Small Intestinal Bacterial Overgrowth (SIBO) is estimated to affect 60% of people with Irritable Bowel Syndrome (IBS) yet is largely unknown.
In this episode of The Healthy Gut Podcast, Rebecca Coomes is joined by the Queen of SIBO, Dr. Allison Siebecker to discuss this condition.
Plus, included in this episode is a free download of our SIBO guide, giving you an easy checklist of the causes, risk factors and associated conditions.
In Episode 2 of The Healthy Gut Podcast, we discuss:
✓ Hear Dr. Allison Siebecker’s own personal journey with Small Intestinal Bacterial Overgrowth (SIBO)
✓ Why SIBO is a chronic illness for 2/3 of all patients, and how treatment should be about management rather than cure
✓ What SIBO is, how it is caused (only a few causes) and why there are multiple risk factors that can lead to it developing
✓ The common symptoms of SIBO; both physical and mental
✓ How to test for SIBO: which ones are accurate and which ones aren’t
✓ The different treatment options: antibiotics, herbs and the Elemental Diet
✓ The different diet options and which one you should use
Dr. Allison Siebecker’s website is jam packed full of useful information, resources and links to research. She also produces a quarterly newsletter which is a must-read for anyone interested in learning more about SIBO. She offers Skype consultations, which can be organised via her website.
Would you like to make a financial contribution to help support the continuation of The Healthy Gut Podcast? The podcast is funded entirely by Rebecca Coomes as she is passionate about sharing quality information about gut health to help others on their journey to health.
You can contribute $5, $10, $20 or any amount you choose. Your contribution will go towards the costs involved in producing and hosting this podcast, and will ensure we are able to continue bringing you top quality episodes.
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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.
REBECCA: Welcome to the show Dr. Allison Siebecker.
[00:04] ALLISON: Hi
[00:05] REBECCA: it’s so great to have you on the Healthy Gut podcast talking all about SIBO today. So I would love to talk to you Allison about your story. How you came to be such an expert on the topic of SIBO?
[00:22] ALLISON: Right, although I will say that i don’t refer to myself as an expert because I find that term intimidating. Because you know then it makes people think that another person who is an expert knows everything and I don’t. And neither does anybody. So I prefer the term specialist.
[00:40] REBECCA: Specialist. Ok.
[00:41] ALLISON: It takes the pressure off. So my story is that I was born without GI symptoms but when I was very young I got GI symptoms probably around the age of 5. And I suffered from them and mostly it was bloating, abdominal bloating, constipation, and pain (not all the time) but a significant amount of pain. And I had these ongoing my whole life and I didn’t even know that I had a diagnosable disorder until I was in medical college. And then it got diagnosed as IBS which isn’t all that helpful because before a lot of this information of SIBO was well known, all that we knew about IBS is that all it meant was that it had all those symptoms that I just described or maybe diarrhea. And we don’t know why and we don’t know what to do for it. Great.
[01:45] REBECCA: Thanks so much
[01:46] ALLISON: So much help. And the doctor gave me a few things to try and I did try them and they didn’t help. So anyway there I was suffering from a chronic illness and it really at times it would be debilitating to me and then in other times I was alright. So then I am in college and my gastroenterology professor had this recommended reading list and on it was “Breaking the Vicious Cycle” by Elaine Gottschall which describes the specific carbohydrate diet. And I read it and I thought that what she was talking about might have been what I have wrong with me. And she was talking about small intestine bacterial overgrowth but she didn’t call it by that name. But she used those words – bacterial overgrowth in the small intestine. And what she was trying to do was she was trying to explain why the specific carbohydrate diet worked for her daughter who had inflammatory bowel disease and why it worked for all the people that it worked for which were most people with inflammatory bowel disease and coeliac disease. And so her theory, one of her theories that she was putting forward in the book, was that maybe really maybe what it was treating was SIBO and the diet and maybe that’s why it worked.
Just caveat to that, on the side here is that I don’t think that’s true. There are lots of people with celiac disease and inflammatory bowel disease who don’t have SIBO and the specific carbohydrate diet works for them too. So there is more going on than that. I just wanted to say that.
Ok. So anyway, I read it and I was like, “Oh my Gosh. I think this is what I have. I want to do this!” but I was in the middle of college, medical school and you know it was extremely daunting. Hours were extremely long. I had no more effort to do much about it. So once I graduated I was reminded of the book. I was suffering very badly from my symptoms and I thought, “Now I am going to do this.” And so I did the diet and within 24 hours, my pain was gone which was unbelievable. The diet just gave me my life back and the bloating was reduced, a very good amount, maybe 50%.
Constipation… It didn’t do anything for it. In a way I didn’t really care because I was like “Oh my God, my pain!” So this just lit this fire under me to understand it. I entered medical school, I had the disease and didn’t know what this was all about. So then I had a strange encounter with my predecessor college professor and he mentioned SIBO. Now that phrasing wasn’t in Elaine Gottschall’s book. He mentioned that phrasing to me and sort of together we thought that’s maybe what she was describing this sort of condition that was now being described as SIBO. So I went and started doing research and so that’s what I did. I just threw myself into research. I actually stopped practicing. I was doing primary care. I stopped practicing for over a year and all I did was research. And all day long, every day.
And then after that I began teaching. And so my previous gastroenterology professor is Dr. Steven Sandberg-Lewis who has been my partner in crime so to speak ever since. So anyway, then we began teaching after I had studied for over a year and a half non-stop. Nothing else that I was doing day in, day out.
Then we began teaching and I was encouraged, soon after I first taught, I was encouraged to make the website. The first class that I taught was at the annual naturopathic convention in the United States; national convention and there was a lot of doctors there. And I was getting all flooded with emails from them and phone calls to answer their questions. Everybody took to the topic like wildfire. You know they were just totally into it and they had tons of questions and I could not live a life like that were I was just answering all day long for free everybody’s questions. At one point I tried to do that for two weeks and I worked 80 hours a week for 2 weeks straight for free answering the public and doctors questions.
So I realized I can’t do that. So I made a website to try and answer the questions. So I spent many months just writing all the information down so people would have a reference. Also, I was rather outraged that the condition didn’t have anything like that. When I first got into SIBO, it was six or I guess 7 years… I can’t remember how many years ago. I tried to find how to test for it and I typed in all sorts of search terms and Quintron who is the manufacturer of the breath testing machine, they came up like on page 3. It was insane. You could not find anything online. Nothing. There was one Medscape article. So where I had to go to learn about it was into PubMed. And at that time Naturopathic training didn’t stress reading MD research articles on PubMed. Now this ruling has changed and has very much stressed in my school. Back then it wasn’t. We went to other sources and so that was something I had to learn all about.
And I guess I just had to summarize some of those things. Basically when I read Breaking the Vicious Cycle I just had so many more questions. So many deep questions I wanted to answer for myself. And that’s really what spurred me on and honestly that still what spurs me on. There are so many things I don’t understand well enough even though after 6 or 7 years of constant study I understand a lot. But I am still spurred on by that. There are things I still don’t understand and I just read and read and it has also led me to befriend most of many of the authors of these articles reaching out to them in a kind way so that I am not pain, but to talk with them about what they are learning and what they know. And so that is another way that I have come to learn and so I do that all the time. I call these amazing gastroenterologists because I know so many of them. We Skype or we talk or whatever so that I can ask them questions about what they have written and what I still don’t understand.
[8:05] REBECCA: I was just going to ask… at what point in this journey were you able to find treatment options that worked for you? And what did you do with your treatment?
[8:16] ALLISON: By the way I am sorry to go on and on so long about it. So I started with diet which is a specific carbohydrate diet and that helped 60% overall which was amazing.
[8:30] REBECCA: And what did you see it actually addressed in that? What was reduced in that 60%?
[8:38] ALLISON: That was my pain in 24 hours right away. My bloating got nearly 50% better and then my overall well being felt vastly improved. But my constipation wasn’t helped. That was not helped. But just not having pain, every time I would eat in most times, it’s unbelievable.
[9:00] REBECCA: I can imagine. Yeah
[9:01] ALLISON: Diet first then I tried antibiotics after long hard study on those antibiotics to make sure I felt ok taking them. And that took away my constipation which was incredible because it meant that my constipation was created by bacteria. An antibiotic could relieve my constipation. But, like what happens to most people, I relapsed within about two weeks. For some people it was longer but for me, it was two weeks because I wasn’t on a pro-kinetic. At that time I didn’t know about pro-kinetics but I was experimenting in myself in all sorts of ways. Before I would treat patients I would do that.
So then later, I had repeated antibiotics. I have tried lots of different herbs and I found 1 herb that we know that actually Dr. Jacobi figured out. It’s helpful for methane which is from Allison products. That actually reduced my bloating.
[10:11] REBECCA: For those listeners that haven’t hear of Dr. Jacobi, she is actually Australia’s leading specialist on SIBO and we are very fortunate to have her in Australia.
[10:22] ALLISON: Yeah, Dr. Jacobi came to that first lecture that I was telling you about that I gave at the National Convention of Naturopath. And then contacted me soon after ad said I wanted to be the SIBO person for Australia and I was like, “Fantastic!” and then she did a little in-office study and very soon after that she was able to find that Allicin which was an extract from garlic works on methanogens. So this was quite extraordinary because there are very few things that work on methanogens which she found this out a long time ago. And the naturopathic community and everyone else has benefited ever since from her figuring that out. So I benefited too.
[11:03] REBECCA: And Allison, were you methane dominant SIBO person?
[11:07] ALLISON: I was because I had constipation and I know we can talk about that a little bit later. But so since then I have tried many different bouts of herbs. Different bouts of antibiotics. I myself have not done the elemental diet although I have many patients who do it. Sort of our third mail killing option. And I still have SIBO. I still have symptoms but I am more of the complicated chronic cases. Sometimes I think that the universe is keeping me with SIBO so I will keep studying and I will figure out the hardest hardest cases what needs to know. I try and tell the universe, “really you can take my SIBO away and I will still study.”
But the thing is, is that with diet and various treatments periodically, I am able to stay at a level that is acceptable to me. I have lived a happy life. So I am very productive. So that is my journey.
[12:14] REBECCA: Yeah that’s great. I think it’s good for people who are listening to this podcast to know that getting a cure or ridding yourself of SIBO might not be what happens for you but it doesn’t mean that life isn’t worth living still that you can get it into a position were life can still be pretty good and that is just about managing a chronic illness rather than looking for that finite point in the future which is where you are given the all clear.
I’d like to back track a little bit… Sorry
[12:49] ALLISON: Can I just say one thing on that? So many people, when they are suffering when they haven’t had treatment yet and symptoms are at their worst and they discover, “ok this has name”… The idea of not being cured, you know people have a way of thinking about that as in I will never feel any better than I feel right now. But cure doesn’t mean that. Chronic illness is a fact of life for a majority of human beings actually. Various chronic illnesses. But it doesn’t mean that they feel bad all time.
Just like the funny example of that, you know like chicken pox. That virus stays within us our entire life. We are never cured of it but we are not suffering the outbreak symptoms. So it is important that we remember what does cure really mean. I think people, in their mind are thinking they just want to know, “Am I going to feel better?” and that is possible for almost everybody.
[13:43] REBECCA: yeah definitely. And I think I know, myself when I was at the worst and feeling pretty miserable with this stage of health that I was in. all you want is for it to go away. You just don’t want to feel like that anymore. So if not feeling like that at the height of the illness is something that can change then anything from their feels good.
I would like to back track now and just talk about SIBO itself. What is SIBO in very layman terms?
[14:14] ALLISON: it’s just an accumulation of the normal bacteria that normally lives in our digestive track. It’s an accumulation of them in the small intestine. And so for people who don’t know the anatomy of the small intestine, we start with the mouth then the esophagus then the stomach. After the stomach comes the small intestine and it’s very long and it coils around in our abdomen. Then after that comes the large intestine which is also called the colon. And while it is wider, it is much shorter and it has three segments. And then that’s the end of the tract where the stool comes out of. So normally the large intestines have bacteria. Most people are familiar with that. We have good bacteria and just normal bacteria that don’t cost us any disease. Lots of them living in our large intestine. They do good things for us.
So sometimes what can happen is those bacteria that are down below can come up into the small intestine and also bacteria are constantly entering into our digestive tract through our mouth and our nose just as we breathe and we swallow as we eat and drink because bacteria are everything, everywhere. We are just living in a world filled with bacteria. So they come in and they normally will just pass down and through the small intestine. But there can be reasons why they then wouldn’t pass through so they can accumulate from above as well.
So it’s when bacteria are accumulated in the small intestine. We call it the overgrowth. Sometimes we call it a colonisation and that is improper. They shouldn’t be very large numbers and the body actually has many protections and mechanisms to make it so that the bacteria pass through the intestine. And the reason it is trying to do that is because the small intestine is where we break apart and absorbs our food. Breaking apart digestion. Breaking apart the food’s digestion and absorbing it is taking it into the rest of our body. And so to do those functions, we don’t want bacteria around because they do those same things for themselves. Basically they would compete and try and digest and absorb our food. And that’s what they do when we have SIBO. So the body doesn’t want that to happen. It doesn’t want that bacterial competition for our food so they shouldn’t be there. So just in summary, it’s too many bacteria in the wrong location.
[16:35] REBECCA: And what causes that to occur?
[16:40] ALLISON: There are a lot of causes or I have to call them risk factors. But it might be easier to think of it first as what the underlying causes are. The things that go wrong in the body. Just a few of those. It is basically when those protections against it fail and so some of the most common would be the deficiency of motility and it is a certain kind of motility called the migrating motor complex that happens in the small intestine itself. Most people are familiar with having a bowel movement. That is a form of motility that happens from the large intestine. And also we are familiar with a process called peristalsis which is where food is pushed down through the digestive tract after it’s getting absorbed. This is a little different. It is a strongly propulsive movement that just happens right in the small intestine. Sometimes we can feel it as those hunger pains like we hear sort of a gurgling kind of movement. We feel it. And it can be happening and you don’t hear those hunger sounds. But that is the sign of it. So what that function is, it is meant to actually… it happens… backtracking here. It happens when you don’t eat. So it happens between our meals and then overnight when we are sleeping. And its function is the clear the small intestine of bacteria and any sort of indigestible food residue. It’s basically like washing the dishes after eating. It’s like a housekeep wave, tidying up making sure everything is fixed up.
And so this is really the number one way people get is the migrating motor complex doesn’t work very well because it’s deficient or it works improperly. That’s probably the number thing. The second most common way or cause of getting SIBO would probably be some sort of structural problem. Like for instance a partial obstruction. Some other piece anatomy might be pushing in on the small intestines clogging the clear passage of the bacteria or maybe there is an adhesion which is like a scaring even within the small intestine or wrapped around it. Kind of squeezing it and then once again passage through it is blocked.
And there are other structural things that can happen. But those are part of the two most common underlying causes of SIBO. Another one that are similar or that are sort of have a lot of press is for people who know about it would be a deficiency of stomach acid. The hydrochloric acid in the stomach kills bacteria. And that can kill bacteria that comes in and if we take proton pump inhibitors or we just happen to have low stomach acid, then the bacteria aren’t killed and then they can spill over into the small intestine and possibly accumulate. Now this one is debatable underlying cause in here.
And here is another debatable underlying cause. It would be the iliocecal valve. This is the valve that separates the small and the large intestine. It’s like a sphincter and it is closed at most times and it opens to allow the passage of contents through. But if it’s opens all the time, then the bacteria from the large intestine would be able to move upward into the small intestine more easily. This is also a little bit debated because the idea is that if you have your migrating motor complex working well then both of those avenues of having bacteria accumulates, technically they really should be overcome, because if you have spillover from above or migration of bacteria up from below, wouldn’t the downward curve of migrating motor complex pushed it out And there are studies to show that that’s true. So we are still all trying to figure out how do these all work together. Which one is more important in that sort of thing?
It’s not clear but we do know that these are the underlying causes. Just let me skip over to the causes or risk factors for a minute and mention proton pump inhibitors.
If we think of what actually causes the underlying causes, the deficiency of the migrating motor complex or structural abnormality, we can class those into some category like diseases, drugs, lifestyle factors, surgery, maybe genetics. Things like that. So proton pump inhibitors would be in the class of drugs. They can lower the stomach acid. Opioid narcotic painkillers that people might get prescribed after a surgery, those slow motility throughout the whole GI tract. So they decrease the migrating motor complex. That’s actually a very common way people can get SIBO because the motility slows down and bacteria accumulates. And then when they stop taking drugs, their motility might come back but they have the situation now that might be a little hard to clear. Sometimes it will clear on its own overtime and then sometimes people will be treated after that.
Surgery is another one where it is very common to get adhesions and scar bands after abdominal surgery and in instance adhesions form in such a way that they compress the small intestine. That could be a way to get SIBO. So I am just giving you examples. Now here is probably the most common one. That would be food poisoning which is also known as stomach flu or travellers’ diarrhoea. This is the most common way for people to get SIBO. It’s that they get about a food poisoning and then what happens is… now food poisoning is caused by pathogenic bacteria. Not the normal bacteria that accumulates in SIBO.
These are different. These are pathogenic bacteria that come in and cause acute illness then leave. When they come in, they secret a toxin that can trigger our immune system to actually damage some of our small intestines nerves cells because the toxins looks like our small intestines nerve cells. So kind of like a friendly fire or mistaken identity. Our immune system can damage these nerve cells and the nerve cells that it damages are the ones responsible for the migrating motor complex. Now this thing I just mentioned here is actually phenomenal information that has only been really recently been fully discovered and published. And so we have new learning here on how come a lot of people get SIBO and this seems to be the number one cause.
So those are some of the risk factors. I actually didn’t mention a lot of the disease so let me just mention that.
There are diseases that slow motility like diabetes and scleroderma and cystic fibrosis and even hypothyroid. Hypothyroid is pretty famous for causing constipation. It can slow motility in the small intestine. And hypothyroid is very common. Of course you can treat the hypothyroid and then it gets better. Kind of like coming off the opioid drug.
So there are all kinds of ways people can get SIBO from drugs they are taking, temporarily from drugs they are taking long terms. From diseases that might be incurable like scleroderma or diseases that might be curable. And from lifestyle factors and things like that and surgery. So all sorts of ways can cause SIBO. There are so many ways. It gets to be a huge list. There are so many ways that we can disrupt those underlying protection. But then it is good to remember that what is really underlying is just a few things like deficiency of the migrating motor complex or some sort of partial distraction.
[24:07] REBECCA: What are some of the risk factors when it comes to lifestyle that can contribute to SIBO?
[24:15] ALLISON: the main one, there besides the drugs that people take, that’s kind of a lifestyle factor is stress. And the way stress can affect SIBO is because it can decrease stomach acid production and also it can decrease the migrating motor complex. So it can decrease that positive motility in the small intestine. Now can stress in itself cause SIBO. Could it be enough?
I have heard of some situation where there are people who have acute stress that it did seem to cause SIBO. And I also heard a couple of situations where people have very severe chronic stress and we think that’s what caused it. Now one other thing I can say on that is that, in most of those situations except for maybe one or two, people did have other risk factors. So that’s again where we wonder, how much does it need to be a combination? But one thing we can say that is never going to be bad for someone to reduce their stress. So it’s not like the primary cause but it is an important factor.
[25:26] REBECCA: Yeah definitely. And when I think about my own journey I had so many elements of that that I believed could have contributed to SIBO like food poisoning and I had parasite infections and I’ve got endometriosis. I’ve had abdominal surgery. I’ve had a lot of stress in my life. Is it a case of that these things could just layer on top of each other until then you have SIBO or is there one defining moment that is the cause of SIBO in your opinion?
[26:02] ALLISON: I have seen it both ways. I have absolutely seen both ways. There are lots of people who are just like you. They tell me. Each one of those… all of the single things you mentioned is a big enough risk factor in itself to cause people SIBO. But yet not any one of them cause it. Like you might have one and then another. So I see that a lot. It’s like all these risks factors stacked on top of each other and then there’s the straw that broke the camel’s back. You are not really sure… I guess that was just the last trigger. And it particularly was food poisoning that can happen because studies have shown that damage to those nerves is cumulative. Most people have had multiple bouts of food poisoning, at least 3 for most people and the damage can keep accumulating so the nerve’s function might go down and down a little bit more and the last time its low enough. It slows the migrating motor complex. Now you get SIBO.
So that’s one way. But then I also see it the other way. I see it were somebody had perfect gastrointestinal health. Never a problem in their life. They went traveling to a 3rd world country. They got travelers’ diarrhea food poisoning and bam that was it. Never well since they got their SIBO.
So it happens in all kinds of ways.
[27:17] REBECCA: and I look at my journey and my digestive health I can now look back on and see it was pretty compromised almost from the start. But it just got progressively worst with every occurrence of risk factor occurring until it then got unbearable. And I couldn’t ignore it any longer. So I suspect for myself, I had SIBO for a very long time. But I was able to tolerate it to an extent for many years before I then decided I can’t live like this anymore.
[27:58] ALLISON: I bring up a really good point because there is a spectrum of severity of SIBO. And I think it is true that a lot of people have a milder form of SIBO and they are not even really knowing that they have something wrong. They sort of know but it’s just and annoyance. And that could be SIBO just in a milder form. You know versus then it gets worst and worst and then finally it’s just the unbearable point. So I do see people with stories like that were I think they probably had a mild form for a long time and progressively got worst. And you know it’s unfortunate because we can treat it in the mild form, it’s a lot easier for you to handle.
[28:40] REBECCA: so I would like to talk a little bit about the symptoms that you see commonly with SIBO and what people…perhaps if someone is listening to this podcast who hasn’t received a diagnosis of SIBO but is interested to know whether maybe some of the symptoms they are experiencing might be associated with the condition.
[29:01] ALLISON: Ok. So the main symptoms are abdominal bloating, abdominal pain or discomfort, it doesn’t have to be pure pain and either constipation or diarrhoea or a mixture of the two. Those are the core symptoms. And the bloating and sometimes that is called distention. What we are talking about here are really sort of two things. One is when physically the abdomen swells out like a balloon or looking like pregnant. And the other part is the feeling that the abdomen is swelling out and sometimes people can have that feeling without the physical swelling and that is still a part of it. And then often they go together.
[29:45] REBECCA: And would that be a feeling of fullness even if you haven’t eaten for a while? Is that what you are referring to?
[29:53] ALLISON: It could be interpreted that way. It’s actually, it’s more of a sensation as if the belly was outstretched even if you look in the mirror and it’s not. That feeling is actually called bloating, technically. Medically that’s what bloating is. And the physical swelling medically is called distention. But nobody uses those terms. We all just say bloating to mean the actual swelling and then the feeling is a secondary thought.
[30:26] REBECCA: and I think anyone that suffers from bloating especially visible bloating, they know exactly what that is because it is embarrassing and it’s uncomfortable. And as a woman, Allison I know… and you have said this and I very much experienced this. It can often render you looking pregnant when you’re not. Which I don’t know that there are many people that want to look around looking pregnant when they are not actually pregnant.
[30:52] ALLISON: It’s terrible for your self-esteem. It can be terrible for your libido and your sex drive and just on and on it goes. And also men have the same thing and they say, “I look 7 months pregnant.” Maybe it is even worst for a man. They’ll look pregnant. So pretty awful.
[31:10] REBECCA: What are some of the less known symptoms with SIBO?
[31:14] ALLISON: A whole constellation of symptoms goes with it. There aren’t any core symptoms but almost always what goes with it. Food intolerance, food sensitivity… these symptoms are most often caused by eating. So people react to all kinds of foods and have a terrible time. They get their symptoms from food. So another symptom that can come with that are the food you don’t speak up a lot about is fear of food. And this is a like a condition response. Sometimes when we are trying to expand people’s diet, the practitioner might want to say to the person, “Don’t be afraid, it’s time to expand and try things.” But that’s a little insensitive because it’s a condition response. You eat something it causes you pain or horrible diarrhea. You are not going to want to eat it. So it takes time to get over that fear as a person heals and get better.
Another sort of mental thing are emotional that can come with it is anxiety. Sometimes depression comes with it but more often I see anxiety and I don’t think that this is… I mean there is an obvious level of emotional upset that comes with these symptoms of having symptoms and being ill or chronically ill. But actually I am talking more about an anxiety that seems to be produced I think from bacterial metabolites. I think the local polysaccharides and another word for that is endotoxin. One of their effects is to cause anxiety through gut brain access. So that symptom can come with it.
And then we have a whole constellation of other GI symptoms. For instance excessive burping or farting. There can be food feeling like it sits in the stomach and won’t go down. There can be nausea, sometimes vomiting. Although that’s not that common. And there can be acid reflux. That is very common. And then of course fatigue. It’s a very fatiguing illness for various reasons. Bloating in and of itself is quite fatiguing. Diarrhea is very fatiguing due to electrolyte and fluid loss and many of the other symptoms are too.
And then one other thing is SIBO can cause leaky gut. So one of the main symptoms of leaky gut is reacting to food again but this time with systemic systems like headache or nasal mucus or skin rash, joint pain. Things like this. So that can be a part SIBO as well.
[33:59] REBECCA: Definitely, like I look up my own experience and I use to break out in hives, very itchy hot hives after certain foods, I would have headaches. I was often quite phlegmy and mucous and I had really strong back pain for a long time, for many years. And when I treated my SIBO that all disappeared.
[34:24] ALLISON: You had it all.
[34:26] REBECCA: I had it all. I was the text book case.
[34:32] ALLISON: One of things you think about here is that you know, these are sort of the core symptoms then the constellation symptoms. And you are probably going to ask me about this anyway but there is a whole list of diseases that are associated with SIBO that aren’t necessarily gastrointestinal. Any gastrointestinal disease can have SIBO along with and one may cause the other or the other may cause the other one. But there are conditions that it might be helpful for people to know are associated with SIBO like for instance acne and acne rosacea and restless leg syndrome and prostatitis and interstitial cystitis. These are some actual classic conditions that seem to go with SIBO and we don’t know the exact reason why. And even rheumatoid arthritis.
So if somebody have any of these symptoms the idea here is that if you have tried treatment for those conditions, standard treatment for those conditions and it has failed, you may want to look into SIBO because studies show that when SIBO is treated in these disease it is better associated with, the original disease has greatly improved. For instance restless leg syndrome, the study showed an 80% improvement wen the SIBO was treated.
[35:56] REBECCA: wow! I wish I had known that so many years ago. I remember as a child, I used to want to rip my legs and feet off because they were so irritating to me. And then when I was 11 and I hit puberty I developed the most extreme acne which took… I spent years and I now know how damaging it was for my gut health. But I spent years and years on antibiotics with the doctors using antibiotics as a treatment option for my acne and it wasn’t until I was 16 and I went on a very strong drug called Roacutane that cleared my acne up. But I looked at what… it was almost like a holocaust for my digestive health at that time with all those years of antibiotics in an attempt to clear up a condition which possibly I could have been treating my SIBO then and would have seen a huge improvement in my condition for both restless leg and acne.
[36:57] ALLISON: Yes, and if people want a full list of that… I didn’t even mention my actual website but it’s SIBOinfo.com and on there is a section for associated diseases and you can see the full list and I have a study. So if you want to look at them and have your doctor look at them. You can see everything.
[37:17] REBECCA: Yeah Great! And that link is also in the show notes. So Allison talk to me about how you can test for SIBO? Someone suspects that they have got SIBO, they are matching up with some of the symptoms that you have talked about, what next?
[37:30] ALLISON: Well the test that most people do is the SIBO breath test. There is another test that it can be used to diagnose SIBO. That is a small intestine culture. But that is invasive. You do it with an endoscopy like an in-office procedure usually with some anesthesia. But this is much simpler and there are so many testes to diagnose SIBO. So the hydrogen and methane breath test and the test will be three hours long and there are different sugars basically that you drink. And the idea of that is you drink these sugars that are meant to feed the bacteria in the small intestine because then they will transform those into gas, they will eat them and make gas. And then that gas, some of it will diffuse across into our lungs and will expire it out. We can collect the breath and then see how much gas is there.
So the sugars, there are two main sugars that are used. One is glucose and one is lactulose. And that’s lactulose and not lactose. And they both have pros and cons. Most physicians I know only use lactulose because it is non-absorbable. Meaning it is going to traverse the whole small intestine and be able to feed and reach and feed the bacteria that might be lower down throughout the whole small intestine. Whereas glucose is absorbed in the first 2 to 3 feet of the small intestine. So it can only diagnose SIBO that is on the first top 2 or 3 feet of the small intestine. It does a very very good job in identifying SIBO because basically it won’t have any false positives because bacteria loves glucose. If they eat it, you will see it, you will know you have SIBO. But then the unfortunate thing is then you are missing the bottom like 18 feet.
So probably the best option of all would be to do the glucose and the lactose. But that takes a little more time and a little more money. So what most people do is they just choose lactose because it will cover the whole small intestines. And the other thing that is quite important is to be sure that both hydrogen and methane gas are being tested for with the labs that you are using because there are some machines that are older that don’t test methane or there are some physicians that are not fully up to speed on the research and don’t need that you have to represent the methane. So the machine might test it but they don’t even record it. So that is the key.
And three hours is the last piece that is quite important because that really helps us with distinguishing another gas that we cannot actually test for which is calls hydrogen sulfide. There is currently no commercial test for that. But we can see a good sense of it by seeing what happens in the third hour of the test. So that’s the test.
[40:26] REBECCA: Right. And why is it important that you are seeing both hydrogen and methane results in the test?
[40:35] ALLISON: It is important because it changes your treatment and it also changes the prognosis or how easy we think it is going to be to treat, how long this might go on. It really informs us about the whole situation and particularly the treatment.
[40:54] REBECCA: And so is one more difficult to treat than the other?
[40:59] ALLISON: Methane is harder. Methane is harder to treat and harder to get rid of and it’s tricky. And very often when I inform people that they have methane and it’s trickier to treat and little harder they go, “yeah I thought I told you that already?” a lot of them are already familiar with…intimately familiar with their condition and they know when they’ve got a tricky case. So it really helps the physician manage the treatment when we have the test. And then if I might just say, “why testing in general?” Is it a good idea?
It’s because the core symptoms that I mentioned bloating, pain, constipation, diarrhoea, these are non-specific symptoms. They are very common symptoms that can happen from multitudes of reasons and conditions. So there are about 35 or 40 other common conditions that can cause those exact same symptoms. So who’s to say is just try and treat these symptoms. Who’s to say you don’t have one of those 35 or 40 conditions. We need to diagnose it especially if our treatments are going to be antimicrobial in nature. Whether you are using what we believe is to be kinder or gentler treatments like herbs or not.
I think if we are going to be altering someone’s micro biome with anti-microbials we should be sure that that is called for. A common example I like to give of this difference what a person might have is the lactose malabsorption or lactose intolerance. Many people do have genetic primary genetic lactose intolerance and don’t know it. They really have not linked their symptoms with the consumption of lactose containing dairy. There are actually studies on this to show the prevalence of how much people link it or don’t link it. And a lot of people don’t. And so if that was the problem that the… the underlying cause there is the deficiency, a genetic deficiency of an enzyme, not a bacterial overgrowth.
So lactose intolerance can have the same symptoms. So let’s just say you bomb someone with antibiotics or what we think the kinder gentler herbal antibiotics. But you are not treating the right thing because there is not a bacterial overgrowth, there is just deficiency of an enzyme. So it’s not the proper treatment. So we really need test that for conditions and inform us of our treatment
[43:31] REBECCA: Yeah. And that moves us nicely unto what are the treatment options for SIBO.
[43:38] ALLISON: Ok so there’s 4 new treatment options. There’s diet, there’s antibiotics (pharmaceutical antibiotics), there’s herbal antibiotics, and then there’s the elemental diet. So these are the 4 main treatments. And what I would say there is that diet is a bit of a supplementary treatment to the other 3 which are kind of like killing strategies more really going after killing and eliminating the bacteria where the diet is useful to support all of those and very much helps symptoms. But it doesn’t seem to be the best which is truly eliminating the bacteria the way that the others are.
[44:16] REBECCA: So with regards to antibiotics and herbal supplements, is there a time when you would use one over the other or together? Would you use for say hydrogen or one for methane? I am really interested to know when you choose what type of herbal or antibiotic treatment to choose for a patient?
[44:36] ALLISON: Ok. I find that all three of those killing strategies are equally effective. And so really it just comes down to the pros and cons of each one and sort of customising it to the person you have in front of you to the individual. So ways that we might choose are things like philosophy first and foremost. There are people who don’t ever want to take another pharmaceutical antibiotic and won’t do it and they want herbs. So then we choose that. There are people who have tried herbs and react terribly to them and so then we choose pharmaceutical antibiotics. It’s only just an individual case by case thing.
Once you know that they are equally effective then it’s just all the pros and cons. Another thing is time. Antibiotics course is usually 2 weeks. Herbal course is usually 4 weeks. There are some people that might make the decision based on that. For instance they have an important event coming up. We have patients who have a wedding incoming and they really want a treatment under their belt for the event. Things like that.
Now, typically, the patients that I see need multiple rounds of one of the three: antibiotics, herbal antibiotics or elemental diet, to successfully treat their SIBO and that’s because it’s not like what we think of like a urinary tract infection were you take a course of antibiotics and then it completely goes away and you are all better. Unless you happen to have the chronic type of relapsing urinary tract infection, but that is less common.
Well with SIBO it seems to be more common to not get it handled with one round of treatment. Just because there is just probably so many bacteria in there, there’s only so much a treatment can do. What I find is that I use all three methods with most of my patients. We might start with herds and then we go to antibiotics and then elemental diet. Or we do even two rounds of antibiotics and then we do two rounds of herbal. So for me I just use everything. You asked the question – might we combine them? Sometimes we do. Sometimes we combine and antibiotic with an herbal antibiotic. Most often I don’t. Most often I just do pharmaceutical antibiotic and then herbal antibiotic.
And elemental diet is something you do… maybe I should just describe what it is. It is a medical food and so what is it either comes in a powder form or premixed liquid form. And it’s the nutrients that we would need, we would get from food in their most broken down form. So its protein comes as amino acids. And then fat, it’s not actually too broken down. It comes as oil. And then the carbohydrate usually comes as a monosaccharide. So the most broken down simple form of carbohydrate like glucose for example. Sometimes it’s a little longer chain something called maltodextrin.
An then we have all the vitamins and minerals in there as well and salt for electrolytes. So it’s basically everything you nutritionally should be getting from your food but broken down in the form of medical food. And so you need to mix the powder with water or you take the premixed drink. And the idea behind it is that it feed s person but it starves the bacteria because it absorbs quickly up high in the small intestine before it gets the chance to feed the bacteria. And so the bacteria die from starvation. By the way it is done for usually two weeks like how pharmaceutical antibiotics are. And within that timeframe it seems to be very effective.
One thing that is quite special about elemental diet is that it is able to reduce a high level of gas or bacteria that makes that gas in one two week course. Whereas the pharmaceutical antibiotics and the herbal antibiotics, they can’t reduce gas as much in their courses. So we often will choose elemental diet for somebody that has high gas. Another reason it’s good to have the test because it informs which of the choices you are going to make. We’ll do that for them and then for two weeks you will not be able to get gas as high as 150 down to negative in one two week course.
So where was I going with this? Elemental diet is not done with antibiotics or herbal antibiotics because the bacteria sort of goes to a hibernation mode and they need to be replicating for the mechanism of action that antibiotics and herbal antibiotics have. So it’s sort of useless to do them with. So we don’t combine that with anything else.
[49:33] REBECCA: And that leads me on to my next question which is around should you be having a restricted diet whilst using herbs or antibiotics or should you be eating to feed the bacteria to allow them to reproduce and multiply so that then the herbs and antibiotics can attack them while they are in full force?
[49:56] ALLISON: Well, there are different opinions on this. So Dr. Pimentel, the lead researcher on SIBO, he likes the idea of feeding them. And so that’s the way he does it. I am not so keen on that idea. It’s just because of patient feedback that I’ve had. I think that that might be a good way to do it or someone who has not yet gone on a restricted carbohydrate diet which is what the diet that treats SIBO is all about – they restrict carbohydrate.
If you are just new to treatment I would say, don’t alter your diet while you are doing your antibiotic treatment. But then as you start to finish the treatment, begin to get yourself on a diet. In that way you can take advantage of Dr. Pimentel’s idea. But what I see is that people who have been to a restricted carbohydrate diet then added high carbohydrates to their treatment to see that would help when they have discussed this. I have got very negative feedback on that. People say that it seems to be less effective than when they did the low carb diet. I have talked to a lot of my fellow practitioners about it. I have seen that echoed.
[51:08] REBECCA: Sure. And I think that is such an important point to make that this isn’t a one size fits all treatment or even condition. It’s completely unique to us as individuals because our micro biome is unique to us.
Unless you are on the elemental diet which is a liquid diet, the rest of us are eating food everyday… I know that there are some confusion around which diet to choose from. There’s the specific carbohydrate diet, there’s the low FODMAP diet, there’s the GAPS diet, there’s a fast track diet, there’s the bi-phasic diet. What’s your advice or approach when it comes to people choosing a particular diet protocol to follow?
[51:53] ALLISON: My main advice is just to choose one, to just pick and not worry too much about it. Pick whatever one you are drawn to. I don’t even really care. Just pick one and then start customising it to you, because all of those diets they all are targeting and reducing carbohydrates which is the general point. But the problem is that which carbohydrates are going to be aggravating, are going to be different. Most aggravating are going to be different from one person to the next. And so there is no diet that can be written on a page that can predict that. So that’s why in a way it doesn’t even matter. Just pick one and then begin customizing it. Now the problem there is you’re following a guide and then have rules. It’s saying you must eat this and you are not allowed to eat that. You have to be actually wiling to break those rules to be able to modify the diet to you successfully. So I would say pick any diet and then break the rules to find out what really works for you and doesn’t work for you.
Now I have other advice I can give but that’s my main advice. Don’t sweat it basically.
[53:11] REBECCA: Yeah. And I think it can be so easy to fall into the trap of really sweating it because especially if you have been sick for a long time and you have been reacting to foods for a while. You can become, and I know I was, obsessive over what you are consuming. SO I really like your advice of don’t sweat it. Find what works for you
[53:36] ALLISON: I can give some other advise for people who are really suffering is…a lot of people will just come to this on their own, is the more you can reduce carbohydrates, the less carbohydrates you can eat, the better you will feel, the better the symptom control. And that’s because carbohydrates are the primary food for bacteria and then they take that and they make gas out of it and the gas produces the symptoms. All of the symptoms we talked about actually come from gas. So there are another factors involved, there’s the underlying cause generating symptoms. A lot of things. But predominantly the symptoms come from bacteria eating carbohydrates. So any diet…
[54:17] REBECCA: And what are the carbohydrates that people could sort of list of people that they could…” oh yes I have been eating that. Oh I didn’t realize that was a carbohydrate.”
[54:29] ALLISON: It might be easier to start with that thing that isn’t carbohydrate. So carbohydrates are the hugest category foods. So protein is meat, any kinds of meat, fish or fowl, eggs and dairy like cheese. That is sort of concentrated protein. Now there are other foods that have protein in them but those are protein foods. Now fats are going to be oil and then there’s fat in other protein foods. Like there’s fat in egg so there’s fat in meat. And then the carbohydrate is a huge category. So vegetables, fruits, all grains. So grains would mean any baked goods or bread or anything like that. Cere al, granola, etc. Nuts, seeds, beans, or legumes and then there’s any sweetener, any sugar or sweetener and the natural sugars that existed in certain foods like lactose – sugar that is in milk. A lot of dairy products that have lactose. That’s a carbohydrate. And even the natural saccharides that exist in animal parts and particularly that gets concentrated when we make broth like bone broth. It’s mostly concentrated in the cartilage. So if you eat like say… if you have ribs and you make in a crock pot that might bothers someone’s symptoms. There’s a lot of saccharides or something like that.
So it’s the largest category of foods. It’s the foods that people tend to most crave and enjoy and use as their reward in life. So it just sucks! So it’s like thank you very much for giving me this condition that takes away these lovely foods or use these foods and have these symptoms.
So just a general tip is if someone is really suffering, reducing as many of these foods as possible will help symptoms.
Back to your question of what to do during treatment, I generally favor following a diet that helps your symptoms during the other treatment. And that can take time to figure out. And then the diet that I sort of compiled, two diets, low FODMAP diet and specific carbohydrate diet, I call it SIBO specific food guide. I think that tends to be the most restrictive on carbs and therefore it can give the best symptom release. But you may not want to start with that it if you are not really suffering. And by the way Dr. Jacobi diet… it’s her version. It’s a particular clinical version of the SIBO specific diet. But if you are not suffering terribly, you might want to start with just SCD – specific carbohydrate diet or low FODMAP. You know there’s a lot of ways to choose. But the end result is just be willing to modify it to you and over time you are going to figure it out.
[57:38] REBECCA: Yeah. Definitely. And just moving on sort of the final question for the part 1 of the SIBO interview with you Allison, what do you see as some of the biggest misconceptions around SIBO?
[57:56] ALLISON: There are two that I can think of. One is that people tend to think eating a lot carbohydrates, eating like a junk food diet or a poor heavily laden carbohydrate diet causes SIBO. And I can’t see a way that that can happen. That’s just not true to my knowledge. You need one of those underlying protections to fail first and I can’t imagine any way in which eating a carbohydrate rich diet could cause those to fail. There are no studies on that. Nobody has ever felt that that is true. But yeah, I mean experts who write. But people tend to think that, “Oh I give it to myself because I eat a lot of potato chips.”
No. That’s not going to do it. And I think it’s important to know. First of all because you don’t blame yourself and second of all to get accurate information about what really is wrong in your body so that you can better target it. Because just stopping to eat the potato chips isn’t going to make it go away completely. Your symptoms will probably be reduced because now you are eating the bacteria and you are not making gas but it’s just not accurate.
And people come up honestly with a lot of crazy ideas about how they think they got their SIBO because they haven’t had education on the subject and this includes a lot of practitioners and a lot of doctors. They haven’t taken any courses, food education courses. They are just going to come up with wackadoodle ideas. It’s kind of a good to get grounded.
The other misconception I can think of is that the urine organic acid test can be used to diagnose SIBO and it can’t. It can give a reflection. The urine organic acid test will show bacteria, yeast metabolites in the intestines. But the problem with the test is it can’t distinguish small from large intestines. So it cannot diagnose SIBO. What you might have seeing could be in the large intestine. Now it might be that your treatment is going to be the same depending on how much treatment you choose. But it goes back to the question – does the person have lactose intolerance?
I think it is really important to properly diagnose the condition.
[1:00:20] REBECCA: Definitely. So we are going to wrap up part 1 of the SIBO discussion with Dr. Allison Siebecker. But we will be back in part 2 talking more about how to find a practitioner, what happens if you are quite a sensitive patient. Are you finding treatment very difficult and also some of the lifestyle pieces around life with SIBO. So Allison I would like to thank you so much on this part 1 of the SIBO podcast and we look forward to speaking to you in part 2.