The Healthy Gut Podcast Episode 8

The Healthy Gut Podcast with Angela Pifer

the healthy gut podcast episode 8

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be your own health detective with angela pifer

SIBO can be a debilitating condition for many people so it is important to become your own private investigator to really understand what went wrong in your body to allow SIBO to occur. In today’s episode, Rebecca talks to functional medical nutritionist aka SIBO Guru, Angela Pifer, about the importance of really listening to your body. Treating SIBO is a marathon, not a sprint, so taking

In today’s episode of The Healthy Gut podcast, Rebecca Coomes talks to functional medical nutritionist aka SIBO Guru, Angela Pifer, about the importance of really listening to your body. Treating SIBO is a marathon, not a sprint, so taking time to find what works for you can have a positive impact.

in today’s episode

In Episode 8 of The Healthy Gut Podcast, we discuss:

✓ Why we should all be our own private investigator when it comes to understanding why we developed SIBO

✓ SIBO is a secondary condition – something must have gone wrong for it to develop

✓ Why Angela is passionate about taking a full and detailed health history to uncover why SIBO developed

✓ 25-45 million Americans are estimated to experience IBS, with 1 in 5 Australians estimated to have it

✓ Why Angela is passionate about being mindful when using antibiotics and eating a restricted diet

✓ The emotional impact treating SIBO can have on a person and Angela’s suggestions on how to break the vicious cycle

✓ Why stepping away from the SIBO chat rooms and research obsession, and going outside for a walk or spending time with friends can have a positive impact on your health

✓  The importance of sticking with a treatment protocol for a period of time

✓  Why it’s ok to get a second opinion

✓  How you can learn to find your IC valve and some symptoms you may experience if it is not working properly

resources mentioned in today’s podcast

connect with angela pifer

Angela Pifer

Angela Pifer, SIBO GURU has had a thriving clinical practice for the past 11 years, working clinically as a licensed Certified Nutritionist. She holds a bachelor’s degree in psychology and a master’s degree in nutrition science from Bastyr University, where she also taught as adjunct faculty. She was trained in Functional Medicine, even before the term ‘functional medicine’ became a buzz word.

Specialising from the start in functional gut disorders, for the past 4 years her practice has focused solely on SIBO. As the SIBO Guru, instead of chasing symptoms, she helps her patients get to the root of their illness.

SIBO - Be Your Own Health Investigator

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about the host

Rebecca Coomes

rebecca coomes

Rebecca Coomes is an author, entrepreneur, passionate foodie and intrepid traveller. She transformed her health after a lifetime of chronic illness, and today guides others on their own path to wellness. She is the founder of The Healthy Gut, a platform where people can learn about gut health and how it is important for a healthy mind and body and coaches people on how to live well with SIBO. Rebecca is the author of the world’s first cookbooks for people treating Small Intestinal Bacterial Overgrowth (SIBO) and the host of the SIBO cooking show and The Healthy Gut podcast.

Read more about Rebecca >>

podcast transcript

[1:18] REBECCA: Welcome to the show Angela.

ANGELA: thank you Rebecca.

REBECCA: So Angela and I met at the SIBO symposium in Portland Oregon this year. We sat next to each other on the first day of symposium and we heated off pretty much as soon as we sat down and started talking to each other. I think we are very much…we’ve got kindred spirits and we both share very similar visions around just helping people to get well again. So I am so excited that you can go on to the podcast today.

[1:51] ANGELA: Me too. And absolutely and it was so interesting sitting down and we just sat next to each other. We felt how in tuned we were. On the first day like we are meant to do something together. I don’t know what it would be yet but it’s something. It’s been great knowing you and seeing where you have gone to. It’s wonderful.

[2:14] REBECCA: Yeah and the same goes for you. So I would love to, for my listeners that haven’t heard of you, all those that have and would like to know a little bit more about you, I would love for you to tell us how you came to be the SIBO guru.

[2:29] ANGELA: initially I was going to get my PhD in psychology and I really wanted to focus more on emotional eating in my practice and I took one nutrition class called nutrition and nursing at the university of Washington. And I realized very quickly that this is the only undergrad nutrition class that is offered. It is not required by nursing students let alone doctors. And it was just a moment of clarity. I changed class right then and there and completed my masters in nutrition science at Bastier. From the start I had a focus on IBS and functional gut disorders and also emotional eating from the start. So I still have that spark in me as I initially did when I was thinking about the PhD track for psychology.

You know initially I was really really successful at helping my patients overcome IBS and even if they have been dealing with IBS for 30 years and know where every bathroom was in Seattle, I could get their symptoms under control within a week. And about 4 to 5 years ago I started to get very resistant cases. These were what we now know as SIBO and what we were doing for very successfully, wildly successfully with IBS patients, it wasn’t working. No longer working. So we weren’t seeing that immediate recovery with the symptoms. In fact the fiber probiotics, eating more soluble fiber foods, eating more consistently, all of that was brining other more symptoms of these people and they were feeling worst.

So as a functionally trained practitioner, you know we are investigators, we want to know why things are happening. To really get on the roots of why things are happening and so I had to dig in, I had to research more, I had to pull together a close team of colleagues to share clinical wisdom. Worked for a lot of hours every single week to really help patients who were dealing with this. I then said, “That’s just how my practice was shaped.” And I have been focusing more solely on SIBO about the last four years because of it.

[4:26] REBECCA: And I think that SIBO people out there are so grateful for you for focusing on SIBO because it can be quite a complex condition and for those of us like myself who suffered it for years without any understanding as to what was causing all of these IBS type symptoms. It’s great to have someone out there who takes that investigative approach and really looks for the root cause of what is going wrong. I think when we think about numbers of people who have IBS, in Australia they predict and I think this is very conservative that one in five Australians have irritable bowel syndrome. Which is about 5 million Australians. But talk to me about how many is predicted have IBS in America?



[5:14] ANGELA: yes, it’s actually 25 to 45 million that they predict have IBS in America. And it is interesting when you look at… to me I could back up…. IBS symptoms to me or IBS the diagnosis is really a catch-all of symptoms that can’t label as anything else. And there are some people that definitely do have IBS but there are reasons why they have it. it could be lactose intolerance. It could be high stress. It could be that they are not digesting well, not sleeping well. And there is a lot of things that can contribute to IBS in IBS symptoms. When we look at studies that are trying to differentiate how many of those at that population has SIBO, depending on the study that you look at, it’s anywhere from 20 to 50%. And I think 50% is actually going a little bit too far but it’s still in terms of millions, it’s still a lot of people. So I would say the vast majority of people that have IBS do not have SIBO. IBS is not SIBO and SIBO is not IBS. There are other factors that set SIBO up that are quite distinct. And again very being very complex in nature, there are a lot of factors that contribute to it.

[6:31] REBECCA: There are definitely. So I would love to know your thoughts on what causes SIBO, what you see in your clinic practice and what is being presented to you with your patients.

[6:43] ANGELA: SIBO I think… just one thing I think we all need to look at when we think about SIBO is that SIBO is a secondary condition. It’s not that everything is going really well and SIBO just started. SIBO is present usually because of multiple factors that have led up to it. And then there is usually an event that kicks it over. More times than not intestinal dismotility is a factor in more times because somebody has had some sort of intestinal resectioning. That doesn’t necessarily involve intestinal dismotility. And so there’s other things that can set this up but we usually have a dismotlity piece. Sometimes that is from taking pain meds and having slowed motility but that same population might have had low stomach acid and had long use of NSAIDS like Tylenol or non-steroidal anti- inflammatory drugs. Maybe they use proton pump inhibitors long term. Maybe they will endure a lot of stress and then something happens and they have to take pain meds that further slows the motility and that can set SIBO up. So it’s kind of like a cascade of events that kind of trickled down to set this up usually for people. I think the most common reason that people can get SIBO is the post infectious IBS were they get a food poisoning event. They are exposed to a toxin during that event. That is the reason our body tries to flush it out in both ways sometimes. And their body produces antibodies against that toxin to combat that and in doing so some people, small percentage of those people       might also have those antibodies cross over and start to attack vinculin which is N-communication protein within the gut lining and if that gets attacked then we have slowed motility. And this interrupts the work of the migrating motor complex. So it comes back to that food poisoning even kicking off the dismotility that then sets SIBO up.

Adhesions can be a risk factor. I love to work with the broad range of people who have SIBO. But I think a lot of times when people seek me out they are very complex cases and they have been through a series of other practitioners or doctors who are trying the best they but they are just not having a meeting of the minds. They are not getting better. And so sometimes we find out and we identify that they have an adhesion and this is the reason no matter what they are doing and trying to treat this, SIBO keeps coming back because there are adhesions within the abdominal area that are pulling on the intestines and allowing a little pocket to occur behind it which allows organisms to overgrow. You know I always ask about adhesions if they had any abdominal surgery, C-sections, appendectomy which is right next to the IC valve which can be really concerning. That is what is going to close off the small intestines and the large intestine and the appendix bursting or rupturing or an appendectomy can definitely contribute to this.

And if they had a cyst rupture, so those can be issues. Sometimes if we are not seeing something more acute, we will kind of go back and look to see if there has been a concussion. If they’ve had a tonsillectomy where they might have a vagal nerve interruption, so their digestive tract isn’t getting good innervation and helping support digestion from the top down and then maybe they are under a bunch of stress and that is adding to the top of it. so there is a lot and I think that is where…I think everyone I know uses the word complex when we talk about SIBO and I don’t think we can use another word. That is such a perfect word to describe SIBO. That is why you respect a ton of people who have SIBO. It’s all presenting in a different way. There are different factors that led up to this. As much as we need to look at SIBO and treat it, most cases we have to look at what is underlying it. if it’s a secondary condition, what set it up and has that been addressed fully? Otherwise you are going to feel like you are stuck in the cycle of treating it. Symptoms get a little bit better. Now it came back. Treating it. Symptoms got a little bit better. Now it came back and you might lose a little bit of endurance. You know as you move along. So you really have to look at it. Take a step back and really look at the whole picture when we are treating SIBO.

[11:18] REBECCA: and I think that is such a great approach and it is what often makes me feel sad is that there are some folks out there that believe they can just take a pill and then it will be gone. I think you have explained very eloquently that SIBO has happened because something went wrong first. We didn’t just wake up one day with too much bacteria in our gut and we will take a few pills and then that will be gone and will be forever fixed.

[11:51] ANGELA: Yeah. Absolutely. And think of too, if I may really quick, that digestion is supposed to be moving forward. I mean this is not how the body wants to do things. It’s like whenever we swallow something, the esophagus pushes it back up which doesn’t even compute right? Everything should be forward moving and nothing should be stagnant. So it really does take a lot to get SIBO to set up. There are many checks and balances that we have from again that forward moving motility, the migrating motor complex clearing things out. Different ways that we can flush and clean out our small intestine where this shouldn’t be an issue. So it’s a lot ot unwind once people get SIBO. It can be done. It absolutely can be done but that’s a lot to unwind and to come in and think we can take, to me take in antibiotic and walk away and say this is fixed. I don’t see it. that might be 5% of patient groups but they keep saying how much this is a reoccurring condition but that is how they are treating it and that doesn’t make sense to me because we are not looking at why this got set up and we don’t think about the other ramifications and balances that we have to do and healing and any modulation that we have to do with the gut to get everything.

And always, motility support to get the gut back to moving in the right direction.

[13:21] REBECCA: And I think what you called yourself right at the start which is your investigator and I think that we all as people that have experienced or are experiencing SIBO we know someone that has it that we need to be our own PIs, our own private investigators in our own health.

[13:39] ANGELA: I totally agree. And get second opinions. This is my clinic day. At the end of my clinic day today and I was off the phone. Today was a new patient and Zyfaxin, I met with my doctor. This was last year. And Zyfaxin wasn’t approved by her insurance and so she asked her doctor what her doctor wanted to do and the doctor said we’ll do Cypro. And Cypro is a very very heavy hitting antibiotic. It’s like going into your doctor with a headache and they give you really heavy migraine medication. It’s way stronger than we need to do first of all for the small intestine and I always think about how much endurance that person is going to lose when they use something that strong let along just dumping antibiotics into the system that is going to have wide reaching effect on the whole system.

I work with a ton of doctors. I have great respect for all modalities. I think we need a team approach with this and I know sometimes people seek out theses podcasts and read articles after they have met with their doctor, gone through treatment, it didn’t work. So I know sometimes a lot of people are on the other side of this trying to find something that has worked when they have tried other things already. But really, you know look at this a little bit more holistically, get another opinion. Antibiotics aren’t usually going to fix this out of the gate let alone fix it long term.

[15:09] REBECCA: and how do you advise your patients how to build a team for themselves. A health care team for themselves.

[15:17] ANGELA: yeah absolutely. I would say you got to find a practitioner that can deal with a little bit more hand holding with this. My favorite doctors are integrated GI doctors which are really hard to come by. Jerry Mullins comes to mind at John Hopkins. He was awesome. But finding it more of an integrated GI doc, finding an integrated medical doctor or a good naturopath to work with that does a lot of work around the gut because they are going to look at things. They have more time for you and they are going to look at things a little but more holistically. And then it might make sense to try to find another practitioner maybe more on the nutrition side, maybe somebody that works a little bit more on the consider side in medicine. So they have more time for you because there is a lot that comes up with SIBO and I think a lot of what I do is help keep people stable on the treatment plan. And when symptoms come up as we talk through those, where are those coming from, what happens, how do we overcome it, and how do we stay in the course versus feeling like every single symptom is making SIBO worst. Because the person has SIBO they are going to react things. We are doing everything we can to keep things stable but often times I find that people really chase treatment plans from all the chat rooms to the blog articles. Everybody that I work with has at least 50 supplements at home that I have them taken a picture of what they have and send them over. Stock your closet first. See what you have there and see what we can use. Then I will ask when did you take that? How much did you take? What did it do? and they are kind of started and stopping without really getting a plan in place and realizing, “Ok if I take these 4 things this is what it’s going to do for me. Now let’s monitors symptoms and see how I do and see what comes up along the way versus trying something for a couple of weeks and then stepping into the next thing.”

Well if somebody has SIBO, they are going to react to things. Sometimes I find that when we are on protocol and we are addressing SIBO with herbal antibiotics and we have the patient very stable. It might be a couple of months in where they had really high SIBO levels, high parts per millions on their lab and a couple of months in they will eat off plants and say, “Oh my gosh I reacted, why is that happening.” You still have SIBO. Instead of having 20 parts per million, now you are at 60. We are making huge headway in knocking these organisms down but you still have SIBO, you still are likely going to react. And you think when people are trying to self-treat, I get why they are trying to do that because they might not be getting the support that they need with their team. I find that people kind of chase their symptoms a little bit too much.

[18:12] REBECCA: Angela I would love to know how you work with your patients to uncover what occurred in their personal health journey for SIBO to develop in their bodies? How do you do that investigation with them?

[18:26] ANGELA: Yeah, we start with a health history timeline and really start to look at milestones that happened over their lifetime. I have a SIBO questionnaire that I have everyone fill out. I am going to ask this very classic questions like DO probiotics make you worst? Does fiber make things worse? Have you had a food poisoning event? Have you had a tonsillectomy? Have you had any kinds of stomach surgeries of any kind? So there is a very long list of questions that are not too long. Well comprehensive shall we say a comprehensive list of questions about what people go through and from there we do further investigating. So again with the call that I just had today, with the new patient, we kind of go back to say, “When did the symptoms kick in? What happened that year?” that really gives us a focus on where we are going to be looking? What is different? what came up that year?

For this particular patient, she had hysterectomy. Everything kind of started 3 years ago for her and so she had a hysterectomy. She had about a year of unrelenting stress up to it that year. She had a hysterectomy and she had a really bad food poisoning event and so I asked, “Had you had the IBS check test done? That is a test that is available in the United States by Dr. Mark Pimentel and his group developed that.” I can’t stand the title of it. I can’t stand it because we are not looking to see if somebody has IBS.

I feel like that task gives a little bit too much of leeway with the name of it. If it’s a positive test, you would be a candidate for SIBO treatment. We look at SIBO testing. To explain that a little bit better, the IBS check test basically looks to see if somebody has a post infectious IBS issue. Basically it is looking for anti-body production to the CDTB toxin. And so again if I got food poisoning event, I am going to be exposed to a toxin. It is called CDTB toxin and my body will produce anti-bodies to that. In a small percent of people, those anti-bodies are going to cross over and attach vinculin.

So the IBS check test, what that is going to look for is if you have antibody production to the CDTB toxin. It is also going to look to see if you have antibody production to vinculin. So it is such a cool test because if you have antibodies to vinculin we know there is a motility issue and we know that that is contributing if not the cause for SIBO. Like we nailed it. There it is. So it is a really great test. What I take a little bit of issue is that it should be called the SIBO check test. Not the IBS check test. Because I don’t want all IBS looped in to this test because just some people are going to have post-infectious IBS. Other people can have IBS and it’s not post-infectious and I don’t think IBS in its entirety connected to antibiotic use. And that is what it is doing in fact.

In fact in the States, we have lovely drug commercials that play in all hours of the day on our TV and there is a little gut running around saying if you have IBS symptoms, you should go to your doctor and get Zyfaxin. It doesn’t mention SIBO, it doesn’t mention getting a SIBO test and we are kind of back where we were 10 years ago when everybody that had indigestion should go and run and get a proton-pimp inhibitor. It just makes no sense to me. That is not a good connection. So for this particular patient, I recommended that she goes and get an IBS check test with her doctor so we can determine if her SIBO was indeed brought about by that post-infectious exposure to food poisoning event and then we can do something about the vinculin issue and that nerve regeneration issue. We know there are things that we can do for that.

I also asked if she has had her adhesions assessed. And she had not. So first we are going to do the IBS check test and then next we are going to have her screened for the adhesions. So we really use the timeline we can hone in on when these symptoms get off. We can really look at that year to say what set this off. It’s usually an event. It is rare that there is not an event. And if there is not an event, what I found is there are some people were it’s been more stress that kicked us in but it’s been because there is a concussion early on. There might be something like a colon infection like lyme that is affecting their gut motility that they didn’t know about. We just have to keep investigating it until we find it.

[23:19] REBECCA: Right back to that part were you said at the start which is that you are an investigator, that you would keep going and I think that what sounds so interesting for me is that when someone comes and sees you, it sounds like you are one of those people that won’t give up. You will keep searching for a solution.

[23:38] ANGELA: Right and I have to. We have to figure out why. I’ll just kind of go back to that. if somebody has antibodies to vinculin, they are going to have inconsistent bowel motility. They are not going to have consistent use of their migrating motor complex to sweep better clean. They are going to have an issue that at the same time the IC valve that closes off the small intestine to the large intestine, there is high density of interstitial cells that could haul that basically are the cells that set the pace of the gut. They are kind of the pacemaker of the gut. There is a high density of those at the IC valve. And in that area, an issue of antibodies to vinculin is going to affect your IC valve. So we know that we have to do an ongoing self-assessment with that. They would probably do great with a visceral manipulation therapist so they can work on digestion and making sure that the IC valve is sitting down.

We would look at some nerve regeneration support. It’s like the peripheral neuropathy issues that we see with diabetes. We can use some of that support to help if vinculin has been an issue, to help reestablish those nerves. There are definitely things that we can do about it that we need to know about it to be able step into that.

[24:49] REBECCA: definitely. And just for those people that are listening that might be new to SIBO, just clarity around IC valve. What does that actually stand for and what is its primary purpose?

[25:14] ANGELA: the ileocecal valve is the valve between the small intestine and the large intestine. The ileum is the last section of the small intestine and the cecum is the first section of the colon. So it’s the ileocecal valve, it should open to the forward moving matter form the small intestine to the large intestine and it should close back up to prevent things from moving to the large intestine back up into the small intestine.

[25:38] REBECCA: and is there a way that people could test themselves if their ileocecal valve isn’t working?

[25:45] ANGELA: I would say that, test is the right word…it can be assessed. Basically the ileocecal valve, you can put your finger on yoru nose and kind of move it around a little bit. A little pat of your finger. That’s what the IC valve should feel like. a little bit of cartilage. Like the tip of your nose. And where it is located is about 2 finger distances on your right hip, right inside about 2, probably 3 or 4 inches down from your belly button and straight over and 2 inches in from your right hip. And you can assess it by laying on your back and putting your feet flat on the floor and have your knees bent and just with your fingertips kind of manipulate around in there until you feel that little bump.

That area should feel like you are touching the tip of your nose. Zero pain. There is no pain, there is no tenderness. If it is tender at all there are issues.

What is also interesting…. A lot of wisdom out of the fast patient. She was telling me her story and had taken around antibiotics with her doctor and was getting these symptoms that came back and she was sure it was SIBO and the way she was describing it and I said, “do you really think that was your IC valve having issues being stuck open?” so often times there is a deferred pain on the IC valve that is stuck open. It never hurts in that area until you put yoru fingers on and feel it. and where people feel that deferred pain is when they get a lot of pressure right up the middle of the ribs, right underneath the sternum. They will get a lot of pressure. They will feel almost like sharp pains up under their sternum and they will radiate to the back usually on the right hand side. Their right shoulder, when they did it on their right shoulder, they press with their thumb, that will be really inflamed. And so we get these really deferred pains that happen when that is stuck open. And in one hand we need to assess it and address it because we need it to lay down and not allow organisms to move back up but at the same time there is a lot of pain.

I want everyone to know…. They feel like go to the hospital, go to the hospital… but a lot of times people with SIBO will end up in the hospital with these symptoms and pain and they will look at everything, gallbladder, liver, everything and they look at them and go, “Go home, we don’t know what it is.” And it can absolutely, if everything else has been looked at, feel down there and see if there is an issue. The other thing in that area of course is your appendix. Obviously people could have… I witnessed these similar symptoms. Usually you really hurt in that lower area if you have appendicitis or if you got something going on with your appendix. You are not going to feel a little like nose cartilage protection from where your appendix is at that the ileocecal valve is right there.

[28:54] REBECCA: You know it’s so interesting with you talking about the symptoms of an ileocecal valve that is open and I have just realized just listening to you that my symptoms that I have suffered in the past are so in line with what you say symptoms of an open ileocecal valve. That referred pain. That pain under my sternum, referred pain into my back. It’s just I have actually had a bit of a light bulb moment talking to you just now Angela.

[29:22] ANGELA: It’s not talked about enough. It really isn’t. I think if I may say, I don’t know what happened exactly in your case but I think sometimes people start chasing food a lot more. They will start twiddling their food down or they are looking in different directions and it might very well be that they ate something that caused a little bit of bloating and that stick open. That happened but again if there are some issues with vinculin and that post infectious IBS, you are not going to have good integrity with the IC valve or somebody has just been chronically constipated. Obviously that can affect that valve as well.

[29:57] REBECCA: This leads us nicely to my next question around diet. So I think diet can be one thing that people can get quite fixated on and it is something that we can control. And I would love to know your thoughts around the importance of our die and nutrition when treating SIBO and if we can cure SIBO through diet alone.

[30:19] ANGELA: I hope you have a minute… obviously one of my favorite subjects to talk about and there is just so much confusion around the diet. From all the different blogs that are out there, to which diet to follow, to the chat rooms. Or even the advice of the doctors can be quite different from one doctor to the next. You know no one seems to be in agreement here about what to do about the diet. So you k now we’ve got this specialized diet. We have FODMAP, we have SCD, we have gaps, and these are the main ones in America. And they each have very strict rules over which carbohydrates are in and out and they don’t agree with each other usually at all. Gaps is really well known for helping the autistic community, SCD as well is known for helping the IBD community. And FODMAPS is really well known for calming IBS symptoms. Although none of these were really created to address SIBO.

So a couple of years back Doctor Siebecker combined the FODMAP and SCD and she brought us what she calls the SIBO specific diet. And you know really her thoughts when she created it were that there were polysaccharides and carbohydrates that were continuing to come in in a diet and feed these gutter organisms and prevent SIBO from being here. And this was why we saw so much reoccurrence. And so we needed to pull these to really starve out the gut bugs. And I say this with the utmost respect because initially when this diet is used people get their symptoms calmed down but I don’t feel and I don’t think she feels at this point that really is played out clinically you know over the years. If you listen to her presentation at the last SIBO symposium and on our latest interviews she shares more of an updated view on the diet stating that she only changes the diet if there are symptoms to address otherwise she doesn’t change it during the treatment.

So really, for the diet piece, to answer this in a nutshell, we modify the diet to help produce and manage symptoms while patient is being treated for SIBO. And that’s whether with antibiotics or as what I prefer to do it with herbal antibiotics. Then we work on gut healing and modulation and we start to challenge some of these foods to see which we can bring back in. Most people with SIBO can handle half a cup of sweet potato at a sitting or half a cup of jasmine rice at a sitting. If you are not getting symptoms from that you can include it. it doesn’t bring SIBO on, it doesn’t make SIBO worst. It is going to keep a person nourished. It is going to keep them fed and healthy while they are trying to really evoke all these change within their gut and their system.

If they eat a cup of rice and they get symptoms, look at reduce single load. Try a quarter cup, try a quarter cup. I would say across the board with my patient load. Half a cup of sweet potato or turnip or jasmine rice or some of those starches. Even quinoa. I don’t have any problem having people bringing that in and also conversely I have had patients with SIBO who have chronic watery stool. And I’ve had them actually do congee which is basically take a cup of rice you add about ten cups of water to it. you cook it for about 5 or 6 hours. You cook it down until it is really soupy, watery mix. I have them drink it and it stops their watery loose stool and it doesn’t trigger SIBO reaction.

So I think there has been so much fear set up over starches and grains that it’s really unfounded and we need some to come in. we really have to look at this more in terms of getting people nourished, keeping their endurance up so they have the endurance to heal their gut. And we can’t do this when somebody is malnourished or not sleeping, or in adrenal fatigue or when anemic. When we are trying to heal the gut, we are really running a marathon. We need a lot of energy from the system and nutrients from the system to help do this. I mean with the immune system really calmed down and participating versus being hyper responsive because the system is in such as stress state.

We do need to manage symptoms. This has to be in a case to case basis so that bloating again doesn’t hold up in the IC valve and allow the organisms to migrate up to the large intestine. But this means really adjusting portions more than pooling all grains and starches. There might be someone that just does, maybe they can’t do nitrate at all but maybe they don’t do well on potato. It’s totally fine but they will probably be fine on a little bit of rice or a little bit of quinoa.

On a side note, if a patient is extremely sensitive to all starches, grains or fructose, like in fruit and they are really quick to react to these, it might be that they have SIBO on the upper small intestine and this does complicate the diet more and this group would do very well as a regroup plan with the SIBO specific diet which is grain and starch free. That would be a really god place for them to start. But for the maybe other 90 plus percent of people who have SIBO, they don’t have to go that restrictive. This is more about if you got to be on treatment for 2 or 3 months and rebuild your gut and your lifestyle and work on stress, in all of that, we need to keep you fed and nourished. We need to keep you on as much rice as we can. So the consensus really is if you are not reacting to something that food is in, it doesn’t feel things more. And I look at. Even Dr. Pimentel includes white bread and white rice for his plan. He has always used those and I always use grains and starches with my plan and have really good success with it.

I think that main point which I think is really important for people to understand is they are looking at….they are not feeling well and I totally get that. They are not feeling well and they will go through some sort of treatment and it doesn’t work and it starts to feel like just like you said. It’s what they can’t control. It starts to feel like, if I pull potato it will make it all better.

“Oh, I shouldn’t have had that carb or that starch. That’s why I didn’t get better. I got to pull those now and treat this again and then I will get better.” And it doesn’t work. It really doesn’t work. So I feel really strongly that when people widdle themselves down to concentrate foods and have that strong strong fear of feeding SIBO and if they get a bloat reaction they feel if SIBO was growing and getting worst. This is adding to the stress in the system and it’s going to make things worse. Stress from emotional stress and/or from malnutrition or from the lack of fuel. For the healthy organisms in your gut, it’s all going to add on an additional load on the system and make this all the more difficult to overcome.

[37:21] REBECCA: and I think the point you have raised around the emotional side of eating, I think that that can actually become, it can be problematic. I know. I suffered from an eating disorder when I was younger and when I got in to my SIBO treatment, I remember feeling concerns that it may trigger this sort of eating again in me because it was so kind of strict for a period of time. and with my treatment we were eliminating foods for a short period of time and then the whole plan was to reintroduce as much and as quickly as possible. But I found security and comfort in very restricted eating. And so I would love to talk to you whether you see kind of emotional or disordered eating that has a reason as a result of SIBO treatment with your patients?

[38:15] ANGELA: Yeah, I find that for a lot of people and it makes sense. It really makes sense when someone has a functional gut disorder. They are under chronic symptoms in dealing with chronic symptoms on and off and in a day to day basis. And there is hyper awareness that comes with that for every hiccup, breath that didn’t feel right, symptom that pops up if they have gas which is completely normal. You know I think people with very normal digestion may not have a good digestive day on occasion. They are still might not be perfectly well formed every day and I think when this level of symptoms happens for someone it really breaths this hyper awareness that people can get very anxious about. And I see this all the time. Instead of paying as much attention to their symptoms, I would rather they go out for a walk. Try to do yoga class. Go hang out with their friends and try to pull themselves out of this very respectful, as I say this with great empathy, as I work with patients who are feeling this way all the time. It’s kind of like feeling like they are in this rabbit hole they can’t get out and the symptoms are really overwhelming.

And I think what we have to do is really try to find a foundation of support to get them 10% better and get them out of their own head for a little bit. You know in a day so they can start to step away from that. I can’t say that I found that I have seen more of that on a disorder eating side come out of SIBO. But I really see much more than anything really hypersensitive responses to anything digestive or body symptoms and there must be something wrong and that anxiety that that breeds and adds on that load to the system.

[40:29] REBECCA: What is your advice for someone that is currently in that state that they are hypersensitive, they feel that they literally only got a handful of foods that they can eat and everything they do causes a reaction? What would your advice be in terms of what can they do today to try and help calm their system down?

[40:51] ANGELA: Try to go out for a walk. Try to do something more of a group hobby. I am not saying that in any condescending way whatsoever. I promise that. I know anyone saying, “Gosh I don’t feel like going on a walk.” It doesn’t even sound good but it’s like trying to get themselves out of that environment for a little but can be so helpful for calming things down and I think all of those who have done it, if we are really stressed out with work or something and we go do something like… you know the veil has lifted. We have a moment were we are not thinking about things. And so I think that can be really helpful. I would say it’s difficult to give people… you know I know a lot of things to do to settle down. Jen tea is lovely and terra cotta peppermint oil is lovely. A soothing warm water bottle is awesome. Taking a bath with Epsom salt and try to relax. There are some different things that I think that can relax the system but there are so many reasons why that gut might be a little bit set off. So it’s hard to give… and I know 20 things that would help 20 different people in terms of calming that gut down just a little bit for them. To me, trying to schedule in time to research and not having that consumed I think is a really important one to bring up as well because if you have SIBO and you are hanging out in the chat rooms, a lot of people in the chat rooms are going to listen to this. I am all for them. They are lovely. They are great to know that other people are out there dealing with this. They are great for that camaraderie. There is a lot of information posted in there and it can cause a lot of anxiety for people as well because there are unfortunately some people that feel very caught in this cycle and they share a lot about that which I so appreciate and respect that they are because they are looking for some help and some camaraderie with it. and I think sometimes when people are in that space and reading that, it can cause a lot of anxiety because they feel that things are never going to get better.

So I would say that I love an educated patient. I love it absolutely. I’ll give them things to with that. We’ll talk about it. I think it is wonderful. But I can tell sometimes when patients are spending every single night for hours because I’ll get emails – What about this? What about that? What about this? I have read about this?

Did you cook for yourself? Did you go for a walk? Did you spend time with your friends? You know where is all of that space too because we have to reestablish that. We can’t keep up with this space. And we really have to kind of get out of that world a little bit, a little more often.

[43:32] REBECCA: We can get so into that and so inward looking when we are not feeling well and I know that I was guilty of that at times but now I really try and look upward rather than inward. Meal times, I would love to know your thoughts around whether we should be… there’s a conversation around that we should have 12 hour fast between dinner and breakfast, that we should live 4 to 5 hours between each meal. Do you feel that we should be quite regular with our meal times or do you feel that this is quite individual.

[44:10] ANGELA: My response is that it depends. When we are looking at classic SIBO symptoms, we really want to have a little bit more space in between the meals and this is especially true if there is a post infectious IBS issue present were the motility is an issue. We want and try to reestablish that by giving people a little bit more space between their meals. I would say that my steadfast rule with one little asterisk on it… my steadfast rule is when dinner is around 6:30 and there is a 12 hour… maybe 7 and there’s 12 hours between that and breakfast, I would really like that break for people. The rest of it, we have to really take again on that case by case basis because SIBO is a secondary condition. There is almost always other things going on with the patient and I see a ton of people with adrenal dysfunction and dysregulation with blood sugar dysregulation, with insomnia. And we have a hierarchy of needs with the system. If you are not sleeping that comes first. If your blood sugar is not regulated, that comes first. SIBO is third. It’s all in a close tight little race to the end but that is the hierarchy of needs.

So I am not going to look at that patient and say, “Ok you are not sleeping. Your blood sugar is completely dyregulated. You are going to eat 3 times a day and we are going to treat SIBO head on and turn you into a detox spiral. We can’t do that. We really have to look at each person. You know it’s a really important clinical note that I see all the time. When there is a functional gut disorder like SIBO which is so taxing on the system, we have this added stress on the system. I think this goes back to when we were talking about grains and starches. If people are pulling grains and starches completely, worried about kind of feeling those gut bugs and we have to get away from the idea “we don’t kill the gut bugs. Nobody is killing the gut bugs.” We knock them down and we rebalance the system. That’s how we look at this. So if we are looking at this from that perspective, if somebody has pulled grain and starches, it can really amplify an adrenal issue and increase adrenal dysregulation and blood sugar dysregulation and sleep disturbance. And this is really a vicious cycle.

So I frequently see on a health history timeline were someone went paleo which I had no problem with that diet which is for example someone went paleo or they went grain free on the timeline and from that point on, I see adrenal fatigue diagnosis. Sleep issues pop up. Chronic fatigue symptoms. And all that’s happening…when all of those are happening together,, they are going to be even more sensitive to the foods that they are eating and they are going to keep widdling down on their food choices. And I we look back they are basically in blood sugar dysregulation. They are not sleeping well which means they are in fight or flight all the time. and they are not going to digest because they are in fight or flight all the time. So they are getting symptoms were their gut is already hypersensitive. They are even more symptomatic. And they are going to keep widdling down on foods throughout their endurance and then any time they try to add any food back in, it’s an overwhelming sensitive reaction. It’s such a rabbit hole but it is really a rabbit hole that people go down and I think it is so unfortunate and this is why I am so strongly against pulling greens and starches in a vast majority of SIBO cases because I see this all the time, all the time.

So if you are waking up between midnight and 2:30 in the morning, you are having a blood sugar disregulaton issue were your body would naturally have a blood sugar dip at that time. You should release a little cortisol. Won’t even know it. you are sleeping soundly. The most sound of all time. In the middle of the night, your body releases a little cortisol which signals your liver to release a little glucose store. And if that doesn’t happen because there is adrenal dysregulation and you don’t have enough cortisol available, your body will release adrenaline. It will, when it does that, have a very quick release of glucose because that’s the way we quickly adapt to something stressful and you will have a surge of insulin which is inflammatory and you are going to wake up.

So if you are waking up between that times, you got adrenal dysfunction, you got blood sugar dysfunction and dysregulation, and eating 3 times a day isn’t going to work. We’ve got to look at meals, snack, meal snack, meal and regulating your blood sugars so you don’t have too long without eating or your blood sugar dips. Your body again can’t regulate that and you are going to release adrenaline. So we’ve got to take this again on a case to case basis. I always ask how frequently you wake up. What time do you wake up? And if it anywhere in there and I will say I will come wide awake. And then they think they have to urinate and that’s not what woke them up because that is the most dead asleep time that we should have. It’s because they have an adrenal reaction that really woke them up.

So I think ideally with SIBO, we want breakfast, lunch and dinner with really that 12 hour fast between those. Some people can handle fasting. Other people I think it’s… I have never found anyone that can handle fasting. Let me say that one. When somebody has SIBO as a secondary condition, there is so much more that goes with it. and their system is already taxed so I don’t know why fasting would help. I want to keep them more stable, better blood sugar balance and get them sleeping better. And from there they have better endurance to start tackling the SIBO piece

[49:55] REBECCA: It’s interesting you say that and I don’t know whether I would have felt so good doing intimate and fasting when I still had an active case of SIBO. But since coming through my SIBO journey, I now fast two days a week. So I only eat one meal of 500 calories which I have as my dinner and I feel amazing for it. And it works really well for me but I know that there’s other people that just can’t do it. It just doesn’t work for them. I also know that my system is really hypersensitive to the blood glucose that arises from eating grains and sort of starchy carbohydrate foods.

So I feel a lot better when I have a much more reduced load of them in my diet. So again it’s just so individual on… you know an individual person’s make up and whilst it’s great that we have these dietary guidelines out there that help these people, we have to have our own investigation to find what works for us and stick with that.

[50:54] ANGELA: I agree. I think if we can pull off the table that grains and starches at a low level, feed SIBO. If we can set that aside then at least there is kind of an even playing field for figuring out what is the best diet that is going to support my needs. So I agree with you. So if we can look at it from that perspective, I think it’s helpful. Again I see… I love the paleo style diet for some people. If someone is insulin resistant and overweight, I think fasting is fantastic. Not right out of the gate but something that we might use later on. And definitely more space between meals. If somebody has they get a little bit tired after they eat grains or starches, it is not an immune response. It is more of a blood sugar response. Then they are not regulating their blood sugars that well and frequent eating is really the best approach to that. So it is, it is very individual. And so that is why I think working with someone that can do a little bit more handholding along the way to kind of look at patterns across a couple of weeks to say, “Aha this is what is happening!” you are either reacting every time you eat this one food. Or you are not eating enough breakfast so you are overeating at dinner. And you are having too large of a meal that your gut can really handle. So it’s kind of setting things off.

We look at the patterns over time to really help adjust things.

[52:22] REBECCA: Wonderful. Angel when would you use the elemental diet with your patients?

[52:28] ANGELA: to me, I find that the elemental diet is best placed when someone maybe has Crohns and is in a flair and it really helps to give their gut a rest and help them go into remission. That’s where I found it works best. I personally, professionally have not found that the elemental diet works for SIBO that well. Again I kind of go back to having an issue with the concept of starving out the gut bugs because that is really not what we are trying to do. you know it’s interesting at the SIBO symposium, not this year but the previous year there are three case studies presented on the elemental diet and two of the three had a SIBO reoccurrence easily within a month of coming off of it. so my though is it is a lot to put a person through and someone has to be really really stable to step into that and I think it’s people that are not very stable that want to do it.

And I say that again with great respect. There symptoms are all over the place and they just want something so they can feel better for a few days and I appreciate that very much but I think in terms of a treatment I don’t see it clinically as much as it is presented at the SIBO symposiums. There is a new product out by Integrative therapeutics the physicians elemental diet that actually tastes very decent and I think some are seeing suggestions being presented at the symposium and I have used with a couple of patients were we might just do a single meal replacement within a day to give them a bit of a longer rest between breakfast and dinner. And that comes in handy again with my patients were we have to eat a little bit more consistently.

So what I have them do is do kind of a snack, a scoop or a snack in the afternoon and then do 2 -3 scoops for dinner depending on where their weight is at. So we get basically from lunch to the next day a rest in terms of fermentable carbohydrates coming in and yet we still get to keep their calories up and they are on two week kind of fast with an elemental diet.

[54:30] REBECCA: and with regards to weight, I think this is a concern for some people around keeping their weight up or losing too much weight when they use the elemental diet, do you see that that is an issue with patients?

[54:45] ANGELA: Yeah. I think it has been an issue more so when people made the home made diet or actually purchase the other ones that were on the market because they tasted so disgusting that we could not…I don’t use it as… it’s not what I have ever used because when I go out, I am on a clinicians group of 400 doctors. I also lead a group here. When we talk about it, nobody that I can find uses this on a regular basis with success. You know kind of take that as you may but the ones that were on the market prior to the integrated therapeutic tasted horrific that you just could not get a patient to take in enough servings of it to get enough calories and to keep their weight so people often lost weight on it. And I think SIBI in general, I see people that lose… their symptoms come on. They eat food. They hurt. They don’t eat food. And they will drop 20 pounds in a few months. It’s quite scary how quickly they can lose weight. Trying to stay away from food and how sad. It’s so sad to me that that food is being acquainted with pain because food is so nourishing and lovely and celebratory. And I take great pride in getting people back to that helping them reconnect with food again which I think is so so important.

[56:01] REBECCA: it is and it is one of the reasons why I developed my cookbooks because food is to be enjoyed. It’s fantastic. I love food and I love what it’s there to do which is to nourish us.

ANGELA: Yes. Absolutely. And it’s health. I mean it’s so much. It’s our energy source and it’s very sad. I mean emotionally it’s very wearying on people to all of a sudden lose that connection.

REBECCA: it is. Angela, I have just thoroughly enjoyed talking to you today. So I would love to know what is next? What is on the horizon for you?

ANGELA: yes, the horizon for us my dear. Absolutely… we knew when we met each other at the symposium we were destined to do something together and we jumped at the chance. So we have created a recipe site for low fermentable eating and it is doing wildly amazing. And basically it’s my self and a colleague of mine who is a dietician and you lovely Rebecca and we came together to bring, there’s a 400 plus recipes on the site at this point. People are really enjoying them and we are making low fermentable and you know kind of FODMAP eating enjoyable again and doable so people can really enjoy eating again and know what to eat they can put a meal plan together and print a shopping list and these are easy and doable. So it’s called I would definitely visit and Rebecca’s site for the link to check out our sites and we would love to have you join. We would love it.

REBECCA: That’s great and the link for that is in the notes with the show notes. Angela I myself have learned so much on our chat today and I am sure my listeners have learned a lot from you as well. You really are a brilliant investigator when it comes to supporting people with their journey of regaining their health. So thank you so much for taking the time to come on to the healthy gut podcast with us today.

ANGELA: Thank you for having me. I very much enjoyed myself. Thanks Rebecca.

The Healthy Gut Podcast with Angela Pifer

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