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Topics:
1. Updates [3:16]
2. Introducing our guest, Dr. Allison Siebecker [4:07]
3. How to tell if you have SIBO [7:31]
4. SIBO and leaky gut [9:50]
5. Diagnosis options for SIBO [18:34]
6. Why is there a bacterial overgrowth in the first place? [24:25]
7. Preventing possible SIBO when you get gastroenteritis [36:46]
8. Approach to treating SIBO with food [44:39]
9. SIBO and FODMAPs [50:57]
10. Treatment of SIBO [55:09]
11. Resistant starch and SIBO [1:00:09]
12. Prevention, avoidance, maintenance of SIBO [1:03:44]
Links
Upcoming events
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Dr Allison Siebecker
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Diane Sanfilippo: Hey everyone! Welcome back to the Balanced Bites podcast. Episode 135. Diane here. Giving Liz a break again this week to tend to the goats who, hilariously, seem to… goats jump on pretty much everything, it looks like. So, if you guys haven’t been to Liz’s Cave Girl Eats or Real Food Liz Facebook pages and Instagram and all those great places, definitely check them out. Stay tuned with what’s going on over on the farmstead, as she calls it. But I’m here this week with a fantastic guest. We have Dr. Allison Siebecker, and we’re going to be talking all about gut health and SIBO, which is small intestinal bacterial overgrowth, which, to those of you who are new listeners, our seasoned listeners are jumping up and down in their cars right now because they are excited about this topic, and if you’re new to the show, stay tuned because I think you’re going to find this really interesting information. And, we kind of rotate between Q&A episodes where Liz and I answer your questions, and these fantastic interviews where we get to ask some of our resources and the folks that we turn to for more insight on specific topics. So, our new sponsor this week is Rickaroons . They’re 100% organic, gluten and soy-free, paleo friendly, family owned company making these really, really delicious macaroons, and I think we will have a really great coupon code for you guys. We haven’t figured out what that coupon will be yet, but check out the blog post for this episode, we are in number 135, so you can check that out on the blog. We have, of course, Pete’s Paleo, bringing fine dining to your cave. Make your weeknights, or weekends a little bit easier. Check out Pete’s Paleo meal plans. You will get a free pound of bacon with any meal plan that you order, just enter code BBLOVESBACON at petespaleo.com, and you’ll get that free pound of bacon. And finally, of course, Chameleon Cold-Brew, which you can find at grocery stores nationwide. They should have website ordering back up soon; I don’t know what was going on, I think they were just super slammed and had to fix some infrastructure. So, I know a couple of folks have asked me about that, but stay tuned to the website for the coupon code for that, or check them out in stores locally. We love the organic, fair trade, smooth, rich cold brew. That’s it from our sponsors.
1. Updates [3:16]
Diane Sanfilippo: A couple of quick updates about events coming up. You can come see me and Liz in Denver, Colorado on Saturday April 26th, and on Sunday April 27th I will be in Boulder, just by my lonesome signing books and talking to all of you guys, answering questions and whatnot. So, come see us. What else is going on? We also have, well, this episode will be airing, hopefully we met a bunch of you at PaleoFx, what would have been last weekend. And I’ve got a TBD event on my calendar for April 19th in New York City, but I’m not sure what’s going on with that, so stay tuned for any other details on that, and we’ll keep you updated on whatever else is coming up.
2. Introducing our guest, Dr. Allison Siebecker [4:07]
Diane Sanfilippo: So, without anything further, let me get into introducing our guest today, Dr. Allison Siebecker. She has worked in the, ugh, I can’t even. Tongue twisting! She has worked in the nutritional field since 1988, and is a 2005 graduate of the National College of Natural Medicine, where she earned her doctorate in naturopathic medicine and her master’s in oriental medicine. Dr. Siebecker is the medical director of the SIBO Center for Digestive Health at the NCNM clinic in Portland, Oregon, where she specializes in the treatment of SIBO. She’s an instructor of advanced gastroenterology at NCMN, teaching continuing education classes for physicians, and is the author of the educational website, SIBOinfo.com. She’s also writing a book, synthesizing the SIBO data into one source. In 2005 and 2013, she received the Best in Naturopathy award from the Townsend letter for her articles “Traditional Bone Broth in Modern Health and Disease”(2005) and also “Small Intestine Bacterial Overgrowth: Often Overlooked Cause of IBS” (2013). So I’m very, very excited to welcome Dr. Siebecker to the show. I’m sorry for all my tongue twisting! I don’t know what’s going on, I think I need some water!
Dr. Allison Siebecker: {laughs} Hi!
Diane Sanfilippo: Hi, welcome!
Dr. Allison Siebecker: Thank you.
Diane Sanfilippo: I’m super excited to talk with you today, and I would love for you to just give our listeners any other information you want to tell them just about yourself and the work that you’re doing, and how that relates to some of the stuff that Liz and I are doing with teaching folks about real food and lifestyle choices.
Dr. Allison Siebecker: Well, I think you covered it pretty well with the bio, but I guess what I can say on the topic of food and real food is that, I speak to all of my patients about diet, with the SIBO diets, and they all emphasize home cooking and real food and non-processed foods. And they are all basically all the SIBO diets are versions of paleo. We just see phenomenal results. I don’t know what the full base of your listenership is, but I know a lot of people that I see get really frustrated with their doctors, whether it’s primary care or gastroenterologists, that no one has ever talked to them about diet, so I think it might be heartwarming at least to know that myself and all my associates, we talk to our patients about diet every single time.
Diane Sanfilippo: It is comforting to know, and I think a lot of folks out there feel like they’re just kind of a little lost, and they don’t have great access to doctors who are doing the same type of work that you’re doing. And so, I think shows like this are really what help people to take information either back to their doctor or to help find a new doc in their area who can help them, who is willing to work on nutritional approaches or perhaps some more natural approaches, if that’s possible, versus some other prescription meds and things like that. So, I think a lot of our questions really center around some of the, probably frequently asked questions about SIBO, but I think we can probably get through some of them and really start to educate folks a little bit more on the topic. So, can we start with some of the basics, like, how can you tell if you have small intestinal bacterial overgrowth and what might be the difference between SIBO and something like leaky gut?
3. How to tell if you have SIBO [7:31]
Dr. Allison Siebecker: Oh, sure. The main ways you could tell would be the symptoms. The symptoms of SIBO are the same as irritable bowel syndrome, although not everybody necessarily knows what they are. The symptoms are abdominal bloating and distention. Most people use the word bloating to mean distention, and distention means physical swelling. But it is possible to have a feeling of bloating without the swelling. Either one would classify. So bloating, and altered bowel movements. So either constipation, or diarrhea, or a combination or a mixture of the two, and then abdominal pain. And the pain could be severe, but it could be mild. It could be a mild discomfort, or maybe a cramping pain. Those are the three main problems. But additionally what could go along with it are acid reflux, nausea, excessive farting or burping, and other sorts of digestive symptoms, but the main ones you’re looking for would be bloating, pain, and constipation or diarrhea. So, that’s main reason you’re going to suspect it. Now, in terms of what would make SIBO symptoms different from leaky gut, the primary symptoms of leaky gut are not going to be gastrointestinal. They’re going to systemic. Because what leaky gut is about is opening in the intestinal wall that allows larger particles of food and other substances that are not normally supposed to get through into the blood where the immune system then reacts to them. So, we’re thinking more about immune generated symptoms. And so, these are symptoms that could be anything. It could be skin symptoms like rashes, respiratory like a stuffy nose, or maybe asthma gets triggered, body pain is classic, joint pain, muscle pain. Honestly could go on and on. It could be headaches; that’s very, very common, headaches. So, it’s more the systemic symptoms that are associated with leaky gut, and the gastrointestinal symptoms that are associated with SIBO.
4. SIBO and leaky gut [9:50]
Diane Sanfilippo: So, can SIBO cause leaky gut?
Dr. Allison Siebecker: Yeah. There are many, many things that can cause leaky gut. And I learned, my big list of things that could cause leaky gut from Dr. Datis Kharrazian
Diane Sanfilippo: I did too.
Dr. Allison Siebecker: Yeah, ok {laughs}. So, you know it’s very humbling because I specialize just in this one thing, which is bacteria, only bacteria, overgrown in just one area of the body, and when I look at his huge chart, it’s one tiny little speck on his chart. So many other things can cause it. But SIBO can cause it. Now, what’s really interesting is, there are only two studies on SIBO and leaky gut to show it’s relationship. And both of those studies that showed about 50% of people with SIBO get leaky gut. So, that’s lower than what I think a lot of people imagine. I think a lot of people imagine it’s 100%. But only half the people with SIBO will actually have leaky gut. And what’s really astonishing to me is that once the SIBO is irradiated, and in both of these studies they did this with antibiotics, and then what they did was they retested them one month later. So, they knew that the SIBO was gone, and they knew that they had leaky gut when they first had SIBO. Then they retested them one month later on the leaky gut, and in one study, in 75% of the people the leaky gut was healed, and in the other study, 100% of the people the leaky gut was healed. And no leaky gut supplements were given. So, I think it’s so important for all of us to remember that simply removing the cause is often all you need to do. We don’t have to throw a whole ton of supplements at something, and the way I like to think of it is, the intestinal membranes are similar to the skin, because they sort of are our protective barrier from, technically the outside of the body is the inside of the intestinal tract. And so when we cut our skin, it heals. Unless you have excessively high blood sugar, or some other sort of disease, the skin heals. And that’s what happens with all of these people, too. I think in the study where 75% of them healed, and 25% of them didn’t, I think those 25% probably fit into Dr. Kharrazian’s big chart. There are some other causes going on. So, pretty interesting information.
Diane Sanfilippo: Yeah, I think that’s really interesting, because I think a lot of folks may work on trying to heal a leaky gut with, I know a lot of folks will take a basic paleo approach where they remove what they consider to be potentially offending foods, and it’s just not working. And there’s also other steps to heal the gut that, if they don’t have the SIBO infection causing their leaky gut, some of this can really help, there’s a lot they can do. But, if it turns out that this is the cause of their leaky gut, it’s something that they really will probably need to get tested and find out that that’s the cause, because they’ll be spinning their wheels trying to heal it and never really getting anywhere. One quick question I had before I kind of get a little deeper on that is, when you talk about the symptoms being the distention, the bloating, the gas, even belching, and potentially diarrhea, did you also say constipation? Just pretty much broad spectrum seemingly like IBS symptoms.
Dr. Allison Siebecker: Yes, absolutely.
Diane Sanfilippo: Ok.
Dr. Allison Siebecker: So let me just say them again. The key symptoms of IBS and SIBO are bloating, constipation or diarrhea or a mixture of the two, and then pain which could be discomfort. And let me just make a comment on that. Many, many people who hear about IBS they think that equals diarrhea. They think that what IBS is is a person who suffers from diarrhea.
Diane Sanfilippo: Mm-hmm.
Dr. Allison Siebecker: And that is not the case. And, honestly, I did not even know myself until I was in medical school that IBS has a diarrhea type, a constipation type, and now what’s called a mixed type.
Diane Sanfilippo: Yeah.
Dr. Allison Siebecker: It used to be called alternating, but that definition was a little too narrow, because that definition implies that you have constipation for a few days, and then you have diarrhea, and then you go back and forth. Mixed means that you could have a mixture that is not like that. Maybe you go to the bathroom 8 times a day, but only, whenever you do, comes out one tiny small ball.
Diane Sanfilippo: Right.
Dr. Allison Siebecker: And you feel incomplete, and it’s hard, and rough. That is a mixed type. Another type could be you only go every 4 days, but when it comes out, it’s watery.
Diane Sanfilippo: Right.
Dr. Allison Siebecker: So that could be a way it could be mixed. You could also have that alternating type, where it’s constipation for some days and diarrhea for other days. But it’s very, very important for people to know that constipation is a feature of IBS and SIBO.
Diane Sanfilippo: So, my one other question there, when it comes to, because I get this question a lot about poop, {laughs} because I have a chart about poop in Practical Paleo. Sometimes people ask, if it’s a one-off sort of, you know, I’m going long for a week or two weeks, and everything seems to be “normal” they’re eliminations are looking like Miss Ideal in Practical Paleo, and then there’s a day or two where it’s just not really right, you know. Things are a little bit weird. Is that a case where you just, you know, maybe there was something that you ate that just wasn’t balancing right for you, or is that a time when any disruption is maybe a sign that something is not right, or does this really have to show for a consistent time period to really identify with something that could be a bigger issue.
Dr. Allison Siebecker: Yeah, it needs to show. It needs to show for a consistent time. It needs to be a really longer term, consistent problem. I think you’d need to be having that problem for a good 3 months before you’d consider you’d moved into a state of a syndrome like IBS.
Diane Sanfilippo: I think that’s really important to know, because I think a lot of folks have an intermittent experience, maybe they are eating paleo but maybe nightshades don’t work for them and they haven’t yet learned that, you know, and they eat nightshades once or twice a week and then they’re having a disrupted bowel movement, and they don’t realize that it’s not necessarily SIBO or leaky gut, it’s just you ate something that you don’t really do too well with once or twice.
Dr. Allison Siebecker: That’s such a good point. No reason to get all worried when a little something is out of the ordinary. That’s really normal for human beings. We live in a dynamic world with changes all the time, and our system has to adapt to things. Of course, there are some people that are like clockwork and always have been their entire life and they’re amazing, but most people it’s not like that. And I think it’s really good that you bring up the point of, you know, some more simple solutions. If it’s not an ongoing problem, simple solutions should be looked at before considering IBS or SIBO.
Diane Sanfilippo: I think those are all really good points because we have a lot of really smart listeners. A lot of people who are taking action, and they’ve changed their diets, and they’re working on different types of supplements because those things can help them. They don’t have a deeper underlying issue, perhaps, but I think what I see in practice and in working with folks who are asking questions at book signings or seminars, a lot of times people are talking themselves into having these conditions.
Dr. Allison Siebecker: {laughs}
Diane Sanfilippo: And I’m like, you guys, everybody needs to just calm down. If you had one off bowel movement; one off bowel movement does not an infection make.
Dr. Allison Siebecker: Yes. We called that second yearitis in medical school.
Diane Sanfilippo: {laughing}
Dr. Allison Siebecker: Because in second year, everybody has pathology, and they get shown every disease described, seen all the pictures, and everyone leaves every class going, oh my god I have that, oh my god I have that.
Diane Sanfilippo: That’s hilarious. That happened in nutrition school, as well. In holistic nutrition school. It’s like you go through; well first of all, you go through every lesson and then you want to stop eating 5 more foods, or all of a sudden you start eating chlorella, because there was one nutrient that seemed like you might be deficient in it. Anyway, it’s pretty crazy. {laughs} That’s funny, second yearitis. Oh, boy. Ok, so, we have a lot of questions from my readers, and I think, I’m trying to just kind of see what’s making the most sense in terms of the order to go through here. So, I think what would be next is, if somebody thinks they have SIBO, what would be the best way to detect it? And then what is the best way to really get rid of it, combining options that are more natural and then perhaps going to prescription medications?
5. Diagnosis options for SIBO [18:34]
Dr. Allison Siebecker: The best way to test for it is going to be the lactulose breath test. And this can be ordered by doctors in most states. I can’t remember; it’s state by state as to who gets to order this test. And so because of that, some practitioners who aren’t allowed to order it, they wind up using a test that actually can’t diagnose SIBO, and that is the urine organic acid test. I think in lieu of having access to that breath test, that’s what practitioners are using, but it’s important to know that it can’t diagnose SIBO. And there are two problems with thinking that it could, or why can’t it. The two problems are, according to the researchers who helped develop that test, they’ve published some articles saying you can’t really distinguish the organic acids that indicate a bacterial abnormality, you can’t distinguish between the small and large intestine very well on that test. That’s one thing. And the second thing is that it hasn’t been studied or validated yet. So, there’s been about six studies that have looked at that test to see if it correlates with breath test or culturing, and I’ll explain culturing in a minute. Six is not very many, and they found all the way from zero correlation to really excellent correlation! So, it hasn’t been figured out if this test can be used yet, so I just want to mention that because it’s important to know that can’t actually diagnose SIBO. It could lead you in the direction of either a small or large intestine bacterial problem. But the breath test, when you talk about the breath test there’s a couple of different sugar drinks you can use to figure out if you have SIBO. Over in Europe, they prefer using the glucose breath test, and here in the US we prefer the lactulose breath test. And the difference is, glucose is absorbed in the first 2 feet of the intestines, and so it can only diagnoses SIBO in the top 2 feet of the small intestine, so that’s the duodenum. So it can only diagnose duodenal overgrowth. Whereas lactulose travels the whole way down. It doesn’t get absorbed, it actually goes all the way through into the large intestine, so that one is better for diagnosis SIBO anywhere in the small intestine. And it turns out most people have the overgrowth in the lower, or distal part, of the small intestine. But, the reason why some people like to use the glucose breath test is because it is even more accurate than the lactulose for the one location it’s doing. I mention that just in case if that comes up for people wondering which test to do, the glucose test can be ordered by anybody. So that could be done; anybody, even just a regular person can order it for themselves and do it. It’s just that if that test comes back negative, then you have to do a lactulose breath test. And it’s very unfortunate that the lactulose breath test isn’t available to anyone who wants to order it, I wish it was. And the problem is that lactulose is a prescription item, and I don’t believe it should be. I think that’s a mistake, {laughs} and it should be taken off of the prescription only list. But currently, that’s the situation. And just to specify here, it sounds like your listeners are very well educated, but lactulose is different than lactose. They are two different things, so let’s not confuse them.
Diane Sanfilippo: Awesome. I think that’s really great information.
Dr. Allison Siebecker: Oh, and you know what I didn’t mention culturing. Let me just mention that really quick. Culturing is when you go in for an endoscopy, which is a tube that is put down through the mouth and samples the upper small intestine. And, fluid from the intestine, can be gathered and then bacteria can grow, and we can see how much overgrowth of bacteria there is. That is considered to be the gold standard, but it’s considered to be a very poor gold standard because, once again, it only reaches the top portion of the small intestine, this time about 3 feet, maybe a teeny bit more, and there’s all sorts of problems with culturing. Oftentimes the anaerobic bacteria that are overgrown in SIBO, the oxygen is fatal to them so once removed from the body, they won’t grow. So we can’t culture them. And also, there can be contamination as the tube is taken out of the mouth. It’s considered the gold standard, but there’s problems. So the two main tests are going to be culturing which is invasive, and it’s not done very often, and then the lactulose breath test, and that’s very common, it’s inexpensive, and it’s easy to do.
Diane Sanfilippo: Ok. In a minute, I’ll jump ahead to some of those other follow-ups on healing and treatment and things like that, but actually I want to go backwards for just a minute, because I think that, while a lot of our listeners are pretty well versed on what this whole thing is, can you explain why we would even get an infection in our small intestine to begin with?
Dr. Allison Siebecker: Oh, yes.
Diane Sanfilippo: Why we even have this bacterial overgrowth, because I don’t know if most people understand. I’ve mentioned it a bunch of times that when we talk about gut health and gut bacteria, and correct me if I’m misstating this, please, most of what we’re talking about is going to be more in the large intestine, we shouldn’t have much of a bacterial colony, at least in this way, in the small intestine? Is that correct?
6. Why is there a bacterial overgrowth in the first place? [24:25]
Dr. Allison Siebecker: Yes. You’re absolutely right. I think the reasons why we get SIBO is the most fascinating part of the whole thing, so I’m glad you asked me. You’re absolutely right; the small intestine should be relatively clear of bacteria. As it gets towards the bottom portion of it, it gets closer to the large intestine, there is more bacteria from natural reflux through the ileocecal valve from the large intestine into the small intestine, that’s just natural. And so there’s more down there. But still, we know what level they should generally be at, and we can see when it gets too high. So, let me tell you how it occurs. I like to classify it into 3 main underlying causes. And these are going to be anything, it’s really anything that allows bacteria to back up and accumulate in the small intestine. And the first one is the most important one I think, it’s decreased motility in the small intestine itself. And you could think of this like peristalsis. Peristalsis is the downward movement that mixes and moves food downward. So you could think of this as a form of peristalsis, but really we’re not talking about the food moving down, we’re talking about another motion that’s called the migrating motor complex that happens in the small intestine in between meals. And I’m going to explain it to you more, but let me just tell you the other two. So we’ve got decreased motility, and then we have obstruction. So basically, anything that would block the pathway for bacteria to move down and out of the small intestine. So that would be things like a tumor, a scar band, an adhesion, a hairpin turn, something like that. So, a physical obstruction impeding the path of clearing away bacteria out of the small intestine. And then the last one is what I call non-draining pockets. And so this would be something like a surgical blind loop that gets created, or a diverticuli or many of them in the small intestine. Diverticuli are little out pouch pockets off the side of the tubing in the small intestine, and so is a blind loop, essentially. All it means, imagine a little, like a half full balloon or something, off the side of a tube. It can collect water, and it can collect all kinds of debris; there’s no way to clean it out. So they can accumulate like that. So, one other thing before I go back to the motility, is that bacteria come into us all the time with every swallow we take and all the food we eat, they are just naturally in the environment, and we’re constantly swallowing down bacteria, with our food or without. And so that’s why this is essential to keep the small intestine clear. The other thing is that we have this huge, as you mentioned, huge colony of bacteria that we’re meant to have in the large intestine. And without a downward pressure movement against it, those bacteria, where do they have to grow, if they keep eating and keep multiplying, they can only go backward and go up into the small intestine. So you need a downward movement to keep them in their place, as well as some other factors. So let me just go back to the motility. The obstruction and the non-draining pockets I think I’ve described; something like cancer or surgery could cause those, and diverticulosis. But the motility is really interesting. There’s a couple of ways this can happen, this decreased motility. The primary way, it turns out, is from acute gastroenteritis. Which is otherwise known as food poisoning, stomach flu, or traveler’s diarrhea. So this is when you get acutely sick and have vomiting and diarrhea, or at least one of them. And it lasts a day or two, and you wish you would die because it’s so awful. I’m sure we’ve all experienced this; have you ever had this, Diane?
Diane Sanfilippo: Yeah, actually, not long ago. A couple of months ago, and I had so much compassion for friends of mine who’ve suffered from things like ulcerative colitis because I had a minor experience that seemed similar for one day. You know, not months on end, so it was rough.
Dr. Allison Siebecker: It’s so awful. Well, it turns out, this is probably one of the primary causes of SIBO. And, I want to explain it to you because it’s so fascinating. What happens is, when we get sick like that with gastroenteritis, it’s caused by a pathogenic bacteria. And a really important point is that SIBO is an overgrowth of nonpathogenic bacteria. It’s an overgrowth of the bacteria that’s normally within us. Pathogenic bacteria are not normally within us. When they come into us, they give us gastroenteritis. We have diarrhea and vomiting until we expel them all. So, these pathogenic bacteria common names are Salmonella, E. coli, certain type of E. coli, Cholera, and Yersinia. Things like that. When these bacteria come in, they secrete a toxin, and it’s called cytolethal distending toxin. And it’s abbreviated as CDT. All these bacteria have the same toxin. It turns out that the B portion of this CDT toxin; there’s an A, B, and C portion of this toxin. The B portion looks like a protein on one of the nerve cells in our small intestine. And so through an autoimmune process, an autoimmune mediated process of cross-reactivity or molecular mimicry, as it’s also called, our immune system attacks the protein on our nerve cells in our small intestine at the same time that it’s attacking the CDT toxin, because they look very similar.
Diane Sanfilippo: That’s fascinating.
Dr. Allison Siebecker: It’s unbelievable. This is like one of the greatest discoveries {laughs} for me of all time.
Diane Sanfilippo: That’s fascinating, yeah.
Dr. Allison Siebecker: We actually know, now, and this is all the work of Dr. Mark Pimentel, who is the lead researcher on SIBO, and he’s just doing the most amazing job at helping us all understand how this happens and what is happening. So, what happens is, this protein on the nerve, it’s called vinculin, and the nerve cell is called the interstitial cell of cajal, and abbreviated as ICC. And these cells are pacemaker cells in the small intestine that are necessary for doing the migrating motor complex. And what they have been able to figure out is that the damage is successive oftentimes, so it depends on how severe the gastroenteritis was, or is. So, these cells will be damaged by a bout of gastroenteritis. But they may not get to the threshold at which SIBO develops. It’s actually been figured out exactly the amount of cells that need to be damaged, and that need to be still there when a person will then develop SIBO. So I think what can happen for a lot of people is, most everyone has had gastroenteritis in their life multiple times. In fact, young children get sick like this a lot, you know vomiting and diarrhea, and I think we even lose count, who even knows before 5 if we can even remember, we probably all had it, you know? {laughs} So I think damage can accumulate for people, setting a stage. Which is why some people don’t get SIBO or IBS until adulthood, and it might just be that they have a triggering event, like one last bout of gastroenteritis, and that was enough to do it. But it’s important to think about this, because why then, you know if there’s two people standing next to each other, they both get this gastroenteritis, how come one goes on to develop SIBO or IBS and the other doesn’t? Well, it might have to do with the accumulation of damage that one person had and the other didn’t. So this is what’s considered to be the primary underlying cause. This is also called post infectious IBS. And what Dr. Pimentel’s theory is is that post-infectious IBS is none other than SIBO. They are one and the same thing. And a really interesting thing to talk about here is the recovery rate. So, what has been found is that about 50% of the people who develop post-infectious IBS or SIBO, will spontaneously recover within 5 years. It can take some time; it can take quite a bit of time. But after 5 years, it doesn’t seem any more people are improving. After 5 years, that’s about it. {laughs} So then, the 50% of people who didn’t recover, it seems that it’s permanent nerve damage. Now, why would the 50% that could recover, why did they recover? Well, it turns out the interstitial cells of cajal are very plastic. They have a high degree of plasticity, which means they have an ability change and heal. And what they do is really phenomenal. When there’s some sort of assault to them, they switch from a nerve cell into a muscle cell. Now, they can no longer do the nerve cell function anymore, which is why you see that you don’t have those cells, but there’s the potential for them to switch back. And clearly, in 50% of people in a time period of over 5 years, they’re switching back. And those people recover. So, what Dr. Pimentel is doing right now is conducting a lot of research to see if he can help the 50% of the people who don’t recover. Is there any way he can stimulate those ICCs to turn back into nerve cells? And I just cannot wait to hear his results.
Diane Sanfilippo: The face I just made went from my jaw on the floor, to holy cow, what? That’s crazy! Our bodies are crazy!
Dr. Allison Siebecker: It’s unbelievable.
Diane Sanfilippo: {laughs} That is wild.
Dr. Allison Siebecker: When I read this stuff, I feel like I’m reading an esoteric sci-fi novel.
Diane Sanfilippo: Sci-fi. It does. It sounds so crazy. So, wow. That’s really interesting, and I think one of the reasons why these types of infections and bacterial overgrowths are so, sometimes seem intangible and weird and made us is that because they do have these different root causes. They do have these different triggers for different people where, as you said, it could develop over time, and how it may spontaneously heal for some people, so pinpointing these things becomes really tricky. Because it’s not a black and white cause and effect, and here’s what to expect for every person, you know? And I think that just gets really confusing, and it’s almost like {laughs} the beauty and the curse of human bodies, you know. It’s awesome, and it’s also so frustrating.
Dr. Allison Siebecker: Yes! And when you don’t know what the underlying cause is, and you’re just looking from the bird’s eye view, like you just described, it is too confusing to make any sense of. But thank goodness we’re finally getting to the understanding of what the heck is going on now, it can all fall into place, you know? {laughs}
Diane Sanfilippo: I still have, for folks listening, when is she going to talk about what to do about it?
Dr. Allison Siebecker: Oh, sorry.
Diane Sanfilippo: And eating and all that. No, no, no. We will get there. It’s in my notes, so don’t worry. But one thing I want to ask, because I know this is probably something people are wondering, if you know that you’ve had an issue with gastroenteritis, maybe recently, or if you’re anticipating, ok what do I do when. We’ve got blog posts on what to do when we feel like we’re getting a cold, or that type of thing. But what if we are struck with some type of infection, a gastroenteritis, are there tips for dealing with the pathogenic bacteria when it hits and helping to prevent SIBO by doing whatever we can to either support our bodies in flushing that out or perhaps if there’s any sort of benefit to repopulating certain gut flora or helping to encourage that. Anything we can do if we’re like, ok, I think I just got food poisoning, you know. How do I keep myself on track?
7. Preventing possible SIBO when you get gastroenteritis [36:46]
Dr. Allison Siebecker: I know. This is so important. Doctors are looking at this, because now that this information is out, we are realizing how very serious gastroenteritis can be. Now, we did already know this, because in the non-industrialized world, gastroenteritis is still a major cause of death, actually. It’s very sad, particularly for children. But in the industrialized countries, it isn’t fatal. Usually we can get past it, but now we realize there’s these serious chronic long-term consequences. So what doctors are saying to do is basically take some kind of antibiotic, whether it’s natural or pharmaceutical, as soon as you think you’re having this. In fact, what a lot of doctors is recommending is to take them prophylactically when you go traveling. Because it’s very common to get gastroenteritis when traveling, particularly in a non-industrialized countries. So, for the pharmaceutical option, what’s recommended is the same antibiotic that is used to treat SIBO, which is rifaxamin. And then, if you’re wanting to do the natural option, then you could use any of the natural antibiotics we use for SIBO as well. One doctor I know recommends, we use Allicin that is extracted out of garlic. Is it ok if mention brand names?
Diane Sanfilippo: Oh, sure. Yeah, whatever you feel comfortable.
Dr. Allison Siebecker: I always have to be so careful, because whenever I teach continuing education classes, I’m not allowed to mention brand names, or we lose our CE, so I have to be so careful! {laughs}
Diane Sanfilippo: No, you can. I mean, this is really, we make sure that everybody knows that this is not direct medical advice, and everybody should be seeking help from their own practitioners, but I think it is great for them. They will ask us, what are the brands that are out there at least, at least that they can trust, even if you’re not saying, this is the one that you should only buy.
Dr. Allison Siebecker: Yeah!
Diane Sanfilippo: If you trust it, that’s good information.
Dr. Allison Siebecker: Yeah, so the one we use is called Allimed. It’s the strongest concentration of Allicin, the antibacterial ingredient in garlic, concentrated on the market that I know of. So, one of my doctor friends recommends to his patients that are traveling that they prophylactically take that daily. I think he recommends 6 a day, which is a very high dose, but I can understand why he’s recommending that.
Diane Sanfilippo: Yeah.
Dr. Allison Siebecker: You do not want to get these consequences. And before we move on, I did just want to make one other point about causes. Because I spoke a lot about acute gastroenteritis, because that’s the number one cause that we know of so far. But the other causes are important too, which are there are many diseases which slow that migrating motor complex. And many people get SIBO because of having a disease that slows motility. And some common ones are diabetes and hypothyroid. So I just wanted to mention those. I have all this listed on my website and in other places, and lastly surgery. We talked about how there can be obstructions created; but there could also be nerve damage done in surgery that affects the migrating motor complex. And also drugs. There are some drugs that can bring this on, particularly opiates. Opiates, if anyone has ever been on a pain med after surgery, you know that they shut the gut down and people become constipated. And that is another underlying cause. It usually needs to be in combination with one of the other factors, but it can be a big triggering event.
Diane Sanfilippo: So, really important for me to mention now is that one of the team members I have, Holly, she’s an NTP, nutritional therapy practitioner, and she attended a conference that you were teaching at, I believe. She’s writing up a review for us on the conference, all about SIBO. We are going to have a recap of that as well as some guides available to our emailing list subscribers only coming up soon. So, if you’re not on the emailing list yet, some of the changes we have in the pipeline is that we’re going to have a lot more exclusive content just for folks who are subscribed, so make sure that you go ahead and subscribe to that. If you’re really curious about a lot of the stuff that Dr. Siebecker is talking about today, and really getting it in an easy to understand, sort of listed out visual way as well as a little bit more information of a recap there. A couple of questions I just wanted to follow up on that. This has been my understanding, that sort of the more natural form of antibiotics, while they can be very, very potent and effective, they’re also not necessarily going to be as detrimental in the longer term. So, if you’ve got someone prophylactically taking the Allicin, or the Allimed, or even something like what I use typically is oil of oregano. I’ll use that now and then, I just thought the other day I might be getting a cold and I’ll take it for a couple of days. It’s been my understanding that if you’re not abusing that, it won’t have the same negative, perhaps, consequences. Is that accurate, or we don’t know?
Dr. Allison Siebecker: I think that’s true. I think that’s what all of us are believing. I don’t know if we have proof for it yet. I don’t know if there are any studies to prove that. Maybe there are. But I tend to think that way. I will say that the one main antibiotic, Rifaxamin, that’s used has been studied to be shown to be not very damaging at all, and that really puts my mind at ease, because I do need to use it with many of my patients. And that’s because it stays only in the intestines. And that’s really important. It just treats right where we want it to. In fact, it’s activity is fairly localized just to the small intestine, which really puts a lot of people’s mind at ease, which means it’s not going to carpet bomb out the large intestine.
Diane Sanfilippo: It’s not the same as those broad-spectrum.
Dr. Allison Siebecker: It’s not. Well, it is broad-spectrum, but it doesn’t absorb into the blood system.
Diane Sanfilippo: Gotcha.
Dr. Allison Siebecker: So that means you’re much less likely to get urinary tract infection or some other thing as a side effect from the antibiotic, so that’s good. And also, rifaximin is anti-inflammatory, and it’s been studied and shown that it doesn’t cause yeast overgrowth, and lastly it’s been studied for up to, I think, 6 repeats without antibiotic resistance developing.
Diane Sanfilippo: Very interesting.
Dr. Allison Siebecker: It’s just good to know; I mean, I’m a naturopath so you’d think I would be opposed to antibiotics.
Diane Sanfilippo: Yeah, and you’re not being paid to tell anyone to…
Dr. Allison Siebecker: No, I’m not on Salix, you know, I don’t get any money. I’ve done my own research. If I was going to use it, I needed to find out if it was bad or not. And you know, I just am practical, and I don’t like black and white thinking. I don’t like the thinking that all antibiotics are bad, and all natural substances are good. The world just isn’t like that, you know? {laughs} And there’s no reason for these divides. Let’s figure out what’s what with each thing we’re talking about. I generally love the idea of using the natural antibiotics, but what I can say is that there are pros and cons to each, and the patients that I see, because I’m a specialist in SIBO, I happen to see often more severe patients, particularly patients who have been to many other doctors for the SIBO, and the treatment has failed. So I get a lot of complicated cases, and I have to use anything and everything I can. I need my toolbox to be as big as it can to help these people. So, I think, for someone who is starting out with someone who has never had any treatment, please by all means, start with the naturals! Go with the least offensive thing first. But, just know that there’s other options if that fails.
Diane Sanfilippo: I think that’s really good advice. So, let’s talk quickly about what you typically recommend nutritionally, either if somebody suspects they have SIBO and they want to maybe test avoiding certain foods, and if they feel better, that’s kind of maybe a sign that it is SIBO, or what you have them eating once they’ve been diagnosed and they’re doing treatment. Some of the questions I’ve had are, would they be eating low FODMAP, or just low carb in general, or none of the above? What kind of approach do you typically take?
8. Approach to treating SIBO with food [44:39]
Dr. Allison Siebecker: Ok. So, {laughs} there were so many questions in there!
Diane Sanfilippo: I know, I have a lot. I’ll recap them if we get off track, no worries.
Dr. Allison Siebecker: Ok, so first you’re wanting to know which diets help SIBO. Is that right?
Diane Sanfilippo: Yeah, what do you usually recommend. Because our listeners are pretty familiar with the fact that you’re going to be recommending that folks aren’t eating processed refined foods. Perhaps grain free, I don’t know, so I want to check out what your approach is.
Dr. Allison Siebecker: Oh yeah. Absolutely.
Diane Sanfilippo: And if there are different levels to that, too. You know, if there’s a basic approach that if the person responds to you stick with that, or if there are different layers to that.
Dr. Allison Siebecker: Yeah, this is a good question. So what I typically use are grain-free diets. And there are a few standard SIBO diets. And what I have to do is just customize it to where the person’s at. I mean, I think that’s the best thing. I just recently had an interesting conversation with someone, it helped me so much. A gastroenterologist who sees patients who have never done any dietary alterations, so I don’t see people like that. I usually get to see people who have been on one of the SIBO diets, and I’ll explain them in a minute, for many years actually without enough help. So he and I were at 2 ends of the spectrum, and it really helped me to hear his experience, because it solidified for me the importance of taking a look at where someone is starting from, and choosing a diet based on that. So, the main diets for SIBO are grain-free, and that would be the specific carbohydrate diet; so that’s grain-free, and therefore, of course, gluten free. It does emphasize all home cooking, and it takes away all sugars except honey and maybe a little bit of stevia. Technically, on that diet they allow saccharin, but nobody that I know chooses to use that {laughs} .
Diane Sanfilippo: {laughs}
Dr. Allison Siebecker: And then it limits the starchy tubers, so no starchy tubers. Carrots are allowed, but no potatoes or sweet potatoes. But, winter squash is allowed and summer squash. Beans are eliminated at first, and then as a person heals and gets better, then there are only some beans that are allowed back in. And let me just think if there are any other main; oh, and nuts and seeds are allowed, but a person may not do well with them at first, so they have to be careful with them.
Diane Sanfilippo: Can you touch on the issue of home cooking and why that is something you recommend?
Dr. Allison Siebecker: Yeah, the home cooking is recommended because of basically, how do you call it, it’s like food fraud. Mislabeling.
Diane Sanfilippo: Oh yeah.
Dr. Allison Siebecker: I think a lot of the people who first started using the specific carbohydrate diet did have celiac disease. And I think then they were getting contamination. But it’s true for even people without celiac disease. Often things aren’t put on the label that are in there. And so she just felt like labels just can’t be trusted, an don’t even risk it, and just make all your own food. You have control, you know what’s what. Don’t buy anything in a bottle. So she even recommends making your own tomato sauce.
Diane Sanfilippo: And she would be Elaine Gottschall.
Dr. Allison Siebecker: Yeah, sorry.
Diane Sanfilippo: Breaking the Vicious Cycle is her book, correct?
Dr. Allison Siebecker: That’s exactly it, thank you.
Diane Sanfilippo: So that’s the root of some of the dietary recommendations. And I think SCD and paleo have some cross over and some, like you had mentioned, legumes and things like that that don’t necessarily cross over, but it’s very, very similar.
Dr. Allison Siebecker: It’s very similar. I think the biggest, because I lectured on this at AHS, what’s the difference here, between the SIBO diets and the paleo diets. I tell you it was hard, because there are so many versions of paleo these days. I don’t know, and there’s a lot of different SIBO diets. It’s like, well which ones am I talking about here? But, I think one of the key interesting things to point out in the difference, which I didn’t yet mention, is that the specific carbohydrate diet recommends to cook all your fruits and vegetables at first, and even peel and deseed them, to reduce the fiber and to make them more digestible. Just imagine baby food, essentially. You don’t give a baby, a brand new little baby without teeth, raw fruit and vegetables. And the paleo diet, I think for many people, they emphasize a lot of salads and a lot of raw fruits and vegetables and getting a lot of fruits and vegetables, and that can make the key difference for people. Honestly. It’s just not doing raw when you’re having digestive distress.
Diane Sanfilippo: Yeah.
Dr. Allison Siebecker: And, one other thing is that also a lot of people on paleo add a lot of fiber on purpose, like chia seeds or psyllium or other things like this. And the SIBO diet deemphasize and decrease fiber because fiber is an exclusive food for bacteria. So it can worsen the problem. I think those are some key differences.
Diane Sanfilippo: That is something that I touched on and boy, you’ll find this after your book comes out when you get a little bit of book blackout where you wrote so many things, and you’re like, I’m pretty sure I said this. I’m pretty sure I addressed this in the book.
Dr. Allison Siebecker: {laughs}
Diane Sanfilippo: Because you talk about it all over, and you’re like, did this get into the book? But I did talk about that in the digestive health meal plan that focusing on more well cooked foods is always helpful, because it’s sort of that predigestion of cooking. That’s what the cooking is doing, it’s sort of predigesting, prebreaking down the food for us, making that a little bit easier, and as you mentioned breaking down some of that fiber. So, I think we’ve covered a lot of really good questions. I’m trying to see what else. So, if they are doing a paleo or SCD approach, again, are there some gradations where perhaps if somebody is in a situation where they’re really struggling, do you see that avoiding more FODMAP foods, and for folks who haven’t researched that or don’t know what it is, I wouldn’t worry too much about it, but specific categories of carbohydrates, are you finding that avoiding those, if someone is avoiding those and feeling better, that that could be a sign that they’re dealing with SIBO or is it just kind of too tough to call?
9. SIBO and FODMAPs [50:57]
Dr. Allison Siebecker: No, I do think so. Honestly, patient after patient tells me; it’s almost like a keynote of how you could know if you have SIBO, is basically carbs bother me.
Diane Sanfilippo: Mm-hmm.
Dr. Allison Siebecker: And the carbs could be anything, but honestly for the most part I find it to be grains and baked goods. That’s the number one thing that bothers people. The simple sugars, the single sugars, if it’s really just that that’s bothering someone, I tend to think a little bit more about yeast.
Diane Sanfilippo: Mm-hmm.
Dr. Allison Siebecker: Yeast overgrowth. But in terms of the FODMAPs and the gradations, yes. For anyone who is interested, they can buy any of the lectures that we had at the SIBO symposium. I did a lecture just on diet where my whole premise was that there’s a spectrum of which diet you use based on the severity of the person. And what I would say is, when someone is really having a lot of trouble with their diet, nothing is much working, what I go to is a combination of the specific carbohydrate diet with a low FODMAP diet.
Diane Sanfilippo: Mm-hmm.
Dr. Allison Siebecker: And I find that has really, really helped the more different patients. Somewhere in the middle would be the specific carbohydrate diet and GAPS. And you know, I’m not mentioning paleo because there are so many different versions. You could fit any version of paleo probably anywhere along the continuum. And then over on the other side, where people have a little better tolerance would be more like just the regular low FODMAP diet, because that allows gluten-free grains. It has the wonderful thing of lowering the fruits and vegetables that are highly fermentable are lowered, and that’s great, but I find that most people can’t tolerate the grains when they’re not doing very well. But if they have a less severe case, then they might be able to just be on the low FODMAP diet. So, I would say, anyone who goes on, say a low FODMAP diet, specific carbohydrate, this sort of thing, if they go on paleo and are grain free, so long as they’re not overeating fiber and raw foods, and they feel better, absolutely they should be thinking about SIBO.
Diane Sanfilippo: I think that’s a good tip, and a good sort of heads up for people. And again, if you want to get that deeper information, will point you to the website that Dr. Siebecker is talking about, and we will also have more information available in these guides that we’re creating here. There was something that you just kind of spurred me to think about, and you know, one thing that happens pretty frequently on my 21-Day Sugar Detox program, which is not exclusively paleo, but it is gluten-free, soy-free, all of that good stuff. I sometimes will have folks who, a week or two into it, so they’ve reduced their sugar intake, they’re eating very limited fruit, if any, very limited starch, and some of them are finding that they are experiencing more bloating. And just perhaps some constipation, some bloating, and I’ve found for a lot of them, as you had mentioned, it becomes an issue that they’ve started taking in a lot more fiber and a lot more raw foods. Is that something you’ve seen commonly happen with people who kind of just, you know, they just go ahead and reduce sugar and starch or grains, and all of a sudden it sort of has this effect that they weren’t expecting?
Dr. Allison Siebecker: Well you know, I don’t usually get to see that. Because, by the time people come to me, they’ve already read my website. They’ve put themselves on the specific carbohydrate diet, and when people chose one of the SIBO diets, like SCD, that won’t happen because it’s tailored for digestion. So I don’t get to see it, but I am not surprised at all you’re seeing that. I mean, I have had a couple of patients; well, more than a couple, who just say “I went paleo” and they come in and we have to tweak it, we have to now get them on really like a SIBO diet.
Diane Sanfilippo: Gotcha. Ok, so.
Dr. Allison Siebecker: One thing you did ask me a while back that we didn’t answer was basically how to treat it.
Diane Sanfilippo: Yep, that’s kind of my last couple of wrap up questions.
Dr. Allison Siebecker: Ok!
Diane Sanfilippo: Treatment and the approach, if anybody can heal it, just kind of with food, and the most natural approach beyond food, and then beyond that, the prescription which we have talked about a little bit.
10. Treatment of SIBO [55:09]
Dr. Allison Siebecker: Ok. So let me just give you an overview of treatment. How I like to classify it is that there are 4 treatment options, but really more so 3. And I think I can answer the first and second question with this. The four options are: antibiotics, herbal antibiotics, elemental diet, and diet. Now, what I haven’t been able to see, because I see more of the challenging cases, I have never been able to see diet alone, like the specific carbohydrate diet or a combination with low FODMAPs, that sort of thing. I haven’t ever been able to see that cure someone’s SIBO. I don’t believe that it couldn’t, I just don’t get to see it. So I can’t comment on it, because I see more severe cases. Now, this gastroenterologist I was talking to I was mentioning, about a week ago he has seen it. He takes people who have never done any dietary modification; they’re really new to this kind of thing. I don’t think they know what a carbohydrate is, kind of thing. {laughs} And he puts them on a slightly broader version of the specific carbohydrate diet, not quite as strict, and they’re having like 90% symptomatic relief. That’s fantastic. And he’s testing their SIBO, and it’s working. So, now I know from someone else that it could happen. So I think that is where you start from. But the patients I see often have been on specific carbohydrate diet, low FODMAP for 2 or 3 years. And then I test them, and they’re still positive for SIBO. So, in these people’s cases, pretty much all the patients I see, diet alone has not been enough to get rid of their SIBO. So then, we go to the three other options. Antibiotics, herbal antibiotics, or elemental diet. And these I think of as the more quick-killing methods. Just to reduce that bacteria quickly, get it out of that small intestine. So we know about antibiotics, we just talked about that. There are particular ones that are used. Herbal antibiotics, what we’ve been using is the Allimed, we use oregano like you do, we use goldenseal or other berberine containing herbs, and we use neem, and sometimes cinnamon. What we haven’t found to work as well is those big combination formulas, with everything but the kitchen sink in there. A lot of times they’ll have antivirals, they’ll have antiparasitics, and a lot of real antifungal focused herbs, and I think it just waters down the potency of the treatment. We have to use pretty dang high doses of the herbal antibiotics I just mentioned, and we usually have to do it for 4 weeks, if not longer, and that’s only one treatment course. One round. When people come in with a pretty severe case, where the gas is very high, it could take multiple treatment courses to get their SIBO gone. So, the last one is one to consider in a case like that, and that would be is elemental diet. What that is it’s like space age nutrition; it’s all the nutrients in powder form. Predigested, and then in powder form that you then mix with water, and you take as a drink so that you are feeding yourself, and the idea is that it will absorb so quickly so high up in the small intestine, it won’t get a chance to feed the bacteria. And, so it kills the bacteria by starvation. So in a certain way, you could think of this as o