182 | Untangling SIBO: From Diagnosis to Recovery with SIBO Expert Dr. Allison Siebecker - Inflammation Nation: Science Informed Wellness

Episode Transcript
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Dr. Noseworthy (00:03):
Hey everyone, welcome to the Func Med Nation
podcast.
I'm your host, dr Steve Noswery.
The views and opinions ofguests on this podcast are their
own and may differ from my own,but as always, I try to be
respectful of other people'sopinions, even when we might
disagree.
All right, guys, welcome backto the podcast or I should say

(00:25):
podcasts, because this episodeis actually going to air on both
of my podcasts, both theInflammation Nation as well as
the Funk Med Nation podcast, andthe topic today is SIBO, which
stands for small intestinalbacterial overgrowth, and I'm
sure our conversation isprobably going to range a little
bit around just the topic ofgut health in general.

(00:46):
But my guest today is Dr AllisonSiebecke , and she's been
specializing in SIBO since 2011.
She received a LifetimeAchievement Award for her work
in SIBO and outstandingcontributions to the field from
Gastro A&P.
She's been teaching advancedgastroenterology at National
University of Natural Medicinesince 2013 and is an

(01:07):
award-winning author.
She was the co-founder andformer medical director of the
SIBO Center for Digestive Healthat National University of
Natural Medicine, and herintegrative SIBO protocols have
helped thousands worldwide.
Allison, first of all, welcomeand I'm glad we had a chance to
connect, and I have to tell youthat I've been podcasting for a

(01:29):
few years now and from the verybeginning, your name was on a
short list that I had writtendown, probably three years ago,
of people that I really wantedto make sure that I connected
with, and I feel bad and I'msorry that it's taken me so long
to reach out to make thishappen.

Dr. Siebecker (01:46):
nice to know that I was a name on that list.
Thank you, yeah, there you goWell it's.

you know.
I truly consider you to be oneof the expert voices in the
field, and I would say that youknow you are, to my knowledge,
in our world as clinicians,because SIBO research existed
before, at least certainlybefore I became aware of it.
But as far as I know from myexperience, you were one of the

(02:13):
early voices on the clinicalside bringing SIBO to the
forefront of our let's call itour collective awareness.
And so I want to talk a littlebit about your background before
we get into the nitty-gritty ofSIBO, and I'm always interested
in people's origin stories,like how you got into natural

(02:33):
medicine.
So I kind of want to break itdown into two things.
Number one is what is it thatattracted you to natural
medicine to begin with?
And then I would like to knowwhat was going on in your mind
and in your practice that putSIBO on your radar, especially
to the point where you becameone of these leading voices.
So let's just start with theorigin story, like what were you

(02:55):
doing before you went tonaturopathic college and why did
you pick naturopathy?

Well, you know, I was always interested in
natural health and alternativehealth.
I think it started for me maybein high school, where I had
some friends who's who were intohealth food.
In high school, Like they,their parents bought like whole
wheat bread instead of whitebread and I I was really
attracted to that and I wasjealous that like they got the

(03:24):
whole wheat brown bread and Ihad the white bread.
And I mean, my mom did the bestshe could but she, she wasn't a
health food person, and so Igot totally into it and I like
lobbied my local health foodstore to let me start working
there, and so I did, and so Ijust got into that whole field.
I had also been really intomassage and so that sort of was

(03:48):
another gateway into more health, the health medical world.
And then I worked in healthfood stores as a career.
Actually, I was a manager atvarious health food stores
before I went to naturopathicschool.
But what actually, you know,made me want to go to
naturopathic school, but whatactually, you know, made me want
to go to naturopathic school is, I would say, like a calling,

(04:09):
like it was almost like aspiritual calling.
I actually had an experience.
I was.
I was at an herbal medicineconference just attending that
for me, because I worked, youknow, managing health food
stores.
We sold herbs and everything.
And I actually had thisexperience where I felt like a
lightning metaphorical lightningbolt like came down and hit me
and I stopped in my tracks.

(04:30):
I was walking, stopped and waslike I need to be a naturopathic
doctor, I have to go tonaturopathic medical school.
And I'll tell you what.
Thank God for that, Because ifI hadn't felt like it was, you
know something divine, I don'tknow where people get the
motivation to make it throughmedical school, If it was just
only their own ego or somethinglike oh man, it's just like a

(04:52):
career choice, right.
Just a career choice or justbecause, like, they want like a
status, job or I don't know whatthe heck motivates people.
But oh it's, and I did twodegrees at the same time.
I did a master's and adoctorate, and so it was just so
, so, so grueling, you know.
So thank God I had that becauseit was like, well, I can't say
no to that.

(05:13):
So I got to keep going.

Yeah, but you know, yeah, and that fuels the
fire as you keep going throughthe challenges.

Totally, totally.
And then, in terms of you knowwhat was I doing in my after I
graduated?
I was doing general medicine.
A lot of my master's was inoriental medicine, so a lot of
acupuncture as well.
But really the thing is is thatI had IBS my whole life and that
turned out to be SIBO from notmy whole life, from about when I

(05:41):
was five as near as I can tellis when I got it, cause I was
born with normal, um, you know,gi function according to my
parents.
But but since I was about fiveI had it and struggled a lot
with it.
My whole life struggledterribly with it.
So so, like so many of ourpatients stories saw so many
doctors, tried just abouteverything you can think of and

(06:03):
I really mean that and wentthrough medical school still no
answers.
And it wasn't until afterwardswhen I found out about SIBO from
my gastroenterology professorwas a friend of mine also and he
was writing a book and happenedto have just found out about
SIBO and just put like aparagraph in his book about it

(06:24):
and I was helping edit andreview his book and I was like
what?
And I went and looked it up andjust went down a rabbit hole
and it was hard back then I mean, that was like 15 years ago but
then again another sort of firegot lit in me.
Really, what did it for me waswhen I tried a treatment for it.
I actually started with diet.

(06:46):
I tried diet for it.
I tried the specificcarbohydrate diet, sed for short
, and within 24 hours my painthat I had suffered terribly
with abdominal pain was gone,and so you can imagine how that
would light a fire.
I just thought about all of thepatients and people that I know
with IBS who struggle and tothink that they could get that

(07:07):
kind of relief, you know,overnight.
Then that's what lit the firefor me to want to raise
awareness and, yes, I sort oftook it on as my job to raise
awareness of this, becausenobody knew.

Yeah, and I think you know that there's some
elements to the origin storythat I think we kind of all
share, and I won't bore you withmy own.
But you know, I was dealingwith some orthopedic issues that
surgery and steroid injectionsand different things didn't fix
back when I was in well, and I'dnever seen one before, right,

(07:43):
and so I had that personalexperience that just changed my
life and I thought, well, how?
And at the time I was working,uh, I was living and working in
downtown Toronto, I'm Canadianoriginally and um, and I thought
well, how, how neat would it be, for if I could change somebody
else's life, the way that thisguy changed mine?

That's exactly it .

But I think that that's a very common thing Now.
I do remember when I was infirst year at Logan Chiropractic
College in St Louis, one of ourearly instructors in the first
semester asked for a show ofhands, like how many of you are
here because your dad's achiropractor, your mom's a
chiropractor, your uncle andabout half the class raised
their hand and the other halfdidn't.

(08:27):
And he said this is quiteinteresting because five years
ago everybody would have raisedtheir hand because, you know,
being a chiropractor, you werekind of raised with chiropractic
or raised as chiropracticfamily.
And he said it's an interestingshift that now people are
starting to choose chiropracticjust simply out of an array of
different professions.

(08:48):
Right, and so it makes sense tome, because I I had wanted to
ask you the question like whydid you pick naturopathy versus
acupuncture?
And I know that you're alicensed acupuncturist as well.
Now I'm assuming that can likecame later no right.

At the same time, well at the same time.
Well, where it came was youright at the same time.
Well, where it came was you'reright, though the desire to do
it came when I was innaturopathic school and they had
a program and we all have totake some Chinese medicine
classes anyway in naturopathy.
And then, yes, then I justdecided to do it, and so I just
did it together.
But you're right, that desirecame later.

Yeah.
So let me ask you to do thisbecause we're bandying around,
because this podcast is going togo out to the general public as
well as to clinicians Definenaturopathy and maybe
distinguish that between a moreumbrella term of a natural
medicine doctor, Because we usethese terms kind of like
interchangeably and I might tellsomeone I do functional

(09:41):
medicine and they think I'm anaturopath, right?
So what?
Like just as succinctly as youcan, let's say you're talking to
general public, how would youdefine what naturopathy is and
what you do as a naturopathicmedicine doctor?

Yeah, it's a similar training in sort of what
you see in the books as thebasics, to an MD, a medical
doctor, and it's its own degree.
It's its own, you know, schooltraining and degree, but it's a
similar base training.
But then in addition we add inthings like training in

(10:17):
different, basically we wouldcall treatments or modalities.
So we have training in actuallymanual adjustment.
We only do a year.
So you know, I personally sendeveryone to a chiropractor who's
had their four years, you know.
So we have some manualadjustment training.
We have homeopathy, we haveherbal medicine or botanical
medicine.
We have actually hydrotherapy,which is like use of hot and

(10:40):
cold, various sort of old schoolhome treatments that you know,
things like that.
We learn physical medicine,like using TENS machines, things
like that, some sort of sportsmedicine and we learn.
We also like the base training,we also learn and
pharmaceutical antibiotics.
So we, you know we have thesame base training and we also

(11:00):
learn minor surgery.
So the same base training isthere.
But then we add in the naturalmodalities and of course diet,
nutrition and diet is highlystressed as well as like
lifestyle.
But we take all the samepathology classes and all that,
but we have different modalitiesand we also have different
philosophy and we actually haveclasses in like natural medicine

(11:22):
philosophy.
You know, first do no harmreally bringing that through.
How do we really bring thatinto our practice?
And then I think the otherthing I would say is is that the
the ability to practice isdifferent state to state.
But for naturopathic medicinethere are states where we are
licensed primary care physicianswhich need legally to be

(11:45):
covered by insurance.
Sometimes they try not to, andthen also we can prescribe not
in all states, but so that isone thing that's a little
different from maybe like achiropractic degree.
I don't think there are anystates where chiropractors are,
like allowed to prescribe.

There are some very forward thinking states and
state associations like thereand I want to say it's Arizona
can do some injections.

We can prescribe any medicine, you know, like
just anything, any, anyantibiotic, and we're trained,
we're trained in it, so so inthat way it's kind of like the
best of both worlds, but what wedon't do, we don't do major
surgery, we do only minor, so wedon't go below a certain level.
We're not working in hospitalsdoing my major surgery.

(12:32):
So, and we don't have the same.
We have some specialties but wedon't have the same specialties
, so you know.
So think of it as it's likeyou're getting your basic
training but you're getting allyour natural training too.
So it's a wonderful thing.
And functional medicine.
That gets confusing too,because I think where that was
originally created for MDs whowanted, after they've gotten
their MD, they're reallyattracted to natural medicine

(12:53):
and they want to incorporatemore of that.
And the big thing there is thatMD has quite an emphasis on
structural organic problems,missing out on some of the
function of the body, and that'swhere the functional medicine
came in to sort of fill that gapyou know.

yeah, well, let me ask you about that because
I've asked other um otherclinicians and say subject
matter experts, like how we cango back to jeff bland's original
paper on functional medicineand kind of the rules and the
tenets of that that theydeveloped.
But functional medicine I thinkthe term is used very loosely

(13:33):
to describe many differentthings and you can have two
clinicians that say they dofunctional medicine but they
actually do two very differentthings.
How would you describe that?
How would you like if you wereto put pen to paper and outline
a framework?
This is what functionalmedicine is.
What is it and, in your opinion, how does that differ from,

(13:53):
let's say, the basicphilosophies and principles of
naturopathy?

Well, you know, I haven't gone through the
Institute for FunctionalMedicine Training, but from the
outside, what I can say and I'vetaken classes from some people
who are functional medicineteachers, so you know, I'm not
sure if I've got it right, butwhat I would say is,
philosophically, functionalmedicine is really trying to
focus more on root causes,identifying root causes, which,

(14:20):
you know, that's the hugecriticism in MD world is this
it's more about fixing thesymptoms right, um, and also
trying to restore function backto normal as best as can be.
And so that's where they may usedifferent um test, uh, you know
, test positive criteria, notjust what gives you the disease,

(14:42):
but looking at opening thoselevels a little to say what's
the pre-disease, let's get,let's get you before you get all
the way there.
So, prevention function, reallymaking sure how well is your
thyroid function, how well iseverything functioning, things
like that, um, and you know, Iguess the difference is that, um
, naturopathy, of course we haveroot cause built into

(15:05):
everything.
We have both structure andfunction built into everything.
I think it's probably more sothe modalities.
I think a typical functionalmedicine practitioner would have
been an MD that wouldn'treceive extensive herbal
medicine training or homeopathytraining or things like that,
but then they may learn some ofthat later.
They learn a lot of nutritionalsupplement, I think in the

(15:27):
Institute of Functional Medicine, of course we learn all that as
well.
So maybe there's just somemodalities or treatments that
aren't quite incorporated in tofunctional medicine but could be
.
You know, if they have classesin that.

Yeah, and there's certainly a lot of
crossover and like if you couldcreate a Venn diagram of all the
different natural medicinedisciplines, there would be a
lot of crossover and, like ifyou could create a Venn diagram
of all the different naturalmedicine disciplines, there
would be a lot of intersection,right, but then there would be
some things that might bespecific and unique to one
particular discipline that youtypically don't see in the
others.

Yeah, and I just want to say that just generally
for me, all of thesedistinctions, generally for me,
all of these distinctions in mymind, I don't care so much.
I mean, what matters to me ispeople have good training and
have goodwill, good heart and,you know, are trying to help

(16:21):
people and you know we've allmet.
Any discipline can have peoplethat meet those criteria and are
doing a phenomenal job and arenot annoying, and then every
profession can, every disciplinecan have people that you know
you're disappointed in theamazing resilience and
flexibility of how the humanbody is framed and designed that

(16:49):
sometimes it doesn't take muchof a change or an input to
course correct.

But then as conditions evolve, as cases
become more complicated, ittakes a lot more effort right.
As cases become morecomplicated, it takes a lot more
effort right.
And again I go back to some ofmy early stories.
When I was being trained inchiropractic we had this one old
.
He was an old I'm going to callhim a geezer.
At the time he was probably noolder than I am right now, but

(17:18):
that was a while ago and he saidsome people, you just need to
hit them in the butt with abroomstick and they're going to
get better.
And I see that in some of my ownclients.
Sometimes the only thing Ireally needed to do was maybe
optimize their diet or if weneed to do supplementation.
It doesn't take much Likeyou're not taking six different

(17:39):
formulas three times a day for12 weeks to make something shift
and change.
But then there might be somecases that do require that.
And so there's like this hugewide range of different case
presentations.
But you know what I like theseconversations about things like
principles and concepts, andbecause I've always attributed
this next question, I'm going toask you to naturopathy, and I

(18:00):
don't know if I should.
I'm sure the concepts kind ofpredate what we consider to be
modern naturopathy.
But there's this again, I'mgoing to say old naturopathic
principle that says that healthbegins in the gut.

Great, because the saying I think that I've
heard that is attributed whoknows if it's true to like,
isn't it Hippocrates?
Is all disease begins in thegut, and I like that you flipped
it All health begins in the gut.

I prefer that.
Yeah, that just underlies, like, the difference in how we're
trained to think Right, becauseI, when I work with my own
clients, I don't think that I'mcertainly not treating disease.
When I work with my own clients, I don't think that I'm
certainly not treating disease.
I'm trying to find out wherepeople have lost wellness and
how to restore that.
That's the way my mind works interms of what it is we're doing

(19:01):
in an exchange with clinicianand patient or client.
I want to ask you about thisidea because there are a lot of,
and I'm going to use looselynaturopathic and functional
medicine kind of interchangeably, because there is a lot of
overlap.
So forgive me if I don't wantto step on any terminology.

No, it doesn't bother me at all.
I don't care about linguistics.

Yeah, there you go.
So I mean, I know that thereare a lot of docs that, no
matter what walks into theiroffice or what someone's
clinical presentation is, orreally what their underlying
true causes are, they're soconvinced that health begins in
the gut that that's where theystart every single time.
Now I'm not judging whetherthat's the right or the wrong
thing to do, because I thinkthat judgment has to be done on
a case-by-case basis, mixed inwith how the clinician thinks.

(19:40):
But let me get your take onthat as someone who's been
trained differently than I.
Is that what you believeclinically?
And again, I'm not judging onedirection or another, but do you
think that that's always a goodthing to do is to figure out
what's going on with the gut andto fix that?

I can't imagine it's always, always the right
thing.
I mean, you know, I've heardsayings, other sayings, that
people in their own disciplinessay all disease or all health
begins in there, the thing theyspecialize in, right, so but you
know, I can say that there is alot of truth to it and you know

(20:18):
, sibo is a fascinating exampleof it in that when we take a
look at like, I have aneducational website, free
educational website, and onething I do is I, every time
there's new studies come out, Ido it quarterly, I add them into
this associated disease list,and the associated disease list
is like massive.

(20:39):
And so what I mean is that SIBOhas links with diseases in all
parts of the body neurological,kidney, cardiovascular and
atherosclerosis, and liver andskin, dermatological mood.
It goes on and on and on.
So I can see the underpinningof truth in that statement for

(21:03):
sure, even just looking at SIBO.
But I can't imagine it's alwaysthe way to go.
I think people have their ownways to practice where they like
to start, and I think theydevelop that over time and
everybody has to follow theirown medical intuition with what
they want to do Exactly.

And I totally agree with that.
I absolutely agree with that.
I absolutely agree with that,and you know I'm thinking about.
You know we're going to have aconversation coming up here in a
little bit about causes andconsequences of sebo, right,
because if somebody has sebo,something caused it, and if
we're really truly concernedabout root cause, the question
we're asking is not simply doyou have sebo, how do I treat it

(21:42):
?
It's oh, you have sebo, why doyou have SIBO?
How do I treat it?
It's oh, you have SIBO, why doyou have SIBO?

Yeah.

Right, because one of our and I would say we're
probably pretty close of thesame mindset that if we were to
critique the medical approach,the pharmaceutical approach to
SIBO, it's typically, you know,a round of antibiotics or so and
not necessarily any otherchanges.
And that might depend on theknowledge base and experience of

(22:09):
the prescribing physician.
But the mindset is typically,well, you've got these
infections, let's useantibiotics to kill that, and
then we're done.
We kind of wipe our hands andwalk away unless it recurs, and
then are going to see you inthree months or six months down
the road.
But never in that model or thatapproach is there this question
about what's causing the SIBOand, if you don't mind, let's

(22:31):
put a pin in that and come backto it, because I think that's a
very it's a great conversation,particularly for the clinical
side of things.
But it might be helpful foranyone out there listening who's
not a clinician, who thinksthey might have SIBO, who could
look back in their own historyand go, oh, maybe that's why.
And I want to keep going, butlet me just pause.

(22:52):
I do have a couple of otherquestions, just in terms of the
general realm of discussionbefore we get into details.
So I'm always interested in howother clinicians explain things
, especially complex things likeSIBO, to their clients and
their patients.
So I want you to pretend thatI'm a prospective client.

(23:14):
I'm sitting in your consultroom.
You walk in, we meet for thefirst time.
You go through my history.
Maybe I've got some labs, maybeI don't.

And you start thinking in your mind okay, I
think Steve's got SIBO.
And then you bring that up andI say SIBO, what's that?
Okay, now I have to tell yousomething funny.
I'm going to answer thequestion.
But I've been a SIBO specialistsince I started in SIBO I, when
I went, I was a specialist, soeverybody who came to me already
knew what it was.
But I have an answer and here's, here's how I would describe it
.
So you know, but I'm luckycause I didn't have to have that

(23:51):
first conversation, right?
Yeah, I would say you know.
So it's small intestinalbacterial overgrowth and that it
it sounds like what its name isin that bacteria don't normally
, we don't typically have alarge amount of bacteria in our
small intestine.
The place for that is a largeintestine.
Most people know we have, youknow, a microbiome that's

(24:14):
beneficial in our largeintestine, so that's, that's
good.
But typically in the smallintestine we don't have, you
know, a very large, and so whathappens is there's like a
colonization or an overgrowth ofbacteria there and they mess
with the structure and thefunction in that area, and the

(24:34):
function is to digest our foodand absorb our food, and so the
bacteria just wreak havoc withthat and they mess up all of our
digestion and absorption.
And they also mess up thestructure.
They cause damage to the liningof the small intestine and so,
once again, that hasramifications on what we're
absorbing and it also leads to awhole bunch of symptoms because
we're not supposed to have thisamount of bacteria there and

(24:57):
it's just not the place for them.
It's kind of like location,location, location right In real
estate.
So then we get all thesesymptoms like abdominal bloating
, bowel movement changes, painor discomfort, and the list goes
on.
So that's basically it.
They shouldn't be so many there.
They've had the opportunity togrow there.

(25:17):
We haven't talked about why,and we need to reduce that.

Well, that sounds great, doc.
How do people get SIBO?

Great, let's move into the conversation.
Okay, but instead of just doingit right like to a patient, I
want to tell you something alittle bit more background,
which is that I like to thinkabout it in two levels the
physiologic, underlying causes,meaning what's gone wrong in the
body to allow it to happen, andthen for now, I'll just call it
the causes or the risk factors.

(25:46):
So these are like the diseasesand things that lead to it, but
if we think about it, in thebody we have a lot of
protections, naturally, thatmake it, so we don't get this.
I mean, this is not the waywe're supposed to be and they've
been able to figure out.
Really, the most important oneis this movement or kind of form
of peristalsis in the smallintestine, the migrating motor
complex, and it doesn't actuallyhappen with food.

(26:08):
It happens when we're fastingand it's called the housekeeper
wave because it cleans up afterwe eat, and one of its main
functions is, besides, like sortof cleaning up is to sweep
bacteria on a regular basis awaydown into the large intestine
to be excreted, keeping it clean.
It's just like constantlysweeping away whatever bacteria
are accumulating, and we nowknow that this is one of the

(26:31):
main reasons why people get SIBOis this becomes deficient, we
don't have as much sweepingcleaning action, and that's
really the main underlying cause, physiologically, of SIBO.
And so what would then cause?
That would be really anythingthat could damage the smooth
muscles or the nerves thatcreate this movement.

(26:51):
And it's a large list of things, a large list of things, but I
can tell you some of the mostcommon.
The most common of all is foodpoisoning, also called
traveler's diarrhea or stomachflu.
But really here we're talkingabout bacterial food poisoning,
because food poisoning it's mostcommon from virus, norovirus.

(27:12):
But this is not that.
This is bacterial foodpoisoning and, as you know, this
pathophysiology sequence hasbeen figured out and basically
what occurs is an autoimmunesituation is triggered,
unfortunately, and the bodydamages its own nerves that
create this migrating motorcomplex and then those waves

(27:35):
diminish.
And just think of it sort oflike this this is a great
analogy for you know, justnon-practitioners as well is
think of it like a flowing river.
When a river is flowing,there's not much chance for
bacteria to accumulate, but ifit becomes stagnant and still we
know bacteria overgrow, itbecomes like a swamp.
So it's like that If it slowsdown, bacteria overgrow and

(27:58):
small intestine is a dark, warm,moist environment.

So without much movement there you go.

That's sort of the main thing.
And then let me just I can saythe other risk factors for the
slow motility.
But let me just say the othersort of key physiologic reason
would be something anatomicallystructurally wrong or not normal
, we'll say, and the most commonfor this would be an
obstruction, or really herewe're talking about a partial
obstruction and here we can sortof think about it like a log
jam in that same river analogy.

(28:33):
If some things pile up in anarea in the river, stuff's going
to back up behind where thoselogs are, so just physically,
and so this can be things likestrictures, that's a narrowing
of the intestine, it could be avolvulus which is a twist, or a
kink, it could be a tumor, youknow.

(28:53):
It could be a compression, anarea where something's getting
compression.
Most common is adhesions, andadhesions are scar bands,
they're they're a repairsubstance, they're supposed to
be helping, but sometimes theyconform in such a way where they
compress parts of the smallintestine, causing a narrowing.
And then you know, and then ifyou have an area like this, the

(29:14):
river can't flow as well andstuff can back up behind it.

And so you know, you'll get an area of narrowing
and an area of dilation aboutit.
So, um, two questions that arejust relevant to things that
you're just saying.
First question is and I'll putthem both out and we can just
answer them one at a time Handleon what percentage of cases
that you're dealing with thatyou're seeing a history of food

(29:38):
poisoning, because I routinelyask that in my intake form,
especially if they have gastrosymptoms that I think look like
SIBO, I'll ask them have youever had a viral gastroenteritis
, ever had food poisoning?
I don't always see it, butpersonally I don't know what the
percentages would be.
I'd be interested in yourfeedback.

(29:59):
And the other thing about thescar tissue.
I know that abdominal surgeryis a risk factor for SIBO and
abdominal surgery doesn'tnecessarily mean intestinal
surgery.
Right, because I've seen somepapers that have looked at scar
tissue, post-hysterectomy, forexample, or post-gallbladder

(30:22):
removal.
Well, technically that's kindof intestinal because it's the
GI tract, but it doesn't have tobe.
I had surgery on my bowels andthat's where my scar just came
from.
Yeah, yeah, Okay, so thatanswers that question.
And what?
What is your impression of?
What percentage of all SIBOcases do you see?
Have a history of foodpoisoning that you think is

(30:44):
causative?

That's the majority.
So you know, when I was a SIBOspecialist, that's all I saw and
you know at least 60%, I wouldsay.
And here's the key thing tonote is that many people do not
remember having food poisoningwho actually have food poisoning
as their cause of SIBO.
So it's vitally important toask it in history because you're

(31:07):
going to grab the most peoplethat way.
However, particularly inmystery cases, very often when
you're like you really can'tfigure out what the underlying
cause is and, by the way, thisis not the easiest thing to do.
We haven't really talked itthrough, but there's a huge list
of underlying causes of SIBO,many of which are specialty

(31:30):
fields in and of themselves tolearn how to diagnose, so it
takes referrals.
It's not the easiest thing.
It's very easy to say find theroot cause and we need to try,
but it's not so easy to justwhip that out.
You know Right.
Agreed, but yeah right, youknow.
So it's important to know this.
So we don't get you knowwhatever, but we do have a test.
That's a blood test that checksfor this particular cause of
SIBO and in cases where I can'tfigure it out, I run this very

(31:54):
often I run this and it comesback positive and the person has
no memory of having foodpoisoning, and that's because,
contrary to popular belief, foodpoisoning can occur with mild
symptoms.
We all think of the.
You know both ends coming out,both ends horrible.

And they're doing that, yeah.

You wish you could die.
You know, just awful, but itcould just be some mild, soft
stool one night and you don'tthink anything of it.
That actually can correlate,and so I've seen that very often
where people don't remember.
And one other thing is that thecause of food poisoning it can

(32:31):
move from food poisoning.
The symptoms can change andmove right into the SIBO, ibs
symptoms and you have SIBO, butmore commonly there's a delay.
It takes time for that nervedamage to occur from the
autoimmune damage and it'stypically three to six months
after.
And so if it's three monthsafter, people are not linking it

(32:52):
, doctors are not linking it,and so that's a key thing to
note for people is that it's notlike one right after the other.

Yeah, maybe a failing in our collective
approach is sometimes we'relooking for the cause too
proximal to when we're talkingto somebody, like we don't go
back 10 years, 20 years orwhatever the case might be.
So I'm interested what test areyou running if you have this
like a mystery case?
What test do you use?

Yeah, so this test is generally called the IBS
blood test, but some of thespecific labs are.
Ibs Smart is the main test.
This is the second generationversion of this test.
Ibs Smart there's also IBSCheck was the original version
of it.
And then I think, vibrantAmerica and Vibrant Wellness and

(33:41):
Cyrex have their own versions.

Vibrant Wellness and Cyrex have their own
versions.
So you're looking forantibodies to cytolethal
distending toxin?
Is that your approach?

Yeah, we didn't explain that, but this is the
toxin that all the bacteria thatcause this food poisoning.
They all secrete the same toxin.
So we're looking for antibodiesagainst that and also
antibodies against the nerve,the protein that's on the nerve
cell that the immune system isdamaging and that's called
vinculin.
So antibodies against vinculin.

So that's what this test is.

It checks for those two and there's a
different prognosis dependingupon which is positive.
Vinculin is the sort of moresevere form of it.

And that's positive.

But it lets us know if this is the cause of
SIBO.
There are many other causes,right, sure, but this one, and
also this will also then let usknow that it's the migrating
motor complex as the actualphysiologic underlying cause,
because that is what occurs inthis pathophysiology Doesn't
mean there couldn't be otherthings too.

No, and it's probably also good to point out
that you can have more than onecause.
Yeah Right, there's no rulethat says you know, thou shalt
only have X, and you shall nothave Y.
That's right, yeah.

And I have many patients like that.
They have like four, three orfour main causes of SIBO.

Yeah.

So maybe I'll just quickly mention a few of
the others, just so people canget a smattering idea, so maybe
I'll just quickly mention a fewof the others just so people can
get a smattering idea.
So inflammatory bowel diseasethat can cause strictures and
all sorts of structural problems.
Diabetes that can cause nervedamage which can damage the
migrating motor complex.
We know that many people withdiabetes get gastroparesis
within like five years of theirdiagnosis.

(35:20):
Gastroparesis is slow stomachemptying and there's a migrating
motor complex that begins inthe stomach so that sort of
automatically affects that.
Hypothyroid of course has slowmotility.
We know constipation, but itaffects the migrating motor
complex.
Ehlers-danlos syndrome theseare all diseases Ehlers-Danlos I
don't know how familiareveryone's becoming with it.

(35:41):
It's like newer within the last10 years to many of us.
But it's not rare and it canhave both structural components
and migrating motor issues.
It's a double whammy.
Many people, with a very highpercentage of people with
Ehlers-Danlos, have SIBO.

One of the aspects of that is just like,
let's say, weakened connectivetissue right.

Yeah, and that can cause prolapse in the
intestines and sort of almostlike blind loops and twists and
kinks and things um parasites.
We don't have a lot of good uhliterature yet, but we're pretty
sure it slows the migratingmotor complex.
Various infections um someclassic sort of risks, are like
hypochlorhydria.

(36:23):
That's one of the body'sprotections.
So many people havehypochlorhydria.
That's one of the body'sprotections.
So many people havehypochlorhydria.
And then of course there'smedications like proton pump
inhibitors that on purpose causehypochlorhydria, so they're a
risk factor.
Other medicines would be opiatenarcotics.
We know they cause constipation, painkillers, but they also
slow the migrating motor complex.

(36:44):
And even antibiotics have beenlinked with slowing the
We use some pharmaceuticalantibiotics for SIBO and they
work, but there are someantibiotics that could
potentially slow the migratingmotor complex and this is
important because so manypatients come in feeling that
medications like this, andincluding antibiotics, were what

(37:04):
caused their SIBO, and sothere's some truth there.
And then we have things liketraumatic brain injury this is
considered to be an epidemicthese days that can slow the
Parkinson's disease one of thefirst signs is constipation and
slowing of the migrating motorcomplex.
We have Lyme and co-infectionsslow the migrating motor complex

(37:26):
.
We have Lyme and co-infectionsslow the migrating motor complex
.
And then we have, you know,generally adhesions, things that
cause that.
You know things likeendometriosis, very high degree
of SIBO in that Appendicitis.
People can have smolderingappendicitis, not just even
acute, where it gets removed and, as you mentioned, abdominal
surgery, radiation, but honestly, adhesions can be caused by

(37:51):
infection.
So that'd be like appendicitis,inflammation same thing there
or injury.
And so a lot of people haveabdominal adhesions from
sporting accidents or justliving, you know living their
life, falling off a bike, youknow you can.
Car accidents, you can get themfor many, many reasons, and
that is probably our second mostcommon cause of SIBO across the

(38:13):
board, I'd say I'd say thatadhesions abdominal adhesions
which you know people are notthinking about, Right, Right.
And I'd say the third mostcommon cause would be all of
these diseases I'm mentioningand medications like is it
clumped risk factor?
So, and one last I must mention, is mold, toxic mold illness.

(38:35):
This is another thing many ofus have learned more about in
the last you know, five-ishyears.
We could say there's anepidemic of that.
You know, water damage in homes, work, buildings, cars and uh.
Mold illness also slows themigrating motor complex and mold
illness is what's typicallyinvolved, one of the first

(38:55):
things we think of when we havea very challenging, tough case
of SIBO.
And actually, while I think ofit, there's one other thing I
want to mention.
You talked about finding theroot cause and the relapse rate,
and I just want to say thatfrom the studies that have been
done, we know that SIBO has avery high relapse rate.
It's about two-thirds of caseswill relapse.

(39:17):
You know that will just comeback.

And that's independent of the treatment
methodology, because I wouldimagine relapse rate is higher
with certain treatments thanothers.

No, that is not true.
All treatments have equalefficacy and equal relapse rates
.

Oh, okay, as we can tell, that's a new thing for
me, yeah.

Yeah, all the treatments have the same success
rates, so they all work equally.
But just briefly, what arethose treatments?
Pharmaceutical antibiotics,herbal antibiotics and elemental
diet they all work equally well, and relapse has nothing to do
with that.
What the relapse has to do withis there's an underlying cause
there, like well everything wejust mentioned diabetes.

(39:56):
There's no known cure at thistime for diabetes.
It can be very well managed.
Ehlers-danlos same thing, youknow.
Food poisoning same thing.
There's no known cure at thistime for the autoimmune damage
that is triggered by that.
So there are many chronicunderlying causes.
There are other causes that canbe gotten rid of Lyme and
co-infection that can be gottenrid of, and many other things.

(40:17):
You can stop taking opiates,you know, but we have to look
for these things and there are alot of underlying causes.
So that's enough for me.

Yeah, no, it's a lot.
It's a lot to think about.
So back to the adhesions andscar tissue.
Are you doing any imaging?
Can we see this on MRIdiagnostic ultrasound?

Such a good question because the best test
for this is actually a bariumswallow with follow-through, and
this is considered to be anoutdated, old test that's fallen
out of favor and everybodywants to do MRI or CT first and
what I would say is you know, ifyour doc wants to run those
tests first, fine, and yourinsurance will cover it.

(41:01):
Fine, let them do what theywant to do.
But eventually you're going toneed to come to the barium
swallow.
This is not a barium enema.
It's a barium that you drinkand the thing here is that it
actually needs specialinstructions because most
radiologists they don't want todo this test and they'll just
take five films, five images orjust a few.

(41:26):
So I would encourage anybody, ifyou're going to ask for this
test, to to write an instructionor ask for this so that the
radiologist knows what to do,which is rule out adhesions with
multiple spot films andpositional changes to visualize
each segment of the bowel.
Then they will take like 30films and give you and they know
what they're looking for now.
But adhesions can be seen on abarium as right angles and the

(41:50):
radiologist will do theinterpretation.
We don't need to know how to dothis, but just for you know,
the bowel always has curves, butif there's right angles, that's
how they'll know, and the otherthing they'll see is an area of
narrowing because they can seethe white barium with an area of
dilation above it.

Yeah.

And they'll let you know.

I'll tell you, like that tip right, there is
gold, yeah Thanks.
So did you go through a periodof time where you're looking at
MRIs or diagnostic ultrasoundand it just couldn't find what
you were looking for?
No, how did you stumble on?
I'm going to do barium swallows.

Oh, I'm so lucky because we have our lead
researcher in SIBO is Dr MarkPimentel.
He's out of Cedars-Sinai in LosAngeles and of course we're
colleagues and friends.
And he is the one who told meyou know, he's the one who's
been teaching so much of this toall of us.
So he had spent years figuringthis all out and it was for me

(42:49):
talking to him and also the headradiologist, who they called,
like the they had a name,something like the, something
whisperer, I can't remember Likehe was so good at reading the
images, and I spent time withthem, following both of them in
clinic and spent more than a daywith the radiologist and I
asked them for their advice howcan we get local radiologists to

(43:13):
get a good test?
And I just took what they saidand put it into that little
saying I gave you.
I sort of made up that littlesaying from their advice, you
know.

So no it was Dr Pimentel.

He's the lead in SIBO and he says you need a
barium.
That's how you're going to findthis.
So, thankfully he gave me theshortcut.

There you go, Just thinking about how things
have changed over the lastdecade or so.
When I first heard of SIBO, Ithought, oh, that's interesting.
I don't think I have anyclients like that.
And then I started to payattention and then I started
going like forgive the language,Holy crap, everyone's got SIBO.

Totally right.

When you start and I'm just wondering first of
all, is that a common experiencefor clinicians?
Is to all of a sudden somethingjust clicks, that light bulb
bulb and all of a sudden you'reseeing things completely
different.
And you know I've been doingthis long enough that.
I know I'm not making it up inmy head, but I just wonder if
there are detractors, like youknow how, for many, many years

(44:17):
and still today, some clinicians, mostly on the conventional
medicine side, say leaky gut'snot a real thing.
Do we still have resistanceLike SIBO is not a real thing,
that's just that's just IBS.

That's all it is, it still exists, it's, it's.
It's kind of crazy, you know,but look, things, we know things
take a long time in the medicalfield to get adopted, and
actually it's not the worstthing, because you you have to
have a lot of studies to proveit.
I'm I'm good with that.
I like that.
Make sure there's enoughevidence that scientific debate
needs to go on for some time.

(44:52):
I think I would say, though,that at this point we have an
overabundance of evidence, andit's a little bit over the edge
now the people who are stillsaying that.
But what goes on is theyhaven't read all the evidence
because they're already opposedto it, so they're not going to
go and read about it.
So then what changes their mind?

(45:14):
I don't know.
I wish more people were likeyou, who, where they had the
click and go, oh.
But yes, of course it's common,because, look, everybody's
overwhelmed in life and we allgot, we have so many things
coming at us.
If something new comes, it'sgoing to take a little while

(45:36):
till till we can integrate itand decide what we think about
it.
So it's common and I just wishmore people would would get that
realization.

Yeah, have that the aha moment.
You know we've been talkingabout SIBO, but I know in the
literature there's otherterminology like emo intestinal
methane overproduction or iso,iso sulfide, hydrogen sulfide
overproduction, and it's been along time, but I do remember
seeing at least a couple ofpapers that talked about fungal

(45:59):
overgrowth or SIFO.
Is it useful to make thesedistinctions, either, even if
it's just to sort out ourthought process or, even better
yet, to guide clinical decisions, or it's practical enough that
we can just kind of lump all ofthat into this overarching
concept of of so, even though itmight not actually be bacteria

(46:24):
I know.

I sort of feel like both of those are true or
good.
Um, I still use SIBO as sort ofan umbrella term to mean all of
it.
But let me just quickly defineit.
So we've already defined SIBO.
Imo is intestinal methanogenovergrowth.
So basically we have a fewtypes of SIBO, and these are
based on the gases that theovergrown microbes make hydrogen

(46:47):
methane and hydrogen sulfide,and then we can have mixes of
those and the methane SIBO wefound out actually we've known
for quite some time it's notactually bacteria making them,
it's archaea, which are alsocalled methanogens, methanogens,
and so this is just a technical, linguistic primarily thing,

(47:08):
which is that it's not correctto call it bacterial overgrowth
because they aren't bacteria.
So so, no matter what we thinkthe name kind of had to be
changed because that's nottechnically correct, even though
I still sort of refer to it asSIBO, methane SIBO, you know.
But so intestinal methanogenovergrowth and then similar for
intestinal sulfideoverproduction.

(47:28):
Eso is a new term because thereour bodies make hydrogen
sulfide gas, not just bacteria,it's bacteria that is making
this, and so that's confusing,because people look in the
literature.
They hear about hydrogensulfide, sibo.
They go and read a study that'stalking about the benefits of

(47:49):
hydrogen sulfide and how ithelps things, and then they get
really confused.
And it's because it's when it'soverproduced.
We can all understand thatconcept normal amount, that's
healthy, too much not healthy.
So that's why I think they madethat terminology overproduction
.
But but back to the other point,it is also helpful for our

(48:10):
mindset because the treatment isdifferent.
That is a key thing is that,particularly for pharmaceutical
and herbal antibiotics, wechoose different ones of those
based on the gas type, andthat's a crucially important
point.
That causes some of the biggesttrouble in treating SIBO.
When people aren't educated,they just think there's one
thing they can use for all thetypes treating SIBO.
When people aren't educated,they just think there's one

(48:30):
thing they can use for all thetypes of SIBO Right.

Right and maybe we can come back to that because
I think before we get there canwe talk about the testing.
And I know before we startedrecording we talked about
testing very, very briefly.
But I have for a long timeoperated under the understanding
that there was a very highfalse negative rate in SIBO

(48:57):
breath testing and I'll ask youto explain that here in a second
symptomatic response to dietarychange.
To either affirm or deny SIBO,insert any other linguistic term
you want, and that's from apractical standpoint.

(49:19):
That seems to have worked outquite well.
I feel like I have a decenttrack record and success rate.
I don't fix everybody.
I would never claim that Nobodydoes, yeah, I would never claim
that, but I have scared clientsaway over the years from
spending money on the breathtest because I felt I could get

(49:40):
good clinical guidance justsimply by changing the diet for
say, three to five days and thenmonitoring the response, and if
I had any confusion, we wouldput some foods back in and see
what happened.
Now, having said that, it almostbegs two questions what is the
current understanding?
Because my MO right now isbased on things that I learned

(50:02):
10, 12 years ago-ish somewherearound there, and I understand
the research changes on aconsistent basis.
And I understand researchchanges on a consistent basis,
and so I'm interested to hearfrom you as the expert what is
the current state ofunderstanding of the value of
testing, what tests are best,what are we looking for and what
direction does that lead us in?

(50:23):
And then that will lead intoperhaps a discussion in terms of
effective treatment.
So why don't we just startthere?
Let's just talk about test ordon't test, like is it
sufficient to just change thediet and see what happens?

to bloating and distension, for example.
Well, clearly you have a methodthat's been working clinically,
so I would never want toencourage anyone who has a
successful method to change itright.
And so we also have to thinkabout the nature of our
practices, because I, as a SIBOspecialist, was pretty much
always seeing people who hadalready undergone treatment and

(51:01):
failed you know, diagnosis andtreatment and failed right.
So that puts me in a differentcategory, not the first line.
I mean.
Occasionally somebody wouldcome to me right away just
because they think they had itand they know I'm a specialist.
But so really the role of aspecialist is quite different
and at that point testing isalways involved because patients

(51:23):
are absolutely demanding it.
It can be the opposite whenyou're the first line, they do
not want testing right andthey're mad even that other
doctors have suggested it.
But at this point it's likeit's all about the testing,
because we have to, weabsolutely have to figure it out
.
I'm the specialist, I have toknow exactly what's going on, et

(51:44):
cetera.
So, putting that in context, Ialways test it Now in terms of
what's changed and what's new.
Well, maybe I should give youthe basis.
First, like with falsenegatives, here's what we know.
There are different substratesthat are used for the test, and
these are sugars that are meantto feed the bacteria.
Bacteria eat carbohydrates,sugars, and turn them into gas

(52:07):
for methane, and that's whatwe're testing in the breath the
hydrogen, the methane, thehydrogen sulfide.
Most tests check for hydrogenand methane.
There is one test on the marketnow that checks for hydrogen
sulfide additionally, and that'scalled TrioSmart, similar to
that IBSmart, same company there, gemelli Labs.
So these sugar substrates thisis where there's been a huge

(52:30):
debate over all the years andglucose is the one that's used
most often in research.
That's fine for researchbecause basically the issue is
it absorbs into our body out ofthe small intestine within about
the first two to three feet ofsmall intestine.
So it is only able to check forSIBO or any of the others

(52:53):
overgrowths in the top threefeet of small intestine.
Sibo is most common at the endof the small intestine.
The small intestine is 18 to 25feet long, so this is a test
that has very high falsenegatives meaning like it
because it can't even test therest of the small intestine so
you can get a negative test whenyou actually have SIBO.

(53:14):
So for this reason, most of usclinicians don't like glucose
Researchers like it, becausethey just absolutely know for
sure if the SIBO is there, it'sright there in the top of the
small intestine.
So we use lactulose.
Lactulose is available theentire small and large intestine
.
That's actually very important,because one thing I didn't
mention is the methaneovergrowth and the hydrogen

(53:36):
sulfide overgrowth can overgrowin the large intestine as well,
not just the small intestine.
So when we do a three-hour testwith lactulose, we can also see
what's going on in the largeintestine.
It's extremely helpful.
We can also see what's going onin the large intestine.
It's extremely helpful.

So now back to what's.
Can I ask one question on that?
Yeah, it's my understandingthat the lactulose does that not
require either a medical doctorto request, or someone like
yourself who's licensed as achiropractor.
And this is again.
It's been a while since I'velooked at this testing.
But can any clinician of anycredential chiropractor

(54:16):
acupuncturist, naturopath,whatever can they order a
lactulose breath test with triosmart, or does there need to be
a different type of licensedclinician to order that for us?

yeah, this is such an important point.
Lactulose is a prescription inthe US.
It shouldn't be.
It's kind of a mistake thatit's on there.
There's no reason for it to be.
However, it costs millions toget something anything off of
that formulary, so that's nevergoing to get done.
Who's going to pay for that?
So, it's very frustrating.
However, there's plenty ofworkarounds Genova Labs and all

(54:52):
the places you can get theGenova test, like Rupa Labs,
True Health Labs, Direct Labs,they all will.
They have like.
Basically, they have like aphysician on staff On staff.
Yeah, that will handle that andso then anyone can order that.
And TrioSmart also justcontracted with a group that's
doing that Okay, so that must berecent, that must be recent,
because I was looking Threeweeks ago.

I was going to say, like I was looking at this
two months ago, yeah, yeah, oh,that's good, that's really good.

They had it originally when they first came
out, and then, whatever servicethey were using, I guess they
had to stop using, and nowthey've offered it again.
Yeah, again.
So just so.
But what I would also saythere's plenty of ways for those
in the US to, like I justmentioned, to get lactulose.
But a second option would befructose.
You can also use fructose.
Lactulose is a little bitbetter.

(55:38):
It's it's more sure that it'sgoing to be there the whole way.
Now what's changed is we shouldbe soon having sort of like a
big article coming out all abouttesting, sort of settling this
debate.
We've been waiting for thisarticle to come out.
It hasn't come out yet.
But what's changed is thatthere's been deep sequencing now
done in the small intestine,correlating that with lactulose

(56:03):
and culture, and I know I'mgetting technical here, but
actually some new techniques hadto be developed for actual
sampling in the small intestine.
It's difficult to do.
You need to protect your samplein a special way because it can
get contaminated with oralbacteria on the way back out.

(56:25):
And also you need to releasesome of the bacteria that are
stuck in mucus.
So Dr Pimentel actuallydeveloped and then validated
this new sampling technique,then used deep sequencing and
compared a lactulose breath testto culture, to deep sequencing.
Because the issue in the pastwas that people didn't think the

(56:46):
breath test was accurate enoughbecause they were comparing
testing to culture.
It turns out culture was not agood gold standard.
We call it a tin standard.
It had a lot of problems.
Now, with these improvedtechniques and with the DNA
sequencing, now the lactulosebreath testing is lining up

(57:07):
perfectly with the deepsequencing showing that the
culture test was the problem.

And when you say culture, you're not talking
culture from the stool sample,but from endoscopy.

From the small intestine, from endoscopy.

Right small endoscopy.

To actually try to find the overgrowth.
And you can also imaginethere's issues there, because
where is it?

I mean, we talked about the 25 feet, yeah
there's almost like thisassumption that a bacterial load
is evenly distributedthroughout the intestine and you
know, if you stick a claw downthere and try to take a sample,
you know you're guaranteed toget a hit.

And you're not.
No, that's not true at all, andthis is like you know.

prior to this we saw this with, say, H pylori,
right, Right, Endoscopy andbiopsy for H pylori.
Oh, biopsy said I didn't have Hpylori.
Well, you didn't have it in thespot that they biopsy.

That's all we can say.
Yeah, so it's issues, but thereason I brought that up is just
because you've asked sort ofwhat's changed and there has
always been a big um, a bigcontroversy saying glucose test
was actually better and thereason why is it lined up with
culture better, but there's thismassive false negative with
glucose and so people wereworried, based on the studies,
about lactulose.
But what I can say is,clinically, lactulose is

(58:22):
absolutely the one to use.
Now, as to the importance ofdoing it, I personally would
find it very difficult to nottest because I'm basing my
treatments so long as aside fromelemental diet, because that
works for all types on the gasesand what I find is you can't

(58:43):
tell, based on symptoms, whichgases are there, because we
typically have a pattern wherewe say diarrhea is correlated
with hydrogen and hydrogensulfide, constipation is
correlated with methane.
But what we actually seeclinically is, if we just look
at, say, hydrogen sulfide, it'sabout 50 percent of the time
constipation and 50 percentdiarrhea.

(59:04):
Even though the studies saydiarrhea, clinically we see 50%
of the time constipation.
And then we see all the timewhere people have sort of like a
pattern that doesn't quitematch with that hydrogen,
methane, diarrhea, constipationit happens a lot so we can't
really just tell oh, you haveconstipation or you don't.

(59:26):
Really the issue is, you don'thave constipation so you don't
have methane.
That's really where we get intothe trouble.
So by doing the breath test youcan see the exact gases and then
also you can see how high theyare.
So it's not a yes and no test,it's a real informative test and
when we see how high they gothat also informs our treatment.
Because if gases are very high,like say 150, 150, we know

(59:49):
exactly about how much onaverage gas comes down.
Per each treatment type we do.
It's about 30 parts per million, 30, 35, for antibiotics and
herbal antibiotics on average.
There are certainly those caseswhere you see 70.
I've got plenty of those cases,but on average.
And then for elemental diet weknow it's more like 70 to 100.

(01:00:10):
So if somebody has a super highgas level, which, by the way,
you can't tell by symptomseverity, that is very
unfortunate.
Symptom severity doesn'tcorrelate with gas severity.
I'd say 40 percent of the timeit does.

Dr. Noseworthy (01:00:25):
Why do you think that is If we can take that
money trail for a second.
I really don't know.

Dr. Siebecker (01:00:29):
I've thought about for a second.
I really don't know.
I've thought about it.
I just don't know.
I think it's just a greatindividual variation.
What was the terrain likebefore?
What?
Is the terrain like now.
What are all their enzymesdoing?
What's their hydrochloric acidlike?

What other diseases?

do they have?

The gut environment is so complex.
What's their?

microbiome.

Yeah.

And those things you know, and are they leaning
to visceral hypersensitivity ornot?
Most will have visceralhypersensitivity, but not all
you know.
People are just so complex andindividual.

Have you seen, I'm sorry, one more question.
No, go ahead.
Have you seen any correlationin symptom severity with, say,
the degree of elevation ofvinculin antibodies or
cytolethal distending toxins?

Let me think about that, because that's a
smaller amount of cases that wehave those tests for.
No, I can't say.
I can't say that I have noRight.
So back to it, since we can't.
You know, sometimes the gas andseverity of symptoms do match,
but often they don't, so wecan't judge by that.
So then if we have this gasnumber, we can see oh my gosh,

(01:01:40):
you've got 150 parts per million.
You know hydrogen or methane.
Why don't we just skip forward?
Do elemental diet, because weknow we're going to get.
We could get a hundred, wecould even get 150 parts per
million of gas brought down intwo weeks, and then we'll save
you six months of round afterround after round of antibiotic

(01:02:00):
or herbal antibiotic.
So this is how, how come?
I like the test, because itreally informs treatment and it
it helps us with a prognosis andmakes us not be guessing.
So those are my thoughts.

Yeah, and you say herbal antibiotics.
I mean obviously that's acategory.
There's so many different herbsthat fall into that category
that have either antibacterialproperties specifically or
they're just broadlyantimicrobial.
So I'm interested in whether ornot you see correlations.

(01:02:34):
I did an interview with a docwho works with doctor's data and
a couple of years ago I thinkit was, they did an internal
study where they looked atmicrobial sensitivities.
They took a thousand differentstudies and looked at their
antimicrobial sensitivities.
They took a thousand differentstudies and looked at their
antimicrobial sensitivities andit turned out that I call it my
GUS protocol grapefruit seedextract, uva, ursi and silver

(01:02:58):
tended to have the mostfavorable antimicrobial effects
on the things that they wereculturing and then testing
inhibitory sensitivities too.
And so you know that's one lab.
Now it's 1,000 people.
That's a decent number to lookat, but it's one lab and I don't
know if we asked other labs,like Genova or whomever

(01:03:19):
diagnostic solutions, to do thesame thing, would we come up
with the same answers.
So I have two questions when itcomes to treatment.
One is choosing specificantimicrobial herbs, and the
second thing is talking aboutthe distinctions in utility
between the elemental diet, orspecific carbohydrate diet, and

(01:03:41):
the low FODMAP diet Because Ilistened to one of your
interviews not long ago I thinkit was Dr Silverman, might have
been and you had made a commentthat the low FODMAP diet was not
made for SIBO.

It's true.

And not always effective, and so that
fascinates me.

It's about one of our least effective diets for.

SIBO Okay, all right, we got to get there, so
let's back up.

However, that doesn't really matter.
I can tell you why.
When we get there, Okay, yeah.

So let's talk about the antimicrobial herbs
because, like when I haveconversations, particularly if
there are docs that are new tofunctional medicine, they all
want to know what's the bestprobiotic.
That's another question.
Do you use them, do you not?
Oh, my gosh, what's the bestantimicrobial herb?
What's the best enzyme?

(01:04:29):
What's the best antimicrobialherb?
What's the best enzyme?
What's the best?
This and my answer is I don'tknow.
Like I think you just have tohave a reasonable starting point
and then have the mentalflexibility to change your plan
if what you initially choseisn't working the way that you
want to.
And I know that that frustratespeople because we want
protocols.
Do this exactly like this for Xamount of time and everything's

(01:04:51):
going to be fine.
And, yeah, every once in awhile that works out.
But I kind of have a rule.
I shared this with Datis DrKarazian once and I teach for
him and a lot of times, if Ihave a lot of new docs in, say
like a blood chemistry analysiscourse, and they're just
starting out, I'll put upSteve's rules for interpreting

(01:05:13):
blood chemistry.
And the very last one is yourclients or your patients are
under no obligation to followanything I teach you this
weekend Right, and that's justclinical reality.
It's like we're doing the bestthat we can and we base as much
as we can on science and maybeeven a scientific method, but

(01:05:34):
even then it doesn't always work, right so absolutely.

By the way, detise is who I learned
functional medicine from wayback there you go so glad to
hear you teach from love drkarazian absolutely for sure um,
so we actually do have someprotocols for for SIBO and this
is hard one.
Um, it's from doing before andafter testing on every treatment
we gave at our SIBO specialtycenter.

(01:06:00):
Okay, um, but one thing I wantto say about those herbs you
mentioned for doctor's data.
I think that is so incrediblyhelpful that they have that
information.
But let's just remember that'sstool testing and that's
different.
They've only just recentlyadded in some of the
microorganisms that so, um, theyadd m smithii in some of these

(01:06:31):
stool tests and, um, some what'swhat's overgrown for hydrogen
sulfide?
It's prevotella fusobacteriumvarium.
Um, I'm sorry, not prevotellaum proteus, proteus um mirabilis
, uh.
Fusobacterium varium and umdisulfovibrio piger.
And then for methane it's msmithii, methanobrevibacter

(01:06:52):
smithii, but this is just newand we hardly even know what it
means and what are the levels.
We were that's totally not evenbeen figured out for right.

And then it almost begs the question like
can you?
Can you use a stool test todiagnose SIBO?
You cannot you cannot um no,absolutely not.

Except now we, now that we know what I just
said, that those bacteria canovergrow in the large intestine
Now maybe we can, but that workhasn't been done yet to figure
out what are those levels, stooltests, jumping on board and
adding those in.
I'm glad that'll help us figureit out, because we used to say
absolutely not the two differentorgans.

(01:07:30):
And you know I used to runstool tests on everybody.
I did a breath test for it.
You could see perfect largeintestine tests.
Amazing, I would ever see anyof those, but I would with with
the rampant SIBO, so you know,and because you'd imagine
there'd be spillover.
Right, but no, not necessarily.
Okay, so so back to it.
Yeah, there are distinct thingsthat seem to work, for we know

(01:07:55):
the exact bacteria that areovergrown.
Now, that's been years of workand we only just have those
final hydrogen sulfide ones thatcame out one year ago with
studies.
So that's been the real thrustof work in the last few years is
which exact bacteria andmethanogens are overgrown in
these different types of SIBO.
Now we have that information,now we can really figure out

(01:08:19):
what treatments are going towork.
However, clinically, we've beenfiguring it out for years right
.
So what we know is what worksfor hydrogen is oregano, neem
and berberine.
And berberine is a constituentin many herbs.
So you know golden seal, oregongrape coptis, you know
valedictorian Berberine yeah, weknow that.

(01:08:43):
What works for it so here'swhere we get into trouble is
those same things don'tnecessarily work for methane.
These are not bacteria, they'rearchaea.
Different things work on them.
We know different antibioticswork in different.
You know infections.
You know I've seen it all thetime People take an antibiotic
it doesn't work.
You switch to a different one.
You know you've got to get theright thing for the right bug

(01:09:05):
you're trying to target.
I hate to think so, like that,but this is the truth of it, you
know.
So for methane, we know thatallicin works, the constituent
from garlic.
We don't like to use wholegarlic, aged garlic, garlic oil
because it can trigger symptomsbecause garlic is very high
fermentable.
So we really try to use thepurified allicin.

(01:09:27):
So we use Alimed or Alimax Prois the one we tend to use and
that's the one we just we didall our testing on.
I mean, others may work, I'msure they would, but that's the
one we did the testing on.
And when we tried products thatwere like Holgar, like we just
ran into so much aggravation ofsymptoms.
And then also AtronTeal, thatis a little three herb combo

(01:09:47):
that's been tested and shown toreduce methane and it works
differently.
It's not so much a straight onkiller, so it's got peppermint,
red cabracho bark and concordtree, which is horse chestnut,
and what this is doing isactually making it so the
methanogens are not being ableto produce methane gas.

(01:10:08):
It's not so much killing them,they just are not able to make
the gas, and it's the gas thatcauses the slowing of the causes
, the constipation.

So do you have to?
Just right from a clinicalperspective?
Do you have to use Autrantilwith something like what did you
say kills the allicin, thehighly purified allicin?
Do you have to use thosetogether?

No, you don't, so you choose one or the other.
So what we typically do I callthis the single-herb approach.
It's not really single, but asopposed to just grabbing a big
formula off the shelf that haslike 25 things in it, because
that's another way to go and wecan talk about that.
But you choose something forhydrogen, because there's always
hydrogen there.
The reason why, even if youdon't see it on a test, is

(01:10:52):
because methane is made fromhydrogen, so there are always
the bacteria there that aremaking the hydrogen, but then
the methanogens are turning thathydrogen into methane.
Sorry to get so technical.

No, this is exactly what I'm looking for.

So even if you only see methane on a test, you
always have to treat hydrogen atthe same time.
That's the way we do it.
So you choose one of thehydrogen herbs, and if we were
talking pharmaceuticalantibiotics it'd be the same.
You choose one of the hydrogenpharmaceutical antibiotics, and
then you add the herb orantibiotic that treats methane.
So then you choose eitherallicin or atron teal, and so in

(01:11:28):
the case where there's methane,you're always doing two.
We always do two for hydrogenalso, by the way.
Let's just take this on.
Why don't we just add more andmore and more?
Because it doesn't increaseefficacy.
We've tested it, and so moredoes not equal a bigger
reduction in gas.
You peter out at about three.
Three herbs Now, with theexception of something like

(01:11:50):
AtronTeal.
That's a small little formula.
You know that has three herbs,and so we'll use that with a
hydrogen herb.
And then for hydrogen sulfide,what we know works is bismuth,
which is not actually an herb.
It's like a mineral andhigh-dose oregano.
And high-dose oregano issomething that came to us from a
patient years and years agowhich was originally an old

(01:12:11):
chiropractic blastocystishominis treatment.
It came from the chiropracticworld and it's very high dose,
but when you say high dose, whatdo you mean?
So typically we're using ADPthe.
That's like the dry oregano.
We're not using the liquid.

Biotics, isn't it yes?

And the reason we did that is because that came
from Dr Jerry Mullen from JohnsHopkins.
He had been using that.
He teaches for the FunctionalMedicine Institute.
He had been using it withsuccess.
So we began using it and whatwe found was that dry form was
better tolerated, actually, thanthe oil form.
Oregano can be pretty causticon mucous membranes and even the

(01:12:52):
dry form, but the dry form isbetter tolerated.
So we're talking five pillsthree times a day for the first
week, that's 15 pills a day, andthen nine pills a day, three
pills three times a day for thenext three weeks to make a month
treatment.
That's something we haven'tmentioned.
Herbs the typical herbaltreatment round is four weeks
can extend to six weeks, whereasfor elemental diet and

(01:13:15):
pharmaceutical antibiotics it'stwo weeks.
So they have the sameeffectiveness, but herbs just
take a little longer.

So you just have to and is that six-week cycle?
Is that, in your opinion,unique to SIBO, or would you
include any large intestinedysbiotic case to be the same
rules?

I don't know because I don't treat.

Because you only do.

SIBO.
Right, of course I have createdsome LIBO, but I wouldn't want
to pin my.
You know, I want to ask someonewho does run stool tests and
treat that regularly.

Well, can I share something with you?
Because this?
Is like when I first startedand I learned functional
medicine from Dr Karazin as well, and I've been doing it Well.
I've been teaching for himsince 2008.
So sometime before that, Istarted learning 2008,.

Did you say?

Yeah, I've been teaching for Apex and Detease
since then.

Oh, that's so long.

I love it, I feel like I blinked and now it's
2025 that's amazing.
Yeah, I think I I first startedstudying with him in 2006, I
think yeah, so right, yeah, andso we probably got involved with
him somewhere around the sametime, probably in different
parts of the country.
I was, yeah, but in the in thelike and this is before um

(01:14:28):
detise and, and the company heformulates were called Apex
Energetics before they startedto increase the number of
formulas that Datis had broughtto the market, and so I was
using predominantly Genova'sGIFX test and I was using and

(01:14:48):
it's my own podcast, I couldmention anything I want.
I was using Apex's HPLR andanother product called Mycozyme.
I was using those two things incombination and I would run and
I would probably do twocapsules two times a day of each
of those and I would run a12-week protocol and I would

(01:15:08):
retest the stool in nine weeksand 90%-ish of the time the
second stool test was eitherperfectly normal or very close
to it.
Every once in a while you'd seethat wacky second test that
looked worse than the first oneand it confused me for such a

(01:15:28):
very long time until I startedreading about biofilm, right,
and so I want to bring that tothe SIBO discussion.
Do we have to account forbiofilm with SIBO?
If the answer is no, we canmove on, but if the answer is
yes, can we talk about biofilmand maybe talk about the
strategies that you're using forbiofilm disruption?

Yeah, so this is very interesting to me.
I think we're still figuringthis out.
Early on we made an assumptionwhen we were treating I mean
heck.
I mean 90% or more of relapsinginfection type diseases are
biofilm diseases.
So could this be the part ofthe reason why we're seeing so

(01:16:13):
much relapse?
Right Is if there's biofilm andwe didn't get it and so the
infection can just come back.
So, on that assumption, we gavemany, many of our patients
antibiofilms.
We worked real hard at it andwe used the enzymes.
We used EDTA and we used thewell, that's mostly it the

(01:16:35):
seratopeptidase that was also anenzyme, you know, like lipophos
, edta and all the classic ones,right, and oh, and NAC.
We used NAC because NAC isexcellent antibiofilm for H
pylori Really good studies onthat.
So we use all of those hardcore, not on everybody.
So we had samples to see backand forth.

(01:16:57):
This isn't a formal study, butthis is just clinically, I'd say
, for about two or more years,maybe like three years, and it
seemed to make no difference atall and we were very
disappointed.
Okay, so then fast forward.
I have a conversation with DrPaul Anderson, who's an elder in
the naturopathic profession,treats very difficult cases, a

(01:17:17):
lot of biofilm infections and hesaid well, that's because the
antibiviral films you were usingare not good enough and you
really need to use a bismuthbased a bismuth I all based
antiviral and at the time he hadthis compounded formula.
It's prescription that he hehad developed and not not even
every compounding pharmacy couldmake it and you had to get it

(01:17:40):
special from certain places.
Now more, more can make it, soI started using it.
That made a difference.
Hmm, that made a difference.
That helped.
That moved the had to get itspecial from certain places.
Now more, more can make it, so Istarted using it.
That made a difference.
That made a difference thathelped that move the needle on
some really tough cases.
Then this was quite a long timeago.
Then he came out with anover-the-counter version of it
and that is priority one.
Biofilm.
Phase two advanced.

I use that all the time.

And I may have those.
I sometimes I say those wordswrong Cause it's a lot of words.
I use that all the time thinkthe compounded is more effective
.
So, okay, so there's that piece.
What I would say is, if you andalso I want to say that so

(01:18:31):
there were a lot of people wedidn't treat with antibiofilm,
that got completely better andand we and yes, like the classic
scenario in SIBO is, it's notcleared with one round.
There are one and dones, butthat is a smaller, smaller
proportion.
Particularly in a specialtypractice, most people will need
multiple rounds.
But even still, with multiplerounds, no antibiothelium, they
got all better.
So clearly, not everybody doesbiofilms need to be addressed in

(01:18:54):
SIBO.
But if you're really havingtrouble, that's when I would
think of it.
Okay, so we have this.
Then we have somethingadditional to add.
Just last year out came a studyfrom Dr Pimentel and team usinga
special formulation of NAC withrifaximin.
Now, from my understanding,it's complex with the rifaximin

(01:19:14):
and there's a time releasesituation going on there and
that greatly increased theefficacy of the success of the
rifaximin.
Rifaximin, for anyone listening, is our main antibiotic we use
for hydrogen SIBO.
It's also called Sifaxan.
So this was at first when Iheard this.

(01:19:35):
I didn't hear the specialformulation part and I was like
what are you talking about?
We used NAC for years with zerobenefit.
I'm like I am having a hardtime believing this.
Then I heard about the specialformulation because we were just
using, you know, immediatelyabsorbed NAC, and so what Dr
Pimentel has said is you reallyhave to get it down into the

(01:19:57):
small intestine, hence thespecial time release situation
there, or sustain, you knowthere is a sustained release by
Jaro.
So if anyone is going to trythis with any, any of their SIBO
treatments, I'd at leastrecommend that until until
whatever they because they'rethey're developing a product, so
until that comes out.
So so that's more to add to thebiofilm piece.
So apparently, you know, drPimmel tell us talked about how

(01:20:21):
methanogens and certain of theseovergrown bacteria are living
in biofilms.
He's been able to see that withhis endoscopy, the scope going
down and the sampling, so Ithink that could be important.
So maybe we should all beadding sustained release NAC to
our treatments.

You know, I was teaching a course in West Palm
Beach many years ago and it wasaround the time where we as a
group in the Apex ecosystem werestarting to teach on biofilm
and I remember a young guycoming up on a break and he told
me that his uncle if I rememberthe story, his uncle was a

(01:21:01):
biofilm researcher at one of theuniversities in Israel and I
asked him immediately like whatis he seeing is working?
And he said the two things thatthey're seeing is working is
cranberry extract and stevia.

Wow.

Yeah, and I know that a lot of people that are….
Oh, that's a great tip.
Thank you, yeah, a lot of thedocs that are lime literate rely
a lot on both either Stevia orCranberry as their primary
biofilm strategy.
Now I wonder, like you hearstuff like that and that's great
.
You hear stuff about bismuth,and that's great.
And then I wonder aboutindividual variability, like do

(01:21:38):
we have to account for that?
Is Cranberry going to bust allbiofilm in all places and all
people right?
Or do we have to have a stableof things to choose from and
then we mix and match dependingon their response?
And that brings me to the nextquestion you mentioned.
Some people need multiplerounds and a round, I guess,

(01:21:59):
roughly, is six weeks long.

I'd say four weeks.

Okay, four weeks , four weeks is a typical round.

We stretch it to six if they have higher gas.

Okay, and then how long in between each round?
Is it only when a relapsehappened or is this pre-planned?
You're going to do four weeks,take X amount of time off, do a
second round and if that's thecase, or either way, do you
change the protocol each time?

Oh, these are such good questions, okay.
So protocol each time?
Oh, these are such goodquestions, okay.
So it brings up the, you knowsort of a an underneath question
was why not just go longer?
Why stop?
Why, right, believe me, wetried it, and what we found over
and over now once again, thisis in the patient population
that we were seeing which is ata specialty center.
Um, so, it may not be the samefor the first, you know, for

(01:22:43):
primary care or something, butwe just found that the treatment
lost efficacy somewhere aroundfive or six weeks, and so what
would happen is somebody mighthave had some improvement in
their symptoms and they wouldjust begin relapsing while still
on, while still on it.
While still on it.
So this happened so often, sooften, and so this is how we

(01:23:08):
learn right.
And so that's why four weeksyou really have a potent
treatment.
You know, even at five weeks wecould start seeing some people.
Now people are going to saythey're going to know they're
going to have experiencedexceptions to this rule.
I will tell you, I haveexperienced exceptions to this.
I have certainly seen peoplethat have been on the same thing
for two years.
It's working, and they come tome to help me get them off of it

(01:23:31):
.
It's the only thing that works,and they don't want to be
taking it every day.
Of course, there are exceptions.
I'm just talking about patterns, right?
So what we do is now.
This is again, you know, if youhave testing and people have to
figure out their own way thatis going to work for them.
But typically after a round, weneed to see how the patient is
off of the treatment, becausethe treatment could be giving

(01:23:51):
them symptoms or die off orwhatever.
We have to see.
How are they?
We have to assess are theybetter?
We're looking for 90% better,so we need a little time to see
what that's like.
If they are not better, that'swhen, typically, we will do a
retest and find out what'shappened.
A lot of times the gases havechanged things.
It helps again inform ourtreatment, but the key thing is

(01:24:14):
you don't want to wait more thanabout two weeks.
Why is this?
Before you start your nexttreatment?
If they're still positive andyou can do this without testing,
we can talk about that.
But why that is is becauserelapse or really here we'll
call it backsliding is so commonat about two weeks.
It's just classic.

And that's two weeks after stopping a four-week
round.

Yep, or if it was antibiotics or elemental diet,
the two-week round.
And it's because we don't wantto lose ground.
So what we do in this two-weekperiod is we put someone on a
prokinetic.
Prokinetics we haven't talkedabout yet, an absolute,
essential part of SIBO treatmentthat gets missed often.
You want a moment or twowithout them on the prokinetic
too, like a day or something, ifyou can, because what if they

(01:25:00):
start to have some sort ofreaction to that?
You need to see how are youThen get them on the Prokinetic
while you're waiting for thetest to come back or figuring
out what you're gonna do.
But if you wait more than twoweeks, if they're not clear of
their SIBO, that overgrowth canreally start to come back and
you lose ground of what you justdid.
So if you don't have a test,let's say you have an initial

(01:25:22):
test and you saw they were, youknow, at 70, you can calculate.
Well, with herbs it's about 30parts per million and, by the
way, that information is gold,comes from just kajillions of
before and after tests and it'sjust an average.
Okay, so one round we'll expect.
You know, 70 minus 30, they'restill positive.
We kind of suspect they'regoing to need another round.

(01:25:44):
So see how they are after oneround, because what if it did it
?
And you know if?
But if they're stillsymptomatic, maybe you don't go
for that next retest due tobudget and time and logistics.
And then you have in mind whatyour next round is going to be.
So to your next question.
I always typically switchbecause we're concerned about

(01:26:04):
clinical resistance or clinicaltolerance to what we're giving,
because we see it so commonly.
We see that happening even torifaximin, which has been
studied and shown to have sevenrepeat rounds with no
antibacterial resistance.
Yet we saw it, we saw it a lot,so we'll switch.
Now you don't have to switch.

(01:26:25):
Let's say somebody was reallydoing great, they weren't having
any backsliding at all.
You take a two week break or aweek and a half break just so
you can assess or whatever.
You can use the same thingagain if you really think it was
working and if you got somefeedback from the patient.
Yeah, we do that.
But the typical thing is toswitch and switch around, which

(01:26:48):
is then where we start to runout of.
Well, what are all of ouroptions that treat each thing?
And then just one other thingto just mention here just
briefly.
We didn't talk about bigformulas because there've been
some formulas studied for SIBOcandybactin, ar, br and
F-C-Cytol, um and uh, f-c-cytoland dysbiocide.

(01:27:09):
Those were studied for SIBO andshown to be efficacious.
Really, these are going to workfor hydrogen.
They don't really have anythingin it much for methane,
although oregano sometimes worksfor methane and that is in
those Um.
It's's not as reliable thoughon a day-in, day-out basis.
The issue for me with these bigformulas is that I think they're

(01:27:32):
great for primary care whenyou're not even sure am I
dealing with SIBO?
Could there be LIBO?
Is there yeast?
We didn't really talk aboutthat.
It throws a big net and that isgreat and I think appropriate.
But when you're really tryingto dial it in and you're really
just trying to treat the SIBO,you do need to get a bit more
specific.
I find you know if, so long asI mean maybe that took care of

(01:27:55):
it, I just mean, if you are nowcontinuing to struggle with a
SIBO, then you need to dial itin and get get specific with
those organisms that areovergrown.
And the other thing is theclinical resistance.
We know so many people aregoing to need multiple rounds,
just as a matter of course.
Most people need two to fivetreatment rounds, and we don't

(01:28:16):
want them getting.
If we have everything in one,what will we use for our next
round if they become resistant?
So we're just being practicaland lastly, is we see so many
sensitive patients.
They have histamine intolerance, they have mold, mcas, all
these things, and they have avery hard time with various
herbs, using a lot of herbs atonce.

(01:28:37):
How can we figure out what wasbothering them if there's 25
things in there?
If we're using two things, wecan take one away and we can
easily figure it out.
So this is just clinicalpracticality.

So would it be a workable framework to perhaps
anticipate whether you actuallydo it or not, but anticipate
multiple rounds, four weeks each, maximum of two weeks in
between each round, especiallydependent on either return of
symptoms or if you post-test theresults.

Right, exactly.

And maybe up to four or five four-week rounds.

Yes, that can happen, it's common actually,
yeah, yeah.
Yeah, that's one thing.
People give up too soon.
You know.
They're like well, I took around of something.
We see it in the medical world.
All the time, and I think youalluded to that they threw a
refaxment at someone, or I tooka round of something.
I'm not better.
I must have a tough case orI'll never get rid of it.

It's like no you just started or the doctor's
incompetent right that's theother option is blame the doctor
.

Or I must not really have SIBO, if it wasn't a
test.
It's like what you know.
It's like what you just didyour first round.
See, if you don't know, it'slike you know.

No, you're just going test, or would you rely
more on dietary tolerance andchanges?
Uh, maybe put them on either afew days of a low FODMAP diet

(01:30:10):
we'll come back to that or anelemental diet and and if so
like an elemental diet.

That is different .
That is an actual antibacterialtreatment, so that that's like
an antibiotic in essence okay,so why don't we?

why don't we?
Why don't we switch?
Are you okay with time, can we?

Yes.

Okay, that's great Cause I'm not done yet.
So let's talk about the dietaryapproaches, because, like even
like in in the apex ecosystem,we've taught a one day seminar
on a small intestinal bacterialovergrowth.
Right, this is something thatthe T's developed back, probably

(01:30:46):
2014 or something like that.

Yeah, I think it was right around the time he and
I were having a lot ofconversation.

Yeah, and I think that that's.

He has an extremely different approach and
thinking on SIBO than all of us.

Well, and this is yeah.
This is why I want to broachthis subject, because and maybe
what I've been calling SIBO isnot SIBO because I've been using
a low FODMAP diet.
Now, each iteration of thatdiet is highly patient-specific
and, as you know, there's abajillion different SIBO low

(01:31:19):
FODMAP diet lists out there.
Right?
Everyone seems to have theirown list, and I'm interested in
this because you were talkingabout using allicin and how
garlic in various forms istypically not tolerated.
Very well, let's go back tocontext, and maybe this is a
hypothetical.
You can't or don't really wantto answer, and that's okay.

(01:31:41):
But if you were the first linedog, would you tend to rely on a
dietary challenge, removecertain foods, see what that
does and then make decisionsbased on that?
Or would you still be doing,say, a trio smart test, even
though it's the first line andyou're not a complicated case
that's failed?
A bunch of other things.

Personally, I would test and I wouldn't use
diet.
Um, this is just me.
I, I don't want to.
You have a method that worksfor you, so I don't.
You know.
It's like why listen, I, I'malways looking.

I'm always looking to be a better clinician
.

So if it works, great, but I want it to work
better so I would test becausewe know that, um, the
differential diagnosis for SIBOis 35 to 40 diseases big.
Those same symptoms can becaused by so very many things
and dietarily I feel it'ssimilar.

(01:32:39):
You know, it's like we reallywe're not going to have
specificity knowing it's SIBOwithout that actual test.
So if I'm actually, if Iactually want to figureity
knowing it's SIBO without thatactual test, so if I actually
want to figure out if it's SIBO,then personally I would test,
especially because the breathtest yeah, it's that problem of
the differential diagnosis andalso because, like just for

(01:33:02):
example, the classic example islactose intolerance, which can
be genetic but could also besecondary to something else like
SIBO, right, but let's say theyhave genetic lactose
intolerance.
Studies have shown many peoplewho have it honestly don't know
it.
They don't know that it's milkor dairy products giving them
their symptoms for their wholelife.

(01:33:22):
It's like amazing, there arestudies showing that.
And because you know there'sstudies showing that, and
because you know it's aneducation issue, and you give
them a FODMAP diet at that, theyremove lactose, they respond.
So then you think they haveSIBO, but in fact the solution
is to avoid lactose or bring inan enzyme and why are we now

(01:33:44):
giving them antibacterials andmessing with their microbiome?
So it's this differentialdiagnosis list that causes a
problem for us.
But we do have a solution,which is the test.
So that is the reason I woulddo it, just to be sure,
especially I personally feellike I'm ever going to use an
antibacterial of any kind.

(01:34:05):
I want to be sure that it isthe right thing for the problem.
So that's why I like the test.
And then, additionally, becausewe get so much nuanced
information the gas types andthe severity, prognosis,
treatment type, et cetera.

It really helps, right?
So let's talk about the dietsthat we've listed.
For anyone listening whodoesn't know what a FODMAP diet,
it's F-O-D-M-A-P.
It's fermentableoligosaccharides, disaccharides,
monosaccharides and polyols incertain foods than others,

(01:34:47):
mostly fruits and vegetables,certain starches and grains.
And the theory that I've beenoperating under and again, this
is how I was taught, I didn'tquestion it was that certain
people need to go on a lowFODMAP diet because eating those
foods feeds the little crittersin the small intestine that
shouldn't be there anyways, andthen they produce hydrogen,
methane, certain gases thatcause bloating and distension.
Now you're saying that theFODMAP diet was never intended

(01:35:10):
for SIBO.
So what was it Like, if youknow what was the original
intent for the FODMAP diet?

Well, originally it was like Crohn's in the small
intestine, so IBD and IBS, ibsof the large intestine.
They did actually mention SIBOin some of their early papers,
but it was not created for SIBO,it was created for IBS, with
the mindset of the largeintestine Interesting.
The issue where we run intoproblems with BodMap is that

(01:35:42):
they are not removing fiber.
Of course, fiber has a lot ofdefinitions.
Well, I'm going to call it longchain fiber, what we think of
as fiber, you know, likesupplemental fiber and like
flaxseed and things like that,and in fact they encourage
increasing it.
They want to be sure you don'tgo too low fiber and fiber is

(01:36:03):
direct food for the overgrownbacteria and directly will
contribute to symptoms.
So this is why I say it doesn't.
Who cares what it was originallydeveloped for?
I don't care this diet, yes,it's true, if you do it just as
written, I would say it's one ofour least effective compared to
the other main diets we havefor SIBO.

(01:36:25):
But that doesn't matter,because you can start with any
of these reduced carbohydratediets any of them at all, even
ones that are just for weightloss, you know and just start
tweaking it to the individualwhich you already indicated you
do all the time anyway, and sothat's.
It doesn't matter what diet youstart with, because whatever
diet you start with, I thinkthat's a key thing to understand

(01:36:47):
is to know that no diet that isused for SIBO will be right for
each person, and that it'sreally encouraged to experiment,
because there are usuallyalways things on that diet that
you will have no problem eatingand that they say you shouldn't
be eating and you should testthat because you want to include
as many foods and vice versa.

(01:37:07):
There'll be things on the dietthat you're reacting to that you
need to remove.
And I think where that mindsetcomes in is with SCD specific
carbohydrate diet, because thatwas also created for
inflammatory bowel disease.
Well, actually, sorry, it wascreated for celiac.
They think it's for for celiac,but um, really it's, we really
think it's inflammatory boweldisease that originally Dr Haas

(01:37:30):
was treating.
Um, I know that it's way backinto history, but um, but that
diet has this idea of fanaticaladherence.
They have it right in theirbook, fanatical adherence, and
that you, you know you, youcan't go off it even one tiny
bit, and so that is not anappropriate attitude with SIBO.

So for anyone who's been indoctrinated through
there know that we want you toexperiment with your diet and
SIBO, so yeah, and so is there adistinction between the SCD
diet and an elemental diet, andwhich one are you using as your
starting point for most of yourclients?

Yes.
So elemental diet is not a dietin the way we think of specific
carbohydrate diet, FODMAP diet,any of these other diet like.
It's not a.
It's not a food diet, it's a.
It's an antibacterial treatment, but in a slightly different
way.
So what it is is, it's amedical food beverage that's a
powder of nutrients in theirmost broken down form.

(01:38:27):
So it's amino acids for protein,it is oil for fat, and then the
carbohydrates are eitherglucose or maltodextrin, which
is more broken down, and thenthere's vitamins, minerals and
salt, and it used to just belike you know, you'd have things
like Vivinex Vivinex Plus isthe one that was studied for

(01:38:48):
SIBO originally, and then therewere things like Neocate Junior
and these are used in hospitalsto give the digestion a rest.
So for a long time I actuallydidn't even use the word diet.
I changed it to elementalformula because people were
getting confused, thinking itwas a diet.
It's not a diet, it's a specialtreatment.
So how we do it for SIBO is theprotocol developed by Dr

(01:39:12):
Pimentel is you take this drinkand no other food, so you're not
eating any solids, you're notdrinking just anything but water
, and this for two weeks.
So it's kind of like a form offasting and what you're doing is
starving the bacteria, starvingthe methanogens or bacteria,
while still feeding the patientor the person, because that

(01:39:32):
those nutrients are absorbing soquickly across the top of the
small intestine they're gettinginto the body before the
bacteria have a chance toconsume them.
So it's a different method ofkilling.
Antibiotics and herbalantibiotics are our typical sort
of, you know, hurt the cellwall DNA replication.
This is just starving thebacteria, and what Dr Pimentel

(01:39:54):
has found is it takes about 10days to really get the
appropriate killing because thebacteria can eat our mucus, they
can eat various aspects of ourintestine.
Eat our mucus, they can eatvarious aspects of our intestine
.
So you need a good 10 days, but14 days is.
You know, two weeks is thetypical round.
Sometimes we go to a third week.
So that's kind of like howsometimes we go to six weeks of

(01:40:18):
herbs.
You know, sometimes we go to athird week If a person's willing
and needed.
We usually do a retest to findout.
So this, where this comes in isit's one of it's.
When you are deciding howyou're going to attack the
bacteria overgrowth itself withkilling agents.
You're going to choose eitherpharmaceutical antibiotics,
herbal antibiotics or elementaldiet.
We have these three choices andfor myself personally, I

(01:40:40):
decided to practice in a waywhere I was using all three
equally.
I would offer them all three tomy patients and together we
would make the decision of whatwe were going to do, except for
the fact that when someone isvery high gas level, as I
explained, elemental Diet hasthis amazing ability to reduce
gas.
You know, 100 parts per millionin two weeks.

Yeah, well, you're taking away the fuel
supply.

Yeah, so it's really you know, in that per
million in two weeks, yeah, well, you're taking away the fuel
supply, yeah, so it's really,you know, in that way it's more
effective, but it's, you know,just because it can reduce more
gas in a shorter amount of time.
But then again, sometimes itjust doesn't work at all, just
like with everything we use forevery problem we ever treat.

(01:41:24):
So nothing is guaranteed.
And believe me, when you treatenough things, I mean you will
see your morning patient dropped.
Amazing, they're all better.
The second patient, sametreatment, didn't do a darn
thing.
You know.
This is just what happens, youknow Now.
So then diet.
As to your question, which dietdo we use?
First, I myself used about fourdifferent diets with regularity

(01:41:48):
.
I used SCD, I used low FODMAP,I did use GAPS in the beginning
quite a bit, but we dropped that.
We found that wasn't quite asgood of a match.
And then I created my ownversion of combining, because
SCD and FODMAP are opposite insome of the things that they

(01:42:08):
eliminate.
So I combine them together.
So that's called the.
I just gave it the name SIBOspecific food guide.
I used to call it SIBO specificdiet, but I prefer food guide
just because it's more like youknow.
So that's my version of thosetwo together, more like you know
, um.
So that's my version of thosetwo together.
Then my friend Dr Jacoby tookthat diet, my diet, the SIBO

(01:42:29):
specific food guide, and justput it into phases and she calls
her the SIBO biphasic diet.
It's the same, they're the samediet.
Hers just is in phases.

And hers is much more structured.

It's better for people who want more structure,
whereas the food guide is reallyalmost like a shopping guide.
You know gotcha, um so.
So I was using my sebo specificfood guide, fodmap, scd and
gaps, and there was one oh, oh,and then the other one is the
cedar sinai diet.
This is developed by drpimentel and he now has renamed
it and sort of made it a lotmore comprehensive, and it's

(01:43:03):
called the good good eating,good life eating, or something
like that.
I forgot the new name, but it'son my free website.
I've changed the name on mywebsite, I just don't have it
memorized yet.
Good life, I think it is lowfermentation eating, low
fermentation eating.
That's it.
Lfe good LFE diet Okay, got it.

(01:43:23):
So, yes, so, honestly, I chosebetween those diets for each and
every patient.
There wasn't one I always wentto.
Now, in my larger communitybecause so many people knew me
and they, honestly, what wefound is that the SIBO-specific
food guide it is the mostrestricted out of all the diets.

(01:43:43):
It's the combination of twodiets.
It therefore honestly works thebest in terms of reducing the
most symptoms, simply becauseit's reducing the most, removing
the most carbohydrates.
But I don't always go to thatfirst, but many people in my
larger community would use thatfirst that's the same as SIBO
biphasic diet because they couldget the best symptom results.

(01:44:05):
But I don't think that's alwaysthe way to go and I would
customize my choice to eachperson.
I understand that's notpractical for a lot of people.
This is my entire specialty.
I'm in and out back and forthfamiliar with every one of these
diets.
I could immediately see whichone was going to be right for
each person, based on theirlifestyle and various factors,

(01:44:25):
from using them all for years.
So that's why I say it doesn'tmatter which one you use.
Choose whichever one you thinkhas the prettiest cover design,
who cares?
Just start with something.
But the key is get them totweak and experiment.
Now here's the other side.
Do you even need to do all thatexperimentation and tweaking?
And how much do you even needto use diet If you can just get

(01:44:48):
right in there with killingagents, get rid of the bacteria?
The whole point of having allthese food issues.
What does the diet really helpwith?
It helps with symptoms.
And what are the symptoms fromthe overgrowth?
If you could just get rid ofthe overgrowth, do you even need
to do a diet?
So Pimentel just waits andbrings the diet in after the
fact as a sort of help inpreventative measure, and his

(01:45:09):
Cedars-Sinai diet lowfermentation eating is a more
expanded diet and very good forthe prevention phase.
But honestly, even still, hisdiet is probably better at
symptomatic reduction, aswritten, than low FODMAP.
But I don't mean to say I mean.
Of course I had people with lowFODMAP who got a hundred

(01:45:29):
percent symptom relief, but itwas a few, you know you just
have to tweak it you know?

Yeah, so I have a ton of questions.
Going back to the elementaldrink, so that's the only food
that they're consuming, right?
So it's like you said, it's afast.
Do you, off the top of yourhead?
Do you know with whatever,whatever drink you're using?
Do you know what the calorieslevel levels are?

(01:45:56):
Do you know what the proteinintake is?

Yeah, they want you to.
The recommendation is800calories a day.
Some people may need 2,000.
You can also calculate that forthe individual, the protein I
don't remember.
Off the top of my head, thestandard elemental diet formulas
are higher in carbs and what wefound a problem with way back

(01:46:20):
when, when I first startedtreating SIBO, there was only
Vivinex Plus and like Neocate Jron the market, and Vivinex Plus
was very expensive.
These aren't covered byinsurance, they're over the
counter and my patients couldn'tafford it, and so I created
recipes, homemade recipes.
Took me quite a long time tofigure out.
I was really trying to exactlymatch Vivinex Plus, because that

(01:46:42):
is the one that was studied andshown to work.
Took me a long time, but I havethose free on my website.
Those recipes, and one of thekey things there is I have a low
carb version because so manypeople do not want that high of
a carbohydrate that comes inthose elemental diets.

Yeah, I mean, and I'm wondering like, because,
like these people who do haveSIBO or things that might
masquerade as SIBO, they usuallyhave other metabolic challenges
right.
They might have reactivehypoglycemia, for example.
So yeah, so do you find like,if you put somebody with SIBO on
this elemental approach, do yousee their blood sugar

(01:47:17):
destabilizing or do you actuallysee it getting better, do you?

see it.
No, because it's hard.
There's a big bolus ofcarbohydrates and we often see a
lot of die-off symptoms andreactions because more things
could be dying too Sure.
But we think a lot of thedie-off and symptoms we're
seeing is reactive hypoglycemia,and so the recommendation is

(01:47:41):
not to drink it as bam, slam itdown and three distinct meals,
but sip it over time.

Throughout the day.

Over maybe an hour or something, instead of
just because it's just too much.
Yeah, for sure.

Yeah, so is it your general approach?
I want to make sure I'mtracking with you as we're
talking through all thesedifferent variables.
It doesn't sound like you startor finish the same way with
every person, which I like right, everyone's different.
But if you were to say, when Ilook at all the ways that I
approach these problems, this isthe most common way that I do

(01:48:16):
it, would that be a couple ofweeks of this elemental drink
and no food, and then merginginto some dietary choice, and
you might have three or fourdifferent options and you try to
match the diet to theindividual and it's not just
about what you think they willor won't react to, it's what
they can adhere to Some peopleneed more structure.

(01:48:38):
Some people just like it's moreof a DIY.
Like here's your guidelines.
Go ahead and you know somepeople bristle against structure
.

They don't tell me what to do, and so okay,
here's just this simple.
And some people are like I willnever stop drinking diet Coke.
I'm like, okay, I know whichdiet to give you.
You know, I mean not that theycan't have the diet Coke on
whatever diet they want, but I'mjust saying to start with, you
know it's like okay.

Yeah, just recently I've been getting
emails.
I probably should have lookedat it before you and I jumped on
, but I'm getting emails from acouple of different companies
I've never heard of that arelike we've got this elemental
approach for SIBO and nowcompanies are creating products
to address some of thesechallenges.

Oh yeah, we have a whole slew of wonderful
commercial elemental diets onthe market now.
Yeah, in fact I was involvedwith I.
I begged various companies tomake cleaner versions of
elemental diets and I wasinvolved in advising.
The first one who made it wasphysicians elemental diet who
made it way back when, but nowwe actually have a phenomenal um
new one on the market came outa year ago.

(01:49:42):
Dr pimentel was involved increating this one.
It's called M-Biota ElementalDiet and the reason I'm
mentioning it is becausepalatability is a significant
challenge and issue in all ofthese elemental diets.
These companies try so hard toget them to be very palatable.
This is way above all.

(01:50:04):
I'm sorry all the other ones inpalatability, I'm sorry.
Other brands, I love you too,but it needs to be mentioned
that this one tastes better.
So there you go.

Yeah.
So when you go and trying tofold this back into things we
were talking about earlier, ifwe think about four week
iterations and that's usuallyyou have to do more than one
four week course are youproceeding each four week with a
two-week elemental approach orno?

no, no, no, because four week is just for
herbs.
So remember choosing betweentwo weeks of pharmaceuticals or
two weeks of elemental or fourweeks of herbal.
Those are our, those are ourthree choices and we're choosing
one of those as our killingstrategies for our first round.
And then we're assessing, ofcourse, get them on the
prokinetic and then assess andthen, if they need more

(01:50:55):
treatment rounds, we are onceagain choosing between
pharmaceutical for two rounds,herbal for four weeks.
Herbal for four weeks areelemental for two weeks.
We come back four weeks orelemental for two weeks.
But you know we come back tothose choices each and every
time, each and every time.
Yeah, yeah, I personally, I, asa specialist, couldn't treat
SIBO with just herbs.

(01:51:16):
I wouldn't.
I would lose my job.
I just there's.
No, I have to have more toolsthan that.
It just that just wouldn't.
I couldn't do it.

If you were, if you really had to choose, if
somebody somehow had the powerover you to say you can either
only treat SIBO clients withdiet or nutraceuticals and you
can't use both, which one wouldyou choose?

Now, do you mean between antibiotics, herbal
antibiotics and elemental diet,or do you mean like diet?

Well, no, so let's include those three.
So someone proverbially puts agun to your head and says you
can only use one toolpharmaceuticals, nutraceuticals
or diet to treat chemo andnutraceuticals.

you mean herbal antibiotics right, yes, I'm
sorry.

Herbal, okay, okay.

It's extremely difficult because the reason
being is due to sensitivity ofpatients, because, as a
specialist, I see so many highlysensitive patients meaning
which I think many people knowwhat I mean but they react
easily to supplements, medicinesand foods.
People like that do best withpharmaceuticals, absolutely

(01:52:36):
Without a doubt, if I was to put, but I don't want to put
everybody on a pharmaceuticalantibiotic, so so therefore,
let's put that aside.
Let's pretend I don't have ahuge amount of sensitive
patients I have to deal with.
Okay, patients I have to dealwith, then I would probably
choose elemental diet becauseit's um, it, it can bring the

(01:52:58):
super high gas level down.
Um, but then not everybodywants to do that.
In fact, most everybody willwill come to that last because
it's like fasting.
It's difficult, it'schallenging.

People don't want to do it yeah.

Yeah, they don't want to do it.
So, um so, but what you know, Ialways say this what people
always say like we do all theserounds of all these herbs, all
these other things, and thenfinally we need to come to
elemental, because they'vebecome clinically tolerant to
all these other things, and thenthey go.
Oh my god, I just wish I'd donethis first, and that's why I
would choose that one, becauseof so many.

Yeah, that feedback from your clients is
very important.

But they also say this, but I wasn't ready to.

I wasn't ready.

They had to go through all that to be okay,
I'll do the other.
And then they go oh, why didn'tI just do this at first?
Bam, it's gone, you know.
All the super high gas levelgone, you know.
But it's difficult.
So, but that's the one I wouldchoose.

Is your goal in treatment to get the follow-up
breath tests down to perfectbaseline, or do you look for a
combination of good quality oflife, control of symptoms, lack
of flare-ups and close enough tocall it good?

My goal is 90% better in symptoms and that's
subjective, that's judged by thepatient and myself together
figuring that out, and I don'tretest if somebody is 90% better
in symptoms.

And they don't relapse within that two-week
window or three-month window.

Well, most classic time for relapse is
actually at about two and a halfto three months post
eradication of SIBO, but somepeople it's a year.
You know that they're not goingto relapse for a year.
So of course we don't want tosee them relapse.
But my, my treatment goal forlike the killing agents, is 90%
better in symptoms and becauseif they're 80% better, many

(01:54:50):
gastroenterologists shoot for80% and what I found is if
somebody, if we really kind ofdecide they're 80% better, if I
do one more treatment round wecan usually get them to 90%.
So that's why I like 90%.
I mean, some people get 100%,but we're shooting for 90.
90 is darn good yeah for sure.

(01:55:11):
And so yeah, and then that's mygoal.
Um and then, in terms of like,what is there?
Are they going to relapse ornot?
We're going to see.
And if they relapse, that'swhat I'm going to focus on
figuring out underlying causewhat if they?
What if they never relapse?
I don't, why would I need?
I don't need to really thinkabout that unless they're going
to relapse Right and um and what, what's their diet like after?

(01:55:32):
We'll manage that as it goesand take it from there.

Have you developed any predictors of
relapse, things that you lookfor that increase the
probability or at least yourexpectation?

Well, I've been able to identify one thing that
predicts not a relapse.
This is when you.
It's an interesting pattern,it's when somebody does the
treatment, whatever treatment,and afterwards they're maybe
they're 80% better.
But we so you know I don'talways move to another round

(01:56:09):
when they're 80% better, becauseobviously I had to figure it
out first that I wanted to dothat and then over the next
month they get like a hundredpercent better.
Those people do very well.
The people that are like maybethey're not perfect right after
the treatment.
I think what's going on isthey're healing, like because

(01:56:32):
there's physical damage thatoccurs to the lining of the
intestines Enzymes are removed,lactase enzyme is removed, leaky
gut is caused in many people,etc.
And I think now that thebacteria is gone, it takes a
couple weeks.
For we know, like, after youknow about a food poisoning,
some people can have temporarylactose intolerance.
It heals in about two weeks.

(01:56:53):
So in about two weeks I thinkyou know about a food poisoning.
Some people can have temporarylactose intolerance.
It heals in about two weeks.
So in about two weeks I thinkyou know they're starting to get
better and better and then eventhey even improve.
So then we don't repeat.
And then, of course, you haveto be in communication with them
about this.
And then they just even getbetter after that, and so then
after about a month they'regolden, those people.

So that's like a critical window month.
They're golden, those people.
So that's like a like acritical window.
Yeah, that's true.
Yeah, all right, we're, we'reright at two hours.
So let me know, well, this is,this is great, this is exactly
the kind and we never even talkabout prokinetics.

So we don't have to talk about people you have to
know how.

No let's do.
I didn't and I do.
I kind of want to end on one.
So let's talk about prokineticsand we can go.
I'm not restricted on time, butI would like to ask you maybe,
as the last segment after theprokinetics is to ask when
you're dealing with difficultcases, how often do you have to

(01:57:52):
go outside of what you're doingfor SIBO to look for reasons why
people are not?

responding All the time.
Okay, 100% Okay.

So let's deal with that.
Now We'll get to the fuckingedit.
So do you have a short list ofthe, let's say, the usual
suspects?

Susual suspects Of that.
Yeah, mold Top Number one.

Number one.
So my big question on the moldis you're talking about, like
stachyboitris, you're talkingabout black mold, toxic mold, or
are you talking about thefoodborne mycotoxins that make
up most of the analytes onurinary mold testing?

Mycotoxins, as well as mold.

So just in general.

Yep, yes, that's right, and I'm not an expert in
this, but all I know is thatmold illness, including
mycotoxins it causes verydifficult cases of SIBO and it's
the first place we want to lookwhen we have a tough case.
Now how do we even define atough case?
That we should discuss.

(01:58:57):
But we can leave that foranother time because I just want
to say it's as we mentionedbefore.
It's not doing a few rounds andit not working.
You know, it's not that Likethe classic thing with mold,
when you want to think aboutmold pattern is a person
improves somewhat, verytemporarily, after every
treatment you give.
I mean, it's like you knowthey're improved maybe during a

(01:59:19):
little bit or for a few daysafterwards and immediately back.
You cannot make headway.
There's something preventing youfrom making headway.
So other things that could belike that would be parasites
We've seen that sometimes Hpylori, which almost could be

(01:59:40):
considered like a parasite.
It's not but, you know, just interms of like a chronic sort of
infection and all those othercauses that we talked about,
those underlying conditions,those need to be, you know,
managed.
Those need to be looked at andmanaged when you have a very
tough case but you know, toughcases are, you know, very

(02:00:00):
difficult, relapsing, not beingable to move forward there's a
lot of ways we can define toughcases.
Another thing is not respondingto all these treatments.
I mentioned that we know worknot responding at all to them.
What's going on there?
You know obviously there.

Obviously there's a block.
Yeah.

Yeah, there's right, so those sorts of things.
But basically, yes, we we'regoing to look at all the
underlying causes and associateddiseases, particularly
underlying causes Um and MCAS.
And histamine is a huge issuein um in difficult cases.
Uh, because it prevents peoplefrom taking the treatments we
need to give them.

(02:00:34):
It limits their diet much, muchfurther and they're just
sensitive to everything.
It's very difficult and, ofcourse, mold can cause that.

What kind of diagnostics are you running in a
case where you suspect mold?

I'm referring yeah, I refer to a mold literate
practitioner.
Okay, yeah.
So, let me come in through theside door and ask what kind of
testing are you seeing them do?
Well, I know that they checkfor mycotoxins, like urine
mycotoxins and also mold Various, I mean, there's various labs.

(02:01:08):
When I ask practitioners whatare their favorite labs,
everybody says all the labs thatare available.
You know, everybody has adifferent favorite.
They have a different reasonwhy.
Sure, so I don't.
I don't even run those tests.

It's not my area , so you stay in your lane, send
them out, fix that problem andcome back and we'll start up
again.

That's right.
I mean I can get someone going.
I mean I know the tenants ofmold treatment, you know, which
include antifungals internallyand in the nose.
Binders is usually how theystart.
For SIBO, really, the bestbinders are usually activated
charcoal.
There's pharmaceutical ones,there's chlorella, there's other
ones, but some people with SIBOcan actually fermentable, can

(02:01:50):
be like the clays and thingslike that.
So charcoal's best way to start, I think, for a SIBO patient
with binders.
So things like bentonite, clayor humic and fulvic acids yes,
the people can bloat from thoseand have terrible reactions and
you could try them, butcharcoal's the safest.

No, I'm thinking .
Well, that explains, and I'mthinking of four patients I'm
working with right now.

There you go.

Yeah, a clinical nugget.

Yeah, all these fabulous binder formulas.
They are so amazing and we havetrouble with some of the
patients so binders, antifungalsand I know I'm forgetting, oh,
liver detoxification for mold.
I know these tenants, but no, Idon't.
It's a specialty unto itself,especially with all the
sensitivities and how slow youneed to go with everything.

So yeah, All right, let's move on to the last
thing, and that is the motilityissue.
Oh, the prokinetics.

Okay, so prokinetics are simply agents
that move the migrating motorcomplex.
We already talked about howthat's the main underlying cause
for so many people.
These can be pharmaceutical ornutraceutical or herbal, and key
thing to know is that they'renot laxatives.
And another key thing to knowis that a laxative doesn't an

(02:03:06):
actual laxative doesn'tstimulate the migrating motor
complex.
This is a big confusion for somany, including like
prescription ones, like AmetizaLinzess.
Those are prescriptionlaxatives.
They don't stimulate themigrating motor complex.
It's just so important becausemany gastroenterologists don't
know this and they'll be likewell, I've given you a
prokinetic, it's like no, thatis not stimulating the migrating

(02:03:27):
motor complex.
So what are they?
By the way, there are unsafeprokinetics and so because of
that, pharmaceutically, becauseof that, many doctors think
prokinetics are unsafe.
But we have safe prokinetics.
So a safe prokinetic that weuse, a really excellent one, is
procalipride.
In the US that's calledMotegrity.

(02:03:48):
It's phenomenal.
It has many beneficial sideeffects or effects like heals
nerves, protects and healsnerves.

And that's a pharmaceutical or prescriptive,
it's a pharmaceutical.

It's a pharmaceutical, it's a
prescription.
It helps against tumors, ithelps with cognition, it helps
with depression.
It's amazing, safe, incredible.
Star in the prokinetic category.
Then we have low-doseerythromycin.
Erythromycin is an antibioticbut at low dose it is a

(02:04:22):
prokinetic.
And we have LDN uh, low dosenaltrexone.
It is not technically aprokinetic but studies have
shown it has prokinetic effects.
It's anti-inflammatory, helpsimmune system.
Amazing, right, um.
Then on the over the counter,those are all prescription.
On the the over-the-counter wehave Iberogast, which is an
old-time German over-the-counterformula, herbal formula, nine
herbs.
Now it's been changed to sixherbs Still good, still studies

(02:04:45):
coming out on that.
It's good.
And we have dupe formulas.
So, like on Amazon, there's IBSShield, which is a dupe for the
original nine herb, iberogasit's excellent.
Heron Botanicals has, I thinkit's, gut Motivator.
It's also a dupe.
So there's that.
And this is a complex formula.

(02:05:06):
It's not just the mainingredient, iberosomar, that's
doing the prokinetic effect.
Studies have shown when theyjust check that one ingredient,
no, no, it's the complex.
Then we have ginger root um,and you could just take ginger
root.
And then now, luckily, we haveall of these over-the-counter
prokinetic formulas that includeginger I call them the ginger
containing prokinetic formulaslike motility activator, modal

(02:05:27):
pro pro, kind, um, sebo, mmc.
There's like eight of them, um,one of them is like the one
that's in.
Motility Activator is a patentof artichoke and ginger.
It's a patented formula calledProDigest and so like five
brands carry it.
Sometimes they'll have it withapple cider vinegar, so people
with histamine intolerance needto watch out for that.
But that one is less spicy onthe ginger.

(02:05:51):
Sometimes ginger can cause likeginger burn almost like acid
reflux.
So I would choose the ones withProDigest if that's a concern.
And then there's a new one onthe market that has bitter
orange as its main prokinetic.
Good animal studies on that asa prokinetic.
No human trials yet.
So we'll be the human trials.
And that's by Gaia, gaia Pro,and I can't remember the exact

(02:06:14):
name of it, but it's a bitterorange based.

So you find that they, like one formula tends to
work for everyone, or is it oneof those things where you have
to Absolutely not, in fact withprokinetics.
I find prokinetics to be one ofthe most reactive categories
that I've ever given.

People have, in my experience, have a lot of
reactions to prokinetics to beone of the most reactive
categories that I've ever given.
People have, in my experience,have a lot of reactions to
prokinetics and I sometimes haveto go through.
You know all six of the mainones, the three pharmaceuticals,
the three main you knowover-the-counter I'll have to go

(02:06:49):
all.
It's like sleep aids and thenyou know, finally, the last one
you try is the one that's theone that works, yeah.
So don't give up on thecategory if people have
reactions.

So what do you?
So?
Is it you're looking for anadverse reaction, or is there a
good clinical sign that aprokinetic is working, other
than I'm not reacting to it?

This is the hard part.
What is the benefit?
That they don't relapse.
This is the hard part.
What is the benefit?
That they don't relapse.
So no, you're not going to feelor see anything.
It's preventative againstrelapse.
What the studies show is byadding a prokinetic you can
extend the remission period byfour times as much.
You know, not double, butquadruple.

(02:07:29):
Of course that waspharmaceutical, but still.
This is why we give it.
Who wouldn't want four timeslonger remission period?
So, that's why prokinetics areso important.
So no, all we're looking for ishow soon do they relapse?
And once you really starttreating a lot of SIBO, then
you'll have a sense if you thinkit's too soon in that

(02:07:50):
particular case, with what theirunderlying cause is, if they're
a chronic patient, and then youcan do things like if they are
relapsing sooner than you wish.
Of course you just starttweaking, like very often we'll
use a prokinetic at night and inthe morning two different ones,
or we'll use the same one atnight and the morning and add a
second one at night.
So now there's two at night,one in the morning, extra in the

(02:08:11):
morning.
So because most all theseprokinetics I mentioned have
different mechanisms of actionfrom each other, so it's fine to
overlap them, except be carefulwith erythromycin and like
Domperidone I didn't mentionthat one those can't go together
.
But um, pharmaceuticallyDomperidone is hard to get
anyway, which is why I didn'tmention it.
But so this is prokinetics.

(02:08:33):
It's one of the most number one, I'd say maybe number two most
common problem in SIBO treatmentis someone was not given a
prokinetic and so after theyfinish their antibacterial, give
them a day or so so they cansee how they feel they need to
go on a prokinetic.

So you don't dose that throughout the
four-week cycle.

Well, you can Now , because they're going to go on
to further rounds.

they can continue it through the next
treatments, but you don'tintroduce it until after the
first round.

Yeah, and then the key thing is it doesn't
matter if they take it duringnext rounds.
The key is they need to be onit in between rounds and when
they're done, when the whenyou're finished, as a prevention
.

yeah, um, and so that is what's missing in so
many people's treatment, andit's just a terrible oversight
yeah and um, like in the in therealm of prokinetics I don't
know how long ago, but I wouldsay at least seven years there's

(02:09:42):
been a lot of talk about vagalstimulation to drive the vagal
system and increase motility.
My experience with that becauseI play with that with clients
it's hit or miss.
It works for some people, notfor others.
Same thing whether it's anxietyor depression or anything like
that.
Have you used that?
What's been your experience andwhat's your opinion?

I tried a little bit of it long ago from what I
learned from Dr Karazian andunfortunately we didn't find
much of any help and it was verydifferent from what Dr Karazian
was finding.
He was reporting all thesemiracles and we were really
bummed out.
Really bummed out we just didn'tsee that at all.
I still recommend.
I think it's a fine idea.

(02:10:18):
The thing is that there's twomigrating motor complexes.
There's one that starts in thestomach and one that starts in
the small intestine.
The one that starts in thestomach is vaguely mediated.
The one that starts in thesmall intestine is not, and they
don't even still fullyunderstand all the instigating
factors in that.
But, however, the one thatstarts in the stomach from some
of the literature I've read thatis supposed to be the stronger

(02:10:42):
It starts in the stomach andgoes through the whole small
intestine.
Maybe it's not.
Maybe it's not.
Maybe the one that starts inthe small intestine itself is
the more vital one to SIBO.
Is that why the vagalstimulation has been?

maybe not, as helpful as we wished.
I don't know.

I still recommend it because it helps with so
many things.

With some people , yeah, and other things, you're
right.
So one thing that I'm playingwith lately and it's way too
soon for me to give an opinionon this, but do you know what
the insular cortex is?

No.
I probably should I took all ofKarazin's brain courses.
I don't remember.

Well, let's call it a new lobe of the brain.
Not that it's new, we never hadit before but our understanding
of it is actually a lobe of thebrain.
So, like when a when a baby isborn, we just have the baby has
a massive neuron.
So there's very littleorganization and as the brain
grows within the confined spaceof the skull, it starts to
invalidate, it starts to fold inon itself.

(02:11:45):
And just under the junction ofthe frontal, parietal and
temporal lobes, just around thetemple, right above the ear,
underneath the section therefrontal, parietal and temporal
lobes, just around the temple,right above the ear, underneath
this section, there's aninfolding of the cortex and
that's what's called the insularcortex.
And the insular cortex has asomatotopic representation.
No, that's the wrong word, ithas a viscerotopic

(02:12:08):
representation.
So in the brain, in theparietal lobe, we have a sensory
homunculus which is basically amap of the entire body as it
relates to sensation.
So if someone comes up andtouches my shoulder, my brain
shouldn't be confused and thinkthat someone touched my ankle
right.
So there's a picture of everybody part in the parietal lobe

(02:12:28):
on both sides, so that weunderstand sensation.
There's also a motor homunculusin the primary motor strip,
which is a picture of everyjoint and muscle in the body.
So when my brain says, hey, Iwant to wave my hand, I don't
kick my foot out.
There is a visceralrepresentation in the insular
cortex and it's in terms ofneurological hierarchy it's a

(02:12:51):
couple of steps above the vagus,but it integrates with the
vagus.
And so my working theory rightnow and that's all it is is that
when we have cases where vagalstimulation makes sense, perhaps
in some of these cases, reallywhat we're doing is we're
stimulating the vagus to try toget activity in the insular

(02:13:12):
cortex.
Does that make sense?
So sometimes I I think the inmy, in my theory, the cases
where vagal stem works is that'sthe choke point, so to speak.
And so the insular cortex mightbe fine, but some things
decrease the frequency of firingof the vagal system.
So you stimulate it directlyand now you get great things
happening.
But what if that system'sintact and the problem's higher

(02:13:34):
in the vagal system?
So you stimulate it directlyand now you get great things
happening.
But what if that system'sintact and the problem's higher
in the chain, if that makessense?
And so I'm playing right nowwith using different forms of
transcranial direct stimulationto put electrodes over the
insular cortex, trying to getthe brain to understand the
intestinal system better so thatit can more efficiently
organize signals going to andfrom that system.

(02:13:56):
I'll let you know what happens.

Great, I'd love to hear.

Yeah, yeah.
So, like I said, it's somethingrecently that I've been playing
with, and way too early for meto come out and say, yeah, this
is what we need to be doing, butso far so good.
What we need to be doing, butso far, so good.
I'll say that Great, yeah.
Well, listen, you have beenamazing and so generous with
your time.
This has been one of myfavorite interviews.

(02:14:22):
I tend to say that because I geta chance to talk to some really
cool people who know thingsthat I don't, and especially on
the Funk Med Nation podcast,where it's really geared towards
practitioners.
I know that I don't knoweverything and it drives me
crazy.
I quite often joke.
It just pisses me off that Idon't know everything because I
desperately want to.

(02:14:42):
And so when I get to talk topeople like you, who clearly,
like you, are an expert in yourfield, and I so appreciate not
just the facts and the detailsbut the clinical nuance and I
think you're just an amazingclinician and I'm so very happy

(02:15:04):
that you decided, yes, you'regoing to come on and have this
chat with me.
So, whether it's clinicians orthe general public, where can
people find you?

Well, I have a free educational website.
It's SIBOinfocom, and it's forboth patients and practitioners.
It's been that way for I don'tknow how long since 2010 or
something I guess 15 years and Idon't see patients anymore.
But I mostly just focus oneducation and so I have courses.
I have courses for patientsanymore, but what I mostly just
focus on education and so I havecourses.
I have courses for patients andfor practitioners.

(02:15:37):
I've got a mini course forpractitioners, I've got a
testing masterclass, a testingmini course and a comprehensive
training for practitioners and,as I say, for patients as well.
So you can see all that on mywebsite.
And also signing up for mynewsletter is a great idea.
I don't send too many.
I know people can't standgetting too many things in their
emails, but I often give freeclasses on SIBO and when there's

(02:15:59):
updates, I just updateeverybody, like, for instance,
about how TrioSmart startedoffering lactulose.
I just sent an email about that, so you know it keeps people in
the know on practical things.
And there's new research.

Every year, the the big gastroenterology
conference just happened theweekend before we're recording
this ddw and uh, there's allbrand new research and I do an
annual interview every year withdr pimentel, where we share all
the new research, and so that'swhy I'd say, if you sign up for
my newsletter, you'll getincluded in that yeah, and
that's amazing that you you playthat role because it's so easy

(02:16:33):
as a practitioner just to putyour head down and treat, treat,
treat, and then you look upfive years later and you realize
that the clinical world hasmoved on and things have changed
and all of a sudden you're adinosaur and you're doing things
the old way, right.
So I appreciate the fact thatyou've dedicated some of your
time to not just stay up on theresearch yourself but to share

(02:16:58):
that with other people, andmaybe we can use this as a
parting question when is SIBOresearch going right now?
What do you think is going tocome out in the next year or so?

Well, there's always more coming out about
treatments.
So I think like that NACrifaximin compound thing will
come out and I think we're goingto learn more about what's best
to treat each of the differenttypes of SIBO in those different
organisms.
I think we'll have probably newstuff in testing.
I've been seeing articlescoming through over the years

(02:17:30):
with developing various capsulesand various things like that.
It'd be fascinating to see whatwe develop with that.
But I think, and also just moreon understanding the
pathophysiology, we're going tosee more with that.
Like I said, we've gotten thebacterias figured out exactly.
I think we're going to learnmore about that.
Some complicated things Ididn't mention are.
There's these things calledsyntrophs.

(02:17:50):
They're actually bacteria thatsort of pre-make, the gas that
others make.
I think we're going to see moreon the pathophysiology.
It's more on the microbiomeaspect and how to treat that, I
think.
Yeah, I mean that's one thingthat's fascinating about SIBO is
it's a current emerging field,like I mean the, the, the

(02:18:13):
research is being done now andyou know, and, and when we first
entered it was being done, andit's being done now and we are
still learning.
We do not have all of itfigured out yet.

Yeah, yeah, and I, I love this, this whole field
, because it's like, as aclinician, like you have to
evolve or die.
Now, that's a little extreme,but you know what I'm saying.
Like, things change all thetime and you know, I've been
doing functional medicine nowfor not quite 20 years, but
going close to that, and it's atotally different world than 20

(02:18:44):
years ago.
Right, the cases are different,the things I have to think
about are different, thecomplexity is different, and
maybe that's just because themore I know, the more I think
about are different.
That complexity is differentand maybe that's just because
the more I know, the more Ithink about.
I mean, that's entirelypossible as well.
I lied, I'm not done yet.
I have one question.
Okay, you talked about dosingthe prokinetic at night and in
the morning.

(02:19:04):
That makes total sense, right?
Do you ever because I have donethis and again I'm a little bit
undecided on whether or notit's a good idea Do you ever
take your antimicrobials andgive them a bolus right before
they go to bed, maybe to takeadvantage of the slower transit
time so it stays in theintestinal system a little
longer?
Or do you think that's?

(02:19:25):
You know, sounds good on paper,but practically that's not
going to really do much.

Well, actually, what the studies show is that
the migrating motor complex ismost active at night, when we're
sleeping, and that's why wedose our prokinetics at night
before bed.
So, in fact, I think themotility in the small intestine
would be fastest at night, right?
So I think it makes more senseto take our antimicrobials

(02:19:51):
breakfast, lunch and dinner Withfood, with food, with food, or
they don't have to be with food,but in the day.
During the day when we'reeating meals.

Awesome.
Yeah, all right, I promise I'mgoing to let you go now, but let
me thank you again for being onthe podcast and you're welcome
back anytime.

But thank you so much.
Been a joy to be here.

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182 | Untangling SIBO: From Diagnosis to Recovery with SIBO Expert Dr. Allison Siebecker

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}182 | Untangling SIBO: From Diagnosis to Recovery with SIBO Expert Dr. Allison Siebecker