This week Dr Adam Sandford joins Rebecca to answer questions from The Healthy Gut community about SIBO. Dr Sandford is a Naturopathic Doctor and focuses on blending conventional and alternative medicines, with a special focus on gut and hormone disorders. He and Rebecca get into treatment options, diet, recurrence of SIBO, methylation pathways, thyroid, hormones and much, much more. They also chat about how important the 5 Key Pillars to Health are when treating SIBO, and why you need to look further than just your medical treatment for successful recovery.
In Episode 28 of The Healthy Gut Podcast, we discuss:
✓ The various treatment options for SIBO
✓ Thyroid issues, testing for them and what you can do about them
✓ The hows and whys of SIBO recurrence
✓ What methylation is and why our methylation pathways should be considered
✓ Why different diets work for different patients
✓ The effect of hormone imbalances on your gut
✓ Why you need to look further than just your medical team for support on your journey
✓ The 5 Key Pillars to Health and why they are key to success
Dr Sandford is a Naturopathic Medical Doctor in Los Angeles. He focuses on blending the best of conventional and alternative medicines to create personalized health protocols that meet each patient’s goals, ethics and physiology. While a primary care provider covering the full gambit of concerns, he has a special focus on gut and hormone disorders. Learn more at www.nawellness.com.
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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.
R: Welcome to the show Dr. Adam Sandford. It is so great to have you on the Healthy Gut Podcast today.
A: It is lovely to see you again. Thank you for having me.
R: My pleasure and I have the great pleasure of actually sitting face to face with you in your clinic here in Los Angeles as I am State side having been to the integrative SIBO conference. So it is really pleasurable being able to sit face to face and have a chat.
A: Yeah definitely different than the internet.
R: Yeah very different. So we last saw each other about nearly a year ago actually when I came in and met you for the first time and we did a fun video that i shared with my community.
A: People loved it
R: yeah, we’ve had a lot of views on that video and so it was only natural that I’d want to come and sit down with you and actually record a podcast interview with you.
R: so let’s start off with talking a little bit about how you came be a naturopathic doctor and also with an interest in SIBO.
[1:00] A: That’s a good question. I came to be a naturopathic doctor after 10 years of working in high tech. love it. Had a good time but it wasn’t really feeding me anymore? Looking for ways to use those same skills, medicine called and naturopathic medicine screamed. And so I went from technology. Took 7 years, went off into that land and I have been running ever since. Naturopathic medicine is just a delight to do. you have all the same tools as a conventional doctor plus oodles more where we just really get to pick and choose and base it off what’s right for the patient and what the patient’s philosophy is.
As for how do I get interested in SIBO, I think that SIBO got interested in me. About two or three years ago, we really started seeing more and more of these chronic gut conditions coming in. it’s also when the tools and the trainings really started kicking up in terms of diagnosing it. so it’s picked up and somehow I think I have picked up a reputation for being like one of the SIBO doctors for southern LA and so we just see a ton of it with Dr. Abercrombie and Lavoy and myself.
[2:11] R: You definitely have picked up that reputation as a SIBO doc which is in fact how I came across you when I was searching for docs and your name kept appearing. So yeah that reputation is there.
A: that’s fun
R: It’s amazing what you can find out on the internet. Someone said to me that you are only who you are based on what Google says you are. And so Google was telling me you were a SIBO doc.
[2:40] A: Goodness, well that’s great!
R: So you have all sorts of people coming in to your practice. Can you talk a little bit about generally who’s walking through the door and what they are looking for help with?
[2:55] A: Yeah. It’s a pretty broad array because we are on a primary care facility. It’s anybody that has anything were they want something different than the norm that can be coming in. here in California, NDs have a very broad from some prescriptive rights to ordering labs to everything else. So we have people that find out about us and they think that we really are the next step for what they are looking for. Either we have people coming in that are super healthy, they just want to expand their lives or folks that have been to tons of different specialists, not getting what they are looking for and are looking for that next step. And the thing that I hear the most is they are looking for a plant. They are looking for an idea of what is actually wrong with them and for how all of their myriad things can tie together.
[3:4] R: definitely and I myself had that experience of going to conventional docs for years and then looking for solutions and alternatives to how I could get well because I just wasn’t getting those answers with my conventional medical practitioners back in Australia and I think naturopaths and naturopathic doctors can often be a first place that people go when they start looking outside of the norm. in Australia we don’t have naturopathic doctors. That qualification isn’t available. They can obviously study over here in the states but they don’t have prescriptions rights like you guys do. So a naturopathic doctor who is qualified in America will have to treat or practice as a naturopath in Australia.
And something that Dr. Nirala Jacobi says who is and ND, studied with Bastier University, when she moved to Australia her prescription rights were no longer present. So she claims that she has become a better physician because she has to think outside the square. She can’t just go straight to pharmaceutical medications for her patients.
[5:01] A: I absolutely agree with that. I find myself sometimes using the drugs as a crutch which really isn’t what the patients need and so I don’t do it that often. But she’s very much correct. When you have to limit down the tools that you have to use, you have to get very creative and when you get creative you are able to address the conditions for more than just the single point of focus. For example with SIBO, so many folks think that it’s really just a bacterial overgrowth condition hence the name. And so thus you must carpet bomb it with antibiotics.
Well it has so many more components to it from motility to overall immune system function to thyroid impact. Everything like that where if you are just targeting the bacterial approach, just heading it with pharmaceutical anti-microbial herbs, you are very narrow only on one tiny slice of a very broad condition like we were talking about earlier. Don’t even touch on the psychosocial aspects you are mentioning.
[6:00] R: Yes, so before our interview started, we were talking about the other aspects and I am very passionate about myself which I don’t believe gets enough attention and that’s one of the things why I am so passionate about what I do as a patient advocate is that we need to think about psychology, we need to think about lifestyle, we need to think about movement, we need to think about all these other aspects that are non-medical as such but all impact the health of our body. I really like what you say that SIBO really is looking at the bacterial overgrowth itself is just one slice of the condition. Do you see that SIBO is a disease or do you see that it is symptomatic of something else that’s… or other things that are going on in the body?
[6:45] A: that’s something I have been putting a lot of thought into when I started working with SIBO. It’s very much just like how most of us are treating it. Go after the bacteria. Go after the bacteria. Go after the bacteria. But it’s looking more and more like it’s more of a motility issue, how quickly your body is clearing things out from your stomach to the large intestine and from the large intestine out. You can kill all the bacteria that you want but if that is not address you are still going to have a lot more time and opportunity for the bacteria to come back in and hit that area. So then you have to sort of do what we naturopaths call think upstream. What is causing that slow motility? Is it thyroid? Is it nervous system damage? Is it that the leaky gut has just kicked up inflammation which has just ticked off the nerves in that area which is slowing it down? If it is hypothyroid, what is causing hypothyroid?
You can keep following that chain all the way up. And that’s where i think that SIBO is more than just a killer bacteria kind of condition. You have to look at with what is going on with an individual person and try to nail the root cause well at the same time killing the bacteria so that they stop being in such discomfort.
[7:54] R: and is there an approach that you take to start somewhere? Do you go, “OK let’s look at thyroid first or let’s look at a nervous system damage.” Perhaps because there has been cases of food poisoning that may have damaged the nervous system in the gut which has therefore affected motility. How do you know where to start? Or do you just pick one place and move from there?
[8:18] A: Usually it is based on what the person is saying based off their history. If they have a lot of tiredness or scallop tongues, bumps at the back of their arms, constipation aspect, hair falling out. You think, “Oh ok maybe there is a thyroid thing going on in there.”
If they have nervous system symptoms, maybe you start thinking down that. For the autoimmune, post infectious autoimmune thing with anti vinculin tests, I am not really sold on them quite yet. But that is just a doctor’s opinion out there. I just haven’t seen it playing out clinically yet. But you just start at the place that is resonating the most whilst still trying to cast that light enough in case you accidentally missed the potential root cause.
[9:02] R: And there can be more than one as well, cant there?
A: yeah. It’s a series of dominoes that have many different paths they are falling down. It’s one thing cascaded into another. That’s one of the beauties about this type of medicine is you are constantly playing and engaging with the patient to try and track things down to the roots.
[9:24] R: And my own journey was premature birth, not breastfed. I wasn’t born vaginally but pumped full of antibiotics, multiple rounds of food poisoning over my lifetime I’ve had parasite infections. I’ve had several abdominal surgeries. I’ve had abdominal injuries. Literally everything that could have happened has happened and I look at all of the pathways for bacterial overgrowth to occur and I feel like I ticked most of those. And so like you say it’s a bit of a…sometimes you start somewhere and it’s a domino effect and what I find interesting was currently I don’t have a bacterial overgrowth in my small intestine. I am now working on these other areas within my own body to help support it and continue moving backwards optimal health. So by looking at adhesions currently and looking at methylation which we are going to talk about and looking at other aspects. Thyroid and hormones as well which I can see you are playing a big part in my system at the moment.
So I am not addressing the small intestinal bacterial overgrowth anymore because that isn’t really playing a part. But I am sure that if I don’t address these other areas, it will return.
A: yeah very likely.
[10:48] R: and do you see that with your patients that if they are only addressing it through reduction of bacteria numbers that it is more likely to return?
[11:00] A: Yes absolutely. One of the things that I council patients on these days is I am looking at SIBO more and more as a chronic condition. Just as I set expectations from both of them and myself because you can go through h those cycles. You treat it with anti-bacterials. It goes away. You feel great for a few months and it is back 6 or 8 months later. Or they do that and they do the super restrictive diet for a year and then it comes back. So we get into place the treatment. Get people feeling better, start doing all of the repair components but also I frequently have them doing you know a week per month of herbs or something to maintain it.
If a person is thinking of it as just something obnoxious that they occasionally have to swat down rather than deal with the huge amount of symptoms, it helps their long term engagement and they are focusing on other health conditions that they might have going on.
[12:12] R: Let’s talk about methylation because before we started recording this podcast, you gave me such a great very simplistic explanation of it. And it is something that I had never heard of until more recent times even when I first got diagnosed with SIBO. I had never heard of methylation pathways or the genetic mutation MTHFR. And I have asked many people what it is and I have never… I still never fully understood it. But you gave me such a simple and easy to understand explanation. So would you be able to share with the listeners what methylation actually is?
[12:39] A: well if I don’t say it exactly, remind me what I said. Methylation is a core component in every cell in your body for how the cell creates these tiny little groups called methyl groups. And their main job and this is pretty simplified but it is how my brain works, they turn things on and off in the body from DNA to enzymes to things like that. So pretty important.
The little methyl groups and the methylation process is also involved in detoxification. So getting things out of your body, helping your liver, things like that in another channel, it helps create a thing called glutathione which is your body’s … one of your body’s main antioxidants. So without that, you have much more oxidative damage and things like that that can happen. The whole cycle also helps red blood cells in making and replications of cells and things like that. So if you have methylation, you have dry skin or poor gut healing and things like that. and then there’s a whole slew of things that happens with regards to the production of your neurotransmitters but the long story short it makes stuff that helps things turn on and off in the body.
[13:47] R: You said something to me which was around turning lights one and off and I quite liked that analogy that I could almost visualize a house where lights in rooms were being switched on or off depending on the methylation. Is that fair to say?
[14:03] A: Yeah, it’s a way to help fit it into a matrix if you are thinking about it. Absolutely.
[14:11] R: And if our methylation isn’t working properly, what can happen?
A: given that it is in every cell in your body, it can manifest all over the place. Nervous system and mood conditions really are huge. So a lot of depression and ADHD focus irritability are huge things in there. Anxiety is dramatically impacted by that. Fatigue can impact immune system. And something you and I were just talking about which.. I haven’t seen studies on this yet but could be very interesting for the correlation that we see between methylation and SIBO is if methylation is compromising glutathione production and glutathione is protecting the thyroid and if your thyroid slows down you have slow motility and with slow motility you have SIBO. It’s a very interesting domino cascade. I haven’t seen any studies on this and I haven’t really talked to other docs about it but since that’s what we are talking, that makes really perfect sense for why that correlation is there.
[15:13] R: and I see anecdotally in the SIBO forums on Facebook and the like and also with my own clients that there is a lot of correlation between people with SIBO and people with thyroid dysfunction as well. How can you find out if there is an issue with thyroid and why is the thyroid important?
[15:35] A: SO the thyroid is the main driver of the metabolism in your body. If you feel cold all the type, if you have the scallop tongue I was talking about, bumps at the back, constipation, fatigue, hair falling out. All that stuff, mostly energy, that’s your thyroid that is helping to drive that. Your thyroid as part of controlling metabolism also helps control the rate at which your guts are moving, so emptying things out. Motility.
And you are asking how you can look into it and see. So definitely go to Wikipedia or The Stop the Thyroid madness website. They do a brilliant job of outlining how to do a lot of self-assessments and a lot of the labs that you want to get from your doctors. Usually because how the insurance system in America works, the doctors aren’t running the full cover of the labs. Maybe they might like to. The things that you definitely like to get would be TSH, total T3, free T3, total T4, free T4, reverse T3 (which is missed a lot of the time), anti TPO(which is related to Hashimodos), anti-thyroid globulin, and the sex hormone binding globulin. There is a bunch of others but in order to really get a picture of how well your body cells are doing with regards to the thyroid, those are the ones you really want to fit rather than just the T4 and TSH that you might have only have done previously.
[17:04] R: I know when I have my thyroid checked many times in the past, I have just had that I guess basic introductory test to it. And I am on a bit of testing hiatus of the moment. I got to be really honest. I have got testing fatigue where I just did so many tests and spend so much money on it that I am just having a break from it all. But I feel that there are issues with my thyroid based on symptoms, based on being cold. Particularly in winter, I am frozen to the core all the time, cold hands, cold feet, scallop tongue. In the past I used to suffer quite badly from chronic constipation. I don’t so much anymore but I think it is definitely worthwhile checking out thyroid for me. And my naturopath back in Australia also thinks that there may be some methylation issues with me based on some of my symptoms.
And when you talk about your very simple explanation Adam around those pathways and those domino effects on how one can lead to another and getting back to another, it really supports I think my own personal awareness and my listeners around how it is important to keep looking and that SIBO itself is not the definitive end of…. You know you might be lucky and be able to reduce bacterial numbers. But that is not the end. Sometimes it’s just the beginning.
[18:32] A: Yeah definitely. Although there are other people that just got the food poisoning, just developed SIBO and Xifaxan is the magic pill. And I would have loved those cases.
[18:43] R: I think more practitioners do. it’s simple and I think that sadly for most of my listeners there at the other camp, the 2/3s chronic have been dealing with this condition for many years and in fact I just recently ran a survey with some people and the majority of people had been dealing with this for 3 plus years but with a fair number sitting in the 5 plus year category. So it’s a chronic condition for them now.
[19:14] A: Absolutely. And what is Xifaxan’s marketing material say that 58% of all IBSD is related to SIBO so that they can sell more Xifaxan. But see how people in their entire lives had had IBS and now they finally just have a way, a structure and a framework which to address it rather than just say it’s something you have to deal with. That’s the other reason I think we are seeing so much.
[19:41] R: yeah definitely. And I think that the… my concern with the way that pharmaceuticals are advertised in the states, it’s not the same in Australia. We cannot advertise direct to consumers which is wonderful.
A: Oh my God I love that.
R: whenever I come to the US I would just feel so sad at looking at these commercials on TV and you know these well put together advertisements by the pharmaceutical companies going, “You have IBS, just pop this pill and everything will be right!” but we are not addressing the underlying cause. We are just putting a band aid over the top of it saying, “Here take this tablet and that will be ok.” But it actually won’t be for so many people. For some it is and that is wonderful. But for so many it is not and I think that is where they come looking for services with a naturopathic doctor like yourself because they are not getting the answers from those pharmaceuticals.
[20:37] A: yeah definitely. I want to see the TV ad that says, “Ask your doctor if diet and exercise are right for you.”
[20:47] R: I know. It fills me with horror, those ads….
So as we can see methylation is an incredibly important role that plays in the body. That is a really great thing the way you described before you’ve got this very elaborate diagram in your rooms here that I am looking at. It’s typical to explain exactly what is on it because there is a lot. But you did describe just that pathway of – this one category and this is basically… these are the categories and these are the wheels and the cogs turning. Can you hopefully talk about that again with me for the listeners so that we can kind of again describe that process and what it is doing?
[21:35] A: it might be hard to do without having to point and dance around the picture.
[21:42] R: what I thought was really great was how you said,” this is where you start.” And then you move up into folate and that’s basically a fancy term for folate I think and then the Cogs come together then there is methylation. And maybe dust on the photo.
[21:59] A: we can go from that and just to be clear, these are my simplified statements and while I treat methylation on a daily basis there are many doctors that dedicate their lives to this. I am certain would have to take my words to anything I am about to say. But let’s go ahead and go with it anyway.
[22:17] R: what I think is very important is sometimes we gottta simplify right down so that we can start to understand before we can go deep. If we go deep straight away then it is really difficult and you are just lost and it doesn’t make any sense as it has been the
case for me and I have been trying to learn and understand methylation now for the last probably 12 months.
[22:36] A: it’s one of the more complex things that we deal. I mean if we think SIBO is complex, this whole methylation concept takes it really to the next level. For people to take a look at their own methylation folate cycle stuff, here in the states we have a lab called 23 and Me. I don’t know if you have that in Australia.
[22:55] R: No, I don’t think so but I could be wrong. I don’t think so thought.
[22:59] A: you know actually it is still a mail.
R: I have had to mail samples many times before because just don’t have laboratories in Australia testing. So I send stuff to the States.
[23:14] A: so if you are able to for Australia but also perhaps anywhere in the world. 23 and Me does some great things for genetics. You can see where you family is from and things like that. But the most useful part for our discussion is you can take the raw data that is out of that where they have sequenced most of your genome and run that through some secondary tools. One of them is by the seeking health company and I believe it is called Strategy and that gives you a really good breakdown that utilizes this complex picture and tells the person which of the little cogs and points in this complex picture the person might have issues with. Because at the end of the day we use the term MTHFR a lot but at this big picture we are looking at there’s about a hundred little spots out there all of which looks like the MTHFR block which is the belle of the ball that’s got all the attention. But the reason she gets all that attention is MTHFR doesn’t do its job of converting folate properly then all of these other cogs that turn that make DNA, make the switches, turn light on and off that make your anti-oxidants and your neurotransmitters, if that one thing that processes folate properly doesn’t work then all of those cogs come to a stop.
The body loves redundancy and there’s tons of avenues of redundancy all through the rest of it but that’s one key area that does break down. And so I think that’s why MTHFR itself has gotten such a big name for itself. But so if you are taking a look at your strategy and results or genetics or any of the others that you can run in 23andMe data through, you can see what key areas you have in addition to just the MTHFR. If you have just won the main flavor or MTHFR, it’s pretty easy to work around. You can make a fancy folate called methyltetrahydrofolate for people that like acronyms.
If they have the thing that is right downstream from it, they can take fancy B12 methycobalamine. Ok Great! Then you have all of the supporting players. All of the minerals and zincs and things like that. So it gets pretty complicated at that point.
[25:34] R: SO when the MTHFR, if that is present in terms of the mutation, so you are saying that that stops the cogs in the wheel of turning? Is that what it is doing?
[25:48] A: It slows it down.
R: it slows it down. And then what is happening if those cogs in the wheel are slowing down. It’s just not…yeah I would love to know what it’s doing…
[25:59] R: so fi the cog’s in the wheel. If you think about a machine, if the machine slows down, the output slows down. So you start making the little methyl groups that turn things on and off like light switches throughout the body. So you have processes that slow down. You start making glutathione which has remained an antioxidant far less which means that your body’s ability to deal with toxic chemicals or even just your body doing it’s day to day business slows down, increasing aging, increasing cellular death, increasing damage across the board. If the cogs slow down you also have a difficult time making DNA. So all of your fastly recreating cells like red blood cells they can’t mature as quickly.
One good sign if you are looking at a blood lab for maybe you have a methylation thing is if the size of your red blood cells is above (I’m gonna make up a number) let’s call it 95. And if you have a homocysteine that is high too, yeah you probably do have a methylation defect. But frequently you will have people with the methylation defects where their blood looks fine. Just because you have a genetic thing doesn’t necessarily mean that it is showing up in your body.
What’s that phrase? Maybe Paul Anderson’s got it. Genetics loads the gun but your environment pulls the trigger. You might have just a mishmash of genes that somebody might say are horrible in paper but if you live in a good life, if you are relatively below stress, if you haven’t had any major reasons to trigger it, you might not be showing them up at all. And that’s something really important to remember with all of the methylation components. Just because you have the gene doesn’t mean that it is doing a single thing to you.
[27:49] R: I think that is really important and something interesting from my own experience to share with yourself and the listeners is I have the hemochromatosis genetic mutation. And both my parents are careers of that gene mutation. And when I was diagnosed with SIBO, I just happened to go into my GP and she had said, “Look we haven’t done any blood work for you for quite a while.” And so she ran that and she said, “I just want to check cholesterol and just deal with your sugars and all of the rest.” And my ferritin levels, my saturation levels were incredibly high. And because I had been going to that one GP for many years, we had a history of blood work and when we actually put them side by side we could see that my ferritin saturation had been steadily increasing since I started going to her since returning to Australia from living in the UK.
But really interesting was that 6 months later, once I had cleared my SIBO, my ferritin was back down in a normal range and it had dropped significantly and she was amazed by that. and it just I guess goes to show that I have the genetic mutation but because my diet, my lifestyle, my stress, my gut health, my overall health had dramatically improved because I had been dealing with SIBO in my life that it had a big impact on this gene.
[29:22] A: That’s fantastic. There might be a secondary…
R: I am sure there is more than that…
[29:30] A: Ferritin also spikes when your body is under acute inflammation. If you have SIBO you have all kinds of inflammation going on. Treating yourself well, taking care of your body, fixing your gut is going to drop the inflammation. So it might not have been a genetic component. It may have just been a natural response.
[29:50] R: that is so interesting. It could have been. We won’t know. Who knows? The good thing I have lost count the ferritin and my body has returned to normal. I am just going to watch it with interest and see what happens. I love being a science experiment of one. So much fun and this is why I… one of the reasons why I do the podcast is because I get to talk to people like you and learn so much every single day.
[30:21] A: From a podcast like yours, we are talking to so many doctors and especially patients, patients who have done more research probably than any other doctor out there. It is from engaging with folks like you that we actually learn more. Doctors hanging out in ivory tower don’t grow.
[30:37] R: Yeah. And I think that… and we were talking about this before. It is really important. It is important for me to be sharing information and knowledge out there so that the SIBOers can feel empowered and educated on their own condition but also so that we are sharing knowledge and information amongst our medical community so that people learn. We can only learn with further research and talking to others and hearing what other practitioners are doing in their practice and what works for them and what doesn’t work for them. So yeah I love it.
One other thing that we did talk about before we started recording was the need for food allergy testing. And your views on whether we should be testing, we could literally spend our lives in tests and sometimes when you have got SIBO, of course that’s what you are doing and you are spending a bucket load of money on tests. It’s so expensive sometimes to having this condition. So what are your views on food allergy testing?
[31:41] A: I’d say this is probably one of the more controversial topics amongst all of us. And this is one of the great questions that was on our Facebook or on that SIBO discussion support group page. My personal approach towards food sensitivity tests when somebody has high inflammation high CRP, high IgE which is the allergy related biomarkers, or SIBO or leaky gut, is that it might not be as useful as you want it to be. I view them as a 50/50 for you. So I tell patients that right off it’s a potential gamble. Sometimes they can be glorious and beautiful and really nail exactly a food or a group that’s hitting you. Or and you see this with people that are inflamed or with SIBO, tons and tons of foods come back positive. And so all of a sudden the person is taking a FODMAPS diet and reducing it down even more to where they are eating like a rabbit. And in reality what you will frequently see is you fix their gut, you deal with any leaky gut types of things, you calm down the immune system. Look at the same tests 6 months later or a year later and maybe only 1 or 2 foods are impacted.
So the test has benefit but also has danger. If it comes out useful, it is beautiful. If it comes out artificially inflamed, a person thinks they can’t eat ever again in their life and might continue with that test agnosia. And so I encourage the testing under the appropriate conditions namely your body is not crazy inflamed or if you have the extra funds and you want to do it. Absolutely. I do that for myself. But just do it with open eyes.
[33:28] R: are there certain tests that you think absolutely categorically are the base standard that you would do with a patient? Or is it kind of how long is a piece of string?
[33:40] A: Yeah. Are you talking about just the food sensitivities?
R: In testing in general when it comes to SIBO and gut conditions.
[33:51] A: yeah. Ok. Definitely base thyroid, I do look at methylation type of picture. I do comprehensive regular body analysis and homocysteine and a few other things. A relatively complete blood panel, if I think they have SIBO and definitely obviously doing the lactulose breath test, maybe a glucose one less often. And I might just leave it at that initially. I haven’t really run the anti-viniculin IBS check more than 10 times. It hasn’t correlated clinically but maybe I am just not using it the way that other folks are. I might do a salivary cortisol test if I think that adrenals might be impacting thyroid which might be impacting motility. I might do a stool panel. I use Genova’s but there are many good panels out there. If I think there might be a parasite blasto or candida bacteria. Even those, those don’t always show up, they can be useful. Those can also give you an idea of what bacteria might be overgrowing. There is theory that the bugs that you see in a stool test have no reflection to SIBO. But I consistently see that to be… if you do have something exponentially higher in the bacterial panel they are going to blow positive for SIBO.
That’s another contention thing amongst other doctors. But I see it being useful. That’s a good starting point.
[35:28] R: definitely. And it definitely gives a good picture of their current health and I think that from what I have learned doing this podcast is that the tests can be very useful but they are also just a picture in time of what is going on today.
So with that in mind do you do then retest and if so how quickly do you retest?
[35:51] A: So I’ll do the initial test and then we’ll get together and initiate some treatment. And the way I usually work, but this all depends on the philosophy and means of the patient to around of whatever pharmaceuticals seem appropriate. A round of herbals and then retest. That’s a fairly short treatment but if you don’t see any improvement at that point, well you are doing something wrong or you are choosing the wrong agents. If you are seeing improvement, do that same loop. Maybe mixing and matching with both the pharmaceuticals and the herbs to prevent resistance as we were talking about earlier. And just more to ensure broad spectrum coverage. And do those until the person is feeling like they’ve had a plateau of improvement. And then retest again.
[36:39] R: and do you use the herbs and the antibiotics at the same time or do you run one course and then follow it up by the other course.
[36:49] A: right now I run them pharmaceuticals first followed by herbs but that is an interesting idea and if any of yoru listeners have worked with any doctors that have run then together, I would love to hear about their experience. I might throw in some anti-yeast herbs when I am doing the pharmaceuticals. We throw in some biofilm tools but I typically heat them a little separate.
[37:13] R: and let’s talk about biofilms. Do you do much work around with biofilms and if so what do you do?
[37:22] A: well the concepts of biofilms make a whole ton of sense. The bacteria making this little protective shell that they get to hang out in and if you are trying to carpet bomb the bacteria, you need to be able to get to them through the shell. So the theories make sense. I think they have panned out some studies that Pimentel and a few other folks have done. So if somebody has a longer term type of SIBO, yeah I will run some type of biofilm buster. Personally I use interface or compounded one with bismuth DMPS and I think DMSO. But there’s a lot of different tools out there.
[37:57] R: and given that motility is often compromised in the SIBO, what do you do to support motility in patients?
[38:06] A: the ones that are used most these days, Melanie Keller loves Motile Pro or at least she did last year. And I have seen a ton of good improvement with that. That’s a supplement by pure encapsulations. Also low dose erythromycin , so I believe a fifth of the smallest pill that you can get out there. That one has good studies on that and then Pimentel group uses one called Resolor or Prucalopride, it has another brand name too which has really good effects. So all three of those are useful.
[38:43] R: I actually use motile pro myself. I loved it. it worked really well for me and it also made me feel really good. So it was kind of double whammy.
[38:53] A: how did they make you feel good
[38:55] R: I felt really positive and actually my naturopath was telling me that they’re……(I gotta try and remember their correct information) but I am pretty sure she said that it had an impact on melatonin I think. I might be completely misquoting her. But anyway she said that it did have a positive impact on other things on the body and that was probably why I was feeling so happy and positive. I put it down to the fact that I was going to the toilet every day for the first time in my life. And I didn’t realize how good doing a poo everyday makes you feel.
[39:26] A: everybody loves pooping
R: it was wonderful not having to strain and sit on the toilet for hours.
[39:36] A: we just pulled up the ingredients… I could see why this could make somebody feel good. It has a little bit of 5HTP, a little bit of a happy hormone to it which probably somebody out on SSRI antidepressant might contemplate before they take this. This is not medical advice. And then the ginger, that’s a great boosting energizing herb and that, is also the main motility one. So I want to try that now. I might poop fine.
[40:00] R: one of the questions I’ve had from the SIBO Facebook group was the person currently using Resolor asking if anybody…if you have ever seen people find difficulty sleeping when they are taking that. Have you ever seen that in your clinical practice?
[40:20] A: That is a brilliant question. No I haven’t. You do with LDN Low Dose naltrerxone for up to 2 weeks but I haven’t heard about that with Resolor. The worst I have heard with Resolor is it being a little too strong and people needing to cut the dose back.
[40:37] R: as in you provide some or give some diarrhea?
A: so if any of your listeners have that same experience with the Resolor, post it to your Facebook page or wherever this things comes up. I would love to hear about it.
[40:50] R: Yeah, people can head to the Healthy Gut Facebook page and put in any comments that they have got for Dr. Adam Sanford on my page and he will make sure he sees them. In terms of… so I have talked a little bit about treatment. Are you saying any passions coming through that or becoming resistant to either the herbs or the antibiotics that you are using to treat them with?
[41:15] A: I haven’t seen people that have become resistant and from at least the studies from Pimentel and Weinstock and those guys last year, they haven’t seen too much in terms of Xifaxan resistance. And if you are doing neomycin or metro with the Xifaxan, the Xifaxan prevents theoretically the resistance from building. I think maybe what we end up seeing more is that you have taken care of the initial crop of bacteria that are susceptible to the one agent and now you are dealing with another batch.
I guess this might lead to how one might go about interpreting SIBO labs and all of us do it a little differently so this is just my particular take. If somebody has high methane but they are not showing very much hydrogen, to me that actually means that they still have a whole ton of hydrogen, it’s just being hidden by the methane. So if we do a certain set of antibiotics which is dropping the methane, and then they go from having a constipation to a diarrhea picture and that same treatment over and over again doesn’t work, it means that this shift is necessary.
So I haven’t seen nor heard of them building resistance but the concept of needing to have a broad spectrum approach I think is really important.
[42:40] R: and I hear that quite commonly that numbers will jump after a round of treatment and people are like, “But I just did my treatment, why have my numbers just skyrocketed.”
[42:52] A: well that’s one of the things I love to see. If somebody has really have methane and low hydrogen, I saw this a couple of times in the last two days. Then there methane drops and the hydrogen jumps they go, “Yes, this is great! Things are moving forward. But my numbers went up yet but…” it’s a math thing. You have CH4 for methane. So there are 4 hydrogens and H2 is the other one. So methane bugs gobble up the hydrogen. Ok that is totally beside the point.
[43:18] R: but I think it is important to understand how the base level of how that works because it can be very confusing and upsetting to think if you are looking at your test results going, the number one objective for me is to have my numbers reduced and then you see the results and they have actually gone up. Understanding that the methane is gobbling up hydrogen and so by reducing the methane producing bugs that that is going to potentially lead to more hydrogen then that’s not so upsetting.
[43:49] A: ok…
A: No that’s exactly my interpretation of it. And if people are worried about that when they look at their labs, I completely agree. It is important to understand, that concept.
[44:00] R: yeah definitely. Let’s quickly touch on nutrition. Because nutrition is something we all think about a lot when we have got SIBO. What do you do with your patients? Do you put them on one of the SIBO diets? Do you give them the options? Do you try and modify something so it’s specific to them? What is your approach?
[44:24] A: I’ll usually start by putting them on to one of the low FODMAPs SCD1 either doctor Jacobi or Siebecker’s lower FODMAP ones to see what their response is because if that right there can reduce a lot of the diarrhea and discomfort, hey go with it. I am hit or miss as to whether or not it should be done long term. It can be pretty limiting. It can also drop people’s compliance in terms of getting better. But then again, if you are not doing the proper work to limit your diet, to prevent the bacterial growth, then you may be one of the many many people that come back in 6 to 9 months. Or is it due to motility.
But the diets I use, they are typically one of those too. There is one of the food delivery services I am totally going to plug them.
[45:19] R: free advertising for a living.
A: this is in the states and the group is caveman chefs. I already looked at them for paleo stuff but they will actually customize and so they have gotten to making low FODMAPs food delivery. So you can take it, pop at the microwave. So if you are getting super tired of eating in a certain cooking and restaurant and having to do that crazy selection, you can buy other stuff and just have something in the freezer as easy quick food.
[45:48] R: that is so wonderful. When I was going through treatment, I used to think I just wish there was somebody that could just deliver food. I love to cook and I am such a foodie. But there are times when you just don’t want to cook. You are tired you are exhausted, fatigued and over it.
[46:03] A: You know what I would love to see?
R: what’s that?
A: I would love to see you collaborate with them because they are just taking the food list that I gave them. You know how to execute them best. If you could help them execute on this and help all the people here and then maybe help somebody replicate the same model in Australia, you could do a ton of good more than ever.
[46:23] R: definitely. Let’s see what we can do. Let’s see what magic we can do. There was a food system… there is a café in Melbourne who reached out to me and they were doing a home delivery in Melbourne. So obviously not even national. Only in the city of Melbourne in Australia and they had taken Doctor Jacobi’s biphasic diet sheet and they were creating SIBO meals based on what phase you were in. there’s three phases if you like.
I road tested it for them because I said to them, look let me see what it is like because I know the world of SIBO so intimately and I still relatively recently out of my SIBO treatment. I will tell you what, just having someone create your own food, create food for you that was compliant, they modify it to any additional requirements that you had so you could say, “look here’s the food guide but I can’t tolerate pumpkin. I personally can’t have any quinoa,” and Nirala Jacobi had recently introduced quinoa as an additional kind of carbohydrate, it’s not a grain but it’s a seed that acts like a grain. And I have violent reactions to it. My system hates it. I am violently ill with crippling stomach cramps from it. Anyway I said to them, “Look I haven’t eaten it in sometimes but when I included it, it wasn’t a great outcome.” But what was real lovely was that they were able to modify.
But just knowing that I could go home after a busy day and there was a dinner prepared for me and I could just heat it up and it was really beautiful food from local providers, local producers or mostly organic and just gorgeous. And if I had that when I was going through a treatment and if I had been that person struggling with compliance that would have made all the difference because my food was there. It was prepared for me. It would have been absolutely worth the investment and I would have stuck to it. And I think having more services like that both here and the states and across the world will just help people to support getting well again.
[48:41] A: I completely agree and I came across them because in January I was doing the whole30. So I came across every food delivery service that I thought I wanted to approach. And I don’t know I spent a ridiculous amount of money testing all 5 companies over January. And yeah having the food when you are doing a restrictive diet just being able to be magically dropped onto you like the stork and a baby is delightful.
[49:05] R: it is. And it is one of the reasons why I developed a cookbook. Whilst my cookbooks aren’t actually putting food in you fridge ready to go, it’s a next step forward at least so that you can have delicious recipes that are easy to make that you don’t have to think. You can just open a book and go, “tonight I am having the beef rending.” And being able to take dishes that would normally be completely off limits and making them SIBO friendly. And I know that has helped a huge number of people who are still happy to cook to take away some of the stress and anxiety and one of my absolute passions in life us that there are enough support services out there for our SIBOers so that we can return to living a great life. Not an average life, not a mediocre life, but a really happy and fulfilling and wonderful life through our entire life and that we are not focusing so much on how sick we feel but we are focusing on other things because some of the stressors in life are taken away from us. Like, “what the hell do I eat?”
Some other aspects that I developed Adam is I went through my journey. What I call the 5 key pillars to health and they are awareness, nutrition, movement, mindset, and lifestyle. I have talked a little bit about nutrition. I have also talked a little bit about awareness but I realized that in order to truly regain my health and I am still on that path, I wouldn’t say that I have regained optimal health but I am definitely a hell of a lot better that I have ever been in my life was that A) I need to stop being aware of my surroundings, my body, my education, everything which is why I have ended up doing this. My nutrition is fundamentally important because what I eat is what I become both today and in the future. My movement is important I believe because without moving my body I am sedentary slug and we were designed to move. My mindset is equally as important because what I think is what I am and if I think in a very negative way then my body I believe will sit in a very negative state.
And then the final piece being lifestyle was how I supported this body of mine through sleep, through stress, through relationships. All of that. Do you talk to any of your patients about these other I guess complimentary and supportive approaches to regaining health?
[51:38] A: absolutely. At the social aspect, I look at the personal aspect, the self-cultivation, the self-care. From what you are saying about stress is dramatically huge. And exercise, that’s going to control a whole ton of the metabolism. And so I do touch on it. But I think that that’s an area that most physicians including myself don’t do enough in. we are just so in the trenches of fixing the one little area that is causing you the greatest distress but we are not engaging to the depth and the level that we like to, time constraints whatever.
For the ultimate perfect long term cure, there needs to be a collaboration between the doctors that are doing the direct day to day training or treatment and the professionals like you that are engaged all in those other aspects. It’s like there’s a nutritionist that I worked with some times in the Seattle area who helps pick up some of the nutrition load because it’s just not an area that I have the time to focus on but I think all of us SIBO doctors need somebody like you or other people who focus in this area to help us deliver to the patients that complete holistic full circle approach.
So if you have any thoughts about how you might engage with all of the SIBO doctors that would be great. It’s like you were saying with the most recent conference, there was a huge amount of that direct care, self-care component that was just missing. It was all out treating bugs and motility and methylation.
[53:28] R: it was a great conference and I’ve taken away in having learned a lot from it again. One of my big bug bears in the world of SIBO treatment is that we are being very narrow focused on it because we are thinking about just the bacterial overgrowth and we are not thinking about all of these other aspect of life which contribute or can hinder return to health. And if someone is eating good quality food or they are only getting 5 or 6 hours sleep at night and they are incredibly stressed. They’ve got a really stressful, the body is under stressed naturally from this overgrowth of bacteria then you are pouring more stress on perhaps you are in a relationship that you fundamentally know isn’t right but you feel that you can’t leave. You might have a sick child that is causing a lot of stress.
All of these things are limiting our ability to get well and I have just really… I am driven to support SIBO patients on these other areas because I just don’t see that we are talking about them enough. Some people are but I don’t feel like it’s being talked about enough nor is it being addressed in their medical consultations and perhaps that is never going to be the role of those medical consultations and perhaps it’s the role of people like myself that need to really be driving that awareness on these things.
[54:54] A: no, I think it is the role of the doctor to be able to provide that and the role of the professional coach is like you to be able to do that too. But if we are talking about a role for you come up with scaffolding that the doctors can wrap their brains around to deliver the things that you think that the patients need by your assisting us your reach could extend tenfold. And I personally going to be all that.
[55:25] R: interesting. Well it’s really interesting having these conversations. You never know exactly where they’ll go. So to all the patients and the practitioners listening to today’s podcast, drop me an email at [email protected] and let me know what you think that you know how I could be of service to both the treatment of the patient and also from the patient’s perspective because I’ll tell you what I am dedicating my life to supporting people to move away from chronic illness and move towards health and happiness because even though I wouldn’t say that I am the most optimal health now, I tell you what – life is absolutely bloody amazing today for me and I was sick for 36 years and I don’t want another single person to feel like I did and nor should they have to. So I am driven to make a change in this world and to my dying breath I will be passionately doing that.
[56:25] A: I am happy to help you figure out how to engage with us.
R: thanks Adam. Dr. Adam Sanford, it has been an absolute pleasure to have you come onto the healthy gut podcast today. We have talked about all sorts of things. We have answered quite a few of the questions that my gorgeous SIBO pips from the Facebook group had asked me to try and get answers on. So I appreciate the time that you have spent with me today and also sharing your knowledge. Thanks for coming on the show.
A: absolutely. See you next year.