolutely the way to go.

Ben:  Now, walk me through this whole mycobiome diet. I want to hear how this diet came to be, like eating to actually control the fungus, whether any research has been done on it, and then let's get into the details of what a typical day of eating would look like on this mycobiome type of diet to control fungus.

Mahmoud:  Yeah. So, really, how it came about is when we looked at what issues do we have in our–okay, especially to do with our Westernized diet, Western diet. The Western diet, we are eating a lot of red meat, we are eating a lot of sugars, and everything is oversized, and this whole thing. The sugar of course, it can feed the Candida, as we have established. Now, you have the red meat and the high-fat food. What you are encouraging, you are encouraging bacteria that is pro-inflammatory. In other words, it loves to break down by loving organisms, which cause inflammatory symptoms.

Now, we wanted to do–okay, what can we do to try to limit the growth or starve the growth of the bad guys? And this includes the Candida, as well as the pro-inflammatory bacteria. So, the Candida, I looked into the literature and the experience we have and we found that, as you said, we talked a lot about sugars, we found that people who are low in vitamins A, B, and C tend to have GI Candida issues, and also the type of protein you select. We need a good protein from plants or fish, for example. So, that's the first [00:47:56] ______. Then we wanted to encourage the good beneficial bacteria. And with that, that's where we come out with fibers, we come out with resistant starch. Okay?

Now, we also wanted to make sure we are able to disrupt the biofilms because the biofilms or digestive plaque is causing an issue to our gut lining, as well as inflammation. And we wanted to add finally, like cruciferous vegetables, for example, because they have good antioxidants and anti-inflammatory. So, this is with respect to the mycobiome. Also, because of our experience that you may be eating the best food yet at the same time you may have imbalance in your mycobiome in your gut.

We said there should be certain lifestyles that we should follow. Number one, you need to exercise. You need to have less stress. Go out, enjoy yourself. Go for hikes, walks. If you are so stressed out, take a few minutes during the day and relax. I never did yoga before, and now I do yoga and I find it so relaxing because all the time, I'm thinking about how I can do these moves and how I can do breathe and whatever. And by the end of the one and a half hour, I definitely feel much, much better.

Ben:  Yeah. Although as you note in the book during extreme exercise, blood can get diverted away from the GI system to the heart, or to the lungs, to the muscles. And that's why a lot of these more extreme sports or hard and heavy exercise can actually lead to, like a state of intestinal ischemia where the intestines get starved of blood, or a state of leaky gut due to increased intestinal permeability during exercise. So, I think this is why anyone who's on a path to heal their gut get rid of SIBO, get rid of SIFO, et cetera, should do more of the aerobic sunshine walking, the yoga, the swimming, some of the light restorative exercise or things that aren't going to divert as much blood away from the GI tract because it gets so much harder to heal your gut when you're doing a lot of that, kind of like metcon, high-intense training, or the long bouts of endurance.

Mahmoud:  I really agree with you, absolutely. To me, I wake up in the morning during the week, like five o'clock, I do my exercise half an hour in an elliptical machine. I found that running is not great because at my age, it's not great for my knees or my ankle. So, I do this elliptical for the last few years. I love it. And then before I do that, a little bit of stretching, some yoga moves. It's half an hour. It's not huge. At the weekend, I don't do it because I do a lot of taking my dog for a walk. I love to go out in nature. We are very lucky we have beautiful nature reserves here. So, go out, take your dog for a walk, and this altogether is going to help you really feel much, much better.

Ben:  Yeah, yeah. And I want to ask you a few specifics about the diet, too. Like, for example, there's no full-fat dairy. You have a specific section on the mycobiome diet where you say no full-fat dairy. What's the link between dairy and fungus?

Mahmoud:  I mean, really, it's not necessarily related directly to the fungus because you have the saturated fat. And as you know, saturated fats are not very good for our heart and the cardiovascular issues.

Ben:  Well, not necessarily. I mean, it would depend on your genetic status, like if you have the FTO gene, and also what those saturated fats are–how much of your total fat intake those are comprised of. And certainly, some people do have pretty robust ability to be able to handle higher amounts of saturated fat. So, I personally don't think there's a direct link, depending on the person between high saturated fat intake and cardiovascular disease, for example.

Mahmoud:  I mean, from my point of view is I would like to keep the good stuff. Like, I don't want to say, “Don't take dairy product,” because I think dairy products have other advantages from the minerals, for example, the vitamins, the proteins, casein. So, really, you should have some of it, but why not limit some of the stuff, which as you appropriately said, could not be helpful for others while others can handle it? So, it's a way in the median or in the middle. I'm always a moderate person of guy, and that's why I think this will be much better for a general use.

Ben:  Okay. Got it. Now, what about certain herbs or spices? Are there any that are particularly good at killing fungi? For example, I know you mentioned coconut oil earlier, and I think it's wonderful. Just start off the day with some coconut oil poling to help with the bacterial profile in the mouth. It can also, of course, have an antifungal effect from what I understand in the gut. But other than coconut oil, are there other key staples of an anti-fungal diet that you think have a real impact on Candida or other fungus?

Mahmoud:  I think turmeric, for example, is very good. I tend to have an egg in the morning and then add a little bit of that. And garlic is fantastic. I published many years ago again, three papers about the effect of garlic on Candida. It's fantastic, I tell you. So, these two I would go with anytime.

Ben:  And then you also said–I think earlier you said apple cider vinegar.

Mahmoud:  Yes. Apple cider vinegar have been shown to have a very good activity against the biofilms, which of course include ability of Candida to fall biofilm.

Ben:  Okay. Got it. And then you talked about these antifungal medications. But in addition to that, would there be other supplements that you think would pair really well with something like this mycobiome diet?

Mahmoud:  Yes. One is using a probiotic that have Saccharomyces boulardii. And I mentioned, the BIOHM product has that because studies have been shown–and we in our hand, we published this paper, which I mentioned before. We showed that having Saccharomyces boulardii, as well as lactobacillus, acidophilus, rhamnosus, and Bifidobacterium breve have very good activity against Candida by itself, as well as when it forms a biofilm with others. What other thing which I think is very good is some enzymes like amylase, for example, which is also part of the probiotic of BIOHM where studies have been shown to show it has anti-biofilm activity.

Ben:  And amylase, you mean like you were getting a digestive enzyme complex?

Mahmoud:  Yes, yes. That's why like also, it made sense to add it because it's quite safe because we have it and [00:55:09] ______. Now, other supplements are the vitamins. As I mentioned to you before, people who are deficient in vitamins A, B, and C really should take them to keep Candida at day. Yeah.

Ben:  Now, another thing regarding the actual kind of the supplementation piece is when it comes to these enzymes, like amylase you mentioned, don't a lot of doctors use enzymes like interface or serrapeptase or things like that to help to break down the biofilm as well?

Mahmoud:  For example, peptidase, it's going to break down the protein portion. With the biofilm, it's more a card type of thing because the matrix, which I mentioned, is complex polysaccharides. In addition to breaking some proteins, it will be good to have also something that can break the polysaccharide.

Ben:  Okay. Got it. So, what would be a sample breakfast? I want to hear a few sample meals, sample breakfast, sample lunch, and a sample dinner on this diet.

Mahmoud:  Okay. I can tell you what I do. I mean, what I do in the morning is I like to have–I still got oatmeal. I love it. I add to it sometimes banana, especially when they are ripe inside. I add, for example, some berries. Berries are great. So, that's during the week because I am in a hurry. That's what I do. Sometimes I had just one spoon of honey, even though it has sugar, but it's not too much. That's allowable. During a week–a weekend, sorry, I like to have an egg. I like to have tomatoes as well, some turmeric, as I mentioned in them. And of course, I love olives. Where I come from, we had a lot of olive tree and my mom used to have a cup on the table where we have olives. You eat it like you are eating peanuts.

Ben:  I love that.

Mahmoud:  Yeah. So, that's in the morning. At lunchtime, I tend to go after one of two ways, either I go after soup, particularly lentil soup. I love lentil soup. It has a lot of benefits. Also, to that, I add a little bit of spring onions. I add lemon. I love lemon, squeezed lemon on it. That's great. A little bit of pieces sometimes of a protein, like a little bit of chicken and the sort of thing. So, that's one thing. Or if I am in the mood, I'll take salad. I love the cucumber. My salad usually, it has cucumber, it has spring onion, it has garlic, it has lettuce, and of course, I love to add some like salmon as a protein. I love that. Now, sometimes between breakfast and lunch, depending on how I'm feeling, if I feel a little bit hungry about 10 o'clock because I wake up early, so I think some nuts, pistachio. I love pistachio. And actually, studies —

Ben:  Yeah. Those are fantastic for the biome, aren't they?

Mahmoud:  Isn't it? It's really great, and the studies have shown that. Now in the evening, my wife, she really takes care of me. Like for example, now this autumn, fall vegetables are really, really nice. So, we had like asparagus, we have cauliflower, we have Brussels sprout. So, that's our vegetable baked, and we have sometimes chicken, roasted chicken. We love fish as well. So, variety in what different vegetables to have and the variety of what different–what you call proteins. We focus mainly on chicken. Turkey is good, especially in certain times of the year if it's available, as well as fish.

Ben:  Yeah. It sounds like very much a Mediterranean diet without a lot of added sugar sweeteners. I would guess not a lot of alcohol-based on what you've said before, not a lot of refined grains. And it sounds kind of low on the oils and fats, and even the full-fat dairy products like we talked about a little bit earlier. But do you track your blood sugar at all or do you think that there are any issues in terms of like oats and berries and kind of like weaving the carbs in throughout the day? Do you ever use a continuous blood glucose monitor or a blood glucose monitor to track your blood glucose?

Mahmoud:  I really don't, but whenever I go to my primary physicians, I never had an issue. I mean, as far as these, especially oils and whatever. I love olive oil, again for the same reason that when I was growing up, that's what we had. I think it's very healthy. Now, I think as you said rightly, it's like Mediterranean diet, but it is customized. We make sure we reduce the fungus, encourage the others. So, I don't want people to misunderstand that part that diet is bad, not at all. It's a great diet. We take all the beneficial component of that and we avoid the ones which science have shown that they really could be detrimental.

Ben:  Right, right. And then I guess the other thing is a lot of these compounds, like the onions, the Brussels sprouts and things like that, if people did have a concurrent SIBO issue, I know that in many cases, the high amount of FODMAPs, like the fermentable compounds, oligosaccharides, things like that can contribute to gas and bloating if someone had SIBO. So, could someone, if they had SIBO and SIFO at the same time, do something similar to what you're doing, but then reduce some of those FODMAP foods or the high amount of raw veggies, things like that?

Mahmoud:  Yes. I really agree with you. I really agree with you. That's why again, I stressed the FOD, this is customizable diet. All of us, even in the diet itself description, we say, “Look, you need to ease into this diet.” We all sometimes eat in certain way and suddenly we would like to change our diet drastically. Try to do it slowly. Again, moderation built into it and then you will be able to have a nice transition from something which, let's say, have so much sugar into one more manageable and then you will feel much, much better.

The other thing which was interesting is we did a clinical study where we had people, we took their fecal samples before they started the diet, the mycobiome diet, which we have, and let them go for four weeks on the diet. And we took another sample in the middle, fecal sample. Also, we gave them a questionnaire to try to–sorry, a sort of list of their weight, how did they feel with respect to their constipation. All these questions we added and lo and behold at the end of the trial, we looked at the mycobiome and it really shifted into better profile of bacteria and fungus toward more beneficial one, which really pleased me tremendously.

Also, we looked at the symptoms that they had. One lady had SIBO, and the first week did not do much to her, second week, and the same, but she started a little bit to feel different by week three. By week four, she said, “I have never felt as good as this.” So, this really as a scientist, it makes me happy because sometimes you do something, you don't know whether it's going to work or not. So, lo and behold, this lady was a very happy camper. Other people where they had, for example, craving for sugars, they lost these cravings, but better sleeps some of the participants reported. So, all in all, it was very pleasing. And now, I'm doing even a larger trial because I like to have more and more data as you can imagine because of my background.

Ben:  Yeah, yeah. Well, it sounds like that is the place to start, like getting this–by the way, it's spelled B-I-O-H-M, this BIOHM Health test for fungus. And then from there, if you have it, then you could go into looking into whether getting on a pharmaceutical regimen for breaking down the biofilms and some of these antifungals you talked about combined with this mycobiome diet. And I'm curious, obviously, you're just one guy. I don't imagine that you can handle every person on the planet who has SIFO, but is there a way to find a doctor who's actually well-versed in something like SIFO? Do you have a practitioner network or anything like that?

Mahmoud:  Yes, sure. We have at the University Hospitals of Cleveland, I am professor at Case Western Reserve University and also member of the University Hospitals of Cleveland, we have a great Gastrointestinal and Hepatology Institute. We have really good people who can help, especially when it comes to the actual clinical symptoms and whatever, which I really don't do. What I can do is we can partner–well, I have my–it's called integrated microbiome core where we analyze the data, and then the physician in these institutions can help.

Ben:  Okay.

Mahmoud:  Yeah.

Ben:  Got it. Well, what I'll do is I'll link to your profile on the shownotes, which are going to be at BenGreenfieldFitness.com/totalgutbalance. That's BenGreenfieldFitness.com/totalgutbalance. And if you guys go there, I'll include links to all the things that Dr. Ghannoum and I talked about today, and then also some of the other resources for finding out if you have SIFO, some of the tests and his website, as well as his book, “Total Gut Balance,” which is just really fantastic, and I thought very educational on this whole concept of fungus, which I think, as I mentioned in the introduction, I think sometimes tends to get underemphasized compared to bacterial issues, but it's pretty important.

And I'm always shocked when I'm looking over the gut results of some of the clients that I've had tested, how many people have really high levels of things like Candida, and they are symptomatic at the same time, but it's more than just swallowing some coconut oil, like there's a pretty systematic dietary approach and often a supplement and a medication approach that you need to take into consideration. So, this book is a really good way to navigate all of that.

So, Dr. Ghannoum, thank you so much for coming on the show and sharing all this stuff with us, man.

Mahmoud:  I really appreciate. It was great pleasure.

Ben:  Awesome. Well, folks, I am Ben Greenfield along with the author of “Total Gut Balance,” Dr. Mahmoud Ghannoum signing out from BenGreenfieldFitness.com. Again, all the shownotes are at BenGreenfieldFitness.com/totalgutbalance. Have an amazing week.

Well, thanks for listening to today's show. You can grab all the shownotes, the resources, pretty much everything that I mentioned, over at BenGreenfieldFitness.com, along with plenty of other goodies from me, including the highly helpful “Ben Recommends” page, which is a list of pretty much everything that I've ever recommended for hormone, sleep, digestion, fat loss, performance, and plenty more. Please, also know that all the links, all the promo codes that I mentioned during this and every episode, helped to make this podcast happen and to generate income that enables me to keep bringing you this content every single week. So, when you listen in, be sure to use the links in the shownotes, use the promo codes that they generate because that helps to float this thing and keep it coming to you each and every week.

 

 

Dr. Ghannoum is a tenured professor and director of the Center for Medical Mycology at Case Western Reserve University and University Hospitals Cleveland Medical Center in Cleveland, Ohio. Educated in Lebanon, England and the United States, he received his PhD in microbial physiology from the University of Technology in England and an Executive MBA from the Weatherhead School of Management at Case Western Reserve University. He has spent his entire career studying medically important fungi and publish-ing extensively about their virulence factors, especially in microbial biofilms.

Over the past decade, Dr. Ghannoum recognized the role of the microbial community (both bacterial and fungal) in human health and published the first study describing the oral fungal community, coining the term “mycobiome.” He described the bacterial microbiome (bacteriome) and the mycobiome in HIV-infected patients and led the characterization of the interaction between bacteria and fungi as they relate to health and disease. In 2016, he published an opinion piece in The Scientist on the contribution of the mycobiome to human health and was consequently invited to speak at a number of meetings organized by the National Institutes of Health. He conducted a study characterizing the bacterial and fungal communities in Crohn’s disease patients that resulted in the first model of microbiome dysbiosis that implicated cooperation between bacteria and fungi in biofilms. This work resulted in a publication that received national and international coverage.

Dr. Ghannoum is also a fellow of the Infectious Disease Society of America and a past president of the Medical Mycological Society of the Americas (MMSA). He has received many distinguished awards for his research, and in 2013, he was selected as “Most Interesting Person” by Cleveland Magazine. In 2016, he received the Rhoda Benham Award presented for his continuous outstanding and meritorious contributions to medical mycology from the Medical Mycological Society of the Americas and the Freedom to Discover Award from Bristol-Myers Squibb for his work on microbial biofilms. In 2017, he was inducted as a fellow of the American Academy of Microbiology. He continues to be a pioneer in the characterization of the human microbiome.

With over 400 peer-reviewed publications to his credit and six published books on antifungal therapy, microbial biofilms, Candida adherence, and related topics, Dr. Ghannoum continues to be a prominent leader in his field. The National Institutes of Health has continually funded his research since 1994, and he recently received a large NIH grant to study the mechanisms of bacterial/fungal interaction in intestinal inflammation, such as in colitis and Crohn’s disease. He has also consulted for many international pharmaceutical and biotech companies and co-founded multiple successful and profitable companies, including BIOHM Health, launched in 2016, that engineer products and services to address the critical role of the bacterial and fungal communities in digestive and overall health and wellness. BIOHM Health was just awarded the Science and Innovation Award by Nutrition Business Journal. Dr. Ghannoum lives in Cleveland with his wife, children, and grandchildren.

During this discussion, you'll discover:

-The story behind Dr. Ghannoum coining the term “mycobiome”…7:40

• Mycology is the study of fungi; mycobiome refers to the fungi in our gut and parts of our body
• Focusing just on bacteria leads to overgrowth of candida
• Showed through research that over 100 fungal species exist in a typical human mouth

-Why the human body benefits from having fungus inside it…10:15

• We need fungi in our gut; good fungi, even candida in low doses, helps the body
  • Helps in breaking down, fermenting food
  • Candida or fungi at colonizer level cleans the immune system
• Gut Report to test fungus levels in the body
• Other microbiome tests examine the bacteria only
• biohmhealth.com

-What good and bad fungi are…14:18

• It varies by the species
• Saccharomyces boulardii and Pichia are good all the way around
• The level of candida is the determining factor, good or bad
  • There are different strains of candida

-Signs and symptoms of a fungal overgrowth…18:32

• Diarrhea
• Allergies
• Pain in the GI tract
• Damage to gut lining results

-How biofilms protect the gut…21:38

• Candida cooperates w/ E. coli and Serratia Marcescens (both pathogens) to make a biofilm
  • Plaque on teeth is an example of a biofilm
• Organisms in the gut are not free-floating; they stick to the gut
• Complex polysaccharides form around organisms; shields from drugs or immune cells
• Biofilms are resistant to being broken down
• Echinocandins inhibit the synthesis of the fungal cell wall:
  • Caspofungin
  • Micafungin
  • Anidulafungin

-How people get fungal infections…29:00

• Immunocompromised patients typically have lots of antibiotics (killing useful bacteria and allowing candida overgrowth)
• Goes through GI tract and attacks blood
• Nurses and doctors are carriers
• Surgery
• Steroids exacerbate susceptibility to candida infections

-Differences and similarities between SIFO and SIBO…35:40

• Similar symptoms
• Nausea is more prevalent and severe in SIFO patients
• Abdominal pain and gas is more prevalent in SIBO
• SIFO patients grow candida
• 19% of patients can have both SIBO and SIFO

-How popular diets may contribute to fungal overgrowth…39:05

• Mediterranean diet:
  • Lots of grains, carbs, pasta (can encourage growth of candida)
  • Follow the diet, provided you consume alcohol in moderation (sugars are problematic)
• Paleo diet may contain too little prebiotic content
• Mycobiome diet is customizable to the individual

-What life looks like on the mycobiome diet…46:10

• Goal is to limit growth of candida, and pro-inflammatory bacteria
• People low in Vitamins A, B, C are vulnerable
• Encourage beneficial bacteria (fibers, resistance starches)
• Stop biofilms (harming gut lining and causing inflammation)
• Cruciferous veggies are anti-inflammatory and antioxidant
• The best food can still result in imbalance in the gut
• Lifestyle factors:
  • Exercise, walk, hike, etc.
  • Blood can divert from the heart, lungs during extreme exercise
• No full-fat dairy
• Herbs and spices that are particularly efficacious:
  • Coconut oil
  • Turmeric
  • Garlic
  • Apple cider vinegar
• Supplements
  • Probiotic w/ Saccharomyces boulardii (Biohm)
  • Multivitamin w/ Vitamin A,B,C
• Sample breakfast:
  • Steel-cut oatmeal w/ bananas, berries, honey
  • Egg w/ tomatoes, turmeric, olives
• Sample lunch:
  • Lentil soup, spring onions, lemon, chicken
  • Salad w/ cucumber, spring onion, garlic, lettuce, salmon
  • Pistachios are great for the biome
• Sample dinner:
  • Asparagus, cauliflower, Brussels sprouts
  • Chicken roasted, fish

-How to find a physician who is knowledgeable in treating SIFO…1:05:11

• BIOHM Health testing

-And much more…

Resources from this episode:

– Book: Total Gut Balance: Fix Your Mycobiome Fast for Complete Digestive Wellness

– BIOHM Health testing

– Great Lakes Pharmaceuticals B-Lock for biofilms

– Fiber and Colon Health On A Well-Formulated Ketogenic Diet: New Insights Question Its Role As An Unconditional Requirement

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–Kion Aminos: Building blocks for muscle recovery, reduced cravings, better cognition, immunity, and more. Get 10% off your order of Kion Aminos, and everything at the Kion site when you use discount code: BGF10 at checkout.

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–Comrad Socks: Seriously comfortable compression socks designed to support your every move. Receive 20% off your Comrad purchase when you use discount code: KION

–ButcherBox: Delivers healthy 100% grass-fed and finished beef, free-range organic chicken, and heritage breed pork directly to your door on a monthly basis. All their products are humanely raised and NEVER given antibiotics or hormones. For 2 lbs of 100% grass-fed beef and 2 lbs of pure bacon for FREE, PLUS $20 off your first box go to ButcherBox.com/BEN.