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

The mystery of stubborn digestive issues often leads to a single culprit hiding in plain sight: Small Intestinal Bacterial Overgrowth (SIBO). In this illuminating conversation with world-renowned SIBO expert Dr. Allison Siebecker, we unravel the complexities of this common yet frequently misunderstood condition.

Dr. Siebecker explains why SIBO occurs when bacteria normally found in our large intestine inappropriately colonize the small intestine, creating a cascade of symptoms from bloating and pain to irregular bowel movements. Most surprisingly, she reveals that past food poisoning episodes are the leading trigger, causing an autoimmune reaction that damages the gut's critical "housekeeper wave" – the migrating motor complex that normally sweeps bacteria away.

The conversation dives deep into practical clinical wisdom, exploring why testing matters (symptoms don't reliably predict which bacterial gases are present), why treatments often fail (most cases require 2-5 treatment rounds), and why prokinetics are non-negotiable (they can quadruple remission time). Dr. Siebecker shares her preferred protocols for each type of SIBO – hydrogen, methane, and hydrogen sulfide – with specific herbal and pharmaceutical recommendations refined through years of clinical experience.

Perhaps most valuable for long-suffering patients is the discussion of challenging cases. When SIBO seems impossible to resolve, underlying factors like mold illness, parasites, or histamine intolerance may be the missing piece. The episode also clarifies the confusing world of SIBO diets, explaining why the Low FODMAP diet isn't optimal for SIBO despite its popularity, and how the elemental diet can dramatically reduce bacterial levels when other approaches fail.

Whether you're a clinician treating digestive disorders or someone struggling with persistent gut symptoms, this episode provides the roadmap you need to navigate the journey from diagnosis to lasting recovery. Visit siboinfo.com for free educational resources mentioned in the episode.

Episode Links: www.SIBOinfo.com

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Transcript

Introduction to Dr. Allison Siebecker

Dr. Noseworthy 0:03

Hey everyone, welcome to the Func Med Nation podcast. I'm your host, dr Steve Noswery. The views and opinions of guests on this podcast are their own and may differ from my own, but as always, I try to be respectful of other people's opinions, even when we might disagree. All right, guys, welcome back to the podcast or I should say podcasts, because this episode is actually going to air on both of my podcasts, both the Inflammation Nation as well as the Funk Med Nation podcast, and the topic today is SIBO, which stands for small intestinal bacterial overgrowth, and I'm sure our conversation is probably going to range a little bit around just the topic of gut health in general.

Dr. Noseworthy 0:46

But my guest today is Dr Allison Siebecke , and she's been specializing in SIBO since 2011. She received a Lifetime Achievement Award for her work in SIBO and outstanding contributions to the field from Gastro A&P. She's been teaching advanced gastroenterology at National University of Natural Medicine since 2013 and is an award-winning author. She was the co-founder and former medical director of the SIBO Center for Digestive Health at National University of Natural Medicine, and her integrative SIBO protocols have helped thousands worldwide. Allison, first of all, welcome and I'm glad we had a chance to connect, and I have to tell you that I've been podcasting for a few years now and from the very beginning, your name was on a short list that I had written down, probably three years ago, of people that I really wanted to make sure that I connected with, and I feel bad and I'm sorry that it's taken me so long to reach out to make this happen.

Dr. Siebecker 1:46

nice to know that I was a name on that list. Thank you, yeah, there you go Well it's.

Dr. Noseworthy 1:50

you know.

Dr. Noseworthy 1:51

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

Dr. Noseworthy 2:10

But as far as I know from my experience, you were one of the early voices on the clinical side bringing SIBO to the forefront of our let's call it our collective awareness. And so I want to talk a little bit about your background before we get into the nitty-gritty of SIBO, and I'm always interested in people's origin stories, like how you got into natural medicine. So I kind of want to break it down into two things. Number one is what is it that attracted you to natural medicine to begin with? And then I would like to know what was going on in your mind and in your practice that put SIBO on your radar, especially to the point where you became one of these leading voices. So let's just start with the origin story, like what were you doing before you went to naturopathic college and why did you pick naturopathy?

Dr. Siebecker 3:01

Well, you know, I was always interested in natural health and alternative health. I think it started for me maybe in high school, where I had some friends who's who were into health food. In high school, Like they, their parents bought like whole wheat bread instead of white bread and I I was really attracted to that and I was jealous that like they got the whole wheat brown bread and I had the white bread. And I mean, my mom did the best she could but she, she wasn't a health food person, and so I got totally into it and I like lobbied my local health food store to let me start working there, and so I did, and so I just got into that whole field. I had also been really into massage and so that sort of was another gateway into more health, the health medical world. And then I worked in health food stores as a career. Actually, I was a manager at various health food stores before I went to naturopathic school.

Dr. Siebecker 4:03

But what actually, you know, made me want to go to naturopathic school, but what actually, you know, made me want to go to naturopathic school is, I would say, like a calling, like it was almost like a spiritual calling. I actually had an experience. I was. I was at an herbal medicine conference just attending that for me, because I worked, you know, managing health food stores. We sold herbs and everything. And I actually had this experience where I felt like a lightning metaphorical lightning bolt like came down and hit me and I stopped in my tracks. I was walking, stopped and was like I need to be a naturopathic doctor, I have to go to naturopathic medical school. And I'll tell you what. Thank God for that, Because if I hadn't felt like it was, you know something divine, I don't know where people get the motivation to make it through medical school, If it was just only their own ego or something like oh man, it's just like a career choice, right.

Dr. Siebecker 4:53

Just a career choice or just because, like, they want like a status, job or I don't know what the heck motivates people. But oh it's, and I did two degrees at the same time. I did a master's and a doctorate, and so it was just so, so, so grueling, you know. So thank God I had that because it was like, well, I can't say no to that. So I got to keep going.

Dr. Noseworthy 5:14

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

Dr. Siebecker 5:18

Totally, totally. And then, in terms of you know what was I doing in my after I graduated? I was doing general medicine. A lot of my master's was in oriental medicine, so a lot of acupuncture as well.

Dr. Siebecker 5:31

But really the thing is is that I had IBS my whole life and that turned out to be SIBO from not my whole life, from about when I was five as near as I can tell is when I got it, cause I was born with normal, um, you know, gi function according to my parents. But but since I was about five I had it and struggled a lot with it. My whole life struggled terribly with it. So so, like so many of our patients stories saw so many doctors, tried just about everything you can think of and I really mean that and went through medical school still no answers.

Dr. Siebecker 6:08

And it wasn't until afterwards when I found out about SIBO from my gastroenterology professor was a friend of mine also and he was writing a book and happened to have just found out about SIBO and just put like a paragraph in his book about it and I was helping edit and review his book and I was like what? And I went and looked it up and just went down a rabbit hole and it was hard back then I mean, that was like 15 years ago but then again another sort of fire got lit in me. Really, what did it for me was when I tried a treatment for it. I actually started with diet.

Dr. Siebecker 6:46

I tried diet for it. I tried the specific carbohydrate diet, sed for short, and within 24 hours my pain that I had suffered terribly with abdominal pain was gone, and so you can imagine how that would light a fire. I just thought about all of the patients and people that I know with IBS who struggle and to think that they could get that kind of relief, you know, overnight. Then that's what lit the fire for me to want to raise awareness and, yes, I sort of took it on as my job to raise awareness of this, because nobody knew.

Dr. Noseworthy 7:20

Yeah, and I think you know that there's some elements to the origin story that I think we kind of all share, and I won't bore you with my own. But you know, I was dealing with some orthopedic issues that surgery and steroid injections and different things didn't fix back when I was in well, and I'd never seen one before, right, and so I had that personal experience that just changed my life and I thought, well, how? And at the time I was working, uh, I was living and working in downtown Toronto, I'm Canadian originally and um, and I thought well, how, how neat would it be, for if I could change somebody else's life, the way that this guy changed mine?

Dr. Siebecker 8:04

That's exactly it.

Dr. Noseworthy 8:05

But I think that that's a very common thing Now. I do remember when I was in first year at Logan Chiropractic College in St Louis, one of our early instructors in the first semester asked for a show of hands, like how many of you are here because your dad's a chiropractor, your mom's a chiropractor, your uncle and about half the class raised their hand and the other half didn't. And he said this is quite interesting because five years ago everybody would have raised their hand because, you know, being a chiropractor, you were kind of raised with chiropractic or raised as chiropractic family. And he said it's an interesting shift that now people are starting to choose chiropractic just simply out of an array of different professions. Right, and so it makes sense to me, because I I had wanted to ask you the question like why did you pick naturopathy versus acupuncture? And I know that you're a licensed acupuncturist as well. Now I'm assuming that can like came later no right.

Dr. Siebecker 9:02

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

What is SIBO and Common Root Causes

Dr. Noseworthy 9:19

Yeah. So let me ask you to do this because we're bandying around, because this podcast is going to go out to the general public as well as to clinicians Define naturopathy and maybe distinguish that between a more umbrella term of a natural medicine doctor, Because we use these terms kind of like interchangeably and I might tell someone I do functional medicine and they think I'm a naturopath, right? So what? Like just as succinctly as you can, let's say you're talking to general public, how would you define what naturopathy is and what you do as a naturopathic medicine doctor?

Dr. Siebecker 9:57

Yeah, it's a similar training in sort of what you see in the books as the basics, to an MD, a medical doctor, and it's its own degree. It's its own, you know, school training and degree, but it's a similar base training. But then in addition we add in things like training in different, basically we would call treatments or modalities. So we have training in actually manual adjustment. We only do a year. So you know, I personally send everyone to a chiropractor who's had their four years, you know. So we have some manual adjustment training.

Dr. Siebecker 10:32

We have homeopathy, we have herbal medicine or botanical medicine. We have actually hydrotherapy, which is like use of hot and cold, various sort of old school home treatments that you know, things like that. We learn physical medicine, like using TENS machines, things like that, some sort of sports medicine and we learn. We also like the base training, we also learn and pharmaceutical antibiotics. So we, you know we have the same base training and we also learn minor surgery. So the same base training is there. But then we add in the natural modalities and of course diet, nutrition and diet is highly stressed as well as like lifestyle. But we take all the same pathology classes and all that, but we have different modalities and we also have different philosophy and we actually have classes in like natural medicine philosophy.

Dr. Siebecker 11:23

You know, first do no harm really bringing that through. How do we really bring that into our practice? And then I think the other thing I would say is is that the the ability to practice is different state to state. But for naturopathic medicine there are states where we are licensed primary care physicians which need legally to be covered by insurance. Sometimes they try not to, and then also we can prescribe not in all states, but so that is one thing that's a little different from maybe like a chiropractic degree. I don't think there are any states where chiropractors are, like allowed to prescribe.

Dr. Noseworthy 12:04

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

Dr. Siebecker 12:12

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

Dr. Siebecker 12:32

So, and we don't have the same. We have some specialties but we don't have the same specialties, so you know. So think of it as it's like you're getting your basic training but you're getting all your natural training too. So it's a wonderful thing. And functional medicine. That gets confusing too, because I think where that was originally created for MDs who wanted, after they've gotten their MD, they're really attracted to natural medicine and they want to incorporate more of that. And the big thing there is that MD has quite an emphasis on structural organic problems, missing out on some of the function of the body, and that's where the functional medicine came in to sort of fill that gap you know.

Dr. Noseworthy 13:10

yeah, well, let me ask you about that because I've asked other um other clinicians and say subject matter experts, like how we can go back to jeff bland's original paper on functional medicine and kind of the rules and the tenets of that that they developed. But functional medicine I think the term is used very loosely to describe many different things and you can have two clinicians that say they do functional medicine but they actually do two very different things. How would you describe that? How would you like if you were to put pen to paper and outline a framework? This is what functional medicine is. What is it and, in your opinion, how does that differ from, let's say, the basic philosophies and principles of naturopathy?

Dr. Siebecker 15:54

Well, you know, I haven't gone through the Institute for Functional Medicine Training, but from the outside, what I can say and I've taken classes from some people who are functional medicine teachers, so you know, I'm not sure if I've got it right, but what I would say is, philosophically, functional medicine is really trying to focus more on root causes, identifying root causes, which, you know, that's the huge criticism in MD world is this it's more about fixing the symptoms right, um, and also trying to restore function back to normal as best as can be.

Dr. Siebecker 16:30

And so that's where they may use different um test, uh, you know, test positive criteria, not just what gives you the disease, but looking at opening those levels a little to say what's the pre-disease, let's get, let's get you before you get all the way there. So, prevention function, really making sure how well is your thyroid function, how well is everything functioning, things like that, um, and you know, I guess the difference is that, um, naturopathy, of course we have root cause built into everything. We have both structure and function built into everything. I think it's probably more so the modalities. I think a typical functional medicine practitioner would have been an MD that wouldn't receive extensive herbal medicine training or homeopathy training or things like that, but then they may learn some of that later. They learn a lot of nutritional supplement, I think in the Institute of Functional Medicine, of course we learn all that as well.

Dr. Siebecker 17:26

So maybe there's just some modalities or treatments that aren't quite incorporated in to functional medicine but could be. You know, if they have classes in that.

Dr. Noseworthy 17:35

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

Dr. Siebecker 17:53

Yeah, and I just want to say that just generally for me, all of these distinctions, generally for me, all of these distinctions in my mind, I don't care so much. I mean, what matters to me is people have good training and have goodwill, good heart and, you know, are trying to help people and you know we've all met. Any discipline can have people that meet those criteria and are doing a phenomenal job and are not annoying, and then every profession can, every discipline can have people that you know you're disappointed in the amazing resilience and flexibility of how the human body is framed and designed that sometimes it doesn't take much of a change or an input to course correct.

Dr. Noseworthy 18:51

But then as conditions evolve, as cases become more complicated, it takes a lot more effort right. As cases become more complicated, it takes a lot more effort right. And again I go back to some of my early stories. When I was being trained in chiropractic we had this one old. He was an old I'm going to call him a geezer. At the time he was probably no older than I am right now, but that was a while ago and he said some people, you just need to hit them in the butt with a broomstick and they're going to get better.

Dr. Noseworthy 19:23

And I see that in some of my own clients. Sometimes the only thing I really needed to do was maybe optimize their diet or if we need to do supplementation. It doesn't take much Like you're not taking six different formulas three times a day for 12 weeks to make something shift and change. But then there might be some cases that do require that. And so there's like this huge wide range of different case presentations. But you know what I like these conversations about things like principles and concepts, and because I've always attributed this next question, I'm going to ask you to naturopathy, and I don't know if I should. I'm sure the concepts kind of predate what we consider to be modern naturopathy. But there's this again, I'm going to say old naturopathic principle that says that health begins in the gut.

Dr. Siebecker 20:15

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

Dr. Noseworthy 20:31

I prefer that. Yeah, that just underlies, like, the difference in how we're trained to think Right, because I, when I work with my own clients, I don't think that I'm certainly not treating disease. When I work with my own clients, I don't think that I'm certainly not treating disease. I'm trying to find out where people have lost wellness and how to restore that. That's the way my mind works in terms of what it is we're doing in an exchange with clinician and patient or client. I want to ask you about this idea because there are a lot of, and I'm going to use loosely naturopathic and functional medicine kind of interchangeably, because there is a lot of overlap. So forgive me if I don't want to step on any terminology.

Dr. Siebecker 21:09

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

Food Poisoning and Autoimmunity Connection

Dr. Noseworthy 21:12

Yeah, there you go. So I mean, I know that there are a lot of docs that, no matter what walks into their office or what someone's clinical presentation is, or really what their underlying true causes are, they're so convinced that health begins in the gut that that's where they start every single time. Now I'm not judging whether that's the right or the wrong thing to do, because I think that judgment has to be done on a case-by-case basis, mixed in with how the clinician thinks. But let me get your take on that as someone who's been trained differently than I. Is that what you believe clinically? And again, I'm not judging one direction or another, but do you think that that's always a good thing to do is to figure out what's going on with the gut and to fix that?

Dr. Siebecker 21:52

I can't imagine it's always, always the right thing.

Dr. Siebecker 21:56

I mean, you know, I've heard sayings, other sayings, that people in their own disciplines say all disease or all health begins in there, the thing they specialize in, right, so but you know, I can say that there is a lot of truth to it and you know, sibo is a fascinating example of it in that when we take a look at like, I have an educational website, free educational website, and one thing I do is I, every time there's new studies come out, I do it quarterly, I add them into this associated disease list, and the associated disease list is like massive.

Dr. Siebecker 22:35

And so what I mean is that SIBO has links with diseases in all parts of the body neurological, kidney, cardiovascular and atherosclerosis, and liver and skin, dermatological mood. It goes on and on and on. So I can see the underpinning of truth in that statement for sure, even just looking at SIBO. But I can't imagine it's always the way to go. I think people have their own ways to practice where they like to start, and I think they develop that over time and everybody has to follow their own medical intuition with what they want to do Exactly.

Dr. Noseworthy 23:17

And I totally agree with that. I absolutely agree with that. I absolutely agree with that, and you know I'm thinking about. You know we're going to have a conversation coming up here in a little bit about causes and consequences of sebo, right, because if somebody has sebo, something caused it, and if we're really truly concerned about root cause, the question we're asking is not simply do you have sebo, how do I treat it? It's oh, you have sebo, why do you have SIBO? How do I treat it? It's oh, you have SIBO, why do you have SIBO?

Dr. Siebecker 23:43

Yeah.

Dr. Noseworthy 23:43

Right, because one of our and I would say we're probably pretty close of the same mindset that if we were to critique the medical approach, the pharmaceutical approach to SIBO, it's typically, you know, a round of antibiotics or so and not necessarily any other changes. And that might depend on the knowledge base and experience of the prescribing physician. But the mindset is typically, well, you've got these infections, let's use antibiotics to kill that, and then we're done. We kind of wipe our hands and walk away unless it recurs, and then are going to see you in three months or six months down the road. But never in that model or that approach is there this question about what's causing the SIBO and, if you don't mind, let's put a pin in that and come back to it, because I think that's a very it's a great conversation, particularly for the clinical side of things. But it might be helpful for anyone out there listening who's not a clinician, who thinks they might have SIBO, who could look back in their own history and go, oh, maybe that's why.

Dr. Noseworthy 24:45

And I want to keep going, but let me just pause. I do have a couple of other questions, just in terms of the general realm of discussion before we get into details. So I'm always interested in how other clinicians explain things, especially complex things like SIBO, to their clients and their patients. So I want you to pretend that I'm a prospective client. I'm sitting in your consult room. You walk in, we meet for the first time. You go through my history. Maybe I've got some labs, maybe I don't.

Dr. Siebecker 25:26

And you start thinking in your mind okay, I think Steve's got SIBO. And then you bring that up and I say SIBO, what's that? Okay, now I have to tell you something funny. I'm going to answer the question. But I've been a SIBO specialist since I started in SIBO I, when I went, I was a specialist, so everybody who came to me already knew what it was. But I have an answer and here's, here's how I would describe it. So you know, but I'm lucky cause I didn't have to have that first conversation, right? Yeah, I would say you know.

Dr. Siebecker 25:51

So it's small intestinal bacterial overgrowth and that it it sounds like what its name is in that bacteria don't normally, we don't typically have a large amount of bacteria in our small intestine. The place for that is a large intestine. Most people know we have, you know, a microbiome that's beneficial in our large intestine, so that's, that's good. But typically in the small intestine we don't have, you know, a very large, and so what happens is there's like a colonization or an overgrowth of bacteria there and they mess with the structure and the function in that area, and the function is to digest our food and absorb our food, and so the bacteria just wreak havoc with that and they mess up all of our digestion and absorption.

Dr. Siebecker 26:39

And they also mess up the structure. They cause damage to the lining of the small intestine and so, once again, that has ramifications on what we're absorbing and it also leads to a whole bunch of symptoms because we're not supposed to have this amount of bacteria there and it's just not the place for them. It's kind of like location, location, location right In real estate. So then we get all these symptoms like abdominal bloating, bowel movement changes, pain or discomfort, and the list goes on. So that's basically it. They shouldn't be so many there. They've had the opportunity to grow there. We haven't talked about why, and we need to reduce that.

Dr. Noseworthy 27:17

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

Dr. Siebecker 27:21

Great, let's move into the conversation. Okay, but instead of just doing it right like to a patient, I want to tell you something a little bit more background, which is that I like to think about it in two levels the physiologic, underlying causes, meaning what's gone wrong in the body to allow it to happen, and then for now, I'll just call it the causes or the risk factors. So these are like the diseases and things that lead to it, but if we think about it, in the body we have a lot of protections, naturally, that make it, so we don't get this. I mean, this is not the way we're supposed to be and they've been able to figure out.

Dr. Siebecker 27:55

Really, the most important one is this movement or kind of form of peristalsis in the small intestine, the migrating motor complex, and it doesn't actually happen with food. It happens when we're fasting and it's called the housekeeper wave because it cleans up after we eat, and one of its main functions is, besides, like sort of cleaning up is to sweep bacteria on a regular basis away down into the large intestine to be excreted, keeping it clean. It's just like constantly sweeping away whatever bacteria are accumulating, and we now know that this is one of the main reasons why people get SIBO is this becomes deficient, we don't have as much sweeping cleaning action, and that's really the main underlying cause, physiologically, of SIBO. And so what would then cause? That would be really anything that could damage the smooth muscles or the nerves that create this movement. And it's a large list of things, a large list of things, but I can tell you some of the most common.

Dr. Siebecker 28:54

The most common of all is food poisoning, also called traveler's diarrhea or stomach flu. But really here we're talking about bacterial food poisoning, because food poisoning it's most common from virus, norovirus. But this is not that. This is bacterial food poisoning and, as you know, this pathophysiology sequence has been figured out and basically what occurs is an autoimmune situation is triggered, unfortunately, and the body damages its own nerves that create this migrating motor complex and then those waves diminish. And just think of it sort of like this this is a great analogy for you know, just non-practitioners as well is think of it like a flowing river. When a river is flowing, there's not much chance for bacteria to accumulate, but if it becomes stagnant and still we know bacteria overgrow, it becomes like a swamp. So it's like that If it slows down, bacteria overgrow and small intestine is a dark, warm, moist environment.

Dr. Noseworthy 29:58

So without much movement there you go.

Dr. Siebecker 30:07

That's sort of the main thing.

Dr. Siebecker 30:08

And then let me just I can say the other risk factors for the slow motility.

Dr. Siebecker 30:10

But let me just say the other sort of key physiologic reason would be something anatomically structurally wrong or not normal, we'll say, and the most common for this would be an obstruction, or really here we're talking about a partial obstruction and here we can sort of think about it like a log jam in that same river analogy. If some things pile up in an area in the river, stuff's going to back up behind where those logs are, so just physically, and so this can be things like strictures, that's a narrowing of the intestine, it could be a volvulus which is a twist, or a kink, it could be a tumor, you know. It could be a compression, an area where something's getting compression. Most common is adhesions, and adhesions are scar bands, they're they're a repair substance, they're supposed to be helping, but sometimes they conform in such a way where they compress parts of the small intestine, causing a narrowing. And then you know, and then if you have an area like this, the river can't flow as well and stuff can back up behind it.

Dr. Noseworthy 31:13

And so you know, you'll get an area of narrowing and an area of dilation about it. So, um, two questions that are just relevant to things that you're just saying. First question is and I'll put them both out and we can just answer them one at a time Handle on what percentage of cases that you're dealing with that you're seeing a history of food poisoning, because I routinely ask that in my intake form, especially if they have gastro symptoms that I think look like SIBO, I'll ask them have you ever had a viral gastroenteritis, ever had food poisoning? I don't always see it, but personally I don't know what the percentages would be. I'd be interested in your feedback.

Dr. Noseworthy 31:55

And the other thing about the scar tissue. I know that abdominal surgery is a risk factor for SIBO and abdominal surgery doesn't necessarily mean intestinal surgery. Right, because I've seen some papers that have looked at scar tissue, post-hysterectomy, for example, or post-gallbladder removal. Well, technically that's kind of intestinal because it's the GI tract, but it doesn't have to be. I had surgery on my bowels and that's where my scar just came from.

Dr. Noseworthy 32:28

Yeah, yeah, Okay, so that answers that question. And what? What is your impression of? What percentage of all SIBO cases do you see? Have a history of food poisoning that you think is causative?

Dr. Siebecker 32:42

That's the majority. So you know, when I was a SIBO specialist, that's all I saw and you know at least 60%, I would say. And here's the key thing to note is that many people do not remember having food poisoning who actually have food poisoning as their cause of SIBO. So it's vitally important to ask it in history because you're going to grab the most people that way. However, particularly in mystery cases, very often when you're like you really can't figure out what the underlying cause is and, by the way, this is not the easiest thing to do. We haven't really talked it through, but there's a huge list of underlying causes of SIBO, many of which are specialty fields in and of themselves to learn how to diagnose, so it takes referrals. It's not the easiest thing. It's very easy to say find the root cause and we need to try, but it's not so easy to just whip that out.

Dr. Siebecker 33:33

You know Right. Agreed, but yeah right, you know. So it's important to know this. So we don't get you know whatever, but we do have a test. That's a blood test that checks for this particular cause of SIBO and in cases where I can't figure it out, I run this very often I run this and it comes back positive and the person has no memory of having food poisoning, and that's because, contrary to popular belief, food poisoning can occur with mild symptoms. We all think of the. You know both ends coming out, both ends horrible.

Dr. Noseworthy 34:05

And they're doing that, yeah.

Dr. Siebecker 34:06

You wish you could die. You know, just awful, but it could just be some mild, soft stool one night and you don't think anything of it. That actually can correlate, and so I've seen that very often where people don't remember.

Dr. Siebecker 34:22

And one other thing is that the cause of food poisoning it can move from food poisoning. The symptoms can change and move right into the SIBO, ibs symptoms and you have SIBO, but more commonly there's a delay. It takes time for that nerve damage to occur from the autoimmune damage and it's typically three to six months after. And so if it's three months after, people are not linking it, doctors are not linking it, and so that's a key thing to note for people is that it's not like one right after the other.

Testing Methods for SIBO Diagnosis

Dr. Noseworthy 34:55

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

Dr. Siebecker 35:16

Yeah, so this test is generally called the IBS blood test, but some of the specific labs are. Ibs Smart is the main test. This is the second generation version of this test. Ibs Smart there's also IBS Check was the original version of it. And then I think, vibrant America and Vibrant Wellness and Cyrex have their own versions.

Dr. Noseworthy 35:39

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

Dr. Siebecker 35:48

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

Dr. Noseworthy 36:05

So that's what this test is.

Dr. Siebecker 36:06

It checks for those two and there's a different prognosis depending upon which is positive. Vinculin is the sort of more severe form of it.

Dr. Noseworthy 36:16

And that's positive.

Dr. Siebecker 36:17

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

Dr. Noseworthy 36:35

No, and it's probably also good to point out that you can have more than one cause. Yeah Right, there's no rule that says you know, thou shalt only have X, and you shall not have Y. That's right, yeah.

Dr. Siebecker 36:49

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

Dr. Noseworthy 36:55

Yeah.

Dr. Siebecker 36:56

So maybe I'll just quickly mention a few of the others, just so people can get a smattering idea, so maybe I'll just quickly mention a few of the others just so people can get a smattering idea.

Dr. Siebecker 37:02

So inflammatory bowel disease that can cause strictures and all sorts of structural problems. Diabetes that can cause nerve damage which can damage the migrating motor complex. We know that many people with diabetes get gastroparesis within like five years of their diagnosis. Gastroparesis is slow stomach emptying and there's a migrating motor complex that begins in the stomach so that sort of automatically affects that. Hypothyroid of course has slow motility. We know constipation, but it affects the migrating motor complex. Ehlers-danlos syndrome these are all diseases Ehlers-Danlos I don't know how familiar everyone's becoming with it. It's like newer within the last 10 years to many of us. But it's not rare and it can have both structural components and migrating motor issues. It's a double whammy. Many people, with a very high percentage of people with Ehlers-Danlos, have SIBO.

Dr. Noseworthy 37:52

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

Dr. Siebecker 37:59

Yeah, and that can cause prolapse in the intestines and sort of almost like blind loops and twists and kinks and things um parasites. We don't have a lot of good uh literature yet, but we're pretty sure it slows the migrating motor complex. Various infections um some classic sort of risks, are like hypochlorhydria. That's one of the body's protections. So many people have hypochlorhydria. That's one of the body's protections. So many people have hypochlorhydria. And then of course there's medications like proton pump inhibitors that on purpose cause hypochlorhydria, so they're a risk factor. Other medicines would be opiate narcotics. We know they cause constipation, painkillers, but they also slow the migrating motor complex.

Dr. Siebecker 38:40

And even antibiotics have been linked with slowing the migrating motor complex. We use some pharmaceutical antibiotics for SIBO and they work, but there are some antibiotics that could potentially slow the migrating motor complex and this is important because so many patients come in feeling that medications like this, and including antibiotics, were what caused their SIBO, and so there's some truth there. And then we have things like traumatic brain injury this is considered to be an epidemic these days that can slow the migrating motor complex. Parkinson's disease one of the first signs is constipation and slowing of the migrating motor complex. We have Lyme and co-infections slow the migrating motor complex. We have Lyme and co-infections slow the migrating motor complex.

Dr. Siebecker 39:25

And then we have, you know, generally adhesions, things that cause that. You know things like endometriosis, very high degree of SIBO in that Appendicitis. People can have smoldering appendicitis, not just even acute, where it gets removed and, as you mentioned, abdominal surgery, radiation, but honestly, adhesions can be caused by infection. So that'd be like appendicitis, inflammation same thing there or injury. And so a lot of people have abdominal adhesions from sporting accidents or just living, you know living their life, falling off a bike, you know you can. Car accidents, you can get them for many, many reasons, and that is probably our second most common cause of SIBO across the board, I'd say I'd say that adhesions abdominal adhesions which you know people are not thinking about, Right, Right.

Dr. Siebecker 40:18

And I'd say the third most common cause would be all of these diseases I'm mentioning and medications like is it clumped risk factor? So, and one last I must mention, is mold, toxic mold illness. This is another thing many of us have learned more about in the last you know, five-ish years. We could say there's an epidemic of that. You know, water damage in homes, work, buildings, cars and uh. Mold illness also slows the migrating motor complex and mold illness is what's typically involved, one of the first things we think of when we have a very challenging, tough case of SIBO. And actually, while I think of it, there's one other thing I want to mention. You talked about finding the root cause and the relapse rate, and I just want to say that from the studies that have been done, we know that SIBO has a very high relapse rate. It's about two-thirds of cases will relapse. You know that will just come back.

Dr. Noseworthy 41:18

And that's independent of the treatment methodology, because I would imagine relapse rate is higher with certain treatments than others.

Dr. Siebecker 41:24

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

Dr. Noseworthy 41:29

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

Dr. Siebecker 41:32

Yeah, all the treatments have the same success rates, so they all work equally. But just briefly, what are those treatments? Pharmaceutical antibiotics, herbal antibiotics and elemental diet they all work equally well, and relapse has nothing to do with that. What the relapse has to do with is there's an underlying cause there, like well everything we just mentioned diabetes. There's no known cure at this time for diabetes. It can be very well managed. Ehlers-danlos same thing, you know. Food poisoning same thing. There's no known cure at this time for the autoimmune damage that is triggered by that. So there are many chronic underlying causes. There are other causes that can be gotten rid of Lyme and co-infection that can be gotten rid of, and many other things. You can stop taking opiates, you know, but we have to look for these things and there are a lot of underlying causes. So that's enough for me.

Dr. Noseworthy 42:24

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

Dr. Siebecker 42:37

Such a good question because the best test for this is actually a barium swallow with follow-through, and this is considered to be an outdated, old test that's fallen out of favor and everybody wants to do MRI or CT first and what I would say is you know, if your doc wants to run those tests first, fine, and your insurance will cover it. Fine, let them do what they want to do. But eventually you're going to need to come to the barium swallow. This is not a barium enema. It's a barium that you drink and the thing here is that it actually needs special instructions because most radiologists they don't want to do this test and they'll just take five films, five images or just a few.

Dr. Siebecker 43:22

So I would encourage anybody, if you're going to ask for this test, to to write an instruction or ask for this so that the radiologist knows what to do, which is rule out adhesions with multiple spot films and positional changes to visualize each segment of the bowel. Then they will take like 30 films and give you and they know what they're looking for now. But adhesions can be seen on a barium as right angles and the radiologist will do the interpretation. We don't need to know how to do this, but just for you know, the bowel always has curves, but if there's right angles, that's how they'll know, and the other thing they'll see is an area of narrowing because they can see the white barium with an area of dilation above it.

Dr. Noseworthy 44:03

Yeah.

Dr. Siebecker 44:04

And they'll let you know.

Dr. Noseworthy 44:06

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

Dr. Siebecker 44:23

Oh, I'm so lucky because we have our lead researcher in SIBO is Dr Mark Pimentel. He's out of Cedars-Sinai in Los Angeles and of course we're colleagues and friends. And he is the one who told me you know, he's the one who's been teaching so much of this to all of us. So he had spent years figuring this all out and it was for me talking to him and also the head radiologist, who they called, like the they had a name, something like the, something whisperer, I can't remember Like he was so good at reading the images, and I spent time with them, following both of them in clinic and spent more than a day with the radiologist and I asked them for their advice how can we get local radiologists to get a good test? And I just took what they said and put it into that little saying I gave you. I sort of made up that little saying from their advice, you know.

Dr. Noseworthy 45:16

So no it was Dr Pimentel.

Dr. Siebecker 45:19

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

Dr. Noseworthy 45:28

There you go, Just thinking about how things have changed over the last decade or so. When I first heard of SIBO, I thought, oh, that's interesting. I don't think I have any clients like that. And then I started to pay attention and then I started going like forgive the language, Holy crap, everyone's got SIBO.

Dr. Siebecker 45:49

Totally right.

Dr. Noseworthy 45:50

When you start and I'm just wondering first of all, is that a common experience for clinicians? Is to all of a sudden something just clicks, that light bulb bulb and all of a sudden you're seeing things completely different. And you know I've been doing this long enough that. I know I'm not making it up in my head, but I just wonder if there are detractors, like you know how, for many, many years and still today, some clinicians, mostly on the conventional medicine side, say leaky gut's not a real thing. Do we still have resistance Like SIBO is not a real thing, that's just that's just IBS.

Dr. Siebecker 46:27

That's all it is, it still exists, it's, it's. It's kind of crazy, you know, but look, things, we know things take a long time in the medical field to get adopted, and actually it's not the worst thing, because you you have to have a lot of studies to prove it. I'm I'm good with that. I like that. Make sure there's enough evidence that scientific debate needs to go on for some time. I think I would say, though, that at this point we have an overabundance of evidence, and it's a little bit over the edge now the people who are still saying that. But what goes on is they haven't read all the evidence because they're already opposed to it, so they're not going to go and read about it. So then what changes their mind? I don't know. I wish more people were like you, who, where they had the click and go, oh. But yes, of course it's common, because, look, everybody's overwhelmed in life and we all got, we have so many things coming at us.

Dr. Siebecker 47:30

If something new comes, it's going to take a little while till till we can integrate it and decide what we think about it. So it's common and I just wish more people would would get that realization.

Dr. Noseworthy 47:35

Yeah, have that the aha moment. You know we've been talking about SIBO, but I know in the literature there's other terminology like emo intestinal methane overproduction or iso, iso sulfide, hydrogen sulfide overproduction, and it's been a long time, but I do remember seeing at least a couple of papers that talked about fungal overgrowth or SIFO. Is it useful to make these distinctions, either, even if it's just to sort out our thought process or, even better yet, to guide clinical decisions, or it's practical enough that we can just kind of lump all of that into this overarching concept of of so, even though it might not actually be bacteria I know.

Dr. Siebecker 48:20

I sort of feel like both of those are true or good. Um, I still use SIBO as sort of an umbrella term to mean all of it. But let me just quickly define it. So we've already defined SIBO.

Dr. Siebecker 48:33

Imo is intestinal methanogen overgrowth. So basically we have a few types of SIBO, and these are based on the gases that the overgrown microbes make hydrogen methane and hydrogen sulfide, and then we can have mixes of those and the methane SIBO we found out actually we've known for quite some time it's not actually bacteria making them, it's archaea, which are also called methanogens, methanogens, and so this is just a technical, linguistic primarily thing, which is that it's not correct to call it bacterial overgrowth because they aren't bacteria. So so, no matter what we think the name kind of had to be changed because that's not technically correct, even though I still sort of refer to it as SIBO, methane SIBO, you know. But so intestinal methanogen overgrowth and then similar for intestinal sulfide overproduction. Eso is a new term because there our bodies make hydrogen sulfide gas, not just bacteria, it's bacteria that is making this, and so that's confusing, because people look in the literature. They hear about hydrogen sulfide, sibo. They go and read a study that's talking about the benefits of hydrogen sulfide and how it helps things, and then they get really confused. And it's because it's when it's overproduced. We can all understand that concept normal amount, that's healthy, too much not healthy. So that's why I think they made that terminology overproduction.

Dr. Siebecker 50:01

But but back to the other point, it is also helpful for our mindset because the treatment is different. That is a key thing is that, particularly for pharmaceutical and herbal antibiotics, we choose different ones of those based on the gas type, and that's a crucially important point. That causes some of the biggest trouble in treating SIBO. When people aren't educated, they just think there's one thing they can use for all the types treating SIBO. When people aren't educated, they just think there's one thing they can use for all the types of SIBO Right.

Dr. Noseworthy 50:29

Right and maybe we can come back to that because I think before we get there can we talk about the testing. And I know before we started recording we talked about testing very, very briefly. But I have for a long time operated under the understanding that there was a very high false negative rate in SIBO breath testing and I'll ask you to explain that here in a second symptomatic response to dietary change. To either affirm or deny SIBO, insert any other linguistic term you want, and that's from a practical standpoint. That seems to have worked out quite well. I feel like I have a decent track record and success rate. I don't fix everybody.

Dr. Noseworthy 51:23

I would never claim that Nobody does, yeah, I would never claim that, but I have scared clients away over the years from spending money on the breath test because I felt I could get good clinical guidance just simply by changing the diet for say, three to five days and then monitoring the response, and if I had any confusion, we would put some foods back in and see what happened.

Treatment Approaches: Antibiotics and Herbs

Dr. Noseworthy 51:49

Now, having said that, it almost begs two questions what is the current understanding? Because my MO right now is based on things that I learned 10, 12 years ago-ish somewhere around there, and I understand the research changes on a consistent basis. And I understand research changes on a consistent basis, and so I'm interested to hear from you as the expert what is the current state of understanding of the value of testing, what tests are best, what are we looking for and what direction does that lead us in? And then that will lead into perhaps a discussion in terms of effective treatment. So why don't we just start there? Let's just talk about test or don't test, like is it sufficient to just change the diet and see what happens?

Dr. Siebecker 52:36

to bloating and distension, for example. Well, clearly you have a method that's been working clinically, so I would never want to encourage anyone who has a successful method to change it right. And so we also have to think about the nature of our practices, because I, as a SIBO specialist, was pretty much always seeing people who had already undergone treatment and failed you know, diagnosis and treatment and failed right.

Dr. Siebecker 53:00

So that puts me in a different category, not the first line. I mean. Occasionally somebody would come to me right away just because they think they had it and they know I'm a specialist. But so really the role of a specialist is quite different and at that point testing is always involved because patients are absolutely demanding it. It can be the opposite when you're the first line, they do not want testing right and they're mad even that other doctors have suggested it. But at this point it's like it's all about the testing, because we have to, we absolutely have to figure it out. I'm the specialist, I have to know exactly what's going on, et cetera. So, putting that in context, I always test it Now in terms of what's changed and what's new. Well, maybe I should give you the basis. First, like with false negatives, here's what we know.

Dr. Siebecker 53:55

There are different substrates that are used for the test, and these are sugars that are meant to feed the bacteria. Bacteria eat carbohydrates, sugars, and turn them into gas for methane, and that's what we're testing in the breath the hydrogen, the methane, the hydrogen sulfide. Most tests check for hydrogen and methane. There is one test on the market now that checks for hydrogen sulfide additionally, and that's called TrioSmart, similar to that IBSmart, same company there, gemelli Labs. So these sugar substrates this is where there's been a huge debate over all the years and glucose is the one that's used most often in research. That's fine for research because basically the issue is it absorbs into our body out of the small intestine within about the first two to three feet of small intestine. So it is only able to check for SIBO or any of the others overgrowths in the top three feet of small intestine.

Dr. Siebecker 54:53

Sibo is most common at the end of the small intestine. The small intestine is 18 to 25 feet long, so this is a test that has very high false negatives meaning like it because it can't even test the rest of the small intestine so you can get a negative test when you actually have SIBO. So for this reason, most of us clinicians don't like glucose Researchers like it, because they just absolutely know for sure if the SIBO is there, it's right there in the top of the small intestine. So we use lactulose. Lactulose is available the entire small and large intestine. That's actually very important, because one thing I didn't mention is the methane overgrowth and the hydrogen sulfide overgrowth can overgrow in the large intestine as well, not just the small intestine. So when we do a three-hour test with lactulose, we can also see what's going on in the large intestine. It's extremely helpful. We can also see what's going on in the large intestine. It's extremely helpful.

Dr. Noseworthy 55:50

So now back to what's. Can I ask one question on that? Yeah, it's my understanding that the lactulose does that not require either a medical doctor to request, or someone like yourself who's licensed as a chiropractor. And this is again. It's been a while since I've looked at this testing. But can any clinician of any credential chiropractor acupuncturist, naturopath, whatever can they order a lactulose breath test with trio smart, or does there need to be a different type of licensed clinician to order that for us?

Dr. Siebecker 56:23

yeah, this is such an important point. Lactulose is a prescription in the US. It shouldn't be. It's kind of a mistake that it's on there. There's no reason for it to be. However, it costs millions to get something anything off of that formulary, so that's never going to get done. Who's going to pay for that?

Dr. Siebecker 56:41

So, it's very frustrating. However, there's plenty of workarounds Genova Labs and all the places you can get the Genova test, like Rupa Labs, True Health Labs, Direct Labs, they all will. They have like. Basically, they have like a physician on staff On staff. Yeah, that will handle that and so then anyone can order that. And TrioSmart also just contracted with a group that's doing that Okay, so that must be recent, that must be recent, because I was looking Three weeks ago.

Dr. Noseworthy 57:09

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

Dr. Siebecker 57:14

They had it originally when they first came out, and then, whatever service they were using, I guess they had to stop using, and now they've offered it again. Yeah, again. So just so. But what I would also say there's plenty of ways for those in the US to, like I just mentioned, to get lactulose. But a second option would be fructose. You can also use fructose. Lactulose is a little bit better. It's it's more sure that it's going to be there the whole way. Now what's changed is we should be soon having sort of like a big article coming out all about testing, sort of settling this debate. We've been waiting for this article to come out. It hasn't come out yet. But what's changed is that there's been deep sequencing now done in the small intestine, correlating that with lactulose and culture, and I know I'm getting technical here, but actually some new techniques had to be developed for actual sampling in the small intestine. It's difficult to do. You need to protect your sample in a special way because it can get contaminated with oral bacteria on the way back out.

Dr. Siebecker 58:21

And also you need to release some of the bacteria that are stuck in mucus. So Dr Pimentel actually developed and then validated this new sampling technique, then used deep sequencing and compared a lactulose breath test to culture, to deep sequencing. Because the issue in the past was that people didn't think the breath test was accurate enough because they were comparing testing to culture. It turns out culture was not a good gold standard. We call it a tin standard. It had a lot of problems. Now, with these improved techniques and with the DNA sequencing, now the lactulose breath testing is lining up perfectly with the deep sequencing showing that the culture test was the problem.

Dr. Noseworthy 59:09

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

Dr. Siebecker 59:13

From the small intestine, from endoscopy.

Dr. Noseworthy 59:15

Right small endoscopy.

Dr. Siebecker 59:16

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

Dr. Noseworthy 59:22

I mean, we talked about the 25 feet, yeah there's almost like this assumption that a bacterial load is evenly distributed throughout the intestine and you know, if you stick a claw down there and try to take a sample, you know you're guaranteed to get a hit.

Dr. Siebecker 59:37

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

Dr. Noseworthy 59:40

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

Dr. Siebecker 59:58

That's all we can say. Yeah, so it's issues, but the reason I brought that up is just because you've asked sort of what's changed and there has always been a big um, a big controversy saying glucose test was actually better and the reason why is it lined up with culture better, but there's this massive false negative with glucose and so people were worried, based on the studies, about lactulose. But what I can say is, clinically, lactulose is absolutely the one to use. Now, as to the importance of doing it, I personally would find it very difficult to not test because I'm basing my treatments so long as aside from elemental diet, because that works for all types on the gases and what I find is you can't tell, based on symptoms, which gases are there, because we typically have a pattern where we say diarrhea is correlated with hydrogen and hydrogen sulfide, constipation is correlated with methane. But what we actually see clinically is, if we just look at, say, hydrogen sulfide, it's about 50 percent of the time constipation and 50 percent diarrhea. Even though the studies say diarrhea, clinically we see 50% of the time constipation. And then we see all the time where people have sort of like a pattern that doesn't quite match with that hydrogen, methane, diarrhea, constipation it happens a lot so we can't really just tell oh, you have constipation or you don't. Really the issue is, you don't have constipation so you don't have methane. That's really where we get into the trouble.

Dr. Siebecker 1:01:28

So by doing the breath test you can see the exact gases and then also you can see how high they are. So it's not a yes and no test, it's a real informative test and when we see how high they go that also informs our treatment. Because if gases are very high, like say 150, 150, we know exactly about how much on average gas comes down. Per each treatment type we do. It's about 30 parts per million, 30, 35, for antibiotics and herbal antibiotics on average. There are certainly those cases where you see 70. I've got plenty of those cases, but on average. And then for elemental diet we know it's more like 70 to 100. So if somebody has a super high gas level, which, by the way, you can't tell by symptom severity, that is very unfortunate. Symptom severity doesn't correlate with gas severity. I'd say 40 percent of the time it does.

Dr. Noseworthy 1:02:21

Why do you think that is If we can take that money trail for a second. I really don't know.

Dr. Siebecker 1:02:25

I've thought about for a second. I really don't know. I've thought about it. I just don't know. I think it's just a great individual variation. What was the terrain like before? What? Is the terrain like now. What are all their enzymes doing? What's their hydrochloric acid like?

Dr. Noseworthy 1:02:41

What other diseases?

Dr. Siebecker 1:02:42

do they have?

Dr. Noseworthy 1:02:44

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

Dr. Siebecker 1:02:46

microbiome.

Dr. Noseworthy 1:02:47

Yeah.

Dr. Siebecker 1:02:48

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

Dr. Noseworthy 1:02:59

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

Dr. Siebecker 1:03:13

Let me think about that, because that's a smaller amount of cases that we have those tests for. No, I can't say. I can't say that I have no Right. So back to it, since we can't. You know, sometimes the gas and severity of symptoms do match, but often they don't, so we can't judge by that. So then if we have this gas number, we can see oh my gosh, you've got 150 parts per million. You know hydrogen or methane. Why don't we just skip forward? Do elemental diet, because we know we're going to get. We could get a hundred, we could even get 150 parts per million of gas brought down in two weeks, and then we'll save you six months of round after round after round of antibiotic or herbal antibiotic.

Dr. Siebecker 1:03:57

So this is how, how come? I like the test, because it really informs treatment and it it helps us with a prognosis and makes us not be guessing. So those are my thoughts.

Dr. Noseworthy 1:04:09

Yeah, and you say herbal antibiotics. I mean obviously that's a category. There's so many different herbs that fall into that category that have either antibacterial properties specifically or they're just broadly antimicrobial. So I'm interested in whether or not you see correlations.

Dr. Noseworthy 1:04:30

I did an interview with a doc who works with doctor's data and a couple of years ago I think it was, they did an internal study where they looked at microbial sensitivities.

Biofilm Disruption and Treatment Resistance

Dr. Noseworthy 1:04:43

They took a thousand different studies and looked at their antimicrobial sensitivities. They took a thousand different studies and looked at their antimicrobial sensitivities and it turned out that I call it my GUS protocol grapefruit seed extract, uva, ursi and silver tended to have the most favorable antimicrobial effects on the things that they were culturing and then testing inhibitory sensitivities too. And so you know that's one lab. Now it's 1,000 people. That's a decent number to look at, but it's one lab and I don't know if we asked other labs, like Genova or whomever diagnostic solutions, to do the same thing, would we come up with the same answers. So I have two questions when it comes to treatment. One is choosing specific antimicrobial herbs, and the second thing is talking about the distinctions in utility between the elemental diet, or specific carbohydrate diet, and the low FODMAP diet Because I listened to one of your interviews not long ago I think it was Dr Silverman, might have been and you had made a comment that the low FODMAP diet was not made for SIBO.

Dr. Siebecker 1:05:51

It's true.

Dr. Noseworthy 1:05:52

And not always effective, and so that fascinates me.

Dr. Siebecker 1:05:55

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

Dr. Noseworthy 1:05:58

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

Dr. Siebecker 1:06:01

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

Dr. Noseworthy 1:06:05

So let's talk about the antimicrobial herbs because, like when I have conversations, particularly if there are docs that are new to functional medicine, they all want to know what's the best probiotic. That's another question. Do you use them, do you not? Oh, my gosh, what's the best antimicrobial herb? What's the best enzyme? What's the best antimicrobial herb? What's the best enzyme? What's the best? This and my answer is I don't know.

Dr. Noseworthy 1:06:30

Like I think you just have to have a reasonable starting point and then have the mental flexibility to change your plan if what you initially chose isn't working the way that you want to. And I know that that frustrates people because we want protocols. Do this exactly like this for X amount of time and everything's going to be fine. And, yeah, every once in a while that works out. But I kind of have a rule. I shared this with Datis Dr Karazian once and I teach for him and a lot of times, if I have a lot of new docs in, say like a blood chemistry analysis course, and they're just starting out, I'll put up Steve's rules for interpreting blood chemistry. And the very last one is your clients or your patients are under no obligation to follow anything I teach you this weekend Right, and that's just clinical reality. It's like we're doing the best that we can and we base as much as we can on science and maybe even a scientific method, but even then it doesn't always work, right so absolutely.

Dr. Siebecker 1:07:35

By the way, detise is who I learned functional medicine from way back there you go so glad to hear you teach from love dr karazian absolutely for sure um, so we actually do have some protocols for for SIBO and this is hard one.

Dr. Siebecker 1:07:51

Um, it's from doing before and after testing on every treatment we gave at our SIBO specialty center. Okay, um, but one thing I want to say about those herbs you mentioned for doctor's data. I think that is so incredibly helpful that they have that information. But let's just remember that's stool testing and that's different. They've only just recently added in some of the microorganisms that so, um, they add m smithii in some of these stool tests and, um, some what's what's overgrown for hydrogen sulfide? It's prevotella fusobacterium varium. Um, I'm sorry, not prevotella um proteus, proteus um mirabilis, uh.

Dr. Siebecker 1:08:40

Fusobacterium varium and um disulfovibrio piger. And then for methane it's m smithii, methanobrevibacter smithii, but this is just new and we hardly even know what it means and what are the levels. We were that's totally not even been figured out for right.

Dr. Noseworthy 1:08:56

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

Dr. Siebecker 1:09:05

Except now we, now that we know what I just said, that those bacteria can overgrow in the large intestine Now maybe we can, but that work hasn't been done yet to figure out what are those levels, stool tests, jumping on board and adding those in. I'm glad that'll help us figure it out, because we used to say absolutely not the two different organs. And you know I used to run stool tests on everybody. I did a breath test for it. You could see perfect large intestine tests. Amazing, I would ever see any of those, but I would with with the rampant SIBO, so you know, and because you'd imagine there'd be spillover. Right, but no, not necessarily. Okay, so so back to it. Yeah, there are distinct things that seem to work, for we know the exact bacteria that are overgrown. Now, that's been years of work and we only just have those final hydrogen sulfide ones that came out one year ago with studies. So that's been the real thrust of work in the last few years is which exact bacteria and methanogens are overgrown in these different types of SIBO. Now we have that information, now we can really figure out what treatments are going to work. However, clinically, we've been figuring it out for years right. So what we know is what works for hydrogen is oregano, neem and berberine. And berberine is a constituent in many herbs. So you know golden seal, oregon grape coptis, you know valedictorian Berberine yeah, we know that.

Dr. Siebecker 1:10:39

What works for it so here's where we get into trouble is those same things don't necessarily work for methane. These are not bacteria, they're archaea. Different things work on them. We know different antibiotics work in different. You know infections. You know I've seen it all the time People take an antibiotic it doesn't work. You switch to a different one. You know you've got to get the right thing for the right bug you're trying to target. I hate to think so, like that, but this is the truth of it, you know.

Dr. Siebecker 1:11:07

So for methane, we know that allicin works, the constituent from garlic. We don't like to use whole garlic, aged garlic, garlic oil because it can trigger symptoms because garlic is very high fermentable. So we really try to use the purified allicin. So we use Alimed or Alimax Pro is the one we tend to use and that's the one we just we did all our testing on. I mean, others may work, I'm sure they would, but that's the one we did the testing on. And when we tried products that were like Holgar, like we just ran into so much aggravation of symptoms. And then also AtronTeal, that is a little three herb combo that's been tested and shown to reduce methane and it works differently. It's not so much a straight on killer, so it's got peppermint, red cabracho bark and concord tree, which is horse chestnut, and what this is doing is actually making it so the methanogens are not being able to produce methane gas. It's not so much killing them, they just are not able to make the gas, and it's the gas that causes the slowing of the causes, the constipation.

Dr. Noseworthy 1:12:12

So do you have to? Just right from a clinical perspective? Do you have to use Autrantil with something like what did you say kills the allicin, the highly purified allicin? Do you have to use those together?

Dr. Siebecker 1:12:26

No, you don't, so you choose one or the other. So what we typically do I call this the single-herb approach. It's not really single, but as opposed to just grabbing a big formula off the shelf that has like 25 things in it, because that's another way to go and we can talk about that. But you choose something for hydrogen, because there's always hydrogen there. The reason why, even if you don't see it on a test, is because methane is made from hydrogen, so there are always the bacteria there that are making the hydrogen, but then the methanogens are turning that hydrogen into methane. Sorry to get so technical.

Dr. Noseworthy 1:12:58

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

Dr. Siebecker 1:13:01

So even if you only see methane on a test, you always have to treat hydrogen at the same time. That's the way we do it. So you choose one of the hydrogen herbs, and if we were talking pharmaceutical antibiotics it'd be the same. You choose one of the hydrogen pharmaceutical antibiotics, and then you add the herb or antibiotic that treats methane. So then you choose either allicin or atron teal, and so in the case where there's methane, you're always doing two. We always do two for hydrogen also, by the way. Let's just take this on. Why don't we just add more and more and more? Because it doesn't increase efficacy. We've tested it, and so more does not equal a bigger reduction in gas. You peter out at about three. Three herbs Now, with the exception of something like AtronTeal. That's a small little formula. You know that has three herbs, and so we'll use that with a hydrogen herb. And then for hydrogen sulfide, what we know works is bismuth, which is not actually an herb. It's like a mineral and high-dose oregano.

Dr. Siebecker 1:14:01

And high-dose oregano is something that came to us from a patient years and years ago which was originally an old chiropractic blastocystis hominis treatment. It came from the chiropractic world and it's very high dose, but when you say high dose, what do you mean? So typically we're using ADP the. That's like the dry oregano. We're not using the liquid.

Dr. Noseworthy 1:14:24

Biotics, isn't it yes?

Dr. Siebecker 1:14:27

And the reason we did that is because that came from Dr Jerry Mullen from Johns Hopkins. He had been using that. He teaches for the Functional Medicine Institute. He had been using it with success. So we began using it and what we found was that dry form was better tolerated, actually, than the oil form. Oregano can be pretty caustic on mucous membranes and even the dry form, but the dry form is better tolerated. So we're talking five pills three times a day for the first week, that's 15 pills a day, and then nine pills a day, three pills three times a day for the next three weeks to make a month treatment. That's something we haven't mentioned. Herbs the typical herbal treatment round is four weeks can extend to six weeks, whereas for elemental diet and pharmaceutical antibiotics it's two weeks. So they have the same effectiveness, but herbs just take a little longer.

Dr. Noseworthy 1:15:17

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

Dr. Siebecker 1:15:30

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

Dr. Noseworthy 1:15:32

Because you only do.

Dr. Siebecker 1:15:33

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

Dr. Noseworthy 1:15:43

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

Dr. Siebecker 1:15:58

Did you say?

Dr. Noseworthy 1:15:59

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

Dr. Siebecker 1:16:01

Oh, that's so long.

Dr. Noseworthy 1:16:02

I love it, I feel like I blinked and now it's 2025 that's amazing.

Dr. Noseworthy 1:16:08

Yeah, I think I I first started studying with him in 2006, I think yeah, so right, yeah, and so we probably got involved with him somewhere around the same time, probably in different parts of the country. I was, yeah, but in the in the like and this is before um detise and, and the company he formulates were called Apex Energetics before they started to increase the number of formulas that Datis had brought to the market, and so I was using predominantly Genova's GIFX test and I was using and it's my own podcast, I could mention anything I want. I was using Apex's HPLR and another product called Mycozyme. I was using those two things in combination and I would run and I would probably do two capsules two times a day of each of those and I would run a 12-week protocol and I would retest the stool in nine weeks and 90%-ish of the time the second stool test was either perfectly normal or very close to it.

Dr. Noseworthy 1:17:17

Every once in a while you'd see that wacky second test that looked worse than the first one and it confused me for such a very long time until I started reading about biofilm, right, and so I want to bring that to the SIBO discussion. Do we have to account for biofilm with SIBO? If the answer is no, we can move on, but if the answer is yes, can we talk about biofilm and maybe talk about the strategies that you're using for biofilm disruption?

Dr. Siebecker 1:17:49

Yeah, so this is very interesting to me. I think we're still figuring this out. Early on we made an assumption when we were treating I mean heck. I mean 90% or more of relapsing infection type diseases are biofilm diseases. So could this be the part of the reason why we're seeing so much relapse? Right Is if there's biofilm and we didn't get it and so the infection can just come back.

Dietary Interventions and Elemental Diet

Dr. Siebecker 1:18:17

So, on that assumption, we gave many, many of our patients antibiofilms. We worked real hard at it and we used the enzymes. We used EDTA and we used the well, that's mostly it the seratopeptidase that was also an enzyme, you know, like lipophos, edta and all the classic ones, right, and oh, and NAC. We used NAC because NAC is excellent antibiofilm for H pylori Really good studies on that. So we use all of those hardcore, not on everybody. So we had samples to see back and forth. This isn't a formal study, but this is just clinically, I'd say, for about two or more years, maybe like three years, and it seemed to make no difference at all and we were very disappointed. Okay, so then fast forward.

Dr. Siebecker 1:19:07

I have a conversation with Dr Paul Anderson, who's an elder in the naturopathic profession, treats very difficult cases, a lot of biofilm infections and he said well, that's because the antibiviral films you were using are not good enough and you really need to use a bismuth based a bismuth I all based antiviral and at the time he had this compounded formula. It's prescription that he he had developed and not not even every compounding pharmacy could make it and you had to get it special from certain places. Now more, more can make it, so I started using it. That made a difference. Hmm, that made a difference. That helped. That moved the had to get it special from certain places.

Dr. Siebecker 1:19:43

Now more, more can make it, so I started using it. That made a difference. That made a difference that helped that move the needle on some really tough cases. Then this was quite a long time ago. Then he came out with an over-the-counter version of it and that is priority one. Biofilm. Phase two advanced.

Dr. Noseworthy 1:19:56

I use that all the time.

Dr. Siebecker 1:19:58

And I may have those. I sometimes I say those words wrong Cause it's a lot of words. I use that all the time think the compounded is more effective.

Dr. Siebecker 1:20:04

So, okay, so there's that piece. What I would say is, if you and also I want to say that so there were a lot of people we didn't treat with antibiofilm, that got completely better and and we and yes, like the classic scenario in SIBO is, it's not cleared with one round. There are one and dones, but that is a smaller, smaller proportion. Particularly in a specialty practice, most people will need multiple rounds. But even still, with multiple rounds, no antibiothelium, they got all better. So clearly, not everybody does biofilms need to be addressed in SIBO. But if you're really having trouble, that's when I would think of it. Okay, so we have this. Then we have something additional to add.

Dr. Siebecker 1:20:58

Just last year out came a study from Dr Pimentel and team usinga special formulation of NAC with rifaximin. Now, from my understanding, it's complex with the rifaximin and there's a time release situation going on there and that greatly increased the efficacy of the success of the rifaximin. Rifaximin, for anyone listening, is our main antibiotic we use for hydrogen SIBO. It's also called Sifaxan. So this was at first when I heard this. I didn't hear the special formulation part and I was like what are you talking about? We used NAC for years with zero benefit. I'm like I am having a hard time believing this.

Dr. Siebecker 1:21:43

Then I heard about the special formulation because we were just using, you know, immediately absorbed NAC, and so what Dr Pimentel has said is you really have to get it down into the small intestine, hence the special time release situation there, or sustain, you know there is a sustained release by Jaro. So if anyone is going to try this with any, any of their SIBO treatments, I'd at least recommend that until until whatever they because they're they're developing a product, so until that comes out. So so that's more to add to the biofilm piece. So apparently, you know, dr Pimmel tell us talked about how methanogens and certain of these overgrown bacteria are living in biofilms. He's been able to see that with his endoscopy, the scope going down and the sampling, so I think that could be important. So maybe we should all be adding sustained release NAC to our treatments.

Dr. Noseworthy 1:22:36

You know, I was teaching a course in West Palm Beach many years ago and it was around the time where we as a group in the Apex ecosystem were starting to teach on biofilm and I remember a young guy coming up on a break and he told me that his uncle if I remember the story, his uncle was a biofilm researcher at one of the universities in Israel and I asked him immediately like what is he seeing is working? And he said the two things that they're seeing is working is cranberry extract and stevia.

Dr. Siebecker 1:23:10

Wow.

Dr. Noseworthy 1:23:11

Yeah, and I know that a lot of people that are…. Oh, that's a great tip.

Dr. Noseworthy 1:23:15

Thank you, yeah, a lot of the docs that are lime literate rely a lot on both either Stevia or Cranberry as their primary biofilm strategy. Now I wonder, like you hear stuff like that and that's great. You hear stuff about bismuth, and that's great. And then I wonder about individual variability, like do we have to account for that? Is Cranberry going to bust all biofilm in all places and all people right? Or do we have to have a stable of things to choose from and then we mix and match depending on their response? And that brings me to the next question you mentioned. Some people need multiple rounds and a round, I guess, roughly, is six weeks long.

Dr. Siebecker 1:23:57

I'd say four weeks.

Dr. Noseworthy 1:23:58

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

Dr. Siebecker 1:24:00

We stretch it to six if they have higher gas.

Dr. Noseworthy 1:24:03

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

Dr. Siebecker 1:24:18

Oh, these are such good questions, okay. So protocol each time? Oh, these are such good questions, okay. So it brings up the, you know sort of a an underneath question was why not just go longer? Why stop? Why, right, believe me, we tried it, and what we found over and over now once again, this is in the patient population that we were seeing which is at a specialty center. Um, so, it may not be the same for the first, you know, for primary care or something, but we just found that the treatment lost efficacy somewhere around five or six weeks, and so what would happen is somebody might have had some improvement in their symptoms and they would just begin relapsing while still on, while still on it.

Dr. Siebecker 1:24:58

While still on it. So this happened so often, so often, and so this is how we learn right. And so that's why four weeks you really have a potent treatment. You know, even at five weeks we could start seeing some people. Now people are going to say they're going to know they're going to have experienced exceptions to this rule. I will tell you, I have experienced exceptions to this. I have certainly seen people that have been on the same thing for two years. It's working, and they come to me to help me get them off of it. It's the only thing that works, and they don't want to be taking it every day. Of course, there are exceptions. I'm just talking about patterns, right? So what we do is now. This is again, you know, if you have testing and people have to figure out their own way that is going to work for them. But typically after a round, we need to see how the patient is off of the treatment, because the treatment could be giving them symptoms or die off or whatever.

Dr. Siebecker 1:25:49

We have to see. How are they? We have to assess are they better? We're looking for 90% better, so we need a little time to see what that's like. If they are not better, that's when, typically, we will do a retest and find out what's happened. A lot of times the gases have changed things. It helps again inform our treatment, but the key thing is you don't want to wait more than about two weeks. Why is this? Before you start your next treatment? If they're still positive and you can do this without testing, we can talk about that. But why that is is because relapse or really here we'll call it backsliding is so common at about two weeks. It's just classic.

Dr. Noseworthy 1:26:30

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

Dr. Siebecker 1:26:34

Yep, or if it was antibiotics or elemental diet, the two-week round. And it's because we don't want to lose ground. So what we do in this two-week period is we put someone on a prokinetic. Prokinetics we haven't talked about yet, an absolute, essential part of SIBO treatment that gets missed often. You want a moment or two without them on the prokinetic too, like a day or something, if you can, because what if they start to have some sort of reaction to that? You need to see how are you Then get them on the Prokinetic while you're waiting for the test to come back or figuring out what you're gonna do. But if you wait more than two weeks, if they're not clear of their SIBO, that overgrowth can really start to come back and you lose ground of what you just did. So if you don't have a test, let's say you have an initial test and you saw they were, you know, at 70, you can calculate. Well, with herbs it's about 30 parts per million and, by the way, that information is gold, comes from just kajillions of before and after tests and it's just an average. Okay, so one round we'll expect. You know, 70 minus 30, they're still positive. We kind of suspect they're going to need another round. So see how they are after one round, because what if it did it? And you know if? But if they're still symptomatic, maybe you don't go for that next retest due to budget and time and logistics. And then you have in mind what your next round is going to be. So to your next question.

Dr. Siebecker 1:27:56

I always typically switch because we're concerned about clinical resistance or clinical tolerance to what we're giving, because we see it so commonly. We see that happening even to rifaximin, which has been studied and shown to have seven repeat rounds with no antibacterial resistance. Yet we saw it, we saw it a lot, so we'll switch. Now you don't have to switch. Let's say somebody was really doing great, they weren't having any backsliding at all. You take a two week break or a week and a half break just so you can assess or whatever. You can use the same thing again if you really think it was working and if you got some feedback from the patient. Yeah, we do that. But the typical thing is to switch and switch around, which is then where we start to run out of. Well, what are all of our options that treat each thing? And then just one other thing to just mention here just briefly.

Dr. Siebecker 1:28:52

We didn't talk about big formulas because there've been some formulas studied for SIBO candybactin, ar, br and F-C-Cytol, um and uh, f-c-cytol and dysbiocide. Those were studied for SIBO and shown to be efficacious. Really, these are going to work for hydrogen. They don't really have anything in it much for methane, although oregano sometimes works for methane and that is in those Um. It's's not as reliable though on a day-in, day-out basis.

Dr. Siebecker 1:29:23

The issue for me with these big formulas is that I think they're great for primary care when you're not even sure am I dealing with SIBO? Could there be LIBO? Is there yeast? We didn't really talk about that. It throws a big net and that is great and I think appropriate. But when you're really trying to dial it in and you're really just trying to treat the SIBO, you do need to get a bit more specific. I find you know if, so long as I mean maybe that took care of it, I just mean, if you are now continuing to struggle with a SIBO, then you need to dial it in and get get specific with those organisms that are overgrown. And the other thing is the clinical resistance. We know so many people are going to need multiple rounds, just as a matter of course. Most people need two to five treatment rounds, and we don't want them getting. If we have everything in one, what will we use for our next round if they become resistant?

Dr. Siebecker 1:30:20

So we're just being practical and lastly, is we see so many sensitive patients. They have histamine intolerance, they have mold, mcas, all these things, and they have a very hard time with various herbs, using a lot of herbs at once. How can we figure out what was bothering them if there's 25 things in there? If we're using two things, we can take one away and we can easily figure it out. So this is just clinical practicality.

Dr. Noseworthy 1:30:45

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

Dr. Siebecker 1:31:04

Right, exactly.

Dr. Noseworthy 1:31:05

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

Dr. Siebecker 1:31:09

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

Dr. Noseworthy 1:31:25

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

Dr. Siebecker 1:31:31

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

Dr. Noseworthy 1:31:40

No, you're just going test, or would you rely more on dietary tolerance and changes? Uh, maybe put them on either a few days of a low FODMAP diet we'll come back to that or an elemental diet and and if so like an elemental diet.

Dr. Siebecker 1:32:12

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

Dr. Noseworthy 1:32:18

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

Dr. Siebecker 1:32:21

Yes.

Dr. Noseworthy 1:32:22

Okay, that's great Cause I'm not done yet. So let's talk about the dietary approaches, because, like even like in in the apex ecosystem, we've taught a one day seminar on a small intestinal bacterial overgrowth. Right, this is something that the T's developed back, probably 2014 or something like that.

Dr. Siebecker 1:32:44

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

Dr. Noseworthy 1:32:47

Yeah, and I think that that's.

Dr. Siebecker 1:32:49

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

Dr. Noseworthy 1:32:53

Well, and this is yeah. This is why I want to broach this subject, because and maybe what I've been calling SIBO is not SIBO because I've been using a low FODMAP diet. Now, each iteration of that diet is highly patient-specific and, as you know, there's a bajillion different SIBO low FODMAP diet lists out there. Right? Everyone seems to have their own list, and I'm interested in this because you were talking about using allicin and how garlic in various forms is typically not tolerated. Very well, let's go back to context, and maybe this is a hypothetical. You can't or don't really want to answer, and that's okay. But if you were the first line dog, would you tend to rely on a dietary challenge, remove certain foods, see what that does and then make decisions based on that? Or would you still be doing, say, a trio smart test, even though it's the first line and you're not a complicated case that's failed? A bunch of other things.

Dr. Siebecker 1:33:57

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

Dr. Noseworthy 1:34:11

I'm always looking to be a better clinician.

Dr. Siebecker 1:34:13

So if it works, great, but I want it to work better so I would test because we know that, um, the differential diagnosis for SIBO is 35 to 40 diseases big. Those same symptoms can be caused by so very many things and dietarily I feel it's similar. You know, it's like we really we're not going to have specificity knowing it's SIBO without that actual test. So if I'm actually, if I actually want to figureity knowing it's SIBO without that actual test, so if I actually want to figure out if it's SIBO, then personally I would test, especially because the breath test yeah, it's that problem of the differential diagnosis and also because, like just for example, the classic example is lactose intolerance, which can be genetic but could also be secondary to something else like SIBO, right, but let's say they have genetic lactose intolerance.

Dr. Siebecker 1:35:10

Studies have shown many people who have it honestly don't know it. They don't know that it's milk or dairy products giving them their symptoms for their whole life. It's like amazing, there are studies showing that. And because you know there's studies showing that, and because you know it's an education issue, and you give them a FODMAP diet at that, they remove lactose, they respond. So then you think they have SIBO, but in fact the solution is to avoid lactose or bring in an enzyme and why are we now giving them antibacterials and messing with their microbiome? So it's this differential diagnosis list that causes a problem for us. But we do have a solution, which is the test. So that is the reason I would do it, just to be sure, especially I personally feel like I'm ever going to use an antibacterial of any kind. I want to be sure that it is the right thing for the problem. So that's why I like the test. And then, additionally, because we get so much nuanced information the gas types and the severity, prognosis, treatment type, et cetera.

Dr. Noseworthy 1:36:15

It really helps, right? So let's talk about the diets that we've listed. For anyone listening who doesn't know what a FODMAP diet, it's F-O-D-M-A-P. It's fermentable oligosaccharides, disaccharides, monosaccharides and polyols in certain foods than others, mostly fruits and vegetables, certain starches and grains. And the theory that I've been operating under and again, this is how I was taught, I didn't question it was that certain people need to go on a low FODMAP diet because eating those foods feeds the little critters in the small intestine that shouldn't be there anyways, and then they produce hydrogen, methane, certain gases that cause bloating and distension. Now you're saying that the FODMAP diet was never intended for SIBO. So what was it Like, if you know what was the original intent for the FODMAP diet?

Dr. Siebecker 1:37:13

Well, originally it was like Crohn's in the small intestine, so IBD and IBS, ibs of the large intestine. They did actually mention SIBO in some of their early papers, but it was not created for SIBO, it was created for IBS, with the mindset of the large intestine Interesting. The issue where we run into problems with BodMap is that they are not removing fiber. Of course, fiber has a lot of definitions. Well, I'm going to call it long chain fiber, what we think of as fiber, you know, like supplemental fiber and like flaxseed and things like that, and in fact they encourage increasing it. They want to be sure you don't go too low fiber and fiber is direct food for the overgrown bacteria and directly will contribute to symptoms. So this is why I say it doesn't.

Dr. Siebecker 1:38:08

Who cares what it was originally developed for? I don't care this diet, yes, it's true, if you do it just as written, I would say it's one of our least effective compared to the other main diets we have for SIBO. But that doesn't matter, because you can start with any of these reduced carbohydrate diets any of them at all, even ones that are just for weight loss, you know and just start tweaking it to the individual which you already indicated you do all the time anyway, and so that's. It doesn't matter what diet you start with, because whatever diet you start with, I think that's a key thing to understand is to know that no diet that is used for SIBO will be right for each person, and that it's really encouraged to experiment, because there are usually always things on that diet that you will have no problem eating and that they say you shouldn't be eating and you should test that because you want to include as many foods and vice versa. There'll be things on the diet that you're reacting to that you need to remove.

Dr. Siebecker 1:39:07

And I think where that mindset comes in is with SCD specific carbohydrate diet, because that was also created for inflammatory bowel disease. Well, actually, sorry, it was created for celiac. They think it's for for celiac, but um, really it's, we really think it's inflammatory bowel disease that originally Dr Haas was treating. Um, I know that it's way back into history, but um, but that diet has this idea of fanatical adherence. They have it right in their book, fanatical adherence, and that you, you know you, you can't go off it even one tiny bit, and so that is not an appropriate attitude with SIBO.

Dr. Noseworthy 1:39:44

So for anyone who's been indoctrinated through there know that we want you to experiment with your diet and SIBO, so yeah, and so is there a distinction between the SCD diet and an elemental diet, and which one are you using as your starting point for most of your clients?

Dr. Siebecker 1:40:02

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

Prokinetics: Essential for Preventing Relapse

Dr. Siebecker 1:40:23

So it's amino acids for protein, it is oil for fat, and then the carbohydrates are either glucose or maltodextrin, which is more broken down, and then there's vitamins, minerals and salt, and it used to just be like you know, you'd have things like Vivinex Vivinex Plus is the one that was studied for SIBO originally, and then there were things like Neocate Junior and these are used in hospitals to give the digestion a rest. So for a long time I actually didn't even use the word diet. I changed it to elemental formula because people were getting confused, thinking it was a diet. It's not a diet, it's a special treatment. So how we do it for SIBO is the protocol developed by Dr Pimentel is you take this drink and no other food, so you're not eating any solids, you're not drinking just anything but water, and this for two weeks. So it's kind of like a form of fasting and what you're doing is starving the bacteria, starving the methanogens or bacteria, while still feeding the patient or the person, because that those nutrients are absorbing so quickly across the top of the small intestine they're getting into the body before the bacteria have a chance to consume them. So it's a different method of killing.

Dr. Siebecker 1:41:39

Antibiotics and herbal antibiotics are our typical sort of, you know, hurt the cell wall DNA replication. This is just starving the bacteria, and what Dr Pimentel has found is it takes about 10 days to really get the appropriate killing because the bacteria can eat our mucus, they can eat various aspects of our intestine. Eat our mucus, they can eat various aspects of our intestine. So you need a good 10 days, but 14 days is. You know, two weeks is the typical round. Sometimes we go to a third week. So that's kind of like how sometimes we go to six weeks of herbs. You know, sometimes we go to a third week If a person's willing and needed. We usually do a retest to find out.

Dr. Siebecker 1:42:17

So this, where this comes in is it's one of it's. When you are deciding how you're going to attack the bacteria overgrowth itself with killing agents. You're going to choose either pharmaceutical antibiotics, herbal antibiotics or elemental diet. We have these three choices and for myself personally, I decided to practice in a way where I was using all three equally. I would offer them all three to my patients and together we would make the decision of what we were going to do, except for the fact that when someone is very high gas level, as I explained, elemental Diet has this amazing ability to reduce gas. You know, 100 parts per million in two weeks.

Dr. Noseworthy 1:42:58

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

Dr. Siebecker 1:43:00

Yeah, so it's really you know, in that per million in two weeks, yeah, well, you're taking away the fuel supply, yeah, so it's really, you know, in that way it's more effective, but it's, you know, just because it can reduce more gas in a shorter amount of time.

Dr. Siebecker 1:43:10

But then again, sometimes it just doesn't work at all, just like with everything we use for every problem we ever treat. So nothing is guaranteed. And believe me, when you treat enough things, I mean you will see your morning patient dropped. Amazing, they're all better. The second patient, same treatment, didn't do a darn thing. You know. This is just what happens, you know Now.

Dr. Siebecker 1:43:35

So then diet. As to your question, which diet do we use? First, I myself used about four different diets with regularity. I used SCD, I used low FODMAP, I did use GAPS in the beginning quite a bit, but we dropped that. We found that wasn't quite as good of a match. And then I created my own version of combining, because SCD and FODMAP are opposite in some of the things that they eliminate. So I combine them together. So that's called the. I just gave it the name SIBO specific food guide. I used to call it SIBO specific diet, but I prefer food guide just because it's more like you know. So that's my version of those two together, more like you know, um. So that's my version of those two together. Then my friend Dr Jacoby took that diet, my diet, the SIBO specific food guide, and just put it into phases and she calls her the SIBO biphasic diet. It's the same, they're the same diet. Hers just is in phases.

Dr. Noseworthy 1:44:34

And hers is much more structured.

Dr. Siebecker 1:44:37

It's better for people who want more structure, whereas the food guide is really almost like a shopping guide. You know gotcha, um so. So I was using my sebo specific food guide, fodmap, scd and gaps, and there was one oh, oh, and then the other one is the cedar sinai diet. This is developed by dr pimentel and he now has renamed it and sort of made it a lot more comprehensive, and it's called the good good eating, good life eating, or something like that. I forgot the new name, but it's on my free website.

Dr. Siebecker 1:45:08

I've changed the name on my website, I just don't have it memorized yet. Good life, I think it is low fermentation eating, low fermentation eating. That's it. Lfe good LFE diet Okay, got it.

Dr. Siebecker 1:45:19

So, yes, so, honestly, I chose between those diets for each and every patient. There wasn't one I always went to. Now, in my larger community because so many people knew me and they, honestly, what we found is that the SIBO-specific food guide it is the most restricted out of all the diets. It's the combination of two diets. It therefore honestly works the best in terms of reducing the most symptoms, simply because it's reducing the most, removing the most carbohydrates. But I don't always go to that first, but many people in my larger community would use that first that's the same as SIBO biphasic diet because they could get the best symptom results. But I don't think that's always the way to go and I would customize my choice to each person. I understand that's not practical for a lot of people.

Dr. Siebecker 1:46:10

This is my entire specialty. I'm in and out back and forth familiar with every one of these diets. I could immediately see which one was going to be right for each person, based on their lifestyle and various factors, from using them all for years. So that's why I say it doesn't matter which one you use. Choose whichever one you think has the prettiest cover design, who cares? Just start with something. But the key is get them to tweak and experiment.

Dr. Siebecker 1:46:37

Now here's the other side. Do you even need to do all that experimentation and tweaking? And how much do you even need to use diet If you can just get right in there with killing agents, get rid of the bacteria? The whole point of having all these food issues. What does the diet really help with? It helps with symptoms. And what are the symptoms from the overgrowth? If you could just get rid of the overgrowth, do you even need to do a diet? So Pimentel just waits and brings the diet in after the fact as a sort of help in preventative measure, and his Cedars-Sinai diet low fermentation eating is a more expanded diet and very good for the prevention phase. But honestly, even still, his diet is probably better at symptomatic reduction, as written, than low FODMAP. But I don't mean to say I mean. Of course I had people with low FODMAP who got a hundred percent symptom relief, but it was a few, you know you just have to tweak it you know?

Dr. Noseworthy 1:47:31

Yeah, so I have a ton of questions. Going back to the elemental drink, so that's the only food that they're consuming, right? So it's like you said, it's a fast. Do you, off the top of your head? Do you know with whatever, whatever drink you're using? Do you know what the calories level levels are? Do you know what the protein intake is?

Dr. Siebecker 1:47:56

Yeah, they want you to. The recommendation is800 calories a day. Some people may need 2,000. You can also calculate that for the individual, the protein I don't remember. Off the top of my head, the standard elemental diet formulas are higher in carbs and what we found a problem with way back when, when I first started treating SIBO, there was only Vivinex Plus and like Neocate Jr on the market, and Vivinex Plus was very expensive. These aren't covered by insurance, they're over the counter and my patients couldn't afford it, and so I created recipes, homemade recipes. Took me quite a long time to figure out. I was really trying to exactly match Vivinex Plus, because that is the one that was studied and shown to work. Took me a long time, but I have those free on my website. Those recipes, and one of the key things there is I have a low carb version because so many people do not want that high of a carbohydrate that comes in those elemental diets.

Dr. Noseworthy 1:48:53

Yeah, I mean, and I'm wondering like, because, like these people who do have SIBO or things that might masquerade as SIBO, they usually have other metabolic challenges right. They might have reactive hypoglycemia, for example. So yeah, so do you find like, if you put somebody with SIBO on this elemental approach, do you see their blood sugar destabilizing or do you actually see it getting better, do you?

Dr. Siebecker 1:49:16

see it. No, because it's hard. There's a big bolus of carbohydrates and we often see a lot of die-off symptoms and reactions because more things could be dying too Sure. But we think a lot of the die-off and symptoms we're seeing is reactive hypoglycemia, and so the recommendation is not to drink it as bam, slam it down and three distinct meals, but sip it over time.

Dr. Noseworthy 1:49:43

Throughout the day.

Dr. Siebecker 1:49:44

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

Dr. Noseworthy 1:49:49

Yeah, so is it your general approach? I want to make sure I'm tracking with you as we're talking through all these different variables. It doesn't sound like you start or finish the same way with every person, which I like right, everyone's different. But if you were to say, when I look at all the ways that I approach these problems, this is the most common way that I do it, would that be a couple of weeks of this elemental drink and no food, and then merging into some dietary choice, and you might have three or four different options and you try to match the diet to the individual and it's not just about what you think they will or won't react to, it's what they can adhere to Some people need more structure.

Dr. Noseworthy 1:50:34

Some people just like it's more of a DIY. Like here's your guidelines. Go ahead and you know some people bristle against structure.

Dr. Siebecker 1:50:41

They don't tell me what to do, and so okay, here's just this simple. And some people are like I will never stop drinking diet Coke. I'm like, okay, I know which diet to give you. You know, I mean not that they can't have the diet Coke on whatever diet they want, but I'm just saying to start with, you know it's like okay.

Dr. Noseworthy 1:50:57

Yeah, just recently I've been getting emails. I probably should have looked at it before you and I jumped on, but I'm getting emails from a couple of different companies I've never heard of that are like we've got this elemental approach for SIBO and now companies are creating products to address some of these challenges.

Dr. Siebecker 1:51:17

Oh yeah, we have a whole slew of wonderful commercial elemental diets on the market now. Yeah, in fact I was involved with I. I begged various companies to make cleaner versions of elemental diets and I was involved in advising. The first one who made it was physicians elemental diet who made it way back when, but now we actually have a phenomenal um new one on the market came out a year ago. Dr pimentel was involved in creating this one. It's called M-Biota Elemental Diet and the reason I'm mentioning it is because palatability is a significant challenge and issue in all of these elemental diets.

Dr. Siebecker 1:51:53

These companies try so hard to get them to be very palatable. This is way above all. I'm sorry all the other ones in palatability, I'm sorry. Other brands, I love you too, but it needs to be mentioned that this one tastes better. So there you go.

Dr. Noseworthy 1:52:10

Yeah. So when you go and trying to fold this back into things we were talking about earlier, if we think about four week iterations and that's usually you have to do more than one four week course are you proceeding each four week with a two-week elemental approach or no?

Dr. Siebecker 1:52:28

no, no, no, because four week is just for herbs. So remember choosing between two weeks of pharmaceuticals or two weeks of elemental or four weeks of herbal.

Dr. Siebecker 1:52:37

Those are our, those are our three choices and we're choosing one of those as our killing strategies for our first round. And then we're assessing, of course, get them on the prokinetic and then assess and then, if they need more treatment rounds, we are once again choosing between pharmaceutical for two rounds, herbal for four weeks. Herbal for four weeks are elemental for two weeks. We come back four weeks or elemental for two weeks. But you know we come back to those choices each and every time, each and every time. Yeah, yeah, I personally, I, as a specialist, couldn't treat SIBO with just herbs. I wouldn't. I would lose my job. I just there's. No, I have to have more tools than that. It just that just wouldn't. I couldn't do it.

Dr. Noseworthy 1:53:22

If you were, if you really had to choose, if somebody somehow had the power over you to say you can either only treat SIBO clients with diet or nutraceuticals and you can't use both, which one would you choose?

Dr. Siebecker 1:53:37

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

Dr. Noseworthy 1:53:42

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

Dr. Siebecker 1:53:54

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

Dr. Noseworthy 1:53:56

Herbal, okay, okay.

Dr. Siebecker 1:54:06

It's extremely difficult because the reason being is due to sensitivity of patients, because, as a specialist, I see so many highly sensitive patients meaning which I think many people know what I mean but they react easily to supplements, medicines and foods. People like that do best with pharmaceuticals, absolutely Without a doubt, if I was to put, but I don't want to put everybody on a pharmaceutical antibiotic, so so therefore, let's put that aside. Let's pretend I don't have a huge amount of sensitive patients I have to deal with. Okay, patients I have to deal with, then I would probably choose elemental diet because it's um, it, it can bring the super high gas level down. Um, but then not everybody wants to do that. In fact, most everybody will will come to that last because it's like fasting. It's difficult, it's challenging.

Dr. Noseworthy 1:55:05

People don't want to do it yeah.

Dr. Siebecker 1:55:07

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

Dr. Noseworthy 1:55:27

Yeah, that feedback from your clients is very important.

Dr. Siebecker 1:55:31

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

Dr. Noseworthy 1:55:33

I wasn't ready.

Dr. Siebecker 1:55:35

They had to go through all that to be okay, I'll do the other. And then they go oh, why didn't I just do this at first? Bam, it's gone, you know. All the super high gas level gone, you know. But it's difficult. So, but that's the one I would choose.

Dr. Noseworthy 1:55:48

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

Dr. Siebecker 1:56:05

My goal is 90% better in symptoms and that's subjective, that's judged by the patient and myself together figuring that out, and I don't retest if somebody is 90% better in symptoms.

Dr. Noseworthy 1:56:18

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

Dr. Siebecker 1:56:23

Well, most classic time for relapse is actually at about two and a half to three months post eradication of SIBO, but some people it's a year. You know that they're not going to relapse for a year. So of course we don't want to see them relapse. But my, my treatment goal for like the killing agents, is 90% better in symptoms and because if they're 80% better, many gastroenterologists shoot for 80% and what I found is if somebody, if we really kind of decide they're 80% better, if I do one more treatment round we can usually get them to 90%. So that's why I like 90%. I mean, some people get 100%, but we're shooting for 90. 90 is darn good yeah for sure.

Dr. Siebecker 1:57:07

And so yeah, and then that's my goal. Um and then, in terms of like, what is there? Are they going to relapse or not? We're going to see. And if they relapse, that's what I'm going to focus on figuring out underlying cause what if they? What if they never relapse? I don't, why would I need? I don't need to really think about that unless they're going to relapse Right and um and what, what's their diet like after? We'll manage that as it goes and take it from there.

Dr. Noseworthy 1:57:33

Have you developed any predictors of relapse, things that you look for that increase the probability or at least your expectation?

Dr. Siebecker 1:57:41

Well, I've been able to identify one thing that predicts not a relapse. This is when you. It's an interesting pattern, it's when somebody does the treatment, whatever treatment, and afterwards they're maybe they're 80% better. But we so you know I don't always move to another round when they're 80% better, because obviously I had to figure it out first that I wanted to do that and then over the next month they get like a hundred percent better. Those people do very well.

Dr. Siebecker 1:58:19

The people that are like maybe they're not perfect right after the treatment. I think what's going on is they're healing, like because there's physical damage that occurs to the lining of the intestines Enzymes are removed, lactase enzyme is removed, leaky gut is caused in many people, etc. And I think now that the bacteria is gone, it takes a couple weeks. For we know, like, after you know about a food poisoning, some people can have temporary lactose intolerance. It heals in about two weeks. So in about two weeks I think you know about a food poisoning. Some people can have temporary lactose intolerance. It heals in about two weeks. So in about two weeks I think you know they're starting to get better and better and then even they even improve. So then we don't repeat. And then, of course, you have to be in communication with them about this.

Dr. Siebecker 1:59:00

And then they just even get better after that, and so then after about a month they're golden, those people.

Dr. Noseworthy 1:59:07

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

Dr. Siebecker 1:59:21

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

Dr. Noseworthy 1:59:24

No let's do. I didn't and I do. I kind of want to end on one. So let's talk about prokinetics and we can go. I'm not restricted on time, but I would like to ask you maybe, as the last segment after the prokinetics is to ask when you're dealing with difficult cases, how often do you have to go outside of what you're doing for SIBO to look for reasons why people are not?

Dr. Siebecker 1:59:52

responding All the time. Okay, 100% Okay.

Dr. Noseworthy 1:59:58

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

Dr. Siebecker 2:00:05

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

Dr. Noseworthy 2:00:12

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

Dr. Siebecker 2:00:28

Mycotoxins, as well as mold.

Dr. Noseworthy 2:00:31

So just in general.

Dr. Siebecker 2:00:32

Yep, yes, that's right, and I'm not an expert in this, but all I know is that mold illness, including mycotoxins it causes very difficult cases of SIBO and it's the first place we want to look when we have a tough case. Now how do we even define a tough case? That we should discuss. But we can leave that for another time because I just want to say it's as we mentioned before. It's not doing a few rounds and it not working. You know, it's not that Like the classic thing with mold, when you want to think about mold pattern is a person improves somewhat, very temporarily, after every treatment you give. I mean, it's like you know they're improved maybe during a little bit or for a few days afterwards and immediately back. You cannot make headway.

Dr. Siebecker 2:01:20

There's something preventing you from making headway. So other things that could be like that would be parasites We've seen that sometimes H pylori, which almost could be considered like a parasite. It's not but, you know, just in terms of like a chronic sort of infection and all those other causes that we talked about, those underlying conditions, those need to be, you know, managed. Those need to be looked at and managed when you have a very tough case but you know, tough cases are, you know, very difficult, relapsing, not being able to move forward there's a lot of ways we can define tough cases.

Dr. Siebecker 2:01:59

Another thing is not responding to all these treatments. I mentioned that we know work not responding at all to them. What's going on there? You know obviously there.

Dr. Noseworthy 2:02:08

Obviously there's a block. Yeah.

Dr. Siebecker 2:02:10

Yeah, there's right, so those sorts of things. But basically, yes, we we're going to look at all the underlying causes and associated diseases, particularly underlying causes Um and MCAS. And histamine is a huge issue in um in difficult cases. Uh, because it prevents people from taking the treatments we need to give them. It limits their diet much, much further and they're just sensitive to everything. It's very difficult and, of course, mold can cause that.

Dr. Noseworthy 2:02:38

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

Dr. Siebecker 2:02:42

I'm referring yeah, I refer to a mold literate practitioner. Okay, yeah. So, let me come in through the side door and ask what kind of testing are you seeing them do? Well, I know that they check for mycotoxins, like urine mycotoxins and also mold Various, I mean, there's various labs. When I ask practitioners what are their favorite labs, everybody says all the labs that are available. You know, everybody has a different favorite. They have a different reason why. Sure, so I don't. I don't even run those tests.

Dr. Noseworthy 2:03:16

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

Dr. Siebecker 2:03:23

That's right. I mean I can get someone going. I mean I know the tenants of mold treatment, you know, which include antifungals internally and in the nose. Binders is usually how they start. For SIBO, really, the best binders are usually activated charcoal. There's pharmaceutical ones, there's chlorella, there's other ones, but some people with SIBO can actually fermentable, can be like the clays and things like that. So charcoal's best way to start, I think, for a SIBO patient with binders.

Addressing Complex Cases and Mold Illness

Dr. Siebecker 2:03:52

So things like bentonite, clay or humic and fulvic acids yes, the people can bloat from those and have terrible reactions and you could try them, but charcoal's the safest.

Dr. Noseworthy 2:04:02

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

Dr. Siebecker 2:04:10

There you go.

Dr. Noseworthy 2:04:10

Yeah, a clinical nugget.

Dr. Siebecker 2:04:12

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

Dr. Noseworthy 2:04:34

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

Dr. Siebecker 2:04:41

Okay, so prokinetics are simply agents that move the migrating motor complex. We already talked about how that's the main underlying cause for so many people. These can be pharmaceutical or nutraceutical or herbal, and key thing to know is that they're not laxatives. And another key thing to know is that a laxative doesn't an actual laxative doesn't stimulate the migrating motor complex. This is a big confusion for so many, including like prescription ones, like Ametiza Linzess. Those are prescription laxatives. They don't stimulate the migrating motor complex. It's just so important because many gastroenterologists don't know this and they'll be like well, I've given you a prokinetic, it's like no, that is not stimulating the migrating motor complex.

Dr. Siebecker 2:05:25

So what are they? By the way, there are unsafe prokinetics and so because of that, pharmaceutically, because of that, many doctors think prokinetics are unsafe. But we have safe prokinetics. So a safe prokinetic that we use, a really excellent one, is procalipride. In the US that's called Motegrity. It's phenomenal. It has many beneficial side effects or effects like heals nerves, protects and heals nerves.

Dr. Noseworthy 2:05:52

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

Dr. Siebecker 2:05:56

It's a pharmaceutical, it's a prescription. It helps against tumors, it helps with cognition, it helps with depression. It's amazing, safe, incredible. Star in the prokinetic category. Then we have low-dose erythromycin. Erythromycin is an antibiotic but at low dose it is a prokinetic. And we have LDN uh, low dose naltrexone. It is not technically a prokinetic but studies have shown it has prokinetic effects. It's anti-inflammatory, helps immune system. Amazing, right, um. Then on the over the counter, those are all prescription.

Dr. Siebecker 2:06:28

On the the over-the-counter we have Iberogast, which is an old-time German over-the-counter formula, herbal formula, nine herbs. Now it's been changed to six herbs Still good, still studies coming out on that. It's good. And we have dupe formulas. So, like on Amazon, there's IBS Shield, which is a dupe for the original nine herb, iberogas it's excellent. Heron Botanicals has, I think it's, gut Motivator. It's also a dupe. So there's that.

Dr. Siebecker 2:06:59

And this is a complex formula. It's not just the main ingredient, iberosomar, that's doing the prokinetic effect. Studies have shown when they just check that one ingredient, no, no, it's the complex. Then we have ginger root um, and you could just take ginger root. And then now, luckily, we have all of these over-the-counter prokinetic formulas that include ginger I call them the ginger containing prokinetic formulas like motility activator, modal pro pro, kind, um, sebo, mmc. There's like eight of them, um, one of them is like the one that's in. Motility Activator is a patent of artichoke and ginger. It's a patented formula called ProDigest and so like five brands carry it. Sometimes they'll have it with apple cider vinegar, so people with histamine intolerance need to watch out for that. But that one is less spicy on the ginger. Sometimes ginger can cause like ginger burn almost like acid reflux.

Dr. Siebecker 2:07:51

So I would choose the ones with ProDigest if that's a concern. And then there's a new one on the market that has bitter orange as its main prokinetic. Good animal studies on that as a prokinetic. No human trials yet. So we'll be the human trials. And that's by Gaia, gaia Pro, and I can't remember the exact name of it, but it's a bitter orange based.

Dr. Noseworthy 2:08:13

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

Dr. Siebecker 2:08:24

People have, in my experience, have a lot of reactions to prokinetics to be one of the most reactive categories that I've ever given. People have, in my experience, have a lot of reactions to prokinetics and I sometimes have to go through. You know all six of the main ones, the three pharmaceuticals, the three main you know over-the-counter I'll have to go all. It's like sleep aids and then you know, finally, the last one you try is the one that's the one that works, yeah. So don't give up on the category if people have reactions.

Dr. Noseworthy 2:08:54

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

Dr. Siebecker 2:09:04

This is the hard part. What is the benefit? That they don't relapse. This is the hard part. What is the benefit? That they don't relapse. So no, you're not going to feel or see anything. It's preventative against relapse. What the studies show is by adding a prokinetic you can extend the remission period by four times as much. You know, not double, but quadruple. Of course that was pharmaceutical, but still. This is why we give it. Who wouldn't want four times longer remission period?

Dr. Siebecker 2:09:33

So, that's why prokinetics are so important. So no, all we're looking for is how soon do they relapse? And once you really start treating a lot of SIBO, then you'll have a sense if you think it's too soon in that particular case, with what their underlying cause is, if they're a chronic patient, and then you can do things like if they are relapsing sooner than you wish. Of course you just start tweaking, like very often we'll use a prokinetic at night and in the morning two different ones, or we'll use the same one at night and the morning and add a second one at night. So now there's two at night, one in the morning, extra in the morning.

Dr. Siebecker 2:10:14

So because most all these prokinetics I mentioned have different mechanisms of action from each other, so it's fine to overlap them, except be careful with erythromycin and like Domperidone I didn't mention that one those can't go together. But um, pharmaceutically Domperidone is hard to get anyway, which is why I didn't mention it. But so this is prokinetics. It's one of the most number one, I'd say maybe number two most common problem in SIBO treatment is someone was not given a prokinetic and so after they finish their antibacterial, give them a day or so so they can see how they feel they need to go on a prokinetic.

Dr. Noseworthy 2:10:46

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

Dr. Siebecker 2:10:49

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

Dr. Noseworthy 2:10:53

they can continue it through the next treatments, but you don't introduce it until after the first round.

Dr. Siebecker 2:10:59

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

Dr. Noseworthy 2:11:12

yeah, um, and so that is what's missing in so many people's treatment, and it's just a terrible oversight yeah and um, like in the in the realm of prokinetics I don't know how long ago, but I would say at least seven years there's been a lot of talk about vagal stimulation to drive the vagal system and increase motility. My experience with that because I play with that with clients it's hit or miss. It works for some people, not for others. Same thing whether it's anxiety or depression or anything like that. Have you used that? What's been your experience and what's your opinion?

Dr. Siebecker 2:11:53

I tried a little bit of it long ago from what I learned from Dr Karazian and unfortunately we didn't find much of any help and it was very different from what Dr Karazian was finding. He was reporting all these miracles and we were really bummed out.

Dr. Siebecker 2:12:07

Really bummed out we just didn't see that at all. I still recommend. I think it's a fine idea. The thing is that there's two migrating motor complexes. There's one that starts in the stomach and one that starts in the small intestine. The one that starts in the stomach is vaguely mediated. The one that starts in the small intestine is not, and they don't even still fully understand all the instigating factors in that. But, however, the one that starts in the stomach from some of the literature I've read that is supposed to be the stronger migrating motor complex. It starts in the stomach and goes through the whole small intestine. Maybe it's not. Maybe it's not. Maybe the one that starts in the small intestine itself is the more vital one to SIBO. Is that why the vagal stimulation has been?

Dr. Noseworthy 2:12:53

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

Dr. Siebecker 2:12:56

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

Dr. Noseworthy 2:13:00

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

Dr. Siebecker 2:13:13

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

Dr. Noseworthy 2:13:19

Well, let's call it a new lobe of the brain. Not that it's new, we never had it before but our understanding of it is actually a lobe of the brain. So, like when a when a baby is born, we just have the baby has a massive neuron. So there's very little organization and as the brain grows within the confined space of the skull, it starts to invalidate, it starts to fold in on itself. And just under the junction of the frontal, parietal and temporal lobes, just around the temple, right above the ear, underneath the section there frontal, parietal and temporal lobes, just around the temple, right above the ear, underneath this section, there's an infolding of the cortex and that's what's called the insular cortex. And the insular cortex has a somatotopic representation. No, that's the wrong word, it has a viscerotopic representation. So in the brain, in the parietal lobe, we have a sensory homunculus which is basically a map of the entire body as it relates to sensation. So if someone comes up and touches my shoulder, my brain shouldn't be confused and think that someone touched my ankle right. So there's a picture of every body part in the parietal lobe on both sides, so that we understand sensation. There's also a motor homunculus in the primary motor strip, which is a picture of every joint and muscle in the body. So when my brain says, hey, I want to wave my hand, I don't kick my foot out. There is a visceral representation in the insular cortex and it's in terms of neurological hierarchy it's a couple of steps above the vagus, but it integrates with the vagus.

Dr. Noseworthy 2:14:52

And so my working theory right now and that's all it is is that when we have cases where vagal stimulation makes sense, perhaps in some of these cases, really what we're doing is we're stimulating the vagus to try to get activity in the insular cortex.

Dr. Noseworthy 2:15:17

Does that make sense? So sometimes I I think the in my, in my theory, the cases where vagal stem works is that's the choke point, so to speak. And so the insular cortex might be fine, but some things decrease the frequency of firing of the vagal system. So you stimulate it directly and now you get great things happening. But what if that system's intact and the problem's higher in the vagal system? So you stimulate it directly and now you get great things happening. But what if that system's intact and the problem's higher in the chain, if that makes sense? And so I'm playing right now with using different forms of transcranial direct stimulation to put electrodes over the insular cortex, trying to get the brain to understand the intestinal system better so that it can more efficiently organize signals going to and from that system. I'll let you know what happens.

Dr. Siebecker 2:15:55

Great, I'd love to hear.

Dr. Noseworthy 2:15:58

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

Key Takeaways and Clinical Pearls

Dr. Noseworthy 2:16:18

I tend to say that because I get a chance to talk to some really cool people who know things that I don't, and especially on the Funk Med Nation podcast, where it's really geared towards practitioners. I know that I don't know everything and it drives me crazy. I quite often joke. It just pisses me off that I don't know everything because I desperately want to. And so when I get to talk to people like you, who clearly, like you, are an expert in your field, and I so appreciate not just the facts and the details but the clinical nuance and I think you're just an amazing clinician and I'm so very happy that you decided, yes, you're going to come on and have this chat with me. So, whether it's clinicians or the general public, where can people find you?

Dr. Siebecker 2:17:12

Well, I have a free educational website. It's SIBOinfocom, and it's for both patients and practitioners. It's been that way for I don't know how long since 2010 or something I guess 15 years and I don't see patients anymore. But I mostly just focus on education and so I have courses. I have courses for patients anymore, but what I mostly just focus on education and so I have courses. I have courses for patients and for practitioners. I've got a mini course for practitioners, I've got a testing masterclass, a testing mini course and a comprehensive training for practitioners and, as I say, for patients as well. So you can see all that on my website. And also signing up for my newsletter is a great idea. I don't send too many. I know people can't stand getting too many things in their emails, but I often give free classes on SIBO and when there's updates, I just update everybody, like, for instance, about how TrioSmart started offering lactulose. I just sent an email about that, so you know it keeps people in the know on practical things. And there's new research.

Dr. Noseworthy 2:18:06

Every year, the the big gastroenterology conference just happened the weekend before we're recording this ddw and uh, there's all brand new research and I do an annual interview every year with dr pimentel, where we share all the new research, and so that's why I'd say, if you sign up for my newsletter, you'll get included in that yeah, and that's amazing that you you play that role because it's so easy as a practitioner just to put your head down and treat, treat, treat, and then you look up five years later and you realize that the clinical world has moved on and things have changed and all of a sudden you're a dinosaur and you're doing things the old way, right. So I appreciate the fact that you've dedicated some of your time to not just stay up on the research yourself but to share that with other people, and maybe we can use this as a parting question when is SIBO research going right now? What do you think is going to come out in the next year or so?

Dr. Siebecker 2:19:04

Well, there's always more coming out about treatments. So I think like that NAC rifaximin compound thing will come out and I think we're going to learn more about what's best to treat each of the different types of SIBO in those different organisms. I think we'll have probably new stuff in testing. I've been seeing articles coming through over the years with developing various capsules and various things like that. It'd be fascinating to see what we develop with that. But I think, and also just more on understanding the pathophysiology, we're going to see more with that. Like I said, we've gotten the bacterias figured out exactly. I think we're going to learn more about that. Some complicated things I didn't mention are. There's these things called syntrophs. They're actually bacteria that sort of pre-make, the gas that others make. I think we're going to see more on the pathophysiology. It's more on the microbiome aspect and how to treat that, I think.

Dr. Siebecker 2:20:01

Yeah, I mean that's one thing that's fascinating about SIBO is it's a current emerging field, like I mean the, the, the research is being done now and you know, and, and when we first entered it was being done, and it's being done now and we are still learning. We do not have all of it figured out yet.

Dr. Noseworthy 2:20:20

Yeah, yeah, and I, I love this, this whole field, because it's like, as a clinician, like you have to evolve or die. Now, that's a little extreme, but you know what I'm saying. Like, things change all the time and you know, I've been doing functional medicine now for not quite 20 years, but going close to that, and it's a totally different world than 20 years ago. Right, the cases are different, the things I have to think about are different, the complexity is different, and maybe that's just because the more I know, the more I think about are different. That complexity is different and maybe that's just because the more I know, the more I think about. I mean, that's entirely possible as well. I lied, I'm not done yet.

Dr. Noseworthy 2:20:58

I have one question. Okay, you talked about dosing the prokinetic at night and in the morning. That makes total sense, right? Do you ever because I have done this and again I'm a little bit undecided on whether or not it's a good idea Do you ever take your antimicrobials and give them a bolus right before they go to bed, maybe to take advantage of the slower transit time so it stays in the intestinal system a little longer? Or do you think that's? You know, sounds good on paper, but practically that's not going to really do much.

Dr. Siebecker 2:21:26

Well, actually, what the studies show is that the migrating motor complex is most active at night, when we're sleeping, and that's why we dose our prokinetics at night before bed. So, in fact, I think the motility in the small intestine would be fastest at night, right? So I think it makes more sense to take our antimicrobials breakfast, lunch and dinner With food, with food, with food, or they don't have to be with food, but in the day. During the day when we're eating meals.

Dr. Noseworthy 2:21:56

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

Dr. Siebecker 2:22:06

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