Many SIBO treatments do a great job of killing your unwanted bacteria, but they don’t necessarily set you up for long-term good gut health. In today’s episode, we are going to go a little bit deeper into some of the herbs and natural supplements that can be used as part of your SIBO toolkit. My guest, Dr. Will Cole, is a leading functional-medicine expert and author of the new bestselling book, Ketotarian, in which he melds the powerful benefits of a ketogenic diet with a plant-based one. More importantly, he treats acute digestive issues like SIBO with the whole microbiome in mind.
In today’s conversation, we dive deeper into his approach and cover so much ground, including:
- What effect non-steroidal anti-inflammatory drugs (NSAID’s – like advil) can have on the microbiome
- the role of epigenetics in SIBO, meaning how our lifestyle choices can switch genes on and off
- how your microbiome is more than just your SIBO, and ways to support it overall
- histamine intolerance and how that effects your natural treatment plan
- Whether you should take probiotics while using herbs to kill your SIBO
- Biofilm and how to fight it
- Die-off symptoms (also known as Herxheimer response) and how to know if this is what you’re experiencing versus an intolerance of something in your treatment
- What supplements to take to prevent relapse
- How to use your diet as a way to prevent relapse
- Gut-brain connection: Stress management and how that influences SIBO
- And some other lesser known options like Helminth therapy
Because I prerecorded most of this season, I wanted to make sure that there’s an opportunity for listeners to get their questions answered. I’ll be adding a bonus episode called “Ask a Doctor” and using it to ask some of your follow-up questions to our guests. To have your question added to the mix, join the SIBO Made Simple Facebook Community Page on Facebook and leave me some crumbs!
Resources, Mentions and Notes:
- Will’s website
- Will’s new book, Ketotarian
- Supplements recommended in this episode:
- Digestive enzymes to help you break down food
- Hydrochloric acid (HCL with pepsin) to ensure you have proper stomach acid
- L glutamine and marshmallow root for repairing the gut lining and taming inflammation
- Mushroom based probiotics like Megaspore and HU58 from Microbiome Labs to encourage bacterial diversity
- Cat’s claw for biofilm disruption
- My post that summarizes a lot of these strategies: How to Find the SIBO Treatment That’s Right For You, Natural or Otherwise
- Join the SIBO Made Simple Facebook Community Page
This episode is brought to you by 4 Weeks to Wellness, my online program for finding the sweet spot between health and hedonism. Need 4-weeks worth of easy low FODMAP recipes with a step-by-step meal plan laid out for you? You’ll receive a 20-recipe cookbook, complete with shopping lists, elimination diet guidance and reintroduction worksheets, in addition to the many other program resources like my symptom and activity tracker, lymphatic massage videos, doable desk stretches, and so much more. The 300+ people who have joined the tribe have reported clearer skin, calmer tummies, less bloat, tamer food cravings, and a general ease over their newfound habits. To find out more details about when the next session starts, click here. Use the code SIBOMADESIMPLE at checkout for $40 off!
HOW TO HEAL SIBO NATURALLY WITH DR. WILL COLE
PHOEBE: Well Dr. Cole, I may call you, Will, since I know you.
WILL: Yeah, you can call me that, for sure.
PHOEBE: It’s so wonderful to have you on and to introduce our SIBO sufferers, SIBO amigos, as I call them, to you and your work.
WILL: Thanks so much for having me. It’s an honor to be talking to you, and really, I’m so excited through your own journey you’re able to really shed so much light, and hope, and guidance for people that are struggling with this, which as you know, it’s sadly ubiquitous. People are left to fend for themselves who’ve got problems like SIBO. And you’re really providing such valuable information.
PHOEBE: Well thank you. I didn’t expect for you to start with so many comments.
WILL: I mean it.
PHOEBE: So tell us a little bit about how you even got into the functional, holistic side of medicine, just so we know who we’re dealing with here.
WILL: Yeah, so I’m a functional medicine practitioner. I primarily see patients throughout the week. We primarily have a virtual functional medicine practice where we see patients around the world via webcam consultation. About 90% of our patients are seen virtually, and then about 10% are seen locally in Pittsburgh. How I got to functional medicine preceding that, I grew up in a household that was into alternative health. So in the 1980s and the 1990s when it was not cool, I was the kid drinking some weird adaptogenic tonic, and having some weird sprouted this and organic that when it was not cool. There was no social media to take pictures of their pretty meal. It just was normal for me.
PHOEBE: I was also that kid, for the record.
WILL: Oh, cool, that’s awesome. See, we resonate on so many levels. So that was that. That’s my foundation. And then I was at this integrated school because I was interested in health, Southern California University of Health Sciences, where there’s DCs, and MDs, and acupuncturists, and oriental medicine doctors all there learning different modalities in healthcare.
And I heard of a guy called Datis Kharrazian who is one of the godfathers of functional medicine without the mafia. He’s the guy that’s been talking about it, I think, one of the longest times in the public sphere. He teaches for the Institute for Functional Medicine, and he had gone to my school, was older than I was. Hearing him talk is who introduced me to functional medicine. And that was a long time ago. That was 12, 13 years ago, and I never looked back.
PHOEBE: So SIBO, the condition is obviously something that’s not new, but it’s starting to become more widely known. When did you first start recognizing it in your practice and learning all the various ways you can treat it?
WILL: So it’s one of those things where it’s the foundational persistent struggle for people, the people that I talk to, the people that I do life with and spend my time with in dealing with these issues. It’s really a sacred journey to deal with it because there’s not a quick fix, there’s not a magic pill for it, there’s not a magic protocol for it. It’s about really looking at labs comprehensively, looking at what works in their life, and balancing the art and science of functional medicine. It’s really an individual process.
So I started seeing it early on because I was running labs and seeing what was going on, and seeing the impact that dysbiosis, and specifically in the context here, small intestinal bacterial overgrowth was having on people’s digestion, yeah, certainly. But also the ripple effect of an imbalanced microbiome, and the impact it’s having on the immune system, and on inflammation levels, and the impact it has on hormones.
It’s the far-reaching implications of imbalanced microbiome and what it can do to the human body. It’s definitely what we call in functional medicine an upstream issue. It typically is one of those core root problems that you can see the downstream ripple effect in seemingly unrelated areas, like the brain, and your hormones, and inflammation levels where they may not even connect that to what’s going on in their gut, but it really is making quite a wave in their physiology.
PHOEBE: There’s obviously still a lot that’s unknown about what causes SIBO. But I’m just curious, in your experience, since you just brought it up, is anything that we’re doing that’s generally damaging our microbiome, I don’t know, maybe overuse of antibiotics, do you see that as a contributing factor to SIBO, or is it separate?
WILL: Yeah, I would think it’s – for most people, it’s a confluence of a lot of different issues, a confluence mostly of epigenetic lifestyle things that it’s the perfect storm. It’s not just one thing. There may be the tipping point. there may be the straw that broke the camel’s back. But it normally – even if there was a tipping point, there were preceding things that added up to that catalyst where they started being triggered symptoms in their life.
It’s NSAIDs, like Tylenol, and aspirin, and these things that people are taking, as well as the antibiotics that people are on. I mean, just talk about those two things by itself. You’re talking about NSAIDs and antibiotics, and you think about how many people use those and the amount that people are using those. So you have to take those into consideration for some of these cases, but for some people it’s not that at all. That’s why you can’t hang your hat on one story to this, or one facet to it.
It’s normally a conglomeration of a lot of different factors that vary from person to person. But I would say that some of the low hanging fruit, some of the more common things that you see in a comprehensive health history when you’re working a case up like this, you will see things like the two things we talked about, as well as the diet, the foods that we’re eating definitely play as a part into the microbiome and the dysbiosis that we see. And if you get even more detailed, and you look at things like motor vehicle accidents, and whiplashes, and things like traumatic brain injuries where it can decrease the migrating motor complex, this wave-like motion in the gut through the gut-brain axis. And we know that brain injuries can impact the gut, and the gut can influence the brain.
So this bidirectional influence between both is something that we have to take into consideration too. So yeah, there’s a lot of things to consider. It’s not just one thing, but it’s a lot of epigenetic things. And then I would assume that about a third of this autoimmune inflammation spectrum puzzle is genetics. And I think that there are some people that are more prone to these inflammatory immune responses.
And I would put SIBO, for many people, on this spectrum of inflammation autoimmunity where what epigenetic thing in our life can awaken and trigger that genetic predisposition. It’s estimated that about a third of that puzzle is genetics, but two-thirds is epigenetics. These are the lifestyle things that can really constantly and dynamically instructing our genetics how to be expressed.
PHOEBE: So to focus in on one of them that you just mentioned, since our conversation largely is revolving around various types of medication treatment. But the NSAIDs, the Advil and such, can you explain the connection for people?
WILL: So NSAIDs, many people are on them for different things like pains, like aches, and pains, and migraines. And they’re linked to impacting the microbiome in many ways. They’re linked to increasing gut lining permeability, and increasing the permeability of the tight junctions, which is the guts line of defence, gut barrier mechanisms, increasing leaky gut syndrome as they call it. It can really impact the gut with chronic use, with use of these NSAIDs.
So it’s one of those things that we have to take into consideration as what impact is this having on overall gut health. And I’m not saying that everybody shouldn’t be on those, and you can never use them. That’s not what I’m saying. I’m not making any extreme, broad sweeping statements here. But I think that we have to look at what are the things that are likely to hinder gut function, and this is one of them.
PHOEBE: So would you say that most people who come to see you have multiple gut issues? And if so, how does that affect a general SIBO treatment plan?
WILL: Absolutely, and I think that this is a really important idea and concept that people need to at least consider is that there’s now doubt that we just said that SIBO, and dysbiosis, and gut problems as a whole are more upstream. But we can’t see SIBO in a vacuum. We cannot see SIBO as this isolated thing that is completely removed from the rest of the body because your body is intraconnected. And certainly the microbiome is – anybody with SIBO, the microbiome is more than just their SIBO. There may be good things going on, and there may be other bad things going on, or other imbalanced things going on. So it’s important, I think, to get a comprehensive health history first, and then a comprehensive lab overview where we want to be comprehensive in functional medicine, but still be cost effective and practical.
So we realize that obviously these labs, in general, most of them are not covered by insurance, even though some of these SIBO tests definitely are. But beyond that, there’s definitely tests that are not covered by insurance. So we want to be practical but still be comprehensive. So looking at things like candida overgrowth, looking at things like other dysbiosis that’s not just SIBO, it’s not necessarily a locational issue into the small intestine, but it is some sort of bacterial dysbiosis or imbalance that’s going on in addition to SIBO. Leaky gut syndrome, which we mentioned, measuring antibodies to zonulin and include in these proteins that govern gut lining permeability, and associated problems that I find specifically with SIBO, obviously the symptomatic issues of acid reflux, and GERD, and IBS, and the ripple effect of that.
But lesser known, but still I find associated with SIBO, is histamine intolerance, where people are not breaking down histamines, which are found in food, primarily when I see food-induced histamine responses. So their body’s not breaking down histamines. Higher histamine foods are some of these healthy foods that are very “gut healing” foods that they’re reading online or told by a doctor to have, like fermented foods, and probiotic foods, and bone broth. These are higher histamine foods that some of these people, not everybody, but some people with SIBO, dysbiosis, and histamine intolerance, they’re having a problem breaking down these healthy gut healing foods.
They feel like, well, what the heck? This healthy food’s making me feel worse. It’s important to, again, keep an open mind. And that’s the art, the other side of that coin of functional medicine to really see that person and use real life as a lab. And it’s a variable to say, okay, how do we adjust this for the individual instead of making over-general protocols which doesn’t really exist.
WHERE TO START YOUR SIBO TREATMENT
PHOEBE: So when it comes to where to start for that specific protocol, specifically I guess for what I would call the kill phase. What are you looking at besides maybe hydrogen versus methane, and how are you developing the protocol from there?
WILL: I think the food is primary and think that that’s one thing that I would say everybody should start there because I think a lot of people coming from that specific SIBO world, whether it’s a doctor that specializes in SIBO, or the patient that is hey, this is my problem. And they put that label on them. And then they’re almost myopic, I think, as to saying well, that’s only SIBO. They put it in a box, and that’s what they’re focusing on.
And it’s just about the treatment. The treatment’s certainly needed, and certainly a part of that, meaning the specific kill phase, and the specific antimicrobials, or the probiotic they’re supposed to be on. All that stuff’s essential. I’m not saying that. But ultimately speaking, I believe that you can’t just do that. I think it has to be part of a greater health foundation, which may be a no-brainer for a lot of people, but I feel like some people that are just worried about I have this overgrowth, let’s kill it, they’re not realizing the body’s all interconnected. And the SIBO may be just part of this other imbalance that’s beyond just the dysbiosis and the microbiome.
PHOEBE: Interesting. So where do you start on the diet piece?
WILL: Well, depends on the case. It depends on where their starting point is. So let’s just say they are the standard American diet. So then you want to lean them into a cleaner way of eating, I think softer, gentler foods, lots of brothing and souping, a GAPS approach but not too aggressive. You can blend a low FODMAP GAPS approach with an AIP, autoimmune protocol. I think general rule – I’m just giving general labels here because specific cases require different things I think those are some modalities, some practices, as far as food and medicine is concerned – I think those are really foundationally important. For people that are already there, which is a lot of my patients – they’re already very well-read. They know more than most doctors do about health, but they’re still struggling. I’m used to super-difficult cases where they are very bright and they’ve tried everything under the sun, but they’re still struggling. For those people, I would lean into more intermittent fasting protocols, more brothing, more souping, more – a heavier GAPS approach, sometimes longer-standing GAPS approach, modified, not complete GAPS, but we tailor it to the individual.
Then for some cases – and this is counter-intuitive, probably, coming from me when I have a plant-based keto book out, but I think for some of these SIBO cases, my allegiance isn’t to one way of eating. My allegiance is to getting whatever works for that patient and let’s do it. I’m finding a lot of these people with these real sensitive reactivities and dysbiosis and bacterial overgrowths, they do well with a more carnivore diet for a while, which again maybe people are like, what the heck is he talking about? I’m not saying that for long-term the carnivore diet would be good, but I think it is the ultimate elimination diet for these people that are really reactive and have bloating and flare-ups to just about everything. That works for some people; not for everybody. I just definitely want to tailor it to the individual but I have to calm things down. So the kill phase with antimicrobials, proper probiotic, that’s needed, paired with, I think, a really sensitive carnivore-type approach of brothing and souping or at least puréed vegetables, really soft vegetables for a time while the kill phase is happening. From there, we can try to reintroduce slowly and systematically to tolerance.
PHOEBE: What is the GAPS protocol for those who don’t know? I actually don’t even know a ton about it except for that broth is an essential component.
WILL: GAPS is an acronym that stands for Gut and Psychology Syndrome. It has to do with the gut/brain axis of which SIBO is a part of that. It’s for people with brain issues and they’re looking to deal with the gut/brain axis that way, but it’s also really good for reactive guts, so people with SIBO, people with histimmune intolerance. You have to modify their broth there. By modifying the broth, I mean you make it lighter, you cook it less, and make it less histamine-rich. It’s good for inflammatory bowel issues, too, so colitis, ulcerative colitis and Crohn’s, too, of which you can have SIBO and have those things, as well. That’s really what it is. It’s a very structured, reintroduction of soft, cooked foods, puréed foods, gentle foods for the gut. You can still have vegetables on a GAPS protocol, but it’s going to be soft, slow reintroduction to tolerance. Then you have all these intricate phases that we walk the patients through and lead them and give them direction on that, but the phases are really self-paced in the sense that we don’t progress a patient to the next phase of reintroduction of certain things until they’re ready for it. Again, I don’t do a straight GAPS protocol for most people. I take the tenets of it and then I blend more of a SED approach or low FODMAP approach and an AIP approach, which can sound super-restrictive, but I think they all have components based on the individual. Books are helpful, good resources, but I realize okay, I can’t encapsulate all biochemical individuality, all the uniqueness of each case that I have, into one single protocol. I have to adapt it and adjust it to these really resistant patients who have, honestly, done most of these things on their own. I’m looking to really take it to the next level to not just add to the pile of labs, add to the pile of doctors that they’ve seen. I really have to meet them them where they’re at and really adjust it to what they need at that moment.
PHOEBE: We talk about diet and SIBO. I feel like there’s one camp that’s using it as one part of the strategy to starve out the bacteria, maybe another strategy to provide some sort of healing, especially for those with leaky gut, and then another just simply to help alleviate the symptoms. Are you an all of the above? Where does your strategy primarily lie?
WILL: My strategy is to get multiple labs’ perspective from their vantage point what’s going on here, looking at the microbiome, looking at beyond the microbiome, what’s going on here, and really seeing those labs as a reflection of what’s going on and how that patient’s feeling and what do I have to do to get those labs improved. That’s why yes, I look at the gut. It’s probably why I look at the gut more than most things, but I don’t want to just be looking at the gut and be super myopic. I realize that the body’s interconnected and some of these downstream things can influence the upstream things. We have to look at all different aspects to this.
To answer your question, I’m all of the above approach. We have to be aggressive where we need to be aggressive, but we also have to have – we have to realize that sometimes, the aggressive protocols from the kill standpoint, these natural antimicrobials, or these other things that we need to bring like the biofilm disruptors – we have to work with the patient’s body and sometimes you can’t say well, this protocol says two capsules three times a day and that’s what you do for every SIBO case. If you hang your hat on one way of doing things for somebody, you’re going to be proven wrong all day long. Even with 100 cases of SIBO, you really have to adjust it to the individual. That’s where my focus is is just seeing what works for the individual.
PHOEBE: Cool. Talking about the antimicrobials, what are the pros and cons to using those over antibiotics?
THE BEST HERBS FOR SIBO TREATMENT
WILL: There’s a few ways to look at this. I think there is a place for pharmaceutical antibiotics, and people can definitely experiment with them with SIBO. They can work with their doctor and sometimes they are solutions for people. They can get their microbiome proverbial head above water, so to speak, and start breathing and having function back. I’m not against them as a general rule. I just have found that the natural antimicrobials, while they are a little bit longer as far as their turnaround, they are more gentler on the system. They have significantly less potential side effects that some of these antibiotics have. They are generally more tolerated for people that are already really reactive and sensitive to a lot of stuff. And they aren’t as aggressive in the sense that they’re decimating tons of different good probiotics, too. I see it as is there a place for the atomic bomb, to use that analogy for a pharmaceutical antibiotic? Yeah, there is a place for that. But I think a lot of times, it needs a pruning and needs a recalibrating. Instead of seeing all these bacteria, which SIBO by its very definition, these are not pathogenic bacteria. These are not horrible things. These are things that humans have, but there’s an imbalance of them. Instead of us thinking we just need to kill it, and kill it, and kill it, and that’s really the Western American way. If you have a bad thing, let’s decimate it. I think there’s a place for that, but to say that’s every case of SIBO needs an atomic bomb, I just think anybody that’s gone through a conventional treatment and hasn’t got better will tell you that’s not the entire puzzle for them.
I prefer the natural antimicrobials. I prefer rotating between them. I typically will do a month of one antimicrobial, blend, and another month switching on and off to get variety Everybody responds differently. Everybody’s specific colony-forming unit – like overgrowths will respond differently. I think diversity is important here. A multi-pronged approach is important here instead of saying what’s just for rifaximin or it’s just this antibiotic for everybody I think fall short many times and many people fall through the cracks for that over-generalized approach to SIBO.
PHOEBE: Do you ever use the kind of compound herbals that have a whole variety of different herbs in each capsule, or do you like to use one at a time?
WILL: I typically use blends of them to, again, be multi-pronged against it. I find that that more spectrum approach works really well for people but still alternating the blends, not sticking with the same one. There are definitely some single-agent tools that we use as well. Specifically with that, the oregano oil and allicin. I think you have the general blends of antimicrobials and then some specific ones, too. Let me just say this: there are some people that are really sensitive and we prefer just sticking with the single one so we can suss out what they’re having a problem to. They’re reactive, and that’s not necessarily just due to the SIBO. People have real reactivities or sensitivities to a lot of food reactivities. They don’t do well with blends, and there’s too many things to consider on was it the terpenylic acid? Was it the pao d’arco? Was it the berberine? When you separate them out and you phase them in appropriately, then you can see if something’s not working for somebody. You can just take it out versus the blends; it makes it difficult to do. I like the blends, but it doesn’t work for everybody.
PHOEBE: That makes perfect sense. The allicin, I know, has a lot of efficacy for methane dominant. Is oregano good for both, or does that have more of a specific targeted leaning?
WILL: I find that the oregano’s good for both. The dosage varies from person to person, not necessarily hydrogen to methane and saying there’s a – I don’t find a correlation there, per se. it’s good for both as a general rule.
PHOEBE: What other tools are in your box besides just the herbs? Are there other supplements that help with the symptoms for people who are hyper-sensitive or maybe experiencing some of the negative effects of the bacteria die-off?
WILL: I like – in addition to the killing antimicrobials, I like digestive enzymes. I like blends of hydrochloric acid with pancreatic enzymes, pepsin but betaine HCL with pepsin, so blends of those to help with digestion overall. I like alglutamine when it comes to repairing the gut lining. Marshmallow root help repair the mucosal lining and calm inflammation levels down in the gut. Those are some things to consider in the context of SIBO. I also – let me talk about two different things. One is I like these two spore-based probiotics I like MegaSpore and pairing MegaSpore with their [Hugh]-58, which was pretty exciting data on these blends of these probiotics to help with bacteria diversity, to encourage bacterial diversity. They are shelf-stable; you don’t have to refrigerate them. The study specifically for this Hugh-58 blend of this colony-forming unit, this probiotic, of improving tight junction, lowering inflammation levels in the gut, and improving bacterial diversity. Specific, I’ve seen really good results with people with dysbiosis and people with SIBO. Those are some things I consider.
The weirder thing that I use for some people when we’ve tried everything and we see results but maybe we’re stuck at a plateau is something called a helminth therapy or helminthic therapy. People are going to love this because it is really cool, and I just recommend people educating themselves. That’s all I’m saying about it. Just look into it, educate yourself on it. It’s exciting studies surrounding it, but helminthic therapy or helminth therapy is a really fancy medical Greek word to make it sound less weird, but it really is parasite therapy. Helminth is just the Greek word for a parasite, and it is basically swallowing microscopic, non-human protozoan tapeworm, hookworm, this family of worms that won’t live in humans long-term. It doesn’t grow and proliferate. You know microbiome; the body will just pass it out. The theory is and what the mechanism that researchers are looking at is the impact is has on modulating the microbiome and modulating the immune system.
Basically when you look at the West, America and Europe and all the modernized Western nations, you have an epidemic rise of GI issues, autoimmune inflammation spectrum issues, SIBO being a part of that, where 75 percent of the immune system’s in the gut. You have a lot of gut problems here. Now you do not see those rates of autoimmunity in gut issues in developing countries. One component to that is this over-sanitization and the lack of diversity in the microbiome. So back to that point of we just want to decimate everything and even in our mind, we think of a parasite as being a problem, but humans would’ve evolved with these for a long time and because we’ve evolved with these over a long period of time, we have this symbiotic relationship with helminth and they’ve created these mechanisms to survive in humans and in living creatures. They can actually secrete these proteins to actually attenuates and balances the immune system and increases t-regulatory cells, which basically calms inflammation in the body and really can shift the environment of a microbiome.
This is something I’ve seen be a game-changer for people with persistent SIBO who’ve tried everything and they’re maybe 50 percent better, 60 percent better, maybe 80 percent better. But they still feel like hey, I am not 100 percent yet, but I’m better than I was. I’m not where I want to be. They try something like helminth therapy, and we coordinate that from a functional medicine standpoint and get them the proper protocol they need to really push them past that plateau. I’m impressed by the results we’re seeing over the past years with these therapies, these more advanced protocols. Probably freaking some people out, but this is facilitated by medical doctors. It is monitored appropriately. This is not just done by yourself. I don’t think everybody’s a candidate for this. Definitely should talk to your doctor about it, educate yourself about it, and this is beyond the basics. This is not like don’t eat junk food and then swallow parasites. This is down the line for the more advanced cases.
PHOEBE: I understand why that would maybe help with autoimmunity and I have read about this. I just didn’t know the official name. How does it actually help with the overgrowth?
WILL: Specifically, I would say it’s not going to kill the bacteria overgrowth, but it’s going to really calm the digestive flares. It’s going to rebalance the landscape of the microbiome. I still would use cofase. I still would do all of that stuff that I talked about prior, but this is something where people are still having bloating. They’re still having constipation, diarrhoea They’re still having maybe acid reflux symptoms. These things are attenuated with the helminthic therapy.
PHOEBE: Back to the probiotic piece, are you using this and the probiotics in conjunction with the antimicrobials, or is that an afterwards?
WILL: There’s two ways of looking at this. I typically will do them simultaneously. I don’t think they have to be separate. I think there are some people who do better with it separate. I think there’s a time and place for that, but I don’t really think there’s any strong research to show – if you look at probiotics, some of these probiotics are antimicrobial in the sense that they are regulating the microbiome. They will kill off some of these bacterial overgrowths. So I don’t see it as kill and then reinoculate and add the probiotics. I don’t think it works that way. I think you can really do them together. Some people don’t do well with swallowing tons of capsules at the same time, and it’s just too much too soon. You want to organize it so there’s a little bit less all at once, but I think it’s completely fine and there’s really no data to show otherwise that someone couldn’t in theory do an antimicrobial and a probiotic at the same time. Again, it’s about regulating the microbiome. The probiotic and the antimicrobial are regulating the microbiome.
PHOEBE: Got it. Finally, back to something you mentioned a little earlier, biofilm. Can you explain to us what that is and what supplements targeting it do?
WILL: Biofilm is this mucosal lining on our tissue in our body and specifically with SIBO, what researchers are looking at are these basically dysbiotic, pathogenic biofilms that we need to basically disrupt to allow those things to be cleared out and the body to get good bacteria on there or beneficial, expected beneflora there and not these pathogenic ones or not these dysbiotic ones. There are many herbs that will disrupt the biofilm. Digestive enzymes can do that because it’s good breaking it down that way, so that’s one thing to consider. I think having proper stomach acid with the betaine HCL, with pepsin, those are good things to consider when it comes to healthy biofilm. The one that I like specific to a healthy biofilm is cat’s claw.
PHOEBE: What’s cat’s claw?
WILL: That is an herb that is an antimicrobial, but it’s also a biofilm disruptor, so it’s just a specific herb that we use.
PHOEBE: So back to maybe this idea of bacteria die-off but when people come to you and they say they’re feeling worse during treatment, which is something I’ve heard from my readers, what is it that’s causing that? How do you navigate that?
WILL: This is a difficult thing because anybody that’s listening to this will know there’s always this concept, an idea in conversation that we have to have with patients and to the bigger point here, I mean, real life happens when you’re not talking to a doctor. Real life – bad days happen; flare-ups happen; questions arise; uncertainty arise in the in between. The reason why we even operate the way we operate functional medicine-wise is to give them that in between guidance because that’s so important. When we’re talking about Herxheimer response and die-off, this is super-important because you give someone a protocol and then their visit’s in three weeks or four weeks. There are a lot of stuff that can happen in between visits that we need to adjust it accordingly sometimes.
Specifically, it’s then having this conversation of okay, let’s look at what they’re doing. How are they feeling? How long’s it persisting? What does it look like, putting it in context with how you know them as a human being and what they’ve experienced so far because you can have a die-off symptom response or they could just be having an intolerance or this supplement’s not working for them, or they’re dosing too high. There’s a lot of variables on is this a Herxheimer die-off detox response, or is this supplement just not working for them, or is it something completely unrelated, too?
I’ve gone back to my point of starting supplements all at once I don’t think works for a lot of these cases. I think some people, they can do it. I don’t want to say there’s never a place for it, but I tend to prefer phasing supplements in with patients with these reactive microbiome because there’s a lot of variables to consider. Sometimes it is a matter of just helping the body clear things out, get things like activated charcoal and making sure you’re well-hydrated and doing lots of broths and soups, giving their body as much assistance as we can to support those detox pathways. During that die-off response, sometimes it requires us to lean up on treatment, lighten up on treatment, and whatever dosage we had them on, to go down from there or take a break from treatment. Sometimes, that’s needed, too. It’s about really adjusting a protocol according to the day-to-day experience of what the patient’s going through.
PHOEBE: How does the activated charcoal help and how does it not conflict with some other medications that you might be taking?
WILL: Well, activated charcoal, the one that we typically recommend is ones from coconuts, a coconut charcoal. It basically is a drawing agent. It draws things out of the gut, out of the gastrointestinal system. It absorbs and draws out. Because of that, it can affect other medications. You want to definitely take it away from any other prescribed medication. I think they recommend about two hours away from it just to be safe. Some can be less than that, obviously, but for some of the specific medications that people can be on for other problems, maybe, we have to just phase it away, normally take it in the evening away from food as well to help draw things out during these Herxheimer responses that can happen when you are in this kill phase or these antimicrobial phases.
PHOEBE: So let’s talk about relapse for a second. Do you have any recommendations for medications, supplements that people should take after treatment to prevent SIBO from coming back?
WILL: I think that a lot of the things that we have in the kill phase or the reinoculation phase is antimicrobials and probiotics, the digestive enzymes, the betaine HCL. A lot of these things are things you would keep in long-term for some of these people at a lower dosage, because we don’t want a relapse, because we don’t want a flare-up of everything, and because as we know, these issues tend to be persistent and the gut can take two-plus years to heal and even more for some people to really get a place – and it has a tendency to go back to where it was before. I’d like to just have a slight light pruning, nothing aggressive, nothing too intense, but just so the body’s getting some support in regulating itself when you’ve dealt with – when you’ve gotten out of the woods. I don’t think that you should abandon what you were doing supplement-wise, at least entirely. You can probably go off some things, but working with your doctor to say okay, which ones aren’t needed but which ones should you keep just to keep things stabilized I almost see it like the cast is off out of that broken microbiome physiology and now you need a brace. You need a – more flexible, but still you need a brace while that microbiome is mending, while that is balancing, and I think that takes a lot longer than some of the protocols people are put on.
Same with the diet. I don’t think that you should just completely left field when you’re coming to food is concerned, because that is a major driver of microbiome balance, too. We have to keep your diet as a brace, too, during these phases to prevent flare-ups.
PHOEBE: What’s your recommended way to reintroduce foods gradually? I know you use a lot of different components of different diets during treatment. How do you transition afterwards?
WILL: The transitions are always systematic and they’re always based on what the patient misses or wants to eat. We basically look at where they’re at, so what protocol are they even doing of this collection of different protocols. What are they eating and then what are they not eating? Out of the list of what they’re not eating, talking to the patient, what do you want to bring back in? This is anywhere between three months to six months to a year before we have these conversations. At that point, it’s a matter of systematically reintroducing them. I typically do reintroduction protocols similar to the classic autoimmune protocol reintroduction where it’s a small amount, and then it’s tested over the course of a day, and then we wait about five days to see the response. That is not just the SIBO response, which is typically sooner, but the immunological response, the food reactivity, food sensitivity responses that can happen as a result of a weakened, imbalanced microbiome. Then we slowly bring that back in. The reintroduction would look different depending on how many foods the person wanted to bring back in and what their starting point was. They were on a more restrictive diet with more things to bring back in, that’s going to be a longer process than somebody that didn’t need to be that aggressive. It was a mild case, so they just took a few things out. Depends on their – where they’re coming from.
PHOEBE: Is that a good rule of thumb for people to parse out what is the reaction of some lingering bacteria in the small intestine versus what’s an actual intolerance that you may be feeling better simply from removing, from the diet having nothing to do with SIBO?
WILL: Yeah, exactly, I do. I do think that. I think that giving yourself a couple days allows you to see how fast is the response happen, if at all, and then is it due to the SIBO or is it due to an immune and gut-centric, I would say, immune response that’s not specific necessarily directly specific to the microbiome even though I would say these things do often hand-in-hand.
PHOEBE: Okay. Finally, are there any other lifestyle tips that, besides just diet, people should keep in mind as part of their treatment plan and ongoing strategy to not relapse?
WILL: I would say in addition to considering some of the things we talked about today, I would say that maybe an obvious thing that I’m going to say but is not given the attention it deserves is stress levels. I think you talked to a lot of people with SIBO, a lot of people with bloating and IBS and acid reflux and GERD, and the majority of them will tell you their symptoms are worse when they’re stressed. At that point, you have to see what is the influence that your body has and the rest of your body has beyond your gut. How does that influence your SIBO symptoms? That can show you many things about your body that is not just the SIBO. The body interacts with the SIBO and the SIBO interacts with the rest of your body. It’s important to see that bidirectional response there.
Stress management, getting proper sleep, very important, and I do not mean it in a light, fluffy-sounding Hallmark card. I just – it has to be this concrete protocol lifestyle where you live and breathe a life of healthy margins and that is managing your stress to what you can do and to what your body needs. Same with sleep. I think if you’re not getting sleep and you’re not optimally managing your stress during your healing journey, which you may get better adaptation distress as you’re healing, but in the meantime, people need to put better margins on their life. I found it’s fascinating. When you talk about all these protocols we’re doing and all these different antimicrobials and probiotics and biofilm disruptors and helminth therapy, all this stuff, and food – I’ve found that those things are amazing but for sometimes, it’s actually the stress than can be a major lynchpin in people’s healing journey. They can get all that other stuff on point but if not dealing with that stress component, that’s fuel for that dysbiosis in their body. The power that stress wields on the microbiome never ceases to amaze me. I have people that don’t eat as clean, they’re off of their protocol, but they go on vacation and are less stressed, and their symptoms are better.
PHOEBE: Yes, I personally experience that all the time.
WILL: Yeah, and then you have to think about wait, what is that? With the bacteria, did the bacteria change? Why am my symptoms better when I’m eating stuff I never would eat at home? You know what I mean? The body is just amazing and this connection between the gut and the brain, the brain and the gut, and the impact stress has on both of those systems is powerful. Sometimes it is just taking care of yourself in addition to the practical stuff. I definitely feel like that’s something we don’t talk a lot about in the SIBO world.
PHOEBE: Totally. Is there anything else that you’d like to add, any clearing up of some SIBO or microbiome myths or just general advice besides that very important message about stress, which I completely agree with?
WILL: Something we talked about before we started recording that I am fascinated about is the impact that – most of my patients are on this autoimmune inflammation spectrum The exciting study’s showing ketones specifically having on inflammation on the body, and this isn’t specific to SIBO, but I think a lot of people – it will resonate with inflammation and autoimmunity and their body. Specifically, the study’s about betahydroxy butyrate, the main ketone, has an attenuating calming NF-kappaB talks to these inflammasomes, these NLRP3 inflammasomes in the body, these things that are associated with a lot of the inflammatory problems we’re talking about today. This main ketone calms that down and it up-regulates these pro-antioxidant pathways like the NRF2 pathway, the ANPK pathway, super-important for attenuating inflammation, which is a commonality between many people with dysbiosis, SIBO, gut problems. I’m fascinated about that. That’s one of the reasons why; because most of my patients are on this autoimmune inflammation spectrum that I wrote Ketotarian, which is my plant-based ketogentic approach to calming inflammation levels down and helping people on this spectrum attenuate inflammation levels. That’s what I’m most excited about. Maybe it’s because I’m talking about it so much and I’m reading these studies and I’m diving into it. That’s definitely something that I would like for people to know about.
PHOEBE: For sure, and is there a certain stage of someone’s SIBO journey that you would recommend experimenting keto with? I know we talked about before about being carnivorous in certain phases, but at what points would you recommend your ketotarian approach?
WILL: Depends on the patient. I think some people – and I’ve seen this before. People that have SIBO symptoms do really well right out of the gate eating that way. There’s vegan keto, vegetarian keto, pescatarian keto options. I would say if you generalize those umbrellas, those ketotarian umbrellas, some people go right out of the gate and they do really well with that. I would say a lot of people, I would do that after this brothing, souping, gentle, even carnivore diet for a little bit approach just to calm things down, do a slow, systematic reintroduction, and then as far as a long-term, sustainable wellness, which is why I wanted ketotarian to be what it is – it’s more of a lifestyle for somebody to improve their health. I would probably do that after these initial kill phases as a general rule, even though many people will go right out of the gates and eat that way with their kill phases and do great because it’s still real food, healthy foods, low inflammatory foods, and you get the benefits of ketones, which is good for the immune system.
PHOEBE: Amazing. Thanks so much for sharing all your incredibly wisdom with us today. I can’t wait for people to listen to this. If you want to learn more about you and your book, where should they go?
WILL: First of all, thank you so much for having me on. This is such a cool thing that you’re doing. Everything’s at drwillcole.com. That’s D-R-W-I-L-L-C-O-L-E-dot-com, and you can order Ketotarian there. The link’s on Amazon and Barnes and Noble are all there. There’s video classes about the stuff we’re talking about, and we offer free webcam evaluation or phone if people want to get more specific functional medicine perspective on their case or run labs or whatever they need.
PHOEBE: Amazing. Thank you! You’re the best!
WILL: Thank you so much.
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