There’s no one approach to SIBO, which is what often makes patients so confused. And today’s guest has also stood in those shoes. This week, I’m joined by Dr. Allison Siebecker, who is nicknamed “the Queen of SIBO.” She is a naturopathic physician, award-winning author, clinician and teacher. And if you’ve already done a deep dive on SIBO, you have likely already landed on her free informational website, siboinfo.com, which is an unparalleled resource for treatment and awareness. More importantly, she’s a chronic SIBO case herself, and we’ll hear about how her own struggles inspired the amazing work she’s now doing in the field.
This episode covers a ton of ground, including the SIBO-IBS connection, symptoms, testing, root causes, risk factors, the three main treatments for SIBO, how to choose a diet that’s right for you, and the best methods for prevention. It’s a perfect starting point if you want to understand all aspects of SIBO in under an hour.
Resources, Mentions and Notes:
- Allison’s website
- Allison’s online course for patients: The SIBO Recovery Roadmap
- More on SIBO Testing
- Study on SIBO antibiotics versus herbals
- How to Treat SIBO Naturally
- How to Choose a SIBO Diet That’s Right for You
- Supplements to calm your symptoms during a relapse: FREE download
- Join the SIBO Made Simple Facebook Community Page
This episode is brought to you by Fody Foods, my favorite resource for condiments, sauces and spice blends that are low FODMAP and use real ingredients to promote digestive health. Everything is Gluten-Free, Dairy-Free, non-GMO, and most importantly, delicious. The garlic-infused oil and tomato-basil sauce are my personal favorites. Use code SIBOMADESIMPLE at checkout for 15 percent off your order!
WHAT IS SIBO AND HOW IS IT DIFFERENT FROM IBS
PHOEBE: Dr. Siebecker, I would love it if you could tell us a little bit about how you became the de facto Queen of SIBO, SIBO secretary of state, and whatnot.
ALLISON: That’s a new one. Thank you. I like that one. It’s like so many people’s stories in that I myself have suffered from digestive troubles for almost my whole life, starting from about five years old. That’s about what my memory seems to give me. It’s a long time ago, but I know that I wasn’t born with digestive troubles from the reports of my parents and everything like that.
Since then and on I did, and then eventually I never really knew what was wrong with me. Maybe I still don’t, but eventually I figured out I had IBS and then SIBO. I figured out I had SIBO, and this was before SIBO had any really awareness to it at all. It was very obscure. It was about eight, nine years ago, something like that. If you searched real hard, you could find some stuff, and there’s certainly plenty of medical research articles, but for the layperson, which technically I’m not, but it wasn’t in medical school curriculum, which I have now changed. I have worked to change that, so I as I doctor didn’t know about it, and if you’re coming as a patient or a layperson to it, it was extremely difficult to find anything about it unless you were going go and read articles on PubMed, which now seems like everybody does, but back then you couldn’t even really do that. Believe it or not, the internet and the world has changed so much. When I wanted articles, I would have to request them through special libraries and everything.
I did figure out that’s what it was, and then I applied diet first. That’s the first thing I did, and I got significant relief within 24 hours. That is what really put the fire under me to devote my career to raising awareness on SIBO and educating, being a real passioned educator on the subject. It just seems so unnecessary that somebody like myself, and how many other stories are there out there like my own, a lot, had suffered for at that time something like 35 or 40 years, maybe more, with symptoms, had seen doctors about it. The doctors didn’t have this information and then figured out an appropriate diet to do and got significant relief in 24 hours. It’s like, okay, 35 years to 24 hours, let’s see if we can shorten this gap for other people.
PHOEBE: That’s amazing. Were you already interested in the holistic side of medicine, or did your experience with the SIBO diet detour your medical profession completely towards holistic outlooks?
ALLISON: No, I was always interested in holistic natural health, alternative health, and my medical degree is a holistic, alternative, natural one. It’s naturopathic. I’m a naturopathic physician, so we get trained in herbs, and supplements, and diet, and all sorts of things, very natural modalities, including chiropractic adjustments, although we’re not allowed to call them chiropractic because we’re naturopaths, but you get the idea.
For me, I will just say it’s been very interesting coming from a holistic side because there are some treatment approaches that are on the conventional side, so to speak, that are extremely helpful and very appropriate, and it’s interesting to see the prejudices from the holistic side towards those treatments for SIBO and from the conventional side towards the natural treatments for SIBO. I’m in the middle. Naturopaths are kind of trained in the middle anyway. What I am interested in is not following a philosophy of either holistic or conventional. I’m interested in getting patients better, so we will do what we need to do based on the situation.
PHOEBE: That’s amazing, and I’m going to want to pick your brain on both sides of the spectrum in terms of treatments, but just for those who are new to this whole subject, maybe recently diagnosed, can you give us the SIBO for dummies explanation about what’s going on with this type of condition?
SEIBECKER: Absolutely! S-I-B-O, SIBO, stands for small intestine bacterial overgrowth, and that describes pretty well what’s going on. There are bacteria that are overgrowing in the small intestine. What the problem is is that there are not supposed to be a lot of bacteria in the small intestine. There are supposed to be a lot of bacteria in the large intestine. Most people are aware of that, where we take probiotics to help our microbiome and all that. That’s more so the large intestine. It houses a lot of bacteria that interact with us in a positive way.
The mouth also is supposed to have a lot of bacteria that’s normal, as well, but not so much for the small intestine. When we get too many bacteria there, it’s a problem. The other key thing here is that when people think of good bacteria and bad bacteria, and there’s a lot of ways to divide that up, but in the most strict sense of that definition, bad bacteria would be pathogenic bacteria. That’s not what’s overgrowing in SIBO. It’s normal bacteria. It’s the bacteria that would’ve been in the mouth, would’ve been in the small intestine. There are some there, or it would’ve been in the large intestine, just normal intestinal bacteria in the wrong place and too many of them.
The problem is that because we’re not designed for that we get symptoms from it. We get problems. The main thing is that those bacteria interfere with the digestion or the breaking down of our food and then the absorption of that food into our body. That’s really where all the symptoms come from. The bacteria themselves, they eat some of that food that comes in because they’re high up now where they shouldn’t be, and they get exposed to it. Then they ferment it, or eat it, and they turn it into gas.
Those gasses have a lot of effects on our body, not just like farting or burping. When people say gas, that’s the way they think of, but they can affect the movement, the motility in the intestines, so those gasses can lead to diarrhea or constipation and abdominal bloating or swelling and pain. Gas can cause pain and just the whole host of other symptoms that you can get with SIBO.
PHOEBE: A lot of those symptoms that you just said are what are traditionally thought of as IBS symptoms. Personally, I’ve always thought of IBS as kind of a BS diagnosis. I’m just curious to hear what exactly the relationship is between SIBO and IBS.
ALLISON: That’s a perfect question. It’s called a wastebasket diagnosis. That’s actually what it’s called. IBS stands for Irritable Bowel Syndrome. Most people used to think of that as somebody who has a lot of diarrhea but maybe not always. They get diarrhea and then they have periods where they don’t, and they get diarrhea. In fact, technically, it encompasses the constipation, as well. It’s like either you have the diarrhea type, or you have the constipation type, or you have a mixture somewhere in between of those mixed up in some way.
The relationship is that SIBO has been shown in studies, and certainly clinically we can see this, to be the actual cause of IBS in a majority of cases, not all cases. Some of what we describe as IBS, meaning people who have those symptoms, and how can somebody get diagnosed with IBS? There’d be two things. Officially, it should be they have those symptoms. The symptoms are bloating, abdominal pain or discomfort, constipation, diarrhea, or some sort of mixture. Those are the key symptoms.
The first way would be they don’t have anything else, officially, right? They don’t have anything else, but they have these symptoms. It’s sort of a functional disease. You’ve looked. They don’t have an ulcer. They don’t have celiac disease, et cetera. Then they get told they have these symptoms. In this circumstance, we have figured out that the majority of them, somewhere about 60 to 70 percent, have SIBO. That is what’s causing those symptoms. Now that we’ve identified that, we can treat that and hopefully resolve the situation.
I do just want to say the second thing about IBS diagnosis, and that’s that somebody hasn’t looked. This is what happens a lot is that a person walks into a doctor’s office. They have those symptoms, and with no further discussion at all, they’re told they have IBS. That would be in the worst cased scenario of a conventional doctor’s office. It’s not as likely to happen in a more holistic practice or a naturopathic office because naturopaths are more so trained to really investigate and look.
I’m sure there are plenty of doctors that actually do investigate and look, so I don’t want to give them a bad rap. We’re on the conventional side, but it is a typical story you hear. That is very unfortunate for everyone involved because really, there can be about somewhere around 40 conditions that could cause those symptoms that we then are going to call IBS. It’s just that SIBO would be sort of the number one in terms of 60 to 70 percent. That’s the relationship. It causes IBS.
WHAT ARE SIBO SYMPTOMS?
PHOEBE: Is there one symptom in particular or a few symptoms in particular that when a patient comes in and they mention you think, ah-ha, SIBO, mostly likely.
ALLISON: Absolutely. The number one symptom is abdominal bloating. There’re two words that can describe that, bloating or distension, and technically, medically, bloating is a feeling. It’s a actually a feeling or a sensation that your abdomen is swelling out. Distension is the observable swelling so you look nine months pregnant or whatever. You can’t fit in any of your pants. Just in common language, everybody uses the term bloating to mean both and to mean the physical swelling out. That’s the keynote of SIBO.
Now, there are people that can have SIBO that don’t have bloating or it’s very minor because that’s just how the world goes. We used to say oh, they didn’t read the book, so they don’t match up quite right. If for people who are listening, you still could have SIBO if you don’t have bloating, but that is the keynote.
PHOEBE: If SIBO is the underlying cause of the majority of IBS, what is the underlying cause of SIBO?
SEIBECKER: Now that is not easy. Let me do what I can to make it easy. That’s the $50 million question. Good job! In terms of the history of all of this, SIBO has been known about for a long time, but it was thought to be a little bit more obscure. It wasn’t until around the year 2000 that it was linked to IBS and then a lot of attention came because IBS is the most common gastrointestinal disorder in the world, and that makes sense, because anybody who has those symptoms totally has IBS, right? That brought attention and money to research. Now people are trying to figure out that question.
Here’s what we got so far. There’s really two main ways to think about what causes SIBO, and this is in terms of physiologically what’s going wrong in the body. Then I’ll back back out and say what causes those things.
First off would be that the motility slows down in the small intestine. There’s two types of motility. There’s peristalsis. It’s a little bit more about our food, like when we eat our food and the food moves down and is digested and absorbed. Then there’s this other motility called the migrating motor complex. It’s nicknamed the housekeeper wave or cleansing waves. They clean up after the meal. That motility is what really makes sure bacteria doesn’t accumulate in the small intestine. There’s always bacteria moving through us, like from our mouth down, just as we swallow and as we eat and everything. It has to constantly clean it up. If that motility slows down, then that bacteria can accumulate just because there’s stagnation. There’s stasis and then bacteria accumulate. That’s number one.
Number two would be a blockage, so they’re trying to be cleaned out. They’re trying to be moved downward, and there’s a wall. There’s something blocking them and they back up behind it. That would be like a structural problem, an anatomic abnormality, things like a partial obstruction, most commonly. There are some other ways we can have problems structurally, so things like adhesions, which are scar bands that conform in the abdomen, or a volvulus, which is a twisting or kinking of the small intestine, or a narrowing, which is like a stricture. There’s all sorts of anatomical things. One other would be like a compression where another piece of the anatomy, a vein, an artery, or another organ, or a tumor, is pushing in on the small intestine and narrowing its tube there. Those are the two main physical ways that you can get SIBO, either slow motility or structural problem.
WHAT CAUSES SIBO?
PHOEBE: Is there a way to tell from your symptoms which your issue is?
ALLISON: That’s a good question. Not really. Either way it gives you the SIBO and you get the same symptoms. There might be some real fine-tuned ones when we come into what diseases and such cause those, but no, not really. You need tests for that, which is very frustrating for both doctor and patient. I’ll tell you that. Let me just briefly tell you very simply that how would you get those problems in your body? You’d get it from diseases, or injuries, or surgeries, diet and lifestyle factors, more so lifestyle like stress, possibly genetics.
I would say diseases would be the number one reason, and this is what I really wanted to mention is the number one most common cause of SIBO. It causes the slow motility is food poisoning, which is an acute disease. Most people think of diseases as long-term and chronic. It’s a disease, but it’s short-lived, so food poisoning is also traveler’s diarrhea and stomach flu. That is the most common way you can get your motility to be slowed, and then you can get SIBO.
PHOEBE: What happens? What about the food poisoning causes an issue with the motility?
ALLISON: It’s a very interesting scenario that Dr. Pimentel, who’s the lead researcher in SIBO, has figured out and published. It’s like this. When you get food poisoning, it could be from many different organisms. The food poisoning, it could be parasitic, or viral, or bacterial.
If it’s bacterial then the pathogenic bacteria that cause it all release a certain toxin, the same toxin. It’s called CDT for short. A portion of that toxin looks really similar to a protein that lives on our small intestine nerve cells. A process of autoimmunity happens where the body goes out to attack the toxin with its immune system, but the protein on one of our nerve cells, this certain type of nerve cell, looks so similar it can get damaged, too. The immune system might attack it, too, so that’s called cross-reactivity. It’s also called molecular mimicry. It’s also called friendly flier, in common terms.
Then what happens is damage occurs to these cells, these nerve cells, and these nerve cells are responsible for part of the creation of the migrating motor complex, that movement I just mentioned, the housekeeper wave. Now if those cells decrease in number, in amount, you don’t have enough of them to perform the migrating motor complex, and then you get stasis, the bacteria build-up, and you get SIBO. That’s how it works.
PHOEBE: It’s interesting because SIBO’s not a problem of bad bacteria existing, per se, but it is caused potentially by bad bacteria at one time.
ALLISON: You’re absolutely right. In a majority of cases, it was originally instigated and triggered and caused by bad bacteria, absolutely, you got it, but then they leave. Then the actual condition is now what’s occurring is regular bacteria.
PHOEBE: What is the way to fix that, right? What’s the way to fix that?
ALLISON: We don’t know. That is what Dr. Pimentel, he has been working on this. We didn’t even know that food poisoning was the number one cause of SIBO until six or seven years ago. He’s been researching, pretty much spending all his time, trying to figure out how to cure that scenario. Now someone, if they had food poisoning, now they’re left some time later because it doesn’t even necessarily come right after. Your food poisoning clears up. It might be a month. It might be two months later. You then get SIBO or IBS, which is SIBO in this case. Anyway, how do you fix that? We don’t know yet.
PHOEBE: You may not have an answer to this either yet, but is it essentially an autoimmune disease then in some respects, or is it only something that affects the nerve cells in the short term and then they eventually repair?
ALLISON: It is an autoimmune condition. Dr. Pimentel says it’s not an autoimmune disease in the same way that lupus is, and I’m not exactly sure what he means, but I think what he means is it has better potential for repair. Those nerve cells, part of their characteristic is they’re really good at repairing fast. What has to stop is the autoimmune trigger. Basically, just stop the damage. Stop the immune system deciding they’re a problem and attacking them. As soon as that would stop, they can repair very well.
He has shared with everyone that’s the area of research that he’s focusing on, how to stop that trigger, that autoimmune decision to attack them.
PHOEBE: It’s so interesting and one of the reasons why I was curious is just because I have an autoimmune disease, Hashimoto’s thyroiditis, and there’s such a high correlation between certain autoimmune disease and SIBO. I was curious, the chicken or the egg relationship?
ALLISON: That would be one of them. I’m saying everything else simply, but then people are more complicated. Somebody like yourself, if you have two conditions, hypothyroid, in and of itself, is a suspected cause or risk factor for getting SIBO because it slows motility. That’s another disease different from food poisoning that in and of itself slows those migrating motor complex waves, hypothyroid.
I’ve only mentioned one disease that can slow motility. Now here’s number two. Is the reason that you have SIBO Hashimoto’s? It might be. Could you also have had a food poisoning situation? A lot of people have, and there’s a test that you can test that. A lot of my patients have three or four solid causes of SIBO, so what are we left to do, especially if we don’t have cures for many of these? We just work our way through them and do our best to try and correct the underlying causes of SIBO, so a person with SIBO doesn’t just constantly chronically have SIBO and relapse. A lot of people will because of the scenario.
PHOEBE: In terms of other conditions to rule out, what are some of the other coexisting issues? I know a lot of my readers have asked about fungal overgrowth and yeast. How do you parse out the differences and what someone actually has?
ALLISON: That’s called differential diagnosis. Is it SIBO only, or is it SIBO plus two, or three, or four other things? It’s different person to person. One way a person can do this is if they have a positive SIBO test, so they know they have SIBO for sure, go through the treatments for SIBO until one of two things happen. Either they get 90 percent better with their symptoms, and then they don’t need to worry about other conditions because they’re 90 percent better, which is better, or they get a negative test.
They go through their treatments, and even if they’re not feeling better, retest to find is the SIBO gone. A lot of the times, that’s what happens. You’ll get a certain percentage better, like maybe 40, 50, 60 percent better. You take the test and your SIBO is now gone, but you still have symptoms. Now you know you have something else, and now you have to figure out what that is.
One of the more common things is yeast overgrowth, as you mentioned, or fungal overgrowth it can also be called, or candida. People just call it that, too. Luckily testing for SIBO is very easy. I don’t know if everybody’s insurance will cover it, but a lot of people’s will cover that test. That’s the SIBO breath test three-hour. You’re testing for hydrogen and methane gasses with the substrate of lactulose.
Testing for yeast overgrowth is not so easy. The more practical ones would be – there’s three options. There would be a stool test. Now that’s only going to be testing the large intestine and really the end of the large intestine pretty much at that. That’s only going to tell if you have yeast overgrowth down there. Second would be a urine organic acid test. That samples both small and large intestine without distinguishing the difference, so just intestinal tract. Third would be a blood test for specifically candida. You can check the antibodies to candida and also antigen antibody immune complex.
This test just lets you know if your immune system has decided that it’s upset about yeast and it’s decided to fight it. Here it’s not about the quantity. It’s about if your body’s decided it’s a problem or not. You might not even have a physical overgrowth, an actual too much amount, but your body decided it doesn’t like it. That’s an interesting test because what if you do have an actual overgrowth but your immune system is depressed and decided not to fight it? No one of these tests is perfect because they miss locations or there’s these sorts of things. It’s troubling. A lot of practitioners will run all three. Others will run none and go off history and questionnaire. All of these are valid options. It’s just not easy.
PHOEBE: The rule of thumb is to start with SIBO, since it’s easier to test for. Can you tell us a little bit more about the breath test, the different options, and what to make sure someone’s doctor or lab is checking for?
HOW DO YOU TEST FOR SIBO?
ALLISON: There are all types of breath tests. The conditions they’re testing for are based on the substrate or basically the sugar solution that you drink. We would just call this probably the SIBO breath test, to be easy, but the substrates are going to be either lactulose, and that’s different than lactose. It’s lactulose, or glucose. Both of these are valid options. Most of us in the US are using lactulose, and the reason why is that this is a nonabsorbable laboratory-created sugar or carbohydrate. It won’t be absorbed into our body like glucose would be, so when we drink it, it travels down through the whole small intestine, which is really long. It’s like 25 feet, and there could be small intestinal bacterial overgrowth anywhere within the whole tract. It could be at the bottom. It could be in the middle. That’s the advantage of lactulose. It let’s us see SIBO anywhere in the small intestine. That’s lactulose glucose. It’s actually even better at detecting SIBO but only in the top two to three feet, pretty much, of the small intestine. It’s better because everybody eats glucose. All bacteria pretty much eat glucose. Not every single bacteria might eat lactulose. However, the problem is glucose will absorb into our body after about three feet and then we’re not testing eighteen feet of small intestine. It’s a problem.
I guess the best of all worlds if I suppose it was covered on insurance and so it wasn’t expensive to a person or if money was no object would be to get both tests separated by a day. In the meantime, if you have to choose one, my vote is for lactulose because it shows the whole small intestine and SIBO is more common in the bottom portion. That’s the substrates.
The other things you have to check for is make sure, particularly if your doctor’s ordering from their local hospital – we’ve run into a lot of trouble with this. Make sure that both gasses, hydrogen and methane, are being tested for, and also that the test is occurring for three hours, that you’re collecting breath samples for three hours instead of an hour and a half or two hours. Two hours is acceptable but three hours is best. The reason why is because there’s a third gas, hydrogen sulfide, that we don’t yet have the machinery commercially available to test. It has been invented just recently, but it’s not available yet. This gas is important too, and you could look like you have a negative SIBO test when you’re actually positive for hydrogen sulfide That’s why we need the third hour. What will happen – this is a bit technical, but I’m just going to mention it – in the third hour, you will see close to no hydrogen gas, but you should normally see quite a lot because the third hour represents the large intestine, on average, we hope, and so they’re normally are a lot of bacteria living in your large intestine, and they’re going to eat whatever sugar given them and ferment it into gas. If you see zero or close to zero, maybe as high as six parts per million – that’s the measurement – in the third hour of the test, that probably, to me, you’re positive for hydrogen sulfide, but it could be interpreted as a negative test, so that’s why we really need three hours.
PHOEBE: What is your argument for people who say oh, money is an object. All the symptoms you just described totally fit me. You say the majority of IBS is SIBO anyway. Maybe I should just move on to the treatment plan. What’s the argument for having any sort of test at all?
ALLISON: A person can do that, absolutely, sure, if you want to, but there’s two problem that could happen. Let me just go back to the first scenario. What if you do that and you get better? Great, everything’s great. But what if you move on to treatment without any kind of testing and you don’t get better? In that scenario, you now need to start doing some testing Either that or you’re going to be wasting your time. You’re just wasting your time and money after that. Now you need to figure out what’s going on. Here are some scenarios.
Let’s say you do herbal antibiotic treatment and you don’t get better. What if your problem is not SIBO and you’re one of the 30 to 40 percent that has something else, like – the classic example would be lactose malabsorption, lactose intolerance. Then you don’t have a bacterial overgrowth problem. Antibiotics are not going to be the appropriate treatment. You have an enzyme deficiency and you need an enzyme and/or to stop eating lactose. You could take antibiotics til the cows come home or whatever, and you’re never going to feel better. You need to figure out what’s wrong with you. That’s one scenario.
Another scenario is you were right; you have SIBO. But you didn’t test it, so you don’t know how severe you have it. You can have very, very high gas levels. When you have high gas levels – so that would be a more severe case. Multiple treatment rounds are needed, usually three to four. People will probably start getting relief on around the second or third. Again, you don’t know what’s going on. What a lot of people will go is oh, well, I didn’t have SIBO because I did one round of treatment, and I’m not feeling better, so it must not be SIBO when in fact, it could be really bad SIBO. It’s okay if you didn’t start with a test, but now test and see what the landscape says now.
Third thing on this is what if the treatment type that you’re using is just a poor match for you as a person? How are you supposed to know that? This happens all the time in my practice because I have a specialty practice; this is the only condition I treat. I wind up seeing tough cases. They’ve had trouble getting better, but we know they have SIBO, so they come to me. I see tons of this where, I don’t know, maybe the herbs we’re giving, maybe the pharmaceuticals we’re giving, they just weren’t the right match; it didn’t work, so we switch treatment types and now, it works. Also, there’s little subtitles with treatments that you need to be sure your doc knows about. It happens a lot, so again, a person might think well, I tried a treatment; I tried one treatment. It didn’t work, so I must not have SIBO when in fact, maybe you do but you just need to switch the treatment type. Again, time to get a test.
One last thing; this is a separate thing with why you might not want to rush right into treatment. There’s four main treatments and except for one, they’re antimicrobial. We have pharmaceutical antibiotics, herbal antibiotics, and elemental diet, all of which are aimed at drastically decreasing and reducing the amount of bacteria in your small intestine, but they may or may not have effects on the large intestine, depending upon the treatment.
Now, you’ve just decided to rush headlong into a treatment that does have some risk. It is of concern. Are you sure you want to do that without knowing that that’s the appropriate treatment? Lots of people will say yeah, I do. Screw that; I’m doing it. Okay, but I just wanted to bring it up. It’s worth a pause and a thought.
PHOEBE: I’d love for you to expand on those three main prongs that you just talked about, so antibiotics, herbal, elemental diet, and also talk about the difference between hydrogen and methane and which one is maybe more appropriate for either/or.
ANTIBIOTIC TREATMENTS FOR SIBO
ALLISON: Pharmaceutical antibiotics, there’s three main ones that have been proven to be most effective that I would certainly recommend are the ones to use; rifaximin, which is sold under the brand name in the US of Xifaxan, and then metronidazole and neomycin. More studies than I can even count have been done on rifaximin and also rifaximin plus neomycin. No studies have been done on rifaximin plus metronidazole, but clinically it gives the same results as rifaximin plus neomycin. I’m sectioning these off already, and here’s the deal; rifaximin is best for people who have hydrogen gas or the symptom of diarrhoea, maybe if they have a little mixed constipation in there, but that really the diarrhoea is predominant.
If you have methane gas, methane gas is known to cause constipation. It’s associated and known that it can cause constipation. If you have methane gas or constipation or a mixed pattern where constipation is more predominant, then you use rifaximin plus either neomycin or metronidazole. That’s the basics. The key thing to know here is that rifaximin is not a typical antibiotic. It’s really wonderful for us who have this disease. I myself have it still. I’m a chronic case.
If we do need to use rifaximin, it is not like a typical antibiotic. Just off the top of my head, here’s some things I can recall about its properties. It doesn’t harm the large intestine microbiome. In fact, it increases bifidus and lactobacilli in the large intestine when you use it, so completely opposite of a normal antibiotic. It doesn’t cause yeast overgrowth, again, opposite of a normal antibiotic.
It doesn’t have its own antibiotic resistance yet, according to all the studies. In fact, it can even decrease and prevent the antibiotic resistance that occurs with neomycin. It is anti-inflammatory in and of itself. It actually turns off this important intestinal inflammatory pathway called NF-kappaB, which is a self-perpetuating inflammation. This can turn it off, really amazing at that.
PHOEBE: That’s your argument for maybe naturopaths who may not be as excited about pharma and antibiotics. Are there any drawbacks that should be taken into consideration?
ALLISON: Expense. Rifaximin, if you don’t have insurance coverage, is hideously expensive, criminally expensive in my mind. What some people do is they get it through Canadian pharmacies. There are some brands that are horrible that you do that with, whatever generic brands, and others that are better. I’m so sorry I don’t remember them off the top of my head, so a little caution there with going overseas, but sometimes you don’t have any other choice because of the price. That’s a drawback.
The other drawback is going to be the use of neomycin or metronidazole because they are typical. They can cause yeast overgrowth. They can harm the microbiome. At least with neomycin, I didn’t mention this, but both rifaximin and neomycin are not absorbed into the body. They’re not absorbed into the blood and the circulation. They stay in the intestines and just do their job there, so that’s at least one step better for the neomycin because it’s less likely to cause some of the other side effects that you can get from antibiotics like urinary tract infection because it’s not reaching that area.
PHOEBE: How about the herbals? How do they actually stack up in practice?
ALLISON: Equal. It’s fantastic, equal efficacy in my experience. Luckily we have a study to prove it as well, although we knew this before the study came out, but then the study came out. By the way, the effectiveness of all of these three antimicrobial treatments are in the 80 to 95 range, which is outrageous. Most diseases, the treatments that you have for them don’t get anywhere near that. They’re lucky if they even come close to 50%. These are remarkable success rates that they have.
The herbals, equal as effective. Before I describe them all, I would say the biggest drawback is probably that it takes longer. One course of antibiotics is two weeks, and you might go to three weeks if a person has really high gas because you have to do so many rounds. The reason we don’t go past usually three weeks with antibiotics is because it’s sort of like a point of diminishing returns. You kind of get what you’re going to get at about three weeks, and you usually don’t get too much more after that.
With herbal antibiotics, four weeks would be one course, so it’s double as long. That’s one drawback, but they work just as well. It just takes a little longer. Then if somebody has high gas, we might go to six weeks, possibly even eight. It’s the same thing here, point of diminishing returns. You just don’t gain any more after a certain point.
Let me tell you what the herbs are that we use. People can use all kinds of herbs, but the core ones that seem to be the most focused as antibacterial are berberine-containing herbs like goldenseal, Oregon grape, coptis, barberry, then oregano, and neem. Sometimes we might use cinnamon, but I would say those are the three main ones. Then we have allicin, and that comes from garlic. It sounds just like my name. It comes from garlic, but I don’t want to say garlic because garlic is highly fermentable by bacteria as a food, as a spice, and is one of the key food ingredients that can bother people’s symptoms.
Whole garlic or garlic oil tends to be bothersome to people. It’s better if you use a product that is more like purified allicin. The one that we’ve been using is Allimed. That one is excellent for the methane. You’ve got three options for the hydrogen and diarrhoea, and I usually use two at once. I don’t typically use more than two single herbs together at any time because I find a point of diminishing returns. I don’t get better effect when I use more, so why would I?
Often multiple rounds are needed and antibiotic resistance or clinical resistance, I see it pretty commonly with herbs and also with pharmaceuticals. I need to reserve things to use for the next rounds. I don’t believe more is better. I don’t think if you used ten things you’ll get it gone in four weeks versus if you use two. You would choose from berberine, oregano, and neem, two of those.
Then if you have methane you would just use one of those and use the allicin with it. There is also another herbal combo product, [00:41:35]. It’s peppermint, red [00:41:39] bark, and conker tree, which is horse-chestnut. That has been shown to have good effect against methanogens. You could use that alone or you could use that in place of the Allimed.
One other thing I want to say is what a lot of doctors do is they don’t use this single herb approach that I’m describing. They use just their favourite antimicrobial formula from whatever company they like. They might have their favourite Usually in addition to those types of herbs will be herbs that are targeted a bit more at yeast like Uva ursi and pau d’arco, caprylic acid, undecylenic acid, things like that. Then herbs that are targeted at parasites, the two most common there are wormwood and black walnut.
There will be other things in there too, so it’s like an everything but the kitchen sink formula, big combination. That’s an absolutely valid way to go as well. I’m a specialist just in this one thing in the bacteria. I know that’s what people have, and I like to be a bit more specific.
I find what can happen is when you do that if somebody did have yeast or parasites, you get a lot worse die off and moving forward in your treatment is a lot slower progress. It’s still a fine thing to do. Really there’s no one way better than another. I just happen to have my own preference. The other way is just fine as well.
PHOEBE: Tell us quickly about your third method, the elemental diet, and why someone would ever want to do that to themselves.
ALLISON: That was figured out by Dr. Pimentel. It’s a different way of going at it. Instead of killing the bacteria, it’s just trying to starve them. It’s a powder that you mix as a drink or sometimes it comes as a liquid, and you drink it in place of all meals. You don’t eat. All you do is drink this liquid for two weeks.
It’s just like the time frame of a pharmaceutical antibiotic. What it does is it’s pre-digested nutrients. It doesn’t take time being digested in your system, so it can just absorb as soon as it hits your stomach and your upper small intestine. The idea there is that it absorbs so quickly it wouldn’t get a chance to feed bacteria, even they were overgrown right up there at the top. It would just slip on by them.
Then you get nutrition. You get fed, but they get starved. It’s very effective. The reason you would want to use it is because it’s really effective, particularly in the case of high gas. This is where having your breath test helps decide which treatment you might choose. Maybe you would never ever choose elemental diet because you don’t want to not eat and only drink this shake for two weeks. Who really wants to?
I will tell you, there are some people that do. I’ve had them. Most people don’t. Let’s say you run your test and you see that your gas is 150 parts per million. Something I didn’t mention is you can calculate how many rounds are going to be needed because we know each round of antibiotics or herbal antibiotics brings gas down somewhere around 30 parts per million. It could be less. It could be more. That’s an average.
You’ve got 150, great. You just divide that by 30 and see how many rounds you might need. It’s depressing. By the way, somebody might say why not just stay on them? I was mentioning that we just see a point of diminishing returns. You need to stop, often take a break for a couple weeks, and then maybe start with something else.
You may not take a break. You might just flip right into something else. We do get a point of diminishing returns very commonly. It turns out elemental diet is different. It can decrease gas as much as 70 parts per million in one 2-week course. It may not do that much, but it could even do more.
Now you see 150, and you’re like I don’t want to do 5 rounds of different pharmaceuticals and herbals. Why don’t I just do this elemental diet to start with and see what I can get? I might even still need one or two more treatments after that, but let’s see what I can get. By the way, same thing with elemental diet; you can go longer. We’ll go to three weeks, just like we do with pharmaceuticals in cases of even higher gas if a person is willing to do three week.
Believe it or not, there are people who on their own decide to go four weeks without even saying that’s what I want them to do because they don’t mind it. They feel good. Some people, it’s not feeding bacteria. All their symptoms are gone. They don’t have to worry about cooking. They have all this free time. It’s amazing how people are just different from one another.
PHOEBE: Free time to not hang out with anyone. One more question on the diet front is, of course, all of these other approaches like low FODMAP. I know you have your own specific approach. Is that an actual treatment? How does that factor in?
CAN YOU TREAT SIBO WITH LOW FODMAP DIET?
ALLISON: That’s the fourth treatment. I guess we could get into vocabulary or linguistics, but I would call it a treatment. It’s not an antimicrobial treatment. It’s not a main treatment in the way those three other antimicrobials are. I do believe that it can lower the amount of bacteria. I do think it can do that, but it doesn’t seem to hold for people.
If you put yourself on diet and nothing else, it doesn’t seem like you can then go back to eating the way you were before and be done with SIBO. I’m sure there probably are cases like that, and I’ve never heard of it because there’s exceptions to everything. There’s always outliers. In general, diet is more adjunctive and supportive along with everything else you’re doing, these antimicrobial approaches. What I would say is if you don’t want to do these other antimicrobial approaches, you don’t have to at first.
This is sort of like that empiric thing where I don’t want to test, but let me just jump into treatment. You could just jump right into diet and see how it goes for you, experiment with it, give it a good month, and then see if you can expand and take it from there. There are people that get 100% symptom relief from diet, and they don’t need to be that restricted. Their diet looks healthy, and they’re not unhappy about it at all. If that’s a scenario, you’re golden. What else do you need to do? You’re controlling it with diet, a diet that you would maybe eat anyway.
For the rest of people, it’s not something that they’re pleased with. They don’t like how restricted they need to be. As point of context here, what all these diets are doing is reducing carbohydrates in some way or another because that’s bacteria’s primary food. It’s their favourite food, and that’s what they ferment into the gas and that’s what causes the symptoms.
PHOEBE: Similar to elemental diet, the idea is starvation. Unlike the elemental diet, which is elemental in nature, you’re not completely taking away every single food source.
ALLISON: Unless you were to do a zero carb diet, which I’m not that familiar with, but I know they exist. Absolutely no carbohydrates at all, which would be pretty much meat and fat, something like that. It’s very strict and a different sort of diet. Most of the diets that are made for SIBO are still including carbohydrate foods.
The main category of carbohydrate foods that is most frustrating is vegetables. People think of carbohydrates as bad junk food snacks and sweets, but it’s vegetables and fruits and beans and grains. It’s all plant food, very healthy, desirable food. It’s remarkable. Diet can give some people up to 100% symptoms relief. I would say in most people it gives at minimum 60% symptomatic relief. On average it’s more like 70 to 80. It’s incredible.
There are quite a lot of diets you can use. Let me mention what all the diets are. There’s low FODMAP diet. There’s the specific carbohydrate diet. There’s Dr. Pimentel’s Cedars-Sinai low fermentation diet. We call that Cedars-Sinai. Then there’s my combination of low FODMAP and specific carbohydrate diet, and that’s called the SIBO-specific food guide.
By the way, there’s now been a variant of my combo, which is called the SIBO Bi-Phasic Diet by Dr. Jacobi. Then there’s the Fast Tract Diet by Dr. Robillard. Then there’s various forms of Paleo because Paleo is reducing carbohydrates. These are all diets. I honestly prescribe a different diet based on the case in front of me almost every time.
I like having a lot of tools in my toolkit, but I need that because this is my entire career and I see tough cases. If you’re a person listening, if you’re a practitioner listening, you don’t have to choose from amongst all of these. You could just pick one that you like because what you’re going to do with absolutely any and all of them is you’re going to modify them to yourself.
PHOEBE: How do you usually combine these diets with the antibiotic or herbal antibiotic treatments?
ALLISON: Well, practitioners do it differently from one another. Some like to start the diet before the antimicrobials. By the way, my recommendation would be to test before starting the diet so you know your baseline of what you’re working with. I think diet can lower bacteria to some degree, and it could lower your test score. That’s fine if you’ve already started.
If you have the choice, then I would say test before you start the diet. You could start the diet right away before you get into antimicrobials. You take your test. Then you’d start the diet and while you’re waiting for your test results to come back, you’re getting on the diet. A good reason to do that is because it helps symptoms so much. All of a sudden your symptoms go right down.
By the time you come back for your test, you might not even care because you feel so much better. The second thing with that is that since you’re reducing the bacterial load a little bit, it could reduce die off. Die off is just an awful exacerbation of symptoms and group of symptoms where you feel sick with bacteria or viruses, parasites when some organism is dying within you. That’s one way to do it.
Another way to do is get going on the antimicrobial treatment. Then start the diet somewhere into that, maybe halfway through if its herbs because that’s four weeks. Maybe about week two start getting yourself on the diet because it can take a little while. It takes a couple weeks to figure it all out, buy the right food, read, and all that stuff. By the time the treatment is over, you’re on the diet. Maybe you would do that with antimicrobials.
Dr. Pimentel, he likes to wait to start diet until after doing the antimicrobial treatment. He doesn’t want the interference. He also thinks that if you go too low carb, it might hinder the effect of the pharmaceutical antibiotics. I actually don’t have that concern and haven’t seen that clinically. I’m not concerned about that.
He does have people start the diet towards the end. The last two to three days he wants you to start getting on the diet. That’s the way to do it. Another way to do it is just do the antimicrobials. Don’t do diet at all until after to just really see what they did and what you’re left with. What if you’re feeling really good? Maybe you need not a very strict diet now, just a little tweaking.
For instance, Dr. Pimentel’s Cedars-Sinai diet is made for that kind of scenario where you’re feeling better. His diet is just a help to make sure it doesn’t come back. It’s a prevention diet. It’s not that strict, so something like that. Maybe the most expanded version of SCD or low FODMAP, which a lot of these diets are progressive and not meant to be super strict at all times. You’re meant to expand. That’s got its merits too is wait until after and see what you’re left with. Then get on a diet within a week or so, at least two weeks finishing.
There’s many different ways. I would feel uncomfortable to say this is the one way you need to do it. There are probably doctors that just have one way they like to do it, and they’ll say that. Again, I’m coming from a perspective where I need to be as flexible as I can because I’m at the end of the road for people. I can’t just hold to one way because I just can’t do it.
PHOEBE: That was actually a good segue to the subject of relapse. As you said, some of these treatment options are incredibly effective, but that doesn’t necessarily stop the issue from recurring. What are some of your biggest recommendation for preventing relapse?
ALLISON: The biggest thing would be to be on a diet, some kind of reduced carbohydrate diet. We don’t really know what’s best, but some kind of reduced carbohydrate diet along with a prokinetic. A prokinetic is also called a motility agent. What we’re really trying to do here, we’re not trying to affect the large intestine. It’s okay for people with diarrhoea or that tendency to take these. We’re just trying to affect the small intestine, that slow motility in the small intestine.
If the body cannot do it very well on its own, we try and help it with these agents. There are pharmaceutical agents and natural agents. Really, your best bet is to do a combination of reduced carbohydrate diet with a prokinetic and also meal spacing. You can start the meal spacing right away whenever you start diet. Even if you’re not doing a SIBO-type diet, you can still do meal spacing.
What that’s about is waiting if you can four to five hours between meals, so no snacking between meals. No coffee or calorie beverages between meals, just water. That allows the migrating water complex to have a chance to do its thing. The migrating motor complex occurs during fasting when we’re not eating. If you can give it a chance to not be eating, it can come out and sweep bacteria out, at least as best as it can as its working. The other time it does this is overnight when we’re sleeping.
There are some other things a person can do. There’s some herbs that may help nerve repair, if we think that’s the problem there. If we think structural issues are more of the problem, then I think visceral manipulation is a really good option. Those are some other things that we can do to help prevent relapse. Prokinetic and diet are key.
Very briefly let me just mention the prokinetics we use. Pharmaceutically we use prucalopride, which is sold as Resolor. Currently in the US we have to get that from Canada because it hasn’t come here yet. It is completely safe. It’s not for safety reasons that it’s not here. It was for political reasons that it didn’t come here yet.
We use erythromycin. That’s an antibiotic, but we use it at very low dose. It’s a prokinetic and not an antibiotic. The dose there is 50 milligrams. These are all taken at night before bed to stimulate the migrating motor complex when you sleep. The third one is low-dose naltrexone, called LDN for short. Those are the pharmaceuticals.
The naturals would be Iberogast. That’s a liquid herbal formula, then ginger and ginger-containing formulas. There are a lot of ginger-containing formulas on the market now; these are like [00:56:31], Prokine, Motility Activator, and SIBO-MMC. They primarily have ginger, but they have other ingredients too. Any of these would be taken at night before bed.
One other thing to think about is how long should a person be doing that? I would say a minimum of three months. Then if it’s not back, you could decide maybe you want to stop taking one of those or expand your diet more. You just play that by ear and see how it goes. If you relapse, start those things again. Start the prokinetic and the diet again as soon as you start having symptoms because maybe that will be enough to take care of it. If it’s not enough, then you might need to have another treatment.
A lot of times if you catch it quick enough, you might not even need a full treatment. Half of the length of the treatment might put you good again. Then just go back on your prevention strategies.
PROKINETICS AND SIBO
PHOEBE: Should you not take a prokinetic while you’re doing an antibiotic treatment?
ALLISON: No, it’s okay. You can certainly take it during an antibiotic treatment. For instance, with LDN, we have to ramp up that dose over time to prevent any side effects. You don’t want to have to stop it and then ramp back up again. It’s practical to just continue it.
For something like prucalopride, it’s not the cheapest thing. You don’t need to take it during the antimicrobial. Save yourself some money. It’s just a matter of practicality, whether you are going to take it or not. You don’t need to take it, but it’s not bad if you take it.
PHOEBE: This has been so incredibly informative. I want to be respectful of your time. Just to end, are there any kind of big SIBO myths or common questions that come to you that you haven’t answered yet that you want to clear up?
ALLISON: I don’t think so. Any come to your mind that you can think of?
PHOEBE: Just the whole issue of diet and relapse. I see a lot of people who are really afraid to start reincorporating foods that they’ve removed during their healing phase.
ALLISON: I really think it’s a great idea to expand your diet and see what you can tolerate. In fact, people are probably often too strict even when they have SIBO before its gone. That’s really this thing I was saying of don’t worry about the rules and customize it to yourself. Go on something strict at first to see if your symptoms get better. Then no matter where you are in your journey, you can start testing various foods to see how well you did with them. Even if they’re not specifically on the diet that you’re following, who cares? Test them. Find out how they do for you.
My concern is if there are triggering symptoms in a person. If there are triggering symptoms, we know they’re feeding the bacteria and they’re making gas. If there’s no symptoms, I don’t see a problem. I think that’s where people get too strict in their mind of the rules of these different diets and this concept of feeding the bacteria. I think a lot of this comes from SCD, unfortunately. It’s a brilliant diet for what it was invented for, but we’re adapting it here for SIBO.
We have to adapt the rules as well. Where we get scared is because we eat something, and it hurts us. It causes horrible symptoms. Then people don’t want to test because they’re afraid what if it causes symptoms? You’re stuck between a rock and a hard place. Are you going to stay on this super strict diet and miserable? You’re going to have to find the bravery and have your family give you the support to test things and also have around you supplements that you can use to help mitigate or calm your symptoms.
I have a whole sheet of those. It’s free. It’s on my website. We haven’t mentioned my website, but it’s free informational and educational website for everybody; SIBOinfo.com. If you go under Resources and Handouts, there’s handout called SIBO symptomatic relief suggestions. It’s so chalk full. Have some of those remedies with you, test your food, and see what happens. If something awful happens, take those remedies, and they will help. I know because I’ve done it a million times.
PHOEBE: That’s great advice. I’m so glad you reminded people where they can find you. I’ll have more links in the show notes. Thank you so much, Dr. Siebecker. This has been very eye opening for me, and I know it’s going to help so many people.
ALLISON: You are so welcome. Thank you for having me.
Disclaimer: this website offers health, wellness, and nutritional information for educational purposes only. Information provided is not intended as a substitute for the advice provided by your physician or other healthcare professional. Always speak with your physician before trying any new treatment.