SIBO Advanced Concepts with Dr. Allison Siebecker: Rational Wellness Podcast 123
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Dr. Allison Siebecker discusses SIBO advanced concepts with Dr. Ben Weitz.
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3:24 There is some confusion about what IBS/SIBO patients mean when they report some of their symptoms, such as constipation and gas and bloating. Different patients who complain about constipation can mean a number of things. Dr. Seibecker has a whole section in her new course about this.
Dr. Weitz’s observation: For some people, constipation means that they haven’t gone to the bathroom in three or four days. Other people, they’re going to the bathroom multiple times but nothing is coming out. Then some people go to the bathroom and they just sit there for an hour straining.
Dr. Siebecker: Constipation is defined by both the texture and the frequency of the stool. Texture has to do has to do with whether it’s loose, that will be more like diarrhea, or whether it’s formed that’s normal, or whether it’s in these little balls or pellet, which is a form of constipation. So a person could be having high frequency, so they’re going and sitting down on the toilet and having a bowel movement say 10 times a day, but every time it’s one little pellet. So that’s mixed, that’s a mixture of diarrhea and constipation because then they have the texture of constipation but the frequency of diarrhea. With respect to diarrhea, the texture there would be loose or watery and the frequency would be more than 3 times a day. So the normal range is 1-3 bowel movements per day. The other way to categorize it has to do with the sensation, whether they have urgency or are straining. If they are straining, this is a form of constipation. A person might have loose texture, but not go very frequently. They sit on the toilet and strain and strain and then out comes water, which another form of mixed, though they might call this constipation. The other consideration is to look at the Bristol Stool Chart, which Dr. Siebecker has on her pencil holder.
Type 1 is the small balls characteristic of constipation. 3 and 4 are normal. 5-7 is the diarrhea side of things. When you have patients with mixed pictures, what matters is not what you call it, but that both you and the patients are on the same page with what they are talking about.
When it comes to bloating, there are two terms–distention and bloating. Distention is when the abdomen swells out with gas. Bloating is technically the sensation or feeling of bloating, basically of the abdomen swelling out like you get a feeling that your abdomen is swelling, but it may or may not be. Some patients have the sensation or feeling of bloating, of their abdomen swelling, but it never does. This relates to visceral hypersensitivity. The sensation of bloating can be very aggravating and some patients need to put on looser pants due to the discomfort. We must differentiate this from edema, which can occur from water retention, which in women could be related to the menstrual cycle. If you do a percussion on the abdomen as part of your physical exam, you can hear a hollow tympanic sound when it’s gas and not when it’s fluid or fat.
13:25 When a new patient comes to see Dr. Siebecker, usually they have been to see several other doctors, so her examination and approach is a bit different than a doctor seeing a patient for IBS who has not seen anyone else yet. Before doing any testing, she usually likes to use first line therapy, including diet and lifestyle. She makes sure they are eating healthily, chewing their food, using stress reduction, fresh air, and exercise. The next steps are basic supplements and low risk modalities, like digestive enzymes, hydrochloric acid, and probiotics.
17:52 If the first and second line therapies fail, then Dr. Siebecker will recommend some testing, including a three hour lactulose SIBO breath test, a Functional Medicine oriented stool test, perhaps the IBS Smart serum test, and screening blood work. Dr. Siebecker prefers using lactulose over glucose, since glucose is primarily absorbed in the proximal portion of the small intestine, so you don’t learn about the rest of the small intestine. She prefers the three hour SIBO test, since any elevation of methane of 10 ppm or above even in the third hour is considered a positive. Also, Dr. Siebecker mentioned that Dr. Pimentel uses a cutoff of 3 ppm for methane and Dr. Siebecker also thinks that a cutoff point of 10 is too high and thinks that it should be 8 or perhaps even 6. Dr. Siebecker also said that while The North American Consensus on Breath Testing says that a positive finding for hydrogen requires a rise in hydrogen of ≥20 p.p.m. by 90 min, Dr. Siebecker considers a rise at 120 min positive for SIBO as well, esp. if there is reason to think that there is slow transit time, such as constipation. She pointed out that this is the criteria that the manufacturer of the breath test recommends.
24:42 What has become understood in the SIBO world recently is that methane is now being thought of as a different disorder and not necessarily SIBO. The methane may be in the small intestine, the large intestine or both. Even if they are primarily in the small intestine, since they are not bacteria but archaea, then it is not technically bacterial overgrowth. Now we also need to consider that they are normal commensal bacteria in certain populations. But on one level, it doesn’t matter if the methanogens or in the small intestine, the large intestine, or both, since the treatment is the same.
27:24 There is a blood test that Dr. Pimentel developed called the IBS Smart Test from Gemelli that helps to distinguish if the origin of SIBO is due to food poisoning and Dr. Siebecker said that also usually includes this in her initial testing for patients with IBS. This test will tell us if using a prokinetic is an essential part of the treatment. Cyrex has also developed a similar test but that measures more antibody markers called Cyrex Array 22, but Dr. Siebecker said that she prefers the IBS Smart Test because it has been validated with published studies, while the Cyrex Test has not been. Dr. Siebecker said that she has run organic acid urine testing, but she may not do it, since you will hopefully find out about fungal overgrowth from the stool test and she will also find out about parasites as well, that the organic acid test will not tell you about.
36:12 Methane SIBO is so much more difficult to treat than hydrogen and Dr. Pimentel speculated that this may be because the archaea live down in the mucosal layer of the intestine and are harder for antibiotics or antimicrobials to reach. Also, we know that methanogens make biofilms. Dr. Siebecker said that she used to use biofilm busting enzyme formulations and did not notice much benefit, but she thinks that some new products that Dr. Paul Anderson designed may be more effective. Dr. Andersen says this may be because you have to use stronger right products to break up the biofilms, including a product containing bismuth, which is also in Pepto Bismol. Bismuth is a heavy metal that has a low level of toxicity and which is used to treat H-pylori bacterial infections and is considered an antidiarrheal agent. Dr. Anderson has a prescription product called Biosolve-PA, which contains Bismuth and DMPS and also an over the counter supplement called Biofilm Phase-2 Advanced, which contains Alpha Lipoic Acid, bismuth subnitrate, and black cumin.
40:05 Dr. Rahbar, who spoke at the last SIBO conference, at Los Angeles Integrative Gastroenterology, finds that his methane SIBO patients often have co-infections with viruses or Lyme disease or other parasites or mold toxicity or glyphosate toxicity. He thinks that methane SIBO is partially a form of immune dysregulation. Therefore, taking IgG products, such as Serum Bovine Immunoglobulins, like ImmunoLin or SBI Protect, can be helpful. Dr. Siebecker also finds IgG products very helpful for SIBO patients. Dr. Siebecker said she has been taking it and besides its benefits for the gut, it has helped lower her LDL cholesterol, which is genetic. These IgG products are purified forms of colostrum, which Functional Medicine practitioners have been using to heal the gut for many years. Also methane is related to TMAO levels, since TMAO, which is the latest marker for heart disease, is mostly manufactured in the colon by gut bacteria. Higher levels of archaea result in lower levels of TMAO, which has led some to propose supplements of archaea, called archaeabiotics, to help lower TMAO levels.
48:03 Some Functional Medicine doctors have been using peptides to help with gut health, such as BPC 157, and Dr. Siebecker has tried it and she is not sure it is making much of a difference.
49:53 Visceral (gut) hypersensitivity is often a factor in SIBO and curcumin and bifidus infantis, that’s sold as Align, are both effective treatments for reducing this hypersensitivity.
51:38 To prevent recurrences of SIBO you can recommend a low dose of antimicrobials, such as 2 capsules of oregano daily on an ongoing basis. Dr. Siebecker pointed out that if patients are at 80% cured, if you do one more round of treatment, you can almost always get them to 90%. She recommends prokinetics to prevent recurrence rather than antimicrobials. She said that the natural prokinetics are not as strong as the prescription prokinetics, like low dose erythromycin or prucalopride. These prescription prokinetics are more effective and prucalopride is also neuroregenerative and helps to heal leaky gut and to protect against cancer. The other thing that patients will do as they are expanding their diet is to use digestive enzymes.
57:19 Dr. Siebecker is very excited about her new advanced course for practitioners to learn how to treat SIBO called the SIBO Pro Course. It’s essentially a doctorate level course that she teaches at Naturopathic Medical School that she expanded. It incorporates answers to all the questions she has gotten over the years and it is in a very organized format. There are 2 versions of it. There is the self-study version that you do it on your own schedule and they she is also running it kind of like a college quarter over eight weeks and this version starts September 28. You watch 2 1/2 hours per week and you meet for office hours and this version includes learning enhancements, optional quizzes and study guides that you can use as you’re watching to help with the learning. Here is the affiliate link if you would like to sign up the SIBO Pro Course: https://smpl.ro/al/7TEGvvBoGSzFtdoZLL7BGpGM/15770-Ben-Weitz.
Dr. Allison Siebecker is a Naturopathic Doctor and Acupuncturist and she is very passionate about education. She specializes in the treatment of Small Intestinal Bacterial Overgrowth (SIBO) and she teaches advanced gastroenterology at the National University of Natural Medicine. She has the most incredible resource of research articles and information about SIBO on her website, siboinfo.com. Dr. Siebecker has a new course for clinicians Advanced Training for Practitioners On Small Intestine Bacterial Overgrowth Taught by Allison Siebecker, ND To sign up for this course, please use this affiliate link that will include a small commission for me: https://smpl.ro/al/7TEGvvBoGSzFtdoZLL7BGpGM/15770-Ben-Weitz
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Dr. Weitz: This is Dr. Ben Weitz, with the Rational Wellness Podcast, bringing you the cutting-edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to Apple podcasts and please give us a review and a rating. That way more people will find out about the Rational Wellness Podcast. Also, you can see a video version on my YouTube. If you go to my webpage drweitz.com, you can find complete transcripts and detailed show notes.
Our topic for today is small intestinal bacterial overgrowth and irritable bowel syndrome, how best to understand these, what are some of the latest diagnostic methods and gain some insights into an integrative reproach to treating these. This is the second interview with our special guest, the queen of SIBO, Dr. Allison Siebecker in a few months. I’m regarding this as part two, and I’m mostly going to ask questions, which we did not get to in part one, which is Rational Wellness episode 110; please check that out. To put it in another way, whereas Dr. Siebecker laid some very clear recommendations for understanding hydrogen and methane SIBO, how to treat them, I suspect that this episode will not be quite as clear since I planned to take Dr. Siebecker into some of the murkier waters related to SIBO where answers are not quite as clear cut.
Dr. Allison Siebecker is a naturopathic doctor and acupuncturist. She is very passionate about education, and she has a wonderful new program for educating practitioners about treating patients with IBS and SIBO. She specializes in the treatment of small intestinal bacterial overgrowth. She teaches advanced gastroenterology at the National University of Natural Medicine. She has the most incredible resource of research articles and information about SIBO at her website, siboinfo.com. Allison, thank you so much for joining me today.
Dr. Siebecker: Thank you, Ben.
Dr. Weitz: So there’s a form of IBS and nobody ever talks about. It’s called podcast-induced IBS. Every time I do a podcast even if I’d just been to the bathroom when I’m about ready to get started, I have to run to the bathroom one more time even though there’s nothing there. It’s one of those stress-induced things. I note Dr. Pimentel doesn’t feel the stress is really a factor in IBS, but it’s got to be a factor.
Dr. Siebecker: It has an influence.
Dr. Weitz: Anyway, have you noticed when speaking to patients about IBS and SIBO that there’s a lot of confusion about some of the terms? When I interviewed Dr. Pimentel, I talked about the fact that there’s a range of different things people mean by constipation. For some people, constipation means that they haven’t gone to the bathroom in three or four days. Other people, they’re going to the bathroom multiple times but nothing is coming out. Then some people go to the bathroom and they just sit there for an hour straining. The same thing when we ask patients, “Do you have gas and bloating?” I think for a while I would just say, “You have gas or bloating,” or they would check it off and I go, okay, that’s it. Then the more I talk to patients, I realize that there’s a number of things they mean by gas or bloating. Some patients have abdominal distention due to gas. I think there’s some patients that feel bloated because they just ate a large amount of food and they have this thing about not having a lot of food. Some feel if they pass gas, they call that gas or bloating. I even had one patient that we have been going back and forth with. I’m trying to understand his bloating. By the time we’ve been testing him and treating him, I realize a part of it is just that he has a large stomach. He just feels it’s bloat and I think it’s really not.
Dr. Siebecker: So you just told me a little bit about this and these stories right before we started. I was like, “Oh, my God. This is so fabulous.” Because I agree completely with the importance of making sure we understand what patients mean that we’re on the same page with how we’re using the words of the symptoms. I have a whole section on this in my pro course, which is… So shameless promotion here. It’s starting September 28, and I invite everyone to join me– 20-hours and there’s a continuing education. So let’s just go through with some of these symptoms. So for constipation-
Dr. Weitz: Hey, Allison, your volume is kind of going in and out a little bit. I think if you lean forward a little bit-
Dr. Siebecker: It’s better if I lean?
Dr. Weitz: Yeah, right there, yeah.
Dr. Siebecker: Why don’t I… I’ll just hold my microphone.
Dr. Weitz: Oh, okay.
Dr. Siebecker: You know what, everyone listening, Ben and I we’re just talking about having terrible IT problems with my webinars lately. So I’m just going to hold it so you can hear me well.
Dr. Weitz: Okay, good.
Dr. Siebecker: So constipation is defined by both the texture and the frequency. So when we talk to patients, we have to clarify it. Also, the easiest, really the easiest thing to do is to ask patients what do you mean, tell me more, just start with that, and then you can start in with your clarifying questions. So the texture has to do like texture in amount that has to do with whether it’s loose that will be more like diarrhea, or whether it’s formed that’s normal, or whether it’s in these little balls or pellets. So some people say rabbit pellets or balls or things like that. So that’s a form of constipation. So a person could be having high frequency, so they’re going and sitting down on the toilet and having a bowel movement so to speak 10 times a day, but every time it’s one little pellet. So that’s mixed, that’s a mixture of diarrhea and constipation because then they have the texture of constipation but the frequency of diarrhea. So it’s weird how these things can all mix together.
Dr. Weitz: I tend to think of that as constipation, right?
Dr. Siebecker: It is, but there’s… It’s true, it’s more constipation, but they’re having a constant frequency thing.
Dr. Weitz: Right.
Dr. Siebecker: So then the frequency typically for constipation is less than one bowel movement a day. That is like how it’s defined by the experts in the papers. Now if we go over to diarrhea, I’ll come back to constipation in a minute, but if we go over to diarrhea, the texture there would be loose or watery and the frequency would be more than three times a day. So the normal range would be one to three. Now some people they don’t like three bowel movements a day, but that is considered normal. So it’s when you get above that.
So the other thing has to do with the sensation, so the urgency and the straining. So another way to define constipation would be are they straining. Again, this is where we get into those odd little mixed pictures because a person might have loose texture but maybe they only go once a day. They sit on the toilet and strain and strain and strain and then out comes a whole bunch of water. What is that? That’s probably constipation with fecal loading, but it’s still considered mixed. The reason they came up with this terminology for mixed is to; because this is new, is to include these types of circumstances. Because previously what we have was alternating, so it’s IBS-A or IBS-C or alternating. That’s when you have some of days of constipation and then some amount of days of diarrhea, or sometimes it’s weeks some cycle. These mixed patterns are not that. It’s odd, odd, joinings of texture, frequency and then straining or urgency. One last thing is the Bristol Stool Chart. I have it here on my pencil holder.
Dr. Weitz: Only you would have the Bristol Stool Chart on your pencil holder.
Dr. Siebecker: I also have it on a mug, but I’m not drinking today. I just keep it here because then I can look at it, because I don’t really have it memorized like all these cool gastroenterology people. They’re like are you a type one or are you a type two. I don’t actually have it memorized. So type one is the balls, the constipation. Type four is three… Really four is normal and then up to seven is the watery. So you can just keep that handy and then just to remind yourself. So that’s basically the thing with diarrhea and constipation. Sorting out the mixed I think is the thing. It doesn’t matter what you really call it or consider it. It matters that you and the patient are on the same page with what they’re calling what. Because I’ve had patients who have very frequent watery stools, but they strained before going, and they call themselves constipated. So like five, five watery stools a day of big volume and they call themselves constipated because they strained beforehand. So this is what we have. It’s like, okay, so sure. Just so long as you know what they’re talking about.
So now the bloating. Technically, there’s two terms here, distention and bloating. Technically, distention is when the abdomen swells out with gas. Bloating is technically the sensation or feeling of bloating, basically of the abdomen swelling out like you get a feeling that your abdomen is swelling, but it may or may not be. So I definitely have patients who have the feeling that it swells out and it never does. It physically does not swell out and they’re terribly bothered by this. In fact, I think honestly the feeling… So this would relate to visceral hypersensitivity. The feeling is probably more bothersome because that’s a level of pain and discomfort. It’s very aggravating. Although the physical distention is also very aggravating because then sometimes throughout the day people have to change their pants. I used to have to do that because I have SIBO. When it wasn’t well, treated and controlled, I would have to bring… I would buy this like bands that go around the belly the pregnant women will wear so that they can open their buttons of their pants and put the band around it and still keep their pants up.
So then I like to bring that to work and then in the middle of the day with the swelling I have to do that. It was terrible. So the other things that we could differential diagnosis with it would be edema, so particularly for women with menstrual cycle changes. Many women will retain water around their abdomen. This you can tell with physical exam. So one of the main things you can do here is; I’m going to put my microphone down for a minute, is just do a percussion on the abdomen in your basic physical exam. When you do this, you can hear a hollow tympanic sound when it’s gas and just compare. Go over your thigh and do this and then you know that’s not a hollow sound-
Dr. Weitz: You’re talking about with the stethoscope.
Dr. Siebecker: No, this is physically.
Dr. Weitz: Oh.
Dr. Siebecker: This is how you do percussion on the abdomen. So here’s the abdomen. You actually place your fingers right here and you go, and you put your ear next.
Dr. Weitz: Oh, okay.
Dr. Siebecker: So compare the swollen belly with air to the thigh or something, and you’ll hear that difference. That’s how you can sort of tell what if it’s edema from menstrual cycle or something. Then the other thing would be what if it’s just visceral fat or not even visceral fat, just fat not weight gain. It won’t sound hollow. It’s a distinctive sound. That’s the main way you can tell, is it gas in there, is it fat, is it water. So those are the things we have to pull apart.
Dr. Weitz: Great, awesome. So when you have a patient who comes to see you with symptoms of IBS, what’s your full examination, lab testing consist of?
Dr. Siebecker: Well, for me, it’s different because I’m a SIBO specialist. All I do is treat SIBO. My neighbor’s dog is starting to bark at squirrels. Can I close the window? Is it annoying?
Dr. Weitz: Yeah, you better close it.
Dr. Siebecker: I’m going to close the window, you guys.
Dr. Weitz: Okay.
Dr. Siebecker: His name is Bandit by the way. You’ll probably hear my neighbor screaming at him-
Dr. Weitz: Bad Bandit.
Dr. Siebecker: Did you hear him scream? He’s a cute little thing, but boy he’s naughty, okay. So for me, it’s different because I don’t really have the opportunity to start from the beginning and do a workup. People come, I’m a second and third opinion kind of doc. So people come after having failed multiple, multiple treatments. So it’s a little different for me, but I’ll just give you my general recommendations. Usually what most people do is they’ll start with first and second line therapies. By the way, again, shameless plug. This is all in my SIBO pro course. I go through this in a very organized fashion. So first line therapy of course is diet and lifestyle. That’s stress reduction, meal hygiene, are you chewing enough, stress reduction, exercise, fresh air and diet. So diet, so there’s a lot we can do to start with diet that’s simple.
Dr. Weitz: Before you get into treatment, what about testing?
Dr. Siebecker: I’m going to get there.
Dr. Weitz: Oh, okay.
Dr. Siebecker: Then next second line is supplements and low-risk modalities. So here’s where we would try things like digestive enzymes and hydrochloric acid and various things like probiotics, prebiotics, all that.
Dr. Weitz: By the way, can we take a diversion for one second? You just mentioned digestive enzymes and that’s spurred a question. So I think a lot of Functional Medicine practitioners use digestive enzymes and yet, I remember asking Dr. Pimentel about that. He thought it didn’t really seem to make sense because there’s very few patients who have pancreatic insufficiency. We know that pancreatic enzymes help because we’ve seen it and many, many doctors have seen it symptomatically. So what do you think is going on with pancreatic enzymes? Is it that the patients don’t have enough or maybe they’re having some benefits despite the fact that they might have adequate pancreatic secretion?
Dr. Siebecker: I think a lot of people don’t have adequate pancreatic secretion.
Dr. Weitz: Oh, okay, you think that they don’t.
Dr. Siebecker: The reason I think that is from all the years of running stool tests and oh, my God, now I’m forgetting the marker that is the marker for..
Dr. Weitz: Elastase.
Dr. Siebecker: Yeah, yeah, yeah, and we see it all the time. Also, the other reason why I think a lot of them are not having sufficient enzyme secretion is because hypochlorhydria is very common and that is very well-known. We need acid to stimulate the secretion of pancreatic enzymes. So just think about how many people don’t have enough acid, they’re not then having enough enzymes. That’s why we always say hydrochloric acid and enzymes. So it very well maybe what Dr. Pimentel is like, I don’t think he runs a kind of functional stool test we all run. So he’s not seeing-
Dr. Weitz: I’m sure he doesn’t.
Dr. Siebecker: … the elastase. He might be referring to maybe a more narrow window of what pancreatic insufficiency is more a full-blown disease sort of the functional pre. Then the last thing would be, it’s just a matter of who even cares. It’s just a matter of, are they helping or are they not? I find many people are helped and many people aren’t helped. So this tails right back into what I was saying. What most practitioners tend to do when someone comes in with IBS is they try first and second line therapies first before testing. They just do very simple measures before even wracking up cost and test to just see if they can make corrections, are you chewing your food, lets like they put you on organic and let’s have you not drink 10 cokes a day. You know what I’m saying here. Then if you move in for more forward, let’s try some enzymes, let’s try some probiotics, whatever. A lot of people get handled this way. So then it’s for when those first and second line therapies fail. Here I’m just describing what most practitioners wind up doing. You don’t have to do it this way, but this is just honestly how it seems to go for most people. Then if those things failed, you move on to testing. So now testing. What I think makes a lot of sense is if someone has IBS symptoms is to run a SIBO breath test because 60 to 70% of IBS is caused by SIBO, so that’s very reasonable, and-
Dr. Weitz: Do you always do lactulose or do you sometimes do glucose or do you ever do both?
Dr. Siebecker: Let me answer that in a second.
Dr. Weitz: Okay.
Dr. Siebecker: Then stool testing. So I think if you just at least do those and also, sorry also, screening blood work, which I can tell you some of the things I think are good to look for. If you just do those, you’re checking for so many things. So let me just answer your question now. I always do lactulose and it’s because, the reason why is, it assesses the entire small intestine. So if I’m choosing one test only, I want to choose the one that assesses the whole organ. Glucose is primarily absorbed within the first three feet [of the small intestine]. Some might go lower especially if somebody has fast transit or malabsorption issues. For the most part, that’s what I want to do. I think in the best of all worlds because no one test is perfect, you do want both. I haven’t found I need that. What I think is good is when the lactulose and if you’re not sure about something, maybe you think there is a false negative, you could run a glucose as a sort of a backup, because there’s cost and the time and everything like that.
Dr. Weitz: I’ve really been enjoying this discussion, but I’d like to pause for a minute to tall you about our sponsor for this podcast. I’m proud that this episode of the Rational Wellness Podcast is sponsored by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturing of clinician design, cutting-edge nutritional products with therapeutic dosages of scientifically proven ingredients to help our patients prevent chronic diseases and feel better naturally. Integrative Therapeutics is also the founding sponsor of TAP Integrative. This is a great resource for education for practitioners. I’m a subscriber to TAP Integrative. There’s videos. There’s lots of great information constantly being updated and improved upon by Dr. Lise Alschuler who runs it.
One of the things I really enjoyed about TAP Integrative is that it includes a service that provides you with full copies of journal articles, and it’s included in the yearly annual fee. If you use a discount code Weitz, W-E-I-T-Z, you’ll be able to subscribe for only $99 for the year. Now back to our discussion.
Dr. Weitz: By the way, I’m assuming you do the three-hour test, that’s what everybody seems to be doing.
Dr. Siebecker: Oh, God, yeah. It’s absolutely for me essential because it helps so much with your methane diagnosis and figuring out what you’re going to do for treatment. It really makes a difference and-
Dr. Weitz: Well, can you explain why that is? Because anything past 90 minutes we ignore, right, because that means it’s in the colon.
Dr. Siebecker: God, no. No, no, no, no.
Dr. Weitz: So if there’s a spike at 120 minutes, you don’t consider that positive for SIBO?
Dr. Siebecker: Yes, let’s talk about this.
Dr. Weitz: Okay.
Dr. Siebecker: The second reason why we need the lactulose is to diagnose hydrogen sulfide. Now Pimentel is coming out with a new test, but it’s not out yet.
Dr. Weitz: Oh, yeah. He’s been saying that for a while.
Dr. Siebecker: I know. Also, so you have to see the third hour. So we can go through that. Also, even when that test comes out, it’s going to be offered by one lab. So it’s going to be years before people have that machinery and technology, so we’re still going to need to do three hours and look at that. So let me go back to the methane.
Dr. Weitz: Okay.
Dr. Siebecker: So the diagnosis for methane is not just in the first two hours. It hasn’t been for years, for years and years. So I think it was the second SIBO symposium that I put on, in 2015 Dr. Pimentel said he uses three, a methane of three and the whole three hours of the test. So since 2015, that’s been out there and that’s what all of us have been doing. All of us meaning all of us who put on the SIBO symposiums, my colleagues who had SIBO center and all that. Absolutely that is what I would recommend. Now I have to say I hardly ever see a case where it’s positive after, like in the three-hour, after the two-hour mark so after 120 minutes only. Occasionally, where you’re trying to see that is when you’re doing retests. Now you see proximal clearing and then you see some left down there and then you still work on that because you’re doing your retest. Let me tell you what the actual diagnosis levels are. So three and above… So basically it was 12 and above was SIBO, right, for years. Then when Dr. Pimentel said he uses three, what we wound up doing was using three to 11 with constipation would be positive. Because basically what the lower level is indicating-
Dr. Weitz: Now that’s more liberal than the North American-
Dr. Siebecker: I’ll get there.
Dr. Weitz: … Consensus?
Dr. Siebecker: Yeah, I’ll get there.
Dr. Weitz: Okay.
Dr. Siebecker: Hold on. Because basically what the lower level is showing is methanogen overgrowth and constipation, not necessarily SIBO. So that’s why we wanted to-
Dr. Weitz: Wait, wait, wait.
Dr. Siebecker: I’ll get there. Just let me continue. By the way, I have this laid out beautifully in all my slides in the Pro Course in a lovely organized fashion, so, okay, so. Then what happened was they all convened and they voted to, the experts, to bring it from 12 down to 10 and Pimentel tried to get them to bring it to three. They didn’t feel there was enough evidence so they brought it to 10 and that’s very, very good. In my clinical experience, I knew 12 was too high. I think 10 is too high. I’m absolutely sure about eight. I’m absolutely sure about that from all of the tests and symptoms that have correlated. I’m not absolutely sure about three. So now it’s the same thing I described except it’s the 10.
Now amongst all this discussion, what has come out is methane is now being thought of as a different disorder and not actually SIBO and that what they’re figuring out is the methane could be in the small intestine. The methanogens producing the methane could be in the small intestine, okay, then it’d be SIBO. If they could be in the large intestine only, then it’s not SIBO, and/or they could be in both the small and the large intestine. When Dr. Pimentel did culture studies, he found lots of methanogens in the small intestine. It’s just that they might not be in a certain case and so this is why we need the whole three hours of the test. We cannot go by just 90 minutes, absolutely not. I don’t even use 90 minutes, I use 120 let me talk about that, so that’s the thing.
Now does it matter that we’re distinguishing SIBO versus, or if they’re in the small intestine or not? Well, one way you can kind of distinguish that is if you actually see the rise of the breath, of the gas in the small intestine time and then coming back down and maybe even another peak like a classic double peak. Honestly, I see that a lot so I know that people are having their methanogens in their small intestine. The key thing here is that it doesn’t matter whether they’re in the small or large intestine or both. The treatment is the same. It’s just that the concept of it is changing and I think it’s good. It’s like they don’t want to call it SIBO anymore because first of all they are not bacteria. They’re archaea, so the B doesn’t fit, right? Then they might not be in the small intestine. Also, they want to change the name overgrowth because that means something different to the gastroenterologist. It actually means small intestine only. It doesn’t mean that to any other discipline out there so it kind of irritates me. How come they get to make a name that just works for them but for the largest amount of people? I think it should be methanogen overgrowth. I like-
Dr. Weitz: By the way, there’s also methanogens in the mouth in some patients.
Dr. Siebecker: I think in other places actually as well. They are normal commensal bacteria in certain populations. So what I think is good about this is that we’ve always known that it’s very hard to treat and that it needs different treatment, and then we … Okay, right. Well, that’s because they’re archaea, they’re not bacteria. So certain antibiotics are not going to work on archaea. We have to find the ones that do. Also, the main underlying cause is probably different. The main underlying cause for diarrhea and mixed type is food poisoning, not necessarily for methane. So go ahead, I’ve talked about it.
Dr. Weitz: Okay, yeah. Because of that blood test that Dr. Pimentel developed that measures the antibodies, do you order that test frequently.
Dr. Siebecker: I used to. I’m on hiatus right now, well, on somebody’s project. I did it all the time. The way I used it… Oh, I should have mentioned. That’s also an excellent test to consider right upfront, so breath, stool, screening blood work, and the IBS blood test so ibs-smart, because it can tell you so much right away. The way I used it was to investigate underlying cause of SIBO so that I would know did somebody get it from food poisoning, and what that did for me was a couple of things. First, it would be that I know that their migrating motor complex is deficient because that is an indirect test for that if it’s positive. So then I know their physiologic underlying cause and then I know that prokinetics are absolutely essential part of treatment. While I always probably already knew that, then we could get into patient compliance. So when they have that test and then they know, now they know they need to keep taking their prokinetic and not stop it and they’re convinced why they need it.
Dr. Weitz: Do you usually use the ibs-smart test from Gemelli or have you used the Array 22 from Cyrex?
Dr. Siebecker: Well, that one has not been validated the way that Dr. Pimentel’s has. He spent years and years validating, so. I want to use the one that I know for sure is validated. However, what I like about the Array, the Cyrex one, is that it has some markers that that’s what Cyrex always does, right? They always have alternate markers like their test for celiac with tTG. They have two and six. So I like that it could catch people that the other one might have missed, but I haven’t run it. What I really need to do is run dual, side by side and see do they catch everything that ibs-smart is catching basically validated against the validated-
Dr. Weitz: By the way, the data that I saw from Cyrex is that they are able detect a larger percentage of patients with methane on their test.
Dr. Siebecker: That’s interesting. So I think at this point I wouldn’t feel comfortable. This is just me. By the way, I love Cyrex and I love Dr. Vodjani who created it. I’m just talking as a practicing practitioner here. I would use ibs-smart and then I would run Cyrex secondarily if a patient can afford that and start checking the validation.
Dr. Weitz: Right. Just since we’re on testing, one more question. Do you ever do organic acid urine testing?
Dr. Siebecker: Yes, I used to do a lot of that and that is another test that a person could consider running. I’m not sure I do it all at once in the very beginning. I think small intestine check and your large intestine and your screening blood work and take it from there. I think one of the other things is one would hope that the stool test would show if there were parasites and yeasts, because that’s such a big differential-
Dr. Weitz: Right, yeah, and that’s one of the things we got out of urine testing is evidence for candida or fungal overgrowth.
Dr. Siebecker: Not the parasites, so it’s like that’s why at least if you do the stool test you’re getting kind of both, so.
Dr. Weitz: The stool test, you get some other stuff too like you were talking about the enzymes. You can see if there’s fat in their stool, which means they’re not breaking down fat and maybe have bile insufficiency and-
Dr. Siebecker: Both of those are markers of SIBO actually that SIBO could be causing but could be caused by other things, too.
Dr. Weitz: Right, and inflammation as well.
Dr. Siebecker: I didn’t explain the hydrogen sulfide and the testing, but basically you just need to see the whole three hours for your methane. Not only that, but what if the methane in the beginning is three, eight, 10 and then towards the end in the third hour it’s 155. It utterly changes your treatment protocol, utterly, utterly. So you might choose a whole different treatment mix based on that.
Dr. Weitz: What if you have a patient, they’re very symptomatic, you’d swear they have SIBO, you run the breath test, everything seems to be normal and then right at the 120 minutes shoots up, do you ever say, “You know, I know technically it’s not elevated by 90 minutes but I know this patient has SIBO.”
Dr. Siebecker: Well, yeah, now first of all, I don’t use 90 minutes. I use 120.
Dr. Weitz: You do?
Dr. Siebecker: Yeah. So I always go to 120, that’s the manufacturer’s standard and I go by that. I’ve seen that proven time and time-
Dr. Weitz: The manufacturer’s standard, okay. Because most of the-
Dr. Siebecker: The actual maker of the breath test machine goes by two hours.
Dr. Weitz: Okay.
Dr. Siebecker: Yeah, so if individual-
Dr. Weitz: That conflicts with the North American Consensus?
Dr. Siebecker: It does.
Dr. Weitz: Okay.
Dr. Siebecker: Absolutely, it does. So I have a whole discussion on this, too in the Pro Course, we can get into it. Basically just it’s not a black and white. This is an art, not a science. I’ve seen so many times where… Now this is a judgment call if you’re going to between 90 minutes and 120 because of the breath test consensus. Before that, it really wasn’t. It was really two hours, but now I’ll call it a judgment call. I will say most often patients are positive by 90 minutes. Most often they are, so it’s going to be more rare cases where you have to think about it. Now but your question was nothing goes up until after, right, until-
Dr. Weitz: Right at 120.
Dr. Siebecker: … right at 120.
Dr. Weitz: It starts going up a little bit at 90 and then at 120 bam [it shoots up].
Dr. Siebecker: Yeah, this is often SIBO, often, and so it’s a judgment call. Now one thing you’d want to think about here is, is this a constipation patient, because they probably have slower transit and the lactulose didn’t more through as fast. So this would be hmm and you have to think about it. You take into account the history and symptoms and the whole picture, because that’s the art, right?
Dr. Weitz: Right, exactly.
Dr. Siebecker: The differential, well, I mean maybe are there other things positive, maybe you treat those first.
Dr. Weitz: By the way, you mentioned motility there. I wanted to try to get clarification. Is there a difference between the neurological and specific structural mechanisms involved in the cleansing waves that occur that we refer to as the migrating motor complex and the peristaltic activity that happens when you eat food? They both involve this rhythmic contraction of the intestines. They both involve increased secretion of hydrochloric acid, bile, digestive enzymes. I remember asking Dr. Pimentel when he came to our Functional Medicine meeting. He said basically they were the same thing except one happens when you’re eating and one happens when you’re not eating.
Dr. Siebecker: Wow, okay. So I don’t really know the answer, but I think the interesting thing for me would be how involved are the ICCs, the interstitial cells of Cajal and in food peristalsis. Is it the same exact mechanism it sounds like? Dr. Pimentel is saying it is. The other thing is what’s the rhythmic pattern, because the rhythmic pattern is very different. We’ve got phase one, two, three, sometimes four with migrating motor complex and I don’t think it’s that at all for peristalsis. Other thing is we have-
Dr. Weitz: Right, and by the way, that’s one of the reasons why if patients are taking motility agents especially nutritional ones; I assume for the prescription once as well. We want them to take those at night or in between meals and not during a meal.
Dr. Siebecker: Absolutely, because it’s during fasting. Such a good point, yeah. I was just going to say with peristalsis, there’s sort of these two aspects. One is this segmentation thing where it’s basically mixing and churning the food so that it gets presented to the walls where all the enzymes are and everything and then, then it moves down. It only moves down like this, a couple of inches. So I don’t know the actual physiology. It’s a great question.
Dr. Weitz: Hey, one more question. We were talking about the methane. This is funny. We were talking before are we going to have anything else to talk about in this?
Dr. Siebecker: Forever, we have so much.
Dr. Weitz: Dr. Pimentel was speculating that maybe one of the reasons why methane is so hard to treat is because the archaea are sort of down in the mucosal layer and harder for the antibiotics or antimicrobials to reach them.
Dr. Siebecker: Right, so this brings up the whole anti-biofilm issue, right?
Dr. Weitz: Right.
Dr. Siebecker: We know methanogens make biofilms. Of course, we know that. I think where I’ve seen the best effect is with anti-biofilms that actually use bismuth. I don’t know if you know the work of Dr. Paul Anderson. Have you heard him talked about this?
Dr. Weitz: I’ve heard of him. I heard you talked about bismuth on the interview with Ruscio about the hydrogen sulfide. I know that bismuth is part of the protocol for H. Pylori, the triple antibiotic thing.
Dr. Siebecker: Right. Well-
Dr. Weitz: By the way, what is bismuth?
Dr. Siebecker: What a good question. Heavy metal basically, I don’t know.
Dr. Weitz: Right. I mean, we can have bismuth toxicity in your brain.
Dr. Siebecker: Good question. I didn’t look up safety studies before I ever started prescribing it. There’s good safety data for the dose ranges we use and the time period we use, but still it’s a thought. That’s probably, I don’t know. It’s probably not a heavy metal. I just said that. I don’t what it is. I don’t want people… Sometimes I make joking comments or off comments and then because we’re on a podcast. People take it a gospel or something like that. Sometimes I make a joke and people didn’t know it was a joke. God, I guess my funny bone is not good enough but anyway, so, okay.
So basically, Dr. Anderson… I had terrible trouble seeing that anti-biofilms helped any kind of SIBO, methane or not. I tried it for years. So I talked to him about it and he basically suggested that maybe the standard products that we use aren’t good enough. They’re not strong enough and those are basically digestive enzymes and NAC and EDTA. So he then suggested this method. So he had a prescription formula that he made that I used called Biosolve-PA. Then he now made one it’s in supplement form. It’s a priority one or something like that, advanced and so I tried. I tried the prescription version and I saw some difference. So it might be that we need a stronger anti-biofilm.
Dr. Weitz: Interesting. So bismuth is an anti-biofilm agent.
Dr. Siebecker: Yeah. In his prescription formally, he uses… There was BMPS also.
Dr. Weitz: Oh, wow.
Dr. Siebecker: Yeah, if I’m not mistaken. I could look it up.
Dr. Weitz: Which is a heavy metal chelator.
Dr. Siebecker: Yeah, I could look it up. Sorry I don’t remember-
Dr. Weitz: You put the bismuth and then you take the heavy metal chelator to get rid of the bismuth.
Dr. Siebecker: It is so. So I do think that that could be helpful, but I don’t think that the standard anti-biofilms were helpful. I tried, this patient had one, this patient didn’t, on and on. Myself, my colleagues, even Dr. Ruscio, we never saw any clinical difference in relapse rates or how fast we could get a test negative. Dr. Pimentel [Dr. Siebecker intended to say Dr. Ruscio] had an unpublished study he presented on where he saw that there was a slight reduction in hydrogen actually, but it was only on… It was statistically significant so he could say it, but it was a small amount. There was no clinical difference like the symptomatology didn’t change, it wasn’t.
Dr. Weitz: One more thing on the methane I wanted to point out. Dr. Rahbar, who is here in LA, he finds that his methane patients often have co-infections with viral infections and Lyme disease. He thinks that methane SIBO is partially a form of immune dysregulation.
Dr. Siebecker: He could very well be right. I was just telling you this that he presented in the spring on his thoughts of why methane is hard, basically one of the underlying causes of methane and I’ve included that in my course; we can go over it right now. He says Lyme and TMAO metabolism, which is new to me, and mycotoxins, so mold and mycotoxin exposure, general immune dysregulation high glyphosate; Paneth cells is quite interested in that, and parasites. I have several colleagues who believe that parasites are probably one of the first places you should look when somebody has methane especially if it’s hard to treat. Not all methane is hard to treat. Some people you give a round or two and it resolves when it gets troublesome. I think the two things that I’ve heard the most from my colleagues speculating on underlying causes with methane are Lyme and parasites.
Dr. Weitz: It’s interesting that we describe methanogens as this other thing. Normally anything we see in the gut that’s not a bacteria or virus, we call a parasite. So technically methanogens could be described as a parasite, can we?
Dr. Siebecker: Well, we have their whole own classification as archaea. So when you look at it, is it phylums? I don’t remember. When you look… Even if you’re in museums and you look on their wall display, it’s bacteria, archaea, and one other grouping.
Dr. Weitz: Oh, okay.
Dr. Siebecker: They have their special own classification.
Dr. Weitz: Right. I know that Dr. Rahbar told me that when he gets a case of methane SIBO before he does any other treatments, he might start with supporting the immune system and using a IgG type of formulation. I heard Ruscio talking about using IgG and that seems to be getting more attention now, including that one non-dairy product that’s available out there.
Dr. Siebecker: I absolutely love this idea. I, myself, have gotten into it again. I heard about it years ago from Dr. Weinstock. He was having excellent results. He’s published… He had great cases resolved particularly when diarrhea was really hard to treat, and so it’s the serum bovine immunoglobulins. Actually, everybody who offers it no matter what brand it is, it’s a patented formula so it’s all the same actual formula. It’s called ImmunoLin. ImmunoLin is the item.
Dr. Weitz: Oh, okay.
Dr. Siebecker: Various people put it in their own label and put it in powder, so. I’m really pleased with it. I’m loving it for myself. It has so many benefits, leaky gut. I have genetic high cholesterol and it actually has helped to reduce that.
Dr. Weitz: Wow, interesting.
Dr. Siebecker: There’s actually a study on it reducing cholesterol. So it’s been very hard to budge because it’s genetic, so.
Dr. Weitz: So what particular marker did you see change? Was it your LDL-P or did your LDL particle size change, and what about Lp(a)?
Dr. Siebecker: It was LDL and total because of that. I can’t remember if I had the band size on my recent test. I don’t remember it. My type is type two-A so I have always high HDL so I always have that, but LDL was high. Something else was high, can’t remember I’m sorry, right now but anyway. It’s wonderful so I love that idea. For people who-
Dr. Weitz: By the way, this is kind of the newest version of colostrum, which Functional Medicine practitioners have been using for many years for digestive disorders.
Dr. Siebecker: This is just what I was going to say, for people…
Dr. Weitz: Great minds think alike.
Dr. Siebecker: Every time you ask a question, I was going there. Well, you know what the saying is, great minds think alike, and so do ours. Anyway, so for people who are vegetarian, there’s colostrum. There’s actually one brand that has the equal amount of the IgG in it, in its colostrum. Not all brands do and that’s NuMedica. It’s called PRP… I can’t remember the whole thing. It’s about NuMedica and it basically has a lot of IgG in their colostrum. So I have to say, I used colostrum for years in my patients, years and years, because it was kind of my number one leaky gut treatment because it has epithelial growth factors in it. I have to say I don’t think the results were as good as IgG, direct IgG, which is really actually surprising to me because IgG is purified out. I would have felt the whole colostrum it has so many things.
Dr. Weitz: It could be at the same maybe was helping the dairy was creating irritation to the gut.
Dr. Siebecker: Could be, absolutely good thought.
Dr. Weitz: Now you mentioned TMAO levels and TMAO is the latest marker for cardiovascular disease risk. Dr. Stanley Hazen from Cleveland Heart Labs developed this and he is testing it in the serum. TMAO levels are… TMAO it is contained in fish, but mostly it’s produced in the gut. It turns out that when you have higher levels of archaea in your colon, you have lower levels of TMAO. They actually are considering supplements of archaea which will be called archaea biotics-
Dr. Siebecker: Oh, my goodness.
Dr. Weitz: … as a consideration for this. I’m very dubious of this TMAO thing because if this hypothesis is right, I know this Stanley Hazen has a bunch of data on it, but it would mean that eating fish increases the risk for heart disease as well as consuming choline and L-carnitine. There’s so much data that those are so beneficial. I think that one of the things that’s happened is there’s politics in nutrition like there is in everything. We’ve got people who are trying to promote a certain way of eating as the way and so this another tool in the arm of those promoting a plant-based way of eating and so you hear that a lot.
Dr. Siebecker: That’s very interesting. I had never heard of it before. I heard Dr. Rahbar discussed some of his mixed theories and thoughts surrounding methane. So I was very glad for you to explain it because I look at it briefly and I’m like, “Wow, okay.”
Dr. Weitz: I talked to Dr. Bob Rountree about this. He actually thinks that TMAO is a marker for not having enough choline and it all has to do with the liver, but that will take us down another road. Have you used substances called peptides? These are basically strings of amino acids that are not long enough to be considered proteins. It’s really become a hot topic now especially in the integrative and anti-aging communities. One of the peptides is something called BPC 157 or Body Protective Compound 157 and some Functional Medicine practitioners are using it as part of their protocol to heal the gut. Have you used that before?
Dr. Siebecker: I got so excited about it. I heard a whole bunch of podcasts, webinars on it. I just got so excited and so I want to try it, but right now I’m not with patients. So I’ve tried it. Some of my colleagues are trying it and some of my friends and family members have tried it. So far in the people that I’m talking to, I’m not seeing any difference, but I just don’t think that you should listen to me. Because small of a sample size and not enough time, it would be really different if I’m in there with patients trying it. One of the problems is that it is fairly expensive. So it’s an expensive experiment, but I sure love what I’ve been hearing about it, really I do. I know that at our SIBO com, you and I were both there in the spring. We had two doctors presented. They’ve been using it, Dr. Rahbar and Doctor… What’s her name, Kristine… another doctor.
Dr. Weitz: Yeah, I can’t remember.
Dr. Siebecker: I’m so sorry. So people are starting to experiment with it and I’m sure we’ll hear more. I think it’s very exciting and I don’t know yet.
Dr. Weitz: Oh, one more thing that you mentioned. You mentioned gut hypersensitivity. I saw a paper showing an herb called curcumin, which I’m sure you’re familiar with, down regulates gut hypersensitivity. I’ve started experimenting with using curcumin in some of the SIBO protocols and I think it’s having a benefit. Have you looked into and somebody at SIBOCON talked about gut hypersensitivity as well.
Dr. Siebecker: We had a whole presentation on it by my former student, fabulous doctor, Dr. Megan Taylor. She did the whole presentation on giving treatment options; curcumin is one. Another one is actually bifidus infantis that’s sold as Align. That’s been studied for visceral hypersensitivity. We have a whole bunch of stuff we can try. Curcumin often helps people. It’s a fabulous anti-inflammatory. Then there’s a subgroup of people that just really tolerate it poorly and it often causes vomi
Dr. Weitz: Exactly.
Dr. Siebecker: It’s so incredible. I think a lot of times liquid and lipid forms are often well absorbed and do well with that. By the way, I have about five, seven more minutes.
Dr. Weitz: Oh, okay. So in terms of preventing SIBO from coming back or what about… How about this? You have a patient and they’ve gotten 80% better. They feel a lot better. They still have a little bit of symptoms. Do you ever put somebody on or recommend that they do a little bit of an antimicrobial say they take one or two capsules of Oregano just every day for a long time, and they say it sort of seems to improve the way they feel?
Dr. Siebecker: Is this something you’re doing? You have some experience?
Dr. Weitz: I have been doing this with some patients.
Dr. Siebecker: So it’s working well.
Dr. Weitz: It’s interesting. I mean it seems to go against cycling and everything else, but-
Dr. Siebecker: So tell me how you’re doing it, you’re doing just two pills a day or something like that.
Dr. Weitz: Exactly, exactly. This kind of started because, as you know, you put patients on a certain diet and you go, okay, now we’re going to go. We’ll start broadening the diet. They’re like, no, no, no, no. I feel so good. I don’t want to eat anything else again for the rest of my life and I don’t want to stop doing anything that I’m doing and it’s like, no, no, no.
Dr. Siebecker: I think that that is so smart to just give them a little bit of antimicrobials, calm their fears. It takes care of any little bleeps of they tested, if they tried a food, tested it and didn’t work well. I know lots of practitioners that do that. I just wanted to say that if someone is at 80%, so I like to always try and get to 90%. The reason why is because I found that when patients weren’t 80% and this is their report, right? They’re saying they weren’t 80%, although we talk it through and kind of decide together. If I would do one more full round, I can almost always get people to 90%.
Dr. Weitz: Oh, cool.
Dr. Siebecker: I just wanted to mention that. Because 80% was sort of the gastroenterologist standard, but I just began finding usually you can get people to 90%. So this idea of the antimicrobials, it’s so funny because I have a whole section on this exactly. Again, shameless plug for my course, a whole section on basically prokinetics versus ongoing antimicrobials for relapse prevention. You can do it either way. I think prokinetics can do the same thing. Honestly, they really can. I think one of the problems that I’ve seen is that the natural prokinetics, the over-the-counter herbal ones, so we’ve got Iberogast, ginger and all the ginger-containing formulas; I think there are six now, prokinetic ginger-containing formulas [Motilpro, Motility Activator, SIBO-MMC, etc.] and that and LDN are often not strong enough especially for the more difficult cases. Sometimes they are strong enough, but they’re not always strong enough. So I think what I’ve seen is that a lot of practitioners were let down by prokinetics that wasn’t really doing the job so they returned to antimicrobials. See for me, I can prescribe so I would use erythromycin or prucalopride, which are stronger prokinetics. So I didn’t need the antimicrobials because they actually do work better. They are more effective and I almost always will start with the natural ones because sometimes that works, also just depends on where someone’s went or when they’re coming in to me. If they’re coming in to me and they’re terribly chronic, we just go right to the prescriptions. So I think it’s interesting. I also think there are practitioners that just either don’t know enough about prokinetics or just really don’t like the idea of them. I sense a general distaste of prokinetics out there in the community and-
Dr. Weitz: Well, certainly they’re going to have a distaste for low dose erythromycin.
Dr. Siebecker: Yeah, because it’s a low-dose antibiotic. However, it doesn’t have antibacterial effects at that level, so-
Dr. Weitz: There’s also a lot of patients will tell you, oh, I took antibiotics and ever since then I’ve had problems, so they don’t-
Dr. Siebecker: They’re afraid of it, of course. Just like then they’re afraid to use rifaximin even though it’s so beneficial and isn’t like a normal antibiotic. We have to educate our patients, of course. Well, prucalopride actually regenerates nerves, so it’s neuro-regenerative. It’s neuro-protective. It heals leaky gut. It protects against cancer and tumors. So there should be no concern there. Erythromycin, yeah, there can be distaste and concern. Honestly, I felt that way too in the beginning. I stopped feeling that way when I generally, I mean in principle I feel that way. Generally, I stopped feeling that way when I saw how much it helped the patients. The whole reason we use it is for this effectiveness. I just wanted to sort of make the point that it’s an interesting thing to think what’s worse even… Let’s even take the worst-case scenario of low-dose erythromycin that actually has no antibiotic activity. What’s worse? That, or something that keeps pounding the microbiome. It’s very interesting like prokinetics are meant so that you don’t have to keep doing antimicrobials. Do we really want to keep doing that?
This is all me saying after I liked your idea. I’m just pro-ing and con-ing it here and that’s what we need to do as practitioners. It’s not like a life. There’s no answer and cases are different in each one in front of us. The other thing a lot of people would do if people are extending their diet and feeling nervous is they will use digestive enzymes as well and certainly some of the natural prokinetics like some ginger and things like that.
Dr. Weitz: Great. So can you tell everybody about your new program?
Dr. Siebecker: Yeah. By the way, the reason I keep saying shameless plus is because I used to listen to Car Talk. Did you ever listen to Car Talk? That was on NPR radio and it was two brothers.
Dr. Weitz: Oh, maybe two guys talking about cars?
Dr. Siebecker: Yeah. They were very funny and they would always say shameless plug for whatever, so that’s why I’m saying that. Here we go, shameless plug. Yeah, it’s called SIBO Pro Course. I’m so happy that I’ve spent so long working on it. I mean, I think over a year and a half. I’ve given this course. It’s a course that I created and teach at Naturopathic Medical School, so it’s a doctorate-level course, but it’s shorter there. It’s a six-hour course. Over the years that I’ve given it, I’ve given it a couple times outside of the school to practitioners and I’ve just listened to all the questions. As you can see, pretty much everything you brought up I have in the course. So I’ve listened to all the questions, what if people really want to know and I’ve put it right in the curriculum. I’m very organized that’s just my thing. I think good leaning is when everything is very organized. So I present it in hopefully a flow that helps a person understand and retain the material. So anyway, you can go to… Well, you’ll have a link here, right?
Dr. Weitz: Yes.
Dr. Siebecker: It’s The SIBO Pro Course [here is the affiliate link to sign up for it: https://smpl.ro/al/7TEGvvBoGSzFtdoZLL7BGpGM/15770-Ben-Weitz]. I’ve got two versions of it, my self-study just in case you just want to have it on your own, do it on your own schedule, and then I’m running it kind of like a college quarter where it’s over eight weeks and I’ve pasted out what the schedule, about a two and a half hours per week that you would watch. It’s optional. You can do it how you want, but I’m giving you a schedule and then we’ll meet for office hours. On that version, I’ve included learning enhancements, optional quizzes and study guides that you can use as you’re watching through, just to all to help with learning.
Dr. Weitz: Cool, that’s great.
Dr. Siebecker: So I hope everyone will join me. It’s just a wonderful course, I think. I think I did a good job.
Dr. Weitz: When this it start?
Dr. Siebecker: Oh, yeah that’s important. It starts September 28. It opens September 28.
Dr. Weitz: Okay, cool. Okay, awesome. Thank you, Allison.
Dr. Siebecker: Oh, you are so welcome. It’s so fun talking with you, Ben.
So if only methanogens make biofilms a biofilm for hydrogens isn‘t necassary or? 🙂
*biofilm disruptor i meant 😀