“Is SIBO real?” An Evidence Based Response and Conversation with Shivan Sarna and Dr. Allison Siebecker

I wanted to share with you today an interview that was performed between Shivan Sarna, Dr. Allison Siebecker, and myself regarding the article I wrote a few weeks ago entitled “Is Sibo a Real Condition?” This was my response to a number criticisms of SIBO as a condition and whether or not there is efficacy regarding SIBO testing, SIBO treatment and whether or not SIBO is a real condition or is something that is somewhat fictitious. The nuts and bolts are in the article that I wrote but they wanted to interview me on the article, ask some questions, have a dialogue and I figured you might benefit from and enjoy listening in or watching the video.

Shivan Sarna: Hi, everybody. We are live. I’m Shivan Sarna with SIBO SOS. We’re so glad to have you. And we have the incredible, right up there, Dr. Allison Siebecker of siboinfo.com. And right there, wait for it, there you are, there is Dr. Michael Ruscio, who is here to talk to us about his very thoughtful response to, “Is SIBO real: An evidence based response.”

So, it’s a pleasure to have you both here. Thank you so much. Dr. Siebecker, thanks for chiming in and greeting us and welcoming Dr. Ruscio and the whole crowd who’s here. And Dr. Ruscio, thanks for taking the time to share this insight.

Dr. Michael Ruscio DC: My pleasure.

Dr. Allison Siebecker: I just wanted to say hi and thank Michael for writing this incredible response because I know so many people were—so many patients were really concerned, upset, worried, freaked out. I heard that from so many people. And everyone was like, “Can someone please make a reply?” And then, Dr. Ruscio, you did it. So, thank you. I can’t imagine how much time it must have taken for you to do that. It’s really a labor of love. And I really appreciate it. Thank you.

DrMR: Yeah. Well, the fact that it’s helping people is worth all the hard work. So, my pleasure. Thank you for letting me elaborate on it.

SS: We’re in. Okay. So Allison, are you going to hangout for a little while?

DrAS: Yeah. I’ll be turning my camera off and I’m just going to listen.

SS: Okay, great. Love you. Thank you, Dr. Siebecker.

Okay, Dr. Ruscio. So I know that there was an alarm that went through the functional health community when that blog post from another credible expert really questioned whether or not SIBO is real. And you took your time and you really dove into what I feel you already knew, from your own experience. And created a very thoughtful reply based on evidence and your own personal observation. So tell us what you observed and how you want to approach this and how you want everyone to be thinking about, is SIBO real?

DrMR: Well, as we wade in those conversations, I think there’s a foundational issue that kind of undergirds this entire topic. It’s very important to understand, which is, if you find someone who uses very strong language, I would be extremely cautious. And one of the more notable critics of SIBO, one if these recent critical articles used very strong language. He had a very friendly demeanor. But the word choice was very strong. “SIBO does not exist. People do not derive benefit. The condition is bogus. The testing does not assess the amount of bacteria in the small intestine.” These are all very strong statements.

So the reason I took a very strong issue with one of these criticisms was that the person was clearly ill informed and they were making very absolute criticisms. I would have had absolutely no problem if the same article was written and it was written more of a curious tone. For example, “There have been some questions brought up about the validity of SIBO testing. Here are some concerns that we should be discussing. There have been some criticisms of the efficacy of the treatment. Here are some concerns.”

But when you go to the endpoint of saying, “The treatments are not effective, period, full stop. The testing is not accurate, period, full stop.” That is an incredibly damaging, ill-informed, intellectually dishonest thing to do. And when you look at—again, one of the pointing criticisms, using six references to try to refute an entire condition and body of literature is laughable. It’s absolutely laughable. And, I think, it’s from Leviticus, the saying, “Let the fool speak, so that he may reveal himself.” And this is one of those cases, where some of the criticisms have been absolutely poorly done. And for patients listening to this, it’s disheartening. Because if you hear someone, in a confident way, saying SIBO is not a real condition, a layperson, a patient has a very hard time discerning, is that actually true? Or when someone else says, “No, SIBO is a real condition.” Is that true?

The scientific evidence is what helps us to answer that question. And unfortunately, again, when you hear someone use very strong language that usually means they are more ill informed. Because the more informed someone is, they understand there are data supporting a position, there are data refuting a position. And so, that makes someone’s position somewhat tempered. And this is why I say that dogmatism or a strong opinion can only exist in the presence of ignorance. You have to be somewhat ignorant to the contradictory information to have a very strong opinion.

So, sorry to be a little long winded in this, but it’s a philosophical piece that’s really important for people to understand that where you get your information from is incredibly important. And if the person you’re getting your information from makes many strong statements, I would be very cautious that that person is likely ill informed. And hence, that’s where their strong stigmas are coming from. So that, I think, is maybe the most important foundational piece as we wade into this conversation.

SS: So the evidence is out there. Your experience is certainly years and years with thousands of patients. And I think what you said was so powerful, all of it. But like it was a very friendly presentation. And it was a very much like—I felt very baited and the switched.

DrMR: Yeah. And to me, it was infuriating to sit there with a laugh-y, smiley, giggly presentation. And then, coming off like you’re a friendly, thoughtful person. But then, making these statements that are absolutely intellectually dishonest. And sometimes, it’s the most challenging to identify dishonesty when someone’s being dishonest with a friendly demeanor. And that’s where you have to really look at the content of the message, rather than the way it’s articulated.

And as an example, the paper that I wrote contained about 106 references to support an approach that I think is probably a bit more conservative regarding SIBO than many would recommend. And I think, that’s okay. I think that’s a process of learning. We’re going to be auto-correcting. As science learns more, there will be parts of our assumptions that we’ll have to cut off, because we’ve learned now that that assumption is no longer valid. And we’re always going to be morphing to a more accurate opinion. And perhaps on SIBO testing, that may be one of the more differed from the norm opinions. And I think, that’s okay. But again, we want to do this in a constructive way, and not go from one extreme to another.

So, yeah, and I’m happy to jump in on any of the details of the paper. Wherever you want to start, I’m happy to start there.

SS: Well, I think one of the first things is—if we just do a little mini premise that it is real, one of the things that I think stuck out for me was that there was a question as to whether or not rifaximin was even close to working. I mean, that was my interpretation. It was like it was saying rifaximin bah humbug. Yes, there are a lot of relapses. But my understanding, what I took from part of it was that that wasn’t even a valid therapy. Did you take that and is that your observation?

DrMR: Yes. So maybe two things, just to start from a high level, or one preface and then to your comment about rifaximin. If you look at the evidence, SIBO is a real condition. The largest body in gastroenterology, arguably in the world, the premiere body in gastroenterology is the Rome Foundation. And the Rome Foundation did convene an expert consensus panel, which means they took numerous experts and convened multiple meetings, multiple panels, multiple voting sessions, over several months, to come up with a consensus. It’s way better than one guy who decided to read for three days and tell you that SIBO is not a real condition.

So the Rome Foundation opinion is very, very high quality science. They take a conservative position on small intestinal bacteria overgrowth. But they do recognize small intestine bacteria overgrowth as the underlying cause of some conditions. And they do recommend, in this case, glucose breath testing. And they do recognize it as a legitimate, diagnosable, treatable condition.

And also in North America, the North American Consensus convened a panel. And they also conclude that SIBO is a real condition and laid out guidelines for when to test. They recommend the lactulose testing. They recommend a bit more liberal use of the testing. But we see two of the largest bodies in gastroenterology convening expert opinions and coming to the same conclusion that SIBO is a real condition.

And we also see meta-analyses, which is arguably, the highest level of scientific evidence, showing that SIBO breath testing does have a role in identifying dysbiosis. I use the word “dysbiosis” discerningly, because they indicate that abnormal levels of bacteria and fermentation are clearly identifiable on the test. Whether or not it’s SIBO per se is debatable. And this is likely because the definition of SIBO is still being worked out. Meaning, do we cut off the time at 120 minutes or 80 or 90 minutes? And what values do we consider positive? And that’s likely why they say, we can’t quite say it’s SIBO per se, because there’s not a lot of agreement in the data in terms of what exactly we’re calling SIBO and what exactly we’re not calling SIBO. But clearly, we see this pattern of altered fermentation on the breath testing that indicates bacteria and bacterial overgrowth play a role in SIBO. And we also see a number of papers showing that SIBO treatments lead to improvements in breath testing and improvements in patients’ symptoms.

So to say SIBO is not a real condition is laughable, because there is no highly credible scientific evidence that points in that direction. There may be a paper, two or three, that are challenging the condition. But if you look at the body of evidence at large, there is no good summative piece of information that’s come to that conclusion.

And then, to the point of rifaximin. Rifaximin is a viable treatment for small intestinal bacterial overgrowth. And rifaximin, I believe, has a number needed-to-treat of—I believe it’s 11. And in my article, I comprised a number of needed-to-treat table, looking in different therapies. And you see that natural therapies actually seem to, for the most part, outperform drug therapy. But it doesn’t mean that rifaximin isn’t a viable therapy. And rifaximin has shown, I believe, anywhere from a 50% to 70% response rate, when you look at some of the meta-analyses. Is it a perfect treatment? No. Are the studies using rifaximin perfect? No, because they only use rifaximin. They use rifaximin as a monotherapy, meaning no dietary changes, no lifestyle changes, no post treatment prokinetics, no probiotics. So we can, of course, have a much better extended effect—theoretically anyway—when using rifaximin in conjunction of a more holistic and global plan.

Also, in that paper, and in one of the recent criticisms, hypnotherapy was mentioned to be more effective than the low FODMAP diet. And that’s a very intellectually dishonest statement because there’s something known as positive selection bias. Meaning, when you’re first studying a treatment, the study showing that that treatment was effective are more likely to get published. So if something is new, there’s more of the selection pressure for studies that have shown to be effective. So the less studies there are, the more risk there is a bias that kind of overestimates the effectiveness of the therapy. So we have one trial in hypnotherapy, whereas we have about 80 or 90 studies in probiotics; and even more than that with rifaximin.

So again, it’s intellectually dishonest and incredibly and scientifically ill informed and naïve to think that you can take one study and compare it to a meta-analyses of 80 studies and say that you have an equal effectiveness.

So hypnotherapy was shown, in the short-term, to be slightly more effective than the low FODMAP diet. In the longer term, the low FODMAP diet was shown to be more effective. We have one study in hypnotherapy. We have 11 studies, I believe, randomized clinical trials in the low FODMAP diet.

So there’s another issue here, which was bringing up peppermint as a treatment. And, sorry, if I’m kind of monologuing.

SS: Fine. No, that’s what we’re here for.

DrMR: Peppermint oil was shown to have a number needed to treat, I believe, 2.2. Whereas the low FODMAP diet had a number needed to treat of about 2 to 3. And then, probiotics had a number needed to treat of about 8 to 9. And the number needed to treat means, you have to treat these many patients until one has a positive response. So for every 2.2 people you treat with a low FODMAP diet, you’ll have one person who responds. And for every 2 to 3 people you treat with peppermint oil, you’ll have one person positively responding. For every 8 to 9 people you treat with probiotics, you’ll have one person who positively responds.

But again, this is where understanding how science works is very helpful. Because there have been, I think, four trials with peppermint oil; where, again, there’s 80 to 90 trials with probiotics. So we see that positive selection bias with peppermint oil. And that would mislead one to think that peppermint oil is more effective than probiotics. But I can tell you clearly, in my clinical experience, and I have for the past several months been giving patients, alone, peppermint oil; and then later, having them go on probiotics. So I can kind of compare just to see if this shakes out the way it should shake out, which is we should see probiotics outperforming peppermint oil, even though probiotics have a less favorable number needed to treat. That’s been a more studied condition. So that removes the bias in making probiotics look more effective than they actually are. Which has not been done for peppermint, because there have only been four studies. And clearly, probiotics are more effective in clinical practice than peppermint is for IBS.

Peppermint can certainly be helpful. But to say that something like peppermint oil and hypnotherapy are going to be better than a low FODMAP diet and probiotics, it’s really irritating. I have to admit. It’s just irritating when people who have platforms make these comments in an area where they don’t have a level of expertise in the particular body of literature. And again, I have no problem if these things were written in a constructive, conservative, inquisitive way. But when they’re couched in language that’s absolute, it causes more damage than it does help people. And that was evident by the plethora of e-mails I received by people freaking out that this person is now saying that SIBO is not a real condition. So I mean, there’s so much I could say. And sorry for the monologue. But those are just few things that come right to my head.

SS: It really was irritating, wasn’t it? And the person, we don’t need to be mysterious, nor do we also give extra energy to the sensationalism of this. But that person has a good reputation, I thought, online, as being somebody who is very well schooled. I don’t know, I don’t know him personally. But I do know you. And I do know what an expert you are and where your heart is and where your mind and soul are. So that’s why I trust you so much, like how so many other people trust you as well, including you colleagues, Dr. Siebecker, and the like.

So somebody’s may be new small intestinal bacterial overgrowth. I just got a diagnosis or a suspicion of it being S-I-B-O. It is real. There are studies as well as thousands and thousands of clinical experiences by professionals. So it’s worth investigating. There are studies you can go—what’s the best place to go find some studies? We’ll put the link for your article here as well. But let’s say somebody wants to be totally neutral and do their own digging, which is going to be a lot of their time, because I know this even took you so long. But is PubMed the place to go?

DrMR: Yeah. I think PubMed is a good place to go. I would start with my article, because I try to showcase both sides of the evidence. When there is substantial evidence that’s critical of a certain point in the article I wrote. I’d make a point and then I’d follow that point by saying, “But not all the data here agree.” And then I’d cite the studies looking at the other side. And that, I think, is very important if you’re not going to go directly to PubMed. Which, if you’re not a scientist, that’s going to be a very slow boat to China, because it’ll take you a very long time to figure out what the broader body of literature says. It’s like trying to navigate from East Coast to the West Coast looking through a magnifying glass. You need to have a broader understanding of the issue. But you could go to PubMed and there are several links to PubMed in my article.

I would start there because, again, I lay out many of the meta-analyses. And what a meta-analysis does is it summarizes a body of data. And so, it’s very hard to cherry pick with meta-analyses because meta-analyses, their nature is to be a summarizing study. So if you want to cherry pick, you take one study that shows something misleading. But a meta-analysis will include that, as well as all the other relevant data, and then give you a summary in terms of what the trend and the data is showing. But, yeah, PubMed is a very good place to start if someone wanted to do a direct dive.

SS: Okay. And then I’ve also put a link right now up on the screen, as well as in the comment area of this Facebook live. And also, I’m going to be sending this out to our entire sibosos.com community and an e-mail. I’ll also get you a copy of this video so you can share it with your community. And Dr. Siebecker is going to be sharing it with hers as well.

So we’ve got the studies. We’ve got the experience. Were there any points in that article that you felt were like, “I’ve never thought about it like that. That’s a really good point.” Did that happen at all?

DrMR: That didn’t happen. But there were some points that I thought were valid criticisms. And so, this is to play to the other side of the coin, which are that SIBO is over tested and over diagnosed; and there is excessive fear surrounding the condition of SIBO. And so, that’s very important to understand. And those, I think, are valid criticisms. And that part, I liked, I agreed with. And I stated that as such in my article. I said, “Here’s the points I agree with.” There is over diagnosis, over treatment, and too much fear regarding SIBO.

And some of this comes down to the simple fact that in my opinion, which is a reflection of what the research literature shows, you should never be using a SIBO breath test as your only guiding factor in making any treatment decision. I do not think we have strong enough data there. I do not think that’s what the consensus of literature shows. I like the approach of testing at baseline to establish if you have SIBO on the chessboard or not, and then treating them until you obtain positive response.

And if you look at the Rome consensus, and you look at the North American consensus, the Rome consensus recommends conservative use of the test. The North American consensus recommends liberal use of the test. And I’m kind of in between those two, where I’m a little bit more liberal than Rome, but I’m a bit more conservative than the North American consensus. But I think this, in clinical practice, ends up being a very effective method. Meaning, you have some data to help you, but you’re not going to hinder yourself with serial repeat lab testing that uses up time and money.

But it’s also important to remember that not every positive on a SIBO breath test means someone actually has SIBO. And this does not mean that it’s an inaccurate test. Many tests suffer from a degree of false positives or false negatives. Meaning, the test shows positive but you don’t actually have the condition; or the test shows negative and you actually have the condition. So that happens in some testing. So, the SIBO testing is not perfect. But many tests are not perfect. But this is why it’s important not to only look at a SIBO breath test and say, “Someone has a positive SIBO breath test, but they’re feeling generally very well and they’re healthy. But now, they’re going to be inundated with fear and anguish, because the SIBO breath test says that they’re still positive.” It’s a very, very important point to make.

And then, also, there seems to be a degree of fear about SIBO that is far in excess to what is justifiable. And I think, that’s another criticism that is valid. And I think that comes from the fact that people who obtain benefit, after treating SIBO, don’t typically hang out on SIBO message boards and chat groups and what have you. So there’s this confirmation bias or a selection bias, where the most challenging cases are the ones that are most vocal. So that makes it sound like SIBO is worse than it actually is.

When you combine that with the fact—really unfortunately—that people are trying to yell louder and louder to try to grab the consumers’ attention that, now, you have people making more and more drastic claims. It’s almost like advertising in a town. If no one puts up bright flashing signs, the first person to put up a bright, flashing sign is going to get a lot of attention. But then everyone starts doing that. So then you have to go a level higher and put up a billboard that’s a bright, shining sign that’s five times the size of the original sign.

So what’s happening, I think, in the internet is people are yelling louder and louder and making stronger and stronger claims trying to capture your attention. And I think, that’s a huge mistake. Because that misleads people to think that SIBO is far worse than it is. So those were a couple of criticisms that I thought were valid and important for us all to be aware of.

SS: I love that you’re making such a great like psychological observation as well, because that is the way we behave. And there’s this very strange combination of a little bit of hysteria. And if you have it, which I have since I was probably five years old, I get that. And then, I also understand that there might be like a backlash, or like resentment about that. I mean it’s a whole thing. The bottom-line is, guys, work with your practitioners; learn from people like Dr. Ruscio, Dr. Siebecker; learn from the summits and all these great opportunities that I’ve been personally busting my butt to get out to everybody. And everybody has been so gracious in supporting that. Because as they say, “The truth is out there,” and that’s what we want to do, is we want to get it out there. So how much more time do you have, Dr. Ruscio?

DrMR: About 5 minutes.

SS: About 5 minutes. So I’ve put the post up. Everybody, go look at drruscio.com’s website. Sign-up. You’re going to learn so much from him. He does these super recaps of the hottest news in functional health every Friday. If you’re a practitioner, you can sign up for these great summaries that he does. And I think, it’s a very nominal fee. And I think, you can even get some for free. And just if you want reliable information from a very smart, thoughtful source, with lots and lots of clinical experience, as well as the research and the tests he’s doing, even in his own practice, please do find Dr. Ruscio.

What is the final thought for—sorry, I know this was short. But if everybody will just go read that article, which by the way, I’ll put in our e-mail, as well to our community, what’s the final thought?

DrMR: What I would offer people as a final thought is understanding that SIBO, yes, is a real condition. And it’s a very treatable condition. Now, yes, are you going to have a small pocket of severe cases? Yes. And we could use inflammatory bowel disease as maybe a simple illustration of this concept. The most severe cases of inflammatory bowel disease, like Crohn’s and ulcerative colitis, will be working very hard to stave off surgical removal of part of their intestinal tract. That’s the most severe.

But there are some people coming with inflammatory bowel disease, we make a small change in their diet and they never have a symptom ever again. So it’s important to understand that there is a spectrum of disease activity or condition activity. And not to automatically lump yourself in with the smallest subset that is the most severe.

The importance of that can’t be overstated because one’s self-perception of their health does manifest in health outcomes. And so if you think you are sick, then you are going to manifest it. This is known as the placebo effect. And this is why it’s incredibly important that clinicians are very cautious and deliberate in discerning, in the language that they use because you’re going to impart a degree of mental anguish onto a person, depending on what you tell them that they have or they don’t have.

So, SIBO is a real condition. It’s probably not as bad as most people think. It’s certainly something to work with, because optimizing your gut health can have a wide range of positive health impacts. And there are a number of effective treatments out there. And it’s just important to obtain your education and your information from someone who’s dispassionate, whose objective, and who is going to try to get you solutions as simply and as easily as possible. Because unfortunately, there’s probably 50% of knowing what to do and then 50% of knowing what not to do that’s important in successfully navigating this landscape.

So those are few of the things that I think are most relevant to the SIBO conversation. And I would also say, don’t lose your grip on your life. Make sure you maintain a life. There’s a great quote by Nietzsche. To paraphrase it, ‘He who has a why to live can overcome almost any how.’ So you need to have that why. Don’t lose grip of your why. Because if you have nothing else in your life other than your health journey, I’ve seen those people really struggle, because there’s nothing pulling them out of their health and into something bigger than themselves.

And there’s a ton of science and treatment options laid out in that in the article. But it’s important not to, again, lose that grip on the other aspect of your life that you’re trying to get yourself healthier so that you can bring more vibrant you to what. Don’t lose track of that what.

SS: And if you are watching The Human Longevity¸ I think it’s that longevity documentary that’s out right now, floating around the Internet. That’s one of the big points that they talk about is, when people have a purpose to live, when people have a social community, and family members that they want to care for, then they do, they live longer. And it’s a beautiful thing.

Well, you are a God-send. Thank you so much, Dr. Ruscio. We will put the information out there. I’m going to spell your name right, even. It’s going to be awesome. And I’m going to see you in the masterclass at SIBO SOS Speaker Series on March 22nd, where you and I are going to be talking about the masterclass you’re doing for an hour on the elemental diet, which is one of the most surefire ways to treat SIBO. And then also followed by two hours of Q&A.

Before you go, we do have one question. What will we say to our doctors when the doctor says, ‘Your tester is also wildly different than they were before, and you haven’t even treated,’ and then they just go to the conclusion, “SIBO’s not real.”

DrMR: So you’re saying that someone has done two tests with no treatment and they have disparate results?

SS: Wildly different. Yeah. They have had time in between. But that’s—Rohan is asking this question. But generically, when the doctor or your practitioner says, “I just read something on the internet, SIBO’s not real.” We’re going to send them to your article.

DrMR: I mean, the best thing you can do is to send them to our article. And also, understand that no one anywhere is saying—the claim has not been made that SIBO tests are static. Meaning, they’re always going to be the same unless you treat them. There will be a fair amount of dynamic shift in the testing. And if you know how to interpret the tests and you’re able to cut off when you have a true positive in the positive range from being borderline or being into the false positive range—if you’re diagnosing a true positive, in my opinion, the likelihood that you’re going to flip from a true positive to a negative is very slim. But if you don’t understand, most notably the important cut-off time of 80 to 90 minutes and looking at the levels, and if you’re skirting right around positive to negative, then there’s a higher possibility that you may flop in between positive and negative as there’s a slight shifting in your digestion.

But also, if you’re looking at SIBO testing conservatively, my commentary to someone who had a borderline case would be, well, we show you’re just over the cusp, showing that you have SIBO. And we may or we may not even treat this. And we would look at the context of the patient, which is exactly what the Rome consensus recommends. So you’re never making the SIBO, as I say—and also, as I’ve said earlier, you’re never treating a SIBO breath test in isolation. You’re always looking at that in the clinical context of the patient, their history, their presentation, their response to other treatments. And you’re using all that information collaboratively. So it’s almost a misdirected question to say, “What if the test shifts?” Because, again, it’s not all about the test because the test and the greater context and also reading the test conservatively will give you the highest probability that you’ll see a consistent positive or a consistent negative in repeat SIBO breath testing.

SS: And by the way, really good practitioners in the testing world like Gary Stapleton, he will say exactly what you just said. It’s not in a vacuum. He always wants to know the rest of the story. So, more support for your concepts.

Thank you so much, Dr. Ruscio. Have a beautiful day. We will see you on May 22nd, 5 p.m. to 8 p.m., East Coast time for that masterclass on the elemental diet. You guys can find out more information about that by e-mailing us at [email protected] and in our SIBO SOS virtual summit Facebook group. Go ahead and if you’re not in it already, just like go and say, “Hey, I want to join the group.” And we’ll get you in there.

Okay. Namaste. Thank you so much, sir.

DrMR: My pleasure.

SS: Take care. Bye-bye.

DrMR: Bye.

SS: Bye-bye.