SIBO breath testing has been the subject of some pushback in the wider medical community. Today’s episode discusses some of the controversy around the effectiveness of breath testing, when it’s worth doing, how to make sure your results are accurate, and what other tests might be better at getting to the bottom of your gut issues.
Joining me is Dr. Patrick Fratellone, a functional cardiologist and herbalist who used to practice with the late Dr. Robert C. Atkins. He takes us through how he does his gut detective work as a functional medicine doctor, including what comprehensive tests on genetics, vitamin levels and intestinal permeability can tell you about your bigger gut picture.
If you’re someone who’s been debating whether or not to get a breath test for SIBO, this episode might help you weigh that decision.
A quick taste of what we’ll cover:
- Whether doing a SIBO breath test is worth your time, money and energy
- What other tests are necessary to determine how your small intestine is functioning
- Why vitamin D levels are great indicators of your gut health
- How Dr. Fratellone goes through his process of elimination (hint: SIBO is not the first condition to rule out)
- MTHFR genes and what they tell you about your health picture, including SIBO
- Genetic origins of IBS and how to test for them
- Candida versus SIBO: how to tell the difference
- Testing for leaky gut / intestinal permeability and why it’s important
- How to prepare properly for a SIBO breath test so your results are accurate
- IGG reactivity testing and what it actually tells you
Resources, mentions and notes:
- Where to find Dr. Patrick Fratellone
- Genova Diagnostics Digestive Stool Analysis
- Thorne Onegevity Stool Test
- 3-Hour Lactulose Breath Test for SIBO
- Intestinal permeability test for leaky gut
- Leaky gut treatment: liquid vitamin D + powdered L-glutamine
- Viome microbiome kits
- IgG reactivity testing
- Become a recipe tester for the SIBO Made Simple BOOK!!
- Join the SIBO Made Simple Facebook Community Page
- Subscribe to receive a free download of the episode transcript
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ALL ABOUT SIBO BREATH TESTING
PHOEBE: Thank you so much for coming on the show, Dr. Fratellone. To get people acquainted with your work and your practice, I know you’re a cardiologist by training but also practise internal medicine. Just tell us a little bit about how you got into more the integrative side, and how you’d describe your approach today?
DR. FRATELLONE: It really dates back to when I was a kid because I was born with a heart defect and I was a blue baby, and how my parents, in the late ’50s surgery wasn’t that great, my grandmother and my mother gave me a lot of herbs since I was a kid. I’ve been using herbs, unknown to me, from a young age. I always wanted to be a doctor, and I actually wanted to be in infectious disease, so I sought out to do an internal medicine – after medical school, internal medicine. I went to medical school in England, which I think advanced my knowledge of that they take a better care of the patients because they actually talk to the patients. I went to school there, came back to the United States, did internal medicine, infectious disease, cardiology.
My first medical partner was the late Robert Atkins of the Atkins Diet. We worked together for a number of years, and even though people know him as a diet doctor, he was the one who told me, or taught me about supplements. We wrote a couple of books together. He had a book called the Vita-Nutrient Solution. We had a radio show, so doing this kind of podcast, it’s not new to me because I’ve been doing radio with Dr. Atkins all those years we were on WOR.
He introduced me to a doctor on one of the shows named Andrew Weil. When Dr. Atkins passed away and I inherited his practice, I then went to do a fellowship with Dr. Weil, the first fellowship of integrative medicine. I stayed in Arizona, I met him, and just like I did a fellowship in cardiology, I now did a fellowship in integrative medicine. I learned more about the topics we’re going to talk about, but I also met someone there who change my life, Tieraona Low Dog. Do you know here?
PHOEBE: I do. Not personally, but I know her work. She’s amazing.
DR. FRATELLONE: She’s great. She was one of my – she was the professor of botanical medicine and a socio professor at the school, and she convinced me when I finished this fellowship that I would be great being an herbologist. I then did a lot of herb courses, and through her and through another herbalist named 7Song in Ithaca, I applied to The American Herbal Guild professional member to get a registered herbalist degree. Not only am I fellow of cardiology, a fellow of integrative medicine, I actually am more proud to say that I’m a herbalist.
From that I did other courses, but I would say I use a different approach, including SIBO and heart disease, using herbs more than medicines. That was how I started.
PHOEBE: Yeah, you’re not alone there, certainly for SIBO. Today we are going to focus on the topic of testing. I know some of your patients. I know you do a very thorough job of testing! I wanted to first of all just answer the question that I get asked from a lot of people, which is why is it even important to test for SIBO in the first place? Some of these people are getting practitioners who think it’s better to just skip immediately to treatment. I want to just talk about what the testing options are later, but first, what is the argument to even start with a test?
DR. FRATELLONE: I’ll take a step back. You start with the test, but you really have to find out – since the gut is the gateway of all disease, you have to find out how the gut is working. When I say gut, I’m talking about the small intestines. You have to do some preliminary blood work before you test for SIBO to see if the gut is leaky, leaky gut, or malabsorbing. Though there’s many diseases, such as sprue, celiac, irritable bowl, Crohn’s, ulcerative colitis, you still have to get the basic physiology. I think physicians miss that they have to find out if the basic physiology of the small intestines is working.
When a patient comes here, and although they think they have SIBO, I want to find out is the gut inflamed, and what is the insult to the gut? The first thing I do is simple blood tests, examination of the patient, good history, and blood tests. The first blood test that gives you a clue is the vitamin D level. Once you get a low vitamin D you know that the three functions of the gut are compromised. One function of the gut is absorption, second is vitamin D, making vitamin D3, and the third function of the gut, which is [04:48] SIBO, is neurotransmitters.
We know that 90% of neurotransmitters are made in the gut and travel to the brain, so this is the gut–brain connection. I think you have to know that before you start treating SIBO because they’ve now found out that certain bacteria are prime – you need certain bacteria to make these neurotransmitters, so I do that first.
WHAT VITAMIN D LEVELS TELL YOU ABOUT YOUR GUT
PHOEBE: Could the vitamin D be low for any other reason than a damaged gut?
DR. FRATELLONE: Yeah, well, low, when I mean low – everyone thinks that vitamin – we all have a low vitamin D in the northeast where I live, and that’s about 35 to 40, but there’s not many reasons where vitamin D is in the 9s, 10s and 12s. That means there’s an insult to the gut. My job, if you get a D that low, before thinking of SIBO, which I’m going to think of anyway, I want to heal the gut from any insults first.
Now, if all those things that are insulting the gut are negative, that’s when you think of SIBO. I think we go – I don’t go to SIBO right away because I want to go to heavy metals, I want to go to autoimmune, I want to go to EBV, which is in the news a lot today, I want to go to Lyme disease. If I get all negative results for that, then I’m saying, oh my God, this is a SIBO problem that we have small intestinal bacterial overgrowth, maybe because the patient’s been taking the same probiotic for 20 years and not rotating it.
PHOEBE: In terms of testing for all of the things that you just listed, is that just a very comprehensive blood test, it’s all done through blood?
DR. FRATELLONE: Yes, they do a comprehensive blood test looking at vitamin D, B12, folic acid, but the other test that should be part of every workup is to check if the person has a methylation problem. I do methylation blood testing because if the person has a methylation problem of MTHFR, whether it’s the 677 gene of the 1298, that means the person cannot detox. That means definitely something is toxic in the small intestines causing the low vitamin D that could be SIBO, but then also I want to rule out other things.
I always get a methylation initial test on patients, all the time, because it is present in 40% of the population. I don’t think a lot of doctors think of all that. I think they go – some doctors, the GI – well, now the GI – the gastroenterologists are now trying to get on the bandwagon, where me as a functional medicine person have been doing this for a long time. My patients are educating their own doctors to treat SIBO.
PHOEBE: If SIBO could cause some of these issues, like not detoxing properly, why not start there? Why look into all of these reasons that could be downstream damager effects?
DR. FRATELLONE: SIBO could cause all this, but what happens if we treat for the SIBO and the person doesn’t get better? I rather do a comprehensive approach from the beginning, include all the stuff and SIBO, just not go directly to SIBO because people, if they have methylation problems, that means they have heavy metals. If they have a methylation problem they never got rid of their Epstein-Barr. All of this plays a role in SIBO.
I know you’re trying to differentiate it, but to me it’s all the – my job is to find out why the gut is insulted, and repair and restore the gut. Mine is a more comprehensive approach that will include SIBO testing although it’s not that good.
PHOEBE: Great, we’re skipping to the controversial questions that I had written down as well!
DO SIBO BREATH TESTS WORK?
DR. FRATELLONE: Well, no, but we know – look, I think only recently due to some – testing in medicine, whether I talk about SIBO testing or Lyme testing, we’re missing some things, but let’s get to the basic thing. If I told you the gut is the gateway of all inflammation, we should really be comprehensive. I think every physician who treats any disease should start in the gut first.
PHOEBE: Besides the blood test, what are some of your favorite other tests for getting a good idea of other types of dysbiosis? Do you like some sort of stool test? I’m curious.
DR. FRATELLONE: Yes, I do, and I don’t just pick a stool test from a lab. I’ll pick Genova Diagnostics because it’s a comprehensive stool test. I will pick – I’ll do an H. pylori breath test or a stool analysis. If I don’t find – I do parasitologist analysis. If I don’t find a parasite but the person has all the symptoms of parasite, I will send the person to get a rectal swab for parasites and actually look at the stool under the microscope.
PHOEBE: Do you ever use a GI-MAPs test, something that can – I don’t know how that stacks up to other tests?
DR. FRATELLONE: No, I don’t use that because the thing is I think that makes it too cook-book.
PHOEBE: What does that mean?
DR. FRATELLONE: I think you have to do different kinds of tests, so right now Genova’s a good one, but there’s other stool analysis tests by Metagenics that are good. There’s one coming out by Thorne Research which is called [One Genetics]. It’s a better analysis right now for SIBO than what we already have out there.
PHOEBE: Is that one you have to get through a doctor or is it one of these at-home kits?
DR. FRATELLONE: No, you have to get it through a doctor. It’s looking at genes, microbes, metagenes, and the pathology of irritable bowel by doing one stool sample versus three from Genova. It is costly. It’s about $395 dollars. The thing I don’t like about it, it takes six weeks to get the result back, so that’s the only thing, but I think it’s a really good assessment.
PHOEBE: I think this is really interesting. I think a lot of people, I wouldn’t say get misled, but run into issues down the line because they’ve been diagnosed with SIBO and then no one even thinks to investigate further into what the root causes are. I think it’s great that you’re starting with what all the possible root causes could be, and then eventually, once you have the full picture, getting to SIBO.
DR. FRATELLONE: I include SIBO, but I don’t want to be one of these doctors, and there are some GI people out there, that when they can’t figure it out because they didn’t feel like doing the work, automatically they go on treatment. Our functional medicine model is the triggers of foods. When you think about it, is there genetics associated with all this? What has been their diet? What food allergens do they have? What toxins do they have? What are biological mediators, like [cytokinin]. This test gets everything.
PHOEBE: How does that tell you about SIBO? How do the genetics –
DR. FRATELLONE: These are the triggers, so when you think about IBS as a functional medicine model, you first look at genetics, then you look at the triggers, and then when you look at the biological mediators, whether you’re looking at cytokines, neurotransmitters, free radical, all of this is the cause of irritable bowel. The basic lab work we get. You could do the fecal occult blood, you could do a breath test, you could do lactulose, but to do gut microbiome by DNA sequencing, that tells us what’s going on in the system. That’s what this test is all about.
PHOEBE: Would you go as far as to say is that the breath tests are a waste of time for people for those who maybe can’t afford to have a functional medicine doctor doing as in-depth testing as you are? What can people take away from just a simple SIBO breath test?
DR. FRATELLONE: I think a simple SIBO breath test could help us make the diagnosis, but what it’s not telling you is that there are 60 or more genes that are involved in IBS which is affecting SIBO, such as serotonin, [12:32], so it’s only giving you a little picture. I think the breath test just gives us a diagnosis and a little picture, it’s not expanding the whole role of the gut. I think it’s good for the person, you’re right, if you can’t afford going to see a functional medicine doctor, we have to start somewhere. You start with the blood test, you start with a simple breath test, and maybe you’ll do some stool testing, but that does not give you the full answer of what’s going on with the gut.
PHOEBE: You’re number one recommendation right now is the Thorne Onegevity test for the one-stop shop, but if you can’t get that, for sure the blood work and the breath test?
DR. FRATELLONE: Blood work and testing, there we have it. You know what, everyone does not have the ability to get this kind of test, and gastroenterologists are not going to use this because they don’t have time to do gene work and looking at what bacteria produces what neurotransmitter, so they will get the basic testing. That’s good enough, that’s good enough. I think we’ve missed SIBO over these years because no one thought about it.
PHOEBE: That’s actually getting back to the controversial side of things. There are some people who think that the breath test isn’t actually measuring SIBO and it’s creating a precedent for this fad that may not actually exist.
DR. FRATELLONE: I agree with that because I think that’s… You’re giving a disease to people based on a test that is not specific for SIBO.
PHOEBE: So what is being measured? How does it work?
HOW TO TEST FOR GUT OVERGROWTH AND OTHER FORMS OF DYSBIOSIS
DR. FRATELLONE: You’re making a diagnosis of overgrowth, but you’re really not getting into what bacteria, and you’re not getting into the basic pathophysiology of SIBO. You’re just saying, okay, you have SIBO, we’re going to treat you. I feel it’s like a cookie-cutter thing, the test is cookie-cutter. It gives you a diagnosis and you treat. I know people who have gone to gastroenterologists, got the lactulose test, got treated for SIBO, did rounds of antibiotics, and three months later they feel just as worse as they did after they finished a whole round of treatment.
PHOEBE: I think that’s very common. What’s happening in that case?
DR. FRATELLONE: The test is just treating it, it’s not looking at the gut microbiome. It’s not looking at the metabolic variables and the clinical phenotypes of all the bacteria. I think it’s just treating. It’s sort of like, you have thyroid disease; treat with Synthroid – which is not what I do, but I’m trying to make an analogy. You have heart disease; let’s treat the cholesterol. You’re not looking at the whole picture.
PHOEBE: In terms of getting the breath – the argument of getting the breath test to figure out if you’re hydrogen or methane dominant, do you think that’s a worthwhile thing to do as a step one?
DR. FRATELLONE: I think that’s a basic test to start because it gives you an idea. I’m just thinking, since this test has come out – and I really didn’t mean to talk about it, I forgot the topic was on SIBO, but when you think about it, that is the beginning, but if you have something else, then we should use something else. Because that we know the hypothesis is that an imbalance in the gut leads to dysbiosis. We know that. That leads to activation of the gut immune system and low-grade inflammation. I think we know that, but right away we rather give a treatment, or let’s say oh, it’s due to whether you’re producing methane or not, and this is SIBO.
I think the gut is more complicated than that. Let’s face it, we’re talking about 50 billion bacteria here, so how are we going to blame it on one thing? I think it’s multifactorial. There’s a lot of data to suggest that even fungi play a greater role in SIBO than the actual intestinal pathogens.
PHOEBE: I’m glad you brought that up because I’ve talked about it on other episodes with other physicians about how do you distinguish between SIBO and SIFO or Candida.
DR. FRATELLONE: This is why I think this test should be done because this will tell you – without doing five different tests. The problem with testing is that certain states do not allow it. For instance, Onegevity is not licensed in the state of New York and New Jersey. It’s only licensed in Connecticut. Well, I have a Connecticut license and I just opened a practice in Connecticut, so I’m bringing the Onegevity kits into New York and I’m going to get it done, but I have to mail them from Connecticut.
PHOEBE: You’re already citing so many hurdles that people have to jump through just to obviously get the ideal comprehensive testing, which is why I do think I do want to get back to just the simple SIBO breath test for a second!
DR. FRATELLONE: Look, I think in all fairness, the simple breath test is a place to start. Give the doctor a clue that there is a possibility of small intestinal bacterial overgrowth, it’s commonly accepted by insurance, it’s covered, and you start there. I agree with that 100%.
PHOEBE: Let’s dive in further for maybe someone who’s trying to DIY at home, which is obviously never recommended but is a reality. Do you have a position on whether to use lactulose or to do other substrates as well, or is lactulose you think the best starting point?
DR. FRATELLONE: I think lactulose is the most commonly used and it’s the one that we – there’s more studies with it, but you could do a lactulose or glucose, and decide if you’re going to [do it for] hydrogen or methane SIBO production, but that’s that. I think you need to do the lactulose:mannitol test for testing of permeability.
PHOEBE: That’s the test for leaky gut?
DR. FRATELLONE: Yeah. I think you not only need to do a breath test – say we do lactulose, it’s very common, it’s covered, do it, but then you have to do an intestinal permeability test.
PHOEBE: What additional does that tell you, since I know a lot of people’s thinking is if you have SIBO you probably have leaky gut, you’re going to want to fix that anyway?
DR. FRATELLONE: You do, but I want to know to what degree. Listen, I’m a cardiologist doing this! I know more about gastrointestinal disease now than I did in medical school. The thing is, yes, you’re right, people will say well, why are you going to do another test? I want to find how bad your dysbiosis or leaky gut is. And leaky gut is thrown around too much, that term. By me doing the lactulose:mannitol test, I’m finding out the degree of intestinal permeability and how bad this so-called leaky gut is.
PHOEBE: How do you treat from there, just in terms of the leaky gut?
HOW TO TREAT SIBO WHEN YOU HAVE LEAKY GUT
DR. FRATELLONE: I’ll give you – we’re going to do conventional treatment, but let’s do herbal treatment first. The job is to – how do you treat leaky gut? Get rid of the offending substances. Increase the vitamin D by giving liquid vitamin D because it’s better absorbed. If you give liquid vitamin D, vitamin D goes up, that means more serotonin will be made in the gut and travel to the brain. The more serotonin travels to the brain, epinephrine will be better, you’ll be more focused, less anxious. You have to use vitamin D.
You have to also use glutamine. Glutamine is an amino acid that does help with the gut. If you’re going to use a probiotic, I use one that is powdered because anyone with leaky gut, you’re not going to give them tablets. I know doctors that prescribe a whole bunch of vitamins for the person, they have leaky gut, and they’re all tablets and they’re not being absorbed. My beginning treatment for leaky gut is everything is in liquid or powder form. The best way to get things in for the gut, and there’s been studies, why not use what Mother Earth gave us, use a bunch of herbs.
I make teas. Not tinctures because tinctures could aggravate it, because if you have alcohol in a tincture it aggravates the gut. If you have glycerine in the tincture it aggravates the gut. You could do that later on, but I make teas for people, individualized teas. The tea for one person might be, let’s say, slippery elm, which is Ulmus, with meadowsweet, with catnip because catnip is great for Crohn’s. If a person doesn’t have Crohn’s and it’s leaky gut due to ulcer colitis, I would maybe use meadowsweet, marshmallow, and slippery elm. I use a lot of teas to heal the gut.
PHOEBE: That’s really interesting. I guess my question is, again for maybe people at home who don’t want to do all the tests, I know we want to understand how bad the leaky gut is, but isn’t there an argument to be made that if you have SIBO you’re probably better off doing the liquid or the powder approach anyway?
DR. FRATELLONE: Correct, yeah, you’re right. I’ll give you that. I just want to say it the way I do it because [if] there’s a – I’m thinking of – [21:06] is that don’t give a tablet if you have a gut problem. Give something that can be absorbed. Yeah, you assume you don’t need to do the test on permeability, but I need to know how many weeks am I going to treat them with herbs, how many weeks am I going to give them glutamine, how much glutamine, so that’s why I want to do the lactulose:mannitol test to find out the degree of permeability.
You’re right, start off with just regular blood work. Maybe get a fecal occult blood, and the next test should be a breath test. Totally agree.
LACTULOSE SIBO BREATH TESTS VERSUS GLUCOSE AND HOW TO INTERPRET RESULTS FOR HYDROGEN AND METHANE
PHOEBE: For the breath test itself, I know there’s a lot of disagreement over what constitutes a positive result, which feeds into what people believe to be the overdiagnosis and fad nature of SIBO. How do you read a SIBO breath test, and how should someone at home, per your recommendation, interpret their results, or even re-evaluate some of their results they’ve got in the past from practitioners?
DR. FRATELLONE: The thing is – the problem is the testing is not easy, but so, okay, you do the test, what it stands for, and we do all that. I think they have to understand that it’s designed to take a – it’s an overall picture of three hours in the gut of what’s going on and what’s functioning. It’s a three-hour window, even though it’s one test. Lactulose, they have to understand what lactulose is – man-made sugar that humans cannot digest but SIBO bacteria love it.
Here you’re taking something that we don’t make but your bacteria use. That’s why I like the lactulose test. I do like the test versus other ones because of that. People have to understand that when you drink the lactulose it doesn’t cause that same sugar high that you get from other sugars like sucrose or fructose. I think it is a good test. I think the reason we have to say lactulose because, just for the listener out there, it’s not the same as lactose.
PHOEBE: The lactulose, from what I understand, versus the glucose, is that it works in a larger span of the intestinal tract?
DR. FRATELLONE: Yes, it works in a larger span. The other reason I use lactulose because you don’t get the same glycemic push that you do with the glucose.
PHOEBE: What is the argument for the glucose?
DR. FRATELLONE: Now you’re going to get into physiology of bacteria. Lactulose picks up a majority of the bacteria, but glucose picks up some that lactulose won’t pick up. I think we should do… Look, let’s not think of zebras; do the lactulose.
PHOEBE: Wait, zebras! What?
DR. FRATELLONE: In medicine I always tell the student when I teach them, think of the diseases that occur the most. Think of the thing that’s going to give you the most yield. Don’t think of a zebra that’s only going to give you a couple of things like the bacteria. If you do lactulose you’re going to get 80% of your answers.
PHOEBE: What specific count do you see as a positive result for SIBO?
DR. FRATELLONE: This is where the limitations – there are limitations to this test.
PHOEBE: Tell us about the limitations.
HOW TO PREPARE PROPERLY FOR YOUR SIBO BREATH TEST
DR. FRATELLONE: The limitations have to do – one is that if you’re not going to follow a strict rule before doing it, the limitations are that if you’re going to take supplements and doing certain things, you’re going to offset the test. For instance, so two weeks before the test, even though the person’s been on, let’s say, my slippery elm [gutsy] tea, they can’t have any botanicals in their system, they can’t have any supplements such as magnesium, vitamin C. Maybe for the average person out there, they’re not taking all this stuff, but to do a SIBO test in my office most people have to stop everything they’re taking.
PHOEBE: This is really good advice because this isn’t talked about. I had a question on here about just the 24-hour prep that’s recommended in terms of –
DR. FRATELLONE: No, that’s bullshit…
PHOEBE: Oh, okay, please go on.
DR. FRATELLONE: Twenty-four-hour prep is not – you need two-week prep to have a proper test.
PHOEBE: What does that look like?
DR. FRATELLONE: That means there’s no antimicrobial conventional medicine in the last two weeks. There’s no botanicals and then no nutrients or nutraceuticals. That’s two weeks before the test.
PHOEBE: What do you mean by a botanical?
DR. FRATELLONE: That means you can’t take any herb, so there’s no drugs, no botanicals, and no nutraceuticals. That’s for two weeks, so that’s definitely more than a 24-hour period. Four days before the test you have to make sure they didn’t do Vitamin C, magnesium, or any laxative. Twenty-four to 48 hours before the test you have to make sure they have no fiber, no lactose containing foods, no eggs, no spices. You only have to consume lean meats, and you want to avoid spices and limit fats and oils. I would bet that no one does this.
PHOEBE: Right, well, I mean, the only advice I got from the test itself or maybe I guess my practitioner was the eat lean meats and rice and nothing else 24 hours prior.
DR. FRATELLONE: Okay, what about exercise?
PHOEBE: No advice on exercise.
DR. FRATELLONE: Okay, you can’t exercise 12 hours before the test.
PHOEBE: Why do these things throw off the test? Why does exercise throw off the tests?
DR. FRATELLONE: Vigorous exercise changes your whole biochemistry of the gut because you produce more lactic acid.
PHOEBE: Then what happens?
DR. FRATELLONE: That’s going to change the results of the test. You get a false positive test.
PHOEBE: Why would the lactic acid create a false positive test?
DR. FRATELLONE: The lactic acid then affects the pH, and then it causes more intestinal permeability. You’re not going to see the same bacteria exercise versus non-exercise. Studies have been done where people didn’t exercise, and you got bacteria present. People exercised vigorously, and the bacteria were masked by the production of lactic acid.
PHOEBE: Wait, so you might get a false negative if you exercised.
DR. FRATELLONE: That’s what I meant, false negative. Yeah, so I think, when you do a SIBO test, you have to hand out a sheet that says what exactly you have to avoid.
PHOEBE: I’m curious because I actually – I didn’t realize egg wasn’t allowed. What would happen if you had just egg and white rice instead of chicken and white rice?
DR. FRATELLONE: You get a false negative test.
PHOEBE: I guess, I mean, this is something I’ve learned. I’m a chef, and doing something that’s so limited like that, for me, I’m always trying to look for the loopholes. I’m like can I add a tablespoon of sesame oil to this rice?
DR. FRATELLONE: Yeah, okay, but that could change the test.
PHOEBE: Right, this is great to know because I’ve gotten the question from other people too. Are these little things actually going to make a difference, or are they just telling me to do that?
DR. FRATELLONE: I think the reason why it makes a difference – because when you look at making the – if you look at interpreting the results, there’s a specificity and a sensitivity. The sensitivity is only 40% for a breath test and 80% specificity. With that long range, 40% sensitivity, 80% specificity, I think you have to make sure that the prep is done exactly right.
PHOEBE: If these are the tools available, we have to be extra certain that we’re not going to offset the results.
DR. FRATELLONE: Right, and when you think about more statistics done, sensitivity and specificity of the lactulose test to diagnose SIBO is 31% sensitive and 86% specific. That’s not great odds.
PHOEBE: That leads me back to the question is why do the test?
DR. FRATELLONE: Why do we give chemo? It’s the best of what we have, and it creates revenue for the company that’s making the kits. Look, I just gave you the quote. These are the exact sensitivity and specificity of the results of the tests. If it’s 31 sensitive and only 86 specific, it’s not – it’s an okay test.
It’s not the best test on the market, but that’s all we have.
PHOEBE: I guess that just feeds into the question then – I think of people who are skeptical of if SIBO is real. If we’re using this one test as the main barometer for how many people have it to begin with and the test is unreliable, then…
DR. FRATELLONE: When you get a rise in the hydrogen 20 parts per million above baseline within the first hour and a half, that’s diagnostic for SIBO.
PHOEBE: There’s nothing else. What else could possibly cause that?
SIBO BREATH TEST ACCURACY
DR. FRATELLONE: Nothing else, you’re right. I mean, look, I think the test is useful, but I want more testing. I want more of a specific test like the one that’s coming out where we’ll give you more – it may give you the diagnosis but give you the actual causes. What does that mean when you’re – say you’re 25 parts per million in the first 90 minutes. You have SIBO. What does that tell you?
PHOEBE: It tells you you have other problems likely.
DR. FRATELLONE: Yes, exactly, that’s the point. If you had another test that gave more specific, do that test because you get the diagnosis and the causes.
PHOEBE: Yeah, no, I mean, you’re preaching to the choir. I get it.
DR. FRATELLONE: Then you say what – okay, so we already talked about, yes, it’s the only test we have. The limitations besides the fact that everyone didn’t follow the same prep, only 33% of patients are diagnosed with SIBO when they do the breath test, only 33%. This is the problem. We do not have a gold standard test for SIBO. That’s the bottom line. The bottom line is cardiac catheterization is the gold standard for making a diagnosis of coronary artery disease. We do not have a gold standard for making a diagnosis of SIBO. It only captures 33%. You’re missing 67%.
PHOEBE: Sixty-seven percent of people who actually do have SIBO.
DR. FRATELLONE: It’s only able to make a diagnosis about one-third, which is about 33%. You’re missing other people. They might have something else going on, and you just missed it. You did a test, and it comes up negative for SIBO. You don’t treat the patients, and their symptoms persist. I think that goes back to why we need a more specific test. There are certain bacteria in certain individuals that do not produce hydrogen, and that’s who you’re missing.
PHOEBE: I see why you would prefer to do other things first, so let’s talk about what other things first that are more accessible to the general population people can turn to. Let’s go to this example of Viome. Viome is going to be giving you a more complete picture of your microbiome as a whole, correct?
DR. FRATELLONE: Correct, and it’s going to give you – it’s the first step after a breath test, or even not doing the breath test, that it tells you exactly what’s going on in the microbiome. Maybe not everything but you’re getting a pretty good assessment.
PHOEBE: Would you suggest doing something like that before you even do a breath test? Just get a general lay of the land.
DR. FRATELLONE: I would, yes. I love that.
PHOEBE: Okay, cool.
DR. FRATELLONE: I think that’s a better idea. For me, who’s like a scientist and wants to figure out, I want to know the underlying cause, so that test gives me the underlying cause. The breath test doesn’t tell me anything.
PHOEBE: Viome, I haven’t done it myself. I’ve done, I think, uBiome a long time ago, but Viome will give you advice based on what they’ve actually found, right?
DR. FRATELLONE: Which is good, it’s good. I like that. I think that’s a good test. It takes the guess work out. It helps you. I like companies that have spent some time to tell the patients this is what you need to take.
PHOEBE: Are there any other examples besides Viome of…
DR. FRATELLONE: Onegevity coming out.
PHOEBE: That’s not a direct-to-consumer test.
DR. FRATELLONE: I think they’re coming up with – look, since all these tests have come up, what they have is they have a lot of apps now. I think Viome is the one that I like the best and the one I use the most.
PHOEBE: That’s very helpful advice for people who just want to – who maybe can’t find a functional medicine doctor or anyone integrative with a good grasp on the testing for them to try some things themselves at home to get some answers.
DR. FRATELLONE: Right, they have to get test done. It tells you about some nutrition, right? It tells you about some toxins in your gut. It tells you what foods you could have, so I think it does help the patient. I think it’s worth the money to get it done.
PHOEBE: How about, this is switching gears a little bit, the food sensitivity at-home testing, the IgG reactivity test?
IgG REACTIVITY TESTING AND FOOD SENSITIVITIES
DR. FRATELLONE: I don’t want at home. I do food sensitivity testing in Connecticut, and in New York, I do Connecticut testing. I like IgG by blood.
PHOEBE: The IgG reactivity test at home that just used the finger prick, are they useful?
DR. FRATELLONE: I think they’re good, but they’re not as sensitive as direct blood.
PHOEBE: How should someone interpret that kind of testing? Obviously, if you have leaky gut/SIBO, you’re going to have food sensitivity.
DR. FRATELLONE: The problem with this kind of testing with IgG is if you’re gluten free, the test might show that you’re – the IgG will be negative for gluten because you’ve been staying away from it for so long, so there’s limitations to that test. See, this is why I think a better – and this incorporates what you’re talking about. I think you do the test. You do the test, but then you sit down and analyze all the reports and come up with a plan. If you’ve been staying away from carrots, it’s not going to come up, but you don’t want the person to eat the carrots if they’re allergic to it. Someone who definitely can’t have gluten but you want to see if they’re allergic to gluten, what are you going to tell them, to go back on gluten for two weeks so that you know? That’s why the sensitivity of that test is not good, but it gives clues. For instance, the person says, geez, I haven’t never had a green pepper, but green peppers came up on the test to be positive.
PHOEBE: How is that possible? Similar to the gluten, if you don’t have it in your system, how can it…
DR. FRATELLONE: They actually have antibodies in their gut, you see?
PHOEBE: The results that you do get for things you are sensitive to are for real, but it could be missing something else.
DR. FRATELLONE: Yes, it’s missing, but the ones that you get positive we know are real allergies.
PHOEBE: Do you think that’s – on the grand spectrum of all these tests, where does that fall in the order of priority?
DR. FRATELLONE: Oh, I get that at the first visit.
PHOEBE: You get every test the first visit.
DR. FRATELLONE: No, I mean, I think – look, after I talk to the patient and they say, “Geez, I tried this diet, this diet, I did this – I did an elimination diet. I did the DASH diet.” I said, “Did you ever have food sensitivity testing?” “Yeah, I had it by skin.” “No, did you have it by blood?” “No.” Then it’s part of the initial program. I don’t want people to think that they come here, and they spend $2,000 for testing. I don’t do that. Every patient is individualized based on the history and physical by either myself or the naturopathic doctor that we work –that I work with. I would say that 80% of the patients do get a food sensitivity test on the first meeting.
PHOEBE: Okay, lastly, because we’re going to wrap this up, a lot of things to think about, a lot of tests, what about fungal overgrowth, candida? You mentioned it earlier. I know it’s a bit harder to test for, which is why often times people test for SIBO first.
DR. FRATELLONE: You have to think – look, there’s a book years ago called The Yeast Connection. I think, in general, we all have yeast. I don’t think we need to do extensive testing or give a diagnosis, oh, you have yeast overgrowth. I think we have to assume that if you have SIBO you have yeast. I don’t think we should go – yeah, if the person now did all the workup and they treated the SIBO and they’re still having symptoms, well, maybe then I would search for a specific candida species by either a swab, a blood test, but to do to everyone, we live in a world that yeast is there all the time.
PHOEBE: How does that affect the treatment plan?
DR. FRATELLONE: Look, I’m an MD, so I have the advantage that I can give a combination. I might give Diflucan 100 mg twice a day for 3 days, and do it for every month for 3 days out of the month. While on the days that you’re not doing Diflucan, you’re doing Berberine, pau d’arco, and certainly, propiolic acid to kill the yeast. I have the availability to do conventional meds and integrative meds.
PHOEBE: That’s amazing. Dr. Fratellone, is there anything else that you want people at home who are grappling with IBS symptoms, wondering if they should get a SIBO test – do you have any advice for them on the best next steps or anything else to keep in mind?
DR. FRATELLONE: Yeah, I think the person who’s suffering with a lot of issues and maybe not be related to gut, it comes down to that it’s probably the gut. The gut, again, is the pathway, so I think you should really get to have a good assessment of your gut. You could do some of this home testing, but you should not be your own doctor. You could get this home testing. You still have to seek a healthcare professional who specializes in this to help you interpret it. Having this testing now available that people get and test themselves, a lot of the times they’re following things that might not be correct.
Most of them are not taking herbs, and that’s a disadvantage. I think Mother Nature could cure all the problems.
PHOEBE: I actually think that a lot of people who are trying to go it alone at home actually are turning to the herbs because they can get them. They don’t need a prescription.
DR. FRATELLONE: Yes, which is good.
PHOEBE: Your point is very pertinent that there are so many things that could go wrong. I mean, I went through my doctor who’s wonderful, and I still didn’t know about the exercise. I still didn’t know about some of these other prep elements, so it’s just very important to keep in mind all of these things. If you are going to try – if you are going to spend the money because it is money even if you’re doing it at home without the help of a doctor to have the breath test.
DR. FRATELLONE: There’s a lot of – like Healthline, which is on the internet, they have a lot of good information. You could follow these major – Healthline and say this is how you should do it. I think we’re all mixed up because there’s so much availability of stuff on the internet. We don’t know what we’re reading and what’s right or wrong.
PHOEBE: Correct, that is the central problem of modern medicine in addition to many other things.
DR. FRATELLONE: I hope this helps.
PHOEBE: Yeah, thank you so much for taking the time to chat with us. It was real interesting to hear your approach. I also love your willingness to cast doubt or question some of these methodologies. I think it’s important for people to hear. Especially with SIBO, there’s so much that’s still unknown. At the end of the day, sometimes we are at the mercy of the best available, but I think it’s important to consider that there are other ways to skin a fish or whatever the saying goes in terms of investigating the gut as a whole.
DR. FRATELLONE: Thank you so much for the opportunity. I look forward to listening to this.
Disclaimer: The information in this podcast does not provide medical advice, professional diagnosis, opinion, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.